Science Nutritional Self Analysis Discussion

Hello!So I have attached my template for this paper on the bottom. I am 117 pounds and 5’2 just in case you need that for my BMI calculation. Also, I do not have a set food plan these past 3 days. U can honestly make anything up. Please have this done by 11 latest pls pls pls

1
Your Name Here
University Name
Course Number: Course Name
Instructor’s Name
Due Date
You can use this template to format your paper. Remove all directions under the header, the
screenshot example and anything else that is red . This is an APA paper; all information must be in
paragraph form with indents. Use proper headings for each section. Font: Times New Roman,
Font size: 12. Double-spaced, Margins 1” all around. Do not use bullets or numbers. Explain your
information in detail.
2
Nutritional Self Analysis (Title of paper)
BMI & Hamwi:
Calculate your weight based on the BMI formula and the Hamwi method. All actual
calculations must be present in your paper.
•
Analyze your place on the BMI and Hamwi scales in terms of health. Based on these
numbers, how healthy are you?
•
Use at least one source other than your class text to provide documentation and
references to support your position.
Food Diary
Document your food intake for three days. Your paper must include a food diary documenting all
food, drink and medications consumed for the three days. Compare your intake of food and
nutrients to the recommended RDA. Refer to the nutrient report spreadsheet percentages that you
recorded.
1. Provide nutritional information for all foods contained in our food diary including the
serving size, amount consumed, total calories, total fat calories, total carbohydrates
calories, total protein calories, grams of sodium, vitamins, and minerals in the nutrient
spreadsheet. This can be detailed in a screenshot of your daily diary (see below).
2. Insert the nutritional information charts (screenshots) from each of the three days in your
paper.
3. Include “Food Notes” that detailed situational information including where you were
when you were eating the food, what you were doing, and why you chose to eat what you
ate (convenience, habit, intentional, etc.).
3
4. Within your Food Notes, discuss where did most of your calories come from fats,
proteins, or carbohydrates for that day? Provide examples.
EXAMPLE OF A SCREENSHOT
Food Notes
Breakfast – had a coffee when I woke up. I was hungry but didn’t eat until I came home from the gym. I felt verysatisfied after my
meal.
Lunch – was at home for lunch. I was studying and had hunger pains, so I made something that was easy to eat. I feltsatisfied
after the meal.
Dinner – had left over noodles in the fridge so I made meatballs to go with it. I was not very hungry but
wanted to eatdinner with my husband. I felt bloated after the meal.
Snack – stayed up later than I planned and had a craving for something sweet. It was very satisfying.
Calorie notes – Most of my calories for the day came from carbohydrates, specifically the French Fries at
lunch. Although I am trying to lose weight, I really like carbs and can’t help eating what I like.
Example of
food notes
4
Analysis
(The information for this chart will come from the spreadsheet)
Provide an analysis of each nutrient below. Each nutrient should be a separate paragraph.
Include for each nutrient:
1. What is your RDA?
2. How close to the RDA did you come?
3. If you were deficient in a nutrient, provide food choices that would improve your diet for
this nutrient.
4. If you had an over consumption of a nutrient, explain what foods caused the over
consumption and provide food choices that would improve your diet for this nutrient.
5. Use AT LEAST ONE SOURCE OTHER than your class text for EACH nutrient to
support your position.
5
Carbohydrates (g):
Fat (g):
Protein (g):
Fiber (g):
Sugar (g):
Saturated:
Polyunsaturated:
Monounsaturated:
Trans (g):
Cholesterol (mg):
Sodium (mg):
Potassium (mg):
Vitamin A %:
Vitamin C %:
Calcium %:
Iron %:
Diet Plan
Develop a diet plan that best suits your actual dietary needs based on your height, weight, BMI
and overall activity (be specific, this should be well developed and detailed)
1. Your diet plan should be detailed and identify specific changes that will need to be made
to comply with the diet plan.
2. Include how this diet plan will be beneficial to your health.
3. Use AT LEAST ONE SOURCE OTHER than your class text to provide
6
documentation and references to support your position.
Goals
Develop THREE properly formatted SMART goals. Your goals must be Specific, Measurable,
Achievable, Realistic and Timed (By December 31, I will walk around the block for 30 minutes
3x per week)
Implementation/Obstacles
1. For EACH of your SMART goals develop at least one implementation strategy that will
help you to achieve your goal. Your implementation strategy should be specific to your
goal.
2. For EACH of your SMART goals identify at least one obstacle that will prevent you
from achieving your goal. Your obstacle should be specific to your goal. Include a plan to
overcome the obstacle.
Conclusion
1. Reflect on what you have learned from the assignment.
2. How will you incorporate nutritional education into your clinical practice?
7
References
Smith, J. (2021). Example of a reference. Journal in Italics, 225(1), 12-345.
https://doi.org/thisisanexampleonly123456
The references heading should begin on a separate page and it is not BOLD. Each reference is
alphabetized by author last name, title of reference is only capitalized on first word or after a
colon and should be hanging indents.
Nutrition
Essentials
for Nursing
Practice
Susan G. Dudek, RD, CDN, BS
Nutrition Instructor, Dietetic Technology Program
Erie Community College
Williamsville, New York
Consultant Dietitian for Employee Assistance
Program of Child and Family Services
Williamsville, New York
S E V E N T H
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E D I T I O N
3/29/13 1:13 AM
Acquisitions Editor: David Troy
Product Manager: Maria McAvey
Production Project Manager: Marian Bellus
Editorial Assistant: Latisha Ogelsby
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Seventh Edition
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Copyright © 2010, 2007, 2006, 2001 by Lippincott Williams and Wilkins. Copyright © 1997 by Lippincott-Raven Publishers. Copyright © 1993, 1987 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part
of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other
electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright
owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To
request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia,
PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services).
9 8 7 6 5 4 3 2 1
Printed in China
Library of Congress Cataloging-in-Publication Data
Dudek, Susan G.
Nutrition essentials for nursing practice / Susan G. Dudek. — 7th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4511-8612-3 (alk. paper)
I. Title.
[DNLM: 1. Diet Therapy—Handbooks. 2. Diet Therapy—Nurses’ Instruction. 3. Nutritional Physiological Phenomena —
Handbooks. 4. Nutritional Physiological Phenomena—Nurses’ Instruction. WB 39]
RM216
615.8’54—dc23
2013007075
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions or for any consequences from application
of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or
accuracy of the contents of the publication. Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and
universal recommendations.
The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text
are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing
research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions,
the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings
and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each
drug or device planned for use in his or her clinical practice.
LWW.com
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In loving memory of my mother, Annie M. Maedl—
everyone should be so lucky to have a mom like her.
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Reviewers
Zita Allen, RN, MSN
Professor of Nursing
Alverno College
Milwaukee, Wisconsin
Marina Martinez-Kratz, RN, BSN, MS
Carmen Bruni, MSN, RN, CAN
Assistant Professor
Texas A&M International University
Laredo, Texas
Janet Tompkins McMahon, RN, MSN
Ann Cleary, DNS, RN, NP-C
Associate Professor of Nursing
Long Island University, Brooklyn Campus
Brooklyn, New York
Patricia J. Neafsey, RD, PhD
Professor
University of Connecticut School of Nursing
Storrs, Connecticut
Tammie Cohen, RN, BS
Nursing Instructor, Faculty Advisory Committee
Chairperson
Western Suffolk BOCES
Northport, New York
Cheryl L. Neudauer, PhD, MEd
Biology Faculty
Center for Teaching and Learning Campus Leader
Minneapolis Community and Technical College
Minneapolis, Minnesota
Janet Goeldner, MSN
Professor
University of Cincinnati—Raymond Walters College
Cincinnati, Ohio
Christine M. Prince, RN, BSN, CCM
Nursing Faculty
Brown Mackie College Indianapolis
Indianapolis, Indiana
Coleen Kumar, RN, MSN
Associate Professor Nursing
Department Deputy Chairperson
Kingsborough Community College
Brooklyn, New York
Rhonda Savain, RN, MSN
Nursing Instructor
Ready to Pass Inc.
West Hempstead, New York
Professor of Nursing
Jackson Community College
Jackson, Michigan
Clinical Associate Professor of Nursing
Towson University
Towson, Maryland
Nancy West, RN, MN
Karen Lincoln, RNC, MSN
Nursing Faculty
Montcalm Community College
Sidney, Michigan
Professor of Nursing
Johnson County Community College
Overland Park, Kansas
Carol Isaac MacKusick, PhDc, MSN, RN, CNN
Adjunct Faculty
Clayton State University
Morrow, Georgia
iv
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Preface
L
ike air and sleep, nutrition is a basic human need essential for survival. Nutrition provides
energy and vitality, helps reduce the risk of chronic disease, and can aid in recovery. It is a
dynamic blend of science and art, evolving over time and in response to technological advances
and cultural shifts. Nutrition at its most basic level is food—for the mind, body, and soul.
Although considered the realm of the dietitian, nutrition is a vital and integral component of nursing care. Today’s nurses need to know, understand, apply, analyze, synthesize,
and evaluate nutrition throughout the life cycle and along the wellness/illness continuum.
They incorporate nutrition into all aspects of nursing care plans, from assessment and
nursing diagnoses to implementation and evaluation. By virtue of their close contact with
patients and families, nurses are often on the front line in facilitating nutrition. This text
seeks to give student nurses a practical and valuable nutrition foundation to better serve
themselves and their clients.
NEW TO THIS EDITION
This seventh edition continues the approach of providing the essential information nurses
need to know for practice. Building upon this framework, content has been thoroughly
updated to reflect the latest evidence-based practice. Examples of content updates that are
new to this edition are as follows:
■
■
■
■
■
■
■
MyPlate, which replaces MyPyramid as the graphic to illustrate the Dietary Guidelines for
Americans
Recommended Dietary Allowances (RDAs) for calcium and vitamin D
Inclusion of a validated stand-alone nutrition screening tool for older adults that is appropriate for community settings and in clinical practice
Expanded coverage of bariatric surgery and obesity in general, particularly with regard
to the importance of behavioral strategies for navigating our increasingly obesogenic
environment
The low-FODMAP (fermental oligo-, di-, and monosaccharides and polyols) diet for
irritable bowel syndrome and possibly other gastrointestinal disorders
A shift in focus from single nutrients (e.g., saturated fat) to a food pattern approach (e.g.,
the DASH diet) for communicating and implementing a heart healthy diet
Updated 2011 nutrition therapy guidelines for patients with chronic kidney disease who
are not on dialysis
ORGANIZATION OF THE TEXT
Unit One is devoted to Principles of Nutrition. It begins with Chapter 1, Nutrition in
Nursing, which focuses on why and how nutrition is important to nurses in all settings.
Chapters devoted to carbohydrates, protein, lipids, vitamins, water and minerals, and energy
balance provide a foundation for wellness. The second part of each chapter highlights health
promotion topics and demonstrates practical application of essential information, such as
how to increase fiber intake, criteria to consider when buying a vitamin supplement, and the
risks and benefits of a vegetarian diet.
