Nutrition For Nurses-WEB

Nutrition for Nurses
SENIOR CONTRIBUTING AUTHORS

EMERALD CHARITY BILBREW, FAYETTEVILLE TECHNICAL
COMMUNITY COLLEGE
JODY VOGELZANG, GRAND VALLEY STATE UNIVERSITY
KELLI WHITTINGTON, SOUTHERN ILLINOIS UNIVERSITY
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Contents
Preface 1
UNIT 1 NUTRITION BASICS FOR NURSES

CHAPTER 1
Introduction to Nutrition for Nurses 7
Introduction 7
1.1 What Is Nutrition? 7
1.2 Interdisciplinary Teams and Nutrition in Nursing Practice 10
1.3 Nutrition and Population Health 12
1.4 Vulnerable Populations 17
1.5 Evidence-Based Practice and Nutrition 19
Chapter Summary 22
Key Terms 22
Review Questions 22
Suggested Reading 24
CHAPTER 2
A Holistic View of Macronutrients 25
Introduction 25
2.1 Carbohydrates 25
2.2 Fats 29
2.3 Protein 32
2.4 Hydration 36
Chapter Summary 38
Key Terms 38
Review Questions 38
CHAPTER 3
A Holistic View of Micronutrients 41
Introduction 41
3.1 Vitamins 42
3.2 Minerals 50
3.3 Supplements 53
Chapter Summary 57
Key Terms 57
Review Questions 57
CHAPTER 4
The Digestive Process 61
Introduction 61
4.1 Digestion 61
4.2 Physical Assessment of Digestive Organs 64
4.3 The Function of Digestive Organs 68
4.4 The Nurse’s Role in the Promotion of Gut Health 71
Chapter Summary 74
Key Terms 74
Review Questions 74
UNIT 2 NUTRITION AND NEUROLOGICAL

WELLNESS
CHAPTER 5
Applying Clinical Judgment to Promote Nutrition for
Neurological Wellness 77
Introduction 77
5.1 Assess and Analyze the Impact of Nutrition on the Neurologic System 78
5.2 Plan Nutritional Strategies to Impact Neurologic Wellness 96
5.3 Implement Nutritional Strategies to Impact Neurologic Wellness 99
5.4 Evaluate Nutritional Strategies to Impact Neurologic Wellness 101
Chapter Summary 104
Key Terms 104
Review Questions 105
CHAPTER 6
Special Nutritional Considerations for Neurological Health
107
Introduction 107
6.1 The Impact of Nutrition on Neurological Wellness Across the Lifespan 108
6.2 Nutrition and Chronic Neurological Illnesses 117
6.3 Neurologic Condition Treatments, Medications, and Nutrition 119
Chapter Summary 124
Key Terms 124
UNIT 3 NUTRITION AND ENDOCRINE WELLNESS

CHAPTER 7
Applying Clinical Judgment to Promote Nutrition for Endocrine
Wellness 127
Introduction 127
7.1 Assess and Analyze the Impact of Nutrition on the Endocrine System 128
7.2 Plan Nutritional Strategies to Impact Endocrine Wellness 134
7.3 Implement Nutritional Strategies to Impact Endocrine Wellness 138
7.4 Evaluate Nutritional Strategies to Impact Endocrine Wellness 139
Chapter Summary 142
Key Terms 142
Access for free at openstax.org

CHAPTER 8
Special Nutritional Considerations for Endocrine Health 145
Introduction 145
8.1 The Impact of Nutrition on Endocrine Wellness Across the Lifespan 146
8.2 Nutrition and Chronic Endocrine Illnesses 157
8.3 Treatments and Nutrition 163
Chapter Summary 166
Key Terms 166
UNIT 4 NUTRITION AND HEMATOLOGICAL

