NUTRITION

I. PRINCIPLES OF NUTRITION
nutrition – study of nutrients and how they are handled by the body as well as
the impact of human behavior
and environment on the process of nourishment

nutrients – specific biochemical substances used by body for growth,

development, activity, reproduction,
lactation, health maintenance, and recovery from illness or injury
- needs change throughout the life cycle in response to changes in body
size, activity, growth,
development, and state of health
- considered essential because they either are not synthesized in the
body or are made in insufficient
amts. - - must be provided in diet or through supplements

Classes: 3 – supply energy (carbohydrates, protein, lipids)

3 – regulate body processes (vitamins, minerals, water)

II. DEFINITION OF ENERGY AS RELATED TO NUTRITION

A. ENERGY BALANCE - energy is derived or obtained from foods consumed
- only carbohydrates, protein, and fat provide energy

calories – energy in the diet measured in the form of kilocalories

- energy in the body is used to carry on any kind of activity whether

voluntary or involuntary
- total daily energy expenditure is the sum of all calories used to perform
physical activity, maintain
basal metabolism, and digest, absorb, and metabolize food
- if daily energy intake is equal to total daily energy expenditure, weight
will remain stable
- if energy intake is less than energy expended, weight will decrease
- if energy intake exceeds energy expenditure, weight will increase

B. METABOLIC REQUIREMENTS
basal metabolism – amt of energy required to carry on the involuntary
activities of the body at rest, such as
maintaining body temperature and muscle tone, producing and releasing
secretions, propelling food
through the gastrointestinal (GI) tract, inflating the lungs, and contracting
the heart muscle
- as amt of energy used on physical activity declines, proportion of
calories used for basal metabolism
increases
- men have higher basal metabolic rate (BMR) than women because of
their larger muscle mass
BMR = 1 cal/kg of body weight per hour for men
BMR = 0.9 cal/kg of body weight per hour for women
 - factors that increase BMR include growth, infections, fever, emotional
tension, extreme
environmental temperatures, and elevated levels of certain
hormones, especially epinephrine
and thyroid hormones
- factors that decrease BMR include aging, prolonged fasting, and sleep

C. SPECIFIC DYNAMIC ACTION (SDA)

- ideal body weight (IBW) or health body weight is an estimate of optimal
weight for optimal health
Rule-of-Thumb (ROT) - determines ideal weight based on height
Females: 100 lbs (for height of 5’) + 5 lbs for each additional inch
over 5’
Males: 106 lbs (for height of 5’) + 6 lbs for each
additional inch over 5’
(add or deduct 10% from this figure based on body frame
size)

Body Mass Index (BMI) – ratio of height to weight, providing a more

accurate reflection of total body
fat stores in general population

Kilograms and Meters: Pounds and Inches:

Weight in Kilograms (2.2 lb = 1 kg) Weight in Pounds x
704.5
Height2 in meters (39.37 in = 1 m) Height in Inches

- provides an estimation of relative risk factors for diseases such as

heart disease, diabetes,
and hypertension
- may not be accurate for people such as athletes, with a
large muscle mass, or
people with edema
- BMI of 25 is considered overweight, 30 or greater indicates
obesity

Methods of Calculating Calorie Requirements:

1. Resting Energy Equivalent (REE) – amt of calories necessary to
maintain body at rest
Male Ex.: 65 kg x 1 cal/kg x 24 hr = 1560 cal/day
Female Ex.: 65 kg x 0.9 cal/kg x 24 hr = 1404
cal/day

- determine calories needed for specific activity level

- REE is multiplied by one of the following: light activity
REE x 0.55 – 0.65
moderate REE x 0.65 –
0.7
heavy REE x 0.75 –
1.0
 Male Ex.: 1560 x 0.55 = 858 calories
Female Ex.: 1404 x 0.55 = 772 calories

- total REE and calories needed based on activity level

Male Ex.: 1560 + 858 = 2418 calories
Female Ex.: 1404 + 772 = 2176 calories

D. CLASSES OF NUTRIENTS
1. Carbohydrates – known as sugars and starches, are organic compounds
composed of carbon,
hydrogen, and oxygen
- only animal source of carbohydrate in the diet is lactose, or “milk
sugar”
- relatively easy to produce and store, most abundant and least
expensive course of calories
in diet
- more easily and quickly digested than protein and fat
- converted to glucose for transport through the blood or for use as
energy
- cells oxidize (burn) glucose to provide energy, carbon dioxide, and
water
- depending on person’s state of energy balance, the period
between when
carbohydrate is consumed and when it is used for
energy may vary from
minute to months or longer
- when supply of glucose exceeds what is needed for energy and
for maintaining serum
levels, it is stored
- when glycogen stores are adequate, body converts excess
glucose to fat and stores it as
triglycerides in adipose tissue

