Nutrition in Health and Health Care

Check Your Knowledge

True	False
□	□	1	Chronic diseases, such as cardiovascular disease and type 2 diabetes, are responsible for approximately 25% of deaths worldwide.
□	□	2	Chronic health conditions such as hypertension and type 2 diabetes occur only in adults.
□	□	3	Poor diet quality, physical inactivity, smoking, and excess body weight are modifiable risk factors that increase the risk of chronic disease.
□	□	4	The typical American eating pattern is low in fruits, vegetables, whole grains, dairy, and oils.
□	□	5	Older adults tend to have worse eating patterns than young and middle-aged adults.
□	□	6	For several chronic diseases, healthier eating and increased physical activity may provide benefits equal to medication, with lower cost and reduced risk of side effects.
□	□	7	Genomics will help researchers determine how specific nutrients interact with genes and other body substances to predict the health of an individual.
□	□	8	Nutrition care affects the practice of all health-care professionals.
□	□	9	Nurses are usually responsible for completing nutrition screening.
□	□	10	Most nutrition screenings address body mass index (BMI), appetite, weight change, and severity of disease.

Learning Objectives

Upon completion of this chapter, you will be able to

1 Describe the purpose of Healthy People 2020.

2 List four modifiable lifestyle risk factors for chronic disease.

3 Give examples of chronic diseases that are linked to a poor quality diet.

4 Describe the characteristics of a healthy eating pattern.

5 Give examples of questions that are driving nutrition research.

6 Compare nutrition screening to nutrition assessment.

7 Describe nutrition care responsibilities of the nurse.

When nutrition was a young science, the focus of healthy eating was to consume enough of all essential nutrients to avoid deficiency diseases. Today, nutrient deficiency diseases are generally rare in the United States except among specific population subgroups such as the elderly, alcoholics, fad dieters, and hospitalized patients. In fact, several of the leading causes of death in the United States are associated with dietary excesses—namely, heart disease, cancer, stroke, and diabetes. Many other health problems, such as obesity, hypertension, and hypercholesterolemia, are related, at least in part, to dietary excesses. But nutritional excesses are only part of the story: Americans are not eating enough of the specific foods or food groups that may help protect against chronic disease.

This chapter discusses the relationship between nutrition and human health, the future of nutrition research, and nutrition in health care.

NUTRITION AND HEALTH

Throughout time, all civilizations have linked nutrition with health (Meyer-Abich, 2005). Across the lifespan, good nutrition supports all aspects of health, including healthy pregnancy outcomes; normal growth, development, and aging; healthy body weight; lower risk of disease; and helping to treat acute and chronic disease (DiMaria-Ghalili et al., 2014). Nutrition is intimately entwined with health.

The World Health Organization (WHO, 1948) defines health as “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.” In practice, health is subjectively and individually defined along a continuum which is influenced by an individual’s perception of health. For instance, a recent survey found that although 57% of respondents ranked their health as very good or excellent, 55% of those are overweight or obese (International Food Information Council Foundation, 2015). Likewise, older adults may consider themselves healthy despite having arthritis because they consider it a normal part of aging, not a chronic disease.

Healthy People 2020

Under the jurisdiction of the U.S. Department of Health and Human Services (USDHHS), Healthy People is a program that focuses on improving the health of all Americans and eliminating health disparities. Updated every 10 years after its inception 30 years ago, Healthy People sets public health goals and objectives and monitors the nation’s progress toward meeting those objectives.

The newest edition, Healthy People 2020, has approximately 1200 objectives organized into 42 focus areas ranging from cancer and diabetes to substance abuse and immunizations. At the time of its launch in December 2010, 911 objectives were measurable with baseline data and established targets (USDHHS, 2010). The overall objectives under nutrition and weight status are listed in Box 1.1.

Chronic Disease

Preventable chronic disease is a major challenge to global health, responsible for 68% of all worldwide deaths in 2012 (WHO, 2014). In the United States, chronic diseases are responsible for 7 of the top 10 causes of death (Box 1.2) and are the main causes of poor health and disability (Bauer et al., 2014). In 2012, about half of all American adults had one or more chronic health conditions and 1 in 4 adults had two or more chronic health conditions (Table 1.1) (Ward, Schiller, & Goodman, 2014). Children and adolescents also have chronic diseases, such as hypertension and type 2 diabetes. At all ages, chronic disease risk is linked to overweight and obesity (Dietary Guidelines Advisory Committee, 2015).

BOX 1.1 Healthy People 2020: Summary of Nutrition and Weight Status Objectives

Goal: Promote health and reduce chronic disease risk through consumption of healthful diets and achievement and maintenance of healthy body weights.

Healthier Food Access

Increase the number of states with nutrition standards for foods and beverages provided to preschool-aged children in child care.
Increase the proportion of schools that offer nutritious foods and beverages outside of school meals.
Increase the number of states that have state-level policies that incentivize food retail outlets to provide foods that are encouraged by the Dietary Guidelines for Americans.
(Developmental) Increase the proportion of Americans who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans.

