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Second Example of Assessment of Infant Nutrition

| Filed under Nutrition

Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patient’s symptoms, including:
a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) Infant has cried constantly since coming home from the hospital. The parents think that this is his “hungry cry” and feed him almost every 1-2 hours. He rarely goes 2 hours between feedings. Despite these frequent feedings, he never seems satisfied and is very irritable. He appears to have lost weight since coming home from the hospital 4 weeks ago. He has very frequent bowel movements but no emesis. The parents also report a significant diaper rash and streaks of blood in the diaper. The boy appears to be somewhat lethargic.
b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient’s symptom(s) Crying is relieved briefly by feeding.
c. description of the parent’s efforts to relieve the symptoms The parents’ efforts to relieve the crying have just been to feed him more.
2. Gather essential patient history information:
a. patient’s identity Miquel Alvarez-Lopez
b. patient’s age, sex, height, and weight Hispanic, 4-week-old boy born at 38 weeks gestational age; birth weight 7 lb 11 oz (3.5 kg)
c. parents’ occupation Mother works at a local hospital on the housekeeping staff; father works at the shipping port.
d. patient’s dietary habits Miquel is receiving a standard, term infant formula, Good Start Supreme (see Table 26-6). The parents cannot verbalize the exact amount he is taking because they cannot keep up with it.
e. patient’s sleep habits Rarely sleeps more than 2 hours at a time
f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements Term infant with no preexisting medical conditions
g. allergies NKA
h. history of other adverse reactions to medications None
Assessment and Triage
3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). Primary problem: dehydration

Secondary problems: malabsorption of feedings and failure to thrive
4. Identify exclusions for self-treatment. Dehydration and failure to thrive are exclusions for self-care.
5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the parents. Options include:

(1) Refer to the PCP.

(2) Refer to the pediatric emergency department.

(3) Recommend a formula change.

(4) Take no action.
Plan
6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Depending on the time of day and availability of the PCP, the parents should be instructed to take Miquel either to the PCP or to the emergency department. This decision should be made prior to allowing the family to leave, if possible. Discussion with the PCP would also be prudent.
7. Describe the recommended therapeutic approach to the parents. Miquel appears to be suffering from dehydration and needs to see a doctor right away. You should take Miquel to see his primary care provider [or go to the emergency department, depending on what was decided] right away. [Be sure Miquel's family understands the directions and the directions to the facility; use an interpreter, if necessary.]
8. Explain to the parents the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Miquel does not appear to be tolerating his formula well. He is hungry all the time, because he is not absorbing the nutrients in the formula. Currently, he needs immediate medical attention to correct his dehydration. After that problem is corrected, the doctors will evaluate him to determine the cause of his malabsorption and failure to thrive.
Patient Education
9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the parents. Criterion does not apply in this case.
10. Solicit follow-up questions from parents. Why can’t we just change formulas and see if he does better?
11. Answer parents’ questions. Dehydration can quickly lead to serious problems in small infants including seizures and other complications. He should be evaluated by a medical professional prior to making any interventions related to his feedings.
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First Example of Assessment of Infant Nutrition

| Filed under Nutrition

Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patient’s symptoms, including:
a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) Infant has been spitting up formula after every feeding, almost always with a little force. Although some emesis has occurred since birth, the amount and frequency has increased over the last week. The infant also appears to have more gas, often crying from “gas pains.” The infant girl appears well hydrated.
b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient’s symptom(s) Emesis occurs only after feedings. The infant appears to be more comfortable after each episode of emesis. Irritability associated with gas pains appears to be relieved by simethicone.
c. description of the parent’s efforts to relieve the symptoms Simethicone has been given for gas. Nothing specific has been done for the emesis.
2. Gather essential patient history information:
a. patient’s identity Lauren Smith
b. patient’s age, sex, height, and weight 6-week-old girl; 22 inches; 8 lb 5 oz (3.8 kg)
c. parents’ occupation Father is a mechanic; mother is a receptionist at an insurance agency.
d. patient’s dietary habits Lauren was receiving breast milk plus Enfamil LI PI L 20 kcal/oz, if desired, until 1 week ago when her mother stopped breast-feeding. The infant was changed to Enfamil LIPIL. Per the mother’s report, the formula is being mixed to a 24 kcal/oz concentration on the advice of her PCP. The infant takes approximately 120 mL (4 oz) every 3 hours. No extra water or juice is given during the day.
e. patient’s sleep habits Lauren has not started sleeping through the night.
f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements Lauren is a healthy, term infant.
g. allergies NKA
h. history of other adverse reactions to medications None
Assessment and Triage
3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). Primary problem: emesis with feedings

Secondary problem: increased intestinal gas
4. Identify exclusions for self-treatment. Bloody or bilious emesis
Signs of dehydration: sunken fontanelle, dry mucous membranes, decreased wet

diapers, dark urine, decreased oral intake
5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the parents. Options include:

(1) Call Lauren’s PCP to verify the caloric density and volume of feedings desired. Give Lauren’s parents instructions on the proper feeding of the infant.

(2) Refer Lauren’s parents to the PCP.

