The Nurse Practitioner's Guide to Nutrition E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 744

Veröffentlichungsjahr: 2012

Beschreibung

The Nurse Practitioner's Guide to Nutrition is a comprehensive clinical resource for nurse practitioners working in a variety of clinical care settings. Emphasizing practical nutrition information, this accessible guide provides guidance on incorporating nutrition history questions and counselling techniques into routine care across all clinical settings. The book begins by discussing fundamental concepts in nutrition assessment, giving readers a solid framework from which to approach subsequent chapters. Section Two focuses on nutrition from a lifespan perspective, organizing information by the issues most pertinent to patients at different stages of life. Section Three presents nutrition counselling across clinical care settings ranging from cardiology, endocrinology, oncology, and gastroenterology to caring for the obese patient. Each chapter includes essential information distilled in quick-access tabular format and clinical scenarios that apply key concepts discussed to real-world examples. Ideal for both in-training and qualified advanced practice nurses, The Nurse Practitioner's Guide to Nutrition is an essential tool for assessing, managing, and treating nutrition-related conditions, as well as promoting nutritional health for all patients. This activity has been approved for 35 nursing continuing education contact hours through the Temple University College of Health Professions and Social Work Department of Nursing Provider Unit, an approved provider of continuing nursing education by the Pennsylvania State Nurses Association, itself an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. For e-book users: CNE materials are available for download after purchase. This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from Google Play or the MedHand Store.

Leseprobe

Contents

About the Editors

Contributors

Section 1 Introduction to Nutrition Concepts

1 The Role of Nurse Prazitioners

Nutrition for Life

Assessment and Diagnosis

Effecting Change

2 Nutrition Assessment for Nurse Practitioners

Integrating Nutrition into the Assessment

Patient History

Physical Examination

Laboratory Data to Diagnose Nutritional and Medical Problems

Assessing Protein Status

Estimating Resting Energy Expenditure (REE)

Energy and Protein Needs of Hospitalized or Critically Ill Patients

Determination of the Problem List

3 Nutrition Counseling for Effective Behavior Change

Introduction

Understanding Patients’ Stage of Change

Motivational Interviewing

The Importance of Self-Efficacy

Practice What You Preach

Summary: Role of Nurse Practitioners

Section 2 Nutrition During the Lifespan

4 Nutrition from Pre-conception Through Lactation

Introduction

Obesity Rates in Pregnancy

Components of the Prenatal Evaluation

Assessing Nutrition Prior to Pregnancy

Nutritional Recommendations During Pregnancy

Maternal Nutrient Needs: Current Recommendations (RDA Shown in Appendices S and T)

Nutrition and Substance Abuse During Pregnancy

Maternal Weight-Gain Recommendations

Low Pre-Conception BMI (Underweight)

Overweight and Obesity

Conditions Affecting Nutritional Status of Pregnant Women

Diabetes During Pregnancy

Strategies for Managing Nausea, Vomiting, Heartburn, and Constipation

Lactation

5 Nutrition from Infancy Through Adolescence

Introduction

Growth

Overweight and Obesity

Laboratory Assessment

Energy and Protein Requirements

Deviations from Normal Growth

The Importance of Breakfast

Infant Nutrition

Nutrition for the Term Infant

Toddler and Preschool Nutrition

Managing the “Picky Eater”

Nutrition for School-age Children

Nutrition During Adolescence

Summary: Role of Nurse Practitioners

6 Nutrition for Older Adults

Introduction

Alterations in Nutritional Needs

Social and Economic Considerations

Cultural Issues

Health Literacy

Fluid and Hydration

Macronutrients

Identifying Individuals at Risk for Malnutrition

Nutritional Frailty

Etiology of Malnutrition

Interventions for Malnutrition and Nutritional Frailty

Summary: Role of Nurse Practitioners

Section 3 Nutrition in the Clinical Setting

7 Obesity and Bariatric Surgery Care

Introduction

Health Consequences of Obesity

Prevalence of Overweight and Obesity

Etiology of Obesity

Diagnosis and Assessment of Overweight and Obesity

Treatment of Overweight and Obesity

8 Cardiology Care

Introduction

Evidence-Base for Diet and Heart Disease

Dietary Lipids

Trans Fatty Acids

Dietary Cholesterol

Hyperlipidemia

Metabolic Syndrome

Nutrition Therapy for Hyperlipidemia and Metabolic Syndrome

Other Nutritional Components

Weight Control to Reduce the Risk of CHD

Hypertension

Heart Failure

Summary: Role of Nurse Practitioners

9 Endocrinology Care of the Diabetic Patient

Introduction

Prevalence of Diabetes

Diagnosis of Diabetes Mellitus and Pre-diabetes

Pathophysiology of Diabetes

Clinical Management of Diabetes

Community Efforts

10 Digestive Disorders and Gastrointestinal Care

Introduction

Digestion and Absorption

Gastric Disorders

Inflammatory Bowel Disease

Irritable Bowel Syndrome

Diverticulosis

Diverticulitis

Liver Disease

Gallbladder Disease: Cholelithiasis

Summary: Role of Nurse Practitioners

11 Renal Care

Introduction

Urinary Tract Infections

Nephrolithiasis (Kidney Stones)

