welcome to lecture two nutrition and health care we'll go ahead and just jump right in so i want you to think about before we start to move and groove where do you get your nutrition information from so think about that where do you get your information from maybe you browse through instagram or reddit maybe you look at different ads on the internet but are those necessarily accurate valid credible we'll go through a lot of that information today and discuss whether or not we should believe everything that we see on the internet all right so you can most certainly find some reliable nutrition information on the web but you need to be careful about where you're looking and what websites you go to so here we can see a list of some sort of some warning signs for nutrition quackery and then also some tips so these are some things to consider when looking at different things on the internet so one thing to think about first is the source so choose sites that have web addresses that end in dot gov dot edu and these are it's very hard to write like this edu and dot org so anything that ends in dot gov dot eduard.gov is going to signify a government agency um an educational industry or a professional organization for so these are things that are considered credible some other things to think about are do they do they give the names and the credentials of the information for the people that provided that stuff so for example do is it a registered dietitian that's providing this information is it a medical doctor is it just a joe schmo from the website so think about that as well and then also look at the evidence so health decisions are best based on medical and scientific research not just your an opinion so look at the sources of information for that specific website are they pulling from double-blind placebo-controlled trials are they pulling from peer-review studies these are all things to consider when looking at things on the internet um is the is the website updated regularly so as we'll see nutrition information is going to change rapidly so what is recommended today may not be recommended tomorrow or the next week so it's important to make sure that the websites that you are looking at are updated pretty regularly uh so you might not not necessarily want to be looking at information that dates back to let's say 2012 because it might not be accurate also what is the purpose of the site so is the purpose of the site to provide credible information or is it to sell you something in addition if available read the quote about section on the site to help determine the reliability of the information on the site does the site charge a fee to gain access to it trusted sites are typically going to provide information for free um and so if there is some sort of fee to receive the information that may be a sign that it's not the most credible site and as i mentioned before here are some warning signs for nutrition quackery so if something let's say offers a quick and easy fix if it has a lot of personal testimonies like i lost 15 pounds on the blank diet you can too probably not going to be a credible site you can go through each one of these and look at more specifics of some of these warning signs but if if a website that you're at offers some of these different things and that might be a little ding-ding-ding that something is not accurate and maybe not the most credible all right let's change up my pen let's do a highlighter all right so now we're going to switch gears and talk a little bit about nutrition and health care so as we've already alluded to illness can influence the nutritional status and how nutrition therapy contributes to the medical care so providing optimal nutrition or correcting any nutritional problems or deficiencies in the clinical setting can approve both short-term and long-term outcomes for medical treatment and also can help prevent any complications so the hospitalized patient is at a pretty high risk for some nutrition deficiencies so first poor nutrition can impact the patient's health of course it's frequently reported in hospitalized patients that uh present with some sort of acute illness and although it's a very wide range right here it's estimated that 15 to 60 percent of all hospitalized patients have been categorized with some degree of malnutrition great glad to hear it okay my watch is happy to hear that sorry about that um so why do we talk about poor nutrition so it influences health um but what are some negative implications so poor nutrition can weaken your immune functions and reduce the ability of an individual to heal so it may disturb the course of the action of the illness and the treatment which may result in delayed delayed healing and increased duration of the hospital stay so um this is just let's say acute that we're talking about oh you can't see that um acute malnutrition acute problems but what if you pres if you have a patient that presents with long-term inadequate nutrition so long-term inadequate nutrition may lead to the development of malnutrition so malnutrition is defined as any condition that's caused by the deficient or excess energy or nutrient intake or by some sort of imbalance of nutrients so i think it's important here to like take a second and pause so he said malnutrition is defined by a condition that is caused by a deficiency so inadequate or excess of energy or nutrient intakes so a lot of times we think of malnutrition as someone who is not eating enough they don't have enough nutrients in their diet but i think it's important to note that that excess peace so let's say you have a patient that presents and um they are very picky eater so all they eat all day long is french fries and goldfish so if they're eating french fries and goldfish all day long they may have an increased bmi it just kind of depends upon how much calories they're taking in but what do you think that