(3) Take no action.
Plan
6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Lauren’s current feeding schedule, 120 mL every 3 hours of 24 kcal/oz formula, provides 252 mL/kg/day and 202 kcal/kg/day. Both significantly exceed the usual recommended intakes for a healthy, term infant (see Tables 26-2 and 26-14). The most appropriate plan would be to decrease the overall intake. The PCP should be contacted to verify the caloric density of the formula. The family should then be instructed to feed Lauren approximately 2.5 ounces every 3 hours or 3-3.5 ounces every 4 hours. This decreased intake of formula should decrease the episodes of emesis, and decrease fussiness and irritability caused by overfeeding.
7. Describe the recommended therapeutic approach to the parents. The primary care practitioner should be contacted to verify the desired concentration of Enfamil LIPIL The volume of the feedings should be reduced to the volumes listed in step 6. If the symptoms persist after these interventions, Lauren should be taken to the PCP.
8. Explain to the parents the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Because the symptoms started (or acutely worsened) with the change from breast milk to infant formula, and both the caloric density and the volume of the infant formula exceed the usual needs of a healthy term infant, overfeeding is the most likely cause of Lauren’s emesis and irritability. If overfeeding is the major issue, decreasing the caloric density and volume of feedings will have almost immediate results.
Patient Education
9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the parents:
a. appropriate dose and frequency of administration New feeding regimen: Enfamil LIPIL 2.5 ounces every 3 hours or 3-3.5 ounces every 4 hours. Watch for cures to the baby’s hunger and satiety patterns to avoid under- or overfeeding.
b. maximum number of days the therapy should be employed If no improvement is seen in 2-3 days, then the primary care provider should be contacted for a possible change in the formula (see Table 26-6).
c. product administration procedures The formula should be mixed per product instruction (e.g., 1 scoop in 2 ounces of water to make 20 kcal/oz formula) per the information given in the box Patient Education for Infant Nutrition.
d. expected time to onset of relief Several days
e. degree of relief that can be reasonably expected Emesis likely will not be eliminated. All infants have some gastroesophageal reflux and spit or vomit from time to time. Forceful emesis and emesis with every feeding as well as irritability from gas pains should improve.
f. most common side effects None
g. side effects that warrant medical intervention should they occur Persistent vomiting, especially if severe, bilious, or bloody; weight loss; dehydration
h. patient options in the event that condition worsens or persists Contact primary care provider to evaluate for other causes such as cow-milk intolerance, gastroesophageal reflux, or other conditions.
i. product storage requirements Infant formula should be used soon after mixing or kept tightly covered in the refrigerator and used within 24 hours of preparation. See product information for any specific storage requirements.
10. Solicit follow-up questions from parents. What if Lauren doesn’t appear to be satisfied with the smaller volume of feedings?
11. Answer parents’ questions. From the history, it sounds like Lauren’s stomach is too full after each feeding, resulting in a forceful emesis to remove the extra volume. If she receives only the amount needed, she should feel satisfied, without an episode of emesis. If she takes the smaller amount and still appears to be hungry, then an additional 0.5 ounces can be given.
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Assessment of Enteral Nutrition and Meal Replacements

| Filed under Nutrition

Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patient’s symptoms, including:
a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) Patient describes difficulty swallowing solid foods for several weeks and requests a “low-cost Ensure product” that she can drink. She describes solid foods as “getting stuck” in her throat.
b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient’s symptom(s) She can drink liquids, but all solid food seems to be a problem, even soft foods.
c. description of the patient’s efforts to relieve the symptoms She takes only liquids, avoids solid foods, crushes all pills and mixes them with water.
2. Gather essential patient history information:
a. patient’s identity Abigail Quinn
b. patient’s age, sex, height, and weight 74-year-old female; 5 ft 5 in; 120 lb
c. patient’s occupation Retired bookkeeper
d. patient’s dietary habits She has been taking only liquids for the past several weeks.
e. patient’s sleep habits Averages 5-6 hours per night but naps during the day
f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements Hypertension, treated with hydrochlorothiazide/triamterene; osteoporosis, treated with calcium, vitamin D, and alendronate; multivitamin
g. allergies NKA
h. history of other adverse reactions to medications None
i. other (describe) Weight loss over the past 2-3 months; usual weight 135 lb; history of stroke several years ago
Assessment and Triage
3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary

problemfe).

 Dysphagia is of unknown cause but could be related to stroke or esophageal damage related to alendronate. Weight loss of 11% over 2-3 months is significant, and may place the patient at risk of electrolyte and fluid abnormalities associated with refeeding syndrome.
4. Identify exclusions for self-treatment. Significant weight loss
5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the patient. Options include:
(1)  Refer Mrs. Quinn to her PCP for evaluation of her dysphagia and assessment

of nutritional status.
(2)  Recommend a liquid meal replacement product that can be used without

medical supervision.
(3) Take no action.
Plan
6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Refer the patient to her PCP for evaluation.
7. Describe the recommended therapeutic approach to the patient. N/A
8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. You need to see your PCP, because the swallowing problem may be related to the alendronate you take to improve your bone strength or to something more serious. Your weight loss also indicates that blood tests might be needed to monitor your electrolytes when you start taking the liquid nutrition product.
Patient Education
9. When recommending self-care with nonprescription medications and/or nondrug therapy, convey accurate information to the patient. Criterion does not apply in this case.
10. Solicit follow-up questions from patient. Why is the weight loss so concerning? I thought it was good for me to weigh less.
11. Answer patient’s questions. Many people are overweight and they are encouraged to lose weight. However, your usual weight was considered a healthy weight; you had a body mass index of 22.4, which is considered normal. Any time weight loss is not planned, there are concerns about the cause. Rapid weight loss can cause changes in blood tests (your electrolytes) that could affect your heart and breathing.
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Use Of Functional Foods For A Patient With A Family History Of CHD

