CMS	Centers for Medicare & Medicaid Services
DV	Daily Value
F	Fahrenheit
GI	Gastro-intestinal
ID	Identification
I&O	Intake and output
mg	Milligram
mL	Milliliter
NPO	Non per os; nothing by mouth
OBRA	Omnibus Budget Reconciliation Act of 1987
oz	Ounce
USDA	United States Department of Agriculture

Food and water are physical needs. They are necessary for life. The person’s diet affects physical and mental well-being. A poor diet and poor eating habits:

• Increase the risk for infection

• Increase the risk of acute and chronic diseases

• Cause chronic illnesses to become worse

• Cause healing problems

• Affect physical and mental function, increasing the risk for accidents and injuries

Eating and drinking provide pleasure. They often are part of social times with family and friends. A friendly, social setting for meals is important. Otherwise, the person may eat poorly.

Many factors affect dietary practices. They include culture, finances, and personal choice. See Caring About Culture: Meal Time Practices. Dietary practices also include selecting, preparing, and serving food. The health team considers these factors when planning to meet the person’s nutrition needs.

CARING ABOUT CULTURE

Meal Time Practices

Many cultural groups have their main meal at mid-day. The Austrians do so. They eat light meals in the evening. Persons from Brazil also eat their main meal at noon. They have a light meal in the evening. A main meal at lunch also is common in Finland, Germany, and Greece. In Iran, the most important meal is eaten at mid-day.

Modified from D’Avanzo CE: Pocket guide to cultural health assessment, ed 4, St Louis, 2008, Mosby.

The Centers for Medicare & Medicaid Services (CMS) require that the health team assess the resident’s nutritional status. This will include:

• Drugs that affect taste or cause dry mouth, nausea, confusion, and so on

• Weight and height (Chapter 34)

• Appearance

• Food intake (p. 396) and fluid intake (p. 388)

• Factors affecting eating and nutrition (p. 381)

The health team then must develop a care plan to meet the person’s nutritional needs. CMS surveyors may ask you about the following. You will learn how to answer their questions as you study this chapter.

• How the person’s food and fluid intake is observed and reported.

• How the person’s eating ability is observed and reported.

• How the person’s weight is measured and reported.

• What measures are taken to prevent or meet changes in the person’s nutritional needs. Snacks and frequent meals are examples.

• The goals for nutrition in the person’s care plan.

Basic nutrition

Nutrition is the processes involved in the ingestion, digestion, absorption, and use of foods and fluids by the body. Good nutrition is needed for growth, healing, and body functions. A well-balanced diet and correct calorie intake are needed. A high-fat and high-calorie diet causes weight gain and obesity. Weight loss occurs with a low-calorie diet.

Foods and fluids contain nutrients. A nutrient is a substance that is ingested, digested, absorbed, and used by the body. Nutrients are grouped into fats, proteins, carbohydrates, vitamins, minerals, and water.

Fats, proteins, and carbohydrates give the body fuel for energy. The amount of energy provided by a nutrient is measured in calories. A calorie is the fuel or energy value of food:

• 1 gram of fat—9 calories

• 1 gram of protein—4 calories

• 1 gram of carbohydrate—4 calories

Older persons need fewer calories than younger people. Energy and activity levels are lower.

Dietary guidelines

The Dietary Guidelines for Americans, 2010 (Box 24-1) is for persons 2 years of age and older. It is also for persons at risk for chronic disease. Certain diseases are linked to poor diet and lack of physical activity. They include cardiovascular disease, hypertension (high blood pressure), diabetes, obesity, osteoporosis, and some cancers. The Dietary Guidelines help people:

• Attain and maintain a healthy weight

• Reduce the risk of chronic disease

• Promote over-all health

Box 24-1

Key Recommendations from Dietary Guidelines 2010

Balancing calories to manage weight

• Prevent and/or reduce overweight and obesity through improved eating and physical activity behaviors.