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vi
PREFACE
Unit Two, Nutrition in Health Promotion, begins with Chapter 8, Guidelines for
Healthy Eating. This chapter features the Dietary Reference Intakes, the Dietary Guidelines for Americans, and MyPlate. Other chapters in this unit examine consumer issues and
cultural and religious influences on food and nutrition. The nutritional needs associated
with the life cycle are presented in chapters devoted to pregnant and lactating women, children and adolescents, and older adults.
Unit Three, Nutrition in Clinical Practice, includes nutrition therapy for obesity and
eating disorders, enteral and parenteral nutrition, metabolic and respiratory stress, gastrointestinal disorders, diabetes, cardiovascular disorders, renal disorders, cancer, and HIV/
AIDS. Pathophysiology is tightly focused as it pertains to nutrition.
RECURRING FEATURES
This edition retains popular features of the previous edition to facilitate learning and engage
students.
■
■
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■
■
Check Your Knowledge presents true/false questions at the beginning of each chapter
to assess the students’ baseline knowledge. Questions relate to chapter Learning
Objectives.
Key Terms are defined in the margin for convenient reference.
Quick Bites—fewer and more condensed to improve layout and readability in the new
edition—provide quick nutrition facts, valuable information, and current research.
Nursing Process tables clearly present sample application of nutrition concepts in context of the nursing process.
How Do You Respond? helps students identify potential questions they may encounter
in the clinical setting and prepares them to think on their feet.
A Case Study and Study Questions at the end of each chapter challenge students to
apply what they have learned.
Key Concepts summarize important information from each chapter.
TEACHING AND LEARNING RESOURCES
Instructors and students will find valuable resources to accompany the book on
at http://thePoint.lww.com/Dudek7e.
Resources for Instructors
Comprehensive teaching resources are available to instructors upon adoption of this text
and include the following materials.
■
■
■
■
■
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A free E-book on thePoint provides access to the book’s full text and images online.
A Test Generator lets instructors put together exclusive new tests from a bank containing NCLEX-style questions.
PowerPoint Presentations provide an easy way to integrate the textbook with the classroom. Multiple-choice and true/false questions are included to promote class participation.
An Image Bank provides the photographs and illustrations from this text for use in
course materials.
Access to all student resources is also provided.
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PREFACE
vii
Resources for Students
Students can activate the code in the front of this book at http://thePoint.lww.com/
activate to access the following free resources.
■
■
■
A free E-book on thePoint provides access to the book’s full text and images online.
NEW! Practice & Learn Interactive Case Studies provide realistic case examples and
offer students the opportunity to apply nutrition essentials to nursing care.
Journal Articles provided for each chapter offer access to current research available in
Lippincott Williams & Wilkins journals.
I hope this text and teaching/learning resource package provide the impetus to embrace
nutrition on both a personal and professional level.
Susan G. Dudek, RD, CDN, BS
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Acknowledgments
I am humbled and grateful to be still writing this book after six editions. It is a project that
has been professionally rewarding, personally challenging, and rich with opportunities to
grow. In large part, the success of this book rests with the dedicated and creative professionals at Lippincott Williams & Wilkins. Because of their support and talents, I am able to
do what I love—write, create, teach, and learn. I especially thank
■
■
■
David Troy, Senior Acquisitions Editor, who provided the spark to ignite the project.
Maria McAvey, Editorial Product Manager, for her meticulous attention to detail and
gentle guidance.
Marian Bellus, Production Project Manager; Holly Reid McLaughlin, Design Coordinator;
John Johnson, Education Marketing Manager, Nursing; and Latisha Ogelsby, Editorial
Assistant, the behind-the-scene professionals whose efforts help transform an ugly duckling into a beautiful swan.
■
The reviewers of the sixth edition, whose insightful comments and suggestions helped
shape a new and improved edition.
■
My friends and family—my sideline cheerleaders—who so patiently gave me the time and
space to work on “my story.”
■
I am especially thankful to my husband Joe . . . always there through thick and thin.
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Contents
U N I T
O N E
CHAPTER 1
CHAPTER 2
CHAPTER 3
CHAPTER 4
CHAPTER 5
CHAPTER 6
CHAPTER 7
U N I T
Nutrition in Nursing 2
Carbohydrates 18
Protein 46
Lipids 66
Vitamins 92
Water and Minerals 124
Energy Balance 156
T W O
CHAPTER 8
CHAPTER 9
CHAPTER 10
CHAPTER 11
CHAPTER 12
CHAPTER 13
U N I T
Nutrition in Health Promotion 177
Guidelines for Healthy Eating 178
Consumer Issues 200
Cultural and Religious Influences on Food and Nutrition 230
Healthy Eating for Healthy Babies 257
Nutrition for Infants, Children, and Adolescents 286
Nutrition for Older Adults 320
T H R E E
CHAPTER 14
CHAPTER 15
CHAPTER 16
CHAPTER 17
CHAPTER 18
CHAPTER 19
CHAPTER 20
CHAPTER 21
CHAPTER 22
Principles of Nutrition 1
Nutrition in Clinical Practice 353
Obesity and Eating Disorders 354
Feeding Patients: Oral Diets and Enteral and Parenteral Nutrition 393
Nutrition for Patients with Metabolic or Respiratory Stress 423
Nutrition for Patients with Upper Gastrointestinal Disorders 443
Nutrition for Patients with Disorders of the Lower GI Tract and
Accessory Organs 461
Nutrition for Patients with Diabetes Mellitus 497
Nutrition for Patients with Cardiovascular Disorders 535
Nutrition for Patients with Kidney Disorders 567
Nutrition for Patients with Cancer or HIV/AIDS 593
A P P E N D I C E S
APPENDIX 1
APPENDIX 2
APPENDIX 3
APPENDIX 4
Dietary Reference Intakes (DRIs): Recommended Dietary Allowances
and Adequate Intakes, Total Water and Macronutrients 624
Dietary Reference Intakes (DRIs): Recommended Dietary Allowances
and Adequate Intakes, Vitamins 625
Dietary Reference Intakes (DRIs): Recommended Dietary Allowances
and Adequate Intakes, Elements 628
Answers to Study Questions 630
INDEX 633
ix
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U N I T
O N E
Principles of
Nutrition
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1
Nutrition in Nursing
CHECK YOUR KNOWLEDGE
TRUE
FALSE
1 The nurse’s role in nutrition is to call the dietitian.
2 Nutrition screening is used to identify clients at risk for malnutrition.
3 The Joint Commission stipulates the criteria to be included on a nutritional screen for
hospitalized patients.
4 Changes in weight reflect acute changes in nutritional status.
5 A person can be malnourished without being underweight.
6 The only cause of a low serum albumin concentration is protein malnutrition.
7 “Significant” weight loss is 5% of body weight in 1 month.
8 People who take five or more prescription or over-the-counter medications or dietary
supplements are at risk for nutritional problems.
9 Obtaining reliable and accurate information on what the client usually eats can help
identify intake as a source of nutrition problems.
10 Physical signs and symptoms of malnutrition develop only after other signs of malnutrition are apparent (e.g., abnormal lab values, weight change).
LEARNING OBJECTIVES
U p o n c o m p l e t i o n o f t h i s c h a p t e r, y o u w i l l b e a b l e t o
1 Compare nutrition screening to nutrition assessment.
2 Evaluate weight loss for its significance over a 1-month or 6-month interval.
3 Discuss the validity and reliability of using physical signs to support a nutritional diagnosis
of malnutrition.
4 Give examples of nursing diagnoses that may use nutrition therapy as an intervention.
5 Demonstrate how nurses can facilitate client and family teaching of nutrition therapy.
6 Explain why an alternative term to “diet” is useful.
2
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CHAPTER
1
Nutrition in Nursing
3
B
ased on Maslow’s hierarchy of needs, food and nutrition rank on the same level as air in
the basic necessities of life. Obviously, death eventually occurs without food. But unlike
air, food does so much more than simply sustain life. Food is loaded with personal, social,
and cultural meanings that define our food values, beliefs, and customs. That food nourishes the mind as well as the body broadens nutrition to an art as well as a science. Nutrition
is not simply a matter of food or no food but rather a question of what kind, how much,
how often, and why. Merging want with need and pleasure with health are keys to feeding
the body, mind, and soul.
Although the dietitian is the nutrition and food expert, nurses play a vital role in nutrition care. Nurses may be responsible for screening hospitalized patients to identify patients
at nutritional risk. They often serve as the liaison between the dietitian and physician as
well as with other members of the health-care team. Nurses have far more contact with the
patient and family and are often available as a nutrition resource when dietitians are not,
such as during the evening, on weekends, and during discharge instructions. In home care
and wellness settings, dietitians may be available only on a consultative basis. Nurses may
reinforce nutrition counseling provided by the dietitian and may be responsible for basic
nutrition education in hospitalized clients with low to mild nutritional risk. Nurses are intimately involved in all aspects of nutritional care.
This chapter discusses nutrition within the context of nursing, including nutrition
screening and how nutrition can be integrated into the nursing care process.
NUTRITION SCREENING
Nutritional Screen:
a quick look at a few
variables to judge a
client’s relative risk for
nutritional problems.
Can be custom designed for a particular
population (e.g., pregnant women) or for
a specific disorder
(e.g., cardiac disease).
Malnutrition: literally
“bad nutrition” or any
nutritional imbalance
including overnutrition.
In practice, malnutrition
usually means undernutrition or an inadequate
intake of protein and/or
calories that causes
loss of fat stores and/or
muscle wasting.
Dudek_CH01.indd 3
Nutrition screening is a quick look at a few variables to identify individuals who are malnourished or who are at risk for malnutrition so that an in-depth nutrition assessment
can follow. Screening tools should be simple, reliable, valid, applicable to most patients
or clients in the group, and use data that is readily available (Academy of Nutrition and
Dietetics, 2012). For instance, a community-based senior center may use a nutrition
screen that focuses mostly on intake risks common to that population, such as whether
the client eats alone most of the time and/or has physical limitations that impair the ability to buy or cook food (Fig. 1.1). In contrast, common screening parameters in acute
care settings include unintentional weight loss, appetite, body mass index (BMI), and
disease severity. Advanced age, dementia, and other factors may be considered. There is
no universally agreed upon tool that is valid and reliable at identifying risk of malnutrition
in all populations at all times.
The Joint Commission, a nonprofit organization that sets health-care standards and
accredits health-care facilities that meet those standards, specifies that nutrition screening be
conducted within 24 hours after admission to a hospital or other health-care facility—even
on weekends and holidays. The Joint Commission allows facilities to determine screening
criteria and how risk is defined. For instance, a hospital may use serum creatinine level as a
screening criterion, with a level greater than 2.5 mg/dL defined as “high risk” because the
majority of their patients are elderly and the prevalence of chronic renal problems is high.
