Sylvia Escott-Stump - Nutrition and Diagnosis-Related Care (2015, LWW)

Thank you

for purchasing this e-book. To receive special offers and news about our latest products, sign up below.

Nutrition and Diagnosis-Related Care E

Escott-Stump_FM.indd i

11/7/14 5:26 AM

Escott-Stump_FM.indd ii

11/7/14 5:26 AM

Nutrition and Diagnosis-Related Care E

Sylvia Escott-Stump, MA, RDN, LDN Dietetic Internship Director East Carolina University Greenville, North Carolina Consulting Dietitian Nutritional Balance Winterville, North Carolina Board Member International Confederation of Dietetic Associations

Escott-Stump_FM.indd iii

11/7/14 5:26 AM

Acquisitions Editor: Jonathan Joyce Product Development Editor: Eve Malakoff-Klein Editorial Assistant: Tish Rogers Production Project Manager: Priscilla Crater Creative Director: Doug Smock Art Director: Jennifer Clements Manufacturing Coordinator: Margie Orzech Prepress Vendor: Absolute Service Inc. Eighth Edition Copyright © 2015 Wolters Kluwer. Copyright © 2012 Wolters Kluwer Health/Lippincott Williams & Wilkins. Copyright © 2008 Lippincott Williams & Wilkins, a Wolters Kluwer business. Copyright © 2002 Lippincott Williams & Wilkins. Copyright © 1997 Lippincott-Raven Publishers. Copyright © 1992, 1988, 1985 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer Health at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [emailprotected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Escott-Stump, Sylvia, author. Nutrition and diagnosis-related care / Sylvia Escott-Stump.—Eighth edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-9532-3 (paperback) I. Title. [DNLM: 1. Nutrition Therapy—Handbooks. 2. Nutritional Physiological Phenomena—Handbooks. WB 39] RM217.2 615.8⬘54--dc23 2014039415 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Wolters Kluwer online at http://www.lww.com. Customer service representatives are available from 8:30 am to 6:00 pm, EST.

Escott-Stump_FM.indd iv

11/7/14 5:26 AM

FOREWORD This book is a valuable resource for registered dietitiannutritionists, dietetic interns and students, and other health care professionals involved or interested in medical nutrition therapy. Efficient time management is required to deliver high-quality patient care. However, the registered dietitiannutritionist (RDN) must be both efficient and effective. Tools such as Hot Topics related to inflammation will trigger important critical thinking, as will the content related to gene– nutrition interactions and the nutrition care process. Indeed, this latest edition provides key updates for prioritizing patient care and planning nutrition therapies. The guidance provided by Nutrition and Diagnosis-Related Care charts the course for each patient, especially for clinical conditions that the practitioner does not routinely treat.

This book presents an extensive yet succinct compilation of nutrition information. The most impressive attribute is that the germane information required by dietitians is presented in a single resource. This greatly simplifies the development of nutrition care plans and interventions. Thus, dietetic practitioners have this superb resource to provide evidence-based interventions and to achieve excellent patient outcomes. Sonja L. Connor, MS, RDN, LD Research Associate Professor Oregon Health & Science University 2014–2015 President The Academy of Nutrition and Dietetics

Escott-Stump_FM.indd v

11/7/14 5:26 AM

Escott-Stump_FM.indd vi

11/7/14 5:26 AM

PREFACE Health care professionals must identify all elements of patient care capable of affecting nutritional status and outcomes. The registered dietitian-nutritionist (RDN) must provide nutritional care in a practical, efficient, timely, and effective manner regardless of setting. Various environments provide unique and special considerations. The astute dietitian is sensitive to the patient/client’s current status in the continuum of care, meticulously adapting the nutritional care plan. Communication between facilities saves time for screenings and assessments and will simplify making progress with interventions. With electronic health records, data and summary reports must be shared confidentially from one practitioner to the next. Nutrition and Diagnosis-Related Care has evolved since 1985 to supplement other texts and references and to quickly assimilate and implement medical nutrition therapy (MNT). This guide can be used to help write protocols, establish nutrition priorities, and demonstrate cost-effective therapies. The majority of disorders are described where nutrition interventions can decrease complications, further morbidity, and lengthy hospital stays. Adequate nutritional intervention often results in financial savings for the patient, the family, and the health caresystem. Evidence-based knowledge solidifies the role of nutrition as therapy and not just a basic daily requirement. The eighth edition updates and clarifies the current status of nutrition therapy guidance. A major factor influencing health is inflammation. For example, a recent study provided vitamin D, omega-3 fatty acids, melatonin, and methylated vitamin B12 to individuals with Alzheimer’s disease. Results have shown improvement in overall functioning. Thus, Hot Topic boxes provided in this edition hone in on the current knowledge about the role of nutrition in reducing inflammatory conditions. The format of the book continues to promote easy navigation for quick retrieval of information. Appendix A summarizes the nutrients, requirements, functions, and food sources. AppendixB highlights the nutrition care process for the profession of dietetics. Sample forms are included, including language related to the critical thinking involved with A-D-I (assessment, nutrition diagnosis, interventions) and M-E (monitoring and evaluation). The nutritional acuity level ranking for prioritizing dietitian services is found in Appendix C. As nutrition knowledge continues to evolve at a rapid pace, the Recommended Dietary Allowances (RDA) and Dietary Reference Intakes (DRI) tables included in prior editions of this text should now be accessed online to ensure that the most current information is used. The tables are available at http://fnic.nal.usda .gov/dietary-guidance/dietary-reference-intakes/dri-tables. The field of dietetics continues to be a focus for health promotion and disease prevention. The profession is a top career choice for making a difference in people’s lives: changing them for the better!

ASSUMPTIONS ABOUT THE READER For this text, the following assumptions have been made: 1. The reader has an adequate background in nutrition sciences, physiology and pathophysiology, medical terminology,

biochemistry, basic pharmacotherapy, and interpretation of biochemical data to understand the abbreviations, objectives, and interventions in this book. 2. An individualized drug history review is essential, as only a few medications are included here. Note as well that drugs are often removed from the market; check with a pharmacist for more guidance. 3. Herbs, botanicals, and dietary supplements are discussed because they are often used without prior consultation with a dietitian or a physician. They have side effects as well as perceived or real benefits. Products may be “natural” but not necessarily “safe” for an individual. 4. For teaching, the nutrition professional must provide appropriate handouts, printed materials, and teaching tools to prepare the patient for independent functioning. The educator must identify teachable moments and share what is needed at the time. “More information” is not always the best option for a single intervention. When possible, multiple visits should be scheduled to address nutrition and lifestyle changes. 5. The nutrition counselor must use evidence-based techniques with the patient and significant other(s). Follow-up interventions are highly recommended to evaluate successful behavioral changes by the patient/client. Appendix B provides a brief overview; the reader must devote adequate time to develop counseling skills that will achieve desirable outcomes. 6. Dietitians must prioritize nutritional diagnoses that can be managed within a given time frame. A realistic plan must be designed and goals should include a time frame. 7. With assignments in ambulatory centers, extended care facilities, subacute or rehabilitative centers, private practices, grocery stores, Web-based practices, rehabilitation facilities, and home care, the “seamless” continuum affords registered dietitian-nutritionists the possibility of lifelong patient relationships. The “patient-centered medical home” affords continuity through monitoring, follow-up, and evaluation by one team. 8. Clinical Indicator lists offer common tests, disease markers, and biochemical evaluations reviewed by physicians or dietitians for that condition. Because laboratory test results are not always available in nonhospital settings, changes in appetite, intake, and weight are the most viable screening factors. Physical changes and signs of malnutrition should always be noted during assessments and reassessments. 7. A current nutrition care manual or textbook should be used to write dietary modifications. Comprehensive lists are not included with this book. 8. Evidence-based guides provide predictable types of interventions over multiple visits. Identify and use relevant guidelines, such as those at http://www.andeal.org/default.cfm 9. Except where specifically noted for children, nutrition therapy plans in this book are for adults over the age of 18. 10. Vitamin and mineral supplements are needed in cases of a documented or likely deficiency. However, in large doses, they may cause food–drug interactions. Note all supplements when planning meals and nourishments to avoid

vii

Escott-Stump_FM.indd vii

11/7/14 5:26 AM

viii

P R E FA C E

excessive intakes. Athletes, women, elderly individuals, and vegetarians tend to take vitamin and mineral supplements more often than other individuals. 11. Food from a healthy, varied diet is the best “nutritional medicine.” Evidence points to the benefits of whole foods for their nutrient–chemical mix. A well-balanced diet follows the U.S. Department of Agriculture MyPlate food guidance system. Various ethnic, vegetarian, pediatric, geriatric, and diabetes food guides are available for menu planning and design. 12. With awareness of the interacting roles of diet and nutrients with genes and vice versa, greater emphasis has been placed on personalized nutrition counseling. It is no longer acceptable to prescribe a “one size fits all” nutrition plan. When genetic testing is available, the skilled RDN must

Escott-Stump_FM.indd viii

provide advice that considers the ethical, legal, economic, and social implications for the patient/client and family. 13. Ethics, cultural sensitivity, and a concern for patient rights should be practiced at all times. When known, the wishes and advanced directives of the patient are to be followed, even if they preclude the administration of artificial nutrition. 14. Interesting and varied websites have been included for additional insights into various diseases, conditions, and nutritional interventions. 15. It is essential to use the current standardized nutrition language, as terms and definitions may change as the profession evolves. Access the latest information at http://www .eatright.org/NCP/. The electronic version (eNCPT) provides access to the terminology and many countries have translated the standardized terminology into their own language.

11/7/14 5:26 AM

ACKNOWLEDGMENTS Thanks to all reviewers who made valuable suggestions for changes. I wish to thank Jonathan Joyce, Eve Malakoff-Klein, Teresa Exley and their team members for valuable suggestions, insights,

and edits. This book is dedicated to my family (Russ, Matthew, and Lindsay Stump) and to my students, interns, and colleagues around the globe. They make it all worthwhile! Sylvia Escott-Stump, MA, RD, LDN

Escott-Stump_FM.indd ix

11/7/14 5:26 AM

Escott-Stump_FM.indd x

11/7/14 5:26 AM

REVIEWERS Ann Gaba, EdD Assistant Professor and Dietetic Internship Director School of Urban Public Health CUNY School of Public Health at Hunter College New York. NY

Karen Schmitz, PhD Chairperson, Biological and Health Sciences Director, Dietetics Madonna University Livonia, Michigan

Rubina Haque, PhD Associate Professor School of Health Sciences Eastern Michigan University Ypsilanti, Michigan

Jennifer Weddig, PhD, RD, CLC Professor Department of Nutrition Metropolitan State University of Denver Denver, Colorado

Tania Rivera MS, RD, LD/N Assistant Clinical Professor Department of Dietetics and Nutrition Florida International University Miami, Florida

Mary Width MS, RD Lecturer Coordinated Program in Dietetics Wayne State University Detroit, Michigan

Cynthia A Knipe, RD, LD Clinical Liaison, Dietetic Internship Keene State College Keene, NH

Sara Long Roth. PhD Professor Emeritus Animal Science, Food and Nutrition Southern Illinois University Carbondale, Illinois

Alice Lindeman, PhD Associate Professor School of Public Health-Bloomington Indiana University Bloomington, Indiana

Jean Zancanella Assistant Professor (Lecturer), Nutrition University of Utah Salt Lake City, Utah

Lori Maddox, MS, RD, LD Instructor Department of Dietetics and Nutrition, College of Health Professions University of Arkansas for Medical Sciences Maumelle, Arkansas

Escott-Stump_FM.indd xi

11/7/14 5:26 AM

Escott-Stump_FM.indd xii

11/7/14 5:26 AM

COMMON ABBREVIATIONS A1c AA abd ADIME ABW ACE ACO ACTH Alb ALP ALT amts ARF ASHD AST ATP BCAAs BEE BF BMR BP BS BSA BUN BW bx c C CA Caⴙⴙ CABG CBC CF CHD CHF CHI CHO Chol Clⴚ CNS CO2 CPK CPR CrCl CRP CT Cu CVA DAT dec decaf def DJD dL DM

A1c test (glycosylated hemoglobin) amino acid abdomen, abdominal assessment-diagnosis-intervention-monitoringevaluation average body weight angiotensin-converting enzyme affordable care organization adrenocorticotropic hormone albumin alkaline phosphatase alanine aminotransferase amounts acute renal failure atherosclerotic heart disease aspartate aminotransferase adenosine triphosphate branched-chain amino acids basal energy expenditure breastfeeding basal metabolic rate blood pressure blood sugar body surface area blood urea nitrogen body weight biopsy cup(s) coffee cancer calcium coronary artery bypass grafting complete blood count cystic fibrosis cardiovascular heart disease congestive heart failure creatinine-height index carbohydrate cholesterol chloride central nervous system carbon dioxide creatine phosphokinase cardiopulmonary resuscitation creatine clearance C-reactive protein computed tomography copper cerebrovascular accident diet as tolerated decreased decaffeinated deficiency degenerative joint disease deciliter diabetes mellitus

DNA DOB DRI DV D5W EAA ECG, EKG EEG EFAs Elec EN eNCPT ESRD ETOH Feⴙⴙ F&V FSH FTT FUO G, g GA GBD GE gest GFR GI Gluc GN GTT H&H HbA1c HBV HBW HCl Hct HDL HEN HLP HPN HTN Ht I I&O IBD IBS IBW IEM INR IU IUD IV Kⴙ kcal kg L lb

deoxyribonucleic acid date of birth dietary reference intakes daily value 5% dextrose solution in water essential amino acid electrocardiogram electroencephalogram essential fatty acids electrolytes enteral nutrition electronic nutrition terminology reference manual end-stage renal disease ethanol/ethyl alcohol iron fruits and vegetables follicle-stimulating hormone failure to thrive fever of unknown origin gram(s) gestational age gallbladder disease gastroenteritis gestational glomerular filtration rate gastrointestinal glucose glomerular nephritis glucose tolerance test hemoglobin and hematocrit hemoglobin A1c test high biological value healthy body weight hydrochloric acid hematocrit high-density lipoprotein home enteral nutrition hyperlipoproteinemia or hyperlipidemia home parenteral nutrition hypertension height infant intake and output inflammatory bowel disease irritable bowel syndrome ideal body weight inborn error of metabolism international normalized ratio (coagulation) international units intrauterine device intravenous potassium food kilocalories kilogram(s) liter(s) pound(s)

xiii

Escott-Stump_FM.indd xiii

11/7/14 5:26 AM

xiv

C O M MO N A BBREVIA TIO NS

LBM LBV LBW LCT LDH LDL LE LGA LH lytes M MAC MAMC MAO MCH MCT MCV Mgⴙⴙ mg ␮g MI mm MODS MSG MUFA N&V N Na NCEP NCP NEC NG NPO NSI O2 OP OT oz P PAD PCMH PCM PEM

Escott-Stump_FM.indd xiv

lean body mass low biological value low birth weight long-chain triglycerides lactate dehydrogenase low-density lipoproteins lupus erythematosus large for gestational age luteinizing hormone electrolytes milk midarm circumference midarm muscle circumference monoamine oxidase mean cell hemoglobin medium-chain triglycerides mean cell volume magnesium milligram(s) microgram(s) myocardial infarction millimeter(s) multiple organ dysfunction syndrome monosodium glutamate monounsaturated fatty acids nausea and vomiting nitrogen sodium National Cholesterol Education Program Nutrition Care Process necrotizing enterocolitis nasogastric nil per os (nothing by mouth) Nutrition Screening Initiative oxygen outpatient occupational therapist ounce(s) phosphorus peripheral artery disease patient-centered medical home protein-calorie malnutrition protein-energy malnutrition

pCO2 PG PKU PN pO2 PRN Prot PT PTH PUFA RAST RBC RDA RDS REE RQ RRT Rx SFA SGA SI SIADH SIDS SOB Sx t, tsp T, tbsp TB TF TIBC TLC TPN Trig TSF UA UTI UUN VMA VO2max WBC WNL Zn

partial pressure of carbon dioxide pregnant, pregnancy phenylketonuria parenteral nutrition partial pressure of oxygen pro re nata (as needed) protein prothrombin time; physical therapy parathormone polyunsaturated fatty acid(s) radioallergosorbent test red blood cell count recommended dietary allowance (specific) respiratory distress syndrome resting energy expenditure respiratory quotient renal replacement therapy treatment saturated fatty acids small for gestational age small intestine syndrome of inappropriate antidiuretic hormone sudden infant death syndrome shortness of breath symptoms teaspoon(s) tablespoon(s) tuberculosis tube feeding; tube fed total iron-binding capacity total lymphocyte count total parenteral nutrition triglycerides triceps skinfold uric acid urinary tract infection urinary urea nitrogen vanillylmandelic acid maximum oxygen intake white blood cell count within normal limits zinc

11/7/14 5:26 AM

LIST OF TABLES SECTION 1 1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8 1-9 1-10 1-11 1-12 1-13 1-14 1-15 1-16 1-17 1-18 1-19 1-20 1-21 1-22 1-23 1-24 1-25 1-26 1-27 1-28 1-29 1-30 1-31 1-32 1-33 1-34 1-35 1-36 1-37 1-38

Public Health: Ten Achievements and Ten Essential Services 2 Dietary Guideline Systems 3 Prenatal Risk Assessment 7 Special Issues in Pregnancy 9 Recommendations for Pregnant Women 10 March of Dimes Campaign to Reduce Preterm Births 11 Content of Mature Human Milk 14 Recommendations for Lactation 16 Common Breastfeeding Difficulties and Reasons Why Women Discontinue Breastfeeding 18 Recommendations for Infants Ages 0 to 6 Months 21 Special Problems in Infant Feeding 22 Feeding Babies in the First Year of Life 25 Recommendation for Infants Ages 6 Months to 1 Year 26 Recommendation for Children Ages 1 to 13 30 Estimated Calorie Needs per Day by Age, Gender, and Physical Activity Level 30 General Dietary Recommendations for Children Ages 2 Years and Older 31 Special Considerations in Childhood: Lead Poisoning and Measles 32 Tips for Encouraging Children to Enjoy Nutrition and Physical Activity 32 Recommendation for Males and Females Ages 14 to 18 36 Special Considerations for Adolescent Pregnancy 36 International Society of Sports Nutrition Position Statements 40 Percent Body Fat Standards 41 Protein Intake for Athletes 41 Guidelines for Planning Meals for Athletes 42 Supplements Commonly Used by Athletes 43 Leading Causes of Death and Nutritional Implications for Men in the United States 45 Disorders and Their Related Genes 46 Special Nutrition-Related Concerns of Adult Women 48 Nutrient Recommendations for Adults 49 Functional Foods and Ingredients 50 Medications and Nutrients Commonly Used by Adults 52 Tips for Eating More Fruits and Vegetables 54 Key Nutrients in Fruits and Vegetables 55 Food Labeling Terms 56 Health Claims 57 Summary of Nutrition Screening and Assessment Tools for the Elderly 61 Dietary Reference Intakes for Older Adults 64 Formula for Calculating Stature Using Knee Height 66

SECTION 2 2-1 2-2

Herbal, Botanical, and Dietary Supplement Intake 71 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects 72

2-3 2-4 2-5 2-6 2-7 2-8 2-9 2-10 2-11 2-12 2-13 2-14 2-15 2-16

Common Religious Food Practices 86 Potential Complications of a Vegetarian Diet 90 Nutrients Needed for Proper Oral Tissue Synthesis and Dental Care 98 Dental Problems, Treatment, and Prevention 100 Nutrients for Healthy Vision 111 Skin Changes with Aging and Pressure Ulcer Stages 117 Vitamin Deficiency Summary 120 Gastrointestinal Allergic Manifestations 124 Major Food Allergens and Nutritional Consequences 127 Specifics of Food Allergies 128 Tips for Educating Individuals about Food Allergies 130 Sources, Symptoms, and Pathogens That Cause Food Poisoning 133 Safe Food Handling and Food Safety Guidelines 136 Refrigerator and Freezer Food Storage 137

SECTION 3 3-1 3-2 3-3 3-4 3-5

3-6 3-7 3-8 3-9 3-10 3-11 3-12 3-13 3-14 3-15 3-16 3-17 3-18 3-19

Useful Assessments in Pediatrics 140 Nutritional Risks Associated with Selected Pediatric Disorders 142 Adequate Intakes of Water in Infancy and Early Childhood 143 ADHD Medications Approved by the FDA 147 Glycogen Storage Diseases: Deficiency of a Glycogen Synthase That Normally Converts Glycogen to Glucose 157 Signs and Symptoms of Cerebral Palsy 159 Medications for Congenital Heart Disease 165 Normal Growth Rates for Height and Weight in Children 171 Grading for Hirschsprung Enterocolitis 177 Laxative Foods for Children 178 Nutritional Deficits in the Premature or Low-Birth-Weight Infant 188 Nutrient Needs of Preterm Infants 190 Parenteral Vitamin and Mineral Needs in Preterm Infants 190 Types of and Nutrition Interventions for Maple Syrup Urine Disease 192 Causes of Childhood Obesity 204 When to Initiate Weight Loss Diets in Children 205 Components of Successful Weight Loss for Children 206 Risk Factors for Developing Intrauterine Growth Restriction in Pregnancy 217 Urea Cycle Disorders 221

SECTION 4 4-1 4-2 4-3 4-4 4-5

Brain Parts and Their Functions 230 Cranial Nerves and Those Specifically Affecting Mastication and Swallowing 230 Disorders of Mental Health and Their Relevance to Nutrition 231 Neurotransmitters and Their Nutritional Relevance 233 Nutrients for Brain Health 234

Escott-Stump_FM.indd xv

11/7/14 5:26 AM

xvi 4-6 4-7 4-8 4-9 4-10 4-11 4-12 4-13 4-14 4-15 4-16 4-17 4-18 4-19 4-20 4-21 4-22

L I S T O F TA BLES

Medications for Alzheimer’s Disease and Possible Side Effects 238 Consequences of Withholding Food and Fluid in Terminally Ill Patients 246 Medications Used in Epilepsy 250 Foods Implicated in Various Types of Headaches 257 Types of Multiple Sclerosis 259 Medications for Parkinson’s Disease and Possible Side Effects 265 Expected Functional Level of Spinal Cord Disruption 266 Most Common Stroke Symptoms 269 Strategies Used to Prevent Strokes 271 Average Woman versus “Fashion Woman” 276 Tips for Helping Patients with Eating Disorders 277 Assessment of Oral Manifestations in Bulimia Nervosa 281 Other Disordered Eating Patterns 282 The Bipolar Spectrum and Symptoms 284 Antipsychotic Medications and Possible Side Effects 292 Medications for Depression and Mood Disorders and Potential Side Effects 293 Common Addictions and Issues 298

SECTION 5 5-1 5-2 5-3 5-4 5-5 5-6 5-7 5-8 5-9 5-10 5-11 5-12 5-13 5-14

Causes of Malnutrition in Patients with Pulmonary Disease 305 Respiratory Quotient and Nutrients 305 Early Warning Signs of Asthma 306 Nutrients and Their Potential Mechanisms in Asthma 307 Medications Used in Asthma 309 Tips for Adding Calories to a Diet 316 Tips for Adding Protein to a Diet 316 Nutritional Management for Cystic Fibrosis 323 Medications Used in Cystic Fibrosis and Potential Side Effects 325 Types of Pneumonia 329 Causes of Respiratory Failure 335 Ventilatory Dependency Feeding Stages 335 Medications Used for Lung Transplant Patients 345 Medications Used for Tuberculosis 349

SECTION 6 6-1 6-2 6-3 6-4 6-5 6-6 6-7 6-8 6-9 6-10 6-11

Level I—Best Evidence in Dietary Recommendations for Heart Disease 353 Key Influences and Factors Related to Heart Disease 353 Herbs and Supplements Commonly Used in Heart Disease 355 Key Sources of Folate, Potassium, Calcium, and Magnesium 356 The DASH Diet Principles 357 Signs of the Metabolic Syndrome (Any Three of the Following) 359 Drugs Affecting Lipoprotein Metabolism 366 Sodium Content of Common Foods 375 Tips for Lowering Sodium in the Diet 375 Medications Used in Heart Failure 376 Medications Used after Transplantation 379

Escott-Stump_FM.indd xvi

6-12 6-13 6-14 6-15 6-16 6-17 6-18

Categories for Blood Pressure Levels in Adults (Ages 18 Years and Older) 383 Sodium and Potassium in Salt, Salt Substitutes, and Herbal Seasonings 385 Medications for Hypertension 386 Risk Factors for Myocardial Infarction 388 Complications after Myocardial Infarction 389 Sites Where Peripheral Arterial Disease Produces Symptoms 393 Common Causes of Thrombophlebitis 395

SECTION 7 7-1 7-2 7-3 7-4 7-5 7-6 7-7 7-8 7-9 7-10 7-11 7-12 7-13 7-14 7-15 7-16 7-17 7-18 7-19 7-20 7-21 7-22 7-23 7-24 7-25 7-26 7-27

Gastrointestinal Conditions That May Lead to Malnutrition 400 Enteral Nutrition, Prebiotics, Probiotics, and Synbiotics in Gastrointestinal Tract Function 401 Conditions That May Benefit from Use of Intestinal Fuels 401 Knowledge and Skills of Dietitians in Gastrointestinal Specialty 401 Standard Questions in the Evaluation of Dysphagia 403 Common Causes of Dysphagia 404 Typical Caffeine Content of Beverages and Medications 425 Medications Used in Peptic Ulcer Disease 426 Grains and Starches to Use Freely in Celiac Disease 433 Medications for Constipation 436 Diarrhea: Etiologies and Comments 438 Bristol Stool Scale 440 UNICEF/WHO Oral Rehydration Therapy 440 How to Eat More Fiber 443 Altered Stools and Related Disorders 445 Fecal Fat Study 445 Medium-Chain Triglycerides 446 Medications Used after Intestinal Transplantation 459 Foods to Limit on the FODMAPS Diet 461 Types of Lactose Maldigestion 464 Lactose Content of and Substitutes for Common Foods 464 Types of Colostomies 468 Implications of Bowel Resections 474 Malabsorption Concerns in Short Bowel Syndrome 474 Medications Used in Short Bowel Syndrome 476 Fecal Incontinence: Causes and Comments 481 Fiber Content of Common Foods 483

SECTION 8 8-1 8-2 8-3 8-4 8-5 8-6 8-7 8-8 8-9

Liver, Gallbladder, and Pancreatic Functions 489 Stages of Alcoholic Liver Disease and Related Effects 492 Hepatitis Symptoms, Transmission, and Treatment 497 Causes of Malnutrition in Cirrhosis 501 Medications Used in Cirrhosis 503 Stages of Hepatic Encephalopathy—West Haven Classification 505 Nutrient Relationships in Hepatic Failure and Hepatic Encephalopathy 506 Medications Used for Hepatic Encephalopathy 507 Prebiotics, Probiotics, and Healthy Foods Shopping List 508

11/7/14 5:26 AM

L I S T OF T AB L E S

8-10 8-11 8-12 8-13 8-14 8-15

Post–Transplant (Liver or Pancreas) Nutrition Guidelines 512 Medications Used after Liver Transplantation 513 Medications Used in Acute and Chronic Pancreatitis 516 Antioxidants and Sources 517 Oxygen Radical Absorbance Capacity (ORAC) Rating of Foods 519 Medications Used after Pancreatic Transplantation 524

SECTION 9 9-1 9-2 9-3 9-4 9-5 9-6 9-7 9-8 9-9 9-10 9-11 9-12 9-13 9-14 9-15 9-16 9-17 9-18 9-19 9-20 9-21 9-22 9-23

Etiologic Classification of Diabetes Mellitus 539 Types of Diabetes in Children and Teens 539 Assessment of Diabetes 540 Potential Complications of Diabetes 541 Key Concepts in Diabetes Management 544 Recommended Medical Nutrition Therapy Visits for Diabetes 547 Sugar and Sweetener Summary 549 Insulin Onset, Peaks, and Duration 550 Herbs and Supplements in Diabetes Management 552 Glycemic Index and Glycemic Load 553 General Guidelines for Regulating Exercise in Diabetes 553 Glucose Testing for Gestational Diabetes Mellitus 555 Prediabetes Classifications and Tests 558 Number of Nutrition Visits Reimbursed by Medicare for Type 2 Diabetes 562 Medications Used for Type 2 Diabetes 563 Quick Sources of Glucose 576 Endocrine Glands and Their Functions 584 Symptoms of a Pituitary Disorder 586 Causes of Syndrome of Inappropriate Antidiuretic Hormone (SIADH) 594 Catecholamines 603 Thyroid Test Results 605 Symptoms of Hypothyroidism by Life Stage 609 Phosphorus Facts 614

SECTION 10 10-1 10-2 10-3 10-4 10-5 10-6 10-7 10-8 10-9 10-10 10-11 10-12 10-13 10-14 10-15 10-16

Escott-Stump_FM.indd xvii

Concerns with Undernutrition 618 Concerns with Overnutrition 621 Weight Calculations and Body Mass Index Guidelines 621 Calculations of Ideal Body Weight Range 623 Body Mass Index Table for Adults 624 Short Methods for Calculating Energy Needs 624 Suggested Weights for Initiation of Weight Management Counseling 627 Calculation of Fat Grams 627 Night Eating Syndrome Description and Questionnaire 628 Power of Food Scale 628 Medications That Cause Weight Gain 632 Medications Used for Weight Reduction in the United States 633 Portion Adjustments Using Everyday Objects 634 Physical Activity Equivalents 634 Weight Management for Sleep Apnea and Pickwickian Syndrome 635 Managing Weight Gain after Smoking Cessation 635

10-17 10-18 10-19 10-20 10-21 10-22 10-23 10-24 10-25

xvii

Diet Program Comparisons 636 Strengthening Tips 640 Indicators of Malnutrition 641 Complicating Effects of Chronic Malnutrition on Body Systems 644 Malnutrition Universal Screening Tool 647 Severe and Nonsevere Malnutrition in Adults 648 Selected Biochemical Changes Observed in Severe Malnutrition 649 Poor Prognosis and Consequences of Not Feeding a Patient 650 Conditions with High Risk for Refeeding Syndrome 652

SECTION 11 11-1 11-2 11-3 11-4 11-5 11-6 11-7 11-8 11-9 11-10 11-11 11-12 11-13 11-14

Body Systems Affected by Autoimmune Disorders 656 Phytochemicals and Dietary Factors Affecting Rheumatic Disorders 657 Recommendations for the Prevention of Osteoporosis 660 Acquired Causes of Hyperuricemia 661 Clinical, Metabolic, and Endocrine Issues in Muscular Dystrophies 668 Medications Commonly Used for Osteoarthritis 675 Side Effects of Herbs, Supplements, and Extracts Commonly Used for Arthritis 676 Food, Nutrients, and Bone Health 680 Risk Factors for Osteoporosis 682 Tips on Calcium Supplements 684 Medications Commonly Used for Management of Osteoporosis 685 Features of Rheumatic Arthritis 692 Variant Forms of Rheumatic Arthritis 692 Medications Used in Rheumatoid Arthritis 695

SECTION 12 12-1 12-2 12-3 12-4 12-5 12-6 12-7 12-8 12-9 12-10 12-11 12-12 12-13 12-14 12-15 12-16 12-17 12-18 12-19 12-20

Nutritional Factors in Blood Formation 705 Anemia Definitions 706 Iron Tests 706 General Signs and Symptoms of Anemia 706 Signs and Symptoms of Aplastic or Fanconi Anemias 713 Symptoms of Copper Insufficiency and Anemia 716 Food Sources of Copper 717 Conditions and Medications That Deplete Folic Acid 718 Folic Acid Sources 719 Types of Hemolytic Anemia 721 Stages of Iron Deficiency 722 Normal Iron Distribution in the Body 722 Factors That Modify Iron Absorption 722 Medications to Correct Iron Deficiency Anemia 725 Micronutrient Deficiencies in Parasitic Anemias Such as Malaria 728 Risks and Causes of Pernicious Anemia or Vitamin B12 Deficiency Anemia 730 Equation to Predict Energy Needs in Adolescents with Sickle Cell Disease 735 Blood Clotting Cascade 738 Food Sources of Vitamin K 740 Iron Overloading and Hemochromatosis 741

11/7/14 5:26 AM

xviii

L I ST O F TA BLES

SECTION 13

SECTION 16

13-1 13-2

16-1 16-2 16-3

13-3 13-4 13-5 13-6 13-7 13-8 13-9 13-10 13-11 13-12 13-13 13-14 13-15 13-16 13-17 13-18 13-19 13-20

Cancer Definitions 751 Phytochemicals, Functional Food Ingredients, and Cancer 753 Cancer Risk Factors by Site 757 Use of Nutrition Support in Cancer Patients 759 Side Effects of Cancer Treatment and Common Nutrition-Related Problems of Cancer 760 Cancer Drugs and Chemotherapy Agents 764 Antineoplastic Agents: Generic and Brand Names 765 Herbs, Dietary Supplements, and Cancer 765 General Patient Education Tips 769 Neutropenic Diet Guidelines 773 Drugs Commonly Used in Bone Marrow or Stem Cell Transplantation 774 Types of Brain Tumors 776 Risks and Protective Factors for Colorectal Cancer 780 Key Factors in Types of Head and Neck Cancer 782 Risks for Gastric Cancer 785 Risk Factors for Liver Cancer 790 Staging of Breast Cancer 802 Preventive Dietary Factors for Prostate Cancer 807 Antioxidant Color Link 809 Types of Leukemia 811

SECTION 14 14-1 14-2 14-3 14-4 14-5 14-6 14-7 14-8 14-9 14-10

Postsurgical Phases in Nutrition 820 Time Required to Deplete Body Nutrient Reserves in Well-Nourished Individuals 821 Measuring Energy Expenditure in Critical Illness 823 The Small Intestine after Surgery 824 Managing Fluid and Electrolyte Imbalances 824 Signs and Symptoms of Fluid and Electrolyte Imbalances and Nutritional Concerns 825 Herbal Medications and Recommendations for Discontinued Use before Surgery 828 Percentage of Body Weight in Amputees 829 Surgeries, Level of Nutritional Acuity, and Nutritional Recommendations 829 Tips for Diet after Gastric Bypass 834

SECTION 15 15-1 15-2 15-3 15-4 15-5 15-6 15-7 15-8 15-9 15-10 15-11 15-12

How the Immune System Works 843 Immunocompetence Concerns 844 Nutritional and Host Factors in Immunity 845 Factors of Importance in Critical Care 846 Infections, Febrile Conditions, and Nutritional Implications 847 Virulence Increased by Iron 851 WHO Clinical Staging of HIV/AIDS for Adults and Adolescents 853 Guidelines for Nutrition Therapy in HIV Management 855 Medications Used for HIV Infections and AIDS 858 Pharmacotherapy for Burns 864 Intestinal Parasites and Treatments 870 Stages of Sepsis 877

Escott-Stump_FM.indd xviii

16-4 16-5 16-6 16-7 16-8 16-9 16-10 16-11 16-12 16-13 16-14 16-15

Human Kidney Functions 886 Renal Abbreviations 887 Stages, Symptoms, and Preventive Measures for Chronic Kidney Disease 890 Protein–Energy Malnutrition in Renal Patients 892 Spice and Condiment Substitutes for Salt 894 Tips for Managing Potassium and Phosphorous in the Diet 894 Drugs Used in Chronic Kidney Disease and Dialysis Patients 895 Tips for Managing Thirst and Fluid Restrictions 896 Nutrition Therapy for Dialysis Patients 899 Vitamin D3 Repletion 900 Role of the Renal Dietitian in Dialysis Care 900 Risk Factors for Developing Kidney Stones 906 Dietary Treatment of Specific Renal Stones 908 Complications after Renal Transplantation 916 Immunosuppressant Drugs Used after Renal Transplantation 918

SECTION 17 17-1

17-2 17-3 17-4 17-5 17-6 17-7 17-8 17-9 17-10

American Society for Parenteral and Enteral Nutrition Definition of Terms Related to Nutrition Support 925 Ethics of Nutrition Support Therapy and End-of-Life Care 926 Consequence Statement: Not Feeding a Resident/ Patient When Oral Intake Is Inadequate 929 Clinical Practice Guidelines for Nutrition Support 930 Sample Formula Types 931 Key Enteral Issues 932 Critical Control Point Checklist for Tube Feedings 933 Candidates for Central Parenteral Nutrition in Adults 936 Sample Basic Adult Daily Requirements for Central Parenteral Nutrition 939 Complications in Parenteral Nutrition 940

APPENDIX A A-1 A-2 A-3 A-4 A-5 A-6 A-7 A-8 A-9 A-10 A-11 A-12 A-13 A-14 A-15 A-16 A-17

Carbohydrate and Fiber 946 Food Sources of Dietary Fiber 947 Fats and Lipids 948 Amino Acids 949 Biological Value of Proteins 951 Protein Sources 951 Food Sources of Calcium 953 Food Sources of Magnesium 954 Food Sources of Potassium 955 Food Sources of Iron 959 Food Sources of Vitamin A 963 Food Sources of Vitamin D 964 Food Sources of Vitamin E 965 Food Sources of Vitamin K 966 Food Sources of Folic Acid 969 Food Sources of Vitamin B12 970 Food Sources of Vitamin C 971

11/7/14 5:26 AM

L I S T OF T AB L E S

APPENDIX B B-1 B-2 B-3 B-4 B-5 B-6 B-7 B-8 B-9 B-10

Advantages of Interdisciplinary Team Care 974 Sample Hospital Nutrition Department Scope of Services 978 Dietary Intake Assessment and Nutrition History 980 Initial Adult Nutrition Assessment 981 Clinical Signs of Malnutrition and the NutritionFocused Physical Examination 982 Calculation of Adult Energy Requirements 983 Calculations of Adult Protein Requirements 985 Pediatric Nutrition Assessment 985 Interpretation of Lab Values 986 Quick Reference: Food–Drug Interactions 997

B-11 B-12 B-13 B-14 B-15 B-16

xix

Sample Worksheet for Using Standardized Nutrition Terminology 998 Clinical Case Review and Audit 999 Tips for Adult Education and Counseling 1000 Terms and Phrases Useful in Open-Ended Questioning 1004 Health-Promotion Intervention Models 1004 Monitoring and Evaluation for Patient Education/ Counseling Outcomes 1007

APPENDIX C C-1 C-2

Nutrition Acuity and Medical Diagnosis– Related Survey Questions 1011 Acuity for Dietitian Roles in Medical Diagnoses 1011

xix

Escott-Stump_FM.indd xix

11/7/14 5:26 AM

Escott-Stump_FM.indd xx

11/7/14 5:26 AM

CONTENTS Foreword v Preface vii Acknowledgments ix Reviewers xi Common Abbreviations xiii List of Tables xv Alphabetical List of Topics xxv

SECTION 1 NORMAL LIFE STAGES 1 Pregnancy and Lactation 5 Pregnancy 5 Lactation 13 Infancy, Childhood, and Adolescence 19 Infant (0 to 6 Months) 19 Infant (6 to 12 Months) 23 Childhood 27 Adolescence 34 Physical Fitness and Stages of Adulthood 39 Sports Nutrition 39 Adulthood 44 Nutrition in Aging 59

SECTION 2 NUTRITION PRACTICES, FOOD SAFETY, ALLERGIES, SKIN, AND MISCELLANEOUS CONDITIONS 69 Complementary-Alternative or Traditional Nutrition 70 Complementary-Alternative or Traditional Nutrition 70 Cultural Food Patterns, Vegetarianism, and Religious Practices 85 Cultural Food Patterns 85 Vegetarianism 89 Eastern Religious Dietary Practices 92 Western Religious Dietary Practices 94 Middle Eastern Religious Dietary Practices 96 Orofacial Conditions 98 Dental and Oral Disorders 98 Periodontal Disease and Gingivitis 103 Temporomandibular Joint Dysfunction 106

Food Allergy and Autoimmune Inner Ear Syndrome 122 Food Allergy 122 Autoimmune Inner Ear Disease (Ménière Syndrome) 131 Food Poisoning 132 Food Poisoning 132

SECTION 3 PEDIATRICS: BIRTH DEFECTS AND GENETIC AND ACQUIRED DISORDERS 139 Abetalipoproteinemia 144 Attention Deficit Disorders 145 Autism Spectrum Disorder 148 Biliary Atresia 151 Bronchopulmonary Dysplasia 153 Carbohydrate Metabolic Disorders 156 Cerebral Palsy 159 Cleft Lip and Palate 162 Congenital Heart Disease 164 Cystinosis and Fanconi Syndrome 166 Down’s Syndrome 168 Failure to Thrive 170 Fatty Acid Oxidation Disorders 173 Fetal Alcohol Syndrome 175 Hirschsprung Disease (Congenital Megacolon) 177 HIV Infection, Pediatric 179 Homocystinuria and Inborn Errors of Cobalamin and Folate 181 Large for Gestational Age (Macrosomia) 184 Leukodystrophies 186 Low Birth Weight or Prematurity 188 Maple Syrup Urine Disease 192 Mucopolysaccharidoses 194 Necrotizing Enterocolitis 197 Neural Tube Defects: Spina Bifida and Melomeningocele 199 Obesity, Childhood 202 Otitis Media 208 Phenylketonuria 209 Prader-Willi Syndrome 212 Rickets 214 Small for Gestational Age and Intrauterine Growth Restriction 216 Tyrosinemia 218 Urea Cycle Disorders 220 Wilson Disease 224

SECTION 4

Sensory Impairment 107 Sensory Impairments: Vision, Coordination, Chewing, and Hearing 107

NEUROPSYCHIATRIC CONDITIONS 227

Skin Conditions, Pressure Ulcers, and Vitamin Deficiencies 113 Skin Disorders 113 Pressure Ulcers 116 Vitamin Deficiencies 119

Neurologic Disorders 235 Alzheimer’s Disease and Dementias 235 Amyotrophic Lateral Sclerosis 239 Brain Trauma 241

xxi

Escott-Stump_FM.indd xxi

11/7/14 5:26 AM

xxii

C O NTENTS

Cerebral Aneurysm 244 Coma or Persistent Vegetative State 246 Epilepsy and Seizure Disorders 248 Guillain–Barré Syndrome 251 Huntington Disease 252 Migraine 255 Multiple Sclerosis 258 Myasthenia Gravis and Neuromuscular Junction Disorders 261 Parkinson’s Disease 263 Spinal Cord Injury and Paralysis 266 Stroke (Cerebrovascular Accident) 269 Trigeminal Neuralgia 273 Psychiatric Disorders—Eating Disorders 275 Anorexia Nervosa 275 Binge Eating Disorder 278 Bulimia Nervosa 280 Psychiatric Disorders–Other 283 Bipolar Disorder 283 Depression 288 Schizophrenia 291 Sleep and Circadian Rhythm Disorders 294 Substance Use Disorder and Addiction 297 Tardive Dyskinesia 300

SECTION 5 PULMONARY DISORDERS 303 Asthma 306 Bronchiectasis 310 Bronchitis 312 Chronic Obstructive Pulmonary Disease 315 Chylothorax 319 Cor Pulmonale 320 Cystic Fibrosis 322 Interstitial Lung Disease 326 Pneumonia 328 Pulmonary Embolism 331 Respiratory Distress Syndrome 333 Respiratory Failure and Ventilator Dependency 335 Sarcoidosis 337 Sleep Apnea 340 Thoracic Empyema 342 Transplantation, Lung 344 Tuberculosis 346

SECTION 6 CARDIOVASCULAR DISORDERS 351 Angina Pectoris 358 Arteritis and Vasculitis 361 Atherosclerotic Cardiovascular Disease 363 Cardiac Cachexia 368 Cardiomyopathies 370 Heart Failure 373 Heart or Heart–Lung Transplantation 378 Heart Valve Diseases 380 Hypertension 383

Escott-Stump_FM.indd xxii

Myocardial Infarction 388 Pericarditis and Cardiac Tamponade 391 Peripheral Artery Disease 393 Thrombophlebitis 395

SECTION 7 GASTROINTESTINAL DISORDERS 399 Upper GI: Esophagus 403 Dysphagia 403 Esophageal Disorders 406 Esophageal Trauma 408 Esophageal Varices 409 Esophagitis, GERD, and Hiatal Hernia 411 Stomach 414 Dyspepsia, Indigestion, or Bezoar Formation 414 Gastrectomy and Vagotomy 416 Gastritis and Gastroenteritis 418 Gastroparesis and Gastric Retention 420 Giant Hypertrophic Gastritis and Ménétrier Disease 422 Peptic Ulcer Disease 423 Vomiting, Pernicious 427 Lower GI: Intestinal Disorders 429 Carcinoid Syndrome 429 Celiac Disease 431 Constipation 435 Diarrhea, Dysentery, and Traveler’s Diarrhea 437 Diverticular Diseases 442 Fat Malabsorption Syndrome 444 Inflammatory Bowel Disease: Crohn’s Disease 447 Inflammatory Bowel Disease: Ulcerative Colitis 451 Intestinal Fistula 454 Intestinal Lymphangiectasia 456 Intestinal Transplantation 457 Irritable Bowel Syndrome 460 Lactose Maldigestion 463 Megacolon 466 Ostomy: Colostomy 467 Ostomy: Ileostomy 470 Peritonitis 472 Short Bowel Syndrome and Intestinal Failure 473 Tropical Sprue 477 Whipple Disease (Intestinal Lipodystrophy) 479 Rectal Disorders 480 Fecal Incontinence 480 Hemorrhoids 484 Proctitis 485

SECTION 8 HEPATIC, PANCREATIC, AND BILIARY DISORDERS 487 Liver Disorders 490 Alcoholic Liver Disease 490 Ascites and Chylous Ascites 494 Hepatitis 496 Hepatic Cirrhosis 500 Hepatic Failure, Encephalopathy, and Coma 504 Liver Transplantation 511

11/7/14 5:26 AM

CON T E N T S

Pancreatic Disorders 514 Pancreatitis, Acute 514 Pancreatitis, Chronic 522 Pancreatic Insufficiency 525 Pancreatic Islet Cell Transplantation 527 Zollinger–Ellison Syndrome 529 Biliary Disorders 531 Biliary Cirrhosis 531 Cholestasis 532 Gallbladder Disease 534

SECTION 9 ENDOCRINE DISORDERS 537 Diabetes Mellitus 545 Diabetes Mellitus, Type 1 545 Gestational Diabetes 554 Prediabetes 558 Type 2 Diabetes in Adults 560 Type 2 Diabetes in Children and Teens 565 Diabetes Complications and Related Conditions 568 Diabetic Gastroparesis 568 Diabetic Ketoacidosis 570 Hyperosmolar Hyperglycemic Syndrome 573 Hypoglycemia 575 Hypoglycemia with Hyperinsulinism 577 Metabolic Syndrome 579 Preeclampsia and Hypertensive Disorders in Pregnancy 581 Pituitary Gland (Anterior) 587 Acromegaly 587 Pituitary Gland (Anterior) 588 Cushing Syndrome 588 Pituitary Gland (Posterior) 590 Diabetes Insipidus 590 Pituitary Gland 592 Hypopituitarism 592 Pituitary Gland 594 Syndrome of Inappropriate Antidiuretic Hormone 594 Ovary 596 Polycystic Ovarian Syndrome 596 Adrenal Gland (Cortex) 598 Adrenocortical Insufficiency and Addison Disease 598 Adrenal Gland (Cortex) 600 Hyperaldosteronism 600 Adrenal Gland (Medulla) 602 Pheochromocytoma 602 Thyroid Gland 604 Hyperthyroidism 604 Thyroid Gland 607 Hypothyroidism 607 Parathyroid Glands 610 Hypoparathyroidism and Hypocalcemia 611 Hyperparathyroidism and Hypercalcemia 613

Escott-Stump_FM.indd xxiii

xxiii

SECTION 10 MALNUTRITION: OVERNUTRITION AND UNDERNUTRITION 617 Overnutrition 625 Overweight and Obesity 625 Undernutrition 637 Underweight, Unintentional Weight Loss, and Sarcopenia 637 Undernutrition and Malnutrition in Children and Adults 643 Refeeding Syndrome 651

SECTION 11 MUSCULOSKELETAL AND COLLAGEN DISORDERS 655 Gout 660 Immobilization 663 Lupus 665 Muscular Dystrophy 668 Myofascial Pain Syndromes: Fibromyalgia and Polymyalgia Rheumatica 671 Osteoarthritis 673 Osteomyelitis 677 Osteomalacia 679 Osteopenia and Osteoporosis 681 Paget Disease (Osteitis Deformans) 686 Polyarteritis Nodosa 688 Rhabdomyolysis 690 Rheumatoid Arthritis 691 Ruptured or Herniated Disk 697 Scleroderma (Systemic Sclerosis) 699 Spondyloarthritis 701

SECTION 12 HEMATOLOGY: ANEMIAS AND BLOOD DISORDERS 703 Anemias 707 Anemia of Chronic Disease 707 Anemias in Neonates 709 Anemia of Renal Disease 711 Aplastic Anemia and Fanconi Anemia 713 Copper Deficiency Anemia 715 Folic Acid Deficiency Anemia 717 Hemolytic Anemias 720 Iron Deficiency Anemia 722 Malaria and Parasitic Anemias 726 Megaloblastic Anemias 729 Pernicious and Vitamin B12 Deficiency Anemias 729 Sideroblastic Anemia 732 Hemoglobinopathies 733 Sickle Cell Anemia 733 Thalassemias 736 Other Blood Disorders 738 Bleeding Disorders: Hemorrhage and Hemophilia 738 Hemochromatosis and Iron Overload 741 Polycythemia Vera 743 Thrombocytopenia 745

11/7/14 5:26 AM

xxiv

C ONTENTS

SECTION 13

SECTION 16

CANCER 749

RENAL DISORDERS 885

Cancer Treatment and Survival 758 Cancer: Treatment Guidelines 758 Bone Cancer and Osteosarcoma 770 Bone Marrow or Hematopoietic Stem Cell Transplantation 772 Brain Tumor 776 Colorectal Cancer 778 Esophageal, Head-Neck, and Thyroid Cancers 782 Gastric Cancer 785 Kidney, Bladder, and Urinary Tract Cancers 787 Liver Cancer 790 Lung Cancer 793 Pancreatic Cancer 795 Skin Cancers 798

Chronic Kidney Disease and Renal Failure 888 Dialysis 897 Glomerular and Autoimmune Kidney Diseases 901 Glomerular Basement Membrane Disorders 904 Kidney Stones 906 Nephrotic Syndrome 909 Renal Metabolic Disorders: Hypophosphatemic Rickets and Hartnup Disorder 912 Polycystic Kidney Disease 914 Renal Transplantation 916 Urinary Tract Infections 919

Hormonal Cancers 802 Breast Cancer 802 Choriocarcinoma 805 Prostate Cancer 807 Hematological Cancers 810 Leukemias 810 Lymphomas 814 Myeloma 816

SECTION 14 SURGICAL DISORDERS 819 General Surgical Guidelines 820 Surgery 820 Gastrointestinal Surgeries 832 Bariatric and Weight Loss Surgeries 832 Bowel Surgery 837

SECTION 15 HIV-AIDS AND IMMUNOLOGY, BURNS, SEPSIS, AND TRAUMA 841 AIDS and HIV Infection 853 Burn Injury 861 Fractures 866 Intestinal Parasite Infections 868 Multiple Organ Dysfunction Syndrome 873 Sepsis and Systemic Inflammatory Response Syndrome 876 Trauma 881

Escott-Stump_FM.indd xxiv

SECTION 17 ENTERAL AND PARENTERAL NUTRITION THERAPY 923 Enteral Nutrition 927 Parenteral Nutrition 935

APPENDIX A Nutritional Review 943 Recommended Dietary Allowances and Dietary Reference Intakes 943 Macronutrients 943 Micronutrients 952 Vitamins 961

APPENDIX B Nutrition Care Process and Forms 973 Introduction to the Practice of Dietetics 973 Nutrition Care Process Tools and Documentation Forms 978

APPENDIX C Acuity Ranking for Dietitian Services 1011 Index 1017

11/7/14 5:26 AM

ALPHABETICAL LIST OF TOPICS Abetalipoproteinemia 144 Acromegaly 587 Adolescence 34 Adrenocortical Insufficiency and Addison Disease 598 Adulthood 44 AIDS and HIV Infection 853 Alcoholic Liver Disease 490 Alzheimer’s Disease and Dementias 235 Amyotrophic Lateral Sclerosis 239 Anemia of Chronic Disease 707 Anemia of Renal Disease 711 Anemias in Neonates 709 Angina Pectoris 358 Anorexia Nervosa 275 Aplastic Anemia and Fanconi Anemia 713 Arteritis and Vasculitis 361 Ascites and Chylous Ascites 494 Asthma 306 Atherosclerotic Cardiovascular Disease 363 Attention Deficit Disorders 145 Autism Spectrum Disorder 148 Autoimmune Inner Ear Disease (Ménière Syndrome) 131 Bariatric and Weight Loss Surgeries 832 Biliary Atresia 151 Biliary Cirrhosis 531 Binge Eating Disorder 278 Bipolar Disorder 283 Bleeding Disorders: Hemorrhage and Hemophilia 738 Bone Cancer and Osteosarcoma 770 Bone Marrow or Hematopoietic Stem Cell Transplantation 772 Bowel Surgery 837 Brain Trauma 241 Brain Tumor 776 Breast Cancer 802 Bronchiectasis 310 Bronchitis 312 Bronchopulmonary Dysplasia 153 Bulimia Nervosa 280 Burn Injury 861 Cancer: Treatment Guidelines 758 Carbohydrate Metabolic Disorders 156 Carcinoid Syndrome 429 Cardiac Cachexia 368 Cardiomyopathies 370 Celiac Disease 431 Cerebral Aneurysm 244 Cerebral Palsy 159 Childhood 27 Cholestasis 532 Choriocarcinoma 805 Chronic Kidney Disease and Renal Failure 888 Chronic Obstructive Pulmonary Disease 315 Chylothorax 319 Cleft Lip and Palate 162 Colorectal Cancer 778 Coma or Persistent Vegetative State 246

Complementary-Alternative or Traditional Nutrition 70 Congenital Heart Disease 164 Constipation 435 Copper Deficiency Anemia 715 Cor Pulmonale 320 Cultural Food Patterns 85 Cushing Syndrome 588 Cystic Fibrosis 322 Cystinosis and Fanconi Syndrome 166 Dental and Oral Disorders 98 Depression 288 Diabetes Insipidus 590 Diabetes Mellitus, Type 1 545 Diabetic Gastroparesis 568 Diabetic Ketoacidosis 570 Dialysis 897 Diarrhea, Dysentery, and Traveler’s Diarrhea 437 Diverticular Diseases 442 Down’s Syndrome 168 Dyspepsia, Indigestion, or Bezoar Formation 414 Dysphagia 403 Eastern Religious Dietary Practices 92 Enteral Nutrition 927 Epilepsy and Seizure Disorders 248 Esophageal Disorders 406 Esophageal Trauma 408 Esophageal Varices 409 Esophageal, Head-Neck, and Thyroid Cancers 782 Esophagitis, GERD, and Hiatal Hernia 411 Failure to Thrive 170 Fat Malabsorption Syndrome 444 Fatty Acid Oxidation Disorders 173 Fecal Incontinence 480 Fetal Alcohol Syndrome 175 Folic Acid Deficiency Anemia 717 Food Allergy 122 Food Poisoning 132 Fractures 866 Gallbladder Disease 534 Gastrectomy and Vagotomy 416 Gastric Cancer 785 Gastritis and Gastroenteritis 418 Gastroparesis and Gastric Retention 420 Gestational Diabetes 554 Giant Hypertrophic Gastritis and Ménétrier Disease 422 Glomerular and Autoimmune Kidney Diseases 901 Glomerular Basement Membrane Disorders 904 Gout 660 Guillain–Barré Syndrome 251 Heart Failure 373 Heart or Heart–Lung Transplantation 378 Heart Valve Diseases 380 Hemochromatosis and Iron Overload 741 Hemolytic Anemias 720 Hemorrhoids 484 Hepatic Cirrhosis 500

xxv

Escott-Stump_FM.indd xxv

11/7/14 5:26 AM

xxvi

A L PH A BETIC A L LIST O F TO PIC S

Hepatic Failure, Encephalopathy, and Coma 504 Hepatitis 496 Hirschsprung Disease (Congenital Megacolon) 177 HIV Infection, Pediatric 179 Homocystinuria and Inborn Errors of Cobalamin and Folate 181 Huntington Disease 252 Hyperaldosteronism 600 Hyperosmolar Hyperglycemic Syndrome 573 Hyperparathyroidism and Hypercalcemia 613 Hypertension 383 Hyperthyroidism 604 Hypoglycemia 575 Hypoglycemia with Hyperinsulinism 577 Hypoparathyroidism and Hypocalcemia 611 Hypopituitarism 592 Hypothyroidism 607 Immobilization 663 Infant (0 to 6 Months) 19 Infant (6 to 12 Months) 23 Inflammatory Bowel Disease: Crohn’s Disease 447 Inflammatory Bowel Disease: Ulcerative Colitis 451 Interstitial Lung Disease 326 Intestinal Fistula 454 Intestinal Lymphangiectasia 456 Intestinal Parasite Infections 868 Intestinal Transplantation 457 Iron Deficiency Anemia 722 Irritable Bowel Syndrome 460 Kidney Stones 906 Kidney, Bladder, and Urinary Tract Cancers 787 Lactation 13 Lactose Maldigestion 463 Large for Gestational Age (Macrosomia) 184 Leukemias 810 Leukodystrophies 186 Liver Cancer 790 Liver Transplantation 511 Low Birth Weight or Prematurity 188 Lung Cancer 793 Lupus 665 Lymphomas 814 Macronutrients 943 Malaria and Parasitic Anemias 726 Maple Syrup Urine Disease 192 Megacolon 466 Metabolic Syndrome 579 Micronutrients 952 Middle Eastern Religious Dietary Practices 96 Migraine 255 Mucopolysaccharidoses 194 Multiple Organ Dysfunction Syndrome 873 Multiple Sclerosis 258 Muscular Dystrophy 668 Myasthenia Gravis and Neuromuscular Junction Disorders 261 Myeloma 816 Myocardial Infarction 388 Myofascial Pain Syndromes: Fibromyalgia and Polymyalgia Rheumatica 671 Necrotizing Enterocolitis 197 Nephrotic Syndrome 909

Escott-Stump_FM.indd xxvi

Neural Tube Defects: Spina Bifida, and Melomeningocele 199 Nutrition in Aging 59 Obesity, Childhood 202 Osteoarthritis 673 Osteomalacia 679 Osteomyelitis 677 Osteopenia and Osteoporosis 681 Ostomy: Colostomy 467 Ostomy: Ileostomy 470 Otitis Media 208 Overweight and Obesity 625 Paget Disease (Osteitis Deformans) 686 Pancreatic Cancer 795 Pancreatic Insufficiency 525 Pancreatic Islet Cell Transplantation 527 Pancreatitis, Acute 514 Pancreatitis, Chronic 522 Parenteral Nutrition 935 Parkinson’s Disease 263 Peptic Ulcer Disease 423 Pericarditis and Cardiac Tamponade 391 Periodontal Disease and Gingivitis 103 Peripheral Artery Disease 393 Peritonitis 472 Pernicious and Vitamin B12 Deficiency Anemias 729 Phenylketonuria 209 Pheochromocytoma 602 Pneumonia 328 Polyarteritis Nodosa 688 Polycystic Kidney Disease 914 Polycystic Ovarian Syndrome 596 Polycythemia Vera 743 Prader-Willi Syndrome 212 Prediabetes 558 Preeclampsia and Hypertensive Disorders in Pregnancy 581 Pregnancy 5 Pressure Ulcers 116 Proctitis 485 Prostate Cancer 807 Pulmonary Embolism 331 Recommended Dietary Allowances and Dietary Reference Intakes 943 Refeeding Syndrome 651 Renal Metabolic Disorders: Hypophosphatemic Rickets and Hartnup Disorder 912 Renal Transplantation 916 Respiratory Distress Syndrome 333 Respiratory Failure and Ventilator Dependency 335 Rhabdomyolysis 690 Rheumatoid Arthritis 691 Rickets 214 Ruptured or Herniated Disk 697 Sarcoidosis 337 Schizophrenia 291 Scleroderma (Systemic Sclerosis) 699 Sensory Impairments: Vision, Coordination, Chewing, Hearing 107 Sepsis and Systemic Inflammatory Response Syndrome 876 Short Bowel Syndrome and Intestinal Failure 473 Sickle Cell Anemia 733 Sideroblastic Anemia 732 Skin Cancers 798

11/7/14 5:26 AM

ALPHABE T I CAL L I S T OF T OP I CS

Skin Disorders 113 Sleep and Circadian Rhythm Disorders 294 Sleep Apnea 340 Small for Gestational Age and Intrauterine Growth Restriction 216 Spinal Cord Injury and Paralysis 266 Spondyloarthritis 701 Sports Nutrition 39 Stroke (Cerebrovascular Accident) 269 Substance Use Disorder and Addiction 297 Surgery 820 Syndrome of Inappropriate Antidiuretic Hormone 594 Tardive Dyskinesia 300 Temporomandibular Joint Dysfunction 106 Thalassemias 736 Thoracic Empyema 342 Thrombocytopenia 745 Thrombophlebitis 395 Transplantation, Lung 344

Escott-Stump_FM.indd xxvii

xxvii

Trauma 881 Trigeminal Neuralgia 273 Tropical Sprue 477 Tuberculosis 346 Type 2 Diabetes in Adults 560 Type 2 Diabetes in Children and Teens 565 Tyrosinemia 218 Undernutrition and Malnutrition in Children and Adults 643 Underweight, Unintentional Weight Loss, and Sarcopenia 637 Urea Cycle Disorders 220 Urinary Tract Infections 919 Vegetarianism 89 Vitamin Deficiencies 119 Vitamins 961 Vomiting, Pernicious 427 Western Religious Dietary Practices 94 Whipple Disease (Intestinal Lipodystrophy) 479 Wilson Disease 224 Zollinger–Ellison Syndrome 529

11/7/14 5:26 AM

Escott-Stump_FM.indd xxviii

11/7/14 5:26 AM

Normal Life Stages

CHIEF ASSESSMENT FACTORS ● ●

● ● ● ● ● ●

●

● ●

● ● ● ● ● ● ●

Priority factors: unintentional weight loss with appetite changes in adults, protein-energy deficiency or growth retardation in children Body fat and muscle mass: weight, height, body mass index (BMI), percentage of healthy body weight (HBW) for height, loss of lean body mass (LBM), previous weight percentile or curve, weight changes, waist circumference, skinfold measurements, visceral proteins, estimated basal energy expenditure, and nitrogen balance Illiteracy or low educational level: low socioeconomic status, food insecurity Hair or nails: changes, rashes, itching, lesions, turgor, petechiae, pallor Eyes: glasses, blurred vision, glaucoma, cataracts, or macular degeneration Ears, nose: hearing loss, chronic otitis media, altered sense of smell, nasal obstruction, sinusitis Dental and mouth: ill-fitting dentures, loose or missing teeth, caries, bleeding gums, severe gum disease, poor oral hygiene, taste alterations, dysphagia Neurologic: headache, seizures, convulsions, altered speech, paralysis, altered gait, anxiety, memory loss, altered sleep patterns, depression, substance abuse, low motivation, fatigue, weakness, fever or chills, excessive sweating, tremors Heart: chest pain, dyspnea, wheezing, cough, hemoptysis, ventilator support, altered blood gas levels, abnormal blood pressure, electrolyte imbalance, cyanosis, edema, ascites, low cardiac output Blood: anemias, altered heart rate, arrhythmias, blood loss Gastrointestinal (GI): cachexia, anorexia, nausea, diarrhea, vomiting, jaundice, constipation, indigestion, ulcers, hemorrhoids, melena, altered stool characteristics, gluten intolerance, lactase insufficiency Therapies: radiation, chemotherapy, physical therapy, dialysis, recent surgery or hospitalizations Urinary and renal: hematuria, fluid requirements, specific gravity, urinary tract infections, renal disease or stones Hormonal balance: altered blood glucose, hyper- or hypothyroidism, goiter, glucose intolerance or metabolic syndrome Immunity: food allergies or intolerances, sensitivities, cellular immunity, HIV or other chronic infections, inflammation Musculoskeletal system: pain, arthritis, numbness, amputations, limited range of motion or muscular strength Phenotype or genotype Nutrition: any special diets or nutrition support, dietary pattern, typical intake of food and alcohol, use of vitamin/minerals/herbs/botanicals/supplements, overthe-counter and prescribed medications, knowledge of food and nutrition

Escott-Stump_Ch01.indd 1

11/7/14 8:14 PM

N U T R I TIO N A ND D IA GNO SIS-RELA TED C A RE

OVERVIEW Noncommunicable diseases (NCD) contribute to morbidity and mortality in both developed and developing countries; most are preventable through modification of lifestyle and nutrition. Alleviating undernutrition, correcting nutritional deficiencies, promoting better quality diets, and incorporating functional foods may alleviate chronic disease burden (Lenoir-Wijnkoop et al, 2013). Food intake, lifestyle behaviors, and obesity are linked to the development of chronic diseases and certain life stages are especially important for health promotion efforts (Fitzgerald et al, 2013). Public health measures have been established to promote wellness and reduce disease for all ages (Table 1-1). Demographic shifts in the age and racial/ethnic composition of the U.S. population will require new medical nutrition therapies that are cost effective, health promoting, and culturally appropriate (Haughton and Stang, 2012). Because primary prevention is the most effective, affordable method to prevent chronic disease, the Nutrition Care Process should be used by Registered Dietitians (RDs) and dietetic technicians, registered (DTRs) for carrying out these steps (Fitzgerald et al, 2013). Positive influence can be applied across the spectrum of engagement: at intrapersonal, interpersonal, institutional, community, and public policy levels (Slawson et al, 2013). Two of the most important aspects will be the avoidance of obesity and the consumption of an anti-inflammatory diet. These will help to protect against cancer and heart disease, as well as metabolic disorders. TABLE 1-1 Public Health: Ten Achievements and Ten Essential Services 10 PUBLIC HEALTH ACHIEVEMENTS IN THE 20TH CENTURY • Development of immunizations • Increased motor vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water

HOT H OT TOPIC Inflammation Obesity leads to a chronic low-grade inflammation of adipose tissue, which disrupts endocrine function and results in metabolic derangements, including type 2 diabetes (Siriwardhana et al, 2013). Dietary bioactive compounds can be eaten to suppress both systemic and adipose tissue inflammation. Curcumin, resveratrol, catechins (tea-polyphenols), quercetin, and isoflavones suppress nuclear factor-B (NF-B) and other inflammatory pathways (Siriwardhana et al, 2013). Dietary polyunsaturated fatty acids, such as eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), conjugated linoleic acid (CLA), and monounsaturated oleic acid have anti-inflammatory effects by down-regulating tumor necrosis factor (TNF)alpha and other inflammation markers (Murumalla et al, 2012). Thus, eating an anti-inflammatory diet should be a major focus of public health messaging by RDs.

International and U.S. regulatory, policy, and clinical practitioners are working together on a variety of topics, including clinical guidelines (Wong et al, 2011). The field of “nutrition economics” merges nutrition, influences on health outcomes, and economics to estimate the monetary impact of health measures (Lenoir-Wijnkoop et al, 2011). The Food and Agriculture Organization (FAO) and the World Health Organization (WHO) have frequently brought together scientists and experts in agriculture to address nutrition and malnutrition (FAO, 2013). Dietary guidelines offer dietary advice for the population to promote overall nutritional wellbeing. As a result, many countries have established food-based dietary guidelines. Table 1-2 highlights several key principles. The MyPlate campaign (Fig. 1-1) provides a simplified illustration of the U.S. guidelines. MyPlate is divided into sections of approximately 30% grains, 30% vegetables, 20% fruits, and 20% protein-rich foods. A smaller circle represents dairy foods like a glass of low-fat/nonfat milk or a cup of yogurt.

• Recognition of tobacco as a health hazard 10 ESSENTIAL PUBLIC HEALTH SERVICES

REFERENCES

• Monitor health status to identify community health problems.

Fitzgerald N, et al. Practice paper of the Academy of Nutrition and Dietetics abstract: the role of nutrition in health promotion and chronic disease prevention. J Acad Nutr Diet. 2013;113:983. Food and Agriculture Organization (FAO). The International Conference on Nutrition. Available at: http://www.fao.org/docrep/v7700t/v7700t02.htm. Accessed June 13, 2014. Haughton B, Stang J. Population risk factors and trends in health care and public policy. J Acad Nutr Diet. 2012;112:35S. Lenoir-Wijnkoop I, et al. Nutrition economics—characterising the economic and health impact of nutrition. Br J Nutr. 2011;105:157. Lenoir-Wijnkoop I, et al. Nutrition economics—food as an ally of public health. Br J Nutr. 2013;109:777. Murumalla RK, et al. Fatty acids do not pay the toll: effect of SFA and PUFA on human adipose tissue and mature adipocytes inflammation. Lipids Health Dis. 2012;11:175. Siriwardhana N, et al. Modulation of adipose tissue inflammation by bioactive food compounds. J Nutr Biochem. 2013;24:613. Slawson DL, et al. Position of the Academy of Nutrition and Dietetics: the role of nutrition in health promotion and chronic disease prevention. J Acad Nutr Diet. 2013;113:972. Wong JB, et al. Economic analysis of nutrition interventions for chronic disease prevention: methods, research, and policy. Nutr Rev. 2011;69:533.

• Diagnose and investigate health problems and hazards in the community. • Inform, educate, and empower people about health issues. • Mobilize community partnerships to identify and solve health problems. • Develop policies and plans that support individual and community health efforts. • Enforce laws and regulations that protect health and ensure safety. • Link people to needed personal health services and assure the provision of health care when otherwise unavailable. • Assure competent public health and personal health care workforce. • Evaluate effectiveness, accessibility, and quality of personal and populationbased health services. • Research for new insights and innovative solutions to health problems. Adapted from: Centers for Disease Control and Prevention. Ten great public health achievements in the 20th century. Available at: http://www.cdc.gov/about/history/tengpha.htm. Accessed June 15, 2014; and from American Public Health Association. Available at: http:// www.health.gov/phfunctions/public.htm. Accessed June 15, 2014.

Escott-Stump_Ch01.indd 2

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-2 Dietary Guideline Systems ENERGY • Nutritional guidelines should aim to prevent the consequences of either energy deficit or excess. • Food-based dietary guidelines should promote appropriate energy intakes by encouraging adequate food choices from a balance of foods containing carbohydrates, fats, proteins, vitamins, and minerals. • The role of physical activity in the energy balance equation should be addressed. PROTEIN • For high-quality proteins, requirements for most people are met by providing 8%–10% of total energy as protein. • For predominantly vegetable-based, mixed diets, which are common in developing country settings, 10%–12% is suggested to account for lower digestibility and increased incidence of diarrheal disease. • In the case of the elderly, where energy intake is low, protein should represent 12%–14% of total energy. FAT • In general, adults should obtain at least 15% of their energy intake from dietary fats and oils. • Women of childbearing age should obtain at least 20% to better ensure an adequate intake of essential fatty acids needed for fetal and infant brain development. • Active individuals who are not obese may consume up to 35% fat energy as long as saturated fatty acids do not exceed 10% of energy intake. • Sedentary individuals should limit fat to not more than 30% of energy intake. • Saturated fatty acids should be limited to less than 10% of intake. CARBOHYDRATE • Carbohydrates are the main source of energy in the diet (50%) for most people. • Grain products, tubers, roots, and some fruits are rich in complex carbohydrates. Generally, they need to be cooked before they are fully digestible. • Sugars usually increase the acceptability and energy density of the diet. Total sugar intake is often inversely related to total fat intake. Moderate intakes of sugar are compatible with a varied and nutritious diet, and no specific limit for sugar consumption is proposed in the report. MICRONUTRIENTS • Vitamins and minerals include compounds with widely divergent metabolic activities and are essential for normal growth and development and optimal health. • Micronutrients may help to prevent infectious and chronic diseases. Epidemiological, clinical, and experimental studies define the role of specific foods and nutrients in disease development and prevention. AMERICAN DIETARY GUIDELINES An evidence-based, scientific approach is used to update the Dietary Guidelines for Americans. The latest guidelines were enhanced to describe the need for a Total Diet approach because there is no single “American” or “Western” diet. According to the National Health and Nutrition Examination Survey (NHANES), Americans eat too many calories, solid fats, added sugars, refined grains, and sodium. Americans also eat too little dietary fiber, vitamin D, calcium, potassium, omega-3 fatty acids, and other important nutrients that are mostly found in vegetables, fruits, whole grains, low-fat milk and milk products, and seafood. See http://www.health.gov /dietaryguidelines/2015.asp for the evidence-based recommendations.

Balancing Calories to Manage Weight • Prevent and/or reduce overweight and obesity through improved eating and physical activity behaviors. • Control total calorie intake to manage body weight. For people who are overweight or obese, this will mean consuming fewer calories from foods and beverages. • Increase physical activity and reduce time spent in sedentary behaviors. • Maintain appropriate calorie balance during each stage of life—childhood, adolescence, adulthood, pregnancy and breastfeeding, and older age.

Foods and Food Components to Reduce • Reduce daily sodium intake to less than 2,300 milligrams (mg) and further reduce intake to 1,500 mg among persons who are 51 and older and those of any age who are African American or have hypertension, diabetes, or chronic kidney disease. The 1,500 mg recommendation applies to about half of the U.S. population, including children, and the majority of adults. • Consume less than 10% of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids. • Consume less than 300 mg per day of dietary cholesterol. • Keep trans fatty acid consumption as low as possible by limiting foods that contain synthetic sources of trans fats, such as partially hydrogenated oils, and by limiting other solid fats. • Reduce the intake of calories from solid fats and added sugars. • Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars, and sodium. • If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and two drinks per day for men—and only by adults of legal drinking age.

(continued)

Escott-Stump_Ch01.indd 3

11/7/14 8:14 PM

N U T R I TIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-2 Dietary Guideline Systems (continued) Foods and Nutrients to Increase • Individuals should meet the following recommendations as part of a healthy eating pattern while staying within their calorie needs. • Increase vegetable and fruit intake. • Eat a variety of vegetables, especially dark-green and red and orange vegetables and beans and peas. • Consume at least half of all grains as whole grains. Increase whole-grain intake by replacing refined grains with whole grains. • Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese, or fortified soy beverages. • Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds. • Increase the amount and variety of seafood consumed by choosing seafood in place of some meat and poultry. • Replace protein foods that are higher in solid fats with choices that are lower in solid fats and calories and/or are sources of oils. • Use oils to replace solid fats where possible. • Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are nutrients of concern in American diets. These foods include vegetables, fruits, whole grains, and milk and milk products.

Building Healthy Eating Patterns • Select an eating pattern that meets nutrient needs over time at an appropriate calorie level. • Account for all foods and beverages consumed and assess how they fit within a total healthy eating pattern. • Follow food safety recommendations when preparing and eating foods to reduce the risk of foodborne illnesses. VISUAL FOOD GUIDES • United States: USDA MyPlate (http://myplate.gov) (see Fig. 1-1) • Canada: Health Canada—Eating Well with Canada’s Food Guide (http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php) • People’s Republic of China: Chinese Nutrition Society—Balance Dietary Pagoda (http://www.cnsoc.org/en/nutrition.asp?s=9&nid=806) • European Food Guides (http://www.eufic.org/article/en/expid/food-based-dietary-guidelines-in-europe/) • Mexico: Food Guide Plate (http://familyconsumersciences.com/wp-content/uploads/Mexicos-Food-Guide.jpg) Adapted from: Dietary guidelines for Americans. Available at: http://www.health.gov/DietaryGuidelines. Accessed June 15, 2014; and Dietary Guidelines 2010. Available at: http://www.cnpp.usda .gov/DGAs2010-DGACReport.htm. Accessed June 15, 2014.

Functional Genomics: From Genome to Phenome . . . the“Physiome”

Figure 1-1. MyPlate. (Reprinted from USDA. Available at: http://www.choosemyplate.gov/print-materials-ordering/graphic -resources.html. Accessed June 15, 2014.)

Escott-Stump_Ch01.indd 4

The human body has about 25,000 genes, representing the human genome. The transcriptome contains over 100,000 RNA molecules, with gene expression profiling the multiple copy variants in an individual. The transcriptome is the precursor of the proteome, the complete set of proteins found in an organism; humans have over 1 million proteins. Metabolome describes the low molecular weight biochemical compounds (metabolites) that have led to most biomarker discoveries. The phenome represents what is visible (eye and skin color, height, body shape or size) and is affected by environmental influences, mutations, and genetic single nucleotide polymorphisms (SNPs.) Genes are inert when inherited; they are turned on by diet and environmental factors. Nuclear receptors (NRs) regulate the expression of target genes in response to activation by steroid hormones and other signaling pathways. They are central regulators of pathophysiologic processes (Bolt et al, 2013). Coactivators are cellular factors recruited by activated NRs that complement their function as mediators of the cellular response to endocrine signals; they induce structural changes in agonist-bound NRs that are essential for NR-mediated transcriptional activation (Johnson and O’Malley, 2012). The best known coactivators are the steroid receptor

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

coactivators (SRCs) 1, 2, and 3. SRCs are widely implicated in NR-mediated diseases, especially in cancers (Johnson and O’Malley, 2012). The SRC genes have the following essential functions: • SRC-1: For gluconeogenesis, sugar metabolism, and weight (Zhu et al, 2013) • SRC-2: For fat absorption, energy accretion, fertility, circadian rhythm management (SRC-2 is a master regulator; disruption can lead to changes in physiology, behavior, performance, metabolic disease, cancer, heart disease) • SRC-3: For proper cell signaling and functioning; increased levels may lead to cancer (Long et al, 2012) The identification of these genetic, molecular, and cellular mechanisms provides a new level of management for health as well as for cancer and other chronic disorders.

For More Information ●

Academy of Nutrition and Dietetics http://www.eatright.org/Public/landing.aspx?TaxID=6442451979

●

Academy of Nutrition and Dietetics – Evidence Analysis Library http://andevidencelibrary.com/category.cfm?cid=27&cat=0

●

Food and Nutrition Information Center (FNIC) – Dietary Guidance http://fnic.nal.usda.gov/dietary-guidance

REFERENCES Bolt MJ, et al. Coactivators enable glucocorticoid receptor recruitment to fine-tune estrogen receptor transcriptional responses. Nucleic Acids Res. 2013;41:4036. Johnson AB, O’Malley BW. Steroid receptor coactivators 1, 2, and 3: critical regulators of nuclear receptor activity and steroid receptor modulator (SRM)based cancer therapy. Mol Cell Endocrinol. 2012;348:430. Long W, et al. ERK3 signals through SRC-3 coactivator to promote human lung cancer cell invasion. J Clin Invest. 2012;122:1869. Zhu L, et al. Steroid receptor coactivator-1 mediates estrogenic actions to prevent body weight gain in female mice. Endocrinology. 2013;154:150.

PREGNANCY AND LACTATION

PREGNANCY NUTRITIONAL ACUITY RANKING: LEVEL 1 (UNCOMPLICATED); LEVEL 3 (HIGH RISK)

DEFINITIONS AND BACKGROUND Women should have a “preconception risk assessment” from 3 to 6 months before conception if desired (March of Dimes, 2013). They should be aware of their personal genetic biomarkers that could cause problems with infertility, pregnancy, childbirth, or chronic diseases. They should also consider other risks that work against a healthy pregnancy outcome (WebMD,2013). Pregnancy is an anabolic state that affects maternal tissues, using hormones synthesized to support successful pregnancy. Progesterone induces fat deposition to insulate the baby, supports energy reserves, and relaxes smooth muscle, which will cause a decrease in intestinal motility for greater nutrient absorption. Estrogen increases tremendously during pregnancy for growth promotion, uterine function, and water retention. Progesterone and estrogen secreted during pregnancy in combination also help prepare for successful lactation. Adequate weight gain is needed to ensure optimal fetal outcome (Figs. 1-2 and 1-3). The energy costs of pregnancy vary by the BMI of the mother (Thomas et al, 2012). Tissue growth in pregnancy is approximately: breast, 0.5 kg; placenta, 0.6 kg; fetus, 3 to 3.5 kg; amniotic fluid, 1 kg; uterus, 1 kg; increase in blood volume, 1.5 kg; and extracellular fluid, 1.5 kg. Rapid weight losses or gains are not desirable. Brain development starts during pregnancy and continues into adulthood. Deficiency of various micronutrients has longterm implication for cognitive development. Because pre- and postnatal brain growth correlates specifically with duration of gestation and lactation, the rate of fetal brain growth is related to the mother’s energy turnover and sufficiency (Barton and Cappellini, 2011).

Escott-Stump_Ch01.indd 5

Nutritional deficits are serious (Procter and Campbell, 2014). During pregnancy, food insecurity has been found to correlate with greater weight gain, more complications, and gestational diabetes (Laraia et al, 2010). Maternal underweight is associated with small-for-gestational-age (SGA) or preterm deliveries. Energy restriction during gestation or lactation impacts the developmental programming of energy balance in the infant. Susceptibility to obesity, incapacity to regulate energy balance, altered leptin and insulin sensitivity, and changes in body composition may result (Pico et al, 2012).

Figure 1-2. The fetus shortly before birth. (Reprinted with permission from Anatomical Chart Company.)

11/7/14 8:14 PM

N U T R I TIO N A ND D IA GNO SIS-RELA TED C A RE

Figure 1-3. A mother and her healthy newborn.

A short span between pregnancies or an early pregnancy within 2 years of menarche increases the risk for stunting or preterm infants. Maternal nutrient depletion of energy and protein leads to poor nutritional status at conception and may alter pregnancy outcomes. Stunting (low height-for-age) and major diseases including heart disease, hypertension, and type 2 diabetes originate from impaired intrauterine growth and development. Environmental insults (poor diet, chemicals, infections) during pregnancy can adversely affect the long-term health of the offspring. This result is called the Developmental Origins of Health and Disease (DOHaD) paradigm (Fig. 1-4) (Uuay et al, 2011). Poor maternal iron and folate intakes have been associated with preterm births and intrauterine growth retardation, common in early or closely spaced pregnancies. Use of prenatal folic acid supplements around the time of conception has been associated with a lower risk of autistic disorder; thus, prenatal folic acid supplementation is important for many reasons (Suren etal, 2013). Higher maternal weight before pregnancy increases the risk of late fetal death, although it protects against the delivery of an SGA infant. Obesity increases the risk for first trimester or recurrent miscarriages and the need for caesarean delivery; thus, obesity should be corrected before pregnancy when possible

Environmental chemicals

Figure 1-4. Developmental Origins of Health and Disease (DOHaD) paradigm. (Adapted with permission from Barouki R, Gluckman PD, Grandjean P, et al. Developmental origins of non-communicable disease: implications for research and public health. Environ Health. 2012;11:42.)

Escott-Stump_Ch01.indd 6

Nutritional imbalance

(Mamun et al, 2011). Bariatric surgery can improve fertility. Pregnancy after bariatric surgery reduces complications such as gestational diabetes mellitus, hypertensive disorders, and fetal macrosomia but may increase risk for an SGA birth (Willis and Sheiner, 2012). Planned pregnancies usually have the most favorable outcomes. Continuous dietary monitoring of pregnant women and pregnant teens is essential, especially for calcium, iron, folate, vitamins A, C, B6, and B12 (American College of Obstetricians and Gynecologists [ACOG], 2013). Other nutrients of importance include magnesium, fiber, zinc, vitamin D, and biotin. Table 1-3 lists risk assessments and indicators of potentially poor maternal or fetal outcomes. Many birth defects may be prevented by maternal use of multivitamins during the periconceptual period. To prevent SGA births, a mother is encouraged not to smoke, to manage cardiac disease or hypertension, and to gain sufficient weight. If HIV-positive pregnant women experience weight loss, energy intake recommendations should be based on direct measurements of total daily energy expenditure (TDEE,) especially with concurrent malnutrition and coinfection (Kosmiski, 2011). A multidisciplinary approach is recommended. Eating disorders such as anorexia or bulimia nervosa must be managed carefully during pregnancy to avoid complications such as weight loss, miscarriage, and poor infant feeding practices. Women with unmanaged phenylketonuria (PKU) may also have poor reproductive outcomes. Prevention requires initiation of the low-phenylalanine (Phe) diet before conception or early in pregnancy, with metabolic control and sufficient intake of energy and proteins. Certain complications are more likely to occur during a twin gestation, including preeclampsia and other hypertensive disorders, antepartum hospitalization for preterm labor or abnormal bleeding, nutritional deficiencies, cesarean delivery, and postpartum hemorrhage (Young and Wylie, 2012). For twin and multiple pregnancies, close monitoring, sufficient energy intake, multimineral supplementation, and early patient education may reduce complication risk. Each individual has a unique genetic profile and phenotype. Because both parents contribute genes and chromosomes to the fetus, a genetic family history may be beneficial. Epigenetics involves inherited changes in chromatin and DNA that affect human pathologies, including inflammatory disorders and

Hormone regulation

Epigenetic regulation

Metabolic pathways

DNA methylation Histone modifications

Cellular differentiation/ stress

Long-term effects on gene expression

Increased disease risk

Noncoding RNAs

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-3 Prenatal Risk Assessment PRE-PREGNANCY ❑ Poor eating habits

❑ Hx eating disorder (anorexia or bulimia)

❑ Hx 3 or more pregnancies in past 2 years

❑ Hx multiple abortions

❑ Obesity (120% desirable BMI for age)

❑ Weight of 85% desirable BMI for height and age

PAST PREGNANCY ❑ Anomalies (Congenital)

❑ Preterm Labor

❑ Birthweight, Low (2500 gms)

❑ Pre-eclampsia / Eclampsia

❑ Miscarriages

❑ Prematurity or SGA

❑ Death (Infant or stillbirth 20 wks)

❑ Other: Indicate________________

CURRENT PREGNANCY

CURRENT/CHRONIC MEDICAL CONDITIONS

❑ Age, Maternal (35 years)

❑ Asthma

❑ Hypertension, Chronic

❑ Age, Maternal (15 years)

❑ Cardiac Disease

❑ Pyelonephritis

❑ Bleeding, 12 wks gestation

❑ Diabetes Mellitus

❑ Seizure Disorder

❑ Cervix, Incompetent

❑ Disability, Physical

❑ Sickle Cell Disease

❑ Gestational Diabetes

❑ Dysplasia, Cervical

❑ Tuberculosis, Active

❑ Hyperemesis Gravidarum (after 12 wks)

❑ HIV positive

❑ Other:

❑ Intrauterine Growth Retardation ❑ Multiple Pregnancy (twins, triplets, etc) ❑ Placenta Previa, Degree of: ❑ Preterm Labor ❑ Short Pregnancy Interval ❑ Risk for anemia — Hgb (11 g) or Hct (33%) ❑ Risk of toxemia (2-lb weight gain per wk) ❑ Weight loss during PG or gain 2 lb/month in the last two trimesters ❑ Other: Indicate NUTRITIONAL OR SOCIO-ECONOMIC CONCERNS ❑ Financial or food insecurity

❑ Smoker (

❑ Food faddism or pica

❑ Modified diet for diabetes

❑ Drug or alcohol use

❑ Poorly managed vegan diet

❑ Poor nutrient intake

❑ Inadequate energy intake

❑ Homeless

❑ Inability to shop/prepare meals

/day) celiac

PKU

Adapted from: Neighborhood Health Plan of Rhode Island. Available at: http://www.nhpri.org/matriarch/default.asp. Accessed June 15, 2014.

cancers, and nutritional factors have a profound effect on gene expression. Disruption of epigenetic programs in response to environmental stimuli during prenatal exposure disturbs the fetal epigenome, potentially impacting susceptibility to disease later in life (Kaur et al, 2013). The Academy of Nutrition and Dietetics suggests at least three visits for medical nutrition therapy in high-risk pregnancies. More visits will be needed for individuals who have multiple risk factors, such as diabetes with celiac disease.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Carrier screening for inherited genetic disorders (Tay-Sachs, PKU, cystic fibrosis [CF], sickle cell, thalassemia)

Escott-Stump_Ch01.indd 7

Clinical/History • • • • • • • • • • • • • • • • •

Previous fertility problems? Gravida (number of pregnancies) Para (number of births) Abortus (number of abortions) Height Prepregnancy weight (% standard) Obesity? Weight grid or prenatal BMI Present weight for gestational age Desired weight at term Blood pressure (BP) Multiple gestation? Diabetes, hepatitis B, HIV-AIDS, hypothyroidism, or other chronic disease? History of births with neural tube defects History of preterm delivery or multiple births Family history of PKU or CF Uterine or cervical abnormalities

11/7/14 8:14 PM

Weight gain (kg)

• Diet history including folate, fish (mercury risk), alcohol • Smoking habits, herbs, botanicals, illicit drug use • Exposure to isotretinoin (Accutane), diethylstilbestrol (DES), anticoagulants, anticonvulsants • Nausea or vomiting (frequency, duration, impact on intake) • Pica or harmful beliefs • Vegan or disordered eating pattern • Rubella immunity? • Ultrasound, chorionic villous sampling, or amniocentesis

Fetus

8 ta cen Pla luid f c i t nio Am id ellular flu c a r t Ex ) t a f ( e Other tissu

6 4

Uterus + breast

Lab Work

• • • • • • • • • • • • • • •

Hemoglobin and hematocrit (H&H) Serum iron (Fe) Urea nitrogen (N) Glucose (by 24 to 28 wk) Calcium (Ca), magnesium (Mg) Albumin (Alb) Transferrin Ceruloplasmin T3, T4, thyroid-stimulating hormone (TSH) Blood urea nitrogen (BUN) Creatinine Homocysteine Cholesterol (may be increased) Alkaline phosphatase (ALP) (may be increased) Total iron-binding capacity (TIBC) (often increased in late pregnancy) • Alpha fetoprotein (for open neural tube defects)

8 12 16 20 24 28 32 36 Duration of pregnancy (weeks from LMP)

0 40

Figure 1-5. Gestational weight gain. (Adapted with permission from Pitkin RM. Nutritional support in obstetrics and gynecology. Clin Obstet Gyn. 1976 Sep;19(3):489-513).

• •

•

Objectives

Escott-Stump_Ch01.indd 8

2 Blood

INTERVENTION

• Maintain adequate gestational duration; prevent preterm delivery. • Provide additional nutrients and energy (net cost of pregnancy varies from 20,000 to 80,000 kcal total). Women carrying more than one fetus must add extra kilocalories to support multiple births. • Achieve adequate weight gain during pregnancy; avoid delivery of low-birth-weight (LBW) infants. The Institute of Medicine (IOM) gestational weight gain (GWG) guidelines suggest the following (Fig. 1-5) (IOM, 2013): 1. Underweight women (BMI 18.5) should gain 28 to 40lb. 2. Normal weight women (BMI 19 to 24.9) should gain 25 to 35 lb total; 46 lb with twins. 3. Overweight women (BMI 25 to 29.9) should gain 15 to 25lb; 42 lb with twins. 4. Obese women (BMI 30) should gain 11 to 20 lb; 35 lb with twins. • Encourage proper gestational weight gain, such as 2 to 4 lb first trimester, 10 to 11 lb second trimester, and 12 to 13lb third trimester. More weight should be gained if preconceptual weight was low, especially in younger women. Adolescents risk gaining an excessive amount of weight during pregnancy and should be closely monitored. • Prevent or correct hypoglycemia, ketosis, and hyperglycemia. • Provide adequate amino acids to meet fetal and placental growth. Approximately 950 g of protein are synthesized for

Fetus

N U T R I TIO N A ND D IA GNO SIS-RELA TED C A RE

Mother

•

• •

the fetus and placenta. Low protein intake may lead to a smaller infant head circumference. Promote development of an adequate fetal immune system. Prevent or correct iron deficiency, which occurs in over half of pregnancies. Iron deficiency is correlated with low birth weight (Pena-Rosas et al, 2012). Low neonatal iron status negatively affects cognitive and neurobehavioral development (Cao and O’Brien, 2013). Folate deficiency and elevated homocysteine levels may lead to miscarriage, cleft lip and palate, club foot, structural heart disease, anencephaly, and neural tube defects. A woman with a history of spontaneous abortion in her immediate prior pregnancy and short interpregnancy interval is especially vulnerable. l-Methylfolate is the active form of folate used for DNA reproduction and regulation of homocysteine levels. Women with altered genetic alleles may not have sufficient methyl-tetrahydrofolate (MTHFR) to metabolize folic acid properly; these women may need special prenatal supplements, such as Neevo. Vitamins B6 and B12 are also needed for hyperhomocysteinemia. Vitamin A deficiency (VAD) is strongly associated with depressed immune system and higher morbidity and mortality due to blindness, measles, diarrhea, and respiratory infections. On the other hand, doses of 10,000 to 30,000 IU vitamin A may cause birth defects, such as cleft palate. Avoid zinc and calcium deficiencies. Poor maternal zinc status may be associated with fetal loss, congenital malformations, intrauterine growth restriction, reduced birth weight, prolonged labor, and preterm or postterm deliveries (Chaffee and King, 2012). Inadequate and deficient vitamin D status in pregnant women ranges from 5% to 84% globally (Brannon, 2012). Low maternal vitamin D status increases maternal risk for preeclampsia, gestational diabetes, obstructed labor, and infectious disease; infants have greater risk for SGA birth and for developmental programming of type 1 diabetes, inflammatory and atopic disorders, even schizophrenia (Brannon, 2012). Systematic provision of iodine supplementation is recommended to prevent cretinism (Stagnaro-Green et al, 2012). Use of iodized salt may be encouraged. Limit caffeinated beverage intake. Avoid alcohol, which increases the risk for orofacial clefts and spina bifida.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

• Support the individual patient. Pregnant women who are fatigued, stressed, and anxious tend to consume more energy but fewer micronutrients. • Develop or improve good eating habits to prevent chronic health problems postnatally. The interaction between genes, nutrition, and environmental stimuli has been found to cause permanent changes in metabolism. • Discuss the importance of a high-quality prenatal diet. Fetal undernutrition can predispose to hypercholesterolemia and other health concerns. • Women should drink plenty of fluids to remain adequately hydrated. • Multiple gestation creates nutritional challenges. There are more risks for adverse outcomes, including diabetes, hypertension, eclampsia, and delivery of a premature or LBW infant. For twins, weight gain should reflect the period of gestation and prepartum BMI; 35 to 45 lb is often recommended with twins, and 50 lb overall is recommended for triplets. • Monitor BP and blood glucose regularly to prevent or to identify complications such as preeclampsia or gestational diabetes.

• Monitor or treat other complications, such as nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum. Table 1-4 discusses special problems in pregnancy; see also appropriate disorder entries.

Food and Nutrition • Desired pattern of food intake: Two to three servings of milk–yogurt–cheese group (for calcium, protein); 6 oz of meat or protein substitute (protein, iron, zinc); three fruits and four vegetables, including citrus (vitamin C) and rich sources of vitamin A and folacin; nine servings of grains and breads, three of which are whole grain or enriched breads/ substitutes (iron, energy); three servings of fat. • Include in diet: 1 g protein/kg body weight daily (or 10 to 15g above recommended dietary allowances for age). Young teens: 11 to 14 years (1.7 g/kg); 15 to 18 years (1.5 g/kg); over 19 years of age (1.7 g/kg); high risk (2 g/kg). • Energy: In women of normal weight, energy requirements increase minimally in the first trimester, by 350 kcal/d in the second trimester, and by 500 kcal/d in the third trimester (Table 1-5) (IOM, 2013). Increase for high levels of physical

TABLE 1-4 Special Issues in Pregnancy ISSUE

CONSIDERATIONS

Allergies, personal or family history

Nutritional strategies to program the microbiota composition to favor a more beneficial bacterial population and to support the development of the metabolic and immune systems may provide a good opportunity to prevent later health problems such as obesity, diabetes, and allergy (Nauta et al, 2013). Women may wish to take a prescribed probiotic to stimulate health-producing microbes in their fetus for greater gut immunity.

Hyperemesis (intractable, dehydrating vomiting)

This affects 20% of pregnancies in the first trimester. Half of these patients have some liver dysfunction. Check also for Helicobacter pylori infection. Early hospitalization with tube feeding may be needed. Metoclopramide (Reglan) may help. When eating orally, liquids taken between meals, extra B-complex vitamins and vitamin C, and limited fat may be beneficial. Low birth weight and greater length of hospital stay are common. Avoid electrolyte imbalances.

Liver dysfunction such as viral hepatitis, gallstones, orintrahepatic cholestasis in pregnancy

With pruritus, elevated bile acids in the second half of pregnancy, high levels of aminotransferases and mild jaundice, immediate delivery may be needed.

Multiple gestation

Energy regimen of 20% protein, 40% carbohydrate, and 40% fat is useful. Supplement with calcium, magnesium, zinc, multivitamins, and essential fatty acids.

Nausea and vomiting of pregnancy (NVP)

Initial treatment of nausea and vomiting should be conservative with dietary changes, emotional support, and perhaps use of ginger. NVP affects 80% of pregnancies. Evaluate for H. pylori. Frequent, small meals should be consumed separately from fluids. Offer high-protein snacks, such as cheese or lean meat. Avoid lying down immediately after meals and suggest not skipping meals. Do not force eating; suck on ice chips or other frozen items and make up lost calories later. Eat meals and snacks in a well-ventilated area, free of odors; avoid strong spices and aromas. Eat and drink slowly and rest after meals. Try lemonade and potato chips or saltines. Avoid large meals, very sweet, spicy, or high-fat foods if not tolerated. Eat dry crackers before rising in the morning. Multivitamin–mineral supplements may also trigger NVP; it may be helpful to try a different brand. Minimize offensive odors. Rehydration may be essential. NVP often abates by 17 weeks of pregnancy. Ondansetron and metoclopramide may be safely used.

Preeclampsia

Calcium supplementation appears to approximately halve the risk of preeclampsia, to reduce the risk of preterm birth, and to reduce the rare occurrence of morbidity (Hofmeyr et al, 2010).

Pica (intake of nonnutritive substances)

Chronic intake of ice, freezer frost, baking soda, baking powder, cornstarch, laundry starch, baby powder, clay, or dirt may significantly lower hemoglobin levels. WIC and prenatal counselors must be aware. Discussion of practices should be nonjudgmental; pica may have strong cultural history. Food cravings and aversions often subside after pregnancy.

Severe gastrointestinal problems

Consider total parenteral nutrition with adequate lipids (10%–20% of energy) for the fetus, as well as protein and carbohydrate. Check blood sugar regularly. Use adequate fluid according to estimated needs. Complications may include bacteremia, decreased renal function with preexisting disease, neonatal hypoglycemia, or subclavian vein thrombosis.

Vegans or vegetarians

Vitamin B12, zinc, calcium, and vitamin D supplements may be needed.

Women with high levels of inflammatory cytokines

Reduced placental perfusion and a tendency toward preeclampsia may occur. An anti-inflammatory diet may be used.

Women who have previously given birth to an infant with neural tube defect or anencephaly

Test for folic acid alleles; consider use of Neevo or 600 g folate daily throughout PG.

References: Hofmeyr GJ, Lawrie TA, Atallah AN, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD001059; NautaAJ, Ben Amor K, Knol J, et al. Relevance of pre- and postnatal nutrition to development and interplay between the microbiota and metabolic and immune systems. Am J Clin Nutr. 2013;98:586S.

Escott-Stump_Ch01.indd 9

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-5 Recommendations for Pregnant Women AGE 18 YEARS OR UNDER

AGES 19–30 YEARS

AGES 31–50 YEARS

1st tri 0 kcal/d

2nd tri 340 kcal/d

3rd tri 452 kcal/d

Protein

71 g/d

Calcium

1300 mg/d

1000 mg/d

Iron

27 mg/d

Folate

600 g/d

Phosphorus

1250 mg/d

700 mg/d

Vitamin A

750 g

770 g

Vitamin C

80 mg/d

85 mg/d

Thiamin

1.4 mg/d

Riboflavin

1.4 mg/d

Niacin

18 mg/d

NUTRIENT Energy

Data from: Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Washington, DC: National Academy Press; 2002.

• • • •

• •

•

• •

activity. Evaluate teens individually according to age and prepregnancy weight. With twins, insufficient weight gain may lead to preterm delivery (Gonzalez-Quintero et al, 2012). The diet and supplement should provide 27 mg of ferrous iron. Increase zinc by 5 mg, easily obtained from meat or milk. Encourage use of vitamin C foods with iron-rich foods or an iron sulfate supplement. Use adequate vitamins A and D to match daily reference intake (DRI) for age. Avoid hypervitaminosis; monitor use of dietary supplements and fortified foods carefully. Extra vitamin B6 and copper are readily obtained from a planned diet and a prenatal supplement. Use iodized salt, but avoid salt intake greater than that recommended for healthy adults. Women need 250 mcg of iodine during pregnancy. Magnesium plays a role in preventing or correcting high BP. Follow the Dietary Approaches to Stop Hypertension (DASH) diet and include whole grains, nuts, black beans, green vegetables, and seafood. Omit alcohol. Reduce caffeine intake to the equivalent of 2 cups of coffee or less per day; this includes intake from colas, chocolate, and tea. Essential fatty acids (EFAs) from fats, such as corn, canola or safflower oils and nuts, should equal 1% to 2% of daily calories. Include at least 200 mg of DHA for brain growth and cognitive development. Include fish and seafood (e.g., tuna, mackerel, salmon) for natural omega-3 fatty acids twice weekly, after consideration of potential allergies or mercury. Encourage whole fruit over fruit juice when possible for greater antioxidant (phenolic) intake (Crowe and Murray, 2013). Food taboos and cultural and religious dietary rules are often associated with special events such as pregnancy and childbirth and should be honored unless they are harmful (Meyer-Rochow, 2009).

Escott-Stump_Ch01.indd 10

Food–Drug Interactions Common Drugs Used and Potential Side Effects • After the fourth month, encourage use of a basic vitamin– mineral supplement between meals (with liquids other than milk, coffee, or tea) for better utilization. Supplements vary greatly; read labels carefully. Discuss the tolerable upper intake levels (ULs) from the latest dietary reference intakes of the National Academy of Sciences. • Iron is the only nutrient that cannot be met from diet alone (30 mg needed after the first trimester). Avoid taking iron supplements with antacids; bedtime is often the best time. • Avoid taking isotretinoin (Accutane), 13-cis-retinoic acid (CRA), or vitamin A in 10,000 IU or more, especially in the first trimester. • Insulin may be needed with consistently high blood glucose levels over 120 mg/dL; monitor and avoid overfeeding. • Antiemetic agents may be used to control NVP and include ondansetron (Zofran), cyclizine (Marezine), buclizine (Bucladin-S), metoclopramide (Reglan), meclizine (Antivert), prochlorperazine (Compazine), promethazine (Phenergan), or antihistamines such as Benadryl. Side effects include sedation, dizziness, changes in BP, or tachycardia. • Women who have chronic diseases such as epilepsy, thyroid disorders, diabetes, and cardiac disorders will require careful medical supervision. • Women who develop preterm labor are often treated with one of several drugs (tocolytics) to stop premature labor. Drugs include calcium channel blockers, terbutaline, ritodrine, magnesium sulfate, indomethacin, ketorolac, and sulindac. Use is short term, and side effects are not significant. • Neevo contains 1.13 mg l-methylfolate calcium (as Metafolin). It may be used for women who have MTHFR alleles. Herbs, Botanicals, and Supplements • Pregnant women should not use herbs, botanical supplements, and herbal teas. There are no rigorous scientific studies of the safety of dietary supplements during pregnancy. It should not be assumed that they are safe for the embryo or fetus. Women who are using such supplements should stop immediately when they discover they are pregnant. • Pregnant women should avoid supplements containing aloe, apricot kernel, black cohosh, borage, calendula, chaparral, chasteberry, comfrey, dong quai, ephedra, euphorbia, feverfew, foxglove, gentian, ginseng, golden seal, hawthorne, horehound, horseradish, juniper, licorice root, nettle, plantain, pokeroot, prickly ash, red clover, rhubarb, sassafras, saw palmetto, senna, skullcap, St. John’s wort, tansy, wild carrot, willow, wormwood, yarrow, or yohimbe. Willow bark (salicin) may cause stillbirth, prolonged gestation, or LBW. • Ginger may be an effective treatment for nausea and vomiting in pregnancy (NVP). Sips of ginger ale or use of small amounts of ginger in cooking may be useful. However, ginger is a powerful herbal product with anticoagulant action; avoid large doses and discontinue use when preparing for surgery or if taking anticoagulants (Tiran, 2012).

Nutrition Education, Counseling, Care Management • Describe adequate patterns and rates of weight gain in pregnancy; explain the rationale. Individualize according to goals (e.g., shorter women at lower range of gain). Excess equals more than 6.5 lb gained monthly after 20 weeks. Inadequate intake is 2 lb or less gained monthly after the first trimester.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

• Encourage adequate calcium intake. If needed, discuss what to do for milk allergy/intolerance and lactose intolerance. • Discourage fad and trendy diets, pica, or skipping breakfast. Discuss ketosis related to low glucose levels and its undesirable effect on fetal brain development. • Encourage intake of high-density nutrients; obese women tend to have poorer quality. Women may also have low intakes of vitamins B6, B12, and D during pregnancy (Elmadfa and Meyer, 2012). • Encourage breastfeeding and explain immunological benefits, bonding, and weight stabilization. • Mothers who are HIV-positive should consider highly active antiretroviral therapy (HAART), which can drastically reduce the risk of transmission of HIV from breastfeeding (Slater etal, 2010). • For excessive weight gain, restore eating patterns to match a normal growth curve. Severe calorie restriction should be avoided and at least 175 g of carbohydrates (CHO) will be needed. • Ensure a balanced intake of fluoride and iodine from water, table salt, and seafood is needed. • Discuss tobacco, cocaine, alcohol, and marijuana use; they contribute to decreased birth weight and congenital malformations. • Eligible women should be referred to the WIC program, especially to prevent LBW. Many barriers hinder participation in nutrition education programs, including lack of transportation or child care. Facilitated discussions, support groups, cooking classes, and websites may be useful. • For constipation, suggest extra fiber, activity, and fluid (35 to 40 mL/kg); avoid laxatives. • For swelling of ankles, hands, and legs, become more physically active. Avoid excessive salt at the table but do not restrict severely.

TABLE 1-6 March of Dimes Campaign to Reduce Preterm Births • Consume a multivitamin containing 400 g of the B vitamin folic acid before and in the early months of pregnancy. Women who need L-methylfolate should receive a special formulation. • Stop smoking, drinking, and/or using illicit drugs; avoid prescription or overthe-counter drugs (including herbal preparations) unless prescribed by a doctor who is aware of the pregnancy. • Once pregnant, get early regular prenatal care, eat a balanced diet with enough calories (about 300 more than a woman normally eats), and gain enough weight (usually 25–35 lb). • Talk to a doctor about signs of premature labor and what to do if warning signs are evident. Derived from: March of Dimes. Available at: http://www.marchofdimes.com/mission /prematurity_wpd.html. Accessed June 15, 2014.

• For heartburn, eat smaller meals more frequently, eat slowly, and cut down on spicy or high-fat foods. Avoid antacids unless approved by the physician. • All infections are cause for concern among pregnant women because they pose a risk to the health of the baby. Prostaglandins may stimulate early labor and cause delivery of an LBW infant. Women should have a periodontal evaluation to rule out gum disease and to eliminate infection. • Discuss postpartum issues, including physical activity, breastfeeding, anemia, and control of hyperglycemia. Attention to psychosocial needs may help to improve dietary intakes. • The March of Dimes has a campaign to reduce rates of preterm birth (Table 1-6). November 17 has been designated World Prematurity Day to bring attention to the risks. • Encourage pleasant meal times and a healthy appetite, as stress has negative effects on nitrogen and calcium and may lead to preterm birth (Fig. 1-6).

BIOLOGIC SYSTEM(S) genetic and

STRESS

Vascular

epigenetic regulation

Infection

Endocrine

PRETERM BIRTH genetic and

Malnutrition

epigenetic regulation

CNS

Immune Psychosocial

Hypoxia

Vascular

Figure 1-6. Effects of various stressors on the risk for preterm birth. (Adapted with permission from Wadhwa PD, Entringer S, Buss C, et al. The contribution of maternal stress to preterm birth: issues and considerations. Clin Perinatol. 2011;38:351.)

Escott-Stump_Ch01.indd 11

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Patient Education—Food Safety • Helicobacter pylori should be suspected as one possible cause of nausea and vomiting. Hepatitis A, Salmonella, Shigella, Escherichia coli, and Cryptosporidium are common causes of diarrhea during pregnancy. Careful hand washing is recommended. • Pregnant women can select safe kinds of fish, such as shellfish, canned fish, smaller ocean fish, and farm-raised fish. They can safely eat 12 oz of cooked fish per week, with a typical serving size being 3 to 6 oz. Keep fish and shellfish refrigerated or frozen until ready to use. • Guidance during pregnancy requires omission of: 1. Unpasteurized, raw milk or uncooked eggs, and foods made with them (raw cookie dough, homemade eggnog, etc.) 2. Raw fish or shellfish (including sushi), undercooked meat/ poultry 3. Soft cheeses, such as brie, Camembert 4. Unpasteurized juice or cider 5. Certain fish (swordfish, tilefish/white snapper, shark, king mackerel) 6. Salads made in a store (ham, tuna.) • For additional information, see http://www.eatright.org /Public/content.aspx?id=5984.

For More Information

See the video “Client Intake/Pre-treatment” and listen to the audio review “Physical Examination: Pregnant Women” at www.thepoint.lww.com/escottstump8e.

●

American Association of Birth Centers http://www.birthcenters.org/

●

American College of Nurse-Midwives (ACNM) http://www.midwife.org

●

Centers for Disease Control and Prevention—Pregnancy http://www.cdc.gov/ncbddd/pregnancy_gateway

●

Food Safety during Pregnancy http://www.foodsafety.gov/poisoning/risk/pregnant/chklist_pregnancy.html

●

Mayo Clinic—Pregnancy http://www.mayoclinic.com/health/pregnancy-nutrition/PR00110

●

National Center for Education in Maternal-Child Health http://www.ncemch.org/

●

National Foundation—March of Dimes http://www.modimes.org/

●

National Healthy Mothers, Healthy Babies Coalition http://www.hmhb.org/

●

WIC Program—Supplemental Food Programs Division http://www.fns.usda.gov/wic/

SAMPLE NUTRITION CARE PROCESS STEPS Inadequate Protein Intake for Multiple Gestation Assessment Data: Dietary recall indicating low use of protein-rich foods; labs such as albumin, BUN, and H&H; insufficient rate of weight gain on prenatal grid. Nutrition Diagnosis (PES): Inadequate protein intake related to needs for twin pregnancy as evidenced by dietary intake records (60% of goal) and slow growth on prenatal growth grid. Intervention: Education on protein and protein-sparing kilocalories during pregnancy for twins. Counseling for individual needs, snack habits, recipes, tips for reducing nausea, physical activity. Monitoring and Evaluation: Changes in dietary intake, improved lab values, improved weight gain on prenatal growth grid, successful pregnancy outcomes.