does to the other nutrients in their diet they're not getting any so vitamin c vitamin d all of these nutrients may be low um and again leading to that risk of malnutrition so i thought that was important to pause and talk about that so it is important that we talk about nutritional status because malnutrition especially long-term malnutrition can of course lead to even greater problems for the hospitalized patient so we know malnutrition can present but how do illnesses cause malnutrition so here we can see symptoms and effects of illness and then treatments so the illness itself or the treatment can lead to the development of malnutrition caused by an overall reduction in your food intake which can of course interfere with digestive and absorptive problems or alter the way that nutrients are metabolized or excreted so for example anorexia due to illness so let's say a cancer patient presents with inadequate oral intakes due to metallic taste from their cancer medications that's going to lead to reduced intake which can of course lead to malnutrition but same for treatment so if you have a patient who is on a bowel rest post surgery they're unable to take anything in my mouth and so again that reduction in food intake can increase risk for malnutrition some other things that we have impaired digestion and absorption so symptoms and effects of illness so an inflammation associated with bowel conditions can lead to impaired digestion absorption radiation therapy as well or gastrointestinal surgeries and here you can see altered nutrient metabolism and excretion so these right here so reduced illness impaired digestion and absorption altered nutrient metabolism and excretion would all be considered what side effects of disease causes of disease what what do we think those are so i would say that these are considered some of the implications on how malnutrition gets developed so here on the side we can see that symptoms and illness as well as treatment can all cause potentially cause these reductions in intake impairment and digestion altered nutrient metabolism which of course can lead to the development of malnutrition so once the source of malnutrition so is it reduced food intake is it impaired digestion and absorption is it altered nutrient metabolism and excretion so once the source of malnutrition is recognized dietary and nutritional interventions can be tailored for each patient depending upon how what their treatment method would be all right so nutrition and health care so who's involved so in the hospital setting we have members of an interdisciplinary healthcare team that are going to work together to ensure that the nutritional needs of the patients are met during their stay these members include our physicians our nurses our registered dietitians registered dietetic technicians and other health care members such as speech language pathology pathologists occupational therapists respiratory therapists the list goes on and on so what are these people's responsibilities so each person has a varying responsibility so registered dietitian nutritionist rdns are the food and nutrition expert they have completed education training required by the academy of nutrition and dietetics including a bachelor's degree in nutrition a supervised internship in a national registration examination registered dietitians are qualified to provide medical nutrition therapy m t which includes nutritional assessments nutritional diagnoses nutritional interventions amongst other things education they are also responsible for planning and improving menus and helping with diet orders they provide nutrition counseling and they may be involved in food and cafeteria services and healthcare systems i would say typically in a healthcare system you have clinical dietitians which are the ones that are seeing the patients you may have a dietitian or two that's in the food service place so helping out with many development patient services those types of things registered dietitian technicians are they work alongside registered dietitians to assist with the implementation and monitoring of nutrition services they have similar roles as dietitians but they must work under the supervision of an rd so registered dietitian technicians have completed that undergraduate bachelor's degree in dietetics and sit for a national registration examination however they do not complete the internship and their examination is different than that of the rd physicians are typically responsible for prescribing diet orders and other ins instructions related to nutrition care including referrals for nutrition assessment education they often rely on other members of the health care team so example nutrition to provide guide guidance when it comes to placing diet orders i would say the placement of diet orders is different per state and also different per hospital so really depends upon where you're at with regards to whether or not the dietitian can actually place the diet order themselves nurses are going to be the ones that screen patients for nutrition problems as soon as they enter into their care they provide nutrition care by helping patients eat their foods recording patient food intake answering any questions about specialized diets they may also be the ones that are responsible for administering tube feedings and intravenous feedings again really depends upon which health system you are a part of i would say that nurses are dietitians rely heavily on nurses when it comes to hey how did sally eat food today especially if sally is an elderly patient with dementia because you know the dietitian jan can go and say hey sally how was your day how did you eat but sally may be like oh yeah i ate mcdonald's had a burger blah blah blah and then the nurse is like oh no she ate macaroni and cheese for lunch so it's important to just note that there and then other members of the healthcare team as