nutrition 3 8

Nutrition for Young Children Handout 1

Nutrition for Young Children

Module Objectives:

Describe how nutritional intakes in childhood must match needs for growth.

Utilize and interpret growth charts; describe the parameters of normal growth.

List consequences of undernutrition on growth, and describe failure to thrive.

Provide age-appropriate dietary guidelines.

Describe the absorption of water, sodium and other nutrients.

Module Outline:

Introduction

Title and Authors

Table of Contents

Introduction & Module Objectives

Normal Growth

Normal Growth in Infancy

Growth in Childhood and Adolescence

Growth as a Nutrition Indicator

Growth Charts

Nutritional Needs for Growth

What Children Need for Growth

Macronutrient Needs in Childhood

Mineral Needs in Childhood

Nutrition-Related Problems in Children

Common Nutrition-Related Problems

Defining Overweight in Children

Screening for Overweight

Failure to Thrive

Criteria for Failure to Thrive

Practice Charts

Nutrients for Brain Development

Brain Growth

Choline

Taurine

Folate

Iron


Iron Deficiency

Problems with Restrictive Diets

Docosahexaenoic Acid (DHA)

Growth Case - Assess Growth

Meet the Patient

The Mother's Concern

Track Changes Over Time

Parental Height Assessment

Jessica's Growth Charts

Interpret the Growth Pattern

Infant Feedings

Introducing Solids

Transitioning to a Mixed Diet

Introducing New Foods

Food Transitions: Food Groups

Food Transitions: Timing

Adverse Food Reactions

Diarrhea

Water Absorption: Sodium-Potassium Pump

Water Absorption: SGLT-1

Water Absorption: Aquaporins

Water Absorption: Summary

Imbalanced Intestinal Secretions and Absorption

Oral Rehydration Therapy

Choose the Best Rehydration Beverage

Integrated Practice (Diarrhea Case)

Diarrhea Case

Protein Basics

Amino Acid Uses

Essential and Non-essential Amino Acids

Importance of Providing Essential Amino Acids

Transamination and Amination

Vitamin B6

Normal Protein Requirements

Marasmus and Kwashiorkor

Amino Acid Metabolism

Glucogenic and Ketogenic Amino Acids

Genetic Defects in Amino Acid Metabolism

Phenylketonuria

Homocysteinemia


Maple Syrup Urine Disease

Protein Quality

Definition of Protein Quality

Protein Quality of Foods

Vegetarian Diets and Protein

Preschooler's Nutritional Needs

Dietary Recommendations for Preschool Children

Fat Intake

Food Jags

Nutritional Problems in U.S. Preschoolers

Choking Hazards

Growth Case - Investigate Causes

Your Next Task

Rule Out Digestive Problems

24-hour Recall

Breakfast

Snacks and Lunch

Dinner and Snack

Ask Additional Questions

Compare to Standard Recommendations

Identify Primary Cause

Choose an Intervention

Two Referrals

Increasing Energy Density

Assign Homework

Goals for Catch-up Growth

Trace Minerals

Iron

Copper

Zinc

Regulation of Iron Absorption: Deficiency

Regulation of Iron Absorption: Repletion

Copper Absorption and Release

Zinc Absorption

Growth Case - Iron Deficiency

A Follow-up Visit

Consequences of Iron Deficiency

Conveying the Diagnosis

Determine the Treatment Plan

Correcting the Deficiency

Conclusion


Vitamin A

Vitamin A Metabolism

Vitamin A Precursors

Interaction: Retinal Content of Carotenoids

Retinol Activity Equivalents

Integrated Practice (Delayed Growth Case)

Delayed Growth Case


Objectives, Key Concepts, and Key Concept Summaries by Topic

Topic: Normal Growth

Objective:

Describe the parameters of normal growth and explain the use of CDC charts in tracking

growth.

Key Concept:

Growth spurts occur in infancy and adolescence; irregular patterns of growth can indicate

nutritional problems.

Growth is not linear. The most rapid period of growth occurs during the first year of life;

slower, steady growth then follows until adolescence, when the growth rate increases.

Body composition changes along with stature. Growth charts are useful for plotting

growth patterns for comparison to peer standards. In general, values between the 5th and

85th percentile are considered within normal range, as long as the pattern of growth

approximates the shape of the growth curve. Values out of this range, or significant

changes in growth, can identify potential problems of over- or undernutrition and warrant

further investigation. BMI-for-age charts can identify children who are obese,

overweight, or underweight.

________________________________________________________________________

Topic: Nutritional Needs for Growth

Objective:

Explain how the nutritional needs of children differ from those of adults.

Key Concept:

Needs for specific nutrients on a per-kilogram basis are highest early in life and later

decrease to adult levels.

Although young children need lower absolute amounts of nutrients, their needs on a per-

kilogram basis are much higher than those of adults. Infants may require some nutrients,

such as DHA, until they are able to synthesize enough on their own. Some organs and

tissues are sensitive to deficiencies, especially during growth. Relative to body size,

needs for calories and other nutrients generally decrease over the lifecycle. To meet their

relatively high needs, infants and children should consume foods that are rich in

micronutrients, not just high in calories and protein. For infants, human milk or iron-

fortified formula provides the majority of energy and nutrient intake. Children gradually

transition to more adult patterns of food

intake.__________________________________________________________________


Topic: Nutrition-Related Problems in Children

Objective:

Identify failure to thrive and overweight in children.

Key Concept:

The major nutrition-related problems in childhood range from undernutrition to

overnutrition.

The most common nutrition-related problems reflect poor dietary habits that can lead to

overweight, anemia, growth retardation, or dental caries. Children in the US are

considered overweight when their body mass index (BMI) values for age and gender

equal or exceed the 85th percentile. The term failure to thrive describes inadequate

growth and may result from insufficient nutrition, numerous medical conditions, and

environmental circumstances.

________________________________________________________________________

Topic: Nutrients for Brain Development

Objective:

Describe the influence of infant nutrition on brain growth and development.

Key Concept:

Important nutrients for brain growth and development include DHA, choline, taurine,

folate, and iron.

The brain grows rapidly during the first year of life. Certain nutrients have critical roles

in brain structure and function. Membranes and photoreceptor rods contain high

concentrations of docosahexaenoic acid (DHA). Choline is a precursor for phospholipid

and neurotransmitter biosynthesis. Taurine has roles in osmoregulation, neuroprotection,

and neuromodulation. Folate mediates one-carbon transfers and DNA synthesis. Iron is

necessary for energy metabolism, regulation of mRNA translation, and myelin synthesis.

Iron deficiency, the most common nutrient deficiency world-wide, can delay speech and

cognitive development, slow growth, and cause anemia. Children on highly restrictive

diets can have low intakes of iron, vitamin D, fat, and zinc. A lack of these nutrients can

impair optimal development of the brain and central nervous

system._________________________________________________________________


Topic: Infant Feedings

Objective:

Explain the process of introducing solid foods to an infant.

Key Concept:

Introducing solid foods to an infant should begin when the child is developmentally

ready, usually between 4 to 6 months.

Signs of readiness include: disappearance of the extrusion reflex, hand-to-mouth

movements, and ability to sit with support. Generally the appearance of these signs will

coincide with maturation of the gastrointestinal system and the kidneys. During the first

year of life, foods should be gradually introduced in the following order: cereals, fruits

and vegetables, and then meats and dairy products. At one year, children should be eating

70% liquids and 30% solids. Introducing foods earlier or later than recommended can

contribute to the development of food allergies. Delaying the introduction of solid foods

later than 6 months can increase risks of iron and zinc deficiency. Advise parents to

introduce foods one at a time so that food allergies/intolerances can be identified or

avoided.

________________________________________________________________________

Topic: Diarrhea

Objective:

Describe the use of oral rehydration therapy to treat diarrhea.

Key Concept:

Oral rehydration therapy utilizes sodium- and glucose-coupled transport to replenish

fluids following diarrhea.

More children under the age of five die from diarrhea than from any other cause. Oral

rehydration therapy (ORT), the gold standard for treating diarrhea in children, uses a

solution of sodium and glucose (along with chloride, potassium, and citrate) to promote

water uptake via the activity of the sodium-glucose co-transporter (SGLT-1). Sodium-

and glucose-coupled transport effectively replenishes fluids following diarrhea. Other

goals of ORT include maintenance of adequate hydration and attention to nutritional

status.

________________________________________________________________________


Topic: Protein Basics

Objective:

Explain the need for an adequate intake of protein during childhood.

Key Concept:

For proper growth and development, a young child must have adequate intakes of protein and

vitamin B6.