| Filed under Nutrition

Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patient’s symptoms, including:
a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) Patient has no symptoms; older brother was recently diagnosed with coronary heart disease and her mother died from this disease. The patient wants to do what she can to avoid heart disease and is particularly interested in “functional foods” because of an article she saw in a magazine.
2. Gather essential patient history information:
a. patient’s identity Mary Romero
b. patient’s age, sex, height, and weight 33-year-old female, 5 ft 4 in, 135 lb
c. patient’s occupation Clerk at a department store
d. patient’s dietary habits Eats breakfast most mornings: usually a cup of coffee and cold cereal with reduced-fat (2%) milk

Lunch: something from the mall’s food court; often a sandwich with potato chips and soft drink

Afternoon snack: typically a candy bar or granola bar

Dinner: meat (beef, pork, or chicken mostly; fish every once in a while when someone has gone fishing); potatoes or pasta most nights; fresh, frozen, or canned vegetable 4-5 times per week; sweet dessert (cake, pie, baked goods) or ice cream 5-6 times a week; typically has a soft drink with dinner, occasionally an alcoholic drink
e. patient’s sleep habits Usually sleeps 7-8 hours per night
f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements None; birth control pill and multivitamin
g. allergies NKA
h. history of other adverse reactions to medications None
i. other (describe)
Assessment and Triage
3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). Mrs. Romero has no signs/symptoms of disease but wants to follow a preventive strategy with diet.
4. Identify exclusions for self-treatment. None
5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the patient. Options include:
(1) Refer Mrs. Romero to her PCP for assessment of heart disease and evaluation of her risk.
(2)  Refer Mrs. Romero to a registered dietitian for comprehensive nutritional assessment and counseling.
(3) Inform Mrs. Romero of foods that have health claims associated with reduced risk of heart disease.
(4) Take no action.
Plan
6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Mrs. Romero may require a combination of the options.

(1)  Provide basic information and counseling related to functional foods with health claims associated with heart disease. Emphasize authorized and authoritative health claims (Table Authorized and Authoritative Health Claims), because these have strong scientific evidence supporting the claim. The limited evidence for qualified claims and structure-function claims can be presented along with a discussion of where they fit, if at all, in the patient’s overall plan.
(2)  Refer Mrs. Romero for cholesterol screening (or perform screening in the pharmacy) and assessment for heart disease.
(3)  Refer Mrs. Romero to a dietitian if she wants/needs more than basic counseling on nutrition or have her request a referral from her PCP (may be necessary for insurance coverage).
7. Describe the recommended therapeutic approach to the patient. A number of foods with health claims are associated with decreased risk of heart disease. For several foods, there is significant scientific agreement regarding the potential benefits. Using these foods in place of some of your current foods may reduce your risk of heart disease. However, it would also be helpful to know what your risks are, including your cholesterol level.
8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Given your family history, you should have your cholesterol checked periodically and be evaluated for other risk factors for heart disease.

I can provide you basic information on foods that have health claims related to heart disease and may be of benefit in maintaining heart health. Dietitians are the food and nutrition experts; they can do a comprehensive assessment of your diet and provide more in-depth dietary counseling if you want that.
Patient Education
9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the patient:
a. appropriate dose and frequency of administration (1)  Decreased dietary saturated fat and cholesterol: Recommend not more than 10% of calories from saturated fat and not more than 300 mg cholesterol a day, but less is better. Most people find 1% milk to be more acceptable than nonfat (skim) milk, so you might want to try it in place of 2% milk, or you could try soy milk.
(2)  Fruits, vegetables, and grain products that contain fiber, particularly soluble fiber: Recommend replacement of white breads and pasta with whole grain. Total dietary fiber should be at least 25 g/day (Al for women 19-50 years of age).
(3)  Soluble fiber from oat bran, rolled oats, or whole oat flour in certain foods, or barley: Incorporate these products into the diet as replacement for breads and cereals that are not whole grain.
(4)  Soy protein: 25 g/day is required in conjunction with a diet low in saturated fat and cholesterol. For many people, the major dietary modifications needed to eat this much soy are very difficult to make, especially if all family members are not committed to the changes.
(5)  Plant sterol and stanol esters: Total intake is at least 1.3 g/day of sterol esters or 3.4 g/day of stanol esters, as part of a diet low in saturated fat and cholesterol. You usually need to eat the products at least twice a day to get the recommended amount. Some margarines and orange juice have added plant/stanol esters.
(6)  Whole-grain foods: This health claim overlaps somewhat with that for “grain products that contain fiber” (#2) but does not specify “particularly soluble fiber.” Insoluble fibers are also important in health. Look for whole grain, such as whole wheat, as the first ingredient on labels.
To make these health claims, foods must generally contain a certain amount of the component. Check food labels for these claims and for ingredient amounts.