The Joint Commission also leaves the decision of who performs the screening up to individual facilities. Because the standard applies 24 hours a day, 7 days a week, staff nurses are
often responsible for completing the screen as part of the admission process. Clients who
“pass” the initial screen are rescreened after a specified amount of time to determine if their
status has changed.
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4
UNIT
1
Principles of Nutrition
DETERMINE YOUR NUTRITIONAL HEALTH
The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if
you or someone you know is at nutritional risk.
Read the statements below. Circle the number in the “yes” column for those that apply to you or
someone you know. For each “yes” answer, score the number in the box. Total your nutritional
score.
YES
I have an illness or condition that made me change the kind and/or amount of food I eat.
2
I eat fewer than two meals per day.
3
I eat few fruits or vegetables, or milk products.
2
I have three or more drinks of beer, liquor or wine almost every day.
2
I have tooth or mouth problems that make it hard for me to eat.
2
I don’t always have enough money to buy the food I need.
4
I eat alone most of the time.
1
I take three or more different prescribed or over-the-counter drugs a day.
1
Without wanting to, I have lost or gained 10 pounds in the last six months.
2
I am not always physically able to shop, cook and/or feed myself.
2
TOTAL
Total your nutritional score. If it’s –
Nutritional
Assessment: an
in-depth analysis of a
person’s nutritional
status. In the clinical
setting, nutritional
assessments focus on
moderate- to high-risk
patients with suspected
or confirmed protein–
energy malnutrition.
0-2
Good! Recheck your nutritional score in six months.
3-5
You are at moderate nutritional risk. See what can be done to improve your eating
habits and lifestyle. Your office on aging, senior nutrition program, senior citizens
center or health department can help. Recheck your nutritional score in three
months.
6 or more You are at high nutritional risk. Bring this checklist the next time you see your doctor,
dietitian 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.
■ F I G U R E 1 . 1 Determine your nutritional health. American Academy of Family
Physicians, the American Dietetic Association, the National Council on the Aging, Inc.
The Nutrition Screening Initiative.
NUTRITION CARE PROCESS
Clients considered to be at moderate or high risk for malnutrition through screening are
usually referred to a dietitian for a comprehensive nutritional assessment to identify specific risks or confirm the existence of malnutrition. Nutritional assessment is more accurately called the nutrition care process, which includes four steps (Fig. 1.2). While nurses
use the same problem-solving model to develop nursing or multidisciplinary care plans that
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CHAPTER
1
Nutrition in Nursing
5
Screening
Nutrition
assessment
Nutrition monitoring
and evaluation
■ F I G U R E 1 . 2 The nutrition care process.
Like the nursing process, the nutrition care
process is a problem-solving method used to
evaluate and treat nutrition-related problems.
Nutrition
diagnosis
Nutrition
intervention
may also integrate nutrition, the nutritional plan of care devised by dietitians is specific for
nutrition problems. Some obvious differences in focus are described below:
■
■
■
■
■
■
Dudek_CH01.indd 5
Dietitians may obtain much of their preliminary information about the patient from the
nursing history and physical examination, such as height and weight; skin integrity;
usual diet prior to admission; difficulty chewing, swallowing, or self-feeding; chief complaint; medications, supplements, and over-the-counter drugs used prior to admission;
and living situation. Dietitians may request laboratory tests to assess vitamin levels when
micronutrient deficiencies are suspected.
Dietitians interview patients and/or families to obtain a nutrition history, which may include
information on current dietary habits; recent changes in intake or appetite; intake of snacks;
alcohol consumption; food allergies and intolerances; ethnic, cultural, or religious diet influences; nutrition knowledge and beliefs; and use of supplements. A nutrition history can help
differentiate nutrition problems caused by inadequate intake from those caused by disease.
Dietitians usually calculate estimated calorie and protein requirements based on the
assessment data and determine whether the diet ordered is adequate and appropriate for
the individual.
Dietitians determine nutrition diagnoses that define the nutritional problem, etiology,
and signs and symptoms. While a nursing diagnosis statement may begin with “Altered
nutrition: eating less than the body needs,” a nutrition diagnosis would be more specific,
such as “Inadequate protein–energy intake.”
Dietitians may also determine the appropriate malnutrition diagnosis code for the patient
for hospital reimbursement purposes.
Nutrition interventions may include requesting a diet order change, requesting additional
laboratory tests to monitor nutritional repletion, and performing nutrition counseling or
education.
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6
UNIT
1
Principles of Nutrition
NUTRITION IN THE NURSING PROCESS
In nursing care plans, nutrition may be part of the assessment data, diagnosis, plan,
implementation, or evaluation. The remainder of this chapter is intended to help nurses
provide quality nursing care that includes basic nutrition, not to help nurses become
dietitians.
Assessment
Subjective Global
Assessment (SGA):
a clinical method of
assessing nutritional
status based on findings
in a health history and
physical examination.
It is well recognized that malnutrition is a major contributor to morbidity, mortality, impaired quality of life, and prolonged hospital stays (White et al., 2012). However, there is
currently no single, universally agreed upon method to assess or diagnose malnutrition.
Approaches vary widely and may lack sensitivity (the ability to diagnose all people who
are malnourished) and specificity (misdiagnosing a well-nourished person). For instance,
albumin and prealbumin have been used as diagnostic markers of malnutrition. These proteins are now known to be negative acute phase proteins, which means their levels decrease in response to inflammation and physiologic stress. Because they are not specific
for nutritional status, failure of these levels to increase with nutrition repletion does not
mean that nutrition therapy is inadequate (Fessler, 2008). Although their usefulness in
diagnosing malnutrition is limited, these proteins may help identify patients at high risk for
morbidity, mortality, and malnutrition (Banh, 2006). BMI and some or all of the components of a subjective global assessment (Box 1.1) are commonly used to assess nutrition
(Fessler, 2008).
Medical History and Diagnosis
The chief complaint and medical history may reveal disease-related risks for malnutrition
and whether inflammation is present (Fig. 1.3). Patients with gastrointestinal symptoms or
disorders are among those who are most prone to malnutrition, particularly when symptoms
such as nausea, vomiting, diarrhea, and anorexia last for more than 2 weeks. Box 1.2 lists
psychosocial factors that may impact intake or requirements and help identify nutrition
counseling needs.
Box 1.1
CRITERIA INCLUDED
IN
Weight Change
■ Unintentional weight loss and the time
period of loss
Functional Capacity
■ Normal or suboptimal; ambulatory or
bedridden
Dietary Intake
■ Change from normal, duration, type of
diet consumed
Disease and Its Relation to Nutritional
Requirements
■ Primary diagnosis; severity of metabolic
stress
Gastrointestinal Symptoms Lasting
Longer than 2 Weeks
■ Nausea, vomiting, diarrhea, anorexia
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SUBJECTIVE GLOBAL ASSESSMENT
Physical Signs and Severity of Findings
■ Loss of subcutaneous fat (triceps, chest),
muscle wasting (quadriceps, deltoids),
ankle edema, sacral edema, ascites
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Chronic illness
(e.g., cancer, AIDS, COPD)
Inadequate intake/
nutrient availability
(anorexia, malabsorption)
Acute illness
(e.g., infection,
trauma, pancreatitis)
■ FIGURE 1.3
Malnutrition
Inflammation/
catabolism
Frequent infection,
altered GI function
Factors that may be involved in the etiology of illness-related malnutrition.
Body Mass Index
Body Mass Index:
an index of weight in
relation to height that
is calculated mathematically by dividing weight
in kilograms by the
square of height in
meters.
Q U I C K
Interpreting BMI
⬍18.5
18.5–24.9
25–29.9
30–34.9
35–39.9
ⱖ40
Box 1.2
underweight
healthy weight
overweight
obesity class 1
obesity class 2
obesity class 3
Body mass index (BMI) is an index of a
person’s weight in relation to height used
to estimate relative risk of health problems
related to weight. Because it is relatively
quick and easy to measure height and weight
and requires little skill, actual measures, not
estimates, should be used whenever possible
to ensure accuracy and reliability. A patient’s
stated height and weight should be used only
when there are no other options.
PSYCHOSOCIAL FACTORS THAT MAY INFLUENCE INTAKE,
NUTRITIONAL REQUIREMENTS, OR NUTRITION COUNSELING
Psychological Factors
■ Depression
■ Eating disorders
■ Psychosis
■
Social Factors
Illiteracy
■ Language barriers
■ Limited knowledge of nutrition and food
safety
■ Altered or impaired intake related to
culture
■ Altered or impaired intake related to
religion
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B I T E
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Lack of caregiver or social support
system
Social isolation
Lack of or inadequate cooking
arrangements
Limited or low income
Limited access to transportation to
obtain food
Advanced age (older than 80 years)
Lack of or extreme physical activity
Use of tobacco or recreational drugs
Limited use or knowledge of community
resources
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“Healthy” or “normal” BMI is defined numerically as 18.5 to 24.9. Values above and
below this range are associated with increased health risks. Although BMI can be calculated with a mathematical formula, tables and nomograms are available for convenience
(see Chapter 14). One drawback of using BMI is that a person can have a high BMI and
still be undernourished in one or more nutrients if intake is unbalanced or if nutritional
needs are high and intake is inadequate.
Weight Change
Unintentional weight loss is a well-validated indicator of malnutrition (White et al., 2012).
The significance of weight change is evaluated after the percentage of usual body weight
lost in a given period of time is calculated (Box 1.3). Usually, weight changes are more
reflective of chronic, not acute, changes in nutritional status. The patient’s weight can be
unreliable or invalid due to hydration status. Edema, anasarca, fluid resuscitation, heart
failure, and chronic liver or renal disease can falsely inflate weight.
Dietary Intake
A decrease in intake compared to the patient’s normal intake may indicate nutritional
risk. However, like other data, validity and reliability may be an issue. Although the nurse
may only be required to fill in a blank space next to the word “appetite,” simply asking the client “How is your appetite?” will probably not provide sufficient information.
A better question may be “Has the type or amount of food you eat recently changed?
If so, please explain.” Consuming only liquids and severely limiting the type or amount
of food are risks.
Another question to avoid while obtaining a nursing history is “Are you on a diet?” To
many people, diet is synonymous with weight loss diet; they may fail to mention they use
nutrition therapy to avoid sodium, modify fat, or count carbohydrates. A better question
would be, “Do you avoid any particular foods?” or “Do you watch what you eat in any
way?” Even the term “meal” may elicit a stereotypical mental picture. Questions to consider
when asking a client about his or her usual intake appear in Box 1.4.
Box 1.3
CALCULATING
AND
EVALUATING PERCENT WEIGHT CHANGE
Calculating Percent Weight Change
(usual body weight ⫺ current body weight)
% weight change ⫽ _____ ⫻ 100
usual body weight
Significant Unintentional Weight Loss
Time Period
(% of Weight Lost)
1 week
1 month
3 months
6 months
⬎2
⬎5
⬎7.5
⬎10
Source: Academy of Nutrition and Dietetics. (2012). Nutrition Care Manual. Available at http://nutritioncaremanual
.org/content.cfm?ncm_content_id=79554. Accessed on 8/16/2012.