Rapid Weight Gain in Pregnancy Assessment Data:Dietary history reflects high-caloric food intake; patient statements reflect misinformation; weights and rate of weight gain exceed recommended rate. Nutrition Diagnosis (PES):Excessive energy intake related to misinformation about nutrition needs during pregnancy as evidenced by dietary recall showing daily intake of high-calorie foods, 3-lb body weight gain per week during the second trimester, and 20-lb weight gain by the middle of the second trimester. Intervention: Education on food and nutrient needs during pregnancy. Referral to WIC program if eligible financially and medically. Monitoring and Evaluation: Monthly appointment; include diet history and rate/amount of weight gain.

Escott-Stump_Ch01.indd 12

REFERENCES American College of Obstetrics and Gynecology. Patient fact sheets. Available at: http://www.acog.org/For_Patients. Accessed June 14, 2014. Barton RA, Cappellini I. Maternal investment, life histories, and the costs of brain growth in mammals. Proc Natl Acad Sci U S A. 2011;108:6169. Brannon PM. Vitamin D and adverse pregnancy outcomes: beyond bone health and growth. Proc Nutr Soc. 2012;71:205. Cao C, O’Brien KO. Pregnancy and iron homeostasis: an update. Nutr Rev. 2013;71:35. Chaffee BW, King JC. Effect of zinc supplementation on pregnancy and infant outcomes: a systematic review. Paediatr Perinat Epidemiol. 2012;26:118S. Crowe KM, Murray E. Deconstructing a fruit serving: comparing the antioxidant density of select whole fruit and 100% fruit juices. J Acad Nutr Diet. 2013;113:1354. Elmadfa I, Meyer ML. Vitamins for the first 1000 days: preparing for life. Int J Vitam Nutr Res. 2012;82:342. Gonzalez-Quintero VH, et al. The association of gestational weight gain per institute of medicine guidelines and prepregnancy body mass index on outcomes of twin pregnancies. Am J Perinatol. 2012;29:435. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Available at: http://www.nap.edu/openbook.php?record_id=12584&page=77. Accessed June 14, 2014. Kaur P, et al. The epigenome as a potential mediator of cancer and disease prevention in prenatal development. Nutr Rev. 2013;71:441. Kosmiski L. Energy expenditure in HIV infection. Am J Clin Nutr. 2011;94:1677S. Laraia BA, et al. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain, and pregnancy complications. J Am Diet Assoc. 2010;110:692. Mamun AA, et al. Associations of maternal pre-pregnancy obesity and excess pregnancy weight gains with adverse pregnancy outcomes and length of hospital stay. BMC Pregnancy Childbirth. 2011;11:62. March of Dimes. Preconception risk assessment. Available at: http://www .marchofdimes.com/pregnancy/getready_indepth.html. Accessed June 14, 2014. Meyer-Rochow VB. Food taboos: their origins and purposes. J Ethnobiol Ethnomed. 2009;5:18. Pena-Rosas JP, et al. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev. 2012 Dec 12;12:CD004736. Pico C, et al. Metabolic programming of obesity by energy restriction during the perinatal period: different outcomes depending on gender and period, type and severity of restriction. Front Physiol. 2012;3:436. Procter SB, Campbell CG. Position of the academy of nutrition and dietetics: nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014;114:1099–1103. Slater M, et al. Breastfeeding in HIV-positive women: what can be recommended? Paediatr Drugs. 2010;12:1.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

Stagnaro-Green A, et al. Iodine supplementation during pregnancy and lactation. JAMA. 2012;308:2463. Suren P, et al. Association between maternal use of folic acid supplements and risk of autism spectrum disorders in children. JAMA. 2013;309:570. Thomas DM, et al. Dynamic energy-balance model predicting gestational weight gain. Am J Clin Nutr. 2012;95:115. Tiran D. Ginger to reduce nausea and vomiting during pregnancy: evidence of effectiveness is not the same as proof of safety. Complement Ther Clin Pract. 2012;18:22.

Uuay R, et al. How can the Developmental Origins of Health and Disease (DOHaD) hypothesis contribute to improving health in developing countries? Am J Clin Nutr. 2011;94:1759S. WebMD. What is a high risk pregnancy? Available at: http://www.webmd.com /baby/guide/high-risk-pregnancy-overview. Accessed June 14, 2014. Willis K, Sheiner E. Bariatric surgery and pregnancy: the magical solution? J Perinat Med. 2012;8:1. Young BC, Wylie BJ. Effects of twin gestation on maternal morbidity. Semin Perinatol. 2012;36:162.

LACTATION NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND Breastfeeding should be supported and encouraged because of its immunologic, physiologic, economic, social, and hygienic effects on mother and infant. Exclusive breastfeeding for the first 6 months of life is desirable. Breast milk is a living fluid. Infants receive beneficial nucleotides, macrophages, leukocytes, lymphocytes, and neutrophils from human milk. Lactoferrin, secretory immunoglobulin A (IgA), lysozyme, and bifidus factor protect against diarrhea, allergies, ear infection, necrotizing enterocolitis, urinary tract infection, and pneumonia. Infants who are exclusively breastfed for 6 months experience fewer gastrointestinal infections than those who are partially breastfed or formula fed (Kramer and Kakuma, 2012). Unfortunately, two-thirds of women who intend to exclusively breastfeed are not meeting their goals (Perrine et al, 2012). The environment during early development affects health and disease in adulthood, probably via DNA methylation, histone modifications, RNA silencing, or a combination (Nauta et al, 2013). The gastrointestinal microbiota plays an important role in maintaining health by preventing the colonization of pathogens, fermenting dietary compounds, and maintaining normal mucosal immunity (Thum et al, 2012). Early microbial colonization of the almost sterile GI tract of the newborn infant influences body composition, digestion, metabolic homeostasis, and the maturation process of the immune system (Nauta et al, 2013). With a vaginal birth, the newborn GI tract has contact with maternal fecal and vaginal bacteria; this yields a microbial community that is influenced by feeding type (Thum et al, 2012). Bacterial flora of breastfed infants are generally Lactobacillus, not E. coli like those of formula-fed infants. Maternal GI tract microbiota, vaginal microbiota, and breast milk composition are all influenced by maternal diet (Thum et al, 2012). Breastfeeding is an anabolic state, requiring extra energy. The composition of breast milk varies over time. Colostrum contains mainly immunological factors (days 1 to 4); a short transition occurs in days 5 to 9; and milk secreted between days 9 and 28 is primarily nutritional—the content is equally valuable for immunity and nutrition thereafter. Because maternal intake and breastfeeding practices vary over the duration of lactation, regular assessment is needed to determine if the infant needs supplemental foods or nutrients. Only rarely is supplementation needed. In fact, adding formula

Escott-Stump_Ch01.indd 13

or solids to the diet of the exclusively breastfed infant almost guarantees lactation failure. Unless mom is severely malnourished, she can keep making sufficient milk. Human milk is better digested and absorbed by infants than other forms of milk; it has more DHA for cognitive and visual development, and carnitine for mitochondrial oxidation of the long-chain fatty acids. Breast milk has 1.5 times as much lactose as cow’s milk; consequently, protein is absorbed better. The whey to casein ratio of 60:40 is more desirable than that of many formulas. In comparison, cow’s milk has twice as much protein, sodium, and mineral content. The composition of breast milk changes to meet the developing baby’s needs (i.e., the fat content decreases over time). In many cases where a mother cannot breastfeed, the use of banked human milk may be a better option than cow’s milk formulas (Wojcik et al, 2009). Table 1-7 provides a breakdown of the nutrient content of human milk. Breastfeeding has played an important role in improving child health by providing optimum nutrition, protection against common childhood infections, and child spacing. Food allergies are less frequent in infants who are exclusively breastfed, especially if maternal diets are higher in omega-3 fatty acids. Compared with cow’s milk formula, breast milk has more antibodies and over 45 bioactive factors in digestive enzymes, hormones, immune factors, and growth factors. If the mother uses alcohol or illicit drugs, receives chemotherapy, has HIV infection, or if the infant has galactosemia, breastfeeding is not recommended (Slater et al, 2010). Women must be fully informed about the risks of breastfeeding transmission of HIV. The Committee on Pediatric AIDS (2013) recommends that HIV-infected women not breastfeed their infants, regardless of maternal viral load or antiretroviral therapy. Women should be encouraged to breastfeed until the child is 1 year of age or as long as mutually desirable. In developing countries, mothers may be encouraged to increase the breastfeeding time to 2 years, but mothers should not deprive themselves. The volume of milk decreases in a poorly nourished mother (James et al, 2009). New mothers who are breastfeeding should try not to lose weight rapidly. Obese women need extra encouragement to breastfeed. Prolonged breastfeeding helps to lower postpartum weight, although this benefit decreases in older mothers. Breastfeeding reduces the risk of breast and ovarian cancers, protects bone density in the mother, improves glucose profiles in gestational diabetes, and saves money not spent on formula (James et al, 2009).

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-7 Content of Mature Human Milk NUTRIENTS

UNITS

1 CUP/240 ml

PROXIMATES

NUTRIENTS

UNITS

1 CUP/240 ml

Vitamins

Water Energy Protein (casein, IgA, IgG, lactalbumin, lactoferrin, albumin, B-lactoglobulin) Total lipid (fat) Carbohydrate (lactose, oligosaccharides) Fiber, total dietary Amino acids

g kcal g

Tryptophan Threonine Isoleucine Leucine Lysine Methionine Cystine Phenylalanine Tyrosine Valine Arginine Histidine Alanine Aspartic acid Glutamic acid Glycine Proline Serine

g g g g g g g g g g g g g g g g g g

215.25 171.125 2.53

g g g

10.775 16.95 0.00 0.042 0.113 0.138 0.234 0.167 0.052 0.047 0.113 0.130 0.155 0.106 0.057 0.089 0.202 0.413 0.064 0.202 0.106

Vitamin C Thiamin Riboflavin Niacin Pantothenic acid Vitamin B6 Folate

mg mg mg mg mg mg

Vitamin B12

g IU

Vitamin A, IU Vitamin A, RE

g IU mg

Vitamin D Vitamin E

12.300 0.034 0.089 0.435 0.549 0.027 12.792 0.111 592.860 157.440 9.840 2.214

Lipids Fatty acids, saturated Fatty acids, monounsaturated Fatty acids, polyunsaturated Cholesterol

g g g mg

4.942 4.079 1.223 34.194

mg mg mg mg mg mg mg mg mg

79.212 0.074 8.364 33.702 125.952 41.574 0.418 0.128 0.064 4.428

Minerals Calcium, Ca Iron, Fe Magnesium, Mg Phosphorus, P Potassium, K Sodium, Na Zinc, Zn Copper, Cu Manganese, Mn Selenium, Se

Other Antimicrobial Factors

Cytokines and Anti-inflammatory Factors

Growth Factors

Secretory IgA, IgM, IgG

Tumor necrosis factor

Epidermal (EGF)

Lactoferrin

Interleukins

Nerve (NGF)

Lysozyme

Interferon-

Insulin-like (IGF)

Complement C3

Prostaglandins

Transforming (TGF)

Leucocytes

Acetyl hydrolase

Taurine

Bifidus factor

1-antichymotrypsin

Polyamines

Lipids and fatty acids

Platelet-activating factor

Antiviral mucins, GAGs Oligosaccharides

Digestive Enzymes

Potentially Harmful Substances

Hormones

Amylase

Viruses (e.g., HIV)

Feedback inhibitor of lactation (FIL)

Bile acid-stimulating esterase

Aflatoxins

Insulin

Bile acid-stimulating lipases

Trans-fatty acids

Prolactin

Lipoprotein lipase

Nicotine, caffeine

Thyroid hormones

Food allergens

Corticosteroid, ACTH

PCBs, DDT, dioxins

Oxytocin

Radioisotopes

Calcitonin

Drugs

Parathyroid hormone Erythropoietin

Sources: Jensen RG, ed. Handbook of milk composition. New York: Academic Press; 1995; Scrimshaw NS. Protein and amino acid requirements. Food Nutr Bull. 1996;17(4); United Nations University Centre. Constituents of human milk. Available at: http://archive.unu.edu/unupress/food/8F174e/8F174E04.htm. Accessed June 15, 2014.

Escott-Stump_Ch01.indd 14

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

The long-term effects of breastfeeding an infant include lower incidences of type 2 diabetes, Crohn’s disease, some types of cancer, allergies, and neurologic disabilities. Several minerals and peptides found in milk have a BP lowering effect, which may be protective later in life. Exclusive and prolonged breastfeeding is also associated with higher cognitive development than formula feeding, likely from long-chain fatty acids DHA and EPA (Morse, 2012). Dietetics professionals have an essential role in promoting and supporting breastfeeding by providing up-to-date, practical information to pregnant and postpartum women, involving family and friends in breastfeeding education and counseling, removing institutional barriers to breastfeeding, collaborating with community organizations that promote and support breastfeeding, and advocating for policies that position breastfeeding as the norm (James et al, 2009). Support of breastfeeding and other healthy feeding practices are especially important for low socioeconomic children who are at increased risk of early childhood obesity (Gibbs and Forste, 2013). During pregnancy, immune and metabolic functions of the fetus depend on the mother, including her diet (Sanz, 2011). The establishment of healthy gut microbiota is crucial in neonatal development, influencing health throughout life (Jost et al, 2012). Promotion of predominant breastfeeding for at least 4 to 6 months could reduce the burden of allergic manifestations and infections in infancy, partly by exposure to higher doses of n-3 and arachidonic acid received from colostrum (Morales et al, 2012). Despite the lack of current recommendations, nutritionists still recommend a maternal exclusion diet during pregnancy to lessen the onset of allergies (Ribeiro et al, 2013). Probiotics and an immune-enhancing diet may be the better recommendation. Billions of dollars would be saved if breastfeeding were increased to 6 months or longer to reduce otitis media, gastroenteritis, and necrotizing enterocolitis. The Ten Steps to Successful Breastfeeding program provides standards to encourage hospitals to support breastfeeding (UNICEF, 2013). Figure 1-7 lists factors that play a part in breastfeeding success or failure.

Nutrition Access to food Consumer role Complementary fdg

Health Health care system Consumer role

Work (Re)production Job/career options Value of human milk Power and rights Poverty/wealth Race/class

Autonomy Mother-baby dyad Independence/ interdependence

Escott-Stump_Ch01.indd 15

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Each individual has a unique genetic profile and phenotype. Infants with galactosemia should not breastfeed.

Clinical/History • • • • • • • • • • • • • •

Height Current weight Weight history Prepregnancy weight HBW range for height Date of birth (DOB) for infant BP Smoking Alcohol or medication use Sedentary lifestyle? Mother’s intake and breastfeeding practices Extent to which infant is breastfeeding Composition of milk, variable with use of medications Breastfeeding difficulties for mother or infant

Lab Work • • • • • • • • • • •

Glucose Alb or transthyretin (if needed) H&H, serum Fe ALP Prothrombin time (PT) or international normalized ratio (INR) Chol Triglycerides (Trig) Homocysteine Ca Serum phosphorus Serum 25-hydroxyvitamin D [25(OH)D]

Feelings Attachment Emotional/spiritual concerns Family life Child care Child develop. Family roles

Breastfeeding

Mobility Public acceptance Clothing Modesty

Time use Stress/overwork Rest/leisure Sleep

Learning Brain development (mom & baby) Mothering skills Embodiment Sexuality Body image Maternal body

Figure 1-7. Factors affecting successful breastfeeding. (Adapted with permission from Mulford C. Isbreastfeeding really invisible, or did the health care system just choose not to notice it? Int Breastfeed J. 2008;3:13.)

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

INTERVENTION Objectives • Support adequate lactation (usual secretion is 750 to 800mL/d). Human milk provides 67 kcal/dL. Good energy intake improves milk production, especially in undernourished women. • Breast milk can meet nutrient needs during the first 6months, with possible exception of vitamin D and iron in certain populations. • Exclusive breastfeeding for 6 months has many nutritional benefits. Have the mother continue breastfeeding for up to 1 year when possible. Support the efforts of “baby-friendly” hospitals (Labbok, 2012). • Decrease nutritional risks from use of alcohol, stimulants, and medications while breastfeeding. Alcohol intake inhibits the letdown reflex from oxytocin. Discourage excessive use of caffeine from coffee (limit to 2 cups daily) and tea, colas, and chocolate. • Promote adequate infant growth and development, including bone mineralization. Lactation increases the normal daily loss of calcium for the mother yet is generally beneficial for protecting bone health. • Normalize body composition gradually so that the mother returns to ideal weight. Promote gradual weight loss even in obese women. • Support brain health and visual acuity by including EPA and DHA fatty acids in the mother’s diet (Morse, 2012).

Food and Nutrition • In the first 6 months, increase the mother’s energy by 330kcal over recommended daily allowance (RDA) for age. In the next 6 months, increase energy by 400 kcal over RDA for age. Recommendations may vary because individuals vary in prepregnancy weights, activity levels, and rates of weight gain (Table 1-8). TABLE 1-8 Recommendations for Lactation NUTRIENT

AGE 18 YEARS OR UNDER

AGES 19–30 YEARS

AGES 31–50 YEARS

Energy, 1st 6 months

330 kcal/d

Energy, 2nd 6 months

400 kcal/d

Protein

61 g/d or 1.1 g/kg/d

Calcium

1200 mg/d

1300 mg/d

Iron

10 mg/d

9 mg/d

Folate

500 g/d

Phosphorus

1250 mg/d

700 mg/d

Vitamin A

1200 g

1300 g

Vitamin C

115 mg/d

120 mg/d

Thiamin

1.4 mg/d

Riboflavin

1.6 mg/d

Niacin

17 mg/d

Escott-Stump_Ch01.indd 16

• Consider the special needs of adolescents or women older than 35 years of age. Energy and nutrient requirements will change accordingly. • Increase the mother’s intake of protein (approximately 65 g daily), especially sources of high-quality protein. • Encourage intake of usual sources of vitamins and minerals. Intake of calcium should be 1200 to 1300 mg/d. Increases of B-complex vitamins and vitamins A and C should be included. Supplementation may be needed for women with poor dietary intakes or chronic illnesses. • Adequate vitamin D is needed for the infant if maternal intake is poor, if infant receives little sunshine exposure or has high levels of skin pigmentation. Daily vitamin D supplements of 400 IU/L will keep serum 25(OH)D concentrations higher than 50 nmol/L to prevent rickets in infants and young children (Pettifor, 2013). • Levels of both iron and copper decrease with progression of lactation; there is no evident need for supplementation in the first 6 months. • Increase intake of fluids. Omit alcohol unless permitted by a physician. • After 3 months of lactation, mothers should increase energy intake if weight loss has been excessive. • Women who follow vegan diets may need zinc, calcium, vitamin D, or vitamin B12 supplementation. These diets also may also be low in carnitine. • If breast milk tube feeding is needed, some fat losses can occur. Formula enhancers may be added if long-term use is required.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Discuss the relevance of tolerable ULs from the latest dietary reference intakes of the National Academy of Sciences. These levels were set to protect individuals from receiving too much of any nutrient from diet and dietary supplements. Lactating mothers should be especially aware of what they are consuming between diet and supplements to avoid hypervitaminosis A and D. Read food and supplement labels carefully. • Alcohol and nicotine are transmitted through breast milk to infants; discourage use. Cigarette smoking reduces the amount of milk produced. • Moderate amounts of caffeine are acceptable in the equivalent of 2 cups of coffee. • Cimetidine, fluoxetine, lithium, cyclosporine, cold medicines, and some other drugs may be contraindicated. Otherwise, prescribed medications are used only under supervision of the doctor. • Drugs that may be used during breastfeeding include acetaminophen, some antibiotics and antihistamines, codeine, decongestants, insulin, quinine, ibuprofen, and thyroid medications. • Parlodel (bromocriptine mesylate) inhibits secretion of prolactin and decreases lactation; it is used for women who do not wish to breastfeed. Constipation or anorexia may result. Herbs, Botanicals, and Supplements • Herbs and botanical supplements should not be used without first discussing with the physician. In general, these supplements have not been proven to be safe for breastfeeding mothers and their infants. • Folk traditions are commonly communicated during breastfeeding education (Schaffir and Czapla, 2012). Although the use of metoclopramide, fenugreek, asparagus, and milk

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

thistle are sometimes promoted as “galactagogues,” efficacy and safety data in the literature are lacking (Forinash et al, 2012). Domperidone and oxytocin have shown moderate efficacy. • Lactating women should not take kava, chasteberry, dong quai, Asian ginseng, licorice root, or saw palmetto. • Strategies to manipulate the microbiota during infancy may prevent the development of some diseases later in adult life (Thum et al, 2012).

•

Nutrition Education, Counseling, Care Management • Primary care physicians should support breastfeeding efforts during visits, but a lactation consultant may be even more useful. Indeed, a routine post-discharge outpatient lactation visit coordinated within a primary care practice improves breastfeeding initiation and intensity (Witt et al, 2012). The consultant can explain the composition of breast milk, the benefits of breastfeeding, nipple care, and what to do during illness or infection. • Promote self-esteem and self-efficacy. Help mom believe that she can do it; give positive feedback and help her handle negative comments from others. To prevent early discontinuation, lay support (peer counseling) is effective. • Help mom address barriers, such as short maternity leave, lack of private places to pump, coworker comments, minor health barriers, lack of support from doctor or nurses, and old wives’ tales (e.g., breastfeeding spoils the baby, restrictive diet). Other concerns may include adequacy of infant nutrition, maternal illness or the need for medicine, or infant illness (Odom et al, 2013). • Women with delayed onset of lactation need additional support during the first week postpartum; recommend frequent nursing. To ensure baby receives enough milk, mom should nurse at least eight times in each 24-hour period, no longer than 1 hour at a time. Baby should be able to rest for about 2hours between feedings. • Breastfed infants should have at least five wet diapers in each 24 hours. Stools of breastfed babies differ from formula-fed infants by being more loose. By day 4, there should be three stools a day, yellowish in hue. • Explain the meaning of a balanced diet. Stress food sources of nutrients often limited in mothers’ diets: calcium, zinc, folate, and vitamins E, D, and B6. • Breastfed infants may be deficient in vitamin B12, especially after 6 months. Vegetarian women may need supplemental vitamin B12 and vitamin D. • Encourage the mother to normalize weight after delivery but not start a weight loss program while nursing. Weight loss should not be initiated until breastfeeding is discontinued, with no more than 1 lb/wk. Other than postpartum diuresis, average loss is 0.67 kg/month. Total weight gained during pregnancy affects weight loss afterward. Mothers should try to maintain their postpartum weight during lactation. • Moderate exercise has no adverse effects on breastfeeding among healthy mothers. Extra energy intake would be needed with vigorous exercise. • Exercise alone does not usually achieve the desired level of weight reduction. Once lactation is established, overweight women can reduce energy intake by 500 kcal/d to allow gradual weight loss of 0.5 kg/wk. • Lactating women are at high risk for energy and nutrient inadequacies, especially in low-income communities.

Escott-Stump_Ch01.indd 17

• •

Strategies must ensure adequate intakes. For example, the WIC food package offers low-fat milk, whole grains, canned beans, salmon and tuna, and fruit/vegetable cash vouchers. The program offers a formula/breastfeeding option to encourage breastfeeding. Depressive symptoms in postpartum mothers should be identified and addressed. In general, postpartum women who breastfeed show fewer signs of depression (Hamdan and Tamim, 2012). Exposure to pesticides and polychlorinated biphenyls (PCBs) is undesirable. Some exposure occurs from breast milk. Discuss issues related to safe handling of breast milk. Table 1-9 provides common problems and guidance during breastfeeding.

Patient Education—Food Safety • Avoid soft cheeses such as feta, brie, camembert, Roquefort, and Mexican soft cheese; they may have been contaminated with Listeria, which can cause fetal death or premature labor. If they are used, cook until boiling first. • Avoid raw eggs, raw fish, and raw and undercooked meats because of potential viral and bacterial food poisoning. H. pylori should be suspected as one possible cause of nausea or vomiting; careful hand washing is recommended. • Nursing mothers should not eat shark, swordfish, king mackerel, and tilefish. These long-lived larger fish contain the highest levels of methyl mercury, which may harm a baby’s developing nervous system. Nursing women should select a variety of other kinds of fish, such as shellfish, canned fish, smaller ocean fish, or farm-raised fish. They can safely eat 12 oz of cooked fish per week, with a typical serving size being 3 to 6 oz. • After expressing milk, it should be stored in a clean, tightly enclosed container. An opaque container may help to protect riboflavin more than a clear container if there is any exposure to light. • Human milk can be stored safely if refrigerated but not at room temperature because bacterial growth and lipolysis are rapid. Milk to be used within 48 hours can be refrigerated; if milk is to be used after 48 hours, try freezing (up to 6months) immediately.

SAMPLE NUTRITION CARE PROCESS STEPS Harmful Beliefs about Food and Nutrition Assessment Data:Food records; signs of infant GI distress or excessive sleep. Nutrition Diagnosis (PES): Harmful beliefs/attitudes about food or nutrition-related topics related to consumption of four beers daily while breastfeeding as evidenced by food diary, discussion with mom about “beer making more breast milk,” and reports that the infant is lethargic during daytime. Intervention: Education about appropriate dietary and substance intake for pregnancy. Counseling about dangers of consuming alcohol. Monitoring and Evaluation: Omission of alcohol intake while breastfeeding. Infant weight and infant growth charts; reports about infant sleep and GI patterns.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-9 Common Breastfeeding Difficulties and Reasons Why Women Discontinue Breastfeeding BREASTFEEDING DIFFICULTIES

Birth Control Pills High estrogen-types are not recommended as they can decrease milk supply. A progestin-only pill is usually recommended by a physician.

Engorgement The best way to prevent engorgement is to begin breastfeeding as soon as possible after birth followed by nursing regularly throughout the day. Rapid filling of the breasts and blocked mammary ducts may cause a painful engorgement. Frequent nursing, breast massage or warm shower before feedings, use of cold packs shortly after nursing, wearing a firm bra that is not too tight, and avoiding the use of nipple shields can help alleviate this condition.

Inadequate Milk Supply Poor milk supply can be a cause of failure to thrive in breastfeeding infants. Maternal causes of poor milk supply are hypothyroidism, excessive antihistamine use, smoking, oral contraceptive use, acute illness, inadequate intake after bariatric surgery, poor diet, decreased fluid intake, infrequent nursing, or fatigue. Correction of these causes may improve milk supply. Increasing frequency of nursing is the best way to increase milk supply.

Jaundice Breast milk jaundice occurs in about 1% of the population of breastfeeding newborns, is caused by the presence of a substance that alters liver function, and may cause red cell hemolysis. Mothers should breastfeed 10 to 12 times per day to correct elevated serum bilirubin levels.

Latching On For problems with baby latching on, the trick is to have the baby open his or her mouth wide. Brush baby’s lips with the nipple to encourage him or her to open wide, as if yawning. Once baby’s mouth is open wide, quickly pull the baby onto the breast by pulling the baby toward mom with the arm that is holding him or her (not moving mom toward the baby). Baby’s gums should cover an inch of the areola behind the nipple. Be sure the baby’s lips are everted and not inverted (turned in). Almost the entire areola should be in the baby’s mouth.

Mastitis Breast infection causes fever, chills, redness, flu-like symptoms, and breast sensitivity. A clogged mammary duct, maternal anemia, stress, or an infection carried from the baby may cause mastitis. The primary goal is emptying the infected breast; frequent nursing (every 1–3 hours during the day and 2–3 hours at night) is encouraged. The physician should be notified so that antibiotics or pain relievers can be prescribed. Application of heat to the breast, drinking plenty of fluids, and adequate rest are useful measures for treatment.

Nipple Confusion Infants who are breastfed may refuse to take a bottle as the weaning of breastfeeding occurs. Mothers should be encouraged to continue attempts at breastfeeding.

Sore Nipples Frequent, short nursing, repositioning the infant at the breast, applying cold packs or heat to breasts, avoiding irritating soaps or lotions on nipples, air-drying nipples after nursing, exposing nipples to direct sunlight or 60-watt bulb for 15 minutes several times per day, applying vitamin E squeezed from capsules or ointment such as vitamin A and D or pure lanolin cream to nipples, and avoiding the use of nipple shields may help ease the pain.

Thrush Thrush is a common yeast infection (Candida albicans) that can be passed between the mother and the baby during breastfeeding. Mother may have deep-pink nipples that are tender or uncomfortable during and immediately after nursing. White patches and increased redness in the baby’s mouth are symptoms. An antifungal medication may be needed. REASONS WHY WOMEN DISCONTINUE LACTATION

Infant Issues • Self-weaning (after third month) • Weakness or oral anomalies

Mother’s Issues • Acute infections • Concerns about lactation and nutrition issues • Depression • Illness (e.g., tuberculosis, severe anemia, chronic fevers, cardiovascular or renal disease) and/or use of medications • Perception that the infant was not satisfied by breast milk alone • Worksite issues: lack of part-time jobs, flexible scheduling, and convenient day care for mothers who must work; inadequate privacy • Lack of information and support and/or inadequate preparation • Hospital practices including physician and nurse apathy or misinformation Sources: Li R, Fein SB, Chen J, et al. Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics. 2008;122:S69; Medline Plus. Overcoming breastfeeding problems. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/002452.htm. Accessed June 15, 2014.

Escott-Stump_Ch01.indd 18

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

For More Information

See the video “Assisting the Client with Breastfeeding” at www.thepoint.lww.com /escottstump8e.

●

Academy of Breastfeeding Medicine http://www.bfmed.org/Default.aspx

●

Breastfeeding a Cleft-Lip/Palate Baby http://www.cleft.org/breastfeeding.htm

●

Breastfeeding Basics Course http://www.breastfeedingbasics.org/

●

Breastfeeding Promotion Committee: Healthy Mothers, Healthy Babies National Coalition http://www.hmhb.org/

●

CDC Breastfeeding topics http://www.cdc.gov/breastfeeding/

●

Center for Breastfeeding Information -La Leche International http://www.lalecheleague.org/

●

Human Milk Banking Association of North America http://www.hmbana.org/

●

Keep Kids Healthy – Breastfeeding Center http://www.keepkidshealthy.com/breastfeeding/

●

Medline Plus – Overcoming Breastfeeding Problems http://www.nlm.nih.gov/medlineplus/ency/article/002452.htm

●

National Breastfeeding Month http://www.usbreastfeeding.org/Communities/BreastfeedingPromotion /NationalBreastfeedingMonth/tabid/209/Default.aspx

●

Storage Guidelines for Human Milk http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm

REFERENCES Committee on Pediatric AIDS. Infant feeding and transmission of human immunodeficiency virus in the United States. Pediatrics. 2013;131:391. Forinash AB, et al. The use of galactagogues in the breastfeeding mother. Ann Pharmacother. 2012;46:1392.

Gibbs BG, Forste R. Socioeconomic status, infant feeding practices and early childhood obesity. Pediatr Obes. 2014;9:135–146. Hamdan A, Tamim H. The relationship between postpartum depression and breastfeeding. Int J Psychiatry Med. 2012;43:243. James DC, et al. Academy of Nutrition and Dietetics. Position of the American Dietetic Association: promoting and supporting breast feeding. J Am Diet Assoc. 2009;109:1926. Jost T, et al. New insights in gut microbiota establishment in healthy breast fed neonates. PLoS One. 2012;7(8):e44595. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012 Aug 15;8:CD003517. Labbok MH. Global baby-friendly hospital initiative monitoring data: update and discussion. Breastfeed Med. 2012;7:210. Morales E, et al. Effects of prolonged breastfeeding and colostrum fatty acids on allergic manifestations and infections in infancy. Clin Exp Allergy. 2012; 42:918–928. Morse NL. Benefits of docosahexaenoic acid, folic acid, vitamin D and iodine on foetal and infant brain development and function following maternal supplementation during pregnancy and lactation. Nutrients. 2012;4:799. Nauta AJ, et al. Relevance of pre- and postnatal nutrition to development and interplay between the microbiota and metabolic and immune systems. Am J Clin Nutr. 2013;98:586S. Odom EC, et al. Reasons for earlier than desired cessation of breastfeeding. Pediatrics. 2013;131:e726. Perrine CG, et al. Baby-Friendly hospital practices and meeting exclusive breastfeeding intention. Pediatrics. 2012;130:54. Pettifor JM. Nutritional rickets: pathogenesis and prevention. Pediatr Endocrinol Rev. 2013;10:347S. Ribeiro CC, et al. Knowledge and practice of physicians and nutritionists regarding the prevention of food allergy. Clin Nutr. 2013;32:624–629. Sanz Y. Gut microbiota and probiotics in maternal and infant health. Am J Clin Nutr. 2011;94:2000S. Schaffir J, Czapla C. Survey of lactation instructors on folk traditions in breastfeeding. Breastfeed Med. 2012;7:230. Slater M, et al. Breastfeeding in HIV-positive women: what can be recommended? Paediatr Drugs. 2010;12:1. Thum C, et al. Can nutritional modulation of maternal intestinal microbiota influence the development of the infant gastrointestinal tract? J Nutr. 2012;142:1921. UNICEF. Ten Steps to Successful Breastfeeding. Available at: http://www.unicef .org/newsline/tenstps.htm. Accessed June 14, 2014. Witt AM, et al. Integrating routine lactation consultant support into a pediatric practice. Breastfeed Med. 2012;7:38. Wojcik KY, et al. Macronutrient analysis of a nationwide sample of donor breast milk. J Am Diet Assoc. 2009;109:137.

INFANCY, CHILDHOOD, AND ADOLESCENCE

INFANT (0 TO 6 MONTHS) NUTRITIONAL ACUITY RANKING: LEVEL 1

DEFINITIONS AND BACKGROUND Normal gestation is 40 weeks. The average birth weight of an infant ranges between 5.5 and 10 lb; the average is approximately 7 to 7.5 lb. Healthy, full-term infants lose some weight in the first days after birth but tend to regain it within the first week. Infants often double their birth weight by 4 to 6 months and triple it within 1year. For assessment of an infant, monitoring growth is the best way to evaluate intake sufficiency. Head circumference increases about 40% during the first year, and brain weight should almost double.

Escott-Stump_Ch01.indd 19

In early life, the composition of microbiota profoundly influences the development and maturation of the GI tract mucosa, affecting health in later life (Thum et al, 2012). Transmission of bacteria from the mother to the neonate through direct contact with maternal microbiota during birth and through breast milk seems to influence the infant’s gut colonization (Sanz, 2011). Colonization of the fetus with the maternal GI tract microbiota may actually start in utero (Thum et al, 2012). Thus, the ideal scenario would be a vaginal delivery with breastfeeding for 6 to 12 months to support the healthiest immunity. Breastfeeding takes longer than cup or bottle feeding but has more benefits and is the preferred method (Academy of

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Nutrition and Dietetics, 2009). When breastfeeding is not possible or not desired, formula feeding is used. For formula feedings in infants with oral or developmental problems, administration times, amounts ingested, and physiologic stability of infants are similar when newborn infants are fed using a bottle or a cup. Infants are composed of approximately 75% to 80% water, whereas adults are composed of 60% to 65% water. Infants may become dehydrated easily, especially in hot weather or after bouts of diarrhea. When infants are ill, special techniques (doubly labeled water studies or test weighing) may be used to determine intakes of breast milk. Section 3: Pediatrics describes conditions where alternative feeding methods may be needed. Mineral status should be carefully assessed. Infants are born with a 4- to 6-month supply of iron if maternal stores were adequate during gestation. Anemia from severe iron deficiency (ID) is the most prevalent and widespread nutrition-related health problem in infants and young children in low-income countries. Correcting ID anemia may prevent developmental and behavioral delays. Calcium is important during infancy to set the stage for healthy bones. Zinc and copper may be nutrients that are insufficient, especially in low-income populations. Infants of vegan mothers may require calcium, zinc, and vitamin B12 supplementation (Academy of Nutrition and Dietetics, 2013). Low vitamin D in breast milk leads to growth failure, lethargy, irritability, and rickets. Excesses of vitamin D should also be avoided. Early feeding behaviors are important, especially for the prevention of childhood obesity. Age-inappropriate complementary feeding increases energy intakes and infant weight; these behaviors shape infant appetite, food preferences, and metabolism (Thompson and Bentley, 2013).

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • • • • • • • • • • • •

Birth weight Birth length Present weight for gestational age Height-weight percentile Head circumference Breast milk or formula intake Weight gain patterns Appetite changes Numbers of wet diapers in 24 hours Numbers of dirty diapers in 24 hours BP Pink, firm gums Use of vitamins, herbs, supplements Early introduction of other foods Disordered eating patterns? Intake of inappropriate foods

Lab Work • • • •

H&H, serum ferritin Glucose Cholesterol Other labs as indicated by medical exam or family history

Escott-Stump_Ch01.indd 20

INTERVENTION

Objectives • Promote normal growth and development: Assess sleeping, eating, and attentiveness habits. Compare infant’s growth to the chart of normal growth patterns. Weight for length (height) is the most meaningful measurement. Use updated Centers for Disease Control and Prevention (CDC) growth charts and monitor growth trends, not a singular value. Chronic malnutrition results in decreased weight, then height, and then head circumference. • Overcome any nutritional risk factors or complications, such as otitis media or dehydration. • If the infant is breastfed, assess the mother’s prepregnancy nutritional status and risk factors, weight gain pattern, food allergies, and medical history (e.g., preeclampsia, chronic illnesses, or anemia). Discuss any current conditions that may affect lactation (e.g., smoking, use of alcohol). If the infant is formula-fed, advise the mother about concerns such as early childhood caries prevention and overfeeding. • Promote growth and development through adequate fatty acid intake, especially for visual acuity. • Effects of soy formulas on the thyroid must be monitored in infants with hypothyroidism. Iodine has been added to most infant formulas; check labels. Iodized salt has been found to be beneficial for infants, especially in developing countries.

Food and Nutrition • Follow the American Academy of Pediatrics (2009) guidelines for feeding infants: 1. Breastfeed exclusively for the first 6 months. Feeding of iron-fortified commercial infant formula may be done for the first year as an alternative to breastfeeding. 2. Supplement with vitamin D from birth and use iron supplementation as ferrous sulfate drops or iron-fortified cereal after 4 months of age. Ensure that the daily requirements are being met for all nutrients for each stage of growth. When in doubt, a liquid multivitamin–mineral supplement may be used. 3. Delay the introduction of semisolid foods until 4 to 6months of age or until the infant demonstrates signs of developmental readiness, such as head control and ability to sit with support. 4. Fluoride supplementation may be required after 6 months of age, depending on the fluoride content of the city water. Fluoride supplements are needed only if the water supply provides less than 0.3 ppm, or if bottled water is used to prepare formula. 5. Delay the use of whole cow milk until after 1 year of age. Early introduction of whole cow’s milk protein during infancy may contribute to ID anemia by increasing GI blood loss. Whole cow’s milk has an increased renal solute load compared to infant formulas. 6. Reduced-fat milks should be delayed until after the second year of life. Adequate fat intake is important for the developing brain, and milk is usually the primary source of fat for infants and toddlers.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

• Fluid requirements are: 60 to 80 mL/kg water in newborns; 80 to 100 mL/kg by 3 days of age; 125 to 150 mL/kg up to 6months of age. Assess individual needs during illness. • Energy needs are estimated to decrease between birth and 6months; this can be met in about 28 to 32 oz of human milk or infant formula. • Protein requirement is generally 1.52 g/kg, or about 9.1 g/d. Sick infants may need a higher ratio. Use the nutrient recommendation chart provided in Table 1-10. • Breastfed infants: Discourage the mother from using drugs and alcohol; limit caffeine intake to the equivalent of 2cups of coffee per day. Breast milk yields approximately 20kcal/ oz. These infants will need vitamin D (Casey et al, 2010), fluoride, and iron supplements (at about 3months of age). Teach parents about use of diluted fruit juice (perhaps apple) at 4months of age. • Formula-fed infants: Select formula such as milk-based or soy. Discourage use of evaporated milk formula, which is low in vitamin C but high in protein, sodium, and potassium. Review significant ingredients and volume needed for 24 hours. Standard formulas have a 60:40 whey to casein ratio and they provide 20 kcal/oz; examples include Enfamil, Similac, Gerber Formula, or Good Start. Avoid sweetened beverages or calorie-containing formula between meals or at bedtime. Warm bottles carefully; folic acid and vitamin C may be destroyed by heat. Soy formulas are available for cow’s milk allergies; they are fortified with zinc, iron, and carnitine. Nutramigen may also be used for allergies to both soy and cow’s milk protein. Nutramigen, Alimentum, or Pregestimil are used for complex GI problems. Alimentum and Pregestimil contain medium-chain triglycerides (MCTs) for malabsorption. • Enteral or parenteral needs: For tube-feeding, standard formula should contain 10% to 20% protein, 30% to 40% fat, and 40% to 60% carbohydrates. An elemental diet may be needed for severe protein intolerance or cow’s milk allergy. Monitor carefully for hydration; do not modify nutrients because of altered osmolality. Breast milk has an osmolality of 285 mOsm/kg; formulas vary from 150 to

TABLE 1-10 Recommendations for Infants Ages 0 to 6Months

380 mOsm/kg. Formulas over 400 mOsm/kg may cause diarrhea or vomiting. Total parenteral nutrition (TPN) may be used when the infant cannot tolerate oral or tube feedings. Include 1% to 2% EFAs (linoleic and linolenic acids) to prevent inadequate wound healing, growth, immunocompetence, and platelet formation. Minimal enteral feeding protects against necrotizing enterocolitis and should be started early when using TPN. • Introduction of solids (complementary foods): At 4 to 6months, introduce plain (not mixed, sweetened, or spiced) strained or pureed baby cereals, then nonallergenic vegetables (such as carrots or green beans), and then fruits. Start with 1 to 2teaspoons and progress as appetite indicates. Try a single new item for 7 to 10 days to detect any food allergy. Intake of solids should not decrease breast milk or formula intake to less than 32 oz per day. Limit juice to 4 to 6 oz daily.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Drugs and medications used for infants should be prescribed only by a physician. • Infants with hypothyroidism should receive their thyroid hormone by crushing a single tablet daily of the correct dose and suspending it in one teaspoon of liquid and administering it properly. Infants requiring thyroid hormone therapy should NOT be treated with purchased liquid suspensions. Herbs, Botanicals, and Supplements • Infants may be highly susceptible to some of the adverse effects and toxicity of herbs and botanical products because of their physiology, immature metabolic enzyme systems, and differing doses for a lower body weight. • Most topical preparations are benign; however, garlic poultices can cause burns. • Internal use of herbs containing saturated pyrrolizidine alkaloids (comfrey) should be avoided. • Discuss the relevance of tolerable ULs from the latest dietary reference intakes of the National Academy of Sciences. These levels were set to protect adults from receiving too much of any nutrient from diet and dietary supplements; infants are especially at risk for toxicities.

NUTRIENT

AMOUNT

Nutrition Education, Counseling, Care Management

Energy

570 kcal/d males; 520 kcal/d females

Protein

9.1 g/d or 1.52 g/kg/d

Calcium

210 mg/d

Iron

0.27 mg/d

Folate

65 mg/d

Phosphorus

100 mg/d

Vitamin A

400 g

Vitamin C

40 mg

Thiamin

0.2 mg/d

Riboflavin

0.3 mg/d

Niacin

2 mg/d

• Explain the proper timing and sequence of feeding. Discuss successful feeding as trusting and responding to cues from the infant about timing, pace, and eating capacity. • Explain growth patterns (e.g., an infant who is 4 to 6 months of age should double his or her birth weight). Discuss problems related to inadequate growth. • Support adequate bonding between mother and child. • Explain the proper care of infant’s teeth, including risks of early childhood caries. Ad lib nocturnal feeding should be discontinued after the first teeth erupt. Bottle-fed infants should not be put to sleep with the bottle. • Explain the proper timing and sequence of solid food introduction. Avoid use of stringy foods or foods such as peanut butter that are hard to swallow. Hard candies, grapes, and similar foods may increase the risk of aspiration. • Discuss the rationale for delaying introduction of cow’s milk (risk for GI bleeding).

Escott-Stump_Ch01.indd 21

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

• Discuss why fluid intake is essential. Explain that infant needs are much greater (as a percentage of total body weight) than for adults. • Breastfed infants usually have four to six soft stools each day. After the first month, they will tend to have fewer bowel movements; by 2 months, they are even more infrequent. However, a doctor should be consulted if the baby has not had a bowel movement in 3 days, or whenever diarrhea occurs. • For resolution of special feeding problems, see Table 1-11. Patient Education—Food Safety • Safe infant feeding involves the production of microbiologically clean infant formula by industry, and education and support of the caregivers in preparing and handling powdered infant formula (PIF) (Turck, 2012). • Hand washing with soap and hot water is recommended before breastfeeding or before formula preparation. Use clean TABLE 1-11 Special Problems in Infant Feedinga ALLERGY

•

• •

Avoidance of food allergens in infancy has provided no clear evidence in allergy prevention and is no longer recommended; focus is on tolerance induction (West et al, 2010).

utensils and containers for mixing formula. Wash the top of cans before opening. Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. Well water should not be used since it may contain bacteria. Three main interventions for preparation and handling of PIF: (1) Dilute the powdered milk in water at a temperature of at least 70°C to inactivate Cronobacter spp.; (2) provide milk right after each preparation; and (3) store reconstituted milk at 5°C (Turck, 2012). In home settings, PIF should be prepared fresh for each meal and be kept warm in bottle warmers or thermos bottles. Discard leftover formula that has been left at room temperature; do not reuse. Decrease potential exposure to botulism; avoid use of honey. Avoid using raw or partially cooked eggs, raw or undercooked fish or shellfish, and raw or undercooked meats because of potential food poisoning. Avoid using raw (unpasteurized) milk or products made fromit. Avoid using unpasteurized juices and raw sprouts.

SAMPLE NUTRITION CARE PROCESS STEPS

COLIC Check for hunger, food allergy, incorrect formula temperature, stress, or other underlying problems. Give small, frequent feedings and parental encouragement. Colic is equally common in breastfed or formula-fed infants. If breastfed, continue to breastfeed. Rarely, removal of cow’s milk products from the mother’s diet is useful. If formula fed, discontinue expensive elemental formulas if symptoms do not improve. Curved bottles allow infants to be fed while they are held upright. Collapsable bags decrease swallowing of air. Infants should be burped regularly during feedings.

Inadequate Iron Intake Assessment Data: Food records; lab reports for H&H, serum ferritin. Nutrition Diagnoses (PES): Inadequate mineral intake related to intake of insufficient amounts of iron-fortified formula as evidenced by mother’s report of diluting formula with cow’s milk for infant at 3 months of age to save money.

CONSTIPATION The doctor will make a careful assessment and may suggest adding 1 teaspoon of a carbohydrate source to 4 oz of water or formula, one to two times daily. Avoid use of honey and corn syrup to prevent infant botulism.

Intervention: Education about appropriate preparation and use of formula for infants. Referral to WIC program if eligible.

DIARRHEA

Monitoring and Evaluation:Lab reports for H&H, serum ferritin; dietary history indicating proper use of ironfortified formula.

Replace fluids and electrolytes (e.g., Pedialyte) as directed by the doctor. After an extended period of time, have the doctor rule out allergy. Monitor weight loss and fluid intake carefully. REGURGITATION Position the infant in an upright, 40°–60° position after feeding for approximately 30minutes; have the doctor rule out other problems. Use smaller, more frequent feedings to avoid overfeeding. Use prethickened formulas if the doctor thinks it is necessary.

For More Information See the video “Developmental Considerations in Caring for Children: Infants” at www.thepoint.lww.com/escottstump8e.

PALE, OILY STOOLS Check for fat malabsorption. Use a formula containing medium-chain triglycerides if necessary. SPITTING UP OR REFLUX If there is no weight loss concern, just offer encouragement that the problem will resolve in a few months. Positioning is an important consideration during feeding. Feed more slowly and burp often. Use feeding volumes and a schedule that is set. Avoid exposure to secondhand smoke. Offer parental reassurance. a

See also Academy of Nutrition and Dietetics. Pediatric manual of clinical dietetics and Children with special health care needs: Nutrition Care handbook; Family Doctor. Available at: http:// familydoctor.org/familydoctor/en/health-tools/search-by-symptom/feeding-problems-infants -children.html. Accessed June 15, 2014; Feeding Underweight Children. Available at: http:// www.feeding-underweight-children.com/infantfeedingproblems.html. Accessed June 15, 2014; Merck Manual. Children’s Health Issues. Available at: http://www.merckmanuals.com/home /childrens_health_issues/problems_in_infants_and_very_young_children/feeding_problems_in _infants_and_young_children.html. Accessed June 15, 2014.

Escott-Stump_Ch01.indd 22

●

Abbott Laboratories (products for infants) http://abbottnutrition.com/

●

American Academy of Pediatrics http://www.aap.org/

●

Centers for Disease Control and Prevention—Infants and Toddlers http://www.cdc.gov/LifeStages/infants_toddlers.html

●

Complementary Foods http://wicworks.nal.usda.gov/infants/complementary-foods

●

Gerber and Nestle—Start Healthy, Stay Healthy http://www.gerber.com/public/default.aspx

●

Growth Charts http://www.cdc.gov/growthcharts/

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

●

Heinz Baby Foods http://www.heinzbaby.com/

REFERENCES

●

Kids Health http://www.kidshealth.org/

●

National Center for Maternal and Child Health http://www.ncemch.org/

●

National Perinatal Association http://www.nationalperinatal.org/

●

Pediatric Nutrition Practice Group http://www.pnpg.org/

●

Sudden Infant Death Syndrome http://www.sidscenter.org/

●

USDA/ARS Children’s Nutrition Research Center http://www.bcm.tmc.edu/cnrc/

●

WIC Topics A-Z http://wicworks.nal.usda.gov/topics-z

Academy of Nutrition and Dietetics. Feeding Vegetarian and Vegan Infants and Toddlers. Available at: http://www.eatright.org/public/content.aspx?id=8060. Accessed July 31, 2014. Academy of Nutrition and Dietetics. Position of the American Dietetic Association: Promoting and Supporting Breastfeeding. J Am Diet Assoc. 2009;109:1926. American Academy of Pediatrics. Pediatric nutrition handbook. 6th ed. Chicago, IL: AAP Committee on Nutrition, 2009. Casey CF, et al. Vitamin D supplementation in infants, children, and adolescents. Am Fam Phys. 2010;81:745. Sanz Y. Gut microbiota and probiotics in maternal and infant health. Am J Clin Nutr. 2011;94:2000S. Thompson AL, Bentley ME.The critical period of infant feeding for the development of early disparities in obesity. Soc Sci Med. 2013;97:288–296. Thum C, et al. Can nutritional modulation of maternal intestinal microbiota influence the development of the infant gastrointestinal tract? J Nutr. 2012;142:1921. Turck D. Safety aspects in preparation and handling of infant food. Ann Nutr Metab. 2012;60:211.

INFANT (6 TO 12 MONTHS) NUTRITIONAL ACUITY RANKING: LEVEL 1–2 DEFINITIONS AND BACKGROUND Infants older than 6 months of age are beginning the developmental stages that will lead to walking and talking. Many of the same principles associated with infant feeding during the first 6months will continue, with addition of more solids. Growth patterns of breastfed and formula-fed infants differ in the first 12 months of life. The most recent CDC growth charts were developed with a larger proportion of breastfed infants. Without awareness, it is easy to overfeed older infants, establishing patterns that could lead to obesity (Thompson and Bentley, 2013). Timing of the introduction of complementary foods (solids) is an important consideration. Early introduction is considered to be at 3 to 4 months of age, and late introduction is considered to be at 6 months of age. Unfortunately, many foods that are introduced are of low nutritional value, including sweetened beverages, cookies, processed meats, cakes, and pies. High stunting rates are common in toddlers from underdeveloped countries. Meat consumption reduces stunting; interventions to improve complementary feeding practices are important (Krebs et al, 2011). Introduction of cow’s milk at 12 months of age brings new problems and risks related to EFA deficiency if low-fat or skim milks are used. Long-chain fatty acids are useful in normal growth and development of infants and young children. It is not necessary to alter the diets of infants to prevent heart disease or to lower cholesterol. Breastfed and formula-fed infants maintain a characteristic serum cholesterol ester fatty acid pattern for months even after they begin to receive solid food. Growth and development at this stage are affected by underlying or acute illnesses, nutritional intake, and related factors. Breastfed infants have a strong prevalence of bifidobacteria and lactobacilli, which stimulate formation of oligosaccharides with a protective prebiotic effect. Infants who are breastfed for 4 months or longer also have stronger lung function (Ogbuanu et al, 2009) and tend to have healthier diets later in childhood (Grieger et al, 2011).

Escott-Stump_Ch01.indd 23

Sodium and chloride intakes may be higher than desirable in infants and toddlers. Delaying the introduction of cow’s milk, limiting the amount of salt used in food processing and preparation, and increasing intake of fruits and vegetables are reasonable measures. Overall, interventions for improving the diets of young children should focus on breastfeeding and the whole continuum of diet. Lead depletes iron and replaces calcium in the bone; deposition may be seen in x-rays of the knee, ankle, or wrist. Children who live in older homes or spend time in older buildings or day care centers may eat lead-based paint that is chipping away from walls. Lead poisoning may result. Dietary habits are formed early in the life. Home fortification of foods with multiple micronutrient powders is an effective intervention to reduce anemia and iron deficiency in young children (De-Requil et al, 2012). Early growth faltering is difficult to reverse after the first 2 years of life (Krebs et al, 2011). Effective nutrition messages for parents and caregivers are needed about complementary foods and ways to enhance nutrient density of meals and snacks.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Each individual has a unique genetic profile and phenotype. Because both parents contribute genes and chromosomes to the fetus, a genetic history may be beneficial.

Clinical/History • • • •

Length Current weight Birth length/weight Percentile weight/length

11/7/14 8:14 PM

24 • • • • • • • • • • •

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Diet/intake history Age in months Head circumference Developmental stage Tooth development Physical handicaps Appetite Hydration status Intake and output (I&O) Persistent vomiting Diarrhea

•

• •

•

Lab Work • • • •

Glucose Cholesterol H&H, serum ferritin Serum lead levels

INTERVENTION

•

Objectives • Continue to promote normal growth and development during this second stage of very rapid growth. Use updated CDC growth charts. Monitor trends in growth, not a singular value. • Prevent significant weight losses from illness or inadequate feeding. Malnutrition results in decreased weight, then height, and then head circumference. • Avoid dehydration. • Prevent or correct such complications as diarrhea, constipation, and otitis media. • Begin to encourage greater physical activity; prepare for walking by ensuring adequate energy intake. • Continue to emphasize the role of good nutrition in the development of healthy teeth. • Delay food allergens until 12 months of age (e.g., citrus, egg white, cow’s milk, corn, peanut and nut butters). • Use of follow-up formulas with higher percentage of kilocalories from protein and carbohydrates (CHO) and less from fat have questionable benefits at this time. • Prevent nutrient deficiencies upon weaning (e.g., zinc, iron). Iron supplementation, even during breastfeeding, may be beneficial. • Support feeding skills and introduce solids, at appropriate periods of time, singly.

•

• •

•

Food and Nutrition • Continue to provide breast milk or iron-fortified formula. The presence of DHA and arachidonic acid (ARA) in human milk, along with reports of higher IQ in individuals who were breastfed versus formula fed as infants, suggest that exogenous DHA and ARA are essential for optimal development. Intakes of EFAs may require emphasis once breast milk or formula is replaced with cow’s milk. • After 6 months, breastfed infants need complementary foods to meet DRIs for energy and most micronutrients. Amounts needed from complementary foods will vary depending upon the intake of human milk or formula. • All infants need complementary foods for exposure to a variety of flavors and textures as well as to acquire self-feeding

Escott-Stump_Ch01.indd 24

•

• •

•

skills. Repeated exposure to a particular food is suggested; adozen exposures may be necessary. The Feeding Infants and Toddlers Study (FITS) indicate a longer duration of breastfeeding; however, 17% of infants receive cow’s milk before the recommended age of 1 year (Siega-Riz et al, 2011). Special milk substitutes are not necessary unless there is an allergy to soy protein or cow’s milk. Meats and fortified cereals contribute significant amounts of iron. Yet, declining use of infant cereal after 8 months may contribute to iron deficiencies (Siega-Riz et al, 2011). Rickets due to vitamin D deficiency has been observed in dark-skinned, breastfed infants and other infants without adequate sun exposure; 200 IU of vitamin D3 is recommended for breastfed infants and infants receiving less than 500 mL of formula per day. Children often eat three small meals and two to three appropriate, healthy snacks throughout the day. Portions should provide essential nutrients but not exceed energy requirements. Occasional picky eating is normal. However, consuming a single food or foods for extended periods of time (food jag) may require monitoring of growth more frequently if it persists for a long time. For energy, the current DRI recommends about 743 kcal/d for males and 676 kcal/d for females. Monitor using CDC growth charts and identify growth problems early. Fluid requirements are approximately 125 to 150 mL/kg up to 1 year of age; needs decline slightly during this stage. Protein requirement for a 6-month-old infant is generally 1.5 g/kg and changes as the infant grows; this equals about 13.5 g/d. By 12 months, the need is only 1.1 g/kg. Table 1-12 provides additional information on feeding infants and toddlers. Table 1-13 provides nutrient recommendations. Avoid raw vegetables and fruits (other than ripe banana or soft, peeled apple). Beware of foods that may cause choking (e.g., hot dogs, popcorn, nuts, grapes, seeds) because toddlers do not have molars. As tolerated, introduce coarsely ground table foods by 10 to 12 months of age. Introduce cow’s milk at 12 months of age, ensuring that intake does not go above 1 quart daily to prevent anemia. Use whole milk to include sufficient fatty acids. Begin to offer fluids by cup at approximately 9 to 12 months of age; weaning often occurs by about 1 year of age. Avoid sugar-sweetened beverages at this age whenever possible. Taste buds are very acute at this stage. Spicy foods often are not liked or not tolerated. This is also affected by culture and the seasoning of foods that are introduced. Continue use of iron-fortified baby cereal after 12 months of age to ensure adequate intake. Approximately 10 mg of iron is required. WIC-approved cereals are iron fortified. Adult cereals are generally inappropriate for infants and children younger than 4 years of age. Discourage use of low-density, high-energy foods such as carbonated beverages, French fries, candy, and other sweets. Generally, healthy infants and toddlers can achieve recommended levels of intake from food alone; use foods rather than supplements. When indicated, vitamin–mineral supplements can help infants and toddlers with special nutrient needs or marginal intakes. However, avoid excessive intakes of vitamin A,

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-12 Feeding Babies in the First Year of Life AGE

FOODS TO ADD

HOW MUCH TO FEED

Birth to 4 months

Breast milk or iron-fortified infant formula

Feed on demand as long as baby chooses

4–6 months

Baby cereal—rice first, and then oatmeal or barley

1–2 tablespoons

6–8 months

Vegetables—cooked, strained, pureed, or mashed

2–3 tablespoons

Fruits—strained or mashed

2–3 tablespoons

Fruit juice—using a small cup

3 oz

Meats—cooked and strained or chopped

1–2 tablespoons

Dry beans—cooked and mashed

1–2 tablespoons

Cooked, mashed egg yolks

Allow baby to decide how much to eat.

Fruits—soft and peeled, in small pieces

Do not encourage baby to eat more than he wants

8–10 months

Cottage cheese Yogurt Crackers or bread Vegetables—cooked and in small pieces 10–12 months

Allow baby to eat the same foods as the family

Allow baby to decide how much to eat

Foods should be in small pieces and cooked or soft

Do not encourage baby to eat more than he wants

ADDITIONAL FACTORS • The infant’s developmental readiness, age, appetite, and growth rate are factors that help determine when to feed solid foods. • Before feeding solid foods, the baby should be able to swallow and digest solid foods, sit with support and have neck and head control, and close their lips over a spoon. Semisolid foods and juices are a significant change and should not be started until 4–6 months. • Introduce single-ingredient foods one at a time; wait 5–7 days before introducing a new food. This process helps identify any food sensitivities the child might have. Offer new food when baby is in a good mood, not too tired, and not too hungry. Serve solids after the baby has had a little breast milk or formula. Hold the baby on the lap or use an infant seat or feeding chair if the baby can sit. Use a baby spoon and place a small amount (about 1/2 teaspoon) of food on the baby’s tongue. Give the baby time to learn to swallow these foods and get used to the new tastes. • The sequence of new foods is not critical, but rice cereal mixed with breast milk or formula is a good first choice. Add vegetables, fruits, and meats to the infant’s diet one at a time. Serving mixed foods is not recommended in the beginning. • Introduce juices when the baby can drink from a cup, around 6–9 months. Dilute adult juices half and half with water or strain them before giving to a baby. Avoid sweet drinks; they can promote tooth decay. In addition, avoid sweetened foods because they also can promote tooth decay and may cause a preference for sweets. Do not offer fruit desserts that contain unnecessary sugar. • Food can be homemade or commercially prepared. Choose plain, strained fruit such as applesauce, peaches, or mashed ripe bananas. Boil fruits until tender; cool; blend until there are no lumps. If it is too thick, add breast milk, baby formula, or a little water. Use the same process for vegetables. • Feed the baby when he or she is hungry but do not overfeed. Make meal time a happy time. Never force a child to finish bottles or food; watch for cues that he or she is full. • Delay introduction of the major food allergens, such as eggs, milk, wheat, soy, peanuts, tree nuts, fish, and shellfish, until well after the first year of life. Foods that are associated with lifelong sensitization (e.g., peanuts, tree nuts, and shellfish) should not be introduced until even later years. • Combination foods (instead of single-ingredient foods) may be given to older infants after tolerance for the individual components has been established. • Hungry toddlers may point at foods or beverages, ask for foods or beverages, or reach for foods. Full toddlers may slow the pace of eating, become distracted or notice surroundings more, play with food, throw food, want to leave the table or chair, and/or not eat everything on the plate. To help avoid underfeeding or overfeeding, parents and caregivers must be sensitive to the hunger and satiety cues of the healthy infant and young child. • Avoid raw carrots, nuts, seeds, raisins, grapes, popcorn, and pieces of hot dogs during baby’s first year as they may cause choking. • Age-appropriate, daily physical activity in a safe, nurturing environment may help promote physical development and movement skills and teach the healthy habit of activity. Encourage parents and caregivers to promote enjoyment of movement and motor skill confidence at an early age. Fundamental motor skills (e.g., walking, running, jumping) begin to develop. When activity is encouraged, these skills can further develop into advanced patterns of motor coordination. • Television viewing should be discouraged for children under 2 years of age. For more information, see Start Healthy Feeding Guidelines for Infants and Toddlers. Website accessed July 31, 2014 at http://medical.gerber.com/nutrition-health-topics/infant-early-childhood-nutrition/articles/the-start-healthy-feeding-guidelines-for-infants-and-toddlers. Adapted from: Feeding Your Baby in the First Year. Available at: http://wicworks.nal.usda.gov/wicworks/Topics/infantfeedingtipsheet.pdf. Accessed June 15, 2014.

zinc, and folate, which are commonly fortified in the food supply. • If the infant needs a tube feeding (e.g., for poor weight gain, low volitional intake, failure to thrive, slow and prolonged feeding, oral or motor problems), use a standard isotonic formula with 30 kcal/oz and intact proteins. If necessary, lactose-free and gluten-free formulas are available. Added fiber and a mix of long- and medium-chain fatty acids may be useful. Osmolality of 260 to 650 mOsm/kg is common; monitor tolerance and use

Escott-Stump_Ch01.indd 25

sufficient water. The infant may tolerate bolus feedings in the day and continuous feedings at night.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-13 Recommendation for Infants Ages 6 Months to 1 Year NUTRIENT

RECOMMENDATION

Energy

743 kcal/d males; 676 kcal/d females

Protein

13.5 g/d

Calcium

270 mg/d

Iron

11 mg/d

Folate

80 mg/d

Phosphorus

275 mg/d

Vitamin A

500 g

Vitamin C

50 mg/d

Thiamin

0.3 mg/d

Riboflavin

0.4 mg/d

Niacin

4 mg/d

•

and suspending it in 1 teaspoon of liquid and administering it properly.

•

Herbs, Botanicals, and Supplements • Infants and children may be even more susceptible to some of the adverse effects and toxicity of these products because of differences in physiology, immature metabolic enzyme systems, and dose per body weight. • Herbs and botanical supplements should not be used without discussing with the physician. In general, these types of supplements have not been proven to be safe for infants. • Discuss the relevance of tolerable ULs from the latest dietary reference intakes of the National Academy of Sciences. These levels were set to protect adults from receiving too much of any nutrient from diet and dietary supplements; infants are even more at risk for toxicities.

•

Nutrition Education, Counseling, Care Management • Early childhood is a critical time for development of appropriate food choices and eating habits. Discuss healthy guidelines that are available. Offer suggestions, such as using the MyPlate tools for planning menus. • Discuss adequate weight pattern: Infants generally double or triple birth weight by 12 months of age; body length increases by about 55%; head circumference increases by about 40%; and brain weight doubles. • For lunches or snacks at home, offer suggestions about appropriate and easy to serve foods. • For teething, bread crust is better than a biscuit, which contains sugar and may crumble and cause choking. • Parent–child feeding interactions during the first 2 years of life shape child appetite and obesity risk; the Responsiveness to Child Feeding Cues Scale (RCFCS) is a reliable tool for working with caregivers of children 2 years of age (Hodges et al, 2013). Special counsel may be needed for mothers who are single, those with children in day care, or those with limited literacy. • Assure parents and caregivers that infants and toddlers have an innate ability to regulate energy intake. However, environmental cues may diminish natural hunger-driven eating behaviors. Overfeeding may result if children are not

Escott-Stump_Ch01.indd 26

•

• •

•

taught to recognize their natural cues about hunger and satiety. Breastfeeding for 1 year and low sugar-sweetened beverage (SSB) intake during the toddler years can have profound effects on reducing the prevalence of obesity in toddlers (Davis et al, 2012). Encourage milk as the preferred beverage at home, restaurants, or friends’ homes. Discuss iron intake, fluid intake, and other nutritional factors related to normal growth and development, including calcium for bone health. Plan toddler snacks with fruits, vegetables, and whole grains that are culturally appropriate rather than fruit drinks, cookies, and crackers. Prompting a child to eat and using positive rewards or bargains during a mealtime interaction may decrease rejection of new foods (Blissett et al, 2012). Showing a visual picture of the foods may also encourage tasting it. Homemade baby food is easy. Use 1 cup diced or chopped, cooked food and 2 to 4 tablespoons of liquid (water, milk, unsweetened juice). More liquid may be needed for meats, poultry, or fish items. Blend for a pureed consistency. For mashed consistency, use a fork or potato masher. Moisten foods as needed. Discuss the role of fat-soluble vitamins, their presence in whole milk, and the role of EFAs in normal growth and development of the nervous system. Bottled waters are not a substitute for formula as hyponatremia may result. Fluoridated water is recommended; check the community status. Fluoride supplements are not needed when the water supply is fluoridated and the infant receives adequate water from this source. Well water and most bottled waters are not fluoridated; when used, the doctor may recommend a supplement. When brushing toddler teeth, use a very small amount of fluoridated toothpaste. If planning a vegan diet, breast milk should be the sole food, with soy-based formula as an alternative. Breastfed vegan infants may need supplements of vitamin B12, zinc, and vitamin D. Protein sources for older vegan infants may include tofu and dried beans. Intensive nutrition education can help mothers provide more effective feeding practices. This is especially important in developing countries where inappropriate feeding, poor hygiene, and poor health often lead infants to a malnourished state. Support maternal–infant bonding.

Patient Education—Food Safety • Hand washing with soap and hot water is recommended before breastfeeding or before formula preparation. Use clean utensils and containers for mixing formula. Wash the top of the can before opening. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Well water should not be used since it may contain bacteria. • Follow the 2-hour rule: discard any formula, beverage, or food that has been left at room temperature for 2 hours or longer. Do not reuse. • Do not use honey in the diets of infants; this decreases potential exposure to botulism. • Avoid using raw or partially cooked eggs, raw or undercooked fish or shellfish, and raw or undercooked meats because of potential food poisoning.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

• Do not use raw (unpasteurized) milk or products made fromit. • Avoid using unpasteurized juices and raw sprouts. • For hospital preparation of infant formula, use available guidelines.

●

Complementary Foods http://wicworks.nal.usda.gov/infants/complementary-foods

●

Feeding Your Baby 6-12 months http://www.health.gov.nl.ca/health/publications/feedingyourbaby6 _12months.pdf

●

Growth Charts http://www.cdc.gov/growthcharts/

SAMPLE NUTRITION CARE PROCESS STEPS

●

Heinz Baby Foods http://www.heinzbaby.com/

Inadequate Energy Intake

●

Kids Health http://www.kidshealth.org/

Assessment Data:Food records; weight loss or failure to thrive on growth charts.

●

Medline Plus http://www.nlm.nih.gov/medlineplus/infantandtoddlernutrition.html

●

Pediatric Nutrition Practice Group http://www.pnpg.org/

●

USDA/ARS Children’s Nutrition Research Center http://www.bcm.tmc.edu/cnrc/

●

Washington State DOH http://www.doh.wa.gov/portals/1/Documents/Pubs/960-025-Circle ChartInfants6-12Months.pdf

●

WebMD http://www.webmd.com/parenting/guide/what-and-how-much-to-feed -your-toddler

Nutrition Diagnoses (PES): Inadequate energy intake related to mother’s withholding of formula and infant cereal when infant cries “excessively” as evidenced by intake diary and perceptions of colic. Intervention: Education about appropriate dietary intake for age of infant. Counseling about desired foods for a healthy growth; tips for introducing new foods to the diet and for handling an infant with colic. Monitoring and Evaluation: Weight and growth charts; successful growth for child; lab reports for H&H, serum ferritin; dietary history indicating improved variety of food choices.

For More Information

See the video “Developmental Considerations in Caring for Children: Infants” at www.thepoint.lww.com/escottstump8e.

●

Centers for Disease Control and Prevention—Infants and Toddlers http://www.cdc.gov/LifeStages/infants_toddlers.html

REFERENCES Blissett J, et al. Predicting successful introduction of novel fruit to preschool children. J Acad Nutr Diet. 2012;112:1959. Davis JN, et al. Effects of breastfeeding and low sugar-sweetened beverage intake on obesity prevalence in Hispanic toddlers. Am J Clin Nutr. 2012;95:3. De-Requil LM, et al. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age (Review). Evid Based Child Health. 2013;8:112–201. Grieger JA, et al. Dietary patterns and breast-feeding in Australian children. Public Health Nutr. 2011;14:1939. Hodges EA, et al. Development of the responsiveness to child feeding cues scale. Appetite. 2013;65:210–219. Krebs NF, et al. Meat consumption is associated with less stunting among toddlers in four diverse low-income settings. Food Nutr Bull. 2011;32:185. Ogbuanu IU, et al. Effect of breastfeeding duration on lung function at age 10years: a prospective birth cohort study. Thorax. 2009;64:62. Siega-Riz AM, et al. New findings from the Feeding Infants and Toddlers Study 2008. Nestle Nutr Workshop Ser Pediatr Program. 2011;68:83. Thompson AL, Bentley ME. The critical period of infant feeding for the development of early disparities in obesity. Soc Sci Med. 2013;97:288–296.

CHILDHOOD NUTRITIONAL ACUITY RANKING: LEVEL 1–2 DEFINITIONS AND BACKGROUND Children between the ages of 2 and 11 years need to develop appropriate eating habits so they can achieve optimal physical and cognitive development, a healthy weight, enjoyment of their meals, and reduction of the risk for chronic disease (Academy of Nutrition and Dietetics, 2013). Children are not “little adults” and should be treated individually. Conversation with an adult is usually required to discuss a child’s actual food intake. The ability to recall by children is often limited because of vocabulary and attention span. Children benefit from portion training, as with pictures, food models, and measuring cups.

Escott-Stump_Ch01.indd 27

Growth during this stage involves changes in appetite, physical activity, and frequency of illnesses. The CDC growth charts provide a guideline for monitoring successful growth related to weight, height, and age. BMI calculations are available for use with children, and calculations may be used to identify underweight, potential stunting, or obesity. Prevalence of low height for age (stunting), low weight for age (wasting), and illness is higher than desirable in the U.S. During the early years of life, eating occurs primarily as a result of hunger and satiety cues. Evidence suggests that, by the time children are 3 or 4 years of age, eating is influenced by a variety of environmental factors and parenting behaviors. Exposure to food advertising while watching TV may trigger automatic snacking (Harris et al, 2009). Intake

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Experience-dependent synapse formation

(V isu

u od pr h a) ec pe are /S s ea ca’ ar ro /B

/hearing eing Se x/sensory cor tex) orte c al

tive lang cep ua Re ge (Angular gy ru s

Prefront al

Cell migration (6–24 prenatal weeks)

-8

-7

-6

-5

-4

-3

Synaptogenesis (-3 months to 15–18 years?)

cortex

Adult levels of synapse

Myelination (-2 months to 5–10 years)

-2

-1

Birth

Neurulation

Conception

-9

tio n

Neurogenesis in the hippocampus

(18-24 prenatal days)

Hig her cog (Fro nit nta ive l co fun rte cti x) on s

Months

9 10 11 12 1

Months

9 10 11 12 13 14 15 16 17 18 19 20 30 40 50 60 70

Years

Decades

Age Fetus

Late infancy/toddler

Figure 1-8. Human brain development over the lifespan. (Adapted with permission from Georgieff MK, Innis SM. Controversial nutrients that potentially affect preterm neurodevelopment: essential fatty acids and iron. Pediatr Res. 2005;57:99R.)

of added sugars and solid fats, such as savory snacks, pizza/ calzones, mixed Mexican dishes, sweet snacks and candy, and fruit juice have increased over the past two decades (Ford et al, 2013). The preschool period (1 to 5 years of age) is a time of rapid and dramatic postnatal brain development, neural plasticity, and fundamental acquisition of cognitive development such as working memory, attention, and inhibitory control (Rosales et al, 2009; see Fig. 1-8). Variable intakes, food jags, and anemia are common. Monitor for exposure to lead, atypical development, and intake of milk, fruits, vegetables. Children from low-income households often have poor intake of milk, whole grains, fruits, and vegetables. Barriers for adherence to dietary recommendations include taste, cost, intake of preferred foods (sweets, junk food, fast food), and allergies (Nicklas et al, 2013). Intake of energy-rich, nutrient-poor foods is a big concern. Sugar-sweetened beverages (SSBs), high-fat foods, and refined carbohydrates often displace nutrient-dense foods. Heavy total SSB consumption (500 kcal/day) and intake of fruit drinks has increased among children, especially those from low-income households (Han and Powell, 2013). Because high dietary salt intake and SSB consumption are often related, salt reduction strategies may be useful for childhood obesity prevention efforts (Grimes et al, 2013). Serving a larger portion of fruits and vegetables at a meal can improve actual consumption (Mathias et al, 2012). Adding pureed vegetables to an entrée or pureed fruit to a dessert is a useful strategy. Serving age-appropriate entrée portions is another strategy (Savage et al, 2012). A low-energy-dense vegetable soup served at the beginning of a meal can decrease total energy intake from that meal (Spill et al, 2011). School-age children often have a limited ability to recall foods eaten. Children should have access to an adequate supply of healthful and safe foods that promote optimal physical, cognitive, and social growth and development (Academy of Nutrition and Dietetics, 2010). Nutritional deficits (especially

Escott-Stump_Ch01.indd 28

folate and vitamin B12) have negative consequences on the developing brain. Because even mild undernutrition affects brain growth and function, food assistance programs should be used whenever possible. Adult diseases often have a fetal or childhood onset. Childhood height, growth, diet, and BMI have been associated with breast cancer. Size at birth, rapid weight gain, and childhood growth patterns affect the onset of diabetes. Elevations in homocysteine begin in childhood, with implications for stroke. Indeed, evidence links early childhood diarrhea or growth failure with an increased risk for cardiovascular disease in later life, including dyslipidemia, hypertension, and glucose intolerance (DeBoer et al, 2012). Persistent household food insecurity is often related to later child obesity, mostly related to maternal weight status; vulnerable groups should be targeted for early interventions (Metallinos et al, 2012). Many children living in poverty are exposed to lead, with an increased risk for iron deficiency anemia. Children need nutritious snacks to eliminate transient hunger. Attention is easily diverted, and total food intake may vary from day to day. Consumption of school meals is positively related to improved intakes of fresh fruit, whole grains, and a greater variety of vegetables (Condon et al, 2009). Scheduling of lunch after physical activity generally increases intake of all served foods. Dietary fat restriction may compromise growth and should not be implemented. There is no proof of long-term safety and efficacy for restricting fat in children’s diets. Lowered intake of calcium, zinc, magnesium, phosphorus, vitamins E and B12, thiamin, niacin, and riboflavin intakes may result. Peak bone mass requires attention to vitamin D and calcium. The current recommended adequate intake for children 9 to 18 years of age is 1300 mg/d of calcium (Food and Nutrition Board, 2002). Both calcium and vitamin D are essential during growth and into puberty, especially during periods of rapid bone growth and mineralization. Increased 25-hydroxyvitamin D intake occurs but may decrease serum ferritin; 2 cups of cow’smilk

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

per day appears sufficient to maintain healthy vitamin D and iron stores for most children (Maguire et al, 2013). Infectious diseases during childhood may be related to poor nutrition, especially lack of vitamin C, zinc, and vitamin A. Children who are prone to repetitive illness may benefit from a basic multivitamin–mineral supplement in addition to a carefully planned diet. Where anemia is a concern, participation in the WIC program may be helpful.

Clinical/History • • • • • • • • • • • • •

Age Weight Height Growth percentile for age Diet/intake history Dental status Physical handicaps Appetite Intake patterns, food jags Hydration (I&O) Triceps skinfold (TSF) Midarm muscle circumference (MAMC) Midarm circumference (MAC)

Lab Work • • • • • • • •

Glucose H&H, serum Fe Chol, Trig (check family history for risks) Homocysteine ALP Ca Alb (if needed) Serum vitamin D levels

• Monitor long-term drug therapies and related side effects, such as use of anticonvulsants and the effects on folate, vitamin D, and growth. • Assess nutritional deficiencies, especially iron. If possible, detect and correct pica (eating nonfood items or any one food to the exclusion of others—even ice chips). Prevent “milk anemia” from drinking too much milk and too little iron-rich meat, grains, or vegetables. • Evaluate status of the child’s dental health. Prevent or correct dental decay. • Support adequate nutritional immunity through a balanced diet; encourage vaccinations to prevent infectious diseases such as measles, mumps, and tetanus. • Promote adequate intake of calcium, vitamins B12 and D, iron, fiber, and zinc, which are nutrients that are often poorly consumed by young children. The risks are higher among vegetarians (Craig, 2010). • Help reduce onset of chronic diseases later in life by prudent menu planning and meal intakes. Early lesions of atherosclerosis begin in childhood. Universal and comprehensive childhood dyslipidemia screening (both lifestyle and genetic factors) is recommended by the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel (Lipshultz et al, 2012). • Avoid labeling overweight children as “fat,” which may trigger eating disorders (EDs) later. All providers should be aware of the problems of childhood obesity and refer accordingly. See entry in the text about childhood obesity. • To promote proper growth, especially for stature, parents/ caregivers should limit sweetened beverage intake to 12 fl oz/d; fruit juice should be only 4 to 6 oz daily for proper dental health and to prevent diarrhea. Encourage sufficient calcium intake from dairy beverages and foods. • Emphasize food variety to reduce fear of new foods (neophobia), which may reduce nutritional status. Introduction of many new foods and flavors before age 4 is an important way to enhance acceptance of new food items. • For school-age children, schools are attempting to enhance the nutrition environment. Attention and visual memory performance in the morning are reduced when children skip breakfast (Maffeis et al, 2012). More than 25% of public elementary schools across the United States participate in the U.S. Department of Agriculture’s Fresh Fruit and Vegetable Program; participation offers healthier food availability in school meals (Ohri-Vachaspati et al, 2012). Requiring foodservice managers to hold a nutrition-related college degree and pass a foodservice training program would be a good option (Thomson et al, 2012).

INTERVENTION Food and Nutrition Objectives • Assess growth patterns, feeding skills, dietary intake, activity patterns, inherited factors, and cognitive development. Promote adequate growth and development patterns such as increased independence at 12 to 18 months (stop bottle, begin eating with a spoon) and growth slowdown from 18months to 2 years (less interest in food, begin eating with utensils); energy intake varies from 2 to 3 years (control exerted), and brain growth triples by age 6. • Avoid food deprivation, which may decrease ability to concentrate, cause growth failure or anemia, aggravate stunting, and lead to easy fatigue.

Escott-Stump_Ch01.indd 29

• Energy and nutrient requirements vary by age and sex. Table1-14 provides recommendations. • The Academy of Nutrition and Dietetics (2013) supports the following macronutrient distribution: 1. Carbohydrates—45% to 65% of total calories. Added sugars should not exceed 25% of total calories to ensure sufficient intake of essential micronutrients. 2. Fat—30% to 40% of energy for 1 to 3 years and 25% to 35% of energy for 4 to 18 years. 3. Protein—5% to 20% for young children and 10% to 30% for older children. Include protein foods with 50% high biological value when possible.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

• Table 1-15 provides suggested calorie intake by age, gender, and activity level. • Calcium is needed to increase mineral density. Yogurt, plain or flavored milks, calcium-fortified juices or soy milk, soft-serve ice cream, and cheeses are generally well accepted. If dairy foods are not used, include foods such as 1 oz of cooked dried beans (161 mg), 10 figs (169 mg), spinach (120 mg), 1packet of oatmeal (100 mg), 1 medium orange (50 mg), ½cup of mashed sweet potato (44 mg), or ½ cup of cooked broccoli (35 mg). • Phosphorus intake should be relatively similar to calcium intake. • Give 50 to 60 mL/kg of fluids daily. Milk, fruit juice, vegetable juices, and water should be the basic fluids offered. Cut out SSBs as much as possible. • Encourage exposure to sunlight and monitor dietary intake of vitamin D. Wintertime vitamin D supplementation is particularly important among children with darker skin pigmentation (Maguire et al, 2013). • Adequate folate, magnesium, selenium, and vitamin E are important to obtain from dietary sources. • Day care meals given for a 4- to 8-hour stay should provide ⅓ to ½ of daily needs. School lunch programs generally provide ⅓ of daily needs. Thus, meals at home should make up the energy and nutrient differences. • Encourage fluid and fiber intake. Intake of fruits, vegetables, grains, and legumes may help to prevent or alleviate constipation. Efforts to increase children’s dietary fiber consumption should be encouraged (Clemens et al, 2012; Kranz et al, 2012). Encourage whole fruit over fruit juice whenever possible (Crowe and Murray, 2013).

TABLE 1-14 Recommendation for Children Ages 1 to 13 AGES 9–13 YEARS

NUTRIENT

AGES 1–3 YEARS

AGES 4–8 YEARS

Energy

1046 kcal/d

1742 kcal/d

2279 kcal/d males; 2071 females

Protein

13 g/d or 1.1 g/kg

19 g/d or 0.95 g/kg

34 g/d or 0.95 g/kg

Calcium

500 mg/d

800 mg/d

1300 mg/d

Iron

7 mg/d

10 mg/d

8 mg/d

Folate

150 g/d

200 g/d

300 g/d

Phosphorus

460 mg/d

500 mg/d

1250 mg/d

Vitamin A

300 g

400 g

600 g

Vitamin C

15 mg/d

25 mg/d

45 mg/d

Thiamin

0.5 mg/d

0.6 mg/d

0.9 mg/d

Riboflavin

0.5 mg/d

0.6 mg/d

0.9 mg/d

Niacin

6 mg/d

8 mg/d

12 mg/d

Fiber

19 g

25 g

26 g females; 31gmales

Sodium

1500 mg

1900 mg

2200 mg

Potassium

3000 mg

3800 mg

4500 mg

Data adapted from: A Report of the Panel on Macronutrients, Subcommittees on Upper Reference Levels of Nutrients and Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes; Food and Nutrition Board; and Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: The National Academies Press; 2005:1357.

TABLE 1-15 Estimated Calorie Needs per Day by Age, Gender, and Physical Activity Levela Estimated amounts of calories needed to maintain calorie balance for various gender and age groups at three different levels of physical activity. The estimates are rounded to the nearest 200 calories. An individual’s calorie needs may be higher or lower than these average estimates. PHYSICAL ACTIVITY LEVELb GENDER Child (female and male) d

Female

Male

AGE (YEARS)

SEDENTARY c

MODERATELY ACTIVE 1000–1400

ACTIVE 1000–1400c

2–3

1000–1200

4–8

1200–1400

1400–1600

1400–1800

9–13

1400–1600

1600–2000

1800–2200

14–18

1800

2000

2400

19–30

1800–2000

2000–2200

2400

31–50

1800

2000

2200

1600

1800

2000–2200

4–8

1200–1400

1400–1600

1600–2000

9–13

1600–2000

1800–2200

2000–2600

14–18

2000–2400

2400–2800

2800–3200

19–30

2400–2600

2600–2800

3000

31–50

2200–2400

2400–2600

2800–3000

2000–2200

2200–2400

2400–2800

a Based on Estimated Energy Requirements (EER) equations, using reference heights (average) and reference weights (healthy) for each age/gender group. For children and adolescents, reference height and weight vary. For adults, the reference man is 5 feet 10 inches tall and weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126 pounds. EER equations are from the Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC): The National Academies Press; 2002. b Sedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life. Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life. c The calorie ranges shown are to accommodate needs of different ages within the group. For children and adolescents, more calories are needed at older ages. For adults, fewer calories are needed at older ages. d Estimates for females do not include women who are pregnant or breastfeeding.

Source: Adapted from U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Table 2-3.Washington, DC: U.S. Government Printing Office; December 2010. Available online at www.dietaryguidelines.gov.

Escott-Stump_Ch01.indd 30

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Anticonvulsants may cause problems with the child’s growth and normal body functions. Diets should be adjusted for increasing folate. • Corticosteroids may cause growth stunting if given over an extended time in large doses. • Monitor dietary calcium intakes by children who take medications that alter bone metabolism. • Nutritional supplements should be taken only when prescribed by a physician, although over-the-counter use is common. Avoid serving cereals to children that fulfill the adult RDAs for vitamins and minerals. Poly-Vi-Fluor contains fluoride; use caution in areas where water is fluoridated. Too much can cause fluorosis. • Stimulants such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) work on dopamine levels and may cause anorexia, growth stunting, nausea, stomach pain, or weight loss; use frequent snacks. Strattera (atomoxetine) works on norepinephrine; it may also decrease appetite. • Tofranil (imipramine), used for bedwetting, can cause dry mouth. Include adequate liquids. Herbs, Botanicals, and Supplements • Herbs and botanical supplements have not been proven to be safe for children. Use of vitamin–mineral supplements is common in children (Waddell, 2012). • Discuss the relevance of tolerable ULs from the dietary reference intakes of the National Academy of Sciences. These levels were set to protect individuals from receiving too much of any nutrient from diet and dietary supplements. • Children are more prone to toxicity than adults. For example, jinbuhuan causes bradycardia and central nervous system (CNS) and respiratory depression and is to be avoided in children; fenugreek may trigger asthma in susceptible individuals.

Figure 1-9. Young children actively at play.

• Where overweight or obesity is present, family-based approaches are best (Hoelscher et al, 2013). • Education is needed to support optimal nutrition and physical activity; see Table 1-16. • With toddlers, continue use of iron-fortified cereal and juices that are naturally high in vitamin C. • Children should be allowed to vary in their food acceptance, choices, and intake. An authoritative style is more effective than one that is authoritarian.

TABLE 1-16 General Dietary Recommendations for Children Ages 2 Years and Older Balance dietary calories with physical activity to maintain normal growth. Get 60 minutes of moderate to vigorous play or physical activity daily.

Nutrition Education, Counseling, Care Management

Use fresh, frozen, and canned vegetables and fruits and serve at every meal.

• Children should be treated respectfully. Talk with the child, not just with a parent. A personalized conversation elicits the most effective response. • Review Erikson’s developmental phases of childhood (1963): toddlers 1 to 3 years of age want autonomy; preschoolers 4 to 6 years of age seek initiative; and school-age children, 6 to 12 years of age, are industrious. Figure 1-9 shows children at play. • Explain the age-appropriate diet for children. Encourage parents to use finger foods for toddlers. Young children have food jags, and they often prefer single foods. Older children need nutritious snacks such as cheese cubes and iron-rich desserts. • Misconceptions must be corrected, such as “good foods/bad foods” or “foods that are good for you taste bad.” Use highenergy foods with low nutrient value less often. Because major sources of energy and empty calories include soda, grain desserts, pizza, and whole milk, these are targets for discussion and change (Reedy and Krebs-Smith, 2010). • Encourage a relaxed atmosphere at mealtime, without pressure to eat, hurry, or finish meals. Bribery or rewards for eating should not be used; rewards can actually decrease acceptance. Parents must not “control” meals or foods; disordered eating may result.

Limit high-calorie sauces such as Alfredo sauce, cream sauces, cheese sauces, and hollandaise.

Escott-Stump_Ch01.indd 31

Use canola, soybean, corn, safflower, or olive oils in place of solid fats during food preparation. Reduce the intake of sugar-sweetened beverages and foods. Limit juice intake to 1–2 servings. Use nonfat (skim) or low-fat milk and dairy products daily. Remove the skin from poultry before eating. Use only lean cuts of meat and reduced-fat meat products. Introduce and regularly serve fish as an entree, especially oily fish, broiled, orbaked. Use recommended portion sizes on food labels when preparing and serving food. Eat whole-grain breads and cereals rather than refined products; read labels for “whole grain” as the first ingredient. Eat more legumes (beans) and tofu in place of meat several times a week. Reduce salt intake, including salt from processed foods (breads, breakfast cereals, soups). Read food labels and choose high-fiber, low-salt/low-sugar alternatives. Sources: Academy of Nutrition and Dietetics. Nutrition guidance for healthy children aged 2to 11 years. Available at: http://www.eatright.org/About/Content.aspx?id=8371. Accessed June 15, 2014; American Heart Association. Dietary recommendations for healthy children. Available at: http://www.heart.org/HEARTORG/GettingHealthy/Dietary-Recommendations-for -Healthy-Children_UCM_303886_Article.jsp. Accessed June 15, 2014.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

• Proper atmosphere is important to children since their eating patterns are strongly influenced by both the physical and social environment. Children are more likely to eat foods that are available and easily accessible. They tend to eat greater quantities when larger portions are provided. • Many children skip breakfast each day. Discuss the importance of eating breakfast for enhancing the abilities to concentrate, learn, and retain new information. Breakfasts should contain a variety of foods, with high-fiber and nutrient-rich whole grains, fruits, and dairy products. • Promote healthy meals at school. School-age children need adequate meals and snacks to eliminate transient hunger. Recess before lunch is a good way to increase intake. • Both school and the community share responsibility to provide students with high-quality foods and school-based nutrition (Bergman and Gordon, 2010). Establish at least one “champion” for nutrition issues at school (e.g., a parent, the principal, the foodservice manager), and promote teamwork. Standards should allow children to have access to nutritious choices. • Knowledge and training are needed to improve food consumption patterns as children consume foods away from home and as they take on greater responsibility for meal preparation and food selection. • Zinc absorption is improved when consumed with dairy products (Baylor College of Medicine, 2013). • Vegan children should be encouraged to consume adequate sources of vitamin B12, riboflavin, zinc, and calcium, and vitamin D if sun exposure is not adequate (Vidailhet et al, 2012).

TABLE 1-17 Special Considerations in Childhood: Lead Poisoning and Measles LEAD POISONING Lead poisoning is the most common environmental health problem affecting American children. Exposure occurs through ingestion of lead-contaminated household dust and soil in older housing containing lead-based paint. Lead replaces calcium in the bone; deposition may be seen in x-rays of the knee, ankle, or wrist. Anemia may also occur. Lead is also a confirmed neurotoxicant; lower arithmetic scores, reading scores, nonverbal reasoning, and short-term memory deficits occur. Nutritional interventions suggest regular meals with adequate amounts of calcium, and iron supplementation. Parents need education about lead exposure, hygiene, and housekeeping measures to prevent ingestion of dust and soil. Use drinking water from the cold tap, not hot water tap. Bottled water is not guaranteed as a safe alternative. Blood lead screening may be recommended universally at ages 1 and 2 years. VITAMIN A, MEASLES AND BLINDNESS Vitamin A deficiency (VAD) is an important public health problem worldwide. VAD causes xerophthalmia and infectious disease risk. Childhood blindness and visual impairment in developing countries is a significant public health issue; control is a priority within the World Health Organization’s VISION 2020 program. Globally, the prevalence of VAD has been declining due to widespread vitamin A supplementation in conjunction with measles immunization in at-risk populations. Sources: Centers for Disease Control and Prevention. Lead. Available at: http://www.cdc.gov /nceh/lead/. Accessed June 15, 2014. Environmental Protection Agency. Lead. Available at: http://www.epa.gov/lead/. Accessed June 15, 2014. Maida JM, Mathers K, Alley CL. Pediatric ophthalmology in the developing world. Curr Opin Ophthalmol. 2008;19:403; Semba RD, et al. Coverage of vitamin A capsule programme in Bangladesh and risk factors associated with non-receipt of vitamin A. J Health Popul Nutr. 2010;28:143; Sherwood JC, et al. Epidemiology of vitamin A deficiency and xerophthalmia in at-risk populations. Trans R Soc Trop Med Hyg. 2012;106:205.

Escott-Stump_Ch01.indd 32

TABLE 1-18 Tips for Encouraging Children to Enjoy Nutrition and Physical Activity Children should be empowered to make food choices that reflect the Dietary Guidelines for Americans. Good nutrition and physical activity are essential to children’s health and educational success. School meals that meet the Dietary Guidelines for Americans should appeal to children and taste good. Programs must build upon the best science, education, communication, and technical resources available. School, parent, and community teamwork is essential for encouraging children to make food and physical activity choices for a healthy lifestyle. Messages to children should be age appropriate and delivered in a language they speak, through media they use, and in ways that are entertaining and actively involve them in learning. Focus on positive messages regarding the food choices children can make. Support education and action at national, state, and local levels to improve children’s eating behaviors. Source: USDA. Team nutrition. Available at: http://www.fns.usda.gov/tn. Accessed June 15, 2014.

• Because 20% of U.S. households have at least one child with a special health care need, the “medical home” is effective because this includes one usual source of care; care that is “family centered”; coordination of care services and needed referrals (Derigne and Porterfield, 2010). • Children who have chronic illnesses fare better if parents give them age-appropriate responsibilities, such as meal planning and taking their own medications. • Nutrition education targeting low-income African American parents should address planning and preparing convenient and economical meals and snacks that include fruits and vegetables, along with social support (Hildebrand and Shriver, 2010). • Specific considerations about lead poisoning and measles are found in Table 1-17. • Too much time in front of the television or computer results in low energy expenditure. Table 1-18 provides tips to promote healthy forms of activity. Patient Education—Food Safety • In areas with poor sanitation, children experience vicious cycles of enteric infections and malnutrition, resulting in poor nutrient absorption as a result of changes in the intestinal mucosa, “environmental enteropathy” (DeBoer et al, 2012). Safe, clean water and food are necessary. • Children should be taught to wash their hands before eating and after use of the toilet, sneezing, and petting animals to prevent the spread of various infections and food poisoning. • Children can be taught to avoid food and beverages that have an unusual flavor or odor. • Avoid raw or partially cooked eggs, raw or undercooked fish or shellfish, and raw or undercooked meats because of potential food poisoning. • Five of the most commonly eaten varieties of fish are acceptably low in mercury (shrimp, canned light tuna, salmon, pollack, and catfish). • Do not use raw (unpasteurized) milk or products made fromit.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

• Avoid serving unpasteurized juices and raw sprouts. • Only consume deli meats and frankfurters that have been reheated to steaming hot temperature. • Child care centers should follow guidelines for safe food handling and for inclusion of nutritious meals and snacks (Academy of Nutrition and Dietetics, 2010).

●

American School Food Service Association http://www.asfsa.org/

●

Bright Futures http://www.brightfutures.org

●

Centers for Disease Control and Prevention—Children http://www.cdc.gov/LifeStages/children.html

●

Children’s Nutrition Research Center—Baylor University http://www.bcm.tmc.edu/cnrc/

●

Competitive Foods in Schools http://www.cdc.gov/healthyyouth/nutrition/pdf/compfoodsbooklet.pdf

●

Growth Charts http://www.cdc.gov/growthcharts

●

MedlinePlus – Child Nutrition http://www.nlm.nih.gov/medlineplus/childnutrition.html

●

Pediatric Nutrition Practice Group http://www.pnpg.org/

●

RD411 – Toddler and Kid Center http://www.nutrition411.com/tkcenter/

SAMPLE NUTRITION CARE PROCESS STEPS Lead Poisoning in Childhood Assessment Data:Dietary recall; labs such as H&H, serum ferritin, and serum lead levels; growth charts. Nutrition Diagnosis (PES): Excessive bioactive substance intake related to lead consumption from lead-based paint exposure in environment as evidenced by high serum lead levels, documented ID anemia, and deposition seen on x-rays. Intervention:Education and counseling tips on avoiding accidental lead intake; increasing sources of iron and calcium in the diet; tips on reducing environmental lead sources; running water awhile before drinking. Monitoring and Evaluation: Reduced intake of sources of lead; improved lab values, improved weight gain on growth grid; successful growth and development.

Limited Fruit-Vegetable Consumption Assessment Data:Dietary recall; growth charts; physical signs of malnutrition. Nutrition Diagnosis (PES): Inadequate vitamin intake (vitamin C) related to minimal consumption of fruits and vegetables as evidenced by diet history, no use of children’s vitamins or fortified foods, and signs of bleeding gums, petechiae, irritability, and easy bruising. Intervention:Education and counseling tips on improving intake of fruits and vegetables; recipes and tips for increasing citrus fruits and good sources of vitamin C in foods well accepted by children. Referral to WIC program if eligible. Monitoring and Evaluation:Improved signs of nutrition and resolution of bleeding gums, etc.; diet history and mother’s description of improved vitamin C intake; assistance from WIC.

For More Information

See the videos “Developmental Considerations in Caring for Children: Toddlers,” “Developmental Considerations in Caring for Children: Preschoolers,” and “Developmental Considerations in Caring for Children: School Agers,” at www.thepoint.lww.com/escottstump8e.

●

Academy of Nutrition and Dietetics http://www.eatright.org

●

American Academy of Pediatrics http://www.aap.org/

Escott-Stump_Ch01.indd 33

REFERENCES Academy of Nutrition and Dietetics. Dietary guidance for healthy children ages 2 to 11 years. Evidence analysis library website. Available at: http:// andevidencelibrary.com/conclusion.cfm?conclusion_statement_id=251766. Accessed June 14, 2014. Academy of Nutrition and Dietetics. Position of the American Dietetic Association: child and adolescent nutrition assistance programs. J Am Diet Assoc. 2010;110:791. Baylor College of Medicine. Children’s Nutrition Research Center. Available at: http://www.bcm.edu/cnrc/consumer/nyc/vol_2005_1/page4.htm. Accessed June 14, 2013. Bergman EA, Gordon RW. Position of the American Dietetic Association: local support for nutrition integrity in schools. J Am Diet Assoc. 2010;110: 1244. Clemens R, et al. Filling America’s fiber intake gap: summary of a roundtable to probe realistic solutions with a focus on grain-based foods. J Nutr. 2012;142:1390S. Condon EM, et al. School meals: types of foods offered to and consumed by children at lunch and breakfast. J Am Diet Assoc. 2009;109:S67. Craig WJ. Nutrition concerns and health effects of vegetarian diets. Nutr Clin Pract. 2010;25:613. Crowe KM, Murray E. Deconstructing a fruit serving: comparing the antioxidant density of select whole fruit and 100% fruit juices. J Acad Nutr Diet. 2013;113:1354. DeBoer MD, et al. Early childhood growth failure and the developmental origins of adult disease: do enteric infections and malnutrition increase risk for the metabolic syndrome? Nutr Rev. 2012;70:642. Derigne L, Porterfield S. Employment change and the role of the medical home for married and single-mother families with children with special health care needs. Soc Sci Med. 2010;70:631. Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for energy, carbohydrate, ﬁber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Washington, DC: National Academies Press; 2002. Ford CN, et al. Trends in dietary intake among US 2- to 6-year-old children, 1989-2008. J Acad Nutr Diet. 2013;113:35. Grimes CA, et al. Dietary salt intake, sugar-sweetened beverage consumption, and obesity risk. Pediatrics. 2013;131:14. Han E, Powell LM. Consumption patterns of sugar-sweetened beverages in the United States. J Acad Nutr Diet. 2013;113:43. Harris JL, et al. Priming effects of television food advertising on eating behavior. Health Psychol. 2009;28:404. Hildebrand DA, Shriver LH. A quantitative and qualitative approach to understanding fruit and vegetable availability in low-income African-American families with children enrolled in an urban head start program. J Am Diet Assoc. 2010;110:710. Hoelscher DM, et al. Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity. J Acad Nutr Diet. 2013;113:1375. Kranz S, et al. What do we know about dietary fiber intake in children and health? The effects of fiber intake on constipation, obesity, and diabetes in children. Adv Nutr. 2012;3:47. Lipshultz SE, et al. Can the consequences of universal cholesterol screening during childhood prevent cardiovascular disease and thus reduce long-term health care costs? Pediatr Endocrinol Rev. 2012;9:698. Maffeis C, et al, Breakfast skipping in prepubertal obese children: hormonal, metabolic and cognitive consequences. Eur J Clin Nutr. 2012;66:314.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Maguire JL, et al. The relationship between cow’s milk and stores of vitamin D and iron in early childhood. Pediatrics. 2013;131:e144. Mathias KC, et al. Serving larger portions of fruits and vegetables together at dinner promotes intake of both foods among young children. J Acad Nutr Diet. 2012;112:266. Metallinos E, et al. A longitudinal study of food insecurity on obesity in preschool children. J Acad Nutr Diet. 2012;112:1949. Nicklas TA, et al. Barriers and facilitators for consumer adherence to the dietary guidelines for Americans: the HEALTH Study. J Acad Nutr Diet. 2013;113:1317. Ohri-Vachaspati P, et al. Fresh Fruit and Vegetable Program participation in elementary schools in the United States and availability of fruits and vegetables in school lunch meals. J Acad Nutr Diet. 2012;112:921. Reedy J, Krebs-Smith SM. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. J Am Diet Assoc. 2010;110:1477.

Rosales FJ, et al. Understanding the role of nutrition in the brain and behavioral development of toddlers and preschool children: identifying and addressing methodological barriers. Nutr Neurosci. 2009;12:190. Savage JS, et al. Serving smaller age-appropriate entree portions to children aged 3-5 y increases fruit and vegetable intake and reduces energy density and energy intake at lunch. Am J Clin Nutr. 2012;95:335. Spill MK, et al. Serving large portions of vegetable soup at the start of a meal affected children’s energy and vegetable intake. Appetite. 2011;57:213. Thomson JL, et al. Associations among school characteristics and foodservice practices in a nationally representative sample of United States schools. J Nutr Educ Behav. 2012;44:423. Vidailhet M, et al. Vitamin D: still a topical matter in children and adolescents. A position paper by the Committee on Nutrition of the French Society of Paediatrics. Arch Pediatr. 2012;19:316. Waddell L. The power of vitamins. J Fam Health Care. 2012;22:14.

ADOLESCENCE NUTRITIONAL ACUITY RANKING: LEVEL 2 DEFINITIONS AND BACKGROUND Adolescents need to consume food and beverages that provide adequate energy and nutrients to reduce risk for poor outcomes including growth retardation, anemia, poor academic performance, development of psychosocial difficulties, and an increased likelihood of developing heart disease and osteoporosis (Academy of Nutrition and Dietetics, 2010). Breakfast consumption is important to enhance cognitive function related to memory, test grades, and school attendance. A low-glycemic index breakfast may help to improve learning as opposed to a high-glycemic index breakfast or none (Cooper et al, 2012). Physiologic growth is more accurately assessed by using Tanner stages than by chronological age alone. Teens require increased nutrients for accelerated growth; deficiencies can lead to loss of height, osteoporosis, and delayed sexual maturation. Skeletal growth is unpredictable, and girls may gain 3.5inches in 1 year, and boys may gain 4 inches in 1 year. When the teen years begin, the adolescent has achieved 80% to 85% of final height, 53% of final weight, and 52% of final skeletal mass. Teens may almost double their weight and can add 15% to 20% in height. Maintaining adequate calcium intake during childhood and adolescence is necessary for the development of peak bone mass, which may be important in reducing the risk of fractures and osteoporosis later in life. Daily requirement tables separate preteens as ages 9 to 13 years and teen years as ages 15 to 18 years. The growth spurt of girls occurs at 9½ to 13½ years of age; menarche generally occurs at 12½ years. For boys, the growth spurt occurs between 11and 14½ years. Boys have greater increases in LBM (muscle) and greater increases in height before epiphyseal closure of long bones. Most skeletal growth is completed by age 15 in girls and age 19 in boys. Sexual maturation occurs at ages 10 to 12 years for girls and at ages 12 to 14 years for boys. Girls have more total body fat and less total body water than boys. The increase in percentage

Escott-Stump_Ch01.indd 34

of total body fat in girls is 1.5 to 2 times than that in boys at this time. Some teens develop more rapidly than others (early maturers), while others may develop more slowly (late maturers). Using the Tanner stages of sexual maturity is suggested. Dietary intake and body size influence age at menarche and growth patterns in teen girls. Puberty comes early for some girls because of a gene (CYP1B1) that speeds up the body’s breakdown of androgens. This gene has implications for later development of diseases, including breast cancer, even heart disease. Earlier sexual maturation in males is manifested by faster early postnatal growth and weight gain, leading to higher adult BMI (Ong et al, 2012). Girls who mature early may be prone to depression, EDs, and anxiety. Sociocultural influences affect adolescent eating patterns and behaviors. Meal skipping, snacks at odd hours, laxative or diuretic use, fasting, bulimia, self-induced vomiting, physical activity, and frequent intake of fast food are important components of an assessment (Sebastian et al, 2009). Some teens take up dieting to lose weight. Other teens reject a meat-based diet to become vegetarians. Semi-vegetarians who restrict only red meat from their diet, and flexitarians who occasionally eat red meat, are significantly more often restrained eaters than omnivores (Forestell et al, 2012). Because vegetarianism may serve as a mask for restrained eating, counselors must ensure that teen concerns about weight loss do not lead to unhealthful or disordered eating patterns (Forestell et al, 2012; Larson etal, 2009). Food choices established during childhood and adolescence persist into adulthood (Fitzgerald et al, 2010). Intakes change often during teen years, especially during growth spurts and stages of physical maturation. While obesity is an increasing trend, pubertal status should be taken into account. Waist-toheight ratio is a convenient and appropriate measure of adiposity (Lewitt et al, 2012). According to Erickson’s psychological stages of development (1968), teens (12 to 18 years of age) are working on “identity.” In cognitive development, the concrete, “here and now” stage

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

lasts from ages 11 to 14 years in girls and from ages 13 to 15 years in males. Early abstract thinking and daydreams are common among 15- to 17-year-old females and 16- to 19-yearold males. True abstract thinking and idealism (faith, trust, and spirituality) occur for young women at ages 18 to 25 years and for males at 20 to 26 years of age. The brain continues developing through late adolescence, especially with the nerve fiber system that transmits messages from one hemisphere to the other. There is an increase in gray matter at the onset of adolescence, followed by a substantial loss in the frontal lobes from the mid-teens through the mid-20s, where inhibiting impulses and regulating emotions may be altered. Teens should make the most of their brains during this time, when they can “hard wire” their ability to process skills in academics, sports, and music. Parental influence begins to diminish for teens; they exercise more autonomy over their food choices (Fitzgerald et al, 2010). In the National Growth and Health Study during three age periods (9 to 13, 14 to 18, and 19 to 20 years), 90% of girls failed to consume the recommended amounts of fruit, vegetables, and dairy; 75% consumed less than the recommended amounts in the protein group; and most had inadequate intakes of calcium, magnesium, potassium, and vitamins D and E (Moore et al, 2012). Healthier choices are imperative. Teens need adequate, nutritious, and safe foods that promote optimal physical, cognitive, and social growth and development. Nutrition assistance programs can play a vital role (Academy of Nutrition and Dietetics, 2010).

Clinical/History • • • • • • • • • • • • • • • • • • • •

Age Height Weight Weight/height percentile BMI or HBW Waist to hip ratio Recent changes (height, weight) Rapid or delayed growth spurt Dietary intake patterns, meal skipping History of fasting, dieting Tanner stage of sexual maturation Early or late puberty Intake altered during growth spurts? Excessive or inadequate physical activity? Hydration status (I&O) Physical activity level or athletics Physical handicaps Disordered eating patterns GI complaints Abuse of drugs, alcohol, diuretics, prescription drugs, laxatives

Escott-Stump_Ch01.indd 35

• Signs of polycystic ovary syndrome in girls • Sleep disorder screening

Lab Work • • • • • • • • •

H&H, serum Fe Glucose Chol Trig Alb (if needed) Na, K Ca, Mg, phosphorus Homocysteine Serum vitamin D levels

INTERVENTION Objectives • Provide adequate energy for growth and development, especially for current and future growth spurts. • Evaluate the patient’s weight status. Many obese adolescents will be overweight as adults (Psaty and Rivara, 2012). To prevent obesity in a teen whose parents are obese, a family-based approach and regular breakfast consumption are considerations (Hoelscher et al, 2013). Physical activity promotion is also important. • Encourage healthy food choices according to the factors of greatest interest to teens: taste and appearance. Health, energy, and price are not viewed as relevant. • Prevent or correct nutritional anemias. Determine a girl’s sexual maturity, onset of menstruation, and growth spurts, which are often associated with iron depletion. Alter diet accordingly to provide sufficient vitamins and minerals. • Evaluate use of fad diets, skipping meals, unusual eating patterns, or tendency toward EDs. If problems are noted, seek immediate assistance. Family therapy may be beneficial. • Encourage adequate calcium intake by all members of the family. Low-fat dairy products, fruits and vegetables, and appropriate physical activity are important for achieving good bone health. • Introduce food changes one at a time. • Monitor for dyslipidemia. Girls may have higher total serum cholesterol concentration than boys, somewhat related to differences in male and female hormones. • Vegetarians should be encouraged to consume adequate sources of vitamin B12, riboflavin, zinc, iron, calcium, protein, energy not only for growth but also for adequate cognitive performance. Vegan children tend to have higher intakes of fiber and lower intakes of saturated fatty acids and cholesterol than omnivore children; they may need to increase intake of omega-3 fatty acids. • Screen and treat vitamin D deficiency, which is highly prevalent in overweight and obese teens (Turer et al, 2013).

