CHAPTER 7 Nutrition Roger A Shewmaker The goal of this chapter is to provide evidence-based information to help clinicians counsel patients regarding the latest nutritional approaches to di isease prevention and health promotion. It also attempts to clarify the strong relationships between nutrition and the prevention of chronic disease and the important influence of nutrient deficiencies and excesses For a large majority of the population, the food choices made daily over time, will either benefit or impair health. Food choices and habits are very complex and personal issues that reflect preferences developed through association with family and friends, as well as habits developed through ones ethnic heritage, culture, traditions, ethnicity religion, and social interactions Food is used for celebrations of all aspects of life and therefore can serve as"comfort foods, "especially at emotionally stressful times. In the current rushed environment, the availability, convenience, and economy of food often sway personal choices. Individuals select foods for a variety of reasons but the diet ingested over time can make important contributions to health Nutrient effects are a common thread that runs through many of the chronic diseases that affect populations Consuming a diet high in refined carbohydrates and fat, along with low-fiber intake, high caloric density, low nutrient density, and inadequate physical activity, are common risk factors for cardiovascular disease, diabetes, obesity, and hypertension among other diseases and negative health conditions. As discussed in Chapter 8 the prevalence of overweight and obesity is increasing in the United States, which in turn increases the risk of many chronic diseases(e. g, hypertension, diabetes, and some forms of cancer)and of premature death. See Chapter 8 for further details on the assessment and treatment of overweight and obesity According to the American Heart Association(AHA)(1) 1."There are dietary and other lifestyle practices that all individuals can safely follow throughout the lifespan as a foundation for achieving and maintaining cardiovascular and overall health over an extended period of time and not on the intake of a single meal take 2. Healthy dietary practices are based on one's overall pattern of food in
170SECT|ON‖· WHAT TO DO WITH THE INFORMATI○N 3. "The guidelines form a framework within which specific dietary recommendations can be made for individuals based on their health status dietary preferences, and cultural background. This chapter focuses on the components of a healthy diet. It includes a ractical discussion of the influence of macronutrients, vitamins and minerals upon health, with special emphasis on nutrition's effect upon lipoproteins blood pressure, diabetes, and the lifecycle. Chapter 6 discusses the important role of physical activity, which must generally be combined with the nutrition interventions discussed here to promote wellness and reduce weight. NUTRITIONAL ASSESSMENT Dietary Assessment Chapter 2 discusses screening and exploratory questions that clinicians can use in the periodic health examination to quickly assess a patient,'s dietary habits. The 24- to 72-hour dietary recall has also been a useful tool in evaluating normal habits, intakes, and evidence of possible deficiencies in the dict. An ongoing record or a checklist that is possibly conpleted at mealtime may be one of the better methods of completing a dietary recall. Limited memory, cognitive impairment, increased time to complete the recall, and other difficulties created by health problems may make it difficult to obtain representative information without multiple sampling Anthropometric Assessments See Chapter 3(pages 57-61)regarding the measurement of height and weight to calculate the body mass index (bmi) Biochemical Assessment of nutritional Status Serum prealbumin has a half-life of 2 days and is more sensitive than albumin in evaluating nutritional changes Improved nutritional intake can increase prealbumin levels by approximately 10 mg/L/day. A lower increase may indicate inadequate nutritional support, poor response, and a poor prognosis Low levels of insulin-like growth factor 1, another very sensitive indicator of nutritional change, is associated with increased morbidity. Evidence does not support the use of either serum prealbumin or insulin-like growth factor as a single marker of nutritional status Nutrition Screening of older Adults Nutritional screening of seniors has gained in popularity as an effort to identify individuals who are at risk and need further intervention. The Nutrition Screening Initiative, a project of the American Academy of Family Physicians, American Dietetic Association, and the National Council on Aging, provides
