Study Guide 10 NUTRITION

Topic Outline
1. SOCIAL AND CULTURAL ASPECTS OF FOOD
2. DEMOGRAPHICS OF THE AGING POPULATION
3. PHYSIOLOGIC CHANGES IN AGING THAT AFFECT NUTRITIONAL STATUS
4. PSYCHOSOCIAL AND SOCIOECONOMIC FACTORS RELATED TO MALNUTRITION
5. NUTRITIONAL SCREENING AND ASSESSMENT Course Code and Title
a. Nutritional Screening
b. Nutritional Assessment
c. Diet History
d. Anthropometrics
e. Laboratory Values
6. NUTRITIONAL GUIDELINES FOR ALL AGES
a. Dietary Reference Intakes
b. Food Labeling
7. DRUG–NUTRIENT INTERACTIONS
8. NURSING DIAGNOSES ASSOCIATED WITH NUTRITIONAL PROBLEMS
9. SPECIALIZED NUTRITIONAL SUPPORT
10. FAILURE TO THRIVE

Learning Objectives
After studying this module, you will be able to:
1. Differentiate between the social, cultural, and emotional aspects of food as well as the physiologic aspects of
nutrients in food.

2. Correlate the physiologic changes of aging with food intake patterns.

3. Differentiate between a nutritional screen and a nutritional assessment.

4. Identify the steps and core data collection elements of a nutritional assessment.

5. Describe the changes in nutritional requirements for aging persons.

6. Describe the role of therapeutic diets and nutritional support in nutritional therapies.

7. Identify major dietary guidelines and recommendations for healthy persons of all ages.

Introduction

Although the core role of food is simply the provision of energy and nutrients for bodily functions, very few
individuals view food from this perspective. Throughout history, different types of foods have served as
poisons, potions, or panaceas for health, potency, long life, and love. Hippocrates (460–377 bc), the
“Father of Medicine,” reflected his commitment to the importance of diet in a statement from the
Hippocratic Oath: “I will apply dietetic measures for the benefit of the sick according to my ability and
judgment; I will keep them from harm and injustice” (Tannahill, 1988). Cato the Elder (234–149 bc), a
Roman statesman, ate large amounts of cabbage in the belief it had special healing properties. A later
Roman scholar, Pliny the Elder (23–79 ad), ate the foot and snout of the hippopotamus to enhance sexual
potency, whereas a Chinese physician of the 6th century bc prescribed certain foods for patients to
stimulate the yin (female principle) and the yang (male p

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 Activating Prior Knowledge

PLS. Differentiate between the social, cultural, and emotional aspects of food as well as the physiologic
aspects of nutrients in the Philippines.

Course Code and Title

1.1 Discussion of Key Concepts

SOCIAL AND CULTURAL ASPECTS OF FOOD

In today’s fast-paced, complex society, food is often purchased prepared and prepackaged. Food and diet
are manipulated to enhance athletic performance, carbohydrates are avoided to force the body into
ketosis in an effort to burn fat for weight loss, and supplements are taken to replace the vitamins and
minerals missing from the “fad diets” many Americans try. Water is bottled, sold, and purchased at
extraordinary costs under the assumption that “it is better for me.” Comfort foods are now a designated
and popular category, particularly after the terrorist attacks on September 11, 2001, when purchases of
donuts and pastries increased significantly (Balon, 2002; Comforted but unfattened, 2002).
Food is much more than fuel for the body; food in our society is a social centerpiece, a source of comfort,
and a symbol of celebration. Consider the monthly calendar:
• January: New Year’s Day and the Super Bowl
• February: Valentine’s Day
• March: St. Patrick’s Day, March Madness
• April: Passover and Easter
• May: Mother’s Day and Memorial Day
• June: Father’s Day and Weddings
• July: Fourth of July • August: Summer fairs
• September: Labor Day
• October: Halloween
• November: Thanksgiving
• December: Holidays