we mentioned speech therapy slps ot occupational therapists as well so um we've talked about we know what malnutrition is but how do we identify whether or not somebody has malnutrition so to identify if a patient is malnourished or at risk for malnutrition a nutrition screening is conducted within 24 hours of admission into the hospital this screening involves the collection of data that can clearly indicate if the patient has risk or is at risk or it has or is at risk excuse me for protein energy malnutrition or if they have other nutrition related problems such as history of type 2 diabetes or cardiovascular disorder disease the screening tools are usually very short questionnaires and again are administered by the nurse the nurse technician the dietitian or the diet dietetic technician this is part of the admission process and helps to inform the physicians to set diet orders and cues a diet consult if appropriate so here you can see some examples that are included to identify risk of malnutrition sorry that looks crazy okay so administ uh administ admission data anthropometric data such as height weight pmi functional assessment like hey are you able to feed yourself historical information so past medical histories any laboratory test results such as hemoglobin a1c hb81c and then any signs and symptoms like patient says that there haven't been chewing well for a couple days patient notices you have generalized edema and we'll talk about email later on this semester so those are just some things that are looked at um a little bit more nursing diagnoses with nutritional implications so since nurses are typically the personnel that conduct the nutrition assessment their plan often includes a nursing diagnosis you do not need to memorize all of these but just familiarize your stuff yourself with some of them the diagnosis in the figure indicates some problem that may need nutrition intervention and are mainly related to developmental disabilities diseases involving the esophagus or some sort of neurological condition so for example impaired intention tension so if the patient let's say lost their dentures they're not going to be able to chew hard foods and may need to be put onto a softer diet if the patient presents with um let's see nausea they may not want to eat as much so those are some things to look at so um i went through two of those so take a look at this list and think about a few different nursing diagnoses with nutritional implications what do you think are some what do you think someone with chronic confusion um why do you think someone with chronic confusion may require a nutritional consult um so also what about overweight so think about that um and how you can apply that to um real life situations all right so there are several screening tools that use a combination of the patient's information as well as some information that may be collected at their admission such as their admitting diagnoses physical measurements and laboratory results as well as some of the symptoms that they may have um upon presenting themselves the hospital one of the screening tools that was utilized to measure risk of malnutrition is a questionnaire called the subjective global assessment the subjective global assessment evaluates a person's risk of malnutrition by ranking key variables of the medical history and physical examination these variables are given given an a b or c rating based upon the nourishment status so some different factors so medical history so looking at body weight changes so has a patient exhibited unintentional body weight loss dietary changes so has the patient is the patient following a specific diet have they had changes to their diet gi symptoms nausea vomiting diarrhea anorexia functional abilities so their ability are they able to move are they able to feed themselves and also the the degree of disease physical assessment things that are looked at are subcutaneous fat loss as well as muscle loss looking at edema at the ankles as well as sacral edema and ascites and if these words don't sound familiar to you no worries we will go into detail later so based upon the rating for each one of these in the medical history and physical examination the patient will end up with the category of a b or c so a being well nourished b being moderate malnutrition and c being severe malnutrition so please note that the subjective global assessment is not the only assessment tool there are definitely other screening tools out there that provide and utilize less variables such as just evaluating unintentional weight loss reduced appetite those types of things oops sorry all right there we go so the nutrition care process this is a big one for dietitians so oftentimes a nutrition screening will read to the referral of nutrition services so here a registered dietitian will use a systematic approach to provide medical nutrition therapy which is called the duns nutrition care process all right as i block that out let's erase okay there we go um so there are four different steps that are provided in the nutrition care process which we can see depicted here as mentioned this is a process and dietitians will frequently go back and forth between steps while the patient progresses throughout their day thursday so each step is well documented in the medical record to facilitate communication with the rest of the health care team these steps first involve the nutrition assessment the nutrition assessment involves the collection analysis of health-related data including the abcs that we just mentioned a abcd's that we will mention in a few slides so no worries that doesn't mean anything to you yet but involves the collection and analysis of health related data next we have our nutrition diagnosis so each problem identified during this step the assessment so step one there we go we'll receive a diagnosis with the purpose of guiding the appropriate