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Nutrition and Diet Therapy Course Standards Dina Starks, MS, RDN, LDN

Nutrition and Diet Therapy Course Standards Dina Starks, MS, RDN, LDN Deputy Director of Student Success Division of Career and Technical Education. Today’s Takeaways. By the end of today’s session, you will be able to: Perform the steps involved in nutrition assessment.

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Nutrition and Diet Therapy Course Standards Dina Starks, MS, RDN, LDN

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  1. Nutrition and Diet Therapy Course Standards Dina Starks, MS, RDN, LDN Deputy Director of Student Success Division of Career and Technical Education

  2. Today’s Takeaways By the end of today’s session, you will be able to: • Perform the steps involved in nutrition assessment. • Develop a basic nutrition care plan to address diet and nutritional needs for a variety of diseases and disorders. • Create rigorous and relevant lesson plans for your nutrition and diet therapy course based on a deeper understanding of the subject. Realizing Postsecondary and Career Readiness Through CTE

  3. Agenda • Review of nutrients and A&P of the digestive system • Process of digestion from chewing to cellular respiration • Alphabet soup of nutrition assessment: BEE, TEF, EER, TEE, METs • Determining energy needs – Activity! • Nutrition and Burns – Activity! • BREAK • Person-centered health care and the nutrition care process • Assessment ABCDs • Anthropometrics – Activity! • Nutrition and digestive disorders • Nutrition and cancer • Osteoporosis, calcium and vitamin D • Food intolerances, allergies, and celiac disease Realizing Postsecondary and Career Readiness Through CTE

  4. Norms for Today’s Session • Be student-centered in your thoughts. • Balance urgency and patience. • Be present and engaged. • Challenge with respect. • Risk productive struggle. • Monitor airtime and share your voice. Realizing Postsecondary and Career Readiness Through CTE

  5. Realizing Postsecondary and Career Readiness Through CTE

  6. Digestive Organs Pharynx (Throat) • Mouth (Oral Cavity) • Teeth & Gums • Tongue • Salivary Glands Epiglottis Esophagus Stomach • Accessory Organs • Liver • Gall Bladder • Pancreas • (behind liver) Large Intestine (Colon) Rectum Small Intestine Realizing Postsecondary and Career Readiness Through CTE

  7. Upper Gastrointestinal System Pharyngoesophagel Sphincter Esophagus Diaphragm Stomach Liver Gastroesophageal Sphincter Pyloric Sphincter Fundus Pylorus Duodenum Realizing Postsecondary and Career Readiness Through CTE

  8. Lower Gastrointestinal System Transverse Colon Large Intestine (Colon) Descending Color Ascending Colon • Small Intestine • Duodenum • Jejunum • Ileum Cecum Appendix Sigmoid Colon Rectum Anus Realizing Postsecondary and Career Readiness Through CTE

  9. Process of Digestion Realizing Postsecondary and Career Readiness Through CTE

  10. Mechanical Digestion BOLUS Pharynx Mouth Epiglottis Teeth Gums Tongue Esophagus Chemical Digestion Begins • Saliva • Salivary Amylase Stomach Salivary Glands CHYME Small Intestine Realizing Postsecondary and Career Readiness Through CTE

  11. Chemical Digestion Pancreas • Pancreatic Juices • Trypsin, Peptidase • Lipase • Amylase • Sucrase, Maltase, Lactase • Gastric Juices • Hydrochloric Acid • Pepsinogen Insulin CHYME Stomach Duodenum Gastrin Jejunum Bile Ileum NUTRIENTS Gall Bladder FECES Anus Cecum Liver WATER Rectum Ascending Colon Descending Colon Transverse Colon Realizing Postsecondary and Career Readiness Through CTE

  12. Cellular Respiration Carbohydrates Fats Proteins Kreb’s Cycle Occurs in the mitochondrion, the “powerhouse” of the cell Energy Carbon Dioxide Continue to Electron Transport Chain Realizing Postsecondary and Career Readiness Through CTE

  13. Kreb’s Cycle, a.k.a. The Citric Acid Cycle Glucose Aerobic (in presence of O2) (as ATP) CO2 CO2 FAD+, 2H+ 3NAD+ FADH2 3NADH, 3H+ CO2 CO2 (as ATP) CO2 CO2 Realizing Postsecondary and Career Readiness Through CTE

  14. Oxidative Phosphorylation, a.k.a. The Electron Transport Chain 3ATP 3ADP Realizing Postsecondary and Career Readiness Through CTE