The body uses proteins to build tissues and synthesize many compounds. Proteins are also

catabolized for energy. Humans can synthesize some amino acids (non-essential) but not

others (essential). Synthesis of non-essential amino acids occurs via transamination and

amination reactions. Pyridoxal-5-phosphate, the active form of vitamin B6, functions as a

cofactor for many enzymes involved in protein metabolism. Protein requirements per kilogram

decrease rapidly after the first year of life. A lack of dietary protein may lead to the wasting

diseases marasmus and kwashiorkor.

________________________________________________________________________

Topic: Amino Acid Metabolism

Objective:

Describe normal amino acid metabolism and identify genetic defects that disrupt the

actions of key enzymes.

Key Concept:

All amino acids can be catabolized for energy; genetic defects in amino acid metabolism can

cause brain damage if untreated.

Most amino acids have carbon skeletons that can be converted to glucose. Some amino acids

are ketogenic and can generate acetyl CoA and ketone bodies. Certain genetic defects can

disrupt amino acid metabolism and, if untreated, can lead to the accumulation of toxic

compounds or cause deficiencies of critical products. Phenylketonuria, a relatively common

inborn error of metabolism, usually results from a defect in the enzyme phenylalanine

hydroxylase. Irreversible dementia may occur if phenylalanine intake is not restricted.

Homocysteinemia results from a defect in cystathione beta-synthase but can be treated with

dietary restrictions and supplementation. An infant with maple syrup urine disease cannot

metabolize branched-chain amino acids and must receive a special diet with reduced quantities

of valine, leucine, and isoleucine.

________________________________________________________________________


Topic: Protein Quality

Objective:

Define protein quality and describe strategies for meeting protein needs with a variety of

foods.

Key Concept:

Plant and animal proteins can meet nutritional needs.

Several factors determine the quality of a protein: its amino acid composition, its ability to

sustain growth, its effect on nitrogen retention, and the presence of compounds that interfere

with nutrient uptake and metabolism. The ability of a food to sustain growth and development

depends on the quantity and quality of its protein. The protein digestibility corrected amino

acid score (PDCAAS) is the standard method for determining protein quality. According to

this system, animal and soy products provide higher quality proteins than do grains and other

legumes. Plant proteins, though less digestible than animal proteins, can provide all of the

necessary amino acids and nitrogen if eaten in complementary mixtures throughout the day.

________________________________________________________________________

Topic: Preschoolers Nutritional Needs

Objective:

Describe the nutritional needs of preschool children and identify the major dietary

concerns for this age group.

Key Concept:

By the age of five, children should be eating a diet similar to that of adults.

After the age of two, a child should gradually decrease fat intake to about 30% of total

calories. Occasionally children will go through periods where they will only eat a limited

number of foods. These periods, called food jags, are usually not of great concern unless

they persist for more than a few weeks. Many preschool children in the US have a diet

that needs improvement or is poor. Problem areas include inadequate intakes of iron,

fluid, and fiber, as well as over-consumption of sweets, which may lead to dental caries.

Certain foods pose a choking hazard and should not be given to children under four years

of age; these include whole grapes, cherries with pits, hot dog slices, hard candies, nuts,

and popcorn.

________________________________________________________________________


Topic: Trace Minerals

Objective:

Explain how iron, zinc and copper are critical for normal growth and development.

Key Concept:

Many enzymes require trace minerals (iron, copper, and zinc) for proper function.

Iron, an essential mineral, participates in oxygen transport, respiration, defense against free

radicals, and in the metabolism of many compounds. Deficiency symptoms include anemia,

growth retardation, and impaired immune function. Low iron status stimulates the expression

of proteins that promote iron uptake. Copper, a cofactor for many enzymes, has a role in

energy production and protects against oxidative damage. Deficiencies rarely occur, but high

levels of dietary iron and zinc may decrease copper absorption. Zinc is a constituent of so

many critical enzymes that deficiencies have severe consequences, including growth

retardation, delayed wound healing, immune dysfunction, and cognitive impairment.

Excessive iron intake decreases zinc absorption.

________________________________________________________________________

Topic: Vitamin A

Objective:

Describe the functions of vitamin A precursors and metabolites.

Key Concept:

Vitamin A is needed for vision, regulation of gene expression, and control of cell

proliferation and differentiation.

In intestinal cells, retinol is esterified for transport to the liver via chylomicrons. Retinol

is either stored in the liver as retinyl esters or bound by retinol-binding protein and

transthyretin for transport in plasma. Biologically active forms of vitamin A include

retinol metabolites, which control cell growth; retinal, needed for vision; and retinoic

acid, which regulates gene expression. Vitamin A deficiency impairs vision and

compromises the immune system. Note that excess intake of preformed retinol, but not

provitamin A carotenoids, can cause birth defects. Only a few carotenoids have the right

structure to generate retinal. To determine the vitamin A content of foods, use conversion

factors to express retinol and carotenoids as retinol activity equivalents.

________________________________________________________________________


Bibliography

2000 CDC growth charts: United States. Available at www.cdc.gov/growthcharts/

Accessed 4 April 2007.

Himes JH, Deitz WH. Guidelines for overweight in adolescent preventive services:

recommendations form an expert committee. The Expert Committee on Clinical

Guidelines for Overweight in Adolescent Preventive Services. Am J Clin Nutr. 1994;

59:307-16.

Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,

Protein, and Amino Acids (Macronutrients). Institute of Medicine, National Academy

Press, Washington, DC. 2005. Available at www.nap.edu

Dietary Reference Intakes for Calcium and Vitamin D. Institute of Medicine, National

Academy Press, Washington, DC. 2010. Available at www.nap.edu

Olsen EM. Failure to thrive: still a problem of definition. Clin Pediatr (Phila).

2006;45(1):1-6.

Leigh SR. Brain ontogeny and life history in Homo erectus. J Hum Evol. 2006;50(1):104-

8.

Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin

B12, Pantothenic Acid, Biotin, and Choline. Institute of Medicine, National Academy

Press, Washington, DC. 1998. Available at www.nap.edu

Dominy J, Eller S, Dawson R Jr. Building biosynthetic schools: reviewing

compartmentation of CNS taurine synthesis. Neurochem Res. 2004;29(1):97-103.

Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium,

Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc.

Institute of Medicine, National Academy Press, Washington, DC. 2000. Available at

www.nap.edu

Cunnane SC, Francescutti V, Brenna JT, Crawford MA. Breast-fed infants achieve a

higher rate of brain and whole body docosahexaenoate accumulation than formula-fed

infants not consuming dietary docosahexaenoate. Lipids. 2000;35(1):105-11.

Wright CM, Cheetham TD. The strengths and limitations of parental heights as a

predictor of attained height. Arch Dis Child. 1999 Sep;81(3):257-60.

American Dietetic Association. Start healthy, stay healthy: feeding guidelines. Available

at http://www.eatright.org/ada/files/infant_book.pdf Accessed 5/03/07.


Burks AW, Jones SM, Boyce JA, Sicherer SH, Wood RA, Assa'ad A, Sampson HA.

NIAID-sponsored 2010 guidelines for managing food allergy: applications in the

pediatric population. Pediatrics. 2011;128:955-65. Review. PMID: 21987705

World Health Organization. Oral Rehydration Salts - Production of the new ORS. 2006.

Available at www.who.int/child-adolescent-

health/New_Publications/CHILD_HEALTH/WHO_FCH_CAH_06.1.pdf Accessed

5/4/07

ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the

use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter

Enteral Nutr: 2002 Jan-feb;26(1 Suppl):1SA-138SA.

Messina V, Mangels R, Messina R. The dietitian's guide to vegetarian diets. 2nd edition.

Jones and Bartlett Publishers, Inc. Sudbury, MA. 2004.

Information available at mypyramid.gov Accessed 5/08/07.

U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. The Healthy

Eating Index. 1995. Available at www.cnpp.usda.gov/publications/hei/HEI89-

90report.pdf Accessed 9 May 2007.

Schwartz, I. David. Failure To Thrive: An Old Nemesis in the New Millennium.

Pediatrics in Review 2000 21: 257-264

Monsen ER. Iron nutrition and absorption: dietary factors which impact iron

bioavailability. J Am Diet Assoc. 1988;88(7):786-90.

Prasad AS, Kucuk O. Zinc in cancer prevention. Cancer Metastasis Rev. 2002;21(3-

4):291-5.

Fleming RE, Bacon BR. Orchestration of iron homeostasis. N Engl J Med. 2005

28;352(17):1741-4.

Sharp P. The molecular basis of copper and iron interactions. Proc Nutr Soc.