WELLNESS
CHAPTER 9
Hematologic Wellness 169
Introduction 169
9.1 Assess and Analyze the Impact of Nutrition on the Hematological System 170
9.2 Plan Nutritional Strategies to Impact Hematological Wellness 177
9.3 Implement Nutritional Strategies to Impact Hematological Wellness 179
9.4 Evaluate Nutritional Strategies to Impact Hematological Wellness 181
Chapter Summary 185
Key Terms 185
CHAPTER 10
Special Nutritional Considerations for Hematologic Health
187
Introduction 187
10.1 The Impact of Nutrition on Hematologic Wellness Across the Lifespan 188
10.2 Nutrition and Chronic Hematologic Illness 198
Chapter Summary 203
Key Terms 203
UNIT 5 NUTRITION AND CARDIOVASCULAR

WELLNESS
CHAPTER 11
Cardiovascular Wellness 207
Introduction 207
11.1 Assess and Analyze the Impact of Nutrition on the Cardiovascular System 208
11.2 Plan Nutritional Strategies to Impact Cardiovascular Wellness 216
11.3 Implement Nutritional Strategies to Impact Cardiovascular Wellness 221
11.4 Evaluate Nutritional Strategies to Impact Cardiovascular Wellness 223
Chapter Summary 225
Key Terms 225
CHAPTER 12
Special Nutritional Considerations for Cardiovascular Health
229
Introduction 229
12.1 The Impact of Nutrition on Cardiovascular Wellness Across the Lifespan 230
12.2 Nutrition and Long-Term Cardiovascular Illnesses 239
Chapter Summary 245
Key Terms 245
UNIT 6 NUTRITION AND PULMONARY WELLNESS

CHAPTER 13
Applying Clinical Judgment to Promote Nutrition for Pulmonary
Wellness 249
Introduction 249
13.1 Assess and Analyze the Impact of Nutrition on the Pulmonary System 250
13.2 Plan Nutritional Strategies to Impact Pulmonary Wellness 261
13.3 Implement Nutritional Strategies to Impact Pulmonary Wellness 266
13.4 Evaluate Nutritional Strategies to Impact Pulmonary Wellness 268
Chapter Summary 270
Key Terms 270
CHAPTER 14
Special Nutritional Considerations for Pulmonary Health 273
Introduction 273
14.1 The Impact of Nutrition on Pulmonary Wellness Across the Lifespan 274
14.2 Nutrition and Chronic Pulmonary Illnesses 280
Chapter Summary 291
Key Terms 291

UNIT 7 NUTRITION AND RENAL WELLNESS
CHAPTER 15
Applying Clinical Judgment to Promote Nutrition for Renal
Wellness 295
Introduction 295
15.1 Assess and Analyze the Impact of Nutrition on the Renal System 296
15.2 Plan Nutritional Strategies to Impact Renal Wellness 303
15.3 Implement Nutritional Strategies to Impact Renal Wellness 306
15.4 Evaluate Nutritional Strategies to Impact Renal Wellness 308
Chapter Summary 311
Key Terms 311
CHAPTER 16
Special Nutritional Considerations for Renal Health 315
Introduction 315
16.1 The Impact of Nutrition on Renal Wellness Across the Lifespan 316
16.2 Nutrition and Chronic Renal Illness 324
Chapter Summary 329
Key Terms 329
UNIT 8 NUTRITION AND GASTROINTESTINAL

WELLNESS
CHAPTER 17
Gastrointestinal Wellness 333
Introduction 333
17.1 Assess and Analyze the Impact of Nutrition on the Gastrointestinal System 334
17.2 Plan Nutritional Strategies to Impact Gastrointestinal Wellness 341
17.3 Implement Nutritional Strategies to Impact Gastrointestinal Wellness 343
17.4 Evaluate Nutritional Strategies to Impact Gastrointestinal Wellness 344
Chapter Summary 346
Key Terms 346
CHAPTER 18
Special Nutritional Considerations for Gastrointestinal Health
349
Introduction 349
18.1 The Impact of Nutrition on Gastrointestinal Wellness Across the Lifespan 350
18.2 Nutrition and Chronic Gastrointestinal Illnesses 359
Chapter Summary 363
Key Terms 363
UNIT 9 NUTRITION AND MUSCULOSKELETAL