• Control total calorie intake to manage body weight. For people who are overweight or obese, this will mean consuming fewer calories from foods and beverages.

• Increase physical activity and reduce time spent in sedentary behaviors.

• Maintain appropriate calorie balance during each stage of life—childhood, adolescence, adulthood, pregnancy and breastfeeding, and older age.

Food and food components to reduce

• Reduce daily sodium intake to less than 2300 milligrams (mg) and further reduce intake to 1500 mg among persons who are 51 and older and those of any age who are African-American or have hypertension, diabetes, or chronic kidney disease. The 1500 mg recommendation applies to about half of the U.S. population, including children and the majority of adults.

• Consume less than 10% of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids.

• Consume less than 300 mg per day of dietary cholesterol.

• Keep trans fatty acid consumption as low as possible by limiting foods that contain synthetic sources of trans fats, such as partially hydrogenated oils, and by limiting other solid fats.

• Reduce the intake of calories from solid fats and added sugars.

• Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars, and sodium.

• If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and two drinks per day for men—and only by adults of legal drinking age.*

Food and nutrients to increase

Individuals should meet the following recommendations as part of a healthy eating pattern while staying within their calorie needs.

• Increase vegetable and fruit intake.

• Eat a variety of vegetables, especially dark-green, red, and orange vegetables and beans and peas.

• Consume at least half of all grains as whole grains (Fig. 24-1). Increase whole-grain intake by replacing refined grains with whole grains.

• Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese, or fortified soy beverages.*

• Choose a variety of protein foods, which include seafood, lean meat, and poultry, eggs, beans, and peas, soy products, and unsalted nuts and seeds.

• Increase the amount and variety of seafood consumed by choosing seafood in place of meat and poultry.

• Replace protein foods that are higher in solid fats with choices that are lower in solid fats and calories and/or are sources of oils.

• Use oils to replace solid fats where possible.

• Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are nutrients of concern in American diets. These foods include vegetables, fruits, whole grains, and milk and milk products.

Recommendations for specific population groups

Women capable of becoming pregnant*

• Choose foods that supply heme iron, which is more readily absorbed by the body, additional iron sources, and enhancers of iron absorption such as vitamin C-rich foods.

• Consume 400 micrograms (mcg) per day of synthetic folic acid (from fortified foods and/or supplements) in addition to food forms of folate from a varied diet.*

Women who are pregnant or breastfeeding*

• Consume 8 to 12 ounces of seafood per week from a variety of seafood types.

• Due to their high methyl mercury content, limit white (albacore) tuna to 6 ounces per week and do not eat the following four types of fish: tilefish, shark, swordfish, and king mackerel.

• If pregnant, take an iron supplement, as recommended by an obstetrician or other health care provider.

Individuals ages 50 years and older

• Consume foods fortified with vitamin B₁₂, such as fortified cereals, or dietary supplements.

Building Healthy Eating Patterns

• Select an eating pattern that meets nutrient needs over time at an appropriate calorie level.

• Account for all foods and beverages consumed and assess how they fit within a total healthy eating pattern.

• Follow food safety recommendations when preparing and eating foods to reduce the risk of foodborne illnesses (Fig. 24-2).

Fig. 24-2 Food temperature guide. (Redrawn from U.S. Department of Health and Human Services and U.S. Department of Agriculture: *Finding your way to a healthier you: based on the dietary guidelines for Americans,* updated April 5, 2005.)