2004;63(4):563-9.

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2006;66(7):606-30.

Readings

Center for Disease Control, Atlanta, Georgia.

http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm

Nutrition for School Aged Children Handout 1

Nutrition for School Age Children

Module Objectives:

Characterize the nutritional requirements of school-aged children.

Describe the roles of nutrients involved in bone growth and development.

Explain the major steps of macronutrient digestion and absorption, and the causes and consequences of malabsorption.

Describe the spectrum of eating behaviors, including eating disorders, and disordered eating.

List common nutritional deficiencies at different ages.

Module Outline:

Introduction

Title and Authors

Table of Contents

Introduction and Module Objectives

Nutritional Needs during the School Years

Energy Needs in Childhood

Glucose Metabolism in the Fasting State

Glucose Metabolism in the Fed State

Nutritional Concerns in Children

Micronutrients in Energy Metabolism

Thiamin, Biotin, Pantothenate

Thiamin

Thiamin Deficiency

Biotin

Review Carboxylases

Pantothenate

Intestinal Absorption

Predigestion

Pancreatic Secretions

Fat Digestion

Brushborder

Malabsorption Overview

Exocrine Pancreatic Insufficiency

Inadequate Bile

Loss of Intestinal Mucosa Function

Is it Maldigestion or Malabsorption

Cystic Fibrosis Case - part 1

A Child with Chronic Illness

Introduce the Student


Concerns About Weight Gain

Nicole's Weight-for-Age Chart

Nicole's Stature-for-Age Chart

Interpret the Growth Pattern

About Cystic Fibrosis

Interview the Patient

Identify the Problem

Fat Malabsorption

Changing Digestive Enzyme Needs

Nutritional Outcomes

Healthy Habits Last a Lifetime

Dental Caries

Breakfast and Mental Performance

Integrated Practice (Fuel Metabolism)

Fuel Metabolism Case

Growth Needs & Spurts

Body Composition Changes During Growth

Gender Differences in Adolescence and Into Adulthood

Diverging Growth Patterns

Nutritional Problems in Prepuberty/Puberty

Bone Minerals

Bone Mineral Density

Bone Mineralization

Calcium

Calcium Intakes

Phosphate

Bone Regulation

Vitamin D Metabolism

Vitamin D Nutriture

Cystic Fibrosis Case - part 2

Fat Malabsorption

Bone Development

Resistance

Plan for Follow-Up

Conclusion

Dietary Patterns in Teens

Teens' Nutritional Needs

Problem Nutrients for Teens

Identifying Nutritional Concerns


Food Choices/Healthy Eating

Vegetarianism

Athletic Performance

Hydration and Fluids

Body Image

Changes During Adolescence

Spectrum of Eating Behaviors

Development of Eating Disorders

Types of Eating Disorders

Adolescent Case

Introduction to the Patient

Consider Potential Diagnoses

Need to Assess Diet and Symptoms

Adolescence: A Time of Change

Rapid Weight Loss

Investigate Contributing Factors

Summary of Cassandra's Responses

Make a Determination

Address the Issue with the Patient

A Team Approach

Early Intervention

Focus on Common Goals

Medical Clearance

Conclusion

Teen Pregnancy

Teen Pregnancy Concerns

Nutrients of Concern During Pregnancy

Integrated Practice (Teen Athlete)

Teen Athlete Case



Topic: Nutritional Needs during the School Years

Objective:

Explain how the flux of macronutrients between organs while fasting helps the growing

body meets its high energy needs.

Key Concept:

During fasting the brain depends on glucose sent into the bloodstream by the liver.

Children have much higher energy and macronutrient needs per weight than adults. Four

to six-year-old children have nearly the same energy and fat requirements as an adult

woman, because they have higher activity levels and must sustain growth. The brain

depends on a continuous supply of glucose. After meals glucose is supplied directly from

absorbed carbohydrates. During fasting, the liver converts glycogen stores or precursors

(amino acids, lactate, and other intermediates) to glucose for release into blood.

Nutritional concerns in children include overall dietary quality, including improving

intake of fruits and vegetables, ensuring adequate calcium, vitamin D, and iron intake,

and moderating fat intake.

________________________________________________________________________

Topic: Nutrients in Energy Metabolism

Objective:

Describe how the micronutrients thiamin, biotin, and pantothenate are essential for fuel

metabolism.

Key Concept:

The vitamins thiamin, biotin, and pantothenate are critical cofactors in energy

metabolism in both fed and fasted states.

Thiamin deficiency may cause edema, wasting and congestive heart failure, most likely

due to the critical role of thiamin triphosphate (TPP) in fuel metabolism of muscle and

neuron function. The best sources of thiamin are pork, fortified grains, legumes, and

yeast. Biotin-dependent carboxylases replenish TCA intermediates, regulate lipid

metabolism, and metabolize some amino acids. Biotin is found in food and intestinal

flora. Pantothenate as coenzyme A participates in the metabolism of most nutrients; good

sources include yogurt, other fermented dairy products, broccoli, legumes, chicken, milk,

sweet potato, and intestinal bacteria. The deficiency symptoms of these vitamins reflect

their role in fuel metabolism. Thiamin deficiency is commonly seen with alcohol abuse,

but in most cases, deficiencies of thiamin, biotin and pantothenate are rare.

________________________________________________________________________


Topic: Intestinal Absorption

Objective:

Explain major steps of macronutrient digestion and absorption, and causes and

consequences of malabsorption.

Key Concept:

Nutrient digestion and absorption requires enzymes, water and ions from saliva, stomach,

pancreas, bile and intestine.

Nutrient digestion and absorption of most foods is dependent on adequate function of the

entire intestinal tract. A lack of pancreatic enzymes limits absorption of fat and fat-

soluble vitamins, proteins, and complex carbohydrates. Lack of bile interferes with

absorption of fat and fat-soluble vitamins. Loss of brushborder function limits digestion

and uptake of peptides, sugars and many micronutrients including folate and B12.

________________________________________________________________________

Topic: Nutritional Outcomes

Objective:

Explain the importance of parental role modeling, eating breakfast, and a low cariogenic

diet.

Key Concept:

Having a good role model and developing healthy habits during childhood is important to

avoid adverse nutritional outcomes.

Parents are important role models for their children. Parents should strive to get enough

exercise and consume adequate and appropriate amounts of fruits, vegetables, whole

grains, and low-fat dairy. Dental caries can be avoided by choosing foods that help

protect against caries such as cheese, raw vegetables, and hard breads. At the same time,

cariogenic foods (sticky foods high in sugar) should be avoided as these cause prolonged

exposure of teeth to fermentable carbohydrate. Skipping breakfast should be discouraged

because this can lead to decreased performance on mental function tests. It is important to

develop healthy habits during childhood, not only to avoid adverse nutritional outcomes,

but to promote health into adulthood as well.

________________________________________________________________________


Topic: Growth Needs & Spurts

Objective:

Relate how the growth spurt of puberty changes stature and body composition and

influences nutrient needs.

Key Concept:

Puberty is a time of great gains in mass and height in both males and females.

In girls, puberty begins at 10-11 and peaks at age 12 while in boys it begins at age 12-13

and peaks at 14 years. Females grow ~15 cm (~6 in) and gain ~16 kg (~35 lbs) while

males grow ~20 cm (8 in) and gain ~20.5 kg (45 lbs). The biggest difference in growth

patterns during this time is body fat: in females fat mass increases to ~23% while in

males is declines to ~12%. Failure to meet energy needs for growth can prevent the

adolescent from reaching their full potential for body height and delay sexual maturation.

Particularly in girls, dietary quality declines during adolescence. Significant bone

mineralization occurs during this period, while inadequate calcium and vitamin D intakes

are common. Zinc is needed for muscle growth and sexual maturation. Iron requirements

are increased in males due to muscle mass expansion and in females due to menses.

________________________________________________________________________

Topic: Bone Minerals

Objective:

Describe the roles of nutrients involved in bone growth and development.

Key Concept:

Calcium, phosphorus, vitamin D, ascorbate, copper, magnesium and other nutrients are

essential to bone formation.

Bones require calcium, phosphorus, vitamin D, ascorbate, copper, magnesium, protein,

and other nutrients to form properly. Lack of critical nutrients interferes with bone

growth and mineralization, especially during growth spurts. Accumulation of bone

minerals continues until the mid-twenties. Adolescent girls fail to consume enough

calcium for bone development, and excessive consumption of phosphate-rich foods by

children and adolescents often decreases calcium absorption and retention.