Acute Kidney Injury

Chronic Kidney Disease (CKD)

Nephrotic Syndrome

Renal Replacement Therapy

Renal Transplantation

Herbal and Dietary Supplement Use in CKD

Summary: Role of Nurse Practitioners

12 Cancer Prevention and Oncology Care

Introduction

Obesity and Cancer

Nutrition and Cancer Prevention

Vitamins and Cancer Prevention

Minerals

Alcohol and Wine

Physical Activity Recommendations

Oncology Care

Summary: Role of Nurse Practitioners

13 Enteral and Parenteral Nutrition Support

Introduction

Enteral Nutrition Support

Parenteral Nutrition Support

Home Nutrition Support

Summary: Role of Nurse Practitioners

Appendices

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Appendix F

Appendix G

Appendix H

Appendix I

Appendix J

Appendix K

Appendix L

Appendix M

Appendix N

Appendix O

Appendix P

Appendix Q

Appendix R

Appendix S

Appendix T

Review Questions

Review Answers

Index

ENROLLMENT FORM/ANSWER SHEET

Continuing Education Activity Evaluation Form

For e-book customers

The Enrolment Form/Answer Sheet and Continuing Education Activity Evaluation Forms are available for downloading on this website:

www.wiley.com/go/hark_forms

To access the forms you will be asked for a password, which is the title of Chapter 11: “Renal Care”.

The completed forms should be sent, along with $40 and also proof of purchase to:Temple UniversityFrances Ward, PhD, RN, CRNPCollege of Health Professions and Social WorkDepartment of Nursing3307 North Broad StreetPhiladelphia, PA 19140

Make check payable to the Temple University Department of Nursing Approvedfor: 35 CE Credit Units Beginning September 1, 2012

This edition first published 2012 © 2012 by John Wiley & Sons, Inc.

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Library of Congress Cataloging-in-Publication Data

The nurse practitioner’s guide to nutrition / editors-in-chief, Lisa Hark, Kathleen Ashton, Darwin Deen. – 2nd ed. p. ; cm. Guide to nutritionIncludes bibliographical references and index.

ISBN 978-0-470-96046-2 (pbk. : alk. paper)I. Hark, Lisa. II. Ashton, Kathleen. III. Deen, Darwin. IV. Title: Guide to nutrition. [DNLM: 1. Nursing Care. 2. Nursing Assessment. 3. Nutrition Assessment. 4. Nutrition Therapy–nursing. 5. Nutritional Physiological Phenomena. WY 100] 610.73–dc23

2012005068

A catalogue record for this book is available from the British Library.

Cover design by Modern Alchemy LLC

About the Editors

Lisa Hark, PhD, RD, is Director of the Department of Research at the Wills Eye Institute and an Associate Professor at Jefferson Medical College in Philadelphia. She was ­previously Director of Nutrition Education and Prevention Program at the University of Pennsylvania School of Medicine from 1995 to 2009. Dr. Hark has broad ­experience in teaching nutrition to nurse practitioners and medical students and is a nationally known nutrition educator. She co-edited four editions of the most popular nutrition textbook for medical students, Medical Nutrition and Disease(Wiley-Blackwell), published in 1995, 1999, 2005, and 2009. She also co-edited ­several other ­Wiley-Blackwell books including: The Complete Guide to Nutrition in PrimaryCare in 2006 and Achieving Cultural Competency: A Case-Based Approach toTraining Health Professionals in 2009. Dr. Hark is also co-editor of Cardiovascular Nutrition: Disease Management and Prevention, published by the American Academy of Nutrition and Dietetics in 2004. In addition, Dr. Hark is the author ofNutritionFor Life and The Whole Grain Diet Miracle, published by Dorling Kindersley in 2005 and 2007. Aimed at consumers, these books have been translated into 15 languages and are available in paperback.

Kathleen Ashton, PhD, RN, ACNS-BC holds a Baccalaureate in Nursing from Coe College, a Masters in Nursing from the University of Maryland, and a Doctorate in Health Education from Temple University. She has taught nursing at the undergraduate and graduate levels for over 30 years and currently holds the rank of Professor of Nursing at Thomas Jefferson University, Jefferson School of Nursing in Philadelphia. Dr. Ashton’s area of practice is adult health with a specialty in cardiovascular nursing. Over the past 20 years, she has conducted numerous funded research studies on women and heart disease. Dr. Ashton has won local, state, and national awards for her research, teaching, advanced nursing practice, and public service, including the 2003 New Jersey Governor’s Merit Award for Advanced Nursing Practice. She recently served as a co-editor for the 4th edition of the book, Nursing Malpractice, and ­regularly reviews for the Journal of Clinical Nursing and the Journal of Legal Nurse Consulting.