  15. Fermentation Anaerobic (in absence of O2) Realizing Postsecondary and Career Readiness Through CTE

  16. Cellular Respiration http://www.mhhe.com/biosci/bio_animations/MH01_CellularRespiration_Web/ Realizing Postsecondary and Career Readiness Through CTE

  17. BEE: Basal Energy ExpenditureUsing the Mifflin St. Joer Equation • Basal Energy Expenditure (BEE), basal metabolic rate (BMR), and the closely related resting metabolic rate (RMR), is the rate of energy expenditure by humans at rest. • The Mifflin St. Joer Equation BMR (female)=(10 x wt) + (6.25 x ht) – (5 x age) – 161 BMR (male)=(10 x wt) + (6.25 x ht) – (5 x age) – 5 (Note: Wt is expressed in kg and ht in cm) • Example - 42 yr old female, 150 lbs, 5’7” tall Convert: 150 lbs 2.2 kg/lb = 68.18 kg Convert: 67 in x 2.54 cm/in = 170.18 cm BMR = (10 x 68.18 kg) + (6.25 x 170.18 cm) – (5 x 42 yrs) – 161 BMR = 681.8 + 1063.62 – 210 BMR = 1535.42 Realizing Postsecondary and Career Readiness Through CTE

  18. TEF: Thermic Effect of Food Thermic Effect of Food – energy needed to stimulate metabolism, digest food, absorb and transport nutrients to the cells Realizing Postsecondary and Career Readiness Through CTE

  19. EER: Estimated Energy RequirementsTEE: Total Energy Expenditure • BMR is multiplied by an activity factor added to the thermic effect of food to determine the estimated energy requirements (EER) or total energy expenditure (TEE). • Example - Take our 42 yr old female, 150 lbs, 5’7” tall with BMR = 1535.42 Walks 30 minutes/day = low active, PAL factor = 1.4 TEE = (BMR x 1.4) + (BMR x TEF) TEE = (1535.42 x 1.4) + (1535.42 x 0.05) = 22263.35 kcals Realizing Postsecondary and Career Readiness Through CTE

  20. METs: Metabolic Equivalents • One metabolic equivalent (MET) is defined as the amount of oxygen consumed while sitting quietly in a chair, approximately 3.5 ml 02/kg/min (1.2 kcal/min for a 70-kg person). • Work at 2 METS requires 2X the resting metabolism or 7.0 ml O2/kg/min and 3 METS requires 3X the resting metabolism (10.5 ml 02/kg/min), and so on. • The MET concept represents a simple, practical, and easily understood procedure for expressing the energy cost of physical activities as a multiple of the resting metabolic rate. Realizing Postsecondary and Career Readiness Through CTE

  21. METs: Metabolic Equivalents METS for Walking at Various Speeds and Surface Grades • Example- Take our 42 yr old female, 150 lbs, 5’7” tall with BMR = 1535.42 • How many calories would she burn if she walks on a 2.5% grade, 3.75 mph for 30 minutes? • {BMR (24 hr x 60 min/hr)} x METs x min of activity = kcals expended • {1535.42 (1440.00)} x 5.2 METs x 30 min = kcals expended • 1.06 kcals/min x 5.2 METs x 30 min = kcals expended • 165.36 kcals expended during activity Realizing Postsecondary and Career Readiness Through CTE

  22. Calculating Calorie Needs for Burn Patients Rule of Nines • Used to calculate % of body surface area (BSA) burned • Add up percentages of each surface burned and use Curreri formula to calculate calorie needs for healing. • Example – Adult burned on: • Front torso – 18% • Front left arm – 4.5% • Both upper front thighs – 9% (whole leg is 9%; front of each leg is 9% so top half of one leg is 4.5%) • 18 + 4.5 + 9 = 31.5% BSA Realizing Postsecondary and Career Readiness Through CTE

  23. Calculating Calorie Needs for Burn Patients Curreri Formula • Adults: 25 kcal / kg + 40 kcal % BSA burned • Children: 60 kcal/kg + 35 kcal % BSA burned • Example – 175 lb adult burned over 31.5% of BSA • Convert lb to kg: 175 2.2 kg/lb = 79.54 kg • Plug into Curreri Formula: (25 kcal x 79.54 kg) + (40 x 31.5% BSA) 1988.5 + 1260.0 = 3248.5 kcal needed for healing Realizing Postsecondary and Career Readiness Through CTE