m t approach that's in step two our nutrition intervention involves counseling and education regarding specific dietary practices to aid with their disease or adjustments in the meals or services during the patient's stay in the hospital they are written as measurable goals or smart goals refer to smart goals before and then lastly we have our nutrition monitoring and evaluation so the patient is going to be monitored closely and updated um and you'll go through and see okay patient has um increased their food intake or patient is not doing great and maybe we need to adjust our goals so we'll monitor and evaluate and then based upon that there may be the need for a new diagnosis maybe a new assessment maybe a new intervention etc so here you can see some historical information used in your nutrition assessment sources of this historical information are typically going to come from the medical record but also through interviewing the patient or the caregiver so some things to think about why do you think supplements are on this list supplements and medications um can disrupt the absorption and metabolisms of certain nutrients and need to be considered in the planning process what about personal and social history these are going to affect food choices and the ability to manage health care and nutrition related problems for diet history detailed information about the patient's dietary practices can really provide us a lot of information about how the patient's doing and how we think the patient will progress moving forward so i mentioned earlier the abcs of nutrition assessment so the four primary components of nutrition assessment will be used via this mnemonic abcd where a stands for anthropometric assessment such as height and weight b stands for biochemical parameters such as serum albumin levels or hemoglobin count c stands for clinical evaluation including the assessment of functional status as well as your physical examination and d will stand for dietary history or dietary evaluation so do you use supplements what does your diet look like how much food do you consume etc etc so we'll go through these abcd's in a little bit more detail and hopefully this will be fun and helpful so anthropometric data this is related to physical measurements of the human body and it can reveal nutrition problems such as over nutrition or protein energy malnutrition examples of anthropometric measurements include height in adults and lengthen children younger younger than 24 months so two years um also if someone has an abil a disability or condition that inhibits their ability to stand estimates can be made for this body mass index which we'll go into more detail later it looks at both your height and your weight to determine where you fall on a scale of where normal is between 18.5 and 24.99 but we'll go into lots of detail about that later head circumference assesses brain growth and malnutrition in children up to three years of age it's used to track drink brain development in premature and for in small four gestational age infants and lastly we have our waist so our waist circumference is a good surrogate measure for our intra-abdominal fat also known as visceral adipose tissue so that's the fat that's going to line your organs that isn't necessarily considered too great for you here we can see some recommendations for infants and children so in children and infants growth patterns below the fifth percentile indicate cause for concern while bmi for age can indicate conditions such as over and under nutrition for adults to assess nutritional risk we are interested in observing overall changes in body weight itself and on the rate of weight loss over time so percentages of usual body weight looks at your current body weight divided by your usual weight by 100 and then there's also a chart that we won't get into but to measure where your body weight should be you'll take your current weight divided by your ideal body weight we've already talked a little bit about some of these but since body composition may change due to illness additional additional measurements may be taken such as skin fold thickness and limb circumference as alluded to one of the things that we like to look at is changes in weight so this is looking at it's important to know involuntary weight loss so if we say involuntary does that mean weight is intentionally lost or unintentionally lost that would be unintentionally lost so if you lose more than two percent of your usual body weight in less than one week if you lose greater than five percent of your usual body weight in one month if you lose greater than seven point five percent of your usual body weight in three months or greater than ten percent in six months this suggests the development of not written on here but malnutrition so malnutrition i'm just going to write out mal so you all know mel so all of these are risks for malnutrition you could also use this for sudden weight gain so sudden weight gain may be attributed to let's say fluid retention due to heart failure or kidney problems so these types of individuals may need to limit their fluid intake to help get some of that water off all right so we just went through a couple different things for the a's and now we're going into our bees so biochemical markers may provide some insight on nutritional status additionally we know that biochemical analyses can be used for disease management to monitor fluid and electrolyte status and to assess the functionings of your organs so if biochemical markers are high or low the doctor may ask you to repeat the analysis to confirm the results and when we look at biochemical analyses these can be from your serum so from your blood also from your urine depending upon what's being assessed here you can see some examples of some of your laboratory tests that are used uh we'll talk about some of these in more detail in our next slide