Darwin Deen, MD, MS, is a Medical Professor at the Sophie Davis School of Biomedical Education at the City College of New York. A board certified family ­physician, Dr. Deen also holds a Masters in Human Nutrition and has been teaching nutrition to health professionals for more than 30 years. He is the author of numerous papers in peer-reviewed journals and has served as a journal contributing editor and manuscript reviewer for family medicine and nutrition journals as well as a popular nutrition text. Dr. Deen is co-editor of The Complete Guide to Nutrition in Primary Care published by Wiley-Blackwell in 2006 and co-author of Nutrition For Life and The Whole Grain Diet Miracle, published by Dorling Kindersley in 2005 and 2007. He has also served as associate editor of four editions of Medical Nutrition and Disease(Wiley-Blackwell) and the first edition of Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals(Wiley-Blackwell).

Contributors

Editors

Lisa Hark, PhD, RDDirector, Department of ResearchWills Eye InstituteAssociate Professor, Jefferson Medical CollegePhiladelphia, PAKathleen Ashton, PhD, RN, ACNS-BCProfessorSchool of NursingThomas Jefferson UniversityPhiladelphia, PADarwin Deen, MD, MSMedical ProfessorSophie Davis School of Biomedical EducationCity College of New YorkNew York, NY

Associate Editors

Michael Clark, CRNP, DRNP, CNLAssistant Professor, Department of NursingCollege of Health Professions and Social WorkTemple UniversityAssistant Director of Nursing ResearchTemple University HospitalPhiladelphia, PACarlene McAleer, RN, MS, MSN, CRNPAssistant Professor, Department of NursingCollege of Health Professions and Social WorkTemple UniversityPhiladelphia, PADiana Orenstein, RD, MsEdClinical DietitianHartford HospitalHartford, CTFrances Ward, PhD, RN, CRNPExecutive DirectorPennsylvania Action CoalitionHarrisburg, PADavid Weiss, BAResearch ManagerDepartment of ResearchWills Eye InstitutePhiladelphia, PA

Managing Editors

Deiana M. Johnson, BSResearch Assistant and Community Health EducatorDepartment of ResearchWills Eye InstitutePhiladelphia, PABianca Collymore, MSProject ManagerDepartment of ResearchWills Eye Institute

Contributors

Virginia Biddle, PhD, RN, PMHNP-BC, CPNP (Counseling)Pediatric Nurse PractitionerFamily Psychiatrist/Mental Health Nurse PractitionerDepartment of Psychiatry and Human Behavior, Division of Child and Adolescent PsychiatryThomas Jefferson UniversityJefferson University PhysiciansPhiladelphia, PACecilia Borden, EdD, MSN, RN (Elderly)Assistant Professor, School of NursingThomas Jefferson UniversityJefferson College of Health ProfessionsPhiladelphia, PARickie Brawer, PhD, MPH, CHES (Endocrine)Associate Director, Center for Urban HealthAssistant ProfessorDepartment of Family and Community MedicineThomas Jefferson University HospitalPhiladelphia, PAFrances Burke, MS, RD (Cardiology)Clinical DietitianPerelman Center for Advanced MedicineHospital for the University of PennsylvaniaPhiladelphia, PAChristine Conner, MPA-HAS, BSN, RN (Elderly)Director of NursingManor Care Health ServicesSkilled Nursing and Rehabilitation FacilityWalnut Creek, CAM. Elayne DeSimone, PhD, NP-C, FAANP (Assessment)Professor, Department of NursingCollege of Health Professions and Social WorkTemple UniversityPhiladelphia, PAPatricia Digiacomo, MSN, RNC (Pregnancy)Assistant ProfessorCollege of Health Professions and Social WorkTemple UniversityPhiladelphia, PADara Dirhan, MPH, RD, LDN (Counseling)Dietetic InternCorporate Wellness DietitianPrivate Practice ConsultingPhiladelphia, PAJennifer M. Dolan, MS, RD, CNSC (Nutrition Support)Advanced Clinical Dietitian SpecialistClinical Nutrition Support ServiceHospital of the University of PennsylvaniaPhiladelphia, PADory Ferraro, MS, APRN-CS (Obesity)Clinical Director of Bariatric ServicesStamford HospitalStamford, CTSusan Breakell Gresko, MSN, CRNP, PNP-BC (Pediatrics)Assistant Professor in NursingDepartment of NursingCollege of Health Professions and Social WorkTemple UniversityPhiladelphia, PAMaureen Huhmann, DCN, RD, CSO (Oncology)Manager, Clinical SciencesNestle Healthcare NutritionFlorham Park, NJTamara B. Kaplan, MD(Oncology)Neurology ResidentJoint Partners Neurology Resident ProgramMassachusetts General HospitalBrigham and Women’s HospitalBoston, MAKathleen Larkins, MSN, CNS, RNC-OB (Pregnancy)InstructorRoxborough Memorial HospitalSchool of NursingPhiladelphia, PACheryl Marco, RD, LDN, CDE (Endocrine)Clinical Dietitian and Diabetes EducatorDepartment of Medicine, Division of Endocrinology, Diabetes and Metabolic DiseasesThomas Jefferson UniversityPhiladelphia, PAAmy McKeever, PhD, CRNP (Pregnancy)Women’s Health Nurse PractitionerAssistant Professor in NursingVillanova University,College of NursingVillanova, PABeth-Ann Norton, MS, RN, ANP-BC (Gastrointestinal)Nurse ManagerInflammatory Bowel Disease CenterMt. Sinai Medical CenterDivision of Gastroenterology/IBDNew York, NYNancy Sceery, LD, RD, CNSC (Nutrition Support)Nutrition Support TeamMassachusetts General HospitalBoston, MALauren Solomon, MSN, ANP-BC, GNP-BC (Renal)Nephrology Nurse PractitionerHospital of the University of PennsylvaniaDepartment of Renal, Electrolytes, and HypertensionIn conjunction with DaVita DialysisPhiladelphia, PANancy Stoner, RN, MSN, CNSC (Nutrition Support)Clinical Nurse SpecialistClinical Nutrition Support ServiceHospital of the University of PennsylvaniaPhiladelphia, PAJean Stover, RD, LDN (Renal)Nephrology DietitianHospital of the University of PennsylvaniaDepartment of Renal, Electrolytes, and HypertensionIn conjunction with DaVita DialysisPhiladelphia, PABridget S. Sullivan, MSN, MS, CRNP, RD (Pediatrics)Pediatric Nurse Practitioner, Registered DietitianMt Airy Pediatrics, LLCPhiladelphia, PAJulie Vanderpool, RD, MPH, RN, MSN, ACNP (Gastrointestinal)GI Nurse Practitioner, Registered DietitianNashville Gastroenterology AssociatesNashville, TNNeva White, DNP, MSN, CRNP, CDE (Endocrine)Diabetes Nurse PractitionerSenior Health EducatorCenter for Urban HealthThomas Jefferson University HospitalPhiladelphia, PATheresa P. Yeo, PhD, MPH, MSN, AOCNPAssociate Director, Jefferson Pancreas Tumor RegistryDepartment of SurgeryThomas Jefferson University HospitalAdjunct Associate ProfessorJefferson School of NursingPhiladelphia, PA