CULTURAL AWARENESS
Selected Examples of Cultural Meanings in Food

Critical life force for survival

• Relief of hunger
• Peaceful coexistence
• Promotion of health and prevention of disease or illness
• Expression of caring for another
• Interpersonal closeness or distance
• Promotion of kinship and familial alliances
• Solidification of social ties
• Celebration of life events (e.g., birthday, wedding)
• Expression of gratitude or appreciation
• Recognition of achievement or accomplishment
• Business negotiations
• Information exchange
• Validation of social, cultural, or religious ceremonial functions
• Means to generate income
• Expression of affluence or social status

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 • Expression of being well traveled or sophisticated

Dietary Practices of Selected Religious Groups*

Prohibited Foods and Beverages

Hinduism
All meats
Islam
Pork and pork products Animal shortenings Alcoholic products (including extracts such as vanilla or lemon)
Marshmallows, gelatin, and other confections made with pork Note: Fasting is common. Course Code andis Title
Fasting
mandatory in the daylight hours during the months of Ramadan.
Judaism
Pork Predatory fowl Shellfish or scavenger fish (e.g., catfish, shrimp, escargot, lobster) (Fish with fins and
scales are permitted.) Mixing milk and meat dishes at same meal Blood by ingestion (e.g., blood sausage,
raw meat) (Blood by transfusion is acceptable.)
Notes: 1. Only meat from cloven-hoofed animals that chew cud (e.g., cattle, sheep, goat, deer) is
allowed. The animals must have been slaughtered observing rigid rules that result in minimal pain to the
animal and maximum blood drainage.
2. Foods should be kosher (meaning “proper” or “fitting”), which is accomplished in one of two methods:
a. Meat is soaked in cold water with coarse salt for a half hour and drained to deplete blood content. It is
then thoroughly washed under cold, running water and drained again before cooking. b. Meat is first
prepared by quick searing or cooking over an open flame, which permits liver to be eaten because it
cannot be prepared by the above method.
3. Meat and dairy products cannot be served at the same meal, nor can they be cooked or served in the
same set of dishes. Milk or milk products may be consumed just before a meal but not until 6 hours after
eating a meal with meat products. Fish or eggs can be eaten with dairy products or meat meals.
Mormonism (Church of Jesus Christ of Latter-Day Saints) Alcohol Tobacco Stimulants (including
beverages containing caffeine, e.g., coffee, nonherbal teas, colas, and selected carbonated soft drinks)
Seventh-Day Adventist Church
Pork Certain seafood, including shellfish Fermented beverages
Notes: 1. Optional vegetarianism includes (a) strict vegetarianism, (b) ovolactovegetarianism, or (c) no
pork or pork products, shellfish, or blood. 2 Snacking between meals is discouraged

DEMOGRAPHICS OF THE AGING POPULATION

The “graying of the American population” is considered one of the most far-reaching medical, nutritional,
and economic issues in our society. Medically, this is a population that has served its country, worked
hard, and now faces a health care system that views patients in terms of cost.
This population of baby boomers has driven and changed the landscape of the United States from
expanding sales of commercial baby food in the 1940s to the construction of houses and new schools in
the 1950s. Their impact on health care, public policy, and other social forces should not be understated.

Given the improvements in pharmaceutical medicines and technology, life expectancy has increased, but
life span has not. Today’s average life expectancy at birth is about 75.7 years, whereas the life span is still
considered to be 115 years, although a record of 128 years appears to have been set in January of 2009
by a woman in Uzbekistan, who has provided documentation to the British Broadcasting Corporation
(BBC) that she was born in July 1881 (BBC News, January 29, 2009). The old-old will continue to be the
fastest-growing group, and it is predicted (by the U.S. Census Bureau) to be 8.6 million by 2030. By 2050,
this group may comprise 25% of the population age 65 or older (American Association of Retired Persons
and Administration.

PHYSIOLOGIC CHANGES IN AGING THAT AFFECT NUTRITIONAL STATUS

Aging produces physiologic changes; however, assumptions about the aged are often generalizations
without merit. A distinction should be made between the healthy aging person and the aging person with
acute or chronic disease. For the healthy aging person, exercise and the resulting maintenance of muscle
mass are emerging in research as one of the greatest determinants of maintaining vitality (Campbell,
Johnson, McGabe, & Carnell, 2008).