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Box 1.4
QUESTIONS
9
TO
CONSIDER ABOUT INTAKE
How many meals and snacks do you eat in a 24-hour period? This question helps to
establish the pattern of eating and identifies unusual food habits such as pica, food
faddism, eating disorders, and meal skipping.
Do you have any food allergies or intolerances, and, if so, what are they? The greater the
number of foods restricted or eliminated in the diet, the greater the likelihood of nutritional deficiencies. This question may also shed light on the client’s need for nutrition
counseling. For instance, clients with hiatal hernia who are intolerant of citrus fruits and
juices may benefit from counseling on how to ensure an adequate intake of vitamin C.
What types of vitamin, mineral, herbal, or other supplements do you use and why?
A multivitamin, multimineral supplement that provides 100% or less of the daily
value offers some protection against less than optimal food choices. Folic acid in
supplements or fortified food is recommended for women of childbearing age;
people older than 50 years are encouraged to obtain vitamin B12 from fortified foods or
supplements. However, potential problems may arise from other types or amounts
of supplements. For instance, large doses of vitamins A, B6, and D have the potential
to cause toxicity symptoms. Iron supplements may decrease zinc absorption and
negatively impact zinc status over time.
What concerns do you have about what or how you eat? This question places the
responsibility of healthy eating with the client, where it should be. A client who may
benefit from nutrition intervention and counseling in theory may not be a candidate for
such in practice depending on his or her level of interest and motivation. This question
may also shed light on whether or not the client understands what he or she should be
eating and whether the client is willing to make changes in eating habits.
For clients who are acutely ill: How has illness affected your choice or tolerance of
food? Sometimes, food aversions or intolerances can shed light on what is going
on with the client. For instance, someone who experiences abdominal pain that is
relieved by eating may have a duodenal ulcer. Clients with little or no intake of food
or liquids are at risk for dehydration and nutrient deficiencies.
Who prepares the meals? This person may need nutritional counseling.
Do you have enough food to eat? Be aware that pride and an unwillingness to admit inability to afford an adequate diet may prevent some clients and families from answering this
question. For hospitalized clients, it may be more useful to ask the client to compare the
size of the meals they are served in the hospital with the size of meals they normally eat.
How much alcohol do you consume daily? Risk begins at more than one drink daily for
women and more than two drinks daily for men.
Physical Findings
Subclinical:
asymptomatic.
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Loss of subcutaneous fat, such as in the triceps and chest, muscle wasting in the quadriceps
and deltoids, ankle edema, sacral edema, and ascites may be indicative of malnutrition.
These abnormal findings are subjectively assessed as mild, moderate, or severe.
Box 1.5 lists other physical findings that may suggest malnutrition. Most physical symptoms cannot be considered diagnostic because evaluation of “normal” versus “abnormal”
findings is subjective, and the signs of malnutrition may be nonspecific. For instance, dull,
dry hair may be related to severe protein deficiency or to overexposure to the sun or use
of hair products such as colorants. In addition, physical signs and symptoms of malnutrition can vary in intensity among population groups because of genetic and environmental
differences. Lastly, physical findings occur only with overt malnutrition, not subclinical
malnutrition.
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Box 1.5
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PHYSICAL SYMPTOMS SUGGESTIVE
OF
MALNUTRITION
Hair that is dull, brittle, or dry, or falls out easily
Swollen glands of the neck and cheeks
Dry, rough, or spotty skin that may have a sandpaper feel
Poor or delayed wound healing or sores
Thin appearance with lack of subcutaneous fat
Muscle wasting (decreased size and strength)
Edema of the lower extremities
Weakened hand grasp
Depressed mood
Abnormal heart rate, heart rhythm, or blood pressure
Enlarged liver or spleen
Loss of balance and coordination
Nursing Diagnosis
A diagnosis is made after assessment data are interpreted. Nursing diagnoses in hospitals
and long-term care facilities provide written documentation of the client’s status and serve
as a framework for the plan of care that follows. The diagnoses relate directly to nutrition
when the pattern of nutrition and metabolism is the problem. Other nursing diagnoses,
while not specific for nutrition, may involve nutrition as part of the plan, such as teaching
the patient how to increase fiber intake to relieve the nursing diagnosis of constipation.
Box 1.6 lists nursing diagnoses with nutritional significance.
Planning: Client Outcomes
Outcomes, or goals, should be measurable, attainable, specific, and client centered. How
do you measure success against a vague goal of “gain weight by eating better”? Is “eating
better” achieved by adding butter to foods to increase calories or by substituting 1% milk
for whole milk because it is heart healthy? Is a 1-pound weight gain in 1 month acceptable
or is 1 pound/week preferable? Is 1 pound/week attainable if the client has accelerated
metabolism and catabolism caused by third-degree burns?
Client-centered outcomes place the focus on the client, not the health-care provider;
they specify where the client is heading. Whenever possible, give the client the opportunity
to actively participate in goal setting, even if the client’s perception of need differs from
yours. In matters that do not involve life or death, it is best to first address the client’s concerns. Your primary consideration may be the patient’s significant weight loss during the
last 6 months of chemotherapy, whereas the patient’s major concern may be fatigue. The
two issues are undoubtedly related, but your effectiveness as a change agent is greater if you
approach the problem from the client’s perspective. Commitment to achieving the goal is
greatly increased when the client “owns” the goal.
Keep in mind that the goal for all clients is to consume adequate calories, protein, and
nutrients using foods they like and tolerate as appropriate. If possible, additional short-term
goals may be set to alleviate symptoms or side effects of disease or treatments and to prevent
complications or recurrences if appropriate. After short-term goals are met, attention can
expand to promoting healthy eating to reduce the risk of chronic diet-related diseases such
as obesity, diabetes, hypertension, and atherosclerosis.
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Box 1.6
11
SELECTED NURSING DIAGNOSES
Pattern Nutrition and Metabolic
High risk for altered nutrition: intake
exceeds the body’s needs
Altered nutrition: intake exceeds the
body’s needs
Altered nutrition: eating less than the
body needs
Effective breastfeeding
Ineffective breastfeeding
Interrupted breastfeeding
Ineffective infant feeding pattern
High risk of aspiration
Swallowing disorder
Altered oral mucosa
High risk for fluid volume deficits
Fluid volume deficits
Excess fluid volume
High risk for impaired skin integrity
Impaired skin integrity
Impaired tissue integrity
High risk for altered body temperature
Ineffective thermoregulation
Hyperthermia
Hypothermia
WITH
NUTRITIONAL SIGNIFICANCE
Examples of Other Diagnoses in Which
Nutrition Interventions May Be Part of
the Care Plan
Altered health maintenance
Ineffective management of therapeutic
regimen
Infection
Constipation
Diarrhea
Bowel incontinence
Altered urinary excretion
Impaired physical mobility
Fatigue
Self-care deficit: feeding
Household altered
Altered tissue perfusion
Pain
Chronic pain
Alterations sensory/perceptual
Unilateral oblivion
Knowledge deficits
Anxiety
Body image disorder
Social isolation
Ineffective individual coping
Ineffective family coping
Defensive coping
Nursing Interventions
What can you or others do to effectively and efficiently help the client achieve his or her
goals? Interventions may include nutrition therapy and client teaching.
Nutrition Therapy
Throughout this book, the heading “Nutrition Therapy” is used in place of “Diet” because,
among clients, diet is a four-letter word with negative connotations, such as counting calories, deprivation, sacrifice, and misery. A diet is viewed as a short-term punishment to
endure until a normal pattern of eating can resume. Clients respond better to terminology
that is less emotionally charged. Terms such as eating pattern, food intake, eating style, or
the food you eat may be used to keep the lines of communication open.
Nutrition therapy recommendations are usually general suggestions to increase/
decrease, limit/avoid, reduce/encourage, or modify/maintain aspects of the diet because
exact nutrient requirements are determined on an individual basis. Where more precise
amounts of nutrients are specified, consider them as a starting point and monitor the client’s
response. Box 1.7 highlights formulas for calculating calorie and protein requirements.
Nutrition theory does not always apply to practice. Factors such as the client’s prognosis, outside support systems, level of intelligence and motivation, willingness to comply, emotional health, financial status, religious or ethnic background, and other medical
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Box 1.7
CALCULATING ESTIMATED NEEDS
A “rule-of-thumb” method of estimating calorie requirements:
Multiply weight in kg by
30 cal/kg for most healthy adults
25 cal/kg for elderly adults
20–25 cal/kg for obese adults
Example: For an adult weighing 154 pounds:
154 pounds ⫼ 2.2 kg/pound ⫽ 70 kg
70 kg ⫻ 30 cal/kg ⫽ 2100 cal/day
Estimating protein requirements
Healthy adults need 0.8 g protein/kg
Example: For an adult weighing 154 pounds:
154 pounds ⫼ 2.2 kg/pound ⫽ 70 kg
70 kg ⫻ 0.8 g/kg ⫽ 56 g protein/day
conditions may cause the optimal diet to be impractical in either the clinical or the home
setting. Generalizations do not apply to all individuals at all times. Also, comfort foods
(e.g., chicken soup, mashed potatoes, ice cream) are valuable for their emotional benefits
if not nutritional ones. Honor clients’ requests for individual comfort foods whenever possible. Box 1.8 suggests ways the nurse can promote an adequate intake.
Client Teaching
Compared with “well” clients, patients in a clinical setting may be more receptive to nutritional
advice, especially if they feel better by doing so or are fearful of a relapse or complications. But
hospitalized patients are also prone to confusion about nutrition messages. The patient’s ability to assimilate new information may be compromised by pain, medication, anxiety, or a distracting setting. Time spent with a dietitian or diet technician learning about a “diet” may be
Box 1.8
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WAYS
TO
PROMOTE
AN
ADEQUATE INTAKE
Reassure clients who are apprehensive about eating.
Encourage a big breakfast if appetite deteriorates throughout the day.
Advocate discontinuation of intravenous therapy as soon as feasible.
Replace meals withheld for diagnostic tests.
Promote congregate dining if appropriate.
Question diet orders that appear inappropriate.
Display a positive attitude when serving food or discussing nutrition.
Order snacks and nutritional supplements.
Request assistance with feeding or meal setup.
Get the patient out of bed to eat if possible.
Encourage good oral hygiene.
Solicit information on food preferences.
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Box 1.9
■
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WAYS
13
TO
FACILITATE CLIENT
AND
FAMILY TEACHING
Listen to the client’s concerns and ideas.
Encourage family involvement if appropriate.
Reinforce the importance of obtaining adequate nutrition.
Help the client to select appropriate foods.
Counsel the client about drug–nutrient interactions.
Avoid using the term “diet.”
Emphasize things “to do” instead of things “not to do.”
Keep the message simple.
Review written handouts with the client.
Advise the client to avoid foods that are not tolerated.
brief or interrupted, and the patient may not even know what questions to ask until long after
the dietitian is gone. Box 1.9 suggests ways nurses can facilitate client and family teaching.
