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General NutritionKathaleen Briggs Early, PhD, RD, CDE
Assistant Professor and Registered Dietitian
Learning Objectives
o Upon completion of this module, the student will be able to:1. Define “macronutrients” and identify what
the food sources are for the macronutrients2. Define “micronutrients” and identify what
the food sources are for the major micronutrients
3. Identify the components of a healthy diet4. Identify patients at nutrition risk5. Identify the causes of malnutrition and
those who are malnourished6. Explain the benefits of breastfeeding during
infancy
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Definitionso A nutrient is any substance in food
that the body can use to– obtain energy,– synthesize tissues, or– regulate body processes
o Macronutrients– Carbohydrates– Proteins– Lipids
o Micronutrients– Vitamins– Minerals
o Water
3
Macronutrients: CARBOHYDRATES
o Primary source of calories (energy) and glucose (4 kcal/gm)– Glucose is the body’s preferred fuel source– Most people get about half of all their calories from
carbohydrateso Food sources
– Breads, grains, cereals, rice and pastas are the biggest sources
– Dairy/non-dairy alternatives (milk, yogurt, soy and rice milk)
– Fruits in any form (fresh, frozen, juice, canned, dehydrated)– Vegetables also have some carbohydrates
• Common vegetable-based carbs in Western diet are Peas, Corn and Potatoes
– Sweets• Cakes, cookies, ice cream, pastries, etc.
o No carbohydrates in meats or cheeseso Carbohydrate-rich foods are also an important source of fiber
and antioxidants
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Macronutrients: FATSo Essential for health– Cellular membrane structure and function– Myelin sheath in nervous system– Fat tissue keeps us warm, provides some
protection to our organso Concentrated source of calories (9 kcal/gm)– Saturated dietary fats
• Animal-based– butter, lard, whole and 2% milk, meat, skin
• Plant-based– coconut and coconut oil, palm kernel oil,
palm oil, cocoa butter
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Macronutrients: FATS– Unsaturated dietary fat
• Monounsaturated fatty acids (MUFA)– Olive and canola oils
• Polyunsaturated fatty acids (PUFA)– Corn, safflower, sunflower, fish oils
– Trans fats• Very small amount of trans fats are naturally
occurring in dairy foods, meat, and darker-meat poultry
– Cholesterol from the diet• Only found in animal-based foods• Whole fat dairy products, egg yolks, meat,
poultry skin and dark poultry meat6
Macronutrients: PROTEINSo Primary role is to maintain structural and
functional integrity–Muscle tissue, skin, bone, organs,
enzymes, hormones, neurotransmitters, fluid and acid-base balance, cellular transport, and blood clotting
o Proteins are made up of amino acidso Some amino acids are essential, others
are non-essential, and still others are “conditionally” essentially
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Macronutrients: PROTEINS in Vegetarian Diets
o Vegetarian diets can be a very healthy optiono Complete vs. Incomplete– Complete proteins contain all 9 essential
amino acids (e.g., milk, egg, chicken, meat, fish)
– Soy is the only plant-based complete protein– Incomplete proteins are lacking in 1 or more
essential amino acids– It is not necessary to combine incomplete
proteins at a meal• More important to eat a variety of foods consumed
throughout the day to provide the most diverse amino acid and protein sources
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Micronutrients: VitaminsWater-solubleo Not stored in the bodyo Deficiencies may
develop quickly if inadequate intake occurs– B vitamins
• Folic acid (folate)• B12 (cobalamin)• Thiamin (B1)• Riboflavin (B2)• Niacin (B3)
– Vitamin C
Fat-solubleo Stored in liver and fat
tissue for long periods of time
o Deficiencies develop very slowly– Vitamin A– Vitamin D– Vitamin E– Vitamin K
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Micronutrients: Major Minerals and their Common
Food Sourceso Calcium
• dairy products, dark leafy green vegetables, tofuo Phosphorus
• Animal proteins, dairy foods, legumes; wide-spread in food supply