________________________________________________________________________


Topic: Bone Regulation

Objective:

Describe the metabolism of vitamin D and identify its role in the body.

Key Concept:

itamin D, coming from dietary sources or skin synthesis, is essential for bone regulation.

Vitamin D is obtained from dietary sources and from light-dependent synthesis in the skin

(although sunscreen blocks this process). Ultraviolet light induces the conversion of 7-

dehydrocholesterol to cholecalciferol. Additional UV exposure inactivates intermediates of

the reaction which tightly limits synthesis in skin and avoids toxic effects. Dietary vitamin D,

in contrast, is absorbed without limit and risks toxicity from overdoses. The hydroxylated

form 1-25-dihydroxy vitamin D acts on many different DNA segments, promoting the

translation of some and inhibiting that of others. It promotes absorption of calcium from the

intestine, calcium mobilization in bone (the 1,25 dihydroxy form) and reabsorption from renal

tubules. When intakes are low, young children are at especially high risk of slow bone matrix

growth and poor bone mineralization.

________________________________________________________________________

Topic: Dietary Patterns in Teens

Objective:

Identify the nutrients of concern for adolescents.

Key Concept:

The typical dietary patterns of teenagers do not match their nutritional needs.

Teenagers typically skip meals, choose sodas or soft drinks as beverages and consume

fast foods. In addition, they have a low fruit and vegetable intake. In general, the diets of

teens are low in calcium, vitamin D, iron (in females) and folate and may be low in

vitamins A, C, E, riboflavin, magnesium, zinc and potassium. Often the diets of teens are

high in fat, saturated fat, cholesterol and sodium. This pattern puts them at risk for

elevated lipid levels (potentially leading to adult heart disease) and overweight

(potentially leading to adult obesity, diabetes and cardiovascular disease). Vegetarianism

and athletic performance warrant special dietary recommendations.

________________________________________________________________________


Topic: Body Image

Objective:

Describe the spectrum of eating behaviors, including eating disorders, and disordered

eating.

Key Concept:

Body image issues that may occur during growth warrant monitoring of teens for signs of

an eating disorder.

Adolescent bodies undergo vast changes in terms of body composition, height, and

secondary sex characteristics, which can create issues around body image and self-

esteem. Anorexia nervosa, bulimia nervosa, and binge eating disorder present serious

medical and psychological concerns. In anorexia nervosa the individual relentlessly

pursues weight loss, seeing oneself as fat despite extreme thinness and emaciation.

Individuals with bulimia nervosa engage in cycles of bingeing and purging, upsetting

electrolyte balance and endangering cardiac function. Binge eating disorder is less

prevalent in teens, but is characterized by binge eating without compensatory actions to

maintain or lose weight. Eating disorders have the highest mortality rate of any

psychiatric illness and necessitate prompt medical attention. Prevention or early

intervention is vital.

________________________________________________________________________

Topic: Teen Pregnancy

Objective:

Relate the concerns for pregnancy outcomes and nutrient needs in a pregnant adolescent.

Key Concept:

Pregnancy during adolescence poses many nutritional challenges.

A pregnant adolescent needs to meet the high nutrient demands of her own growing body

and those of her unborn child. Of the greatest concern are getting sufficient intakes of

iron (27 mg/d needed) and calcium (1300 mg/day or more). An extra 25 g/day of protein

are needed, but energy needs are only 340-450 calories above her normal needs (in the

second and third trimesters respectively), necessitating nutrient-rich dietary choices.

Physically immature teenagers often need to gain 16 kg (35 lbs) during pregnancy if they

were of normal weight status pre-pregnancy. Nutrition-related concerns about pregnant

teens focus on maternal iron-deficiency anemia, low birth-weight, still birth, and birth

defects.

________________________________________________________________________

Bibliography


Report Card on the Diet Quality of Children Ages 2 to 9. Nutrition Insight 25 (a

publication of the USDA Center for Nutrition Policy and Promotion).

http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight25.pdf. Accessed 9 April

2008.

Borowitz D, Baker RD, Stallings V. Consensus report on nutrition for pediatric patients

with cystic fibrosis. J Pediatr Gastroenterol Nutr. 2002 Sep;35(3):246-59. Review.

American Dental Association. Fluoridation facts (2005). Available at

www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf. Accessed 3 April 2007.

Tanner JM, Whitehouse RH. Revised standards for triceps and subscapular skinfolds in

British children. Arch Dis Childhood 1975; 50: 142-145.

Freedman DS, Kettel Khan L, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS.

Racial differences in the tracking of childhood BMI to adulthood. Obesity Research

2005;13:928-935.

Dinour LM, Bergen D, Yeh MC. The food insecurity-obesity paradox: a review of the

literature and the role food stamps may play. J Am Diet Assoc. 2007 Nov;107(11):1952-

61.

Dietary Reference Intakes for Calcium and Vitamin D. Institute of Medicine, National

Academy Press, Washington, DC. 2010. Available at www.nap.edu

Briefel RR, Johnson CL.Secular trends in dietary intake in the United States. Annu Rev

Nutr. 2004;24:401-31. Review.

Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357(3):266-81.

www.ChooseMyPlate.gov

Song WO, Chun OK, Kerver J, Cho S, Chung CE, Chung SJ. Ready-to-eat breakfast

cereal consumption enhances milk and calcium intake in the US population. J Am Diet

Assoc. 2006 Nov;106(11):1783-9.

Perry CL, Mcguire MT, Neumark-Sztainer D, Story M.Characteristics of vegetarian

adolescents in a multiethnic urban population. J Adolesc Health. 2001 Dec;29(6):406-16.

Committee on Sports Medicine and Fitness, American Academy of Pediatrics. Climatic

heat stress and the exercising child and adolescent. Pediatrics 2000;106:158-9.

Bulik CM, Reba L, Siega-Riz AM, Reichborn-Kjennerud T. Anorexia nervosa:

definition, epidemiology, and cycle of risk. Int J Eat Disord. 2005;37 Suppl:S2-9;

discussion S20-1. Review.


Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and

Fluoride.Institute of Medicine, National Academy Press, Washington, DC. 1997.

Available at.www.nap.edu

Readings

www.ChooseMyPlate.gov

Nutrition During Pregnancy: Part I: Weight Gain, Part II: Nutrient Supplements Institute

of Medicine, National Academy Press, Washington, DC. 1990. Available at

www.nap.edu

Infants with Special Needs Handout 1

Infants With Special Needs

Module Objectives:

Compare the nutrient needs for pre-term infants with those born at term.

Describe how digestive tract maturity relates to nutritional needs.

Explain the causes and consequences of malabsorption in infants.

Characterize appropriate enteral feedings for preterm infants.

Name four inborn errors of metabolism that contribute to failure to thrive.

Module Outline:

Introduction

Title and Authors

Table of Contents


Preterm Concerns

Rate of Protein and Fat Gain

Feeding Pre-term Infants

Increased Nutrient Needs

Gut Function in Normal Newborn

Gut Function in Immature Newborn

Milk Composition

Human Milk Composition

Changes over Time

Proteins and Amino Acids

Lactoferrin and Iron

Focus on DHA

Beneficial Components

Major Protective Factors

Other Important Components

Failure to Thrive

Methods for Assessing Infant Growth

Failure to Thrive

Criteria for Failure to Thrive

Why Don't They Gain Weight?

Malabsorption

Malabsorption

Normal Intestinal Lactose Absorption

Lactose Malabsorption

Normal Intestinal Triglyceride Absorption

Triglyceride Malabsorption


Normal Protein Absorption

Protein Malabsorption

Inborn Errors of Metabolism

Inborn Errors of Metabolism

Galactosemia

Cystic Fibrosis

Phenylketonuria

Homocystinuria

Special Feedings

Special Feedings

Human Milk Fortifier

Pre-term Formula

Low-phenylalanine Formula

Integrated Practice (Premature Infant)

Premature Infant Case

Preterm Infant Case

An Infant Delivered at 30 Weeks

Nutritional Concerns for Preterm Infants

Preventing Preterm Birth



Topic: Preterm Concerns

Objective:

Compare the nutrient needs for pre-term infants with those born at term.

Key Concept:

Immaturity increases nutrient needs while at the same time feeding ability and nutrient

utilization are impaired.

On a per weight basis, newborn infants with low birth weight have increased nutrient

needs because the normal rate of growth before birth is greater than after birth and

because they did not have time to build up needed nutrient stores. The relatively

immature gut and kidneys are less effective for nutrient transfer than a healthy placenta,

and some metabolic pathways for the conversion of nutrients (e.g., DHA) are not fully

active, yet. The small size of the stomach and the intestine limits feeding volume. Renal

excretion of urea and retention of minerals are limited. Until late in pregnancy, there is

only a partial barrier that blocks normal gut bacteria from penetrating the intestinal wall

and reaching the bloodstream. Feeding even small amounts promotes the full function of

this intestinal barrier. Colonization with healthy intestinal microflora depends on

feeding.