Food and Nutrition • The MyPlate Food Guidance System: 4 cups of milk or equivalent source of calcium; 2 to 3 servings of meat or equivalent; 6 to 12 servings from the bread group; 2 to 4 servings of fruit or juices; 3 to 5 servings from vegetable group. • Protein intake should be sufficient to support growth.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-19 Recommendation for Males and Females Ages 14 to 18 NUTRIENT

MALES 14–18 YEARS

FEMALES 14–18 YEARS

Energy

3152 kcal/d

2368 kcal/d

Protein

52 g/d or 0.85 g/kg/d

46 g/d or 0.85 g/kg/d

Calcium

1300 mg/d

Iron

12 mg/d

15 mg/d

Folate

400 g/d

Phosphorus

1250 mg/d

Vitamin A

900 mg

700 mg

Vitamin C

75 mg/d

Thiamin

1.2 mg/d

1.0 mg/d

Riboflavin

1.3 mg/d

1.0 mg/d

Niacin

16 mg/d

14 mg/d

• Table 1-19 provides nutrient recommendations for energy needs. • Snacks should be planned as healthy options. Snacking frequency affects intake of macronutrients and a few micronutrients and promotes consumption of an excess of discretionary calories as added sugars and fats (Sebastian etal, 2009). • Adequate zinc and iodine are needed for growth and sexual maturation; use iodized salt and foods such as meat and dairy products. • Calcium is needed for bone growth; vitamins D and A are also essential in this age group. Girls need extra iron for menstrual losses. • Choose whole fruit over juice for a greater antioxidant effect (Crowe and Murray, 2013). • Debut age of drinking alcohol is important to note. If drinking begins before age 15, there is twice the risk of substance abuse and four times the risk of dependence. • Diet for athletes: An acceptable diet for the athlete would be a normal diet for age, sex, and level of activity plus adequate intake of CHO and fluids. Avoid excess of protein and inadequate replacement of electrolytes (see Sports Nutrition entry). • For pregnant teens, follow the guidelines provided in Table 1-20.

TABLE 1-20 Special Considerations for Adolescent Pregnancy ISSUE

COMMENTS

Mother is still growing

Check gynecological age (chronological age less age of menarche) to determine future potential growth of the mother.

Low birth weight (LBW) and prematurity

Fetuses grow more slowly in 10- to 16-year-olds. Increased weight in the last trimester can lessen the incidence of LBW.

Binge drinking or smoking

Alcohol-exposed pregnancy is a serious concern. Maternal smoking negatively affects infant height.

Fetal growth and optimal nutritional status during and after gestation

By the end of the pregnancy, the mother’s desired weight gain should be between 25 and 35 lb. Add desired increments for energy for requirements of same-age nonpregnant teens, or monitor the weight gain pattern to assess the adequacy of the present diet. Adolescents are at high risk of gaining an excessive amount of weight during pregnancy and should be monitored during pregnancy by dietetics professionals.

Protein requirements

Protein requirement is 1.1 g/kg body weight for most adolescents.

Prenatal supplements

The physician will prescribe prenatal vitamins.

Meal patterns

Mom will need 5 cups of milk, 3 servings of protein or meat, 4 servings of fruits/vegetables, 4 servings of breads/ cereals. Three snacks daily will be needed.

Nutrients needed

Frequently missing nutrients are calcium, zinc, iron, folate, vitamins A, and B6, and C. Nutrient-dense choices include: Vitamin A: Chicken liver, cantaloupe, mango, spinach, apricots. Vitamin C: Citrus fruits and juices, broccoli, spinach, melon, strawberries. Calcium: Low-fat milk, yogurt, broccoli, cheddar cheese, low-fat shakes, skim-milk cheeses. Iron: Liver, rice, whole milk, raisins, baked potatoes, enriched cereal. Vitamin B6: White meats, tuna, salmon, bananas, potatoes. Folacin: Wheat germ, nuts, beans, peas, spinach, asparagus, strawberries. Zinc: Beef, crab, oysters, fortified cereal, chicken, peanut butter, tuna, milk.

Bad habits, cravings, and aversions

Discourage skipping of meals. Cravings are common, especially for chocolate, fruit, fast foods, pickles, and ice cream. Watch for aversions to meat, eggs, and pizza during this time.

Iron deficiency anemia (IDA) during pregnancy

Women who conceive during or shortly after adolescence are likely to enter pregnancy with low or absent iron stores. IDA during pregnancy is associated with significant morbidity for mothers and infants; supplementation is a strategy to improve iron balance in pregnant teens.

Resistance to authority figures

Encourage the teen to see herself as having a key role in providing good nutrition for her new family. Allow her to express her feelings and concerns.

WIC Program

Encourage enrollment in programs such as WIC where an individualized nutrition risk profile is developed for each pregnant teen. Positive outcomes are noted in birth weight.

Sources: American Academy of Pediatrics. Teenage pregnancy. Available at: http://www.healthychildren.org/English/ages-stages/teen/dating-sex/pages/Teenage-Pregnancy.aspx. Accessed June 15, 2014; Centers for Disease Control and Prevention. Teen pregnancy. Available at: http://www.cdc.gov/teenpregnancy. Accessed June 15, 2014; MedlinePlus. Teenage pregnancy. Available at: http://www .nlm.nih.gov/medlineplus/teenagepregnancy.html. Accessed June 15, 2014; WebMD. Health & pregnancy. Available at: http://www.webmd.com/baby/guide/teen-pregnancy-medical-risks-and-realities. Accessed June 15, 2014.

Escott-Stump_Ch01.indd 36

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Vitamin–mineral supplements are not needed, except for pregnant teens or teens whose diets are generally inadequate (e.g., those following an unplanned vegetarian pattern or restricted energy plans). The majority of American teens do not use supplements; those who do use them tend to eat a more nutrient-dense diet than those who do not. Vitamins A and E, calcium, and zinc tend to be low regardless of use of supplements. In addition, excesses of these nutrients are not recommended and may lead to toxic levels of vitamins A and D if taken indiscriminately. • Discuss the relevance of tolerable ULs from the dietary reference intakes of the National Academy of Sciences. These levels were set to protect individuals from receiving too much of any nutrient from diet and dietary supplements. • Medications for dyslipidemia are prescribed to teens; statins, Zetia and fenofibrates are often used. • Monitor use of nonprescription medications (e.g., aspirin and cold remedies) and use of illegal drugs, including marijuana and alcohol. Side effects may include poor intakes of several nutrients. • Smoking cigarettes tends to decrease serum levels of vitamin C. Discuss the health effects. Herbs, Botanicals, and Supplements • Herbs and botanical supplements should not be used without discussing with the physician. In general, these supplements have not been proven to be safe for adolescents. There may be subgroups that are at risk with inappropriate use of these products (e.g., athletes or individuals with EDs, chronic diseases, allergies). Females consume herbal weight control products significantly more than males. • The use of multivitamin–mineral preparations is common. • Athletes reported supplementing with creatine and protein. More males than females use creatine and diuretics. In fact, use of muscle-enhancing behaviors is quite high and is cause for concern (Eisenberg et al, 2012).

Nutrition Education, Counseling, Care Management • Explain the MyPlate Food Guidance System and the rationale behind the concepts. School-based interventions to promote healthy choices are beneficial. • Diets of teens are often low in vitamins A and C, folate, and iron. Discuss the concept of nutrient density; food comparison charts are useful. • Encourage a minimum of five servings of fruits and vegetables daily. Make easy access to ready-to-eat, appealing fruits and vegetables. • Educate about nutritious, handy snacks; link discussions to dental and oral health. • Discuss the social and environmental implications of food production practices (Pelletier et al, 2013). Organic, locally grown produce and a sustainable food supply usually appeal to idealistic youth. • Limit the intake of sweetened beverages (soda, sweet tea, fruit drinks) to improve nutrient density (Nelson et al, 2009) and to prevent obesity.

Escott-Stump_Ch01.indd 37

• Explain the relation of diet to the needs of the adolescent athlete, as well as its influence on skin, weight control, and general appearance. • Discuss body image and peer pressure. Boys generally want larger biceps, shoulders, chests, and forearms. Girls often want smaller hips, waistlines, and thighs, and larger bustlines. • The 5-year period between adolescence and adulthood is a time of potential weight gain. Emphasize the importance of not skipping meals, especially breakfast. Discourage obsessions with dieting and weight and promote safe dieting practices when needed. • Discuss calcium and vitamin D. Low-fat dairy products may be helpful for maintaining or achieving a healthy weight; use three to four servings daily. Teens who live in northern climates and those who are obese may need extra vitamin D. Assess current intake by asking questions such as: How many times a day do you drink milk or eat cheese and yogurt? • Help the family recognize the adolescent’s need for independence in choosing meals and snack items. Be respectful of their need for independence. • Teens often feel that “it can’t happen to me,” prompting them to take unnecessary risks like drinking and driving, or smoking. Discussing the effects of various nutrients on appearance or energy levels may be more helpful than a lecture on “health.” • Before recommending self-weighing as a weight-monitoring tool, ensure that young adults are not at risk for an unhealthy preoccupation with body weight or shape (Friend et al, 2012; Quick et al, 2012). • Parents play a large role in modeling eating behavior. Encourage family meals and discuss options for nourishing, portable foods when away from home. Provide access to high nutrient density foods; limit soft drink consumption and encourage intake of calcium-rich beverages. • Work closely with physicians for childhood-onset disorders (Peter et al, 2009). • Consumption of fast food is common and may contribute to weight gain if not carefully monitored. A focus on eating or physical activity behaviors without discussing weight is preferred over direct approaches about weight (Shrewsbury et al, 2010). • Immigrant teens face challenges. Mexican Americans often have poorer diets and more obesity (Liu et al, 2012). Parents of teens with special needs or low income experience more aggravation and anxiety (Yu and Singh, 2012). Patient Education—Food Safety Tips • Since teens may not think about the consequences of their actions, gentle reminders about hand washing and safe food handling may be important. Use of hand sanitizers may be popular among teen girls. • Avoid raw or partially cooked eggs, raw or undercooked fish or shellfish, and raw or undercooked meats because of potential food poisoning. • Do not use raw (unpasteurized) milk or products made fromit. • Avoid serving unpasteurized juices and raw sprouts. • Only serve processed deli meats and frankfurters that have been reheated to steaming hot temperature. • Safe food handling is an important part of school food service.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

SAMPLE NUTRITION CARE PROCESS STEPS Disordered Eating Pattern Assessment Data:Dietary recall; labs such as H&H, serum ferritin; growth charts; recent growth spurt; age at menarche. Nutrition Diagnosis (PES): Disordered eating pattern related to dieting behavior as evidenced by restricted eating, skipping breakfast, frequent infections, BMI of 19, low H&H, irregular intake of nutrient-dense foods, and daily consumption of fast foods. Intervention:Education and counseling tips on desirable nutritional intake in adolescence; consequences on energy, appearance, and health from poor dietary habits. Monitoring and Evaluation: Improved intake of nutrient-dense foods; improved lab values, improved quality of life (energy for school, recreation, and physical activity) and fewer illnesses.

For More Information

See the video “Developmental Considerations in Caring for Children: Adolescents” at www.thepoint.lww.com/escottstump8e.

●

American Academy of Child and Adolescent Psychology http://www.aacap.org/

●

Body and Mind (BAM) http://www.bam.gov/index.html

●

Body Image http://www.focusas.com/BodyImage.html

●

Bright Futures—Adolescence http://brightfutures.aap.org/web/

●

Calorie King http://www.calorieking.com/

●

Centers for Disease Control and Prevention—Adolescents http://www.cdc.gov/healthyyouth/adolescenthealth/index.htm

●

Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents http://guideline.gov/content.aspx?id=35583&search=adolescent+nutrition

●

Food Safety for Teens http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education /teach-others/download-materials/for-kids-and-teens/for-kids-and-teens

●

Healthy Eating and Activity Together http://www.napnap.org/Files/TeenTips2009.pdf

●

President’s Challenge for Physical Activity http://www.presidentschallenge.org/

Escott-Stump_Ch01.indd 38

●

Teens Health http://kidshealth.org/teen/

●

Vegetarian nutrition (VN) evidence-based practice guideline http://guideline.gov/content.aspx?id=35174&search=adolescent+nutrition

●

Vegetarian Nutrition for Teens http://www.vrg.org/nutrition/teennutrition.htm

REFERENCES Academy of Nutrition and Dietetics. Position of the American Dietetic Association: child and adolescent nutrition assistance programs. J Am Diet Assoc. 2010;110:791. Cooper SB, et al. Breakfast glycaemic index and cognitive function in adolescent school children. Br J Nutr. 2012;107:1823–1832. Crowe KM, Murray E. Deconstructing a fruit serving: comparing the antioxidant density of select whole fruit and 100% fruit juices. J Acad Nutr Diet. 2013;113:1354. Eisenberg ME, et al. Muscle-enhancing behaviors among adolescent girls and boys. Pediatrics. 2012;130:1019. Fitzgerald A, et al. Factors influencing the food choices of Irish children and adolescents: a qualitative investigation. Health Promot Int. 2010;25:289. Forestell CA, et al. To eat or not to eat red meat. A closer look at the relationship between restrained eating and vegetarianism in college females. Appetite. 2012;58:319. Friend S, et al. Self-weighing among adolescents: associations with body mass index, body satisfaction, weight control behaviors, and binge eating. J Acad Nutr Diet. 2012;112:99. Hoelscher DM, et al. Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity. J Acad Nutr Diet. 2013;113:1375. Larson NI, et al. Weight control behaviors and dietary intake among adolescents and young adults: longitudinal findings from Project EAT. J Am Diet Assoc. 2009;109:1869. Lewitt MS, et al. Pubertal stage and measures of adiposity in British schoolchildren. Ann Hum Biol. 2012;39:440. Liu JH, et al. Generation and acculturation status are associated with dietary intake and body weight in Mexican American adolescents. J Nutr. 2012;142:298. Moore LL, et al. Food group intake and micronutrient adequacy in adolescent girls. Nutrients. 2012;4:1692. Nelson MC, et al. Five-year longitudinal and secular shifts in adolescent beverage intake: findings from project EAT (Eating Among Teens)-II. J Am Diet Assoc. 2009;109:308. Ong KK, et al. Timing of voice breaking in males associated with growth and weight gain across the life course. J Clin Endocrinol Metab. 2012;97:2844. Pelletier JE, et al. Positive attitudes toward organic, local, and sustainable foods are associated with higher dietary quality among young adults. J Acad Nutr Diet. 2013;113:127. Peter NG, et al. Transition from pediatric to adult care: internists’ perspectives. Pediatrics. 2009;123:417. Psaty BM, Rivara FP. Universal screening and drug treatment of dyslipidemia in children and adolescents. JAMA. 2012;307:257. Quick V, et al. Self-weighing behaviors in young adults: tipping the scale toward unhealthy eating behaviors? J Adolesc Health. 2012;51:468. Sebastian RS, et al. US adolescents and mypyramid: associations between fastfood consumption and lower likelihood of meeting recommendations. J Am Diet Assoc. 2009;109:225. Shrewsbury VA, et al. Adolescent-parent interactions and communication preferences regarding body weight and weight management: a qualitative study. Int J Behav Nutr Phys Act. 2010;7:16. Turer CB, et al. Prevalence of vitamin D deficiency among overweight and obese US children. Pediatrics. 2013;131:e152. Yu SM, Singh GK. High parenting aggravation among US immigrant families. Am J Public Health. 2012;102:2102.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

PHYSICAL FITNESS AND STAGES OF ADULTHOOD

SPORTS NUTRITION NUTRITIONAL ACUITY RANKING: LEVEL 2

DEFINITIONS AND BACKGROUND Many athletes are involved in active sports (running, jogging, weight lifting, or wrestling) when they seek nutritional guidance. Questions about weight control, disordered eating patterns, and wellness are common. During periods of high physical activity, energy and protein intakes must be met to maintain body weight, replenish glycogen stores, and provide adequate protein for building and repairing tissues (Academy of Nutrition and Dietetics, 2009). Protein recommendations for endurance- and strength-trained athletes should be from 1.2 to 1.7 g/kg/d (Philips, 2012). Use of carbohydrate drinks can maintain energy intake and prevent dehydration. Energy drinks or energy shots primarily provide carbohydrate or caffeine; if consuming energy drinks 10 to 60 minutes before exercise, they can improve mental focus, alertness, anaerobic performance, or endurance performance (Campbell et al, 2013). An athlete’s iron stores are compromised via hemolysis, hematuria, sweating, gastrointestinal bleeding, and excessive postexercise hepcidin response, which regulates iron metabolism in the gut and macrophages (Peeling, 2010). All athletes should be screened for iron deficiency using serum ferritin and hemoglobin (Reinke et al, 2012). Female children and adolescent athletes may develop disordered eating, menstrual dysfunction, or decreased BMD. Pediatricians need to carefully monitor for subsequent amenorrhea and osteoporosis, the “female athlete triad.” This triad is serious and requires a multidisciplinary approach. Perfectionism enhances the risk for disordered eating, especially in varsity athletes. Prevention requires de-emphasis on percentage of body fat and adequate emphasis on good nutrition. The consequences of lost BMD can be devastating; premature osteoporotic fractures can occur, and lost BMD might never be regained. Winter sports may protect bone density because of the vigor required. The most important nutritional challenges for winter sport athletes exposed to environmental extremes include increased energy expenditure, accelerated muscle and liver glycogen utilization, exacerbated fluid loss, and increased iron turnover (Meyer et al, 2011). The primary fuel for athletic events using less than 50% VO2max (or aerobic capacity) is fat. Muscle glycogen and blood glucose supply half of the energy for aerobic exercise during a moderate workout (at or below 60% of VO2max or aerobic capacity) and nearly all the energy during a hard workout (above 80% of aerobic capacity). In short-duration events of more than 70% VO2max (as in events like swimming or sprint running), glycogen is the key fuel. In long-duration events or activities of more than 70% VO2max (such as long-distance running, cycling, or swimming), muscle glycogen can be depleted in 100 to 120 minutes; maintaining a high-carbohydrate daily diet while training for adequate glycogen replenishment is necessary.

Escott-Stump_Ch01.indd 39

Carbohydrate (CHO) ingestion during prolonged exercise and CHO loading before exercise can have different effects on fuel substrate kinetics. Performance in endurance events depends on maximal aerobic power, sustained by the availability of substrates (carbohydrates and fats). When compared with fasting, both low- and high-glycemic index foods consumed 3hours before and halfway through prolonged, high-intensity intermittent exercise will improve sprint performance (Little etal,2009). Fatigue is associated with reduced muscle glycogen; increasing muscle glycogen or blood glucose prolongs performance, while increasing fat and decreasing CHO decreases performance. A sports diet aligns 20% protein, 30% CHO, and 30% fat, with the remaining 20% of the energy distributed between CHO and fat, based on the intensity and duration of the sport. Table 1-21 provides the position statements of the International Society of Sports Nutrition. Trained individuals have higher levels of fat oxidative capacity, which spares glycogen during endurance sports. Endurance runners who eat a low-fat diet may not consume enough energy, EFAs, and some minerals, especially zinc; these inadequate intakes may compromise their performance. Gymnasts often have a lower weekly calorie intake but a higher dietary protein intake than nonathletes; this places them at risk of malnutrition and immunosuppression. Athletes should be well hydrated before the start of exercise and should drink enough fluid during and after exercise to balance fluid losses. Consumption of sports drinks containing carbohydrates and electrolytes during exercise will provide fuel for the muscles, help maintain blood glucose and the thirst mechanism, and decrease the risk of dehydration or hyponatremia (Academy of Nutrition and Dietetics, 2009). A qualified dietitian who is a board-certified specialist in sports nutrition can provide individualized nutrition direction and advice following a comprehensive nutrition assessment (Academy of Nutrition and Dietetics, 2009). Figure 1-10 shows differences in levels of energy expenditure for various sports.

Clinical/History • Height • Weight • Goal weight

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-21 International Society of Sports Nutrition Position Statements Individuals engaged in regular exercise training require more dietary protein than sedentary individuals. Protein intakes of 1.4–2.0 g/kg/d for physically active individuals are not only safe but may improve the training adaptations to exercise training. When part of a balanced, nutrient-dense diet, protein intakes at this level are not detrimental to kidney function or bone metabolism in healthy, active persons. While it is possible for physically active individuals to obtain their daily protein requirements through a varied, regular diet, supplemental protein in various forms are a practical way of ensuring adequate and quality protein intake for athletes. Different types and quality of protein can affect amino acid bioavailability; superiority of one protein type over another in terms of optimizing recovery and/or training adaptations remains to be demonstrated. Appropriately timed protein intake is an important component of an overall exercise training program, essential for proper recovery, immune function, and the growth and maintenance of lean body mass. Under certain circumstances, specific amino acid supplements, such as branched-chain amino acids (BCAAs), may improve exercise performance and recovery from exercise. Maximal endogenous glycogen stores are best promoted by following a high-glycemic, high-carbohydrate diet (600–1000 g CHO or 8–10 g CHO/kg/d). Ingestion of free amino acids and protein (PRO) alone or in combination with CHO before resistance exercise can maximally stimulate protein synthesis. Ingesting CHO alone or in combination with PRO during resistance exercise increases muscle glycogen, offsets muscle damage, and facilitates greater training adaptations after either acute or prolonged periods of supplementation with resistance training. Nutrient timing incorporates methodical planning and eating of whole foods, nutrients extracted from food, and other sources. The timing of the energy intake and the ratio of ingested macronutrients allow for enhanced recovery and tissue repair following high-volume exercise, augmented muscle protein synthesis, and improved mood states when compared with unplanned or traditional strategies of nutrient intake. Increased meal frequency appears to have a positive effect on various blood markers of health, particularly LDL cholesterol and insulin. Increased meal frequency does not appear to significantly enhance diet-induced thermogenesis, total energy expenditure, or resting metabolic rate. Increasing meal frequency appears to help decrease hunger and improve appetite control. Sources: Kerksick C, Harvey T, Stout J, et al. International society of sports nutrition position stand: nutrient timing. J Int Soc Sports Nutr. 2008;5:17; LaBounty PM, Campbell BI, Wilson J, et al. International Society of Sports Nutrition position stand: meal frequency. J Int Soc Sports Nutr. 2011;8:4.

• • • •

Cross-country skiers Runners

Lab Work

Swimmers Speed skaters Fencers Female

Sedentary 0

BMI HBW range for height Diet/intake history Hydration (I&O)

12 30 40 50 60 70 Maximal oxygen uptake, mL • kg-1 • min-1

Cross-country skiers Middle-distance runners Speed skaters

• • • • • • • • • • • • • • • •

H&H, serum Fe Ferritin Transferrin Na, K, chloride Serum glucose BP Alb, transthyretin (if needed) Total Chol High-density lipoprotein (HDL) Low-density lipoprotein (LDL) Trig Serum insulin Ca, Mg ALP Homocysteine Serum vitamin D levels

Cyclists

INTERVENTION

Rowers Weight lifters Male

Sedentary 0

Objectives

12 30 40 50 60 70 Maximal oxygen uptake, mL • kg-1 • min-1

Figure 1-10. Oxygen update for different activities. (Adapted with permission from ACSM’s Metabolic calculations handbook. Baltimore, MD: Lippincott Williams & Wilkins; 2006.)

Escott-Stump_Ch01.indd 40

• Promote healthy, safe eating habits and activities that can be continued throughout life. Aerobic activity and resistance training are especially beneficial. Participation in sports activity can be an important component of obesity prevention. • Because physical activity, athletic performance, and recovery from exercise are enhanced by optimal nutrition, adequate energy intake is needed to support peak performance (Academy of Nutrition and Dietetics, 2009).

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

• Correct faddist beliefs, dangerous dieting trends, meal skipping, and other unhealthy eating behaviors. • Prevent or correct amenorrhea, which may result from poor energy and fat intake. Runners may be especially vulnerable. Monitor or correct EDs, including bulimia and anorexia nervosa. • Help prevent injuries, dehydration, overhydration, and hyponatremia. • Enhance overall health and fitness. A certain amount of fat is essential to bodily functions. Fat regulates body temperature and cushions and insulates organs and tissues. Fat intake provides EFAs and fat-soluble vitamins, as well as energy for weight maintenance (Academy of Nutrition and Dietetics, 2009). Table 1-22 provides ranges of body fat standards. • Body weight and composition should not be criteria for sports performance; daily weigh-ins are discouraged (Academy of Nutrition and Dietetics, 2009).

Food and Nutrition • For active individuals, use a normal diet for age and sex with special attention to energy needs for the specific activity and frequency. Most athletes should consume 6 to 10 g of CHO per kg of body weight on a daily basis. Female athletes may not consume sufficient levels of protein and energy, often because they want to lose weight. • Maintain total fat intake at a level determined by age, medical status, type of performance, and endurance required. Focus on heart-healthy fats such as olive oil and canola oil. • Protein eaten in excess of recommendations is used by the body as a fuel; the body will store the excess as fat tissue. Athletes who eat many high-protein foods and take protein supplements in addition may be at risk for dehydration or kidney problems. Protein requirements should be calculated by age and sex, with a slightly higher requirement in endurance sports activity. Table 1-23 provides a chart for calculating protein needs for athletes. • Vitamin and mineral supplements are not needed if adequate energy to maintain body weight is consumed from a variety of foods but may be needed if the individual’s diet is imbalanced (Academy of Nutrition and Dietetics, 2009). Exercise

STAGES

MEN

WOMEN

Essential for life

4%–5%

10%–12%

Athletes

6%–13%

14%–20%

Very lean/underweight

21%

U.S. Department of Defenseb

18%

26%

Recommended

8%–20%

21%–32%

Overweight

20%–25%

32%–38%

Obese

25%

38%

Childrenc

14% newborn

13% 10-year-old boy

19% 10-year-old girl

a These standards are for 20–40 years of age. Add approximately 1% body fat for each additional decade above 40 years of age. b Army Body Fat Standards. Available at: http://www.apft-standards.com/malebodyfat.html. Accessed June 15, 2014. c Shils M, Olson JA, Shike M, et al. Modern nutrition in health and disease. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 1999:799.

Escott-Stump_Ch01.indd 41

TABLE 1-23 Protein Intake for Athletes CATEGORY

PROTEIN INTAKE PER DAY

Sedentary men and women

0.8–1.0 g/kg or 0.4 g/lb body weight

Moderate-intensity endurance athletes, 45–60 minutes four to five times per week

1.2 g/kg or 0.6 g/lb body weight

Elite male endurance athletes

1.6 g/kg or 0.8 g/lb body weight

Competitive sports that emphasize buildingmuscle mass

1.4 g/kg or 0.7 g/lb body weight

Recreational endurance athletes, 30minutes at 55% VO2 peak four to five times perweek

0.8–1.0 g/kg or 0.5 to 0.6 g/lb bodyweight

Football, power sports

1.4–1.7 g/kg

Resistance athletes (early training)

1.5–1.7 g/kg

Resistance athletes (steady state)

1.0–1.2 g/kg

Adapted from: Burke L, Deakin V. Clinical sports nutrition. 3rd ed. McGraw-Hill; 2006:73–112; Clark N. Nancy Clark’s sports nutrition guidebook. 4th ed. Champagne, IL: Human Kinetics Publishers; 2008:127–146.

•

TABLE 1-22 Percent Body Fat Standardsa

•

may increase the requirements for riboflavin and vitamin B6; this is easily met with use of dairy products. Fluid replacement may be essential with a calculation of 1mL/kcal used for an average. Drink too little and dehydration is a risk, as in marathon runners. With too much fluid, there is a risk for hyponatremia in slow runners and marathon walkers. Fluid overconsumption behaviors may occur in hot ultramarathons, irrespective of running speed and gender (Costa et al, 2013). Electrolytes must be carefully monitored and replaced. Sports drinks are formulated to have between 6% and 8% CHO along with an appropriate amount of electrolytes; they should not be diluted. Newer sports drinks on the market contain glucose polymers with lower osmolality than sugared drinks or fruit juice. Gatorade and other recently formulated sports drink products are acceptable. When athletes omit meat from their diets, other sources of zinc and heme iron must be obtained. Dried beans, nuts, seeds, peanut butter, soy products, tofu, and enriched cereals provide protein and some iron. Consume twice as many nonheme foods for the same amount of iron absorption as from heme sources. Adequate calcium intake may prevent osteoporosis, reduce muscle cramping, and protect against stress fractures. For maximum bone density, include four servings of dairy or calcium-fortified foods (or three servings plus a 500 mg calcium supplement) until age 24. Glucose loading is not recommended for athletes who train daily for endurance sports. Complex CHO in the form of starch promotes better glycogen storage. Avoid skipping meals. Breakfast is especially important; small meals or frequent snacks are useful for some athletes. Table 1-24 provides guidance in planning meals for athletes. A quick guide to carbohydrate sources and quantities can be found at http://www.anfponline.org/CE/nutrition _connection/2009_03.shtml.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Check first with the U.S. Olympic Committee or the National Collegiate Athletic Association (NCAA) (http://www.ncaa.org /health-and-safety/policy/drug-testing) before using any drugs.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-24 Guidelines for Planning Meals for Athletes NUMBER OF SERVINGS PER DAYa

Bread/grains group

FEMALE NONATHLETES

FEMALE ATHLETES, MALE NONATHLETES

MALE ATHLETES

6–11

9–15

11–18

Vegetable group

Fruit group

2–4

3–5

4–8

Dairy group

4–5

2 ( 5 oz)

2 ( 6 oz)

3 ( 7–11 oz)

20%–35% calories

Protein/meat group Fats/lipids

Preexercise • Consumption of a CHOb PRO supplement may result in peak levels of protein synthesis. • Eat lightly before an athletic competition; chew foods well. Remember, it takes 4–5 hours to fully digest a meal. Focus on complex carbohydrates (about 65% of the meal). • Avoid bulky foods (raw fruits and vegetables, dry beans and peas, and popcorn), which may stimulate bowel movements; avoid gas-forming foods (cabbage family and cooked dry beans). • Drink water to be adequately hydrated: drink 2 cups of cool water 1–2 hours before the event and 1–2 cups of fluid 15 minutes before the event. • Avoid drastic changes in normal diet routine immediately prior to competition; focus on well-tolerated or favorite foods.

During Exercise • CHO should be consumed at a rate of 30–60 g of CHO/hour in a 6%–8% CHO solution (8–16 fluid oz) every 10–15 minutes. CHO:PRO ratio of 3–4:1 may increase endurance performance and maximally promotes glycogen resynthesis during acute and subsequent bouts of endurance exercise.

Postexercise (within 30 minutes) • Consumption of CHO at high dosages (8–10 g CHO/kg/d) stimulates muscle glycogen resynthesis. Adding 0.2–0.5 g protein/kg/d to CHO at a ratio of 3–4:1 (CHO:PRO) further enhances glycogen resynthesis. Fruits, juices, and high-carbohydrate drinks are examples (Kerksick et al, 2008). • Replace fluids that have been lost; drink 2 cups of fluids for every lost pound. Replace any potassium or sodium that has been lost during competition or training; fruits and vegetables are excellent sources of potassium. Replace sodium by eating salty foods; if activity was vigorous and exceeded 2 hours, a sports beverage may be useful (Kerksick et al, 2008).

Postexercise Ingestion (immediately to 3 hours post) • Protein (essential amino acids) has been shown to stimulate robust increases in muscle protein synthesis, while the addition of CHO may stimulate even greater levels of protein synthesis (Kerksick et al, 2008). • Meat and soy substitutes have 7 g protein/serving; dairy products have 8 g protein/serving; and breads/cereals/grains have 3 g protein/serving.

During Consistent, Prolonged Resistance Training • Postexercise consumption of CHO plus PRO supplements in varying dosages have been shown to stimulate improvements in strength and body composition when compared to control or placebo conditions. a

Source: U.S. Department of Agriculture and the U.S. Department of Health and Human Services. A quick guide to carbohydrates can be accessed at Association of Food and Nutrition Professionals. Nutrition connection: carbohydrates and carb counting. Available at: http://www.anfponline.org /CE/nutrition_connection/2009_03.shtml. Accessed June 15, 2014. b

Reference: Kerksick C, Harvey T, Stout J, et al. International society of sports nutrition position stand: nutrient timing. J Int Soc Sports Nutr. 2008;5:17.

• Androstenedione and anabolic steroids do promote muscle mass enhancement; they are not allowed. Steroids affect numerous nutritional parameters. Take a careful drug history and discuss all side effects. • A balanced sports drink is more desirable than use of salt tablets. • Athletes with cardiovascular, metabolic, hepatorenal, diabetic, or neurologic disease who are taking medications affected by high glycemic load foods, caffeine, or other stimulants should avoid use of these products unless approved by their physician (Campbell et al, 2013). • Discuss the relevance of tolerable ULs from the latest dietary reference intakes of the National Academy of Sciences. These levels were set to protect individuals from receiving too much of any nutrient from diet and dietary supplements. Discuss the fact that excessive use of vitamin– mineral supplements can lead to toxicity, especially for vitamins A and D.

Escott-Stump_Ch01.indd 42

Herbs, Botanicals, and Supplements • Herbs and botanical supplements should not be used without discussing with the physician. • Use of supplements is common in athletes. Ginseng, caffeine, ma huang (Chinese ephedra), ephedrine, and a combination of both caffeine and ephedrine are the most popular herbs used in exercise and sports (Chen et al, 2012). • Creatine in older individuals can increase the short-term capacity to perform quick, repeated episodes of intense activity (Cherniak, 2012). Creatine is not recommended for use in children. • Carnitine may decrease fatigue and increase endurance in older persons (Cherniak, 2012). • Some supplements may be contaminated with banned substances. If an athlete is found to have taken a banned substance, actions are taken by the regulatory agency (e.g., the International Olympic Committee, NCAA, or other sports sanctioned agencies). Athletes must be advised accordingly.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-25 Supplements Commonly Used by Athletes Androgens

Banned by the NCAA, the IOC, the U.S. Olympic Committee, the National Football League, and the Association of Tennis Professionals.

Caffeine

Ergogenic aid for endurance athletes when taken before and/or during exercise in moderate quantities, such as 3–6 mg/kg body mass (Ganio et al, 2009). However, caffeine use is limited in competitive sports.

Chromium picolinate (CrPl)

Widely available in many foods; supplements are not necessary.

Creatine

Increases the capacity of skeletal muscle to perform work during periods of alternating intensity exercises. Creatine is useful for strength training but not for endurance sports. If used, use 20–25g daily for 5–7days, followed by maintenance at 5g/d. It requires a month to completely leave the bloodstream after stopping.

•

Ephedra/ephedrine (Ma Huang)

Raises heart rate. Does not increase energy. Removed from the market by FDA.

•

Ginseng

Often used for performance enhancement. Avoid use with warfarin, insulin, oral hypoglycemics, CNS stimulants, caffeine, steroids, hormones, antipsychotics, aspirin, or antiplatelet drugs.

•

Leucine, alanine

Suggested to improve strength and performance. Paresthesia may result. UL values not regulated.

Tryptophan

Precursor to serotonin. Sometimes used for performance enhancement. May cause psychosis if used with antidepressants, MAO inhibitors.

Whey protein

May cause acne if taken in large doses.

Yohimbe, smilax, tribulus, Cannot be converted by the body to anabolic steroids and wild yams or enhance muscle mass. Zinc

Sometimes taken to enhance performance. Zinc should not be taken with immunosuppressants, fluoroquinolones, and tetracycline.

Sources: Nutrition.gov. Dietary supplements for athletes. Available at: http://www.nutrition .gov/dietary-supplements/dietary-supplements-athletes. Accessed June 15, 2014; Office of Dietary Supplements. Dietary supplement fact sheets. Available at: http://ods.od.nih.gov/fact sheets/list-all/. Accessed June 15, 2014.

• Because regulations specific to nutritional ergogenic aids are poorly enforced, they should be used with caution and only after careful product evaluation for safety, efficacy, potency, and legality (Academy of Nutrition and Dietetics, 2009). Supplements commonly used by athletes are noted in Table1-25.

Nutrition Education, Counseling, Care Management • Dispel myths, such as “milk is for children only,” “meat is bad for you,” “carbohydrates are fattening,” or “dieting is the key to fluid control.” • Refer athletes with traits such as perfectionism, compulsive or controlling behaviors, and a need for attention to a psychologist or health provider. • Educate athletes, parents, coaches, trainers, judges, and administrators about the dangers of restrictive eating. Discuss healthy body weight, family genetics, body type, parenting styles, socioeconomic issues, and environmental cues. • Pre-event meals can be eaten up to an hour before the activity. Choose complex carbohydrates; use less fat and protein

Escott-Stump_Ch01.indd 43

•

because of their slowing effect on digestive processes. After an event, recovery carbohydrate intake is suggested. There is no such thing as “quick energy.” The habit of eating candy before a game can cause an insulin overshoot, leading to hypoglycemia. A well-balanced diet will suffice for most events (Academy of Nutrition and Dietetics, 2009). Discuss a high-calorie, high-complex carbohydrate diet with attention to individual preferences. In vigorous programs such as ultramarathons, 3000 to 6000 kcal may be needed. Prevent dehydration. Drink fluids before, during, and after exercising. Weigh before and after events. Replace lost weight (about 2 cups of fluid per pound lost). Avoid use of alcoholic beverages. Many adults need to reduce intake of alcohol, sugar-sweetened beverages, sports, and energy drinks and choose healthier beverages (Park et al, 2013). Breastfeeding women can exercise reasonably without adverse effects. Male athletes tend to desire size, speed, and power. Female athletes are more concerned with body fat, more likely to restrict protein and energy, and more likely to take weight loss supplements (Muller et al, 2009). Disordered eating, oligomenorrhea or amenorrhea, and low BMD are associated with musculoskeletal injuries in female athletes (Rauh et al, 2010). Signs of exercise addiction include rigid rules about exercising, anxiousness, restlessness when off schedule, working out more than a coach recommends, and rigid or calculated eating patterns to exactly match calories expended on exercise. Runners may benefit from vitamin/calcium supplementation to prevent stress fracture (McCormick et al, 2012).

Patient Education—Food Safety Tips • Reminders about hand washing and safe food handling may be important, especially for athletes with busy lifestyles. Use of hand sanitizers can be encouraged. • Athletes who travel frequently may be vulnerable to food poisoning. They should be advised to choose foods carefully when traveling. • Athletes who compete in other countries should become aware of potential risks where they will be traveling. For example, safe food and water sources are not always available.

SAMPLE NUTRITION CARE PROCESS STEPS Inadequate Fluid Intake in Athlete Assessment Data:Dietary recall; labs (BUN, sodium); I&O descriptions. Nutrition Diagnosis (PES): Inadequate fluid intake related to marathon preparation as evidenced by altered labs, poor skin turgor, frequent headaches, reports of dehydration and limited intake of fluids on workout days. Intervention: Education on fluid intake for body size, extent of training, and types of physical activities. Counseling on use of any supplements or sports drinks. Monitoring and Evaluation: Improved hydration status; improved lab values (BUN, sodium); fewer headaches and signs of dehydration; I&O levels that are balanced.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

For More Information ●

●

Academy of Nutrition and Dietetics: Sports and Cardiovascular Nutritionists http://www.scandpg.org/about-us/ American College of Sports Medicine http://www.acsm.org/ American Council on Exercise http://www.acefitness.org American Council (ACE) Recipes http://www.acefitness.org/healthy-recipes/ Centers for Disease Control and Prevention—Nutrition and Physical Activity http://www.cdc.gov/nccdphp/dnpa/ Ergogenic Aids http://fnic.nal.usda.gov/dietary-supplements/ergogenic-aids Gatorade Sports Science Institute http://www.gssiweb.org/ Health and Human Services: Physical Activity Guidelines for Americans http://www.health.gov/paguidelines/ Hydration http://www.aces.edu/pubs/docs/H/HE-0749/ Intelihealth—Fitness http://www.intelihealth.com/healthy-lifestyle/fitness_b National Institutes of Health http://www.nlm.nih.gov/medlineplus/exerciseandphysicalfitness.html Penn State University Fitness and Sports Nutrition http://nirc.cas.psu.edu/fitness.cfm President’s Council on Physical Fitness and Sports http://www.fitness.gov/ Sports Science Peer-Reviewed Information http://www.sportsci.org/index.html?jour/03/03.htm&1 US Antidoping Agency http://www.usada.org/prohibited-list/?gclid=CMfCm4LMor4CFcU-MgodSGEAUg Women’s Sports Foundation http://www.womenssportsfoundation.org/ World Antidoping Agency http://www.wada-ama.org/en/world-anti-doping-program/sports-and-anti -doping-organizations/international-standards/prohibited-list/

●

Young Men’s Health Site http://www.youngmenshealthsite.org/nutrition-sports.html

●

Young Women’s Health Site http://www.youngwomenshealth.org/nutrition-sports.html

REFERENCES Academy of Nutrition and Dietetics. Position of the American Dietetic Association and the Canadian Dietetic Association: nutrition and athletic performance. JAm Diet Assoc. 2009;109:509. Campbell B, et al. International Society of Sports Nutrition position stand: energy drinks. J Int Soc Sports Nutr. 2013;10:1. Chen CK, et al. Herbs in exercise and sports. J Physiol Anthropol. 2012;31:4. Cherniak EP. Ergogenic dietary aids for the elderly. Nutrition. 2012;28:225. Costa RJ, et al. Water and sodium intake habits and status of ultra-endurance runners during a multi-stage ultra-marathon conducted in a hot ambient environment: an observational field based study. Nutr J. 2013;12:13. Ganio MS, et al. Effect of caffeine on sport-specific endurance performance: a systematic review. J Strength Cond Res. 2009;23:315. Little JP, et al. The effects of low- and high-glycemic index foods on high-intensity intermittent exercise. Int J Sports Physiol Perform. 2009;4:367. McCormick F, et al. Stress fractures in runners. Clin Sports Med. 2012;31:291. Meyer NL, et al. Nutrition for winter sports. J Sports Sci. 2011;29 Suppl 1: S127. Muller SM, et al. Enhancing appearance and sports performance: are female collegiate athletes behaving more like males? J Am Coll Health. 2009; 57:513. Park S, et al. Characteristics associated with consumption of sports and energy drinks among US adults: National Health Interview Survey, 2010. J Acad Nutr Diet. 2013;113:112. Peeling P. Exercise as a mediator of hepcidin activity in athletes. Eur J Appl Physiol. 2010;110:877. Philips SM. Dietary protein requirements and adaptive advantages in athletes. BrJ Nutr. 2012;108 Suppl 2:S158. Rauh MJ, et al. Relationships among injury and disordered eating, menstrual dysfunction, and low bone mineral density in high school athletes: a prospective study. J Athl Train. 2010;45:243. Reinke S, et al. Absolute and functional iron deficiency in professional athletes during training and recovery. Int J Cardiol. 2012;156:186.

ADULTHOOD NUTRITIONAL ACUITY RANKING: LEVEL 2 DEFINITIONS AND BACKGROUND Each person has individual DNA sequencing alterations, but humans are 99.9% identical as a species. At a particular chromosome, slight variations can occur; these are single nucleotide polymorphisms (SNPs). Some changes (alleles) lead to chronic diseases such as heart disease, cancer, or diabetes. Figure 1-11 shows normal DNA sequencing. Heart disease is the number one disabler and killer of women in the United States; cancer is the main cause of premature death. Although abnormal laboratory results are significant predictors of higher mortality, when results fall within the normal clinical range, only three tests—albumin, ALP, and BUN— provide mortality differences (Hu and Duncan, 2013). Although hypertension is the main comorbidity found with renal failure, both sexes face cardiovascular mortality with lower estimated glomerular filtration rates and higher albuminuria (Nitsch et al, 2013). Table 1-26 lists special considerations for men.

Escott-Stump_Ch01.indd 44

Thousands of phenotypes are known to affect disease onset (Online Mendelian Inheritance in Man [OMIM], 2013). Different gene mutations affect age of onset, severity, and outcome of diseases. Polymorphisms affect susceptibility of individuals to adverse environments, or even to reproductive success. For example, folic acid alleles can lead to early pregnancy loss, birth defects, and infertility. Table 1-27 lists a number of conditions with a genetic link. In young adulthood (ages 18 to 40), careers are a priority. Inmiddle adulthood (ages 40 to 65), family is the primary focus. Regardless of life stages, adults need to be aware of their dietary intake and its effect on their health. Unfortunately, many adults are obese or have prehypertension, especially African Americans, older people, and individuals with low socioeconomic status. Over the past 40 years, heights, BMIs, and weights have increased in both sexes and in all ethnic groups. High rates of fast food consumption are prevalent (Garciaetal, 2012). In addition to environmental exposure, genetic variations affect perceptions of sweet, fat, and bitter food components.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

GENE Triplet

A nucleotide consists of: Phosphate Deoxyribose sugar Organic base

A G

A T

G C

C A

T C G

G C A

Figure 1-11. Normal human DNA. (Reprinted with permission from Anatomical Chart Company.)

Salts and acids use ion channels for transduction, while bitter, sweet, and umami (glutamate) stimuli use G-protein-coupled receptors (GPCRs) on highly specialized taste sensory cells (Cohen et al, 2012). Supertasters may taste more bitterness (PROP) in vegetables; they may also avoid high-fat or sweet foods because the oral sensations are too intense or unpleasant. Savory (umami) flavors modify appetite and control food intake better than sweet or bland tastes (Finlayson et al, 2012). The CD36 gene variant alters oral fat preference in African Americans (Keller et al, 2012). Thus, taste and satiety must be considered as genetically individualized issues. Heart disease is a major issue in men and women. LDL cholesterol should be monitored (Barter, 2011). Hyperhomocysteinemia is a risk factor for heart disease, as well as for Alzheimer’s disease and stroke. Eating a more plant-based TABLE 1-26 Leading Causes of Death and Nutritional Implications for Men in the United States 1. Heart disease: hyperlipidemia and hypertension are commonly related (seeappropriate entries). 2. Cancer: prostate, testicular, esophageal, and stomach cancers have special nutritional implications. Increasing intake of soy products, fruits, and vegetables and reducing red meat intake may be beneficial.

diet (PBD) with adequate intake of B-complex vitamins (folic acid, vitamins B6, and B12) will be important. Be aware that not all vegetarians have nutritionally sound eating habits. An insufficient vegetarian or vegan diet may lead to symptoms such as anxiety, brain fog, depression, fatigue, insomnia, neuropathies, and other neurologic dysfunction (Plotnikoff, 2012). Docosahexaenoic acid (22:6n-3; DHA) is absent from vegan diets and present in limited amounts in vegetarian diets (Sanders, 2009). Thus, vegetarians must plan their diets carefully. Longstanding dietary habits, depression, literacy deficits, social influences or barriers, and even the right to refuse treatment make it difficult for patients to follow a modified diet. When adults are hospitalized or when restrictive diets are used, oral intake decreases. The Nutrition Care Process promotes use of a thorough assessment to select relevant nutrition diagnoses, goals, interventions, and desirable outcomes. The Transtheoretical Model for Stages of Change (TTM, or TMSOC) is useful to determine current levels of motivation (Norcross et al, 2011). The five stages of change are (1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance. One of the key components for progress to a later stage is decisional balance, weighing the pros and cons of changing to the target behavior (Kroll et al, 2011). Once the stage of “readiness to change” is identified, appropriate strategies can be designed.

3. Unintentional accidents: excessive alcohol intake may be related (seeappropriate entry). 4. Chronic lower respiratory diseases: weight loss or gain may aggravate breathing problems.

ASSESSMENT, MONITORING, AND EVALUATION

5. Stroke: high intake of sodium and alcohol are problematic, as is chronic hypertension that is untreated. 6. Diabetes: carbohydrate intake should be consistent and consumed at regular intervals. 7. Influenza and pneumonia: infectious diseases burn more energy; weight loss can occur if energy intake is poor. 8. Suicide: depression and excessive alcohol intake may play a role (seeappropriate entries). 9. Kidney disease: many renal diseases have implications for control of protein, sodium, electrolytes, and fluid. Kidney stones are more common in men than in women and drinking plenty of fluids and consuming adequate calcium may prevent onset or recurrence (see appropriate entries). 10. Alzheimer’s disease: research has found links between brain health and heart health. Experts suggest eating a low-fat, heart-healthy diet, maintaining a healthy weight, exercising regularly, and staying mentally and socially active. Source: Centers for Disease Control and Prevention. Leading causes of death in males United States. Available at: http://www.cdc.gov/men/lcod/index.htm. Accessed June 15, 2014.

Escott-Stump_Ch01.indd 45

Genetic Markers • Each individual has a unique genetic profile and phenotype. Because both parents contribute genes and chromosomes to a fetus, a genetic history may be beneficial. There are over 1,000 gene tests available for a variety of conditions.

Clinical/History • • • • • • •

BP Height Weight, current Weight, usual BMI and waist to hip ratio Recent weight changes HBW range

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-27 Disorders and Their Related Genes DISORDERS

RELATED GENES

Neurologic Disorders Premature family Alzheimer’s disease

APP gene PSEN1 gene PSEN2 gene

Late-onset Alzheimer’s disease

APOE gene

Huntington disease

CAG triplet-repeat expansion in the IT15 region of the HD gene

Frontotemporal dementia

MAPT gene

Tay-Sachs disease

HEXA gene

Pantothenate kinase neurodegeneration

PANK2 gene

Hereditary neuropathy with pressure palsies (HNPP)

17p11.2 deletion in the PMP22 gene PMP22 gene

Familial Parkinson’s disease (PARK1)

SNCA gene

Early-onset Parkinson’s disease (PARK2)

PARK2 gene

Autosomal dominant Lewy body parkinsonism (PARK4)

SNCA gene

Rett syndrome

MECP2 gene

Fragile X syndrome (FRAX)

CGG triplet-repeat expansion analysis of the FMR-1 gene

Hematological and Cardiovascular Disorders Thrombophilia

Mutation of G1691 A (Arg506Gln) in the Factor V (Leiden) gene Mutation of G20210 A in the Prothrombin (Factor II) gene Mutation C677 T (Ala222Val) and A1298 C (Glu429Ala) in the MTHFR gene PAI1 gene, plasminogen activator inhibitor Angiotensin enzyme converter gene

Fanconi anemia (complementation group A)

FANCA gene

Fanconi anemia (complementation group C)

Mutation of IVS44 A-T in the FANCC gene FANCC gene

Hemophilia

Intron 22 inversion mutation of F8 gene F8 gene type A; F9 gene in type B

Glucocorticoid-remediable aldosteronism type 1

CYP11B1/CYP11 B2 chimeric gene

Marfan syndrome

FBN1 gene

Congenital thrombocytopenia

MPL gene

Metabolic Disorders Pituitary hormone deficiency

POU1F1 and PROP1 genes

Alpha-1-antitrypsin deficiency

Mutation of E264 V (Allele S) and E342 K (Allele Z) in the PI gene

Fructose-1,6-diphosphatase deficiency

FBP1 gene

Growth hormone deficiency

GH1 gene

Hereditary hemochromatosis

Mutation of C282Y, H63D, and S65 C in the HFE gene

Familial hypercholesterolemia

LDLR gene Mutation of Arg3500Gln, Arg 3531Cys, and Arg3480Trp in the APOB gene Mutations of the CYP11B1 gene and CYP21A2 gene

Homocystinuria

Mutation of Gly307Ser and Ile278Thr in the CBS gene Mutation of C677 T and A1298 C in the MTHFR gene

Muscular and Skeletal Disorders Achondroplasia

Mutation of G1138 A, G1138 C, G375 C in FGFR3 gene

Myoclonus-dystonia (DYT11)

SGCE gene

Rapid-onset dystonia-parkinsonism (DYT12)

ATP1A3 gene

Duchenne/Becker muscular dystrophy

DMD gene

Amyotrophic lateral sclerosis (ALS1)

SOD1 gene

Osteoporosis

BsmI, ApaI, TaqI, and FokI polymorphism in VDR gene Pro463Leu polymorphism detection in the CTR gene PCOL2 (-1997 G/T) and Sp1 (1546 G/T) polymorphisms in COL1A1 gene PvuII (397 TC) and XbaI (351 CG) polymorphism in ESR1 gene Polymorphisms in the IL-6 gene

Escott-Stump_Ch01.indd 46

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-27 Disorders and Their Related Genes (continued) DISORDERS

RELATED GENES

Reproductive Disorders Preeclampsia, eclampsia, HELLP syndrome, or recurrent spontaneous pregnancy loss

Mutation of G1691 A (Arg506Gln) in Factor V gene Mutation of G20210 A in the Factor II gene Mutation of C677 T (Ala222Val) and A1298 C (Glu429Ala) in the MTHFR gene

Neoplastic Disorders Breast/ovarian cancer

Mutation in exons 2, 3, 5, 8, 11, 18, 20, 23 of BRCA1 gene BRCA1 gene Mutation in exons 2, 10, 11, and 23 of the BRCA2 gene BRCA2 gene

Hereditary nonpolyposis colon cancer—Lynch syndrome

Microsatellites instability MLH1 gene or MSH2 gene

Medullary thyroid carcinoma

Mutation in exons 10, 11, 13, 14, 16 of the RET gene RET gene

Cutaneous malignant melanoma 2

CDKN2 A gene

Familial adenomatous polyposis (FAP)

APC gene

Colorectal polyposis

MUTYH (MYH) gene

Retinoblastoma

RB1 gene

Wilms’ tumor

WT1 gene

Multisystemic Disorders Cystic fibrosis

30 prevalent European mutations of the CFTR gene IVS8-Tn (poli-T) polymorphism in CFTR gene

Polycystic kidney disease

PKD1 gene PKD2 gene

Pharmacogenetics Breast cancer

HER2 (NEU) overexpression detection and Herceptin (trastuzumab) treatment

Non-small-cell lung cancer (NSCLC)

Mutation screening in exons 18–21 of the EGFR gene and Gefitinib treatment

CYP2D6 for psychiatric and cardiovascular disorders treatment

Polymorphism of the CYP2D6 gene. This gene is involved in metabolizing different drugs such as Prozac, Zoloft, Haldol, metoprolol, Tagamet, tamoxifen, Paxil, Effexor, hydrocodone, amitriptyline, Claritin, cyclobenzaprine, Allegra, Dytuss, Tusstat, Rythmol

CYP2C9 linked to thrombosis, diabetes, and other disorders’ treatment

Polymorphism of the CYP2C9 gene. This gene is involved in metabolizing Coumadin (warfarin), Viagra, Amaryl, isoniazid, sulfa, ibuprofen, amitriptyline, Dilantin, Hyzaar, tetrahydrocannabinol, Naproxen

CYP2C19 linked to psychiatric diseases, epilepsies, malaria and anesthesia

Polymorphism of the CYP2C19 gene. This gene is involved in metabolizing different drugs: carisoprodol, diazepam, Dilantin, Premarin, and Prevacid

Chronic myeloid leukemia

Mutation screening in exons 4–10 of the ABL gene, for the treatment with Gleevec (Imatinib)

Acute myeloid leukemia

Mutation in the KIT (CD117) gene, for the treatment with Gleevec (Imatinib) Mutation of the FLT3 gene

5-Fluorouracil toxicity

Allele 2 A (IVS141G-A) determination in DPD gene

Thiopurines toxicity

For the treatment of thrombosis, diabetes, and a variety of diseases. The TPMT gene is associated to the different thiopurines metabolism: azathioprine (Imuran,) 6-mercaptopurina (Purinethol), and 6-tioguanina (Lanvis)

Mitochondrial Disorders Neuropathy, ataxia, and retinitis pigmentosa (NARP)

Mutation of T8993G and T8993 C in the MTATP6 gene

Maternal hereditary deafness

Mutation of A1555G, A827G, T961 C, T961insC, T961delTC(n)ins, T1005 C, A1116G, and C1494 T in the MTRNR1 gene Mutation screening of T7445 C and A7443G in the MTCO1 gene

Source: LabGenetics. Available at: http://www.labgenetics.com.es/en/Default.htm. Accessed June 15, 2014.

• • • • • • • •

Diet history Body fat analysis Smoking Illiteracy Biased or false intake reporting? Failure to report use of herbs, alcohol, supplements Unusual work patterns such as shift work Vegan or disordered eating pattern?

Escott-Stump_Ch01.indd 47

Lab Work • • • • • • •

Glucose Chol—LDL Trig Na, K Mg, Ca H&H, serum Fe Homocysteine

11/7/14 8:14 PM

48 • • • • • •

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Serum folic acid and vitamin B12 C-reactive protein (CRP) Alb, transthyretin (if needed) BUN, Creat Sleep disorder screening Serum vitamin D levels

• •

INTERVENTION •

Objectives • Maintain quality of nutrition while compensating for lower energy needs than those during periods of growth. • Maintain a healthy lifestyle for greater longevity. Losing excess weight, exercising, and eating a nearly meat-free diet are tips shared by many centenarians. • Correct obesity resulting from a sedentary lifestyle. Highly sedentary people lose 20% to 24% of overall muscle mass and strength. Every adult should accumulate 30 minutes or more of moderate-intensity physical activity on most days

•

of the week. Also useful are strength training (resistance or weight training with 8 to 12 repetitions), isotonics, and aerobics (20 minutes of walking, jogging, swimming, or bicycling). Prevent or delay the onset of chronic diseases through healthful dietary choices. Improve nutrient density of meals, especially those eaten away from home. The average American eats three to four meals away from home each week. Make “each calorie count more” and select foods that offer more quality per “bite.” Use of a multivitamin–mineral supplement can assure that the basics are met, but a balanced diet provides other beneficial phytochemicals. Lutein and zeaxanthin from food protect against age-related eye diseases, such as macular degeneration. Promote adequate bone mass density, which peaks at 25 to 30 years of age. Osteopenia is common in women over age 40. Men are also at risk as they age. Identify food insecurity which is common in migrant and farm households. Participation in food banks, dependence on family members or friends outside the household for access to food, inadequate transportation, and not having a garden are concerns (Holben et al, 2010).

TABLE 1-28 Special Nutrition-Related Concerns of Adult Womena Benign breast disease (BBD)

50%–60% of all women present with breast nodularity, swelling, and pain with monthly hormonal changes. Benign breast disease andhigh breast density are prevalent, strong risk factors for breast cancer (Tice et al, 2013). Studies fail to support nutrition interventions with decreased sodium or fluid and caffeine; increased use of primrose oil, herbal teas, vitamins A, C, E, B6, iodine, selenium. There is a lower risk for BBD with higher intakes of vegetable fat, nuts, peanut butter, and vegetable protein during high school (Berkeyet al, 2013).

Infertility

Women desiring to become pregnant should stop smoking and drinking alcohol, and increase intakes of multivitamin–mineral supplements (Agrawal et al, 2012). Implantation failure requires cellular changes in the endometrium and modified expression of different cytokines, growth factors, transcription factors, and prostaglandins (Granot et al, 2012). Thus, an inflammatory process is involved.

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)

Up to 40% of women experience symptoms including edema, migraines, depression, and mastalgia. PMDD is generally more severe, although women experience anxiety and irritability in both conditions. Herbal supplements have limited supporting evidence. Thiamin, riboflavin, niacin, vitamin B6, folate, and vitamin B12 are required to synthesize neurotransmitters; thiamin and riboflavin seem to have a role in the pathophysiology of PMS (Chocano-Bedoya et al, 2011). Potassium and zinc are minerals that may also play a role (Chocano-Bedoya et al, 2013).

Perimenopause

In the 2- to 10-year stage before menopause, women may experience vasomotor symptoms (hot flashes, night sweats) and fatigue. Other symptoms may include insomnia, weight gain, loss of libido, irregular periods, fibroids or heavy bleeding, breast pain, mood swings and irritability, cravings for sweets or alcohol, digestive problems, hair loss, stiffness or joint pain, anxiety, and depression. Women should exercise regularly and consume a balanced, healthy diet. Herbal remedies are not very effective. The effects of dietary soy (phytoestrogens) and fiber intake vary by ethnic groups (Gold et al, 2013).

Menopause

Declining levels of estrogens and other hormones, cessation of menstrual periods, and a decreased need for iron occur. Hormone therapy (HT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the most effective treatments (Thacker, 2011). Exercise, calcium, vitamin D, and physical examinations are needed. A diet that is moderate in carbohydrate slows insulin shifts; lean proteins and moderate fat help to prevent weight gain. Food sources of selenium and vitamins C and E contribute antioxidant benefits. Evidence does not support the efficacy of alternative or over-the-counter products, such as phytoestrogens and black cohosh, and their long-term safety is largely unknown (Thacker, 2011).

Postmenopause

Older women may be at risk for poor nutritional intake because their diets tend to be more limited; they may have difficulty chewing; and they may no longer enjoy cooking. After menopause, women have higher total body fat percentage and different distribution, which correlates with cardiovascular disease risk factors (Park et al, 2013). Nutrient supplementation may be beneficial, especially for calcium, zinc, and the vitamins. Exercise and the Mediterranean diet should be encouraged.

See related disorder sections for specific disease advice.

References: Agrawal R, Burt E, Gallagher AM, et al. Prospective randomized trial of multiple micronutrients in subfertile women undergoing ovulation induction: a pilot study. Reprod Biomed Online. 2012;24:54; Berkey CS, Willett WC, Tamimi RM, et al. Vegetable protein and vegetable fat intakes in pre-adolescent and adolescent girls, and risk for benign breast disease in young women. Breast Cancer Res Treat. 2013;141:299; Chocano-Bedoya PO, Manson JE, Hankinson SE, et al. Dietary B vitamin intake and incident premenstrual syndrome. Am J Clin Nutr. 2011;93:1080. Chocano-Bedoya PO, Manson JE, Hankinson SE, et al. Intake of selected minerals and risk of premenstrual syndrome. Am J Epidemiol. 2013;177:1118; Gold EB, Leung K, Crawford SL, et al. Phytoestrogen and fiber intakes in relation to incident vasomotor symptoms: results from the Study of Women’s Health Across the Nation. Menopause. 2013;20:305; Granot I, Gnainsky Y, Dekel N. Endometrial inflammation and effect on implantation improvement and pregnancy outcome. Reproduction. 2012;144:661; Park JK, Lim YH, Kim KS, et al. Body fat distribution after menopause and cardiovascular disease risk factors: Korean National Health and Nutrition Examination Survey 2010. J Womens Health (Larchmt). 2013;22:587; Thacker HL. Assessing risks and benefits of nonhormonal treatments for vasomotor symptoms in perimenopausal and postmenopausal women. J Womens Health (Larchmt). 2011;20:1007; Tice TA, O’Meara ES, Weaver DL, et al. Benign breast disease, mammographic breast density, and the risk of breast cancer. J Natl Cancer Inst. 2013;105:1043.

Escott-Stump_Ch01.indd 48

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

• Anemia affects half of all adult women. A nutritious diet should be consumed. Table 1-28 provides a summary of conditions that affect women specifically. • Modify the type of dietary fat to lower cardiovascular risks. Permanently reduce dietary saturated fat and replace with unsaturates such as extra virgin olive or canola oils (Hooper et al, 2012).

•

Food and Nutrition • Follow the current dietary guidelines and MyPlate Food System: 2 to 3 servings of milk, 2 to 3 servings of meat or substitute, 3 to 5 servings of vegetables, 2 to 4 servings of fruits, and 6 to 12 bread group servings. Modify diets for special medical conditions, such as hypertension, heart disease, and osteoporosis. • Energy needs will vary by sedentary or active status; 30 kcal/kg/d is average. Use 20 to 25 kcal/kg/d when weight loss is desired and 35 to 40 kcal/kg/d when weight gain is needed. Adults are encouraged to maintain their weight rather than gaining weight over the years. • Table 1-29 provides nutritional recommendations for adults. • For most healthy adults, 0.8 g of protein/kg will suffice. Use fish, poultry, and nonmeat entrees (e.g., dry beans, peas, nuts as tolerated) regularly instead of just meat-centered meals. Tofu, edamame, textured soy protein, soy nut butter, or tempeh can be useful. • For carbohydrate, the Institute of Medicine has set the minimum intake at 130 g daily. In general, use of whole grains, fresh fruits or vegetables, and low-fat dairy products will provide high-quality carbohydrates. Refined carbohydrates in sweetened beverages, desserts, and candy should be limited. • Include or exclude fats, oils, sugars, alcohol, and sweets to increase or decrease energy intake. These foods often replace nutrient-dense foods. Limit or eliminate foods that contain trans-fatty acids. • Mineral balance is important. The DASH diet is useful for designing meal patterns that are rich in potassium, calcium, and magnesium. • Vitamins A, C, and E and magnesium tend to be low in most diets; older men and women tend to be low in zinc intakes; TABLE 1-29 Nutrient Recommendations for Adults NUTRIENT

FEMALES 19–70 YEARS

MALES 19–70 YEARS

Energy

2000–1600* kcal/d

2400–2000* kcal/d

Protein

46 g/d or 0.8 g/kg/d

56 g/d or 0.8 g/kg/d

Calcium

800–1000 mg/d

1000–1200 mg/d

Iron

8–5 mg/d

8 mg/d

Folate

320 mg/d

400 mg/d

Phosphorus

580 mg/d

700 mg/d

Vitamin A

500 g/d

900 g/d

Vitamin C

60 mg/d

90 mg/d

Thiamin

0.9 mg/d

1.2 mg/d

Riboflavin

0.9 mg/d

1.3 mg/d

Niacin

11 mg/d

16 mg/d

*Calories will vary by activity level; needs decrease in later decades. Data from: Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Washington, DC: National Academies Press; 2002.

Escott-Stump_Ch01.indd 49

•

and potassium, calcium, vitamin D, vitamin K, and fiber are low as well. Women of childbearing age should include foods rich in folic acid to prevent neural tube defects. Cold cereals, cooked pinto or navy beans, asparagus, spinach, orange juice, lentils, and avocado should be planned into the diet regularly. Pleasant family meals are associated with positive dietary intakes and healthy behaviors. Family interaction can lower risks for obesity, enhance language skills and academic performance, and improve social skills. Functional food ingredients, including fortified, enriched, or enhanced foods, have a potentially beneficial effect on health when consumed as part of a varied diet on a regular basis (Crowe et al, 2013). Each food ingredient should be assessed individually; soybeans, fruits, and vegetables yield the greatest benefit. See Table 1-30 for a list of functional food ingredients and their beneficial effects. Section 2: Nutrition Practices, Food Safety, Allergies, Skin, and Miscellaneous Conditions discusses the benefits of food as a form of alternative medicine. Apply the principles of a Mediterranean or an antiinflammatory diet: • Focus on a plant-based diet, rich in colorful fruits and vegetables plus mushrooms, nuts, seeds, and whole grains. • Eat as much fresh food as possible; minimize intake of highly processed foods. • Include some “super foods” each day, such as salmon, blueberries, bananas, whole-wheat grains, fat-free yogurt, broccoli, cruciferous vegetables (broccoli, cabbage family), avocado, soy foods, dark chocolate (minimum cocoa content of 70%). • Foods rich in vitamins A, C, and E and selenium should be consumed for their antioxidant and phytochemical properties. • Quercetin (found in apples, broccoli, oranges, tomatoes, kale, and onions) may help protect vision. • Phytosterols in sunflower seeds, pistachio nuts, sesame seeds, and wheat germ are good for the heart. • Plant sterols and stanols help to lower serum cholesterol; they are less expensive than statin drugs. • Polyphenols (flavonoids from tea, cocoa, red wine, Concord grape juice, blueberries, and chocolate) support heart and brain health. Drink green or oolong tea daily. • Use liberal amounts of spices and herbs for their potent antioxidants properties: oregano, cinnamon, dill, savory, coriander, turmeric/curcumin, ginger, garlic. • Fiber-rich foods protect against heart disease, stroke, diabetes, hypertension, some types of cancer, constipation, obesity, and diverticulosis. • Soluble fiber is found in pectins, gums, oat bran, beans, lentils, pears, oranges, plums, apples, berries, potatoes, nuts, seeds, psyllium, dried peas, and flaxseeds. • Insoluble fibers are found in wheat bran, wholewheat bread, brown rice, corn bran.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • In general, discuss the relevance of tolerable ULs from the latest dietary reference intakes of the National Academy of

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-30 Functional Foods and Ingredients FOOD

FUNCTION

Almonds

Lower LDL cholesterol to reduce heart disease. Source of potassium, vitamin E, riboflavin, magnesium, and zinc.

Apples

Good source of fiber, quercetin in the skin. May protect against cancer, asthma, and Alzheimer’s disease.

Apricots

Good source of vitamins A and C, as well as lycopene. Cancer prevention.

Avocado

Reduces risk of heart disease, high blood pressure, and osteoporosis. Contains vitamins B6 and E, folate, potassium, and fiber.

Bananas

Good source of potassium and magnesium, which are helpful to prevent heart disease, bone loss, and hypertension.

Barley

Good whole grain source. Contains beta glucan which lowers cholesterol and may help prevent heart disease and cancer.

Blueberries and other berries

Reduce risk of cancer; may improve cognitive function. Contain vitamin C as well as anthocyanins, fiber, and ellagic acid.

Brazil nuts

Supply of selenium, which is a cancer preventive. Use no more than 2 per day.

Broccoli

Reduces risk of cancer and maintains healthy immune system. Sulforaphane detoxifies carcinogens. Source of quercetin.

Brown rice

Rich whole grain with phosphorus and potassium in greater amounts than white rice.

Brussels sprouts

Source of sulforaphane to prevent cancer; also good source of vitamin K.

Cabbage

Contains sulforaphane; consume often as a cancer prevention measure.

Canola oil

Good source of fatty acids, which reduce heart disease and cancer.

Cantaloupe

Great source of beta-carotene and vitamin C.

Carrots

Rich source of beta-carotene.

Cauliflower

Rich in sulforaphane and vitamin C; may protect against cancer.

Cheese

May decrease risk of colon cancer because of calcium content.

Chicken or turkey breast

Skinless poultry is a great source of protein and zinc; turkey is also high in B vitamins and selenium.

Chocolate

May decrease risk for cardiovascular disease; flavonoid content is a powerful antioxidant.

Cinnamon

May lower LDL cholesterol and blood glucose levels. Anticlotting effect. Anti-inflammatory effect in arthritis.

Citrus fruits

Limonoids reduce risk of certain cancers. Oranges are a source of quercetin.

Cloves

Ground cloves are the richest source of polyphenols among the spices.

Cocoa

Rich source of flavonols; reduces risk of cancer and heart disease.

Collard greens

Great source of carotenoids, vitamin C, lutein, sulforaphane, and calcium.

Cranberries

Improves urinary tract health and prevents infection; reduces risk of heart disease; may reduce periodontitis/gingivitis.

Cruciferous vegetables

Sulforaphane content helps to prevent cancer. Brussels sprouts, cauliflower, broccoli, and bok choy are in this family.

Edamame

Green soybeans, a staple in Asia. They can lower LDL cholesterol and may protect against colon cancer.

Fatty fish

Source of omega-3 fatty acids; helpful for brain, eye, and neurological health.

Flaxseed

Reduces risk of heart disease, high blood pressure, and osteoporosis. Provides lignans and alpha linolenic acid, an omega-3 fatty acid.

Garlic

Reduces risk of cancer; lowers cholesterol levels and blood pressure.

Kale

High in antioxidants lutein and zeaxanthin; protects eye health. Source of quercetin.

Kiwifruit

High in potassium, vitamin C, fiber, folate, magnesium, vitamin E, copper, and lutein. Great antioxidant fruit.

Legumes and beans

Lentils, dried beans, and peas provide folate, which reduces DNA damage and helps with cancer prevention. Rich in fiber, magnesium, potassium, protein, iron.

Lycopene

Lycopene is especially rich in tomatoes, pink grapefruit. A substance called Fru-his in rehydrated tomato products protects against prostate cancer.

Marjoram

Good source of polyphenols.

Milk, nonfat

Reduces risk of osteoporosis, high blood pressure, and colon cancer. Good source of vitamin D, calcium, riboflavin, and potassium.

Nuts, seeds

Good source of arginine, magnesium, fiber.

Oatmeal

Reduces LDL cholesterol levels.

Olive oil

Good source of polyphenols and monounsaturated fatty acids (MUFAs), which reduce heart disease and cancer risk.

Onions

Sulfur-rich and full of quercetin (red or yellow are richer). Blood thinning to help lower blood pressure and LDL cholesterol levels.

Oranges

Great source of potassium and vitamin C. Source of quercetin.

Oregano

Good source of polyphenols.

Peaches

Good source of vitamin C, carotenoids, niacin, and potassium.

Peanut butter

Good source of protein, MUFA, and niacin.

Pistachio nuts

Good source of phytosterols for heart health.

Pomegranate

Antioxidant that protects against hormonal and lung cancers, Alzheimer’s disease, and heart disease.

Pork loin

Leanest cut of “red meat” sources. Protein, zinc, and iron source.

Escott-Stump_Ch01.indd 50

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-30 Functional Foods and Ingredients (continued) FOOD

FUNCTION

Prunes

Great source of antioxidants, fiber, potassium, and vitamins A and B6.

Pumpkin seeds

Good source of phytosterols; B vitamins, along with C, D, E, and K; calcium, potassium, niacin, and phosphorous. May protect against depression and learning disabilities. Excellent source of magnesium.

Pycnogenol

Antioxidant plant extract from the bark of a French pine tree; reduces blood sugar in type 2 diabetes patients, allows people to lower their antihypertensive medication, and improves cardiovascular disease risk factors.

Quinoa

Seed containing high amounts of protein, fiber, magnesium, potassium, vitamin E, riboflavin, zinc, copper, and iron.

Sage, tarragon, thyme

Moderately good sources of polyphenols.

Salmon, sardines, mackerel

Improve mental and visual function; reduce risk of heart disease and may prevent cancers. Rich omega-3 fatty acid source.

Shredded wheat

Great source of whole-grain fiber, as well as magnesium; helpful in maintaining normal blood glucose levels.

Soy

Reduces risk of heart disease by lowering LDL cholesterol; eases menopausal symptoms. Isoflavones have weak estrogenic effects.

Spinach and romaine lettuce

Great source of lutein, carotenoids, and vitamin C; maintain healthy vision.

Squash, acorn

Rich in carotenoids, folate, vitamin C, and potassium; all helpful in reducing heart disease and cancer risk.

Strawberries

May lower blood pressure, reduce the risk of heart disease and some cancers, and improve memory.

Sunflower and sesame seeds

Good source of phytosterols for heart health.

Tea, black, green, or white

Reduces risk for stomach, esophageal, and skin cancers, and heart disease. Flavonoids neutralize free radicals.

Tofu

Great meat substitute; rich in protein and isoflavones and may be high in calcium.

Tomatoes

Reduce risk of prostate cancer and heart attack; rich in lutein, lycopene, and vitamin C. Lycopene protects cell membranes. Source of quercetin.

Tuna

Reduces risk of heart disease; high in vitamins B6 and B12, omega-3 fatty acids, and protein.

Turmeric

Natural anti-inflammatory that reduces cancer risk. Thought to slow Alzheimer’s disease.

Walnuts

Lowers LDL cholesterol and reduces risk of heart disease. Good source of vitamin E, alpha linolenic acid, minerals, and folate.

Whey protein

Immune-enhancing properties including lactoferrin, beta-lactoglobulin, alpha-lactalbumin, and immunoglobulins. Useful for intracellular conversion of cysteine to glutathione, a powerful antioxidant. Whey protein is found naturally in milk.

Whole grains

Reduce risk of certain cancers and heart disease. Contain saponins, flavonoids, and lignans.

Wine, red, grapes, and grape juice

Reduce risk of cardiovascular disease and cancer because of resveratrol, a flavonoid (polyphenol).

Winter squash

Butternut squash is one example. Good source of beta-carotene, calcium, potassium, and folate.

Yogurt

Improves intestinal health because of bacterial (probiotic) content; reduces risk of cancer; lowers cholesterol. Rich source of calcium, vitamin B12, magnesium, and protein. May also use cultured dairy products.

Derived from: Functional Foods List. Available at: http://www.mealsmatter.org/EatingForHealth/FunctionalFoods/func_list.aspx. Accessed June 15, 2014; and Fruits and Veggies More Matters. Available at: http://www.fruitsandveggiesmorematters.org/what-are-phytochemicals. Accessed June 15, 2014.

Sciences. These levels were set to protect individuals from receiving too much of any nutrient from diet and dietary supplements (see Table 1-31). • Figure 1-12 lists medications that affect men’s and women’s health. Herbs, Botanicals, and Supplements • Herbs, botanical products, and supplements should not be used without discussing with a physician, especially with underlying medical conditions. (See Table 2-1 for an extensive list of herbs and botanicals.) • Dietary supplements are used by more than half of the adult population in the United States. Multivitamin–mineral products are the most frequently reported type, followed by calcium and fish oil supplements (Bailey etal,2013). • The excessive consumption of omega-6 fatty acids in the modern Western diet displaces DHA from membrane phospholipids (Bradbury, 2011). Many adults are using fish oil supplements to counteract this effect. • Fortification of foods has reduced vitamin and mineral deficits. Now there are safety concerns about exceeding upper levels. Only 23% of products used are based on recommen-

Escott-Stump_Ch01.indd 51

dations of a health care provider (Bailey et al, 2013). There is limited evidence for beneficial health-related effects of supplements taken singly. • Supplement users are more likely to report very good health, use alcohol moderately, do not smoke, and exercise more frequently than nonusers (Bailey et al, 2013). • The use of dietary supplements is potentially harmful to people with CKD; health care providers should discuss the potential risks (Grubbs et al, 2013). • Cancer patients might benefit most from curcumin, glutamine, vitamin D, Maitake mushrooms, fish oil, green tea, milk thistle, Astragalus, melatonin, or probiotics (Frenkel etal, 2013).

Nutrition Education, Counseling, Care Management • Help plan a diet in accordance with individual lifestyle. Explain nutrient density, food cost, and portion sizes. • Explain the benefits of weight management for adults to prevent or delay the onset of chronic diseases. Start with BMI; select a healthy weight goal as needed. Successful weight losers tend to follow a low-fat, high-carbohydrate food plan with high levels of physical activity; they eat breakfast regularly.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-31 Medications and Nutrients Commonly Used by Adults INFERTILITY Smoking can reduce fertility. Oxidative stress is detrimental to sperm function and a significant factor in male infertility. Higher intakes of micronutrients (vitamin C, vitamin E, zinc, and folate) seem to improve infertility (Schmid et al, 2012). WOMEN: CHILDBEARING AGE Infertility and miscarriages

Genetic defects in the MTHFR (methyltetrahydrofolate reductase) enzyme can cause spontaneous abortions and infertility; forms of L-methylfolate (such as Deplin or Neevo) may be needed.

Intrauterine devices

May increase menstrual losses of iron and vitamin C.

Interstitial cystitis/bladder pain syndrome (IC/BPS)

Use buffering products or pain relievers. Calcium glycerophosphate and sodium bicarbonate tend to improve symptoms. Nearly 90% of patients report sensitivities to a wide variety of foods: citrus fruits, tomatoes, vitamin C, artificial sweeteners, coffee, tea, carbonated and alcoholic beverages, and spicy foods tend to exacerbate symptoms (Friedlander et al, 2012). Elimination diet protocols may be needed.

WOMEN: MENOPAUSE Low doses of Megace (megestrol acetate) may be used to decrease hot flashes in postmenopausal women who cannot take estrogen. Megace can cause increased appetite, edema, and sodium retention. Bone density loss

Alendronate (Fosamax) may be used to maintain bone density without breast cancer risk.

MEN: BALDNESS Androgenetic alopecia (AGA) may affect up to 70% of men and 40% of women at some point in their lifetime (McElwee and Shapiro, 2012). 5-Alpha reductase catalyzes the conversion of testosterone to dihydrotestosterone. Disturbances in 5-alpha reductase activity in skin cells might contribute to male pattern baldness, acne, or hirsutism. Rogaine (minoxidil) can cause diarrhea, low blood pressure, nausea, vomiting, and weight gain; it is a vasodilator. A low-sodium, low-calorie diet may be beneficial. New cell-mediated treatments are under study. MEN: PROSTATE PROBLEMS Proscar (finasteride) and other medications are used with some relief. Monitor blood pressure; no nutritional side effects are noted. A plant-based diet is protective; use broccoli and cruciferous vegetables more often. Brazil nuts, seafood, and whole grains are natural sources of selenium. Dietary sources of lycopene (tomato sauce, pink grapefruit) are preferable over supplements. Consumption of fatty acids of animal origin, high body fat, and obesity contribute to prostate disorders. The Mediterranean diet is a beneficial diet (Maillot et al, 2012). References: Friedlander JI, Shorter B, Moldwin RM. Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU Int. 2012;109:1584; Maillot M, Issa C, Vieux F, et al. The shortest way to reach nutritional goals is to adopt Mediterranean food choices: evidence from computer-generated personalized diets. Am J Clin Nutr. 2011;94:1127; McElwee KJ, Shapiro JS. Promising therapies for treating and/or preventing androgenic alopecia. Skin Therapy Lett. 2012;17:1; Schmid TE, Eskenazi B, Marchetti F, et al. Micronutrients intake is associated with improved sperm DNA quality in older men. Fertil Steril. 2012;98:1130.

• Popular low-carbohydrate, high-protein diet plans may contribute to problems such as kidney stones and are not advised for most adults. The South Beach diet, by recommending olive oil and fatty fish, is closer to a Mediterranean diet. • Encourage planned meals. Skipping breakfast may lead to overeating later at night. • Describe the effects of alcohol at the “business lunch”; alcohol intake may equal 300 calories or more. Discourage intake of more than two alcoholic drinks per day for men or one drink for women. • Being physically fit can improve the odds against chronic diseases. Goal setting may be an effective strategy. The Surgeon General recommends 1 hour daily of physical activity. Using a pedometer to count steps is very motivating; “10,000 steps a day” is the goal; one mile is approximately 2,500 steps. Yoga, Pilates, and tai chi can help increase flexibility. • Fluid intake may be lower than desirable. Dehydration can contribute to kidney stones, strain on the heart and cardiovascular system, or even drug toxicity. Encourage daily intake of 30 mL/kg of water and other liquids. • Coffee and tea contain antioxidants that can be preventive against cancers, diabetes, heart disease, and Parkinson’s disease; moderate daily inclusion may be promoted.

Escott-Stump_Ch01.indd 52

• Cholesterol, regular dental checkups, and BP screening should start by age 20. Young women need Pap smears and vaccinations against human papillomavirus and cervical cancer. Tetanus vaccinations are needed every 10 years. • Women over age 35 should schedule mammograms and thyroid tests every 2 to 3 years. Periodic electrocardiograms (EKGs) and fasting blood glucose are important after age 40. • For people in their fifth decade, add a fecal occult blood test, bone density scan, and (for men) a prostate-specific antigen test. Flu, shingles, and pneumonia vaccines are indicated after age 60. • Help clarify conflicting information about a “serving” and a “portion” on food labels. • The American Council on Science and Health (ACSH) ranks the following consumer magazines as reliable for nutrition information: Parents, Cooking Light, and Good Housekeeping. • Discuss food choices when eating away from home. For travelers who experience jet lag, adjust meal times to match new time zone, which may help the liver adjust more readily. • Discuss calcium and vitamin D alternatives with people who omit dairy products. There are calcium-fortified foods and beverages, such as fortified orange juice, cereals, mineral

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

Drugs Affecting Men’s Health and Sexuality

Androgens

Drugs to Treat Benign Prostatic Hypertrophy

testosterone Synthetic testosterones fluoxymesterone methyltestosterone Anabolic steroids oxandrolone stanozolol Polypeptide hormone chorionic gonadotropin

finasteride dutasteride Alpha-1 blockers alfuzosin doxazosin tamsulosin terazosin

Drugs to Treat Male Pattern Baldness Drugs to Treat Erectile Dysfunction minoxidil finasteride sildenafil alprostadil tadalafil vardenafil yohimbine

The symbol indicates the drug class. Drugs in bold type marked with the symbol are prototypes. Drugs in blue type are closely related to the prototype. Drugs in red type are significantly different from the prototype. Drugs in black type with no symbol are also used in drug therapy; no prototype.

Drugs Affecting Women’s Health and Sexuality

Estrogens

conjugated estrogen synthetic conjugated estrogens contraceptives clomiphene gonadotropins gonadotropin-releasing hormone antagonists gonadotropin-releasing hormones human chorionic gonadotropin menotropins synthetic androgens

Progestins

progesterone contraceptives medroxyprogesterone norethindrone norethindrone acetate megestrol mifepristone

Bisphosphonates

alendronate etidronate ibandronate pamidronate risedronate tiludronate zoledronic acid calcitonin, salmon raloxifene teriparatide

Contraceptives

oral contraceptives emergency oral contraceptives transdermal contraceptives vaginal ring contraceptive implanted contraceptives intrauterine system contraceptives

Figure 1-12. Drugs that affect the health of men and women. (Reprinted with permission from Aschenbrenner A, Venable S. Drug therapy in nursing, 4th ed. Philadelphia, PA: Wolters Kluwer Health; 2013.)

Escott-Stump_Ch01.indd 53

11/7/14 8:14 PM

•

• • •

• •

•

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

waters, and margarine. For people with dark skin or living in northern climates, supplemental vitamin D3 may be needed. Discuss the role of diet in managing blood pressure. Ignoring high BP can set the stage for stroke, dementia, and heart disease. Intensive diet and physical activity modifications can greatly reduce disease risk (Ohta et al, 2011). Determine the individual’s readiness for dietary lifestyle change. When patients are ready to lose weight, improve diet, and increase exercise, concentrate on small, gradual changes. The “Total Diet” message is important to share with adults of all ages (Academy of Nutrition and Dietetics, 2013). Working women may need extra encouragement to eat properly. Discuss fiber sources, meatless meals, beneficial fatty acids, nutrient preservation, and phytochemicals. Table 1-32 lists ways to include more fruits and vegetables in their diet, and Table 1-33 describes the key nutrients of these foods. Women in menopause undergo many health changes. DHA plays a unique role in neurodevelopment and the prevention of neuropsychiatric and neurodegenerative disorders (Bradbury, 2011). Fortunately, DHA is increasingly being added back into the food supply as fishoil or algaloil. When needed, provide resources to alleviate food insecurity. The Supplemental Nutrition Assistance Program (SNAP), the largest U.S. federal food assistance program, serves nearly 45million Americans (Leung et al, 2013). Nutrition education and environmental factors must be considered. Nutrition information on packaged food labels is useful. However, many adults do not know how to use the food label effectively. More research is needed to determine the effects of front of pack nutrition labeling on consumers’ actual shopping behaviors and dietary intakes (Hershey et al, 2013). Table 1-34 describes food labeling terms. Figure 1-13 shows a sample nutrition facts panel. The best nutrition-based strategy for promoting optimal health and reducing the risk of chronic disease is to wisely choose a wide variety of nutrient-rich foods (Crowe et al, 2013). Encourage “Slow Food” movement with traditional foods, pleasurable mealtimes, and enjoyment of the aroma and flavors of foods. Food and dietary supplement products claim to improve health, manage conditions, and reduce disease risks. Table 1-35 briefly describes health claims that are approved or under review by the U.S. Food and Drug Administration. The nutrient-rich foods approach to eating uses an index for nutrient profiling to help consumers choose foods that contain more vitamins, minerals, and other nutrients per kcal (Glanz et al, 2012). In general, traffic light symbols (Go,Slow, Whoa) or simple visual cues may be most effective in helping consumers choose foods wisely (McLean etal, 2012).

Patient Education—Food Safety Tips • Reminders about hand washing and safe food handling may be important, especially for those adults who prepare and serve meals for others. • Avoid food preparation when sick with viral or bacterial infections. Use latex gloves if there are any open cuts on the hands. Thoroughly cook meat, poultry, and fish entrées. Keep cold foods cold and hot foods hot.

Escott-Stump_Ch01.indd 54

TABLE 1-32 Tips for Eating More Fruits and Vegetables • Eat at least one vitamin A–rich fruit or vegetable daily: apricots, cantaloupe, carrots, pumpkin, sweet potatoes, spinach, collards, or broccoli. • Eat at least one vitamin C–rich fruit or vegetable daily: oranges, strawberries, green peppers, or tomatoes. • Eat several high-fiber fruits or vegetables daily: apples, grapefruit, broccoli, baked potato with skin, or cauliflower. • Eat berries often; blueberries are highly rated for their antioxidant properties (anthocyanins). Other berries are equally nutritious and contain fiber, quercetin, and other flavonoids. • Eat cabbage family vegetables: cauliflower, broccoli, Brussels sprouts, and cabbage, several times every week. • Add fruit to cereal or plain yogurt. • Use fruit juice instead of water when preparing cakes and muffins. • Drink 100% fruit juice instead of soda. Try green tea mixed with pomegranate or blueberry juice. • Eat a piece of fruit for a morning snack; choose a grapefruit or an orange for an afternoon snack. • Choose the darkest green or red leaf lettuce greens for salads; add carrots, red cabbage, and spinach. • Add more vegetables or add tomato juice to soups and stews for vitamins A and C. • Choose pizza with extra mushrooms, green pepper, onion, broccoli, and tomatoes. • Munch on raw vegetables with a low-fat dip for an afternoon snack. • When dining out, choose at least one side dish of vegetables. • Fill up most of the plate with vegetables at lunch and dinner. • Choose fortified foods and beverages, such as juice with added calcium. • Snack on dried fruits, such as dried apricots, peaches, raisins, or “craisins.” • Use dried plums (prunes) for a natural laxative. • Use dried plum puree as a butter or margarine substitute in recipes to reduce fat; use half the measure required. Refer clients to: Centers for Disease Control and Prevention. Resources for Fruits and Vegetables. Available at: http://www.fruitsandveggiesmorematters.org/quick-guide-to-getting-more-fruits -and-vegetables/. Accessed June 15, 2014.

• Bacteria are commonly found on foods such as green onions (scallions), cantaloupe, cilantro, and many types of imported produce. Wash all fresh fruits and vegetables. Scrub the outside of produce such as melons and cucumbers before cutting. • Avoid tap water and ice made from tap water, uncooked produce such as lettuce, and raw or undercooked seafood when traveling. Moderate use of alcoholic beverages may prevent food poisoning; studies are under way to determine why. • Airline water may not be free from contamination. Use of bottled water is recommended. Coffee and tea may not be hot enough to kill all bacteria. • Throw out cooked foods that have been at room temperature for longer than 2 hours. • Consumption of sulforaphane in foods such as broccoli, cauliflower, cabbage, and Brussels sprouts may reduce the presence of H. pylori. • Avoid raw or partially cooked eggs, raw or undercooked fish or shellfish, and raw or undercooked meats because of potential food poisoning. • Do not use raw (unpasteurized) milk or products made fromit. • Avoid serving unpasteurized juices and raw sprouts. • Only serve processed deli meats and frankfurters that have been reheated to steaming hot temperature.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-33 Key Nutrients in Fruits and Vegetablesa FOOD

VITAMIN A ⬎500 IU

VITAMIN C ⬎6 mg

FOLATE ⬎0.04 mg

POTASSIUM ⬎350 mg

DIETARY FIBER ⬎2 g

Fruits Apple, with skin (1 medium) Apricot, dried (3)

X X

Banana (1 medium)

Blackberries (1/2 cup)

Blueberries (1 cup) Cantaloupe (1 cup)

X X

Grapefruit (1/2 medium)

Grapefruit juice (3/4 cup)

Grapes (1/2 cup)

Honeydew melon (1 cup)

Kiwifruit (2 medium)

Mango (1 medium)

Nectarine (1 medium)

Orange (1 medium) Orange juice (3/4 cup)

X X X

Papaya (1 medium)

Peach, with skin (1 medium)

Pear, with skin (1 medium)

Pineapple (two 3/4 slices)

Plum, with skin (2 medium)

Prunes (4) (dried plums)

Raspberries (1 cup) Strawberries (1/2 cup) Watermelon (1 cup)

X X

Vegetables Artichokes (1 medium)

Asparagus (5 spears)

Beans, kidney (1/2 cup)

Beans, lima (1/2 cup)

Black-eyed peas (1/2 cup)

Bok choy (1 cup cooked) Broccoli (1/2 cup)

X X

Brussels sprouts (1/2 cup) Carrots (1 medium)

X X

Cauliflower (1 cup)

Corn (1 cup)

Green beans (1/2 cup)

Collards (1/2 cup)

Green pepper (1 medium)

Kale (1/2 cup)

Lentils (1/2 cup)

Peas, green (1/2 cup)

Peas, split (1/2 cup)

Potato (1 medium)

Potato, with skin (1 medium) Romaine lettuce (6 leaves)

X X

(continued)

Escott-Stump_Ch01.indd 55

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-33 Key Nutrients in Fruits and Vegetablesa (continued) VITAMIN A ⬎500 IU

FOOD Spinach, cooked (1/2 cup)

VITAMIN C ⬎6 mg

FOLATE ⬎0.04 mg X

POTASSIUM ⬎350 mg

DIETARY FIBER ⬎2 g

Squash, winter (1/2 cup)

Sweet potato (1 medium)

Tomato (1 medium)

Turnip greens (1/2 cup)

X X

X indicates that the item provides 10% or more of the daily value in the serving size specified or at least 2 g of dietary fiber.

Adapted from: Supermarket Savvy newsletter, Linda McDonald Associates Inc., www.supermarketsavvy.com. Used with permission.

TABLE 1-34 Food Labeling Terms LABELING TERMS % Fat free Free

Food must be a low-fat or fat-free food to include thisvalue Food contains 0% of the indicated nutrient

Good source

Contains 10%–19% of the daily value (DV) for a nutrient

High

Contains 20% or more DV for a nutrient

Lean

Contains 10 g fat or less and 95 mg cholesterol or less (extra lean 5% fat by weight)

Less

Food contains 25% less than original food

Light/lite

Food contains fewer calories or 50% less fat than original food OR description of color (if indicated on the label)

Low

Low fat as 3 g or less; low sodium as 140 mg or less; very low sodium as 35 mg or less; low cholesterol as 20 mg or less; low calorie as 40 calories or less

Food contains 110% or more DV than original food

Reduced

Product has 25% or less of a nutrient or the usual calories of that food

Reduced cholesterol

The food contains 75% or less of the cholesterol found in the original product

Derived from: U.S. Food and Drug Administration. Guidance for Industry: A Food Labeling Guide. Available at: http://www.fda.gov/food/guidanceregulation/guidancedocuments regulatoryinformation/labelingnutrition/ucm064911.htm. Accessed June 15, 2014.

Figure 1-13. A sample nutrition facts panel.

Escott-Stump_Ch01.indd 56

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-35 Health Claims Health claims must be supported by significant scientific agreement among experts that the proclaimed benefit of a food or food component on a disease or health-related condition is true.

AUTHORIZED HEALTH CLAIMSa

Diet

Disease

Model Claim

Calcium

Osteoporosis

Regular exercise and a healthful diet with enough calcium help teens and young adult white and Asian American women maintain good bone health and may reduce their risk of osteoporosis.

Sodium

Hypertension

Diets low in sodium may reduce the risk of high blood pressure, a disease associated with many factors.

Dietary fat

Cancer

Development of cancer depends on many factors. A diet low in total fat may reduce the risk of some cancers.

Dietary saturated fat and cholesterol

Coronary heart disease

While many factors affect heart disease, diets low in saturated fat and cholesterol may reduce the risk of this disease.

Fiber-containing grain products, fruits, and vegetables

Cancers

Low-fat diets rich in fiber-containing grain products, fruits, and vegetables may reduce the risk of some types of cancer, a disease associated with many factors.

Fruits, vegetables, and grain products that contain fiber, particularly soluble fiber

Coronary heart disease

Diets low in saturated fat and cholesterol and rich in fruits, vegetables, and grain products that contain some types of dietary fiber, particularly soluble fiber, may reduce the risk of heart disease, a disease associated with many factors.

Fruits and vegetables

Cancer

Low-fat diets rich in fruits and vegetables may reduce the risk of some types of cancer, a disease associated with many factors.

Folate

Neural tube birth defects

Healthful diets with adequate daily folate may reduce a woman’s risk of having a child with a brain or spinal cord birth defect.

AUTHORIZED HEALTH CLAIMS AFTER PETITIONb

When significant scientific agreement is lacking, qualifying statements may be required on the label to describe the strength of the evidence that supports the claim.

Diet

Disease

Approved Health Claim

Sugar alcohols

Dental caries

“Frequent eating of foods high in sugars and starches as between-meal snacks can promote tooth decay. The sugar alcohol [name of product] used to sweeten this food may reduce the skin of dental caries.”

Foods that contain fiber from whole-oat products

Coronary heart disease

“Diets low in saturated fat and cholesterol that include soluble fiber from whole oats may reduce the risk of heart disease.”

Foods that contain fiber from psyllium

Coronary heart disease

“Diets low in saturated fat and cholesterol that include soluble fiber from psyllium seed husk may reduce the risk of heart disease.”

Soy protein

Coronary heart disease

“Diets low in saturated fat and cholesterol that include 25 g of soy protein a day may reduce the risk of heart disease. One serving of [name of food] provides 6.25 g of soy protein.”

Plant sterol/stanol esters

Coronary heart disease

Plant sterols: “Foods containing at least 0.65 g per serving of plant sterols, eaten twice a day with meals for a daily total intake of at least 1.3 g, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease. A serving of [name of the food] supplies g of vegetable oil sterol esters.” Plant stanol esters: “Foods containing at least 1.7 g per serving of plant stanol esters, eaten twice a day with meals for a total daily intake of at least 3.4 g, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease. A serving of [name of the food] supplies g of plant stanol esters.”

QUALIFIED HEALTH CLAIMS NOT APPROVED BY FDAc

Qualified health claims, where FDA has found some support but not enough clear evidence to allow an approved health claim.

Diet–Disease Relationship

Disease

Qualified Health Claim

Omega-3 fatty acids

Coronary heart disease

Consumption of omega-3 fatty acids may reduce the risk of coronary heart disease. FDA evaluated the data and determined that, although there is scientific evidence supporting the claim, the evidence is not conclusive.

Folic acid, B6, B12

Vascular disease

As part of a well-balanced diet that is low in saturated fat and cholesterol, folic acid, vitamin B6, and vitamin B12 may reduce the risk of vascular disease. FDA evaluated the above claim and found that, while it is known that diets low in saturated fat and cholesterol reduce the risk of heart disease and other vascular diseases, the evidence in support of the above claim is inconclusive.

Selenium

Cancer

Selenium may reduce the risk of certain cancers. Some scientific evidence suggests that consumption of selenium may reduce the risk of certain forms of cancer. However, FDA has determined that this evidence is limited and not conclusive.

Phosphatidylserine

Dementia

Very limited and preliminary scientific research suggests that phosphatidylserine may reduce the risk of dementia (cognitive dysfunction) in the elderly. FDA concludes that there is little scientific evidence supporting this claim.

Sources: aFood and Drug Administration. Guidance for Industry: A Food Labeling Guide. Available at: http://www.fda.gov/food/guidanceregulation/guidancedocumentsregulatoryinformation/labeling nutrition/ucm064911.htm. Accessed June 15, 2014; bHasler CM. Functional foods: benefits, concerns and challenges—a position paper from the American Council on Science and Health. JNutr. 2002;132:3772. Reprinted with permission; cUSDA. Voluntary health claims. Available at: http://www.ers.usda.gov/media/1037954/eib108_summary.pdf. Accessed June 15, 2014.

Escott-Stump_Ch01.indd 57

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE ●

Chronic Disease Prevention and Health Promotion http://www.cdc.gov/nccdphp/index.htm

●

Eating Well http://www.eatingwell.com

●

Family Mealtime http://www.cfs.purdue.edu/CFF/promotingfamilymeals

●

Gardasil and Human Papilloma Virus Vaccines http://www.gardasil.com/

●

Healthfinder—Information http://www.healthfinder.gov/

●

Health Statistics http://www.cdc.gov/nchs/fastats/Default.htm

●

Human Genome Project http://www.genome.gov/

●

Human Variome Project http://www.humanvariomeproject.org/

●

Institute for Health Metrics http://www.healthmetricsandevaluation.org/gbd

●

International Food Information Council Foundation http://www.foodinsight.org/

Monitoring and Evaluation: Dietary intake records, increased intake of fruits and vegetables; successful pregnancy where possible.

●

Interstitial Cystitis Association http://www.ichelp.org/

●

Men’s Health http://www.nlm.nih.gov/medlineplus/menshealth.html

Menopause

●

Men’s Health Network http://www.menshealthnetwork.org/

Assessment Data: Dietary recall, side effects of taking multiple herbs, weight history, labs.

●

National Institutes of Health http://www.nih.gov/

●

National Women’s Health Resource Center http://www.4woman.org/

●

RD411 – Grocery Shopping and Food Preparation http://www.nutrition411.com/education-materials/grocery-shopping-and -food-preparation

●

RD411 – Low Literacy Materials http://www.nutrition411.com/education-materials/easy-versions-for-patients -with-low-literacy-skill

●

Recipes: http://www.cookinglight.com http://www.deliciousdecisions.org http://www.mealsforyou.com

●

Shape Up America http://www.shapeup.org/

●

Slow Food Movement http://slowfood.com

●

Sustainable Food Systems http://www.localharvest.org

●

Thyroid Awareness http://www.thyroidawareness.com/

●

U.S. Food and Drug Administration http://www.fda.gov/

●

Web MD – Food and Recipes http://www.webmd.com/food-recipes/default.htm

●

Web MD – Functional Foods http://www.webmd.com/diet/fiber-health-benefits-11/functional-foods

●

Web MD—Men’s Health http://men.webmd.com/

●

Women’s Health Initiative http://www.nhlbi.nih.gov/whi/index.html

SAMPLE NUTRITION CARE PROCESS STEPS Imbalance of Nutrients Assessment Data: Dietary recall, nutrient analysis for vitamins and minerals, results of genetic testing. Nutrition Diagnosis (PES): Imbalance of nutrients related to low micronutrient intake (vitamins A and C, magnesium, and potassium) and C T genetic allele of methyltetrahydrofolate reductase (MTHFR) as evidenced by consistent omission of fruits and vegetables in dietary intake records, genetic inability to metabolize folic acid, and history of three miscarriages in past 5years. Intervention:Education about a healthy diet for promoting optimal reproductive health. Counseling about use of L-methylfolate and multivitamin–mineral supplement in preparation for a healthy pregnancy.

Nutrition Diagnosis (PES): Harmful beliefs about food/ nutrition related to regular intake of dietary supplements as evidenced by dietary recall indicating use of large doses of Chinese herbal remedies that are unsubstantiated by medical efficacy. Intervention:Education about safe use of herbs and supplements for menopausal symptoms (soy, black cohosh, multivitamin–mineral supplements). Counseling about acceptable choices. Monitoring and Evaluation: Dietary recall, dietary supplement usage pattern, side effect reports, improvement of symptoms of menopause. Excessive use of iron from foods, supplements.

For More Information

See the video “Head-to-Toe Assessment (General Survey)” at www.thepoint.lww.com /escottstump8e.

●

American Association of Family and Consumer Sciences http://www.aafcs.org/

●

American Pregnancy Association: Preconceptual Nutrition http://www.americanpregnancy.org/gettingpregnant/preconception nutrition.html American Public Health Association http://www.apha.org/

●

Centers for Disease Control and Prevention—Men http://www.cdc.gov/men/

●

Centers for Disease Control and Prevention—Women http://www.cdc.gov/women/

●

Centers for Disease Control and Prevention—Young Adults http://www.cdc.gov/lifestages/youngAdults.html

Escott-Stump_Ch01.indd 58

REFERENCES Academy of Nutrition and Dietetics. Position of the American Dietetic Association: total diet approach to healthy eating. J Acad Nutr Diet. 2013;113:307. Bailey RL, et al. Why US adults use dietary supplements. JAMA Intern Med. 2013;4:1. Barter P. HDL-C: role as a risk modifier. Atheroscler Suppl. 2011;12:267. Bradbury J. Docosahexaenoic acid (DHA): an ancient nutrient for the modern human brain. Nutrients. 2011;3:529.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

Cohen SP, et al. Regulator of G-protein signaling-21 (RGS21) is an inhibitor of bitter gustatory signaling found in lingual and airway epithelia. J Biol Chem. 2012;287:41706. Crowe KM, et al. Position of the academy of nutrition and dietetics: functional foods. J Acad Nutr Diet. 2013;113:1096. Finlayson G, et al. Susceptibility to overeating affects the impact of savory or sweet drinks on satiation, reward, and food intake in nonobese women. JNutr. 2012;142:125. Frenkel M, et al. Integrating dietary supplements into cancer care. Integr Cancer Ther. 2013;12:369. Garcia G, et al. The fast food and obesity link: consumption patterns and severity of obesity. Obes Surg. 2012;22:810. Glanz K, et al. Effect of a Nutrient Rich Foods consumer education program: results from the nutrition advice study. J Acad Nutr Diet. 2012;112:56. Grubbs V, et al. Americans’ use of dietary supplements that are potentially harmful in CKD. Am J Kidney Dis. 2013;61:739. Hershey JC, et al. Effects of front-of-package and shelf nutrition labeling systems on consumers. Nutr Rev. 2013;71:1. Holben DH, et al. Position of the American Dietetic Association: food insecurity in the United States. Am Diet Assoc. 2010;110:1368. Hooper L, et al. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev. 2012 May 16;5:CD002137. Hu G, Duncan AW. Associations between selected laboratory tests and all-cause mortality. J Insur Med. 2013;43:208.

Keller KL, et al. Common variants in the CD36 gene are associated with oral fat perception, fat preferences, and obesity in African Americans. Obesity (Silver Spring). 2012;20:1066. Kroll C, et al. Evaluating the decisional balance construct of the Transtheoretical Model: are two dimensions of pros and cons really enough? Int J Public Health. 2011;56:97. Leung CW, et al. A qualitative study of diverse experts’ views about barriers and strategies to improve the diets and health of Supplemental Nutrition Assistance Program (SNAP) beneficiaries. J Acad Nutr Diet. 2013;113:70. McLean R, et al. Effects of alternative label formats on choice of high- and low-sodium products in a New Zealand population sample. Public Health Nutr. 2012;15:783. Nitsch D, et al. Associations of estimated glomerular filtration rate and albuminuria with mortality and renal failure by sex: a meta-analysis. BMJ. 2013;346:f324. Norcross JC, et al. Stages of change. J Clin Psychol. 2011;67:143. Ohta Y, et al. Relationship between blood pressure control status and lifestyle in hypertensive outpatients. Intern Med. 2011;50:2107. Online Mendelian Inheritance in Man (OMIM). Available at: http://www.ncbi .nlm.nih.gov/Omim/mimstats.html. Accessed June 15, 2014. Plotnikoff GA. Nutritional assessment in vegetarians and vegans: questions clinicians should ask. Minn Med. 2012;95:36. Sanders TA. DHA status of vegetarians. Prostaglandins Leukot Essent Fatty Acids. 2009;81:137.

NUTRITION IN AGING NUTRITIONAL ACUITY RANKING: LEVEL 2 DEFINITIONS AND BACKGROUND The human life span is between 120 and 140 years, the length of time a person could live. Human life expectancy (average life span) is seldom beyond 114 years. Genetic factors account for about one-third of variations in life expectancy (Langie et al, 2012). Telomeres, the repeated series of DNA sequences that cap the ends of chromosomes, become shorter during cell division and in lifestyle-related diseases, such as atherosclerosis and diabetes (Kagawa, 2012). Altered leukocyte telomere length genes play a role in longevity, particularly in women (BurnettHartman et al, 2012). Indeed, nutrient density, caloric restriction, and proper exercise may extend life expectancy. Aging involves a progression of physiologic changes with cell loss and organ decline. Decreased glomerular filtration rate (GFR) and creatine-height index (CHI), constipation, decreased glucose tolerance, and lowered cell-mediated immunity can occur. LBM declines with each decade, generally replaced by fat. Basal energy needs decrease by as much as 10% by age 50 and by 20% to 25% by age 70. However, being too thin may be detrimental. Weight loss is not desirable in older adults because it is usually difficult for them to recover lost muscle mass. Older patients who start out a little overweight may have more reserves to support immunity. Older individuals may have chronic conditions that would benefit from nutrition interventions. Challenges of nutritional assessment in older adults include limited recall, hearing and vision losses, changes in attention span, and variations in dietary intake from day to day. The inability to perform activities of daily living can be a major concern. Older adults may need assistance with shopping, meal preparation, and in ensuring adequate intake. The practice of nutrition for older adults is no longer limited

Escott-Stump_Ch01.indd 59

to those who are frail, malnourished, and ill (Bernstein et al, 2012). Indeed, grade 1 obesity is not even associated with higher mortality; overweight is associated with significantly lower allcause mortality (Flegal et al, 2013). Where food insecurity exists among senior citizens, it should be addressed. Programs should include adequately funded food assistance and meal programs, nutrition education, screening, assessment, counseling, therapy, monitoring, evaluation, and outcomes documentation to ensure more healthful aging (Kamp et al, 2010). People older than 65 years of age comprise 13% of the U.S. population, one in every eight (Administration on Aging [AOA], 2013). Only about 5% of senior citizens are in nursing homes, the others live in the community, often alone. Culturally appropriate food and nutrition services should be customized to the individual’s needs (Bernstein et al, 2012). Dysphagia is prevalent among aging adults, associated with nutritional deficits, and increased risk of pneumonia. A swallowing rehabilitation program may be needed (Sura et al, 2012). Loss of teeth, decreased salivation, lower nutrient absorption, as well as declining taste and smell are also common problems. Essentially, older persons consume less food, about one-third fewer calories, than younger people. Over 30% of seniors consume less energy than recommended levels, and 50% have low mineral and vitamin intakes. Lower food intake by this population appears to be a result of smaller meals eaten at a slower rate. Inflammatory chronic conditions such as obesity, cardiovascular disease, insulin resistance, and arthritis are often associated with aging (Jensen, 2008). Seniors exhibit loss of muscle strength, easy fatigue, physical inactivity, slow or unsteady gait, poor appetite, unintentional weight loss, impaired cognition, depression, and mortality. Muscle mass and function are progressively lost with aging, so that by the age of 60 many individuals have reached a threshold where function begins to be affected (Wolfe, 2012).