o Magnesium• Whole grains, “hard” water
o Sodium• Processed foods, preserved foods, added salt in
cooking and at the tableo Potassium
• Fruits and vegetables
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Micronutrients: Trace Minerals and their Common
Food Sourceso Copper
• Liver, shellfish, lentils, mushrooms, cashews, sunflower seeds
o Iodine• Iodized salt, seafood
o Iron• Most well absorbed: Beef, dark poultry meat, whole
eggs, tuna, salmon, legumes, iron fortified cereals, liver• Less well absorbed: prunes, raisins, apricots, dark leafy
green vegetables, brown riceo Selenium
• Brazil nuts, tuna, beef, brown riceo Zinc
• Oysters, meat, poultry, legumes, shellfish, whole grains
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Micronutrient (vitamin) Deficiency
o Pellagra (Niacin deficiency)• The 4 D’s: diarrhea, dermatitis, dementia
and deatho Pernicious Anemia (B12 deficiency)
• Caused from autoimmune destruction for stomach cells needed for intrinsic factor production
o Vitamin A deficiency• Leading cause of preventable blindness in
children• Increases the risk of disease and death from
severe infections12
Micronutrient (vitamin) Deficiency
o Scurvy (vitamin C deficiency)• Collagen breakdown resulting in bleeding
gums and petechiae
o Rickets and Osteomalacia (vitamin D deficiency)
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Micronutrient (mineral) Deficiency
o Iodine– Regions at greatest risk include countries of
the former Soviet Union, south Asia and parts of Africa
– Thyroid enlargement (goiter) is an early and visible sign of iodine deficiency
o Iron– Iron deficiency anemia– Fatigue, rapid heart rate, and rapid
breathing on exertion are the most common signs
o Selenium– Kashin disease
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Dietary History
o Questions the nurse can ask the patient directly– Do you eat a wide variety of foods?– Do you have difficulty obtaining adequate food?– Do you have any food allergies/intolerances?– Do you have family? Do you eat alone or with
others?o Questions the nurse should consider in their
assessment– Is the patient obviously under or overweight?– Does the patient have any obvious warning
signs of nutrient deficiencies (see slides 18-27)?
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Optimizing Nutrition
o WHO’s five keys to safer food– Keep clean– Separate raw and cooked– Cook thoroughly– Keep food at safe temperatures– Use safe water and raw materials
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Assessing Physical Activity
o With the world-wide obesity epidemic, addressing physical activity is essential
o Use the FITT principle– F: How many times per week does the
activity occur?– I: How vigorous is the activity?– T: What is the activity? What is its
purpose?– T: How many minutes of the activity are
done per session?17
Anthropometrics
o Height• A key indicator of chronic malnutrition is stunted
growtho Weight
• Recent weight loss is a very sensitive marker of a patient’s nutritional status
• Weight loss of more than 5% of usual body weight in 1 month or 10% in 6 months before hospitalization is clinically significant
o Weight for height• BMI
o Body fat assessmento Activities of Daily Livingo Strength– e.g., grip strength
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Physical Assessment of Nutrition Status
o Orbital fat pads• should be present
o Triceps skinfold thickness• 1 cm or less = malnourished
o Anterior lower ribs• Ribs should not be visible if adequately
nourishedo Temples
• should not be sunkeno Clavicle
• should not be overtly prominento Shoulders
• Should be rounded or sloped, not squared19
Physical Assessment of Nutrition Status
o Interosseus muscle– Should be bulging when thumb and
forefinger pinch togethero Scapula–When hand presses against a wall, back
should be smooth if adequately nourishedo Thigh and Calf– Should be solid– Loose skin upon muscle massage
indicates severe deficit
20
Physical Assessment of Nutrition Status
o Edema– In ambulatory patients, no impression
should remain following pressure application
o Ascites– Should not be present in healthy
individuals– Degree of fluid accumulation in