Reviewers

Kellie Smith, EdD, RNAssistant ProfessorSchool of NursingThomas Jefferson UniversityPhiladelphia, PASharon Rainer, MSN, CRNPInstructor, School of NursingThomas Jefferson UniversityPhiladelphia, PAPat Iyer, MSN, RN, LNCCLegal Nurse ConsultantMed League Support ServicesFlemington, NJ

Section 1

Introduction to Nutrition Concepts

1  The Role of Nurse Prazitioners

Kathleen C. Ashton, PhD, RN, ACNS-BC

OBJECTIVES

Discuss the role of nutrition as a component of practice for Nurse Practitioners.Describe the relationship between nutrition and commonly occurring problems such as obesity.Identify effective methods for integrating concepts of sound nutrition into areas of practice for Nurse Practitioners.

Nurses have outranked all professions in Gallup’s annual Honesty and Ethics Survey1 every year since 1999 (Gallup Poll). This vote of confidence from 81% of Americans participating in the survey comes with the responsibility to provide the best care to those who turn to us for information and advice to prevent disease and maintain health. Given this trust for nurses, we play a pivotal role in educating individuals about nutrition. Research findings demonstrate that consistent, intensive, lifestyle-based interventions can effectively reduce the risk of chronic disease.2–4

Practitioners cite barriers to providing nutrition and lifestyle counseling such as lack of time, lack of nutrition knowledge and confidence, poor patient adherence, low levels of patient health literacy, and lack of teaching materials.5 A major key is consistency, addressing the lifestyle changes at every patient encounter where appropriate. The nutrition objectives for Healthy People 2020 state that 75% of primary care clinician office visits should include nutrition counseling for individuals with diabetes, hyperlipidemia, and hypertension.6 In addition, it may be difficult to translate nutrition science into practical dietary advice. We created The Nurse Practitioner’s Guide to Nutrition to address many of these barriers and to assist Nurse Practitioners in providing useful nutrition education and interventions to those who most stand to benefit.

As healthcare practices and regulations change, nursing practices must evolve to keep abreast of those changes. The Patient Protection and Affordable Care Act of 2010 will provide healthcare coverage to an increased number of individuals. This presents an opportunity to address health disparities and provide resources to many for whom this has not previously been a possibility. Partnerships with nurses and other professionals can help to effect change at the individual and community levels. In whatever setting Nurse Practitioners are working (outpatient, home-based, hospital, nursing home, or community), whatever the reason for the encounter (acute problem vs chronic disease management vs health maintenance), and whatever the patient’s life-cycle stage, we have the opportunity to improve health outcomes. For example, when patients seek care in the office setting, we have an opportunity to identify nutrition-related risks associated with their usual dietary intake. In the hospital, we must ensure that a patient’s diet orders promote restoration of health while minimizing the potential for further deterioration. In nursing homes, where the risk of malnutrition is common, screening and monitoring caloric intake are paramount. Home visits are a unique opportunity to assess how diet and lifestyle information is actually practiced. The community affords opportunities to model healthy nutritional choices and impact population health.5