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 Physiologic changes that are common in older adults may lead to problems with nutrition. Organ function
declines with age; this may alter digestion, metabolism, absorption of nutrients, and the ability to
eliminate waste products via the kidneys (Keithley, 1996)

Satiety triggers are diminished in older adults, yet given the increased risk for skin breakdown and the
likelihood of compromised immune, circulatory, and respiratory systems, the majority of the older adult
populations has increased protein requirements (Zulkowski & Albrecht, 2003).

Course Code and Title

PSYCHOSOCIAL AND SOCIOECONOMIC FACTORS RELATED TO MALNUTRITION
Poverty is a significant problem for older Americans, particularly as individuals age. The U.S. Census
Bureau reports that 10.1% of adults ages 65 or older were below the poverty level; in the 75 or older
subgroup, 43% fell into a substandard level (AARP-AOA, 2005).

NUTRITIONAL SCREENING AND ASSESSMENT

Nutritional Screening

Nutritional screening is an abbreviated assessment of nutritional risk factors that identifies patients who
are in need of a more comprehensive assessment and nutritional interventions. A variety of tools have
been developed to conduct nutritional screening. Perhaps the most widely used of these tools is the
“Determine Your Nutritional Health” screening tool developed as part of the Nutrition Screening Initiative
(NSI) (Figure 10)

The NSI (Dwyer, 1991), a 5-year, multifaceted national effort to promote routine nutrition screening,
began in 1990 under the direction of the American Academy of Family Physicians, the American Dietetic
Association (now the Academy of Nutrition and Dietetics [AND]), and the National Council on Aging.

Nutritional Assessment
A nutritional assessment is a comprehensive evaluation of a patient’s nutritional status and typically
includes data collection in each of the following areas: demographic and psychosocial data, medical
history, dietary history, anthropometrics, medications and laboratory values, and a physical assessment.
Nutritional assessment may be performed as a result of an identified risk on a nutritional screening or
when the risk status is obvious without a preliminary screening. The American Society for Parenteral and
Enteral Nutrition (ASPEN) published standards that identify nutritionally at-risk patients (Box 10-1)
(ASPEN, 1995). ASPEN also identified the goals of a nutritional assessment as follows:
• Establishing baseline subjective and objective nutrition parameters
• Identifying specific nutritional deficits
• Determining nutritional risk factors
• Establishing nutritional needs
• Identifying medical and psychosocial factors that may influence the prescription and administration of
nutritional support
• Setting goals for nutritional deficits; if applicable set goals in area of medical and psychological factors
to be worked on with interdiscliplinary team.

NUTRITIONALLY AT-RISK PATIENTS

• Involuntary loss or gain of 10% or greater of usual body weight within 6 months, or • Loss or gain of 5%
of usual body weight in 1 month • 20% over or under ideal body weight • Presence of chronic disease or
increased metabolic requirements • Altered diets or diet schedules • Inadequate nutrient intake for more
than 7 day

Anthropometrics
Height and weight are the mainstays of anthropometric measurements. Ideally, the patient is weighed in
the morning while wearing light clothing. Height is measured, if possible. For patients who are unable to
stand without assistance, height may be estimated by measuring the distance from the heel to the top of
the knee (knee height) with the use of a broad-bladed caliper. This measure may be used to estimate
height with the following formula (Nutritional assessment of the elderly through anthropometry, 1988)

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 KneeHeight as an Estimateof Stature
Stature for men = × 2 0. h 2 knee height in centimeters cm age
Stature for women ( ) [ ] × + = ( . ) . . 0 04 64 19 1 83 0 24 84 88 ( )