it's important to note that many of these abcs are going to be drawn together so biochemical analyses are not typically done on their own but rather taken together with other assessment data [Music] all right so serum proteins are produced by the liver and can be used to assess protein energy status albumin is used to gauge the severity of illness due to slow rate of degradation transferrin levels are going to increase when iron is low the levels will also decline when iron status improves if someone has an iron deficiency or history of an iron deficiency do not use this protein to assess their protein energy status because we already know that these levels are going to be a little off transparent also known as pre-albumin and retinal binding proteins decrease rapidly during protein energy malnutrition and respond quickly to improved protein intakes c reactive protein crp rises rapidly in response to inflammation or infection it's oftentimes going to be elevated in a critical illness like heart disease and also in some cancers um sensitive to inflammation hydration status so just some things to consider um and i think that's good for our serum proteins the next assessment method that we'll look at is our clinical evaluation or our physical exam so here we're looking for physical signs of malnutrition and oftentimes this requires your clinical judgment most signs are non-specific since they can reflect several nutrient deficiencies or other conditions other assessments again are going to need to accompany the physical exam so your anthropometric data your biochemical data et cetera the signs of malnutrition tend to occur in parts of the body where cell replacement often occurs at rapid rates such as hair mouth tongue skin and digestive tract so here you can see body systems hair the acceptable appearance the signs of malnutrition and other possible causes so you can see your lips what happens your mouth and gums bleeding medications poor taste so again um you don't need to know every single one of these but again it's of course it's important to familiarize yourself all right some other things for physical examination so edema we've already mentioned this what is that edema is a condition caused by diseases such as kidney and liver disease protein energy malnutrition or the obstruction of veins and some medications edema is associated with fluid retention signs include weight gain facial puffiness tissue swelling abdominal distension and lower extremity swelling i'm sure many of you have heard of dehydration dehydration can be caused by gi losses fever and excessive urination it is also seen in wounds and in burns as fluid is lost through the sore signs and symptoms include thirst weight loss dry skin and mouth reduce skin tension so turgor as well as dark colored urine and low urine volume so just meaning that you do not have a lot of urine coming out all right we're getting close um some other assessments that we look at in the in our clinical evaluation include our functional assessments so looking at immunity our heart and lung capacity as well as muscle strength and weakness immunity is commonly seen in protein energy malnutrition as well as zinc deficiency the skin responds to antigens that induce skin redness when nutritional status is accurate is adequate maybe um may be delayed which can lead to skin redness and swelling um so for our hearts that should say heart not earth yeah get rid of that hrt all right that is there we go okay so our heart and lung capacity we look at exercise tolerance and for muscle strength and wasting we can look at our hand grip device all right obtaining food intake data can be quite challenging since they rely heavily on subjects memory and honesty with the interviewer it also relies upon the interview skills to write to ask the right questions some examples of our dietary assessment methods include the 24-hour dietary recall the food frequency questionnaires food records and direct observation 24-hour dietary recalls are guided interviews in which an individual recalls everything that they have consumed in the past 24 hours typically a multiple path method is the most effective approach for these recalls it consists of four to five separate passes through the 24-hour period of interest first a quick list without being prompted the second pass-through is used to determine any forgotten foods such as snacks beverages and dressings past three and four may ask details about the specific foods consumed such as the amounts the preparation method places where the food was consumed and obtained in the last pass consists of a final review to ask if any additional details may happen may be missing this 24 hour recall typically is going to take about 30 to 45 minutes to do and it reflects a typical day our food frequency questionnaire is a food list organized by food groups with checked boxes to indicate the frequency of consumption the food frequency questionnaire helps to identify food patterns some foods are focused on or some are focused on food categories for relative relevant medical conditions one limitation of these is that you must rely on memory additionally they typically only include common foods so they lack diversity they do not have any serving sizes or easy ways to calculate overall intakes so these are only effective for longer term nutritional interventions food records are detailed written accounts of all the foods consumed during a specific period they focus on collecting quantitative data so portion sizes they do not rely on memory and are very accurate but the process itself can be biased and the results it can be kind of time consuming and then some of the things that may be a limitation is that they require literacy and the physical ability to write because the patient or the participant will do these at home typically on two week days and one weekend day to really capture typical intakes the