Classifications:
simple sugars (monosaccharides and disaccharides)
complex sugars (polysaccharides)

recommended dietary allowance (RDA) – recommendations for

average daily amts that
healthy population groups should consume over time

ketosis – abnormal accumulation of ketone bodies that is

frequently associated with acidosis

2. Protein – vital component of every living cell

- classified as essential because they cannot be synthesized in the
body
- remaining amino acids are no less important but because the
body can make them if a
 supply of nitrogen is available, they are termed nonessential
- excess amino acids are converted to fatty acids, ketone
bodies, or glucose and are
stored or used as metabolic fuel
- required for formation of all body structures, including genes,
enzymes, muscle, bone matrix,
and hemoglobin
- RDA for adults is 0.8 g/kg of desirable body weight, or about 56 g
for avg. woman and 63 g
for avg. man
- stress of illness, surgery, or prolonged periods of time on simple IV
without oral intake places
patients at risk for developing protein-calorie malnutrition
(PCM), resulting in weakness, poor wound healing, mental
apathy, and edema

catabolism – tissues continuously being broken down

anabolism – tissues continuously being replaced

- when both are occurring at the same rate, the body is in a

state of neutral nitrogen
balance
- positive nitrogen balance occurs when nitrogen intake is
greater than excretion
(during periods of growth, pregnancy, lactation, and
recovery from illness)
- negative nitrogen balance, an undesirable state that occurs
in situations such as
starvation and catabolism that immediately follows
surgery, illness, trauma,
and stress, indicates that more nitrogen is being
excreted than consumed

3. Fats / Lipids – insoluble in water and, therefore, insoluble in blood

- lipids in the diet are in the form of triglycerides, the predominant
form of fat in food and major
storage form of fat in the body
- difference in degree of saturation depends on the amt of
hydrogen in fat molecules
- saturated fats tend to raise serum cholesterol levels, whereas
unsaturated fats lower serum
cholesterol levels

trans fat – partially hydrogenate liquid oils, they become

more solid and more stable
- raises serum cholesterol

cholesterol – fatlike substance found only in animal

products
 - need not be provided in the diet because the body
synthesizes about twice
as much cholesterol as most people eat
- important component of cell membranes, especially
abundant in brain and
nerve cells
- used to synthesize bile acids and is precursor of
steroid hormones and
vitamin D
- to help lower serum cholesterol levels, eat less total
fat – especially
saturated and trans fat – eat more unsaturated
fat, and increase fiber
intake, which increases fecal excretion

4. Regulatory Nutrients
a. Vitamins – organic compounds needed by the body in small
amounts
- active in form of coenzymes together with enzymes,
facilitate thousands of chemical
reactions in the body
- needed for metabolism of carbohydrates, protein, and fat
- may be destroyed by light, heat, air, and during preparation
- mild or subclinical deficiencies of vitamin A, B6, C, folate
may affect those that 1) in
certain age groups - - infants, adolescents, pregnant
and lactating women,
and older people 2) smoke, abuse alcohol, or use long-
term meds 3)
chronically ill, physically or psychologically 4) are poor
or finicky eaters - -
chronic dieters, strict vegetarians, and food faddists
- will never be a substitute for good nutrition and healthy
lifestyle practices
- classified as:
water soluble (vitamin C and B-complex) – absorbed
through intestinal wall
directly into bloodstream
- deficiency symptoms are apt to develop quickly
when intake is
inadequate
- toxicities are not likely
fat soluble (vitamins A, D, E, K) – absorbed with fat into
lymphatic circulation
- secondary deficiencies can occur anytime fat
digestion or
absorption is altered
- body stores excesses mostly in the liver and
adipose tissue
- daily intake is not imperative
 b. Minerals – inorganic elements found in all body fluids and tissues in
the form of salts or
combined with organic compounds
- function to provide structure within body, help to regulate
body processes
- not broken down or rearranged in the body, but are
contained in ash that remains
after digestion

