General Nutrition Kathaleen Briggs Early, PhD, RD, CDE Assistant Professor and Registered Dietitian kearly@pnwu

1. General Nutrition Kathaleen Briggs Early, PhD, RD, CDE Assistant Professor and Registered Dietitian kearly@pnwu.org

2. Learning Objectives • Upon completion of this module, the student will be able to: • Define “macronutrients” and identify what the food sources are for the macronutrients • Define “micronutrients” and identify what the food sources are for the major micronutrients • Identify the components of a healthy diet • Identify patients at nutrition risk • Identify the causes of malnutrition and those who are malnourished • Explain the benefits of breastfeeding during infancy

3. Definitions • A nutrient is any substance in food that the body can use to • obtain energy, • synthesize tissues, or • regulate body processes • Macronutrients • Carbohydrates • Proteins • Lipids • Micronutrients • Vitamins • Minerals • Water

4. Macronutrients: CARBOHYDRATES • Primary source of calories (energy) and glucose (4 kcal/gm) • Glucose is the body’s preferred fuel source • Most people get about half of all their calories from carbohydrates • Food sources • Breads, grains, cereals, rice and pastas are the biggest sources • Dairy/non-dairy alternatives (milk, yogurt, soy and rice milk) • Fruits in any form (fresh, frozen, juice, canned, dehydrated) • Vegetables also have some carbohydrates • Common vegetable-based carbs in Western diet are Peas, Corn and Potatoes • Sweets • Cakes, cookies, ice cream, pastries, etc. • No carbohydrates in meats or cheeses • Carbohydrate-rich foods are also an important source of fiber and antioxidants

5. Macronutrients: FATS • Essential for health • Cellular membrane structure and function • Myelin sheath in nervous system • Fat tissue keeps us warm, provides some protection to our organs • Concentrated source of calories (9 kcal/gm) • Saturated dietary fats • Animal-based • butter, lard, whole and 2% milk, meat, skin • Plant-based • coconut and coconut oil, palm kernel oil, palm oil, cocoa butter

6. Macronutrients: FATS • Unsaturated dietary fat • Monounsaturated fatty acids (MUFA) • Olive and canola oils • Polyunsaturated fatty acids (PUFA) • Corn, safflower, sunflower, fish oils • Trans fats • Very small amount of trans fats are naturally occurring in dairy foods, meat, and darker-meat poultry • Cholesterol from the diet • Only found in animal-based foods • Whole fat dairy products, egg yolks, meat, poultry skin and dark poultry meat

7. Macronutrients: PROTEINS • Primary role is to maintain structural and functional integrity • Muscle tissue, skin, bone, organs, enzymes, hormones, neurotransmitters, fluid and acid-base balance, cellular transport, and blood clotting • Proteins are made up of amino acids • Some amino acids are essential, others are non-essential, and still others are “conditionally” essentially

8. Macronutrients: PROTEINS in Vegetarian Diets • Vegetarian diets can be a very healthy option • Complete vs. Incomplete • Complete proteins contain all 9 essential amino acids (e.g., milk, egg, chicken, meat, fish) • Soy is the only plant-based complete protein • Incomplete proteins are lacking in 1 or more essential amino acids • It is not necessary to combine incomplete proteins at a meal • More important to eat a variety of foods consumed throughout the day to provide the most diverse amino acid and protein sources

9. Micronutrients: Vitamins Water-soluble Fat-soluble Stored in liver and fat tissue for long periods of time Deficiencies develop very slowly Vitamin A Vitamin D Vitamin E Vitamin K • Not stored in the body • Deficiencies may develop quickly if inadequate intake occurs • B vitamins • Folic acid (folate) • B12 (cobalamin) • Thiamin (B1) • Riboflavin (B2) • Niacin (B3) • Vitamin C

10. Micronutrients: Major Minerals and their Common Food Sources • Calcium • dairy products, dark leafy green vegetables, tofu • Phosphorus • Animal proteins, dairy foods, legumes; wide-spread in food supply • Magnesium • Whole grains, “hard” water • Sodium • Processed foods, preserved foods, added salt in cooking and at the table • Potassium • Fruits and vegetables

11. Micronutrients: Trace Minerals and their Common Food Sources • Copper • Liver, shellfish, lentils, mushrooms, cashews, sunflower seeds • Iodine • Iodized salt, seafood • Iron • Most well absorbed: Beef, dark poultry meat, whole eggs, tuna, salmon, legumes, iron fortified cereals, liver • Less well absorbed: prunes, raisins, apricots, dark leafy green vegetables, brown rice • Selenium • Brazil nuts, tuna, beef, brown rice • Zinc • Oysters, meat, poultry, legumes, shellfish, whole grains

12. Micronutrient (vitamin) Deficiency • Pellagra (Niacin deficiency) • The 4 D’s: diarrhea, dermatitis, dementia and death • Pernicious Anemia (B12 deficiency) • Caused from autoimmune destruction for stomach cells needed for intrinsic factor production • Vitamin A deficiency • Leading cause of preventable blindness in children • Increases the risk of disease and death from severe infections

13. Micronutrient (vitamin) Deficiency • Scurvy (vitamin C deficiency) • Collagen breakdown resulting in bleeding gums and petechiae • Rickets and Osteomalacia (vitamin D deficiency)

14. Micronutrient (mineral) Deficiency • Iodine • Regions at greatest risk include countries of the former Soviet Union, south Asia and parts of Africa • Thyroid enlargement (goiter) is an early and visible sign of iodine deficiency • Iron • Iron deficiency anemia • Fatigue, rapid heart rate, and rapid breathing on exertion are the most common signs • Selenium • Kashin disease

15. Dietary History • Questions the nurse can ask the patient directly • Do you eat a wide variety of foods? • Do you have difficulty obtaining adequate food? • Do you have any food allergies/intolerances? • Do you have family? Do you eat alone or with others? • Questions the nurse should consider in their assessment • Is the patient obviously under or overweight? • Does the patient have any obvious warning signs of nutrient deficiencies (see slides 18-27)?