________________________________________________________________________

Topic: Milk Composition

Objective:

Characterize the composition of human milk.

Key Concept:

Human milk contains optimal nutrients and immunoprotective agents.

Human milk contains macronutrients, vitamins, minerals, and water. In addition to its

nutritional components, human milk also provides the infant with immunoprotection and

stimulates the gastrointestinal tract. The four phases of human milk include colostrum,

transitional milk, mature milk, and milk produced during weaning. Milk contains

proteins, such as lactoferrin, that facilitate the absorption of vitamins and minerals.

Lactoferrin enhances iron absorption. Human milk also has a high fat content and

contains the lipid DHA, which is important in brain development. Newborns have a

limited capacity to synthesize DHA and need to get some DHA from the

diet.____________________________________________________________________


Topic: Beneficial Components

Objective:

Identify protective factors in human milk.

Key Concept:

Human milk contains many protective factors.

Human milk not only contains antimicrobial and anti-inflammatory factors (e.g.,

lactoferrin and lysozyme) but also has components that support the growth of beneficial

bacteria (e.g., bifidus factor and oligosaccharides). Immunoglobulins in milk have the

capacity to bind specific antigens. Other important components in human milk include

hormones that promote growth and enzymes that enhance digestion and absorption. The

amino acid taurine promotes brain and eye maturation, conjugation of bile acids, and

intestinal growth. Nucleotides in milk may also enhance the growth and function of the

intestinal

tract.___________________________________________________________________

Topic: Failure to Thrive

Objective:

Describe how failure to thrive is identified.

Key Concept:

Failure to thrive is a term to describe inadequate growth in children.

Criteria used to identify infants with failure to thrive include growth below the 5th

percentile on standard CDC growth charts, weight less than 80-90% of the median

weight-for-age, or a drop in weight or stature across two or more percentile lines.

Underlying causes of failure to thrive could be faulty breast or bottle feeding techniques,

infections or illness causing increased energy needs or reduced consumption, or in rare

cases, malabsorption or inborn errors of

metabolism.______________________________________________________________


Topic: Malabsorption

Objective:

Describe the causes and consequences of malabsorption in infants.

Key Concept:

Lack of enzymes causes malabsorption of carbohydrate and fat.

When there is a lack of brush-border enzymes, some or all of the lactose in milk or

formula may escape digestion. Enteral infection can reduce lactase activity, while genetic

defects in lactase or sugar transporters are much less common. Malabsorption of

carbohydrates and fat can lead to flatulence, pain, and diarrhea, as well as poor fat-

soluble vitamin uptake and poor weight gain. Dietary proteins are cleaved by pepsin from

the stomach, trypsin, chymotrypsin, elastase, and carboxypeptidase from the pancreas,

and brushborder aminopeptidases and dipeptidases in the small intestine. The precursors

of the gastric and pancreatic enzymes have to be activated by cleavage. Infants with

pancreatic insufficiency typically have poor growth

rates.___________________________________________________________________

Topic: Inborn Errors of Metabolism

Objective:

Identify four inborn errors of metabolism that contribute to failure to thrive in infants.

Key Concept:

Genetic disorders such as galactosemia, phenylketonuria, homocystinuria and cystic

fibrosis can cause growth failure.

Failure to thrive in young infants is most often due to inadequate feeding amounts,

technique, or infection. Genetic causes tend to be rare. Routine newborn screening

usually identifies cystic fibrosis, phenylketonuria (PKU), and a few other genetic

disorders, but will not detect each of the other thousands of rare metabolic disorders.

Failure to thrive may give the first indication of an inborn error of metabolism, and the

underlying causes need to be carefully resolved. Mental retardation and other serious

consequences often can be prevented, if nutritional therapy is started early

enough._________________________________________________________________


Topic: Special Feedings

Objective:

Identify methods of feeding infants with special needs.

Key Concept:

Special supplements and specialized formulas exist to meet the need of some infants.

Some infants need special enteral formulas that limit or omit a potentially harmful

compound, increase energy or protein, or fortify human milk. Children with PKU must

consume a diet with reduced phenylalanine content from the day of birth to avoid brain

damage from the accumulation of toxic breakdown products. Very immature infants may

benefit from increased intakes of conditionally essential nutrients. The needs of preterm

infants can be met by supplementing human milk with a fortifier to increase calories,

protein, calcium, and

phosphorus.______________________________________________________________


Bibliography

Clinical guidelines for the establishment of exclusive breastfeeding. International

Lactation Consultant Association. 2005. Available at www.ilca.org

Legrand D, Elass E, Carpentier M, Mazurier J. Lactoferrin: a modulator of immune and

inflammatory responses. Cell Mol Life Sci. 2005;62(22):2549-59.

2000 CDC growth charts: United States. Available at www.cdc.gov/growthcharts/

Accessed 4 April 2007.

Olsen EM. Failure to thrive: still a problem of definition. Clin Pediatr (Phila).

2006;45(1):1-6.

Kaye CI and the Committee on Genetics. Newborn Screening Fact Sheets. Pediatrics

2006;118;e934-e963.

Ridel KR, Leslie ND, Gilbert DL. An updated review of the long-term neurological

effects of galactosemia. Pediatr Neurol. 2005 Sep;33(3):153-61.

Davies JC, Alton EW, Bush A. Cystic fibrosis. BMJ. 2007 Dec 15;335(7632):1255-9.

Giovannini M, Verduci E, Salvatici E, Fiori L, Riva E. Phenylketonuria: dietary and

therapeutic challenges. J Inherit Metab Dis. 2007 Apr;30(2):145-52. Epub 2007 Mar 8.

Yap S. Classical homocystinuria: vascular risk and its prevention. J Inherit Metab Dis.

2003;26(2-3):259-65.

Quigley M, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast

milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2007

Oct 17;(4):CD002971.

Nutrition Support Handouts 1

Nutrition Support

Module Objectives:

Explain the alterations in energy metabolism in stress and starvation.

Assess energy requirements of patients during stress and starvation.

Summarize feeding routes, indications, and risks for patients who cannot eat.

Describe the consequences of bypassing the gut during feeding.

Outline the pathophysiology and treatment of refeeding syndrome, and identify patients at risk.

Module Outline:

Introduction

Title and Authors

Table of Contents


Gut Nutrition

GI Tract and Metabolism

Normal and Altered Intestine

GI Hormone Response

Glutamine

Glutamine Metabolism in Stress

Sources of Glutamine

Short-Chain Fatty Acids

Feeding Route

Feeding Route

Importance of Enteral and Parenteral Nutrition

Enteral and Parenteral Feeding

Nutrient Transport with Oral or Enteral Feeding

Nutrient Transport with Parenteral Feeding

Patient Case - Nutrition support

Consider Tyler's Nutrition

What Tyler Needs Next

Supplemental Nutrition Support Plan

Tyler's Energy Needs

Energy Expenditure

Components of Energy Expenditure


Basal Energy Expenditure and Thermic Effect of Food

Growth and Lactation

Physical Activity

Body Composition in Non-Obese Individuals

Body Compartments

Creatinine

Calorimetry

Indirect Calorimetry

Oxidation

Respiratory Quotient

Indirect Calorimetry: Sample Calculation

Energy Assessment

Introduction

Prediction Equations

Hypermetabolism and Fever

Refeeding Syndrome

Pathophysiology of Refeeding Syndrome

Patients at Risk for Refeeding

Preventing Refeeding Syndrome

TPN

Implementation

Short-Bowel Syndrome

Complications of Long-Term TPN

Enteral Feeding

Implementation

Complications

Patient Case - Transitioning

A Chocolate Milkshake

Potential Complications

Bowel Sounds Present

The Next Step

Increasing Enteral Feeding

Short Bowel Syndrome

Ready for Discharge

Clear Liquids by Mouth

Conclusion

Nutrition Plan

Nutrition Assessment

The Nutrition Plan


Under- or Overfeeding

Feeding Route

Integrated Practice (Nutrition Support)

Nutrition Support



Topic: Gut Nutrition

Objective:

Explain the effect of feeding via the GI tract on metabolism.

Key Concept:

Bypassing the gut by feeding intravenously alters the structure and function of the

gastrointestinal tract.