c. Water – accounts for between 50 – 60% of adult’s total weight

- infants have proportionately more water accounting for
body weight
- about two-thirds of body’s water is contained within cells
(intracellular fluid), with the
remainder including all other body fluids such as
plasma and interstitial fluid
(extracellular fluid)
- provides medium necessary for all chemical reactions,
participates in many
reactions and is not stored in body
- acts as solvent that dissolves many solutes, aiding in
digestion, absorption,
circulation, and excretion
- helps regulate body temperature
- acts as lubricant needed for mucous secretions and for
movement between joints
- produced through metabolism of carbohydrates, protein,
and fat
- leaves through urine, feces, expired air, and perspiration
- balance may be seriously affected when intake or output is
altered

E. CHOOSING AN ADEQUATE DIET

- nutritional concerns focus more on problems of overnutrition
- promoting health through proper nutrition has been made easier by
labeling regulations that provide
specific information

1. Food Groups
- grain and cereal group are at the base of the pyramid followed by:
fruit and vegetable group
meat and dairy groups
fat, oil, and sweets group at the peak
- pyramid emphasizes grain and cereal group as basic food in diet
with less desirable groups
playing a much smaller nutritional role
- all are required, in proper proportions, for healthy diet
 2. Recommended Dietary Allowance – represents avg daily amts of
nutrients considered to be
adequate to meet known nutritional needs of practically all healthy
people
- safety factor built in to account for individual variations
- some people may not be able to meet individual
requirements
- possible to eat less than RDA and still avoid deficiencies

3. Guidelines from American Dietary Association

Aim for Fitness – aim for a healthy weight; be physically active each
day
Build a Health Base – let pyramid guide food choices; choose
variety of grains daily,
especially whole grains; choose variety of fruits and
vegetables daily; keep food safe
to eat
Choose Sensibly – choose diet low in saturated fat and cholesterol
and moderate in total fat;
choose beverages and food that limit intake of sugars;
choose and prepare food with
less salt; drink alcohol in moderation

II. FACTORS AFFECTING NUTRITION

- patterns and habits may have greater impact on overall food intake
- habits are product of many evolving variables, such as physical factors
(geographic location,
income), physiologic factors (health, hunger), and psychosocial
factors (culture, religion)
- conservative traditional influences, like culture, geographic region, and
religion, have a stabilizing
effect on habits

A. DEVELOPMENTAL CONSIDERATIONS
- nutrient needs change in relation to growth, development, activity, and
age-related changes in
metabolism and body composition
- periods of intense growth and development cause an increase in
nutrient needs
- nutrient needs stabilize during adulthood, although older people may
need more or less of some
nutrients
- consistency of food, eating patterns, and significance of food change
with physical and psychosocial
development

1. Infants – birth to 1 yr is most rapid period of growth

- birth weight doubles in 4 – 6 mos. and triples by 1 yr
- length increases 50%
 - nutritional needs per unit of body weight are greater than at any
other time in the life cycle
- cow’s milk is not recommended for infants under 1 yr
- solid foods are not introduced until 6 mos. because solid foods
given too early may trigger
allergic reactions
- iron fortified foods are recommended

2. Toddlers / Preschoolers – can feed themselves, verbalize food likes and

dislikes and occasionally
use food to manipulate parents
- appetite dramatically decreases and becomes erratic

3. School Aged – nutritional implications focus on health promotion

- needs to be balanced with foods of high nutritional value
- appetite improves but still may be irregular

4. Adolescents – period of rapid physical, emotional, social and sexual

maturation
- needs, especially for calories, protein, calcium, and iron, increase
to support growth

anorexia nervosa – eating disorder characterized by extreme

weight loss, muscle wasting,
arrested sexual development, refusal to eat, and bizarre
eating habits

bulimia – eating disorder characterized by gorging followed by

purging with self-induced
vomiting, diuretics, and laxatives

- nutritional needs may be harder to meet because fewer meals are

eaten at home, peer
influence and busy schedules have an impact

5. Adults – needs level off, fewer calories are required

6. Pregnant and Lactating Women – needs increase to support growth

and maintain maternal
homeostasis, particularly during 2nd and 3rd trimester
- key nutrient needs include protein, calories, iron, folic acid,
calcium, and iodine