AND INTEGUMENTARY WELLNESS
CHAPTER 19
Musculoskeletal and Integumentary Wellness 367
Introduction 367
19.1 Assess and Analyze the Impact of Nutrition on the Musculoskeletal and Integumentary Systems 368
19.2 Plan Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness 379
19.3 Implement Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness 381
19.4 Evaluate Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness 385
Chapter Summary 387
Key Terms 387
CHAPTER 20
Special Nutritional Considerations for Musculoskeletal and
Integumentary Health 391
Introduction 391
20.1 The Impact of Nutrition on Musculoskeletal and Integumentary Wellness Across the Lifespan 392
20.2 Nutrition and Chronic Musculoskeletal and Integumentary Illness 401
Chapter Summary 405
Key Terms 405
Appendix A Apps Frequently Used to Support Nutrition Wellness 409

Answer Key 411
References 425
Index 481

Preface 1
PREFACE
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About Nutrition for Nurses

Summary
Nurses play a pivotal role in educating clients about the importance of nutrition in wellness promotion and illness
prevention. Nutrition for Nurses emphasizes evidence-based practice and holistic assessment to facilitate the
integration of nutritional awareness for pre-licensure nursing students in the provision of client-centered care. This
text prepares students to serve as professionals who are part of an interdisciplinary team, which includes registered
dieticians and nutritionists, and to emphasize nutrition as a key component of wellness, disease prevention, and
disease management.
Nutrition for Nurses is written by nurses and dietitians, and is tailored specifically to nursing students to help them
develop sound clinical judgment. The text promotes evidence-based practice and adheres to the nursing process
2 Preface
steps of assessment, diagnosis, planning, implementation, and evaluation. Nutrition for Nurses helps students
develop nutritional competency that includes explaining the role of macronutrients, micronutrients, and hydration in
nutrition; describing the structure and function of the digestive organs; applying the nursing process to assess the
impact of nutrition on body systems and disease processes; and evaluating the impact of nutrition on body systems
across the lifespan.
Pedagogical Foundation
Nutrition for Nurses is structured to support the flexible integration of nutrition content across both system-based
and nursing competency–based curricula and can be used whether nutrition is taught as a stand-alone course or as
part of another nursing course. The text tailors the presentation of fundamental nutrition concepts to nursing
students, helping to prepare them for nutrition concepts not only throughout the curriculum but also as a
prerequisite to pathophysiology and awareness of disease processes. Throughout, the focus is on assessment of the
client, including normal and abnormal findings, and the role nutrition plays in the body and its systems as a critical
component of wellness. This presentation utilizes concepts promoting the development of clinical judgment by
building upon the systematic model developed by the National Council of State Boards of Nursing (NCSBN).
Although the chapters in Nutrition for Nurses are written to be mostly independent, they do generally build on the
understanding gained in the four fundamentals chapters in Unit 1. (Please bear this in mind when considering
alternate sequence coverage.) Instructors may pair the chapters from this nutrition textbook with similar body
system topics in a disease course.
Organizational Framework
The table of contents for Nutrition for Nurses presents content in 20 chapters, organized into 9 thematic units:
• Unit 1 features four introductory chapters that include foundational nutritional knowledge, the role of
interdisciplinary teams, and agency oversight. The functions of macronutrients, micronutrients, hydration, and
the physiology of digestion are presented. The discussion of these nutritional components explains how
nutrition impacts wellness.
• Units 2–9 cover the impact of nutrition on the body’s organ systems, including the following systems:
◦ Neurological
◦ Endocrine
◦ Hematological
◦ Cardiovascular
◦ Pulmonary
◦ Renal
◦ Gastrointestinal
◦ Musculoskeletal and integumentary
Each unit covers one body system and includes two chapters; the first chapter helps students apply clinical
judgment to promote health and wellness in the identified body system, and the second chapter covers lifespan
considerations and body system illness.
• The appendix identifies common nutritional apps with hyperlinks for easy access to these resources.
Nursing Features
To further enhance learning, Nutrition for Nurses includes the following features:
• Clinical Tips offer practical suggestions that help nurses deliver quality care to the client—for example, asking
clients open-ended questions or helping clients to communicate better with health care professionals.
• Media boxes provide an opportunity to explore related content that reinforces or extends learning. Examples
include a fracture risk assessment tool (FRAX) and a video highlighting changes to the Nutrition Facts label.
• Safety Alerts address provision of care to clients across the wellness continuum and emphasize the
importance of quality and safety in client care. Examples include consuming salt substitutes that contain
potassium chloride and contraindications for deep palpation.
• Special Considerations highlight nutritional considerations related to various client categories, including age/
life stage, race/ethnicity/culture, or sex/gender. Examples include insulin sensitivity in diverse populations and
populations who are at risk for vitamin B12 deficiency.