When patients present for an acute problem we should assess the potential impact of that problem on their ability to maintain healthy eating and activity patterns and identify potential nutrition-related problems. Patients seeking health maintenance need routine dietary screening and appropriate patient education. Those with identified nutrition-related problems require a plan to address those problems, part of which should include a follow-up visit to initiate and monitor behavior changes. Assessing patients’ readiness to change is a critical component in this process (Chapter 3). Patients being seen for chronic disease follow up may require significant change to their routine dietary intake and often will benefit from a referral to a registered dietitian for more in-depth dietary counseling.5

The Nurse Practitioner’s involvement does not cease with referral to a dietitian, as is the case with referral to any specialist. We must follow-up on the nutrition consult, support the plan, provide on-going guidance, evaluate the patient’s ability to adhere to the diet, and revise the plan as needed. The overarching goal is establishing an eating pattern that provides an array of options that incorporate ethnic, cultural, traditional, and personal preferences while considering food cost and availability. Interventions are indicated across the lifespan. With an infant or toddler, we can teach parents a healthy eating pattern to help maximize their child’s growth and development while minimizing the impact of their genetic predisposition for disease (Chapter 4). We can help adults to identify their potential disease risk and educate them about eating properly to minimize that risk or to maximize wellness. As adults age, metabolism slows and small, nutritionally-dense meals are beneficial to minimize the calories consumed and prevent obesity (Chapter 7). In older adulthood we need to screen for nutrition-related problems which affect ongoing health and address the need for a meal plan designed to mitigate the impact of chronic disease (Chapter 6).5

Nutrition for Life

What is the best eating pattern for life? How does one sift through all of the recommendations and fads? And of what benefit is the best nutrition advice if it is not followed? The US Dietary Guidelines for Americans, 2010 was updated amid concern for the growing epidemic of overweight and obese Americans (Table 1-1).7 Approximately one-third of American adults are obese and 72% of men and 64% of women are overweight or obese.8

Table 1-1 Dietary Guidelines for Americans 20107 Key Recommendations

Source: Dietary Guidelines for Americans 2011.

Balancing Calories to Manage Weight

Prevent and/or reduce overweight and obesity through improved eating and physical activity behaviors.

Control total calorie intake to manage body weight. For people who are overweight or obese, this will mean consuming fewer calories from foods and beverages.

Increase physical activity and reduce time spent in sedentary behaviors.

Maintain appropriate calorie balance during each stage of life – childhood, adolescence, adulthood, pregnancy and breastfeeding, and older age.

Foods and Food Components to Reduce

Reduce daily sodium intake to less than 2300 mg and further reduce intake to 1500 mg among persons who are 51 and older and those of any age who are African American or have hypertension, diabetes, or chronic kidney disease. The 1500 mg recommendation applies to about half of the US population, including children, and the majority of adults.

Consume less than 10% of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids.

Consume less than 300 mg per day of dietary cholesterol.

Keep

trans

fatty acid consumption as low as possible by limiting foods that contain synthetic sources of

trans

fats, such as partially hydrogenated oils, and by limiting other solid fats.

Reduce the intake of calories from solid fats and added sugars.

Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars, and sodium.

Consume alcohol, if at all, in moderation – up to one drink per day for women and two drinks per day for men – and only by adults of legal drinking age.

Foods and Nutrients to Increase

Individuals should meet the following recommendations as part of a healthy eating pattern while staying within their calorie needs:

Increase vegetable and fruit intake.

Eat a variety of vegetables, especially dark green, red and orange vegetables and beans and peas.

Consume at least half of all grains as whole grains. Increase whole-grain intake by replacing refined grains with whole grains.

Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese, or fortified soy beverages.

Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds.

Increase the amount and variety of seafood consumed by choosing seafood in place of some meat and poultry.

Replace protein foods that are higher in solid fats with choices that are lower in solid fats and calories and/or are sources of oils.

Use oils to replace solid fats where possible.

Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are nutrients of concern in American diets. These foods include vegetables, fruits, whole grains, and milk and milk products.

Recommendations for Specific Population Groups

Women capable of becoming pregnant

:

Choose foods that supply heme iron, which is more readily absorbed by the body, additional iron sources, and enhancers of iron absorption such as vitamin C-rich foods.

Consume 400 micrograms (µg) per day of synthetic folic acid (from fortified foods and/or supplements) in addition to food forms of folate from a varied diet.

Women who are pregnant or breastfeeding

:

Consume 8–12 ounces of seafood per week from a variety of seafood types.

Due to their high methyl mercury content, limit white (albacore) tuna to 6 ounces per week and do not eat the following four types of fish: tilefish, shark, swordfish, and king mackerel.

Take an iron supplement, as recommended by your health care provider.

Individuals Ages 50 Years and Older

:

Consume foods fortified with vitamin B

12

, such as fortified cereals, or dietary supplements.

Building Healthy Eating Patterns

Select an eating pattern that meets nutrient needs over time at an appropriate calorie level.

Account for all foods and beverages consumed and assess how they fit within a total healthy eating pattern.

Follow food safety recommendations when preparing and eating foods to reduce the risk of food-borne illnesses.