  24. Person-centered Health Care Plan • The Health Care Team plays an important role in developing and maintaining a person-centered health care plan. • The team is made up of health care members as well as the patient, family members and support system. Nutrition Care Process • “A systematic problem-solving method that dietetics professionals use to critically think and make decisions to address nutrition-related problems and provides safe and effective quality nutrition care.” - The Academy of Nutrition and Dietetics STEP 1: Nutrition Assessment STEP 2: Nutrition Diagnosis STEP 3: Nutrition Intervention STEP 4: Nutrition Monitoring and Evaluation Realizing Postsecondary and Career Readiness Through CTE

  25. Nutrition Assessment Information about a patient’s situation must be collected from the patient, family members, the medical chart, oral and written communication with staff and others, etc. • Family history • Medical history • Patient’s nutrition status • Patient’s food habits and living situation • Patient’s needs, desires and goals • ABCD approach to nutrition assessment Realizing Postsecondary and Career Readiness Through CTE

  26. ABCDs of Nutrition Assessment Anthropometric Data – measurements of an individual • Age • Gender • Height – expressed in cm • Weight – expressed in kg • Body frame size • Body composition • Body mass index Realizing Postsecondary and Career Readiness Through CTE

  27. Nutrition Assessment: AnthropometricsA Math-integrated Activity • Height – convert to cm • Conversion of in to cm • Height (in) X 2.54 cm/in = Height (cm) • Example: 5’9” = 69 in 69 in X 2.54 = 175.26 cm • Alternative measures for non-ambulatory patients • Measure arm span, fingertip to fingertip for estimated height • Measure knee height from floor and calculate estimated height with formulas below: Female: [(1.8333 X KH) – (0.24 X Age)] + 84.88 Male: [(2.02 X KH) – (0.04 X Age)] + 64.19 • Example: 45 yr old female, KH = 21 in [(1.8333 X 53.34 cm) – (0.24 X 52 yrs)] + 84.88 = Height (cm) 97.78 – 12.48 + 84.88 = 170.18 cm 170.18 cm 2.54 cm/in = 67 in or 5’7” Height Realizing Postsecondary and Career Readiness Through CTE

  28. Nutrition Assessment: AnthropometricsA Math-integrated Activity • Weight – convert to kg • Conversion of lbs to kg: Weight (lbs) 2.2 kg/lb = Weight (kg) Example: 175 lbs 2.2 kg/lb = 79.54 kg • Calculate Body Frame Size • Ht (cm) wrist circumference (cm) = ht/wrist ratio • Example: 5’8” female, wrist circumference = 7” • 68 in x 2.54 cm/in = 172.72 cm • 7 in x 2.54 cm/in = 17.78 cm • 172.72 cm ht 17.78 cm wrist = 9.71 ratio = LARGE FRAME Realizing Postsecondary and Career Readiness Through CTE

  29. Nutrition Assessment: AnthropometricsA Math-integrated Activity • The calculation of body fatpercentage involves measuring four skinfold sites: triceps, biceps, subscapular and suprailiac. • Add all 4 measurements together and refer to Percent Body Fat chart to determine body fat percentage. Bicep Site Tricep Site Subscapular Site Suprailiac Site Realizing Postsecondary and Career Readiness Through CTE

  30. Nutrition Assessment: AnthropometricsA Math-integrated Activity Realizing Postsecondary and Career Readiness Through CTE

  31. Nutrition Assessment: BMI • Body mass index (BMI) – a measure of body fat based on height and weight that applies to adult men and women. • English BMI Formula BMI = wtin lbs(htin inches x htin inches) x 703 • Example: 135 lb, 5’5” tall BMI = {135 lbs(55 in x 55 in)} x 703 BMI = (135 ÷ 3025) x 703 BMI = 31.37 Realizing Postsecondary and Career Readiness Through CTE