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Approximately 20% to 50% of patients admitted to hospital are malnourished, especially older adults. The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend a standardized set of diagnostic characteristics to identify and document adult malnutrition, with an understanding of the inflammatory response (White et al, 2013). Although the stress response to surgery (decrease in albumin and transferrin) is not affected by age, serum protein levels return to normal more slowly in older individuals. Protein-energy undernutrition contributes to pressure ulcers, immune dysfunction, infections, hip fractures, anemia, muscle weakness, fatigue, edema, cognitive changes, and mortality. Since adverse effects of reasonable increases in protein intake above the RDA of 0∙8 g protein/kg/day have not been reported, the optimal protein intake for an older individual is likely greater than the RDA (Wolfe, 2012). Nutrition alone is not sufficient. While weight loss, depression, dehydration, and feeding problems are the easy to detect, elevated CRP levels should also be noted. Depressed older adults often have poor intake of fruits and vegetables (Payne et al, 2012). Interventions such as physical activity, resistance exercise, calorie restriction, use of anabolic hormones, antiinflammatory agents, nutritional supplements, and antioxidants are important in managing sarcopenia (Jensen, 2008). Support physical activity as much as possible (Fig. 1-14). Although growth hormone supports appetite and intake, secretion declines after puberty. Oral ghrelin mimetics may be used to improve intake, prevent declines in fat-free muscle mass, and reduce abdominal visceral fat (Hanauer, 2009). The rationale for all medications should be reviewed and unnecessary products eliminated. Use of medications including digoxin, furosemide, warfarin, paroxetine, nifedipine, ranitidine, theophylline, amlodipine, ciprofloxacin, and sertraline may cause anorexia or nausea. Thus, multivitamin–mineral supplements are often recommended.

Vitamins E, B12, B6, folate, calcium, and zinc are needed to counteract gastric atrophy, decreased levels of hydrochloric acid, and poor nutrient intakes. Insufficient vitamin D3 plays a role in both depression and dementia. Vegetarian seniors must plan their diets carefully and may need vitamin B12 supplementation (Kwok et al, 2012). Common checklists used for nutritional risk assessments are found in Table 1-36. Older adults often have limited range of motion, mobility, and strength. Figure 1-15 shows hand dynamometry, a useful tool for assessing muscle strength. Always compare abnormal lab work with an evaluation of nutritional intake. Only request additional lab tests that are warranted and cost-effective. Low albumin may indicate infection or a draining wound and not dietary inadequacy. Precipitously declining cholesterol (150 mg/dL) appears to be a marker for depression, poor nutrition, or mortality. At the opposite end of the spectrum, lowering elevated cholesterol and homocysteine levels, managing obesity, and smoking cessation are beneficial for heart and brain health. The prevalence of malnutrition increases with age, institutionalization, susceptibility to infection, and longer hospital stays. Nutrition screening tools include the Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), and the Mini Nutritional Assessment-Short Form (MNA-SF). MST, MUST, MNA-SF, and anthropometric screens of corrected arm muscle area and calf circumference have acceptable validity and can be used to triage nutrition care in the long-term-care setting (Isenring et al, 2012).

HOT H OT TOPIC Inflammation Muscle loss with aging (sarcopenia) comes from changes in anabolic hormones, decreased intake of dietary protein, a decline in physical activity, inflammation driven by cytokines, and oxidative stress with elevated levels of interleukin-6 and CRP (Jensen, 2008). The term “MIA syndrome” reflects the triad of malnutrition, inflammation, and atherosclerosis that includes oxidative stress and elevated cytokines. The malnutrition syndromes include starvation-associated malnutrition, when there is chronic starvation without inflammation; chronic disease-associated malnutrition, when inflammation is chronic and of mild to moderate degree; and acute disease or injury-associated malnutrition, when inflammation is acute and of severe degree (Jensen and Wheeler, 2012).

Figure 1-14. A healthy grandfather stays active with his granddaughter.

Escott-Stump_Ch01.indd 60

For a general intervention, the Mediterranean diet is especially useful. This diet improves cholesterol levels, blood sugar levels, and blood vessel health and reduces inflammation. When done properly, medical nutritional therapy can save thousands of dollars per patient, per hospital stay. Studies by the Academy of Nutrition and Dietetics demonstrate that for every dollar spent on nutrition screening and intervention, at least $3.25 is saved in health care costs. Always consider the wishes of the individual about nutrition or hydration.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-36 Summary of Nutrition Screening and Assessment Tools for the Elderly DETERMINE CHECKLIST NUTRITION SCREENING INITIATIVE:

MNA: MINI NUTRITION ASSESSMENT

For additional information and a complete copy of the tool, contact The Nutrition Screening Initiative • 1010 Wisconsin Avenue, NW • Suite 800 • Washington, DC 20007 http://www.cdaaa.org/images/Nutritional_Checklist.pdf

For additional information and a complete copy of the tool, contact Nestle http://www.mna-elderly.com/; App available at http://www.mna-elderly.com /i-phone.html

Disease (illness affects nutritional intake)

MNA is a reliable and easy-to-use nutritional assessment tool for physicians, dietitians, medical students, or nurses to quickly evaluate the nutritional status of an individual.

Eating poorly, especially fewer than two meals daily Tooth loss, mouth pain, chewing difficulty Economic hardship (too few dollars to buy food) Reduced social contact; eating meals alone Medicines (3 prescribed or over-the-counter medications) Involuntary weight loss or gain (10 lb in 6 months) Needs assistance with self-care (shopping, cooking, eating) Elderly years (older than 80 years of age), with increasing frailty

18 questions, 4 categories: anthropometric assessment, general assessment, dietary assessment, subjective assessment. Asks questions relating to the last 3 months, such as: • Weight loss; BMI • Mobility problems; psychological stress; acute disease • Food intake, digestive problems, chewing or swallowing difficulties • Depression or dementia

SGA: SUBJECTIVE GLOBAL ASSESSMENT

NUTRITION RISK-SCREENING 2002 (NRS-2002)

See Detsky AS, et al. What is Subjective Global Assessment of Nutritional Status? Journal of Parenteral and Enteral Nutrition 1987;11:8–13.

For additional information and a complete copy of the tool, contact http://ncp.sagepub.com/content/23/4/373/F2.expansion.html

SGA classification technique can aid in the recognition of undernutrition by assessing a patient’s nutritional status based on features of the medical history and physical examination.

Impaired nutritional status

• History: dietary intake change; gastrointestinal symptoms; functional capacity; disease and its relation to nutritional requirements

• Moderate: weight loss 5% in 2 months OR BMI 18.5–20.5 impaired general condition or food intake 25%–50% of normal requirement in preceding week

• Physical: loss of subcutaneous fat; muscle wasting, ankle edema; sacral edema; ascites

• Severe: weight loss 5% in 1 month (≈ 15% in 3 months) OR BMI 18.5–20.5 impaired general condition or food intake 25%–50% of normal requirement in preceding week

• SGA rating: well-nourished, moderately (or suspected of being) malnourished; severely malnourished

• Mild: weight loss 5% in 3 months OR food intake 50%–75% of normal requirement in preceding week

Severity of disease • Mild: hip fracture; chronic patients, in particular with acute complications— cirrhosis, COPD, chronic hemodialysis, diabetes, malignant oncology • Moderate: major abdominal surgery, stroke, severe pneumonia, malignant hematology • Severe: head injury, bone marrow transplantation, intensive care patients

‘Malnutrition Universal Screening Tool’ (‘MUST’)

For additional information and a complete copy of the tool, contact http://www.bapen.org.uk; see also Table 10-21 in this volume and http://www.bapen.org.uk/pdfs/must /must_explan.pdf Nutritional Screening: Steps 1 and 2: Gather nutritional measurements (height, weight, BMI, recent unplanned weight loss). If it is not possible to obtain height and weight, use alternative measurements. Step 3: Consider the effect of acute disease. Step 4: Determine the overall risk score or category of malnutrition. If neither BMI nor weight loss can be established, assess overall risk subjectively using “other criteria.” Step 5: Using the management guidelines and/or local policy, form an appropriate care plan.

Figure 1-15. Hand dynamometry is a useful tool for assessing muscle strength.

Escott-Stump_Ch01.indd 61

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

ASSESSMENT, MONITORING, AND EVALUATION

• • • • •

TSF, MAC, MAMC BUN, Creat Transferrin Total leukocyte count PT or INR

Genetic Markers • Each individual has a unique genetic profile and phenotype. Because both parents contribute genes and chromosomes to the fetus, a genetic history may be beneficial. • For example, apolipoprotein E (ApoE) 4 is known as a genetic risk factor for Alzheimer’s disease.

Clinical/History • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Age Height (actual) Weight, current Weight, usual Recent weight changes BMI Waist circumference Diet history Temperature (hypothermia?) BP Dentition Difficulty in chewing Limitations in hearing or sight Monotonous or limited intake Hydration status, I&O Dysphagia Constipation, diarrhea Fecal impaction Changes in bowel habits or incontinence Urinary incontinence or indwelling catheter Skin condition and pressure ulcers History of surgery, radiation, chemotherapy Mini-mental state examination Limited dietary recall Clinical signs of malnutrition Handgrip dynamometry DXA for sarcopenia or osteopenia Changes in appetite Nausea, vomiting, indigestion Chronic illness affecting intake Pain Infection Abnormal gait or motor coordination Sleep disorder screening Polypharmacy

Lab Work • • • • • • • • • • • •

Glucose CRP Ca, Mg Urinary N Na, K H&H, serum Fe Serum vitamin B12, methylmalonic acid Serum vitamin D levels Serum folate Serum homocysteine Chol, Trig Alb or transthyretin (can be high in dehydration)

Escott-Stump_Ch01.indd 62

INTERVENTION Objectives • Provide proper nutrition for weight control, healthy appetite, prevention of acute illness, and complications of chronic diseases such as osteoporosis, fractures, anemia, obesity, diabetes, heart disease, and cancer. • Avoid rapid unintentional weight loss, which often indicates underlying disease and accelerated muscle loss. Determine baseline functional level and evaluate changes over time. • Monitor for signs of malnutrition and cachexia. • Correct existing nutritional deficiencies. Malnourished seniors benefit from consuming oral supplemental beverages or orexigenic drug therapy. • Vitamin B12 deficiency in older people is most often from malabsorption. High serum folate levels along with vitamin B12 deficiency exacerbate anemia and can worsen cognitive symptoms; careful monitoring is important (Tangney et al, 2009). • Low 25-hydroxyvitamin D [25(OH)D] concentrations are common among older adults and are associated with poorer physical performance, strength and falls (Cameron et al, 2012; Houston et al, 2012). Both vitamin D and selenium protect the epigenome. Bioactive substances like resveratrol, curcumin, EGCG (epigallocatechin-3-gallate), and genistein alter gene expression through epigenetic mechanisms (Ong et al, 2011). • Older individuals have fewer taste buds; sweet flavors and stronger seasonings may be required. Dentures alter the taste of foods by increasing bitter and sour taste sensations. • Provide foods of proper consistency and textures. Chop foods as needed; puree only if necessary. Exclude hard, sticky foods that are difficult to chew and swallow. • Evaluate for laxative and enema use or abuse. Recommend suitable alternatives and interventions, such as oat fiber, prunes and other dried fruits, extra liquid. • Evaluate for alcohol abuse; make appropriate referrals as needed. • Maintain oral diet as much as possible. “If the gut works, use it.” For individuals who are unable to regain unintentional weight losses, artificial nutrition may be needed. Review advance directives and proceed accordingly. • Investigate hydration status and any major weight shifts. Diminishing thirst mechanisms and incontinence contribute to dehydration. Generally, older adults should ingest 25 to 30mL/kg of fluids per day. Alter as needed for heart, liver, or renal failure. • Indices of overweight and obesity such as BMI do not correlate as strongly with adverse health outcomes in older individuals. BMI seems to indicate global health status in elderly demented people; a BMI lower than 25 kg/m2 coincides with a worse cognitive status (Coin et al, 2012). • Assess the behavioral and environmental situations (i.e., Who shops? Who cooks? How are finances handled? How often are meals eaten away from home? Is this person depen-

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

dent or independent?). Evaluate family and social support. If there is a need for assistance, make appropriate referrals. • Correct frailty that results from depression, use of multiple medications, and underlying medical illnesses. Low levels of serum cholesterol (189 mg/dL) may indicate signs of occult disease or rapidly declining health. • Encourage physical activity, especially resistance training (Cermak et al, 2012). This can help to maintain metabolically active tissue, stimulate appetite, improve sleep, correct mild constipation, improve cognitive function, enhance nitrogen balance, and promote positive outcomes in memory, selfesteem, and independence.

Food and Nutrition • Promote intake using the MyPlate Food Guidance System: 3 to 4 servings of milk, dairy products, or calcium substitutes; 2 to 3 servings of protein foods (meat or substitute); 3to 5servings of vegetables; 2 to 4 servings of fruits; and 6to 12 bread group servings. • Diet should provide adequate intake of protein: 0.8 to 1 g/kg body weight. This may mean 63 g for men and 50 g for women. Decrease protein intake if needed for renal or liver impairments. Increase protein for pressure ulcers, cancer, infections, and other conditions requiring tissue repair. • Energy: 25 to 35 kcal/kg. The average 75-year-old woman and man need 2403 and 3067 kcal, respectively, if ambulatory. Fewer kilocalories are needed if nonambulatory. Nutritional supplements can provide needed energy and protein for nursing home residents (Avenell and Handoll, 2010). Recommend fats, oils, alcohol, sugars, and sweets to increase or decrease energy intake, as appropriate for the individual. See Table 1-37 for dietary reference intakes. • Include 1200 mg of calcium from milk, yogurt, and dairy products when possible. Include sources of the B vitamins and zinc. Iron needs are lower in women after menopause but include at least the RDA. Ensure sufficiency of other nutrients according to the patient’s age and sex. • Encourage use of the Mediterranean diet. Liberalize where possible to keep intake at a sufficient level. Extra natural vitamin E may be used from nuts, olive and canola oils, and some fruits and vegetables. • The consistency of the food should be altered (i.e., ground, pureed, or chopped) only as required. Try to maintain whole textures as often as possible to enhance the food’s appeal and to increase salivation while chewing. Mechanically altered diets are often not necessary and may compromise taste, acceptability, and micronutrient intake. • Adequate fiber and fluid intakes are necessary. Prudent increases in fiber (e.g., from prunes and bran) can reduce laxative abuse. Dehydration is a common cause of confusion and should be identified or avoided. • Intakes of vitamins C and D, folic acid, and iron are often deficient. Vitamin C levels must be increased for those individuals who smoke. Consider extra fruits and vegetables, which can enhance immunity (Gibson et al, 2012). • When taste and olfactory sensations are weak, the diet should provide adequate intake of zinc, folate, and vitamins A and B12. Season with herbs and spices; add butter-flavored seasonings, garlic, maple or vanilla extract, and cheese or baconflavored seasonings. Consider all possible taste enhancers. • Increased thiamin may be needed because of decreased metabolic efficiency. Men are especially susceptible.

Escott-Stump_Ch01.indd 63

• Reduce intake of excessive sweets; poor glucose tolerance and insulin resistance are common after 65 years of age. • If early satiety is a problem, serve the main meal at noon rather than evening. • Encourage socialization at meals. Healthy individuals have food intakes that are greater when eating with other people, especially family or friends. • Offer substitutes for major foods not consumed. If the individual resides in an institution, it is recommended to try other menu alternatives before offering a nutritional supplement as a meal replacement. Consult a dietitian if intake is chronically poor. If necessary, liquid supplements can provide needed energy, protein, and micronutrients. • Offer menus, cooking, or shopping tips for those who live and eat alone. Cooking in batches and freezing extra portions can be useful. • For hospice patients, provide comfort foods and liquids as requested.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Many drugs affect the nutritional status of the patient. A thorough drug history is needed. Drug metabolism and detoxification require an adequate diet containing methionine and other sulfur amino acids; vitamins A, B12, C, and E; choline; folate; and selenium. • Polypharmacy is common in older adults, especially those living in institutionalized settings. • Long-term use of high-carbohydrate, low-protein diets is undesirable when protein-bound drugs are prescribed. Drug metabolism is slowed, a potentially dangerous occurrence. Herbs, Botanicals, and Supplements • Herbs and botanical supplements should not be used without discussing with the physician, especially for underlying medical conditions. • Discuss the relevance of tolerable ULs from the latest dietary reference intakes of the National Academy of Sciences. These levels were set to protect individuals from receiving too much of any nutrient from diet and dietary supplements. • Older people should be encouraged to report the use of herbs and nutritional supplements to their doctors. Doctors should provide comprehensive and current information about potential herb–drug interactions. Among older adults, herbal supplement users are more likely to perceive their supplements as safe. • Black currant seed oil is rich in both gamma and alpha linoleic acids. • Creatine supplements have been used to increase strength in older individuals. However, results are mixed. • Echinacea may be used as an immune system stimulant. It should not be taken with steroids, cyclosporine, or immunosuppressants. It may aggravate allergies in susceptible individuals. • Gingko biloba is proposed for memory support; studies show no effectiveness. • Ginseng may be used for stress adaptation, impotence, or as a digestive aid. It should not be taken with warfarin, insulin, oral hypoglycemics, CNS stimulants, caffeine, steroids, hormones, antipsychotics, aspirin, or antiplatelet drugs. • Kava is sometimes used as a sleep aid. Discourage use with sedatives, alcohol, antipsychotics, or other CNS depressants.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-37 Dietary Reference Intakes for Older Adults VITAMINS AND ELEMENTS VITAMIN E VITAMIN THIAMIN (mg)e,f,g K (␮g) (mg)

VITAMIN A (␮g)a,b

VITAMIN C (mg)

VITAMIN D (␮g)c,d

900 700 900

90 75 90

10* 10* 15*

15 15 15

120* 90* 120*

Female 700 Tolerable Upper Intake Levels Age 51–70 Male 3000 Female 3000 Male 3000 Age 70

15*

2000 2000 2000

50 50 50

1000 1000 1000

RDA or AI a Age 51–70 Male Female Male Age 70

Female

RIBOFLAVIN (mg)

NIACIN (mg)g

VITAMIN B6 (mg)

FOLATE (␮g)g

1.2 1.1 1.2

1.3 1.1 1.3

16 14 16

1.7 1.5 1.7

400 400 400

90*

1.1

1.5

400

ND ND ND

35 35 35

100 100 100

1000 1000 1000

3000 VITAMIN B12 (␮g)

2000

1000

100

1000

PANTOTHENIC ACID (mg)

BIOTIN (␮g)

CHOLINE (mg)

BORON (mg)

CALCIUM (mg)

CHROMIUM (␮g)

COPPER (␮g)

FLUORIDE (mg)

IODINE (␮g)

2.4 2.4 2.4

5* 5* 5*

30* 30* 30*

550* 425* 550*

ND ND ND

1200* 1200* 1200*

30* 20* 30*

900 900 900

4* 3* 4*

150 150 150

Female 2.4 Tolerable Upper Intake Levels Age 51–70 Male ND Female ND Male ND Age 70

30*

425*

1200*

20*

900

150

ND ND ND

3500 3500 3500

20 20 20

2500 2500 2500

ND ND ND

10,000 10,000 10,000

10 10 10

1100 1100 1100

3500

2500

10,000

1100

RDA or AI a Age 51–70 Male Female Male Age 70

Female

RDA or AIa Age 51–70 Age 70

Male Female Male

Female Tolerable Upper Intake Levels Age 51–70 Male Female Male Age 70 Female

ELEMENTS AND MACRONUTRIENTS MOLYBDENUM NICKEL PHOSPHORUS (mg) (mg) (mg)

IRON (mg)

MAGNESIUM (mg)

MANGANESE (mg)

SELENIUM (ug)

VANADIUM (mg)

ZINC (mg)

8 8 8

420 320 420

2.3* 1.8* 2.3*

45 45 45

ND ND ND

700 700 700

55 55 55

ND ND ND

11 8 11

320

1.8*

700

45 45 45

350 350 350

11 11 11

2000 2000 2000

1 1 1

4000 4000 3000

400 400 400

1.8 1.8 1.8

40 40 40

350

2000

3000

400

1.8

ENERGY (kcal)b

PROTEIN (g)c

CARBOHYDRATES (g)d

ELEMENTS AND MACRONUTRIENTS TOTAL FAT n -6 PUFA n -3 PUFA (% kcal)e,f (g) (g)

TOTAL FIBER (g)

DRINKING WATER, BEVERAGES, WATER IN FOOD (L)

Male Female Male

2204 1978 2054

56 46 56

130 130 130

14* 11* 14*

1.6* 1.1* 1.6*

30* 21* 30*

3.7* 2.7* 2.6*

Female

1873

46 10–35%

130 45–65%

11* 5–10%

1.1* 0.6–1.2%

21*

2.1*

RDA or AIa Age 51–70 Age 70 AMDRa

20–35%

Recommended dietary allowances (RDAs) are in bold type and adequate intakes (AIs) are in ordinary type followed by an asterisk (*). Values are based on estimated energy requirements (EER) for men and women 30 years of age. Used height of 57 , “low active” physical activity level (PAL), and calculated the median BMI and calorie level for men and women. Caloric values based on age were calculated by subtracting 10 kcal/d for males (from 2,504 kcal) and 7 kcal/d for females (from 2,188 kcal) for each year of age above 30. For ages 51–70, calculated for 60 years old, for 70, calculated for 75 years old. 80-year-old-male calculated to require 2,004 kcal, female, 1,838 kcal. c The RDA for protein equilibrium in adults is a minimum of 0.8 g/kg body weight for reference body weight. d The RDA for carbohydrate is the minimum adequate to maintain brain function in adults. e Because percentage of energy consumed as fat can vary greatly and still meet energy needs, an AMDR is provided in absence of AI, EAR, or RDA for adults. f Values for mono- and saturated fats and cholesterol not established as “they have no role in preventing chronic disease, thus not required in the diet.” g Acceptable macronutrient distribution ranges (AMDRs) for intakes of carbohydrates, proteins, and fats expressed as percentage of total calories. The values for this table were excerpted from the Institute of Medicine, Dietary reference intakes: Applications in dietary assessment, 2000, and Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids (macronutrients), 2002. ND—Indicates values not determined. The values for this table were excerpted from the Institute of Medicine, Dietary reference intakes: Applications in dietary assessment, 2000, and Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids (macronutrients), 2002. b

Escott-Stump_Ch01.indd 64

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

TABLE 1-37 Dietary Reference Intakes for Older Adults (continued) ELECTROLYTES POTASSIUM (g)

SODIUM (g)

CHLORIDE (g)

Male

4.7

1.3*

2.0*

Female

4.7

1.3*

2.0*

Male

4.7

1.2*

1.8*

Female

4.7

1.2*

1.8*

RDA or AI a Age 51–70

Age 70

Tolerable Upper Intake Levels Age 51–70

Age 70

Male

2.3

3.6

Female

2.3

3.6

Male

2.3

3.6

Female

2.3

3.6

a Recommended dietary allowances (RDAs) are in bold type and adequate Intakes (AIs) are in ordinary type followed by an asterisk (*). ND—Indicates values not determined. The values for this table were excerpted from the Institute of Medicine, Dietary reference intakes: Water, potassium, sodium, chloride, and sulfate, 2004.

Nutrition Education, Counseling, CareManagement • Efforts to correct malnutrition in seniors are beneficial. Senior citizens often improve protein intake after appropriate counseling. • Emphasize the need to consume adequate amounts of calcium, folic acid, and vitamins A, E, and D. Review the desired nutrient intakes with the client; supplemental iron is not often needed unless there is anemia. Vitamin B12 and thiamin may be needed, depending on medications used and concurrent chronic disease. • Be aware of income limitations. Less-expensive protein sources may be necessary. Discuss shopping and meal preparation tips. • Numerous materials are available and can be used in a variety of settings. Food models and visual teaching tools are quite effective to teach portion control (Fig.1-16). • Prevent excessive use of caffeine from coffee, colas, and tea if it prevents intake of other desirable juices and beverages. Three 6- to 9-oz cups of coffee per day pose no specific health risk and caffeine may also promote improved cognition. • Make every effort to determine whether the patient is using alcohol because multiple deficiencies may result, especially for thiamin, vitamin B12, folate, and zinc. Make appropriate referrals. Older adults may not admit the true intake of alcohol because of embarrassment. • Encourage participation in Meals on Wheels, SNAP, congregate feeding programs, and Senior Farmers’ Market programs when needed. • Ensure adequate fluid intake and fiber for age and medical condition. • Encourage physical activity such as strength conditioning and walking. Yoga may help to prevent weight gain with aging. • Olfactory decline is common. Flavorful foods release endorphins, which boosts the immune system. Discuss adding herbs, spices, and other flavor enhancers to foods.

Escott-Stump_Ch01.indd 65

Figure 1-16. Teaching portion size through pictures. (Reprinted with permission from Anatomical Chart Company.)

• Hypothermia (body temperature of 95°F or lower) can occur easily, with fatigue, weakness, poor coordination, lethargy, slurred speech, and drowsiness. Give hot beverages and keep patient in a warm bed. If body temperature reaches 90°F, death is likely. • Support intake of antioxidants to protect the aging brain. Top choices include grape juice, blueberries, pomegranate, papaya, kiwifruit, cantaloupe, mango, apricot, broccoli, spinach, tomato, sweet potato, and collards. • Encourage physical activity. Peer or leader encouragement for strength training is especially beneficial in this age group. • Depression affects 20% to 40% of older Americans but is not a normal part of aging. It causes a lot of weight loss in nursing homes and in the community and must be treated. • Table 1-38 shows how knee-height can be used to calculate height for individuals unable to stand. • Weight-height charts and BMI calculations may be too restrictive. Being mildly overweight is not a significant risk factor for death in most older adults. Allocation of time and resources for weight reduction interventions among the mild to moderately overweight elderly is not advisable. • In long-term care, research has revealed little benefit to many older individuals with chronic conditions from restrictions in dietary sugar and sodium, as well as little benefit from tube feedings, pureed diets, and thickened liquids. The new Centers for Medicare & Medicaid Services (CMS) standards recommend to clinicians that a regular diet become the default with only a small number of individuals needing restrictions (CMS, 2013). • Restorative dining programs may be useful (Fig. 1-17). The Academy of Nutrition and Dietetics has suggested three visits for medical nutrition therapy to address restorative dining for the aging population. • For patients with a history of or risk for dehydration, the Academy of Nutrition and Dietetics recommends two or more medical nutrition therapy visits.

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 1-38 Formula for Calculating Stature Using Knee Height

A Healthy elderly. B Immobilized elderly. Knee height can be used to estimate standing height in a bedridden or handicapped person. Knee height is not affected by aging. Different populations may require the use of different equations; equations derived from taller statured populations (e.g., Caucasians) may be less accurate when applied to shorter statured populations. Sample formulas are as follows: Stature for Caucasian men 64.19 (0.04 age in years) (2.02 knee height in cm) Stature for Japanese men 71.16 (0.56 age in years) (2.61 knee height in cm) Stature for Caucasian women 84.88 (0.24 age in years) (1.83 knee height in cm) Stature for Japanese women 63.06 (0.34 age in years) (2.38 knee height in cm) Sources: Hwang IC, Kim KK, Kang HC, et al. Validity of stature-predicted Equations using knee height for elderly and mobility impaired persons in Koreans. Epidemiol Health. 2009;31:e2009004. See also: Estimating height in bedridden patients. Available at: http://www.rxkinetics.com/height_estimate.html. Accessed June 15, 2014.

• Terminally ill patients and their caregivers need education, information, advocacy, and emotional support. If advance directives indicate “no heroic measures,” identify if that includes tube feeding and hydration. Effective end of life discussions lead to earlier hospice referral. Neither insertion of percutaneous endoscopic gastrostomy tubes nor timing of insertion affect survival (O’Sullivan Maillet et al, 2013; Teno et al, 2012). Patient Education—Food Safety Tips • Reminders about hand washing and safe food handling may be important, especially for adults who prepare and serve meals for older adults. • Avoid food preparation when sick with viral or bacterial infections; use gloves if needed. • Thoroughly cook meat, poultry, and fish entrées. Keep cold foods cold and hot foods hot. • Because bacteria are commonly found on foods such as green onions (scallions), cantaloupe, cilantro, and imported produce, wash all fresh fruits and vegetables. Scrub the outside of produce such as melons and cucumbers before cutting. • When traveling, avoid tap water and ice made from tap water, uncooked produce such as lettuce, and raw or undercooked seafood. • Airline water may not be free from contamination; use bottled water. Coffee and tea may not reach temperatures hot enough to kill all bacteria.

Escott-Stump_Ch01.indd 66

Figure 1-17. A restorative dining program may help improve appetite and intake among seniors.

11/7/14 8:14 PM

SECTI ON 1 • N OR M AL L I FE S T AG E S

• Throw out cooked foods that have been at room temperature for longer than 2 hours. • Consumption of sulforaphane in foods such as broccoli, cauliflower, cabbage, and Brussels sprouts may reduce the presence of H. pylori. • Avoid raw or partially cooked eggs, raw or undercooked fish or shellfish, and raw or undercooked meats because of potential food poisoning. • Do not use raw (unpasteurized) milk or products made fromit. • Only serve processed deli meats and frankfurters that have been reheated to steaming hot temperature. • If the patient is immunocompromised, avoid deli meats and ready-to-eat meat and poultry products, smoked fish, and brie and blue-veined soft cheeses because of the risk for Listeria. Homemade eggnog, cookie and cake batter, and other foods prepared with raw eggs should be avoided because of the risks of Salmonella. Avoid raw seafood such as oysters, clams, and mussels which may contain Vibrio bacteria. • Avoid serving unpasteurized cider, juices, and raw sprouts because they may contain E. coli.

●

Administration on Aging (AOA) http://www.aoa.gov/

●

Aging Stats.gov http://agingstats.gov/Agingstatsdotnet/Main_Site/default.aspx

●

Aging with Dignity http://www.agingwithdignity.org/

●

American Association of Retired Persons (AARP) http://www.aarp.org/

●

American Federation for Aging Research http://www.afar.org/

●

American Geriatrics Society http://www.americangeriatrics.org/

●

American Medical Directors Association http://www.amda.com/tools/clinical/nutrition.cfm

●

American Society on Aging http://www.asaging.org/

●

Centers for Medicare & Medicaid Services (CMS) http://www.cms.hhs.gov/home/medicare.asp

●

Colorado State Extension http://www.ext.colostate.edu/pubs/foodnut/09322.html

●

Gerontological Society of America http://www.geron.org/

●

Government Page for Seniors http://www.firstgov.gov/Topics/Seniors.shtml

SAMPLE NUTRITION CARE PROCESS STEPS

●

Health and Age http://www.eldercare.com/

Unintentional Weight Loss in Long-Term Care

●

Homecare and Hospice http://www.nahc.org/

Assessment: Intake reports and food preferences, I&O records, weight changes, lab values, psychological issues.

●

Hospice Foundation http://www.hospicefoundation.org/

●

Human Nutrition Resource Center on Aging (Tufts University) http://hnrca.tufts.edu/

●

Meals on Wheels http://www.mowaa.org/

●

Medicare Information http://www.medicare.gov/

●

National Association Directors of Nursing Administration in Long TermCare http://www.nadona.org/

●

National Association of Nutrition and Aging Services Programs http://www.nanasp.org/

●

National Council on Aging (NCOA) http://www.ncoa.org/

●

National Eye Institute http://www.nei.nih.gov/about/

●

National Institute on Aging (NIA) http://www.nih.gov/nia/

●

National Institutes of Health—Senior Health http://nihseniorhealth.gov/

●

National Policy and Resource Center on Nutrition and Aging http://nutritionandaging.fiu.edu/

●

Okinawa Centenarians Study http://www.okicent.org/

●

Older Americans Resource Toolkit http://nutritionandaging.fiu.edu/OANP_Toolkit/

●

Pioneer Network Dining Practice Standards http://www.pioneernetwork.net/Latest/Detail.aspx?id=304

●

RD411 – Long-Term Care Materials http://www.nutrition411.com/clinical-nutrition/long-term-care-resources

●

RD411 – Older Adult Issues http://www.nutrition411.com/education-materials/older-adults-and-geriatric -issues

●

U.S. Senate Committee on Aging http://aging.senate.gov/

●

Young at Heart—Tips for Seniors http://win.niddk.nih.gov/publications/young_heart.htm

Nutrition Diagnosis (PES): Involuntary weight loss related to inadequate food and beverage intake as evidenced by 24-lb weight loss and dining room records indicating intake less than 50% at meals. Intervention: Offer more favorite foods; promote consumption of between-meal nourishments, collaboration with social worker. Monitoring and Evaluation: Changes in weight, verbalized improvement in appetite, dining room food intake records.

Palliative Care Nutrition Assessment:Individual not eating or drinking; physician-ordered palliative care; resident wishes to have “no heroic measures” including tube feeding as per advanced directives. Nutrition Diagnosis (PES): Inadequate food and beverage intake related to patient’s choice to withdraw nutritional support as evidenced by minimal oral intake and palliative care status. Intervention: Make food and fluids available upon patient or family request. Monitoring and Evaluation: Check measures taken for meeting patient or family requests.

For More Information

See the video “The Five Stages of Grief” at www.thepoint.lww.com/escottstump8e.

Escott-Stump_Ch01.indd 67

11/7/14 8:14 PM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

REFERENCES Administration on Aging (AOA). Profile of Older Americans: 2011. Available at: http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2011/3.aspx. Accessed June 15, 2014. Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD001880. Bernstein M, et al. Position of the Academy of Nutrition and Dietetics: food and nutrition for older adults: promoting health and wellness. J Acad Nutr Diet. 2012;112:1255. Burnett-Hartman AN, et al. Telomere-associated polymorphisms correlate with cardiovascular disease mortality in Caucasian women: the Cardiovascular Health Study. Mech Ageing Dev. 2012;133:275. Cameron ID, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012 Dec 12;12:CD005465. Centers for Medicare & Medicaid Services (CMS). Dining Standards for Long-Term Care. Available at: http://surveyortraining.cms.hhs.gov/pubs/VideoInformation. aspx?id=1101&cid=0CMSNEWDINPRSTAN. Accessed June 15, 2014. Cermak NM, et al. Protein supplementation augments the adaptive response of skeletal muscle to resistance-type exercise training: a meta-analysis. Am J Clin Nutr. 2012;96:1454. Coin A, et al. Nutritional predictors of cognitive impairment severity in demented elderly patients: the key role of BMI. J Nutr Health Aging. 2012;16:553. Flegal KM, et al. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013;309:71. Gibson A, et al. Effect of fruit and vegetable consumption on immune function in older people: a randomized controlled trial. Am J Clin Nutr. 2012;96:1429. Hanauer SB. Sarcopenia and the elusive fountain of youth. Nat Clin Pract Gastroenterol Hepatol. 2009;6:1. Houston DK, et al. 25-Hydroxyvitamin D status and change in physical performance and strength in older adults: the Health, Aging, and Body Composition Study. Am J Epidemiol. 2012;176:1025.

Escott-Stump_Ch01.indd 68

Isenring EA, et al. Beyond malnutrition screening: appropriate methods to guide nutrition care for aged care residents. J Acad Nutr Diet. 2012;112:376. Jensen GL. Inflammation: roles in aging and sarcopenia. JPEN J Parenter Enteral Nutr. 2008;32:656. Jensen GL, Wheeler D. A new approach to defining and diagnosing malnutrition in adult critical illness. Curr Opin Crit Care. 2012;18:206. Kagawa Y. From clock genes to telomeres in the regulation of the healthspan. Nutr Rev. 2012;70:459. Kamp BJ, et al. Position of the American Dietetic Association, American Society for Nutrition, and Society for Nutrition Education: food and nutrition programs for community-residing older adults. J Am Diet Assoc. 2010;110:463. Kwok T, et al. Vitamin B-12 supplementation improves arterial function in vegetarians with subnormal vitamin B-12 status. J Nutr Health Aging. 2012;16:569. Langie SA, et al. Early determinants of the ageing trajectory. Best Pract Res Clin Endocrinol Metab. 2012;26:613. Ong TP, et al. Targeting the epigenome with bioactive food components for cancer prevention. J Nutrigenet Nutrigenomics. 2011;4:275. O’Sullivan Maillet J, et al. Position of the academy of nutrition and dietetics: ethical and legal issues in feeding and hydration. J Acad Nutr Diet. 2013;113:828. Payne ME, et al. Fruit, vegetable, and antioxidant intakes are lower in older adults with depression. J Acad Nutr Diet. 2012;112:2022. Sura L, et al. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging. 2012;7:287. Tangney CC, et al. Biochemical indicators of vitamin B12 and folate insufficiency and cognitive decline. Neurology. 2009;72:361. Teno JM, et al. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc. 2012;60:1918. White JV, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112:730. Wolfe RR. The role of dietary protein in optimizing muscle mass, function and health outcomes in older individuals. Br J Nutr. 2012;108:S88.

11/7/14 8:14 PM

Nutrition Practices, Food Safety, Allergies, Skin, and Miscellaneous Conditions

CHIEF ASSESSMENT FACTORS ● ● ● ● ●

● ● ● ● ● ● ● ●

Complementary and integrative medicine Use of herbs, spices, and botanical products Cultural or religious preferences with special diets or practices Vegetarian diets (see also Table 2-4) Mouth: dental problems, periodontal diseases, dentures (ill-fitting), missing or loose teeth, caries, oral hygiene and dental care, increased or decreased salivation, dryness, lesions (see also Tables 2-5 and 2-6) Self-feeding difficulty Vision: cataracts, visual field changes, diplopia, glaucoma, macular degeneration, blindness (see also Table 2-7) Skin: texture or color changes, dryness, ecchymoses, lesions, masses, petechiae, pressure ulcers (see also Table 2-8) Physical signs of nutrient deficiencies Head/face: pain, past trauma, syncope, migraine headaches Ears: hearing problems, discharge, infections, tinnitus, or vertigo Food allergies or intolerances Foodborne illnesses

Escott-Stump_Ch02.indd 69

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

BACKGROUND: NUTRITION PRACTICES Optimal functioning of the immune system and nutrition are major factors regulating health. Eosinophils regulate local immune and inflammatory responses, and their accumulation in the blood and tissue is associated with several inflammatory and infectious diseases, including atopic disorders such as asthma and allergy, as well as autoimmunity and malignancy (Fulkerson and Rothenberg, 2013). Although no single marker predicts the effect of a dietary intervention on different aspects of immune function, three distinct immune system functions play a role: defense against pathogens, avoidance or mitigation of allergy, and control of low-grade (metabolic) inflammation (Albers et al, 2013). Careful identification of possible nutrition diagnoses allows the Registered Dietitian to intervene appropriately to resolve the issue and support overall immunity. Possible nutrition diagnoses in this chapter may include but are not limited to • • • • • • • • • • • • • • • • •

Inadequate intake of bioactive substances Excessive intake of bioactive substances Excessive carbohydrate intake (sugars, sweets, beverages) Inadequate oral food and beverage intake (if foods served are unfamiliar or forbidden) Inadequate fluid intake Inadequate oral food and beverage intake (from nausea, anorexia) Inadequate protein intake Inadequate intake of fat (omega-3 fatty acids) Harmful beliefs about food and nutrition (such as pica) Increased nutrient needs (vitamins) Excessive vitamin intake (from supplements) Excessive sodium intake Inadequate mineral (iron, calcium, zinc) or vitamin intakes (B12, D) Excessive fiber intake (phytates) Disordered eating pattern (unusual diet excluding multiple food groups) Underweight or involuntary weight loss Difficulty chewing (leading to inadequate oral food and beverage intake)

• • • • • •

Difficulty swallowing Self-feeding difficulty (functional, physical, psychological) Malnutrition Altered nutrition-related lab values Altered gastrointestinal (GI) function (vomiting, diarrhea) Intake of unsafe food (allergens, pathogens, unsubstantiated supplements)

REFERENCES Albers R, et al. Monitoring immune modulation by nutrition in the general population: identifying and substantiating effects on human health. Br J Nutr. 2013;110:S1S. Fulkerson PC, Rothenberg ME. Targeting eosinophils in allergy, inflammation and beyond. Nat Rev Drug Discov. 2013;12:117.

For More Information ●

Academy of Nutrition and Dietetics—Nutrition Education for the Public http://www.nepdpg.org/

●

Centers for Disease Control and Prevention—Index for Consumer Questions http://www.cdc.gov/health/diseases.htm

●

Evidence-Based Guidelines http://www.ahrq.gov/professionals/clinicians-providers/guidelines -recommendations/index.html

●

Federal Trade Commission http://www.ftc.gov/

●

Health Finder http://www.healthfinder.gov/

●

Health Fraud and Quackery http://www.quackwatch.com/

●

Health Statistics—Fast Facts http://www.cdc.gov/nchs/fastats/Default.htm

●

Healthy People (2010, 2020) http://www.cdc.gov/nchs/healthy_people.htm

●

Human Anatomy Online http://www.innerbody.com/

●

International Food Information Council http://www.ific.org/

●

PubMed http://www.ncbi.nlm.nih.gov/PubMed/

●

USDA: Food Composition Tables http://fnic.nal.usda.gov/food-composition

COMPLEMENTARY-ALTERNATIVE OR TRADITIONAL NUTRITION

COMPLEMENTARY-ALTERNATIVE OR TRADITIONAL NUTRITION NUTRITIONAL ACUITY RANKING: LEVEL 2 (NUTRITION ADVICE) DEFINITIONS AND BACKGROUND The philosophy that food can be health promoting beyond its nutritional value has gained acceptance within the public arena. Medical students are being taught about the benefits and risks of TCAM (traditional, complementary, and alternative

Escott-Stump_Ch02.indd 70

medicine). For example, children with Crohn’s disease may be using TCAM; health care providers must partner with their patients to discuss efficacy, safety, harm, drug-supplement interactions, and appropriate referral sources (Leiby and Vazirani, 2012). In the nutrition field, functional foods and bioactive products have hit the consumer market. Functional foods are

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

whole foods and fortified, enriched, or enhanced foods that have a potentially beneficial effect on health (Crowe and Francis, 2013). Customization of health care, tailored to the individual as “personalized nutrition,” will require knowledge of these many ingredients. Fatty fish provide fish oils; fermented dairy products have probiotics; and beef has conjugated linoleic acid. Oats provide beta-glucan, soy provides isoflavones, and flaxseed provides lignins and alpha-linolenic acid. Garlic provides organosulfur compounds, broccoli and cruciferous vegetables provide isothiocyanates and indoles. Citrus fruits provide liminoids, cranberry provides polymeric compounds, tea provides cachectin, and wine provides phenolics. For many consumers, the supermarket has become their corner drugstore. Dried culinary herbs contain very high concentrations of antioxidants and contribute significantly to the total intake of plant antioxidants (Yi and Wetzstein, 2011). Indeed, plants and herbs contain biologically active phytochemicals with potential for disease prevention. Many patients use herbal medicines but do not tell their health care providers. Dietary supplementation is common in the United States, with 49% of adults reporting regular use (Shane-McWhorter and Martinez, 2011). The most commonly used supplement type is one-a-day multivitamins/minerals; other common supplements are vitamin C, fish oil, vitamin E, and bone or joint supplements (Murphy et al, 2011). Dietary supplements, nutraceuticals, and functional foods are a subcategory of TCAM called “biologically based therapies” (Ventola, 2010). Nutritional manipulation is an integral part of many complementary therapies for cancer, arthritis, chronic pain, HIV, and gastrointestinal (GI) problems. The use of CAM by cancer patients is increasing, posing serious safety issues (Goey et al, 2013). Dietitians are uniquely qualified to translate sound scientific evidence into practical applications, yet many are not confident about the use of herbs. While they are trained to assess dietary adequacy and the need for nutrient modifications, they need the science behind the recommendations as well (Marra and Boyar, 2009). It is important to respect the cultural or religious

patterns in which herbs and botanicals are used as medical or dietary enhancements. Unfortunately, patients often do not report their use of supplements to their providers (Frenkel et al, 2013). Table2-1 lists questions to ask and Table 2-2 lists common products. Consider any adverse effects and discuss as needed with clients.

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • • • •

Use of vitamin/mineral supplements Herbs and botanical products—amount, frequency Special diets or nutrition support Dietary pattern for food and alcohol Over-the-counter and prescribed medications Knowledge of food and nutrition Family or genetic history Cultural or religious practices using functional ingredients

Lab Work • • • • • • • • • • • • •

Hemoglobin and hematocrit (H&H) Serum iron (Fe) Glucose Sodium (Na⫹), potassium (K⫹), and chloride (Cl⫺) Calcium (Ca⫹⫹), magnesium (Mg⫹⫹) Albumin (Alb) T3, T4, thyroid-stimulating hormone (TSH) Blood urea nitrogen (BUN) Creatinine (Creat) Homocysteine (tHcy) Cholesterol (Chol), triglycerides (Trig) Serum vitamin D Other values as determined by products consumed

TABLE 2-1 Herbal, Botanical, and Dietary Supplement Intake Identify types of supplements that you use: ___None Vitamins/minerals: Multivitamin/mineral Calcium/Vitamin D Other Other nutrients:

Protein supplement

Herbs:

Black cohosh

Aloe Valerian

For how long? ⬎1 year

1 month or less

How did you hear about them?

Fiber supplement Ginseng

My doctor

Fish oil

6–12 months Pharmacy

Indefinitely

Describe any adverse side effects List any allergies to medications, foods, plants, or flowers

Gingko biloba

3–6 months

How long will you use these supplements? 6–12 months Why do you take this supplement(s)? General wellness Energy Other reason (specify)

How have symptoms improved since you started taking this supplement? Feel better More energy Fewer symptoms Other (explain):

Vitamin C

A friend 1–6 months

Prevention against disease Weight loss

To help treat a disease (cancer, arthritis, diabetes If so, what are your medical symptoms? And how long have you had this medical condition? ⬍week 1–3 months 3–12 months ⬎1 year

List any additional illnesses or medical conditions or breastfeeding? No Yes Women: Postmenopausal No Yes

Women: Pregnant

List other over-the-counter and prescription medications (such as aspirin, diuretics, heart medicines, oral contraceptives) that you take How much alcohol do you drink in a day? 2 glasses More than 2 glasses How much do you smoke in a day? 1 pack or more

None

Name any diet or eating plan you follow Was this prescribed for you by a doctor?

None

1 glass

⬍1 pack

For how long? No

Yes

Based on Institute of Medicine. Dietary supplements: a framework for evaluating safety. Available at: http://www.nap.edu/openbook.php?isbn=0309091101. Accessed June17, 2014; Marinac JS, Buchinger CL, Godfrey LA, et al. Herbal products and dietary supplements: a survey of use, attitudes, and knowledge among older adults. J Am Osteopath Assoc. 2007;107:13-23; Rosenbloom C. Sports Nutrition: A Guide for the Professional Working with Active People., 3rd ed. Chicago, IL: American Dietetic Association; 2000.

Escott-Stump_Ch02.indd 71

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Acai berry

There is no definitive scientific evidence based on studies in humans to support the use of acai berry for any health-related purpose.

People allergic to plants in the palm family should not use acai.

Alfalfa (Medicago sativa)

Used for diuretic properties in asthma, diabetes, thyroid gland malfunction, arthritis, high cholesterol, and peptic ulcers. Said to promote menstruation and lactation.

Rats fed with this are prone to colon cancer. Fatalities reported due to ingestion of contaminated alfalfa.

Alpha lipoic acid (ALA)

Used to prevent cancer, HIV, AIDS, and liver disease. Cofactor in insulin-sensitizing and glucose metabolism enzymes. Used to lower triglycerides by reducing endothelial dysfunction. Most human studies are needed. Contained in broccoli, spinach, and tomato.

Its antioxidant activity may antagonize the effects of chemotherapy. Expensive; vitamin E has similar effects at lower cost.

Aloe vera (Aloe barbadensis)

Topical administration of aloe vera gel for burns is generally safe. It may help reduce radiation-induced skin changes, but clinical trials are inconsistent. Aloesin shows promise in lowering blood glucose levels.

FDA rules that it is not safe as a stimulant laxative; causes strong GI cramping. Chronic use can lead to loss of potassium. Do not use with diuretics, corticosteroids, or antihyperglycemic or cardiovascular agents.

Arnica (Arnica montana)

Used as a topical ointment for bruises, osteoarthritis in homeopathy preparations.

If taken orally, causes hypotension and shortness of breath; can be fatal.

Artemisia (Wormwood)

Used as an antimalarial; also used in cancer, fever, infections.

GI upset is a common side effect; causes hyperacidity.

Astragalus (Astragalus membranaceus)

No final evidence but some reports of usefulness in immune disorders or cancer as well as heart and liver disorders.

May interact with medications that suppress the immune system, such as cyclophosphamide taken by cancer patients and similar drugs taken by organ transplant recipients. It may also affect blood sugar levels and blood pressure.

Avlimil

Used to alleviate symptoms of female sexual dysfunction. Contains red clover, capsicum, black cohosh, ginger, and licorice.

Contraindicated in women having hormone-sensitive cancers. Stomach upset is an adverse reaction.

Ayurvedic Plants

Used in diabetes, rheumatoid arthritis (RA), Parkinson’s disease, obesity, cancer, anemia, edema, and postpartum complications of pregnancy. Meditation helps in reducing anxiety, lowering blood pressure, and enhancing general well-being. The herbs show antioxidant, antitumor, antimicrobial, hypoglycemic, and anti-inflammatory properties.

Lead poisoning is a potential complication. Arsenic and mercury can be found in some of these herbs as well because of the practice of mixing metals with medicines (known as rasa shasta).

Barberry (Berberis aristata )

Used as a coagulant herb. Also anti-microbial and anti-pyretic.

May inhibit effects of anticoagulant medications such as warfarin.

Bilberry (Vaccinium myrtillus)

Used in Europe as an antioxidant to prevent diabetic retinopathy; improves visual acuity and retinal function. Used for cataracts, cancer, circulatory disorders, diabetic retinopathy, glaucoma, macular degeneration, hemorrhoids, and varicose veins. Relative of blueberry.

Exhibits antiplatelet activity. May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding. Do not use with anticoagulants or antiplatelet medications. No adverse reactions reported.

Biocell collagen (BCC)

Used as a matrix with hydrolyzed collagen, chondroitin, and hyaluronic acid to counteract photoaging and to reduce symptoms of osteoarthritis.

No long-term studies on safety when taken orally.

Bitter melon (Momordica charantia)

Used in cancer prevention, diabetes, fever, HIV, infections, menstrual disorders.

Contraindicated in children and pregnant women because it causes bleeding, contraction of the uterus, and abortion. Adverse reactions include hypoglycemia and hepatotoxicity, headache, fever, abdominal pain, and coma.

Black cohosh (Cimicifuga racemosa)

Used with hot flashes, headaches, vaginal dryness, mood swings, cough, dysmenorrhea, rheumatoid arthritis, and sedation. It functions as an antispasmodic, sedative, or relaxant.

May alter blood pressure. Can cause vomiting, headache, dizziness, GI distress, and limb pain. May increase the toxicity of doxorubicin and docetaxel or interact with drugs that are metabolized by CYP3A4 enzyme. May interfere with tamoxifen. Often contains salicylates.

Controversial whether black cohosh possesses estrogenic activity.

Warning: should not be confused with blue cohosh (Caulophyllum thalictroides), which is toxic and may be used in attempts to induce abortion.

Borage oil (Borago officinalis)

Used for rheumatoid arthritis, infantile seborrheic dermatitis, cough, chest congestion, and menopausal symptoms. May have some benefit for respiratory distress syndrome in infants. Contains gamma linolenic acid (GLA).

Contains pyrrolizidine alkaloid and amabiline, which are hepatotoxic. Unsafe during pregnancy due to teratogenic effects and premature labor. Adverse effects include constipation and hepatotoxicity after chronic administration.

Boswellia (Boswellia serrata)

Used for arthritis, asthma, colitis, cluster headaches, inflammation, and menstrual cramps. May have antitumor effects in colon cancer.

Long-term effects on humans are unknown.

Brewer’s yeast

Used as a natural source of chromium.

Avoid supplement use with MAO inhibitors such as Nardil, Parnate. May cause hypersensitivity reaction in some individuals.

Escott-Stump_Ch02.indd 72

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Bromelain, from pineapple stem (sulfhydryl proteolytic enzyme)

Used for arthritis, bruises, burns, cancer prevention and treatment, edema, indigestion, and circulatory disorders.

Diarrhea, GI disturbances, allergic reactions. May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding.

Exhibits antiplatelet activity. Contains proteases. Buckthorn bark

Used as laxative herb to speed digestion, which reduces absorption time of drugs.

Chronic use results in a loss of potassium, thereby strengthening effects of cardiac glycosides and antiarrhythmic agents. Use with thiazide diuretics, corticosteroids, or licorice root increases potassium loss.

Bupleurum (Bupleurum chinense, B. scoizone—raefolium)

Used for colds, fever, infections, cirrhosis, hepatitis, liver disease, malaria, and cancer treatment.

Warning: may be associated with interstitial pneumonitis as an ingredient of shosaiko. Adverse reactions include nausea, vomiting, edema, GI disturbance.

Burdock (Arctium majus)

Used for arthritis, HIV, AIDS, psoriasis, diabetes, eczema, and anorexia; no human studies on these proposed claims. Promotes urination.

Contraindicated in pregnancy, lactation, or allergy to chrysanthemum. Warning: Burdock tea sometimes is contaminated with belladonna alkaloids.

Butcher’s broom (Ruscus aculeatus)

Used for hemorrhoids, varicose veins, circulatory diseases, lymphedema, leg cramps, constipation, and inflammation.

Diarrhea. Rarely, hyperglycemia.

Butterbur (Petasites hybridus)

Used as an oral antihistamine for itchy eyes and nasal allergies.

Warning: Raw product contains pyrrolizidine alkaloids which cause liver damage. May cause allergic reaction in people allergic to ragwood.

Calendula (Calendula officinalis)

Used for conjunctivitis, eczema, GI disturbance, inflammation, menstrual cramps, and radiation therapy.

Contraindicated in pregnancy and lactation. Possible allergic reactions.

Capsicum, capsaicin (Capsicum frutescens and C. annuum)

Used as a circulatory stimulant to aid in digestion. Used externally to relieve pain, as from arthritis, circulatory disorders, and diabetic and herpes zoster neuropathy. Suggested to lower high cholesterol or to lessen motion sickness, muscle pain, or toothache. Under study for weight management.

Avoid contact with eyes and irritated or broken skin. Burning skin, urticaria, and contact dermatitis. May damage dental enamel if consumed regularly (i.e., Indian curries.)

Used for cancer treatment and constipation. Often found in over-thecounter laxatives.

Contraindications: should not be used in intestinal obstruction, undiagnosed abdominal symptoms, and inflammatory bowel disease. Adverse reactions include vomiting, intestinal cramps; excessive use can cause diarrhea, weakness, or cholestatic hepatitis.

Cascara (Rhamnus purshiana)

Warning: FDA has ruled that cascara is not safe as a stimulant laxative.

Drug interactions: increases the incidence of cough associated with ACE inhibitors.

Drug interactions: excess loss of K⫹ with digoxin that potentiates cardiac effects; avoid use with cardiovascular agents. Cat’s claw (Uncaria tomentosa, U.guianensis)

Used for osteoarthritis, Alzheimer’s disease, herpes, and HIV.

Side effects are rare but may include headache, dizziness, or vomiting.

Cayenne

Used for muscle spasms and relief of pain in arthritis. Large doses may lead to chronic gastritis and kidney or liver damage. Main ingredient is capsaicin. Exhibits anticoagulant activity. Now common in weight loss pills.

May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding; avoid with anticoagulants or antiplatelet medications. Can cause coronary vasospasms.

Chamomile (Matricaria recutita)

Used for colic, GI disturbance, hemorrhoids, infections, skin ulcers, mucositis. Chamomile soothes indigestion, flatulence. May be useful for depression or anxiety. Topical and oral administration is safe except in patients with allergies to ragweed or chrysanthemum.

Contact dermatitis or anaphylaxis in those allergic to ragweed or chrysanthemum. Drug interactions: increases anticoagulant effects due to its natural coumarin content; avoid with warfarin.

Chasteberry (Vitex agnus castus)

Used for premenopausal symptoms, dysmenorrhea, or menopause.

GI upset, nausea, rash, urticaria, and headache. Should not be taken with hormone replacement therapy or oral contraceptives; an itchy rash can occur. It may interact with dopamine antagonists.

Chinese asparagus (Asparagus cochinchinensis)

Used for cancer treatment, constipation, cough, and hepatitis. Asteroidal saponin.

No adverse reactions or drug interactions reported.

Chitosan

Used as an ingredient in many weight loss supplements, with claims to bind and trap dietary fat. A polysaccharide. Hemostatic action can activate macrophages. Under study in wound healing.

It is clinically insignificant for weight loss.

Chondroitin

Used to support healthy connective tissue and synovial fluid that lubricates joints. Improves functional status of people with hip or knee osteoarthritis, relieves pain, and reduces joint swelling and stiffness. Used with glucosamine in many products.

Being studied in multiple sclerosis; chondroitin sulfate proteoglycans (CSPGs) are found in multiple sclerosis lesions. Implications are not yet clear.

(continued)

Escott-Stump_Ch02.indd 73

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Chromium picolinate

Chromium is essential in lipid and carbohydrate metabolism. Supplement often used by athletes. May have some merit in diabetes management; 40–1000 mcg reduces FBG in T2DM.

Chronic use may lead to impaired iron and zinc metabolism, GI intolerance, nephritis, or chromosomal damage.

Cinnamon (Cinnamomum verum, C. cassia)

Used for bronchitis and gastrointestinal problems. Increases sensitivity to insulin (Magistrelli and Chezem, 2012).

Safe for most people when taken by mouth 6 g or less daily for 6 weeks. Some people may have allergic reactions. Cassia cinnamon contains coumarin; avoid with anticoagulants. No substantial effect on glucose control. Contains coumarin which may cause hepatotoxicity in liver disease.

Chrysanthemum (Chrysanthemum morifolium)

Used for angina, hypertension, fever, common cold. No human studies.

Contraindications: those with allergy to ragweed. Adverse reactions include contact dermatitis, photosensitivity.

Coenzyme Q10

Used for patients with heart failure, hypertension, or early signs of Parkinson’s disease. Useful when taking statin medications. May lower A1c in T2DM.

Coenzyme Q10, superoxide dismutase (SOD), S-adenosyl-Lmethionine methionine (SAM-e), and other products have not been proven to reduce the effects of aging.

Coleus or forskolin

Exhibits antiplatelet activity.

May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding.

Cone flower (Echinacea purpurea, E. pallida, E. augustifolia)

Used for common cold, immunostimulation, infections, viral infections, wound healing.

Contraindications: patients with autoimmune disorders (systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, tuberculosis, HIV). Adverse reactions include headache, dizziness, nausea, rash, dermatitis, anaphylaxis.

Cranberry (Vaccinium macrocarpon)

Used to prevent urinary tract infection caused by Escherichia coli bacteria, especially after menopause. Often used for reducing dental plaque or stomach ailments.

Use large amounts cautiously when taking aspirin or anticoagulants.

Creatine

Used to increase strength in some older individuals and in athletes. More studies are needed.

Heavy use may lead to cardiomyopathy, hypertension, renal impairment.

Curcumin and turmeric

Used for anti-inflammatory and antioxidant effects in cystic fibrosis, cognitive function in Alzheimer’s disease. May inhibit growth of cancer cells.

Bioavailability is low. Piperine from black pepper increases absorption but slows drug clearance (Dilantin, theophylline, Inderal.)

Dandelion (Taraxacum mongolicum)

Used for diabetes, lactation stimulation, promote urination, rheumatoid arthritis, liver disease. Used as salad greens and in teas. Only a few clinical studies.

Allergic reactions, contact dermatitis, dyspepsia. Contraindication in patients with obstruction of the bile duct or gallbladder. Drug interactions: additive effect on hypoglycemic activity.

Da qing ye (Isatis tinctoria)

Used for cancer treatment, diarrhea, GI disorders, hepatitis, HIV and AIDS, respiratory infections.

Adverse reactions include nausea, vomiting, hematuria following injection.

Devil’s claw (Harpagophytum procumbens)

Used for analgesic, anti-inflammatory, osteoarthritis, muscle pain, GI disturbances.

Contraindication in pregnancy. Adverse reactions include dyspepsia, diarrhea, bradycardia.

Dong quai (Angelica sinensis)

Used as Chinese tonic for menstrual cramps, peripheral vasodilator, and pain reliever. It has not shown effectiveness for reducing hot flashes.

Exhibits anticoagulant activity. May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding. It should not be used in pregnancy. Increased doses are carcinogenic. Adverse effects include bloating, loss of appetite, diarrhea, photosensitivity, gynecomastia.

Echinacea (see Cone Flower)

Used as an immune system stimulant. Echinacea is no more effective for upper respiratory tract infections than placebo. Avoid taking for longer than 2 months at a time.

Avoid with corticosteroids, cyclosporine, or immunosuppressants. It may trigger allergies since it is related to the ragweed family (as are butterbur, chamomile, goldenrod, and yarrow).

Elderberry (Sambucus nigra)

Used for pain, swellings, infections, cough.

Uncooked or under ripe berries are toxic and may cause diarrhea or vomiting. May have a diuretic effect; avoid use with other diuretic drugs.

Essiac/Flor Essence

Used as herbal tea; proposed as an anti-inflammatory product. Contains at least four herbs: slipper elm, burdock root, Indian rhubarb root, and sheep sorrel.

Nausea and vomiting may occur. No evidence of a role in cancer.

Eucalyptus

Used for asthma, coughs, arthritis in small doses.

Overdoses can be fatal.

Evening primrose oil (Oenothera biennis)

Used for rheumatoid arthritis, mastalgia, eczema, fatigue, diabetic neuropathy, premenstrual syndrome, menopausal symptoms, cancer treatment. Contains gamma linolenic acid (GLA), which may be useful in cardiac or arthritic conditions.

Contraindication: pregnant women. Adverse reactions are headache, nausea, GI upset. Drug interactions: may lower the seizure threshold in patients taking phenothiazines. Avoid use also with chlorpromazine, fluphenazine, mesoridazine, anticoagulants, or antiplatelet medications.

Naturally found in mushrooms, nuts, bread, yeast.

Escott-Stump_Ch02.indd 74

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Fenugreek (Trigonella foenum-graecum)

Used for laxatives, lactation stimulation, diabetes, high cholesterol, wounds, alopecia, arthritis, GI disturbance, induce child birth.

Contraindication: infants and pregnant women. Adverse reactions: flatulence, diarrhea, bleeding, bruising, hypoglycemia. Interacts with anticoagulants and monoamine oxidase inhibitors (MAOIs).

Feverfew (Tanacetum parthenium)

Used for migraine, psoriasis, arthritis, dysmenorrhea.

Avoid use with nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, antiplatelet, and migraine medicines. Contraindicated in those who are allergic to ragweed or marigold. Adverse reactions cause mouth ulcers. Withdrawal causes anxiety, muscle stiffness, and pain.

DISCONTINUE 2 WEEKS BEFORE SURGERY

Flaxseed (Linum usitatissimum)

Used for cancer prevention, constipation, high cholesterol, menopausal symptoms, periodontal diseases.

Exhibits antiplatelet activity. May enhance effects of anticoagulants such as warfarin and potentiate bleeding. Avoid with radiation therapy. Take plenty of water.

Folk remedy oils

Used for childhood ailments in Mexican culture.

May cause pneumonia in infants and children.

Forskolin (Coleus forskohlii)

See Coleus.

Gamma linolenic acid (GLA)

Used for reducing signs of PMS or menopause. Black currant oil contains GLA.

Avoid with anticonvulsants or anabolic steroids. Liver toxicity may occur.

Garlic

Used to help lower cholesterol. Antibacterial, antifungal, antiviral, and hypotensive benefits have also been noted. Allyl sulfides may promote apoptosis, inhibit tumor growth, and reduce risk for cancers.

Induces cytochrome P450 3A4 and may enhance metabolism of medications such as cyclosporine and saquinavir. Avoid using garlic capsules with warfarin and with diabetes medications (may cause hypoglycemia).

DISCONTINUE 2 WEEKS BEFORE SURGERY Ginger (Zingiber officinale)

Used as a treatment for nausea, motion sickness, vomiting, anorexia, drug withdrawal, rheumatoid arthritis.

Adverse reactions include heartburn, bloating. Increases risk of bleeding if used with anticoagulant or antiplatelet medications. Additive effects with hypoglycemic drugs and histamine antagonists. Mixed results for effects on reducing nausea and vomiting in cancer.

Gingko biloba

Used to improve blood flow, especially in leg arteries. Not proven for hearing loss, cancer, dementias, circulatory disturbance, Raynaud disease, sexual dysfunction, stress, tinnitus, asthma.

Gingko biloba may cause allergic skin reactions or bleeding. Avoid use with warfarin, antihyperglycemic agents, vitamin E, or aspirin. Warning: discontinue before surgery. Adverse reactions include headache, dizziness, GI upset, diarrhea, and seizures in patients predisposed to seizures or on medications that lower seizure threshold.

DISCONTINUE 2 WEEKS BEFORE SURGERY

Ginseng (panax)

American ginseng (panax quinquefolius) is often used for stress adaptation, cognitive or performance enhancement, impotence, a digestive aid, protection against cancer. Siberian ginseng (Acanthopanax senticosus) is used for lessening chemotherapy side effects; for health maintenance, strength, stamina, and immunostimulation. DISCONTINUE 2 WEEKS BEFORE SURGERY

It should not be taken with warfarin, insulin, oral hypoglycemics, CNS stimulants, caffeine, steroids, hormones, antipsychotics, aspirin, cardiovascular agents, warfarin, or other antiplatelet drugs. May interfere with loop diuretics and digoxin action. Ginseng may add to the effects of estrogens or corticosteroids and can elevate BP. Contraindicated in hypertension and in perimenopausal, pregnant, or lactating women.

Glehnia (Glehnia littoralis)

Used for bronchitis, chest congestion, whooping cough.

Photosensitivity may occur due to psoralens component. Contraindicated in radiation therapy.

Glucosamine sulfate

Used to build new cartilage, rebuild old cartilage, lubricate joints, mount a healthy inflammatory response, and ease symptoms of osteoarthritis. It is often taken with chondroitin.

May contain sodium.

Goldenseal

Used for some infections because it contains berberine.

DO NOT TAKE ORALLY.

Gotu kola (Centella asiatica, Hydrocotyle asiatica)

There are wide variations in terpenoid concentrations depending on the location grown. Used for burns, cancer treatment, circulatory disorders, GI disorders, hypertension, memory loss, psoriasis, scars, sedation, varicose veins. Gotu kola should not be confused with kolanut; gotu kola does not contain any caffeine and has not been shown to have stimulant properties.

Adverse effects: contact dermatitis, pruritus, photosensitization, and headache; reduced fertility may occur in women wishing to become pregnant. With toxic levels, hyperglycemia, hyperlipidemia, and sedation have occurred.

Products should be standardized as to asiaticoside, asiatic acid, madecassic acid, and madecassoside content. Grape seed extract

Used for atherosclerosis (hardening of the arteries), high blood pressure, high cholesterol, and poor circulation; complications related to diabetes, such as nerve and eye damage; vision problems, such as macular degeneration; swelling after an injury or surgery; cancer prevention; and wound healing.

May cause dry, itchy scalp; hives; dizziness; hypertension; or nausea.

(continued)

Escott-Stump_Ch02.indd 75

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Green tea

Used for activation of thermogenesis and fat oxidation. Both black and green tea may be preventive for cancers and strokes; they are also a good source of fluoride. Green tea contains polyphenols called catechins: epigallocatechin gallate (EGCG), epicatechin gallate, and gallocatechin gallate. Green tea extract (GTE) may improve endurance capacity and may support weight loss. GTE boosts exercise endurance by using fat as energy source, accompanied by higher rates of fat oxidation. Results come from the equivalent of about 4cups of tea a day.

Avoid use with MAOIs and warfarin since green tea contains vitamin K. Avoid use in pregnancy and infants. Green tea and extracts contain caffeine, which may cause insomnia or anxiety.

Guggul

Used to treat osteoarthritis and bone fractures; suppresses the nuclear factor-␬B activation induced by various carcinogens. Guggul may induce CYP3A4 activity.

Not enough scientific evidence to support the use of guggul for any medical condition. Guggul may cause stomach discomfort or allergic rash. It should be avoided in pregnancy and lactation and in children.

Hawthorn (Crataegus monogyna)

Used for angina, atherosclerosis, heart failure, HTN, indigestion. It seems to be safe for long-term use.

Contraindications: pregnancy, lactation. Adverse reactions: nausea, sweating, fatigue, hypotension, arrhythmia. Because hawthorn lowers blood pressure and cholesterol levels, never take with digoxin. In high doses, it can cause hypotension and sedation and should be monitored carefully. Avoid use with cardiovascular agents.

Horseradish

Used as a natural decongestant.

May cause GI distress.

Hoodia (Hoodia gordonii)

Used as an appetite suppressant. Comes from the Kalahari desert cactus.

Safety is unknown.

Horse chestnut (Aesculus hippocastanum)

Used for chronic venous insufficiency, as in varicose veins or ankle swelling. Exhibits anticoagulant activity.

Don’t take orally. May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding. Side effects may include nausea or itching.

Huang lian (Coptis chinensis)

Used for diarrhea, hypertension, bacterial and viral infections, ear infections, and cancer treatment.

Contraindications in jaundiced neonates. Adverse reactions: nausea, vomiting, dyspnea. Toxicity: seizures, hepatotoxicity, cardiac toxicity.

Indirubin (Indigofera tinctoria)

Used for cancer treatment, inflammation. There are limited clinical data.

Adverse reactions: nausea, vomiting, abdominal pain. Longterm treatment has caused pulmonary arterial hypertension and cardiac insufficiency.

Juniper

Used as a diuretic or for indigestion in some cultures.

Avoid in pregnancy and kidney disease.

Karela

Used to lower blood glucose.

Because it effect blood glucose levels, it should not be used by patients with diabetes mellitus.

Kudzu (Pueraria mirifica, P.thunbergiana, P. montana var. lobata, P. montana var. thomsonii)

Used for estrogenic effects. Promoted for alcoholism, common cold, diabetes, eye pain, fever, menopausal symptoms, neck pain.

Avoid in hormone-sensitive cancers, tamoxifen use, hypersensitivity to kudzu, and estrogen receptor–positive (ER⫹) breast cancer.

Kyushin

Used as a cardiotonic medicine in China.

Kyushin may interfere with digoxin.

Licorice (Glycyrrhiza glabra, G.uralensis)

Used for bronchitis, chest congestion, constipation, GI disorders, hepatitis, inflammation, menopausal symptoms, microbial infection, peptic ulcers, primary adrenocortical insufficiency, prostate cancer. Active ingredient (glycyrrhizin) has an anti-inflammatory role.

Avoid in renal or liver dysfunction, pregnancy, and breastfeeding. Licorice can offset the pharmacological effect of spironolactone or digoxin. Large doses can produce headache, lethargy, or high blood pressure. May increase sodium retention and potassium losses when used with thiazide diuretics. Avoid use in cirrhosis, hypertension, cholestatic liver disease, hypokalemia, kidney failure.

Lycium (Lycium barbarum; L. chinense; L. europaeum)

Used for anemia, burns, cancer treatment, cough, inflammation, pain, sedation, skin infections, visual acuity.

May prolong bleeding time in some individuals.

Mayapple (Podophyllum hexandrum Royle )

Common in Native American medicine. Used for venereal warts (condyloma acuminata); it contains podophyllotoxins.

Meadowsweet (Filipendula ulmaria )

Exhibits antiplatelet activity. Strong antimicrobial effects.

May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding.

Melatonin

Used as a sleep aid or a jet lag adjuster. Antioxidant properties under study.

Avoid use with CNS depressants such as alcohol, barbiturates, corticosteroids, or immunosuppressants.

Escott-Stump_Ch02.indd 76

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Milk thistle (silymarin)

Used for alcoholic liver disease, cirrhosis, infectious hepatitis, drug-induced hepatitis. Best administered by injection. Serves as a natural antidote for death-cap mushroom poisoning.

It may have a mild laxative effect or can cause uterine or menstrual stimulation. May cause allergic reaction in people with ragweed allergy.

Mint

Used in oil form for colds, bronchitis, fever, indigestion. Mildly effective for depression.

Mild GI distress may result. Worsens gastroesophageal reflux disease (GERD) or hiatal hernia symptoms.

Motherwort (Leonurus cardiaca )

Exhibits antiplatelet activity. Antibacterial and anti-inflammatory properties.

May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding.

Mushrooms, edible

Used to prevent hormone-related cancers (breast, prostate). AHCC is obtained from mycelia of several species of basidiomycetes mushrooms. Agaricus blazei, native to Brazil and Japan, is used to treat arteriosclerosis, hepatitis, hyperlipidemia, diabetes, dermatitis, and cancer. Oral administration of Agaricus extract may improve natural killer cell activity and quality of life in cancer patients undergoing chemotherapy.

May enhance resistance to Klebsiella pneumoniae due to its antioxidant effects.

N-Acetyl-L-Cysteine (NAC)

Used to fight aging, alleviate allergies, and fight viruses. It may work as an antioxidant to protect against sun damage and skin lesions. May be useful in managing addictions.

Noni (Morinda citrifolia )

Used for joint pain, skin conditions, heart disease, and diabetes as a general health tonic. Antioxidant properties.

Some reports of liver damage. Noni contains potassium; monitor or avoid in renal patients.

Okinawa spinach (Gynura crepioides)

Used for control of high cholesterol; no scientific evidence.

Contraindications: immunocompromised patients due to the possibility of contamination.

Oregano (origanum )

Used for antioxidant effect. Destroys Helicobacter pylori and Giardia.

Oregon grape root (Vitis vinifera )

Coagulant herb.

May inhibit effects of anticoagulant medications such as warfarin and potentiate bleeding.

Parsley (Petroselinum crispum )

Used for flatulence, indigestion, topical antibiotic. Breath freshener after a meal.

Avoid use in pregnancy as it may stimulate uterine contractions. May work as a diuretic in large doses.

Peppermint oil

Used to relieve excess gas as a digestive aid. It has antispasmodic action; used in irritable bowel syndrome and GI cramping.

Heartburn or allergic reactions are possible.

Policosanols (hexacosanol )

Used to protect against cancers, cardiovascular disease, and obesity by reducing platelet aggregation and hepatic synthesis of cholesterol. Policosanols are phytochemicals extracted from sugarcane.

Poplar (populus trichocarpa )

Exhibits antiplatelet activity.

May enhance effects of anticoagulant medications such as warfarin and potentiate bleeding.

Prickly pear cactus (Opuntia ficus indica)

Safe when eaten orally as food. May lower blood glucose levels.

Stems may have hypoglycemic effects.

Probiotics (good bacteria such as Lactobacillus and Lactobacillus acidophilus)

Used in inflammatory bowel disease and other GI disorders or to replenish gut flora after antibiotic use. May reduce presence of harmful bacteria in the gut and may decrease vaginal infections. Select yogurt and products made with live cultures.

Psyllium (Plantago ovata)

Use as a laxative to alleviate chronic constipation.

Pycnogenol (Pine bark extract; flavangenol)

Used for reducing hot flashes in menopausal transitions; for reducing symptoms of allergic asthma. Antioxidant properties from proanthocyanidins. Reduces leukotrienes. Increases skin elasticity and hydration, reducing signs of aging. Proposed for mild erectile dysfunction but not confirmed. May improve cognition.

Red clover (trifolium )

Used for hot flashes because it contains isoflavones. It may also be used for coughs, eczema, and psoriasis.

Evidence suggests that it has limited effectiveness.

Rhodiola (Rhodiola rosea), arctic root

Used for depression, fatigue.

Side effects are insomnia and irritability.

Avoid use with cardiovascular agents.

(continued)

Escott-Stump_Ch02.indd 77

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Rhubarb or Da-Huang (Rheum palmatum, R. officinale)

Used for cancer treatment, constipation, fever, hypertension, immunosuppression, inflammation, microbial infection, peptic ulcers.

Avoid prolonged stimulant laxative use over 7 days without medical supervision. Patients with arthritis, kidney or hepatic dysfunction, history of kidney stones, inflammatory bowel disease, or intestinal obstruction should not take this herb. Rhubarb may cause uterine stimulation; avoid in pregnancy. Reported effects include abdominal cramps, nausea, vomiting, diarrhea with possible hypokalemia, anaphylaxis, and renal and hepatic damage.

Rice bran oil

It contains tocotrienols, powerful antioxidants in the vitamin E family that protect against coronary heart disease and some forms of cancer.

Rosemary (Rosmarinus officinalis L.)

Used for antioxidant and anticarcinogenic potential. Often used for lowering blood pressure.

Do not use in pregnancy in large doses.

Royal jelly (jelleine )

It is a milky substance secreted by young worker honey bees. Apalbumin 1 (Apa1) is the major royal jelly and honey glycoprotein and has various biological properties, such as cancer prevention. It seems to stimulate macrophages to release TNF-␣.

Avoid use with asthma; may cause allergic reactions.

SAMe (S-Adenosyl-L-Methionine)

Used for osteoarthritis, depression, cholestasis, and liver disease.

Saw palmetto (Serenoa repens)

Used with benign prostatic hyperplasia to increase urine flow. Tannic acids are present.

Saw palmetto should not be taken with oral contraceptives, estrogens, or anabolic steroids. Can cause GI upset in rare cases.

Schisandra (Schisandra chinensis)

Used for asthma, cough, influenza, diarrhea, indigestion, liver disease, premenstrual syndrome, strength, and stamina.

Adverse reactions include depression and heartburn.

Senna (Senna obtusifolia)

Used as a laxative herb; it contains anthraquinone, which stimulates bowel contractions. Safe for constipation, but dependence or obstruction can occur with long use. Psyllium and other naturally high-fiber foods (such as prunes), extra fluids, and exercise are better choices.

Laxative herbs speed digestion, which reduces absorption time of drugs. Chronic use results in a loss of potassium, thereby strengthening effects of cardiac glycosides and antiarrhythmic agents. Simultaneous use of thiazide diuretics, corticosteroids, or licorice root increases potassium loss. Because fluid and electrolyte losses may be severe, avoid during pregnancy and lactation.

Sheep sorrel (Rumex acetosella)

Used for cancer treatment, diarrhea, scurvy, fever, inflammation.

Contraindications: Patients with kidney stones should not use this herb. Adverse reactions: abdominal cramps, gastroenteritis, diarrhea leading to hypokalemia, adrenal and liver damage.

Shepherd’s purse (Capsella bursa-pastoris)

Coagulant herb.

May inhibit effects of anticoagulant medications such as warfarin and potentiate bleeding.

Slippery elm (Ulmus rubra)

Used for bronchitis, cancer treatment, cough, diarrhea, fever, inflammation, peptic ulcer, skin abscess, skin ulcers, sore throat.

Adverse reactions: none known, but no human studies have been done to evaluate its actions.

Spirulina (Blue-green algae)

Used to treat cancers, viral infections, weight loss, oral leucoplakia, increased cholesterol, attention deficit hyperactivity disorder (ADHD). Sold as an immune enhancer or to lower cholesterol levels.

Expensive as a protein source. Adverse effects are uncommon unless contaminated; if contaminated, it is hepato-, nephro-, and neurotoxic. Adulterated form can cause allergies or gastroenteritis.

Stillingia (Stillingia sylvatica)

No clinical data to support its uses in bronchitis, chest congestion, cancer treatment, hemorrhoids, constipation, skin abscess, laryngitis, spasm, syphilis.

Warning: The diaterpene esters in this herb are irritants to the skin and mucous membranes. Adverse reactions: vertigo, burning sensation over the mucous membrane, diarrhea, nausea, vomiting, pruritus, skin eruptions, cough, fatigue, and sweating.

St. John’s wort (Hypericum perforatum)

Mechanism of action for St. John’s wort may involve MAOI, selective serotonin reuptake inhibitors (SSRIs) reuptake inhibition, increased melatonin production, and others. This herb has been shown to induce the drug-metabolizing enzyme cytochrome p450 3A4 and interacts with many medications. Used to alleviate anxiety and nervousness; does not alleviate depression. May make cancer cells more sensitive to light therapies.

It can inhibit iron absorption. May enhance effects of narcotics and SSRIs. Increases side effects of photosensitizing drugs, alcohol, and melatonin. Avoid use with statins, blood pressure medications, donepezil, antidepressants and other central nervous system medications, and chemotherapy.

DISCONTINUE 2 WEEKS BEFORE SURGERY Tannins and saponins (Acacia pennata, Hibiscus spp., Lasianthicaafricana Gouania lupuloides)

Escott-Stump_Ch02.indd 78

Used for dental hygiene and to treat gingivitis.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Tea tree oil (Melaleuca alternifolia )

Used for acne treatment, wound healing, or as an antiseptic for thrush (as in HIV infection). Natural fungicide.

Topical use only; toxic if consumed. Allergy is possible in sensitive individuals.

Thunder god vine (Tripterygium wilfordii)

May fight inflammation, suppress the immune system, and have anticancer effects. Used for rheumatoid arthritis.

Diarrhea, nausea, respiratory tract infections, skin rashes; hair loss if used longer than 5 years.

Tribulus terrestris

Used by athletes. Contains steroidal glycosides and saponins that cause secretion of luteinizing hormone, testosterone. May protect skin against UVB-induced carcinogenesis. Also called puncture vine.

It is phototoxic, cytotoxic, and neurotoxic.

Tryptophan

Used to promote sleep or to correct depression.

L-Tryptophan is the precursor to serotonin. It should not be used with MAOIs, antidepressants, or serotonin receptor antagonists; it can exaggerate psychosis.

Turmeric (Curcuma longa)

Used for immune system enhancement, correcting anorexia, carcinoma prevention, reducing infections (such as reducing Helicobacter pylori) and inflammation, kidney stones.

Warning: Breast cancer patients on cyclophosphamide should restrict intake because it inhibits the antitumor action of chemotherapeutic agents. Contraindications: patients with bile duct obstruction, gallstones, GI disorders.

Ukrain (Chelidonium majus alkaloid-theophosphoric acid derivative)

Used for cancer prevention and treatment, hepatitis, HIV and AIDS, immunostimulation.

Warning: It is not regulated by FDA. Adverse reactions: soreness at the injection site, nausea, diarrhea, dizziness, fatigue, drowsiness, polyuria, hematological side effects, and tumor bleeding have been reported.

Valerian (Valeriana officinalis, Valerianae radix, garden heliotrope)

Used for insomnia, anxiety, colic, menstrual cramps, migraine treatment, sedation, spasms, stomach and intestinal gas. Effective as a sleep aid and is not habit forming.

Headache, uneasiness, cardiac disturbances, morning drowsiness, and impaired alertness can occur. Benzodiazepines, sedatives, alcohol, antipsychotics, and antidepressants should not be used at the same time because of the risk of additional sedation. Long-term use can cause headaches, sleeplessness, cardiac dysfunction, hepatotoxicity. Patients should be warned not to drive or operate dangerous machinery when taking valerian. Valerian should be stopped about 1 week before surgery because it may interact with anesthesia.

DISCONTINUE 2 WEEKS BEFORE SURGERY

Vanadium (vanadyl sulfate)

Used to mimic insulin; it may restore plasma DHEA and seems to improve insulin action. There may be a role for its use in the metabolic syndrome. Found in mushrooms and shellfish.

Vitex (chaste tree)

See Chasteberry.

White willow (salicin)

Used for fever, headache, pain, and rheumatic complaints. Aspirin is derived from white willow.

GI irritation or stomach ulcers can occur with long-term use; similar reactions as aspirin. Avoid use with alcohol, methotrexate, phenytoin, and valproate. Do not use in pregnancy or lactation.

Wild yam (Dioscorea villosa)

Used for amenorrhea, dysmenorrhea, colic, cough, GI symptoms, rheumatoid arthritis, menopausal symptoms, urinary tract disorders, sexual dysfunction, spasms.

Efficacy of hormonal actions is not proven. Topical creams that say that they contain yam extracts as a source of natural progesterone are not accurate.

Willow bark (Salix alba)

Used for fever, headache, inflammation, influenza, muscle pain.

Adverse reactions: nausea, vomiting, GI bleed, tinnitus, renal damage. Drug interactions: increases risk of bleeding with anticoagulants and GI bleed with NSAIDs.

Witch hazel (Hamamelis virginiana L.)

Used as astringent with bruises or varicose veins. Approved for use with hemorrhoid products.

Not for oral use. May cause allergic reactions.

Yew (Taxus baccata, T. wallachiana, T. media)

Used in treatment of some breast tumors. Cultivated varieties are being used to prepare triterpenoid precursors which are used to create paclitaxel and docetaxel, which in turn, have an antiestrogenic effect.

Zinc

Used to prevent viral illness, enhance performance, and correct male infertility.

May cause GI bleeding.

It should not be taken with immunosuppressants, fluoroquinolones, or tetracycline. Large doses may also conflict with copper metabolism.

Hazardous Products

These products should never be consumed.

Aristolochic acid (Aristolochia, birthwort, snakeroot, snakeweed, snagree root, sangrel, serpentary, wild ginger)

Definitely Hazardous

Documented human cancers. Also linked to kidney failure.

Belladonna (atropa belladonna )

Definitely Hazardous

Causes GI pain and spasms; contains toxic alkaloids, which can cause coma and death.

(continued)

Escott-Stump_Ch02.indd 79

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

Very Likely Hazardous

These are banned in other countries, have an FDA warning, or show adverse effects in studies.

Androstenedione (4-androstene-3, 17-dione, andro, androstene)

Very Likely Hazardous

Increased cancer risk and decrease in “good” HDL cholesterol have been reported.

Chaparral (Larrea divaricata, creosote bush, greasewood, hediondilla, jarilla, larreastat)

Very Likely Hazardous

Abnormal liver function and hepatitis or even cirrhosis have been linked to use.

Comfrey (Symphytum officinale, ass ear, black root, blackwort, bruisewort, Consolidae radix, consound, gum plant, healing herb, knitback, knitbone, salsify, slippery root, Symphytum radix, wallwort)

Very Likely Hazardous

DHEA

Very Likely Hazardous

Often used for anti-inflammatory and anticancer effects, arthritis, carcinoma treatment, inflammation, spasm. Used for bronchitis, cancer treatment, rheumatoid arthritis, wound healing.

Used as an immune enhancer or to prevent heart disease. No evidence that it works. Ephedra (ma huang)

Very Likely Hazardous Often used in weight loss products. Banned by FDA. DISCONTINUE 2 WEEKS BEFORE SURGERY

Germander (Teucrium chamaedrys, wall germander, wild germander)

Very Likely Hazardous

Goldenseal (Hydrastis canadensis)

Very Likely Hazardous Used for anorexia, heart disease, coughs, upset stomach, menstrual problems, and arthritis. It has long been used by Native Americans for antiseptic and wound-healing properties.

Kava (Piper methysticum, ava, awa, gea, gi, intoxicating pepper, kao, kavain, kawa pfeffer, kew, long pepper, malohu, maluk, meruk, milik, rauschpfeffer, sakau, tonga, wurzelstock, yagona, yangona)

Very Likely Hazardous

Kelp (laminaria)

Very Likely Hazardous

Used as a stimulant.

Sometimes recommended to lower cholesterol or for weight loss, withlimited evidence. Very Likely Hazardous The fermented product of rice on which red yeast has been grown. A dietary staple in Asian countries; used to lower total cholesterol levels

Likely Hazardous

These have adverse event reports or theoretical risks.

Bitter orange (Citrus aurantium, green orange, kijitsu, neroli oil, Seville orange, shangzhou zhiqiao, sour orange, zhi qiao, zhi xhi)

Likely Hazardous

Escott-Stump_Ch02.indd 80

Abnormal liver function or damage, often irreversible. It contains pyrrolizidine alkaloids and causes hepatic venoocclusive disease or death. Avoid in infants, pregnancy, lactation. FDA has asked all manufacturers to remove products containing comfrey because it is hepatotoxic.

Can actually aggravate heart disease and have effects like steroids; may promote cancers in breast, prostate, or ovaries. Contains cardiac toxins linked to dozens of deaths. Ephedra can cause stroke, insomnia, hypertension, or heart attack. Avoid taking with caffeine, sedatives, antipsychotics, antidepressants, antihyperglycemic agents, decongestants, and cardiovascular agents. Abnormal heart and liver function have been linked to use.

Germander contains flavonoids.

DISCONTINUE 2 WEEKS BEFORE SURGERY

Red yeast rice

ADVERSE EFFECTS

Used as a substitute for ephedra. Contains suphedrine.

GI complaints are common side effects. With toxicity: stomach ulcerations, constipation, convulsions, hallucinations, nausea, vomiting, depression, nervousness, bradycardia, respiratory depression, seizures. It can raise blood pressure, complicating treatment for those taking beta-blockers. For patients taking medication to control diabetes or kidney disease, this herb can cause dangerous electrolyte imbalance. Patients with hypertension or cardiovascular disease and women who are pregnant should not take this herb. Abnormal liver function has been linked to use. Avoid use with alcohol.

If ingested as a source of iodine, it may interfere with thyroid replacement therapies. May worsen hyperthyroidism. It has been removed from the market in the United States. Avoid use with grapefruit juice or niacin.

High blood pressure and increased risk of heart arrhythmias, heart attack, and stroke are risks associated with use.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

TABLE 2-2 Herbs, Botanicals, and Spices: Common Uses and Adverse Effects (continued) HERB/BOTANICAL/SPICE

COMMON USES

ADVERSE EFFECTS

Borage

Likely Hazardous

May cause liver toxicity or even cancers.

Horse chestnut (Aesculus hippocastanum; aescin 50mg)

Likely Hazardous Studies have shown clinical efficacy in chronic venous insufficiency, but no data support the reversal of varicose veins.

Patients with compromised renal or hepatic functions should not consume horse chestnut. It may also interact with anticoagulants and increase the risk of bleeding.

Kombucha tea

Likely Hazardous

Can cause liver damage or intestinal problems or death.

Sometimes used for depression but without confirmation.

It is sometimes suggested for acne or insomnia or in AIDS. Lobelia (Lobelia inflata, asthma weed, bladderpod, emetic herb, gagroot, lobelie, Indian tobacco, pukeweed, vomit wort, wild tobacco)

Likely Hazardous

Difficulty breathing and rapid heart rates are associated with lobelia. Large doses can lead to rapid heartbeat, paralysis, coma, or death. Avoid in children, infants, pregnant women, smokers, and people with cardiac diseases.

Mistletoe/Eurixor (Viscum album)

Likely Hazardous

Warning: Berries and leaves are highly poisonous. Contraindication in pregnancy. Adverse reactions include fever, headache, chest pain, bradycardia, hypotension, coma.

Organ/glandular extracts (brain/adrenal/pituitary/placenta/ other gland “substance” or “concentrate”)

Likely Hazardous

Theoretical risk of mad cow disease, particularly from brain extracts.

Passion flower (passiflora)

Likely Hazardous

It can cause seizures, hypotension, hallucinations.

Used for arthritis, cancer treatment, hepatitis, hypertension, spasm, immunostimulation.

Sometimes recommended for sedative use. Pennyroyal oil (Hedeoma pulegioides, lurk-in-the-ditch, mosquito plant, piliolerial, pudding grass, pulegium, run-by-theground, squaw balm, squaw mint, stinking balm, tickweed)

Likely Hazardous

Poke root (Phytolacca decandra)

Likely Hazardous

May cause low blood pressure and respiratory depression. Extremely toxic.

Sassafras (Sassafras albidum)

Likely Hazardous

Produces sweat and contains safrole, which is banned as a carcinogen. Warning: risk of liver cancer with prolonged use, so it is not safe to use. Adverse reactions: hot flashes, diaphoresis, hallucinations, hypertension, tachycardia, liver cancer, and death.

Used for antimicrobial properties.

Used for detoxification, inflammation, health maintenance, rheumatoid arthritis, mucositis, sprain, syphilis, urinary tract disorders.

Skullcap (Scutellaria lateriflora, S. baicalensis, baikal, blue pimpernel, helmet flower, hoodwort, mad weed, mad-dog herb, maddog weed, quaker bonnet, scutelluria, skullcap)

Likely Hazardous

Wheat grass (Triticum aestivum)

Likely Hazardous

Used for epilepsy, hepatitis, infections, cancer.

Used for carcinoma treatment, chronic fatigue syndrome, immunostimulation, ulcerative colitis. An antioxidant. Yohimbe (Pausinystalia yohimbe, johimbi, yohimbehe, yohimbine, yohimbe bark)

Likely Hazardous May be used for male impotence.

Liver and kidney failure, nerve damage, convulsions, abdominal tenderness, and burning of the throat are risks; deaths have been reported.

Toxicity causes stupor, confusion, seizures. Adverse reactions include hepatotoxicity and pneumonitis.

Adverse reactions: nausea because of contamination. No safety guidelines available. Blood pressure changes, heartbeat irregularities, heart attacks, and paralysis have been reported.

Yohimbe is not effective for male impotence and can cause It causes central nervous system stimulation and vasodilation. In high doses, it is an MAOI. It is to be avoided in individuals with hypotension, side effects such as hypertension and kidney failure; it can also aggravate bipolar disorder or decrease antidepressant congestive heart failure, diabetes, and kidney and liver diseases. effectiveness.

Sources: National Institutes of Health. Herbal medicine. Available at: http://www.nlm.nih.gov/medlineplus/herbalmedicine.html. Accessed June 17, 2014; Office of Dietary Supplements. Dietarysupplement fact sheets. Available at: http://ods.od.nih.gov/Health_Information/Information_About_Individual_Dietary_Supplements.aspx. Accessed June 17, 2014; Magistrelli A, Chezem JC. Effect of ground cinnamon on postprandial blood glucose concentration in normal-weight and obese adults. J Acad Nutr Diet. 2012;112:1806.

Escott-Stump_Ch02.indd 81

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Food–Drug Interactions

INTERVENTION Objectives The White House Commission on Complementary and Alternative Medicine Policy Executive Summary (2013) proposed the following guiding principles for counseling individuals: • Apply a “wholeness orientation” in health care delivery. Health involves all aspects of life—mind, body, spirit, and environment. • Evaluate for evidence of safety and efficacy. Promote the use of science and appropriate scientific methods to help identify safe and effective TCAM services and products. • Identify the healing capacity of the individual person. People have a remarkable capacity for recovery and self-healing; support and promote this capacity. • Respect individuality, recognizing that each person is unique and has the right to health care that is appropriately responsive to him or her, respecting preferences and preserving dignity. • Recognize patient rights. Each has the right to choose treatment, to choose freely among safe and effective care or approaches, and to choose among qualified practitioners who are accountable for their claims and actions and responsive to the person’s needs. • Support health promotion, self-care, and early intervention for maintaining and promoting health. • Develop partnerships. Good health care requires teamwork among patients, health care practitioners, and researchers committed to creating optimal healing environments and to respecting the diversity of all health care traditions. • Educate about prevention, healthy lifestyles, and the power of self-healing. • Disseminate comprehensive and timely information. The quality of health care can be enhanced by promoting efforts that thoroughly and thoughtfully examine the evidence on which TCAM systems, practices, and products are based and make this evidence widely, rapidly, and easily available. • Integrate public involvement. The input of informed consumers and other members of the public must be incorporated in setting priorities for health care and health care research and in reaching policy decisions.

Common Drugs Used and Potential Side Effects • Plants have been used throughout history to improve health. Modern medicines often come from plants (e.g., aspirin from willow bark); herbs used for health purposes are considered drugs. • Eighty percent of the population in developing countries relies on traditional medicine, and 70% to 80% of the population in developed countries use TCAM therapies (Alrawi and Fetters, 2012). • TCAM users may be at risk for drug–supplement interactions. Natural health products often interfere with medications, and caution is necessary. Herbs, Botanicals, and Supplements • Plant food supplements (PFS) are not always assessed for safety before they are marketed. PFS may contain compounds of concern at levels far above those found in the regular diet (van den Berg et al, 2011). The use of dietary supplements may be associated with adverse events. Check www.consumerlab.com to identify reliable brands. Figure2-1 depicts commonly used alternative therapies. • Many cultures use herbs and botanicals in meals, rituals, and celebrations. However, not all plant products are safe, even if they are “natural” or “organic.” • Individual reports of safety are not always reliable. Some people who use an herb will feel better even if there is no evidence of its efficacy (the placebo effect). Use of an herb or tea does not guarantee its safety when used as a supplement (van den Berg et al, 2011). • Flavonoids, found in a wide diversity of plant foods from fruits and vegetables, herbs and spices, essential oils, and

Food and Nutrition • Promote the appropriate use of herbal and botanical products that have shown efficacy and safety. The best strategy for promoting optimal health and for reducing chronic disease is to choose a wide variety of foods (Marra and Boyar, 2009). • Functional foods are available that have health benefits beyond basic nutrition (e.g., omega-3–enriched eggs, stanoland sterol-fortified soft chews and related margarines, or high-flavonol chocolate snacks). Use relevant products and recipes. • Special attention may be needed for intake of iron and folic acid for females in teen and childbearing years; vitamin B12 for adults over age 50 years; and vitamin D for older adults, those with dark skin, and those exposed to ultraviolet radiation (Marra and Boyar, 2009).

Escott-Stump_Ch02.indd 82

Herbs Relaxation techniques Chiropractic

Yoga Massage Special diet

Megavitamins Homeopathy Tai chi

Figure 2-1. Alternative therapies used in the United States. (Adapted with permission from Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular diseases. J Am Coll Cardiol. 2010;55:515.)

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

•

beverages have the potential for promotion of bone health beyond calcium and vitamin D (Weaver et al, 2014). Herbs commonly used by children enrolled in the WomenInfants-Children (WIC) program include aloe vera, chamomile, garlic, peppermint, lavender, cranberry, ginger, echinacea, and lemon (Lohse et al, 2006). Herbs with safety issues may also be used; thorough education should be offered. A majority of cancer patients use self-selected forms of complementary therapies, mainly dietary supplements (Frenkel et al, 2013). Discuss how a threshold of effectiveness can be reached with the use of any single nutrient. For individuals who are already at a nutrient level for optimum functioning, further vitamin supplementation would provide no additional benefit or treatment effect (Morris and Tangney, 2011). Thyme, rosemary, sage, spearmint, and peppermint extracts actually have been found to inhibit colon cancer cell growth (Yi and Wetzstein, 2011). The action of many inflammatory or transcription factors, growth factors, and protein kinases are interrupted by spice-derived nutraceuticals: 1⬘-acetoxychavicol acetate, anethole, capsaicin, cardamom, curcumin, dibenzoylmethane, diosgenin, eugenol, gambogic acid, gingerol, thymoquinone, ursolic acid, xanthohumol, and zerumbone derived from galangal, anise, red chili, black cardamom, turmeric, licorice, fenugreek, clove, kokum, ginger, black cumin, rosemary, hop, and pinecone ginger (Sung et al, 2012). Natural health products (NHPs) such as soluble fiber, alpha lipoic acid, milk thistle, prickly pear cactus, and pycnogenol appear to be beneficial in the treatment of diabetes (Lee and Dugoua, 2012). There may be undesirable side effects; for example, prickly pear cactus may cause hypoglycemia. Herbal products that may cause hypertension include arnica, bitter orange, blue cohosh, dong quai, ephedra, ginkgo, ginseng, guarana, licorice, pennyroyal oil, Scotch broom, senna, southern bayberry, St. John’s wort, and yohimbine (Jalili et al, 2013). Omega-3 fatty acids and chromium have shown some positive effects in bipolar depression but not for mania (Sylvia et al, 2013). Research is ongoing. Alcohol interacts with many medications and possibly with herbs. Mix with caution.

2012). Several natural products isolated from Chinese herbs have been found to inhibit proliferation, induce apoptosis, suppress angiogenesis, retard metastasis, and enhance chemotherapy: flavonoids (gambogic acid, curcumin, wogonin, and silibinin), alkaloids (berberine), terpenes (artemisinin, ␤-elemene, oridonin, triptolide, and ursolic acid), quinones (shikonin and emodin), and saponins (ginsenoside Rg3); they show promise as anticancer agents (Tan et al, 2011). • In the United States, herbs are considered dietary supplements and not medicines. The U.S. Food and Drug Administration (FDA) has no oversight on ingredients or safety and efficacy; there is no guarantee that the herb will work or that the product contains all that is claimed. • In the European Union, the manufacturing and trade in herbs and dietary supplements are regulated by stronger pharmaceutical and food laws (Konik et al, 2011). Patient Education—Food Safety • Discuss food handling, preparation, and storage of herbs and botanical products. • Because bacteria are commonly found on foods such as green onions (scallions), cilantro, and imported produce, wash all fresh fruits and vegetables. • Store spices as directed and discard after shelf-life expiration. Spices such as paprika are easily contaminated.

SAMPLE NUTRITION CARE PROCESS STEPS Harmful Beliefs about Food or Nutrition-Related Topics Assessment Data: Food records; adverse side effects with specific products and amounts taken; blood pressure (BP), lab reports for serum electrolytes. Nutrition Diagnoses (PES): Harmful beliefs/attitudes about food or nutrition-related topics related to intake of unsafe substances as evidenced by intake of ephedra in products otherwise removed from the market by FDA and complaints of rapid heartbeat and undesirable changes in BP. Intervention: Education about appropriate use of herbs and botanical products; dangers of consuming substances with unknown side effects. Counseling about desired foods and use of evidence-based complementary products.

Nutrition Education, Counseling, Care Management • Many physicians are not aware of the frequency of use and adverse events related to dietary supplements. The Supplement Reporting (SURE) study, which quantified dietary supplement use and reasons for taking supplements, found that 76% of participants reported that their dietary supplements were as important as their prescription medications and 27% of participants exceeded the upper limit for at least one nutrient (Albright et al, 2012). • Many types of CAM practitioners try to treat not only the physical and biochemical manifestations of illness, but also the nutritional, emotional, social, and spiritual context in which the illness arises (Barnes and Bloom, 2013). • Demonstrate respect for the beliefs, values, and practices of the patient and family members. Discuss TCAM in a nonjudgmental way; encourage sharing the information with their primary physician. • In traditional Chinese medicine and Ayurveda, health is understood as a state of balance, and diet is considered essential to achieving and maintaining that balance (Blair et al,

Escott-Stump_Ch02.indd 83

Monitoring and Evaluation: Improved quality of life and reduced symptoms; improvements in heart rate and BP.

For More Information ●

American Botanical Council http://www.herbalgram.org/

●

American Council on Science and Health http://www.acsh.org/

●

American Herbal Products Association http://www.ahpa.org/

●

Botanical Dietary Supplements http://ods.od.nih.gov/factsheets/BotanicalBackground.asp

●

Complementary and Integrative Medicine http://www.mdanderson.org/departments/cimer/

●

ConsumerLab.com http://www.consumerlab.com/

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

●

Facts about Dietary Supplements http://www.cc.nih.gov/ccc/supplements/intro.html

REFERENCES

●

Federal Trade Commission (FTC) http://www.ftc.gov/

●

Food and Nutrition Information Center—Dietary Supplements http://fnic.nal.usda.gov/dietary-supplements

●

Herbal Monographs and Frequently Asked Questions on Herbs from RxList.com http://www.rxlist.com/alternative.htm#herbal_mon

●

HerbMed—Interactive, electronic herbal database http://www.herbmed.org/

●

Herb Research Foundation http://www.herbs.org/

●

Herbs and Cultural Uses http://www.asian-recipe.com/herbs.html

●

Herbs At a Glance http://nccam.nih.gov/health/herbsataglance.htm

●

International Food Information Council—Functional Foods http://www.ific.org/nutrition/functional/index.cfm

●

Institute of Food Technologists http://www.ift.org/

●

Mayo Clinic http://www.mayoclinic.com/health/alternative-medicine/CM99999

●

Medfacts—Natural Products http://www.drugs.com/npp/

●

MEDLINE Herbs http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html

●

MEDLINE, Vitamin and Mineral Supplements http://www.nlm.nih.gov/medlineplus/vitaminandmineralsupplements.html

●

National Center for Complementary and Alternative Medicine (NCCAM) http://nccam.nih.gov/

●

NCCAM Statistics http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm

●

National Institutes of Health, Office of Dietary Supplements http://ods.od.nih.gov/

●

RD411—Herbal Fact Sheets http://www.nutrition411.com/education-materials/herbal-fact-sheets

●

Sloan-Kettering Herbs and Cancer http://www.mskcc.org/cancer-care/integrative-medicine/herbs-botanicals -other-products-faqs

●

Special Nutritionals Adverse Event Monitoring System—Searchable database from the FDA http://www.fda.gov/Safety/MedWatch/HowToReport/default.htm

●

Tufts University Nutrition http://www.tufts.edu/med/ebcam/nutrition/

●

University of Illinois Botanical Supplement Research http://www.uic.edu/pharmacy/centers/uic_nih_botanical_dietary _supplement_research/index.php

●

U.S. Pharmacopeial Convention http://www.usp.org/

Albright CL, et al. Differences by race/ethnicity in older adults’ beliefs about the relative importance of dietary supplements vs prescription medications: results from the SURE Study. J Acad Nutr Diet. 2012;112:1223. Alrawi SN, Fetters MD. Traditional arabic & islamic medicine: a conceptual model for clinicians and researchers. Glob J Health Sci. 2012;4:164. Barnes PM, Bloom B. Complementary and alternative medicine use among adults and children. Available at: http://nccam.nih.gov/sites/nccam.nih.gov /files/news/nhsr12.pdf. Accessed June 16, 2014. Blair J et al. Introduction to traditional Asian therapeutic diets: two enduring perspectives. Minn Med. 2012;95:45–49. Crowe KM, Francis C. Position of the academy of nutrition and dietetics: functional foods. J Acad Nutr Diet. 2013;113:1096. Frenkel M, et al. Integrating dietary supplements into cancer care. Integr Cancer Ther. 2013;12:369–384. Goey AK, et al. Relevance of in vitro and clinical data for predicting CYP3A4-mediated herb-drug interactions in cancer patients. Cancer Treat Rev. 2013;39:773. Jalili J, et al. Herbal products that may contribute to hypertension. Plast Reconstr Surg. 2013;131:168. Konik EA, et al. Herbs and dietary supplements in the European Union: a review of the regulations with special focus on Germany and Poland. J Diet Suppl. 2011;8:43. Lee T, Dugoua JJ. Nutritional supplements and their effect on glucose control. Adv Exp Med Biol. 2012;771:381. Leiby A, Vazirani M. Complementary, holistic, and integrative medicine: Crohn disease. Pediatr Rev. 2012;33:83. Lohse B, et al. Survey of herbal use by Kansas and Wisconsin WIC participants reveals moderate, appropriate use and identifies herbal education needs. JAm Diet Assoc. 2006;106:227. Marra MV, Boyar AP. Position of the American Dietetic Association: nutrient supplementation. J Am Diet Assoc. 2009;109:2073. Morris MC, Tangney CC. A potential design flaw of randomized trials of vitamin supplements. JAMA. 2011;305:1348. Murphy SP, et al. Dietary supplement use within a multiethnic population as measured by a unique inventory method. J Am Diet Assoc. 2011;111:1065. Shane-McWhorter L, Martinez L. Dietary supplements for women: clinician considerations. Obstet Gynecol. 2011;117:1170. Sung B, et al. Cancer cell signaling pathways targeted by spice-derived nutraceuticals. Nutr Cancer. 2012;64:173. Sylvia LG, et al. Nutrient-based therapies for bipolar disorder: a systematic review. Psychother Psychosom. 2013;82:10. Tan W, et al. Anti-cancer natural products isolated from chinese medicinal herbs. Chin Med. 2011;6:27. van den Berg SJ, et al. Safety assessment of plant food supplements (PFS). Food Funct. 2011;2:760. Ventola CL. Current issues regarding complementary and alternative medicine (CAM) in the United States : Part 1: the widespread use of CAM and the need for better-informed health care professionals to provide patient counseling. P T. 2010;35:461. Weaver CM. Bioactive foods and ingredients for health. Adv Nutr. 2014;5:306S–311S. White House Commission on Complementary and Alternative Medicine Policy. Final report. Available at: http://www.whccamp.hhs.gov. Accessed June 16, 2014. Yi W, Wetzstein HY. Anti-tumorigenic activity of five culinary and medicinal herbs grown under greenhouse conditions and their combination effects. JSci Food Agric. 2011;91:1849.

●

USP Verified Program http://www.uspverified.org/

Escott-Stump_Ch02.indd 84

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

CULTURAL FOOD PATTERNS, VEGETARIANISM, AND RELIGIOUS PRACTICES

CULTURAL FOOD PATTERNS NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND Dietary intakes vary among people of different ages, cultures, and gender. Assessment of a patient’s cultural food preferences is essential to determine adequacy of nutritional intake. Nutrition planning will be more effective if tailored to the individual (Kittler and Sucher, 2008). Disease prevention strategies must use available knowledge about individual cultures. Soon, over half of the U.S. population will consist of people from different cultural backgrounds (Goody and Drago, 2010). People interpret healthy eating in complex and diverse ways that reflect their personal, social, cultural experiences, and environments (Bisoqni et al, 2012). Early life experiences and family traditions affect many health issues, including perception of obesity. The process by which immigrants adopt the dietary practices is dynamic and complex. Adoption of western dietary patterns that are high in fat and low in fruits and vegetables is not positive. Neighborhood grocery stores may have limited availability of fresh produce, making healthy choices a struggle (Larson et al, 2009). Dietetics practitioners can use the information to study nutrition education efforts directed toward ethnic-specific groups. It is important to become aware of diverse traditions and preferred food resources. Clinicians should be able to offer a wide variety of self-management support systems to meet the needs

of diverse patient populations that vary by race, ethnicity, language proficiency, and health literacy. The Joint Commission has set the standard for meeting individual needs for cultural and religious preferences. Whereas most hospitals attend to the religious (97%), dietary (85%), and psychosocial (78%) cultural needs of patients, fewer institutions respond to patients’ cultural needs related to health literacy (57%); complementary/alternative medicine (43%); cultural brokers, folk remedies, traditions, rituals, and traditional healers (Stein, 2009). It is important to reinforce positive traditional habits while encouraging inclusion of new, healthy ones. Figure 2-2 summarizes essential issues related to cultural competency.

