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Nutrition in Physical MedicineHS-CPM-9. Students will evaluate the importance of nutrition in physical medicine.

SubstandardIdentify the six classes of nutrients and describe the functions of each

Essential NutrientsCarbohydrates: supply energy to the body in the form of sugarFats: source of stored energy; provide and carry the fat soluble vitamins: A,D,E,KProteins: important for growth, maintenance, repair of tissueVitamins: aid in absorbing and using the nutrients. Each vitamin helps one or more specific functions in the body.Adam Freeman's notes on NutritionEssential Nutrients cont.Minerals: helps in activating numerous reactions in the body- building and regulatingWater: regulates body temperature, moistens tissues like eyes, nose & mouth, lubricates joints, protects body organs & tissues, helps prevent constipation, carries nutrients & oxygen to cells, helps dissolve nutrients for use in body, flushes out waste products

Adam Freeman's notes on Nutrition; MayoClinicSubstandardIdentify the five food groups and list several food sources for each group

5 Food GroupsVegetablesFruitsGrainsDairyProteins

5 Food GroupsVegetables: may be fresh, frozen, canned or dried and may be eaten whole, cut-up, or mashed. You should eat a variety of dark green, red and orange vegetables, as well as beans and peas (which are also considered part of the protein group). Examples: broccoli, carrots, collard greens, split peas, green beans, black-eyed peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoes and kidney beans Centers for Disease Control & Prevention

5 Food Groups cont.Fruits: may be fresh, canned, frozen or dried and may be eaten whole, cut-up, or pureed. Examples: apples, apricots, bananas, dates, grapes, oranges, grapefruit, mangoes, melons, peaches, pineapples, raisins, strawberries, tangerines, and 100% fruit juice

Centers for Disease Control & Prevention

5 Food Groups cont.Grains: At least half of the grains you eat should be whole grains, such as whole-wheat bread, whole-grain cereals and crackers, oatmeal, bulgur, and brown rice. Refined grains include white bread, white rice, enriched pasta, flour tortillas, and most noodles.

Centers for Disease Control & Prevention

5 Food Groups cont.Dairy: Most of your choices should be fat-free or low-fat milk and milk products, but all milks and calcium-containing milk products count in this category. Examples include milk, cheeses, and yogurt as well as lactose-free and lactose-reduced products and soy beverages.

Centers for Disease Control & Prevention

5 Food Groups cont.Proteins: Choose a variety of lean meats and poultry, seafood, beans and peas, eggs, processed soy products, unsalted nuts, and seeds. Make sure to eat at least 8 ounces of seafood each week.

Centers for Disease Control & Prevention

SubstandardAssess the nutritional status of patients in physical medicine

Assess Nutritional StatusInfluenced by food intake, quality & quantity, & physical healthGood nutritional history should be obtainedGeneral clinical examination, with special attention to organs like hair, gums, nails, skin, eyes, tongue, muscles, bones & thyroid gland.Detection of relevant signs helps in establishing the nutritional diagnosis

www.pitt.edu/~super7/19011-20001/19801.pptClinical signs of nutritional deficiencyHAIRProtein, zinc, biotindeficiencySpare & thinProtein deficiencyEasy to pull outVit C & Vit AdeficiencyCorkscrewCoiled hairwww.pitt.edu/~super7/19011-20001/19801.ppt14Clinical signs of nutritional deficiencyMOUTH

Riboflavin, niacin, folic acid, B12 Glossitis (swollen tongue, often smooth look)Vit. C,A, K, folic acid & niacinBleeding & spongy gumsB 2,6,& niacinAngular stomatitis (canker sores), cheilosis (painful cracking of corners of mouth) & fissured tongueVit.A,B12, B-complex, folic acid & niacinLeukoplakiaVit B12,6,c, niacin ,folic acid & ironSore mouth & tonguewww.pitt.edu/~super7/19011-20001/19801.ppt15Clinical signs of nutritional deficiencyEYES Vitamin A deficiencyNight blindness, exophthalmia (protruded eyeballs)Vit B2 & vit AdeficienciesPhotophobia-blurring, conjunctival inflammationwww.pitt.edu/~super7/19011-20001/19801.ppt16Clinical signs of nutritional deficiencyNAILSIron deficiencySpooning Protein deficiencyTransverse lines www.pitt.edu/~super7/19011-20001/19801.ppt