There are also health claims with less vigorous supporting data for which evidence suggests a benefit but research is not conclusive (does not prove a benefit; therefore, these claims may not be as effective or the claim might be changed if new studies are reported. Because the following foods are otherwise healthy foods when used in moderation, they can still be safely incorporated into your diet.
(1)  Walnuts and several other types of nuts: 1.5 ounces a day; remember that nuts are a concentrated source of calories, so use judiciously.
(2) Omega-3 fatty acids: specifically eicosapentaenoic acid (EPA) and docosa-hexaenoic acid (DHA), found in salmon, lake trout, herring, and other oily fish.
(3)  Monounsaturated fats from olive oil; 23 g/day (2 tablespoons) in place of a similar amount of saturated fat. A number of salad dressings and a few soft margarines now include olive oil.
(4) Canola oil, unsaturated fatty acids; 19 g/day (1.5 tablespoons) in place of a similar amount of saturated fat. Some cooking oil, a number of salad dressings, a few soft margarines, and some baked goods include canola oil.
b. maximum number of days the therapy should be employed No limit; preferably, these foods will be incorporated as part of an ongoing healthful diet for life.
c. product administration procedures These foods can replace other foods in your diet so that the total calories do not increase. The more “healthful” fats must replace saturated fats and not increase the total fat intake. You will need to read food labels carefully to be sure you are getting whole grains, low-saturated fats, low cholesterol, and sterol/stanol esters in the product. Also look for the amount of soy or soluble fiber.
d. expected time to onset of relief These steps are preventive at this time; for elevated cholesterol, dietary changes typically are effective within a few weeks.
e. degree of relief that can be reasonably       expected Mild-to-moderate decrease in total and low-density lipoprotein cholesterol.You should be able to decrease “borderline” high cholesterol to within an acceptable range, but these foods alone would probably not be enough if you had significantly elevated cholesterol, especially considering the history of heart disease in the family.
f. most common side effects Rapid increases in fiber content of the diet can cause gas and bloating, so it is best to gradually increase the fiber in your diet. Replace 1-2 servings of white bread and pasta with whole-grain products every few days until the refined foods are totally replaced. Also add extra fiber by gradually replacing the low-fiber cereals with a whole-grain cereal or oatmeal. Fruits and vegetables can be increased gradually as well to replace snacks and desserts. Be sure to take plenty of water when eating a high-fiber diet.
g. side effects that warrant medical intervention should they occur Moderate-to-severe abdominal pain, nausea, vomiting; these side effects may be signs of bowel obstruction or diverticulitis.
h. patient options in the event that condition Dietary changes for Mrs. Romero are preventive, unless her cholesterol is worsens or persists                      elevated at the time it is checked. Cholesterol levels should be monitored periodically; if cholesterol increases to an unacceptable level despite these dietary changes, it may be necessary for Mrs. Romero to consider drug (statin) therapy.
i. product storage requirements              See food label.
j. specific nondrug measures                N/A
10. Solicit follow-up questions from patient. Where can I find more information on dietary changes and diet plans to prevent heart disease? May I use dietary supplements instead of changing to functional foods? Most information on the Internet is advertising for dietary supplements.
11. Answer patient’s questions. The Food and Drug Administration Web site (www.fda.gov) includes information on health claims and food labels that you might find helpful. You could consider making an appointment with a registered dietitian who could help develop some menus that incorporate foods you like and provide more specific plans for substituting healthier foods. Your health plan may contract with a dietitian. If not, the American Dietetic Association can provide the name(s) of private consultants and the contact information for a dietitian. The phone number for referrals is on their Web site (www.eatright.org). In general, foods are better than supplements. Many studies have shown beneficial effects from a diet containing fiber-rich foods and whole grains but not with isolated supplements. Psyllium, found in products like Metamucil, fits criteria for a health claim related to soluble fiber and risk of congestive heart disease, and could be used to increase soluble fiber. It also has the added benefit of reducing constipation, as do fibers from whole grains.
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Review of Patients With Nutritional Inadequacy

| Filed under Nutrition

Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patient’s symptoms, including:
a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) Patient does not have any complaints. However, on inquiry of supplementation taken at home, patient says she regularly takes a multivitamin with extra nutrients to reduce stress, an antioxidant supplement plus beta-carotene once daily for vision, and calcium tablets twice daily for osteoporosis prevention.
b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient’s symptom(s) N/A
c. description of the patient’s efforts to relieve the symptoms N/A
2. Gather essential patient history information:
a. patient’s identity Katherine Forest
b. patient’s age, sex, height, and weight 37-year-old female, 5 ft 8 in, 130 lb
c. patient’s occupation Postal worker and mother of 4 children
d. patient’s dietary habits Cereal or toast and fruit for breakfast; soup or frozen meal for lunch; dinner varies between fast-food meals and easy-to-prepare meals at home.
e. patient’s sleep habits N/A
f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements Ibuprofen 400 mg twice daily, levothyroxine 88 meg daily
g. allergies No known allergies
h. history of other adverse reactions to medications Family history of glaucoma and osteoporosis
Assessment and Triage
3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). Taking multiple supplements can increase the risk of exceeding the UL for various nutrients. No evidence exists that this practice is beneficial, and concern exists that long-term supplementation of certain nutrients in doses exceeding the UL may potentially have negative effects.
4. Identify exclusions for self-treatment. None
5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the patient. Options include:

(1)  Focus on only potential drug-nutrient interactions.