16. Optimizing Nutrition • WHO’s five keys to safer food • Keep clean • Separate raw and cooked • Cook thoroughly • Keep food at safe temperatures • Use safe water and raw materials

17. Assessing Physical Activity • With the world-wide obesity epidemic, addressing physical activity is essential • Use the FITT principle • F: How many times per week does the activity occur? • I: How vigorous is the activity? • T: What is the activity? What is its purpose? • T: How many minutes of the activity are done per session?

18. Anthropometrics • Height • A key indicator of chronic malnutrition is stunted growth • Weight • Recent weight loss is a very sensitive marker of a patient’s nutritional status • Weight loss of more than 5% of usual body weight in 1 month or 10% in 6 months before hospitalization is clinically significant • Weight for height • BMI • Body fat assessment • Activities of Daily Living • Strength • e.g., grip strength

19. Physical Assessment of Nutrition Status • Orbital fat pads • should be present • Triceps skinfold thickness • 1 cm or less = malnourished • Anterior lower ribs • Ribs should not be visible if adequately nourished • Temples • should not be sunken • Clavicle • should not be overtly prominent • Shoulders • Should be rounded or sloped, not squared

20. Physical Assessment of Nutrition Status • Interosseus muscle • Should be bulging when thumb and forefinger pinch together • Scapula • When hand presses against a wall, back should be smooth if adequately nourished • Thigh and Calf • Should be solid • Loose skin upon muscle massage indicates severe deficit

21. Physical Assessment of Nutrition Status • Edema • In ambulatory patients, no impression should remain following pressure application • Ascites • Should not be present in healthy individuals • Degree of fluid accumulation in abdominal cavity can be indicative of nutrition status

22. Malnutrition • When more than 20% of usual body weight is lost, most physiologic body functions become significantly impaired • Malnutrition can also reduce cardiac output, impair wound healing, and depress immune function • Nutritional repletion can often reverse these processes and significantly improve patient outcomes • Difficulty is identifying individuals at risk so that appropriate interventions can be made

23. Protein Energy Malnutrition (PEM) • Most common form of malnutrition • Most often seen in the western hospitalized patient with • End-stage liver or renal disease • Cancer cachexia • HIV/AIDS wasting disease • Severe eating disorder • Neglect • Long-term recovery from multiple trauma • Outside industrialized countries, more often seen in areas of severe drought, infectious disease, and war

24. Kwashiorkor • “Pot Belly” appearance due to hepatic edema and fatty liver • Increased extracellular fluid (edema) and low plasma albumin levels • Increase in extracellular fluid may mask underlying weight loss • Rapid onset; may develop in a few weeks

25. Marasmus • Significant deficit of total body fat and body protein with a slight increase in extracellular water • Obvious body wasting • Skin and bones appearance • Eyes may be sunken • Skull and cheekbones may be prominent • Plasma albumin is often in the low-normal range • Usually takes months or years to develop

26. Comparison of the features of kwashiorkor and marasmus FAO/WHO

27. Assessing Malnutrition • Temples (temporalis muscles) should be visualized for evidence of wasting • Dull hair, easily plucked = protein energy deficiency • Brittle hair, breaks easily suggests micronutrient deficiencies http://meded.ucsd.edu/clinicalimg/head_temporal_wasting2.htm http://meded.ucsd.edu/clinicalimg/index.htm

28. Causes of Malnutrition • Hunger • Due to poverty and food insecurity • Micronutrient or protein deficiency • More common in elderly • Disease • Infectious disease (e.g., malaria, TB, see next slide) • Chronic disease (e.g., HIV AIDS, cancer, emphysema, etc)

30. Defining a Healthy Diet • Aids in maintaining a healthy body weight • Promotes general well-being • Satisfies hunger and appetite • Culturally and age appropriate • Suitable to personal preferences • Prevents chronic disease • Adequate in overall nutrition and balance • High consumption of fruits & vegetables • Low consumption of red meat & fatty foods • Whole and fresh foods are preferred to processed or refined foods • Protein primarily from fish, dairy products, and/or legumes • Limited in added salt, sugar, and alcohol

31. World Health Organization’s Five Keys to a Healthy Diet • Give baby only breast milk for the first six months of life • Eat a variety of foods • Eat plenty of vegetables and fruits • Eat moderate amounts of fat and oils • Eat less salt and sugars

32. Benefits of Breastfeeding For infants For mothers contracts the uterus delays return of regular ovulation (especially in exclusively-breastfeeding moms) conserves iron stores protects against breast cancer (especially pre-menopausal forms) aids in return of pre-pregnancy weight • favorable balance of nutrients • improve cognitive development • protects against infections • protect against chronic diseases • Impacts gene expression • protects against food allergies

33. Recommendations for Breastfeeding • World Health Organization: • Exclusive breastfeeding for first six months • Introducing age-appropriate and safe complementary foods at six months • Continuing breastfeeding for up to two years or beyond

34. ContactInformation Kathaleen Briggs Early, PhD, RD, CDE kearly@pnwu.org