17Clinical signs of nutritional deficiencySKINFolic acid, iron, B12PallorVitamin B & Vitamin CFollicular hyperkeratosis (rough, cone-shaped, elevated papules, the openings of which are often closed with a white plug of encrusted sebum)Vit B2, Vitamin A, Zinc & NiacinFlaking dermatitisNiacinPigmentation, desquamation (shedding of outer layer of skin)Vit K ,Vit C & folic acidBruising, purpurawww.pitt.edu/~super7/19011-20001/19801.ppt18Clinical signs of nutritional deficiencyThyroid glandIn mountainous areas and far from sea places Goiter is a reliable sign of iodine deficiency.

www.pitt.edu/~super7/19011-20001/19801.ppt19Clinical signs of nutritional deficiencyJoints & bonesHelp detect signs of vitamin D deficiency (Rickets) & vitamin C deficiency (Scurvy)

www.pitt.edu/~super7/19011-20001/19801.ppt20Anthropometric MethodsAnthropometry is the measurement of body height, weight & proportions.It is used to evaluate both under & over nutrition.The measured values reflects the current nutritional status & dont differentiate between acute & chronic changes.Measurements:Mid-arm circumference

Skin fold thickness

Head circumference

Head/chest ratioHip/waist ratio

www.pitt.edu/~super7/19011-20001/19801.pptAnthropometry for ChildrenAccurate measurement of height and weight is essential. The results can then be used to evaluate the physical growth of the child.http://www.cdc.gov/growthcharts/data/set1clinical/cj41c021.pdf Boyshttp://www.cdc.gov/growthcharts/data/set1clinical/cj41c022.pdf Girls

www.pitt.edu/~super7/19011-20001/19801.pptMeasurement for AdultsHeight:The subject stands erect & bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault & height is recorded to the nearest inch.Weight:Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable. Weigh in light clothes, no shoes. Read to the nearest pound.

www.pitt.edu/~super7/19011-20001/19801.pptBody Mass IndexThe international standard for assessing body size in adults is the body mass index (BMI).BMI is computed using the following formula: BMI = Weight (kg)/ Height (m) OR (weight (lb) / [height (in)]2 x 703) See chart for conversionEvidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity & mortalitywww.cdc.gov/healthyweight/.../bmi/...bmi/childrens_bmi_formula.html24BMI (WHO - Classification)BMI < 18.5 = Under WeightBMI 18.5-24.5= Healthy weight rangeBMI 25-30 = Overweight (grade 1 obesity)BMI >30-40 = Obese (grade 2 obesity)BMI >40 =Very obese (morbid or grade 3 obesity)http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.pdf

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Waist/Hip RatioWaist circumference is measured at the level of the umbilicus to the nearest 0.5 inch.The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together.The measurement should be taken at the end of a normal expiration. www.pitt.edu/~super7/19011-20001/19801.ppt27Waist CircumferenceWaist circumference predicts mortality better than any other anthropometric measurement.

It has been proposed that waist measurement alone can be used to assess obesitywww.pitt.edu/~super7/19011-20001/19801.ppt28Hip Circumference Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 inch.The subject should be standing and the measurer should squat beside him.Both measurement should taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue. www.pitt.edu/~super7/19011-20001/19801.ppt29

Dietary AssessmentNutritional intake of humans is assessed by five different methods. These are:

24 hours dietary recallFood frequency questionnaireDietary history since early lifeFood diary techniqueObserved food consumption www.pitt.edu/~super7/19011-20001/19801.ppt31