7. Older Adults – caloric needs of body decrease

- foods difficult to chew may need to eliminated, whereas an
increase in fiber and fluid intake
can relieve constipation
- nutrient intake, digestion, absorption, metabolism, or excretion
may be altered because of
physiologic changes
B. SEX
- men differ from women in nutrient requirements due to differences in
body composition and
reproductive function
- larger muscle mass translates into higher caloric and protein
requirements
- women have proportionately more adipose tissue
- women of childbearing age have higher iron requirements related to
menstruation

C. STATE OFHEALTH
- alteration in nutrient requirements that results from illness and trauma
varies with intensity and
duration of the stress
- trauma, like major surgery, burns, and crush injuries, is followed by
hormonal changes that
profoundly affect the body’s use of nutrients
- to preserve or replenish body nutrient stores and to promote healing
and recovery, requirements
increase dramatically
- chronic disorders, like diabetes, renal disease, hypertension, heart
disease, GI disorders, and
cancer, can alter nutrient requirements by influencing nutrient
intake, digestion, absorption,
metabolism, utilization, or excretion

D. ALCOHOL ABUSE
- alters body’s use of nutrients and interferes with normal nutrient
absorption
- requirements increase as efficiency of absorption decreases
- need for B vitamins increases because they are used to metabolize
alcohol
- impairs nutrient storage, increases nutrient catabolism, and increases
nutrient excretion

E. MEDICATIONS
- absorption may be altered by drugs that:
• change the pH of GI tract
• increase GI motility
• damage intestinal mucosa
• bind with nutrients rendering them unavailable
- metabolism can be altered by drugs that:
• act as nutrient antagonists
• alter enzyme systems that metabolize nutrients
• alter nutrient degradation
- some drugs alter renal reabsorption of nutrients and increase or
decrease nutrient excretion
F. MEGADOSES OF NUTRIENT SUPPLEMENTS
- excess of one nutrient can lead to a deficiency (or increase the
requirement) of another, especially if
one is absorbed preferentially

III. OBJECTIVE ASSESSMENT

A. DIETARY DATA
- after a screening tool identifies a patient at risk, such as in older adults,
it is imperative that a
nutritional assessment be completed as a follow-up

1. 24-Hour Recall Method – easiest way to collect dietary data, 24-hour

recall of all food and beverages
patient normally consumes during an average day
- includes patient’s usual portion sizes, meal and snack patterns,
meal timing, and location
where food is eaten
- information may not be reliable

2. Food Diaries - frequency questionnaires or diaries may provide a better

overall picture of intake
because patient records all food and beverages consumed in a
specified period, usually 3 – 7
days

3. Risk Factors – Disease, Eating poorly, Tooth loss/mouth pain, Economic

hardship, Reduced social
contact, Multiple medicines, Involuntary weight loss/gain, Needs
assistance in self-care, Elder
years above age 80

B. MEDICAL AND SOCIOECONOMIC DATA

- medical, social, economic, cultural and psychological factors require
evaluation for impact on
nutritional requirements

C. ANTHROPOMETRIC DATA
anthropometric – used to determine body dimensions
- used to assess growth rate; can give indirect measurements of
body protein and fat stores

- standardized equipment and procedures must be used, data must be

compared with appropriate
reference standards for patient’s age and sex
- height and weight, most common measurements, are obtained when
patient is admitted to facility
and periodically thereafter or assessed in home
- weight patient on same scale at same time of day
- because actual weight may be increased if patient has edema,
hydration status must be
 considered
- self-reported weight may be recorded when actual weight is
unobtainable - - highly
inaccurate and must be noted
- actual weight is recorded as soon as feasibly possible
- additional measurements include triceps skin-fold measurements,
measure of subcutaneous fat
stores, midarm circumference, measure of both skeletal muscle
mass and fat stores

D. CLINICAL DATA: SIGNS AND SYMPTOMS OF MALNUTRITION

- signs and symptoms of altered nutrition usually do not appear until
condition is advanced
- further investigation is necessary to determine whether abnormal
findings are actually caused by
nutritional deficiency, are possibly related to a nutritional
deficiency, or are unrelated to
nutritional status

E. BIOCHEMICAL DATA
- lab test, which measure blood and urine levels of nutrients or
biochemical functions that depend on
adequate supply of nutrients, can objectively detect problems in
early stages
- most routine biochemical tests measure protein status, body vitamin,
mineral and trace element
status

hemoglobin – oxygen carrying protein of red blood cells

hematocrit – volume of red blood cells packed by centrifugation in given

volume of blood are
measures of plasma protein that also reflect person’s iron status