Despite the fact that patients accept the old adage “You are what you eat”, they do not seem able to apply this to their day-to-day dietary intake.5 While many of our patients recognize how important it is to “eat right and exercise”, a study from the Pew Research Center found that Americans see weight problems everywhere but in the mirror. According to this report, 90% of American adults say most of their fellow Americans are overweight, but only 70% say this about “the people they know”, and 40% say they themselves are overweight.9

Approximately 75% of adults are not eating enough fruits and vegetables.10 Our culture supports convenience, our policies favor junk food, our restaurants have huge portion sizes to increase the perception of value, and our TV viewing habits demonstrate avoidance of exercise. Convenience foods, ever more popular, are typically not healthy choices. When attempting to counsel a patient about nutrition, the Nurse Practitioner faces the barriers of time, money, taste preference, culture, family, and habit. Health is unfortunately far down on the list of factors that are considered when food choices are made.5

The typical American diet is too high in calories, sugar, saturated fat, and salt, and limited in fruits, vegetables, and low-fat dairy foods. Fewer than 25% of Americans get five servings of fruits and vegetables daily. Even among children, calcium intake is inadequate in almost half of 3–5 year olds, and 70% of 12–19 year olds.11 Whether it is the phosphates in soda that may leach out calcium or the displacement of dairy intake, many teens are losing calcium instead of storing it up during this critical time for building strong bones. Osteoporosis later in life is one complication that may result from over-consumption of soda over many years.12

To correct these imbalances, we need to encourage patients to reduce portion sizes to reduce calories; choose healthy snacks (fruits and vegetables, not candy bars or chips); and reduce the consumption of products made with sugar (cakes, cookies, and pastries) or high fructose corn syrup (soda and sweetened fruit or sports drinks).5 Sugar and other sweeteners hide in baked goods and beverages. Using more herbs and spices can enhance flavor in foods while providing less salt and more health-promoting antioxidants. Low-fat milk and other low-fat dairy foods, lactose-free and soy products supplemented with calcium, and calcium-fortified products (like orange juice) are good alternatives, yet many of these products may also contain sugar.5 Prescribing a calcium supplement will help address a chronic inadequate calcium intake that is prevalent in our population and may reduce the risk of osteoporosis in the elderly (See Chapters 6, and Appendices G and H).

Case 1

Joey is a 16-year-old boy who comes in for a school physical. He is 5’ 9” and weighs 200 lb. He loves junk food and hates vegetables. His mom says he watches a lot of television and when questioned, he reports playing video games for at least 3 hours every day. He is on the honor roll in school, but doesn’t have many friends. You identify the following problems:

BMI: 30 (>95th percentile diagnostic of obesity). No exercise with highly sedentary activities. Excessive fat and sugar from junk food and sweets. Avoids vegetables.

APPROACH: This common case can be overwhelming and it is hard to know where to start. First ask Joey if he likes any kind of exercise and encourage those activities, including walking, biking, or weight lifting. A teenage boy with few friends may find it harder to engage in team activities such as playing street hockey or those that require a partner such as tennis. Quantify the number of hours he plays video games and negotiate that this should be reduced and daily physical activity increased. Discuss the importance of reducing junk food, avoiding candy, cookies, and chips, and emphasize healthier snacks. Always include at least one parent, grandparent or guardian in the discussion and be sure to emphasize that the parent’s role is to stop buying junk food and offer healthier snacks and vegetables when the teenager is most hungry, such as after school. Often overweight children and teenagers have at least one overweight parent and the entire family’s dietary choices and lifestyle need to be addressed. It’s important not to expect rapid results and parents should be discouraged from criticizing. Lifestyle change is hard and changes need to be sustainable! Praise any change in a positive direction.

Assessment and Diagnosis

Successful nutrition interventions begin with careful assessment of the individual including a family history of risk factors, such as obesity, cardiovascular disease or diabetes (Chapter 2). The patient’s meal and exercise patterns can be ascertained through directed questioning and perhaps keeping a food diary to prevent the pitfalls of recall and perception. Body mass index (BMI) should be calculated for everyone, including children and teenagers, followed by a discussion of how the patient’s weight compares with norms (Chapter 7). Use prevention visits as an opportunity to educate patients regarding the deleterious effects of a sedentary lifestyle and unnecessarily large portion sizes.

Food insecurity is a mounting problem in the current economic climate. Research shows that almost 15% of American households do not consume adequate food to meet dietary needs due to lack of sufficient funds or other food resources.12 A thorough dietary assessment includes information on income and resources for obtaining food in addition to food intake and eating patterns.

Case 2

Abby is a 30-year-old consultant who comes in for a check-up. She travels a lot for work and eats most meals out. She likes to exercise but says that she is often too busy. She is 5’4” and weighs 165 lb. She played field hockey in college but has gradually gained weight since that time. You identify the following issues:

BMI: 29 (diagnostic of overweight). Eats a lot of restaurant meals. Not enough exercise.