Monitoring and Evaluation
In the “Nursing Process” sections of this textbook, monitoring and evaluation are grouped
together, even though they are different in practice. In reality, monitoring precedes evaluation as a way to stay on top of progress or difficulties the client is experiencing. Box 1.10
offers general monitoring suggestions. Evaluation assesses whether client outcomes were
achieved after the nursing care plan was given time to work. Given the limitations inherent
in an abstract nursing care plan, monitoring and evaluation are combined in this textbook.
Ideally, the client’s outcomes are achieved on a timely basis, and evaluation statements
are client outcomes rewritten from “the client will” to “the client is.” In reality, outcomes
may be only partially met or not achieved at all; in those instances, it is important to determine why the result was less than ideal. Were the outcomes realistic for this particular client?
Were the interventions appropriate and consistently implemented? Evaluation includes
deciding whether to continue, change, or abolish the plan.
Consider a male client admitted to the hospital for chronic diarrhea. During the 3 weeks
before admission, the client experienced significant weight loss due to malabsorption secondary to diarrhea. Your goal is for the client to maintain his admission weight. Your interventions are to provide small meals of low-residue foods as ordered, to eliminate lactose
because of the likelihood of intolerance, to increase protein and calories with appropriate
Box 1.10
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MONITORING SUGGESTIONS
Observe intake whenever possible to judge the adequacy.
Document appetite and take action when the client does not eat.
Order supplements if intake is low or needs are high.
Request a nutritional consult.
Assess tolerance (i.e., absence of side effects).
Monitor weight.
Monitor progression of restrictive diets. Clients who are receiving nothing by mouth
(NPO), who are restricted to a clear liquid diet, or who are receiving enteral or parenteral nutrition are at risk for nutritional problems.
Monitor the client’s grasp of the information and motivation to change.
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nutrient-dense supplements, and to explain the nutrition therapy recommendations to the
client to ease his concerns about eating. You find that the client’s intake is poor because of
lack of appetite and a fear that eating and drinking will promote diarrhea. You notify the
dietitian who counsels the client about low-residue foods, obtains likes and dislikes, and
urges the client to think of the supplements as part of the medical treatment, not as a food
eaten for taste or pleasure. You document intake and diligently encourage the client to eat
and drink everything served. However, the client’s weight continues to drop. You attribute
this to his reluctance to eat and to the slow resolution of diarrhea related to inflammation.
You determine that the goal is still realistic and appropriate but that the client is not willing
or able to consume foods orally. You consult with the physician and dietitian about the
client’s refusal to eat and the plan changes from an oral diet to tube feeding.
HOW DO YOU RESPOND?
Should I save my menus from the hospital to help me plan meals at home? This is
not a bad idea if the in-house and discharge food plans are the same, but the menus
should serve as a guide, not a gospel. Just because shrimp was never on the menu
doesn’t mean it is taboo. Likewise, if the client hated the orange juice served every
morning, he or she shouldn’t feel compelled to continue drinking it. By necessity, hospital menus are more rigid than at-home eating plans.
Can you just tell me what to eat and I’ll do it? A black-and-white approach should be
used only when absolutely necessary, such as for food allergies or for clients who insist on
a rigid plan rather than the freedom to make choices. In most cases, flexible and individualized guidelines and recommendations will promote the greatest chance of compliance.
Urge the client not to think of foods as “good” or “bad” but rather “more healthy” and
“less healthy,” except in situations of food allergy or intolerance. In most other cases,
foods are negotiable.
CASE STUDY
Steven is a 44-year-old male who is 5 ft 11 in tall and weighs 182 pounds. Over the last
month, he has lost approximately 10 pounds, which he blames on loss of appetite and
fatigue. When he went to his family doctor with flu-like symptoms, a blood test revealed a
very high white blood cell count, low platelet count, and low hemoglobin. The doctor told
him to proceed to the hospital for admission to rule out acute leukemia. Further laboratory
tests are pending. Admitting orders include a regular diet. Steven does not have a significant medical history. He is married, has three children, and enjoys a successful career.
Calculate and evaluate Steven’s weight according to the following standards:
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BMI
Percent weight change
Based on Steven’s weight and weight change, is he at nutritional risk?
Does Steven’s possible diagnosis place him at nutritional risk?
What other criteria would help determine his level of risk?
Calculate his estimated calorie requirements. Calculate his Recommended Dietary
Allowance (RDA) for protein.
If he is treated for leukemia, his protein need may increase to approximately 1.2 g protein/kg.
How much would he then require?
The hospital’s diet manual says that, on average, a regular diet provides 2400 calories
and 90 g of protein. Is this diet adequate to meet his needs?
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STUDY QUESTIONS
1. Nurses are in an ideal position to
a. Screen patients for risk of malnutrition
b. Order therapeutic diets
c. Conduct comprehensive nutrition assessments
d. Calculate a patient’s calorie and protein needs
2. How much weight would a 200-pound adult need to lose in a month to be considered
significant?
a. It depends on the patient’s BMI.
b. More than 5 pounds
c. More than 7.5 pounds
d. More than 10 pounds
3. Which of the following criteria would most likely be on a nutrition screen in the hospital?
a. Prealbumin value
b. Weight change
c. Serum potassium value
d. Cultural food preferences
4. Which of the following statements is accurate regarding physical signs and symptoms
of malnutrition?
a. “Physical signs of malnutrition appear before changes in weight or laboratory
values occur.”
b. “Physical signs of malnutrition are suggestive, not definitive, for malnutrition.”
c. “Physical signs are easily identified as ‘abnormal.’”
d. “All races and genders exhibit the same intensity of physical changes in response
to malnutrition.”
5. Your patient has a question about the cardiac diet the dietitian reviewed with him
yesterday. What is the nurse’s best response?
a. “Ask your doctor when you go for your follow-up appointment.”
b. “What is the question? If I can’t answer it, I will get the dietitian to come back to
answer it.”
c. “Just do your best. The handout she gave you is simply a list of guidelines, not
rigid instructions.”
d. “If I see the dietitian around, I will tell her you need to see her.”
6. Which of the following statements is true regarding albumin?
a. Albumin is a reliable and sensitive indicator of protein status.
b. An increase in serum albumin accurately reflects the adequacy of nutrition therapy.
c. An increase in albumin levels means nutrition therapy is adequate.
d. Low albumin is associated with morbidity, mortality, and risk of malnutrition
because it reflects severity of illness.
KEY CONCEPTS
■ Nutrition is an integral part of nursing care. Like air, food is a basic human need.
■ Nutrition screening is used to identify patients or clients who may be at risk for
malnutrition. Screening tools are simple, quick, easy to use, and rely on available data.
■ The Joint Commission stipulates that nutrition screens be performed within 24 hours
of admission to a health-care facility, but facilities are free to decide what criteria to
include on a screen, what findings indicate risk, and who is to conduct the screen.
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Screens are often the responsibility of staff nurses because they can be completed
during a history and physical examination upon admission.
Patients who are identified to be a low or no nutritional risk are rescreened within a
specified period of time to determine whether their nutritional risk status has changed.
Patients who are found to be a moderate to high nutritional risk at screening receive
a comprehensive nutritional assessment by the dietitian that includes the steps of
assessment, diagnosis, intervention, and monitoring and evaluation.
Dietitians use information from the nursing history and physical examination to begin
the assessment process. They may also obtain a nutritional history from the patient, calculate estimated protein and calorie needs, assess the adequacy and appropriateness of
the diet order, and identify the patient’s diagnostic code for malnutrition, if appropriate.
Nurses can integrate nutrition into the nursing care process to develop care plans that
address the individual’s needs. Nurses are not expected to be dietitians but rather use
nutrition to provide quality nursing care.
Albumin and prealbumin are not valid criteria for assessing protein status because they
become depleted from inflammation and physiologic stress.
Accurate height and weight are essential for assessing risk and monitoring progress.
They are used to determine BMI and percentage of weight loss. Significant unintentional
weight loss is defined according to the length of time over which the loss occurred.
Dietary data can help determine whether a nutrition problem is caused by intake or
by illness or its treatments. The term diet inspires negative feelings in most people.
Replace it with eating pattern, eating style, or foods you normally eat to avoid negative
connotations.
People with gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and
anorexia, that last more than 2 weeks are at risk for malnutrition.
Physical signs and symptoms of malnutrition are nonspecific, subjective, and develop
slowly and should be considered suggestive, not diagnostic, of malnutrition.
Medical–psychosocial history can reveal factors that influence intake, nutritional
requirements, or nutrition counseling needs.
Medications and nutritional supplements should be evaluated for their potential impact
on nutrient intake, absorption, utilization, or excretion.
Nursing diagnoses relate directly to nutrition when the pattern of nutrition or metabolism is altered. Many other nursing diagnoses, such as constipation, impaired skin integrity, knowledge deficits, and infection, may include nutrition in some aspect of the plan.
A nutrition priority for all clients is to obtain adequate calories and nutrients based on
individual needs.
Short-term nutrition goals are to attain or maintain adequate weight and nutritional
status and (as appropriate) to avoid nutrition-related symptoms and complications of
illness. Client-centered outcomes should be measurable, attainable, and specific.
Intake recommendations are not always appropriate for all persons; what is recommended in theory may not work for an individual. Clients may revert to comfort foods
during periods of illness or stress.
Nurses can reinforce nutrition counseling provided by the dietitian and initiate counseling for clients with low or mild risk.
Use preprinted lists of “do’s” and “don’ts” only if absolutely necessary, such as in the
case of food allergies. For most people, actual food choices should be considered in
view of how much and how often they are eaten rather than as foods that “must” or
“must not” be consumed.
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C h e c k Yo u r K n o w l e d g e A n s w e r K e y
1. FALSE The nurse is in an ideal position to provide nutrition information to patients and
their families since he or she is the one with the greatest client contact.
2. TRUE Nutritional screening uses a small number of factors to identify patients or
clients with malnutrition or at risk of malnutrition.
3. FALSE Hospitals and health-care facilities are free to decide what criteria they will use
to identify risk for malnutrition and what defines risk. For instance, one hospital may
use acute pancreatitis as a high-risk diagnosis, whereas another may not.
4. FALSE Changes in weight may be slow to occur. Weight changes are more reflective
of chronic, not acute, changes in nutritional status.
5. TRUE A person can be malnourished without being underweight. Weight does not
provide qualitative information about body composition.
6. FALSE Low serum albumin levels may be caused by problems other than protein malnutrition, such as injury, infection, overhydration, and liver disease.
7. TRUE Weight loss is judged as significant if there is a 5% loss over the course of
1 month.
8. TRUE People who take five or more prescription drugs, over-the-counter drugs, or
dietary supplements are at increased risk for developing drug-induced nutrient
deficiencies.
9. TRUE Determining what the patient normally eats can help diagnose the role of intake
in the nutritional problem as primary, secondary, or insignificant.