ASSESSMENT, MONITORING, AND EVALUATION • • • • • • •

Age and gender Race/ethnicity Language proficiency Health literacy Cultural food preferences Traditional dietary habits Length of time in this country

Cultural context

Human rights

nce

Social justice

Cul

tura

l co

ete

Parternship - Collaboration - Advocacy

Compassion

Cultural preservation Cultural accommodation Cultural repatterning

Figure 2-2. Essential issues related to cultural competency. (Adapted with permission from Andrews MM, Boyle JS. Transcultural concepts in nursing care. Philadelphia, PA: Wolters Kluwer Health; 2011.)

Escott-Stump_Ch02.indd 85

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

INTERVENTION Objectives • Be aware of personal cultural values but avoid imposing them on others. For example, the desire to be thin is more common among Caucasians than people from other ethnic backgrounds. • Assess values, attitudes, beliefs, practices, and rituals of the client before attempting to discuss any lifestyle changes. Observe and interact appropriately. • Provide individualized patterns when they differ from the local standard. Be prepared to understand the differences from a “typical American” diet. • Determine which habits, if any, are detrimental for a healthy lifestyle. Review patterns or foods that aggravate existing or predisposed conditions for each person. Build on healthy practices. • Correct dietary intake patterns for nutrient deficits, such as calcium and riboflavin where dairy products or milk are excluded or not tolerated. Identify other nutrients that are at risk for insufficiency. • Offer suggestions for changes in food preparation (e.g., ways for reducing fat or salt) rather than changing the foods themselves, whenever possible. • Each culture has functional foods and ingredients that have special attributes. Identify and acknowledge these foods or ingredients. • Understand customs, festive occasions, fasting, ceremonial activities, and celebrations. Promote the traditions and welcome special events or activities, as appropriate for the setting.

Food and Nutrition • Review and identify specific ethnic and religious food patterns. Table 2-3 provides an overview of religious dietary

patterns and common practices. More extensive information can be found online and in many cookbooks. • The WIC food package was updated to include foods to help families from diverse backgrounds. Most participants prefer whole versus low-fat milk; whole grain products and peanut butter are preferred over beans or soy foods (Black et al, 2009). • African/African American patterns. Foods such as peanuts, peppers, and corn are traditional, as are fruits, vegetables, meats, and milk. Starch is a main consideration in the diet. Access to healthy foods such as fruits, vegetables, and whole grains should be noted as some community resources may be limited (Franco et al, 2009). In the southern United States, dietary habits may include healthy foods prepared with unhealthy ingredients (e.g., chicken that is fried, greens prepared with lard). Spices and seasonings may vary. Alterations in recipes may be needed for taste and acceptance if healthier choices are offered. • Asian patterns. Asian diets vary from one country to another. Diets may be low in calcium and riboflavin because milk often is not tolerated or consumed. Encourage use of tofu, green vegetables, and fish containing small bones. Diet may be high in sodium if monosodium glutamate (MSG) and soy sauces are used. Snacking is rare. The traditional Chinese diet contains 80% grains, legumes, and vegetables. Stir-frying, deep fat frying, and steaming are common cooking methods. Pork is the preferred meat. Hot peppers may be used daily. “Hot” and “cold” foods may be used during pregnancy or illness but these terms do not refer to food temperatures. Korean Americans tend to have a greater intake of carbohydrates and vitamins A and C than of saturated and total fat or cholesterol (Goody and Drago, 2010). The Japanese diet is very healthy, with many vegetables, tofu, fruit, and fish. In the Hmong (Southeast Asian) pattern, fish, chicken, and pork are common entrées. A highly salted fish sauce is used. Rice is eaten at nearly every meal. Anemia may

TABLE 2-3 Common Religious Food Practices

Beef

SEVENTH-DAY ADVENTIST

BUDDHIST

EASTERN ORTHODOX

HINDU

JEWISH

MORMON

MUSLIM

Pork

All meat

Eggs/dairy

Fish

Shellfish

Alcohol

Coffee/tea

Meat and dairy at same meal

Leavened foods

Ritual slaughter ofmeats

⫹

Moderation Fastinga

⫹

⫹ ⫹

ROMAN CATHOLIC

⫹ ⫹

⫹

a Fasting varies from partial (abstention from certain foods or meals) to complete (no food or drink). A, avoided by the most devout; X, prohibited or strongly discouraged; R, some restrictions regarding types of foods or when a food may be eaten; O,permitted but may be avoided at some observances; ⫹, practiced. References: Asia Recipes. Religious food practices. Available at: http://asiarecipe.com/religion.html. Accessed June 17, 2014; Better Health. Available at: http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Food_culture_and_religion?open.

Escott-Stump_Ch02.indd 86

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

result from parasite infestation in individuals who have been refugees. • Hispanic/Latino patterns. Whole milk is used rarely, but cheese is a common additive to meals. Chile peppers, mangos, and avocados are the primary fruits and vegetables consumed. The main starch is corn or flour tortilla. Rice is the major contributor of energy among the elderly. The diet may be high in sugar and saturated fat (lard). A common main dish is beans with rice. Hot and cold foods are concepts commonly found. Salsa or sofrito seasonings are used frequently. Obesity, type 2 diabetes, hypertension, cardiovascular disease, dental caries, snacking, and undernutrition may be problems. Most Hispanic countries use folk remedies, such as garlic to treat hypertension and cough; chamomile to treat nausea, gas, colic, and anxiety; and peppermint to treat dyspepsia. • Indian patterns. India has some of the most diverse populations and diets in the world. In India, rates for oral and esophageal cancers are high. Indian immigrants in the United States are largely Hindus. Vegetarianism is a primary practice, deriving from religious beliefs in which the cow is sacred. Lentils and legumes are a primary source of protein; sometimes milk, eggs, fish, shrimp are consumed. Sattvic foods are believed to create a healthy life; these include milk products (except cheese made from rennet), rice, wheat, and legumes. Rajasic foods are believed to contribute to aggression; these include meats, eggs, and rich or very salty foods. Tamasic foods are believed to contribute to slothfulness or dullness; these include garlic, pickled foods, stale or rotten foods, and alcohol used for pleasure or to excess. Lack of portion control may be a factor in diabetes, which is common (Goody and Drago, 2010). Combination foods include biryani (grain, meat), samosas (grain, vegetable, meat, fat), kheer “rice pudding” (grain, milk), and curry (meat, vegetable). Turmeric (curcumin) is an ingredient in Indian curry spice that has strong antioxidant properties. • Mediterranean diet pattern (MDP) (Fig. 2-3). The MDP reflect the traditional habits of populations of Italy, Crete, and Greece. Olive oil; fish, poultry, and eggs rather than beef; breads, fruits, and vegetables in abundance; and lots of beans/legumes, yogurt, and cheeses make up this pattern.

Exercise and wine are also mainstays. A Mediterranean-style diet rich in whole grains, fruits, vegetables, legumes, walnuts, and olive oil is effective in reducing both the prevalence of the metabolic syndrome and cardiovascular risks (Drewnowski and Eichelsdoerfer, 2009). • Middle Eastern patterns. Pakistani immigrants are mostly Muslims. Middle eastern countries are varied and include Egypt, Iran, Jordan, Lebanon, Saudi Arabia, and Turkey. Lamb and beef are consumed; pork is eaten only by Christians. Yogurt and cheese provide calcium sources as lactose intolerance is prevalent. Because olive oil is commonly used, lower BP is often found (Goody and Drago, 2010). Parsley, pita breads, olives, honey, sesame seeds and paste (tahini), pomegranates, pistachios, chickpeas and hummus, dates, filo doughs, and mint are common ingredients. Strong coffee and spices are highly regarded. • Native American patterns (American Indian and Alaskan Native). Food has great religious and social significance and is commonly part of many celebrations. Fried foods, fried bread, corn, mutton, and goat are frequently used by American Indians, whereas seafood and game are more common among Alaskan natives. Obesity and type 2 diabetes are very common (Goody and Drago, 2010). Efforts to promote and sustain traditional foods and activities in native populations may lead to improved health outcomes. For sample Native American recipes, see the website http://www.kstrom.net /isk/food/recipes.html.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Drugs may interact with various herbs botanicals and supplements. Individualize care and counseling. Herbs, Botanicals, and Supplements • Knowledge of integrative medicine incorporates herbal and botanical products that are used for preventive or medicinal purposes. Different cultures apply different herbs and practices in folk medicine. • Many cultures use herbs and botanicals as part of their meal patterns, rituals, and celebrations. Identify those that are used and monitor for potential side effects. • In the Multi-Ethnic Study of Atherosclerosis, White, African American, Hispanic, and Chinese American participants aged 45 to 84 years were studied; some met daily reference intake (DRI) guidelines for calcium, vitamin C, and magnesium but effects of supplementation varied according to ethnicity and sex (Burnett-Hartman et al, 2009). Counselors should always ask about use of vitamin–mineral supplements.

Nutrition Education, Counseling, CareManagement

Figure 2-3. Example of a Mediterranean diet meal: salmon, brown rice, lemon, fruit, and vegetables. (Image courtesy S.Escott-Stump.)

Escott-Stump_Ch02.indd 87

• Culturally appropriate counseling and awareness of religious practices are important for improving health issues, such as obesity and intake of fruits and vegetables (Goody and Drago, 2010). • Different methods may be needed for dietary modification for obesity, diabetes, and hypertension, taking into account differences in cultural understanding and food practices. First, demonstrate respect for the beliefs, values, and practices of the patient and family members. • Interpreters may be needed. Bilingual staff or community volunteers are helpful. Speak directly to the individual to show respect and not to the interpreter during sessions.

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

• Alternative solutions to dietary patterns must be gently offered. There is no “one right way” for dietary patterns. Understanding background, health problems, statistics, social issues, and disease patterns is useful when providing multicultural education. • Build relationships through sensitivity and communication. Remove assumptions and stereotypes; cultures are changing, growing, and dynamic. • Family beliefs and behaviors may sabotage a client’s efforts; be aware and be helpful. Develop an intuitive counseling style, reading body language, eye contact, and other behaviors. • Offer tips on food selection, preparation, and storage; identify available resources, ethnic stores, and agencies. • Guidance from a dietitian is recommended for the Mediterranean diet; the internet is not as useful (Hirasawa et al, 2012). • Interpreting food labels and preparing unfamiliar foods can be part of the educational session. • Body language differs between cultures. For example, Hispanic/Latino cultures prefer being close to others in space; sitting within 2 feet demonstrates interest. Asian cultures may prefer a greater distance to demonstrate respect.

●

African American Health http://www.nlm.nih.gov/medlineplus/africanamericanhealth.html

●

American Folklore Society http://www.afsnet.org/

●

Anthropology of Food http://aof.revues.org/

●

Association for the Study of Food and Society http://www.food-culture.org/

●

Eating Healthy with Ethnic Foods http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/eth_dine.htm

●

Food and Culture http://www.foodandculture.org/

●

FNIC Ethnic Resources http://fnic.nal.usda.gov/lifecycle-nutrition/aging/ethnic-and-cultural -resources

●

Food, Culture, and Religion http://www.foodenquirer.com/articles/food-culture-and-religion.html

●

Food Habits and Anthropology http://www.foodhabits.info/

●

Food History Timeline http://www.foodtimeline.org/

●

Foods of Religions http://www.interfaithcalendar.org/Foodsofreligions.htm

●

Gastronomica http://www.gastronomica.org/

●

Hispanic-American Health http://www.nlm.nih.gov/medlineplus/hispanicamericanhealth.html

●

National Center for Cultural Competence http://nccc.georgetown.edu/

●

National Library of Medicine—Asian American Health http://asianamericanhealth.nlm.nih.gov/index.html

●

Native People’s Voices http://www.nlm.nih.gov/nativevoices/

●

Ohio State University Extension Fact Sheets http://ohioline.osu.edu/hyg-fact/5000/index.html

●

Oldways Cultural Food Pyramids http://www.oldwayspt.org/

●

Religious Food Practices http://asiarecipe.com/religion.html#help

SAMPLE NUTRITION CARE PROCESS STEPS

●

Society for Nutrition Education and Behavior http://www.sneb.org/

Unintentional Weight Loss

●

Tufts University—Patient Information in Asian Languages http://spiral.tufts.edu/index.php

Assessment Data: Food records indicating lack of appetite for new foods; weight records; low blood glucose and cholesterol levels.

REFERENCES

Patient Education—Food Safety • Discuss food handling, preparation, and storage within a cultural context. • When traveling, avoid tap water and ice made from tap water, uncooked produce such as lettuce, and raw or undercooked seafood. • Avoid raw or partially cooked eggs, raw or undercooked fish or shellfish, and raw or undercooked meats because of potential foodborne illnesses. • Do not use raw (unpasteurized) milk or products made from it. Avoid serving unpasteurized juices and raw sprouts.

Nutrition Diagnoses (PES): Unintentional weight loss related to limited access to preferred foods as evidenced by 15-lb weight loss since moving to this country 6months ago with a current body mass index (BMI) of 17. Intervention: Education about where to find ethnic food choices for protein choices, whole grains, fruits, and vegetables. Counseling about culturally appropriate choices that are accessible in neighborhood or area stores. Monitoring and Evaluation: Improved BMI and weight for height; lab reports showing improvement in glucose and cholesterol.

For More Information ●

Academy of Nutrition and Dietetics Cultural Food Tip Sheets: http://www.eatright.org/Members/content.aspx ?id=6442459105 Member Resources: http://www.eatright.org/Members/content.aspx?id=1192

Escott-Stump_Ch02.indd 88

Bisoqni CA, et al. How people interpret healthy eating: contributions of qualitative research. J Nutr Educ Behav. 2012;44:282–301. Black MM, et al. Participants’ comments on changes in the revised special supplemental nutrition program for women, infants, and children food packages: the Maryland food preference study. J Am Diet Assoc. 2009;109:116. Burnett-Hartman AN, et al. Supplement use contributes to meeting recommended dietary intakes for calcium, magnesium, and vitamin C in four ethnicities of middle-aged and older Americans: the Multi-Ethnic Study of Atherosclerosis. J Am Diet Assoc. 2009;109:422. Drewnowski A, Eichelsdoerfer P. The Mediterranean diet: does it have to cost more? Public Health Nutr. 2009;12:1621. Franco M, et al. Availability of healthy foods and dietary patterns: the MultiEthnic Study of Atherosclerosis. Am J Clin Nutr. 2009;89:897. Goody CM, Drago L. Cultural Food Practices. Chicago, IL: American Dietetic Association; 2010. Hirasawa R, et al. Quality of Internet information related to the Mediterranean diet. Public Health Nutr. 2012;15:885. Kittler PG, Sucher KP. Food and culture. 5th ed. Belmont, CA: Wadsworth; 2008. Larson NI, et al. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36:74. Stein K. Navigating cultural competency: in preparation for an expected standard in 2010. J Am Diet Assoc. 2009;109:1676.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

VEGETARIANISM NUTRITIONAL ACUITY RANKING: LEVEL 2 FOR MEAL PLANNING DEFINITIONS AND BACKGROUND Vegetarian diets are plant-based with large amounts of cereals, fruits, vegetables, legumes, seeds, and nuts. These diets generally omit meat, poultry, and fish. Vegetable proteins should be carefully planned in the diet (see Fig. 2-4). A vegetarian diet can meet current recommendations for protein, omega-3 fatty acids, iron, zinc, iodine, calcium, and vitamins D and B12 if individual assessment of dietary adequacy occurs (Craig et al, 2009). Conscious combining of complementary protein sources does not appear to be necessary on a regular basis. Vegetarians appear to have lower low-density lipoprotein cholesterol levels, blood pressure, rates of hypertension, and type 2 diabetes; they also have lower BMIs and lower risk of death from ischemic heart disease or cancer than nonvegetarians (Craig et al, 2009). Vegetarians usually consume fewer saturated fats and less cholesterol and the desirable level (25 to 35 g) of fiber per day. Hindus, Seventh-Day Adventists, Buddhists, and some other religious groups may suggest following a vegetarian lifestyle. Vegetarian diets are usually rich in carbohydrates, omega-6 fatty acids, dietary fiber, carotenoids, folic acid, vitamin C, vitamin E, and magnesium, but relatively low in protein, saturated fat, long-chain omega-3 fatty acids, retinol, vitamin B12,

t. ces in owes ur Prote rving to l o S e e rs s ut ain bl n pe M geta of protei umes pean Ve ount Leogasteedans r yb of est am s

h so ntils ean hig s m le g b as pea s n un it peeyed i a m r t G ea t spl ack eans ans ea wh wh bl d b y be ans u) rye lgar re dne be ans of bu let k ki lack be ans d (t r l a e e r b it be cu mi ley ric , d ) wh ima an barown heat meal l ybe br ckw (oat so bu ts eal s a m ed in o rn Se umpk ower co p nfl e su sam ts s Nu lnut ews ts se wa ash l nu c azi ns br eca nds p mo al

t Lis

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • •

Height Weight BMI Diet history

Lab Work • • • • • • • • • • • • • •

Mean cell volume (MCV) Serum Fe and ferritin Transferrin Albumin (Alb), transthyretin Chol, Trig Glucose (gluc) Serum folate Serum B12 total homocysteine (tHcy) Ca⫹⫹, Mg⫹⫹ Na⫹, K⫹ Serum zinc Alkaline phosphatase (ALP) Serum vitamin D

fro

Figure 2-4. Planning for protein in the vegetarian diet. (Adapted with permission from Anatomical Chart Company. Keys to healthy eating.)

Escott-Stump_Ch02.indd 89

and zinc (Key et al, 2006). Dietary total antioxidant capacity (TAC), based on the cumulative antioxidants present in food, is inversely associated with risks of chronic diseases (Wang et al, 2012). An evidence-based review showed that vegetarian diets can be nutritionally adequate even in pregnancy and result in positive maternal and infant health outcomes (Craig et al, 2009). On the other hand, the vegan plan is a very strict vegetarian food pattern (“pure” vegetarianism). Table 2-4 provides guidance on nutrients that may be at risk in a vegetarian diet.

INTERVENTION Objectives • Encourage use of a wide variety of foods in adequate quantity with a mix of nutrients and amino acids throughout the day. • Provide nutritionally adequate menus with sufficient energy for weight goals. Discourage excessive use of sweets. • Monitor carefully if the client is a pregnant woman, lactating mother, or elderly person. • Infants, children, and teens on vegan diets should be monitored even more closely. High-fiber diets may replace calories and cause some stunting or other growth deficits. • Monitor fiber intake; phytate excesses may interfere with absorption of calcium, zinc, and iron.

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-4 Potential Complications of a Vegetarian Diet CALCIUM Calcium absorption may be inhibited as a consequence of the presence of phytates in plant foods. An evaluation of actual intake by vegetarians suggests that calcium intake is adequate (Farmer et al, 2011). Monitor intake by pregnant women, children, and adolescents who are vegetarians. CARNOSINE Nonenzymic protein glycosylation (glycation) promotes aging. Carnivorous diets contain a potential antiglycating agent, carnosine (beta-alanyl-histidine), while vegetarians may be deficient (Hipkiss, 2009). ENERGY DEFICIT OR FIBER EXCESSES This regimen might restrict energy intake in the first few years of life. This is also true for adults who consume large amounts of fiber (phytates) to the extent that nutrients such as zinc or iron are not absorbed in the small intestine. Large intakes of fiber may also lead to dehydration if not careful. IODINE DEFICIENCY Vegans may be at risk for low iodine intake; vegan women of child-bearing age should supplement with 150 ␮g iodine daily (Leung et al, 2011). IRON DEFICIENCY ANEMIA Females should be sure to obtain an adequate amount of absorbable iron. The iron in dairy, eggs, and plant foods is largely nonheme, of which only about 2%–20% is absorbed. A study in pregnant vegetarian women found that iron intake was adequate by diet and supplement use (Alwan et al, 2011). OMEGA-3 FATTY ACIDS AND ESSENTIAL AMINO ACIDS Omega-3 fatty acids and essential amino acids methionine and lysine may be lower in vegetarian diets. It may be necessary to use a supplemental form (Li, 2011). PROTEIN Protein may be limited. Suggest complementary food combinations to acquire all amino acids (Britten et al, 2012). Low dietary intake of protein and sulfur amino acids leads to subclinical protein malnutrition, hyperhomocysteinemia, and increased vulnerability to cardiovascular diseases (Ingenbleek and McCully, 2012). VITAMIN B12 DEFICIENCY An individual following a vegan diet should use supplements to obtain this vitamin (Kwok et al, 2012; Li, 2011). VITAMIN D DEFICIENCY OR RICKETS The human body can synthesize vitamin D from sunlight, but this is only possible when the sun reaches a certain intensity level. For dark-skinned individuals and people who live in northern latitudes, for a few months each year, they will have to seek other sources of vitamin D (Chan et al, 2009). For vegans who do not consume fortified dairy products, supplements are necessary. A very low-fat vegan diet can be nutritionally adequate with the exception of vitamin D; supplementation is needed. ZINC Zinc intake may be lower in vegetarian diets because of poor absorption (Kawade, 2012). Careful micronutrient supplementation may be warranted. References: Alwan NA, Greenwood DC, Simpson NA, et al. Dietary iron intake during early pregnancy and birth outcomes in a cohort of British women. Hum Reprod. 2011;26:911; Britten P, Cleveland LE, Koegel KL, et al. Updated US Department of Agriculture Food Patterns meet goals of the 2010 dietary guidelines. J Acad Nutr Diet. 2012;112:1648; Chan J, Jaceldo-Siegl K, Fraser GE. Serum 25-hydroxyvitamin D status of vegetarians, partial vegetarians, and nonvegetarians: the Adventist Health Study-2. Am J Clin Nutr. 2009;89:1686S; Farmer B, Larson BT, Fulgoni VL 3rd, et al. A vegetarian dietary pattern as a nutrient-dense approach to weight management: an analysis of the national health and nutrition examination survey 1999-2004. J Am Diet Assoc. 2011;111:819; Hipkiss AR. Carnosine and its possible roles in nutrition and health. Adv Food Nutr Res. 2009;57:87; Ingenbleek Y, McCully KS. Vegetarianism produces subclinical malnutrition, hyperhomocysteinemia and atherogenesis. Nutrition. 2012;28:148; Kawade R. Zinc status and its association with the health of adolescents: a review of studies in India. Glob Health Action. 2012;5:7353; Kwok T, Chook P, Qiao M, et al. Vitamin B-12 supplementation improves arterial function in vegetarians with subnormal vitamin B-12 status. J Nutr Health Aging. 2012;16:569; Leung AM, Lamar A, He X, et al. Iodine status and thyroid function of Boston-area vegetarians and vegans. J Clin Endocrinol Metab. 2011;96:E1303; Li D. Chemistry behind vegetarianism. J Agric Food Chem. 2011;59:777.

• Prevent or correct anemias, which could be either microcytic or macrocytic. • The limiting amino acids in typical protein foods are in wheat (lysine), rice (lysine and threonine), corn (lysine and tryptophan), beans (methionine), and chickpeas (methionine). • Vary food mixtures such as using bread with milk, rice with cheese, or pasta with cheese; rice with beans, bread with beans, or corn and beans; garbanzo beans with sesame seeds (as in dips or in roasted snacks). Serve vegetables with nuts, dairy products, rice, sunflower seeds, or wheat germ. • Plant sources of protein can provide adequate amounts of essential amino acids. Using a variety of plant foods is key, and energy needs should readily be met.

Food and Nutrition • An effective food guide for vegetarians includes: 6 to 12 servings from the bread group; 2 to 3 servings of protein-rich foods

Escott-Stump_Ch02.indd 90

such as legumes, nuts and seeds, or eggs (if used); 2 to 3 servings from the dairy group as tofu, yogurt, or fortified soy milk; 4 or more servings of vegetables; 3 or more servings of fruits; 2 to 3 servings of fats and oils, including olives and avocado. • Not all who adhere to vegetarian, vegan, or other special diets have nutritionally sound eating habits (Plotnikoff, 2012). For a balanced diet, minimize intake of empty-calorie sweets and fatty foods. Choose low-fat or nonfat dairy products when they are included in the diet. • Choose whole or unrefined grain products instead of refined products. Include a variety of nuts, seeds, legumes, fruits, and vegetables; use good sources of vitamin C to improve iron absorption. • Vegetarian foods rich in iron include fortified breakfast cereals, oatmeal, raisins, black beans, cashews, lentils, kidney beans, black-eyed peas, soybeans, hempseed, sunflower seeds, chickpeas, molasses, and whole wheat bread.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

Food–Drug Interactions

SAMPLE NUTRITION CARE PROCESS STEPS

Common Drugs Used and Potential Side Effects • Monitor use of medications that deplete vitamins and minerals, especially iron and B-complex vitamins.

Excessive Fiber Intake Assessment Data: Food records; adverse side effects from high fiber intake; low BP; altered nutritional labs for calcium and iron.

Herbs, Botanicals, and Supplements • Many vegetarians use herbs and botanicals. Identify those that are used and monitor side effects. Counsel avoiding herbal teas that may contain unknown or toxic ingredients. • Encourage the use of culinary herbs (Fig. 2-5) (Kaefer and Milner, 2008). Many vegetarians enjoy a cancer-free life.

Nutrition Diagnoses (PES): Excessive fiber intake related to vegan lifestyle as evidenced by complaints of excessive gas at night and intake of 45 g of fiber daily, especially with large amounts at dinner.

Nutrition Education, Counseling, CareManagement

Interventions: Food and Nutrition Delivery: Provide supplementation of a multivitamin and vitamin B12. Educate and counsel patient on following a healthy vegan diet and teach patient how to plan and monitor diet carefully.

• Explain patterns of food intake that provide complementary amino acids. Whole grains, legumes, seeds, nuts, and vegetables contain sufficient essential and nonessential amino acids if taken in the right combinations. • Emphasize the importance of a balanced diet. Carotenoid and flavonoid intakes are higher among men and women whose diets provide sufficient numbers of fruits and vegetables (Murphy et al, 2012). • Counsel about appropriate products for infants and children, as protein may be the biggest problem. Soy milk should be fortified with calcium and vitamin B12. • Vitamin B12 supplementation improves arterial function in vegetarians with subnormal vitamin B12 levels (Kwok etal, 2012). • Supplements or fortified foods can provide important nutrients where needed (Craig et al, 2009). Limit the dose to 100% of the DRI unless directed by a physician.

Nutrition Education: Registered Dietitian (RD) to provide recommend modifications to patient’s diet through instruction and training to lead to a better understanding of the importance of monitoring vegan diet and supplementing to get required nutrients not supplied through diet. Counseling: RD will teach and counsel patient on how to get nutrients she needs while continuing to follow a vegan diet. They will discuss solutions to patient’s vitamin B12 deficiency by discussing vegan foods that are fortified with vitamin B12 and foods such as nutritional yeast that will provide her with a source of vitamin B12 in her diet. Coordination of Care: Refer patient to outpatient RD specializing in vegetarianism.

Patient Education—Food Safety • Discuss food handling, preparation, and storage, especially careful washing of fruits and vegetables. Spinach and sprouts have been contaminated in recent years; wash produce thoroughly. Discuss hand washing. • Starches such as hot cereals and rice should not be prepared and held in large batches because of the risks of Bacillus cereus.

Monitoring and Evaluation: Improved quality of life with reduced symptoms of gas; lab reports for calcium, iron, ferritin; diet history revealing intake of fiber within desired range of 25 to 35 g/d.

For More Information Harmful microbes

Oxidants

Culinary herbs & spices

Inflammation

Cancer incidence & tumor behavior

Carcinogen bioactivation

●

Kids Health Vegetarianism http://kidshealth.org/parent/nutrition_center/dietary_needs /vegetarianism.html

●

Lacto-Ovo Vegetarian Cuisine http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/lacto _ov.htm

●

Mayo Clinic http://www.mayoclinic.com/health/vegetarian-diet/HQ01596

●

North American Vegetarian Society http://www.navs-online.org/

●

Oldways Preservation and Trust http://www.oldwayspt.org/

●

Soy Connection http://www.soyconnection.com/newsletters/soy-connection/health -nutrition/index.php

●

Vegetarian Cuisine and Recipes http://vegweb.com/

●

Vegetarian Network (Victoria, Australia) http://www.vnv.org.au/

●

Vegetarian Recipes http://allrecipes.com/HowTo/Vegetarian-Cuisine/Detail.aspx

●

Vegetarian Recipes for Teens http://kidshealth.org/teen/recipes/

●

Vegetarian Resource Group http://www.vrg.org/

Tumorigenesis

Figure 2-5. The role of culinary herbs in cancer prevention. (Adapted with permission from Kaefer CM, Milner JA. The role of herbs and spices in cancer prevention. J Nutr Biochem. 2008;19:347.)

Escott-Stump_Ch02.indd 91

11/7/14 2:13 AM

92 ●

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Vegetarian Society of the United Kingdom http://www.vegsoc.org/

REFERENCES Craig WJ, et al. Position of the American Dietetic Association: vegetarian diets. JAm Diet Assoc. 2009;109:1266. Kaefer CM, Milner JA. The role of herbs and spices in cancer prevention. J Nutr Biochem. 2008;19:347. Key TJ, et al. Health effects of vegetarian and vegan diets. Proc Nutr Soc. 2006;65:35.

Kwok T, et al. Vitamin B-12 supplementation improves arterial function in vegetarians with subnormal vitamin B-12 status. J Nutr Health Aging. 2012;16:569. Murphy MM, et al. Phytonutrient intake by adults in the United States in relation to fruit and vegetable consumption. J Acad Nutr Diet. 2012; 112:222. Plotnikoff GA. Nutritional assessment in vegetarians and vegans: questions clinicians should ask. Minn Med. 2012;95:36. Wang Y, et al. Dietary total antioxidant capacity is associated with diet and plasma antioxidant status in healthy young adults. J Acad Nutr Diet. 2012; 112:1626.

EASTERN RELIGIOUS DIETARY PRACTICES NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND Hinduism, Jainism, and Sikhism Hindus may be vegetarian while adhering to ahimsa, related to nonviolence as applied to the infliction of pain on animals. Beef is never eaten (the cow is considered sacred), and pork is usually avoided. Foods prohibited may include snails, crab, poultry, cranes, ducks, camels, boars, and some types of fish. The “high caste” Brahmins have stricter rules and practices, and there are differences between the North Indian Brahmins and the South Indian Brahmins. Some foods promote purity of the body, mind, and spirit. Devout Hindus avoid alcoholic beverages and foods that stimulate the senses, such as garlic and onions. Feast days include Holi, Dusshera, Pongal, and Divali (varying each year according to the lunar calendar). In addition, personal feast days include the anniversaries of birthdays, marriages, and deaths. Fasting depends on a person’s social standing (caste), family, age, gender, and degree of orthodoxy. Fasting can be complete, adopting a completely vegetarian diet, or it can be abstaining from favorite foods. Jainism is a branch of Hinduism that also promotes the nonviolence of ahimsa. Jains are expected to practice nonviolence, including against animals. Devout Jains are complete vegans. They avoid blood-colored foods (tomatoes) and avoid root vegetables, which may result in the death of insects clinging to the vegetable when harvested. Jains drink only boiled water. Fasting is a tool for connecting with the inner being during festivals. Fasting is based on three levels of austerity: Uttam, Madhyam, and Jaghanya. When one has finished with the roles of life, he or she willingly gives up food and drink; this can take up to 12 years with a gradual decline in eating. Sikhs participate in many Hindu practices but differ by their belief in a single God. Sikhs abstain from beef and alcohol, but pork is permitted. Everyone is equal, no matter what color, sex, race, wealth, height, weight, or religion; there is only one true race, the human race. Everyone sits on the floor when eating, as equals.

Buddhism Buddhist dietary customs vary considerably depending on sect (Theravada or Hinayana, Mahayana, Zen) and on country of

Escott-Stump_Ch02.indd 92

origin. Most Buddhists subscribe to the concept of ahimsa, and many are lacto–ovo vegetarians. Some eat fish, whereas some only abstain from beef. Others believe that unless they personally slaughter an animal, they may eat its meat. Buddhist monks fast completely on the days of the new moon and full moon each lunar month; they also avoid eating any solid food after the noon hour. Buddhist feasts vary from one region to another. Celebrations include the birth, enlightenment, and death of Buddha in Mahayana Buddhism. The 3 days are a single holiday of Vesak for Theravada Buddhism. Buddhist vegetarian diets promote more natural insulin sensitivity. Compared with omnivores, vegetarians have significantly lower mean BMI, blood pressures, total cholesterol, LDL-c, triglycerides, apolipoprotein B and A-I, as well as lower predicted probability of coronary heart disease (Zhang et al, 2013). However, low intakes of vitamin B12 and zinc may be a concern.

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • •

Height Weight BMI Recent weight changes Diet history BP

Lab Work • • • • • • • • •

Gluc Chol, Trig Serum Na⫹, K⫹ Ca⫹⫹, Mg⫹⫹ ALP H&H, serum Fe Serum B12 Serum zinc Serum vitamin D

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

INTERVENTION

SAMPLE NUTRITION CARE PROCESS STEPS Inadequate Mineral (Iron) Intake

Objectives

Food and Nutrition

Assessment Data: Food records showing low intake of heme iron; altered nutritional labs for iron and ferritin; normal folate and B12 levels; complaints of easy fatigue and irritability. Nutrition Diagnoses (PES): Inadequate iron intake related to Hindu (vegan) lifestyle as evidenced by intake of 4 to 5 g nonheme iron daily and low serum Fe and ferritin levels.

• Support dietary practices as followed by the individual and family members. • Counsel about specific nutritional changes according to the medical diagnosis and current condition.

Intervention: Education about increasing intake of ironrich foods while decreasing excess of wheat bran. Counseling about using iron-fortified cereals or a supplement that provides 100% DRI for iron.

Food–Drug Interactions

Monitoring and Evaluation: Improved energy and less fatigue; improved lab reports for iron and ferritin; diet history revealing improved intake of nonheme iron with supplements as needed.

• Serve appropriate menu choices, and omit foods or beverages that are not permitted. • Respect traditions and preferences of the individual and family members.

Common Drugs Used and Potential Side Effects • During periods of fasting, identify potential interactions from drugs that are dependent on energy sources for their metabolism. Herbs, Botanicals, and Supplements • Many cultures use herbs and botanicals as part of their meal patterns, rituals, and celebrations. Identify those that are used and monitor side effects. • Cultural influences identified among Punjabi Sikh men suggest that three themes intertwine: food consumption, physical exercise, and faith and religion (Galdas et al, 2012). • Counsel about use of herbal teas, especially regarding toxic substances.

Nutrition Education, Counseling, CareManagement • Various types of cancer may prevail in different parts of the world and in different cultures. Discuss diet in relationship to what is common. • While medical students and physicians with healthful personal practices (such as vegetarianism) are more likely to encourage such behaviors in their patients, these beliefs do not affect their actual nutrition counseling (Spencer et al, 2007). Patient Education—Food Safety • Discuss safe preparation and storage of foods to reduce likelihood of bacterial contamination.

Escott-Stump_Ch02.indd 93

For More Information ●

Asian Foods http://asiasociety.org/blog/asia/food-recipes

●

Asian Society http://www.asiasociety.org/

●

Buddhism http://www.buddhanet.net/

●

Ethnic Recipes http://asiarecipe.com/religion.html

●

Faith and Food http://www.faithandfood.com/Hinduism.php

●

Hinduism http://www.hindunet.org/vegetarian/

●

Jainism http://www.diversiton.com/religion/main/jainism/holydays-festivals -rituals.asp

●

Sikhism and Faith http://www.realsikhism.com/index.php?subaction=showfull&id =1248309400&ucat=7

REFERENCES Galdas PM, et al. Canadian Punjabi Sikh men’s experiences of lifestyle changes following myocardial infarction: cultural connections. Ethn Health. 2012;17:253. Spencer EH, et al. Personal and professional correlates of US medical students’ vegetarianism. J Am Diet Assoc. 2007;107:72. Zhang HJ, et al. Attenuated associations between increasing BMI and unfavorable lipid profiles in Chinese Buddhist vegetarians. Asia Pac J Clin Nutr. 2013;22:249.

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

WESTERN RELIGIOUS DIETARY PRACTICES NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND Judaism (Edited by Rabbi Allan Bernstein) Jewish congregations in the United States are either identified as Orthodox, Conservative, or Reform. Orthodox Jews believe the laws are the direct commandments of God to be explicitly followed by the faithful. Reform Jews follow the moral law but believe that the laws are still being interpreted (some are considered dated or currently irrelevant) and may be observed selectively. Conservative Jews fall in between the other congregations in their beliefs and adherence to the laws. About 25% to 30% of Jews in America keep kosher to one extent or another (http://www.jewfaq.org/kashrut.htm). Mizrahi (Sephardi Jews) resided in Spain, Portugal, the Mediterranean (Turkey, Greece, Maghreb) and Arab countries. Their dietary habits focus on vegetables and beans, but less meat overall. Jewish dietary laws are known as Kashrut and are among the most complex of all religious food practices. The term kosher, or kasher, means “fit” and describes all foods that are permitted for consumption. Kosher is loosely used to identify Jewish dietary laws, and to “keep kosher” means that the laws are followed. In brief, the dietary laws address what foods are fit to eat, what foods are prohibited (a lengthy list that includes pork, shellfish, and other foods), how animals must be slaughtered, how foods must be prepared, and when foods may be consumed (specifically, rules regarding when dairy products can be consumed with meat products). Jewish feast days include Rosh Hashanah, Sukkot, Hanukkah, Purim, Passover, and Shavout (dates vary because Judaism uses a lunar calendar). Specific foods are associated with the feasts but may differ nationally. Complete fast days (no food or water from sunset to sunset) include Yom Kippur and Tisha b’Av. Partial fast days (no food or water from sunrise to sunset) include Tzom Gedaliah, Tenth of Tevet and Seventeenth of Tamuz, Ta’anit Ester, and Ta’anit Bechorim. Special kosher laws are observed during Passover, including the elimination of any products that can be leavened.

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • •

Height Weight BMI Recent weight changes Diet history BP

Lab Work • Gluc • Chol, Trig

Escott-Stump_Ch02.indd 94

• • • • • •

Serum Na⫹, K⫹ Ca⫹⫹, Mg⫹⫹ ALP H&H, serum Fe Serum vitamin D Serum tHcy

INTERVENTION Objectives • Observe dietary practices as followed by the laws of Judaism: Meats are limited to cud-chewing animals with cloven hooves (e.g., cows, sheep) that are properly slaughtered. Pork (including ham and all pork products), shellfish, and scavenger fish are forbidden. • Separate utensils are used for preparation and eating, especially for separating meat and milk foods. • The kosher diet tends to be high in saturated fat and sodium. Encourage application of the DASH diet principles where possible. • Reduce lactose where necessary for intolerance.

Food and Nutrition The Jewish dinner table follows these guidelines (http://www .jewfaq.org/kashrut.htm): • Certain animals may not be eaten at all. This restriction includes the flesh, organs, eggs, and milk of the forbidden animals. No pork, ham, bacon, pork products, rabbit, shellfish, or eel may be eaten. • Of the animals that may be eaten, birds and mammals must be killed in accordance with Jewish law. All blood must be drained from the meat or broiled out of it before it is eaten. Certain parts of permitted animals may not be eaten. Sheep, cattle, goats, and deer are kosher but must be slaughtered according to the laws of kashrut. • Meat (the flesh of birds and mammals) cannot be eaten with dairy. Fish, eggs, fruits, vegetables, and grains can be eaten with either meat or dairy. According to some views, fish may not be eaten with meat. • Dairy: Milk may be consumed before a meal, but once meat is eaten, 3 to 6 hours (depending on individual traditions) must pass before dairy products can be consumed. Omit lactose if not tolerated; provide other sources of calcium and riboflavin. • Utensils that have come into contact with meat may not be used with dairy and vice versa. Utensils that have come into contact with nonkosher food may not be used with kosher food. • Fruits, vegetables, and grains can be used, except that breads made with milk products are forbidden with meat meals. Grape products made by non-Jews may not be eaten. • Leavened (raised) bread is forbidden during Passover. Matzoh bread or crackers may be used. Haroset and fried matzoh

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

are traditional Passover foods. The Seder dinner marks the beginning of Passover and includes drinking 4 cups of wine, eating unleavened bread (matzoh), and partaking of symbolic foods placed on the Seder plates. For more information about the Seder dinner, see http://www.chabad.org/library /article_cdo/aid/645207/jewish/Seder-Preparations.htm • Common food choices include matzoh-ball soup, chicken soup with kreplach, gefilte fish with beet horseradish, cheese blintz with sour cream, flanken tzimmes, chopped liver, noodle kugel, and kishka. Frozen kosher meals may be available for patients in hospitals or nursing homes. • Fasting is common during Yom Kippur. • Traditional Hanukkah fare include foods cooked in oil such as potato pancakes (latkes) and doughnuts (sufganiyot) and dairy foods.

•

Nutrition Education, Counseling, CareManagement • Show the patient how to limit foods high in cholesterol/fat if weight and elevated lipid levels are a problem. • Discuss sodium and obesity in relationship to hypertension, as appropriate. Recommend other herbs, spices, and cooking methods. • Low-fat cheeses should be substituted for high-fat cheeses such as cream cheese. • Note that food labels with a “U” with an “O” encircling it are considered kosher. Many other foods are considered kosher, but an inquiry should be made. • Discuss holiday preferences and alternatives when needed.

•

Patient Education—Food Safety • Discuss safe preparation and storage of foods to reduce likelihood of bacterial contamination.

•

For More Information ●

Judaism 101 http://www.jewfaq.org/kashrut.htm

●

Kashrut–Dietary Laws http://www.myjewishlearning.com/daily_life/Kashrut.htm

●

Kosher certification http://www.ok.org/about

●

Kosherfest http://www.kosherfest.com/

●

Union for Traditional Judaism http://www.utj.org/

•

(40 days before Easter). Food and beverages (except water) are to be avoided for 1 hour before communion is taken. Eastern Orthodox Christianity: The 14 self-governing churches that form the Orthodox Church differ from Catholicism in their interpretation of the Biblical theology, including the use of leavened bread instead of unleavened wafers in communion. Numerous feast and fast days are observed (dates vary according to whether the Julian or Gregorian calendar is used). Feast days include Christmas, Theophany, Presentation of the Lord into the Temple, Annunciation, Easter, Ascension, Pentecost Sunday, the Transfiguration, Dormition of the Holy Theotokos, Nativity of the Holy Theotokos, and Presentation of the Holy Theotokos. In addition, Meat Fare Sunday is observed the third Sunday before Easter (all meat in the house is consumed, and none is eaten again until Easter). Cheese Fare Sunday is observed on the Sunday before Easter (all cheese, eggs, and butter are consumed). On the next day, Clean Monday, the Lenten fast begins. Food and drink are avoided before communion. Meat and all animal products (milk, eggs, butter, and cheese) are prohibited on fast days; fish is avoided, but shellfish is permitted. Some devout followers may avoid olive oil on fast days, too. Fast days include every Wednesday and Friday (except for three fast-free weeks each year), the Eve of Theophany, the Beheading of John the Baptist, and Elevation of the Holy Cross. Fast periods include Advent, Lent, the Fast of the Apostles, and Fast of the Dormition of the Holy Theotokos. Protestantism: The only feast days common in most Protestant religions are Christmas and Easter. Few practice fasting. Food puritanical behaviors may be present. The Calvinist ascetic simplicity equates “plain food” with a good life. Mormons (Church of Jesus Christ of Latter Day Saints): Mormons avoid alcoholic beverages, hot drinks (coffee and tea), and caffeine-containing drinks. Followers are encouraged to eat mostly grains and to limit meats. Some Mormons fast 1 day a month and donate that food money to the poor. Seventh-Day Adventists avoid overeating. Most are lacto-ovo–vegetarians, but when meat is consumed, most avoid pork. Tea, coffee, and alcoholic beverages are prohibited. Water is consumed before and after meals. Eating between meals is discouraged. Strong seasonings and condiments, such as pepper and mustard, are avoided.

Christianity The Christian faith has three major branches: Roman Catholicism, Eastern Orthodox Christianity, and Protestantism. Dietary practices vary; some are minimal. • Roman Catholicism: Devout Catholics observe several feast and fast days during the year. Feast days include Christmas, Easter, the Annunciation (March 25th), Palm Sunday (the Sunday before Easter), the Ascension (40 days after Easter), and Pentecost Sunday (50 days after Easter). Catholics in each country observe many food traditions. Fasting (one full meal per day permitted; snacking according to local custom) and/ or abstinence (meat is prohibited, but eggs, dairy products, and condiments with animal fat are permitted) may be practiced during Lent, on the Fridays of Advent, and Ember Days (at the beginning of the seasons) by some Catholics; some fast or abstain only on Ash Wednesday and Good Friday. Today, Catholics may avoid meat only on the Fridays of Lent

Escott-Stump_Ch02.indd 95

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • •

Height Weight BMI Recent weight changes Diet history BP

Lab Work • Gluc • Chol, Trig

11/7/14 2:13 AM

96 • • • • •

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

Serum Na⫹, K⫹ ALP H&H, serum Fe C-reactive protein (CRP) Serum vitamin D

INTERVENTION Objectives • Observe dietary practices as followed by the individual. • Discuss the role of special meals, fasting, or events and plan menus accordingly.

Nutrition Education, Counseling, CareManagement • Health care professionals should tailor practice by integrating their knowledge of specific cultures into care plans (Noble et al, 2009). • Show the patient how to limit foods high in saturated fat if weight and high lipid levels are a problem. • Discuss sodium and obesity in relationship to hypertension, as appropriate. Recommend other herbs, spices, and cooking methods. • Discuss holiday preferences and alternatives where needed. Patient Education—Food Safety • Discuss safe preparation and storage of foods to reduce likelihood of bacterial contamination. For More Information

Food and Nutrition • Promote a healthy diet. The Mediterranean diet may be suitable for many individuals. • Fasting may be common during special holidays. Discuss concerns related to pregnancy, children, the elderly, or those in a malnourished state. • Some individuals avoid caffeine and alcohol as part of their religious preferences; honor those wishes. • Determine if any foods are avoided on special days of the week and plan alternatives accordingly.

●

Intercultural Menu Planning http://www.etiquetteinternational.com/Articles/TableOfferings.aspx

REFERENCE Noble A, et al. Jewish laws, customs, and practice in labor, delivery, and postpartum care. J Transcult Nurs. 2009;20:323.

MIDDLE EASTERN RELIGIOUS DIETARY PRACTICES NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND Islam

poor. Fasting includes abstention from all food and drink from dawn to sunset. Voluntary fasting is common on Mondays and Thursdays; it is undesirable to fast on certain days of the month and on Fridays.

Islam is the world’s second largest religion, representing nearly a quarter of the global population (Inhorn and Serour, 2011). The word Islam is Arabic and means submission, surrender, obedience, and peace. As a religion, Islam stands for complete submission and obedience to God. Followers of the Islamic faith are known as Muslims. Muslims promote the concept of eating to live, not living to eat. They advise sharing food. Prohibited foods as described in the Koran are called haram; those in question are mashbooh. Pork and birds of prey are haram; meats must be slaughtered properly. Alcohol is prohibited, but stimulants, such as coffee and tea, are allowed. Halal is the term for all permitted foods. The flesh of animals must be slaughtered according to Islamic law or halal; kosher items may be used for this reason. Figure 2-6 shows lamb being prepared for kebabs in a Turkish restaurant. Feast days (dates vary because Islam uses a lunar calendar) include Eid al-Fitr, Eid al-Azha, Nau-Roz (a Persian holiday), Al-Ghadeer, and Maulud n’Nabi. Appetizers are called mezze or muqabalat; the usual mezze layout is quite a feast. Fasting is considered an opportunity to earn the approval of Allah, to wipe out sins, and to understand the suffering of the

Figure 2-6 Lamb and skewers are prepared for kebabs in a restaurant in Istanbul. (Image courtesy S. Escott-Stump.)

Escott-Stump_Ch02.indd 96

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

Muslims are required to fast (no food from sunup to sundown) during the entire month of Ramadan and are encouraged to fast 6 days during the month of Shawwal, on the Al-Ghadeer day, and on the ninth day of Zul Hijjah. Surprisingly, weight gain rather than loss is common during Ramadan; lifestyle and dietary modification programs are needed in this population as there is a high prevalence of diabetes (Bakhotmah, 2011).

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • •

Height Weight BMI Recent weight changes Diet history BP

Lab Work • • • • • • •

Gluc Chol, Trig Serum Na⫹, K⫹ Ca⫹⫹, Mg⫹⫹ ALP H&H, serum Fe Serum vitamin D

INTERVENTION

• Typical combination foods include falafel (grain, fat), hummus (grain, fat), kibbeh (meat, grain, fat), tabouli (vegetable, grain, fat), baba ghanouj (vegetable, fat), pilaf (grain, fat), stuffed grape leaves (meat, grain, fat), and shawarma (meat, grain, fat). Khoresh is a stew with meats (lamb, beef, or veal), poultry, or fish with vegetables; fresh or dried fruits; beans, grains, and even nuts. • When milk banks are considered for preterm infants, religious concerns may be raised. The concept that women’s milk creates “milk kinship” is believed to impede marriage in Islamic law and may be a reason for refusal of donated human milk (Ghaly, 2012).

Nutrition Education, Counseling, CareManagement • Middle Eastern patients and their Western health providers often have cultural or linguistic misunderstandings; the importance of family cohesion and interactive attitudes toward ailments and health must be considered (Aboul-Enein and Aboul-Enein, 2010). • Traditional healing practices are common among American Muslims and include religious text–based practices, Islamic worship practices, and folk healing practices (medicinal herbs, mind body therapy, and dietary prescriptions) (Alrawi et al, 2012). Discuss treatment options for managing conditions such as obesity or diabetes. • Fasting may have undesirable side effects, such as hypotension or fainting; it is not recommended for persons who have diabetes, cancer, or HIV/AIDS. • Discuss menu planning for religious occasions. Patient Education—Food Safety • Meals are a social event. If common food sharing is a concern, encourage hand washing. For More Information

Objectives • During fasting, eating occurs only before dawn and after sunset. Plan accordingly. • Monitor dietary patterns, which include fasting 3 days a month. Pregnant and breastfeeding mothers need not fast. • Monitor need for vitamin D in women if sun exposure is minimal.

●

Iranian Cooking http://www.aashpazi.com/

●

Islamic Food and Nutrition Council of America http://www.ifanca.org/

●

Jordanian Food http://www.gondol.com/English/food.htm

Food and Nutrition

REFERENCES

• Pork and pork products (including gelatin) are forbidden, as is shellfish. • Alcohol is not used, even in vanilla extract and other preparations. • Foods such as dates, seafood, honey, sweets, yogurt, milk (goat’s milk also), meat, and olive or vegetable oils are encouraged. Beef, chicken, and lamb are commonly used. Couscous, pita bread, rice, millet, and bulgur are frequently included. Eggplant, cucumbers, green peppers, pomegranates, and tomatoes are acceptable..

Aboul-Enein BH, Aboul-Enein FH. The cultural gap delivering health care services to Arab American populations in the United States. J Cult Divers. 2010; 17:20. Alrawi S et al. Traditional healing practices among American Muslims: perceptions of community leaders in southeast Michigan. J Immigr Minor Health. 2012;14:489. Bakhotmah BA. The puzzle of self-reported weight gain in a month of fasting (Ramadan) among a cohort of Saudi families in Jeddah, Western Saudi Arabia. Nutr J. 2011;10:84. Ghaly M. Milk banks through the lens of Muslim scholars: one text in two contexts. Bioethics. 2012;26:117. Inhorn MC, Serour GI. Islam, medicine, and Arab-Muslim refugee health in America after 9/11. Lancet. 2011;378:935.

Escott-Stump_Ch02.indd 97

11/7/14 2:13 AM

N U T RITIO N A ND D IA GNO SIS-RELA TED C A RE

OROFACIAL CONDITIONS

DENTAL AND ORAL DISORDERS NUTRITIONAL ACUITY RANKING: LEVEL 2–3

DEFINITIONS AND BACKGROUND Diet and nutrition affect many oral diseases. Cell turnover is rapid in the tongue and oral mucosa; therefore, the oral cavity is one of the first areas where signs of systemic disease appear. Proper nutrition is essential for good dental and oral health (Table 2-5). Two oral infectious diseases are primarily diet related: dental caries and periodontal disease. In dental caries, chronic infectious disease leads to progressive destruction of tooth substances from interactions between bacteria and organic tooth compounds. Streptococcus mutans and Lactobacillus form acids within 20 seconds to 30 minutes after contact. Those who are poor or have no dental insurance are at risk for caries. Many Americans lack fluoridated water, an effective safeguard. Water fluoridation can reduce caries by at least 25% (American Dental Association, 2014). Erosion of tooth enamel may occur in patients who chronically consume acidic beverages and/or keep such beverages or foods in the mouth for a period of time. This may include sucking lemons, chewing vitamin C tablets, even chewing lemon hard candy. Figure 2-7 shows the layers of a tooth. Health professionals should check the oral and dental health of their patients. From the NHANES Survey data, 2005 to 2008,

over 20% of people had untreated dental caries and 75% had existing dental restorations (Dye et al, 2012). Some dental problems are age specific. Infants should be monitored for early childhood caries (ECC). Caries are significantly more prevalent among non-Hispanic black and Mexican American children than among non-Hispanic white children (Tomar and Reeves, 2009). Dental decay often occurs during the growth spurts of adolescence. Older patients should be monitored for changes in eating habits, inadequate diet, and caries. Dental caries during childhood is largely preventable but remains a significant and costly public health concern; it is the most prevalent chronic disease of childhood (de Silva-Sanigorski et al, 2011). The key environmental factor is fermentable carbohydrate (Al-Dajani and Limeback, 2012). ECC can be rapid, progressive, and debilitating and may even lead to eventual obesity (de Silva-Sanigorski et al, 2011). Tooth loss is related to a lack of public dental health policies and programs, and a low level of oral health knowledge (De Marchi etal, 2012). According to NHANES data, almost 23% of adults aged 65 and over are edentulous (Dye et al, 2012). Tooth loss can prevent proper bite and may lessen the ability to chew foods properly. Problems with chewing, swallowing, and mouth pain often precede hospitalizations. Individuals who wear dentures may be more prone to malnutrition. Dietary advice should be offered when dentures are placed to improve consumption of fruits and vegetables.

TABLE 2-5 Nutrients Needed for Proper Oral Tissue Synthesis and Dental Care NUTRIENT

EFFECT ON HEALTH

Protein

Needed for healthy tissue growth and maintenance.

Vitamin A

Necessary for epithelial tissue and enamel. Beta-carotene may play a role in oral cancer prevention.

Vitamin B-complex

Deficiencies show a bright scarlet tongue and stomatitis in niacin deficiency; magenta tongue, glossitis, and angular cheilitis in riboflavin deficiency; smooth tongue in vitamin B12 deficiency.

Folate

Needed for a healthy blood supply.

Vitamin C

Enables connective tissue cells to elaborate intercellular substances. Deficiency can lead to easy bleeding or swelling of gums and gingivitis. Forms collagen; helps to heal wounds and bleeding gums.

Vitamin K

Aids with calcium absorption in bone; adequate blood clotting; helps in healing.

Vitamin D

Protects against chronic inflammation of the gums, which can lead to gingivitis or periodontal disease. Necessary for dentin, bony tissue synthesis; mineralization; and jawbone sufficiency.

Calcium and phosphorus

Necessary for dentin and bony tissue synthesis. Poor mineralization occurs with deficiency. Maintains jawbone sufficiency.

Chromium

Needed for proper glucose metabolism. Controlled intake of carbohydrates helps to maintain healthier gums and overall health status.

Copper

Needed for production of blood and nerve fibers.

Fluoride

Consumption of fluoridated water coupled with a reduction in nonmilk sugar intake is an effective means of caries prevention. Keeps bones healthy. Drinking water should contain 1 ppm; toothpaste, mouth rinses, and topical treatments also help.

Iron

Helps produce red blood cells; promotes resistance to disease; improves health of the teeth, skin, and bones. Maintains energy.

Magnesium

Helps in bone development. Enhances use of vitamin C. Deficiency may lead to calcium resorption.

Potassium

Needed for muscle contraction and proper nerve function.

Zinc

Regulates the inflammatory process; aids in wound healing. Deficiencies can lead to poor healing, susceptibility to infection, loss of taste, and altered metabolism.

For more information, see World Health Organization. Risks to oral health. Available at: http://www.who.int/oral_health/action/risks/en/index.html. Accessed June 17, 2014.

Escott-Stump_Ch02.indd 98

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SCE L L AN E OUS CON DI T I ON S

Enamel Dentin

• Taste alterations • Sore or bleeding gums • High intake of sugars and sticky starches

Lab Work

Gums

Nerve

Root

• • • • • • • •

Alb, transthyretin Serum Na⫹, K⫹ Ca⫹⫹, Mg⫹⫹ ALP H&H, serum Fe X-rays (mandible) Serum folate Serum ascorbate and retinol

Bone

INTERVENTION Figure 2-7. The layers of a tooth. (Reprinted with permission from Anatomical Chart Company. Blueprint for health: your digestive system.)

Sore mouth can significantly decrease intake. Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration in healthy individuals (Brocklehurst et al, 2012). With tongue disorders, mastication of food may be affected. The ability to push mashed food with the tongue and anterior hard palate will be affected. Other oral problems may cause pain, problems with chewing, dysphagia, mouth dryness, or infection. Altered immunity and debility can occur as a result of cancer or HIV infection. Dry mouth can be a side effect of medical conditions, including Alzheimer’s disease, diabetes, anemia, cystic fibrosis, rheumatoid arthritis, Sjögren syndrome, hypertension, Parkinson’s disease, and stroke. Fracture of the lower jaw (mandible) requires intermaxillary fixation (wiring). Patients with wired jaws face eating challenges for up to 6 weeks following surgery. Patients have to eat liquefied meals; proper presurgical patient education is essential. Dietetics practitioners and oral health care professionals must screen, educate, and refer appropriately as part of comprehensive patient care (Touger-Decker and Mobley, 2013). Less than one-third of dental students feel competent to discuss the relationship of nutrition and systemic disease with their patients (Akabas et al, 2012). Table 2-6 lists many dental problems, treatment, and prevention issues that can be discussed.

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • • • • •

Height Weight BMI Recent weight changes Diet history Mouth, gum or tongue lacerations Dental caries Missing or loose teeth Dentures, loose or ill-fitting

Escott-Stump_Ch02.indd 99

Objectives Broken or Wired Jaw • Provide adequate nourishment to allow healing while reducing jaw movement. • Decrease complications such as fever, nausea, and vomiting. • Prevent excessive weight loss; up to 10% is common. • Maintain a patent airway. Dental Caries • Alter dietary habits. • Deprive bacteria of substrate; reduce acid by keeping pH at 7.0. • Maintain frequent fluoride contact with tooth surfaces as directed by a dental professional. Early Childhood Caries (ECC) • Because the enamel erodes, tooth surfaces are permanently damaged from long exposure to liquid carbohydrate sources. • ECC is increased by specific eating behaviors; dietary guidance for parents regarding sugar sweetened beverage (SSB) consumption could help reduce severe ECC prevalence (Evans et al, 2013). • Refer to a dentist when children are at risk for caries. Risks include inadequate home dental care, poor oral hygiene, a mother with a high number of cavities, a high sugar intake, enamel defects, premature birth, and special health care needs. • Monitor growth. ECC significantly increases the likelihood of poor growth, development, and social outcomes (de Silva-Sanigorski et al, 2011). Edentulism • Provide proper consistency to allow the patient to eat. • Monitor for nutrient deficiencies. Edentulousness leads to the avoidance of many types of foods; malnutrition is common (Cousson et al, 2012). • Improve quality of life. Extensive tooth loss or edentulism has a negative impact on the quality of life of older adults (DeMarchi et al, 2012). Mouth Ulcers (Aphthous Stomatitis) • Lessen mouth soreness to increase dietary intake; mouth sprays may be available to lessen pain while eating. • Promote healing for a return to normal eating patterns.

11/7/14 2:13 AM

100

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-6 Dental Problems, Treatment, and Prevention SYMPTOMS

LIKELY CAUSE

TREATMENT

PREVENTION

Food caught around and between teeth; infection in gums; improper brushing; sinusitis; digestive problems, such as preulcerative conditions; diabetes

Practice good oral hygiene, including rinsing with mouthwash; brush tongue often; see dentist to evaluate throat, sinuses, tongue, and possible gum infection, and professionally clean teeth and gums; review diet

Regular dental visits; flossing, brushing, and rinsing; good nutrition

Accidental trauma; decay; weak tooth from grinding or improper bite

Do not irritate; place piece of soft dental wax from drugstore over cracked or fractured tooth; see a dentist immediately

Regular dental checkups to discover possible weak teeth, decay, or large, unstable fillings

Bacterial or viral infection; trauma from denture in mouth; stress

Use over-the-counter remedies recommended by the dentist; coat lesions after meals; see dentist to make sure there is no infection or for additional medication if pain persists; the dentist will evaluate dentures for weight-bearing points to be certain the problem does not exist there

Avoid irritating the area; avoid spicy, acidic foods while mouth is sore

Tooth decay; initial eruption of tooth through the gums or fractured tooth; tooth nerve damage

Rinse with salt water solution; use mouthwash; avoid eating on or near tooth; see dentist immediately; may require antibiotics or root canal treatment to prevent spread of infection

Regular dental checkups; good oral hygiene; brushing, flossing, and rinsing

Surface stain from certain foods, such as tea and coffee; internal staining from tooth nerve damage or from rheumatic fever; stains from tetracycline

Improve oral hygiene; brush frequently; diminish coffee or tea intake; rinse with peroxide; consult dentist to check nerve in darkened tooth; consider supervised tooth bleaching/whitening

Good oral hygiene; avoid foods and liquids that can stain teeth, such as tea and coffee

Food debris between teeth; tartar beneath gums; infection; poor bite may worsen this condition

Improve oral hygiene by brushing often and flossing; rinse with mouthwash; consult dentist to evaluate extent of condition; treatment by removing plaque and tartar may require surgery and/or bite adjustment

Good oral hygiene; regular dental checkups and cleanings

Mouth breathing; some medications, such as antihistamines, blood pressure medications, and antidepressants decrease salivary flow

Use oral salivary rinses and toothpastes for dry mouth; improve oral hygiene; consult dentist because this condition can lead to tooth decay, advanced gum disease, or other mouth infections

Ask physician if medications can be changed; consult dentist about obtaining oral rinses and a snoreguard

Gum disease; tooth grinding; orthodontic appliances too tight; cyst, tumor, abscess, or trauma to teeth

See dentist as soon as possible to determine cause; practice good oral hygiene; be aware of tooth grinding or clenching and use appliance to prevent grinding

Regular dental visits; good oral hygiene; have your dentist evaluate your bite; use a bite appliance if your dentist advises

Cold/flu; tooth abscess or infection; tumor

Treat cold/flu symptoms; limit neck movement; check temperature; take pain relievers such as aspirin; see a dentist if symptoms persist to evaluate the extent of swelling and infection

Regular dental checkups; patients should pay special attention to any growth or changes in the head or neck

Bad Breath Odor from mouth; bad, metallic taste; coated tongue

Broken Tooth or Filling Tooth feels sharp; tooth sensitivity to temperature and pressure

Canker Sores Painful red circular area that develops on the tongue, gums, lips, or cheeks; in certain phases, sores have a yellow or white center area; sore to touch; sensitivity to spicy, salty foods

Dental Abscess (swelling around tooth or cheek) Pain, throbbing in gum or tooth; swelling; sensitive bite; loose teeth; sensitivity to heat

Discolored Teeth Teeth have unsightly and discolored appearance; single tooth begins to turn yellow or gray

Gum Disease Gum pain; nonthrobbing ache; swelling; gum bleeding; blood in saliva when brushing; metallic taste

Red Inflamed Gums Color of gums around teeth progresses from pink to red with swelling or puffiness; dry mouth; snoring

Loose Teeth Teeth move; spongy feel to bite; teeth sensitive or even painful when chewing

Lumps Under Jaw or Neck Muscle Neck sore to touch or movement; swelling in neck; sore throat; difficulty swallowing

Escott-Stump_Ch02.indd 100

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

101

TABLE 2-6 Dental Problems, Treatment, and Prevention (continued) SYMPTOMS

LIKELY CAUSE

TREATMENT

PREVENTION

Rinse mouth often with vanilla extract to soothe discomfort; avoid chewing on tooth; see a dentist as soon as possible to determine cause and further treatment

Regular dental visits for prevention; the sooner examined, the better the chance of success

Use desensitizing toothpaste on a daily basis; use a soft bristle brush; avoid temperature differences; consult dentist for appropriate treatment

Good oral hygiene; apply fluoride gel; use desensitizing toothpaste; avoid food temperature differences; avoid hard bristle toothbrushes; become aware of and avoid tooth grinding or squeezing teeth together; have fillings bonded to seal areas of sensitivity; dentist may recommend a biteguard for grinding

Toothache (tooth pain on biting or chewing) Tooth pain related to temperature change or touch or from chewing or biting; dark brown spots on teeth may indicate new decay

Bacterial acids; large filling broken out of tooth; tooth grinding

Tooth Sensitivity to Temperature Change Breathing outside in cold air causes pain; waking up with toothache; pain when eating/drinking cold things

Inflamed gums; gum recession that exposes root surfaces; tooth decay; teeth clenching or grinding that has worn away tooth enamel

Adapted from Rhode Island Dental Association, 200 Centerville Road, Warwick, RI 02886; Phone: (401) 732-6833. Website accessed March 17, 2013, at http://www.ridental.com/dentalproblems.cfm. Used with permission.

• Prevent weight loss or other consequences. RAS can cause significant difficulties in eating and drinking (Brocklehurst et al, 2012). Tongue Disorders • Provide adequate nourishment despite acute or chronic disability. Tube Feeding • Children on tube feedings often have dental problems; attend to oral hygiene more carefully than for those fed orally. • Adults will require special attention to oral hygiene and mouth care while on tube feedings. Xerostomia (Dry Mouth) • Suggest use of artificial saliva. Check for swallowing difficulties and reduced oral intake. • Promote good oral hygiene to prevent dental decay.

Food and Nutrition Broken or Wired Jaw • Pureed or strained foods and high protein/calorie liquids are necessary. Use high-energy supplemental beverages (perhaps 2 kcal/mL). Double-strength milk may also be used to keep protein intake at a high level. • Take adequate amounts of vitamin C for healing. • Monitor food temperatures carefully; extremes may not be tolerated. • Six to eight meals are usually needed. • Follow meals with salt water rinse. Dental Caries—Prevention • Decrease sucrose and cooked or sticky starches as well as the frequency of snacking and duration of exposure time. • Use a balanced diet, avoid eating sweets or starches with meals. • Fluoride exposure should be adequate, including from water supplies. • The sequence, combination, and form of foods and beverages consumed must be monitored carefully.

Escott-Stump_Ch02.indd 101

Early Childhood Caries (ECC)—Prevention • Do not allow a child to fall asleep with a bottle containing milk, formula, fruit juices, or other sweet liquids. • Never let a child walk around with a bottle in his/her mouth. • Never put an infant or child to bed with a bottle filled with SSBs, including fruit juice or Kool-Aid. • Comfort a child who wants a bottle between regular feedings or during naps with a bottle filled with cool water. • Always make sure a child’s pacifier is clean. Never dip a pacifier in a sweet liquid. • Introduce children to a cup as they approach 1 year of age. Children should stop drinking from a bottle soon after their first birthday. • Notify the parent of any unusual red or swollen areas in a child’s mouth or any dark spot on a child’s tooth so that the parent can consult the child’s dentist. • Maintain good oral hygiene. • Monitor for iron deficiency anemia, which is common. Edentulism • Offer texture changes, such as a chopped, ground, strained, or pureed diet. Use the least restricted diet and progress as tolerated. • Identify potential solutions such as obtaining new dentures or repairing current dentures. Mouth Ulcers or Pain • Low-acid and nonspicy foods should be consumed. Avoid citrus juices, vinegar, and other acidic foods. • Include vitamin C–rich foods, protein, and calories to speed healing. • Small, frequent meals and oral supplements may be beneficial to prevent weight loss. • Moist or blenderized foods with additional liquid are helpful. • Soft, cold foods such as canned fruits, ice cream, popsicles, yogurt, cottage cheese, or cold pasta dishes may be used. • Use of a straw may be helpful. • Cut or grind meats or vegetables. • Extra butter, mild sauces, and gravies may be needed. • Follow meals by brushing teeth to reduce possibility of dental caries.

11/7/14 2:13 AM

102

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Tongue Disorders • If the patient is unable to chew, tube feeding should be considered. • Liquids may be added to the diet as tolerated. Many foods are tolerated if liquefied and blenderized. Tube Feeding • Good oral hygiene and mouth care will be needed, even if a patient is not fed by mouth. Tube feeding should include all key nutrients to meet patient need (see Section 17, Enteral and Parenteral Nutrition Therapy). Xerostomia • Moisten foods, adding water or milk when possible. Use sauces or gravies if needed. • Avoid excessive spices. • Avoid excessively chewy foods, crumbly foods, dry foods, or sticky foods. Examples include steak, nuts, popcorn, cake, soft candy, and peanut butter.

• Avoid cariogenic foods such as dried fruits, candy, cookies, pies, cakes, ice cream, canned fruit, soft drinks, fruit drinks, lemonade, gelatin desserts, snack crackers, pretzels or chips, and muffins. • Brush teeth or eat cheese after meals and sugary snacks to normalize pH. • Regular use of fluoride can help reduce the incidence of root caries (Richards, 2009). Health care professionals need to provide information about optimal fluoride exposure (Gussy et al, 2008). Only 27 states provide an adequate amount of fluoridation in the public water supply (Palmer and Gilbert, 2012). Patient Education—Food Safety • When traveling, avoid ice made from tap water. Airline water may not be free from contamination. • Use of bottled water is recommended for brushing teeth in countries where water is not safe.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Dietary fluoride supplements should be prescribed only for children who are at high risk of developing caries and whose primary source of drinking water is deficient in fluoride (Rozier et al, 2010). Luride is one such fluoride supplement. Avoid use with calcium or dairy products as it forms a nonabsorbable product. • For patients with cancer, various therapies affect the mouth and gums. Monitor closely. Herbs, Botanicals, and Supplements • Herbs and botanicals may be used; identify and monitor side effects. • Counsel about use of herbal teas, especially unsuitable products such as comfrey tea.

Nutrition Education, Counseling, CareManagement • If needed for oral or dental problems, blended foods and/or tube feedings should be prepared. Sometimes, using a bulb syringe to feed may be useful. • Provide creative ideas for the seasoning and flavoring of foods. Discuss acceptable restaurant options for persons who are at home. • Ensure that fluoride is provided in some way by the diet, water supply, or dental office. • Read milk labels to ensure vitamin D fortification. • Dental status is an especially important part of assessment and care for the elderly. Health disparities are common in many ethnic groups of seniors (Wu et al, 2011). • Integrate dietary counseling into the dental setting. To Prevent Caries • Encourage good habits in oral hygiene and diet: Detergent foods (raw fruits and vegetables) should be recommended rather than sticky or impactant foods (soft cookies, bread, sticky sweets, dried fruits). • Cariostatic foods should be encouraged, such as cheese, raw fruits and vegetables, peanuts, and cocoa. While dietary change has been demonstrated to reduce Streptococcus mutans, a preventive role is expected for “functional foods” and dietary habit alterations in the future (Al-Dajani and Limeback, 2012).

Escott-Stump_Ch02.indd 102

SAMPLE NUTRITION CARE PROCESS STEPS Chewing Difficulty Assessment Data (sources of info): Food records and intake calculations; dental evaluation for loose dentures; weight changes. Nutrition Diagnosis: Chewing difficulty related to inability to chew foods from poor dentition as evidenced by weight loss of 2 lb in 14 days and ill-fitting dentures. Interventions: Food and Nutrient Delivery • Modify current diet to puree foods until otherwise noted from dentist/physician. • Continue with shakes twice a day to enhance energy intake. • Recommend dental referral for dentures. Monitoring and Evaluation:Intake records, reduction in chewing problems, improved weight after fitting of new dentures.

Inadequate Energy Intake—Early Childhood Caries Assessment Data (sources of info): Food records (high intake of juice, sweetened beverages throughout the day from the bottle); intake calculations; dental evaluation for ECC; weight loss from inability to chew solids and refusal to drink from a cup. Nutrition Diagnosis:Inadequate energy intake related to inability to chew foods as evidenced by early childhood dental caries with poor weight gain. Interventions • Goals: Wean from bottle completely. Increase solid food intake and decrease fluids, especially sweetened fluids. Follow a weight gain of at least 0.6 oz/ wk, 2.7oz/mo, or 1 lb/6 mo. Educate parents on importance of healthy oral hygiene and not allowing child to carry liquids around during day or fall asleep with liquids.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

• Food and Nutrient Delivery: Provide general/healthful diet, provide information on weaning from the bottle, educate on importance of oral hygiene, increase intake of water, decrease intake of juice to a maximum of 4 oz/d diluted with water, eliminate other sweet drinks, and alter diet to reduce need to chew (puree, mash, or chop foods). • Nutrition Education: Provide information on weaning, calorie boosters, importance of oral hygiene, and limiting sweetened beverages. Dentist to perform oral surgery for removal of dental caries to decrease pain and increase intake of solid foods for weight gain. RD to continue to monitor weight gain and food intake. • Counseling: Counsel patient’s caregiver(s) on supporting each other through weaning and the importance of good oral hygiene. • Coordination of Care: Collaborate with physician and dentist on patient’s care through oral surgery and monitoring weight status. Monitoring and Evaluation:Intake records, reduction in chewing problems, improved weight, and health status.

For More Information

See the videos “Assessing the Mouth and Throat,” “Chewing,” and “How to Insert a Denture,” at www.thepoint.lww.com /escottstump8e.

●

American Academy of General Dentistry http://www.agd.org/

●

American Academy of Pediatric Dentistry http://www.aapd.org/

●

American Academy of Periodontology http://www.perio.org/

●

American Dental Association http://www.ada.org/

●

International Association for Disability and Oral Health http://www.iadh.org/

●

Medline—Dental Health http://www.nlm.nih.gov/medlineplus/dentalhealth.html

●

National Institute of Dental and Craniofacial Research (NIDCR) http://www.nidcr.nih.gov/

●

Oral Health America http://www.oralhealthamerica.org/

103

REFERENCES Akabas SR, et al. Nutrition and physical activity in health promotion and disease prevention: potential role for the dental profession. Dent Clin North Am. 2012;56:791. Al-Dajani M, Limeback H. Emerging science in the dietary control and prevention of dental caries. J Calif Dent Assoc. 2012;40:799. American Dental Association, http://www.ada.org/en/public-programs/advocating -for-the-public/fluoride-and-fluoridation. Website accessed August 3, 2014. Brocklehurst P, et al. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012 Sep 12;9:CD005411. Cousson PY, et al. Nutritional status, dietary intake and oral quality of life in elderly complete denture wearers. Gerodontology. 2012;29:e685. De Marchi RJ, et al. Vulnerability and the psychosocial aspects of tooth loss in old age: a Southern Brazilian study. J Cross Cult Gerontol. 2012;27:239. de Silva-Sanigorski AM, et al. Splash!: a prospective birth cohort study of the impact of environmental, social and family-level influences on child oral health and obesity related risk factors and outcomes. BMC Public Health. 2011;11:505. Dye BA, et al. Selected oral health indicators in the United States, 2005-2008. NCHS Data Brief. 2012;96:1. Evans EW, et al. Dietary intake and severe early childhood caries in low-income, young children. J Acad Nutr Diet. 2013;113:1057. Gussy MG, et al. Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural Victoria. Aust Dent J. 2008;53:52. Palmer CA, Gilbert JA. Position of the Academy of Nutrition and Dietetics: Theimpact of fluoride on health. J Acad Nutr Diet. 2012;112:1443. Richards D. Fluoride has a beneficial effect on root caries. Evid Based Dent. 2009;10:12. Rozier RG, et al. Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2010;141:1480. Tomar SL, Reeves AF. Changes in the oral health of US children and adolescents and dental public health infrastructure since the release of the Healthy People 2010 Objectives. Acad Pediatr. 2009;9:388. Touger-Decker R, Mobley C. Position of the Academy of Nutrition and Dietetics: oral health and nutrition. J Acad Nutr Diet. 2013;113:693. Wu B, et al. Oral health among white, black, and Mexican-American elders: an examination of edentulism and dental caries. J Public Health Dent. 2011; 71:308.

PERIODONTAL DISEASE AND GINGIVITIS NUTRITIONAL ACUITY RANKING: LEVEL 1–2 DEFINITIONS AND BACKGROUND Tissues that support teeth in the jaws are collectively known as the periodontium (gums, alveolar bone, periodontal membrane). Any abnormality that leads to a visible change or loss of integrity of any component of the supporting tissue is a periodontal disease. Gingivitis involves minor inflammatory changes in the gums; it may be acute or chronic, local or generalized. Acute necrotizing ulcerative gingivitis (Vincent disease or trench mouth) is an

Escott-Stump_Ch02.indd 103

acute ulceration affecting marginal gingiva with inflamed or necrotic interdental papillae. The onset is abrupt and painful with slight fever, malaise, excess salivation, and bad breath. It can be caused by systemic disease. Periodontoclasia involves destruction of tissues around the teeth. A poor diet and inadequate dental hygiene can cause destruction of the jawbone. Periodontal disease is a painless, chronic inflammatory disease that most commonly manifests as pyorrhea alveolaris. It involves a gross breakdown of supporting tissues with progressive loosening and loss of teeth inflammatory disease

11/7/14 2:13 AM

104

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Periodontal Disease

ASSESSMENT, MONITORING, AND EVALUATION

Diabetes increases the risk of gum disease and mouth infections. This can make blood glucose levels rise, which in turn can make mouth infections worse.

Clinical/History • • • • • • • • • •

Height Weight BMI Diet history Gums—color, friability, receding Oral examination for tooth mobility, calculus Sore mouth Overall nutritional status History of smoking, alcohol use Diabetes, other chronic diseases

Lab Work

Figure 2-8. Periodontal disease, a common problem in diabetes. (Reprinted with permission from Anatomical Chart Company. Understanding diabetes, 2nd ed.)

initiated by oral microbial biofilm (Van Dyke, 2008). Periodontal disease often starts in the second decade; wisdom teeth are a breeding ground for bacteria. Children and teens are also at risk if their oral and dental health needs are not addressed. In the United States, periodontal disease affects a large portion of the population. While inequalities in the treatment of periodontal disease have significantly decreased in the United States, careful monitoring is still needed (Borrell and Talih, 2012). Periodontal disease often presents during pregnancy (Babalola and Omole, 2011). In addition, those at risk include menopausal women, obese individuals, alcoholics, smokers, persons with AIDS or rheumatoid arthritis, persons with respiratory ailments or diabetes (see Fig. 2-8), and those taking heart medicines, antidepressants, and antihistamines. Nutrient deficiencies are also prevalent. Smokers are especially vulnerable to vitamin C deficiency. Immune-enhancing nutrients for good oral health include protein, zinc, vitamins C and E, calcium, and the B-complex vitamins. Periodontal disease may precede bacterial pneumonia, so treatment is important. Evidence-based periodontology includes antimicrobial therapy, regenerative periodontal surgery, periodontal plastic surgery, bone regeneration surgery, and implant treatment.

• • • • • • • •

Serum glucose Serum Na⫹, K⫹ Ca⫹⫹, Mg⫹⫹ Serum ascorbic acid H&H, serum Fe Alb, transthyretin CRP Serum vitamin D

INTERVENTION Objectives • Reduce inflammation and promote healing. • Correct poor nutritional habits that can lead to chronic subclinical deficiencies in levels of vitamins A, C, D, amino acids, riboflavin, folacin, zinc, and calcium. Protect the jawbone with adequate calcium and vitamin D, especially in postmenopausal women. • Review medications. Consider alternatives to those causing mouth or gum problems. • Pregnant women with this condition are at risk for preterm birth and other adverse obstetric outcomes, such as preeclampsia and low birth weight. They should be closely monitored with prenatal medical and dental care. • Prevent further decline in status of bone and gums.

Food and Nutrition

HOT TOPIC Inflammation Osteoporosis and inflammation-associated bone degradation in periodontitis have a common pathogenesis. Low systemic bone-mineral density occurs in alveolar bone, and people with osteoporosis may have an increased risk of tooth loss (Stewart and Hanning, 2012). Periodontal disease is usually evident approximately 10years before osteoporosis.

Escott-Stump_Ch02.indd 104

• Ensure adequate intake of calcium, protein, zinc, phosphorus, vitamin C, fluoride, and vitamin A. Vitamin D–fortified milk and a multivitamin–mineral supplement should be used. • Use high-detergent foods (firm, fresh fruits and raw vegetables or those that are lightly cooked). Include cranberries, blueberries, green tea, and other foods rich in antioxidants and polyphenols (Kushiyama et al, 2009). • Control timing and frequency of meals and snacks to reduce exposure of susceptible gum tissue and teeth to the acids that form plaque. Control blood glucose in diabetes. • Promote a diet containing foods naturally rich in antioxidants and omega-3 polyunsaturated fatty acids (DHA, EPA), and low in refined carbohydrates (Chapple, 2009). When possible, encourage intake of whole fruits instead of

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

fruit juices for more fiber and 35% less sugar (Crowe and Murray, 2013).

SAMPLE NUTRITION CARE PROCESS STEPS

Food–Drug Interactions

Inadequate Oral Food and Beverage Intake— Periodontal Disease

Common Drugs Used and Potential Side Effects • Gingival enlargement is commonly caused by phenytoin (Dilantin) taken by epileptic patients; calcium channel blockers such as nifedipine (Procardia) and verapamil (Calan) for the treatment of hypertension, arrhythmia, and angina; immunosuppressive agents such as cyclosporine (Livada and Shiloah, 2012). • Sodium bicarbonate may be used as a mouthwash. Patients with high BP should not swallow this wash. • Peridex is an oral rinse to control bleeding gums. Taste changes may occur with its use. • Antibiotic treatment of periodontitis includes amoxicillin/ clavulanic acid, metronidazole, and clindamycin. Nonsteroidal anti-inflammatory agents may also be used such as ibuprofen. Herbs, Botanicals, and Supplements • Herbs and botanicals may be used; identify and monitor side effects. Counsel about use of herbal teas, especially those containing toxic substances. • For gingivitis, bloodroot, echinacea, purslane, chamomile, licorice, and sage have been recommended but not confirmed for efficacy. • Chronic marijuana use may result in gingival enlargement (Rawal et al, 2012). • A “Connective Tissue Nutrient Formula” that contains vitamins A, C, and D, glucosamine sulfate, magnesium, oligoproanthocyanidins, copper, zinc, manganese, boron, silicon, and calcium may enhance tissue integrity. • Naturopathic physicians may prescribe Panax ginseng, Withania somnifera, and Eleutherococcus senticosus to reverse the impact of bacterial and psychosocial stressors.

Nutrition Education, Counseling, CareManagement • Encourage a proper diet, especially food sources of omega-3 fatty acids, calcium, and vitamins C and D. • Recommend meticulous oral hygiene and regular dental examinations. Systemic inflammation and poor oral hygiene may be present in both obesity and gingivitis. • Encourage pregnant women and persons with dentures, diabetes, cancer, HIV/AIDS, rheumatoid arthritis, or leukemia to pay special attention to oral hygiene. Mothers’ oral health status is a strong predictor of the oral health status of their children (Dye et al, 2011). • For individuals with diabetes, regular dental care is important along with maintenance of glycemic control. • Brush often and floss after eating sticky foods such as candy, sticky buns, and fruit rolls. Drink lots of water. Cut out SSBs. Consume polyphenols and antioxidant-rich foods, including green tea (Kushiyama et al, 2009).

Escott-Stump_Ch02.indd 105

105

Assessment Data (sources of info): Food records and intake calculations; dental evaluation. Nutrition Diagnosis:Inadequate oral food and beverage intake related to sore and inflamed gums as evidenced by diet history revealing low use of antioxidant foods and vitamin C from fruits and vegetables; weight loss of 5 lb in past month; and diagnosis of periodontal disease. Intervention: Education about the role of diet and oral hygiene in periodontal disease. Recommend nutrient and dietary changes to improve quality of food intake, reduce inflammation, and promote healing. Monitoring and Evaluation:Intake records, rate of healing of gum disease.

Patient Education—Food Safety • Periodontitis involves host-mediated inflammation, with modulation of inflammation at a cellular and molecular level. Avoidance of infection will be needed, related to food handling and sanitation. For More Information ●

American Academy of Periodontology http://www.perio.org/

REFERENCES Babalola DA, Omole F. Periodontal disease and pregnancy outcomes. J Pregnancy. 2010;2010:293439. Borrell LN, Talih M. Examining periodontal disease disparities among U.S. adults 20 years of age and older: NHANES III (1988-1994) and NHANES 1999-2004. Public Health Rep. 2012;127:497. Chapple IL. Potential mechanisms underpinning the nutritional modulation of periodontal inflammation. J Am Dent Assoc. 2009;140:178. Crowe KM, Murray E. Deconstructing a fruit serving: comparing the antioxidant density of select whole fruit and 100% fruit juices. J Acad Nutr Diet. 2013;113:1354. Dye BA, et al. Assessing the relationship between children’s oral health status and that of their mothers. J Am Dent Assoc. 2011;142:173. Kushiyama M, et al. Relationship between intake of green tea and periodontal disease. J Periodontol. 2009;80:372. Livada R, Shiloah J. Gummy smile: could it be genetic? Hereditary gingival fibromatosis. J Mich Dent Assoc. 2012;94:40. Rawal SY, et al. Periodontal and oral manifestations of marijuana use. J Tenn Dent Assoc. 2012;92:26. Stewart S, Hanning R. Building osteoporosis prevention into dental practice. JCan Dent Assoc. 2012;78:c29. Van Dyke TE. The management of inflammation in periodontal disease. JPeriodontol. 2008;79:1601.

11/7/14 2:13 AM

106

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TEMPOROMANDIBULAR JOINT DYSFUNCTION NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND The temporomandibular joint (TMJ) is a diarthrodial joint with moving elements (mandible) and fixed elements (temporal bone). TMJ disorders result from local or systemic inflammatory causes, such as rheumatoid or osteoarthritis and connective tissue disorders. The TMJ undergoes degenerative changes among patients who suffer from arthritis; sustained inflammation in the TMJ induces structural abnormalities (Wang et al, 2012). With this dysfunction, overuse or abuse of any part of normal action affects the mastication process. Patients with TMJ dysfunction have toothaches, facial pain, and food intake problems. The National Institute of Dental and Craniofacial Research (2009) indicates that over 10 million people in the United States suffer from TMJ problems at any given time. Women between the ages of 30 and 60 years account for 75% of all cases. Mandibular deviation may occur from repetitive overloading (stress or habit such as gum chewing, grinding), from functional masseter muscle coordination problems, or from incorrect occlusion (as with missing teeth). Undue muscle tension causes most TMJ, with some other problems stemming from inadequate bite (as from a high filling or a malocclusion). People with TMJ benefit from a visit to their dentist or ear, nose, and throat specialist. Structural problems are treated by surgery (e.g., fusion can be treated by removing the area of fused bone and replacing it with silicone rubber). Sometimes, an artificial joint is the answer; but surgery is recommended for only a few patients. Low-level laser therapy (LLLT) is now an option for some patients.

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • • • • • • •

Height Weight BMI Diet history Stiff neck, face, or shoulders Locking of affected joint Trismus Gum status Mouth/jaw pain or clicking noise Headaches Shoulder or neck pain

Lab Work • Gluc • Serum Na⫹, K⫹ • Ca⫹⫹, Mg⫹⫹

Escott-Stump_Ch02.indd 106

• • • • •

H&H, serum Fe Chol, Trig Alb CRP Serum vitamin D

INTERVENTION Objectives • Reduce repetitive overloading by use of a splint or by breaking bad habits such as grinding (bruxism). • Reduce stress with relaxation techniques. Relieve pain and muscle spasms. • Prevent or correct malnutrition or weight loss. • Ensure adequate intake of soft, nonchewy sources of fiber. • Reduce any existing inflammation and prevent complications such as mitral valve prolapse.

Food and Nutrition • Use a normal diet with soft foods to prevent pain while chewing. • Cut food into small, bite-sized pieces. Avoid chewy foods such as caramel, nuts, toffee, chewy candies, and gummy bread and rolls. • Avoid opening mouth widely, as for large and thick sandwiches. Grate vegetables (e.g., carrots) to reduce need for chewing. • Use adequate sources of vitamin C for adequate gingival health. • Suggest foods rich in antioxidants, such as green tea, to promote health.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Pain medicines may be needed when the condition is active. Monitor side effects for the specific drugs used. Herbs, Botanicals, and Supplements • Herbs and botanicals may be used; identify and monitor side effects. Counsel about use of herbal teas, especially avoiding toxic ingredients.

Nutrition Education, Counseling, CareManagement • Discuss the role of dental care in maintaining adequate health. • Monitor for any tooth or gum soreness; advise the dentist as necessary. Regular oral hygiene must be continued despite mouth pain. • Physical therapy may be needed to correct functioning of muscles and joints. • Nail biting, gum chewing, use of teeth to cut thread, or similar habits should be stopped.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

• Smoking is often a cause of bruxism, and programs to stop smoking should be considered if needed. • Internet sites concerning TMJ are not well organized or maintained (Park et al, 2012). Evaluate resources carefully.

For More Information

See the video “Loads on the TMJ During Chewing” at www.thepoint.lww.com /escottstump8e.

Patient Education—Food Safety • Use general safe food handling measures.

SAMPLE NUTRITION CARE PROCESS STEPS Chewing Problems Assessment Data:Food records and intake calculations; dental evaluation; pain when chewing. Nutrition Diagnosis: Chewing problems related to TMJ and pain when eating as evidenced by diet history. Intervention: Education about soft foods and liquids of high nutrient density. Recommend individualized dietary changes to improve intake and prevent weight loss. Monitoring and Evaluation:Intake records, reduction in TMJ pain, improved intake from nutrient-dense foods.

107

●

Jaw Joints and Allied Musculoskeletal Disorders Foundation http://www.tmjoints.org/

●

TMJ Disorder http://www.tmj.org/

REFERENCES National Institute of Dental and Craniofacial Research. TMJ diseases and disorders. Available at: http://www.nidcr.nih.gov/OralHealth/Topics/TMJ/. Accessed June 16, 2014. Park MW et al. Quality and content of internet-based information on temporomandibular disorders. J Orofac Pain. 2012;26:296. Wang XD, et al. Sustained inflammation induces degeneration of the temporomandibular joint. J Dent Res. 2012;91:499.

SENSORY IMPAIRMENT

SENSORY IMPAIRMENTS: VISION, COORDINATION, CHEWING, AND HEARING NUTRITIONAL ACUITY RANKING: LEVEL 1

DEFINITIONS AND BACKGROUND Sensory impairments often decrease quality of life. Assessment of vision changes, self-feeding difficulty, hearing loss, incontinence, gait and balance, and cognition can reveal a great deal about an individual’s independence. Impairments affect physical and emotional health as well as social functioning. Self-feeding ability, an activity of daily living, can be limited by low vision or blindness, lack of coordination, and chewing problems. Where appropriate, these factors are mentioned in other sections. Dysphagia is described in Section 7, Gastrointestinal Disorders.

Age-related macular degeneration (AMD) is a vascular condition that damages the retina (Fig. 2-9). AMD affects 30 to 50 million individuals and is the leading cause of blindness in the elderly worldwide (Weikel et al, 2012). AMD and cataracts both increase dramatically after age 60 years. Children with

Altered Vision The World Health Organization defines low vision as visual acuity between 20/70 and 20/400 with the best possible correction, or a visual field of 20 degrees or less. Blindness is defined as a visual acuity worse than 20/400 with the best possible correction. Someone with a visual acuity of 20/70 can see at 20 feet what someone with normal sight can see at 70 feet. Someone with a visual acuity of 20/400 can see at 20 feet what someone with normal sight can see at 400 feet. Normal visual field is about 160 to 170 degrees horizontally.

Escott-Stump_Ch02.indd 107

Figure 2-9. Age-related macular degeneration. (Reprinted with permission from Chern KC, Saidel MA. Ophthalmology review manual. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.)

11/7/14 2:13 AM

108

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Eye Disease High blood glucose levels can affect blood vessels in the eyes. Over time, this can lead to vision loss or blindness.

Glaucoma Glaucoma, the buildup of fluid in the eye, causes increased pressure and can damage sight perception.

Cataracts A cataract is the clouding of the normally transparent lens of the eye, which results in fuzzy vision.

Diabetic Retinopathy When one of the arteries that supply blood to the retina becomes blocked, blood flow diminishes which can lead to blindness.

Figure 2-10. Eye diseases may lead to loss of vision. (Reprinted with permission from Anatomical Chart Company, Understanding diabetes. 2nd ed.)

developmental disabilities may also have cataracts or macular degeneration. The Age-Related Eye Disease Study (AREDS), sponsored by the National Eye Institute, found that taking high levels of antioxidants and zinc can reduce the risk of AMD by about 25%. The specific daily amounts are 500 mg vitamin C, 400 IU vitamin E, 15 mg beta-carotene, 80 mg zinc oxide, and 2 mg copper as cupric oxide to prevent copper deficiency anemia. Protective foods include nuts, fish, lycopene, lutein, and zeaxanthin (Ma et al, 2012). Lutein and zeaxanthin are carotenoids that have a role in filtering destructive blue light as photosensitive antioxidants. In addition to the AREDS supplement, a lower dietary glycemic index with higher intakes of DHA and EPA reduces progression to advanced AMD (Chiu et al, 2009). Diets high in saturated fat, animal fat, linoleic acid, and trans-fatty acids along with abdominal obesity, smoking, and diets high in glycemic index should be avoided. Women tend to have a higher risk than men. Smokers should not take beta-carotene supplements. Figure 2-10 depicts several other eye diseases that may lead to loss of vision. • Cataract causes clouding in the crystalline lens of the eye, causing opacity and less passage of light. Blindness occurs if not treated. Regular intake of antioxidant foods, including rich sources of vitamins A, C, E and selenium, can be protective. • Diabetic retinopathy is a major cause of vision loss. All individuals who have diabetes should have a dilated eye exam annually. Diabetic retinopathy affects as many as 80% of individuals who have had diabetes for 10 years or longer. Careful control of blood glucose and hypertension are important measures. Treatment often involves laser surgery. • Glaucoma is a neurodegenerative condition with damage to the optic nerve. Elevated intraocular pressure is one symptom. Primary open-angle glaucoma has a genetic origin but few symptoms. All adults should have a complete eye exam before age 40 years or sooner, with risk factors such as being African American or having a family history of open-angle glaucoma. Congenital glaucoma is caused by abnormal eye movement and is present at birth. Secondary

Escott-Stump_Ch02.indd 108

glaucoma can result from trauma, uveitis, or corticosteroid use. Acute angle-closure glaucoma involves a painful attack; it is a medical emergency with resulting blindness if not treated. Appropriate eye drops, and sometimes, surgery are needed. • Retinitis pigmentosa is a genetic eye disorder in which central and peripheral vision are lost. Cataracts may develop at an early age. Clinical trials are in progress to investigate new treatments including the use of omega-3 fatty acid DHA. • Hemianopia yields loss in half of the field of vision. Figure2-11 shows left-sided hemianopia caused by stroke or brain injury. • Quadrantanopia affects a quarter of the visual field. Vision loss may range from slight to severe. Patients will need guidance at mealtime as they may not see the full plate or tray of food. Vision restoration therapy and the brain’s ability to repair itself provide hope for recovery.

Figure 2-11. Left-sided hemianopia caused by stroke or brain injury. Patients see some areas in their visual field as black, grey, blurred, or distorted.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

109

Chewing, Taste Alterations, and Mouth Problems Chewing problems may cause an inability to consume enough food or foods of varying texture. Total edentulism contributes to deterioration in health. Without chewing, there is less production of saliva and food is not properly mixed before swallowing. Dry mouth (xerostomia), from a variety of causes, may interfere with chewing and swallowing. It should be corrected where possible. Canker sores are a common type of mouth ulcer in which a viral cause may be identified or an injury such as biting the cheek. They may also occur with fever, immune system or hormonal changes, menstruation, or food allergies. Sores will be yellow spots surrounded by bright redness and may take several weeks to heal. If they are frequently recurrent, a doctor may do a more thorough health screening. Oral thrush is a yeast infection in the mouth and often affects infants or elderly people. It may result from reduced immunity.

Coordination Coordination problems may occur at any age. Conditions that can cause coordination problems include Alzheimer’s disease, alcohol abuse, attention deficit disorder, brain cancer, chorea, Down’s syndrome, encephalitis, fetal alcohol syndrome, advanced HIV infection, hydrocephaly, multiple sclerosis, Parkinson’s disease, Rett syndrome, stroke, and Wilson disease. Hand–eye coordination is needed for self-feeding, and when this is not working properly, assistance is needed. Other problems affecting meal intake may include falling forward, feet not touching the floor, leaning to one side, poor balance while sitting, and poor neck control. Sometimes, it is possible to adjust table height, offer pillows or other positioning equipment, offer a footstool, or adjust pedals on a wheelchair. Work with an occupational therapist for the proper types of adjustments to promote better mealtime food intake.

Hearing Loss One form of hearing loss is a congenital anomaly that affects 1 in 1,000 live births. Many genes that affect hearing are active during embryogenesis (Wu and Kelley, 2012). Early Hearing Detection and Intervention programs are useful but not available everywhere. It is important to monitor childhood infections and have them treated. Other forms of oxidative stress may also contribute to hearing loss. Retinoic acid has been noted as essential for a healthy inner ear (Bok et al, 2011). Maternally inherited diabetes and deafness (MIDD) is a rare form of inherited diabetes associated with defects in mitochondrial DNA. Because cardiomyopathy is common with MIDD, coenzyme Q10 and l-carnitine may be beneficial (Azevedo et al, 2010). Presbycusis (hearing loss in aging) is prevalent in nearly twothirds of adults aged 70 years and older in the United States (Lin et al, 2011). This loss may correlate with a decline in cognitive function. Hearing loss is often related to underlying cardiovascular disease, hypertension, or diabetes. A diet high in cholesterol but low in vitamins A and E has an adverse influence on hearing (Gopinath et al, 2011; Gopinath, Flood et al, 2011). Cochlear vulnerability and microvascular changes can occur (Agrawal et al, 2009). Vitamin C is also essential (Kang et al, 2014). Melanocytes not only affect pigmentation but also hearing. Risks for hearing loss are substantially lower in black than in

Escott-Stump_Ch02.indd 109

Figure 2-12. Salicylism may cause temporary hearing loss or tinnitus. (Adapted with permission from Acosta WR. Pharmacology for Health Professionals. 2nd ed. Baltimore, MD: Wolters Kluwer Health; 2013.)

white individuals; skin pigmentation is a marker of melanocytic functioning (Lin et al, 2012). Research is ongoing for nutritional implications. People who take high doses of salicylates (including aspirin) may experience hearing loss or tinnitus (Fig. 2-12).

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Primary open-angle glaucoma is a complex disease with genetic indicators. It has been suggested that MTHFR C677T polymorphisms are related, but more studies are needed. In MIDD, 3243A⬎G mutation on the tRNALeu(UUR) gene has been identified.

11/7/14 2:13 AM

110

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Clinical/History • • • • • • • • • • • • • • • • • •

Height Weight BMI Recent weight changes Diet history Mouth or tongue lacerations Sore or bleeding gums Missing or loose teeth, edentulism Dentures, especially poorly fitting Blindness, cataracts, AMD Hemianopia, low vision Chewing problems Hearing loss Dehydration or edema Coordination problems Dry mouth (xerostomia) Needs feeding assistance Needs adaptive feeding equipment

Lab Work • • • • • • • • •

Gluc Alb, transthyretin Serum Na⫹, K⫹ Ca⫹⫹, Mg⫹⫹ I&O H&H, serum Fe Chol, Trig X-rays (such as mandible) Serum vitamin D

INTERVENTION Objectives • Promote independence in self-feeding, when possible. • Address all nutritional deficiencies and complications individually. Select nutrient-dense foods. • Promote overall wellness and health. • Increase interest in eating. Increase pleasure associated with mealtimes. • Prevent malnutrition and weight loss. • Decrease instances in which constipation, anorexia, or other problems affect nutritional status. • Educate the patient or caregiver about adaptive equipment, utensils, and special food modifications. Patients with hemianopia may require special training to be able to see and eat all of the meals served to them.

Food and Nutrition Low Vision, Blindness, AMD, Glaucoma, Cataracts • Provide special plate guards, utensils, double handles, and compartmentalized plates with foods placed in similar locations at each meal. Place all foods within 18⬙ reach at mealtime. Explain placement of foods. Open packets if needed. • Work with occupational therapist or family to practice kitchen safety and to determine ability to be independent at mealtimes. • Allow sufficient time to complete meals; refrigerate or reheat items as needed.

Escott-Stump_Ch02.indd 110

• Create a feeling of usefulness by delegating appropriate tasks related to mealtime, such as drying dishes and assisting with simple, safe meal tasks. • Support companionship during meals, especially if assistance is needed. • Use straws for beverages unless there is dysphagia. • Include olive oil, omega-3 fatty acids (two servings/week of fish), and a low glycemic index diet (Weikel et al, 2012). Use rich sources of DGA and EPA, such as salmon, sardines, herring, tuna, or a fish oil supplement. • For a diet lower in glycemic index, include whole grains, soybeans, and lentils more often; exclude desserts, candy, sweetened beverages, potatoes, and white bread. • Higher levels of carotenoids may be protective (Weikel et al, 2012). Include lycopene from pink grapefruit, tomato sauce, tomato juice, and watermelon. Lutein and zeaxanthin are found in broccoli, spinach, other leafy greens, and egg yolk. • Antioxidant-rich foods that include good sources of vitamins C and E, selenium, and zinc should be consumed daily. Snacking on nuts is an excellent choice. There is accumulating evidence that taking vitamin E or beta-carotene supplements will not prevent or delay the onset of AMD (Evans and Lawrenson, 2012). • For glaucoma, support neuroprotective measures; antioxidant-rich foods should be consumed (Vasudevan et al, 2011). When possible, consume whole fruit versus juice (Crowe and Murray, 2013). Coordination Problems • Self-feeding requires the ability to suck, to sit with head and neck balanced, to bring hand to mouth, to grasp cup and utensil, to drink from a cup, to take food from a spoon, to bite, to chew, and to swallow. • Each person should be assessed individually to determine which, if any, aspects of coordination have been affected by his or her condition. Adjust self-feeding accordingly. • Use clothing protectors at mealtime to maintain dignity. • Assist with feeding if needed; use adaptive feeding equipment as needed (such as weighted utensils, large-handled cups, larger or smaller silverware than standard). • Adjust table or chair height. • Place all foods within 18⬙ reach at mealtime. Chewing Problems • Dentures should fit well and be adjusted or replaced as needed, such as after weight loss. • Decrease texture only when necessary; use a mechanical soft, pureed, or liquid diet. Season as desired for individual taste. • Progress in textures when possible because chewing is important for saliva production and for proper digestion of foods. • Liquid or blenderized foods may be beneficial. If needed, use a tube feeding. • Speech therapists can assess the ability to use a straw. • Protein-rich foods such as tofu, cottage cheese, peanut butter, eggs, cheese, and milk products can be used when meats or nuts cannot be chewed easily or safely. • If fresh fruits and vegetables cannot be consumed, use cooked or canned sources and juices. Pureed foods only when needed. If whole grain breads and cereals are not tolerated, use cooked cereals. • Avoid rice or foods with small particles in dysphagia (see Section 7, Gastrointestinal Disorders).

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

Hearing Loss • Researchers and international scientists have found a gene that causes deafness in humans: LRTOMT. • Alter diets as needed if diabetes, cardiovascular disease, or hypertension are present. A controlled carbohydrate diet, therapeutic lifestyle diet (low saturated fat), or the DASH diet may be appropriate. • Foods rich in vitamins E, C, and A may be protective (Gopinath, Flood et al, 2011.)

•

Food–Drug Interactions Common Drugs Used and Potential Side Effects • For glaucoma, a combination of medications is used to reduce elevated intraocular pressure and prevent damage to the optic nerve. Some may cause dry mouth or fatigue; monitor individually. • For AMD, cholesterol-lowering medications (statins) may be protective. Clinical trials are in order. Herbs, Botanicals, and Supplements • Nutrients and botanicals that may prevent cataracts include turmeric/curcumin, clove/eugenol, red pepper/capsaicin, black

•

111

pepper/piperine, ginger/gingerol, garlic, onion, and fenugreek (Srinivasan, 2014.) Lutein and zeaxanthin, in whole food or supplemental form, have an impact on retinal function with the potential to preserve vision and prevent degeneration in AMD (Ma et al, 2012; Carpentier et al, 2009). Herbs and botanicals may be used; identify and monitor side effects. Counsel about use of herbal teas to avoid intake of toxic substances. For glaucoma, gingko biloba extract and bilberry anthocyanins seem to improve visual function (Shim et al, 2012). For cataract, rosemary, catnip, and capers have not been found to be effective.

Nutrition Education, Counseling, CareManagement • Discuss the importance of using the various therapies and medications. • Discuss the role of nutrition in health, weight control, recovery, and repair processes. • For healthy eyes, nutrition plays an essential role; see Table2-7. Consume 10 mg of lutein weekly, the equivalent of 1 cup of cooked spinach four times a week. Orange juice

TABLE 2-7 Nutrients for Healthy Vision NUTRIENT

EFFECT

Protein and amino acids

Protein undernutrition is associated with increased risk of cataract. Low protein intake may induce deficiencies of specific amino acids that are needed to maintain the health of the lens.

Vitamin A, lutein, and zeaxanthin

Vitamin A is needed for healthy cornea and conjunctiva. Lutein and zeaxanthin reduce the risk of chronic eye diseases including age-related macular degeneration and cataracts (Ma et al, 2012). Lutein and zeaxanthin are found in green leafy vegetables (kale, collards, spinach, turnip greens, broccoli) as well as eggs, yellow corn, peas, tangerine, and orange bell peppers. Fortified eggs may contain 185 mg of lutein. Lutein is facilitated with ascorbic acid supplementation. Lutein, zeaxanthin, B vitamins, and omega-3 fatty acids decrease AMD progression (Olsonet al, 2011). Beta-carotene supplements may actually increase the risk of late AMD (Olson et al, 2011).

Thiamin

For normal retinal and optic nerve functioning.

Riboflavin

For corneal vascularization. Protective against cataracts. Riboflavin appears to play an essential role as a precursor to flavin adenine dinucleotide (FAD), a cofactor for glutathione reductase activity.

Niacin

For healthy vision. Avoid excesses, which can cause nicotinic acid maculopathy.

Folate

A possible protective influence on cortical cataract from use of folate or vitamin B12 supplements.

Vitamin B6

For healthy conjunctiva. Untreated homocystinuria is known to cause ocular changes; vitamin B6 can help to lower homocysteine levels.

Vitamin B12

For retinal and nerve fibers. Found only in animal foods such as meat and milk.

Vitamin C

For healthy conjunctiva and vitreous humor. Long-term use of adequate vitamin C may delay or prevent early age-related lens opacity. Orange and grapefruit juices, cantaloupe, oranges, green peppers, tomato juice, broccoli, kiwifruit, and strawberries are good sources. Vitamin C (ascorbic acid) is an antioxidant that lowers the risk of developing cataracts, and when taken in combination with other essential nutrients, can slow the progression of age-related macular degeneration and visual acuity loss (American Optometric Association, 2013).

Vitamin D

Helps prevent cancer, heart disease, diabetes, and age-related macular degeneration; it is the most potent steroid hormone in the human body, and is the only vitamin formed with the help of sunlight (American Optometric Association, 2013).

Vitamin E

Important for antioxidant properties. Protects the eyes from free radical damage and may slow the onset of cataracts. Vitamin E is found in almonds, peanuts, peanut butter, sunflower seeds, safflower oil, margarines, fortified cereals, sweet potatoes, and creamy salad dressings. Usefood versus supplements (Olson et al, 2011).

Omega-3 fatty acids

Omega-3 fatty acids and fish are protective against AMD. Eating fish (sardines, salmon, herring, tuna, fortified eggs) weekly and cutting back on saturated fatty acids are important measures. Infants need a supply of DHA for up to a year for healthy visual development. Avoid use of large doses of alpha linolenic acid. The AREDS2 study is evaluating these guidelines.

Omega-6 fatty acids

High doses of canola, flaxseed, and soybean oils may actually increase the risk of cataracts.

Selenium

Cataract formation includes deficient glutathione levels contributing to a faulty antioxidant defense system within the lens of the eye; nutrients that increase glutathione levels and activity include selenium.

Sodium

Sodium-restricted diets may protect against cataracts. More research is needed.

Zinc

For healthy retina, choroid, and optic nerve. Found in beef, chicken, oysters, mixed nuts, and milk. Zinc is an essential trace mineral, bringing vitamin A from the liver to the retina in order to produce melanin for a protective pigment in the eyes (American Optometric Association, 2013). Zinc is highly concentrated in the eye.

Sources: American Optometric Association. Diet and nutrition. Available at: http://www.aoa.org/x11813.xml. Accessed June 17, 2014; Ma L, Yan SF, Huang YM, et al. Effect of lutein and zeaxanthin on macular pigment and visual function in patients with early age-related macular degeneration. Ophthalmology. 2012;119:2290; Olsen JH, Erie JC, Bakri SJ. Nutritional supplementation and age-related macular degeneration. Semin Ophthalmol. 2011;26:131.