Food in the stomach stimulates gastrin secretion and gastric acid production. The

presence of food and a low pH in the duodenum causes cholecystokinin (CCK) secretion

and secretin stimulation. Parenteral feeding bypasses the GI tract and therefore does not

stimulate secretion of intestinal hormones. Absence of CCK secretion can stop bile flow

(cholestasis). With parenteral feeding, changes in the intestinal mucosa can occur. Over

time, intestinal atrophy may allow bacteria and toxins to enter the bloodstream and may

impair nutrient absorption. Glutamine, a conditionally essential amino acid, is an

important oxidative fuel for the intestinal mucosa. During stress the demand for

glutamine may exceed the supply. Inadequate supplies of glutamine can result in

deterioration of the mucosal barrier.

________________________________________________________________________

Topic: Feeding Route

Objective:

Describe feeding routes for patients who cannot eat.

Key Concept:

Patients who cannot eat should receive enteral or parenteral nutrition.

Nutrition can be provided through alternate routes, such as enterally (into the stomach or

small intestine) or parenterally (into a central or peripheral vein). When the GI tract is not

functional, patients should be fed parenterally. In such cases, enteral feeding should begin

as soon as ability to digest and absorb nutrients resumes, even if the majority of nutrition

is provided parenterally. Patients with normal lower GI function, but who cannot

swallow or maintain adequate oral intake should be fed enterally. Appropriate nutrition

decreases length of hospital stay, reduces the risk of post-op complications, and

improves wound healing. There are metabolic consequences to intravenous feedings

because it bypasses the normal absorption and transport processes-- intravenous lipids

enter the circulation as droplets without the apoproteins found on chlyomicrons.

________________________________________________________________________


Topic: Energy Expenditure

Objective:

Describe the components of and factors that influence total energy expenditure.

Key Concept:

Basal metabolism, physical activity, and thermic effect of food comprise total energy

expenditure in healthy individuals.

Total energy expenditure has three components: basal metabolic rate (BMR), physical

activity, and diet-induced thermogenesis (thermic effect of food). BMR represents the

energy used by the body in a restful, awake state. This is the energy needed for ion

pumping, protein synthesis, and all homeostatic functions. BMR depends mainly on body

size and composition. Understanding body composition is important to clinical

assessment of nutritional status. In both stress and malnutrition, body composition is

altered because of loss of protein mass. Energy expenditure increases in stressed patients;

the amount of increase depends upon the degree of illness. Changes in nutritional

recommendations are concurrent with changes in body composition. Physical activity is

the most variable component of total energy expenditure in healthy individuals.

________________________________________________________________________

Topic: Calorimetry

Objective:

Specify how indirect calorimetry can be used to estimate energy expenditure.

Key Concept:

Indirect calorimetry can be used to estimate energy expenditure by using the respiratory

quotient.

Indirect calorimetry is a method of estimating energy expenditure based on CO2

production and O2 uptake. It is often used in a clinical setting to get a reliable estimate of

energy expenditure and prevent over- or under-feeding of critically ill, malnourished, or

extremely obese patients. A metabolic cart can take the measurements, determine the

respiratory quotient (RQ; ratio of CO2 to O2), and convert the RQ into estimated

expenditure. The equations for the oxidation of carbohydrates and fats show that known

amounts of O2 and CO2 correspond to predictable amounts of energy production.

Because glucose and fat are completely oxidized, energy production from glucose or fat

oxidation can be predicted by measuring consumption of oxygen and production of

carbon dioxide. Protein oxidized can be calculated from urinary nitrogen excretion.

________________________________________________________________________


Topic: Energy Assessment

Objective:

Describe how energy needs may be estimated in clinical settings.

Key Concept:

Standardized prediction equations exist for estimating energy expenditure but have

limited usefulness in critically ill patients.

Indirect calorimetry is a reliable method for determining an individual's energy

expenditure, but it is not always feasible in clinical practice. Many standardized formulas

exist to estimate energy expenditure based on a patient's age, height, weight, and physical

activity level. Many of these, however, were developed for healthy people and thus are

not appropriate for critically ill patients. Furthermore, during stress, hypermetabolism and

fever cause energy needs to increase. Stressed patients have high energy expenditures and

increased protein turnover due to the hypermetabolism characteristic of the stress

response. Hypermetabolism increases with severity of the trauma. With many diseases

and traumas, fever is also present. Each degree rise in temperature above 37 degrees C

elevates metabolic rate by about 10%.

________________________________________________________________________

Topic: Refeeding Syndrome

Objective:

Outline the pathophysiology and treatment of refeeding syndrome, and identify patients

at risk.

Key Concept:

Refeeding syndrome is characterized by metabolic events that occur upon feeding

severely malnourished patients.

Refeeding syndrome can occur with any type of feeding following a period of nutritional

deprivation. Glucose moves into cells, and along with it, phosphorous, potassium, and

magnesium, causing the serum concentrations of these minerals to drop abruptly. The

severe mineral and fluid imbalances that occur with refeeding can lead to cardiac arrest,

neuromuscular complications, or respiratory dysfunction. Malnourished patients with

poor nutritional stores due to limited intake (i.e. anorexia nervosa, elderly patients with

depression or dementia, cancer cachexia, malnutrition due to hunger, stress, or fasting)

are at-risk. Refeeding syndrome can be prevented by avoiding sudden overfeeding,

avoiding excess glucose, replacing phosphorus, magnesium, and potassium, restricting

fluid intake, initiating sodium administration slowly, and providing thiamin.

________________________________________________________________________


Topic: TPN

Objective:

List three complications that can occur from long-term parenteral feeding.

Key Concept:

Complications can occur from long-term parenteral feeding.

When nutrition is provided directly into the bloodstream, determining the patient's

nutritional needs as accurately as possible becomes critically important. Short-bowel

syndrome is one condition that may require long-term parenteral feeding. Parenteral

feeding is not without risk. Catheter-related infection, metabolic bone disease, liver

disease, and micronutrient deficiencies are serious risks of long-term parenteral feeding.

________________________________________________________________________

Topic: Enteral Feeding

Objective:

Describe complications that can occur with enteral feeding.

Key Concept:

Enteral feeding is not without risks.

When nutrition is provided directly into the GI tract, determining the patient's nutritional

needs as accurately as possible becomes critically important. Enteral feeding can lead to

reflux of stomach contents into the lungs, which can lead to aspiration pneumonia.

Diarrhea can be a common problem in enterally fed patients. Other serious problems may

include refeeding syndrome, or altered glucose, lipid, or acid-base balance.

________________________________________________________________________


Topic: Nutrition Plan

Objective:

Characterize the factors considered in formulating a nutrition plan.

Key Concept:

Formulating a nutrition plan is essential in the care of critically ill patients.

Nutrition assessment provides a picture of the patient's nutritional risk. This requires

collecting and evaluating information obtained from the patient's history, physical exam,

anthropometric measurements, and labs. From the information obtained in the nutritional

assessment, a plan for the patient is formulated. The plan must be individualized to meet

the patient's requirements for protein, energy, and other nutrients. It should also include

the goals for nutritional intake, and the most appropriate route of feeding and formula

composition to achieve those goals. In the stressed patient, the goal is usually to prevent

further depletion of lean body mass. Underfeeding can result in poor wound healing,

weakness, and malnutrition as protein is used as an energy source. Overfeeding can result

in hyperglycemia, carbon dioxide retention, and fatty liver.

________________________________________________________________________


Bibliography

ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the

use of parenteral and enteral nutrition in adult and pediatric patients.JPEN J Parenter

Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):1SA-138SA.

Skipper, Annalynn. Dietitian?s Handbook of Enteral and Parenteral Nutrition. Jones &

Bartlett Publishers, Inc. 1998.

Pediatric Manual of Clinical Dietetics, Nutrition Support in Critical Care, 1998 copy, p.

548.

Brehm BJ, Spang SE, Lattin BL, Seeley RJ, Daniels SR, D'Alessio DA. The role of

energy expenditure in the differential weight loss in obese women on low-fat and low-

carbohydrate diets. J Clin Endocrinol Metab. 2005 Mar;90(3):175-82. Epub 2004 Dec 14.

Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy,

Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino

Acids(Macronutrients). The National Academics Press, Washington, DC 2002.

Levine JA. Nonexercise activity themogenesis(NEAT): environment and biology. AM J

Physiol Endocrinol Metab 2004;286:E675-E685.

Kattlemann et al, Preliminary evidence for a medical nutrition therapy protocol: enteral

feedings for critically ill patients. J Am Diet Assoc. 2006 Aug;106(8):1226-41. Review.

