174 SECTION II. WHAT TO DO WITH THE INFORMATION TABLE 7.2(Continued) o Involuntary weight loss/gain Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must not be ignored. Being overweight or underweight also increases your chance of poor health D Needs assistance in self-care Although most older people are able to eat, one out of every five has trouble walking, shopping, or buying and 2 cooking food, especially as they get older. v D Elderly, age above 80 years Most older people lead full productive lives But as age increases, the risk of frailty and health problems increases Checking your nutritional health regularly makes good sense Adapted from materials developed by the Nutrition Screening Initiative, Washington, DC 2007 recommended dietary allowances (RDAs) last updated in 1989. The DRIs are based on scientific relationships between nutrient intake, chronic disease, and health status. The new dietary guidelines, which provide evidence-based nutritional guidance for ages 2 years and older, have the goals of inspiring individuals to seek more information about healthy eating, communicating scientifically accurate but understandable information, and guiding federal policy and programs. Public confusion around nutrition is fostered by terms commonly used in commercial and food labels (e. g, whole grain, organic, fat-free, no trans-fats, lI natural. rich b glycemic lowers cholesterol The guidelines make 41 key recommendations, 23 for the general oublic and 18 for special populations. Clinicians should refer to the Dietary Guidelines for Americans 2005 Toolkit for Health Professionals (http://www.health.gov/dietaryguidelines/dga2005/toolkit/),whichcompiles he latest evidence-based nutrition and physical activity recommendations. Food Groups to Encourage a key theme in the guidelines is the consumption of adequate nutrients within caloric needs. This should be accomplished by consuming a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit intake of saturated and trans-fat, cholesterol, added sugars, salt, and alcohol. Diets should emphasize a variety of fiber-rich fruits, vegetables, and whole grains, staying within ones energy needs. Five servings of fruits and vegetables per day is recommended. Patients should consume 3 oz equivalents of whole grains daily(at least half whole grains
CHAPTER 7. NUTRITION 175 TABLE 7.3 Subjective Global Assessment Summary HISTORY 1. Weight change Overall loss in past 6 months: amount % Change in past 2 weeks increase no change decrease 2. Dietary intake change (relative to normal) no change e Duration suboptimal solid diet full liquid diet hy pocaloric liquids starvation 3. Gastrointestinal symptoms(persisting for >2 weeks) nausea-vomiting diarrhea anorexia 4. Functional capacity no dysfunction(e. g, full capacity) dysfunction Duration: T working suboptimally PHYSICAL EXAMINATION For each trait, specify a rating as follows 0=normal, 1+=mild, 2+= moderate, 3+=severe loss of subcutaneous fat(triceps, chest) muscle wasting(quadriceps, deltoids) ankle edema sacral edema SUBJECTIVE GLOBAL ASSESSMENT RATING(select one) ell nourished B= moderately (or suspected of being) malnourished C severely malnourished From Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment?) Parent Ent Nutr1987;11(1):8
176 SECTION II. WHAT TO DO WITH THE INFORMATION TABLE 7. 4 Behavioral Steps for a Healthy diet Food Preparation Preplan your meals Learn to cook the calorie-reduced way Include low-calorie foods at each meal Shop when your control is highest and have a list Mealtime Preload your stomach with liquids and drink ample liquids during meals Use smaller plates, bowls, glasses, and serving spoons Do not keep serving dishes on the table Stop eating for a minute during the meal Leave a little food on your plate(doggy bag) Snacking at Home Keep tempting foods out of the house Eat three healthy meals a day Brush your teeth after every meal and use mouthwash Preplan snacks into your eating plan Try sugar-free guIn, hard candy, diet soda, or fruit when craving sweets Exercise every day Ask family and friends not to offer you snacks Talk to yourself Emotional Snacking Use relaxation exercises Take a warm bubble bath Listen to relaxing music Get out of the house and the rest should be enriched)and three cups per day of fat-free, low-fat or quivalent milk products. Children aged 2-8 ycars should consume two cups of fat-free or low-fat milk or equivalent milk products per day. Other key recommendations include consuming two servings of fish per week (approximately 8 oz total)to help reduce risks from cardiovascular disease, reducing the intake of sugars especially through sweetened beverages, and
CHAPTER 7. NUTRITION 177 consuming less than 2 300 mg of sodium with an increase in foods rich in potassium. See Figure 7. 1 for an example of how to accomplish all of this within the limits of a 2.000-cal diet CARBOHYDRATES Patients should consume 130 g/day of carbohydrates. Carbohydrates should provide 50-60% of total daily calories and should emphasize complex car bohydrates that include dietary fiber (see subsequent text). The intake of refined carbohydrates and sugars should be limited to reduce the risk of caries Glycemic index is a measure of how quickly carbohydrates enter the blood stream and then elevate blood sugar levels. In general, most refined foods in the United States have a high glycemic index whereas nonstarchy vegetables fruits, and legumes seem to have a lower glycemic index. Although some hy pothesize that long-term consumption of high-glycemic index foods may increase the risk of obesity, diabetes, and heart disease, others argue the index is studied primarily under artificial laboratory conditions and does not accurately portray the mixed meals that most individuals consume The American Diabetes Association states that there is insufficient evidence to use glycemic index in the management of diabetes. Clinicians should at least be aware of the glycemic index of certain foods, and that it may cause spikes in blood sugar levels, especially among patients with diabetes (uww.glycemicindex.com) FIBER Individuals older than 4 years should consume at least 25 g of fiber each day(see Table 7.5), yet 50% of women consume fewer than 13 g a day and 50% of men consume fewer than 17 g a day (3). Fiber includes two main types: soluble and insoluble. Insoluble fiber, an important aid in normal bowel function, is provided in high concentrations in whole wheat breads, wheat cereals, wheat bran, rye, rice, barley, cabbage, beets, carrots, Brussels sprouts, turnips, cauliflower, and apple skins. Sources of soluble fiber include oat bran, oatmeal, beans, peas, rice bran, barley, citrus fruits, apple pulp, psyllium, carrots, strawberries, peaches with skin, and apples with skin. Most fber-rich foods contain a mixture of both soluble and insoluble fibers. The aha recommends eating a variety of food fiber sources(1). Fiber, especially insoluble fiber, helps promote bowel regularity Individuals should start slowly and gradually increase their fiber intake over time, while also making sure to increase their intake of fluids. Foods high in fiber tend to be lower in total calories, saturated fat, and cholesterol Fiber may also help to curb appetite and can be an important adjunct to weight management plans
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