24 Hours Dietary RecallA trained interviewer asks the subject to recall all food & drink taken in the previous 24 hours. It is quick, easy, & depends on short-term memory, but may not be truly representative of the persons usual intakewww.pitt.edu/~super7/19011-20001/19801.ppt32Food Frequency QuestionnaireIn this method the subject is given a list of around 100 food items to indicate his or her intake (frequency & quantity) per day, per week & per month.Inexpensive, more representative & easy to use.www.pitt.edu/~super7/19011-20001/19801.ppt33Food Frequency Questionnaire cont.Limitations:Long QuestionnaireErrors with estimating serving size.Needs updating with new commercial food products to keep pace with changing dietary habits.www.pitt.edu/~super7/19011-20001/19801.ppt34Dietary HistoryIt is an accurate method for assessing the nutritional status.The information should be collected by a trained interviewer.Details about usual intake, types, amount, frequency & timing needs to be obtained.Cross-checking to verify data is important.www.pitt.edu/~super7/19011-20001/19801.ppt35Food DiaryFood intake (types & amounts) should be recorded by the subject at the time of consumption.The length of the collection period range between 1-7 days.Reliable but difficult to maintain.www.pitt.edu/~super7/19011-20001/19801.ppt36Observed Food ConsumptionThe most unused method in clinical practice, but it is recommended for research purposes.The meal eaten by the individual is weighed and contents are exactly calculated.The method is characterized by having a high degree of accuracy but expensive & needs time & efforts. www.pitt.edu/~super7/19011-20001/19801.ppt37Interpretation of Dietary Data1. Qualitative MethodUsing the food pyramid & the basic food groups method.Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat-fish-poultry, vegetables & fruits)Determine the number of servings from each group & compare it with minimum requirement.www.pitt.edu/~super7/19011-20001/19801.ppt38Interpretation of Dietary Data cont.2. Quantitative MethodThe amount of energy & specific nutrients in each food consumed can be calculated using food composition tables & then compare it with the recommended daily intake.Evaluation by this method is expensive & time consuming, unless computing facilities are available. www.pitt.edu/~super7/19011-20001/19801.ppt39SubstandardDefine calorie and explain the role of calories in weight maintenance, weight loss, and weight gain

CalorieA unit of heat used to indicate the amount of energy that foods will produce in the human bodyhttp://www.merriam-webster.com/dictionary/calorie

Weight Maintenance/Loss/GainIf you want to lose weight, subtract 500 calories per day for each pound you want to lose every week. Add 500 calories per day for each pound you want to gain every week. 1 pound of fat represents 3500 calories (500 calories per day multiplied by 7 days equals 3500 calories). Calorie levels of less than 1200 calories are not recommended and are too low to meet nutritional requirements. Weight loss of more than 2 pounds per week is not recommended.For a more balanced approach to a 1 pound per week weight loss, increase your activity. Consider cutting calorie intake by 250 calories per day and exercising to expend (use up) the other 250 calories. This approach prevents a decrease in your metabolic rate and promotes increased lean muscle mass.http://www.nutrition.com.sg/ha/hacalcal.aspIf you are...Your caloric balance status is...Maintaining your weight"in balance." You are eating roughly the same number of calories that your body is using. Your weight will remain stable.Gaining weight"in caloric excess." You are eating more calories than your body is using. You will store these extra calories as fat and you'll gain weight.Losing weight"in caloric deficit." You are eating fewer calories than you are using. Your body is pulling from its fat storage cells for energy, so your weight is decreasing.http://www.cdc.gov/healthyweight/calories/

Video Clipshttp://theweightofthenation.hbo.com/digital-assets/Are all calories created equal?Why maintaining a healthy weight is so hard.

SubstandardDistinguish between the signs, symptoms, and treatment of various eating disorders

Anorexia NervosaSymptomsResistance to maintaining body weight at or above a minimally normal weight for age and height.Intense fear of weight gain or being fat, even though underweight.Disturbance in the experience of body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of low body weight.Loss of menstrual periods in girls and women post-puberty.

www.nationaleatingdisorders.orgAnorexia Nervosa cont.Warning SignsDramatic weight loss.Preoccupation with weight, food, calories, fat grams, and dieting.Refusal to eat certain foods, progressing to restrictions against whole categories of food (e.g. no carbohydrates, etc.).Frequent comments about feeling fat or overweight despite weight loss.Anxiety about gaining weight or being fat.Denial of hunger.Development of food rituals (e.g. eating foods in certain orders, excessive chewing, rearranging food on a plate).Consistent excuses to avoid mealtimes or situations involving food.Excessive, rigid exercise regimen--despite weather, fatigue, illness, or injury, the need to burn off calories taken in.Withdrawal from usual friends and activities.In general, behaviors and attitudes indicating that weight loss, dieting, and control of food are becoming primary concerns.