(2)  Discuss the role of balanced nutrition as the ideal route of taking vitamins and minerals. Identify nutritional needs unique to this geriatric client and where supplementation may be recommended.

(3) Take no action.
Plan
6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Assess the client’s perceived need for the nutrient supplements.

Evaluate dietary intake from food groups, encouraging at least 5 servings of produce daily, 3 servings of low-fat dairy products, 2 servings of protein, and 6 servings of whole grain food sources daily.

Discuss the vitamin and mineral content of the various supplements and the total intake in comparison with the dietary reference intakes. Conversion of units of measure for vitamin A may be necessary to assess total intake. For example, if the multivitamin provides 3500 IU of vitamin A and the antioxidant supplement plus beta-carotene provides 25,000 IU of beta-carotene, the patient’s intake of vitamin A is likely excessive. The dietary reference intake for this client is 700 meg as RAE (2330 IU) with a UL of 3 mg (9990 IU) daily.

To convert the client’s supplemented intake to micrograms of RAE per day, you note that 1 meg as RAE = 10 IU vitamin A activity as beta-carotene = 3.33 IU vitamin A activity as retinol. This calculates to 3551 meg as RAE daily in supplements alone.

Suggest limiting vitamin supplementation to a U.S. Pharmacopeia-approved multivitamin with no more than 100% of dietary reference intake for vitamins and minerals.
7. Describe the recommended therapeutic approach to the patient. Unless specifically recommended by your primary care provider or ophthalmologist, reconsider taking the supplement for vision if you are taking a U.S. Pharmacopeia-approved multivitamin with minerals. Take the multivitamin and the calcium supplement at different times. Separate both of these supplements from the levothyroxine.
8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Your current supplemental intake for vitamin A well exceeds the dietary reference intake. Instead of taking multiple supplements, optimize your nutrient intake by eating whole grains, fruits, and vegetables. In addition to fiber and many commonly recognized vitamins and minerals, fruits and vegetables provide lutein, a carotenoid associated with reduced risk of age-related macular degeneration when consumed regularly. Also choose low-fat dairy products and protein sources daily. Complementing a balanced diet with a daily multivitamin with minerals is reasonable to ensure adequate nutrient intake when the regular intake of healthy meals becomes difficult. If vitamin D intake is not sufficient between dietary sources and the multivitamin, a calcium product with vitamin D may be recommended.
Patient Education
9. When recommending self-care with nonpre-scription medications and/or nondrug therapy, convey accurate information to the patient. Criterion does not apply in this case.
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Assessment Of Patients With Nutritional Inadequacy

| Filed under Nutrition

Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patient’s symptoms, including:
a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) Patient inquires about information found on the Internet recommending supplementation with various vitamins to prevent cancer and aging. He states he currently takes Centrum Silver plus extra vitamin C to prevent colds and gingko biloba for his memory.
b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient’s symptom(s) N/A
c. description of the patient’s efforts to relieve the symptoms N/A
2. Gather essential patient history information:
a. patient’s identity Bruce Trappers
b. patient’s age, sex, height, and weight 79-year-old male, 6 ft 1 in, 190 lb
c. patient’s occupation Retired professor of agriculture
d. patient’s dietary habits Eats only two meals daily to help maintain weight: typically cereal and fruit or 3-4 eggs, starch, and fruit for breakfast: balanced meals for dinner with salad, protein, starch, vegetable, and a glass of wine
e. patient’s sleep habits N/A
f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements Patient has a history of hyperlipidemia with family history of myocardial infarction in his brother. Every morning he takes 325 mg aspirin, atorvastatin 10 mg, 2 omega-3 fish oil capsules, 1 Centrum Silver multivitamin, 500 mg vitamin C, and 120 mg of gingko biloba.
g. allergies Sulfa
h. history of other adverse reactions to medications N/A
Assessment and Triage
3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). Taking multiple supplements can increase the risk of exceeding the UL for various nutrients. There is no evidence to suggest that this practice is beneficial, and evidence is mounting that supplementation of certain nutrients can potentially be harmful.
4. Identify exclusions for self-treatment. None
5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the patient. Options include:

