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Nutritional Assessment and Counseling

Jill Endres Endres, MD MD, MS Department of Family Medicine

Objectives
Goal: To increase comfort level in assessing g nutrition and counseling about nutritional concerns during various life stages. Objectives: Obj ti
Define important aspects of a nutritional history. Recognize changing nutritional needs across lifespan lifespan. Review literature on common nutritional health concerns.

Nutritional History
Supplements, herbs, nutritional products Social history Weight changes Diet assessment Physical activity FITT FITT model

Physical Exam
Vitamin/mineral deficiencies/toxicities Eating Disorders Ob it Obesity Oral health Xanthomas Appropriate lab evaluation

Education
BMI---risk factor reduction Estimate caloric requirement g Assess readiness for change Individualize recommendations Dietary guidelines
Food groups Portion sizes

Ad Advise i about b t supplements l t Physical activity

The New Food Pyramid

Estimating caloric requirements


Calculate BMR
Women: BMR = 655 + ( 4.35 x weight in pounds ) + ( 4.7 x height in inches ) - ( 4.7 x age in years ) Men M : BMR = 66 + ( 6.23 6 23 x weight i ht i in pounds d ) + ( 12 12.7 7xh height i ht i in inches ) - ( 6.8 x age in year )

Harris Benedict Formula Multiply BMR by the appropriate activity factor:


1.2 1.375 1 55 1.55 1.725 1.9 sedentary (little or no exercise) lightly active (light exercise 1-3 days/week) moderately active (moderate exercise 3 3-5 5 days/week) very active (hard exercise 6-7 days a week) extra active (very hard exercise & physical job or 2x training)

General
Address nutritional issues at all visits Nutritional needs vary with life stage
Infants Children Adolescents Adults Pregnancy and lactation Elderly

Consider nutritional issues for hospitalized and perisurgical patients Collaborate with registered dieticians

Infant nutrition assessment


Routinely assess at WC visits Growth charts H Hemoglobin l bi assessment t Lead risk assessment/screening Intake Self-feeding Self feeding skills

Infant nutrition education


Appropriate Diet for age Feeding skills development C Common f feeding di problems bl Oral health and preventive care Nutrition supplements

Complementary foods
Initiation Types of foods P ti Portions Progression

12 months
Finger foods Modified adult diet Ch ki h Choking hazards d Cows milk FITS study

Supplements
Iron Vitamin D Fl id Fluoride Other

Oral health
Sugar Calcium Fl id Fluoride Dental care/ visits

Childhood: 2-11 2 11 years


Frequency P ti Portions Snacks Breakfast Supplements

Children & Adolescents


Ann Annual al assessment of n nutritional tritional stat status s Diet history---food groups Assess A for f common feeding f di concerns
Quantity- total calories, restrictive behaviors Quality - nutritional value of snacks Sweetened beverages Meal locations family meals vs vs. fast food Nutrient recommendations

Children & Adolescents


Physical activity TV/computer use Ri k reduction Risk d ti counseling li Screening tests

Fiber
Children older than 2 years: >= age + 5 g/day 20 years and older:
20 to 35 g/day 10 to 13 g of dietary fiber per 1000 kcal.

Fiber - benefits
Cholesterol Normal laxation Digestion and satiety P Prevention/management ti / t of f diabetes di b t Diverticulosis Cancer prevention

Whole grains
Decrease hunger/increase satiety (Liu et et. al al.) ) Diets rich in whole grains protect against
Cardiovascular C di l di disease (RR 0 0.77) 77) Stroke (RR 0.79) Diabetes (RR ( 0.62) ) All-cause mortality (RR 0.83)

67% of consumers say they would eat whole grain products more often if they believed they could decrease the risk of cancer and heart disease.

Fruits & vegetables


Higher intake lowers risk of
Obesity by 24% Stroke by 11 11-26% 26% Ischemic Heart Disease by 15% Cancer C risk i kb by 43% Cognitive decline
He et al. F Feng et. t al l Law et al.

Jansen et al.

Provide P id essential ti l nutrients ti t

Fruits & Vegetables


68% of Americans eat <=2 servings of fruit 63% of Americans eat <=2 servings of vegetables

Refining carbohydrates
Processing whole wheat into white flour
Decreases fiber by 80% Decreases protein by 30% Increases Calories by 10% Increases digestive rate and GI

Calcium RDI
9-18 years 19-50 years 51-70 years >70 years calcium 1300 mg 1000 mg 1200 mg 1200 mg vitamin D 200 IU 200 IU 400 IU 600 IU

Estimating calcium intake


# dairy servings x 300 mg One serving g= 8 oz milk/yogurt 16 oz cottage cheese (2 cups) 1 oz hard cheese

Calcium supplementation
calcium citrate (Citracal) well absorbed with or without food calcium carbonate cheapest form available 40% calcium (500 mg Tums has 200 mg Ca++) high g dietary y calcium intake associated with lower risk of nephrolithiasis high supplemental Ca++ intake associated with slightly risk of renal stones

product (% elemental ca) elemental calcium (mg)/tablet calcium carbonate (40%) 500 mg 200 1260 mg g 500 Caltrate 600 + D 600 Os-Cal 500 + D 500 Tums Regular 200 E-X 300 Ultra 400 Rolaids 220 Viacti e Viactive 500 One-a-Day for Women 450 Centrum Silver 200 calcium citrate (21.2%) Citracal Tablets 200 Citracal Caplets + D 315 Citracal Liquitab 500 Citracal Neutravescent 400 tricalcium phosphate (38%) Posture-D 600

commonly available calcium supplements

vitamin D(IU)/tablet 0 0 200 200 0 0 0 0 100 400 400 0 200 0 0 125

Adult Nutritional Assessment


Annual assessment Diet history S Supplement l t use Physical activity- FITT BMI Screening tests

Adult Nutritional Education


Dietary guidelines Nutrition Facts Labels S Supplements l t Risk reduction Physical activity

Pregnancy & Lactation


Routine assessment Weight gain Di t hi Diet history t Supplement use

Pregnancy & Lactation


Recommend p portion size Recommend food groups/supplements to meet nutrient needs:
Folic acid Iron Zinc Calcium Protein Fiber

Dietician referrals

Pregnancy & lactation


Avoid harmful behaviors
Substance use Mercury Listeria Herbals

Elderly Nutrition assessment


Standardized tools Diet history: food pyramid for 70+
http://commentator.tufts.edu/archive/nutrition/pyramid.html

Age-related Age related factors


Living environment Functional status D Depression i Oral health

Physical exam Screening

Elderly Nutritional Education


Dietary Guidelines Recommend appropriate supplements Ph i l activity Physical ti it and d fl flexibility ibilit t training i i Food-drug interactions Work with dietitians in care facilities