APPROACH: Abby’s current BMI places her close to the diagnosis of obesity and if she continues her current lifestyle, it is likely that her weight will reach a BMI of 30, increasing her risk of chronic diseases. Discussing how to eat healthily in restaurants would be most useful. Suggest strategies such as skipping bread, limiting wine to one glass, ordering salad dressing on the side, ordering broiled, grilled or baked fish or chicken, and limiting portion sizes, especially if she orders a high fat cut of meat. While sharing dessert may not be possible during business dinners, it may be on social occasions. Brainstorm with her regarding ways to increase exercise and suggest she use weight rooms at hotels, climb stairs when possible, and walk instead of taking taxis. Recommend follow-up in 3 months.

Help patients who need to change eating patterns by identifying community resources including websites such as www.choosemyplate.gov and offer advice, encouragement, and referral when indicated.6,14 Start the discussion of healthy eating with everyone, but especially focus on those with hypertension, diabetes mellitus, and hyperlipidemia who stand to benefit the most from improved nutrition. It is important to help those who are not eating what they should or not exercising regularly to begin doing so before they develop the health problems that result from poor lifestyle habits. Small changes are the best way to begin and then monitor progress towards a goal.

Effecting Change

Motivating clients starts with Nurse Practitioners. Patients are likely to take note of, and perhaps even be motivated by, a busy professional who practices what he or she preaches. Following the lifestyle and eating pattern we recommend bolsters our credibility with our patients. Certainly this is a win–win situation for us and our patients, and can be accomplished in various ways. Become knowledgeable about exercise options available in your community, advertise fundraising walks and races where you see patients, join them when you can, and be seen where good nutrition is being promoted. Participate in physical activity yourself, encourage your children’s involvement in team sports, get involved in your local school or community, and be a voice for more physical activity and healthier food choices. Encourage your colleagues to eat healthy and to exercise regularly. If clinicians don’t promote work-site health, who will? The internet, used judiciously, has good nutrition information and can be an excellent resource. When your patients see you living the lifestyle, they will be more inclined to seek out and follow your advice when they need help. Become a resource in your community: volunteer to speak about promoting good nutrition at school and business events, town hall meetings, or church functions. Help your neighbors to identify ways to eat healthier and increase physical activity. The more experience you have with these lifestyle challenges, the more of a resource you will be for those who look to you for assistance.5 Unfortunately, the literature does not provide us with models that have been shown to be universally effective, so it is up to each of us to develop our own approach to addressing eating patterns and activity counseling for our patients. Examples of models that have been developed are described in Chapter 3.

Food is much more than nutrition for every individual. It represents nurturing, love, sociability, and even entertainment (as evidenced by the popularity of the Food Network). For many Americans, a chubby baby is a healthy baby and attempts to direct parents toward a more appropriate feeding style will not be appreciated. The news media is not helping. Each new dietary study is trumpeted with the fanfare of a newly discovered scientific fact. So when contradictory results are found (which happens often in science), patients (and their clinicians as well) are left confused about what to believe and what to include in a “healthy diet”.5

Cultural factors and diet-related attitudes and behaviors strongly influence health.15,16 The cultural milieu that affects a person’s diet includes: the rules surrounding the person’s upbringing, whether or not the person immigrates to a new society, the degree of acculturation to the new society, and the degree to which traditional foods in the culture of origin are available in the new society.15,17 The meanings and uses ascribed to foods in any particular culture may be unique to that culture, even though the foods themselves are commonly available and may have different or no special meaning in other cultures.18–20 Culture influences many food-related behaviors including food choice, food purchasing, preparation, where and with whom food is eaten, health beliefs related to food, and adherence to dietary recommendations.16,21–23

Culturally competent health care builds upon the understanding of these cultural influences and facilitates the development of stronger patient–provider relationships with higher levels of trust. This has been shown to be associated with increased use of recommended preventive services in ethnic minority patients.20 Therefore, understanding the sociocultural context of health for individual patients is very important for effective health care, as culture may influence health knowledge, attitudes, and behaviors, including diet.

At the community level, providers trying to address the behaviors that lead to obesity face a similar unsupportive environment that we had trying to help patients quit smoking in the 1950s. Policy changes currently being considered that may help move our patients from where they are to where they need to be include: requiring fast food restaurants to include nutritional information on their packages, taxing sweetened beverages, and developing devices that monitor television viewing and video game use by our children.5 Change begins with one small step and gains momentum. The Nurse Practitioner’s Guide to Nutrition is a key resource to effectively begin the journey to provide optimal nutrition therapy for patients in order to reduce chronic disease and change diet and lifestyle.

References

1. Gallup Poll. Available at http://www.gallup.com/poll/145043/Nurses-Top-Honesty-Ethics-List-11-Year.aspx

2. Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2007. Available at http://www.cdc.gov

3. National Cancer Institute. Surveillance Epidemiology and End Results (SEER) Stat Fact Sheets: All Sites. Available at http://seer.cancer.gov/statfacts/html/all.html

4. Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension 2006;47:296–308.

5. Deen D, Margo K. Nutrition and the Primary Care Clinician. In: Deen D., Hark L (Eds), The Complete Guide to Nutrition in Primary Care. Wiley-Blackwell, Malden MA, 2007.