CHAPTER 7. NUTRITION 171 a"Determine Your Nutrition Health "checklist. The National Screening Initiative is targeted for identification of elderly individuals who are at nutritional risk. USing the Mnemonic D-E-T-E-R-M-I-N-E, it provides a list of warning signs for malnutrition that should be addressed(see Tables 7.1 and 7.2) Subjective Global Assessment The Subjective Global Assessment of Nutritional Status(see Table 7.3)does not employ objective biochemical and anthropometric measurements. It is a screening tool that requires clinical judgMent to interpret information collected by interviews and observations. The instrument correlates well with other more objective measures and is cost effective (2) THE IMPORTANCE OF NUTRITION COUNSELING A clinician's advice on nutrition is of great im portance in helping patients to modify dietary practices. This chapter provides detailed guidance, but the science of healthy living needs to be made practical for patients. Short and useful recommendations can be as simple as: (a)do not crash diet, (b)eat real foods, (c)watch your portion size, and(d)eat breakfast. Eating breakfast is a caloric plus in that it increases the metabolic rate and can provide nutrients needed for the day Adopting a healthy diet can be simple but is not always easy. Patients can easily become discouraged when they attempt to change too many eating habits at once. Clinicians can advocate small steps, perhaps through a nutrition prescription"of adding one fruit or vegetable today or changing to 1% milk. Remind patients that healthy living is not defined by just one meal or I day but the accumulation of small changes; these changes become habits over time. Behavior modification can begin with modest steps, such as not bringing foods home that are too tempting or replacing them with better choices. Choose/do not choose "lists are often excellent tools to change behavior. The short but essential admonition to watch portions and be active can sum up basic first steps to meeting healthy nutrition goals(see Table 7. 4) THE DIETARY GUIDELINES FOR AMERICANS In 2005, the Food and Nutrition Board of the Institute of Medicine(IOM), along with Health Canada, released the sixth in a series of reports on dietary reference values for the intake of macronutrients and energy (U.S. Dietary Guidelines). This report established Dietary Reference Intakes(DRIs) for carbohydrates, fiber, fatty acids, cholesterol protein, amino acids, energy, and physical activity, replacing older
172 SECTION II. WHAT TO DO WITH THE INFORMATION TABLE 7. 1 Checklist to Help older Adults assess Their Nutritional Health The warning signs of poor nutritional health are often overlooked Yes I have an illness or condition that made me change the 2 kind and/or amount of food i eat I eat fewer than two meals per day I eat few fruits or vegetables, or milk products I have three or more drinks of beer, liquor, or wine almost eve d 222 I have tooth or mouth problems that make it hard for me to eat I dont always have enough money to buy the food I need I eat alone most of the time I take three or more different prescribed or over-the-counter drugs a day Without wanting to, I have lost or gained 10 lb in the last 2 6 months I am not physically able to shop, cook and/or feed myself 2 Total Total your nutritional score. If it is Good! Recheck your nutritional score in 6 months You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your areas office on aging, senior nutrition program, senior citizens center, of health department can help. Recheck your nutritional score in 6 or more You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietician, or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health Remember that warning signs suggest risk, but do not represent diagnosis of any condition The"Determine Your Nutritional Health""checklist was developed by the Nutrition Screenin Initiative,a project of the American Academy of Family Physicians, the American Diet: Association and the National Council on the Aging, Inc. First published: June 1998 Revised: April 2005