www.nationaleatingdisorders.org49Anorexia Nervosa cont.Health ConsequencesAbnormally slow heart rate and low blood pressure, which mean that the heart muscle is changing. The risk for heart failure rises as heart rate and blood pressure levels sink lower and lower.Reduction of bone density (osteoporosis), which results in dry, brittle bones.Muscle loss and weakness.Severe dehydration, which can result in kidney failure.Fainting, fatigue, and overall weakness.Dry hair and skin, hair loss is common.Growth of a downy layer of hair called lanugo all over the body, including the face, in an effort to keep the body warm.

www.nationaleatingdisorders.orgBulimia NervosaSymptomsRegular intake of large amounts of food accompanied by a sense of loss of control over eating behavior.Regular use of inappropriate compensatory behaviors such as self-induced vomiting, laxative or diuretic abuse, fasting, and/or obsessive or compulsive exercise.Extreme concern with body weight and shape.

www.nationaleatingdisorders.orgBulimia Nervosa cont.Warning SignsEvidence of binge eating, including disappearance of large amounts of food in short periods of time or finding wrappers and containers indicating the consumption of large amounts of food.Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics.Excessive, rigid exercise regimen--despite weather, fatigue, illness, or injury, the compulsive need to burn off calories taken in.Unusual swelling of the cheeks or jaw area.Calluses on the back of the hands and knuckles from self-induced vomiting.Discoloration or staining of the teeth.Creation of lifestyle schedules or rituals to make time for binge-and-purge sessions.Withdrawal from usual friends and activities.In general, behaviors and attitudes indicating that weight loss, dieting, and control of food are becoming primary concerns.Continued exercise despite injury; overuse injuries.

www.nationaleatingdisorders.orgBulimia Nervosa cont.Health ConsequencesElectrolyte imbalances that can lead to irregular heartbeats and possibly heart failure and death. Electrolyte imbalance is caused by dehydration and loss of potassium and sodium from the body as a result of purging behaviors.Inflammation and possible rupture of the esophagus from frequent vomiting.Tooth decay and staining from stomach acids released during frequent vomiting.Chronic irregular bowel movements and constipation as a result of laxative abuse.Gastric rupture is an uncommon but possible side effect of binge eating.

www.nationaleatingdisorders.orgBinge Eating DisorderSymptomsFrequent episodes of eating large quantities of food in short periods of time.Feeling out of control over eating behavior during the episode.Feeling depressed, guilty, or disgusted by the behavior.There are also several behavioral indicators of BED including eating when not hungry, eating alone because of embarrassment over quantities consumed, eating until uncomfortably full.

www.nationaleatingdisorders.orgBinge Eating DisorderHealth ConsequencesThe health risks of BED are most commonly those associated with clinical obesity. Some of the potential health consequences of binge eating disorder include:High blood pressureHigh cholesterol levelsHeart diseaseDiabetes mellitusGallbladder diseaseMusculoskeletal problems

www.nationaleatingdisorders.orgEating Disorder TreatmentPsychotherapy or counseling coupled with careful attention to medical & nutritional needsSome medications can helpMust be tailored to the individual, depends upon severity of disorder & patients individual problems, needs & strengthsRecommended care provided by multidisciplinary team, including a psychologist, psychiatrist, social worker, nutritional and/or primary care physicianwww.nationaleatingdisorders.orgEating Disorder Treatment cont.Must address symptoms & medical consequences, as well as psychological, biological, interpersonal & cultural forces that contribute to the disorderNutritional counseling is necessary & should incorporate education about nutritional needs, as well as planning for & monitoring rational choices by the individual treatmentMany respond to outpatient therapy, including individual, group or family therapy & medical management by primary care providerwww.nationaleatingdisorders.orgEating Disorder Treatment cont.Support groups, nutrition counseling & psychiatric medications administered under careful medical supervision have proven helpfulInpatient care is necessary when the eating disorder has led to physical problems that may be life threatening, or when it is causing severe psychological or behavioral problems; typically requires a period of outpatient follow-up to address underlying issuesImportant to find a health professional they trust to help coordinate & oversee their carewww.nationaleatingdisorders.orgSubstandardAnalyze the importance of water and describe signs of dehydration