(1) Assess the client’s perceived need for the nutrient supplements.
(2) Evaluate dietary intake from food groups, encouraging at least 5 servings of produce daily, 3 servings of low-fat dairy products, 2 servings of protein, and 6 servings of whole-grain food sources daily.
(3) Discuss which nutrients may need supplementation, on the basis of the patient’s patterns of dietary intake. Evaluate Centrum Silver for adequacy, while avoiding intakes above the UL.
(4) Discuss the lack of data and potential harm associated with megadoses of vitamin.
(5) Take no action.
Plan
6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Encourage a well-balanced diet, emphasizing that studies repeatedly demonstrate that good nutrition is associated with multiple health benefits, including a lower risk of some cancers and other age-related diseases. Evaluate the Centrum Silver multi-vitamin with the client, comparing the level of supplementation of each nutrient compared with the dietary reference intake. Point out that the product contains gingko biloba and vitamin C; therefore, additional supplementation of these substances is not necessary.
7. Describe the recommended therapeutic approach to the patient. See step 6.
8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. See step 6.
Patient Education
9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the patient:
a. appropriate dose and frequency of administration Consider one U.S. Pharmacopeia-approved multivitamin daily that contains no more than 100% of dietary reference intake for nutrients.
b. maximum number of days the therapy should be employed N/A
c. product administration procedures You may take your multivitamin with your current medications in the morning. However, check with your pharmacist on coadministration of any newly prescribed medications.
10. Solicit follow-up questions from patient. What about antioxidant vitamins?
11. Answer patient’s questions. Data from well-designed trials do not support antioxidant supplementation for the prevention or treatment of cancer. In fact, some trials have suggested potential harm is associated with supplementation of vitamins A, E, and C, selenium, and other nutrients in relation to cancer risk. Therefore, dosing of these nutrients above the dietary reference intake cannot be recommended at this time.
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Nutrition Tips to Manage Sodium, Salt and High Blood Pressure

| Filed under Nutrition

The doctor tells you to “cut back on salt” due to high blood pressure. What do you do? Stop using the saltshaker? Scan the food labels for sodium content? Read on to find out the best way to follow your doctor’s advice.

Salt vs. sodium

Table salt is the common name for sodium chloride, a mixture that is 40% sodium and 60% chloride. The American Heart Association recommends limiting sodium intake to no more than 2400 mg per day, about the amount of sodium present in 1 ¼ teaspoons of table salt.

Sodium’s connection to high blood pressure

High blood pressure affects one in four adults and is a major risk factor for stroke, heart disease, and kidney failure. About 30% of the American population is believed to be sodium-sensitive; meaning too much sodium in their diet contributes to high blood pressure by upsetting the body’s fluid balance. Since there’s no way of knowing if you’re one of the sodium-sensitive people, standard medical advice often begins with lowering dietary intake of sodium. Other minerals may be just as important in regulating blood pressure. Adequate intake of potassium from fruits and vegetables, calcium from dairy products and some vegetables, and magnesium from whole grains is crucial in determining blood pressure levels.

So where’s the sodium?

Seventy five percent of the sodium in the American diet comes from processed foods, not from the salt shaker sitting on your dining room table. A preference for salty foods is acquired through frequent exposure and not an inborn taste preference. Just taste any brand of commercial baby food and you’ll immediately notice the lack of salt. Infants haven’t yet developed a liking for salt, and too much can damage their still fragile kidneys so it is intentionally left out of commercial baby food products.

Sodium helps preserve food by slowing the work of harmful bacteria, yeast and molds to prevent food spoilage and illness. Think back to the days of salt-cured meats and pickled vegetables. Salt was used in preserving these foods for later use, with flavor being only a secondary issue.

Other uses of sodium in food processing include:

- Slowing the fermentation process in cheese, bread dough and sauerkraut

- Holding processed meats such as sausage together

- Improving the texture of breads and crackers

- Enhancing flavors

Label reading for sodium content

The Food and Drug Administration (FDA) closely regulates statements about sodium content on food labels. The following terms found on food labels meet these guidelines:

· Sodium-free – less than 5 milligrams of sodium per serving

· Very low-sodium – 35 milligrams or less per serving

· Low-sodium – 140 milligrams or less per serving

· Unsalted, no salt added or without added salt – made without the salt that is normally used, but still contains the sodium that is a natural part of the food itself.

Sodium content of foods

Processed foods, including canned foods, cured meats, frozen dinners and commercially baked goods such as cookies and pastries contain the most sodium. Take a trip through the grocery store with us to identify foods low and high in sodium:

- Produce section:

· Fruit and vegetables are naturally low in sodium. Some people believe celery is high in sodium, yet one stalk contains only 35 mg of sodium. Fruits and vegetables are also high in potassium, which helps lower blood pressure levels.

- Baked goods:

· Breads, bagels and English muffins typically contain 140-345 mg of sodium per serving (1 slice bread, 1 bagel or English muffin).

· Cookies and crackers may appear low in sodium, but that’s because the serving sizes are small – typically two cookies or crackers. Sodium content per serving ranges from 25-270 mg.

· Muffins contain 150-350 mg sodium per serving. Remember that larger muffins contain more sodium.

· Pancakes and waffles contain 150-300 mg sodium each.

· A slice of pie or cake or a piece of pastry will give you 150-300 mg of sodium.

- Chips and Snack Foods

· One cup of pork skins has 850 mg sodium; one cup of cheese-flavored snacks 700 mg, one cup chips 165 mg, and one cup popcorn has 90 mg sodium. One cup is approximately the amount you can hold in both hands cupped together.

· Pretzels are typically high in salt: one soft pretzel has 770 mg sodium, while 10 small pretzel sticks contains 85 mg.

- Dairy Products

· One ounce of cheese typically contains 160-200 mg sodium. Feta, gorgonzola, and processed cheese contain even more sodium, up to 500 mg per ounce.

· One cup milk contains 120 mg sodium, but remember the calcium in milk helps lower blood pressure.

· One-half cup of most ice cream, frozen yogurt or yogurt contains 50-75 mg of sodium.