last one that we have is direct observation so this would be observing a patient's meal tray or um looking at the specific foods that they have in their hospital room so food intakes are directly observed and analyzed this can be condoned by a nurse for a calorie count so lots of different dietary assessment methods i would say out of all of our different abcs i would know what they all mean but these would be one where you need to go into more detail and understand what each one of these site methods are all right friends we are getting close we are almost there last little push here we're switching gears to talk about nutritional genomics so this is a very much a u-turn from what we've been discussing um almost all of the body's trillions of cells complete contain a complete copy of a person's dna information packaged within thread like structures called chromosomes most human cells contain 46 chromosomes 23 from each patient sperm and eggs contain the 23 chromosomes within a chromosome our dna is tightly wound around proteins called histones kind of depicted there the dna contains the instructions that guide how a cell functions encoded within a sequence of units represented by the letters a t c and g which you can see here sections of dna strands notice genes are translated into proteins and other molecules that help carry out specific functions so proteins as indicated by the central dogma of biology the codogenetic information hardwired into dna is transcribed into individual transportable units composed of messenger rna mrna in which each mrna contains the information required for the synthesis of a particular protein gene expression can be measured by determining the amount of messenger rna in a tissue sample using techniques such as rna sequencing micro tech microarray technology or quantitative pcr nutritional genomics so this is the study of dietary effects on gene expression so also known as nutrigenomics the goal is to custom design dietary prescriptions that fit a person's need so how can nutrients alter the expression of genes they can switch gene expression on and off specifically at the promoter region of the gene so if so that's that um epigenetics is the process that causes heredical changes in gene expression that are separate from the dna nucleotide sequence genes can determine the susceptibility of a disease so from this slide i would make sure you know what nutrient genomics are as well as what epigenetics are very bad at making stars that's okay genetic variation between individuals is very common but some are more significant than other polymorphisms include variations in the dna sequence of a particular gene a single nucleotide polymorphism is the most common type of polymorphism and involves the insertion deletion or substitution of a single nucleotide in the dna strand this variation can result in a change in the function of a protein or altering how a particular gene is regulated genetic variation makes humans stronger but also can make us vulnerable to certain diseases single gene disorders are disorders that affect are affected by a single gene they're much less common and typically occur later in life although not always examples include sickle cell anemia cystic fibrosis pku lactose intolerance and hemochromatosis so iron overload multi-gene disorders are diseases such as heart disease and cancers that result in changes in several genes this typically takes several decades to develop and many genes can contribute but one gene is not enough to cause the disease so um what are some problems of gene testing so genotype directed nutrition on the private sector many companies are already offering genetic tests to customize diets based on an individual's response to specific nutrients for instance that is the case for genetic-based tests for specific metabolisms of caffeine uh the predisposition to weight gain by saturated fats increased development of hypertension by high salt intakes amongst others so what is the problem of doing these genome type directed nutrition one of them is motivation or willingness to make a change knowing that you have a higher risk for a heart disease by genetic testing doesn't necessarily mean you're going to adopt a healthier diet right so it's important that these people who do these testings are ready and willing to make a change confidentiality so who keeps and has access to the data what are the regulations behind these is it the employers is it the health insurance what is it and it might not be the best interest of children due to stigma discrimination and psychological burdens associated with genetic testing so to gather these nutritional recommendations solely based on genetic background represent a straightforward approach to the concept of personalized nutrition although quite similar to the concept of precision nutrition and somewhat used interchangeably the latter so precision nutrition makes reference to a conceptual framework covering a wider set of individual features allowing for an effective and denial dynamic nutritional approach thus while personalized nutrition is basically on genes um it is already being utilized by a lot there's a little bit more that needs to go into this understanding of precision nutrition so i would say that within the next five to ten years precision nutrition and personalized nutrition are going to be in the forefront of nutrition care and education so i'm interested to hear y'all's thoughts on that so i know this last chunk was a little bit heavy here so make sure you take some time to review these key topics these key words so what's polymorphism what is precision personalized nutrition what's nutritional genomics um what's epigenetics make sure you just familiarize yourself with some of those key terms um and with that i'll end us uh thank you all for listening through this lecture too i hope you guys have a great day and talk soon bye