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
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