- Breakfast cereals

· Read breakfast cereal labels carefully for sodium content. Some types such as puffed rice contain almost no sodium while others pack a whopping 475 mg per cup.

- Cured meats

· Smoked meats such as lox contain 220 mg sodium per ounce. Canned tuna ranges from 75 mg sodium per can when unsalted to 500 mg per can when salted. Two pieces of cured bacon contain 500 to 800 mg sodium (about one-third of your daily total), while cured ham contains 345 mg sodium per ounce.

· Sausage and lunchmeat are high in sodium unless you search for unsalted varieties. One slice of lunchmeat contains 250 mg sodium, while one typical sausage can contain 700 mg of sodium.

- Frozen dinners

· The size of frozen dinners varies considerably, yet the sodium content remains consistently high. 550-1300 mg sodium per serving are not uncommon.

- Canned foods

· Canned soups contain 800-1100 mg sodium per cup. Remember that most cans of soups are meant to serve two people; if you eat the entire can yourself you’ll double the sodium content.

· Canned vegetables are processed with salt unless you seek out unsalted varieties. One-half cup of most canned vegetables contains 150-300 mg sodium.

Our recommendations

General recommendations for healthy people without high blood pressure are 2400 mg sodium per day. That’s the amount used on food labels to calculate the percent Daily Value. The American Heart Association recommends no more than 3000 mg sodium per day for healthy individuals. If you have high blood pressure, limiting sodium to the 2400-3000 mg range is a good start, since the typical American diet contains 4000-6000 mg of sodium per day! Physicians may recommend lower amounts of sodium, but it is difficult to follow a plan that contains less than 2000 mg of sodium without purchasing special low-sodium foods. To keep within the 2400-3000 mg sodium range, following the suggestions here:

- choose fresh fruits and vegetables as often as possible
- look for sodium-free frozen and canned vegetables
- use salt-free seasonings such as herbs, spices and vinegar in cooking and at the table
- avoid adding salt when cooking pasta, rice, or vegetables
- choose fewer salty snacks such as salted nuts, popcorn, chips, pretzels and crackers
- read food labels for sodium content.

Do Antidepressants Impair Sexual Function?

| Filed under Health

It has become almost common knowledge that the group of antidepressants called SSRIs (selective serotonin reuptake inhibitors) can cause sexual problems, including lack of interest and difficulty in becoming aroused or reaching orgasm. But research findings presented at the annual meeting of the American Psychiatric Association in Chicago last week suggest that for most depressed patients, sexual interest and function get better, not worse, when depressive symptoms are treated effectively.

"You have a considerably larger number who are reporting improvement during treatment. That’s not generally appreciated," stated Dr. David Michelson, a neuroscientist from Eli Lilly and Company, the manufacturers of Prozac. "The degree to which treating the depressive symptoms seems to actually improve sexual functioning is pretty impressive". Dr. Michelson was part of a team of researchers that studied sexual function in more than 500 adult men and women being treated with fluoxetine (Prozac).

The researchers asked study participants to complete questionnaires rating four aspects of sexual function: interest, arousal, orgasm and overall sexual function. The questionnaires were filled out before beginning to take the drug, after the initial 13-week treatment period and then monthly, during a 25-week continuation study.

Almost half of the women reported a high baseline rate of sexual dysfunction. By the end of the first 13-week treatment, fewer women reported moderate to severe dysfunction, and 70 percent reported minimal or no sexual dysfunction. Overall, men reported lower levels of sexual dysfunction at baseline than women did, and their ratings changed less during the treatment period.

Dr. Michelson reported that about 13 percent of women and 18 percent of men found that their sexual function got worse during treatment, and that these percentages were somewhat higher when patients were asked specifically about orgasm.

A second study, presented by Dr. Christina Dording of Massachusetts General Hospital in Boston, reported similar proportions of patients who develop sexual dysfunction during treatment for major depression. In this study, 127 adult men and women who had responded well to eight weeks of treatment with 20 mg/day of fluoxetine had their doses increased to 40 mg/day.

Overall, 19 percent of the patients who completed the second, 28-week phase of the study reported sexual dysfunction, including inability to reach orgasm, loss of interest, erectile dysfunction and delayed ejaculation. About half of these reported sexual dysfunction during the first eight-week part of the study, and half reported difficulties during the second phase. In six of these 24 patients, sexual difficulties cleared up without treatment, Dr. Dording reported.

"We found that the overall incidence of sexual dysfunction was comparable to that of other studies," said Dr. Dording. She pointed out that the study design did not allow the researchers to tell whether sexual dysfunction was the result of the change in medication dose, or of the passage of time.

"We also found that a significant proportion of patients experienced spontaneous remission of the symptoms of sexual dysfunction. Also, we were surprised that none of the patients who dropped out did so because of sexual dysfunction," Dr. Dording added.

These two sets of findings suggest that about one in five patients who take fluoxetine for depression may experience symptoms of sexual dysfunction. On the other hand, the majority of patients don’t, and in fact many find that with effective treatment of their depressive symptoms, their sexual function improves too.