Health Care and Worksite Settings

Increase the proportion of primary care physicians who regularly measure the body mass index of their patients.
Increase the proportion of physician office visits that include counseling or education related to nutrition or weight.
(Developmental) Increase the proportion of worksites that offer nutrition or weight management classes or counseling.

Weight Status

Increase the proportion of adults who are at a healthy weight.
Reduce the proportion of adults who are obese.
Reduce the proportion of children and adolescents who are considered obese.
(Developmental) Prevent inappropriate weight gain in youth and adults.

Food Insecurity

Eliminate very low food security among children.
Reduce household food insecurity and in doing so reduce hunger.

Food and Nutrient Consumption

Increase the contribution of fruits to the diets of the population aged 2 years and older.
Increase the variety and contribution of vegetables to the diets of the population aged 2 years and older.
Increase the contribution of whole grains to the diets of the population aged 2 years and older.
Reduce consumption of calories from solid fats and added sugars in the population aged 2 years and older.
Reduce consumption of saturated fat in the population aged 2 years and older.
Reduce consumption of sodium in the population aged 2 years and older.
Increase consumption of calcium in the population aged 2 years and older.

Iron Deficiency

Reduce iron deficiency among young children and females of childbearing age.
Reduce iron deficiency among pregnant females.

The mix of food consumed throughout the life cycle can determine whether a chronic disease develops or regresses (Hiza, Casavale, Guenther, & Davis, 2013). Effective and timely nutrition and lifestyle intervention can prevent or minimize morbidity and mortality related to many major chronic diseases such as obesity, cardiovascular disease, diabetes, and certain cancers (Slawson, Fitzgerald, & Morgan, 2013). Other modifiable lifestyle factors that contribute to chronic disease risk are smoking, physical inactivity, obesity, and excessive alcohol intake (Box 1.3).

Table 1.1 Facts about Nutrition- and Physical Activity-Related Health Conditions in the United States

Health Condition	Facts
Overweight and Obesity	For more than 25 years, more than half of the adult population has been overweight or obese. Obesity is most prevalent in those ages 40 years and older and in African American adults, and is least prevalent in adults with highest incomes. Since the early 2000s, abdominal obesity^a has been present in about half of U.S. adults of all ages. Prevalence is higher with increasing age and varies by sex and race/ethnicity. In 2009-2012, 65% of adult females and 73% of adult males were overweight or obese. In 2009-2012, nearly one in three youth ages 2 to 19 years were overweight or obese.
Cardiovascular Disease (CVD) and Risk Factors: Coronary heart disease Stroke Hypertension High total blood cholesterol	In 2010, CVD affected about 84 million men and women ages 20 years and older (35% of the population). In 2007-2010, about 50% of adults who were normal weight, and nearly three-fourths of those who were overweight or obese, had at least one cardiometabolic risk factor (i.e., high blood pressure, abnormal blood lipids, smoking, or diabetes). Rates of hypertension, abnormal blood lipid profiles, and diabetes are higher in adults with abdominal obesity. In 2009-2012, almost 56% of adults ages 18 years and older had either prehypertension (27%) or hypertension (29%).^b In 2009-2012, rates of hypertension among adults were highest in African Americans (41%) and in adults ages 65 years and older (69%). In 2009-2012, 10% of children ages 8 to 17 years had either borderline hypertension (8%) or hypertension (2%).^c In 2009-2012, 100 million adults ages 20 years or older (53%) had total cholesterol levels ≥200 mg/dL; almost 31 million had levels ≥240 mg/dL. In 2011-2012, 8% of children ages 8 to 17 years had total cholesterol levels ≥200 mg/dL.
Diabetes	In 2012, the prevalence of diabetes (type 1 plus type 2) was 14% for men and 11% for women ages 20 years and older (more than 90% of total diabetes in adults is type 2). Among children with type 2 diabetes, about 80% were obese.
Cancer^d Breast cancer Colorectal cancer	Breast cancer is the third leading cause of cancer death in the United States. In 2012, an estimated 3 million women had a history of breast cancer. Colorectal cancer is the second leading cause of cancer death in the United States. In 2012, an estimated 1.2 million adult men and women had a history of colorectal cancer.
Bone Health	A higher percent of women are affected by osteoporosis (15%) and low bone mass (51%) than men (about 4% and 35%, respectively). In 2005-2010, approximately 10 million (10%) adults ages 50 years and older had osteoporosis and 43 million (44%) had low bone mass.
^aAbdominal obesity, as measured by waist circumference, is defined as a waist circumference of >102 centimeters in men and >88 centimeters in women. ^bFor adults, prehypertension was defined as a systolic blood pressure of 120-139 mm mercury (Hg) or diastolic blood pressure of 80-89 mm Hg among those who were not currently being treated for hypertension. Hypertension was defined as systolic blood pressure (SBP)>140 mm Hg, diastolic blood pressure (DBP) >90 mm Hg, or taking antihypertensive medication. ^cFor children, borderline hypertension was defined as systolic or diastolic blood pressure at the 90th percentile or higher but lower than the 95th percentile or as blood pressure levels of 120/80 mm Hg or higher (but less than the 95th percentile). Hypertension was defined as a systolic or diastolic blood pressure at the 95th percentile or higher. ^dThe types of cancer included here are not a complete list of all diet- and physical activity-related cancers.
*Source:* U.S. Department of Health and Human Services & U.S. Department of Agriculture. (2015). 2015-2020 Dietary Guidelines for Americans (8th ed.). Available at http://www.http://health.gov/dietaryguidelines/2015/guidelines/introduction/nutrition-and-health-are-closely-related/#table-i-. Accessed on 3/14/16.