Escott-Stump_Ch02.indd 111

11/7/14 2:13 AM

112

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

is a good choice for vitamin C. The DASH diet is a good plan. • Provide instruction regarding simplified meal planning and preparation. Refer to agencies such as Meals-on-Wheels if needed. • Discuss the tips appropriate for the individual (texture, finger foods, ease of placement at meals). • Hearing loss has been associated with cognitive and functional decline in older adults and may be amenable to rehabilitative intervention (Lin et al, 2011). With hearing loss, postural balance may also be affected, causing a higher risk for falls. Patient Education—Food Safety • Discuss simple hand washing or use of hand sanitizers before meals.

●

Coordination Problems: National Center for Education in Maternal and Child Health http://www.brightfutures.org/physicalactivity/issues_concerns/10.html

●

Hearing Loss Association http://www.hearingloss.org/

●

Low Vision http://www.lowvision.org/

●

National Eye Institute, NIH http://www.nei.nih.gov/health/

●

National Library Service for the Blind and Physically Handicapped (NLS) http://www.loc.gov/nls

●

Prevent Blindness America http://www.preventblindness.org/

●

Vision Aware http://www.afb.org/seniorsitehome.asp

REFERENCES SAMPLE NUTRITION CARE PROCESS STEPS Self-Feeding Problems—Low Vision Assessment Data:Food records and intake calculations; vision and self-feeding problems. Nutrition Diagnosis: Self-feeding difficulty related to blindness and no adaptive equipment as evidenced by limited intake at meals and long period required for eating. Intervention • Education about adaptive equipment with careful orientation to items served at meals. Reading menu choices aloud. • Refer to occupational therapy for proper equipment, techniques for cueing, positioning at mealtime, and encouragement tips. • Counsel about dietary changes to improve intake and prevent weight loss, such as finger foods and easy to handle foods. Monitoring and Evaluation: Intake records showing better intake when using adaptive equipment; weight records; improved quality of life with greater independent functioning at mealtimes.

For More Information ●

Age-Related Macular Degeneration Alliance http://www.amdalliance.org/

●

American Academy of Ophthalmology http://www.aao.org/

●

American Association of Ophthalmology http://www.eyenet.org/

●

American Council for the Blind http://www.acb.org/

●

American Occupational Therapy Association http://www.aota.org/

Escott-Stump_Ch02.indd 112

Agrawal Y, et al. Risk factors for hearing loss in US adults: data from the National Health and Nutrition Examination Survey, 1999 to 2002. Otol Neurotol. 2009;30:139. Azevedo O, et al. Cardiomyopathy and kidney disease in a patient with maternally inherited diabetes and deafness caused by the 3243A⬎G mutation of mitochondrial DNA. Cardiology. 2010;115:71. Bok J, et al. Transient retinoic acid signaling confers anterior-posterior polarity to the inner ear. Proc Natl Acad Sci U S A. 2011;108:161. Carpentier S, et al. Associations between lutein, zeaxanthin, and age-related macular degeneration: an overview. Crit Rev Food Sci Nutr. 2009;49:313. Chiu CJ, et al. Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements? BrJ Ophthalmol. 2009;93:1241. Crowe KM, Murray E. Deconstructing a fruit serving: comparing the antioxidant density of select whole fruit and 100% fruit juices. J Acad Nutr Diet. 2013;113:1354. Evans JR, Lawrenson JG. Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration. Cochrane Database Syst Rev. 2012Jun 13;6:CD000253. Gopinath B, et al. Dietary intake of cholesterol is positively associated and use of cholesterol-lowering medication is negatively associated with prevalent age-related hearing loss. J Nutr. 2011;141:1355. Gopinath B, Flood VM, et al. Dietary antioxidant intake is associated with the prevalence but not incidence of age-related hearing loss. J Nutr Health Aging. 2011;15:896. Kang JW, et al. Dietary vitamin intake correlates with hearing thresholds in the older population: the Korean National Health and Nutrition Examination Survey. Am J Clin Nutr. 2014;99:1407–1413. Lin FR, et al. Association of skin color, race/ethnicity, and hearing loss among adults in the USA. J Assoc Res Otolaryngol. 2012;13:109. Lin FR, et al. Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci. 2011;66:582. Ma L, et al. Effect of lutein and zeaxanthin on macular pigment and visual function in patients with early age-related macular degeneration. Ophthalmology. 2012;119:2290. Shim SH, et al. Ginkgo biloba extract and bilberry anthocyanins improve visual function in patients with normal tension glaucoma. J Med Food. 2012;15:818. Srinivasan K. Antioxidant potential of spices and their active constituents. Crit Rev Food Sci Nutr. 54:352–372. Vasudevan SK, et al. Neuroprotection in glaucoma. Indian J Ophthalmol. 2011;59:102S. Weikel KA, et al. Nutritional modulation of age-related macular degeneration. Mol Aspects Med. 2012;33:318. Wu DK, Kelley MW. Molecular mechanisms of inner ear development. Cold Spring Harb Perspect Biol. 2012;4:a008409.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

113

SKIN CONDITIONS, PRESSURE ULCERS, AND VITAMIN DEFICIENCIES

SKIN DISORDERS NUTRITIONAL ACUITY RANKING: LEVEL 1

DEFINITIONS AND BACKGROUND Human skin is the largest organ of the body, weighing about 8 pounds. The health and attractiveness of the skin are influenced by nutrition. Skin is affected by both internal and external influences. The gastrointestinal (GI) and cutaneous organ systems are closely linked (Thrash et al, 2013). The immune system is also highly involved. Neutrophils have been shown to mediate one pathway of systemic anaphylaxis and to participate in allergic skin reactions (Mocsai, 2013). Nutrition affects hydration status, sebum production, and elasticity. Lutein and zeaxanthin are present in the skin and have shown significant efficacy against ultraviolet light–induced skin damage (Roberts et al, 2009). Retinoids have vitamin A biological activity for reversal of photoaging. A low-fat diet and foods rich in vitamin D and carotenoids may protect against some forms of skin cancer and actinic keratosis. Enzymes of the cytochrome P450 (P450 or CYP) family are drug-metabolizing enzymes that are induced in skin in response to xenobiotic exposure. They also play important roles in metabolism of fatty acids, eicosanoids, sterols, steroids, and vitamins A and D. In psoriasis, for example, some CYP(A) enzymes are elevated and CypB may be reduced (Hibino et al, 2011). Acne affects 85% of young people, causing psychological distress. High glycemic load diets and dairy ingestion (milk, ice cream) are associated (Melnick and Zouboulis, 2013; Ismail et al, 2012). Green tea polyphenols have anti-inflammatory effects, internally and in topical creams. The roles of omega-3 fatty acids, antioxidants, zinc, vitamin A, and dietary fiber are not as clear (Bowe et al, 2010). Address each acne patient individually, offering dietary counseling to reduce milk products and the Western diet (Burris et al, 2013). Atopic dermatitis (AD), or eczema, causes itchy, inflamed skin. It usually affects the insides of the elbows, backs of the knees, and the face but can cover much of the body. AD often affects people who either suffer from asthma and/or hay fever or have family members who do (the “atopic triad”). AD flares when the person is exposed to trigger factors, such as dry skin, irritants, allergens, emotional stress, heat and sweating, and infections; avoiding triggers is the key. Vitamin D is playing an increasing role in the management of atopic dermatitis as well as psoriasis, vitiligo, acne, and rosacea. Probiotics have shown promise (Pelucchi et al, 2012). Dermatitis herpetiformis (DH) is related to celiac disease with villous atrophy and endomysial antibodies (EMAs) as markers. The major treatment strategies for DH are gluten restriction or medical treatment with sulfones (Cardones and Hall, 2012). Dietary gluten restriction improves gastrointestinal morphology, possibly protecting against the development of lymphoma (Cardones and Hall, 2012). Epidermolysis bullosa is a hereditary condition in which blistering of the skin occurs with even slight trauma. It affects

Escott-Stump_Ch02.indd 113

2 of every 100,000 live births, occurring in both sexes and all ethnic groups. Nail dystrophy can occur, with rough, thickened, or absent fingernails or toenails. There may be blisters and problems with the soft tissue inside the mouth. Protein-energy malnutrition, stunting, anemia, and vitamin and mineral deficiencies are common. Treatment involves gastrostomy, careful wound care, and prevention of infections. Nickel dermatitis affects 8% to 15% of women and 1% of men. Sensitization to nickel is often associated with ear piercing. Nickel is present in many dietary items and food is considered to be a major source of nickel exposure. Systemic (gastrointestinal and skin) reactions to ingestion of nickel-rich foods in patients with nickel allergic contact dermatitis characterize systemic nickel allergy syndrome (Braga et al, 2013). Reduce exposure to nickel from foods (mainly vegetables) and other sources (Tammaro et al, 2009). Nummular eczematous dermatitis occurs with a rash; etiology is unknown. The rash is coin shaped and worsens in very hot or cold weather. Wool, soaps, frequent bathing (more than once a day), detergents, and rough clothing may be irritants. No special diet is needed unless food allergies are identified. Psoriasis is an inflammatory disorder. Silver, itchy scales often appear after gentle scratching of a lesion. Stress, streptococcal infection, and drugs including beta-blockers, antimalarials, and lithium may precipitate or exacerbate psoriasis (Tidman, 2013). Psoriasis predisposes to metabolic syndrome and increased risk of ischemic heart disease, hypertension, stroke, type 2 diabetes, hyperlipidemia, inflammatory bowel disease, lymphoma, nonmelanoma skin cancer, chronic obstructive pulmonary disorder, and venous thromboembolism (Tidman, 2013). Vitamin D plays a role. Calcitriol is useful, along with controlled exposure to sunlight. Omega-3 fatty acids (specifically EPA) with a drug regimen of etretinate and topical corticosteroids may improve symptoms. Rosacea is a chronic inflammatory disorder of the facial skin with onset in the third decade. Triggers may include Helicobacter pylori infection or small bowel bacterial overgrowth. Rosacea is a chronic and progressive condition of flare-ups and remissions and can be disfiguring if left untreated. Rosacea affects 1 in 20 people, or 13 million people in the United States. Members of the same family tend to be affected, especially fair-skinned individuals. Green tea extract in creams may have some benefit. Phototherapy is often recommended.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Single genes control mediators such as enzymes, neuroendocrine transmitters, and cytokines that promote rosacea and probably other skin disorders.

11/7/14 2:13 AM

114

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Clinical/History • • • • • • • • •

Height Weight BMI Growth pattern in children Diet history Family history of skin disorders, allergies Psoriasis? Rashes, blisters, pustules? Dermatitis?

•

Lab Work • • • • • • • • • • • • • • • •

Alb (decreased in exfoliative dermatitis) Transthyretin Serum zinc Serum histamine (may be elevated) Skin tests for allergies Anti-tTG, AGA, and/or EMA tests (for celiac) TSH, T4 level H&H, serum Fe Gluc Chol, Trig Serum Na⫹, K⫹ Ca⫹⫹, Mg⫹⫹ Serum carotene Retinol-binding protein (RBP) CRP Serum vitamin D

•

INTERVENTION Objectives • Reduce inflammation, redness, or edema where present. Prevent further exacerbations of the condition. • Apply nutritional principles according to the particular condition (e.g., enhancing food sources of vitamin D, omega-3 fatty acids, carotenoids, zinc). • Identify any offending foods; omit from the diet any food allergens or intolerances, such as gluten.

Food and Nutrition • Acne. Encourage intake of adequate vitamin D, zinc, carotenoids, and vitamin A foods. Drinking green tea is highly recommended. Monitor for excessive intake of milk and ice cream. Because there are no randomized controlled trials investigating the relationship between frequent dairy or milk consumption and acne, address each acne patient individually (Burris et al, 2013). • Acrodermatitis enteropathica. This condition of zinc deficiency affects both the GI and dermatologic systems (Thrash et al, 2013). Supplement with zinc. Use protein of high biological value. • Atopic dermatitis. Do not automatically eliminate important foods such as milk and wheat. Infants may have hypersensitivity to milk, egg albumin, wheat, or linoleic acid but tend to outgrow it. Control energy excess in obese infants. A probiotic mixture containing Lactobacillus acidophilus DDS-1, Biﬁdobacterium lactis UABLA-12, and fructo-oligosaccharide has been associated with significant clinical

Escott-Stump_Ch02.indd 114

improvement in children with AD (Gerasimov et al, 2010). Include vitamin D–rich foods and sufficient exposure to sunshine. Avoid herbal products, such as chamomile tea, for which allergy is possible. Green tea is safe and may be recommended. Dermatitis herpetiformis. A gluten-free diet is quite successful in treating this autoimmune-mediated condition (see Section 7, Gastrointestinal Disorders). Epidermolysis bullosa (EB). A balanced diet that includes extra protein, calories, and a multivitamin–mineral supplement will be useful. Highlight the nutrients that are beneficial, including omega-3 fatty acids, vitamin A, and zinc. Dysphagia is common, and may even lead to esophageal strictures. Anemia, contractures, gastroesophageal reflux (GERD), or scarring of the tongue may occur. Gastrostomy feeding may be needed. Nickel dermatitis. Avoid canned foods, such as tuna fish, tomatoes, corn, spinach, and other canned vegetables. Potatoes, carrots, and onions may absorb nickel from irrigation water. Do not cook with stainless steel utensils. Chocolate, nuts, and beans may have slightly higher naturally occurring nickel than other foods; avoid large quantities. Psoriasis. Psoriasis may precede arthritis; both are inflammatory processes. Calcitriol is highly efficient in the treatment of psoriasis. The therapeutic effect of UVB light therapy may be related to its skin synthesis of vitamin D. Avoid obesity, as it may contribute to metabolic syndrome (Ahdout et al, 2012). A low-energy diet to induce weight loss may improve psoriasis severity (Jensen et al, 2013). Rosacea. Alcoholic beverages (especially red wine), spicy foods, hot beverages, some fruits and vegetables, marinated meats, and dairy products may trigger flare-ups; avoid as needed. Limit use of all forms of pepper, paprika, chili powder, and curry. Recommend drinking green tea. Include good sources of vitamin D.

Food–Drug Interactions Common Drugs Used and Potential Side Effects When using cortisone ointments, use just a little and massage in well. Application once daily does as much good as using it more often. Long-term use may suppress the adrenal gland. Acne • Isotretinoin (Accutane) may be used for acne. Watch for a decrease in high-density lipoprotein (HDL) and an increase in triglycerides. Avoid taking with vitamin A supplements. Dry mouth can occur. Do not use during pregnancy. • Retin A (retinoic acid), adapalene, and benzoyl peroxide are useful for moderate cases of acne; side effects are mild. • Tetracycline should not be taken within 2 hours of use of milk products or calcium supplements. Excesses of vitamin A can cause headaches or hypertension. Use more riboflavin, vitamin C, and calcium in the diet. Protein and iron malabsorption may result from prolonged use. Diarrhea is the major GI effect. Minocycline causes less GI distress and does not affect calcium metabolism as dramatically. Antibiotics are used for their anti-inflammatory effect. Actinic Keratosis • Three days of ingenol mebutate gel has been found to be effective for actinic keratosis.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

Atopic Dermatitis • Topical cortisone (steroid) creams, such as Aclovate, usually have a mild effect on the nutritional status of the patient. Stronger brands or dosages may act like oral steroids and can suppress the adrenal system if taken for prolonged periods. Epidermolysis bullosa • Wound care products are used for tissue regeneration. Fluid replacement and protein loss may be associated with blistering. Psoriasis • Calcitriol and other vitamin D analogs are often effective. Topical products such as tazarotene (Tazorac) and calcipotriene, a form of vitamin D, have been available for years. • TNF inhibitors yield less frequent itching, better quality of life, depression, and fatigue. Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab), or Raptiva (efalizumab) are used for severe chronic plaque psoriasis.

• Sunscreens may prevent vitamin D from penetrating the skin, especially at higher protective levels. If serum levels are low in vitamin D, a supplement may be needed. • Protein, vitamin A, and zinc are also important nutrients for healthy skin; describe good sources. • Discuss the effect of EFAs on membrane function and how to include them in the diet. Omega-3 fatty acids reduce inflammation for some skin conditions. Skin care products containing natural stable fish oil improve skin elasticity. Otherwise, avoid topical products, except as recommended by the doctor. • Flavones have natural antioxidant, cytoprotective properties. Carrots, peppers, celery, olive oil, peppermint, rosemary, and thyme contain natural levels of luteolin. Patient Education—Food Safety • The usual food safety habits are needed for good skin health. With open sores or exudative lesions on hands, cover with a bandage when preparing or serving food.

Rosacea • Antibiotic creams such as topical sodium sulfacetamide, metronidazole (MetroCream), and azelaic acid (Finacea) are commonly prescribed. Tetracycline may also be prescribed; avoid taking within an hour of dairy or calcium-related supplements. • Aspirin may reduce the effects of niacin-containing foods in sufferers affected by the flushing effect of these foods. Monitor multivitamin supplements and intakes carefully. • Spironolactone may have a role in treatment (Spoendlin etal, 2013). Herbs, Botanicals, and Supplements • Counsel about use of herbal teas, especially related to potentially toxic ingredients. Herbs and botanicals may be used; identify and monitor side effects. • For acne, salicylic acid helps break down blackheads and whiteheads and helps cut down the shedding of cells lining the hair follicles. Tea tree oil topical solutions may be beneficial because of anti-inflammatory effects. Ointment containing tea leaf extract is effective for impetigo, acne, and methicillin-resistant Staphylococcus aureus. • Lactobacillus rhamnosus GG, ␥-linolenic acid prebiotics, and black currant seed oil (␥-linolenic acid and ␻-3 combination) have shown efficacy in reducing the development of atopic dermatitis (Foolad et al, 2013). • Extracts of arnica (Arnica montana), chamomile (Chamomilla recutita), tansy (Tanacetum vulgare), and feverfew (Tanacetum parthenium) may cause allergic reactions. • For psoriasis: bishop’s weed, avocado, licorice, red pepper, Brazil nut, and purslane are not confirmed. Red clover is sometimes used; avoid with warfarin or hormone replacement therapy. • For sunburn: topical aloe is used for sunburn and mild burns. Aloe causes GI cramping and hypokalemia if ingested.

SAMPLE NUTRITION CARE PROCESS STEPS Psoriasis Assessment Data:Food records and intake calculations; many skin rashes, with psoriasis diagnosed 15 years ago. Nutrition Diagnosis: Inadequate vitamin and fatty acid intake related to chronic history of psoriasis and poor diet as evidenced by diet history revealing high intake of beer, low intake of vitamin D and omega 3 fatty acids, and low serum vitamin D. Intervention: Education about careful exposure to sunshine and use of vitamin D-fortified foods, and fatty fish such as salmon and mackerel. Counsel about dietary changes to improve intake of omega-3 fatty acids and vitamin D3. Advise cutting beer intake down or out. Coordinate care with physician to evaluate for celiac disease. Monitoring and Evaluation:If positive for celiac, discuss gluten-free lifestyle. Intake records showing better food intake and lower intake of beer; improved quality of life with fewer outbreaks of psoriasis.

For More Information

See the video “Head to Toe Assessment (Adult): The Skin” at www.thepoint.lww.com /escottstump8e.

●

Acne Hotline http://www.niams.nih.gov/hi/topics/acne/acne.htm

●

Acne Resource Center http://www.acne-resource.org/

●

American Academy of Dermatology http://www.aad.org/

●

Dystrophic Epidermolysis Bullosa Research Association of America http://www.debra.org/understanding

●

National Eczema Association http://www.nationaleczema.org/

Nutrition Education, Counseling, CareManagement • Encourage the patient to read food, medication, and supplement labels. A symptom and food diary may be useful to identify any relationship between diet, allergies, and skin flare-ups. • Encourage adequate fluid intake for hydration of the skin. Green tea can be highly recommended. • Help the patient modify his or her diet as specifically indicated by the condition.

Escott-Stump_Ch02.indd 115

115

11/7/14 2:13 AM

116

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

●

National Psoriasis Foundation http://www.psoriasis.org/

●

National Rosacea Society http://www.rosacea.org/

●

NIH—Dermatitis http://www.niams.nih.gov/hi/topics/dermatitis/

●

NIH—Eczema http://www.nlm.nih.gov/medlineplus/eczema.html

REFERENCES Ahdout J, et al. Modifiable lifestyle factors associated with metabolic syndrome in patients with psoriasis. Clin Exp Dermatol. 2012;37:477. Bowe WP, et al. Diet and acne. J Am Acad Dermatol. 2010;63:124. Braga M, et al. Systemic nickel allergy syndrome: nosologic framework and usefulness of diet regimen for diagnosis. Int J Immunopathol Pharmacol. 2013;26:707. Burris J, et al. Acne: the role of medical nutrition therapy. J Acad Nutr Diet. 2013;113:416. Cardones AR, Hall RP. Management of dermatitis herpetiformis. Immunol Allergy Clin North Am. 2012;32:275. Foolad N, et al. Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol. 2013;149:350.

Gerasimov SV, et al. Probiotic supplement reduces atopic dermatitis in preschool children: a randomized, double-blind, placebo-controlled, clinical trial. Am J Clin Dermatol. 2010;11:351. Hibino M, et al. Cyclosporin A induces the unfolded protein response in keratinocytes. Arch Dermatol Res. 2011;303:481. Ismail NH, et al. High glycemic load diet, milk and ice cream consumption are related to acne vulgaris in Malaysian young adults: a case control study. BMC Dermatol. 2012;12:13. Jensen P, et al. Effect of weight loss on the severity of psoriasis: a randomized clinical study. JAMA Dermatol. 2013;149:795. Melnick BC, Zouboulis CC. Potential role of FoxO1 and mTORC1 in the pathogenesis of Western diet-induced acne. Exp Dermatol. 2013;22:311–315. Mocsai A. Diverse novel functions of neutrophils in immunity, inflammation, and beyond. J Exp Med. 2013;210:1283. Pelucchi C, et al. Probiotics supplementation during pregnancy or infancy for the prevention of atopic dermatitis: a meta-analysis. Epidemiology. 2012;23:402. Roberts RL, et al. Lutein and zeaxanthin in eye and skin health. Clin Dermatol. 2009;27:195. Spoendlin J, et al. Spironolactone may reduce the risk of incident rosacea. J Invest Dermatol. 2013;133:2480. Tammaro A, et al. Allergy to nickel: first results on patients administered with an oral hyposensitization therapy. Int J Immunopathol Pharmacol. 2009;22:837. Thrash B, et al. Cutaneous manifestations of gastrointestinal disease: part II. J Am Acad Dermatol. 2013;68:211.e1. Tidman MJ. Improving outcomes in patients with psoriasis. Practitioner. 2013;257:27.

PRESSURE ULCERS NUTRITIONAL ACUITY RANKING: LEVEL 2 FOR STAGE 1 OR 2; LEVEL 4 FOR STAGE 3 OR 4 ULCERS DEFINITIONS AND BACKGROUND Pressure, friction, or shear and a lack of oxygen and nutrition to an affected area are associated with the development of pressure ulcers over bony or cartilaginous prominences (hip, sacrum, elbow, heels, back of the head). Pressure ulcers are common among patients with protein-energy malnutrition in HIV infection, pulmonary and cardiac cachexia, rheumatological cachexia, cancers, renal diseases, and among bedridden or paralyzed patients. With immobility, loss of lean body mass in muscle and skin, and lowered immunity, the risk of pressure ulcers increases significantly. Many patients with pressure ulcers are below their usual body weight and are not consuming enough nutrition. Malnutrition-sarcopenia syndrome is the clinical presentation of both malnutrition and accelerated age-associated loss of lean body mass, strength, and/or functionality. Poor nutritional status, long lengths of stay, and decreased oxygen perfusion often lead to pressure ulcers. The Braden scale risk score is a useful tool. The total score may predict pressure ulcer development, but subscale scores focus on specific risks for the individual patient (Tescher et al, 2012). Friction and shear are the primary risks. Patients with malnutrition have many concerns. Risk factors should be assessed frequently: unintentional weight loss, incontinence, immobility, poor circulation (as in diabetes, peripheral vascular disease, or anemia), infection, prolonged pressure, multiple medications, serum albumin less than 3.4 g/dL, reduced functional ability, poor oral intake (⬍50% of meals over 3 days or longer), chewing or swallowing problems, and serum choles-

Escott-Stump_Ch02.indd 116

terol levels below 160 mg/dL (Vandewoude et al, 2012; Jensen et al, 2010). Poor handgrip strength is a predictor of pressure ulcers, especially in hip fracture patients (Gumieiro et al, 2012). The National Pressure Ulcer Advisory Panel (NPUAP, 2013) reference guide suggests that individuals found to be at risk for pressure ulcers should be given a more thorough assessment. The mini-nutritional assessment is a useful tool. Risks include decreased appetite, feeding dependency, impaired cognition, poor positioning, frequent acute illnesses, medications that decrease appetite or increase nutrient losses, polypharmacy, decreased sense of thirst, intentional fluid restriction because of fear of incontinence, fear of choking, isolation or depression, monotonous diet, and higher nutrient requirements. Because pressure ulcers are a cause of morbidity, expense, and mortality, they should be prevented. Nutrition intervention is a cost-effective approach (Banks et al, 2013). There are situations that render pressure ulcer development unavoidable: hemodynamic instability that is worsened with physical movement, inability to maintain nutrition and hydration status, or the presence of an advanced directive prohibiting artificial nutrition/hydration (Black et al, 2011). Reversible protein-energy malnutrition should be treated; on the other hand, nutrient excesses are wasteful and may gradually harm the immune system. Wound healing is complex and has three distinct phases (inflammatory, proliferative, and maturation). In each phase of wound healing, extra energy and macronutrients are required. During the wound-healing process, much energy is needed and is obtained from energy stores and protein reserves (Wild etal, 2010). However, wound healing is not always linear; it can progress or regress, depending on various intrinsic and extrinsic factors (Wild et al, 2010).

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

Studies have established specific roles for arginine and micronutrients such as vitamins A, C, and K; magnesium; selenium; manganese; zinc; and copper (Wojcik et al, 2011). Healing accelerates when a formula is enriched with protein, arginine, zinc, and vitamin C (Cereda et al, 2009). Immunonutrition that includes long-chain omega-3 fatty acids is also cost-effective in prevention and treatment (Theilla, 2013).

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • • • • • • •

Height Weight Weight changes Unintentional weight loss of ⬎3 kg over past 3 months Low BMI (⬍18.5) BP Diet history Number, size, and stage of ulcer(s) (see Table 2-8) Exudate, infection, or sepsis, fever Pain Abnormal motor coordination

117

• • • • • • •

Changes in appetite, anorexia, indigestion Nausea/vomiting Diarrhea, bowel incontinence Urinary tract infections or incontinence Recent or frequent surgeries Handgrip strength Low muscle mass (as measured by dual-energy x-ray absorptiometry, computed tomography, magnetic resonance imaging, or bioelectrical impedance analysis)? • Decreased gait speed (⬍0.8 m/s)? • Braden scale: intense or prolonged pressure (activity, mobility, sensory perception) and tissue tolerance for pressure (nutrition, moisture, friction, and shear); scores range from 6 to 23, lower scores ⫽ higher risk. • Norton scale: physical condition, mental status, activity, mobility, and incontinence; rating ⬎16 suggests high risk.

Lab Work • • • • • • • •

Gluc CRP Serum Chol BUN, Creat Serum Na⫹, K⫹ Ca⫹⫹, Mg⫹⫹ H&H, serum Fe, serum ferritin Alb, transthyretin, RBP (usually decreased)

TABLE 2-8 Skin Changes with Aging and Pressure Ulcer Stages SKIN CHANGE

CONSEQUENCES

Thinning of epidermis

Increased vulnerability to trauma and skin tears

Decreased epidermal proliferation

Slower production of new skin cells

Atrophy of dermis

Underlying tissue more vulnerable to injury; decreased wound contraction

Decreased vascularity of dermis

Easy bruising and injury; decreased wound capillary growth

Compromised vascular response

Impaired immune and inflammatory responses

Fragility

Easy bruising and tearing

Suspected deep tissue injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/ or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue

Pressure Ulcer Staging Stage I

Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk)

Stage II

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. Bruising indicates suspected deep tissue injury

Stage III

Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling The depth of a stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable

Stage IV

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable

Unstageable

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed

*Adapted with permission from National Pressure Ulcer Advisory Panel. Available at: http://www.npuap.org. Accessed June 17, 2014.

Escott-Stump_Ch02.indd 117

11/7/14 2:13 AM

118 • • • • • •

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Food and Nutrition

N balance, transferrin Total lymphocyte count (TLC) PT or INR Serum zinc Serum vitamin D Serum B12

INTERVENTION Objectives • Determine underlying pathologies (heart failure, hypothyroidism, obstructive lung disease, or peripheral vascular disease), severity of infections, comorbidities (dementia or diabetes mellitus), functional state (activities of daily living), and degree of social and emotional support. • Optimize regional blood flow to the site. • Heal the pressure ulcer(s) and prevent further tissue breakdown. Assess healing using an appropriate scale, such as scales from the National Pressure Ulcer Advisory Panel at http:// www.npuap.org. Figure 2-13 depicts pressure ulcer staging. • Restore nutritional status and correct protein-energy malnutrition. Malnutrition may lead to decreased wound tensile strength and increased rates of infection. • Support the patient’s immune system to prevent complications such as sepsis and osteomyelitis. • Monitor nutrition risks. Evaluate usual food intake pattern and intake over 3 to 5 days. • Alleviate low-grade infections, fever, diarrhea, and vomiting. • Avoid preventable circumstances, such as prolonged immobilization after a hip fracture or acute infections. • For nonhealing chronic ulcers, control symptoms (foul odor, pain, discomfort, and infection) to improve well-being as much as possible.

• Offer high-protein mixed oral nutritional supplements and/ or tube feeding, in addition to the usual diet (NPUAP, 2013). The guidelines for the treatment of pressure ulcers recommend 1.25 to 1.5 g/kg/d protein and 1 mL of fluid intake per kilocalorie per day. • Add protein powders to beverages, casseroles, tube feedings, and liquid supplements to get an adequate amount. Intake of protein ⬎2 g/kg of body weight is not necessary. • Thirty to 35 kcal/kg/d seems appropriate to cover daily requirements in pressure ulcer patients (NPUAP, 2013; Cereda et al, 2011). • Provide small, frequent feedings if oral intake is poor, four to six times daily. • Supplement diet with a general multivitamin–mineral supplement to supply adequate B vitamins, vitamin A, vitamin C, zinc, and copper. Include omega-3 fatty acids; include at least 2% of calories from lipid to prevent EFA deficiency. • Feed by tube if necessary. Note that percutaneous endoscopic gastrostomy feeding tubes are not associated with prevention or improved healing of a pressure ulcer in residents with advanced cognitive impairment (Teno et al, 2012). • For a large sacral pressure ulcer, central parenteral nutrition may be the only way to feed with bowel incontinence.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Monitor the drug profile for potential side effects, especially for depletion of serum proteins or blood-forming nutrients. • Drugs that can affect skin include antibacterials, antihypertensives, analgesics, tricyclic antidepressants, antihistamines, antineoplastic agents, antipsychotic agents, corticosteroids, diuretics, and hypoglycemic agents. • Antibiotics may be needed in bacterial sepsis. • If needed, try an appetite stimulant. Unintentional weight loss may be corrected by using dronabinol or cannabinoids (Marinol), megestrol acetate (Megace), or oxymetholone. Herbs, Botanicals, and Supplements • If herbs and botanicals are used, monitor for side effects and potential drug interactions. • Counsel about use of herbal teas, especially regarding ingredients that may be toxic or ineffective.

Nutrition Education, Counseling, CareManagement Stage I

Stage II

Stage III

Stage IV

Figure 2-13. Pressure ulcer staging. (Reprinted with permission from Lippincott Nursing Advisor, 2009.)

Escott-Stump_Ch02.indd 118

• Instruct nursing personnel and patient’s family about the importance of adequate nutrition for healing of tissues. • Discuss importance of maintaining healthy, intact skin. Skin should be kept clean and dry. Avoid massage over bony prominences. • Provide information about high-protein diets and appropriate calorie and fluid levels. • When possible, improve ambulation and circulation to all tissues. Physical activity can help improve appetite. • Discuss the role of nutrition in wound healing. Collagen and fibroblasts require protein, zinc, and vitamin C for proper formation. Omega-3 fatty acids reduce inflammation. Adequate vitamins A and K and B-complex vitamins are needed for healthy nerves and muscles. • Discuss degree of assistance needed at mealtimes. • Provide ideas for self-help devices to increase overall intake. Examples include using a wet cloth liner to hold the plate,

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

curved flatware, two-handled cup, or other adaptive equipment if needed.

For More Information

Patient Education—Food Safety • Hand washing will be important for patients, caregivers, and nurses before and after meals. • Immaculate wound care procedures are essential.

SAMPLE NUTRITION CARE PROCESS STEPS Pressure Ulcer Assessment Data: Food intake records, weight records, need for enteral nutrition or feeding assistance, pressure ulcer team reports, other nutritional evaluations, and risk measures. Low handgrip scores. Check that nursing staff is turning and repositioning every 2 hours and offering fluids. Nutrition Diagnosis: Inadequate protein intake related to poor appetite and intake as evidenced by new stage 2 and stage 4 sacral pressure ulcers this past month as evidenced by intake of limited protein consumption from milk, eggs, cheese, and entrées; poor nutritional lab values (H&H, transthyretin); and elevated CRP. Intervention:Education of patient, staff, or family members about the role of nutrition in wound healing. Counseling about acceptable sources of protein and enhancing menu items with protein powders or liquid supplements. Encourage use of oral supplements with medication passes; adequate fluid intake calculated as 30 mL/kg. Careful calculation of fluid, protein, and energy requirements according to stage of ulcers; recalculate as needed if healing does not occur. Micronutrient provision with vitamin–mineral supplement meeting 100% DRIs and recommended daily allowance levels for zinc, copper, and vitamins A and C. Monitoring and Evaluation:Healing of pressure ulcers by 14 days after initiation of treatment; improved intake of protein foods to meet higher needs. Greater understanding by patient, family, or staff about the importance of nutrient-dense foods or formulas. Intake and output records indicating sufficient protein and energy intake. Labs improving for H&H, albumin, CRP.

119

See the video “Shearing” at www.thepoint.lww.com/ escottstump8e.

●

Centers for Medicare & Medicaid Services http://www.cms.hhs.gov/

●

National Pressure Ulcer Advisory Panel http://www.npuap.org/

●

RD411—Wound Resource Center http://www.nutrition411.com/wrc/

●

Wound Care Network http://www.woundcarenet.com/index.html

REFERENCES Banks MD, et al. Cost effectiveness of nutrition support in the prevention of pressure ulcer in hospitals. Eur J Clin Nutr. 2013;67:42. Black JM, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage. 2011;57:24. Cereda E, et al. Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial. J Am Geriatr Soc. 2009;57:1395. Cereda E, et al. Energy balance in patients with pressure ulcers: a systematic review and meta-analysis of observational studies. J Am Diet Assoc. 2011;111:1868. Gumieiro DN, et al. Handgrip strength predicts pressure ulcers in patients with hip fractures. Nutrition. 2012;28:874. Jensen G, et al. Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. Clin Nutr. 2010;29:151. National Pressure Ulcer Advisory Panel (NPUAP). Pressure ulcer prevention: Quick Reference Guide. Available at: at http://www.npuap.org/wp -content/uploads/2012/02/Final_Quick_Prevention_for_web_2010.pdf. Accessed June 17, 2014. Teno JM, et al. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med. 2012;172:697. Tescher AN, et al. All at-risk patients are not created equal: analysis of Braden pressure ulcer risk scores to identify specific risks. J Wound Ostomy Continence Nurs. 2012;39:282. Theilla M. Nutrition support for wound healing in the intensive care unit patient. World Rev Nutr Diet. 2013;105:179–189. Vandewoude MFJ, et al. Malnutrition-sarcopenia syndrome: is this the future of nutrition screening and assessment for older adults? J Aging Res. 2012;2012:651570. Wild T, et al. Basics in nutrition and wound healing. Nutrition. 2010;26:862. Wojcik, A et al. Dietary intake in clients with chronic wounds. Can J Diet Pract Res. 2011;72:77.

VITAMIN DEFICIENCIES NUTRITIONAL ACUITY RANKING: LEVEL 3 DEFINITIONS AND BACKGROUND Vitamins are a part of a healthy diet. If a person eats a variety of foods, deficiency is less likely. However, people who follow restricted diets may not get enough of one or more particular nutrients.

Escott-Stump_Ch02.indd 119

Deficiencies may be primary (self-induced by inadequate diet) or secondary to disease process. They are especially common in alcoholics, people who live alone and eat poorly, and among those who follow restrictive food fads. Vegetarians are also susceptible, especially for vitamin B12 deficiency. Appendix A provides greater detail about the vitamins, their sources, toxicities, and deficiencies. Table 2-9 summarizes concerns and physical signs of deficiency.

11/7/14 2:13 AM

120

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-9 Vitamin Deficiency Summary VITAMIN

ISSUES

PHYSICAL SIGNS

Vitamin A

Common in children. Night blindness and eye changes are often early signs. Many infections (such as measles) may cause deficiency. Vitamin A helps form and maintain healthy teeth, mucous membranes, skeletal and soft tissues, and skin. Retinol generates the pigments in the retina. Vitamin A promotes good vision (especially in dim light) and is required for healthy reproduction and lactation. Retinoic acid plays a role in inner ear health. Beta-carotene is a precursor for vitamin A and carotenoids play a role in maintaining good health.

Night blindness, Bitot spots, xerophthalmia, follicular hyperkeratosis.

Thiamin

Common in alcoholics, patients with heart failure, and persons with poor-quality diets. Thiamin helps convert carbohydrate (CHO) into energy; a high-CHO diet can deplete thiamin. It is also important for proper functioning of the heart, nervous system, and muscles.

Impairment of cardiovascular, nervous, and gastrointestinal systems.

Niacin and riboflavin

Often in conjunction with other B-complex vitamin deficiencies. Riboflavin (B2) is important for growth, red cell production, and releasing energy from CHO. Niacin (B3) assists in the functioning of the digestive system, skin, and nerves; it is important in the conversion of food to energy. A deficient diet or failure of the body to absorb niacin or tryptophan can cause signs of deficiency or pellagra. It is common in certain parts of the world where people consume large quantities of corn and is characterized by dermatitis, diarrhea, and schizophrenia-like dementia. It sometimes develops after gastrointestinal diseases or among alcoholics.

Niacin: Symmetrical, pigmented rash on areas exposed to sunlight, bright red tongue; dermatitis, diarrhea, depression, and death (the four Ds of pellagra).

Can occur after surgery or as a result of poor diet. Vitamin B6 deficiency has role in cardiac disorders (atrial fibrillation, hyperhomocysteinemia) and inflammation and in dopamine release in the brain. Because vitamin B6 plays a role in the synthesis of antibodies and red blood cells, a healthy immune system and circulatory system depend on it. The higher the protein intake, the more need there is for vitamin B6; a high protein–low CHO diet may deplete vitamin B6.

Seborrheic dermatitis, stomatitis, cheilosis, glossitis, confusion, depression.

May result in a megaloblastic anemia; supplementation is needed (see Section 12, Hematology—Anemias and Blood Disorders). Folic acid acts as a coenzyme with vitamins C and B12 in the metabolism and synthesis of proteins. It is needed to make red blood cells, to synthesize DNA, and to support tissue growth and cell function. There are roles for folic acid in disease prevention (e.g., neural tube defects, cancers, heart disease).

Depapillation of the tongue, rarely.

Vitamin B12

May also result in megaloblastic anemia (see Section 11, Hematology—Anemias and Blood Disorders). Peripheral neuropathy and a positive Schilling test are needed to indicate B12 deficiency. Folic acid supplementation may mask a B12 deficiency; both should be given.

Tingling and numbness in extremities, diminished vibratory and position sense, motor disturbances including gait disturbances. Pernicious anemia and other anemias; poor vision; some psychiatric symptoms.

Pantothenic acid and biotin

Not common. Pantothenic acid is essential for metabolism and in the synthesis of hormones and cholesterol. Biotin is essential for metabolism of proteins and carbohydrate and the synthesis of hormones and cholesterol.

Pantothenic acid: No visible physical signs of note.

Choline

May occur in long-term TPN use without lipid replacement. Plays a role in preventing neural tube defects along with folic acid.

No visible physical signs of note.

Vitamin C

Occurs overtly with scurvy after 3 months without intake from inadequate consumption of fresh fruits and vegetables. Hypovitaminosis C can occur in the elderly and the homeless, among those who live alone or have psychiatric diseases, and in those who follow food fads. It is more common than realized in the general population. Long-term deficiency can be a concern for people with cancer or cataracts.

Follicular hyperkeratosis, petechiae, ecchymosis, coiled hairs, inflamed and bleeding gums, perifollicular hemorrhages, joint effusions, arthralgia, delayed wound healing. Weakness, myalgia, vascular purpura, loss of teeth. Biological signs include anemia, hypocholesterolemia, and hypoalbuminemia.

Vitamin D

Insufficiency is a low threshold value for plasma 25-OHD (50 nmol/L). Secondary hyperparathyroidism, increased bone turnover, bone mineral loss, and seasonal variations in plasma PTH can occur with insufficiency. Deficiency is defined as 25-OHD values below 25 nmol/L; common among community-dwelling elderly who live in higher latitudes and among institutionalized elderly and patients with hip fractures. Vitamin D is produced in the skin by exposure to the sun and is found in fortified milk and other foods. For individuals who are not getting enough vitamin D in the diet, supplements may be helpful. The average adult under 50 needs 200 IU of vitamin D a day; 1 cup of vitaminD-fortified milk provides 50 IU of vitamin D. Recent studies suggest a role for vitamin D in autoimmune disorders, including multiple sclerosis, type 1 diabetes, or hypertension.

Widening at ends of long bones, rachitic rosary in children, rickets. Abnormal bone growth and repair; osteomalacia in adults; muscle spasms. Decreased immunity.

Vitamin E

It is an antioxidant, protects body tissue from the damage of oxidation, helps form red blood cells, and supports the use of vitamin K. Abetalipoproteinemia is the most severe deficiency and occurs mainly in premature and sick children. Fat malabsorption occurs in deficiency, especially in children.

Rupture of red blood cells; nerve damage.

Vitamin K

Rare except in intestinal problems and short gut syndromes because intestinal bacteria in the healthy gut can make vitamin K. Healthy bones require sufficient vitamin K.

Poor wound healing or blood clotting. Osteopenia.

Vitamin B6

Folic acid

Escott-Stump_Ch02.indd 120

Reduced growth, changes in epithelial tissue, failure of tooth enamel and/or degeneration, loss of taste and smell.

Riboflavin: Sore throat, hyperemia, edema of pharyngeal and oral mucous membranes, cheilosis, angular stomatitis, glossitis, seborrheic dermatitis, and normochromic, normocytic anemia. Magenta tongue.

Convulsions or intractable seizures in infants and young children; anemias; nerve and skin disorders.

Pregnancy-induced anemias; neural tube defects. Cardiovascular disease with elevated homocysteine levels.

Biotin: Inflammation of the lips and skin.

Liver damage and altered DNA function.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • •

Height Weight BMI Diet history Neurologic, hepatic, or renal changes Physical signs of malnutrition (see Table 2-9 and AppendixA)

Lab Work • • • • • • • • • • • •

Vitamin A—serum retinol ⬍0.35 mmol/L Vitamin C—plasma concentrations ⬍0.2 mg/dL Vitamin D—25-OHD values ⬍25 nmol/L Vitamin E—plasma alpha-tocopherol ⬍18 ␮mol/g Vitamin K—elevated prothrombin time, altered INR Thiamin—erythrocyte transketolase activity ⬎1.20 ␮g/ mL/h; AST is often decreased Riboflavin—erythrocyte glutathione reductase ⬎1.2 IU/mg hemoglobin Niacin—N-methyl-nicotinamide excretion ⬍5.8 ␮mol/d Vitamin B6—plasma pyridoxal 5⬘phosphate ⬍20 nmol/L Vitamin B12—serum concentration ⬍180 pmol/L; elevated tHcy Folic acid—serum concentration ⬍7 nmol/L; red cell folate ⬍315 nmol/L Choline—low plasma choline and phosphatidylcholine concentrations; abnormal liver function tests may occur

121

• Niacin deficiency or pellagra. Use a diet including foods high in niacin and other B vitamins: yeast, milk, meat, peanuts, cereal bran, and wheat germ. • Folic acid deficiency. Use fresh, leafy green vegetables, oranges and orange juice, liver, other organ meats, and dried yeast. • Vitamin B6 deficiency. Use dried yeast, liver, organ meats, whole-grain cereals, fish, and legumes. • Vitamin B12 deficiency. Use liver, beef, pork, organ meats, eggs, milk, and dairy products. • Biotin deficiency. Use liver, kidney, egg yolks, yeast, cauliflower, nuts, and legumes. • Pantothenic acid deficiency. Use live yeast and vegetables. • Choline. Include eggs, liver, beef, milk, oatmeal, soybeans, peanuts, and iceberg lettuce. Vitamin C Deficiency (Scurvy) • Use a diet high in citrus fruits, tomatoes, strawberries, green peppers, cantaloupe, and baked potatoes. Vitamin D Deficiency • Use fortified milk, fish liver oils, and egg yolks. Expose skin to sunlight if possible. Vitamin E Deficiency • Use vegetable oil, wheat germ, leafy vegetables, egg yolks, margarine, legumes, creamy salad dressings, and nuts. Vitamin K Deficiency • Use a diet high in leafy vegetables, pork, liver, and vegetable oils.

Food–Drug Interactions

INTERVENTION Objectives • Replenish the deficient nutrient and restore normal serum levels. • Prevent or correct signs, symptoms, and effects of nutrient deficiency. For example, reduced immunity and high maternal and child mortality occur in populations with poor intakes of vitamin A. Vitamin D deficiency can lead to a number of changes in overall immunity and health.

Food and Nutrition Vitamin A Deficiency • Use a diet including foods high in vitamin A and carotene: carrots, sweet potatoes, squash, apricots, collards, broccoli, cabbage, dark leafy greens, liver, kidney, cream, butter, and egg yolk. B-Complex Vitamin Deficiency • Thiamin deficiency (beri-beri). Use a diet including foods high in thiamin: pork, whole grains, enriched cereal grains, nuts, potatoes, legumes, green vegetables, fish, meat, fruit, and milk in quantity. A high-protein/high-carbohydrate intake should be included. • Riboflavin deficiency. Use a diet including foods high in riboflavin: milk, eggs, liver, kidney, and heart. Caution against losses resulting from cooking and exposure to sunlight.

Escott-Stump_Ch02.indd 121

Common Drugs Used and Potential Side Effects or Toxicity Note: The DRI “tolerable upper intake levels” address the toxic side. • Vitamin A. Absorption of vitamin A depends on bile salts in the intestinal tract. Controlled high doses may be prescribed for a short period of time. Beware of doses greater than the recommended upper limit per day for a long time, especially for children. • Thiamin. A common dose is 5 to 10 mg/d of thiamin; anorexia and nausea may be common at the beginning of treatment. Intravenous therapy may be better tolerated. • Riboflavin. Achlorhydria may precipitate a deficiency and may preclude successful correction. Alkaline substances destroy riboflavin. • Niacin. Treatment with niacin may cause flushing. Niacinamide is a better choice; 200 to 400 mg of niacin or niacin equivalents may be used for a short time. Nicotinic acid can cause nausea, vomiting, and diarrhea. • Vitamin B6. Pyridoxine hydrochloride is the common content. • Pantothenic acid. Pantholin is a drug that is prescribed as needed. • Choline. Choline hydrochloride salt may be degraded by intestinal bacteria and cause a fishy body odor. This does not occur when lecithin is eaten in the diet. • Vitamin C. Excesses can cause false-positive glucosuria tests. Cevalin or Cevita are drug sources; 50 to 300 mg/d may be given to correct scurvy. Excesses may have an antihistamine effect or cause diarrhea.

11/7/14 2:13 AM

122

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

• Vitamin D. Calderol, Rocaltrol, Hytakerol, and Calciferol are common drug sources. Be sure to use vitamin D3 [25-hydroxyvitamin D (25-OHD)] for greater effectiveness. • Vitamin E. Aquasol E has no adverse side effects if used within measured dosage for age and daily requirements. • Vitamin K. Vitamin K is usually injected to correct deficiency rather than using diet alone. Synkayvite, Mephyton, and Konakion are trade names.

SAMPLE NUTRITION CARE PROCESS STEPS Vitamin A Deficiency Assessment Data:Food intake records, physical signs of deficiency, frequent bouts of infectious illnesses. Nutrition Diagnosis:Inadequate vitamin A intake related to poor appetite and intake as evidenced by prolonged recovery after measles, recent onset of night blindness, serum retinol ⬍0.35 mmol/L, complaints of lethargy, and frequent illnesses.

Herbs, Botanicals, and Supplements • Herbs and botanicals may be used by many individuals; identify and monitor side effects. • Counsel about use of herbal teas, especially regarding ingredients that may be toxic.

Intervention:Education of patient, staff, or family members about the role of vitamin A for healthy immunity and vision. Counseling about good sources of vitamin A and carotenoids. Micronutrient provision meeting 100% DRI for vitamin A.

Nutrition Education, Counseling, CareManagement • Explain where sources of the specific nutrient may be found. • Demonstrate methods of cooking, storage, etc. that prevent losses. • Help the patient plan a menu incorporating his or her preferences. • Discuss the use of vitamin and mineral supplements. Although they may be appropriate to correct a deficiency state, they may not be warranted for continuous or longterm use.

Monitoring and Evaluation:Total recovery after measles. Improvement in vision. Labs improving for retinol. Fewer infectious illnesses, colds, flu, etc. Improved quality of life.

For More Information ●

Medline Plus http://www.nlm.nih.gov/medlineplus/vitamins.html

●

Merck Manual http://www.merck.com/mmpe/sec01/ch004/ch004a.html

●

NIH Office of Dietary Supplements http://www.cc.nih.gov/ccc/supplements/intro.html

●

Nutrient Data Laboratory http://www.ars.usda.gov/main/site_main.htm?modecode=12354500

●

Nutrition Information http://www.nutrition.org/

●

Vitamin Information Service http://www.vitamins-nutrition.org/

FOOD ALLERGY AND AUTOIMMUNE INNER EAR SYNDROME

FOOD ALLERGY NUTRITIONAL ACUITY RANKING: LEVEL 3–4 (COMPLEX) DEFINITIONS AND BACKGROUND Up to 35% of the population modify their diet for adverse reactions to food. Proper diagnosis would be one of three choices: food-allergic (DFA), self-reported food-allergic or intolerant (SFA), or nonfood-allergic (NFA) (Sommer et al, 2012). Many symptoms can occur. The manifestations of true allergy are caused by the release of histamine and serotonin (Fig.2-14). If genuine, they should be reproducible by a double-blind placebo-controlled food challenge (Ho et al, 2014). It is important to distinguish food allergies from intolerances caused by toxins or drugs and disorders such as lactase deficiency or celiac disease. A food intolerance comes on gradually, often after eating a large amount of the offending food.

Escott-Stump_Ch02.indd 122

Food allergies usually happen quickly, every time the food is eaten, and can be life-threatening. In fact, food allergy is now recognized as a protected disability in the United States. Allergic tendencies are inherited but not necessarily to a specific antigen (i.e., a parent with a genetic predisposition to severe bee sting reactions could have a child with a bee sting allergy, food allergy, or other allergy). Children who have a fever before age 1year are less likely to develop signs of allergy years later, and exposure to pets such as dogs at an early age builds immunity. People with allergic tendency may develop new sensitivities at any time. Food allergies in the United States affect about 6 million people. Worldwide, they affect 3.5% to 4% of all individuals (Taylor, 2008). Prevalence in infancy is increasing; up to 15% to 20% of infants may present with atopic eczema, infantile colic, and gastroesophageal reflux (Ho et al, 2014).

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

Mast cell

123

Basophil

Granules containing histamine

Histamine

H1 receptor antagonist H1 receptors

UU UU

Skin

U U

Blood vessel

Bronchi

Figure 2-14. Food allergy. (Reprinted with permission from Abrams AC, Pennington SS. Foundations of clinical drug therapy. Philadelphia, PA: Wolters Kluwer Health; 2004.)

HOT H OT TOPIC Inflammation Inflammation, allergy, and asthma are the manifestation of biological, cellular, and immunological events that lead to increased vascular permeability, vasodilatation, cellular migration, increased mucus secretion, bronchoconstriction, structural changes of airway architecture, decline in pulmonary functions, release of intracellular mediators, increased formation of reactive oxygen species, cartilage degradation, and loss of function (Naik and Wala, 2013). The GI tract is highly involved. Gut-associated lymphoid tissue is developed after birth with bacterial colonization, supporting development of protective IgA. An imbalance in T cells (type th2 greater than type th1) promotes autoimmune disease and other undesirable reactions (Walker, 2008).

The three types of food allergy are IgE mediated, mixed (IgE/ Non-IgE), and non–IgE-mediated (cellular, delayed type hypersensitivity) allergy (Lee and Burks, 2009). Food allergy reactions usually occur within 2 hours. Immediate (1 minute to 2 hours) or delayed reactions (2 to 48 hours) may also occur. Table 2-10 describes the spectrum of adverse immunologic responses to dietary antigens.

Escott-Stump_Ch02.indd 123

Over 170 different foods have been known to produce an allergy or intolerance. However, 90% of food allergies are caused by only eight foods: eggs, milk, wheat, soy, fish, shellfish, peanuts, and tree nuts. The most common symptoms of food allergies affect the GI tract: diarrhea, nausea, vomiting, cramping, abdominal distention, and pain. Figure 2-15 provides an oral food challenge flow sheet for documentation and evaluation (Nowak-Wegrzyn et al, 2009). Histamine mediates anaphylaxis by triggering a cascade of inflammatory mediators. Histamine intolerance results from excessive accumulation versus the capacity for histamine degradation; diamine oxidase is the main enzyme for the metabolism of ingested histamine (Maintz et al, 2011). Histamine occurs naturally in foods such as cheese, red wines, spinach, eggplant, and yeast extract. The ingestion of histamine-rich food, alcohol, or drugs may provoke diarrhea, headache, rhinoconjunctival symptoms, asthma, hypotension, arrhythmia, urticaria, pruritus, or flushing in patients with histamine intolerance. A reaction may also occur from eating spoiled (scombroid) fish. In addition, persons with chronic urticaria may have impaired small bowel enterocyte function and higher sensitivity to histamine-producing foods. A lowhistamine, balanced diet could be helpful (Chung et al, 2011). Probiotics have a role in reducing undesirable GI tract responses to pathogens and allergens. In addition, omega-3 fatty acids and retinoids regulate immunosuppressive factors within the mucosa. Antioxidant vitamins (vitamins C and E), polyphenols, and carotenoids from dietary vegetable food and oil could exert protective effects against toxic effects exerted by gluten

11/7/14 2:13 AM

124

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-10 Gastrointestinal Allergic Manifestations DESCRIPTION

ETIOLOGY

RESPONSE

SYMPTOMS

Immediate GI hypersensitivity

Often a manifestation of anaphylaxis.

Immunologic and IgE mediated.

Acute immediate vomiting within minutes; lower GI symptoms either immediately or delayed several hours.

Eosinophilic esophagitis (EoE)

Commonly associated with the presence of food-specific IgE, but precise etiology is not well defined.

Both IgE- and non–IgE-mediated mechanisms seem to be involved.

Localized eosinophilic inflammation of the esophagus.

Eosinophilic gastroenteritis (EG)

Precise etiology is not well defined.

Both IgE- and non–IgE-mediated.

EG symptoms vary depending on the portion of the GI tract involved and a pathologic infiltration of the GI tract by eosinophils that may be quite localized or very widespread.

Dietary proteininduced proctitis/ proctocolitis

IgE response to specific foods is generally absent.

Typically presents in infants who seem generally healthy.

Visible specks or streaks of blood mixed with mucus in the stool.

Food proteininduced enterocolitis syndrome (FPIES)

Non–IgE-mediated

In infancy, usually cow’s milk and soy protein are the most common causes.

Severe projectile vomiting, diarrhea, colic, and failure to thrive; severe enough to cause dehydration or shock.

Children will often outgrow an allergy to milk and soy by age5 or 6 years.

In adults, most often related to crustacean shellfish ingestion.

COMMENTS

Tolerance improves when egg or milk products are extensively heated (Sicherer and Leung, 2009).

Oral allergy syndrome (OAS)

Localized IgE-mediated

Pollen-associated FA syndrome. Reaction from direct contact with fresh fruits or vegetables, confined to the lips, mouth, and throat. OAS most commonly affects patients who are allergic to pollens.

Itching of the lips, tongue, roof of the mouth, and throat, with or without swelling, and/or tingling of the lips, tongue, roof of the mouth, and throat.

Rapid onset of symptoms, but it is rarely progressive. Cross-reactivity occurs: ragweed allergy with ingestion of bananas or melons; birch pollen allergy with ingestion of raw carrots, celery, potato, apple, hazelnut, or kiwi; latex allergy with apples, avocado, banana, bell pepper, cherries, chestnut, kiwi, nectarines, peach, plums, potato, and tomato.

Celiac disease and gluten sensitivity

Non–IgE-mediated immune mediated

Contact with gluten

See Section 7, Gastrointestinal Disorders.

Lifelong omission of gluten required

Allergic reaction induced by intense exercise following ingestion of a causative food. FDEIA is often associated with celery, chicken, shrimp and shellfish, alcohol, tomatoes, or cheese.

Itching, hives, lightheadedness, or anaphylaxis.

Avoid trigger foods for several hours before exercise.

Flushing syndrome, anaphylactoid reactions of urticaria/angioedema, asthma, food allergy, or exercise-induced anaphylaxis in susceptible individuals.

Avoid alcoholic beverages. Sulfites in some wines may cause symptoms.

Rapid onset. Itchy lips, tongue, or palate; metallic taste; flushing and itching or urticaria of skin; angioedema and edema of lips and tongue; nausea, vomiting, or diarrhea; tightness in chest or throat; dysphagia; hoarseness; dry cough; shortness of breath or wheezing; rhinorrhea or congestion; bronchospasm; syncope; chest pain; and hypotension. Potentially life-threatening systemic reaction such as cardiovascular shock or serious respiratory compromise due to airway obstruction or bronchoconstriction.

Peanuts, TNs, shellfish, milk, eggs, and fish are the most problematic.

Food-dependent exercise-induced anaphylaxis (FDEIA)

Hypersensitivity to alcohol

Alcohol may promote development of IgEmediated hypersensitivity to different allergens.

Food-induced anaphylaxis

IgE-mediated

Anaphylaxis occurs when a person is exposed to an allergen after being sensitized by at least one previous exposure.

Tropomyosin is the protein that causes allergic reactions in shellfish (Taylor, 2008). In peanut allergy, even miniscule amounts have caused deaths (Lee and Burks, 2009).

References: Lee LA, Burks AW. New insights into diagnosis and treatment of peanut food allergy. Front Biosci. 2009;14:3361; Sicherer SH, Leung DY. Advances in allergic skin disease, anaphylaxis, and hypersensitivity to foods, drugs and insects in 2012. J Allergy Clin Immunol. 2013;131:55; Taylor SL. Molluscan shellfish allergy. Adv Food Nutr Res. 2008;54:139.

Escott-Stump_Ch02.indd 124

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

PATIENT NAME _____________________________________

125

Date _____________________________________

OFC type: Open _____ Single blind _____ Double-blind _____ Location: Office _____ ED _____ Inpatient _____ Food provided by: Patient ___ Physician/dietitian ___ Challenge food __________________ Masking food __________________ Placebo food __________________ Total dose of challenge food _______ Total weight of challenge food mixed with masking food _______ Time

Dose

Symptom score Rash % body area

Base

Pruritus

Urticaria

Rash

Sneezing/ itching

Nasal congestion

Runny nose

Larynx

Wheeze

GI subjective

GI objective

Cardiovascular

Total score

Comments stop/continue

Total dose ingested (%): ____________ TREATMENT Time

Symptoms

Time stopped: ____________ Treatment

Outcome: Passed ___ Failed ___ Vital signs

Comment

Discharge home: Time _____ Discharge instructions: _____________________________________________________________ _______________________________________________________________________________________________________ Physician’s signature _________________________ Date/time _____________ Figure 2-15. Sample oral food challenge flow sheet. (Reprinted with permission from Nowak-Wegrzyn A, Assa’ad AH, Bahna SL, et al. Work group report: oral food challenge testing. J Allergy Clin Immunol. 2009;123[6 Suppl]:S365.)

peptides on intestinal cells (Ferretti et al, 2012). Figure 2-16 shows how certain foods protect against the toxic factor in gluten. Nutrition during pregnancy has been studied for years for the effects on allergy. Reduced vitamin D status in pregnancy may be a risk factor for the development of eczema in infants (Jones et al, 2012). High intakes of margarine, vegetable oils, and some allergenic fruit and vegetables during pregnancy may increase the risk for eczema (Sausenthaler et al, 2011). Maternal supplementation with omega-3 polyunsaturated fatty acids modulates immune responses, decreasing asthma in children (Klemens et al, 2011). These findings need further replication. Guidelines on early nutrition for allergy prevention in children have been published. There is no need to avoid introducing complementary foods beyond 4 months, but evidence does not justify recommendations about either withholding or encouraging exposure to potentially allergenic foods between 4 to 6 months (Muraro et al, 2014.) Indeed, early introduction of wheat, rye, oats, and barley cereals; fish; and egg seems to decrease the risk of asthma, allergic rhinitis, and atopic sensitization in infants (Nwaru et al, 2013). In adults, food allergy prevalence has been found in 50% in patients with atopic dermatitis; eggs, milk, and wheat may be the most problematic (Kwon et al, 2013). Thus, more research is needed. Healthy gut mucosal immunity plus appropriate feeding regimen during early infancy promote food tolerance (Chahine and Bahna, 2010). Excessive protein intake from infant formula

Escott-Stump_Ch02.indd 125

with the absence of desirable bifidobacteria and immune-regulatory microRNAs is a possible etiology (Melnick, 2014). Allergy is facilitated by defects in the gut barrier (immune or nonimmune), food allergen load, and genetic predisposition. In patients with food allergy, the dominant immune response is a skewed T-cell response and the generation of food-specific IgE antibodies from B cells (Berin and Mayer, 2013). Researchers are trying to modify the allergic immune response through oral immunotherapy, sublingual immunotherapy, epicutaneous immunotherapy, modified food protein vaccines, anti-IgE monoclonal antibody adjuvant therapy, or Chinese herbal therapy (Virkud and Vickery, 2012). Peanut sublingual immunotherapy has been tested for desensitizing people who are allergic to peanuts (Fleischer et al, 2013; Varshney et al, 2011). However, allergen-specific peanut oral immunotherapy is not recommended until larger trials prove safety (Nurmatov et al, 2012). Oral immunotherapy can desensitize a high proportion of children with egg allergy (Burks et al, 2012) and milk allergy (Keet et al, 2012). Food ingredient labeling is the first line of defense for those with food allergies and their caregivers. Food ingredient labels should be read every time a food is purchased and used. The Food Allergen Labeling and Consumer Protection Act (FALCPA) requires that food labels are to provide clear, consistent, and reliable ingredient labeling information. The “common English” names of the top eight major food allergens are to be used in food labeling.

11/7/14 2:13 AM

126

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

DIET (vegetable foods, olive oil)

OH HO

Lumen

Gluten

Vitamin C

Polyphenols

O OH OH

HO HO

Gluten

Polyphenols

(+) Altered permeability Inflammation Oxidative stress NF-kB activation Gene expression

HO HO

Vitamin C

O OH

((-) Carotenoids Vitamin E

Figure 2-16. Protective effect of phytonutrients on cytotoxicity of gluten peptides. (Adapted with permission from Ferretti G, Bacchetti T, Masciangelo S, et al. Celiac disease, inflammation and oxidative damage: a nutrigenetic approach. Nutrients. 2012;4:243.)

Legislation requires one of two options for food labeling with these terms. The first is to list the food allergen in parentheses following the required ingredient term; for example, “whey (milk)” or “semolina (wheat).” The second option is to follow the ingredient declaration with a statement such as “contains flounder, pecan, wheat, and soy.” In addition, all spices, flavors, and incidental additives that contain or are derived from a major food allergen will be labeled with the name of an allergen under either ingredient labeling option. For example, a flavor that contains an ingredient derived from milk might say “natural butter flavor (milk).” Genetically modified (GM) foods are the product of biotechnology. Genetic bioengineering may, eventually, be able to reduce the level of allergens in the food supply. For GM foods, possible allergenicity of proteins is evaluated by comparison of their amino acid sequence with that of known allergens and determination of their stability during processing. GM crops that have been grown commercially are regularly evaluated for allergenic properties. Before a GM crop can be commercialized, it must pass through a rigorous regulatory process as outlined by the Food and Agriculture Organization (FAO) and World Health Organization’s (WHO) Codex Alimentarius Commission (Codex) for safety (Young et al, 2012).

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Both genetics and environment play a role in promoting food-specific IgE responses (Tsai et al, 2009). Major food allergens are water-soluble glycoproteins. In normal

Escott-Stump_Ch02.indd 126

individuals, allergens cause an IgA response along with suppressor CD8⫹ lymphocyte production.

Clinical/History • • • • • • • • • • •

Height Weight BMI Recent weight changes Food diaries and symptoms history BP Temperature Chronic GI distress, diarrhea Asthma or rhinitis Angioedema, urticarial Double-blind food challenge test

Lab Work • • • • • • • • • • • • •

H&H, serum Fe Serum tryptase (elevated) Serum histamine Allergen microarray test for IgE profiling Radioallergosorbent test (RAST) Histamine-50 skin prick test: 50% false-positives, but reliable if negative Double-blind, placebo-controlled food challenge Patch tests for delayed hypersensitivity reactions MicroRNA analysis—possible noninvasive disease biomarker CRP Alb, transthyretin BUN, Creat Serum vitamin D

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

INTERVENTION Objectives • Careful clinical history, diagnostic studies, endoscopy, or double-blind food challenge may be needed. Children with atopic dermatitis could have a food allergy that can be diagnosed using a skin prick test and double-blind food challenge. Teach how to keep a food diary to track reactions to food. • The therapy is avoidance of incriminating foods plus education to avoid inadvertent exposures. Exclude or avoid the offending allergen. If it is not known, use an elimination diet to discover the cause. Note that “rotation diets” are not effective and are potentially dangerous. • Monitor speed of onset of reactions—delayed versus immediate. The onset of delayed reaction may take from several hours to as long as 5 days. An immediate response is more common with raw foods; patient history may include diarrhea, urticaria, dermatitis, rhinitis, and asthma (see Asthma in Section5, Pulmonary Disorders). Allergic diarrhea is almost entirely IgE and mast-cell dependent, mediated by serotonin.

127

• Treatment of GI allergic disorders includes strict dietary elimination of offending food. Intake of omega-3 fatty acids, plant flavonoids, and carotenoids may be useful by preserving intestinal barrier integrity (Feretti et al, 2012). More research is needed. • Treat nutritional deficiencies or ensure adequate supplementation. Children who have multiple food allergies tend to have growth problems. Table 2-11 lists the nutritional consequences of food allergy by various allergens. • Follow the National Institute of Allergy clinical practice guidelines at http://www.niaid.nih.gov/topics/foodAllergy /clinical/Documents/guidelines.pdf.

Food and Nutrition • Introduction of wheat, rye, oats, or barley is reasonable at 5 to 5.5 months; egg at 11 months or less; fish at 9 months or less (Nwaru et al, 2013). Pediatricians are less aware than dietitians of the current recommendations (Leo et al, 2012). • The most common allergens in infants are eggs, wheat, milk, and fish. For children, cow’s milk, eggs, soy, peanuts, wheat, tree nuts, and fresh fish are often a problem. • For adults, common allergens include shellfish, peanuts, and tree nuts. Peanuts are implicated in approximately one-third of all cases of anaphylaxis.

TABLE 2-11 Major Food Allergens and Nutritional Consequences MOST COMMON

Nutrients of concern

Milk

Check for deficiencies in protein, riboflavin, calcium, and vitamins A and D.

Eggs

Check for iron from other sources.

Fish and shellfish

Other protein sources will be needed. Niacin, vitamin B6, vitamin B12, omega-3 fatty acids, phosphorus, and selenium should be available from other foods.

Nuts, tree

Protein, fatty acids, and other nutrients will be needed from other sources in the diet. Often, children outgrow a tree nut allergy.

Peanuts

Protein, fatty acids, and other nutrients will be needed from other sources in the diet.

Soy

Protein and other nutrients may be needed from other sources.

Wheat

Check for sufficiency of B vitamins and iron from other sources.

LESS COMMON

Most frequently tied to adverse reactions that can be confused with food allergy are yellow dye number 5, monosodium glutamate (MSG), and sulfites.

Food additives: Tartrazine (not a true food allergen)

Yellow dye number 5 can cause hives, although rarely. FD&C Yellow No. 5, or tartrazine, is used to color beverages, dessert powders, candy, ice cream, custards, and other foods. The color additive may cause hives in fewer than one out of every 10,000 people. By law, whenever the color is added to foods or taken internally, it must be listed on the label so those who may be sensitive to FD&C Yellow No. 5 can avoid it (http://www.cfsan.fda.gov/~dms/qa-top.html).

MSG (not a true food allergen)

Dietary glutamate is a major energy source for the intestines and placenta. The brain is well protected against a flux of glutamate, and it is not toxic. Glutamate is found naturally in foods such as tomatoes and cheeses and is released in protein hydrolysis during stock or soup preparation. It is added to foods in crystalline form as MSG. MSG, which is 14% sodium, is used as a flavor enhancer, known as “umami.” Glutamate helps to stimulate the vagus nerve and helps to facilitate digestion and nutrient absorption. MSG enhances flavor, but when consumed in large amounts, it can cause flushing, sensations of warmth, light-headedness, headache, facial pressure, and chest tightness; these effects are temporary. These adverse reactions, “Chinese restaurant syndrome,” have not been confirmed in double-blind studies.

Mustard

Mustard allergy is not as uncommon as previously believed. There is a relationship with mugwort pollinosis and plant-derived food allergies.

Rice

Certain ethnic groups may have sensitivities to foods that may not be as allergenic for other populations. An example is an Asian person who develops an allergy to rice. Some of this may be dose-related exposure.

Spices

Spices may cause delayed-typed contact allergic or immediate allergic reaction. Sesame seed is a fairly common allergen. Carmine/ cochineal is another minor allergen.

Sulfites (not a true food allergen)

Although not an IgE-mediated allergic response, sulfites can produce life-threatening reactions similar to the major food allergens. To help sulfite-sensitive people avoid problems, FDA requires the presence of sulfites in processed foods to be declared on the label and prohibits the use of sulfites on fresh produce intended to be sold or served raw to consumers. Foods such as wine, beer, dried fruits and vegetables, maraschino cherries, and dried or frozen potatoes may contain sulfites. No specific nutrient deficits are likely if omitted from the diet.

Escott-Stump_Ch02.indd 127

11/7/14 2:13 AM

128

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

• If needed, try an elimination diet. Use an unflavored elemental diet as a hypoallergenic base to which other foods are added as test challenges. Foods that seldom cause an allergic reaction and may be used include apples, apricots, artichokes, carrots, gelatin, lamb, lettuce, peaches, pears, rice, squash, and turkey. • Read labels of foods prepared for the patient and check all menu items served (see Table 2-12). • Monitor food preparation methods to exclude possible cross contact with the allergen. Evaluate for possible “hidden” ingredients.

• Include nutrient needs specific for the patient’s age. Growth delays and nutrient deficiencies can occur in allergic children (Henson and Burks, 2012). • For infants, breastfeeding is best. Longer duration of total breastfeeding, rather than exclusivity, is protective against the development of nonatopic but not atopic asthma (Nwaru et al, 2013). • Include plant flavonoids and carotenoids as often as tolerated.

TABLE 2-12 Specifics of Food Allergies FOOD

COMMENTS

Egg

Reactions are usually mild. Flu shots may contain egg albumin. Yolks are often tolerated. ALWAYS CONTAINS IT: Albumin, cake, cholesterol-free egg, cookies, custard, doughnuts, dried eggs, egg, eggnog, egg noodles, egg rolls, egg solids, egg white, globulin, hollandaise sauce, lecithin, livitin, lysozyme, mayonnaise, meringue, ovalbumin, ovomucin, ovotransferrin, ovovitellin, some puddings, pretzels, Simplesse sweetener, souffle, waffles, vitellin. MAY CONTAIN IT: Baked goods with egg wash (usually shiny,) béarnaise sauce, candy, creamed foods, dry food mixes, frozen dinners, glazes, ice creams, icings and frostings, lemon curd, marshmallows, tartar sauce.

Fish and shellfish

Abalone, clams, crab, crawfish, lobster, oysters, scallops, shrimp, cockle (sea urchin), and mussels are the shellfish that should be avoided. Avoid seafood restaurants. ALWAYS CONTAINS IT: Fish, shellfish, agar, alginic acid, ammonium alginate, anchovies, calcium alginate, caviar, disodium inosinate, potassium alginate, propylene glycol alginate sodium alginate, imitation crab or “surimi,” roe. MAY CONTAIN IT: Asian sauces, Caesar salad dressing, omega-3 fatty acid capsules or oils; Chinese, Vietnamese, Japanese, Indian, Indonesian, and Thai foods; fried foods such as French fries, chicken nuggets (often cooked in the same oil as fish/shellfish); steak or Worcestershire sauces.

Latex

Natural rubber latex contains more than 35 proteins that may be related to type IgE–mediated allergy. Latex-specific IgF may be responsible. CROSS-REACTIVITY: Banana, avocado, kiwi, and European chestnuts. Less commonly with potatoes, tomatoes, peaches, plums, cherries, and other pitted fruits.

Milk

ALWAYS CONTAINS IT: Butter, butter fat, buttermilk, curds, casein, caseinates, cheese, cheese sauces, condensed milk, cottage cheese, cream, cream cheese, cream sauces, dry milk solids, evaporated milk, lactalbumins, lactoglobulins, lactose, nougat, rennet, milk, milk protein hydrolysates, milk solids, nonfat or powdered milks, sour cream, whey, white sauces, yogurt. MAY CONTAIN IT: Artificial butter flavor, biscuits, canned tuna, caramel color or flavoring, custards, deli meats, foods fried in batter, gravy, margarine, natural flavorings, puddings, sauces, sausages, sherbet, soups, soy/vegetarian cheese. It may be necessary to acquire calcium from greens and broccoli or clams, oysters, shrimp, and salmon if not allergic to fish. Calcium supplementation may also be warranted. Persons with a milk allergy can add vanilla or other flavorings to soy milk. Goat’s milk has less lactalbumin, vitamin D, and folate than cow’s milk and supplements may be required. Some people may also be allergic to goat’s milk, so caution must be used. Avoid introduction of cow’s milk before 12 months of age.

Nuts, tree

Tree nuts include almonds, Brazil nuts, cashews, chestnuts, filberts, hazelnuts, hickory nuts, macadamia nuts, pecans, pine nuts, pistachios, and walnuts. Read all food labels. MAY CONTAIN IT: Ground or mixed nuts, nut butter, nut paste, nut oil, and nut extracts.

Peanut

Peanuts are a type of legume. A person is more likely to be allergic to tree nuts than to beans, peas, and lentils. Avoid nut butters; aflatoxins can cause an allergic-like reaction. For the food industry, new inexpensive kits are available to test for presence of peanut proteins in cookies, cereal, ice cream, and milk chocolate. ALWAYS CONTAINS IT: Peanuts, mixed nuts, peanut butter, peanut oil, peanut flour, ground or mixed nuts, artificial nuts, nougat, many types of candy or cookies, ethnic dishes made with peanut oil, some egg rolls, marzipan. MAY CONTAIN IT: Egg rolls, thickener in chili, trail mix, energy bars, artificial nuts, ethnic cuisines such as Thai or Chinese, gravies or chili, nut butters, salad dressing.

Soy

Some people are also allergic to legumes such as chickpeas, navy beans, kidney beans, black beans, pinto beans, lentils, and peanuts. Reading food labels will be very important. ALWAYS CONTAINS IT: Miso, shoyu, sobee, soya, soybeans, soybean flour, soybean oil, soybean oil margarines, soy sauce, soy nuts, soy nut butter, soy milk, soy protein, tofu, tempeh, textured vegetable protein. MAY CONTAIN IT: Baked goods, bread, butter substitutes, canned tuna, crackers, emulsifier, energy bars, gravy, hydrolyzed plant protein, ice cream, lecithin, liquid meal replacements, protein extender, protein filler, salad dressings, vegetable broths, veggie burgers, Worcestershire sauce.

Wheat

Wheat-dependent exercise-induced anaphylaxis and baker’s asthma are different clinical forms of wheat allergy. ALWAYS CONTAINS IT: All-purpose flour, bran, bread crumbs, bulgur, cereal extract, dextrin, durum, farina, enriched flour, gelatinized starch, gluten, graham flour, high-gluten flour, high-protein flour, kamut, malt flavoring, matzoh/matzoh meal, miller’s bran, modified food starch, modified starch, noodles, pastry flour, semolina, spelt, starch, wheat germ, wheat gluten, wheat malt, wheat starch, whole wheat flour. MAY CONTAIN IT: Baby food, baked goods, baking mixes, breaded foods, breads, cakes or cookies, and other baked goods made with wheat flour; cereals, cornstarch, couscous, crackers, cracker meal, gelatinized starch, hot dogs, hydrolyzed vegetable protein, imitation crabmeat, pastas, processed meats, sausage, snack foods, soups, vegetable gum, vegetable starch.

Escott-Stump_Ch02.indd 128

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Epinephrine is the synthetic version of naturally occurring adrenaline. It is the first line of defense for anaphylaxis and often requires an emergency room visit. • Injectable epinephrine should be carried by those who are prone to allergic reactions to food. An Epi-Pen provides a single dose; the Ana-Kit provides two doses. • H1-antihistamines (e.g., ranitidine, cimetidine) are adjunctive treatment therapy for acute anaphylactoid reactions, but they have a slow onset of action when compared with epinephrine. They are a mainstay of therapy for urticaria; nonsedating products include loratadine. • Oral antihistamines, such as Benadryl or Atarax or Vistaril, should be taken with food. Dry mouth, constipation, and GI distress are potential side effects. • Probiotics (beneficial intestinal bacteria), T regulatory cells, and dendritic cells are all essential for generating tolerance by the mucosal immune system; antibiotic usage correlates with a breakdown in immune tolerance (Lambert et al, 2012). Thus, probiotics may be useful for managing allergy (Vanderhoof, 2008). Biologics, vitamin D, and skin creams have also been tested (Sicherer and Leung, 2012). • Studies support influenza vaccination of persons with egg allergy using modest precautions (Sicherer and Leung, 2012). • Xolair is approved for allergic asthma. It may also be beneficial for chronic urticaria. • Consumption of omega-3 fatty acids can reduce the severity of asthma symptoms. Monitor for fish allergy if using fish oils. • Treatment with topical or systemic steroids is used if all dietary measures are unsuccessful. Herbs, Botanicals, and Supplements • Bee pollen does not prevent allergies. It may, in fact, cause asthma, urticaria, rhinitis, or anaphylaxis after eating plants that cross-react with ragweed, such as sunflowers or dandelion greens. • Food/plant sensitivities are common (e.g., melon/ragweed, apple/birch, wheat/grasses). Be cautious with herbal teas, including chamomile. • Chinese herbal formula FAHF-2 shows promise in reducing anaphylaxis (Kim and Burks, 2012). • Jewelweed may be helpful for managing contact dermatitis but should not be taken orally (Abrams Motz et al, 2012). • Parsley, amaranth, gingko, and allium have been proposed for use with allergies or hives; however, long-term studies are needed. Raw parsley, arugula, spinach, and tomato have been known to cause contact dermatitis in sensitive individuals. • Stinging nettle (Urtica dioica) has been used to reduce elevated levels of inflammation and insulin. More studies are needed. • Sweeteners are not usually allergenic. After reviewing scientific studies, the FDA determined in 1981 that aspartame is safe for use in foods. Persons who have phenylketonuria (PKU) should not use it because it is made from phenylalanine. • Clinical trials are under way to determine effectiveness of traditional Chinese medicines for asthma and allergies.

•

• • •

•

129

Nutrient deficiencies will depend on the food groups involved and omitted. Signs of anaphylaxis (hoarseness, throat tightening, difficulty breathing, tingling in hands or feet or scalp, wheezing) should be taken seriously; call 911 immediately. Teach about possible cross-reactivity, such as cow’s milk with goat’s milk, or various types of fin fish. Many challenges are faced by nut-allergic individuals when they are eating in restaurants and other sites (Leftwich et al, 2011). Individuals with egg or milk allergy may be able to tolerate baked products; this compromise can give greater quality of life (Ford et al, 2013). Nonceliac wheat sensitivity is a distinct clinical condition; some have characteristics more similar to celiac disease and the others are more like food allergy (Carroccio et al, 2012).

Patient Education—Food Safety • Intake of food allergens is actually “intake of unsafe food” in susceptible individuals. With GI disturbances and reactive symptoms, individuals with food allergies may be more sensitive to food poisoning. • The “hygiene hypothesis” has proposed that excessive use of hand sanitizers and a lack of microbial exposure in infancy can lead to allergy and other autoimmune challenges later. Discuss what is reasonable cleanliness and proper hand washing for food safety without extremes. • Children who have allergies should wear a Medic-Alert tag or bracelet. Adults with peanut or tree nut allergies may want to do the same. • Always work with an RD to identify foods and ingredients to avoid, and develop an eating plan to ensure that each child gets all the nutrients needed to grow and develop properly. • Table 2-13 provides additional tips on educating individuals about food allergies.

SAMPLE NUTRITION CARE PROCESS STEPS Intake of Unsafe Foods—Food Allergies Assessment:Food diaries, food history, history of previous anaphylaxis, and known food allergens. Nutrition Diagnosis: Intake of unsafe food related to knowledge deficit as evidenced by anaphylaxis reaction after consuming peanuts. Intervention:Education and counseling about identified food allergies (peanuts), food labeling, recipes, and ingredients; evaluation of nutritional adequacy. Teach how to keep a food diary, keeping a chronological record of all foods eaten and any associated adverse symptoms. Monitoring and Evaluation: Review of food diaries; reports of no further problems with anaphylactic reactions to foods.

For More Information

Nutrition Education, Counseling, CareManagement • Education on reading ingredient labels is essential. Ensure extensive nutrition counseling and health education for those who have food allergies to avoid nutrient deficiencies, to limit unnecessary restrictions, and to prevent reactions.

Escott-Stump_Ch02.indd 129

●

AllergenOnline http://www.allergenonline.org/

●

American Academy of Allergy, Asthma, and Immunology http://www.aaaai.org/

●

American College of Allergy, Asthma, and Immunology http://www.acaai.org/

11/7/14 2:13 AM

130

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-13 Tips for Educating Individuals about Food Allergies SHOPPING IN FOOD STORES DELI: Ask to have the deli slicer cleaned before preparing the order. Avoid prepared foods because they often share bins and serving utensils. Request that clean gloves beworn. ICE CREAM SHOPS: Make sure they do not share scoops for different flavors. PACKAGED FOODS: Read labels to detect hidden allergens. Choose foods made in facilities that do not make other problematic products. Re-read labels often as ingredients may change; if unsure, call the manufacturer. SALAD BARS: Be careful with severe allergies because food can drop from one container into another. DINING OUT AVOID FRIED FOODS, which often share oil with other problem foods. INQUIRE AHEAD if possible and consult the chef on best menu picks for safe dining. USE A PLEASANT BUT ASSERTIVE MANNER in explaining the situation to wait staff. Let them know that eating even a small amount of a certain food(s) will make you severely ill. BE CAREFUL of sauces and soups. Make sure you know exactly what is in them before eating. REGULAR PATRONAGE. Choose a favorite eatery that accommodates well and visit often. AT SCHOOL EDUCATE: Schools need to educate their entire staff, improve prevention and avoidance measures, make sure epinephrine is readily available and that the staff knows how to administer it, and use consumer agency resources. The Food Allergy Network has educational kits targeted at schools to assist in the training of the staff on food allergies. MEDIC ALERT: Students should be encouraged to wear a Medic-Alert bracelet. CAFETERIA MEALS: Food allergy continues to rise in childhood, and careful meal planning is needed. AT HOME KEEP A FOOD DIARY. Identify all symptoms, timing, and foods eaten. READ FOOD LABELS every time a food is purchased and used. FIND RECIPE BOOKS THAT PROVIDE ALTERNATIVES. Recipe books are available from formula companies, food manufacturers, the Food Allergy and Anaphylaxis Network, and Registered Dietitians. PATIENT OR PARENT EDUCATION: Patients and parents must stay informed about how to handle allergic reactions. AT THE DOCTOR’S OFFICE TESTING: Cytotoxic testing, sublingual provocative tests, pulse tests, kinesiologic testing, yeast hypersensitivity, and brain allergy theories should be dismissed entirely. AFTER ANAPHYLAXIS To work with anaphylaxis, remember the “3 Rs”: RECOGNIZE symptoms; REACT quickly; REVIEW what happened to prevent it from happening again.

●

Asthma and Allergy Foundation of America http://www.aafa.org/

●

Food Allergies Database http://allergyadvisor.com/

●

Food Allergy Research and Education (FARE) http://www.foodallergy.org/

●

Grocery Manufacturers Association http://www.gmaonline.org/

●

Guidelines for the Diagnosis and Management of Food Allergy http://www.jacionline.org/article/S0091-6749(10)01566-6/fulltext

●

Hidden Allergens http://allergyadvisor.com/hidden.htm

●

International Food Information Council Foundation http://ific.org

●

Kids with Allergies http://www.kidswithfoodallergies.org

●

Mayo Clinic http://www.mayoclinic.com/health/food-allergy/DS00082

●

Medline: Food Allergy http://www.nlm.nih.gov/medlineplus/foodallergy.html

●

National Institute on Allergy and Infectious Diseases http://www3.niaid.nih.gov/

●

Nutrition MD—Allergies http://www.nutritionmd.org/consumers/howto_allergy/food_allergy.html

●

RAST Testing http://www.labtestsonline.org/understanding/analytes/allergy/test.html

Escott-Stump_Ch02.indd 130

●

RD411—Allergies, Intolerances, and Special Diets http://www.nutrition411.com/education-materials/allergies-intolerances -and-special-diets

●

Teen Allergies http://kidshealth.org/teen/food_fitness/nutrition/food_allergies.html

REFERENCES Abrams Motz V, et al. The effectiveness of jewelweed, Impatiens capensis, the related cultivar I. balsamina and the component, lawsone in preventing post poison ivy exposure contact dermatitis. J Ethnopharmacol. 2012;143:314. Berin MC, Mayer L. Can we produce true tolerance in patients with food allergy? J Allergy Clin Immunol. 2013;131:14. Burks AW, et al. Oral immunotherapy for treatment of egg allergy in children. NEngl J Med. 2012;367:233. Carroccio A, et al. Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. Am J Gastroenterol. 2012;107:1898. Chahine BG, Bahna SL. The role of the gut mucosal immunity in the development of tolerance versus development of allergy to food. Curr Opin Allergy Clin Immunol. 2010;10:394. Chung BY, et al. Treatment of atopic dermatitis with a low-histamine diet. Ann Dermatol. 2011;23:91S. Ferretti G, et al. Celiac disease, inflammation and oxidative damage: a nutrigenetic approach. Nutrients. 2012;4:243. Fleischer DM, et al Sublingual immunotherapy for peanut allergy: a randomized, double-blind, placebo-controlled multicenter trial. J Allergy Clin Immunol. 2013;131:119.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

Ford LS, et al. Basophil reactivity, wheal size, and immunoglobulin levels distinguish degrees of cow’s milk tolerance. J Allergy Clin Immunol. 2013;131:180. Henson M, Burks AW. The future of food allergy therapeutics. Semin Immunopathol. 2012;34:703. Ho MH, et al. Clinical spectrum of food allergies: a comprehensive review. ClinRev Allergy Immunol. 2014;46:225. Jones AP, et al. Cord blood 25-hydroxyvitamin D3 and allergic disease during infancy. Pediatrics. 2012;130:e1128. Keet CA, et al. The safety and efficacy of sublingual and oral immunotherapy for milk allergy. J Allergy Clin Immunol. 2012;129:448. Kim EH, Burks AW. Managing food allergy in childhood. Curr Opin Pediatr. 2012;24:615. Klemens CM, et al. The effect of perinatal omega-3 fatty acid supplementation on inflammatory markers and allergic diseases: a systematic review. BJOG. 2011;118:916. Kwon J, et al. Characterization of food allergies in patients with atopic dermatitis. Nutr Res Pract. 2013;7:115. Lambert SE, et al. Erythromycin treatment hinders the induction of oral tolerance to fed ovalbumin. Front Immunol. 2012;3:203. Lee LA, Burks AW. New insights into diagnosis and treatment of peanut food allergy. Front Biosci. 2009;14:3361. Leftwich J, et al. The challenges for nut-allergic consumers of eating out. Clin Exp Allergy. 2011;41:243. Leo S, et al. What are the beliefs of pediatricians and dietitians regarding complementary food introduction to prevent allergy? Allergy Asthma Clin Immunol. 2012;8:3. Maintz L, et al. Association of single nucleotide polymorphisms in the diamine oxidase gene with diamine oxidase serum activities. Allergy. 2011;66:893. Muraro A et al. EAACI food allergy and anaphylaxis guidelines. Primary preven-

131

tion of food allergy. Allergy. 2014;69:590–601. Naik SR, Wala SM. Inflammation, allergy and asthma, complex immune origin diseases: mechanisms and therapeutic agents. Recent Pat Inﬂamm Allergy Drug Discov. 2013;7:62. Nowak-Wegrzyn A, et al. Work Group report: oral food challenge testing. J Allergy Clin Immunol. 2009;123(6 Suppl):S365. Nurmatov U, et al. Allergen-specific oral immunotherapy for peanut allergy. Cochrane Database Syst Rev. 2012;9:CD009014. Nwaru BI, et al. Timing of infant feeding in relation to childhood asthma and allergic diseases. J Allergy Clin Immunol. 2013;131:78. Sicherer SH, Leung DY. Advances in allergic skin disease, anaphylaxis, and hypersensitivity to foods, drugs and insects in 2012. J Allergy Clin Immunol. 2013;131:55. Sommer I, et al. Factors influencing food choices of food-allergic consumers: findings from focus groups. Allergy. 2012;67:1319. Taylor SL. Molluscan shellfish allergy. Adv Food Nutr Res. 2008;54:139. Tsai HJ, et al. Familial aggregation of food allergy and sensitization to food allergens: a family-based study. Clin Exp Allergy. 2009;39:101. Vanderhoof JA. Probiotics in allergy management. J Pediatr Gastroenterol Nutr. 2008;47:S38. Varshney P, et al. A randomized controlled study of peanut oral immunotherapy: clinical desensitization and modulation of the allergic response. J Allergy Clin Immunol. 2011;127:654. Virkud YV, Vickery BP. Advances in immunotherapy for food allergy. Discov Med. 2012;14:159. Walker WA. Mechanisms of action of probiotics. Clin Infect Dis. 2008;46:S87. Young GJ, et al. Assessment of possible allergenicity of hypothetical ORFs in common food crops using current bioinformatic guidelines and its implications for the safety assessment of GM crops. Food Chem Toxicol. 2012;50:3741.

AUTOIMMUNE INNER EAR DISEASE (MÉNIÈRE SYNDROME) NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND Autoimmune inner ear disease (AIED) causes disturbed fluid flow within the inner ear. It is also called Ménière syndrome and affects about 1% of the population and presents with episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness (Hamid, 2009). Aggressive medical therapy can prevent disease progression and hearing loss. This condition was long thought to be caused by excessive fluid retention (hydrops) in the endolymphatic spaces of the inner ear; however, Ménière disease may actually involve viral infection or autoimmune injuries (Berlinger, 2011). The prevalence of autoimmune disorders, such as lupus, SjÖgren syndrome, and rheumatoid arthritis, along with AIED, has important implications. Cochlear gene therapy may be used to protect and even regenerate hair cells of the inner ear (Greco et al, 2012).

ASSESSMENT, MONITORING, AND EVALUATION

• • • • • • • •

BMI Diet history Fluctuating hearing loss Tinnitus with roaring sensation Vertigo, blurred vision Nausea and vomiting Known allergies? BP

Lab Work • • • • • • • • •

IgE levels H&H, serum Fe Alb Electrocochleography (ECOG) Electronystagmography (ENG) or balance test Auditory brainstem response Computed tomography scan or magnetic resonance imaging Serum Na⫹⫹, K⫹ I&O

INTERVENTION

Clinical/History

Objectives

• Height • Weight

• Correct nausea and vomiting; replace any electrolyte losses. • Omit any known food allergens from the diet.

Escott-Stump_Ch02.indd 131

11/7/14 2:13 AM

132

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Food and Nutrition • Use a multivitamin–mineral supplement and foods that are nutrient dense. Calcium and vitamin D strengthen the bones of the inner ear. Folate and vitamins B6 and B12 reduce high levels of tHcy, which can reduce blood flow to the cochlea. Vitamin B12 also protects the nerves of the ear. • Provide a diet that is free of known allergens, specific for the individual. Some people report feeling better after eliminating caffeine, aspartame, or alcohol.

SAMPLE NUTRITION CARE PROCESS STEPS

Food–Drug Interactions

Intervention:Education and counseling about potential food allergens, food labeling, recipes, and ingredients. Teach how to keep a food diary, keeping records of foods eaten and any adverse symptoms related to Ménière.

Knowledge Deficit Assessment: Food diaries and history of previous anaphylaxis or food allergens. Nutrition Diagnosis: Knowledge deficit related to balanced dietary intake as evidenced by statements made during interview.

Common Drugs Used and Potential Side Effects • The administration of etanercept improves symptoms in treated patients (Greco et al, 2012). • Diazepam (Valium) may cause nausea, drowsiness, fatigue, and other effects. Limit caffeine. Herbs, Botanicals, and Supplements • Herbs and botanicals may be used; identify and monitor side effects. Counsel about use of herbal teas, especially regarding toxic substances. • Traditional Chinese medicine is often suggested for Ménière syndrome (Yap et al, 2009). • For earache: ephedra, goldenseal, forsythia, gentian, garlic, honeysuckle, and echinacea are sometimes recommended but have not been proven as effective. • For tinnitus: black cohosh, sesame, goldenseal, and spinach have been suggested; no long-term studies are on record that prove effectiveness. Gingko biloba has been approved for tinnitus in Europe.

Nutrition Education, Counseling, Care Management • Discuss how a balanced diet can affect general health status. • Relaxation and biofeedback techniques may be useful for enhancing pain tolerance.

Monitoring and Evaluation: Review of food diaries; reports of fewer problems related to Ménière syndrome.

For More Information ●

Ear Surgery Center http://www.earsurgery.org/meniere.html

●

Ménière’s Disease Information Center http://www.menieresinfo.com/

●

National Institute on Deafness http://www.nidcd.nih.gov/

●

NIH—Ménière’s http://www.nidcd.nih.gov/health/balance/meniere.asp

REFERENCES Berlinger NT. Meniere’s disease: new concepts, new treatments. Minn Med. 2011;94:33. Greco A, et al. Meniere’s disease might be an autoimmune condition? Autoimmun Rev. 2012;11:731–738. Hamid MA. Ménière’s disease. Pract Neurol. 2009;9:157. Yap L, et al. The root and development of otorhinolaryngology in traditional Chinese medicine. Eur Arch Otorhinolaryngol. 2009;266:1353.

FOOD POISONING

FOOD POISONING NUTRITIONAL ACUITY RANKING: LEVEL 2

DEFINITIONS AND BACKGROUND True food poisoning involves GI tract insults, infections, or intoxications resulting from contaminated beverages or food. The most vulnerable are elderly people, pregnant women, immunocompromised people (HIV or cancer), infants, and children younger than age 6 years. Known pathogens cause an estimated 9.4 million foodborne illnesses annually in the United States (Centers for Disease Control and Prevention [CDC], 2013). Norovirus is the most commonly reported; Salmonella poisoning is second. Chemical agents, viruses, and parasites are also often implicated (see Table 2-14).

Escott-Stump_Ch02.indd 132

All people should have consistent access to safe and nutritious food, clean water, and a sanitary home environment (Nordin et al, 2013). The same is true when they dine away from home. Indeed, personal hygiene is one of the most important steps in food safety. Most health departments require that food handlers with stomach illnesses not work until 2 or 3 days after they begin to feel better. Strict hand washing after using the bathroom and before handling food is important for preventing contamination. Pathogens transmitted via food contaminated by infected food handlers are Salmonella typhi and other species, Shigella, Staphylococcus aureus (see Fig. 2-17), Streptococcus pyogenes, hepatitis A virus, norovirus, Listeria, and Escherichia coli O157:H7. Table 2-14 lists the most common foodborne illnesses, their onset, and duration.

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

133

TABLE 2-14 Sources, Symptoms, and Pathogens That Cause Food Poisoning GENERAL SOURCE OF ILLNESS

SYMPTOMS

PATHOGEN

Raw and undercooked meat and poultry

Abdominal pain and cramping, diarrhea, nausea, and vomiting

Campylobacter jejuni, Escherichia coli O157:H7, Listeria monocytogenes, Salmonella

Raw (unpasteurized) milk and dairy products, such as soft cheeses

Nausea and vomiting, fever, abdominal cramps, and diarrhea

L. monocytogenes, Salmonella, Shigella, Staphylococcus aureus, C. jejuni

Fresh or minimally processed produce

Diarrhea, nausea, and vomiting

E. coli O157:H7, L. monocytogenes, Salmonella, Shigella, Yersinia enterocolitica, viruses, and parasites

SPECIFIC ILLNESS SOURCES

SYMPTOMS

PATHOGEN

ONSET AND DURATION

Meats, milk, vegetables, and fish (diarrhea). Rice products; potato, pasta, and cheese products (vomiting)

Watery diarrhea, abdominal cramping, vomiting

Bacillus cereus

6–15 hours after consumption; duration ⫽ 24 hours

Raw and undercooked meat and poultry; raw milk and soft cheeses

Abdominal pain and cramping, diarrhea (often bloody), nausea, and vomiting. Note: 40% of Guillain–Barré syndrome (GBS) cases in the United States are caused by campylobacteriosis

Campylobacter jejuni

2–5 days after exposure; duration ⫽ 2–10 days

Improperly canned goods especially with low acid content—asparagus, green beans, beets, and corn; chopped garlic in oil; chile peppers; improperly handled baked potatoes wrapped in aluminum foil; home-canned or fermented fish; honey contains spores

Muscle paralysis caused by the bacterial toxin; double vision, inability to swallow, slurred speech and difficulty speaking, and inability to breathe

Clostridium botulinum

18–36 hours after eating contaminated food; can occur as early as 6hours or as late as 10 days; duration may be weeks or months

Canned meats, contaminated dried mixes, gravy, stews, refried beans, meat products, and unwashed vegetables

Nausea with vomiting, diarrhea, acute gastroenteritis

Clostridium perfringens

Within 6–24 hours from ingestion; lasting 1 day

Contaminated food from poor handling

Watery stools, diarrhea, nausea, vomiting, slight fever, and stomach cramps; especially in immunocompromised patients

Cryptosporidium parvum (protozoa)

2–10 days after infection

Contaminated water with human sewage may lead to contamination of foods; infected food handlers; more common with travel to other countries

Watery diarrhea, abdominal cramps, lowgrade fever, nausea, and malaise

Escherichia coli; Enterotoxigenic E. coli (ETEC)

With high infective dose, diarrhea can be induced within 24 hours

Undercooked ground beef and meats; unpasteurized fruit juices such as apple cider; unwashed fruits and vegetables (lettuce, alfalfa sprouts); dry-cured salami, game meat; cheese curds; E. coli O157:H7 can survive in refrigerated acid foods for weeks

Hemorrhagic colitis (painful, bloody diarrhea)

E. coli O157:H7; Enterohemorrhagic E. coli (EHEC)

Onset is slow, 3–8 days after ingestion

Processed, ready-to-eat products (undercooked hot dogs, deli or lunchmeat, unpasteurized dairy products); postpasteurization contamination of soft cheeses, milk, or commercial coleslaw; cross-contamination between food surfaces

Mild fever, headache, vomiting, and severe illness in pregnancy; sepsis in immunocompromised patients; febrile gastroenteritis in adults; meningoencephalitis in infants; may lead to meningitis or septicemia if untreated

Listeria monocytogenes (LM)

Onset is 2–30 days; can be fatal

Direct contact or droplets from contaminated hands or work surfaces (stool or vomit); most common on cruise ships

Gastroenteritis with nausea, vomiting, diarrhea; fever with chills; abdominal cramps; headache; muscle aches; vomiting may be frequent and quite violent, but subsides within a few days; drink liquids to prevent dehydration

Norovirus

24–48 hours after ingestion of the virus but may appear as early as 12hours; lasts only 1 or 2 days

Gram-positive, aerobic spore former

Consider also: sauces, puddings, soups, salads, casseroles, pastries

Infants appear lethargic with poor muscle tone, feed poorly, are constipated, and have a weak cry

In infants or debilitated elderly persons, electrolyte replacement therapy may be necessary The condition may progress to hemolytic anemia, thrombocytopenia, and acute renal failure requiring dialysis and transfusions

Antibiotics are not used as they can spread the infection Hemolytic uremic syndrome can be fatal, especially in young children

Virus cannot multiply outside human body; once on food, it can be transmitted easily to humans

(continued)

Escott-Stump_Ch02.indd 133

11/7/14 2:13 AM

134

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-14 Sources, Symptoms, and Pathogens That Cause Food Poisoning (continued) SPECIFIC ILLNESS SOURCES

SYMPTOMS

PATHOGEN

ONSET AND DURATION

Raw or undercooked meat, poultry, fish, unpasteurized dairy products; unwashed fruits and raw vegetables (melons and sprouts)

Diarrhea, fever, and abdominal cramps. Most people recover without treatment. However, elderly, infants, and those with impaired immune systems are more likely to have a severe illness requiring hospitalization and antibiotics.

Salmonella typhimurium

12–72 hours after infection; duration ⫽ 4–7 days

Raw or undercooked eggs; eggs in foods such as homemade hollandaise sauce, caesar and other salad dressings, tiramisu, homemade ice cream, homemade mayonnaise, cookie dough, frostings

Nausea and vomiting, fever, abdominal cramps, and diarrhea

Salmonella enteritidis

12–72 hours after infection; duration ⫽ 4–7 days

Milk and dairy products; cold mixed egg, tuna, chicken, potato, and meat salads

Bloody diarrhea, fever, and stomach cramps

Shigella (causes Shigellosis)

24–48 hours after exposure

Meat, pork, eggs, poultry, tuna salad, prepared salads, gravy, stuffing, cream-filled pastries

Nausea, vomiting, retching, abdominal cramping, and prostration

Staphylococcus aureus

Within 1–6 hours; rarely fatal; duration ⫽ 1–2 days

Milk, ice cream, eggs, steamed lobster, ground ham, potato salad, egg salad, custard, rice pudding, shrimp salad

Sore and red throat, pain on swallowing, tonsillitis, high fever, headache, nausea, vomiting, malaise, rash, rhinorrhea

Streptococcus pyogenes

Foodstuffs at room temperature for several hours between preparation and consumption

Complications are rare and are treated with antibiotics

Raw or undercooked shellfish, especially raw clams and oysters, contaminated with human pathogen

Vomiting, diarrhea; chills, fever, and collapse

Raw or undercooked pork products. Postpasteurization contamination of chocolate milk, reconstituted dry milk, pasteurized milk, and tofu

Fever, abdominal pain, and diarrhea (often bloody) in children

Need thorough cooking, hygiene, and sanitation

Can be fatal in immunocompromised individuals

Cooking does not destroy the toxin; refrigerate foods immediately after preparation and meal service

Onset ⫽ 1–3 days

Entrance into the food is the result of poor hygiene, ill food handlers, or the use of unpasteurized milk

Vibrio vulnificus, V. parahaemolyticus

16 hours after eating contaminated food; duration ⫽ 48 hours

This bacterium is in the same family as cholera; it yields a norovirus

Yersinia enterocolitica Occurs most often in young children

1–2 days after exposure; duration ⫽ 1–3 weeks or longer

In older children and adults, right-sided abdominal pain and fever may be predominant, Cold storage does not kill the mimicking appendicitis; rarely, skin rash, joint bacteria pains, and sepsis may occur

Adapted from: CDC: http://www.cdc.gov/foodsafety/; NIDDK: http://digestive.niddk.nih.gov/ddiseases/pubs/bacteria/#10. Accessed June 17, 2014.

Staphylococcus aureus • Endocarditis • Cellulitis • Pneumonia • Osteomyelitis • Septicemia Figure 2-17. Staphylococcus aureus. (Reprinted with permission from Anatomical Chart Company. Understanding bacterial infections.)

Escott-Stump_Ch02.indd 134

Foodborne disease outbreaks associated with fresh fruits and vegetables have increased. Leafy greens, herbs, and seed sprouts have been most problematic in Canada (Kozak et al, 2013). Outbreaks, such as spinach contaminated with E. coli O157:H7, resulted in almost 200 cases of foodborne illness across North America and ⬎$300 million market losses (Warriner et al, 2009). An outbreak occurs when two or more individuals develop the same symptoms over the same time period. Nausea, vomiting, diarrhea, abdominal cramping, vision problems, fever, chills, dizziness, and headaches may occur. Some people attribute their symptoms mistakenly to “stomach flu.” School food authorities participating in the National School Lunch Program or the School Breakfast Program have to develop a food safety program for the preparation and service of school meals served to children based on the hazard analysis and critical control point system (Food and Nutrition Services, 2009). Approaches to control foodborne pathogens include antibiotics, natural antimicrobials, bacteriophages, bacteriocins, ionizing radiations, heat, and probiotics (Amalaradjou and Bhunia, 2012). Probiotics offer promise to critically ill patients for the prevention of antibiotic-associated diarrhea and Clostridium

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

diﬃcile infections; however, their use must be carefully monitored for unexpected consequences (Morrow et al, 2012).

ASSESSMENT, MONITORING, AND EVALUATION Clinical/History • • • • • • • • • • • • • •

Height Weight BMI Usual weight Weight loss/changes during illness Diet history Vomiting Diarrhea Nausea Abdominal cramps Blood or parasites in stools? Fever? Timing of symptoms after suspected meal Signs of dehydration; I&O

Lab Work • • • •

Na⫹, K⫹ Chloride (Cl⫺) H&H, serum Fe Gluc

INTERVENTION Objectives • Allow the GI tract to rest after rehydration; progress diet as tolerated. • Prepare and store all foods using safe food-handling practices and good personal hygiene. Temperatures should be maintained below 40°F or above 140°F for safe food handling, storage, and holding. • Teach the importance of hand washing, care of food contact surfaces, and insect or rodent extermination. This is especially important in foodservice operations where members of the public are fed. • Know and use Hazard Analysis and Critical Control Point procedures to evaluate critical control points where food poisoning risk is high; use appropriate precautions, safeguards, and monitoring. • Sanitize all surfaces before food preparation; sanitize after each food item is prepared when using the same surface (e.g., cutting boards and slicers). Table 2-15 lists safe food practices.

Food and Nutrition • For patients with extreme diarrhea or vomiting, feed with intravenous glucose and no oral intake until improvement has been made. Oral rehydration therapy is a useful adjunct treatment in the recovery process. • Progress gradually back to a normal diet. Prolonged inability to eat orally may require tube feeding.

Escott-Stump_Ch02.indd 135

135

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Hydrochloric acid in the stomach protects against pathogens ingested with food or water. A gastric fluid pH of 1 to 2 is deleterious to many microbial pathogens. Neutralization of gastric acid by antacids or the inhibition of acid secretion by various drugs can alter stomach pH and may increase the risk of acquiring food- or waterborne illnesses. • Octreotide (Sandostatin) may be used parenterally. It may alter fat absorption and fat-soluble vitamin absorption. • Antibiotics such as puromycin, erythromycin, or a fluoroquinolone may be prescribed. • For Salmonella, ampicillin, gentamicin, trimethoprim/sulfamethoxazole, or ciprofloxacin may be used. New strains of this bacteria have evolved; they are more resistant to antimicrobial treatment. • Vibrio vulniﬁcus infection is treated with doxycycline or ceftazidime. Herbs, Botanicals, and Supplements • Note that herbs and botanicals themselves could be a source of foodborne bacteria and thus exacerbate an existing foodborne infection. • Counsel about use of herbal teas, especially regarding toxic substances. If other herbs and botanicals are used, identify and monitor for potential contamination and side effects.

Nutrition Education, Counseling, Care Management • Encourage safe methods of food handling. • Monitor water supply for unexpected odors or color changes; report to authorities. • Discuss ways to prevent further episodes of food poisoning. Hand washing is most important. Wash hands with soap before handling raw foods of animal origin, after handling raw foods of animal origin, and before touching anything else. • Prevent cross-contamination in the kitchen. Proper refrigeration and sanitation are also essential. • Avoid raw milk and cook all meats and poultry thoroughly. Drink only pasteurized milk. • Bacteria may be found in raw vegetables and fruits. Wash before eating. • Throw out bulging, leaking, or dented cans and jars that are leaking. • Safe home canning tips can be obtained from county extension services or from the U.S. Department of Agriculture. • Commercial mayonnaise, salad dressings, and sauces appear to be safe due to their content of acetic acid. Prepare recipes using cold dressings. For example, make potato salad or tuna salad with refrigerated mayonnaise; they maintain proper temperatures longer. • To avoid parasite infestation (such as Giardia), monitor for appropriate sewage treatment, proper hand washing, and use of bottled water in vulnerable environments. • Food handlers need more education to understand their role in food safety, especially those who are non-English speaking (DeBess et al, 2009). • Three key practices are needed for safe food handling: careful hand washing, using thermometers, and proper handling of food surfaces (Table 2-16) (Pilling et al, 2008). Barriers in the workplace often include time constraints, inconvenience, inadequate training, and insufficient resources (Howells etal, 2008).

11/7/14 2:13 AM

136

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 2-15 Safe Food Handling and Food Safety Guidelines PREPARING FOOD

Clean Wash hands the right way—for 20 seconds with soap and running water. Clean hands, food contact surfaces, and fruits and vegetables. Wash all fresh fruits and veggies—but not meat, poultry, or eggs! Scrub the outside of produce such as melons and cucumbers before cutting. Discard cracked eggs; avoid using products from dented cans. Avoid food preparation when sick with viral or bacterial infections; use gloves if needed. If a work surface comes into contact with raw food, sanitize after contact with each food. Wash surfaces and utensils after each use. Sanitize work surfaces and sponges daily with a mild bleach solution (2 teaspoons per quart of water).