Editorial Commentary: Sexual dysfunction, primarily decreased sex drive and difficulty with orgasm, has been an important issue since the launch of SSRIs. Some studies have reported such side -effects in over 50 percent of users. Generally, the side effects improve with time, but do not disappear. The studies cited in the accompanying article report moderate rates of sexual side effects, and confirms a generally recognized finding of moderate baseline sexual dysfunction prior to treatment for depression. For patients with SSRI-induced sexual dysfunction, lowering the dose, waiting, and adding an additional medication, such as buproprion, a stimulant, or Viagra, have all been reported to be helpful.

Unexplained Physical Complaints

| Filed under Health

If you’ve ever had a stomachache before an exam or important meeting, or developed a headache during an argument, you have some idea of what somatization is. Although it’s common to experience these types of medically unexplained symptoms, such as pain and digestive upset under stress, somatization is often a part of serious disorders such as depression, anxiety, and schizophrenia.

“Somatization is a normal, daily experience. It’s highly situational, [with] marked individual differences and marked cultural differences, and associated clearly with psychosocial stress,” stated Normal Jensen, M.D., a professor at the University of Wisconsin in Madison. Jensen addressed an audience of physicians at the annual meeting of the American College of Physicians/American Society of Internal Medicine in Philadelphia last week.

Although “full blown” somatization disorder is fairly rare — less than two percent of Americans are diagnosed with it — Jensen explained that features of the disorder are common. “In primary care, anywhere up to three quarters of our patients have medically unexplained symptoms,” he reported. “The impact on health care services is HUGE.”

Physicians who see patients with complaints that can’t be explained are often distressed and frustrated, noted Jensen. And that frustration is shared by patients, who often consult a long series of physicians and specialists who fail to identify what’s wrong. Some doctors, Jensen said, may turn their frustration on the patient, telling them “it’s all in their head.”

But somatization, he emphasized, is real. Our understanding of pain and other somatic complaints has evolved in recent decades to reveal that sensations are affected by thoughts, emotions, and prior experience. In addition, new discoveries about the role of opioid receptors in the nervous system have provided increasing evidence for a physical basis for somatic complaints.

“Patients appreciate knowing that there are possible molecular and neurophysiological reasons for why their sensations vary from [those of] others, and within themselves from day to day,” Jensen explained.

Patients with these kinds of symptoms shouldn’t be told that there’s no physical reason for their complaints, said Jensen. “I tell them that in fact there is a good physiological reason for their symptoms. I tell them that ‘you’ve either acquired, or were born with, an abnormal nervous system.’ I tell them that ‘your nervous system is allowing you to feel sensations that normal people, or you when you are normal, don’t feel.’

“The nervous system quite naturally filters out unnecessary, confusing, distracting information,” Jensen continued. “Think how it would be if I was constantly aware of my clothes, and my watch, and my jewelry. If I had to process all that information all the time, what else would I be able to do? I wouldn’t even be able to read a book!”

One of the difficulties in treating patients with somatic symptoms is that many patients have an additional illness. “It’s not just somatization. It’s somatization with an anxiety disorder, or with a bad mood disorder, or a thought disorder, or a personality disorder,” said Jensen. He noted that he refers patients to psychiatrists when he wants “to be sure that there isn’t a comorbid condition… or when I want help with treating one of these disorders.”

Another concern, according to Jensen, is that one patient may consult a number of doctors, and specialists may diagnose serious medical conditions based on a patient’s complaints. “These people can get in trouble, because if you look closely enough at any of us, you’re going to find something wrong that could be treated,” he explained.

“What that means is that [generalists] and [their] sub-specialty colleagues have to learn to work together with our patients,” stated Jensen.

Right now, there are no medications that modify sensory perception by targeting opioid receptors, and none specifically for somatization symptoms, noted Jensen. In his own practice, he reported, he looks for symptoms of depression and/or anxiety, and tries antidepressant or anti-anxiety medications if the patient has such symptoms, even if they don’t meet the diagnostic criteria for one of these disorders.

Cognitive behavior therapy has proven helpful for patients with somatic symptoms, too. This therapy, which can be delivered by a trained general practitioner or by a mental health professional, focuses on the relationship between variability of a patient’s symptoms and changes in mood and life events.

As for the future, Jensen reports that there has been some recent evidence that gabapentin (neurontin), an anti-epileptic medication used to prevent seizures, may affect the body’s opioid receptors and thus alter sensory perceptions.

It’s important to remember that somatic symptoms can also mask emotional distress, said Jensen. Patients who have been taught or conditioned not to express emotions, particularly negative ones, may not even realize they’re depressed, anxious, fearful, or grief-stricken. “I do believe that there is a sort of transformation of psychological distress into physical symptoms,” he stated.

How Is Cholesterol Measured?

| Filed under Health

Blood cholesterol levels are measured in mmol/L.

Shown below are the recommended levels for cholesterol and lipoproteins for people:

  • With no risk factors
  • With risk factors
  • With heart disease
No Risk
Factors
(mmol/L)		 With Risk
Factors
(mmol/L)		 With Heart
Disease
(mmol/L)
Total Cholesterol below 5.2 5.0 4.5
Triglycerides below 2.3 2.0 1.7
LDL below 3.4 3.0 2.5
HDL above 0.9 1.1 1.2

These are recommended values only. Your cholesterol values may be different depending on your own individual history and conditions.

Any decisions related to lifestyle and therapy should be discussed with your doctor.