From Dietary Guidelines for Americans, 2010, United States Department of Agriculture

The Dietary Guidelines focus on:

• Consuming fewer calories

• Making informed food choices

• Being physically active

Myplate

The MyPlate symbol (Fig. 24-3) encourages healthy eating from 5 food groups. MyPlate, issued by the United States Department of Agriculture (USDA), helps you make wise food choices by:

• Balancing calories

• Eating less

• Avoiding over-sized portions

• Increasing certain foods

• Making half of your plate fruits and vegetables

• Making at least half of your grains whole grains

• Drinking fat-free or low-fat (1%) milk

• Reducing certain foods

• Choosing low-sodium foods

• Drinking water instead of sugary drinks

The amount needed from each food group depends on age, sex, and physical activity (Table 24-1). Activity should be moderate or vigorous (Box 24-2). The USDA recommends that adults do at least one of the following:

• 2 hours and 30 minutes each week of moderate physical activity

• 1 hour and 15 minutes each week of vigorous physical activity

Table 24-1

MyPlate Serving Sizes

Group	Daily Servings	Serving Sizes
Grains	• Adult women: 5 to 6 ounces (oz); at least 3 oz from whole grains • Adult men: 6 to 8 oz; at least 3 to 4 oz from whole grains	1 oz = 1 slice of bread 1 oz = 1 cup of breakfast cereal 1 oz = ½ cup of cooked rice, cereal, or pasta
Vegetables	• Adult women: 2 to 2 ½ cups • Adult men: 2 ½ to 3 cups	1 cup = 1 cup of raw or cooked vegetables or vegetable juice 1 cup = 2 cups of raw leafy greens
Fruits	• Adult women: 1 ½ to 2 cups • Adult men: 2 cups	1 cup = 1 cup fruit 1 cup = 1 cup fruit juice 1 cup = ½ cup dried fruit
Dairy	• Adult women: 3 cups • Adult men: 3 cups	1 cup = 1 cup milk or yogurt 1 cup = 1½ oz natural cheese 1 cup = 2 oz processed cheese
Protein food	• Adult women: 5 to 5 ½ oz • Adult men: 5 ½ to 6 ½ oz	1 oz = 1 oz of lean meat, poultry, or fish 1 oz = 1 egg 1 oz = 1 tablespoon peanut butter 1 oz = ¼ cup cooked dry beans 1 oz = ½ oz of nuts or seeds

Modified from MyPlate, U.S. Department of Agriculture, June 2011.

Box 24-2

Moderate and Vigorous Physical Activities

Moderate physical activities

• Walking briskly (about 3½ miles per hour)

• Bicycling (less than 10 miles per hour)

• Gardening (raking, trimming bushes)

• Dancing

• Golf (walking and carrying clubs)

• Water aerobics

• Canoeing

• Tennis (doubles)

Vigorous physical activities

• Running and jogging (5 miles per hour)

• Walking very fast (4½ miles per hour)

• Bicycling (more than 10 miles per hour)

• Heavy yard work (chopping wood)

• Swimming (freestyle laps)

• Aerobics

• Basketball (competitive)

• Tennis (singles)

From What is Physical Activity?, U.S. Department of Agriculture, June 4, 2011.

Physical activity at least 3 days a week is best. Each activity should be for at least 10 minutes at a time. Adults should also do strengthening activities at least 2 days a week. Push-ups, sit-ups, and weight-lifting are examples.

Grains group

Food made from wheat, rice, oats, cornmeal, barley, or other cereal grain is a grain product. Bread, pasta, oatmeal, breakfast cereals, tortillas, and grits are examples. The two types of grains are:

• Whole grains contain the entire grain kernel. Whole-wheat flour, bulgur (cracked wheat), oatmeal, whole cornmeal, and brown rice are examples.

• Refined grains were processed to remove the grain kernel. These grains have a fine texture. White flour, white bread, and white rice are examples. They have less dietary fiber than whole grains.

Grains have these health benefits:

• Reduce the risk of coronary artery disease.

• May prevent constipation.

• May help with weight management.

• May prevent certain birth defects.

• Contain these nutrients—dietary fiber, several B vitamins (thiamine, riboflavin, niacin, folate), and minerals (iron, magnesium, and selenium).