CHAPTER 7. NUTRITION 173 TABLE 7.2 D-E-T-E-R-M-I-N-E Checklist to Help older Adults Identify Symptoms of Nutritional Problems The Nutrition Checklist is Based on the Warning Signs Described Below. Use the Word D-E-T-E-R-M-I-N-E to Remind You of the Warning Signs O Disease Any disease, illness, or chronic condition that causes you to change the way you eat, or makes it hard for you to eat, puts your nutritional health at risk. Four out of five adults have chronic diseases that affected by diet. Confusion or memory loss that keeps getting worse is estimated to affect one out of five or more of older adults. This can make it hard to remember what, when, or if you have eaten. Feeling sad or depressed, which happens to about one in eight older adults, can cause big changes in appetite, digestion, energy level, weight and well-being D Eating poorly Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not eating fruit, vegetables and milk products daily will also cause poor nutritional health, One in five adults skip meals daily. Only 13% of adults eat the minimum amount of fruit and vegetables needed. One in four older adults drink too much alcohol. Many health problems become worse if you drink more than one or two alcoholic beverages per day. a Tooth loss/ mouth pain A healthy mouth, teeth, and gums are needed to eat. Missing, loose or rotten teeth, or dentures which do not fit well or cause mouth sores, make it hard to eat D Economic hardship As many as 40% of older Americans have incomes of less than $6000 per year. Having less-or choosing to spend less-than $25-30 per week for food makes it very hard to get the foods you need to stay healthy Q Reduced social contact One-third of all older people live alone. Being with people daily has a positive effect on morale, well-being, and eating D Multiple medicines Many older Americans must take medicines for health problems. Almost half of older Americans take multiple medicines daily Growing old may change the way we respond to drugs. The more medicines you take, the greater the chance of side effects, such as increased or decreased appetite, change in taste, constipation, weakness, drowsiness diarrhea nausea, and others. Vitamins or minerals. when taken in large doses, act like drugs and can cause harm t your docto to everything you take (c cd)
174 SECTION II. WHAT TO DO WITH THE INFORMATION TABLE 7.2(Continued) o Involuntary weight loss/gain Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must not be ignored. Being overweight or underweight also increases your chance of poor health D Needs assistance in self-care Although most older people are able to eat, one out of every five has trouble walking, shopping, or buying and 2 cooking food, especially as they get older. v D Elderly, age above 80 years Most older people lead full productive lives But as age increases, the risk of frailty and health problems increases Checking your nutritional health regularly makes good sense Adapted from materials developed by the Nutrition Screening Initiative, Washington, DC 2007 recommended dietary allowances (RDAs) last updated in 1989. The DRIs are based on scientific relationships between nutrient intake, chronic disease, and health status. The new dietary guidelines, which provide evidence-based nutritional guidance for ages 2 years and older, have the goals of inspiring individuals to seek more information about healthy eating, communicating scientifically accurate but understandable information, and guiding federal policy and programs. Public confusion around nutrition is fostered by terms commonly used in commercial and food labels (e. g, whole grain, organic, fat-free, no trans-fats, lI natural. rich b glycemic lowers cholesterol The guidelines make 41 key recommendations, 23 for the general oublic and 18 for special populations. Clinicians should refer to the Dietary Guidelines for Americans 2005 Toolkit for Health Professionals (http://www.health.gov/dietaryguidelines/dga2005/toolkit/),whichcompiles he latest evidence-based nutrition and physical activity recommendations. Food Groups to Encourage a key theme in the guidelines is the consumption of adequate nutrients within caloric needs. This should be accomplished by consuming a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit intake of saturated and trans-fat, cholesterol, added sugars, salt, and alcohol. Diets should emphasize a variety of fiber-rich fruits, vegetables, and whole grains, staying within ones energy needs. Five servings of fruits and vegetables per day is recommended. Patients should consume 3 oz equivalents of whole grains daily(at least half whole grains