10. TRUE Physical signs and symptoms of malnutrition develop only after other signs of
malnutrition, such as laboratory values and weight changes, are observed.
Student Resources on
For additional learning materials, activate the code in the front of this book at
http://thePoint.lww.com/activate
Websites
For more on the nutrition care process used by dietitians, go to http://www.eatright.org/
HealthProfessionals/content.aspx?id=5902
Find tools to assess dietary intake in well people at http://fnic.nal.usda.gov/dietary-guidance/
dietary-assessment
References
Academy of Nutrition and Dietetics. (2012). Nutrition Care Manual. Available at http://www
.nutritioncaremanual.org. Accessed on 8/15/12.
Banh, L. (2006). Serum proteins as markers of nutrition: What are we treating? Practical
Gastroenterology, 30, 46–64.
Fessler, T. (2008). Malnutrition: A serious concern for hospitalized patients. Today’s Dietitian, 10,
44–48.
White, J., Guenter, P., Jensen, G., Malone, A., Schofield, M., Academy Malnutrition Work
Group, . . . ASPEN Board of Directors. (2012). Consensus statement of the Academy of
Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics
recommended for the identification and documentation of adults malnutrition (undernutrition).
Journal of the Academy of Nutrition and Dietetics, 112, 730–738.
Dudek_CH01.indd 17
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2
Carbohydrates
CHECK YOUR KNOWLEDGE
TRUE
FALSE
1 Starch is made from glucose molecules.
2 Sugar is higher in calories than starch.
3 The sugar in fruit is better for you than the sugar in candy.
4 Most commonly consumed American foods provide adequate fiber to enable people to
meet the recommended intake.
5 Enriched wheat bread is nutritionally equivalent to whole wheat bread.
6 Soft drinks and energy/sports drinks contribute more added sugars to the typical
American diet than any other food or beverage.
7 Bread is just as likely as candy to cause cavities.
8 The sugar content on food labels refers only to added sugars, not those naturally present
in the food.
9 The safety of nonnutritive sweeteners is questionable.
10 Sugar causes hyperactivity in kids.
LEARNING OBJECTIVES
U p o n c o m p l e t i o n o f t h i s c h a p t e r, y o u w i l l b e a b l e t o
1
2
3
4
5
6
7
Classify the type(s) of carbohydrate found in various foods.
Describe the functions of carbohydrates.
Modify a menu to ensure that the adequate intake for fiber is provided.
Calculate the calorie content of a food that contains only carbohydrates.
Debate the usefulness of using glycemic load to make food choices.
Suggest ways to limit sugar intake.
Discuss the benefits and disadvantages of using sugar alternatives.
18
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CHAPTER
2
Carbohydrates
19
CARBOHYDRATES
Sugar and starch come to mind when people hear the word “carbs,” but carbohydrates
are so much more than just table sugar and bread. Foods containing carbohydrates can be
empty calories, nutritional powerhouses, or something in between. Globally, carbohydrates
provide the majority of calories in almost all human diets.
This chapter describes what carbohydrates are, where they are found in the diet, and
how they are handled in the body. Recommendations regarding intake and the role of carbohydrates in health are presented.
Carbohydrate Classifications
Carbohydrates (CHO):
a class of energyyielding nutrients that
contain only carbon,
hydrogen, and oxygen,
hence the common
abbreviation of CHO.
Simple Sugars: a
classification of carbohydrates that includes
monosaccharides and
disaccharides; commonly
referred to as sugars.
Complex
Carbohydrates: a
group name for starch,
glycogen, and fiber;
composed of long chains
of glucose molecules.
Monosaccharide:
single (mono) molecules
of sugar (saccharide);
the most common monosaccharides in foods are
hexoses that contain six
carbon atoms.
Disaccharide: “double
sugar” composed of two
(di) monosaccharides
(e.g., sucrose, maltose,
lactose).
Polysaccharides:
carbohydrates consisting
of many (poly) sugar
molecules.
Starch: the storage form
of glucose in plants.
Carbohydrates (CHO) are comprised of the elements carbon, hydrogen, and oxygen
arranged into basic sugar molecules. They are classified as either simple sugars or complex
carbohydrates (Fig. 2.1).
Simple Sugars
Simple sugars contain only one (mono-) or two (di-) sugar (saccharide) molecules; they
vary in sweetness and sources (Table 2.1). Monosaccharides, such as glucose, fructose,
and galactose, are absorbed “as is” without undergoing digestion; disaccharides, such as
sucrose (table sugar), maltose, and lactose, must be split into their component monosaccharides before they can be absorbed.
Glucose, also known as dextrose, is the simple sugar of greatest distinction: it circulates
through the blood to provide energy for body cells; it is a component of all disaccharides
and is virtually the sole constituent of complex carbohydrates; and it is the sugar to which
the body converts all other digestible carbohydrates.
Complex Carbohydrates
Complex carbohydrates, also known as polysaccharides, are composed of hundreds to
thousands of glucose molecules linked together. Despite being made of sugar, polysaccharides do not taste sweet because their molecules are too large to fit on the tongue’s taste
bud receptors that sense sweetness. Starch, glycogen, and fiber are types of polysaccharides.
Starch. Through the process of photosynthesis, plants synthesize glucose, which they use
for energy. Glucose not used by the plant for immediate energy is stored in the form of
starch in seeds, roots, or stems. Grains, such as wheat, rice, corn, barley, millet, sorghum,
Carbohydrates
Simple sugars
■ FIGURE 2.1
Carbohydrate classifications.
Dudek_CH02.indd 19
Complex carbohydrates
Monosaccharides
Disaccharides
Polysaccharides
• glucose
• fructose
• galactose
• sucrose
• maltose
• lactose
• starch
• glycogen
• fiber
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20
UNIT
1
Principles of Nutrition
Table 2.1 Simple Sugars
Relative Sweetness
Monosaccharides
Glucose (also known as
dextrose)
Fructose (also known as
fruit sugar)
Galactose
Disaccharides
Sucrose (composed of
glucose and fructose)
70
170
60
100
Maltose (composed of
two glucose molecules)
50
Lactose (composed of
glucose and galactose)
40
Sources
Fruit, vegetables, honey, corn syrup,
cornstarch
Fruit, honey, some vegetables
Does not occur in appreciable
amounts in foods; significant only
as it combines with glucose to form
lactose
Fruit, vegetables
Extracted from sugarcane and sugar
beets into white, brown, confectioners,
and turbinado sugars
Not found naturally in foods; added
to some foods for flavoring (e.g.,
malted milk shakes) and to beer for
coloring
Is an intermediate in starch digestion
“Milk sugar”; used as an additive in
many foods and drugs
oats, and rye, are the world’s major food crops and the foundation of all diets. Other
sources of starch include potatoes, legumes, and other starchy vegetables.
Glycogen: storage
form of glucose in
animals and humans.
Glycogen. Glycogen is the animal (including human) version of starch; it is stored carbohydrate available for energy as needed. Humans have a limited supply of glycogen stored
in the liver and muscles. Liver glycogen breaks down and releases glucose into the bloodstream between meals to maintain normal blood glucose levels and provide fuel for tissues.
Muscles do not share their supply of glycogen but use it for their own energy needs. There
is virtually no dietary source of glycogen because any glycogen stored in animal tissue is
quickly converted to lactic acid at the time of slaughter. Miniscule amounts of glycogen are
found in shellfish, such as scallops and oysters, which is why they taste slightly sweet compared to other fish.
Fiber. Although there is no universally accepted definition of fiber, it is generally consid-
Insoluble Fiber:
nondigestible
carbohydrates that do
not dissolve in water.
Soluble Fiber:
nondigestible carbohydrates that dissolve
to a gummy, viscous
texture.
Dudek_CH02.indd 20
ered a group name for polysaccharides that cannot be digested by human enzymes.
These polysaccharides include cellulose, pectin, gums, hemicellulose, ␤-glucans, inulin, oligosaccharides, fructans, lignin, and some resistant starch. Often referred to as
“roughage,” fiber is found only in plants as a component of plant cell walls or intercellular structure.
Historically, fibers have been categorized as insoluble or soluble for the purpose of
assigning specific functions to each category. For instance, soluble fibers are credited with
slowing gastric emptying time to promote a feeling of fullness, delaying and blunting the
rise in postprandial serum glucose, and lowering serum cholesterol, whereas insoluble fiber
is credited with increasing stool size to promote laxation. However, there is inconsistent
evidence at best that each type has different and specific functions (American Dietetic
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CHAPTER
2
Dietary Fiber: carbohydrates and lignin that
are natural and intact
components of plants
that cannot be digested
by human enzymes.
Functional Fiber: as
proposed by the Food
and Nutrition Board,
functional fiber consists
of extracted or isolated
nondigestible carbohydrates that have beneficial physiologic effects
in humans.
Total Fiber: total fiber ⫽
dietary fiber ⫹ functional
fiber.
Carbohydrates
21
Association, 2008). In reality, although sources of fiber may be considered either soluble or
insoluble, almost all sources of fiber provide a blend of different fibers.
The National Academy of Sciences recommends that the terms insoluble and soluble be phased out in favor of ascribing specific physiologic benefits to a particular fiber.
Dietary fiber refers to intact and naturally occurring fiber found in plants; functional fiber
refers to fiber that has been isolated or extracted from plants that has beneficial physiologic
effects in the body. The sum of dietary and functional fiber equals total fiber. The rationale
for discontinuing soluble and insoluble fiber is that the amounts of soluble and insoluble
fibers measured in a mixed diet are dependent on methods of analysis that are not able to
exactly replicate human digestion.
It is commonly assumed that fiber does not provide any calories because it is not truly
digested by human enzymes and may actually trap macronutrients eaten at the same time
and prevent them from being absorbed. Yet most fibers, particularly soluble fibers, are
fermented by bacteria in the colon to produce carbon dioxide, methane, hydrogen, and
short-chain fatty acids, which serve as a source of energy (calories) for the mucosal lining
of the colon. Although the exact energy value available to humans from the blend of fibers
in food is unknown, current data indicate the value is between 1.5 and 2.5 cal/g (Institute
of Medicine, 2005).
Sources of Carbohydrates
Added Sugars: caloric
sugars and syrups
added to foods during
processing preparation
or consumed separately;
do not include sugars
naturally present in
foods, such as fructose
in fruit and lactose
in milk.
Whole Grains and
Whole Grain Flours:
contain the entire grain,
or seed, which includes
the endosperm, bran,
and germ.
Phytochemicals:
bioactive, nonnutrient
plant compounds associated with a reduced
risk of chronic diseases.
Refined Grains and
Refined Flours: consist
of only the endosperm
(middle part) of the
grain and therefore do
not contain the bran
and germ portions.
Enrichment: adding
back certain nutrients
(to specific levels)
that were lost during
processing.
Dudek_CH02.indd 21
Sources of carbohydrates include natural sugars in fruit and milk; starch in grains, vegetables, legumes, and nuts; and added sugars in foods with empty calories. Servings of
commonly consumed grains, fruit, and vegetables contain only 1 to 3 g of dietary fiber;
legumes are rich in fiber (Table 2.2). Figure 2.2 shows the average carbohydrate and fiber
content of each MyPlate food group.