Vegetable group

Vegetables can be eaten raw or cooked. They may be fresh, frozen, canned, dried, or juice. You can eat them whole, cut-up, or mashed. The 5 vegetable subgroups are:

• Dark green vegetables—bok choy, broccoli, collard greens, dark green leafy lettuce, kale, mesclun, mustard greens, romaine lettuce, spinach, turnips, watercress

• Red and orange vegetables—acorn, butternut, and hubbard squashes; carrots; pumpkin; red peppers; sweet potatoes; tomatoes; tomato juice

• Beans and peas—black beans, black-eyed peas, garbanzo beans (chickpeas), kidney beans, lentils, navy beans, pinto beans, soy beans, split peas, and white beans

• Starchy vegetables—corn, green bananas, green peas, green lima beans, plantains, potatoes, taro, water chestnuts

• Other vegetables—artichokes, asparagus, avocado, bean sprouts, beets, Brussels sprouts, cabbage, cauliflower, celery, cucumbers, eggplant, green beans, green peppers, iceberg (head) lettuce, mushrooms, okra, onions, parsnips, turnips, wax beans, zucchini

Vegetables have these health benefits:

• May reduce the risk for stroke, coronary artery disease, other cardiovascular diseases, and type 2 diabetes.

• Protect against certain cancers. Cancers of the mouth, stomach, and colon-rectum are examples.

• May reduce the risk of developing kidney stones.

• May reduce the risk of bone loss.

• May help lower calorie intake. Most vegetables are naturally low in fat and calories.

• Contain no cholesterol.

• Contain these nutrients—potassium, dietary fiber, folate (folic acid), vitamins A and C.

Fruit group

Any fruit or 100% fruit juice counts as part of the fruit group. Fruit choices should vary. Fresh, frozen, canned, or dried fruits are best. Avoid fruits canned in syrup. Syrup contains added sugar. Choose fruits canned in 100% fruit juice or water.

Fruits have these health benefits:

• May reduce the risk for stroke, coronary artery disease, other cardiovascular diseases, and type 2 diabetes.

• Protect against certain cancers. Cancers of the mouth, stomach, and colon-rectum are examples.

• May reduce the risk of developing kidney stones.

• May reduce the risk of bone loss.

• May help lower calorie intake. Most fruits are naturally low in fat and calories.

• Contain no cholesterol.

• Are naturally low in sodium.

• Contain these nutrients—potassium, dietary fiber, vitamin C, and folate (folic acid).

Dairy group

All fluid milk products are part of the dairy group. So are many foods made from milk. Low-fat or fat-free choices are best. The milk group includes all fluid milk, yogurt, and cheese. (Cream, cream cheese, and butter are not part of the group.)

Milk has these health benefits:

• Helps build and maintain bone mass throughout the life-span. This may reduce the risk of osteoporosis.

• Improves the overall quality of the diet.

• Contains these nutrients—calcium, potassium, and vitamin D.

Protein foods group

This group includes all foods made from meat, poultry, seafood, beans and peas, eggs, processed soy products, nuts, and seeds.

When selecting foods from this group, remember:

• To choose lean or low-fat meat and poultry. Higher fat choices include regular ground beef (75 to 80% lean) and chicken with skin.

• Using fat for cooking increases the calories. Fried chicken and eggs fried in butter are examples.

• Salmon, trout, and herring are rich in substances that may reduce the risk of heart disease.

• Liver and other organ meats are high in cholesterol.

• Egg yolks are high in cholesterol. Egg whites are cholesterol-free.

• Processed meats have added sodium (salt). They include ham, sausage, frankfurters, and luncheon and deli meats.

Many protein foods are high in fat and cholesterol. Heart disease is a major risk. However, this group provides nutrients needed for health and body maintenance:

• Protein

• B vitamins (niacin, thiamin, riboflavin, and B₆) and vitamin E

• Iron, zinc, and magnesium

Oils

Oils are fats that are liquid at room temperature. Vegetable oils for cooking are examples. They include canola oil, corn oil, and olive oil. Oils come from plants and fish. Because they have nutrients, the USDA includes oils in food patterns. However, oils are not a food group.