Food: More than Just Nutrients

Food is a complex mix of essential and nonessential components in various ratios and combinations. Essential nutrients, such as most vitamins, minerals, amino acids, fatty acids, and water, must be obtained through food because the body cannot make them. Plants provide fiber and a variety of nonnutrient compounds that have health-enhancing biological activity in the body. These beneficial nonnutrient compounds are known as phytonutrients.

Nutrients have long been studied as singular substances and intake recommendations have focused on nutrients more so than food, such as to limit total fat without consideration of the source of fat. Such a narrow focus underestimates the complexity of food and the interactions between its components and ignores the possibility that many constituents of food and eating patterns may act synergistically to impact health (Jacobs & Orlich, 2014). For instance, because populations who consume high amounts of fruits and vegetables were observed to have lower
rates of epithelial cancers, researchers speculated that beta-carotene intake was protective. However, a study of large doses of supplemental beta-carotene resulted in an increase in cancer, necessitating a premature halt to the study (Bjelakovic, Nikolova, Gluud, Simonetti, & Gluud, 2007). This is a glaring example of how although certain food patterns may be associated with lower risk of disease, it is not known which components of a food, in what proportion, acting singularly or synergistically with other substances, are protective or detrimental to health. Thus, the health effects of foods may not be simply and accurately reduced to the effects of single nutrients (Jacobs & Orlich, 2014).

BOX 1.3 Modifiable Risk Factors for Chronic Disease

Smoking

Almost 20% of adults smoke cigarettes.
Is the leading cause of preventable death, contributing to 480,000 deaths annually
Damages nearly every body organ and causes respiratory disease, heart disease, stroke, cancer, preterm birth, low birth weight, and premature death
Shortens lifespan by an average of 10 years

Obesity

Approximately one-third of U.S. adults are obese; it is a leading risk factor for several preventable conditions such as heart disease, type 2 diabetes, stroke, cancer, hypertension, liver disease, kidney disease, and osteoarthritis.
Obesity contributes to an estimated 200,000 deaths annually.

Excessive Alcohol

Can lead to fetal damage, liver diseases, hypertension, cardiovascular diseases, and other major health problems
Contributes to lost workplace productivity, motor vehicle accidents, and property damage

Physical Inactivity

Responsible for 10% of deaths annually; increases the risk of coronary heart disease, type 2 diabetes, hypertension, obesity, certain cancers, and premature death
Only 21% of adults meet the U.S. Department of Health and Human Services’ recommendation of at least 150 minutes of physical activity weekly.

Source: United Health Foundation. (2015). The America’s Health Rankings Annual Report. Available at http://www.americashealthrankings.org. Accessed on 3/3/16.

Healthy Eating

There is a shift away from focusing on nutrients to examining the bigger picture of eating patterns (Mozaffarian & Ludwig, 2010). The Dietary Guidelines Advisory Committee (2015) defines dietary patterns as “the quantities, proportions, variety or combinations of different foods and beverages in diets, and the frequency with which they are habitually consumed.” Nutritional epidemiology consistently shows that healthy eating patterns reduce the risk of chronic disease (Jacobs & Orlich, 2014). For instance, a prospective cohort study of participants in the Women’s Health Initiative Observational Study found that women having better diet quality had 18% to 26% lower all-cause and cardiovascular disease mortality risk and that better diet quality scores were associated with a 20% to 23% lower risk of cancer mortality (George et al., 2014). Likewise, in the Iowa Women’s Health Study, the diet quality score was found to be inversely related to mortality: A high quality score was related to lower total mortality rates during the 22 years of follow-up (Mursu, Steffen, Meyer, Duprez, & Jacobs, 2013). Furthermore, healthier eating and increased physical activity have increasingly shown benefits that equal if not surpass those of pharmacologic intervention for several chronic diseases, often with less risk, fewer side effects, and lower costs (Estruch et al., 2013; Sacks et al., 2001; Wing et al., 2013).

Measures of Diet Quality

Although “poor diet quality” is considered to be a major risk factor for several chronic diseases, there is not a universal definition or measure of diet quality. Numerous indices have been developed to assess diet quality according to how closely eating patterns conform to (1) dietary recommendations, such as the Dietary Guidelines for Americans (e.g., Healthy Eating Index-2010 [HEI-2010]), or (2) healthy eating patterns, such as the Mediterranean-style diet and the Dietary Approaches to Stop Hypertension (DASH) diet. Many indices have several versions and are distinguished by the words “adapted,” “revised,” “alternative,” or by other descriptions added to the name.

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