Grains
This group is synonymous with “carbs” and consists of grains (e.g., wheat, barley, oats, rye,
corn, and rice) and products made with flours from grains (e.g., bread, crackers, pasta, and
tortillas).
Grains are classified as “whole” or “refined” (Box 2.1).Whole grains consist of the
entire kernel of a grain (Fig. 2.3).They may be eaten whole as a complete food (e.g., oatmeal, brown rice, or popcorn) or milled into flour to be used as an ingredient in bread,
cereal, and baked goods. Even when whole grains are ground, cracked, or flaked, they must
have the same proportion of the original three parts:
■
■
■
The bran, or tough outer coating, which provides antioxidants, iron, zinc, copper, magnesium, B vitamins, fiber, and phytochemicals.
The endosperm, the largest portion of the kernel, which supplies starch, protein, and
small amounts of vitamins and minerals.
The germ (embryo), the smallest portion of the kernel that contains B vitamins, vitamin E,
antioxidants, phytochemicals, and unsaturated fat. Its unsaturated fat content makes
whole wheat flour more susceptible to rancidity than refined flour.
Bran cereals and wheat germ are not whole grains because they come from only one part
of the whole.
“Refined” grains have most of the bran and germ removed. They are rich in starch but
lack the fiber, B vitamins, vitamin E, trace minerals, unsaturated fat, and most of the phytochemicals found in whole grains (International Food Information Council, 2009). The process
of enrichment restores some B vitamins (thiamin, riboflavin, and niacin) and iron to levels
3/28/13 4:53 AM
22
UNIT
1
Principles of Nutrition
Table 2.2 Fiber Content of Selected Foods
Food
Total Fiber (g)
Breads (1 slice)
Rye
White
Whole wheat
1.9
0.7
1.9
Cereals (½ cup)
All-Bran
Cream of Wheat
Cornflakes
Oatmeal
Puffed rice
8.8
0.6
0.3
2.0
0.1
Fruit (1 medium unless otherwise specified)
Apple with skin
Banana
Orange
Peach
Strawberries (½ cup)
Tangerine
Watermelon (½ cup)
3.3
3.0
3.0
1.5
1.6
1.5
0.3
Legumes (½ cup cooked)
Baked, vegetarian
Great northern
Lentils
Lima
Navy
White
5.2
6.2
7.8
5.4
9.5
6.3
Nuts (1 oz)
Almonds (24 nuts)
Cashews (18 nuts)
Pistachios (47 nuts)
Walnuts (14 halves)
3.3
0.9
2.8
1.9
Vegetables (½ cup cooked)
Asparagus
Broccoli
Brussels sprouts
Cabbage
Collards
Mustard greens
Sweet potato
Tomatoes
1.4
2.5
2.0
1.5
2.4
1.4
3.0
2.4
Source: U.S. Department of Agriculture National Nutrient Database for Standard Reference, Release 24.
(n.d.). Available at https://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/SR24/nutrlist/sr24a291.pdf.
Accessed 8/28/2012.
Fortified: adding
nutrients that are not
naturally present in the
food or were present in
insignificant amounts.
Dudek_CH02.indd 22
found prior to processing. Other substances that are lost, such as other vitamins, other minerals, fiber, and phytochemicals, are not replaced by enrichment. Enriched grains are also required
to be fortified with folic acid, a mandate designed to reduce the risk of neural tube defects.
Examples of refined grains include white flour, white bread, white rice, and refined cornmeal.
Whether whole or refined, a serving of grain is estimated to provide 15 g of carbohydrates. Fiber content can range from 0 g in refined grains to 10 g or more per serving
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CHAPTER
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Carbohydrates
23
GRAINS
VEGETABLES
FRUITS
DAIRY
PROTEIN FOODS
Make half your grains whole
Vary your veggies
Focus on fruits
Get your calcium-rich foods
Go lean with protein
15g carbohydrate, 1-3g fiber
in:
• 1 medium piece of fruit
• 1/ 2 cup canned fruit
• 3/ 4 cup fruit juice
12g carbohydrate, 0g fiber in:
• 1 cup milk, buttermilk,
artificially sweetened
yogurt, plain yogurt
Higher carbohydrate content
in sweetened milks and
yogurt
No carbohydrate in hard
cheeses
15g carbohydrate per 1
ounce equivalent serving,
One 1 ounce serving is about:
• 1 slice bread
• 1 cup breakfast cereal
• 1/ 2 cup cooked rice,
cereal, pasta
Fiber content varies
5g carbohydrate in 1/ 2 cup
“watery” vegetables, 15g
carbohydrate in 1/ 2 cup
“starchy” vegetables, most
vegetables have 1-3g fiber
in 1/ 2 cup
Dry peas and beans: 15g
carbohydrate, 5-8g fiber
in 1/ 2 cup
Nuts: 4-8g carbohydrate,
1-3g fiber in 1-2 oz.
No other items in this group
naturally provide
carbohydrate
■ F I G U R E 2 . 2 Carbohydrate content of MyPlate groups. (Source: U.S. Department
of Agriculture, Center for Nutrition Policy and Promotion. [2011]. Available at
www.choosemyplate.gov)
of high-fiber cereals. Some items in this group, such as sweetened ready-to-eat cereals,
muffins, and pancakes, have added sugar.
Vegetables
Starch and some sugars provide the majority of calories in vegetables, but the content varies
widely among individual vegetables. A ½ cup serving of the following “starchy” vegetables
provides approximately 15 g carbohydrates:
Corn
Legumes (e.g., pinto beans, black beans, garbanzo beans)
Lentils
Peas
Potatoes, sweet potatoes, yams
Winter squash (e.g., acorn, butternut)
Box 2.1
SOURCES
OF
WHOLE
AND
REFINED GRAINS
Whole Grains
Refined Grains
Whole wheat grain, including varieties
of spelt, emmer, faro, einkorn, bulgur,
cracked wheat, and wheat berries
Cream of Wheat, puffed wheat, refined
ready-to-eat wheat cereals
Products made with whole wheat flour,
such as 100% whole wheat bread,
whole wheat pasta, shredded wheat,
Wheaties, whole wheat tortillas,
whole wheat crackers
Products made with enriched white
or wheat flour as found in white
or wheat bread, white pasta, flour
tortillas, refined crackers
Whole oats, oatmeal, Cheerios
Oat flour
Brown rice
White rice, Rice Krispies, cream of rice,
puffed rice
Corn, popcorn
Whole-grain barley, whole rye, teff, triticale, millet, amaranth*, buckwheat*,
sorghum*, quinoa*, wild rice*
Cornstarch, grits, hominy, cornflakes
Pearled barley
*Considered whole grains but are technically not cereals but rather pseudocereals.
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24
UNIT
1
Endosperm
Storage site
for starch; main
source of flour
Provides:
protein, starch,
small amounts
of vitamins,
and trace minerals
Principles of Nutrition
Bran
Outer layer that protects rest of kernel
from sunlight, pests, water, and disease
Provides:
fiber, antioxidants, B vitamin, iron, zinc,
copper, magnesium, and phytochemicals
from sunlight, pests, water, and disease
Refined grains:
• made only from endosperm
• are enriched with
thiamin, riboflavin, niacin,
and iron lost through processing
• are fortified with folic acid
• are inferior to whole
grains in vitamin B6 , protein,
pantothenic acid, vitamin E,
fiber, phytochemicals
Germ
Embryo that
will sprout into
another plant
if fertilized
Provides:
B vitamins,
some protein,
healthy fat, vitamin E,
minerals, antioxidants,
and phytochemicals
■ F I G U R E 2 . 3 Whole
wheat. The components of the
whole wheat kernel are the
bran, the germ, and the
endosperm.
In comparison, “watery” vegetables provide 5 g carbohydrate or less per ½ cup serving:
Asparagus
Bean sprouts
Broccoli
Carrots
Green beans, wax beans
Okra
Tomatoes
The average fiber content of vegetables is 2 to 3 g per serving.
Fruits
Generally, almost all of the calories in fruit come from the natural sugars fructose and
glucose. (The exceptions to this are avocado, olives, and coconut, which get the majority of their calories from fat.) A serving of fruit, defined as ¾ cup of juice, 1 piece
of fresh fruit, ½ cup of canned fruit, or ¼ cup of dried fruit, provides 15 g carbohydrate and approximately 2 g fiber. Because
fiber is located in the skin of fruits, fresh
Fiber (g/serving)
whole fruits provide more fiber than do
Unpeeled fresh apple (1)
3.0
fresh peeled fruits, canned fruits, or fruit
1.9
Peeled fresh apple (1)
juices. The effect of processing on fiber
Applesauce (½ cup)
1.5
content is demonstrated in the examples
Apple juice (¾ cup)
Negligible
on the left.
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CHAPTER
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Carbohydrates
25
Dairy
Although milk is considered a “protein,” more of milk’s calories come from carbohydrate
than from protein. One cup of milk, regardless of the fat content, provides 12 g of carbohydrate in the form of lactose. Flavored milk
and yogurt have added sugars, as do ice
Carbohydrate (g)
cream, ice milk, and frozen yogurt. With
the exception of cottage cheese, which has
Milk, 8 oz
12
26
Chocolate milk, 8 oz
about 6 g of carbohydrate per cup, cheese
Plain yogurt, 8 oz
15
is virtually lactose free because lactose is
Strawberry yogurt, 8 oz
48.5
converted to lactic acid during production.
Regular vanilla ice
15.6
The carbohydrate content, including both
cream, ½ cup
natural and added sugars, of various dairy
Swiss cheese, 1 oz
1
foods is listed in the box on the left.
Empty Calories
Empty carbohydrate calories are calories that come from added sugars and syrups; these
ingredients provide calories with few or no nutrients. Sometimes, 100% of the calories in
a food are from added sugar, such as in pancake syrup, sweetened soft drinks, and hard
candies. In other products, added sugars account for only some of the caloQ U I C K B I T E
ries. For instance, in the chocolate milk
listed above, added sugars provide 14 g
Sugar content of selected “extras”
(56 empty calories) of the 26 g total
Sugar (g)
carbohydrate—the difference between
White sugar, 1 tsp
4.0
the total carbohydrate in chocolate
Brown sugar, 1 tsp
4.5
milk compared to the total carbohyJelly, 1 tsp
4.5
drate (the natural sugar lactose) in
Gelatin, ½ cup
19.0
plain milk. Only the calories of the
Cola drink, 12 oz
40.0
added sugar are considered “empty.”
How the Body Handles Carbohydrates
Digestion
Cooked starch begins to undergo digestion in the mouth by the action of salivary amylase,
but the overall effect is small because food is not held in the mouth very long (Fig. 2.4).
The stomach churns and mixes its contents, but its acid medium halts any residual effect
of the swallowed amylase. Most carbohydrate digestion occurs in the small intestine, where
pancreatic amylase reduces complex carbohydrates into shorter chains and disaccharides.