McCray S, Walker S, Parrish CR. Much Ado About Refeeding. Practical

Gastroenterology January 2005; series #23:26-44.

Readings

Loucks AB. Energy balance and body composition in sports and exercise. J Sports Sci

2004;2;1-14

Dietary Supplements: Decision Making Handouts 1

Dietary Supplements: Decision Making

Module Objectives:

Outline the steps in the decision-making process.

Identify credible sources to advise patients on safety and efficacy of dietary supplements.

Explain the concept of bioavailability as it pertains to dietary supplements.

Identify individuals at risk for nutrient inadequacy.

Explain the basis for appropriate nutrient supplementation

Module Outline:

Introduction

Title and Authors

Table of Contents

Introduction & Module Objectives

Assessing Your Beliefs

Beliefs Assessment

Decision Making

Four Pillars of Decision Making

A Good Research Question

Good Question vs. Poor Question

Defining the Research Question

Folate-Does It Work?

Neural Tube Closure

Bioavailability

Research Central: Folate Efficacy

Folate Efficacy: Results

Mandatory Food Fortification

Voluntary Food Fortification

Nutrient Recommendations Change

Assessing Folate, B6, and B12 Intake

Assessing Folate, B6, and B12 Intake

Patient scenarios

Folate

Vitamin B6: Pyridoxine

Vitamin B12: Cobalamin

Folate-Is It Safe?

Risks From Excessive Micronutrient Intake

Research Central: Folate Safety

Folate Safety: Results


Is Natural Better?

Evaluating Supplement Use

Decision Analysis

Natural Safe

The Case of a Healthy Baby

Prepare for a Patient Case Assignment

First, Two Questions


Assess Nutrients Related to NTD Risk

Summary of Findings

Advise the Patient

A Targeted Intervention

Revisit Two Questions

Antioxidant Promises


Free Radicals

Bioavailability

Nutrient Excretion and Storage

Natural vs. Synthetic Vitamins

Bioavailability

Ingestion Action Vitamin E Bioavailability

Vitamin E-Does It Work

Research Central: Vitamin E Efficacy

Vitamin E Efficacy: Results

Dietary Reference Intakes

Assess Your Patient's Intake

Assessing Vitamin E, C, Carotenoid Intake

Assessing Vitamin E, C, and Carotenoid Intake

Patient Scenarios

Vitamin E

Vitamin C

Carotenoids

Vitamin E-Is It Safe?

Risks Associated with Supplementation

Botanicals and Drug Interactions

Efficacy Safety Research Central: Vitamin E Safety

Vitamin E Safety: Results


Problems with Antioxidant Supplements

Evaluating Research

Reliability of Research Study Results

Rating the Evidence: Assigning Weight

Randomized, Controlled Clinical Trial

Prospective Cohort/Case Control

Clinical Observation/Ecological Study

Limitations of Trials

Confounding Factors

Statistical Power and Sample Size

Is More Better?

Studies on Vitamin E

Decision Analysis

The Dose Makes the Difference

The Antioxidant Case

First, Two Questions


Targeted Diet Assessment Questions


Make an Assessment

Dietary vs. Supplement Intake

Advise the Patient

Potential Interactions

Mr. Bradley's Intake

Resistance to Change

A Negotiation

Formulating a Plan

Conclusion

Revisit Two Questions

Revisiting Your Beliefs

Beliefs Review



Topic: Decision Making

Objective:

Outline the steps in the decision making process.

Key Concept:

A good clinical question specifies target group, intervention and expected outcome.

Phrasing a clear question is the first step in decision making. It is important to consider

the target group (age, gender, race, health status), define the intervention (characteristics

of supplement, dose and mode of administration, duration of use) and what the

intervention is compared to (bad diet, standard medication), and list the outcomes in

question (abating symptoms, subjective relief, lower disease risk). Most importantly,

there should always be consideration of the impact on overall health and mortality risk.

________________________________________________________________________

Topic: Folate-Does It Work?

Objective:

Identify credible sources to make nutrient recommendations; advise patients on

bioavailability of compounds.

Key Concept:

The DRIs provide current recommendations for nutrient intakes; effectiveness of

supplements depends on bioavailability.

The Institute of Medicine, a division of the National Academy of Sciences of the US,

publishes the "Dietary Reference Intakes" (DRIs) defining required and excessive intake

levels. These authoritative publications provide completely referenced information

regarding typical levels of intake, established benefits and known or potential risks.

Differences in potency of nutrients and other supplement ingredients often are due to

differences in bioavailability, which indicates what percentage of a compound reaches its

target. Nutrients and phytochemicals from herbal and other 'natural' sources may not be

more effective than synthetic compounds. Synthetic folic acid (in supplements and

fortified foods) has higher bioavailability than the polyglutamyl folate in green leafy

vegetables and oranges, and a greater percentage becomes available to cells.

________________________________________________________________________


Topic: Assessing Folate, B6, and B12 Intake

Objective:

Identify individuals at risk for folate, B6 or B12 inadequacy.

Key Concept:

You should memorize assessment questions and criteria related to folate, vitamin B6 and

vitamin B12 intakes.

People with restricted diets who do not take supplements may be at risk for vitamin

deficiency. Good sources of folate are breakfast cereal, dark-green vegetables, legumes,

orange juice, and liver. People who don't like greens and legumes, who consume


Topic: Is Natural Better?

Objective:

Explain when use of a dietary supplement is reasonable.

Key Concept:

Use of a supplement is reasonable when benefits outweigh harm and cost.

Use of a dietary supplement makes sense when the benefits are large and certain, and

adverse effects known to be rare or of little consequence. When the benefits are small or

uncertain and potentially harmful or costly, supplement use is questionable and should

not be encouraged. Physicians need to know about patients' health practices, including

supplement use. It is important that patients do not feel judged about their preferences.

Only when dosage or composition is of concern, is there a strong need to dissuade

patients from use.

________________________________________________________________________

Topic: Antioxidant Promises

Objective:

Describe the function of antioxidants and their potential role in disease prevention and

treatment.

Key Concept:

Antioxidant nutrients interact with free radicals, one another, and some medications.

Antioxidant nutrients like vitamins E, C, beta carotene and selenium at desirable intake

levels are needed to prevent oxidative damage to tissues from excessive free radicals that

can lead to cancer or heart disease. Some nutrients, like vitamins E and C, work

synergistically. The effects of excessive nutrient intakes on the balance between nutrients

are unclear. Furthermore, taking extremely high doses of a nutrient like vitamin E can

have undesirable effects, such as disrupting blood coagulation. Some nutrients can

interact with medications. For example, vitamin E can interact with blood thinning agents

such as warfarin to increase risk of hemorrhagic stroke.

________________________________________________________________________


Topic: Bioavailability

Objective:

Describe factors influencing nutrient absorption and bioavailability.

Key Concept:

A nutrient's form influences its bioavailability; some nutrients persist in the body while

others are rapidly excreted.

The form of a nutrient determines absorption, uptake, metabolism, and excretion.

"Natural" is not always better. Folate is absorbed best as monofolylglutamate (the

synthetic form of supplements), while the natural isoform of vitamin E (RRR-alpha-

tocopherol) is more effective than synthetic forms. The presence of fiber, oxalates, or

phytates in the gut, or malabsorptive factors, can impair nutrient absorption. Because

some nutrients (e.g., iron, zinc, and copper) compete for the same transport mechanisms

severe imbalances in intake can negatively impact the uptake and transport of a nutrient.

Excess of most water-soluble vitamins is rapidly excreted, except for vitamin B12, which

can be stored at levels sufficient to meet needs for several years. Stores of minerals and

fat-soluble vitamins last for a long time, except vitamin K.

________________________________________________________________________

Topic: Vitamin E-Does It Work

Objective:

Describe and apply the Dietary Reference Intakes (DRIs).

Key Concept:

The Dietary Reference Intakes provide current nutrient intake recommendations.

The Dietary Reference Intakes (DRIs) are a set of guidelines for nutrient intakes that will

meet the needs of nearly all healthy people. They are periodically revised by the Food

and Nutrition Board of the Institute of Medicine. The DRIs provide information on the

Estimated Average Requirement (EAR; the level at which 50% of people will have

inadequate intakes), the Recommended Dietary Allowance (RDA; the level at which 97-

98% of the healthy population will meet their nutrient needs), and the tolerable Upper

Intake Level (UL; the highest level for safe intake. An Adequate Intake (AI),

corresponding to the mean intake level of healthy people, is used when data are

insufficient to determine an EAR.

________________________________________________________________________


Topic: Assessing Vitamin E, C, Carotenoid Intake

Objective:

Identify individuals at risk for inadequate antioxidant vitamin intakes.