Adult women are allowed 5 to 6 teaspoons of oils daily. Adult men are allowed 6 to 7 teaspoons daily. Some foods are high in oil—nuts, olives, some fish, and avocados. When making oil choices, remember:

• Oils are high in calories.

• The best oil choices come from fish, nuts, and vegetable oils.

• Some foods are mainly oil. Mayonnaise, certain salad dressings, and soft margarine (tub or squeeze) are examples.

• Oils from plant sources do not contain cholesterol.

• Solid fats are solid at room temperature. Common solid fats include butter, beef fat (tallow, suet), chicken fat, pork fat (lard), stick margarine, and shortening.

Oils contain some fatty acids that are essential for health. Oils also are a major source of vitamin E.

Nutrients

No food or food group has every essential nutrient. A well-balanced diet ensures an adequate intake of essential nutrients.

• Protein—is the most important nutrient. It is needed for tissue growth and repair. Sources include meat, fish, poultry, eggs, milk and milk products, cereals, beans, peas, and nuts. Protein is needed for tissue growth and repair. The diets of some older persons may lack protein. High-protein foods are costly.

• Carbohydrates—provide energy and fiber for bowel elimination. They are found in fruits, vegetables, breads, cereals, and sugar. Carbohydrates break down into sugars during digestion. The sugars are absorbed into the bloodstream. Fiber is not digested. It provides the bulky part of chyme for elimination.

• Fats—provide energy. They add flavor to food and help the body use certain vitamins. Sources include meats, lard, butter, shortening, oils, milk, cheese, egg yolks, and nuts. Dietary fat not needed by the body is stored as body fat (adipose tissue).

• Vitamins—are needed for certain body functions. They do not provide calories. The body stores vitamins A, D, E, and K. Vitamin C and the B complex vitamins are not stored. They must be ingested daily. The lack of a certain vitamin results in signs and symptoms of an illness. See Table 24-2.

• Minerals—are used for many body processes. Bone and tooth formation, nerve and muscle function, and fluid balance are examples. Foods containing calcium help prevent musculo-skeletal changes. See Table 24-3, p. 380.

• Water—is needed for all body processes (p. 388).

Table 24-2

Functions and Sources of Common Vitamins

Vitamin	Major Functions	Sources
Vitamin A	Growth; vision; healthy hair, skin, and mucous membranes; resistance to infection	Liver, spinach, green leafy and yellow vegetables, yellow fruits, fish liver oils, egg yolks, butter, cream, whole milk
Vitamin B₁ (thiamine)	Muscle tone, nerve function, digestion, appetite, normal elimination, carbohydrate use	Pork, fish, poultry, eggs, liver, breads, pastas, cereals, oatmeal, potatoes, peas, beans, soybeans, peanuts
Vitamin B₂ (riboflavin)	Growth, healthy eyes, protein and carbohydrate metabolism, healthy skin and mucous membranes	Milk and milk products, liver, green leafy vegetables, eggs, breads, cereals
Vitamin B₃ (niacin)	Protein, fat, and carbohydrate metabolism; nervous system function; appetite; digestive system function	Meat, pork, liver, fish, peanuts, breads and cereals, green vegetables, dairy products
Vitamin B₁₂	Formation of red blood cells, protein metabolism, nervous system function	Liver, meats, poultry, fish, eggs, milk, cheese
Folate (folic acid)	Formation of red blood cells, intestinal function, protein metabolism	Liver, meats, fish, poultry, green leafy vegetables, whole grains
Vitamin C (ascorbic acid)	Formation of substances that hold tissues together; healthy blood vessels, skin, gums, bones, and teeth; wound healing; prevention of bleeding; resistance to infection	Citrus fruits, tomatoes, potatoes, cabbage, strawberries, green vegetables, melons
Vitamin D	Absorption and metabolism of calcium and phosphorus, healthy bones	Fish liver oils, milk, butter, liver, exposure to sun light
Vitamin E	Normal reproduction, formation of red blood cells, muscle function	Vegetable oils, milk, eggs, meats, cereals, green leafy vegetables
Vitamin K	Blood clotting	Liver, green leafy vegetables, egg yolks, cheese