  32. Nutrition Assessment: BMI Realizing Postsecondary and Career Readiness Through CTE

  33. Nutrition Assessment: Biochemical • Plasma proteins (Albumin and Prealbumin) – evaluate for protein deficiency • Liver enzymes (ALT and AST) – evaluate liver function • BUN (blood urea nitrogen) and electrolytes (Na+, K+,Cl-, etc.) – evaluate kidney function • Urinary urea nitrogen excretion and creatinine height index – evaluate for tissue protein breakdown • Fasting glucose – evaluate for ↑ or ↓ blood glucose level • TLC (total lymphocyte count) – evaluate immune function • CBC (complete blood count) – evaluate anemia, including iron-deficiency, vitamin B12 deficiency, and folate deficiency • Hemoglobin, TIBC (Total Iron Binding Capacity), Transferrin, and Ferritin for iron • Other RBC characteristics for vitamin B12 and folate • Lipid Profile – evaluate cardiovascular risk • Total cholesterol, HDL, LDL, triglycerides Realizing Postsecondary and Career Readiness Through CTE

  34. Nutrition Assessment: Radiographic and Other Tests • Immune system integrity • Skin tests for common antigens • Skeletal system integrity and osteoporosis • X-ray • Dual-energy x-ray absorptiometry • Full-body bone scan • Gastrointestinal (GI) function • X-ray – peptic ulcer disease, malfunctions along GI tract • UGI - upper gastrointestinal x-ray series • Barium enema - lower GI x-ray series • Ultrasound Realizing Postsecondary and Career Readiness Through CTE

  35. Nutrition Assessment: Clinical Observations Realizing Postsecondary and Career Readiness Through CTE

  36. Nutrition Assessment: Clinical Observations Realizing Postsecondary and Career Readiness Through CTE

  37. Nutrition Assessment: Diet Evaluation • Diet history • 24-hour food recall, food diary, usual / current intake, restrictions, modifications • Food frequency questionnaire • Nutritional supplements, vitamin and mineral supplements • Food allergies and intolerances • Activity level • Average energy expended / day Realizing Postsecondary and Career Readiness Through CTE

  38. Nutrition Assessment: Diet Evaluation Student Activity 3-day Record and Diet Analysis • www.myfoodrecord.com – Nutrition Analysis Tool 2.0 • Developed by the University of Illinois • Uses the USDA National Nutrient Database for Standard Reference • Great for diet analysis • http://ndb.nal.usda.gov – USDA • Uses the USDA National Nutrient Database for Standard Reference • National Agriculture Library • Searches only item by item • www.supertracker.usda.gov – USDA • Uses the USDA National Nutrient Database for Standard Reference • Can be used for diet analysis • Limitations in food item search for brand items Realizing Postsecondary and Career Readiness Through CTE

  39. Nutrition Care Process Review Nutrition Care Process STEP 1: Nutrition Assessment √ STEP 2: Nutrition Diagnosis STEP 3: Nutrition Intervention STEP 4: Nutrition Monitoring and Evaluation Realizing Postsecondary and Career Readiness Through CTE

  40. Nutrition Diagnosis • “Identification and labeling an actual or current risk of or potential for developing a nutritional problem that dietetics professionals are responsible for treating independently.” – Academy of Nutrition and Dietetics • Problem • Etiology (cause) • Signs and symptoms Realizing Postsecondary and Career Readiness Through CTE

  41. Nutrition Care Process Review Nutrition Care Process STEP 1: Nutrition Assessment √ STEP 2: Nutrition Diagnosis √ STEP 3: Nutrition Intervention STEP 4: Nutrition Monitoring and Evaluation Realizing Postsecondary and Career Readiness Through CTE

  42. Nutrition Intervention Determining the priorities for patient’s immediate and long-term care consider the following: • Disease modifications for energy, nutrients and texture • Personal adaptations based on: • Personal needs – individual goals, living situation, etc. • Disease – how the disease affect other metabolic processes • Nutrition therapy – changes needed due to disease or condition • Food plan – food choices and preferences • Mode of feeding • Regular oral diet • Routine special diet such as soft, low fat, diabetic, etc. • Assisted oral feeding • Enteral feeding (tube feeding) • Parenteral feeding (TPN) Realizing Postsecondary and Career Readiness Through CTE

  43. Nutrition Care Process Review Nutrition Care Process STEP 1: Nutrition Assessment √ STEP 2: Nutrition Diagnosis √ STEP 3: Nutrition Intervention √ STEP 4: Nutrition Monitoring and Evaluation Realizing Postsecondary and Career Readiness Through CTE

  44. Nutrition Monitoring and Evaluation Monitoring and evaluation of the nutrition care plan is based on the nutrition diagnosis and treatment objectives and considers the following: • Has the diet addressed nutritional concerns? • Should there be any changes to the diet? • Has the patient been able to follow the diet? • Is there any more information needed to assist the patient further? Realizing Postsecondary and Career Readiness Through CTE