Disaccharidase enzymes (maltase, sucrase, and lactase) on the surface of the cells of
the small intestine split maltose, sucrose, and lactose, respectively, into monosaccharides.
Monosaccharides are the only form of carbohydrates the body is able to absorb intact and
the form all other digestible carbohydrates must be reduced to before they can be absorbed.
Normally, 95% of starch is digested usually within 1 to 4 hours after eating.
Absorption
Glucose, fructose, and galactose are absorbed through intestinal mucosa cells and travel to
the liver via the portal vein. Small amounts of starch that have not been fully digested pass
into the colon with fiber and are excreted in the stools. Fibers may impair the absorption of
some minerals—namely, calcium, zinc, and iron—by binding with them in the small intestine.
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26
Dudek_CH02.indd 26
3/28/13 4:53 AM
Some
Small intestine
Stomach
Mouth
Small intestine
Large
intestine
Dextrin
Salivary amylase
Starch, dextrin
Bacteria
Maltose
Pancreatic amylase
Most
Short-chain fatty
acids and gas
Fiber
Absorbed
Excreted
undigested through colon
Intestinal
brush border
Pancreas
Liver
Stomach
Salivary
glands
Glucose
+
Glucose
Maltase
(
Sucrose
Glucose
+
Galactose
Lactase
Glucose
Glucose
Fructose
Fructose
Galactose
Galactose
Monosaccharides
Absorbed through the intestinal mucosa
Glucose
+
Fructose
Sucrase
)
Lactose
Small amounts
of sucrose
fructose + glucose
Maltose
Disaccharides
■ F I G U R E 2 . 4 Carbohydrate digestion. Dietary carbohydrates include the polysaccharides or complex carbohydrates (fiber, starch, and dextrin), the disaccharides (maltose,
sucrose, and lactose), and the monosaccharides (glucose, fructose, and galactose).
Digestion begins in the mouth, where food is chewed into pieces and salivary amylase
begins the process of chemical digestion. The stomach churns and mixes the carbohydrate,
but stomach acids halt residual action of the salivary amylase. The small intestine is the
site of most carbohydrate digestion, and pancreatic amylase reduces complex carbohydrates into disaccharides. Disaccharide enzymes (maltase, sucrase, and lactase) on the surface of the small intestine cells split maltose, sucrose, and lactose into monosaccharides,
thus completing the process of carbohydrate digestion. Fiber is not digested per se, but
most is fermented by bacteria in the large intestine to yield gas, water, and short-chain
fatty acids.
Large intestine
Gallbladder
Esophagus
Tongue
Mouth
Polysaccharides
CHAPTER
2
Carbohydrates
27
Metabolism
Postprandial: following
a meal.
Fructose and galactose are converted to glucose in the liver. The liver releases glucose into
the bloodstream, where its level is held fairly constant by the action of hormones. A rise
in blood glucose concentration after eating causes the pancreas to secrete insulin, which
moves glucose out of the bloodstream and into the cells. Most cells take only as much glucose as they need for immediate energy needs; muscle and liver cells take extra glucose to
store as glycogen. The release of insulin lowers blood glucose to normal levels.
In the postprandial state, as the body uses the energy from the last meal, the blood
glucose concentration begins to drop. Even a slight fall in blood glucose stimulates the
pancreas to release glucagon, which causes the liver to release glucose from its supply of
glycogen. The result is that blood glucose levels increase to normal.
Glycemic Response
Glycemic Response:
the effect a food has
on the blood glucose
concentration; how
quickly the glucose level
rises, how high it goes,
and how long it takes to
return to normal.
It was commonly believed that sugars produce a greater increase in blood glucose levels, or
glycemic response, than complex carbohydrates because they are rapidly and completely
absorbed. This proved to be too simplistic of an assumption, as illustrated by the lower
glycemic index of cola (sugar) compared to that of baked potatoes (complex carbohydrate)
(Table 2.3). A food’s glycemic response is actually influenced by many variables including
Table 2.3 Glycemic Index and Glycemic Load of Selected Foods
Item
White spaghetti
Baked potato
White bagel
Cornflakes
Long-grain white rice
Snickers Bar
Jelly beans
Macaroni
Sweet corn
Honey
Boiled sweet potato
Shredded wheat
Coca-Cola
Steamed brown rice
Pound cake
Unsweetened clear apple juice
Banana
White bread
Chickpeas
All-Bran cereal
Reduced-fat yogurt
Watermelon
Orange
Premium ice cream
Low-fat ice cream
Peanuts
Glycemic Index
(Glucose ⴝ 100)
Glycemic Load/Serving
58
85
72
92
56
68
78
45
60
87
59
83
56
50
54
44
46
70
33
38
26
72
40
37
50
17
28
26
25
24
24
23
22
22
20
18
18
17
16
16
15
13
12
10
10
9
8
4
4
4
3
1
Source: Foster-Powell, K., Holt, S., & Brand-Miller, J. (2002). International table of glycemic index and
glycemic load values: 2002. The American Journal of Clinical Nutrition, 76, 50–56.
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28
UNIT
1
Glycemic Index: a
numeric measure of the
glycemic response of
50 g of a food sample;
the higher the number,
the higher the glycemic
response.
Glycemic Load: a
food’s glycemic index
multiplied by the
amount of carbohydrate
it contains to determine
impact on blood glucose
levels.
Principles of Nutrition
the amounts of fat, fiber, and acid in the food; the degree of processing; the method of
preparation; the amount eaten; the degree of ripeness (for fruits and vegetables); and
whether other foods are eaten at the same time.
To assess a food’s impact on blood glucose response more accurately, the concept of
glycemic index was developed. A food’s glycemic index is determined by comparing the
impact on blood glucose after 50 g of a food sample is eaten to the impact of 50 g of pure
glucose or white bread. For instance, a baked potato with a glycemic index of 76 elicits 76%
of the blood glucose response as an equivalent amount of pure glucose.
Because the amount of carbohydrate contained in a typical portion of food also influences glycemic response, the concept of glycemic load was created to define a food’s
impact on blood glucose levels more accurately (see Table 2.3). It takes into account both
the glycemic index of a food and the amount of carbohydrate in a serving of that food.
For example, watermelon has a high glycemic index of 72, but because its carbohydrate
content is low (it is mostly water), the glycemic load is only 4.
In a practical sense, glycemic load is not a reliable tool for choosing a healthy diet, and
claims that a low glycemic index diet promotes significant weight loss or helps control appetite are unfounded. Soft drinks, candy, sugars, and high-fat foods may have a low to moderate glycemic index, but these foods are not nutritious and eating them does not promote
weight loss. In addition, a food’s actual impact on glucose levels is difficult to predict because
of the many factors influencing glycemic load. However, glycemic index may help people
with diabetes fine-tune optimal meal planning (see Chapter 19), and athletes can use the
glycemic index to choose optimal fuels for before, during, and after exercise (see Chapter 7).
Functions of Carbohydrates
Glucose metabolism is a dynamic state of balance between burning glucose for energy
(catabolism) and using glucose to build other compounds (anabolism). This process is a
continuous response to the supply of glucose from food and the demand for glucose for
energy needs.
Glucose for Energy
The primary function of carbohydrates is to provide energy for cells. Glucose is burned
more efficiently and more completely than either protein or fat, and it does not leave an end
product that the body must excrete. Although muscles use a mixture of fat and glucose for
energy, the brain is totally dependent on glucose for energy. All digestible carbohydrates—
namely, simple sugars and complex carbohydrates—provide 4 cal/g. As a primary source of
energy, carbohydrates also spare protein and prevent ketosis.
Protein Sparing
Although protein provides 4 cal/g just like carbohydrates, it has other specialized functions that only protein can perform, such as replenishing enzymes, hormones, antibodies,
and blood cells. Consuming adequate carbohydrate to meet energy needs has the effect of
“sparing protein” from being used for energy, leaving it available to do its special functions.
An adequate carbohydrate intake is especially important whenever protein needs are increased such as for wound healing and during pregnancy and lactation.
Preventing Ketosis
Fat normally supplies about half of the body’s energy requirement. Yet glucose fragments
are needed to efficiently and completely burn fat for energy. Without adequate glucose, fat
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CHAPTER
2
Ketone Bodies: intermediate, acidic compounds formed from the
incomplete breakdown
of fat when adequate
glucose is not available.
Carbohydrates
29
oxidation prematurely stops at the intermediate step of ketone body formation. Although
muscles and other tissues can use ketone bodies for energy, they are normally produced only
in small quantities. An increased production of ketone bodies and their accumulation in
the bloodstream cause nausea, fatigue, loss of appetite, and ketoacidosis. Dehydration and
sodium depletion may follow as the body tries to excrete ketones in the urine.
Using Glucose to Make Other Compounds
After energy needs are met, excess glucose can be converted to glycogen, be used to make
nonessential amino acids and specific body compounds, or be converted to fat and stored.
Glycogen. The body’s backup supply of glucose is liver glycogen. Liver and muscle cells pick
up extra glucose molecules during times of plenty and join them together to form glycogen,
which can quickly release glucose in times of need. Typically one-third of the body’s glycogen
reserve is in the liver and can be released into circulation for all body cells to use, and twothirds is in muscle, which is available only for use by muscles. Unlike fat, glycogen storage is
limited and may provide only enough calories for about a half-day of moderate activity.
Nonessential Amino Acids. If an adequate supply of essential amino acids is available,
the body can use them and glucose to make nonessential amino acids.
Carbohydrate-Containing Compounds. The body can convert glucose to other
essential carbohydrates such as ribose, a component of ribonucleic acid (RNA) and deoxyribonucleic acid (DNA), keratin sulfate (in fingernails), and hyaluronic acid (found in the
fluid that lubricates the joints and vitreous humor of the eyeball).
Fat. Any glucose remaining at this point—after energy needs are met, glycogen stores are
saturated, and other specific compounds are made—is converted by liver cells to triglycerides and stored in the body’s fat tissue. The body does this by combining acetate molecules
to form fatty acids, which then are combined with glycerol to make triglycerides. Although
it sounds easy for excess carbohydrates to be converted to fat, it is not a primary pathway;
the body prefers to make body fat from dietary fat, not carbohydrates.
Dietary Reference Intakes
Total Carbohydrate
The Recommended Dietary Allowance (RDA) for total carbohydrate (starch, natural sugar,
added sugar) is set at 130 g for both adults and children, based on the average minimum
amount of glucose that is needed to fuel the brain and assuming total calorie intake is
adequate (National Research Council, 2005). Yet at this level, total calorie needs are not
met unless protein and fat intakes exceed levels considered healthy.
A more useful guideline for determining appropriate carbohydrate intake is the Acceptable Macronutrient Distribution Range (AMDR); it suggests that carbohydrates provide
45% to 65% of total calories consumed (National Research Council, 2005). As illustrated
in Figure 2.5, the carbohydrat…