Separate Separate raw, cooked, and ready-to-eat foods while shopping, preparing, and storing foods. Keep meat, poultry, seafood, and eggs separate from all other foods in the fridge. Sanitize work surfaces after each food. Ideally, keep one cutting board for poultry, another for meats, and another for produce to prevent cross-contamination. Discard cutting boards that are badly damaged. Use clean plates and separate utensils between raw and cooked foods. Never marinate or thaw foods directly on the counter. Keep pet foods and utensils separate from those for human use.

Cook Do not partially cook meat or poultry in advance of final preparation. Bacteria may still grow rampantly. Cook foods to a safe temperature to kill microorganisms. Cook beef to proper internal temperature of 160°F, pork to 165°F, and poultry to 175°F. Cook hamburger to the proper temperature of 165°F; “pink in the middle, cooked too little.” Monitor internal temperatures with an accurate food thermometer placed correctly into the meat or poultry. Boil water used for drinking when necessary; hold at boiling temperature for 1 minute. Do not consume raw or partially cooked eggs, raw or undercooked fish or shellfish, and raw or undercooked meats. Avoid raw (unpasteurized) milk and products made from it. Avoid serving unpasteurized juices and raw sprouts.

Chill Refrigerate perishable food within 2 hours. Defrost foods properly. Thaw meats and poultry in the refrigerator, not at room temperature. If necessary, thaw in a sink with cold running water that allows continuous drainage or thaw quickly in the microwave and use immediately. Cool foods quickly in shallow pans (2–4 inches deep). Temperature should reach 70°F within 2 hours. If food has not cooled to that level, place in the freezer for a short time. Then, wrap lightly and return to refrigerator. HOLDING AND SERVING FOODS Hold and serve foods at 140–165°F during meal service. Reheat foods to at least 165°F. Discard leftovers after the first reheating process. Keep hot foods above 140°F and cold foods below 40°F. Discard cooked foods that are left at room temperature for longer than 2 hours. Reheat home-canned foods appropriately. In institutional settings, do not allow home-cooked foods at all. Only serve certain deli meats and frankfurters that have been heated to steaming hot temperature. After a disaster, follow guidelines at http://emergency.cdc.gov/disasters/foodwater/facts.asp and http://emergency.cdc.gov/disasters/floods/sanitation.asp. References: Fight BAC. Guidelines. Available at: http://www.fightbac.org. Accessed June 17, 2014; Food Safety. Cook to the right temperature. Available at: http://www.foodsafety.gov/keep/basics /cook/index.html. Accessed August 4, 2014; Food Safety and Inspection Service. Available at: http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education. Accessed August 21, 2014; Food Safety Charts. Available at http://www.foodsafety.gov/keep/charts/index.html. Accessed June 17, 2014.

Escott-Stump_Ch02.indd 136

11/7/14 2:13 AM

SECTI ON 2 • NU TRI TI ON PRACTI CES, FOOD SAFETY, ALLERGI ES, SKI N, AND MI SC E L L AN E OUS CON DI T I ON S

• Cancer and immunocompromised patients are especially vulnerable to food poisoning. Risk-reducing behaviors, better food handling of routine foods, and hand washing should be encouraged (Medeiros et al, 2008). • Young adults need education about food safety for themselves and for their future families. • Biotechnology has developed food crops that are more resistant to pests and have longer shelf life for food safety. If consumers are concerned about the safety of food irradiation, GM foods, and potential allergens, nutrition professionals should reassure the public that genetically modified items are safe to eat.

SAMPLE NUTRITION CARE PROCESS STEPS

For More Information ●

Academy of Nutrition and Dietetics Home Food Safety Program http://www.homefoodsafety.org/

●

CDC Wonder http://wonder.cdc.gov/

●

Codex Alimentarius—International Food Regulations http://www.fsis.usda.gov/wps/portal/fsis/topics/international-affairs /us-codex-alimentarius

●

Division of Emerging Infections and Surveillance Services (DEISS) http://www.cdc.gov/ncpdcid/deiss/index.html

●

Drinking Water Safety http://www.epa.gov/safewater/dwh/index.html

●

Federal Consumer Information Center http://publications.usa.gov/USAPubs.php?NavCode=XB&Sub2ID=42 &CatID=6

●

Fight BAC http://www.fightbac.org/

●

Food Defense and Emergency Response http://www.fsis.usda.gov/food_defense_&_emergency_response/index.asp

●

FoodNet Incidence Figures http://www.cdc.gov/foodnet/factsandfigures.htm

●

Food Safety Education http://www.fsis.usda.gov/Food_Safety_Education/index.asp

●

Food Safety and Inspection—Risk Assessment http://www.fsis.usda.gov/wps/portal/fsis/topics/science/risk-assessments /risk-assessments

●

Government Food Safety Website http://www.foodsafety.gov/

●

HACCP http://www.who.int/foodsafety/fs_management/haccp/en/index.html

●

HACCP—International Alliance http://www.haccpalliance.org/sub/index.html

●

RD411—Food Safety http://www.nutrition411.com/education-materials/food-safety

●

USDA Home Canning Guide http://www.uga.edu/nchfp/publications/publications_usda.html

Food poisoning Assessment: Food diary reveals intake of unsafe food or beverage, altered GI function (diarrhea, nausea, vomiting). Nutrition Diagnosis: Intake of unsafe food related to Salmonella as evidenced by onset of multiple episodes of vomiting and foodborne gastroenteritis, diarrhea, and lethargy for several days after eating chicken at a picnic. Intervention: Education about rehydration with foods containing sodium and potassium and fluids (such as Gatorade). Counseling about food safety measures, including hand washing, avoidance of cross-contamination, safe food storage. Monitoring and Evaluation: Review of food diaries; fewer problems related to food poisoning from intake of unsafe food.

137

TABLE 2-16 Refrigerator and Freezer Food Storage CATEGORY

FOOD

REFRIGERATOR (40°F OR BELOW)

FREEZER (0°F OR BELOW)

Salads

Egg, chicken, ham, tuna, macaroni salads

3–5 days

Does not freeze well

Hot dogs

Opened package

1 week

1–2 months

Unopened package

2 weeks

1–2 months

Opened package or deli sliced

3–5 days

1–2 months

Unopened package

2 weeks

1–2 months

Bacon

7 days

1 month

Sausage, raw — from chicken, turkey, pork, beef

1–2 days

1–2 months

Hamburger, ground beef, turkey, veal, pork, lamb, and mixtures of them

1–2 days

3–4 months

Luncheon meat Bacon and sausage Hamburger and other ground meats Fresh beef, veal, lamb, and pork

Steaks

3–5 days

6–12 months

Chops

3–5 days

4–6 months

Roasts

3–5 days

4–12 months

Chicken or turkey, whole

1–2 days

1 year

Chicken or turkey, pieces

1–2 days

9 months

Soups and stews

Vegetable or meat added

3–4 days

2–3 months

Leftovers

Cooked meat or poultry

3–4 days

2–6 months

Chicken nuggets or patties

3–4 days

1–3 months

Pizza

3–4 days

1–2 months

Fresh poultry

Source: U.S. Food and Drug Administration. Storage times for the refrigerator and freezer. Available at: http://www.foodsafety.gov/keep/charts/storagetimes.html. Accessed June 17, 2014.

Escott-Stump_Ch02.indd 137

11/7/14 2:13 AM

138

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

●

Water Quality Association http://www.wqa.org/

●

World Health Organization—Biotechnology and GM Foods http://www.who.int/foodsafety/biotech/en/

●

World Health Organization—Foodborne Illnesses http://www.who.int/topics/foodborne_diseases/en/index.html

●

World Health Organization—Food Safety http://www.who.int/topics/food_safety/en/

●

World Health Organization—International Travel and Health http://www.who.int/foodsafety/publications/consumer/travellers/en /index.html

●

World Health Organization—Water Sanitation http://www.who.int/water_sanitation_health/mdg1/en/index.html

REFERENCES Amalaradjou MA, Bhunia AK. Modern approaches in probiotics research to control foodborne pathogens. Adv Food Nutr Res. 2012;67:185.

Escott-Stump_Ch02.indd 138

Centers for Disease Control (CDC). Surveillance for foodborne disease outbreaks— United States, 2009-2010. MMWR Morb Mortal Wkly Rep. 2013;62:41. DeBess EE, et al. Food handler assessment in Oregon. Foodborne Pathog Dis. 2009;6:329. Food and Nutrition Service (FNS), USDA. School food safety program based on hazard analysis and critical control point principles. Final rule. Fed Regist. 2009;74:66213. Howells AD, et al. Restaurant employees’ perceptions of barriers to three food safety practices. J Am Diet Assoc. 2008;108:1345. Kozak GK, et al. Foodborne outbreaks in Canada linked to produce: 2001 through 2009. J Food Prot. 2013;76:173. Medeiros LC, et al. Discovery and development of educational strategies to encourage safe food handling behaviors in cancer patients. J Food Prot. 2008;71:1666. Morrow LE, et al. Probiotics in the intensive care unit. Nutr Clin Pract. 2012;27: 235-241. Nordin S, et al. Position of the Academy of Nutrition and Dietetics: nutrition security in developing nations: sustainable food, water, and health. J Acad Nutr Diet. 2013;113:581. Pilling VK, et al. Identifying specific beliefs to target to improve restaurant employees’ intentions for performing three important food safety behaviors. JAm Diet Assoc. 2008;108:991. Warriner K, et al. Recent advances in the microbial safety of fresh fruits and vegetables. Adv Food Nutr Res. 2009;57:155.

11/7/14 2:13 AM

Pediatrics: Birth Defects and Genetic and Acquired Disorders

CHIEF ASSESSMENT FACTORS Because nutrition is essential for achieving growth and development, screening and assessment are integral parts of health care. Simple nutritional screening tools can help identify children at risk for malnutrition, which affects one-fourth to one-third of children admitted to a hospital. Metabolic disease can be noted by: ● ● ● ● ● ● ● ● ● ● ● ● ●

Cyanosis Diarrhea or abdominal bloating Dysmorphic features Enlarged liver or spleen Failure to feed well Lethargy, irritability, or hyperactivity Hypothermia or fevers due to viral illnesses or other causes Jaundice Neurologic: tone, level of alertness, deep tendon reflexes Nonspecific findings that mimic shock, sepsis, or sudden infant death syndrome (SIDS) Odor Seizures Vomiting

139

Escott-Stump_Ch03.indd 139

11/7/14 8:24 PM

140

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

BACKGROUND AND CONSIDERATIONS Efforts should be made to enhance appetite and intake in children who are not with their families; familiarity is important. The United Kingdom has developed a Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP; see http:// www.stampscreeningtool.org/data/pdfs/stamp_screening_ form.pdf). When there are problems with growth, proper interventions and referrals are important. Table 3-1 provides pediatric assessments and calculations, Table 3-2 lists common problems, and Table 3-3 shows calculations for estimating fluid needs in children. Figure 3-1 shows one means of measuring an infant’s length. Body mass index (BMI) tables used for pediatric patients are provided later in this chapter.

Poor health habits, limited access to services, and long-term use of multiple medications are frequent health risk factors (Van Riper et al, 2012). In particular, children with developmental disabilities and special health care needs have growth alterations (failure to thrive [FTT], obesity, or growth retardation), metabolic disorders, poor feeding skills, medication–nutrient interactions, or dependence on enteral or parenteral nutrition (Van Riper et al, 2012). Mitochondrial diseases are the result of either inherited or spontaneous mutations in mtDNA or nDNA which lead to altered functions of the proteins or RNA molecules that normally reside there (United Mitochondrial Disorder Foundation, 2013). These mitochondrial pathologies disrupt mitochondrial energy production or biosensor functioning. While many of these disorders are apparent during infancy, the signs of oxida-

TABLE 3-1 Useful Assessments in Pediatrics ANTHROPOMETRIC MEASURES Use age-, gender-, and disease-specific growth charts from the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO) with trained personnel and appropriate equipment. • Birth data (weight, length, head circumference, size, gestational age): • Low birth weight 2,500 g or 5.5 lb • Very low birth weight 1,500 g or 3.5 lb • Growth parameters: • Current height (ht) and weight (wt)

• Ht/age 5th percentile • Wt/ht 5th percentile (underweight or FTT) or 85th percentile (overweight) • Head circumference 5th percentile (under 3 years of age) • Pubertal staging (Tanner stages), skeletal maturity staging • Small for gestational age—need catch-up growth to normalize length and weight

• Wt/age 10th percentile or 85th percentile (overweight) or • Unintentional weight loss 95% (obese) BEHAVIORAL–PSYCHOSOCIAL • Developmental disorders: mental retardation, learning disorders, motor skills disorder, communication disorders, or pervasive developmental disorders • Growth and development milestones

• Hunger and satiety; use of food for reward or as pacifier • Home environment and family economics (access to food) • Access to interdisciplinary, family-centered, community-based services

CLINICAL • Altered gastrointestinal function: nausea, vomiting, acute diarrhea, constipation, GERD.

• Inadequate intake because of depression, pain or dyspnea, poor appetite 3 days.

• Altered nutrition-related biochemical values—such as serum cholesterol. Total serum cholesterol should be 170 mg/dL in children and teens. If 170–199 mg/dL, take a second total serum cholesterol, and average the two together. If 200 mg/ dL, a fasting lipid profile is needed.

• Marked weight loss (malabsorption, IBD, hyperthyroidism, or malignancy).

• Birth defects: Some can be diagnosed before birth, using prenatal ultrasound, amniocentesis, and CVS. Ultrasound can help diagnose structural birth defects, such as spina bifida and heart or urinary tract defects. Amniocentesis and CVS are used to diagnose chromosomal abnormalities, such as Down’s syndrome. • Chewing and swallowing difficulties (e.g., from cleft lip or palate, oral lesions). • Chronic illnesses (cancer, cardiac disease or heart failure, diabetes, elevated lipids, FTT, hypertension, kidney disease, malabsorption, HIV/AIDS, trauma). • Congenital or chromosomal abnormalities, inborn metabolic disorders. • Digestive and malabsorptive problems from celiac disease, lactose deficiency, or inflammatory bowel disease; sugar intolerance; foul-smelling, bulky stools indicate fat malabsorption. • Food allergies.

Escott-Stump_Ch03.indd 140

• Increased nutrient demands, as from protein–energy malnutrition, pressure ulcers. • Medications with nutritional side effects: • Antibiotics (energy, protein, minerals; GI problems) • Anticonvulsants (vitamins C, K, D, and B-complex, and calcium) • Corticosteroids (calcium, phosphorus, glucose levels; weight gain or stunting) • Diuretics (potassium, magnesium, calcium, energy; GI problems) • Stimulants such as Ritalin (energy and protein intake, growth, appetite) • Sulfonamides (vitamin C, protein, folate, and iron) • Tranquilizers (energy intake; weight gain) • Inability to consume oral diet (children cannot tolerate fasting as long as adults): • Pediatric tube feeding: prematurity, developmental delays, orofacial defects, cerebral palsy, anorexia nervosa, cystic fibrosis, metabolic disorders, renal failure, HIV infection, or inflammatory bowel disorders • Pediatric TPN: biliary atresia, Hirschsprung disease with enterocolitis, Crohn’s disease, ulcerative colitis, congenital short-bowel syndrome, GI ischemia or fistulas, severe burns or trauma, and bowel transplantation. It may be possible to wean from TPN to tube or oral feeding in some conditions; for others, parenteral nutrition may be permanent. • Increased nutrient needs for trauma, surgery, recent hospitalizations, acute illnesses, chemotherapy, or radiation.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

141

TABLE 3-1 Useful Assessments in Pediatrics (continued) DEVELOPMENTAL DISABILITIES • Altered nutritional status, feeding skills, feeding behaviors including positioning.

• In children whose weight is hard to maintain, catch-up growth is important with a focus on protein and energy intake. • Use specific screening tools for each physical, motor, sensory, or devel- • Individualize care: Design the desired outcomes, determine necessary resources, and seek regular opmental delays. Use arm span where height is difficult to measure. feedback on progress or obstacles. Personal control, independence, and choice must be considered. EATING AND FEEDING SKILLS • Avoidance of easily aspirated foods. • Biting, chewing, or swallowing difficulty requiring texture modifications. • Coordination for safe and proper chewing, sucking, swallowing. • Feeding: length of time, feeding method, skill level, persons involved.

• Food allergies, multiple or severe. • Food intake: ability to eat and retain food. • Food preferences, dislikes, and intolerances. • Special formula or supplements, tube feeding, or parenteral nutrition.

GENETIC AND METABOLIC DISORDERS (March of Dimes, 2013) • Growth failure, skin rashes, developmental delays, vomiting, or diarrhea and other concerns affect nutrition and health status in: • Amino acid metabolism: phenylketonuria; maple syrup urine disease; glutaric acidemia type 1; argininosuccinic academia; tyrosinemia; propionic academia; isovaleric academia; citrullinemia type 1 • Carbohydrate metabolism: galactosemia; glycogen storage disease; galactose-phosphate uridyltransferase • Fatty acid metabolism: medium-chain acyl-CoA dehydrogenase deficiency; carnitine uptake deficiency; very long-chain acyl-CoA dehydrogenase; abetalipoproteinemia • Presently, screening for 29 disorders in the United States consists of testing; follow-up of abnormal screening; diagnostic testing; disease management; continuous evaluation. • Clues that suggest a genetic condition or an inherited susceptibility to a common disease include the following: • Two or more seemingly unrelated medical conditions (e.g., hearing loss and renal disease, diabetes and muscle disease) • A medical condition and dysmorphic features • Developmental delay with dysmorphic features and/or physical birth anomalies • Developmental delay associated with other medical conditions • Progressive mental retardation, loss of developmental milestones • Progressive behavioral problems • Unexplained hypotonia • A movement disorder

• • • • • • • • • • • • • • • • • • • • •

Unexplained seizures Unexplained ataxia Two or more major birth anomalies Three or more minor birth anomalies One major birth defect with two minor anomalies A cleft palate, or cleft lip with or without cleft palate Unusual birthmarks (especially associated with seizures, learning disabilities, or dysmorphic features) Hair anomalies (hirsute, brittle, coarse, kinky, sparse, or absent) Congenital or juvenile deafness Congenital or juvenile blindness Cataracts at a young age Primary amenorrhea Ambiguous genitalia Proportionate short stature with dysmorphic features and/or delayed or arrested puberty Disproportionate short stature Premature ovarian failure Proportionate short stature and primary amenorrhea Males with hypogonadism and/or significant gynecomastia Congenital absence of the vas deferens Oligozoospermia/azoospermia A fetus with: • A major structural anomaly • Significant growth retardation • Multiple minor anomalies

SINGLE GENE DISORDERS (SEEN LATER IN ADULTHOOD) • Neurology • Muscular dystrophy • Spinocerebellar ataxia • Hereditary neuropathy • Dystonia • Early-onset Alzheimer’s disease • Familial multiple sclerosis • Familial amyotrophic lateral sclerosis • Neurofibromatosis • Nephrology • Autosomal dominant polycystic kidney disease • Hereditary nephritis • Disorders of renal physiology • Hematology • Hemoglobinopathies • Hereditary disorders of hemostasis • Hereditary hypercoagulability

• Pulmonary

• Oncology

• Adult-onset cystic fibrosis

• BRCA1/2

• Alpha-1-antitrypsin deficiency

• Familial adenomatous polyposis

• Cardiac

• Hereditary nonpolyposis colon cancer

• Conduction abnormalities

• Familial prostate cancer

• Cardiomyopathy

• Multiple endocrine neoplasia

• Infectious disease • Immune deficiencies • Metabolic

• Hippel-Lindau disease • Li-Fraumeni syndrome • Musculoskeletal

• Hemochromatosis

• Inherited connective tissue disorders

• Lipid disorders

• Marfan, Ehlers-Danlos, osteogenesis imperfect

• Homocysteine

• Dermatology

• Gastroenterology

• Ichthyosis

• Osler-Weber-Rendu disease

• Bullous disorders

• Polyposis

Note: Inborn metabolic disorders are usually due to defects of single genes that code for enzymes, intended to convert substrates into products.

Escott-Stump_Ch03.indd 141

(continued)

11/7/14 8:24 PM

142

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 3-1 Useful Assessments in Pediatrics (continued) ESTIMATING DAILY ENERGY REQUIREMENTS AND TOTAL ENERGY EXPENDITURE FOR INFANTS AND CHILDREN (Derived from Institute of Medicine, 2002; Lucas, 2004) Age (months) 0–3 4–6 7–12 13–35 Boys: Age (years) 3–8 9–19 3–19, overweight Girls: Age (years) 3–8 9–19 3–19, overweight

Equation (89 Wt 100) 175 (89 Wt 100) 56 (89 Wt 100) 22 (89 Wt 100) 20 Equation EER 88.5 61.9 age (y) PA (26.7 Wt 903 Ht) 20 EER 88.5 61.9 age (y) PA (26.7 Wt 903 Ht) 25 TEE 114 50.9 age (y) PA (19.5 Wt 116.4 Ht) Equation EER 135.3 30.8 age (y) PA (10.0 Wt 934 Ht) 20 EER 135.3 30.8 age (y) PA (10.0 Wt 934 Ht) 25 TEE 389 41.2 age (y) PA (15.0 Wt 701 Ht)

PHYSICAL ACTIVITY COEFFICIENTS FOR CHILDREN AGED 3–19 YEARS

Coefficient for Boys Aged 3–19 years

Boys

Coefficient for Girls Aged 3–19 years

Girls

Activity Level

Normal Wt

Overweight

Normal Wt

Overweight

Sedentary Low active Active Very Active

1.0 1.13 1.26 1.42

1.0 1.12 1.24 1.45

1.0 1.16 1.31 1.56

1.00 1.18 1.35 1.60

Age

CHO

Fat

Protein

Full-term infant 1–3 years 4–18 years

35–65 45–65 45–65

30–55 30–40 25–35

7–16 5–20 10–30

ACCEPTABLE MACRONUTRIENT RANGES

Range (% of energy)

CVS, chorionic villus sampling; EER, energy requirements; FTT, failure to thrive; GERD, gastroesophageal reflux disease; GI, gastrointestinal; IBD, inflammatory bowel disease; PA, physical activity; TEE, total energy expenditure; TPN, total parenteral nutrition. References: Harris AB. Evidence of increasing dietary supplement use in children with special health care needs: strategies for improving parent and professional communication. J Am Diet Assoc. 2005;105:34; Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academies of Sciences; 2002; Lucas B, ed. Children with special care needs: nutrition care handbook. Chicago: The American Dietetic Association; 2004; March of Dimes. Available at: http://www.marchofdimes.com/ organic-acid-metabolism-disorders.aspx. Accessed August 5, 2014; McCary JM. Improving access to school-based nutrition services for children with special health care needs. J Am Diet Assoc. 2006;106:1333.

TABLE 3-2 Nutritional Risks Associated with Selected Pediatric Disorders LOW WEIGHT Autism spectrum disorders Bronchopulmonary dysplasia Cerebral palsy Cystic fibrosis Down’s syndrome Fetal alcohol syndrome Heart disease, congenital HIV infection, AIDS Phenylketonuria Prader-Willi syndrome Prematurity, low birth weight Seizure disorder Spina bifida; neural tube defect

X X X X

OVERWEIGHT X X

SHORT STATURE

X X

X X X X X

HIGH ENERGY NEEDS

FEEDING PROBLEMS

X X X X

X X X X X

X X

CONSTIPATION

CHRONIC MEDS

X X X

X X

LOW ENERGY NEEDS

X X

Adapted with permission from: Baer M, Harris A. Pediatric nutrition assessment: identifying children at risk. J Am Diet Assoc. 1997; S107.

Escott-Stump_Ch03.indd 142

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

143

TABLE 3-3 Adequate Intakes of Water in Infancy and Early Childhood AGE

INTAKE

0–6 months

0.7 L/d, assumed to come from breast milk/formula

7–12 months

0.8 L/d from breast milk/formula, complementary foods and beverages

1–3 years

1.3 L/d from foods and beverages including water

4–8 years

1.7 L/d from foods and beverages including water

Data from: National Research Council. Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. Washington, DC: The National Academies Press; 2005.

tive stress may not appear until the young or middle adult years, as in Alzheimer’s or Huntingdon disorders. Further research is needed to identify whether any particular nutrients may be needed, such as coenzyme Q10 or carnitine. Pediatric nutrition services should be provided in a manner that is interdisciplinary, family-centered, community-based, and culturally competent by a qualified and nationally credentialed registered dietitian. When possible, a dietitian who is also a certified specialist in pediatrics (CSP) should be assigned to handle complex cases. If there are ethically charged situations, open discussion with colleagues will be needed to address issues in a proactive, evidence-based, and collegial manner (Orioles and Morrison, 2013).

REFERENCES Orioles A, Morrison WE. Medical ethics in pediatric critical care. Crit Care Clin. 2013;29(2):359–375. United Mitochondrial Disorder Foundation. What is mitochondrial disease? Available at: http://www.umdf.org/site/pp.aspx?c=8qKOJ0MvF7LUG&b=7934627. Accessed June 4, 2014. Van Riper CL, et al. Position of the American Dietetic Association: providing nutrition services for people with developmental disabilities and special health care needs. J Am Diet Assoc. 2012;110(2):296–307.

For More Information about Birth Defects and Genetic Disorders

Figure 3-1. An infant is measured using a stadiometer. (Reprinted with permission from Bickley LS, Szilagyi P. Bates’ guide to physical examination and history taking. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)

●

National Urea Cycle Disorders Foundation http://www.nucdf.org/

●

Organic Acidemia Association http://www.oaanews.org

●

Texas Children’s Hospital Pediatric Nutrition Reference Guide http://www.texaschildrens.org/uploadedFiles/Content/Two_Column _Layouts/Pediatric-Nutrition-Guide-Form.pdf

●

United Mitochondrial Disease Foundation http://www.umdf.org/site/pp.aspx?c=8qKOJ0MvF7LUG&b=7934627

For More Information about Feeding Problems and Assistance ●

The American Occupational Therapy Association, Inc. http://www.aota.org/

●

The Oley Foundation for Home Enteral/Parenteral Therapy http://www.oley.org/

For More Information about Specialty Foods and Formulas ●

Abbott Nutrition http://abbottnutrition.com/Products/Product-Handbook-Landing.aspx

●

Applied Nutrition – PKU Foods http://www.medicalfood.com

●

Centers for Disease Control and Prevention (CDC) Birth Defects Research http://www.cdc.gov/ncbddd/bd/research.htm

●

Cambrooke Foods http://www.cambrookefoods.com/

●

Coalition of State Genetics Coordinators http://www.stategeneticscoordinators.org

●

Dietary Specialties http://www.dietspec.com/

●

Family Voices http://www.familyvoices.org/

●

Ener-G Foods – Gluten Free http://www.ener-g.com/

●

Genetic Alliance Disease InfoSearch http://www.geneticalliance.org

●

Glutino – Gluten Free http://www.glutino.com/

●

Human Genome Project http://www.ornl.gov/sci/techresources/Human_Genome/home.shtml

●

Mead Johnson http://www.meadjohnson.com/pediatrics/us-en/

●

March of Dimes http://www.marchofdimes.com/

●

MedDiet http://www.med-diet.com/

●

National Center for Education in Maternal and Child Health http://www.ncemch.org/

●

Nutricia http://www.nutricia-na.com/

●

National Coalition for Health Professional Education in Genetics http://www.nchpeg.org

●

National Dissemination Center for Children with Disabilities http://www.nichcy.org/

●

Alliance of Genetic Support Groups http://geneticalliance.org/

●

National Institutes of Health Office of Rare Diseases Research http://rarediseases.info.nih.gov

●

Genetics Home Reference http://ghr.nlm.nih.gov/

●

National Newborn Screening & Global Resource Center http://genes-r-us.uthscsa.edu

●

Metabolic Disorders http://themedicalbiochemistrypage.org/inborn.html

Escott-Stump_Ch03.indd 143

For More Information about Rare Disorders and Health Laws

11/7/14 8:24 PM

144

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

●

National Health Law Program http://www.healthlaw.org

●

Newborn Screening – Save Babies Through Screening Foundation http://www.savebabies.org/

●

National Organization for Rare Disorders http://www.rarediseases.org/

●

Office of Rare Diseases Research (National Institutes of Health) http://rarediseases.info.nih.gov/

• • • • •

Scoliosis Retinal degeneration, retinitis pigmentosa Low vision or blindness Developmental delay? Neurologic changes

ABETALIPOPROTEINEMIA NUTRITIONAL ACUITY RANKING: LEVEL 2–3 DEFINITIONS AND BACKGROUND Abetalipoproteinemia (ABL) is a rare, inherited disease characterized by the inability to make plasma lipids or to fully absorb dietary fats through the gut. Mutations in microsomal triglyceride transfer protein (MTP) cause ABL with an absence of plasma apolipoprotein B (apoB)-containing lipoproteins (Khatun et al, 2013). Other names for this condition are Bassen-Kornzweig syndrome, acanthocytosis, or apolipoprotein B deficiency. Acanthocytosis refers to the altered shape of the normal erythrocyte, being thorny in appearance. Infants present with FTT and fatty and pale stools that are frothy and foul smelling. They may also have a protruding abdomen, developmental delays, slurred speech, and problems with balance and muscle coordination after age 10. Mental deterioration and scoliosis also occur. Prognosis is related to the progression of neurologic and visual problems. Degeneration of the basal ganglia occurs (Jung et al, 2011). Severe forms lead to irreversible neurologic disease before age 30. Later in life, deficiency of fat-soluble vitamins is associated with development of atypical retinitis pigmentosa, coagulopathy, posterior column neuropathy, and myopathy (Zamel et al, 2008). Intestinal lipid transport plays a central role in fat homeostasis, and fat-soluble vitamin metabolism (Abumrad and Davidson, 2012). Progressive ataxic neuropathy and retinopathy occur from oxidative damage and deficiencies of vitamins E and A. Therefore, vigorous nutritional supplementation is essential (Chardon et al, 2009). With high oral doses of fat-soluble vitamins, including vitamin E, arrest of the neuropathy and other complications may be possible (Zamel et al, 2008). Other treatments such as stem cell therapy and gene product replacement are under evaluation.

Lab Work • • • • • • • • • • • • • •

Complete blood count (CBC) with abnormal, thorny shaped cells Serum apolipoprotein B levels (low or absent) Albumin (Alb) Total cholesterol (TC) Low-density lipoprotein (LDL) cholesterol (may be low) Very low-density lipoprotein (VLDL) cholesterol (may be low) Fatty acid profile Triglycerides (Trig) Fecal fat study: high levels with steatorrhea Serum retinol and vitamin E Prothrombin time (PT) or international normalized ratio (INR) Serum vitamin D status Ca, Mg Electromyography (EMG) or nerve conduction velocity testing (demyelination of peripheral nerves) • Hemoglobin and hematocrit (H&H)

INTERVENTION Objectives

Genetic Markers

• Decrease rapid progression of disorder by giving large doses of fat-soluble vitamin supplements. This may help prevent deterioration of vision and degeneration of the retina (retinitis pigmentosa). • Avoid use of long-chain triglycerides; use medium-chain triglycerides (MCTs) instead. • Prevent nutrient deficiency symptoms and conditions, such as FTT; impaired balance; difficulty walking; and other complications. Provide linoleic acid supplementation for essential fatty acids (EFAs).

• Microsomal triglyceride transfer protein (MTTP or MTP) deficiency

Food and Nutrition

ASSESSMENT, MONITORING, AND EVALUATION

Clinical/History • • • •

Height Weight Growth chart Diet/intake history

Escott-Stump_Ch03.indd 144

• The diet should contain no more than 5 oz of lean meat, fish, or poultry per day. • Use skim milk instead of whole milk; reduce fats from other types of dairy products. • Use MCT oil in food preparation and with gravies, sauces, and other cooked foods. Avoid excesses to prevent liver problems.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

• The diet should be supplemented with fat-soluble vitamins A, D, E, and K plus linoleic acid to prevent deficiency. Water-miscible forms will be needed.

SAMPLE NUTRITION CARE PROCESS STEPS Steatorrhea

Food–Drug Interactions

Assessment Data: Food records indicating poor intake, changes in weight, cholesterol levels.

Common Drugs Used and Potential Side Effects • Large doses of supplemental vitamins A and E will be prescribed by the physician. Alpha-tocopherol is given as 150 IU/kg/d orally in four divided doses. Vitamin A is given orally, 10,000 IU daily. Vitamin K is given 10 mg orally once a day. Vitamin D is often given daily as 400 IU cholecalciferol orally.

Nutrition Diagnoses (PES): Inadequate fat-soluble vitamin intake (especially E) related to fat malabsorption in ABL as evidenced by frothy stools four to five times daily, low serum cholesterol level, low serum levels of vitamin E, and abdominal distention. Intervention: Education of parents about the need for fat-soluble vitamin supplementation and for linoleic acid supplementation for condition.

Herbs, Botanicals, and Supplements • Herbs and botanicals are not recommended for this condition because there are no clinical trials proving efficacy.

Monitoring and Evaluation: Improved lab reports for vitamin E and cholesterol, weight improvement, fewer frothy stools, and less abdominal distention.

Nutrition Education, Counseling, Care Management • Advise that MCT products should be consumed slowly to avoid side effects such as diarrhea. • Discuss the need for intake of linoleic acid. • A multivitamin–mineral supplement will be recommended. Identify food sources of the fat-soluble vitamins and discuss how the disorder prevents use of these vitamins accordingly. • For persons with low vision, teaching with food models or large pictures may be more beneficial than use of text. Audiotapes may also be developed. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

145

For More Information ●

Genetics Home Reference http://ghr.nlm.nih.gov/condition/abetalipoproteinemia

●

Prevent Blindness http://www.preventblindness.org/

REFERENCES Abumrad NA, Davidson NO. Role of the gut in lipid homeostasis. Physiol Rev. 2012;92:1061. Chardon L, et al. Identification of two novel mutations and long-term follow-up in abetalipoproteinemia: a report of four cases. Eur J Pediatr. 2009;168:983. Jung HH, et al. Neuroacanthocytosis syndromes. Orphanet J Rare Dis. 2011;6:68. Khatun I, et al. Loss of both phospholipid and triglyceride transfer activities of microsomal triglyceride transfer protein in abetalipoproteinemia. J Lipid Res. 2013;54:1541. Zamel R, et al. Abetalipoproteinemia: two case reports and literature review. Orphanet J Rare Dis. 2008;3:19.

ATTENTION DEFICIT DISORDERS NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND Attention deficit hyperactivity disorder (ADHD) has three different subtypes: combined type, predominantly inattentive type, and predominantly hyperactive-impulsive type. ADHD is a neurobiological condition characterized by developmentally inappropriate level of attention, concentration, activity, distractibility, and impulsivity and it is more common in males. ADHD is the most commonly diagnosed behavioral disorder of childhood, affecting 4% to 6% of the population (Searight et al, 2012). The affected child often fails to give close attention to details or makes careless mistakes, often has difficulty sustaining attention to tasks, often does not seem to listen

Escott-Stump_Ch03.indd 145

when spoken to directly, often fails to follow instructions completely, loses or forgets important things, feels restless, often talks excessively, often blurts out answers before hearing the whole question, and often has difficulty awaiting turn (Attention Deficit Disorder Association, 2013). The condition continues into adulthood. The Preschool ADHD Treatment Study (PATS) has guided diagnostic and intervention strategies for children between the ages of 3 and 5. Most ADHD is identified by age 6. While genes account for 70% of hyperactivity and inattention in children, 30% is environmental (Nigg et al, 2010). Birth asphyxia, respiratory distress syndrome, and preeclampsia are independently associated with ADHD, especially in preterm births (Getahun etal, 2013). Children should be assessed for brain injury, seizure

11/7/14 8:24 PM

146

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

disorders, Asperger syndrome, and evidence of lead poisoning (Nigg et al, 2010). Children with ADHD with a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. Positron emission tomography (PET) scan comparisons between the brain of a normal child and the brain of an ADHD child show a significant difference. With glucose as the brain’s energy source, ADHD brain regions actually use less glucose than usual in areas that inhibit impulses and control attention. Maternal diet and metabolic status during pregnancy play a critical role. When the fetal serotonergic system is exposed to a maternal high fat diet (HFD), increased inflammatory cytokines, glucose, fatty acids, insulin, and leptin negatively affect the environment and alter programming of the neural circuitry that regulates offspring behavior (Sullivan et al, 2012). Children with ADHD may also be exposed to nutrient deficits. Iron deficiency causes abnormal dopaminergic neurotransmission. Iron and zinc are supplemented in patients with known deficiencies; they may also enhance the effectiveness of stimulant therapy (Millichap and Yee, 2012). Docosahexaenoic acid (DHA) supplementation appears to offer a safe and effective way to improve reading and behavior in healthy but underperforming children (Richardson et al, 2012). While fatty acid supplementation and artificial food color exclusion produces some positive effects, more evidence from blinded trials is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms (Sonuga-Barke et al, 2013). ADHD is a recognized disability and reasonable accommodations should be made to assist the child in school, or the adult in the workplace. Medication may be needed by some individuals with ADHD. In addition, coping skills and behavior therapy are important.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Polymorphisms in dopaminergic and serotonergic genes, the dopamine transporter (SLC6A3/DAT1) and the dopamine receptor D4 (DRD4), seem to be most strongly related. Recent research also suggests a common genetic link between ADHD, bipolar disorder, major depression, and schizophrenia.

Clinical/History • • • • • • • • • • • • • • • •

Height Weight Growth chart Low birth weight? Diet/intake history Mental retardation, other developmental delay? Head injury? Seizures or history of epilepsy? Electroencephalography (EEG) Sleep disturbances Irritability Learning disabilities Anxiety or depression Nocturnal enuresis Pesticide exposure? Screening tests

Escott-Stump_Ch03.indd 146

Lab Work • • • • • • • • •

Glucose (Gluc) H&H, serum iron (Fe) Ferritin levels Serum lead (elevated?) Serum zinc (low?) Alb Cholesterol (Chol) Liver function tests (LFTs) Serum vitamin D

INTERVENTION Objectives • Prevent nutrient deficiencies if diet is inadequate or with extensive documented food allergies. • Address poor intake and appetite, where present. Offer foods that are liked along with one to two new tastes to encourage expanding preferences. • Correct zinc deficiency and iron deficiency anemia, where indicated. • Rule out lead poisoning. • Provide sufficient intake of omega-3 fatty acids and other micronutrients.

Food and Nutrition • The diet should be balanced and sufficient in energy and protein for age and sex. The MyPlate food guidance system should be the basis for planning (see Section 2: Nutrition Practices, Food Safety, Allergies, Skin, and Miscellaneous Conditions). • Elimination of sugar is not required; moderation is reasonable. Small, frequent healthy snacks are important. • Artificial food colors (AFCs) have not been established as the main cause of ADHD, but some children may respond to elimination of AFCs. Some children, in addition to being sensitive to AFCs, are also sensitive to common nonsalicylate foods (milk, chocolate, soy, eggs, wheat, corn, legumes) as well as salicylate-containing grapes, tomatoes, and oranges (Stevens et al, 2011). • Include DHA and eicosapentaenoic acid (EPA) in the diet from tuna, mackerel, herring, sardines, and salmon (Ramakrishnan et al, 2009). • Offer plenty of whole grains, low-fat dairy, fruits, and vegetables in greater proportion than sugary foods to provide more micronutrients and phytochemicals. • Discuss good food sources of zinc and iron, especially for children with a limited diet or food jags. They may not eat meats, poultry, fish, eggs, and fortified cereals in sufficient amounts.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Stimulants such as Ritalin (methylphenidate) have been used for many years. They may cause weight loss, appetite change, sleep problems, or irritability. Newer, long-acting medications may alleviate some of the burden (see Table 3-4). • Nonstimulant Strattera (atomoxetine) is used to increase attention and the ability to focus; long-term use may cause liver damage or suicidal thoughts; monitor carefully.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

147

TABLE 3-4 ADHD Medications Approved by the FDAa TRADE NAME

GENERIC NAME

APPROVED AGE (YEARS)

Adderall

Amphetamine

3 and older

Adderall XR

Amphetamine (extended release)

6 and older

Concerta

Methylphenidate (long acting)

6 and older

Daytrana

Methylphenidate patch

6 and older

Desoxyn

Methamphetamine hydrochloride

6 and older

Dexedrine

Dextroamphetamine

3 and older

Dextrostat

Dextroamphetamine

3 and older

Focalin

Dexmethylphenidate

6 and older

Focalin XR

Dexmethylphenidate (extended release)

6 and older

Metadate ER

Methylphenidate (extended release)

6 and older

Metadate CD

Methylphenidate (extended release)

6 and older

Methylin

Methylphenidate (oral solution and chewable tablets)

6 and older

Ritalin

Methylphenidate

6 and older

Ritalin SR

Methylphenidate (extended release)

6 and older

Ritalin LA

Methylphenidate (long acting)

6 and older

Strattera

Atomoxetine

6 and older

Vyvanse

Lisdexamfetamine dimesylate

6 and older

Not all ADHD medications are approved for use in adults.

Herbs, Botanicals, and Supplements • Marketing has increased for herbal remedies, elimination diets, and food supplements for ADHD. The evidence-based treatment of choice for ADHD, stimulant medication, continues to be a source of public controversy (Searight et al, 2012). • Omega-3 fatty acids, zinc supplements, and neurofeedback may have some efficacy (Searight et al, 2012). A combination of omega-3, omega-6 fatty acids, magnesium, and zinc has some positive effects (Huss et al, 2010).

Nutrition Education, Counseling, Care Management • A trial elimination diet is appropriate for children who have not responded satisfactorily to conventional treatment or whose parents wish to pursue a dietary investigation (Stevens et al, 2011). • Since glucose is the brain’s source of energy, a sufficient intake of carbohydrate is needed. Assure that healthy choices are made from dairy, fruit and vegetable, and bread and cereal items. Reduce intake of sugary sweets, beverages, and snacks as a common sense approach. • Identify and remove sources of lead in the environment, especially if serum levels are found to be high. • EFAs and zinc are important. Include adequate amounts of fats in the daily diet (Gillies et al, 2012). Include good food sources daily. • Children need help to stay organized and follow directions. Use of a schedule is important; organize everyday routines. • Parent education is useful. Children need clear, consistent rules; praise them when rules are followed. • Individual psychotherapy may be quite beneficial. Encourage full participation. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing meals and snacks. Use clean utensils and containers.

Escott-Stump_Ch03.indd 147

SAMPLE NUTRITION CARE PROCESS STEPS Poor Food Choices Assessment Data: Food records indicating poor intake, weight loss, and food jags. Low H&H levels. Nutrition Diagnoses (PES): Inadequate energy intake related to limited preferences from a diet compared to estimated needs as evidenced by weight loss and dietary intake records. Inadequate iron intake related to a disordered eating pattern as evidenced by low hemoglobin (Hgb) of 10 g/L and few iron-rich food choices. Interventions:Food–nutrient delivery to include iron-rich foods. Educate parents about introducing new iron-rich food items, reducing distractions at mealtime, scheduling of activities to give structure, and the use of small snacks throughout the day to improve overall intake of nutrients and energy. Counsel about the importance of nutrient density in children’s diets. Coordinate care with medical team to test and identify other risks, such as high serum lead or low zinc levels. Monitoring and Evaluation: Improved nutrient density in food intake records. Better attention in school, fewer complaints about hyperactivity.

11/7/14 8:24 PM

148

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

For More Information ●

Attention Deficit Disorder Association http://www.add.org/

●

Help for ADD http://www.help4adhd.org/

REFERENCES Attention Deficit Disorder Association. Fact sheet. Available at http://www.add .org/?page=ADHD_Fact_Sheet. Accessed June 4, 2014. Getahun D, et al. In utero exposure to ischemic-hypoxic conditions and attention-deficit/hyperactivity disorder. Pediatrics. 2013;131:53. Gillies D, et al. Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev. 2012 Jul 11;7:CD007986. Huss M, et al. Supplementation of polyunsaturated fatty acids, magnesium and zinc in children seeking medical advice for attention-deficit/hyperactivity problems - an observational cohort study. Lipids Health Dis. 2010;9:105.

Millichap JG, Yee MM. The diet factor in attention-deficit/hyperactivity disorder. Pediatrics. 2012;129:330. Nigg JT, et al. Confirmation and extension of association of blood lead with attention-deficit hyperactivity disorder (AD/HD) and AD/HD symptom domains at population-typical exposure levels. J Child Psychol Psychiatry. 2010;51:58. Ramakrishnan U, et al. Role of docosahexaenoic acid in maternal and child mental health. Am J Clin Nutr. 2009;89:958S. Richardson AJ, et al. Docosahexaenoic acid for reading, cognition and behavior in children aged 7–9 years: a randomized, controlled trial (the DOLAB Study). PLoS One. 2012;7:e43909. Searight HR, et al. Complementary and alternative therapies for pediatric attention deficit hyperactivity disorder: a descriptive review. ISRN Psychiatry. 2012;2012:804127. Sonuga-Barke EJ, et al. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry. 2013;170:275. Stevens LJ, et al. Dietary sensitivities and ADHD symptoms: thirty-five years of research. Clin Pediatr (Phila). 2011;50:279. Sullivan EL, et al. Maternal high fat diet consumption during the perinatal period programs offspring behavior. Physiol Behav. 2012;pii: S0031-9384(12)00328.

AUTISM SPECTRUM DISORDER NUTRITIONAL ACUITY RANKING: LEVEL 1–2 DEFINITIONS AND BACKGROUND Autism spectrum disorder (ASD) begins in childhood as a developmental disability with altered brain connectivity. ASDs affect over 2 million individuals in the United States. Increased rate of brain growth occurs in the latter part of the first year of life; enlargement of gray and white matter cerebral volumes occurs by age 2 years. Symptoms of ASDs are apparent before age 3 years, with impaired social interaction and communication plus restricted, repetitive patterns of behavior. Autism is a developmental disorder with environmental triggers. Autism affects boys four to five times more often than girls (Autism Speaks, 2013). Exposure to toxins, infections, toxic microbiota, and dietary inadequacies play a role. Propionic acid (PPA) and its related short-chain fatty acids (SCFAs) are fermentation products of ASD-associated bacteria (Clostridia, Bacteroides, Desulfovibrio); SCFAs are derived from the host microbiome and can induce widespread effects on gut, brain, and behavior (Macfabe, 2012).

HOT H OT TOPIC Inflammation Abnormalities in lipid metabolism that affect the nervous system have been found in ASD. Altered membrane fluidity, peroxisomal function, gap junction coupling capacity, signaling, and neuroinflammation occur (Thomas et al, 2012). Increased oxidative stress, glutathione depletion, and altered phospholipid/ acylcarnitine profiles are also noted (Macfabe, 2012). Unique patterns of elevated short-chain and long-chain acylcarnitines suggest abnormalities in fatty acid and glutathione (GSH) metabolism (Frye et al, 2013).

Escott-Stump_Ch03.indd 148

Learning and behavior are influenced not only by nutrients but also by exposure to toxic food contaminants such as mercury that can disrupt metabolic processes and alter neuronal plasticity (Dufault et al, 2009). Mercury exposure can cause oxidative stress and decrease detoxification capacity, leading to decreased plasma methionine, GSH, cysteine, SAM, and sulfate and methylation problems. Availability of GSH can influence the effects of thimerosal (TM) and other mercury (Hg) compounds; TM is used as a preservative in many childhood vaccines, particularly in developing countries (Kern et al, 2013). High fructose corn syrup (HFCS) has been shown to contain trace amounts of mercury; its consumption can also lead to zinc loss, which is needed for mercury elimination (Dufault et al, 2009). Altered folic acid intake during pregnancy can cause epigenetic changes during early embryonic development (Vasquez et al, 2013). Use of prenatal folic acid supplements around the time of conception has been associated with a lower risk of autism (Suren et al, 2013). Allergies or sensitivities are common. Autistic children often have immunoglobulin A (IgA) deficiency, decreased natural killer (NK) cell numbers, antibodies against serotonin receptors, and a tumor necrosis factor (TNF) response to casein, gluten, and soy (Vojdani et al, 2008). Ritualistic eating behaviors, food limitations, messy eating habits, and food jags are common. Variety in texture or colors may not be accepted. Foods that could cause choking should be avoided, and a quiet environment for eating is best. Pica is a common problem, such as eating paper, string, or dirt (Matson et al, 2013). A thorough assessment is warranted to rule out iron deficiency anemia. In fragile X syndrome (found mostly in males), mental retardation and seizures of mild to moderate intensity can be present. Fragile X syndrome, the most common heritable form of cognitive impairment, is caused by epigenetic silencing of the fragile X (FMR1) gene owing to large expansions (200 repeats) of a noncoding CGG-repeat sequence (Hagerman and Hagerman, 2013). Loss of the translational repressor FMRP

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

occurs; the FMRP gene modulates local translation of synaptic proteins (Sidorov et al, 2013). A parkinsonian tremor commonly occurs. Rett syndrome (RTT) occurs primarily in girls and is evident by repetitive hand movements. Gastrointestinal and nutritional problems are prevalent throughout life and may pose a substantial medical burden for caregivers; gastrointestinal (GI) dysmotility, chewing and swallowing difficulties, altered weight, inadequate growth, and bone density problems are commonly found (Motil et al, 2012). Growth failure is prominent (Tarquino et al, 2012). In Asperger syndrome (AS), speech occurs at the usual time, intelligence is normal or above average, but social skills are stunted and interests are limited or obsessive. Individuals with AS are hypersensitive to external stimuli and require a carefully managed environment (Elwin et al, 2012). Children with ASDs have unusual ways of learning, paying attention, or reacting to different sensations. They like to repeat certain behaviors and do not want change in their daily activities. They are hypersensitive to sensory stimuli (tastes, smells, sounds, sights) and withdraw from what is perceived as distressing or painful. People with ASDs have problems with social and communication skills; nearly 40% of those with an ASD do not speak. Those who do speak often repeat back what has been said (echolalia) rather than creating a dialogue. Early intensive behavioral intervention (EIBI), a treatment delivered for multiple years at an intensity of 20 to 40 hours per week, is one of the more well-established treatments for ASD (Reichow et al, 2012). For children who participate in preschool, early interventions aimed at targeting core developmental difficulties, focusing on joint attention and play skills in comprehensive treatment models, is important for long-term spoken language outcomes (Kasari et al, 2012).

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Mutation screening of several genes shows protein-altering mutations, especially among older fathers (Neale et al, 2012; O’Roak et al, 2012).

Clinical/History • • • • • • • • •

Height Weight Head circumference Growth chart Diet/intake history Vineland Adaptive Behavior Scale (VABS) Modified Checklist for Autism in Toddlers (M-CHAT) Childhood Asperger Syndrome Test (CAST) Magnetic resonance imaging (MRI) or computed tomography (CT) scan of the brain • Pica • Endoscopy • Sleep patterns

Lab Work • CBC with differential • Gluc

Escott-Stump_Ch03.indd 149

• • • • • • • • • • • • • • •

149

H&H, serum Fe, ferritin GSH (reduced form; GSSG, oxidized form) Celiac screening panel Lactose breath test Thyroid studies LFTs Lipid profile RAST or allergy testing Alb Chol, Trig Serum lead (with pica) C-reactive protein (CRP) Serum folic acid Serum vitamin D Serum zinc

INTERVENTION Objectives • Ameliorate symptoms and improve developmental outcomes (Whiteley et al, 2012). • Prevent or lessen complications, such as malnutrition and feeding problems. Offer consistency in food textures and tastes that prevent sensory overload. • Identify and treat nutritional deficiencies, including deficiencies in DHA and EPA, methionine, zinc, and selenium, which influence neuronal function (Dufault et al, 2009). Diets may be low in fiber, choline, calcium, vitamin D, vitamin K, potassium, energy, vitamins A and C, zinc, and phosphorus (Hyman et al, 2012). Analyze diets carefully. • Correct constipation if symptoms are present. Extra fluid may be useful. • Work with other therapies, such as speech therapy or occupational therapy, to determine how to best offer foods of greater texture and variety that can be consumed by the child or offered by the caregiver. • Monitor food jags, pica, history of choking on foods, and intolerances for varied textures, and adapt meals and menu items accordingly. The goal is to eat foods from all food groups; change texture as needed. • Frequent infections, chronic constipation or diarrhea, thyroid problems, and allergies require nutritional management. A high prevalence of non-IgE-mediated food allergies and GI symptoms occur in this population (Jyonouchi, 2008).

Food and Nutrition • Offer foods of texture and variety that are desired by the child. Follow a usual pattern and enhance with nutrientdense additives in food preparation that will not alter flavor and texture. • If a multivitamin–mineral supplement is needed, use one that has acceptable taste to the individual. • Gluten–casein elimination diets have success for some individuals but can also lead to nutrient deficiencies. Use under close supervision of a dietitian. Casein-free diets usually produce benefits within a month; gluten-free diets usually take 1 to 3 months to produce benefits. High-quality, largescale randomized trials are needed to prove the true effects (Pietzak, 2012).

11/7/14 8:24 PM

150

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

• Offer extra energy if weight is low, a common finding. Assess needs according to activity levels, weight, and nutritional status, and medications that are prescribed. • Since the brain requires omega-3 fatty acids for membrane integrity and to reduce inflammation, include them in the diet or use them in supplemental form. • Some autistic children have disaccharide deficiencies; alter diet accordingly. Avoid HFCS as much as possible.

• Avoid allergens, where documented. • Support various therapies, such as speech therapy, occupational therapy, use assistive technology and biomedical applications that are evidence-based. • Sleep disorders are common; a medical review may be warranted. • Many parents worry about the mumps, measles, and rubella (MMR) vaccine; a drop of thimerosal is a concern. Parents should discuss concerns with their doctor.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Large numbers of children with ASD are managed medically and receive both pharmacologic and complementary alternative medicine (CAM) treatments, even without comprehensive reviews (Dove et al, 2012; Huffman et al, 2011). • Antipsychotic drugs aripiprazole and risperidone are the only medications approved for autism by the U.S. Food and Drug Administration (FDA). Side effects may include sedation, involuntary muscle spasms, and weight gain. • No single psychopharmacological therapies will treat all symptoms (Reichow et al, 2012). • N-acetylcysteine, a glutamate modulator, has been proposed for irritability (Hardan et al, 2012). • Epilepsy is often found in individuals with ASD. Medications such as levetiracetam may help control seizures and promote better sleep (Larsson et al, 2012). • Folinic acid, betaine, and methylcobalamin may be needed normalize metabolic imbalances or to treat cerebral folate deficiency.

Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers. Sanitize work surfaces before food preparation. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. To avoid wasting foods, serve small portions more frequently.

Herbs, Botanicals, and Supplements • Over half of children with autism are using products such as melatonin, sulfation glutathione, amino acids, chelation, probiotics, or thyroid supplements (Golnick and Ireland, 2009). • Vitamin B6 and magnesium, vitamin C, carnosine, and omega-3 fatty acids show some benefit, but more studies are needed. Mega doses of vitamin B6 and magnesium may have potential risks. • Herbs and botanicals are not recommended for these conditions because clinical trials have not proven efficacy.

• Inadequate protein-energy intake related to highly restricted eating behaviors and pickiness as evidenced by parental report of insufficient intake, below 50% for age for weight, growth failure, and frequent lack of interest in food.

SAMPLE NUTRITION CARE PROCESS STEPS Intake of Unsafe Foods Assessment Data: Food records indicating intake of gluten; loss of weight; chronic rashes, infections, and diarrhea; small bowel biopsy indicating celiac disease. Nutrition Diagnoses (PES):

• Intake of unsafe foods related to sensitivity to gluten in autistic child as evidenced by biopsy positive for celiac disease, rashes, chronic diarrhea. Intervention: Educate parents about gluten-free diet, food labeling, simple meal preparation. Counsel about use of food diaries and routines; how to include frequent nutrient-dense snacks of desired food items.

Nutrition Education, Counseling, Care Management • Evaluate for behaviors such as pica; discuss how this may lead to anemia. • Assist with tips on how to handle picky eating, rigid food behaviors, and nutrient insufficiency. Discuss various ways to include nutrient-dense foods in the diet. Micronutrient powders (MNPs) are single-dose packets containing multiple vitamins and minerals in a powder that can be sprinkled onto semi solid foods (De-Regil et al, 2011). • “Improved diet” techniques may include organic foods, which add expense to the cost of meals and may not be necessary. • Foods that could cause choking should be avoided and a quiet environment for eating is best. • Keep language simple and concrete; avoid abstract concepts. Pictures and simple words are more effective when working with an older child or teen. • Artificial colors and preservatives may have a detrimental effect on behavior, especially red and yellow food dyes. Discuss how to limit their use.

Escott-Stump_Ch03.indd 150

Monitoring and Evaluation: Improved weight records; fewer loose stools, infections, and rashes.

For More Information ●

Asperger Syndrome http://www.aspergers.com/

●

Autism Research Institute http://www.autism.com/

●

Autism Society of America http://www.autism-society.org/

●

Autism Speaks – Toolkits http://www.autismspeaks.org/family-services/tool-kits

●

Centers for Disease Control and Prevention: Autism Spectrum Disorder http://www.cdc.gov/ncbddd/autism/

●

Defeat Autism Now (DAN) http://www.defeatautismnow.net/

●

Interagency Autism Coordinating Committee http://iacc.hhs.gov/strategic-plan/2012/index.shtml

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S ●

National Fragile X Foundation http://www.nfxf.org/

●

NIHM Center for Collaborative Genomics Research on Mental Disorders http://www.nimhgenetics.org

●

Rett Syndrome http://www.rettsyndrome.org/

REFERENCES Autism Speaks. What is autism? Available at: http://www.autismspeaks.org /what-autism. Accessed June 4, 2014. De-Regil LM, et al. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD008959. Dove D, et al. Medications for adolescents and young adults with autism spectrum disorders: a systematic review. Pediatrics. 2012;130:717. Dufault R, et al. Mercury exposure, nutritional deficiencies and metabolic disruptions may affect learning in children. Behav Brain Funct. 2009;5:44. Elwin M, et al. Autobiographical accounts of sensing in Asperger syndrome and high-functioning autism. Arch Psychiatr Nurs. 2012;26:420. Frye RE, et al. Unique acyl-carnitine profiles are potential biomarkers for acquired mitochondrial disease in autism spectrum disorder. Transl Psychiatry. 2013;3:e220. Golnick AE, Ireland M. Complementary alternative medicine for children with autism: a physician survey. J Autism Dev Disord. 2009;39:996. Hagerman R, Hagerman P. Advances in clinical and molecular understanding of the FMR1 premutation and fragile X-associated tremor/ataxia syndrome. Lancet Neurol. 2013;12:786. Hardan AY, et al. Randomized controlled pilot trial of oral N-acetylcysteine in children with autism. Biol Psychiatry. 2012;71:956. Huffman LC, et al. Management of symptoms in children with autism spectrum disorders: a comprehensive review of pharmacologic and complementaryalternative medicine treatments. J Dev Behav Pediatr. 2011;32:56. Hyman SL, et al. Nutrient intake from food in children with autism. Pediatrics. 2012;130:S145. Jyonouchi H. Non-IgE mediated food allergy. Inﬂamm Allergy Drug Targets. 2008;7:173.

151

Kasari C, et al. Longitudinal follow-up of children with autism receiving targeted interventions on joint attention and play. J Am Acad Child Adolesc Psychiatry. 2012;51:487. Kern JK, et al. Thimerosal exposure and the role of sulfation chemistry and thiol availability in autism. Int J Environ Res Public Health. 2013;10:3771. Larsson PG, et al. The effect of levetiracetam on focal nocturnal epileptiform activity during sleep—a placebo-controlled double-blind cross-over study. Epilepsy Behav. 2012;24:44. Macfabe DF. Short-chain fatty acid fermentation products of the gut microbiome: implications in autism spectrum disorders. Microb Ecol Health Dis. 2012;23:19260. Matson JL, et al. Pica in persons with developmental disabilities: approaches to treatment. Res Dev Disabil. 2013;34:2564–2571. Motil KJ, et al. Gastrointestinal and nutritional problems occur frequently throughout life in girls and women with Rett syndrome. J Pediatr Gastroenterol Nutr. 2012;55:292. Neale BM, et al. Patterns and rates of exonic de novo mutations in autism spectrum disorders. Nature. 2012;485:242. O’Roak BJ, et al. Sporadic autism exomes reveal a highly interconnected protein network of de novo mutations. Nature. 2012;485:246. Pietzak M. Celiac disease, wheat allergy, and gluten sensitivity: when gluten free is not a fad. JPEN J Parenter Enteral Nutr. 2012;36:68S. Reichow B, et al. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012 Oct 17;10:CD009260. Sidorov MS, et al. Fragile X mental retardation protein and synaptic plasticity. Mol Brain. 2013;6:15. Suren P, et al. Association between maternal use of folic acid supplements and risk of autism spectrum disorders in children. JAMA. 2013;309:570. Tarquino DC, et al. Growth failure and outcome in Rett syndrome: specific growth references. Neurology. 2012;79:1653. Thomas RH, et al. The enteric bacterial metabolite propionic acid alters brain and plasma phospholipid molecular species: further development of a rodent model of autism spectrum disorders. J Neuroinﬂammation. 2012;9:153. Vasquez K, et al. The effect of folic acid on GABA(A)-B 1 receptor subunit. Adv Exp Med Biol. 2013;775:101. Vojdani A, et al. Low natural killer cell cytotoxic activity in autism: the role of glutathione, IL-2 and IL-15. J Neuroimmunol. 2008;205:148. Whiteley P, et al. Gluten- and casein-free dietary intervention for autism spectrum conditions. Front Hum Neurosci. 2012;6:344.

BILIARY ATRESIA NUTRITIONAL ACUITY RANKING: LEVEL 2–3 DEFINITIONS AND BACKGROUND Biliary atresia (neonatal hepatitis) is a serious condition, affecting 1/15,000 to 1/8,000 live births (Baumann and Ure, 2012). Incidence is higher in the Asian or African-American populations. The bile ducts become inflamed and blocked; bile remains in the liver and causes cirrhosis. Lymphocyte-mediated inflammatory damage of the bile ducts has been noted (Shinkai et al, 2006). Biliary atresia results in persistent jaundice, enlarged spleen, liver damage, portal hypertension, clay-colored stools, dark urine, irritability, and swollen abdomen. The condition becomes evident between 2 and 6 weeks after birth. Portal hypertension may contribute to blood being vomited or passed in the stools. Malnutrition is a critical predictor of mortality and morbidity. Treatment involves surgery; the Kasai procedure bypasses the ducts to connect the liver to the small intestine. It is more successful if performed in the first few months of life. Complications of the surgery can include liver failure, infections, and sepsis. Biliary atresia and other cholestatic disorders are the most frequent cause of end-stage liver disease (ESLD) in children, and malnutrition is a complication (Young et al, 2013). Cholestasis

Escott-Stump_Ch03.indd 151

predisposes to fat-soluble vitamin (FSV) deficiencies (Shneider et al, 2012). The hepatic portoenterostomy (HPE) is the initial operation for biliary reconstruction for biliary atresia, but cholecystojejunostomy may be needed with any later distal biliary obstruction (Tam et al, 2013). If a donor is available, the patient may also be a candidate for a liver transplantation, with a good prognosis. Immunosuppressive drugs are then necessary to overcome organ rejection.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Biliary atresia itself may not be hereditary but seems to have an autoimmune origin related to HLA genes (Mack et al, 2013).

Clinical/History • Birth weight • Height

11/7/14 8:24 PM

152 • • • • • • • • • • •

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Growth (%) Diet/intake history Dark urine Steatorrhea Swollen abdomen (ascites) Jaundice 1 month Itching Clay-colored stools Nuclear hepatoiminodiacetic acid (HIDA) test Liver scan or biopsy Ultrasound

• • • •

• •

Lab Work • • • • • • • • • • • • • • •

Alb Transthyretin H&H Alkaline phosphatase (ALP) Chol, Trig Transferrin Total bilirubin (TB) Blood urea nitrogen (BUN) Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Alpha-1-antitrypsin deficiency PT or INR Serum zinc Serum copper Serum vitamin D

INTERVENTION Objectives Preoperatively • Correct malabsorption and alleviate steatorrhea from decreased bile. • Correct malnutrition of FSVs and zinc. Prevent rickets, visual disturbances, peripheral neuropathy, and coagulopathies. • Prevent hemorrhage from high blood pressure (BP) if there is portal hypertension. Parenteral vitamin K may be needed if coagulopathy is present (McKiernan, 2012). • Prepare for surgery or transplantation. Postoperatively • Support proper wound healing by providing all necessary nutrients (e.g., vitamin C, zinc) using appropriate and tolerated feeding method. • Promote normal growth and development. • Provide regular nutritional assessments to evaluate progress and improvement or decline. • Offer timely and aggressive nutrition support to maximize anabolism and optimize outcomes (Young et al, 2013). • Reduce inflammation, which may continue even after surgery (Asakawa et al, 2009).

Food and Nutrition Preoperative • Infants need 1.5 to 3.0 g protein/kg dry weight to avoid protein catabolism, dependent on enteral versus parenteral source. This translates to 2 to 2.5 g/kg for parenteral

Escott-Stump_Ch03.indd 152

•

nutrition (PN) and 2.5 to 3 g/kg for enteral nutrition, 1 to 1.5 g/kg if encephalopathic. Identify products enriched with branched-chain amino acids (BCAAs). Small, frequent feedings may be useful. Use low total fat from the diet. Supplement with oil high in MCTs; add EFAs for age and body size. Pregestimil or Alimentum or other elemental formulas may be needed to decrease fiber and prevent hemorrhage anywhere along the GI tract. With edema, limit intake of sodium to 1 to 2 g/d. Supplement with vitamins A, D, E, and K. Liquid multiple FSV preparations made with tocopheryl polyethylene glycol-1000 succinate are frequently used in infants with biliary atresia (BA) because of ease of administration (Shneider etal, 2012). Provide antioxidants as serum levels of minerals, such as selenium, zinc, and iron, tend to be low. Avoid use of copper in total parenteral nutrition (TPN) or supplements to prevent toxic buildup. Tube feed especially if recurrent or prolonged bleeding from the GI tract occurs. If nasogastric (NG) feeding is not tolerated, a percutaneous endoscopic gastrostomy (PEG) tube may be used.

Postoperative • Control sodium, protein, and other nutrients only if necessary based on symptoms such as edema and renal failure. Carefully monitor vitamin and mineral requirements. • Use of antioxidants will be needed to reduce inflammatory processes (Asakawa et al, 2009). • For needed catch-up growth, tube feeding may be beneficial. Assure that all key nutrients are included over a long-term basis.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Ursodiol (Actigall, Urso) promotes bile flow and may be used after surgery. Side effects are minimal. • Phenobarbital and cholestyramine are often used to control hyperlipidemia and pruritus. Increase vitamin D, calcium, vitamin B12, and folate intake. Constipation can result. • Corticosteroids may be needed to stimulate independent bile flow. Long-term use can deplete stores of calcium and phosphorus; may elevate glucose, cause stunting, or cause weight gain. • Diuretics may be used; monitor for depletion of potassium, magnesium, calcium, and folate. Anorexia can occur. • Antibiotics such as Bactrim or Septra (sulfamethoxazole and trimethoprim) may be needed to manage cholangitis, common following the Kasai procedure. Anorexia, nausea, or vomiting may result. Use of acidophilus and probiotic products may alleviate loss of intestinal bacteria. • Growth hormone (GH) may be useful to promote catch-up growth. Herbs, Botanicals, and Supplements • Herbs and botanicals are not recommended with this condition because the liver is not able to perform its usual role of detoxification. • Probiotics may be helpful; more studies are needed.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

Nutrition Education, Counseling, Care Management • Teach parents about proper feedings or supplements. Indicate which foods provide antioxidants, including vitamins C and E, and selenium. • If bile flow improves after surgery or transplantation, a regular diet may be used, although continuing use of MCT oil may be better tolerated for a while. • Teach that the FSVs A, D, E, and K can be used only when they are bound to fat. It may be important to take supplemental forms. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

SAMPLE NUTRITION CARE PROCESS STEPS Altered GI Function Assessment Data:Stool and urine tests; abdominal girth; weight changes; poor intake. Nutrition Diagnoses (PES):Altered GI function related to degenerating bile ducts and biliary atresia as evidenced by clay-colored stools, abdominal distention, jaundice, and dark urine.

153

For More Information

See the video “Care of the Hospitalized Child: Parent and Family Participation” at www.thepoint.lww.com/escottstump8e.

●

American Liver Foundation http://www.liverfoundation.org/abouttheliver/info/biliaryatresia/

●

Canadian Liver Foundation – Biliary Atresia http://www.liver.ca/liver_disease/childrens_liver_diseases/biliary_atresia.aspx

●

Children’s Liver Association for Support Services http://www.classkids.org/library/biliaryatresia.htm

●

Children’s Liver Disease Foundation http://www.childliverdisease.org/Information/Medical-stuff/Information -on-liver-diseases/Biliary-Atresia

REFERENCES Asakawa T, et al. Oxidative stress profile in the post-operative patients with biliary atresia. Pediatr Surg Int. 2009;25:93. Baumann U, Ure B. Biliary atresia. Clin Res Hepatol Gastroenterol. 2012;36:257. Mack CL, et al. Lack of HLA predominance and HLA shared epitopes in biliary atresia. Springerplus. 2013;2:42. McKiernan P. Neonatal jaundice. Clin Res Hepatol Gastroenterol. 2012;36:253. Shinkai M, et al. Increased CXCR3 expression associated with CD3-positive lymphocytes in the liver and biliary remnant in biliary atresia. J Pediatr Surg. 2006;41:950. Shneider BL, et al. Efficacy of fat-soluble vitamin supplementation in infants with biliary atresia. Pediatrics. 2012;130:e607–e614. Tam MS, et al. Successful salvage of late failure of hepatic portocholecystostomy (gallbladder Kasai) with Roux-en-Y cholecystojejunostomy. J Pediatr Surg. 2013;48:e37. Young S, et al. Nutrition assessment and support in children with end-stage liver disease. Nutr Clin Pract. 2013;28:317.

Intervention:Educate parents about the needed surgery and need for protein, FSVs. Monitoring and Evaluation:Improved weight and intake after surgery; reduced abdominal distention and normalized stools and urine color.

BRONCHOPULMONARY DYSPLASIA NUTRITIONAL ACUITY RANKING: LEVEL 3–4 DEFINITIONS AND BACKGROUND Bronchopulmonary dysplasia (BPD), the chronic lung disease of prematurity, is the major cause of pulmonary disease in infants (Groothius and Makari, 2012). Extremely immature bronchioles are severely injured by mechanical ventilation of a day or longer; potential repair genes are activated in both extremely and very preterm lungs (Brew etal, 2013).

Escott-Stump_Ch03.indd 153

The likelihood for developing BPD increases with the degree of prematurity and reaches 25% to 35% in very low-birth-weight (VLBW) and extremely low-birth-weight infants (Groothius and Makari, 2012). Infants who develop BPD are most often born more than 10 weeks before their due dates, weigh less than 2lb (about 1,000 g) at birth, and have infections such as neonatal pneumonia or sepsis (Landry and Menzies, 2011). Long-chain polyunsaturated fatty acids and surfactant replacement therapy are often given to prevent BPD in susceptible

11/7/14 8:24 PM

154

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

newborns. VLBW infants with severe respiratory disease need extra nutrients for epithelial cell repair and to support catch-up growth. VLBW infants should be given adequate nutritional attention (e.g., parenteral or enteral nutrition, fluid restriction) from the first day of life. Respiratory failure, supplemental oxygen use, mechanical ventilation, endotracheal intubation, and congenital heart disease all affect nutritional status. Slow growth occurs, and feeding problems are common. Long-term chronic care, comprehensive nutrition, nutrition therapy with adequate energy, parental education, and feeding support may be needed. Many preterm infants with BPD have malnutrition after 2 years of age or suffer from persistent airway obstruction or asthma. Glutamine is the main source for lung energy. Inositol is necessary for surfactant synthesis; vitamin E and selenium have antioxidant effects and vitamin A helps support healthy lung tissue.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Human genetic variants in the promoter of NFKBIA, which encodes I B , the major negative regulator of NF- B, may play a role (Ali et al, 2013).

Clinical/History • • • • • • • • • • • •

Gestational age Length BMI Low birth weight or VLBW (growth charts for height and weight) Size for gestational age (intrauterine growth chart if available) Head circumference Diet/intake history Emesis Stool pattern Urinary output BP Pulmonary hypertension

Lab Work • • • • • • • • • • • • • • • •

H&H Pepsin levels pH Chol, Trig Potassium (K) and chloride (Cl) (tend to be low) Sodium (Na) Alb ALP White blood cell (WBC) count Gluc Oxygen saturation levels Partial pressure of carbon dioxide (pCO2) Partial pressure of oxygen (pO2) Calcium (Ca), magnesium (Mg) Serum vitamin D Urine-specific gravity

Escott-Stump_Ch03.indd 154

INTERVENTION OBJECTIVES • Increase energy intake to improve growth and respiratory functioning by correcting nutritional deficits. • Correct gastroesophageal reflux. Position an infant carefully if formula fed. • Achieve desirable growth. Infants with BPD tend to have delayed development. Energy needs are approximately 25% to 50% above normal. Correct malnutrition and anorexia from respiratory distress and ventilator support. • Provide optimal protein for linear growth, development, and resistance to infection. Improve lean body mass if depleted. • Spare protein by providing extra energy from fat and carbohydrate. However, excesses of carbohydrate can increase CO2 production and prevent extubation; calculate needs carefully. • Avoid parenteral overfeeding, which may lead to PNassociated cholestasis (Robinson and Ehrenkranz, 2008). • Replace lost electrolytes, especially chloride, which may lead to death if uncorrected. • Fluid restriction may be needed if fluid retention is noted; monitor closely. • Prevent EFA deficiency. • Avoid or correct retinopathy. Assure adequate vitamin A intake. • Prevent complications, such as aspiration pneumonia or choking during feeding. • Prevent rickets and metabolic bone disease by including sufficient calcium and vitamin D intake.

Food and Nutrition • Energy requirements will be 25% above normal; provide 120 to 160 kcal/kg to achieve optimal weight. • Within the first few days of life, TPN or tube feeding may be required. Initially, 70 (PN) or 95 (enteral) kcal/kg, increasing gradually to 130 to 180 kcal/kg after acuity subsides. • Protein requirements may be slightly higher than usual. Careful formula management is needed. Initially, use 2.0 g protein/kg, increasing to 2.5 to 3.5 g/kg. TrophAmine is beneficial. • Decrease total carbohydrate (CHO) intake if glucose intolerance develops; monitor blood glucose levels. • Provide at least the normal recommended allowances for antioxidant and other important nutrients. Include vitamins A, D, and E (use water-miscible sources if necessary); provide adequate calcium, phosphorus, and iron if needed. Nutrient- or energy-enriched infant formulas may be needed for catch-up growth. • Fluid intake may be restricted to 150 mL/kg/d and sodium may need to be restricted if there is pulmonary edema or hypertension. • With decreased suck and swallowing ability, tube feeding may be better tolerated. Infants can tolerate most formulas. Nocturnal tube feeding may be useful, especially with growth failures. With gastroesophageal reflux disease (GERD), a gastrostomy feeding tube may be appropriate. • Increase fat:CHO ratio with respiratory distress. To meet EFA needs, start with 0.5 to 1 g/kg and progress to 3 g/kg. • Omega-3 fatty acids, selenium, inositol, and vitamins A and E have been suggested.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

• When ready to progress to an oral diet, use of solids may be better tolerated than liquids. If necessary, thicken liquids or formula (e.g., with baby cereal or other thickeners). Use a supine position to avoid aspiration.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Exogenous steroid therapy (dexamethasone or methylprednisone), if used for pulmonary compliance in ventilated premature infants, may compromise vitamin A status and restrict bone growth. Sodium retention, anorexia, edema, hypertension, and potassium losses are side effects. Take with food to decrease GI effects. Use more protein and less sodium; enhance potassium if needed. • Antibiotics are needed during infections; acidophilus and probiotic products may alleviate losses of intestinal bacteria. • Bronchodilators or caffeine may be used for apnea of prematurity. Anorexia can occur. • Diuretics may be needed to lessen pulmonary edema. Monitor those that deplete serum potassium, such as furosemide (Lasix). Magnesium, calcium, and folate may be also depleted; appetite may decline. Evidence-based guidelines are needed. • Cysteine, N-acetylcysteine, or cystine may be used in combination with chloride.

155

• Oral–motor skills may be delayed from long-term ventilator use; discuss how to make adjustments with caregiver. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

SAMPLE NUTRITION CARE PROCESS STEPS Overfeeding Assessment Data: Weight and growth charts, presence of GERD or vomiting, low serum potassium and chloride. Nutrition Diagnoses (PES): Excessive oral intake of formula in VLBW infant related to respiratory distress and BPD as evidenced by vomiting after most feedings and GERD. Intervention:Educate parents about need for appropriate amounts of formula, feeding tips for discharge to home, appropriate rate of growth and weight change.

Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for BPD because the lungs are not able to perform their role in oxygenation of cells. • Use of acidophilus and probiotic products may be useful with chronic antibiotic therapy.

Monitoring and Evaluation: Weight records, decreased vomiting and episodes of GERD, normalized labs for K and Cl, and other labs.

Nutrition Education, Counseling, Care Management • Because BPD affects many organ systems, infants with BPD are at increased risk for rehospitalization and numerous complications following neonatal intensive care unit (NICU) discharge; thus, a multidisciplinary team consisting of the neonatologist/attending physician, primary care physician, and other specialized staff members must meet regularly to provide continuity of care and accurate patient assessments (Groothius and Makari, 2012). • Diet must be reevaluated periodically to reflect growth and disease process. Assure adequacy of vitamins and related nutrients for lung health (e.g., vitamin A). • Ensure that all foods and beverages are nutrient dense. • New foods may be introduced gradually; thicken as needed to avoid aspiration. • Fluid intake should be adequate to meet needs but not excessive. • Discuss signs of overhydration and dehydration with the parent/caregiver.

Escott-Stump_Ch03.indd 155

For More Information ●

American Lung Association http://www.lungusa.org/

●

National Blood, Heart, and Lung Institute http://www.nhlbi.nih.gov/health/dci/Diseases/Bpd/Bpd_WhatIs.html

REFERENCES Ali S, et al. Functional genetic variation in NFKBIA and susceptibility to childhood asthma, bronchiolitis, and bronchopulmonary dysplasia. J Immunol. 2013;190:3949. Brew N, et al. Mechanical ventilation injury and repair in extremely and very preterm lungs. PLoS One. 2013;8:e63905. Groothius JR, Makari D. Definition and outpatient management of the very low-birth-weight infant with bronchopulmonary dysplasia. Adv Ther. 2012;29:297. Landry JS, Menzies D. Occurrence and severity of bronchopulmonary dysplasia and respiratory distress syndrome after a preterm birth. Paediatr Child Health. 2011;16:399. Robinson DT, Ehrenkranz RA. Parenteral nutrition-associated cholestasis in small for gestational age infants. J Pediatr. 2008;152:59.

11/7/14 8:24 PM

156

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

CARBOHYDRATE METABOLIC DISORDERS NUTRITIONAL ACUITY RANKING: LEVEL 4 DEFINITIONS AND BACKGROUND Glycogen storage diseases (GSDs) and inborn errors of galactose and fructose metabolism are the most common inborn errors of carbohydrate metabolism (Mayatepek et al, 2010). Glucose is transported across cell membranes by active sodium-facilitated transport in the intestinal or renal cells; in all other cells, the GLUT family of glucose transporters is needed. Diagnosis of “carbohydrate malabsorption” occurs during infancy or childhood, with hypoglycemia, hepatomegaly, poor physical growth, and deranged biochemical profiles. GSDs are rare genetic disorders in which glycogen cannot be metabolized to glucose in the liver because of enzyme deficits. Congenital glucose–galactose malabsorption (congenital renal glycosuria) is an extremely rare, autosomal recessive trait. Watery, profuse diarrhea occurs from deficiency in the sodium-coupled cotransport of glucose and galactose in the intestinal mucosa. There is no cure, but removal of lactose, sucrose, and glucose decreases symptoms. Fructose intolerance results from a defect in the enzyme converting fructose to glucose (1-phosphofructaldolase). It is an autosomal recessive disease, as common as 1/20,000 persons in European countries. Fructose intolerance causes GI discomfort, nausea, malaise, and growth failure. Ingesting fructose causes profound hypoglycemia; if left untreated, progressive liver disease results. A strict fructose-restricted diet is needed (Mayatepek et al, 2010). Inherited deficiency of galactose-1-phosphate uridylyltransferase (GALT) can result in a potentially lethal disorder called classic galactosemia. Galactosemia is caused by inherited deficiencies in one of three enzymes involved in the metabolism of galactose—GALT, galactokinase (GALK), and uridine diphosphate galactose-4-epimerase (GALE)—and may occur in 1/60,000 births (Sarkar et al, 2010). The neonatal lethality associated with this disease can be prevented through early diagnosis and a galactose-restricted diet but lack of effective therapy leads to developmental delay, neurologic disorders, and premature ovarian failure (Tang et al, 2012). Many countries now screen for galactosemia in their newborn screening programs (Mayatepek et al, 2010). These infants are unable to fully metabolize the simple sugar galactose and should not be breastfed. High levels of the sugar alcohol, galactitol, may be present. FTT, vomiting or diarrhea, jaundice, and liver disease occur after milk ingestion. Osteopenia, cataracts, encephalopathy, hepatomegaly, and mental retardation can result over time. In females, serum follicle-stimulating hormone levels can be elevated, causing primary ovarian insufficiency (POI) that may prevent successful pregnancy. Glucose transporter type 1 (Glut1) deficiency syndrome is defined by hypoglycorrhachia with normoglycemia, acquired microcephaly, episodic movements, and epilepsy refractory to standard antiepileptic drugs (Pong et al, 2012). Low glucose in the cerebrospinal fluid and developmental delay are also present. Figure 3-2 shows the galactose pathways.

Escott-Stump_Ch03.indd 156

Glut2 deficiency produces Fanconi–Bickel syndrome. Hepatorenal glycogen accumulation results in hepato- and nephromegaly, impaired utilization of glucose and galactose, proximal tubular nephropathy, rickets, and severe short stature (Grunert et al, 2012). Table 3-5 lists the various types of glycogen storage diseases (GSDs). Glycogen is the storage form of glucose found in the liver and muscles; small amounts are also found in the kidney and intestine. Diagnosis of a GSD is usually made by mutation analysis (Mayatepek et al, 2010). Hepatomegaly and hypoglycemia are the main findings in GSD type I, III and IX; frequent daytime feedings of complex carbohydrate and protein are needed. GSD Ia is the most common type. It is caused by deficient activity of glucose-6-phosphatase- , producing fasting-induced hypoglycemia and hepatomegaly, growth delay, anemia, platelet dysfunction, osteopenia, and sometimes osteoporosis; hyperlipidemia and hyperuricemia are almost always present and hepatocellular adenomas and renal dysfunction frequent late complications (Carvalho et al, 2013). With careful management, prognosis is good. Maltase is the enzyme that degrades lysosomal glycogen in liver and muscle. In late adult-onset acid maltase deficiency (GSD II), glycogen accumulates inside muscular lysosomes not only in muscle, but also throughout the body (Pascual and Roe, 2013). Liver transplantation may be needed to correct severe cirrhosis in different types of GSD (Mayatepek et al, 2010). Genetic lactose intolerance has an autosomal recessive trait deficit encoded by the lactase gene on chromosome 2. Ithas a frequency of 5% in northern Europe to 90% in East Asia. Alactose-free infant formula can be life-saving (Mayatepek et al, 2010). See Section 7: Gastrointestinal Disorders for more details. Sucrose intolerance occurs rarely as a genetic defect or temporarily after GI flu or irritable bowel distress. Sucrase and maltase deficiency may occur simultaneously, with an osmotic diarrhea.

Exogenous (dietary) galactose

Endogenous turnover of glycoproteins/glycolipids

Galactose ATP GALK ADP Galactose-1-phosphate

UDP-galactose GALT GALE

UDP-glucose

Glucose-1-phosphate

Figure 3-2. The human galactose pathway. (Adapted with permission from Tang M, Odejinmi SI, Vankayalapati H, et al. Innovative therapy for classic galactosemia—tale of two HTS. Mol Genet Metab. 2012;105(1):44–55.)

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

157

TABLE 3-5 Glycogen Storage Diseases: Deficiency of a Glycogen Synthase That Normally Converts Glycogen to Glucose DISEASE

DESCRIPTION

GSD1: glucose-6 phosphatase deficiency (G6PD), von Gierke disease

Slow or stunted growth, enlarged liver, delayed or absent pubertal development, gout, kidney failure, and a poor ability to withstand fasting due to low blood sugar occur. Patients with this condition are prone to frequent infections, hemolytic anemia, and inflammatory bowel disease. Brain damage can result from low glucose availability.

GSD2: alpha-glucosidase deficiency, Pompe disease

Onset in infancy is the most severe; most patients present with hypotonia and cardiomyopathy. Recombinant human GAA (rhGAA) can be tested for enzyme replacement.

GSD3: debrancher enzyme deficiency, Cori disease or Forbes disease

There may be low bone density and a high risk for osteoporosis.

GSD4: brancher enzyme deficiency, Andersen disease

Glycogen branching enzyme (GBE) deficiency results in the accumulation of an amylopectin-like polysaccharide and presents with liver disease, progressing to cirrhosis.

GSD5: muscle glucagon phosphorylase deficiency, McArdle disease

X-linked liver glycogenosis (XLG) is one of the most common forms; onset is often in adults. Low levels of phosphorylase result in abnormal storage of glycogen in muscle tissue, muscle pain, cramping, stiffness, and poor exercise tolerance. Avoid strenuous exercise.

GSD6: liver phosphorylase deficiency, Hers disease

Gross hepatomegaly and hypoglycemia occur with reduced liver phosphorylase activity.

GSD7: muscle phosphofructokinase deficiency, Tarui disease

This syndrome presents often with exertional myopathy and hemolytic syndrome.

GSD9a: liver glycogen phosphorylase kinase deficiency

Growth retardation, abdominal distention, and hepatomegaly may be present. Liver transplantation results in normal fasting glucose production and normal glucose and insulin concentrations.

GSD9b: -subunit phosphorylase kinase, Fanconi-Bickel syndrome

Hepatorenal glycogenosis is abnormal.

Sources: Stojanov L. Glycogen storage disease 1. Available at: http://emedicine.medscape.com/article/1116574-overview. Accessed March 26, 2013; and Online metabolic & molecular bases of disease. Available at: http://ommbid.mhmedical.com/content.aspx?bookid=474&sectionid=45374051. Accessed August 6, 2014.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • The congenital defects relate to aberrant transporter genes: glucose–galactose malabsorption syndrome, SGLT1; glucose transporter 1 deficiency syndrome, GLUT1; Fanconi–Bickel syndrome, GLUT2; fructose intolerance, fructose-1-phosphate aldolase. The GSDs have deficiency in various types of microsomal glucose-6-phosphatase (G6Pase) activity.

• • • • • • • • •

Urinary and serum galactose or fructose Acetone Hydrogen breath test Serum phosphate Serum lactate Serum ammonia Serum bilirubin Uric acid Alb

INTERVENTION

Clinical/History • • • • • • • • • • • • •

Height or length Weight BMI Growth (%) Diet/intake history Infections Nausea and vomiting Jaundice Infantile seizures Acquired microcephaly Development delay or FTT? Edema Demyelinating neuropathy?

Lab Work • • • • • •

Gluc (decreased in fructosemia) Hepatomegaly? HgbA1 c (decreased erythrocyte glucose uptake) Hypoglycorrhachia (CSF glucose 40 mg/dL) Trig, Chol (elevated in Von Gierke disease) Liver function: ALT, AST, creatine kinase (CK)

Escott-Stump_Ch03.indd 157

Objectives • Eliminate the offending carbohydrate that cannot be digested. Adjust the other macronutrients to promote growth and health maintenance. • Prevent hypoglycemia, where indicated. • Read labels carefully. • Fructose intolerance requires omission of fructose from the diet. • For galactosemia, mothers should not breastfeed. Read product labels carefully; galactose is not always reported. Consider infant formulas containing glucose without lactose or maltose; lactose-restricted diet products; rice-based milk substitutes; lactose-free products that contain glucose. Vitamin E seems to have positive, protective effects. • For (Glut1) deficiency syndrome, a higher fat intake is useful. Gold standard treatment is the ketogenic diet, which provides ketones to treat neuroglycopenia (Pong et al, 2012). Diet should be introduced early and continue into adolescence (Ito et al, 2008; Klepper, 2008). • For the GSDs, maintain glucose homeostasis, prevent hypoglycemia, promote positive nitrogen balance and growth, and correct or prevent fatty liver. Prevent EFA deficiency. Consider

11/7/14 8:24 PM

158

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

carbohydrate-modified products, such as cornstarch, as a low-release glucose source. Correct and manage dyslipidemia. • Sucrose/maltose intolerance requires omission of sucrose and maltose from the diet.

Food and Nutrition Congenital Glucose–Galactose Malabsorption • Use a diet free from sucrose, lactose, and glucose. Add fructose to a CHO-free formula incrementally as tolerated. • Fructose may be used for older children; the other CHO sources should be avoided. Fructosemia • Diet must exclude fructose, sucrose, sorbitol, invert sugar, maple syrup, honey, and molasses. • Read labels carefully. Tube feedings or intravenous solutions may contain sources of fructose. Galactosemia • Use a lactose- and galactose-free diet—no milk, milk products, soybeans, peaches, lentils, liver, brains, or breads or cereals containing milk or cream cheese. Omit fresh blueberries and honeydew melon. • Fresh cherries, citrus, mango, red plums, and strawberries are allowed. • For infants, try Isomil or ProSobee, EleCare, Nutramigen, or formulas containing casein hydrolysate. • Supplement with calcium, vitamin D, vitamin E, and riboflavin. In some disorders, galactose can often be reintroduced later in life. • Read labels carefully; galactose is not reported on labels. Formulas labeled “low lactose” are not good substitutes; they contain lactose in amounts that can seriously harm patients with galactosemia. • Be careful when using tube feedings or intravenous solutions; they may contain lactose. Glycogen Storage Disorders • Increase protein intake to improve muscle strength. • Use small, frequent feedings and, if steroids are used in treatment, a low-sodium diet. Long-term use of steroids can deplete stores of calcium and phosphorus and may elevate glucose, cause stunting, or cause weight gain. • Avoid lactose and sucrose. Read all product labels. • Glucose may be used. Concentrated sweets may be restricted unless made with pure glucose syrup. • Cornstarch is used to prevent hypoglycemia. • Sometimes, night feedings with additional daytime meals work effectively. Giving 4 tbsp cornstarch in 5 oz of fluid and 3 oz of juice, carnitine, and DHA via gastrostomy (24 mL/h) at night may help the liver to maintain a normal blood glucose level. • A multivitamin–mineral supplement with vitamin C, iron, and calcium may be needed because fruits and milk are limited. As necessary, replete nutrients such as vitamin B12, folate, calcium, and iron. Sucrose/Maltose Intolerance • Omit sucrose and maltose from the diet. • For the nongenetic form, gradually add these sugars back into the diet. • Tube feedings or intravenous solutions may contain sources of sucrose or maltose; read labels.

Escott-Stump_Ch03.indd 158

Food–Drug Interactions Common Drugs Used and Potential Side Effects • For persons with galactosemia, eliminate drugs containing lactose; supplement with calcium and riboflavin. • Sucrose and maltose are added to many drugs; check carefully. • All vitamin–mineral supplements must be free of the nontolerated carbohydrates. • If liver transplantation is needed, support the immunosuppression with appropriate nutrition interventions. Changes in fluid or sodium or other nutrients may be required. • In Pompe disease, Myozyme (alglucosidase alfa) may be prescribed. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for these conditions because there are no controlled trials to prove efficacy.

Nutrition Education, Counseling, Care Management • Explain which sources of carbohydrate are allowed specific to the disorder. • Help patients manage comorbidities, such as dyslipidemia (Carvalho et al, 2013). • Read labels carefully. Many foods contain milk solids, galactose (e.g., luncheon meats, hot dogs), and other sugars; omit according to the disorder. Contact formula companies regarding product updates. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

SAMPLE NUTRITION CARE PROCESS STEPS Abnormal GI Function Assessment Data: Weight and growth charts, nausea and vomiting, elevated LFTs, and frequent episodes of hypoglycemia. Nutrition Diagnoses (PES):Abnormal GI function related to metabolic disorder and GSD as evidenced by nausea and vomiting. Intervention: Educate parents about frequency and timing for meals and snacks, enhancing energy intake through six to eight small meals daily plus nightly gastrostomy feeding of a complete nutritional supplement with cornstarch, DHA, and special oil. Monitoring and Evaluation: Weight records, growth, tolerance for various food consistencies, less nausea and vomiting.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

For More Information ●

Association for Glycogen Storage Disease—United States http://www.agsdus.org/

●

Fanconi-Bickel Syndrome http://rarediseases.info.nih.gov/GARD/Condition/2268/Fanconi_Bickel _syndrome.aspx

●

Galactosemia Foundation http://galactosemia.org/

●

International Pompe Association http://www.worldpompe.org/

●

Sucrose/Maltose Intolerance http://www.foodintolerances.org/food-intolerances-sucrose-maltose.aspx

REFERENCES

159

Grunert SC, et al. Fanconi-Bickel syndrome: GLUT2 mutations associated with a mild phenotype. Mol Genet Metab. 2012;105:433. Ito S, et al. Modified Atkins diet therapy for a case with glucose transporter type 1 deficiency syndrome. Brain Dev. 2008;30:226. Klepper, J. Glucose transporter deficiency syndrome (GLUT1DS) and the ketogenic diet. Epilepsia. 2008;49:46S. Mayatepek, E et al. Inborn errors of carbohydrate metabolism. Best Pract Res Clin Gastroenterol. 2010;24:607. Pascual JM, Roe CR. Systemic metabolic abnormalities in adult-onset acid maltase deficiency: beyond muscle glycogen accumulation. JAMA Neurol. 2013; 70:756. Pong AW, et al. Glucose transporter type I deficiency syndrome: epilepsy phenotypes and outcomes. Epilepsia. 2012;53:1503. Sarkar M, et al. Generalized epimerase deficiency galactosemia. Indian J Pediatr. 77:909, 2010. Tang M, et al. Innovative therapy for Classic Galactosemia - tale of two HTS. Mol Genet Metab. 2012;105:44.

Carvalho PM, et al. Glycogen Storage Disease type 1a - a secondary cause for hyperlipidemia: report of five cases. J Diabetes Metab Disord. 2013;12:25.

CEREBRAL PALSY NUTRITIONAL ACUITY RANKING: LEVEL 3 DEFINITIONS AND BACKGROUND Cerebral palsy (CP) results from brain damage to motor centers before, during, or after birth up through the first 2 years of life. One of 500 live births may be affected. Each year, 1,200 to 1,500 preschool-age children in the United States are identified as having CP, causing physical and mental disabilities that are nonprogressive. Infants present with early abnormal rolling, stiffness, irritability, and developmental delays (see Table 3-6). Seizures, TABLE 3-6 Signs and Symptoms of Cerebral Palsy SIGNS (FROM MEDICAL EVALUATIONS AND TESTS) • Not blinking at loud noises by 1 month of age • Not sitting by 7 months of age • Not turning head toward sounds by 4 months of age • Not verbalizing words by 12 months of age

mental retardation, hyperactive gag reflex, tongue thrust, poor lip closure, inability to chew properly, behavioral problems, and visual or auditory problems may occur. Symptoms may be mild or severe, and vary from one person to the next. Skeletal maturation is frequently delayed. The spastic form (uncontrolled shaking or difficult, stiff movement) affects about 75% of individuals with CP. Muscle weakness and joint contractures are common. Persons with an arginase deficiency are sometimes misdiagnosed with CP because of their spastic paraplegia; screening for inborn errors of metabolism is recommended (Tsang et al, 2012). The athetoid form, with involuntary worm-like movement, affects 15% and ataxic (impaired coordination and balance) conditions affect about 10%. Many individuals have a mixed form of CP. In many individuals, wasting of voluntary muscles contributes to reduced resting energy needs. The potential for malnutrition exists because of dysphagia, increased energy requirements, and the inability to close lips or suck properly. Unfortunately, research in this area is minimal (Morgan et al, 2012).

• Seizures • Walking with an abnormal gait

ASSESSMENT, MONITORING, AND EVALUATION

SYMPTOMS (EFFECTS OF IMPAIRMENT) • Choking • Difficulty grasping objects • Difficulty swallowing

Genetic Markers

• Fatigue

• The condition is not genetic in origin.

• Inability to focus on objects • Inability to hear • Pain Source: CerebralPalsy.org. Signs and symptoms of cerebral palsy. Available at: http://www .cerebralpalsy.org/what-is-cerebral-palsy/symptoms/. Accessed June 4, 2014.

Escott-Stump_Ch03.indd 159

Clinical/History • • • •

Low birth weight (LBW) Low 5-minute Apgar score (below 7) Height or length Weight and growth chart (%)

11/7/14 8:24 PM

160 • • • • • • • • • • • • • • • •

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Shaking, worm-like, or stiff movements Impaired balance and coordination Skull x-ray Chewing problems Dysphagia Diet/intake history Self-feeding problems Seizures GERD Constipation EEG MRI of the head Vision testing Gross Motor Function Measure Activities Scale for Kids Functional Mobility Scale (FMS)

Lab Work • • • • • •

Gluc Alb Serum Ca, Mg Transferrin ALP H&H, serum Fe, ferritin

INTERVENTION

• Reduce energy intake for spastic patients or those with severely limited activity: 11 kcal/cm for ages 5 to 11. For moderately active patients, use 14 kcal/cm for ages5 to11. • Increase energy intake (45 kcal/kg) to accommodate for athetoid patients over age 18. • Feeding gastrostomy tubes are a reasonable alternative for severe feeding and swallowing problems and poor weight gain. Daytime bolus feedings of high-calorie, high-protein formulas at scheduled times may provide the necessary nutrition in some cases. Night feedings allow for more normal daytime routines and can be used as well. • For chewing problems, eliminate coarse, stringy foods. Puree foods as needed. • With frequent vomiting, assess actual intake; antiemetic medications may be needed. • For constant dribbling, add cereal or yogurt to fluids. Replace fluids, thickened if needed. • For constipation, use laxative or high-fiber foods such as bran in the diet. Provide extra fluids. In younger children, too much fiber can displace intake of adequate nutrition. • Supplement with a general multivitamin–mineral supplement. • For pressure ulcers or skin breakdown from minimal positioning of the body, ensure adequate protein, vitamins C and A, and zinc. Work with caregivers to turn and reposition every 2 hours. • Children with severe CP often have lower mineral intakes than healthy children (McGowan et al, 2012). • Evidence-based clinical practice guidelines suggest weightbearing activities, vitamin D–calcium supplementation, and bisphosphonate use for children with CP with low bone mass density who are at risk of fragility fractures (Fehlings et al, 2013).

Objectives • Alleviate malnutrition resulting from the patient’s inability to close lips, suck, bite, chew, or swallow. Low resting energy expenditure found in malnourished children with CP is partly due to a low energy intake (Arrowsmith et al, 2012). Patients with CP may have significantly lower caloric requirements than anticipated using predictive equations (Magnuson etal, 2011). Indirect calorimetry is needed to estimate needs effectively. • Promote independence through use of adaptive feeding devices. Eye–hand coordination is often lacking, and grasp may not be strong. • Assess appropriate energy and nutrient needs. When adequately nourished, children and adolescents with CP appear more relaxed and require decreased feeding time. Promote mealtimes in a quiet, unhurried environment. • Correct nutritional deficits, altered growth rate, developmental delays, and loss of bone density. • Prevent or correct aspiration pneumonia, gastroesophageal reflux, and pressure ulcers. • Practice proper bowel care (stool softeners, fluids, fiber, laxatives, regular bowel habits). • Monitor for sodium deficiencies and dehydration in children receiving hypercaloric formulas (McGowan et al, 2012).

Food and Nutrition • Breast milk is recommended for infants with CP (Vohr et al, 2006). • Energy requirements of children and adolescents will vary depending on functional capacity, ambulatory status, severity of disease, and fat-free mass. In preschool-age children with CP, energy requirements decrease as ambulatory status declines and more limbs are involved (Walker et al, 2012).

Escott-Stump_Ch03.indd 160

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Anticonvulsants may increase risk of osteomalacia and nutrient deficiencies; vitamins D, B6, B12, and K, folate, calcium, and biotin are often insufficient. • Botulinum toxin may be given to help with spasticity and drooling. • Dantrolene (Dantrium) inhibits the release of calcium in muscle and skeletal tissue, preventing muscle cramping and spasms. Diarrhea, changes in BP, weight loss, and constipation may all occur. • Klonopin (clonazepam) is a benzodiazepine used to slow down the central nervous system (CNS) for spasticity. Side effects include constipation or diarrhea, dizziness, drowsiness, clumsiness, unsteadiness, headache, nausea, and vomiting. • Laxatives may often be needed; monitor fiber and fluid needs. Milk of magnesia can be used safely in a pediatric dosage. Avoid using laxatives containing mineral oil. • Muscle relaxants such as baclofen may cause diarrhea. Use of acidophilus and probiotic products may be useful. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used; there are no controlled trials to prove efficacy. • Probiotics may be used to alleviate loss of intestinal bacteria. Encourage natural sources such as yogurt or acidophilus milk, if tolerated.

Nutrition Education, Counseling, Care Management • Remind older patients to keep lips closed to avoid losing food from their mouths as they try to chew.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

• Fortify the diet with dry or evaporated milk, wheat germ,and other nutrient enhancers when intake is inadequate. • Allow extra time for feedings. Use of adaptive feeding equipment may be beneficial. Provide special training as needed for a specific feeding procedure (e.g., a preemie nipple for poor suck). • Help parents or caregivers with problems related to dental caries, drugs, constipation, pica, or weight. • Tube feeding may be needed. Ensure proper positioning to avoid aspiration or GERD. • Exercise can be beneficial, such as recreational sports, yoga, and hippotherapy. • Encourage early intervention programs for preterm infants. Improved cognitive and motor outcomes are noted during infancy, and cognitive benefits persist into preschool age (Spittle et al, 2012). • Promote good oral health and visits to the dentist. The presence of GERD contributes significantly to dental erosion in individuals with CP, increasing the risk of oral disease (Guare et al 2012). Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

161

• Care Management: Collaborate with physician and home nurse for highest quality of care for patient. Collaborate with formula company to find highcalorie, high-protein formula that is soy-free. Monitoring and Evaluation: Weight records, improved intake of sufficient energy and protein to rebuild muscle mass and improve in growth percentiles; improved BMI for age.

For More Information ●

American Academy of Developmental Medicine and Dentistry http://www.aadmd.org

●

American Association on Health and Disabilities http://www.aahd.us/

●

American Cerebral Palsy Information Center http://www.cerebralpalsy.org

●

Cerebral Palsy Alliance http://www.cerebralpalsy.org.au/

●

Cerebral Palsy Association of British Columbia http://bccerebralpalsy.com/

●

CP Connection http://www.cpconnection.com/

●

Disability Resource Network http://www.d-r-d.com/

●

Easter Seals http://www.easter-seals.org

●

Hemiplegic Cerebral Palsy http://www.hemikids.org/

●

United Cerebral Palsy Association, Inc. http://www.ucp.org/

SAMPLE NUTRITION CARE PROCESS STEPS Difficulty with Feeding Self and Soy Allergy Assessment Data: Weight and growth charts, medical history of aspiration, difficulty consuming adequate intake orally or by tube, soy allergy. Nutrition Diagnosis (PES):Self-feeding difficulty related to inability to bite properly and use utensils in CP as evidenced by weight loss of 4 lb in 6 months, current BMI of 13, height and weight percentiles both 5%, history of aspiration when tube fed, allergy to soy. Interventions: • Food and Nutrient Delivery: Increase caloric intake through bolus feeding. Provide high-calorie, high-protein formula free of soy. • Nutrition Education: Discuss importance of nutrition and foods child is able to tolerate. • Counseling: Counsel parents/caregivers and home nurse on importance of enhancing high-calorie foods as necessary to prevent weight and muscle loss.

Escott-Stump_Ch03.indd 161

REFERENCES Arrowsmith FE, et al. Nutritional rehabilitation increases the resting energy expenditure of malnourished children with severe cerebral palsy. Dev Med Child Neurol. 2012;54:170. Fehlings D, et al. Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: a systematic review. Dev Med Child Neurol. 2012;54:106. Guare RO, et al. Dental erosion and salivary flow rate in cerebral palsy individuals with gastroesophageal reflux. J Oral Pathol Med. 2012;41:367. Magnuson B, et al. Hypocaloric considerations in patients with potentially hypometabolic disease states. Nutr Clin Pract. 2011;26:253. McGowan JE, et al. An exploratory study of sodium, potassium, and fluid nutrition status of tube-fed nonambulatory children with severe cerebral palsy. Appl Physiol Nutr Metab. 2012;37:715. Morgan AT, et al. Interventions for oropharyngeal dysphagia in children with neurological impairment. Cochrane Database Syst Rev. 2012 Oct 17;10: CD009456. Spittle A, et al. Early developmental intervention programmes post-hospital discharge to prevent motor and cognitive impairments in preterm infants. Cochrane Database Syst Rev. 2012 Dec 12;12:CD005495. Tsang JP, et al. Arginase deficiency with new phenotype and a novel mutation: contemporary summary. Pediatr Neurol. 2012;47:263. Vohr BR, et al. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics. 2006;118:115. Walker JL, et al. Energy requirements in preschool-age children with cerebral palsy. Am J Clin Nutr. 2012;96:1309.

11/7/14 8:24 PM

162

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

CLEFT LIP AND PALATE NUTRITIONAL ACUITY RANKING: LEVEL 3 ASSESSMENT, MONITORING, AND EVALUATION

DEFINITIONS AND BACKGROUND Cleft lip and palate (CL/P) are also called orofacial clefts (OFCs). These are congenital malformations occurring during the embryonic period of development from genetic and environmental factors (Dixon et al, 2011). Figure 3-3 illustrates various forms of CL/P. Maternal injuries during pregnancy are common and may contribute to these birth defects (Tinker et al, 2011). In addition, first trimester maternal use of medications such as topiramate may be associated (Margulis et al, 2012). The malformations result in a fissure in the lip and roof of the mouth, which may be unilateral or bilateral. Incidence is approximately 1 in 700births in Caucasians, or about 5,000 births annually in the United States. Infants with cleft palate are often smaller in size and weight than other infants. Periconceptional folate and folic acid intake helps to prevent orofacial clefts (Kelly et al, 2012). Other nutrients also play a role, and many mothers who eat poorly risk having a baby with OFC. Sufficient preconceptual intake of vitamins B6 and B12, as well as zinc may decrease OFC risk. Prepregnancy diabetes and obesity have been identified as independent risk factors; hyperglycemia and hyperinsulinemia are involved (Parker et al, 2012). Cleft of lip, alveolar process, and palate is the most common defect and will impair breathing, sucking, swallowing, chewing, hearing, and speaking. In complete unilateral cleft lip and palate, several teeth are missing; this is known as tooth agenesis (hypodontia) and is genetically controlled (Dentino et al, 2012). Surgical reconstruction of the cleft anatomic structures is necessary.

Primary palate

Incisive foramen

Uvula

Nostril

Genetic Markers • Interferon regulatory factor 6 (IRF6) gene and chromosome 8q24 have been identified in CL/P. Mutations in genes encoding for homocysteine (cystathionine--synthase and methylenetetrahydrofolate reductase) also play a role (Iacobazzi etal, 2014.)

Clinical/History • • • • • • • • • • •

Length (height) Growth (%) Weight Weight changes Diet/intake history Head circumference Cleft type (unilateral or bilateral; complete or incomplete) Otitis media (OM) or other infections Chewing difficulty Maternal obesity? Maternal use of folic acid?

Lab Work • • • • •

Gluc Alb H&H Serum Ca, Mg Serum folic acid

Lip

Jaw

Philtrum of lip Primary palate

Figure 3-3. Various forms of cleft lip and palate. Ventral view of the palate, gum, lip, and nose. (A)Normal. (B) Unilateral cleft lip extending into the nose. (C) Unilateral cleft involving the lip and jaw and extending to the incisive foramen. (D) Bilateral cleft involving the lip and jaw. (E) Isolated cleft palate. (F) Cleft palate combined with unilateral anterior cleft lip. (Reprinted with permission from Sadler TW. Langman’s medical embryology. Philadelphia, PA: Wolters Kluwer Health; 2012.)

Escott-Stump_Ch03.indd 162

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

INTERVENTION Objectives • Compensate for the patient’s inability to suck because of the air space between the mouth and nose. The extent of clefting is associated with the severity of feeding problems (Miller, 2011). Cleft palate is more of a problem than cleftlip. • Limit choking, air swallowing, coughing, and fatigue. Chronic aspiration during feeding may include recurrent respiratory illness, pneumonia, and lung damage (Miller, 2011). • Encourage breastfeeding where possible to protect against ear infections. • Supply the child with energy to heal and to grow. • Offer tips for meal planning and resources because feeding is a challenge. • For surgery, allow extra energy and protein for healing; use a multivitamin supplement. Before surgery, a custom retainer device may be placed in the mouth and is intended to gradually pull the edges of the cleft closer to achieve better lip repair. The device also aids in the feeding process.

Food and Nutrition • Provide a normal diet in accordance with the patient’s age and dietary recommendations. Monitor diet carefully; mother may have had a poor diet during preconceptual period and pregnancy. • For infant feeding, use a medicine dropper or plastic bottle with a soft nipple and enlarged hole. The use of a squeezable, collapsible bottle with a longer nipple and a large crosscut opening, which allows parents to control the flow of milk, can help. Release formula or milk a little at a time, in coordination with the infant’s chewing movements. Burp infant frequently to release swallowed air. Feed the infant in an upright position to prevent aspiration. • When the infant is 4 to 6 months of age, begin to add solids in the diet. Pureed baby foods can be used, or the infant can be spoon-fed with milk used to dilute the baby foods. Feed solids from a spoon and avoid use of a bottle or commercial syringe feeder, unless prescribed for unique circumstances. • Avoid fruit peelings, nuts, peanut butter, leafy vegetables, heavy cream dishes, popcorn, grapes, biscuits, cookies, and chewing gum as they may get lodged in the palate. Avoid spicy, acidic foods if they cause irritation.