Table 24-3

Functions and Sources of Common Minerals

Mineral	Major Functions	Sources
Calcium	Formation of teeth and bones, blood clotting, muscle contraction, heart function, nerve function	Milk and milk products, green leafy vegetables, whole grains, egg yolks, dried peas and beans, nuts
Phosphorus	Formation of bones and teeth; use of proteins, fats, and carbohydrates; nerve and muscle function	Meat, fish, poultry, milk and milk products, nuts, egg yolks, dried peas and beans
Iron	Allows red blood cells to carry oxygen	Liver, meat, eggs, green leafy vegetables, breads and cereals, dried peas and beans, nuts
Iodine	Thyroid gland function, growth, metabolism	Iodized salt, seafood, shellfish
Sodium	Fluid balance, nerve and muscle function	Almost all foods
Potassium	Nerve function, muscle contraction, heart function	Fruits, vegetables, cereals, meats, dried peas and beans

Food labels

Most foods have labels (Fig. 24-4). They are used to make informed food choices for a healthy diet. Figure 24-5 shows how to use a food label. Food labels contain information about:

• Serving size and the number of servings in each package.

• Calories and calories from fat. The number of servings eaten determines the number of calories of that food. For example: 1 cup of macaroni and cheese contains 250 calories with 110 of them from fat. If you eat 2 cups, you consume 500 calories—220 from fat.

• Nutrients—total fat (saturated fat and trans fat), cholesterol, sodium, carbohydrate (dietary fibers and sugar), protein, vitamins A and C, calcium, and iron.

How a serving fits into the daily diet is called the Daily Value (DV). The DV is expressed in a percent (%). The percent is based on a daily diet of 2000 calories. The % DV helps you decide if a food is high or low in a nutrient. According to the Food and Drug Administration (FDA), a 5% DV is low. A DV of 20% or more is high. In Figure 24-5, a serving of macaroni and cheese is low in dietary fiber, vitamins A and C, and iron. It is high in sodium and calcium.

Factors affecting eating and nutrition

Poor nutrition is common in persons needing long-term care. They need good nutrition to correct or prevent health problems. A team approach is needed to meet a person’s nutritional needs. The nursing team, doctor, dietitian, speech-language pathologist, and occupational therapist are involved. The person is involved. So is the family if necessary. The person’s likes, dislikes, and life-long habits are part of his or her nutritional care plan.

Some of the following factors begin during infancy and continue throughout life. Others develop later.

Culture and religion

Culture influences dietary practices, food choices, and food preparation. Frying, baking, smoking, or roasting food and eating raw food are cultural practices. So is the use of sauces, herbs, and spices. See Caring About Culture: Food Practices.

CARING ABOUT CULTURE

Food Practices

Food practices vary among cultural groups. Rice, corn, and beans are protein sources in Mexico. In the Philippines, rice is a main food. And fish, vegetables, and native fruits are preferred. A diet high in sugar and animal fat is common in Poland. In China, a meal of rice with meat, fish, and vegetables is common. High sodium content is from the use of soy sauce and dried and preserved foods.

Eating beef is common in the United States. In India, Hindus do not eat beef.

Modified from D’Avanzo CE: Pocket guide to cultural health assessment, ed 4, St Louis, 2008, Mosby.

Selecting, preparing, and eating food often involve religious practices (Box 24-3). A person may follow all, some, or none of the dietary practices of his or her faith. You must respect the person’s religious practices.

Box 24-3

Religion and Dietary Practices

Church of jesus christ of latter day saints (mormon)