Laboratory Values
No single laboratory test is diagnostic of malnutrition. Several tests that reflect protein synthesis may
also reflect nutritional status. Serum albumin is the serum protein most frequently cited in reference to
malnutrition; it reflects the liver’s ability to synthesize plasma protein. Albumin has a half-life of about 21
days, so it is not always reflective of current nutritional status. Albumin values may also Course Code and
be affected by Title
immune status and hydration. Given these limitations, albumin levels below 3.5 grams per deciliter (g/dL)
may indicate some degree of malnutrition.
Transferrin is a carrier protein for iron and has a shorter half-life of 8 to 10 days. It is a more rapid
predictor of protein depletion. Levels below 200 milligrams per deciliter (mg/dL) may indicate mild-to-
moderate depletion, respectively. Levels below 100mg/dL may indicate severe depletion.
Prealbumin is a carrier protein for retinol-binding protein and has a half-life of 2 to 3 days. It is sensitive
to sudden demands on protein synthesis and is often used in the acute care setting.
Prealbumin levels that range from 15 to 5mg/dL reflect mild to moderate protein depletion.
Total lymphocyte count (TLC) is sometimes used as a nutritional marker. In severe or prolonged
malnutrition, immune proteins are depleted and the TLC is decreased.

Dietary Reference
Intakes Since its introduction in 1943, the recommended dietary allowances (RDAs) have been utilized to
assess the adequacy and quality of an individual’s dietary intake (Table 10-2). The RDAs would list
protein, vitamins, minerals, and selected trace elements and their recommended daily intake for infants
and children, women and men, ad pregnant and lactating women

It is important to keep in mind that recommended guidelines are simply that—guidelines. Although the
new guidelines have set tolerable upper limits and toxicity parameters for each nutrient, it is important to
keep in mind the unique variations of each individual. In the older adult population, individuals are in
complex situations in which they, for example, consume many types of medications, have a variety of
underlying medical conditions, and perhaps take vitamins and other supplements. It is always advisable to
consult a dietician when considering special dietary needs.

Food Labeling
In 1990, the Nutrition Labeling and Nutrition Act enabled the FDA to develop and enforce labeling in the
food industry. The law requires the label to include the amount of protein in grams, the energy as calories,
the fat-soluble vitamin content (A, D, E, and K), the water-soluble vitamin content (vitamin C, thiamine,
riboflavin, niacin, B6 , folate, and B12), calcium, phosphorus, magnesium, iron, zinc, iodine, and selenium.
The label must also specify calories based on serving size and indicate the number of servings. In
addition, the label specifies the percentage of the DRI that the product pr

DRUG–NUTRIENT INTERACTIONS
Medication use is common in older adults. A medication history should include prescription and over-the-
counter drugs, herbal therapies, and alternative medicines. The interactions between nutrients and
medicines may affect metabolism, absorption, digestion, or excretion of drugs. Table 10-4 lists the
interactions between nutrients and drugs that are commonly taken by older adults.

NURSING DIAGNOSES ASSOCIATED WITH NUTRITIONAL PROBLEMS

Nursing diagnoses are derived from an assessment of the patient during a comprehensive health history
and physical examination, during a patient interview, or while carrying out nursing interventions. The
nursing diagnoses subsequently become the basis for the nursing care plan and goals for nursing care.
Box 10-3 lists nursing diagnoses associated with a primary nutritional problem and diagnoses that
commonly have a nutritional component.
4 SAMPLE OF DRUG–NUTRIENT INTERACTIONS*

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 FAILURE TO THRIVE
Failure to thrive is a label originally applied to infants who did not gain weight and grow despite the
apparent absence of a physiologic, psychological, or pathologic condition. In fact, failure to thrive in
infants often does have disease as its source, and failure to perform a comprehensive diagnostic workup
on these infants may delay appropriate treatment. Failure to thrive in older adults is similar. It is
characterized by deterioration in biologic, psychological, and social domains, weight loss and a lack

Sarkisian and Lachs (1996) have described commonly impaired domains associated with failure to thrive
in older adults, including impaired physical functioning, malnutrition, depression, and cognitive
impairment. Failure to thrive in older adults is described as the 11 D’s: (1) disease (physical), (2)
dementia, (3) delirium, (4) drinking alcohol, (5) drug use, (6) dysphagia, (7) deafnessCourse Code
or other and Title
sensory
deficits, (8) depression, (9) desertion, (10) destitution, and (11) despair (Rocchiccioli and Sanford, 2009).