6. Healthy People2020. Department of Health and Human Services, Washington, DC. www.healthypeople.gov

7. Dietary Guidelines for Americans, 2010. Available at http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf

8. Flegal KM, Carroll, MD, Ogden, CL, et al.Prevalence and trends in obesity among US adults, 1999–2008. JAMA 2010;303:235–241.

9. Taylor P, Punk C, Craighill P, for Pew Research Center, 2006. Americans See Weight Problems Everywhere But In the Mirror. http://pewresearch.org/assets/social/pdf/Obesity.pdf. Report Published April 11, 2006.

10. National Health and Nutrition Examination Survey (NHANES) III. www.cdc.gov/nchs/nhanes.htm. Accessed 2012.

11. Greer FR, Krebs NF; American Academy of Pediatrics Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children, and adolescents. Pediatrics 2006;117:578–585.

12. Tucker KL. Osteoporosis prevention and nutrition. Current Osteoporosis Reports 2009;7:111–117.

13. Nord M, Coleman-Jensen A, Andrews M, et al.Household food security in the US. 2009, Washington, D.C. US Department of Agriculture, Economic Research Service, 2010, Nov. Economic Research Report Number ERR-108. Available at http://www.ers.usda.gov/publications/err108

14. USDA’s MyPlate. http://www.choosemyplate.gov

15. Gans K, Eaton C. Cultural considerations. In: Deen D, Hark L. (Eds), The Complete Guide to Nutrition in Primary Care. Wiley-Blackwell, Malden, MA, 2007.

16. James DC. Factors influencing food choices, dietary intake, and nutrition-related attitudes among African Americans: application of a culturally sensitive model. Ethn Health 2004;9:349–367.

17. Curry KR, Jaffe A (Eds). Nutrition Counseling and Communication Skills. WB Saunders Company, Philadelphia, PA, 1998.

18. Airhihenbuwa CO, Kumanyika S, Agurs TD, et al. Cultural aspects of African American eating patterns. Ethn Health 1996;1:245–260.

19. Karmali WA. Cultural issues and nutrition. In: Carson J, Burke F, Hark L. (Eds), Cardiovascular Nutrition: Disease Management and Prevention. American Dietetic Association, Chicago, IL, 2004.

20. Hark L, Delisser H. Achieving Cultural Competency: A Case-Based Approach. Wiley-Blackwell, Malden, MA, 2009.

21. Kittler PG, Sucher KP. Food and Culture in American: A Nutrition Handbook. 2nd edition. West/Wadsworth Publishing, Belmont, CA, 2001.

22. Burrowes JD. Incorporating ethnic and cultural food preferences in the renal diet. Adv Ren Replace Ther 2004;11:97–104.

23. Graves, DE, Suitor, CW. Celebrating Diversity: Approaching Families Through Their Food. National Center for Education in Maternal and Child Health, Arlington, VA, 1998.

2  Nutrition Assessment for Nurse Practitioners

M. Elayne DeSimone, PhD, NP-C, FAANPLisa Hark, PhD, RD

OBJECTIVES

Discuss the value of nutrition assessment in the comprehensive care of ambulatory and hospitalized patients.Integrate relevant components of the nutrition history into both the comprehensive and episodic evaluation of patients.Demonstrate how to conduct an appropriate physical examination, calculate body mass index, measure waist circumference, evaluate growth and development, and recognize signs of nutritional deficiency or excess.Identify the most common physical findings associated with altered nutritional status including vitamin/mineral deficiencies or excesses.Interpret the laboratory measurements commonly used to assess the nutritional status of patients.Synthesize nutrition assessment data to formulate comprehensive treatment plans.

Integrating Nutrition into the Assessment

The value of incorporating nutrition into the Nurse Practitioner assessment cannot be overstated. Dietary intake affects all body systems and as such, manifests in both subtle and obvious signs and symptoms that may be appreciated through a careful history and physical examination, along with appropriate diagnostic tests. Regardlessof the type of encounter or setting, the effective Nurse Practitioner will includerelevant aspects of nutrition assessment prior to making treatment decisions. This chapter outlines how a comprehensive nutrition assessment should be an integral part of all initial evaluations, with questions tailored to the specific patient’s medical problems. In the initial assessment the nutrition history is expanded, and explored fully in the context of both health and disease. Nutrition assessment requires that the Nurse Practitioner go beyond the disease model to examine influencing factors, such as social and environmental determinants, food security, motivation, adherence, literacy, numeracy, food knowledge, and skills. Given the time constraints in a busy practice or hospital setting, these data may need to be collected over time in multiple encounters. The use of an electronic health record helps to simplify data collection if valid and reliable assessment tools are used. Patients can complete data entry on their own for later review with the Nurse Practitioner. It is important to note that nutrition-­related treatment goals that take into consideration the patients’ environment will be more likely to succeed. For some patients with complex nutrition-related problems, a timely referral to a registered dietitian is beneficial, as it fosters a team approach to assessment and follow-up care. Treatment for many dietary-related disorders often requires repeated nutrition assessment to monitor a patient’s progress. Eligibility for outcomes-based health care reimbursement requires that initial and ongoing nutri