Key Concept:

You should memorize assessment questions and criteria related to inadequate vitamin E,

C, and carotenoid intakes.

People with restricted diets who do not take supplements may be at risk for vitamin

deficiency. Vitamin E is found in oils, fats, nuts, and seeds. People who use mainly fat-

free foods and avoid added fat are at risk for deficiency. Good sources of vitamin C are

fruits and vegetables such as citrus, berries, tomatoes, broccoli, cauliflower, and peppers.

A person who eats < 1 serving/d of fruits and vegetables should raise a red flag for

potential deficiency. Carotenoids are found in orange, yellow, or dark-green fruits and

vegetables. Less than 1 serving/d puts a person at risk.

________________________________________________________________________

Topic: Vitamin E-Is It Safe?

Objective:

Describe how toxicity, interaction, and lifestyle effects must be considered when

evaluating supplement safety.

Key Concept:

Toxicity, interaction, and lifestyle effects are important considerations when evaluating

supplement safety.

When it comes to safety, three aspects of supplement use must be considered: toxicity,

interaction, and lifestyle. Toxicity may occur with a single dose (e.g. vitamin A and fetal

damage), or with accumulation to toxic levels (e.g. iron). The toxic effects may be

unrelated to the normal biologic action of a nutrient (excessive doses of vitamin E inhibit

blood coagulation, a vitamin K-dependent process). Interaction effects include those

between supplement ingredients (zinc and copper), supplement ingredients and drugs

(vitamin E and warfarin), or between medications and herbs (e.g. St. John's Wort and

birth control pills). Lifestyle concerns arise when patients use supplements instead of

proven treatments or when they use supplements to make up for poor dietary or lifestyle

habits (e.g. lack of exercise, smoking).

________________________________________________________________________


Topic: Evaluating Research

Objective:

Explain which types of research studies provide a reliable basis for the assessment of

supplement claims.

Key Concept:

Well-executed double-blind, randomized, placebo-controlled studies are the gold

standard for evaluating supplements.

Double-blind, randomized, placebo controlled studies are the only types of studies that

can establish the effectiveness of a particular intervention. Subjects are randomized to

receive intervention or no intervention. Both the subjects and the investigators cannot

know which treatment is being given to maintain objectivity in reporting outcome

measures; the placebo helps to maintain blinding. Unfortunately, these types of studies

are not available for many dietary supplements due to the large numbers of subjects

required, amount of time, and expense involved. Studies must have sufficient numbers

(sample size) of the right types of subjects (age, gender, etc.) in order to apply their

conclusions to similar populations. Confounding can lead to wrong interpretations, since

an outcome seen in a study could be due to some factor not taken into account.

________________________________________________________________________

Topic: Is More Better?

Objective:

Explain the concept of optimal intake of a nutrient.

Key Concept:

Current science cannot determine optimal intake level for most nutrients.

Optimal intake refers to the amount of a nutrient that promotes health, well-being, and

longevity without overwhelming metabolic capacity or otherwise causing damage. For

most nutrients, the optimal intake level is not known. High intakes of many nutrients may

do more harm than good.

________________________________________________________________________


Bibliography

Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12,

pantothenic acid, biotin, and choline. Institute of Medicine, Food and Nutrition Board.

National Academy Press, Washington, DC. 1998.

Centers for Disease Control and Prevention (CDC). Folate status in women of

childbearing age, by race/ethnicity--United States, 1999-2000, 2001-2002, and 2003-

2004. MMWR Morb Mortal Wkly Rep. 2007 Jan 5;55(51-52):1377-80.

Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Mortality in randomized

trials of antioxidant supplements for primary and secondary prevention: systematic

review and meta-analysis. JAMA. 2007 Feb 28;297(8):842-57.

Dietary reference intakes for vitamin C, vitamin E, selenium, and carotenoids. Institute of

Medicine, Food and Nutrition Board. National Academy Press, Washington, DC. 2000.

Massey LK, Liebman M, Kynast-Gales SA. Ascorbate increases human oxaluria and

kidney stone risk. J Nutr 2005;1673-1677.

Becque MC, et al. Effects of oral creatine supplementation on muscular strength and

body composition. Medicine & Science in Sports & Exercise 2000 32(3):654-8.

Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico. Dietary

supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial

infarction: results of the GISSI-Prevenzione trial. Lancet 1999;354:447-55.

Readings

Miller ER, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E. Meta-

analysis: High-dosage vitamin E supplementation my increase all-cause mortality. Ann

Intern Med 2005;142:37-46.

Dietary Supplements: Reality Check Handouts 1

Dietary Supplements: Reality Check

Module Objectives:

Describe the regulation of supplements, medical drugs, food, and additives.

Outline the safety concerns associated with supplement use.

Explain the importance and process of taking a dietary supplement history.

Describe why new or unusual claims require very good evidence to become credible.

Explain which types of studies provide a reliable basis for assessing supplement claims.

Module Outline:

Introduction

Title and Authors

Table of Contents


Assessing Your Beliefs

Beliefs Assessment

Supplements and Food Extracts

Supplement Labels and Claims

Supplement Composition

Food Extracts


Soy - Does It Work?

Common Mechanisms of Disease Prevention

Activation and Detoxification

Research Central: Soy Efficacy

Soy Efficacy: Results

Assessing Calcium, Vit D, and Phosphate

Assessing Calcium, Vitamin D, and Phosphate Intake

Patient Scenarios

Calcium

Vitamin D

Phosphate

Soy - Is It Safe?

Red Flags

Regulation of Dietary Supplements, Foods, and Drugs in the U.S.

Generally Recognized as Safe (GRAS)

Research Central: Soy Safety

Soy Safety: Results


Decision Analysis: Soy

Decision Analysis

Diet Insurance

Not a "Quick Fix"

Functional Foods

The Case of the Novel Food

Prepare for a Patient Case Assignment


A Medical Conundrum


Mrs. Jordan's Supplement Intake

Advise the Patient

A Nonjudgmental Attitude

Conclusion

Supplement Interview

The Importance of Taking a Dietary Supplement History

The Interview Process

Athletes & Supplements

Supplements in Sports

Interview: Sports Supplements


Creatine - Does It Work?

Fuel Sources for Exercising Muscle

Creatine

Nutritional Requirements of Athletes

Evaluating Supplements

Research Central: Creatine Efficacy

Evaluating Creatine Studies

Creatine Efficacy: Results

Evaluating Efficacy

Assessing Thiamin, Riboflavin, and Protein

Assessing Thiamin, Riboflavin, and Protein Intake

Patient Scenarios

Thiamin

Riboflavin: Vitamin B2

Protein

Creatine - Is It Safe?

Concerns with Ergogenic Aids

Research Central: Creatine Safety


Creatine Safety: Results

Evaluating Risk Information

Decision Analysis: Creatine

Decision Analysis

Wishful Thinking

The Case of the Ergogenic Aid



Summary of Findings

Evaluate Mr. Lohmann's Intake

Make a Recommendation

Creatine: Efficacy and Safety

Rationale for Recommendations

Importance of Taking a Supplement History

Conclusion

Revisiting Your Beliefs

Beliefs Review



Topic: Supplements and Food Extracts

Objective:

Describe how reliable information about the composition of a supplement is needed for

the evaluation of claimed effects.

Key Concept:

Information about the composition of a supplement is the basis for any evaluation of

claimed effects.

Evaluation of a dietary supplement should start with a determination of its composition.

All information on a product must be truthful and conform to FDA rules, but the label

does not have to state the amount of active ingredients. While the product cannot be said

to prevent, treat or cure a disease, allowed claims about structural or functional properties

may appear to promise such a benefit. Other product information may suggest that a

supplement is as good as a healthful food. This claim should not be accepted until proven

because active components may be left out during the manufacturing process, or the

product may contain concentrated doses of potentially harmful compounds.

________________________________________________________________________

Topic: Soy - Does It Work?

Objective:

Explain how a meta-analysis or systematic review can be used to judge the efficacy of a

particular dietary modification.

Key Concept:

A meta-analysis, which combines data from multiple studies with statistical methods,

may be used to evaluate efficacy.

Food compounds may protect against disease by modifying lipoprotein metabolism, free

radical scavenging, regulating gene expression, or promoting the excretion of toxic

compounds. Options for determining the health benefits of a particular compound include

a literature search, a systematic review, published government guideli

nutrition 3 8

Documents

infancy growth

adolescence growth

hazards growth case

growth macronutrient

parameters of normal

absorption of water

young children handout

iron deficiency problems