  45. Nutrition and Digestive Disorders • Choking – Heimlich maneuver • Dysphagia – difficulty swallowing; refer to SLP • Achalasia – lower esophageal sphincter spasms • Heartburn and Acid Indigestion - GERD – gastroesophageal reflux disease • Hiatal hernia • PUD – peptic ulcer disease; Heliobacter pylori • Malabsorption – • Cystic fibrosis – genetic pulmonary disease; enzyme replacement • IBS – inflammatory bowel disease; Crohn’s disease; ulcerative colitis • Celiac disease – aka non-tropical sprue • Diarrhea – a symptom of food/water-borne infections • Constipation • Diverticular disease – lower intestinal “pockets” form • Belching and Gas • Heartburn and Acid Indigestion Realizing Postsecondary and Career Readiness Through CTE

  46. Nutrition and Cancer: Risk • 10 million people develop cancer each year. • 7 million die as a result of cancer each year. • 12% of all deaths are due to cancer. • 50% of all cancers and 30-35% of cancer deaths are related to poor diet and excessive alcohol use. • Obesity ↑ risk of colon, kidney, pancreatic, esophageal, and post-menopausal breast cancer. • Weight gain in adulthood is the strongest predictor of breast cancer risk. (National Cancer Institute) • Obese women are 2-4X more likely to develop uterine cancer than normal weight women. • Abdominal fat seems to play a significant role in colon cancer risk. Realizing Postsecondary and Career Readiness Through CTE

  47. Nutrition and Cancer: Prevention • Red meat intake and processed meats significantly ↑ risk of colorectal cancer. • Processed meats and salt-preserved foods ↑ risk of stomach cancer because of carcinogens (nitrates and nitrosamines) in the meats. • Cooking meats at high temperatures (frying, grilling, barbequing) create carcinogenic compounds in the meat (heterocyclic amines) and ↑ risk of colorectal, pancreatic, and breast cancer . • Medium-well and well-done meats triples risk of stomach cancer. • ↑ intake of whole grains and fiber reduces risk of cancer by 1/3. • Diets ↑ in animal fat ↑ risk of colorectal and prostate cancer. • Omega-3 fatty acids are beneficial while omega-6 fatty acids are harmful and promote cancer cell growth, esp. in prostate cancer. Realizing Postsecondary and Career Readiness Through CTE

  48. Nutrition and Cancer: Prevention • Phytochemicals play important role in preventing tumor growth. • The role of soy intake in helping protect against breast cancer and prostate cancer is controversial. More studies are necessary. • Berries top of the list of potential cancer-fighting foods. • High intake of fruits and vegetables, esp. cruciferous vegetables may reduce cancer risk. (broccoli, cabbage, collards, cauliflower, etc.) • Tomatoes may decrease prostate cancer due to the lycopene content. • Regular physical activity↓ obesity and subsequent risk of certain cancers. Realizing Postsecondary and Career Readiness Through CTE

  49. Nutrition and Cancer: Prevention • Beta-carotene may not be as beneficial as once thought, actually increasing cancer risk in smokers. • Garlic and other vegetables in the Allium family (onions, scallions, leeks, chives) show promising effects on cancer prevention. • Vitamin D has shown protective effects against cancer, esp. breast, ovarian, prostate, and colon. • Selenium has been shown to ward off breast , esophageal, stomach, prostate, liver, and bladder cancers. • Alcohol consumption increases risk of cancer of the mouth, throat, larynx, esophagus, breast, and liver. Oral cancer is 6X greater than non-alcohol users. Realizing Postsecondary and Career Readiness Through CTE

  50. Nutrition and Cancer: Signs and Symptoms • Clinical malnutrition • Anorexia, early satiety, dry mouth, constipation • Difficulty breathing, shortness of breath • Weight loss • Decreased appetite • Body protein loss • Cancer cachexia • Involuntary weight loss > 5% of pre-morbid weight in one month • Common in lung and GI cancers due to hypermetabolism in these cancers • Loss of muscle mass, visceral protein, and body fat to meet energy demands • Due to anorexia, nausea, weakness, fatigue, depression, decreased quality of life • Substrate metabolism • Breakdown of protein = loss of muscle tissue • Breakdown of fat = elevated blood lipids • Abnormal glucose metabolism: glucose intolerance, hyperglycemia, insulin resistance Realizing Postsecondary and Career Readiness Through CTE

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