Importance of WaterFor the human body, water is truly a vital resource. You can go weeks without food but only 5-7 days without water. When the water in your body is reduced by just 1 percent, you become thirsty. At 5 percent, muscle strength and endurance declines significantly and you become hot and tired. When the loss reaches 10 percent, delirium and blurred vision occur. A 20 percent reduction results in death. http://www.chem.duke.edu/~jds/cruise_chem/water/watdiet.htmlImportance of Water cont. http://www.chem.duke.edu/~jds/cruise_chem/water/watdiet.htmlTissuePercent WaterBlood83.0Heart79.2Muscle75.6Brain74.8Skin72.0Bone22.0Importance of Water cont.Blood (83% water) transports oxygen, carbon dioxide, nutrients & waste productsUrine (mostly water) removes waste products from the bodyKeeps mouth moist & washes away dirt on your eyes, lubricates jointsAssists in digestion, accesses stored energy for muscles & organsMaintains electrolyte balance within bodyAssists with temperature regulationhttp://www.chem.duke.edu/~jds/cruise_chem/water/watdiet.htmlSigns of DehydrationMild to moderate dehydration is likely to cause: Dry, sticky mouthSleepiness or tiredness children are likely to be less active than usualThirstDecreased urine output no wet diapers for three hours for infants and eight hours or more without urination for older children and teensFew or no tears when cryingDry skinHeadacheConstipationDizziness or lightheadedness

http://www.mayoclinic.com/health/dehydration/DS00561/DSECTION=symptomsSigns of Severe DehydrationExtreme thirstExtreme fussiness or sleepiness in infants and children; irritability and confusion in adultsVery dry mouth, skin and mucous membranesLack of sweatingLittle or no urination any urine that is produced will be dark yellow or amberSunken eyesShriveled and dry skin that lacks elasticity and doesn't "bounce back" when pinched into a foldIn infants, sunken fontanels the soft spots on the top of a baby's headLow blood pressureRapid heartbeatRapid breathingNo tears when cryingFeverIn the most serious cases, delirium or unconsciousness

SubstandardCompare and contrast different methods of fluid replacement for the physically active person

Fluid Guidelines for Athleteshttp://blogs.harrisonhigh.org/adam_freeman/Fluid_Guidelines.pdf#page=1&zoom=auto,-91,702Gatorade Sports Science Institutehttp://blogs.harrisonhigh.org/adam_freeman/Sports_Drinks_vs_Water.pdf

SubstandardDescribe the components of a pre-event meal.

Pre-Event MealsShould be high in carbohydrates & fluidsCarbs are easier to digest than fat & protein & can be converted into energy to be used immediatelyShould be eaten 3-4 hours before activityWater is the best liquid to drinkBe sure to be well hydrated about an hour before competitionAthletes that are anxious about the competition may use carb-loaded sport drinks because they are digested quickly, helping them avoid feelings of nauseaFundamentals of Athletic Training, 2011Pre-Event Meals cont.When determining pre-event meals for an entire team, must consider diversity of team (specific food preferences or intolerances, religious holidays, ie. Meat restrictions, etc) and determine what types are acceptable before a competitionVegetarians have special protein needsEat familiar foods; pre-event meal is no time to experiment

Fundamentals of Athletic Training, 2011Good Pre-Event FoodsPastaFruitPlain crackersRice cakesCerealVegetarian foodsPotatoesMeatless lasagnaSoupRiceJuiceBreadRaisinsPancakesWaffles

Fundamentals of Athletic Training, 2011

Carbohydrate LoadingAthletes that participate in endurance events may benefitIngest large amounts of carbohydrates for three days prior to an eventTheory: if there is a large carbohydrate store, athlete is less likely to run out of energyDepleting the body of carbs prior to carb loading will cause the body to store more carbsOnce carbs are used up, body begins to break down fat, which takes more energy than breaking down carbs, depleting the body of energyFundamentals of Athletic Training, 2011