HOME CARE
1. Instruct caregivers and homebound older adults to keep a nutritional log for a defined period to enable
the home care nurse to compare it with MyPlate.
2. Instruct caregivers and homebound older adults on nutrients and selected food sources that supply
required vitamins and minerals.
3. Be aware that geographic location, culture, and religion play a part in food patterns, preferences, and
the meaning of food for homebound older adults.
4. Assess physiologic conditions and psychosocial issues that may place homebound older adults at risk
for nutritional deficiencies.
5. Assess homebound older adults’ medications for any that may predispose them to nutritional
deficiencies.
6. Carefully assess older adult patients’ over-the-counter drug and supplement intake to prevent herbal
supplement–drug, herbal supplement– nutrient interactions.
7. Instruct caregivers and homebound older adults on assistive devices that promote independence in
eating (e.g., strong plastic plates, bowls with suction cups, or padded utensils). An occupational
therapist should evaluate the patient and provide assistive devices.
8. Instruct caregivers and homebound older adults on any treatments that provide nutritional support
(e.g., enteral nutrition).
9. Ensure that appliances (such as stoves and microwave ovens) are functioning safely. Assess older
adults’ functional ability to use appliances safely.

Activity (can also be Critical Thinking and Review Questions)

A. DEFINITION OF TERMS: Define the following.

1. Poverty
2. Nutritional screening
3. Nutritional assessment
4. Graying of the American population
5. Nutrition
6. Food

B. EXPLAIN AND DISCUSS: Differentiate between the social, cultural, and emotional aspects of food as
well as the physiologic aspects of nutrients in food.

C. CRITICAL THINKING EXERCISES

A. A 68-year-old man with chronic obstructive pulmonary disease (COPD) has been referred to home
health nursing services for medication instruction and respiratory assessment. During the nurse’s
first visit, the following information is obtained during history taking: overweight for height by
about 30 pounds, weight loss of 10 pounds over the past 2 months, complaints of shortness of
breath while eating, and unable to get to the grocery store (relies on a neighbor for assistance).
How would this information relate to the development of a nursing care plan?
B. 2. An 80-year-old woman who is 5 foot, 4 inches tall, weighs 152 pounds, and is in generally good
health records the following 24-hour intake:

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 Breakfast: 1 glass orange juice, 2 slices whole wheat toast, 1 tablespoon butter Lunch: 1/2 cup cottage
cheese, 1 bag cheese curls, 1/2 peanut butter and jelly sandwich, 1 cup tea Dinner: 1 cup wheat flakes
cereal, 1/2 cup skim milk Snack: 1 candy bar, 1 cup ice cream Analyze this patient’s diet.

Interactive Link
MyPlate for Older Adults. (From Tufts University in Conjunction with Somerville Council on Aging.
Accessed July 3, 2014 from http://hnrca.tufts.edu/wp-content/uploads/81059_TuftsMyPLate.pdf)
Course Code and Title
http://www.dcd.gov/nchs/datawh/nchsdefshealthcondition.htm.

Everyday Connection
Synchronous and asynchronous online learning

Summary

• Appropriate food intake for health maintenance was recognized by Hippocrates (460–377 bc) and other
early scholars.
• Explosion of the older population to more than 32 million people calls for the control of lifestyle factors
such as adequate nutrition.
• Among middle-aged and older adults, age alone is the poorest predictor of capacities, interests,
performance, and health status. Exercise with maintenance of muscle mass is a good predictor of vitality.
• Wellness, as contrasted to health, is an ongoing dynamic process in the state of becoming; it is the
prime objective of health promotion and disease prevention.
• Recent literature has determined a correlation between nutrients and chronic disease.
• A balanced dietary intake, based on the MyPlate and the Healthy People 2020 guidelines, may promote
nutritional health.
• Nurses have the opportunity and responsibility to assess nutritional status and should collaborate with
other members of the health care team to formulate a comprehensive and coordinated nutritional care
plan.

Readings and References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning
care (10th ed.). St. Louis: MO: Elsevier.
AARP, Administration on Aging. (2005). A profile of older Americans. Washington, DC: US Department of
Health and Human Services.
Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. (1994). The effect of vitamin E and
beta carotene on the incidence of lung cancer and other cancers in male smokers. The New England
Journal of Medicine, 330, 1029.
American Dietetic Association (ADA). (2005b). Position of the American Dietetic Association: Nutrition
across the spectrum of aging. Chicago: The Association.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
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