abdominal cavity can be indicative of nutrition status
21
Malnutrition
o When more than 20% of usual body weight is lost, most physiologic body functions become significantly impaired
o Malnutrition can also reduce cardiac output, impair wound healing, and depress immune function
o Nutritional repletion can often reverse these processes and significantly improve patient outcomes
o Difficulty is identifying individuals at risk so that appropriate interventions can be made
22
Protein Energy Malnutrition (PEM)
o Most common form of malnutritiono Most often seen in the western hospitalized
patient with– End-stage liver or renal disease– Cancer cachexia– HIV/AIDS wasting disease– Severe eating disorder– Neglect– Long-term recovery from multiple trauma
o Outside industrialized countries, more often seen in areas of severe drought, infectious disease, and war
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Kwashiorkor
o “Pot Belly” appearance due to hepatic edema and fatty liver
o Increased extracellular fluid (edema) and low plasma albumin levels– Increase in extracellular fluid may mask
underlying weight losso Rapid onset; may develop in a few weeks
24
Marasmus
o Significant deficit of total body fat and body protein with a slight increase in extracellular water
o Obvious body wasting – Skin and bones appearance
o Eyes may be sunken o Skull and cheekbones may be prominent o Plasma albumin is often in the low-normal
rangeo Usually takes months or years to develop
25
Comparison of the features of kwashiorkor and marasmus
Feature Kwashiorkor Marasmus
Growth failure Present Present
Wasting Present Present, marked
Edema Present (sometimes mild)
Absent
Hair changes Common Less common
Mental changes Very common Uncommon
Dermatosis, flaky-paint Common Does not occur
Appetite Poor Good
Anemia Severe (sometimes) Present, less severe
Subcutaneous fat Reduced but present Absent
Face May be edematous Drawn in, monkey-like
Fatty infiltration of liver Present Absent
26FAO/WHO
Assessing Malnutrition
o Temples (temporalis muscles)
should be visualized for evidence of wasting
o Dull hair, easily plucked = protein energy deficiency
o Brittle hair, breaks easily suggests micronutrient deficiencies
http://meded.ucsd.edu/clinicalimg/head_temporal_wasting2.htm
http://meded.ucsd.edu/clinicalimg/index.htm
27
Causes of Malnutrition
o Hunger– Due to poverty and food insecurity
o Micronutrient or protein deficiency–More common in elderly
o Disease– Infectious disease (e.g., malaria, TB, see
next slide)– Chronic disease (e.g., HIV AIDS, cancer,
emphysema, etc)
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Defining a Healthy Diet
o Aids in maintaining a healthy body weighto Promotes general well-beingo Satisfies hunger and appetiteo Culturally and age appropriateo Suitable to personal preferenceso Prevents chronic diseaseo Adequate in overall nutrition and balance
– High consumption of fruits & vegetables – Low consumption of red meat & fatty foods – Whole and fresh foods are preferred to processed or
refined foods – Protein primarily from fish, dairy products, and/or
legumes – Limited in added salt, sugar, and alcohol
30
World Health Organization’s Five Keys to a Healthy Diet
o Give baby only breast milk for the first six months of life
o Eat a variety of foods o Eat plenty of vegetables and fruits o Eat moderate amounts of fat and oils o Eat less salt and sugars
31
Benefits of Breastfeeding
For infantso favorable balance of
nutrientso improve cognitive
developmento protects against
infectionso protect against chronic
diseases– Impacts gene expression
o protects against food allergies
For motherso contracts the uteruso delays return of regular
ovulation (especially in exclusively-breastfeeding moms)
o conserves iron storeso protects against breast
cancer (especially pre-menopausal forms)
o aids in return of pre-pregnancy weight
32
Recommendations for Breastfeeding
o World Health Organization:– Exclusive breastfeeding for first six
months– Introducing age-appropriate and safe
complementary foods at six months– Continuing breastfeeding for up to two
years or beyond
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