CHAPTER 7. NUTRITION 175 TABLE 7.3 Subjective Global Assessment Summary HISTORY 1. Weight change Overall loss in past 6 months: amount % Change in past 2 weeks increase no change decrease 2. Dietary intake change (relative to normal) no change e Duration suboptimal solid diet full liquid diet hy pocaloric liquids starvation 3. Gastrointestinal symptoms(persisting for >2 weeks) nausea-vomiting diarrhea anorexia 4. Functional capacity no dysfunction(e. g, full capacity) dysfunction Duration: T working suboptimally PHYSICAL EXAMINATION For each trait, specify a rating as follows 0=normal, 1+=mild, 2+= moderate, 3+=severe loss of subcutaneous fat(triceps, chest) muscle wasting(quadriceps, deltoids) ankle edema sacral edema SUBJECTIVE GLOBAL ASSESSMENT RATING(select one) ell nourished B= moderately (or suspected of being) malnourished C severely malnourished From Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment?) Parent Ent Nutr1987;11(1):8
176 SECTION II. WHAT TO DO WITH THE INFORMATION TABLE 7. 4 Behavioral Steps for a Healthy diet Food Preparation Preplan your meals Learn to cook the calorie-reduced way Include low-calorie foods at each meal Shop when your control is highest and have a list Mealtime Preload your stomach with liquids and drink ample liquids during meals Use smaller plates, bowls, glasses, and serving spoons Do not keep serving dishes on the table Stop eating for a minute during the meal Leave a little food on your plate(doggy bag) Snacking at Home Keep tempting foods out of the house Eat three healthy meals a day Brush your teeth after every meal and use mouthwash Preplan snacks into your eating plan Try sugar-free guIn, hard candy, diet soda, or fruit when craving sweets Exercise every day Ask family and friends not to offer you snacks Talk to yourself Emotional Snacking Use relaxation exercises Take a warm bubble bath Listen to relaxing music Get out of the house and the rest should be enriched)and three cups per day of fat-free, low-fat or quivalent milk products. Children aged 2-8 ycars should consume two cups of fat-free or low-fat milk or equivalent milk products per day. Other key recommendations include consuming two servings of fish per week (approximately 8 oz total)to help reduce risks from cardiovascular disease, reducing the intake of sugars especially through sweetened beverages, and
CHAPTER 7. NUTRITION 177 consuming less than 2 300 mg of sodium with an increase in foods rich in potassium. See Figure 7. 1 for an example of how to accomplish all of this within the limits of a 2.000-cal diet CARBOHYDRATES Patients should consume 130 g/day of carbohydrates. Carbohydrates should provide 50-60% of total daily calories and should emphasize complex car bohydrates that include dietary fiber (see subsequent text). The intake of refined carbohydrates and sugars should be limited to reduce the risk of caries Glycemic index is a measure of how quickly carbohydrates enter the blood stream and then elevate blood sugar levels. In general, most refined foods in the United States have a high glycemic index whereas nonstarchy vegetables fruits, and legumes seem to have a lower glycemic index. Although some hy pothesize that long-term consumption of high-glycemic index foods may increase the risk of obesity, diabetes, and heart disease, others argue the index is studied primarily under artificial laboratory conditions and does not accurately portray the mixed meals that most individuals consume The American Diabetes Association states that there is insufficient evidence to use glycemic index in the management of diabetes. Clinicians should at least be aware of the glycemic index of certain foods, and that it may cause spikes in blood sugar levels, especially among patients with diabetes (uww.glycemicindex.com) FIBER Individuals older than 4 years should consume at least 25 g of fiber each day(see Table 7.5), yet 50% of women consume fewer than 13 g a day and 50% of men consume fewer than 17 g a day (3). Fiber includes two main types: soluble and insoluble. Insoluble fiber, an important aid in normal bowel function, is provided in high concentrations in whole wheat breads, wheat cereals, wheat bran, rye, rice, barley, cabbage, beets, carrots, Brussels sprouts, turnips, cauliflower, and apple skins. Sources of soluble fiber include oat bran, oatmeal, beans, peas, rice bran, barley, citrus fruits, apple pulp, psyllium, carrots, strawberries, peaches with skin, and apples with skin. Most fber-rich foods contain a mixture of both soluble and insoluble fibers. The aha recommends eating a variety of food fiber sources(1). Fiber, especially insoluble fiber, helps promote bowel regularity Individuals should start slowly and gradually increase their fiber intake over time, while also making sure to increase their intake of fluids. Foods high in fiber tend to be lower in total calories, saturated fat, and cholesterol Fiber may also help to curb appetite and can be an important adjunct to weight management plans
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