163

• Solids may be started at 4 to 6 months. Use thickened baby food or pureed items as tolerated. • Squeezable bottles appear easier to use than rigid feeding bottles (Bessell et al, 2011). • Supplement the diet with vitamin C if citrus juices are not taken well. • Have the parents use only small amounts of liquid when they are feeding an infant. To prevent choking, slow swallowing should be encouraged and proper positioning should be taught. • Discuss the impact of surgery and how to promote effective healing by using a nutrient-dense diet with adequate amounts of protein, energy, vitamins A and C, and zinc. • The infants may fail their newborn hearing tests; serous OM with resulting hearing loss can occur (Chen et al, 2008). Encourage medical follow-up. • Feeding difficulty in CL/P infants is a source of considerable stress for parents and can have a potential negative effect on the parent–infant bonding process (Miller, 2011). • Because of the types of problems that may occur (teeth in the area of the cleft may be missing or improperly positioned, affecting biting and chewing ability; speech difficulties; frequent colds, sore throats, OM, tonsillitis), assistance from a variety of therapists and professionals is needed. • The dietitian assists with nutrition and feeding-related issues. Nutrient density and texture assessments should be ongoing. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants; this will decrease the risk of botulism.

SAMPLE NUTRITION CARE PROCESS STEPS Inability to Bite or Chew Assessment Data: Weight and growth charts, difficulty chewing and biting into foods.

Food–Drug Interactions

Nutrition Diagnoses (PES): Biting/chewing difficulty related to craniofacial malformations as evidenced by prolonged feeding time and decreased intake.

Common Drugs Used and Potential Side Effects • No specific medicines are used for CL/P; surgery is the primary treatment. After surgery, there may be a need for antibiotics if infection sets in. • Women who are taking valproate, lithium, carbamazepine, and other bipolar disorder medicines should discontinue use during pregnancy to reduce risk for CL/P. • If genetic testing indicates an MTHFR allele, l-methylfolate (such as in Deplin) may be prescribed.

Intervention: Educate parents about texture changes, timing for meals, enhancing energy intake through highcalorie foods and supplements, oral health and hygiene. Monitoring and Evaluation: Weight records, growth, tolerance for various food consistencies.

Herbs, Botanicals, and Supplements • Herbs and botanicals are not required for CL/P.

For More Information ●

American Cleft Palate-Craniofacial Association http://www.cleftline.org/

Nutrition Education, Counseling, Care Management

●

Center for Craniofacial Development and Disorders http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas /pediatric_neurosurgery/conditions/craniofacial_syndromes.html

●

FACES: The National Craniofacial Organization http://www.faces-cranio.org/

• Explain how to feed the infant with a special nipple as needed. • There is some evidence that breastfeeding is better than spoon-feeding following surgery for cleft (Bessell et al, 2011).

Escott-Stump_Ch03.indd 163

11/7/14 8:24 PM

164

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

REFERENCES Bessell A, et al. Feeding interventions for growth and development in infants with cleft lip, cleft palate or cleft lip and palate. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD003315. Chen JL, et al. Newborn hearing screening in infants with cleft palates. Otol Neurotol. 2008;29:812. Dentino KM, et al. Is missing maxillary lateral incisor in complete cleft lip and palate a product of genetics or local environment? Angle Orthod. 2012;82:959. Dixon MJ, et al. Cleft lip and palate: understanding genetic and environmental influences. Nat Rev Genet. 2011;12:167–178. Iacobazzi V, et al. Hyperhomocysteinemia: Related genetic diseases and congenital defects, abnormal DNA methylation and newborn screening issues. MolGenet Metab. 2014; pii: S1096–7192.

Kelly D, et al. Use of folic acid supplements and risk of cleft lip and palate in infants: a population-based cohort study. Br J Gen Pract. 2012;62:e466. Margulis AV, et al. Use of topiramate in pregnancy and risk of oral clefts. Am J Obstet Gynecol. 2012;207:405. Miller CK. Feeding issues and interventions in infants and children with clefts and craniofacial syndromes. Semin Speech Lang. 2011;32:115. Parker SE, et al. Dietary glycemic index and the risk of birth defects. Am J Epidemiol. 2012;176:1110. Tinker SC, et al. Maternal injuries during the periconceptional period and the risk of birth defects, National Birth Defects Prevention Study, 1997-2005. Paediatr Perinat Epidemiol. 2011;25:487.

CONGENITAL HEART DISEASE NUTRITIONAL ACUITY RANKING: LEVEL 2 DEFINITIONS AND BACKGROUND Congenital heart disease (CHD) is the most common birth defect in the United States, with an estimated incidence of approximately 1/100 births per year. Usually, some developmental defect occurred between weeks 5 and 8 of pregnancy (e.g., from rubella, alcohol use, or taking certain medications). Nearly half a million adults in the United States live withCHDs. An increased risk for malnutrition, growth failure, or pulmonary hypertension occurs. Energy expenditure is significantly elevated and feeding difficulties are common. Increased levels of ghrelin and other factors may lead to growth retardation and FTT. Children with CHD experience early, simultaneous decreases in growth trajectory across weight, length, and head circumference (Daymont et al, 2013). Supplementary oxygen is often needed, especially during feeding; the child will not grow if oxygen is inadequate. Surgical repair may be delayed to allow weight gain. Surgery is performed when a patient reaches an ideal weight and age, or if FTT precludes further waiting. The neonate undergoing cardiopulmonary bypass surgery experiences profound metabolic response to stress and has less metabolic reserves for wound healing and growth (Owens and Musa, 2009). Tissue-engineered vascular grafts hold great promise for pediatric patients with congenital cardiac anomalies (Dean etal, 2012).

ASSESSMENT, MONITORING, AND EVALUATION

Clinical/History • • • • • • • • • • • • • • • • •

Height Weight Head circumference Growth pattern FTT? Diet/intake history BP Weight changes Edema Intake and output (I&O) Ultrasound Echocardiography Cardiac catheterization Chest x-ray or MRI Heart murmur? Cyanosis? Ventilator dependency?

Lab Work • • • • • • • • • •

Gluc Urinary osmolality Na, K BUN, creatinine (Creat) Chol Trig Serum folate, B12 H&H, serum Fe or ferritin O2, CO2 Serum zinc

INTERVENTION

Genetic Markers • Some CHDs are related to an abnormality of an infant’s chromosomes (5% to 6%), single-gene defects (3% to 5%), or environmental factors (2%) while the majority are multifactorial. Down’s syndrome (DS), Williams syndrome, trisomy 13, or trisomy 18 are conditions that are often linked with CHD (Children’s Hospital Boston, 2013).

Escott-Stump_Ch03.indd 164

Objectives • Support normal growth and weight gains; growth failure is common, especially with associated heart failure. An 8- to 16-oz gain in 1 month might be acceptable. • Improve oral intake. Poor sucking may occur in infants, but it is possible to breastfeed with education and support of the mother.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

• Lessen fatigue associated with mealtimes. Assure adequate oxygen replacement, especially during feeding. • Meet energy needs from increased metabolic rate and the need for catch-up growth, without creating excessive cardiac burden or excessive renal solute overload. • Improve appetite, which can be decreased from the medications. • Promote good oral hygiene to prevent infections.

165

TABLE 3-7 Medications for Congenital Heart Disease GENERIC NAME

BRAND NAME

CONCERNS

Acebutolol

Sectral

GI distress or nausea

Atenolol

Tenormin

GI distress or nausea

Azathioprine

Imuran

Baby aspirin

Bayer

Captopril

Capoten

Food and Nutrition

Cisapride

Propulsid

• Determine and provide calories as needed for age (e.g., 100kcal/kg in second year of life) (see Table 3-1). Most formulas contain 67 kcal/dL or 20 kcal/oz. Severe FTT cases may need an extra 30 to 60 kcal/kg/d over usual; follow standard mixing recommendations for formula concentration and add modular products to reach a desired level. For infants, a formula up to 90 to 100 kcal/dL can be used while carefully monitoring adequacy of fluid ingestion. • The plan should contain approximately 10% protein (avoid overloading), 35% to 50% fat as vegetable oils (readily absorbed), and 40% to 55% CHO. • Sodium intake should be approximately 6 to 8 mEq daily,dependent on diuretic use and cardiopulmonary status. • Continuous 24-hour tube feeding may be useful. PEG tube feeding can be a useful adjunctive therapy, especially using formulas with a lower mineral-to-protein ratio (e.g., partially demineralized whey).

Digoxin

Lanoxin

Enalapril

Vasotec

Furosemide

Lasix

GI distress or nausea; potassium, magnesium, calcium, and folate may be depleted

Hydrochlorothiazide

HydroDIURIL

GI distress or nausea; potassium, magnesium, calcium, and folate may be depleted

Lisinopril

Zestril

Metoprolol

Lopressor

Prednisone

Deltasone

Propranolol

Inderal

Spironolactone

Aldactone

Warfarin

Coumadin

GI distress or nausea

Depletes calcium and phosphorus; may elevate glucose, cause stunting, or cause weight gain

Need steady intake of vitamin K; no big fluctuations

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Diuretics are often prescribed. Other drugs are specific to the individual patient’s requirements (see Table 3-7). Give medicines before feedings to be sure they have been taken. • Infective endocarditis (IE) among children with Staphylococcus aureus bacteremia may require treatment with antibiotics. Use of probiotic products may normalize the intestinal bacteria. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used because there are no controlled trials to prove efficacy. • With prolonged use of antibiotic therapy, probiotic products may be useful. Encourage intake of yogurt, acidophilus milk, and related products.

Nutrition Education, Counseling, Care Management • Discuss the role of nutrition in achieving adequate growth and controlling heart disease. • Discuss growth patterns and goals. • Provide support for breastfeeding mothers who wish to continue as long as possible. • Discuss the role of nutrition in oral health and overall immunity. • Women who wish to become pregnant should be sure they are immunized against rubella, which can cause CHD. • Children with CHD should be advised to comply with public health recommendations of daily participation in 60 minutes or more of moderate-to-vigorous physical activity that is developmentally appropriate, enjoyable, and varied—as long as any necessary precautions are provided (Takken et al, 2012). Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula.

Escott-Stump_Ch03.indd 165

• Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

SAMPLE NUTRITION CARE PROCESS STEPS High Energy Requirements Assessment Data: Weight and growth charts, need for ventilator support, fluid requirements, estimated needs to increase rate of growth. Nutrition Diagnoses (PES):Increased energy expenditure related to breathing difficulties as evidenced by low oxygen saturation levels, inadequate rate of growth, 5% weight for height and age. Breastfeeding difficulty related to poor sucking ability as evidenced by observation of mother during attempts to breastfeed, with infant unable to latch on and sustain intake longer than a few seconds. Intervention:Assist mother with breastfeeding tips and explain how to use supplemental formulas if needed to support growth of infant. Educate parents/caregivers about increasing nutrient density, frequency of meals or snacks, types of formula needed when required, allowing extra feeding time due to dyspnea. Monitoring and Evaluation: Weight records and improved growth rate allowing child to have heart surgery.

11/7/14 8:24 PM

166

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

For More Information See the video “Care of the Hospitalized Child: Parent and Family Participation” at www.thepoint.lww.com/escottstump8e.

●

Heart Center Encyclopedia http://www.cincinnatichildrens.org/health/heart-encyclopedia/default .htm

●

Kids with Heart, National Association for Children’s Heart Disorders, Inc. http://kidswithheart.org/

REFERENCES ●

Children’s Cardiomyopathy Foundation http://www.childrenscardiomyopathy.org/site/overview.php

●

Children’s Heart Institute http://www.childrenheartinstitute.org/

●

Children’s Organ Transplant Network http://www.cota.org/

●

Congenital Heart Defects http://www.congenitalheartdefects.com/

●

Congenital Heart Information Network http://www.tchin.org/

Children’s Hospital Boston. Congenital heart defects. Available at: http://www.childrens hospital.org/az/Site486/mainpageS486P0.html. Accessed June 4, 2014. Daymont C, et al. Growth in children with congenital heart disease. Pediatrics. 2013;131:e236. Dean EW, et al. Current advances in the translation of vascular tissue engineering to the treatment of pediatric congenital heart disease. Yale J Biol Med. 2012;85:229. Owens JL, Musa N. Nutrition support after neonatal cardiac surgery. Nutr Clin Pract. 2009;24:242. Takken T, et al. Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease. Eur J Prev Cardiol. 2012;19:1034.

CYSTINOSIS AND FANCONI SYNDROME NUTRITIONAL ACUITY RANKING: LEVEL 3 DEFINITIONS AND BACKGROUND Cystinosis is an autosomal recessive metabolic disease that belongs to the family of lysosomal storage disorders (Harrison et al, 2013). In cystinosis, crystals of cystine are deposited throughout the body. If left untreated, the diseasemay lead to kidney failure. Toxic accumulations of copper in the brain and kidney account for neurological symptoms. Cystinosis affects approximately 1 in 100,000 to 200,000 newborns. It may be inherited or acquired, such as by lead poisoning. Manifestations are also seen in hereditary fructose intolerance. Myopathy leads to restrictive lung disease in adults who have not received long-term cystine depletion. Infantile nephropathic cystinosis, the most severe form, is a lysosomal membrane transport defect. FTT, rickets, metabolic acidosis, unexplained glucosuria of renal tubular origin, loss of color in the retina of the eyes, and severe photophobia can appear as early as 3 to 18 months of age. In intermediate cystinosis, kidney and eye symptoms become apparent during the teenage years or early adulthood. Polyuria, growth retardation, rickets, acidosis, and vomiting are present. In nonnephrotic, ocular cystinosis, crystalline cystine accumulates primarily in the cornea of the eyes. Adults may present with acidosis, hypokalemia, polyuria, or osteomalacia. Other difficulties include muscle deterioration, blindness, inability to swallow, diabetes, and thyroid and nervous system problems. Fanconi syndrome, a generalized tubular dysfunction, can be either acquired or inherited. The hereditary form may accompany Wilson disease, galactosemia, or glycogen storage diseases. Nephrotoxic drugs, such as use of some chemotherapy agents, streptozocin, antiretrovirals, valproate, or outdated tetracycline, may cause the acquired form. Vitamin D deficiency,

Escott-Stump_Ch03.indd 166

myeloma, amyloidosis, and heavy metal intoxication may also be triggers. Regardless of origin, Fanconi syndrome results in multiple organ damage, with profound renal damage. Excessive urination (polyuria), excessive thirst (polydipsia), and severe hypokalemia occur. Impaired metabolism of glutathione has a role in the pathogenesis of nephropathic cystinosis (Wilmer et al, 2011). The cystine-depleting agent cysteamine significantly improves life expectancy but it offers no cure (Wilmer et al, 2010). Renal transplantation may be needed. Research is also evaluating the use of stem cells to reprogram the mutant cells (Iglesias et al, 2012). Cross-correction is possible (Harrison et al, 2013).

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • The affected gene in the inherited form is CTNS, located on chromosome 17, which codes for lysosomal cystine transporter cystinosin.

Clinical/History • • • • • • • • • •

Birth weight (infant or child) Present weight Length or height Growth (%), head circumference Abnormal sensitivity to light (photophobia) Loss of color in the retina Rickets Dehydration Dysphagia Patchy brown skin

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

• Diet/intake history • Polydipsia, polyuria

Lab Work • • • • • • • • • • • • • • • • •

Gluc Ca, Mg Aminoaciduria Serum phosphorous (decreased) Phosphaturia Na K (decreased) CO2 Alb H&H Serum Fe Serum vitamin D I&O Uric acid (decreased) BUN, Creat Ceruloplasmin WBCs

INTERVENTION Objectives

Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for this condition because there are no controlled trials to prove efficacy. • Use of Chinese herbs may be problematic, causing some forms of cystinosis in susceptible individuals. Discourage use.

Nutrition Education, Counseling, Care Management • Emphasize the importance of correcting fluid and electrolyte imbalances. • Discuss any necessary changes in consistency to assist with dysphagia. • Discuss diet for managing renal failure if necessary. • If transplantation is needed, discuss guidelines for managing side effects such as graft–host resistance. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food thathas been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

• Remove the offending nephrotoxin in the acquired forms. • Prevent bone demineralization, hypophosphatemic rickets, and kidney failure. Correct hypokalemia, hypophosphatemia, vitamin D insufficiency. • Manage swallowing dysfunction. • Support growth, which tends to be stunted in children. • Prevent or delay corneal damage. • Provide sufficient volumes of fluid and supplemental nutrients. • Prepare for renal transplantation if needed. Postoperatively, promote wound healing and prevent graft rejection.

SAMPLE NUTRITION CARE PROCESS STEPS Inadequate Vitamin and Mineral Intakes Assessment Data:Weight and growth charts, lab reports showing losses of potassium and phosphorus in the urine, evidence of rickets (bowed legs). Nutrition Diagnoses (PES): Inadequate mineral intake (potassium and phosphorus) related to excessive urinary losses from cystinosis as evidenced by urine tests, insufficient vitamin D metabolism and rickets.

Food and Nutrition • Use a diet low in cystine, with protein-free diet, PFD1 or PFD2 from Mead Johnson until stabilized with medicine; then, use a normal diet meeting all requirements. • Provide sufficient fluid intake. The nutrient imbalances in the body lead to increased urination, thirst, dehydration, and abnormal acidosis. Check intake and output. • Supplement with vitamin D3 (cannot convert 25-dihydroxycholecalciferol); give phosphate and calcium as appropriate. Bicarbonate is also needed. • Provide sufficient sodium and potassium replacements. • Alter consistency (liquids, solids) as needed. • Prepare for wound healing with sufficient vitamins A, C, zinc, protein, and energy.

167

Intervention: Educate parents about sources of vitamin D, potassium, and phosphorus from medications and diet. Monitoring and Evaluation: Weight records, growth, labs for potassium, phosphorus, and vitamin D.

For More Information ●

Cystinosis Foundation http://www.cystinosisfoundation.org/

●

Cystinosis Research Network http://www.cystinosis.org/

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Sodium bicarbonate or citrate should be used to correct acidosis. Take separately from iron supplements. Edema can occur. • Potassium depletion may require replacement therapy with a potassium-containing salt. • Cysteamine (Cystagon), administered orally, halts glomerular destruction and decreases cystine content in cells. Cysteamine increases total glutathione and restores glutathione redox status (Wilmer et al, 2011).

Escott-Stump_Ch03.indd 167

REFERENCES Harrison F, et al. Hematopoietic stem cell gene therapy for the multisystemic lysosomal storage disorder cystinosis. Mol Ther. 2013;21:433. Iglesias DM, et al. Stem cell microvesicles transfer cystinosin to human cystinotic cells and reduce cystine accumulation in vitro. PLoS One. 2012;7: e42840. Wilmer MJ, et al. The pathogenesis of cystinosis: mechanisms beyond cystine accumulation. Am J Physiol Renal Physiol. 2010;299:905. Wilmer MJ, et al. Cysteamine restores glutathione redox status in cultured cystinotic proximal tubular epithelial cells. Biochim Biophys Acta. 2011; 1812:643.

11/7/14 8:24 PM

168

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

DOWN’S SYNDROME NUTRITIONAL ACUITY RANKING: LEVEL 2 DEFINITIONS AND BACKGROUND Down’s syndrome (DS) is a congenital defect in which patients carry an altered chromosome; trisomy patients have an extra chromosome 21. It affects about 1/800 to 1/1,000 babies. Incidence of the syndrome is often related to older age of the mother but also of the father. First trimester screening is generally recommended. Children with DS have short stature, decreased muscle tone, constipation, intestinal defects, weight changes, and mental retardation. Very distinct facial features include a flat face, a small broad nose, abnormally shaped ears, a large tongue, and upward slanting eyes with small folds of skin in the corners. Individuals who have DS have a higher risk for congenital heart disease, gum disease, celiac disease, Hirschsprung disease, hypothyroidism, leukemia, respiratory problems, and gastroesophageal reflux. After age 40, dementia is common. Life expectancy is about 60 years. Genetic folate polymorphisms are linked for many Caucasians. Women of childbearing age should consume 400mg folic acid daily through food sources and/or supplementation. Elevated homocysteine levels should be reduced (Biselli et al, 2008). Chronic oxidative stress is a consideration; thus, include antioxidant foods containing selenium and vitamins C and E during pregnancy. Children with DS have less favorable lipid profiles than their siblings independent of weight status; they are also more often obese (Adelekan et al, 2012). These individuals are at risk formany cardiovascular effects. The survival of children born with DS has improved, but CHDs are still a significant risk factor for mortality through age 20 (Kucik etal, 2013). Additionally, because zinc metabolism is altered in individuals with DS, clinical disturbances often appear with aging (Lima et al, 2010).

• • • • • • • • • • • • • • •

Diet/intake history Head circumference DS growth chart Growth (%) Hyperextensibility of joints History of prematurity? Large tongue, eye slant Endocardial defects Developmental delay Small nose with flat bridge Pica Skin prick test Eye exam every year during infancy Hearing tests Echocardiogram to check for heart defects

Lab Work • • • • • • • • • • • • •

Gluc Uric acid (increased) Plasma zinc Chol—LDL, HDL Trig Na, K Ca, Mg I&O Serum folate Total homocysteine (tHcy) Serum vitamin D Serum zinc Thyroid testing

INTERVENTION Objectives

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • DS is caused by trisomy of chromosome 21 (Hsa21) which contains 300 to 400 genes. Folate polymorphisms and mitochondrial dysfunction may be involved (Zampieri et al, 2012; Valenti et al, 2014).

Clinical/History • • • • •

Length or height Birth weight Present weight BMI Bioelectrical impedance

Escott-Stump_Ch03.indd 168

• Provide adequate energy and nutrients for growth. Short stature is not caused by nutritional deficiencies; use appropriate DS growth charts. • Monitor introduction of solid food, which may be delayed. Fruits and vegetables may not be consumed in adequate amounts. • To avoid lowered intake of vitamins and minerals, manage obesity in children with DS with a balanced diet plus vitamin and mineral supplements, and an increase in physical activity. • Assist with feeding problems; tongue thrust and poor suck are common. • Reduce emotional problems that lead to overeating. Overfeeding should be avoided. Use proper positioning. • Manage constipation, diarrhea, gluten enteropathy, urinarytract infections (UTIs), and gum and periodontal diseases, which are common. Prevent osteoporosis and bone disease.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

Food And Nutrition • Supply adequate amounts of energy for age; for children aged 5 to 11 years, use 14.3 kcal/cm for girls and 16.1 kcal/cm for boys. • Use protein according to age-dependent dietary reference intakes. • Use a gluten-free diet if celiac disease is present. • Monitor pica, overeating, and idiosyncrasies. • Provide supplemental sources of folate, vitamin A, vitamin E, zinc, iron, and calcium if intake of fruits, vegetables, meats, dairy products, or whole grains is limited. • Provide feeding assistance if needed. Tube feed if the patient is unable to eat orally; gradually wean to solids when possible. • Provide extra fluid for drooling, diarrhea, or spillage. • Encourage complex carbohydrates, prune juice, etc., if constipation is a problem. • Discuss use of a Mediterranean diet if lipids are elevated. • Encourage participation in physical fitness activities to keep weight in control.

• Do not use honey in the diets of infants to decrease potential risk of botulism.

SAMPLE NUTRITION CARE PROCESS STEPS Overweight Assessment Data: Weight and growth charts, BMI normal range. Nutrition Diagnoses (PES): Overweight related to inadequate energy expenditure in DS as evidenced by BMI 28, limited activity levels, and frequent consumption of high-fat foods and snacks. Intervention: Discuss differing growth patterns from usual which may lead to excessive weight gain. Discuss optimal nutrition goals and physical activity, encouraging plenty of daily activity. Review foods to avoid because of risks for choking. Monitoring and Evaluation:Weight records, growth and improved BMI levels, tolerance for various foods and consistencies.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Aricept may have some benefit in individuals with DS. Nausea or diarrhea are sometimes side effects. • For MTHFR alleles, products such as l-methylfolate (Deplin) may be given. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used because there are no controlled trials to prove efficacy.

Nutrition Education, Counseling, Care Management • Explain feeding techniques that may be beneficial. Discuss use of self-feeding utensils if needed. • Help control energy intake and physical activity for appropriate levels. • Never rush mealtime. Encourage socialization. • Discuss how growth patterns differ from usual; weight loss or excessive gains may result as the child grows older. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature 2 hours or longer.

Escott-Stump_Ch03.indd 169

169

For More Information ●

Drexel University—Down’s Syndrome Growth Charts http://www.growthcharts.com/ http://www.growthcharts.com/charts/DS/charts.htm

●

National Association for Down’s Syndrome http://www.nads.org/

●

National Down’s Syndrome Congress http://ndsccenter.org/

●

National Down’s Syndrome Society http://www.ndss.org/

●

Special Olympics http://www.specialolympics.org/

REFERENCES Adelekan T, et al. Lipid profiles of children with Down syndrome compared with their siblings. Pediatrics. 2012;129:e1382. Biselli JM, et al. Genetic polymorphisms involved in folate metabolism and elevated plasma concentrations of homocysteine: maternal risk factors for Down syndrome in Brazil. Genet Mol Res. 2008;7:33. Kucik JE, et al. Trends in survival among children with Down syndrome in 10 regions of the United States. Pediatrics. 2013;131:27. Lima AS, et al. Nutritional status of zinc in children with Down syndrome. Biol Trace Elem Res. 2010;133:20. Valenti D, et al. Mitochondrial dysfunction as a central actor in intellectual disability-related diseases: An overview of Down syndrome, autism, Fragile X and Rett syndrome. Neurosci Biobehav Rev. 2014; pii: S0149–7634. Zampieri BL, et al. Maternal risk for Down syndrome is modulated by genes involved in folate metabolism. Dis Markers. 2012;32:73.

11/7/14 8:24 PM

170

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

FAILURE TO THRIVE NUTRITIONAL ACUITY RANKING: LEVEL 4 DEFINITIONS AND BACKGROUND Failure to thrive (FTT) is a diagnostic term used to describe infants and children who fail to grow or develop at a normal rate. In the United States, FTT is seen in 5% to 10% of children in primary care settings (Cole and Lanham, 2011). FTT usually indicates protein, energy, vitamin, and mineral insufficiency as well as medical or social factors. Without treatment, chronic illnesses or death may ensue. Prompt diagnosis and intervention are important for preventing malnutrition and developmental delays. Careful attention must be paid to growth charts and medical histories. Food refusal, poor feeding, vomiting, gagging, irritability, and FTT are commonly found in both infantile feeding disorders (IFD) and common treatable medical conditions (Levy et al, 2009).

HOT TOPIC

Secondary FTT originates from conditions such as cancer, allergies, chronic infections, cystic fibrosis, CL/P, DS, or other physical or mental disability. Growth failure plus fever of unknown origin and anemia in older children or teens may suggest onset of Crohn’s disease; evaluation is recommended. In addition, children who have Prader-Willi syndrome may first be diagnosed as having FTT (Ma et al, 2012). In severe combined immunodeficiency disease (SCID), hypermetabolism is common and may contribute to the development of FTT (Barron et al, 2011). Indeed, half of the causes of FTT are organic; the other 50% are from inorganic causes. Risks may differ according to the age of onset. Emerging evidence links early childhood diarrhea or growth failure with an increased occurrence of risk factors for cardiovascular disease in later life, including dyslipidemia, hypertension, and glucose intolerance (DeBoer et al, 2012). A multidisciplinary approach to treatment, including home nursing visits and nutritional counseling, has been shown to improve weight gain, parent–child relationships, and cognitive development (Cole and Lanham, 2011). The Academy of Nutrition and Dietetics suggests at least five medical nutrition therapy visits to correctFTT.

Inflammation Where there is a high degree of nutritional stunting (linear growth failure caused by inadequate caloric intake), inflammation and ongoing infections create a vicious cycle, leading to permanent changes in the intestinal mucosa, or “environmental enteropathy” (DeBoer et al, 2012).

Weight is the most reliable marker to consider. FTT is established when weight for age that falls below the 5th percentile on multiple occasions, or weight loss patterns cross two major percentile lines on a growth chart. Other indices include a small head circumference, muscular wasting, apathy, weight loss, or poor weight gain. Learning failure (e.g., slow to talk, behavior problems) can also occur. Routine laboratory testing rarely identifies a cause and is not generally recommended (Cole and Lanham, 2011). Infants with DS, intrauterine growth retardation (IUGR), or premature birth follow different growth patterns than usual; monitor carefully to evaluate for FTT. About 25% of normal infants will shift to a lower growth percentile in the first 2 years of life and then remain at that percentile; this is not FTT. Primary FTT originates from social/environmental deficits, inadequate feeding procedures, or caregiver behaviors. Adolescent mothers may need a lot of support and education. Proximity and touch are especially disturbed in feeding disorders (i.e., mothers provide less touch that supports growth), and children demonstrate signs of touch aversion. Early interventions by trained home visitors may promote a more nurturing environment and reduce developmental delays.

Escott-Stump_Ch03.indd 170

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Genes causing FTT would be related to the specific condition, such as a congenital heart defect, spina bifida, or cystic fibrosis.

Clinical/History • Height • Percent height for age (actual height/expected height) • Weight 3rd percentile or 20% below the ideal weight for height • Growth grid—slowed or stopped after a normal curve? • Very low birth weight? • Apgar scores • Premature or small for gestational age (SGA)? • Head circumference: microcephaly? • Skinfold thickness • Diet and intake history • Feeding schedule and timing • Food allergy; cow’s milk allergy? • GERD • Medical history • Breastfed or bottle fed? • Solid food introduction pattern • Diarrhea or vomiting? • Constipation? • Dehydration • Inadequate access to food? • Infections, parasites?

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

• • • • •

needs from the most current Pediatric Manual of Clinical Dietetics. • Provide the most optimal nutrition compatible with a normal growth pattern. Achieve daily gains of 30 g for young infants; extra may be desirable for catch-up. Nutrient-enriched formulas are probably not necessary (Henderson et al, 2007). • Teach the parent or caregiver how to properly feed and how to determine needs. Advise parents to support nurturing during feeding. • Provide a schedule of feeding for infant’s age to support catch-up growth and improved brain development (Powers et al, 2008). Table 3-8 provides normal growth rates.

Urinalysis; frequent UTIs? Irritability? Excessive crying? Maternal depression? Denver Developmental Screening Test X-rays to determine bone age

Lab Work • • • • • • • • • • •

171

H&H Serum Fe, ferritin Anemia (iron, sickle cell, other) Electrolytes Alb Gluc Chol, Trig BUN Thyroid function tests I&O Sweat test

FOOD AND NUTRITION • Conduct a thorough nutrition assessment and acquire actual intake records when possible. Evaluate the child’s nutritional history and growth in comparison with the percentiles of other same-age children. If special growth charts are needed (as for DS,) use those instead. Discuss findings with parents/ caregivers. • Calculate energy and protein needs carefully. While not easy to do, indirect calorimetry may be needed. • Check recommended intakes for all nutrients. Provide adequate zinc and vitamin B6, as determined by the infant’s age; 120% to 130% is a common practice. • Monitor growth (weight) weekly; feeding behaviors. • If the infant is dehydrated, provide adequate amounts of fluids. However, FTT can be aggravated by excessive consumption of fruit juice and sweetened beverages (often 12–30 oz daily) which may replace other nutrient-dense foods. Limit to 4 to 6 oz daily until overall diet quality and growth rate have improved. • Provide meals and snacks at scheduled times; support a comfortable social and emotional environment. Family meals

INTERVENTION OBJECTIVES • Identify and correct etiologies such as decreased energy intake, increased nutrient losses, and increased metabolic demands. Determine if malnutrition is primary (from faulty feeding patterns or dietary inadequacy) or secondary (from disease process interfering with intake). • Prevent permanent mental, emotional, or physical delays. • All children with FTT need additional calories for catch-up growth at about 150% of the energy requirement for their expected, not actual, weight. Use calculations for determining

TABLE 3-8 Normal Growth Rates for Height and Weight in Children AGE

GROWTH IN LENGTH OR HEIGHT (mm/d)a

GROWTH IN LENGTH OR HEIGHT (in/yr)

0–6 months

1.06 declining to 0.77

7–10

6–12 months

0.47

6–7

1–2 years

0.35 declining to 0.30

4–5

2–3 years

—

3–4

3–4 years

—

2–3

4–10 years

—

2 a

AGE

DAILY GROWTH IN WEIGHT (oz/d)

GROWTH IN WEIGHT

0–4 months

1.0 declining to 0.61

1½ lb/mo

4–10 months

0.61 declining to 0.47

1 lb/mo

10–24 months

0.47 declining to 0.25

½ lb/mo

2–8 years

—

3–4 lb/y

FORMULAS FOR MEASUREMENT CONVERSION One pound 0.455 kg or 2.2 lb 1 kg One inch 2.54 cm Multiply each inch by 2.54 to come up with length in centimeters Multiply each pound by .455 to come up with weight in kilograms, or take the pounds and divide by 2.2 a

See Russell-Silver Syndrome Growth Charts, based on the Centers for Disease Control and Prevention’s federally authorized growth charts, http://www.magicfoundation.org.

Escott-Stump_Ch03.indd 171

11/7/14 8:24 PM

172

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

and allowing children to be a part of meal preparation are also important. • If FTT children are strictly vegan, monitor for vitamins B12, D, B6, iron, zinc, and calcium deficiencies. • Tube feeding may be useful as a supplemental or alternative feeding method; nightly feeding is an effective recommendation if it can be managed by the caregiver.

SAMPLE NUTRITION CARE PROCESS STEPS Slow weight gain Assessment Data: Weight and growth charts, medical conditions causing excessive energy expenditure or requirements, feeding methods used for the child, available financial resources to buy food or formula, access to safe and sufficient food supply.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Evaluate medications given for any reason to determine if some or all affect nutritional intake. Adjust diet as needed. • Endogenous cannabinoids or other appetite enhancers are being studied for their safety and effectiveness in FTT.

Nutrition Diagnoses (PES): Inadequate oral food/beverage intake related to minimal intake of formula and age-appropriate foods as evidenced by drop in more than two percentile lines on the National Center for Health Statistics growth chart after having achieved a previously stable pattern and medical diagnosis of FTT. Interventions:

Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for FTT; there are no controlled trials to prove efficacy. • Probiotics are useful for their live microorganisms with a health benefit for GI disorders, FTT, and infections. • Zinc supplementation may be needed during catch-up growth in malnourished children. Avoid prolonged or excessive doses.

• Food and Nutrition Delivery: Feeding environment to support growth in 12 month olds. Offer increased caloric intake and frequent snacks. • Nutrition Education: Registered dietitian to provide nutrition education to support weight gain in patient and teach parents/caregivers how to properly feed according to infant’s nutritional needs. Discuss adequate timing for feeding child. Educate and teach parents/caregivers about appropriate feeding behaviors and practices for 12 month olds. • Counseling: Counsel parents/caregivers on how to provide nutritional needs for patient and environment to support those need. Goal is to achieve daily gains of weight, 30 g/d. • Coordination of Care: Collaborate with physician; registered dietitian will refer patient for in-home assessment and follow-through. Correct environmental causes of FTT. Refer to WIC or SNAP (food stamps) programs to help with financial challenges and food insecurity.

Nutrition Education, Counseling, Care Management • Describe appropriate nutritional intake according to age and any predisposing medical conditions. • Encourage the use of appropriate growth charts at home to monitor success. Develop a progress chart for developmental milestones. Growth spurts follow sustained weight gains; monitor growth frequently. • Offer simple, specific instructions when needed, such as mechanics of breastfeeding and typical intakes for children of same age. If formula is used, improper mixing of formula is common; help correct any misunderstandings. • Discuss nutrient density (e.g., milk vs. sweetened carbonated beverages; whole fruit vs. juice). • Explain proper use of over-the-counter vitamin–mineral supplements, as age-appropriate for the child. • Address any harmful or unusual dietary beliefs or practices. • Practical suggestions should be offered regarding nurturing and emotional support for the child. Parenting classes may be beneficial. • Coordinate referral to child welfare services if neglect is suspected. Refer to WIC programs, La Leche League, SNAP (food stamps) whenever appropriate. • Follow-up should be provided at outpatient clinics or by home visits. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants; this will decrease the potential risk of botulism.

Escott-Stump_Ch03.indd 172

Monitoring and Evaluation: Weight records, growth, tolerance for various foods or formulas, financial access to food.

For More Information ●

Clinical Key—Failure To Thrive https://www.clinicalkey.com/topics/pediatrics/failure-to-thrive.html

●

Interdisciplinary Nutrition Care Plan: Failure to Thrive http://www.nutrition411.com/clinical-nutrition/care-algorithms/item/646 -interdisciplinary-nutrition-care-plan-failure-to-thrive-ftt

●

Johns Hopkins—Failure to Thrive http://www.hopkinschildrens.org/Failure-to-Thrive.aspx

●

Kids Health http://kidshealth.org/parent/growth/growth/failure_thrive.html

●

MedlinePlus—FTT http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/000991.htm

REFERENCES Barron MA, et al. Increased resting energy expenditure is associated with failure to thrive in infants with severe combined immunodeficiency. J Pediatr. 2011;159:628. Cole SZ, Lanham JS. Failure to thrive: an update. Am Fam Physician. 2011; 83:829.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

DeBoer MD, et al. Early childhood growth failure and the developmental origins of adult disease: do enteric infections and malnutrition increase risk for the metabolic syndrome? Nutr Rev. 2012;70:642. Henderson G, et al. Nutrient-enriched formula versus standard term formula for preterm infants following hospital discharge. Cochrane Database Syst Res. 2007;17(4):CD004696.

173

Levy Y, et al. Diagnostic clues for identification of nonorganic vs organic causes of food refusal and poor feeding. J Pediatr Gastroenterol Nutr. 2009;48:355. Ma Y, et al. Nutritional and metabolic findings in patients with Prader-Willi syndrome diagnosed in early infancy. J Pediatr Endocrinol Metab. 2012;25:1103. Powers GC, et al. Postdischarge growth and development in a predominantly Hispanic, very low birth weight population. Pediatrics. 2008;122:1258.

FATTY ACID OXIDATION DISORDERS NUTRITIONAL ACUITY RANKING: LEVEL 4 DEFINITIONS AND BACKGROUND Fatty acid oxidation disorders disrupt mitochondrial energy generation and ketone production. Organs typically affected include the heart, liver, and skeletal muscles. Muscle protein breaks down and may lead to death if the heart muscle is involved. Short-chain acyl-CoA dehydrogenase (SCAD) deficiency is an autosomal recessive inborn error of mitochondrial fatty acid oxidation. SCAD has been associated with accumulation of butyryl-CoA byproducts in body fluid and tissues, eventually leading to developmental delay, ketotic hypoglycemia, epilepsy, and behavioral disorders (Gallant et al, 2012). Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency is caused by the lack of an enzyme required to convert fat to energy. Children with MCAD cannot use MCTs to make energy, so the body begins to malfunction when they fast (i.e., they have no more long-chain dietary fats available from the diet). MCAD occurs in approximately 1 in every 10,000 live births. MCAD occurs mostly among Caucasians of Northern European background. Symptoms typically begin in infancy or early childhood, often with simple lethargy. While some affected individuals have no symptoms at birth, disorders such as hypoglycemia, seizures, coma, brain damage, or cardiac arrest can occur very quickly with illness. If not detected and treated appropriately, MCAD can result in death. Some SIDS deaths may result from undiagnosed MCAD. Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency affects the degradation of long-chain fatty acids, causing insufficient energy production and accumulation of toxic intermediates. The treatment consists of a diet low in fat, with supplementation of medium-chain triglycerides. Frequent feedings and extra carbohydrates are needed with febrile illnesses to reduce lipolysis (Haglind et al, 2013). To avoid excess weight gain, a diet slightly higher in protein and lower in carbohydrates may be of benefit (Gillingham et al, 2007). An erythrocyte fatty acid profile is done to test for essential fatty acid and DHA deficiencies (Lund et al, 2010). Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency has been identified as a cause in some cases of SIDS. Newborn screening is useful for identifying these infants. Early detection allows treatment and a normal life expectancy. The measurement of creatine kinase is helpful (Lund et al, 2010). Medical nutrition therapy to lower dietary fats does not decrease toxic metabolites because the body can make triglycerides from carbohydrates, proteins, or fats (Isaacs and Zand, 2007). Thus, the appropriate fatty acids must be omitted. Research

Escott-Stump_Ch03.indd 173

is needed on the effectiveness of l-carnitine supplementation (MCAD and LCHAD), restriction of dietary fat, feeding practices for breastfed infants, and the use of essential fatty acids, carbohydrates, cornstarch, and multivitamins (Potter et al, 2012).

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • SCAD involves mutations of the ACADS gene. MCAD involves medium-chain acyl-coenzyme A (CoA) dehydrogenase deficiency; adenosine replaces guanosine at position 985 of the MCAD gene. In LCHAD, the HADHA gene is involved.

Clinical/History • • • • • • • • •

Length (height) Birth weight Present weight Growth (%) Diet/intake history Seizures? Retardation? Liver ultrasonography Eye exams

Lab Work • • • • • • • • •

Gluc Alb Chol Trig Lipid panel H&H Serum Fe Free carnitine Creatine kinase

INTERVENTION Objectives • Avoid periods of fasting, day and night. Use intravenous (IV) glucose when food cannot be tolerated, such as with colds or flu.

11/7/14 8:24 PM

174

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

• Customize protocol for the individual. LCHAD requires a severe dietary restriction of long-chain fats, to the lowest level that can deliver the EFAs and FSVs (Isaacs and Zand, 2007). MCT can be used in LCHAD but not in MCAD. • Provide EFAs. • Prevent metabolic crises and complications, including retinopathy and neuropathy. • Support growth and development.

• Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

SAMPLE NUTRITION CARE PROCESS STEPS Excessive Intake of Types of Fats

Food and Nutrition • Restrict periods of fasting by offering small, frequent feedings. • A diet is needed with avoidance of the specific, problematic fatty acids. For example, do not use enteral formulas that contain MCTs in MCAD. • The diets will be higher in carbohydrates and fat-free protein foods. • Supplement linoleic and -linolenic acids; monitor by laboratory measurements of fatty acids. • Supplemental carnitine has been recommended. • Waking the child at least once during the night, or feeding by gastrostomy or NG tube overnight, is required for most of the fatty acid oxidation disorders (Isaacs and Zand, 2007). • Monitor weight and growth closely to prevent obesity, but do not skip meals or feedings.

Assessment Data:Weight and growth charts. Nutrition Diagnoses (PES): Excessive intake of medium-chain fatty acids related to MCAD deficiency as evidenced by signs of lethargy and elevated levels of triglycerides. Intervention: Educate parents about avoiding sources of MCT; document in medical record about formulas to avoid. Monitoring and Evaluation: Weight records, growth, improvement in lipid levels, reduced lethargy, normal mental development for age.

For More Information ●

Fatty Oxidation Disorders http://www.fodsupport.org/

●

Genetic Metabolic Dietitians International http://www.gmdi.org/

●

MCAD http://www.mcadangel.com/mcad-links.html

●

My Special Diet http://www.myspecialdiet.com/

●

National Newborn Screening & Global Resource Center http://genes-r-us.uthscsa.edu/

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Bezafibrate (BEZ) is an agonist of peroxisome proliferating activator receptor (PPAR) that seems to restore fatty-acid oxidation activity in VLCAD deficiencies (Yamaguchi et al, 2012). Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used because there are no controlled trials to prove efficacy for any related problems.

Nutrition Education, Counseling, Care Management • Educate about the dangers of fasting, including periods during illness. • Share information about frequent feedings and how to avoid the designated fatty acids from supplemental products, formulas, menu items. • Ongoing follow-up and education of the patient is important throughout life to prevent disease morbidity or death from metabolic crises (Lund et al, 2010). Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes.

Escott-Stump_Ch03.indd 174

REFERENCES Gallant NM, et al. Biochemical, molecular, and clinical characteristics of children with short chain acyl-CoA dehydrogenase deficiency detected by newborn screening in California. Mol Genet Metab. 2012;106:55. Gillingham MB, et al. Effects of higher dietary protein intake on energy balance and metabolic control in children with long-chain 3-hydroxy acyl-CoA dehydrogenase (LCHAD) or trifunctional protein (TFP) deficiency. Mol Genet Metab. 2007;90:64. Haglind CB, et al. Growth in long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency. JIMD Rep. 2013;8:81. Isaacs JS, Zand DJ. Single-gene autosomal recessive disorders and Prader-Willi syndrome: an update for food and nutrition professionals. J Am Diet Assoc. 2007;107:466. Lund AM, et al. Clinical and biochemical monitoring of patients with fatty acid oxidation disorders. J Inherit Metab Dis. 2010;33:495. Potter BK, et al. Variability in the clinical management of fatty acid oxidation disorders: results of a survey of Canadian metabolic physicians. J Inherit Metab Dis. 2012;35:115. Yamaguchi S, et al. Bezafibrate can be a new treatment option for mitochondrial fatty acid oxidation disorders: evaluation by in vitro probe acylcarnitine assay. Mol Genet Metab. 2012;107:87.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

175

FETAL ALCOHOL SYNDROME NUTRITIONAL ACUITY RANKING: LEVEL 1–2 DEFINITIONS AND BACKGROUND Alcohol exposure during pregnancy results in a spectrum of birth defects known as fetal alcohol spectrum disorders (FASD) that can negatively impact a child’s growth, development, cognition, behavior, and physical appearance over his or her entire lifespan (Eaton et al, 2011). Generally noted shortly after birth, fetal alcohol syndrome (FAS) is a condition noted in infants with developmental delay, ocular anomalies, LBW, tremors, short stature, retarded intellect, seizures, and microcephaly. It affects approximately 1/1,000 births. FAS is the third leading cause of mental retardation in the United States; it is certainly the most preventable. No level of alcohol consumption during pregnancy is safe. Exposure to alcohol during brain development can permanently alter the physiology of the hippocampal formation. Ethanol damages the developing brain, resulting from enhanced apoptotic death of neurons and cellular variations in GSH homeostasis (Maffi et al, 2008). Disrupted cholesterol homeostasis contributes to neurotoxicity; the developing brain requires cholesterol for proper cell proliferation. Alcohol exposure also disturbs the metabolism of choline (Zeisel, 2011). Finally, acetaldehyde damages RNA (Wang et al, 2009). Despite warnings by the U.S. Surgeon General and others, childbearing age women continue to drink at high levels, even in pregnancy (Eaton et al, 2011).

Microcephaly Epicanthal folds

Early risk assessment is needed, although it may be difficult to find and treat children who have FAS. Using the combination of weight and head circumference below the 10th percentile at birth is useful for identifying children at substantial risk for growth and developmental delays. Children with FAS may have more social and medical needs. Between 10% and 30% of mothers who have one child with FAS have another as well (Cannon et al, 2012). These mothers are often on public assistance, may have confirmed alcoholism or a history of mental illness, and may have drunk heavily (7 days a week) during pregnancy (Cannon et al, 2012). Children with FAS often have facial dysmorphology (Fig.3-4), growth deficiency, CNS dysfunction, muscular problems, pneumonia, dehydration, and anemia (Medina et al, 2011). Clinicians may have difficulty identifying facial dysmorphism, but new methods have become available (Suttie et al, 2013).

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • FAS is considered to be environmental.

Flat nasal bridge Small palpebral fissures

Smooth philtrum Small chin

Short nose Thin vermilion border (upper lip)

Figure 3-4. Features of fetal alcohol syndrome. (A, Reprinted with permission from Porth C. Essentials of pathophysiology. 3rd ed. Baltimore, MD: Wolters Kluwer; 2011; B, Reprinted with permission from Bickley LS, Szilagyi P. Bates’ guide to physical examination and history taking. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)

Escott-Stump_Ch03.indd 175

11/7/14 8:24 PM

176

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Clinical/History • • • • • • • • • •

Birth weight (LBW?) Current weight (often 10th percentile) Length Growth (%) Diet/intake history Head circumference (10th percentile) Seizures Physical growth delay Functional deficits (motor, social, memory, etc.) Facial dysmorphism

Lab Work • • • • • • •

Alb Na, K Gluc H&H Serum Fe Ca, Mg Serum folate

INTERVENTION

• Offer prevention strategies for both pregnant and nonpregnant women who might be at risk for another alcohol-exposed pregnancy (Floyd et al, 2009). • Encourage mother’s participation in alcohol rehabilitation if needed. Discuss her plans for additional pregnancies; encourage counseling to avoid continued alcohol intake. • Suggest interventions with the child that lead to success. Include parent education or training, teach children specific skills they would usually learn by observation or abstraction, and integrate these methods into existing systems of treatment (Bertrand et al, 2009). Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants; this will decrease potential risk of botulism.

SAMPLE NUTRITION CARE PROCESS STEPS

Objectives • Promote effective family coping skills and effective parental bonding. • Prevent additional retardation or developmental delays, blindness, other complications. • Improve intake and nutritional status. • Prevent or correct vomiting, cardiac symptoms, other problems. • Encourage normal growth patterns; prevent FTT.

Excessive Bioactive Substance Intake Assessment Data: Prenatal counseling and intake records; mother has one child with FAS. Nutrition Diagnoses (PES):Excessive bioactive substance intake related to daily alcohol consumption as evidenced by discussion during prenatal counseling and history of child born with FAS. Intervention: Educate mother about nutrient-dense foods and supplements and the need to eliminate alcohol during pregnancy.

Food and Nutrition • Provide a diet appropriate for age and status. Ensure adequate protein and energy for catch-up growth. • If necessary, provide tube feeding or TPN while hospitalized. Some infants may require additional nutrition support in the home setting to promote better growth and development. • Low dietary choline intake should be avoided (Zeisel, 2011).

Monitoring and Evaluation: Intake records indicating that alcohol consumption has now ceased.

For More Information ●

Centers for Disease Control and Prevention: Fetal Alcohol Spectrum Disorders http://www.cdc.gov/ncbddd/fas/

●

FAS Community Resource Center http://www.come-over.to/FASCRC/

●

Fetal Alcohol and Drug Unit http://depts.washington.edu/fadu

●

National Council on Alcoholism and Drug Dependence (NCADD) http://www.ncadd.org/

●

National Organization of Fetal Alcohol Syndrome http://www.nofas.org/

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Anticonvulsants may be needed to correct seizures. Monitor for depletion of vitamins C, D, B6, B12, and K, folic acid, and calcium. • Discuss the long-term, detrimental effects of prenatal exposure to drugs and alcohol. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for FAS because there are no controlled trials to prove efficacy.

Nutrition Education, Counseling, Care Management • Discuss appropriate feeding techniques for the age of infant or child. • Discuss importance of diet in aiding normal growth and development.

Escott-Stump_Ch03.indd 176

REFERENCES Bertrand J, et al. Interventions for children with fetal alcohol spectrum disorders (FASDs): overview of findings for five innovative research projects. Res Dev Disabil. 2009;30:986. Cannon MJ, et al. Characteristics and behaviors of mothers who have a child with fetal alcohol syndrome. Neurotoxicol Teratol. 2012;34:90. Eaton B, et al. Fetal alcohol spectrum disorders: flying under the radar. J Ark Med Soc. 2011;107:260.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

Floyd RL, et al. Prevention of fetal alcohol spectrum disorders. Dev Disabil Res Rev. 2009;15:193. Maffi SK, et al. Glutathione content as a potential mediator of the vulnerability of cultured fetal cortical neurons to ethanol-induced apoptosis. J Neurosci Res. 2008;86:1064. Medina AE. Fetal alcohol spectrum disorders and abnormal neuronal plasticity. Neuroscientist. 2011;17: 274.

177

Suttie M, et al. Facial dysmorphism across the fetal alcohol spectrum. Pediatrics. 2013;131:779. Wang LL, et al. Ethanol exposure induces differential microRNA and target gene expression and teratogenic effects which can be suppressed by folic acid supplementation. Hum Reprod. 2009;24:562. Zeisel SH. What choline metabolism can tell us about the underlying mechanisms of fetal alcohol spectrum disorders. Mol Neurobiol. 2011;44:185.

HIRSCHSPRUNG DISEASE (CONGENITAL MEGACOLON) NUTRITIONAL ACUITY RANKING: LEVEL 4 DEFINITIONS AND BACKGROUND Normally, when the rectum fills up with gas or fecal material, a reflex causes it to open to allow the bowel movement to pass through. When the reflex nerves are missing at birth, the congenital defect is called aganglionosis, or Hirschsprung disease (HSCR). This defect creates abdominal distention, failure to pass meconium stool, vomiting, and constipation. Up to 10% of patients may have severe problems such as enterocolitis (see Table 3-9). In children who are diagnosed when older, growth failure may be a presenting sign. Incidence is 1 in 5,000 live births. The condition can be life threatening, and signs include hypoalbuminemia, diarrhea and vomiting, and anorexia and weight loss. Surgical removal may be required to alleviate bowel obstruction, followed by a temporary colostomy. Often, removal of the affected area and reconnection of the colon occurs at age 6 months or older. Historically, patients had multiple-staged operations, whereas, more recently, single-stage laparoscopic resection and pull-through operations are more common (Huang et al, 2013). Complications after a definitive pull-through procedure include stricture formation, enterocolitis, and wound infection. Over the long term, 20% of patients will have continued constipation, occasional soiling, and incontinence. A small portion of children are left with persistent stooling issues that can be addressed by nonoperative approaches (Ralls et al, 2012).

ASSESSMENT, MONITORING, AND EVALUATION

Clinical/History • • • • • • • • • • • • • • • • • •

Birth weight Length Present weight FTT? Growth (slow) Diet/intake history Failure to pass meconium after birth (newborn) Watery diarrhea (newborn) Constipation Temperature (fever?) Vomiting Abdominal distention Rectal bleeding? Dehydration; I&O Abdominal x-ray Barium enema Malabsorption Enterocolitis?

Lab Work • • • • • • •

H&H Serum Fe, ferritin Alb Na, K Ca, Mg Gluc LFTs

INTERVENTION Genetic Markers • HSCR has been mapped to defects in two chromosomes. The RET proto-oncogene on chromosome 10 was identified as one; the other, EDNRB, is on chromosome 13.

TABLE 3-9 Grading for Hirschsprung Enterocolitis GRADE

CLINICAL SYMPTOMS

Mild explosive diarrhea, mild or moderate abdominal distention; no systemic manifestations

Moderate explosive diarrhea, moderate-to-severe abdominal distention; mild systemic symptoms

III

Severe explosive diarrhea, marked abdominal distention, and shock or impending shock

Escott-Stump_Ch03.indd 177

Objectives • Diagnose early to prevent failure to thrive, enterocolitis, colonic perforation, and dilatation of distal gut (Mandhan, 2011). • Provide adequate nutrition for the patient’s age and development. Growth may be inhibited. • Replace electrolytes and fluids, especially with diarrhea and enterocolitis. • Compensate for poor absorption of nutrients; water-miscible forms of FSVs may be needed. • Prevent complications after surgery, especially constipation, incontinence, or enterocolitis. Bowel management, dietary changes, and laxatives may be necessary (Levitt etal, 2010).

11/7/14 8:24 PM

178

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Food and Nutrition

Nutrition Education, Counseling, Care Management

• Use a high-energy/high-protein diet. Enteral products, oral supplements, or TPN can be used. • Monitor serum electrolytes, especially potassium, if laxatives are used. Encourage a diet high in fiber and fluid to wean off medication if possible. • Provide fluids adequate for the patient’s age, hydration status, and extra fluid requirements. • Use a natural laxative diet as in Table 3-10. • Advance infant feedings as tolerated using human milk or preterm or standard infant formulas, and then gradually progress to soft/bland foods.

• Teach patient about sources of protein, energy, potassium, and other key nutrients from diet. • Discuss wound healing or colostomy procedures after surgery. • For constipation and bowel incontinence, a high-fiber diet may be useful; discuss signs and symptoms of obstruction to report immediately to a doctor. Initial suggestion: age plus 10, example 4 years 10 14 g/d. • Extra fluids will be needed with high-fiber intake.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Antibiotics may be needed if perforation has occurred or when there is enterocolitis. Monitor for side effects. • In constipation, laxatives can deplete numerous nutrient reserves; monitor carefully. Encourage a diet high in fiber and fluid to wean off medication if possible. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for megacolon because there are no controlled trials to prove efficacy.

Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

TABLE 3-10 Laxative Foods for Children FIBER SUPPLEMENTS

Name

Active Ingredient

Serving Size

Amount of Fiber

Metamucil wafers

Psyllium 50% soluble

2 wafers

Metamucil powder

Psyllium 65% soluble

1 tbsp

Ground flax seed

45% insoluble, 55% soluble

1 tbsp

Benefiber

Wheat dextrin, 100% soluble

2 tbsp

Citrucel

Methocellulose, 100% soluble

1 scoop or 4 caplets

Pectin

100% soluble

1.75 oz package

4.3 g

LAXATIVE FOODS • • • • • •

•

Caffeine: known to relax anal sphincter and produce a laxative effect for some patients Chocolate: dark chocolate Foods high in fat: Every person’s digestive tract is different; for some fatty foods will provoke bowel movements but will constipate others. High-fat dairy products: known to produce laxative effect for some; however, may cause constipation for others. Try these foods and if there is no benefit to bowel movements only provide enough dairy to meet calcium needs for age. Spicy foods: may have a laxative effect Soluble fiber: Water-soluble fiber prolongs stomach emptying time so that sugar is released and absorbed more slowly. It forms a gel when mixed with liquid which helps to soften stool. If the child is taking laxatives, water-soluble fiber should be included at mealtimes in addition to following an overall high-fiber mealplan. Foods high in water-soluble fiber include: • cornmeal, winter squash, yams, artichokes, rutabagas, papayas, oranges, tangerine, potato without skin, mango Pectin (fruit pectin) “sure jell” can be found in grocery stores with canning supplies (used for making jam/jelly). Comes in generic brand. In general, it is sour in flavor, but some unflavored products are available. Available in powder and liquid. Find a food or drink that is preferred; some examples are yogurt, jello jigglers, and orange juice. Be sure that as with all other medications that the child eats or drinks the entire serving. Water-insoluble fiber: Water-insoluble fiber moves bulk through the intestines, promotes regular bowel movements, and helps prevent constipation. If the child is not on laxatives and is trying to avoid constipation, encourage sources of insoluble fiber. Foods high in water-insoluble fiber include: • Cauliflower, graham crackers, bulgur, spinach, raw lima beans, popcorn, green cabbage, kidney beans, corn tortilla, corn kernel, strawberries, whole wheat or rye bread, broccoli, raw blueberries, blackberries cranberries, cherries, cucumbers, dates, guava, barley, bran and bran flakes, carrots, tomatoes, prunes, prune juice, green peas, almonds, baked potato with skin, sesame seeds, raisins, melons, brazil nuts, split peas, chick peas, lentils, pears, fresh pineapple

Sources: Academy of Nutrition and Dietetics. Fiber facts: soluble fiber and heart disease. Chicago, IL: American Dietetic Association; 2007; Cincinnati Children’s Colorectal Center. Laxative Diet. Available at: http://healthlibrary.childrenshospital.org/Library/Encyclopedia/90,P01986. Accessed June 4, 2014; Li BW, Andrews KW, Pehrsson PR. Individual sugars, soluble, and insoluble dietary fiber contents of 70 high consumption foods. J Food Comp Anal. 2002;15:715.

Escott-Stump_Ch03.indd 178

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

179

For More Information

SAMPLE NUTRITION CARE PROCESS STEPS

●

Hirschsprung’s & Motility Disorders Support Network http://www.hirschsprungs.info/Index.php

Altered GI Function

●

International Foundation for Functional Gastrointestinal Disorders http://www.iffgd.org/

Assessment Data: Weight and growth charts, constipation, and stool records.

●

United Ostomy Association http://uoa.org/

Nutrition Diagnoses (PES): • Altered GI function related to megacolon as evidenced by current bouts of constipation. Intervention: Educate parents about high-fiber foods and increased use of fruits, vegetables, whole grains, and fluids. Monitoring and Evaluation: Weight records, decreased symptoms of constipation, improved stooling pattern.

REFERENCES Huang EY, et al. Changes in hospital utilization and management of Hirschsprung disease: analysis using the kids’ inpatient database. Ann Surg. 2013; 257:371. Levitt MA, et al. Evaluation and treatment of the patient with Hirschsprung disease who is not doing well after a pull-through procedure. Semin Pediatr Surg. 2010;19:146. Mandhan P. Hirschsprung’s disease scientific update. Sultan Qaboos Univ Med J. 2011;11:138. Ralls MW, et al. Reoperative surgery for Hirschsprung disease. Semin Pediatr Surg. 2012;21:354.

HIV INFECTION, PEDIATRIC NUTRITIONAL ACUITY RANKING: LEVEL 4 DEFINITIONS AND BACKGROUND Unique considerations relate to human immunodeficiency virus (HIV) infection in infants, children, and adolescents. In developed nations, HIV infection is more of a chronic disease with extensive medications and side effects. Mother-to-child transmission (MTCT) of HIV can occur during pregnancy, childbirth, or through breastfeeding. When infected mothers use antiretroviral therapy (ART), transmission risk is minimal. However, MTCT still leads to 90% of all cases of childhood HIV infection, especially where ART is not available. More than 2 million children globally are living with HIV infection and 90% of these reside in sub-Saharan Africa (Musoke and Fergusson, 2011). Infants who are breastfed by HIV-infected mothers have the risk of acquiring the infection as well as other opportunistic pathogens. If breastfeeding is initiated by a mother who is HIV-positive, two interventions are needed to prevent transmission: exclusive breastfeeding during the first few months of life and chronic antiretroviral prophylaxis to the infant (Horvath et al, 2009). NK cells play an important role in the containment of HIV replication during primary infection. HIV infection promotes a decline in NK cells as a percentage of total lymphocytes (Slykeretal, 2012). In the absence of ART, over 50% of HIV-infected infants progress to AIDS and death by 2 years of age (Penazzato et al, 2012). Severe acute malnutrition is an important risk factor for mortality (Musoke and Fergusson,2011). Every child with HIV infection should be assessed at baseline and every 4 to 6 months thereafter to determine risk of nutritional compromise. Severity or degree of nutritional risk is measured with anthropometric, biochemical, dietary intake,

Escott-Stump_Ch03.indd 179

and medical data. Diagnoses of FTT and protein–calorie malnutrition are common. Salivary gland disease is a common finding and xerostomia may be present. The integration of HIV/AIDS and maternal, neonatal, and child health and nutrition services (MNCHN), including family planning, is recognized as a key strategy to reduce child mortality and control the HIV/AIDS epidemic (Lindegren et al, 2012). Delayed ART start, low access to free HIV services for children, and increased workloads are challenges in low-income areas and developing countries (Leroy et al, 2013). Nutritional supplementation is essential and should be budgeted in every HIV program (Cobb and Bland, 2013). In the United States, the Ryan White HIV/AIDS Program provides related services for those who do not have sufficient health care coverage or financial resources. The program hires qualified Registered Dietitians (RD) with expertise in managing HIV/AIDS. The RD should provide at least one to two medical nutrition therapy (MNT) encounters per year for people with HIV infection (asymptomatic) and at least two to six (or more) MNT encounters per year for people with HIV infection (Academy of Nutrition and Dietetics, 2013).

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • HIV infection is not genetic but is transmitted prenatally by the infected mother, or postnatally by contaminated needles or blood transfusions.

11/7/14 8:24 PM

180

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

Clinical/History • • • • • • • • • •

Height Weight Weight for height, BMI Growth percentile and pattern Diet/intake history; energy intake Head circumference (infants) Stunting FTT Mid-arm muscle circumference Opportunistic infections

•

• •

•

Lab Work • • • • • • • • •

H&H Serum Fe Alb Na, K Ca, Mg Gluc Plasma HIV RNA levels CD4 T-cell counts Vitamin A level

INTERVENTION Objectives • Maternal factors, including vitamin A level and CD4 T-cell counts during pregnancy, as well as infant viral load and CD4 T-cell counts, help identify those infants at risk for rapid disease progression. They may benefit from early aggressive nutrition therapy. • Achieve a normal growth pattern; support catch-up growth and monitor closely. • Prevent opportunistic infections by improving or maintaining immune status with good nutrition. • Alleviate wasting syndrome, diarrhea, malabsorption, enteric infections, malnutrition, and immune deficiency. Preserve lean body mass. • Manage oral manifestations as early as possible. Oral candidiasis and ulcerations are common (Duggal et al, 2010). • Recommend saliva substitutes; these include water, artificial salivas (mucin-based, carboxymethylcellulose-based), and other substances (milk, vegetable oil) if there is dry mouth. Encourage regular fluid intake throughout the day. • Prevent or manage complications including electrolyte disorders, micronutrient deficiencies, and severe infections, which contribute to the high mortality (Musoke and Fergusson, 2011). • Follow current evidence-based guidelines for use of drug therapy for immune function and for prevention of tuberclosis, hepatitis B or C, and malaria. 1. Emphasize the important role of effective antiretroviral therapy in augmenting immune function. • Manage drug–drug interactions and drug–nutrient interactions.

Food and Nutrition • Use a high-protein diet. Enteral products, oral supplements, and frequent snacks should be used if required.

Escott-Stump_Ch03.indd 180

•

Protein needs may be 1.5 to 2 times the usual for age and gender. Energy needs vary from 50% to 200% of the usual requirements. Children with severe encephalopathy may be bed bound and require fewer total calories. Assure adequacy of fluid intake, especially with the many medications taken each day. A multivitamin supplement is needed to provide at least 100% of the daily needs. Poor absorption may be a problem for vitamins A, C, B6, and B12, folate, iron, selenium, and zinc. Calcium is needed to prevent loss of bone mass. Naturally occurring antioxidants are safe when consumed in normal amounts. Include sources of vitamin E and selenium, and citrus fruits for vitamin C. Be aware of excesses from supplemental forms; they deplete the immune system. Mega doses have not proven to be of benefit. Aggressive nutritional support is critical. Nocturnal, continuous feedings may be useful.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Few HIV medicines are produced in pediatric formulations. Drugs available as syrups have limitations, such as short shelf life, objectionable taste, difficult measuring of correct doses, and expense. • For a list of FDA-approved medications used in HIV infection, see Section 15. Metabolic complications of antiretroviral drugs (ARVs) include lipodystrophy, dyslipidemia, lactic acidosis, insulin resistance, and osteopenia (Musoke and Fergusson, 2011). • HIV-infected mothers may transmit opportunistic pathogens to their infants. Antibiotics or ARVs should be closely monitored for nutritional and GI side effects. • Complex antiretroviral therapy requires addressing developmental, psychosocial, and family factors. Early treatment saves lives. Herbs, Botanicals, and Supplements • HIV-infected individuals may be attracted to the many possible supplements on the market. Carefully review all items and discuss their viability or potential for harm. Herbs and botanicals should not be used for HIV; there are no clinical trials proving efficacy. • Use of acidophilus and probiotic products may alleviate loss of intestinal bacteria.

Nutrition Education, Counseling, Care Management • There will be a need for medication management, a nutrient-dense diet, doctor visits, and other intervention and therapies. Provide support to the child, the family, and other caregivers. A comprehensive, ongoing program is necessary (Nesheim et al, 2012). • Encourage formula feeding for mothers who have HIV infection. • Discuss HIV infection prevention strategies, especially with noninfected teens. • Children should receive all of their usual vaccinations to prevent other illnesses or complications. Researchers are working on a vaccine for HIV prevention. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

• Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard beverages and foods that left at room temperature for 2 hours or longer. • Avoid honey in the diets of infants to decrease the risk of botulism. • Avoidance of breastfeeding has significant associated morbidity (e.g., diarrheal morbidity if formula is prepared without clean water) in developing countries (Horvath et al, 2009).

●

Elizabeth Glaser Pediatric AIDS Foundation http://www.pedaids.org/

●

National Institute of Allergy and Infectious Diseases (NIAID) www.niaid.nih.gov/daids/

●

National Pediatric AIDS Network http://www.npan.org/

●

Ryan White HIV/AIDS Program http://hab.hrsa.gov/

●

U.S. Coalition for Child Survival www.child-survival.org

181

REFERENCES SAMPLE NUTRITION CARE PROCESS STEPS Inadequate Energy Intake Assessment Data: Weight and growth charts, frequent infections. Nutrition Diagnoses (PES): Inadequate energy intake related insufficient intake, diarrheal losses, and high metabolic demand of HIV as evidenced by weight loss and opportunistic infections. Intervention: Educate parent/caregiver about use of tolerated high-calorie foods and supplements. Monitoring and Evaluation: Weight records, growth, tolerance of formulas or supplemental products.

For More Information ●

AIDS Pediatric Guidelines http://aidsinfo.nih.gov/guidelines

●

AIDS Vaccine Advocacy Coalition (AVAC) www.avac.org

●

American Foundation for AIDS Research (amFAR) www.amfar.org

●

Baylor International Pediatric AIDS Initiative http://bayloraids.org/

Academy of Nutrition and Dietetics. Evidence Analysis Library. HIV/AIDS Nutrition Evidence Analysis Project. Available at: http://andevidencelibrary.com /topic.cfm?cat=4458. Accessed June 4, 2014. Cobb G, Bland RM. Nutritional supplementation: the additional costs of managing children infected with HIV in resource-constrained settings. Trop Med Int Health. 2013;18:45. Duggal MS, et al. Effect of CD4 lymphocyte count, viral load, and duration of taking anti-retroviral treatment on presence of oral lesions in a sample of South African children with HIV/AIDS. Eur Arch Paediatr Dent. 2010; 11:242. Horvath T, et al. Interventions for preventing late postnatal mother-tochild transmission of HIV. Cochrane Database Syst Rev. 2009 Jan 21;(1): CD006734. Leroy V, et al. Outcomes of antiretroviral therapy in children in Asia and Africa: a comparative analysis of the IeDEA pediatric multiregional collaboration. JAcquir Immune Deﬁc Syndr. 2013;62:208. Lindegren ML, et al. Integration of HIV/AIDS services with maternal, neonatal and child health, nutrition, and family planning services. Cochrane Database Syst Rev. 2012 Sep 12;9:CD010119. Musoke PM, Fergusson P. Severe malnutrition and metabolic complications of HIV-infected children in the antiretroviral era: clinical care and management in resource-limited settings. Am J Clin Nutr. 2011;94:1716S. Nesheim S, et al. Comprehensive reproductive health care (including HIV testing) and facilitation of comprehensive clinical care and social services for women and infants. Pediatrics. 2012;130:738. Penazzato M, et al. Effectiveness of antiretroviral therapy in HIV-infected children under 2 years of age. Cochrane Database Syst Rev. 2012 Jul 11;7: CD004772. Slyker JA, et al. The impact of HIV-1 infection and exposure on natural killer (NK) cell phenotype in Kenyan infants during the first year of life. Front Immunol. 2012;3:399.

HOMOCYSTINURIA AND INBORN ERRORS OF COBALAMIN AND FOLATE NUTRITIONAL ACUITY RANKING: LEVEL 3–4 DEFINITIONS AND BACKGROUND The significance of homocysteine (Hcy) in human disease was unknown until 1962, when cases of homocystinuria were correlated with vascular disease (McCully, 2007). Hcy is usually converted to cysteine and partly remethylated to methionine with the help of vitamin B12 and folate. Inherited homocystinurias all have accumulation of homocysteine with subsequent

Escott-Stump_Ch03.indd 181

neurotoxicity. They also have two clinical entities: classical homocystinuria due to cystathionine -synthase (CBS) deficiency and the inborn errors of cobalamin and folate metabolism (Schiff and Blom, 2012). Homocystinuria (HCU) is an autosomal recessive metabolic disorder of amino acid metabolism. Deranged vitamin B6 metabolism or low levels of reductase enzyme may also cause HCU. Abnormal urinary tHcy response after methionine loading is the most sensitive test. Urinary excretion of Hcy occurs but is unusual.

11/7/14 8:24 PM

182

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

HCU type I is deficiency of CBS, which requires vitamin B6 for activation. Human CBS is an S-adenosylmethionine–regulated enzyme that plays a key role in the metabolism of Hcy. HCU type 1 occurs in 1 in 200,000 births worldwide, with stronger prevalence in Ireland, Norway, and Qatar. Hcy accumulates in the blood, methionine builds up, and cysteine decreases. Mental retardation and eye changes can occur from a lack of GSH production (Ramakrishnan et al, 2006). Untreated, it leads to seizures, altered growth, hepatic disease, osteoporosis, thromboses, glaucoma, cataracts, and strokes.Individuals with HCU may be unusually tall in stature, with long arms and legs; this growth is directly mediated byHcy. In HCU types II, III, and IV, methionine is decreased, but no mental retardation occurs. Treatment here involves giving folate and vitamin B12 while avoiding excesses of methionine (Ramakrishnan et al, 2006). Newborn screening is recommended. For some patients, medications can reduce the excretion of Hcy in the urine, increase body weight, and improve mental function. Methionine may be given to correct low serum levels, and pyridoxine may help lower serum Hcy levels. If individuals do not respond to combinations of these drugs, supportive care is offered to reduce symptoms. Disorders of cobalamin metabolism are many. Combined methylmalonic aciduria and homocystinuria, cblC type (cblC disease), is the most common and is caused by MMACHC gene mutations (Wang et al, 2012). Patients with the cblC disorder are defective in the intracellular synthesis of adenosylcobalamin and methylcobalamin (Froese et al, 2009). Presentation of symptoms varies. Newborns may be SGA with microcephaly; infants may present with FTT, pallor, seizures, hemolytic uremic syndrome, or cytopenias; young adults may show signs of confusion, cognitive decline, or megaloblastic anemia (Adams and Venditti, 2013). Over time, macular and retinal degeneration may occur. Methylenetetrahydrofolate reductase (MTHFR) deficiency affects many enzyme systems. MTHFR is a key enzymatic component of the folate cycle, converting 5,10-methylenetetrahydrofolate into 5-methyltetrahydrofolate, the methyl donor for remethylation of homocysteine into methionine (Forges et al, 2010). Severe MTHFR deficiency is a rare recessive disease leading to major hyperhomocysteinemia, homocystinuria, and progressive neurologic distress within the two first decades of life (Forges et al, 2010). It can present with mental retardation, microcephaly, gait disturbance, psychiatric disturbances, seizures, abnormal EEG, and limb weakness. MTHFR deficiency should be considered in cases of anencephaly, spina bifida, and infantile epilepsy (Prasad et al, 2011). Research also suggests a relationship in childhood leukemias (Amigou et al, 2012), migraine (Stuart et al, 2012), autism spectrum disorders (Schmidt et al, 2012), depression (Jain and Jackson, 2012), and stroke (Alsayouf et al, 2011). Thus, early diagnosis and treatment are important.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Mutations in the CBS on chromosome 21 are most common for cobalamin metabolic errors. At least 40 mutations have been noted in the MTFHR gene, causing varied disorders and effects.

Escott-Stump_Ch03.indd 182

Clinical/History • • • • • • • • • • • •

Birth weight Present weight Length Growth (%); FTT? Scoliosis Diet/intake history Nearsightedness Lens dislocation Blood clots in veins Mental retardation Cognitive changes or psychiatric problems Osteopenia or osteoporosis (dual-energy x-ray absorptiometry [DEXA]) • Marfan syndrome (long limbs, tall stature)

Lab Work • • • • • • • • • • • • •

ALT, AST Gluc Plasma methionine (fluctuates) Plasma cysteine Serum Hcy (elevated) Urinary methylmalonic acid Urinary tHcy after methionine load Serum folate Macrocytic anemia? MTHFR activity Serum B12 Serum B6 Serum Ca, Mg

INTERVENTION Objectives • Prevent mental retardation, growth delays, fractures, lens changes. Fractures occur because of defective collagen formation. A lens may become dislocated in CBS deficiency. • Prevent cardiovascular complications (arterial and venous thrombosis, stroke, hypertension). Dramatic decline in cardiovascular mortality in the United States may be attributable in part to voluntary fortification of the food supply with vitamin B6 and folic acid (McCully, 2007). Supplement with essential nutrients. Low folic acid intake aggravates the symptoms. • In HCU, reduce methionine in the diet to prevent accumulation of Hcy. • For disorders of cobalamin metabolism, treat acidosis and reverse catabolism (Adams and Venditti, 2013). • MTHFR deficiency usually involves administration of folinic acid to enhance enzyme activity and l-methylfolate to replace the missing end product. Extra betaine, hydroxycobalamin, carnitine, and riboflavin can assist with related enzymatic actions.

Food and Nutrition • Increase fluid intake. • HCU type I is treated with supplementation of vitamin B6 and cystine (to supply sulfur). If nonresponsive to B6,

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

use a low-methionine diet with a supplement of cystine. Reduce intake of methionine from meat, poultry, fish, and eggs. Soy products (e.g., Isomil, ProSobee, Soyalac) can be used. XMET Maxamaid (SHS North America), Hominex 1 for infants or Hominex 2 for children (Ross Laboratories), or Product HOM 1 or HOM 2 (Mead Johnson) is also useful. • For HCU types II, III, and IV, folate and vitamin B12 are needed. Avoid excesses of methionine from meat, poultry, fish, and eggs. • For cobalamin metabolic disorders, use a high-calorie diet that is low in protein, especially propionic amino acid precursors, and, in some cases, hydroxycobalamin intramuscular injections (Adams and Venditti, 2013). Dietary and oral supplements of vitamin B12 are not effective. Gastrostomy tube placement for feeding may be needed. Therapy with folic acid, vitamin B6, and l-carnitine may improve symptoms (Heil et al, 2007). • With MTHFR deficiency, use l-methylfolate. Vitamins B6 and B12, riboflavin, choline, and betaine may be useful supplements. Monitor closely.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Dipyridamole may be used to decrease thrombosis. • Pyridoxine therapy (vitamin B6) for longer than 1 month is useful for some forms of HCU. The doctor may prescribe 100 to 500 mg or higher. • While other vitamin B12 disorders are treatable with high-dose cyanocobalamin or hydroxocobalamin (OHCbl), cblC patients respond well only to OHCbl (Froese et al, 2009). • For MTHFR deficiency, folic acid and vitamin B12 should be supplied in a methylated form. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for HCU because there are no controlled trials to prove efficacy.

Nutrition Education, Counseling, Care Management • Emphasize the importance of controlling diet, snacks, using proper forms of supplemental nutrients. • Discuss good food sources of folic acid and other B-complex vitamins. Evaluate each case individually and adjust counseling as appropriate. • Because of increased incidence of osteoporosis, high serum Hcy levels interfere with collagen cross-linking. Controlling serum Hcy is important for bone health. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

Escott-Stump_Ch03.indd 183

183

SAMPLE NUTRITION CARE PROCESS STEPS Inadequate Intake of Bioactive Substances Assessment Data: Weight and growth chart showing long limbs, tall stature for age; lab tests showing HCU and low serum levels of vitamins B6, B12, and folate; myopia and history of thrombotic clots in legs. Nutrition Diagnoses (PES): Inadequate intake of bioactive substances related to genetic defect as evidenced by HCU and low serum levels of B6, B12, and folate. Intervention: Educate parents about dietary enhancements for foods rich in B6, B12, and folate. Counsel about appropriate drug therapy and desirable nutritional outcomes. Monitoring and Evaluation:Weight and growth records showing slower increments in added height; improved serum levels of vitamins; decreased or minimal Hcy in the urine.

For More Information ●

Children Living with Inherited Metabolic Diseases http://www.climb.org.uk/

●

Homocystinuria http://ghr.nlm.nih.gov/condition=homocystinuria

●

MTHFR http://ghr.nlm.nih.gov/gene/MTHFR

REFERENCES Adams D, Venditti CP. Disorders of intracellular Cobalamin metabolism. Gene reviews. Available at: http://www.ncbi.nlm.nih.gov/books/NBK1328/. Accessed June 4, 2014. Alsayouf H, et al. Role of methylenetetrahydrofolate reductase gene (MTHFR) 677CT polymorphism in pediatric cerebrovascular disorders. J Child Neurol. 2011;26:318. Amigou A, et al. Folic acid supplementation, MTHFR and MTRR polymorphisms, and the risk of childhood leukemia: the ESCALE study (SFCE). Cancer Causes Control. 2012;23:1265. Forges T, et al. Life-threatening methylenetetrahydrofolate reductase (MTHFR) deficiency with extremely early onset: characterization of two novel mutations in compound heterozygous patients. Mol Genet Metab. 2010;100:143. Froese DS, et al. Mechanism of vitamin B12-responsiveness in cblC methylmalonic aciduria with homocystinuria. Mol Genet Metab. 2009;98:338. Heil SG, et al. Marfanoid features in a child with combined methylmalonic aciduria and homocystinuria (CblC type). J Inherit Metab Dis. 2007; 30:811. Jain R, Jackson WC. Beyond the resistance: how novel neurobiological understandings of depression may lead to advanced treatment strategies. J Clin Psychiatry. 2012;73:e30. McCully KS. Homocysteine, vitamins, and vascular disease prevention. Am J Clin Nutr. 2007;86:1563. Prasad AN, et al. Methylenetetrahydrofolate reductase (MTHFR) deficiency and infantile epilepsy. Brain Dev. 2011;33:758. Ramakrishnan S, et al. Biochemistry of homocysteine in health and diseases. Indian J Biochem Biophys. 2006;43:275. Schiff M, Blom HJ. Treatment of inherited homocystinurias. Neuropediatrics. 2012;43:295. Schmidt RJ, et al. Maternal periconceptional folic acid intake and risk of autism spectrum disorders and developmental delay in the CHARGE (CHildhood Autism Risks from Genetics and Environment) case-control study. Am J Clin Nutr. 2012;96:80. Stuart S, et al. The role of the MTHFR gene in migraine. Headache. 2012;52:515. Wang X, et al. A clinical and gene analysis of late-onset combined methylmalonic aciduria and homocystinuria, cblC type, in China. J Neurol Sci. 2012;318:155.

11/7/14 8:24 PM

184

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

LARGE FOR GESTATIONAL AGE (MACROSOMIA) NUTRITIONAL ACUITY RANKING: LEVEL 1–3 DEFINITIONS AND BACKGROUND Infants whose weight is more than the 90th percentile for gestational age are classified as having macrosomia, or being large for gestational age (LGA). Birth weight is high (3,300 to 4,000g) at 40 weeks. LGA infants may be born to mothers who are multiparous, have diabetes, or are obese (Koyanagi et al, 2013). The higher the mother’s total body weight at birth, the higher the rate of macrosomia (Kamanu et al, 2009). Adequate maternal adiponectin limits fetal growth (Rosario et al, 2012). Upregulation of specific placental amino acid transporter (insulin/IGF-I and mTOR) signaling pathways contributes to fetal overgrowth (Jansson et al, 2013). Gestational diabetes mellitus (GDM) uncovers underlying insulin resistance and beta-cell dysfunction (Imam, 2012). Preexisting diabetes is associated with increased risk for cesarean section delivery, macrosomia, stillbirth, preterm delivery, and low Apgar scores at 5 minutes (Wahabi et al, 2012). Controlling maternal glycemia with MNT, close monitoring of blood glucose levels, and treatment with insulin if blood glucose levels are high has been shown to decrease fetal and maternal morbidities (Imam, 2012). Macrosomia in newborns raises the risk for birth-related problems. Problems may include hypoglycemia, respiratory distress, aspiration pneumonia, bronchial paralysis, or facial paralysis. LGA neonates usually have higher body fat and lower lean body mass than appropriate for gestational age (AGA) infants. After birth, rapid adaptation is necessary for infants to be able to maintain independent glucose homeostasis; this process is compromised in LGA infants (Beardsall et al, 2008). High birth weight may eventually promote impaired glucose tolerance, diabetes, obesity, or cancer in the child. Elevated maternal triglyceride levels measured during pregnancy are associated with complications and adverse outcomes (Vrijkotte et al, 2012). Excessive early gestational weight gain may lead to GDM, LGA, and birth weight greater than 4,000 g (Carreno et al, 2012). Thus, controlling early and total maternal weight gain, lipids, and glucose levels are important for both mother and child.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Mitochondrial RNA deletions may be involved, but no specific gene has been identified.

Clinical/History • Head circumference • Length • Birth weight more than the 90th percentile for gestational age

Escott-Stump_Ch03.indd 184

• Neonatal Growth Assessment Scores • Neonatal Behavior Assessment Scale (motor maturity, autonomic stability, and withdrawal) • Respirations • pCO2, pO2 levels • BP • Maternal diabetes? • Diet/intake history • I&O

Lab Work • • • • • • • • • • •

Diagnosis of GDM between 24 and 28 weeks of pregnancy? 75-g glucose tolerance test Serum Gluc Metabolic syndrome in child? Elevated serum insulin Chol, Trig Alb Hemoglobin Hct (elevated)? Hyperbilirubinemia? Urinary acetone

INTERVENTION Objectives • Reduce macrosomia-associated morbidity and mortality. • Allow adequate growth rate and development. • Maintain energy intake at a desired level while allowing adequate growth in the infant. • Monitor serum lipids or bilirubin as deemed necessary. • Reduce risks for long-term, chronic diseases later in life, including diabetes (Fig. 3-5) (Capra et al, 2013).

Food and Nutrition • Feed the infant often, as indicated by infant’s appetite and goal weight pattern. • Control total glucose intake if infant shows signs of hyperglycemia. • Alter intake of fat as determined by lipid profile. • Maintain a sufficient level of protein if energy needs to be restricted from carbohydrates or fat.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Insulin may be necessary to control hyperglycemia. Beware of any excesses of insulin, which could aggravate hypoglycemia. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for LGA infants because there are no controlled trials to prove efficacy for any related problems.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

Intra-uterine insults: Malnutrition Placental dysfunction Hypoxia Decreased blood flow

Catch up growth

185

SAMPLE NUTRITION CARE PROCESS STEPS

Hypernutrition Obesity Physical inactivity Ageing

Abnormal Nutritional Labs Assessment Data:Abnormal labs for blood glucose, insulin, bilirubin, hematocrit in LGA infant.

PRENATAL

POSTNATAL

Nutrition Diagnoses (PES): Abnormal nutritional lab values related to macrosomia as evidenced by neonatal hyperinsulinism after termination of maternal glucose at birth.

RISK of DM

Interventions:

Retarded development

• Prophylactic IV infusion of 10% dextrose in water until early frequent feedings can be established.

Modifications of histones

• Educate parents/caregivers about monitoring for signs of hypoglycemia, hyperbilirubinemia.

DNA methilation

Monitoring and Evaluation: • Blood glucose levels should be closely monitored by bedside testing.

EPIGENETIC MODIFICATIONS

• Evaluate over first few weeks for blood glucose control and normalization of serum insulin, bilirubin, hematocrit.

Figure 3-5. Effects of intrauterine insults on health later in life. (Adapted with permission from Capra L, Tezza G, Mazzei F, et al. The origins of health and disease: the influence of maternal diseases and lifestyle during gestation. Ital J Pediatr. 2013;39:7.)

For More Information

Nutrition Education, Counseling, Care Management • Discuss normal growth patterns as appropriate for the infant, reviewed in concert with the pediatrician. Signs of hyperglycemia and hypoglycemia should be discussed. • Review risks inherent in another pregnancy, especially if the mother has diabetes. Counseling may be beneficial. • Encourage appropriate levels of physical activity for mother and for the child. Patient Education—Food Safety • Hand washing with soap and hot water is recommended before preparing formula or meals. Use clean utensils and containers for mixing formula. • Before using tap water for formula preparation or to give as a beverage, let cold tap water run for 2 minutes to remove any lead that may be in the pipes. • Follow the 2-hour rule: Discard any beverage or food that has been left at room temperature for 2 hours or longer. • Do not use honey in the diets of infants to decrease potential risk of botulism.

Escott-Stump_Ch03.indd 185

●

American College of Obstetricians and Gynecologists http://www.acog.org

●

Children’s Hospital of Pittsburgh: Large for Gestational Age http://chp.staywellsolutionsonline.com/Library/Encyclopedia/90,P02383

REFERENCES Beardsall K, et al. Insulin and carbohydrate metabolism. Best Pract Res Clin Endocrinol Metab. 2008;22:41. Capra L, et al. The origins of health and disease: the influence of maternal diseases and lifestyle during gestation. Ital J Pediatr. 2013;39:7. Carreno CA, et al. Excessive early gestational weight gain and risk of gestational diabetes mellitus in nulliparous women. Obstet Gynecol. 2012;119:1227. Imam K. Gestational diabetes mellitus. Adv Exp Med Biol. 2012;771:24. Jansson N, et al. Activation of placental mTOR signaling and amino acid transporters in obese women giving birth to large babies. J Clin Endocrinol Metab. 2013;98:105. Kamanu CI, et al. Fetal macrosomia in African women: a study of 249 cases. Arch Gynecol Obstet. 2009;279:857. Koyanagi A, et al. Macrosomia in 23 developing countries: an analysis of a multicountry, facility-based, cross-sectional survey. Lancet. 2013;381:476. Rosario FJ, et al. Chronic maternal infusion of full-length adiponectin in pregnant mice down-regulates placental amino acid transporter activity and expression and decreases fetal growth. J Physiol. 2012;590:1495. Vrijkotte TG, et al. Maternal lipid profile during early pregnancy and pregnancy complications and outcomes: the ABCD study. J Clin Endocrinol Metab. 2012;97:3917. Wahabi HA, et al. Pre-existing diabetes mellitus and adverse pregnancy outcomes. BMC Res Notes. 2012;5:496.

11/7/14 8:24 PM

186

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

LEUKODYSTROPHIES NUTRITIONAL ACUITY RANKING: LEVEL 1 DEFINITIONS AND BACKGROUND Oligodendrocytes are the primary source of myelin in the CNS. Their dysfunction or loss underlies several diseases (Goldman et al, 2012; Potter et al, 2011). Leukodystrophies (peroxisome biogenesis disorders) are genetic disorders that affect the myelin sheath. Glial disorders may be amenable to cell therapy with glial progenitor cells (GPCs) which give rise to astroglia and myelin-producing oligodendrocytes (Goldman et al, 2012). Overall, reduction of oxidative stress is important. Reduced superoxide dismutase activity may contribute to the development of cerebral demyelination in adolescent and adult X-linked adrenoleukodystrophy patients (Brose et al, 2012). In the future, kinase inhibitors may be used to modulate the resulting inflammatory status (El Hajj et al, 2012). There are many phenotypic expression and consequences. Neonatal adrenoleukodystrophy and infantile Refsum disease are milder phenotypes. In Refsum disease, poorly metabolized phytanic acid accumulates in fatty tissues, including myelin sheaths and internal organs, leading to retinitis pigmentosa, peripheral polyneuropathy, cerebellar ataxia, and renal, cardiac, or liver impairment (Zolotov et al, 2012). Phytanic acid is a saturated fatty acid obtained primarily through the consumption of ruminant meat (beef, lamb, goat) and dairy products (Ollberding et al, 2013). Acyl-coenzyme A oxidase 1 (ACOX1) deficiency leads to the accumulation of VLCFAs and inflammatory demyelination in the interleukin (IL)-1 pathway (El Hajj et al, 2012). The observation that dietary fatty acids affect membrane composition has led to the use of modified fatty acid diets. Lorenzo’s oil is a mixture of oleic and erucic (canola) oils, which reduces the production of VLCFA. Early oral administration helps infants and children with the neonatal form. In addition, the omega-3 fatty acid DHA is present in large amounts in infant brains and its use is now recommended. It is important to have a registered dietitian manage this treatment (Berger et al, 2010). X-linked adrenoleukodystrophy (X-ALD) is one of the autosomal recessive disorders with an enzymatic defect in VLCFA oxidation, which is usually abundant in sphingomyelin. Accumulation of saturated VLCFA, especially hexacosanoate (C26:0), occurs because there is a missing or defective ALD protein to process that fatty acid. Ultimately, the myelin sheath surrounding the nerves is destroyed, causing demyelination, neurologic problems, and Addison disease (adrenal insufficiency). The incidence of X-ALD is estimated to be 1/17,000. Onset of X-ALD is usually in childhood, with a rapid, progressive demyelination, hypotonia, and psychomotor retardation. However, at least half of patients with X-ALD are adults with milder manifestations; women who are carriers may become symptomatic (Moser et al, 2005). X-ALD is often misdiagnosed

Escott-Stump_Ch03.indd 186

as ADHD in boys and as multiple sclerosis in men and women (Moser et al, 2005). Lorenzo’s oil is not the treatment of choice for the inflammatory form of X-ALD; it cannot prevent conversion to the inflammatory form (Berger et al, 2010). For boys or adolescents who show early evidence of inflammatory cerebral demyelination, allogenic hematopoietic cell transplantation (HSCT) can reduce inflammatory demyelination (Berger etal, 2010). Unfortunately, for patients in whom inflammatory demyelination has advanced too far for HSCT, all attempts of immunosuppressive or immunomodulating therapies have not been successful (Berger et al, 2010). Prognosis is generally poor, and death may occur up to 10 years after onset of symptoms. Adrenomyeloneuropathy (AMN) is milder and has its onset in adulthood. Satisfactory treatments are not available for male or female X-ALD or for patients with AMN-related symptoms (Berger et al, 2010). Zellweger syndrome is the most severe phenotype. It is characterized by an enlarged liver, high serum levels of iron and copper, and visual changes; it can be fatal. Noninvasive and presymptomatic diagnosis and prenatal diagnosis are available. Family screening and genetic counseling are important before planning future pregnancies.

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • Most of the 34 types of leukodystrophies are genetic. • X-ALD is caused by defects of the ABCD1 gene on chromosome Xq28.

Clinical/History • • • • • • • •

Height Weight Growth chart Diet/intake history Bronzing of skin (Addison disease) Cataracts or glaucoma? Poor sucking; feeding problems Brain MRI

Lab Work • • • • • •

Plasma phosphatidylcholine Fatty acid profile; VLCFA (elevated?) Alb Chol Trig Plasma sphingomyelin

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

• H&H • Pipecolic acid testing

INTERVENTION Objectives • Decrease rapid progression of demyelination of CNS by offering sufficient fatty acids (DHA). Overall, maintain total VLCFA levels while altering fatty acid sources. • Prevent or lessen complications of the disorder, including adrenal dysfunction. • Support the physical therapy by maintaining strength with an adequate diet.

187

SAMPLE NUTRITION CARE PROCESS STEPS Self-Feeding Difficulty

Food and Nutrition • Increase endogenous VLCFA synthesis of monounsaturated fatty acids by restricting exogenous (dietary) VLCFA (C26:0) to less than 3 mg and by increasing oleic acid (C18:1). The typical American diet yields 35% to 40% total energy from fat with 12 to 40 mg C26:0 daily. • Offer a low- to very low-fat diet, with supplementation of oleic and erucic acids (Lorenzo’s oil), plus DHA (Deon etal, 2008). Include sources of omega-3 fatty acids, such as salmon, tuna, or mackerel, for older children and adults. • Use good food sources of vitamins C, E, selenium, and zinc for antioxidant properties. • If the patient requires tube feeding, a formula can be developed that contains nonfat milk, specialty oils, corn syrup or sugar, and a vitamin–mineral supplement.

Food–Drug Interactions Common Drugs Used and Potential Side Effects • Adrenal hormone replacement therapy is necessary in all patients with adrenal insufficiency (Semmler et al, 2008). Long-term prednisone and spironolactone may cause hyperglycemia and osteoporosis. • Because seizures are common, early use of antiepilepsy drugs may be warranted. Herbs, Botanicals, and Supplements • Herbs and botanicals should not be used for this condition because there are no clinical trials proving efficacy. • Dietary sources of vitamin E, selenium, and carnitine should be considered.

Nutrition Education, Counseling, Care Management • Lorenzo’s oil is similar to olive oil (87% C18:1, 4.8% linoleic acid) but lacks measurable fatty acids with a chain length greater than C20. It can be used in cooking, as a supplement in juice, as an oil for salad dressings, or in food preparation instead of margarine, butter, mayonnaise, or shortening. The whole family can support the adapted diet when prescribed. • Restaurant dining can be a problem, and special meals may have to be developed for travel. • If nausea occurs, the oil can be taken in an emulsion.

Escott-Stump_Ch03.indd 187

Assessment Data: Abnormal weight and growth, difficulty with self-feeding. Nutrition Diagnoses (PES):Self-feeding difficulty related to low vision and limited mobility. Intervention:Educate parents about DHA and appropriate fat ratios. Counsel about tips for self-feeding, including special adaptive equipment. Monitoring and Evaluation: Weight records, growth, slower disease progression.

For More Information ●

Coalition for Genetic Fairness http://www.geneticfairness.org/

●

Myelin Project http://www.myelin.org/

●

National Institute of Neurological Disorders and Stroke http://www.ninds.nih.gov/disorders/adrenoleukodystrophy /adrenoleukodystrophy.htm

●

Rare Diseases http://www.rarediseases.org/

●

United Leukodystrophy Foundation http://www.ulf.org/

REFERENCES Berger J, et al. Current and future pharmacological treatment strategies in X-linked adrenoleukodystrophy. Brain Pathol. 2010;20:845. Brose RD, et al. SOD2 as a potential modifier of X-linked adrenoleukodystrophy clinical phenotypes. J Neurol. 2012;259:1440. Deon M, et al. Hexacosanoic and docosanoic acids plasma levels in patients with cerebral childhood and asymptomatic X-linked adrenoleukodystrophy: Lorenzo’s oil effect. Metab Brain Dis. 2008;23:43. El Hajj HI, et al. The inflammatory response in acyl-CoA oxidase 1 deficiency (pseudoneonatal adrenoleukodystrophy). Endocrinology. 2012;153:2568. Goldman SA, et al. Glial progenitor cell-based treatment and modeling of neurological disease. Science. 2012;338:491. Moser HW, et al. Adrenoleukodystrophy: new approaches to a neurodegenerative disease. JAMA. 2005;294:3131. Ollberding NJ, et al. Phytanic acid and the risk of non-Hodgkin lymphoma. Carcinogenesis. 2013;34:170. Potter GB, et al. Myelin restoration: progress and prospects for human cell replacement therapies. Arch Immunol Ther Exp (Warsz). 2011;59:179. Semmler A, et al. Therapy of X-linked adrenoleukodystrophy. Expert Rev Neurother. 2008;8:1367. Zolotov D, et al. Long-term strategies for the treatment of Refsum’s disease using therapeutic apheresis. J Clin Apher. 2012;27:99.

11/7/14 8:24 PM

188

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

LOW BIRTH WEIGHT OR PREMATURITY NUTRITIONAL ACUITY RANKING: LEVEL 3–4 DEFINITIONS AND BACKGROUND Gestational age is classified as one of the following: premature (34 weeks of gestation), late preterm (34 to 36 weeks), fullterm (37 to 42 weeks of gestation), or postterm (42 weeks of gestation). Prematurity is generally correlated with low birth weight. LBW infants may be small for date, have IUGR, or have dysmaturity. LBW infants weigh less than 2,500 g or 5.5lb (10th percentile for gestational age) at birth. VLBW infants (1,000 to 1,500 g) are especially prone to nutritional deficits. Infants who weigh less than 1,000 g are extremely low-birthweight (ELBW) micropreemies. Birth weight is correlated across multiple generations. Short maternal stature reflects intrauterine and infant growth failure; it leads to LBW, child stunting, delivery complications, and increased child mortality, regardless of socioeconomic status (Martorell and Zongrone, 2012). Nutritional advice for pregnant women to increase energy and protein intake reduces the risk of preterm birth, thereby improving fetal growth (Ota et al, 2012). Several other factors may lead to LBW, prematurity, and maternal delivery complications. Inadequate maternal weight gain in early pregnancy, low white blood cell counts, poor mineral intake, and low iron status in late pregnancy are major factors (Hsu et al, 2013; Kozuki et al, 2012). Women who have pneumonia, depression, or elevated homocysteine levels also have a high risk for adverse birth outcomes (Chen et al, 2012; Hogeveen etal, 2012; Liu et al, 2012). Undernutrition at critical stages of development (especially protein) produces long-term short stature, organ growth failure, neuronal deficits of number and dendritic connections, and later behavioral and cognitive outcomes (Hay, 2008). Maternal age is another concern. Infants born to mothers younger than 20 or older than 35 years are more likely to be preterm than infants born to mothers 20 to 35 years old. Teens should be encouraged to delay pregnancy until they are adults. Women of childbearing age should take folic acid. Furthermore, pregnant women should take prenatal vitamins, especially folic acid and iron; intermittent versus daily use is acceptable in healthy women (Pena-Rosas et al, 2012). LBW and premature infants have higher risk of poor growth, morbidity, and mortality. Typical problems include hypoglycemia, hypothermia, jaundice, dry skin, decreased subcutaneous fat, anemia, and respiratory distress. Fluid needs increase because of losses through the skin, increased respiration, radiant warmers, fever, and low body weight. Admission to a NICU is common. Adequate nutrition support almost immediately after birth is important to prevent growth restriction. Without nutrition starting immediately after birth, the infant enters a catabolic condition, which limits normal development and growth (Hay, 2008). During the first months after discharge, VLBW babies need to have nutrition support to help promote early catch-up growth and mineralization. Careful and frequent monitoring of

Escott-Stump_Ch03.indd 188

growth is needed to prevent developmental delays. Table 3-11 lists the nutritional deficits found in premature or LBW infants. Premature breast milk has higher electrolyte, protein, and MCT levels than mature breast milk. Breastfeeding in the NICU has long-term benefits for the child (Vohr et al, 2006). DHA and taurine are especially important (Verner et al, 2007). Feeding “on demand” is best. Preterm infants expend less energy when they are breastfed; overfeeding is less likely as well. Early feeding increases intestinal lactase activity, which is a marker of intestinal maturity and may influence clinical outcomes. Minimal enteral (trophic) feedings promote the capacity to feed enterally (Hay, 2008). Premature infants are at risk for growth failure, developmental delays, necrotizing enterocolitis (NEC), and late-onset sepsis (Underwood, 2013). Human milk from women delivering prematurely has more protein and higher levels of bioactive molecules (Underwood, 2013.) Compared with feeding extremely premature infants with mother’s milk fortified with cow’s milk–based supplements, a 100% human milk–based diet that includes mother’s milk fortified with donor human milk may result in potential net savings on medical care resources by preventing NEC (Ganapathy et al, 2012). Mother’s own milk improves growth and neurodevelopment, decreases the risk of NEC and late-onset sepsis, and should be the primary enteral diet (Underwood, 2013). Early feeding tends to allow babies to mature faster; they have fewer days of intolerance, a shorter hospital length of stay, and earlier tolerance of full feedings. Specific nutrient supplementation for these fragile infants remains controversial. Selenium supplementation decreases sepsis; glutamine may not. The Academy of Nutrition and Dietetics recommends at least five MNT visits for high-risk, premature infants.

TABLE 3-11 Nutritional Deficits in the Premature or Low-Birth-Weight Infant PROBLEM

IMPLICATION

Immaturity at the cellular level

Altered biochemical needs

Underdeveloped digestive/absorptive abilities

Malabsorption

Essential fatty acid deficiency, fatty liver, impaired water balance, red blood cell fragility, and dermatitis

Slowed growth, renal and lung changes

Delayed oral neuromuscular development and small gastric capacity

Limited ability to consume adequate amounts of nutrients

Marginal nutrient stores at birth

Fat, glycogen, and minerals such as calcium and phosphorus

Slow growth

Higher metabolic demands

Poor nutritional intake of the mother

Deficiencies such as folate, zinc, B12

Resources: Preemie toolkit. Available at: https://www.preemietoolkit.com/pdfs /E_PhysicalExamination Assessment/Nutritional%20Deficiencies.pdf. Accessed June 4, 2014.

11/7/14 8:24 PM

SECTI ON 3 • PEDI ATRI CS: BI RTH DEFECTS AND GENETI C AN D ACQUI R E D DI S OR DE R S

ASSESSMENT, MONITORING, AND EVALUATION Genetic Markers • No specific markers predict LBW.

Clinical/History • • • • • • • • • • • • • • •

Birth weight Gestational age Birth length and Length-for-Age Z-score (LAZ) Weight/height percentile (Olsen et al, 2009) Diet/intake history Swallowing reflex Temperature (often decreased) Sucking reflex Apgar score New Ballard Score I&O Hypotension? Infection? Respiratory distress? Retinopathy of prematurity (ROP)?

Lab Work • • • • • • • • • • • • •

Gluc H&H; red blood cells (RBCs) Maternal ferritin, WBC Anemia? Alb Ca, Mg Na, K Transthyretin ALT, AST Serum folic acid and vitamin B12 Serum phosphorus Lecithin-to-sphingomyelin ratio (L:S ratio) Bilirubin

INTERVENTION Objectives • LBW infants who are able to breastfeed should be put to the breast as soon as possible after birth when they are stable. • Assess for risk factors and symptoms of heat loss or cold stress; maintain a neutral thermal environment (NTE). • Continue exclusive breastfeeding for 6 months whenever possible (Agency for Healthcare Research and Quality [AHRQ], 2014). • LBW infants who need to be fed by an alternative oral feeding method should be fed by cup (or palladai, which is a cup with a beak) or spoon (AHRQ, 2014). • If tube feeding is needed, mother can express milk to be given to the infant; it can also be supplemented to meet special needs. Supplement with EFAs and DHA. Assure adequate intake of folate and vitamin B12 to prevent anemias.

Escott-Stump_Ch03.indd 189

189

• Avoid hypoglycemia. Use information determined from the gestational age assessment, growth assessment, and physical examination to evaluate risks. Provide glucose as soon after birth as possible; adjust according to frequent measurements of plasma glucose to achieve and maintain concentrations 45 mg/dL but 120 mg/dL to avoid hypoglycemia, and hyperglycemia respectively (Hay, 2008). • When possible, use enteral nutrition (EN) feedings instead of PN to reduce onset of cholestasis and osteopenia. EN supports healthy GI tract development and primes the gut hormones to stimulate proper maturation. Always check gastric residuals, stool consistency, emesis, and any abdominal distention. • Gradually increase energy and protein to meet the needs of rapid growth. For protein, ensure a proper whey-to-casein ratio. • With parenteral feeding, include amino acids in proper amounts. Parenteral glutamine appears to confer benefit, but optimal dosing is unclear (Yarandi et al, 2011). Intravenous TrophAmine can be used. Few studies have confirmed the clinical efficacy of altered doses of arginine, branchedchain amino acids, cysteine, or taurine (Yarandi et al, 2011). Be sure selenium is provided. • Provide adequate fluid for increased requirements. • Prevent illness, rickets, respiratory distress, hypoglycemia or hyperglycemia, NEC, infections, obstructive jaundice, and tyrosinemia. • Promote catch-up growth and development. While metabolic syndrome occurs among LBW or premature infants later in life, early and effective nutrition support is needed (Greer, 2007).

Food and Nutrition • Promote enteral feeds of expressed breast milk combined with intravenous fluids in VLBW infants (AHRQ, 2014). Mother’s own milk is best; otherwise, expressed donor human milk is acceptable. It must be fortified for premature infants to achieve adequate growth (Underwood, 2013). • While in the radiant warmer, provide water at 60 to 80 mL/kg body weight/d; gradually increase to 150 mL/kg. Add electrolytes (sodium, potassium, and chloride) on at least the second day. • Day 1: Breastfeed or give glucose at 4 to 6 mg/kg/min. Minimal enteral nutrition should be initiated within the first 2 days of life and advanced by 30 mL/kg/d in infants 1,000g (Fallon et al, 2012). • Progress to special formulas such as Similac Special Care 24 or Enfamil Premature Formula (24 kcal/oz) to yield 120 to 150 mL/kg up to 180 to 200 mL/kg/d. NeoSure or EnfaCare is helpful for transition to home (22 kcal/oz with added calcium and phosphorus). • Within 7 days, the diet should provide 120 to 150 kcal/kg body weight daily; carbohydrate should be 40% to 45% total kcal (10 to 30 g/kg). Protein should be age-specific. • There may be subtle and delayed hunger cues from the infant. If poor sucking or swallowing instincts exist, the infant may need gavage feeding. Feed every 2 hours or use continuous drip feeding and change to bolus feedings when full strength is tolerated. If infant weighs 1,000 to 1,750 g, feed more vigorously; if infant weighs 1,750 g or more, feed as a normal term infant. • Excess carbohydrate may not be well tolerated. Use no more than 10 to 12 g/kg; infuse at 4 to 6 mg/kg per minute. Monitor serum glucose levels; goal 70 to 120 mg/dL.

11/7/14 8:24 PM

190

N U TRITIO N A ND D IA GNO SIS-RELA TED C A RE

TABLE 3-12 Nutrient Needs of Preterm Infants Daily basal needs

UNDER 2.5 kg BODY WEIGHT

OVER 2.5 kg BODY WEIGHT

60–80 kcal/kg

40–70 kcal/kg

Fecal losses

10–20 kcal/kg

Growth (tissue synthesis, energy stores)

10 kcal/kg

Total energy needsa

110–130 kcal/kg enteral

100–120 kcal/kg enteral

Parenteral needs (no fecal losses, no thermogenic effect of food)

90–110 kcal/kg

80–100 kcal/kg

Protein

3.5–4.0 g/kg enteral

3.6–4.0 g/kg enteral

Amino acids

2–3 g/kg parenteral

3.2–3.5 g/kg parenteral

Lipid

0.5 g/kg for essential fatty acids

Fluid

80 mL/kg; increase 10–20 mL/kg daily to 120–160 mL/kg

60 mL/kg; increase 10–20 mL/kg daily to 120–150 mL/kg

Add extra kilocalories for fever (7% per 1-degree elevation), cardiac failure, sepsis, failure to thrive, major surgery, and bronchopulmonary dysplasia.

References: Hay WW Jr. Strategies for feeding the preterm infant. Neonatology. 2008;94:245; Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenteral nutrition. J Parenter Enteral Nutr. 2004;28(6):S39–S70.

• Total fat should be 5 to 7 g/kg to meet half of energy needs without excess carbohydrate. Soybean oil provides EFAs (1% to 2% kcals as EFA) in the form of linoleic acid. Exogenous carnitine may be needed to take EFAs into the mitochondria. Inositol may be needed in respiratory distress. • Tube feeding initiation: Start

Sylvia Escott-Stump - Nutrition and Diagnosis-Related Care (2015, LWW) - PDFCOFFEE.COM (2025)