Preface 3
• Trending Today boxes present nutritional and nursing trends via the lens of evidence-based practice. This
feature contains a variety of social media resources and videos as well as questions for reflective thinking.
Examples include promoting wellness with herbs and examining the link between nutrition and aging skin.
Some chapters in this book discuss social media with the intended purpose of preparing nurses to handle
questions clients will ask about nutritional information they have read online and via social media. References
to social media or specific social media sites are not an endorsement of their use as source for nutritional
information or self-diagnosis. The authors advise readers to evaluate nutritional resources for their use of
evidence-based practice (EBP), which uses scientific evidence rather than anecdotal evidence, and to seek the
care of a trained, certified, and experienced health care provider for nutrition-related care.
• Unfolding Case Studies present a hypothetical client scenario that unfolds in two or more parts throughout the
chapter, with each subsequent part presenting new information on the same client, to help foster clinical
judgment. In each part of an unfolding case feature, the scenario is followed by two multiple-choice questions
that require students to apply their knowledge of evidence-based client care. The answers to these questions,
with explanations, are included in the Answer Key for students at the end of the book.
Pedagogical Features
To support student learning, Nutrition for Nurses includes the following standard elements:
• Learning Outcomes: Every chapter section begins with a set of clear and concise student learning outcomes.
These outcomes are designed to help the instructor decide what content to include or assign and can guide
students on what they can expect to learn and be assessed on.
• Review Questions: This end-of-chapter feature presents multiple-choice questions for students to apply their
learned knowledge and integrate the chapter (and unit) concepts. The questions focus on client scenarios and
body system and nutritional concepts review as relevant to the chapter material. The question answers, with
explanations, are included in the Answer Key for students at the end of the book.
• Chapter Summary: Chapter summaries assist both students and instructors by outlining the primary subtopics
addressed within the chapter.
• Key Terms: Key terms are presented in bold text and are followed by an explanation in context. Definitions of
key terms are also listed in the end-of-chapter glossary.
• Suggested Reading: All chapters include a recommended list of readings that either go into more depth about
topics already covered in the chapter or provide content closely related to those topics in order to form a more
comprehensive view.
• References: References are listed at the end of the book, organized by chapter.
About the Authors

Senior Contributing Authors
Senior contributing authors: Emerald Charity Bilbrew (left),

Jody Vogelzang (middle), Kelli Whittington (right)
Dr. Emerald Charity Bilbrew, Fayetteville Technical Community College. Dr. Bilbrew holds an ASN from Southern
Union State Community College, a BSN in Nursing from Jacksonville University, an MSN in Nursing Leadership and
4 Preface
Management from Jacksonville University, a Post Master’s in Nursing Education from Walden University, and a
Doctor in Nursing Practice in Nursing Leadership in Healthcare Systems from Regis University. Dr. Bilbrew has been
a nurse for more than 20 years and is certified in the specialty of medical-surgical nursing. She is a Lead Instructor
of Nursing at Fayetteville Technical Community College where she teaches courses in the Associate Degree Nursing
Program that include clinical, lab, online, classroom, and preceptorship components. Dr. Bilbrew is a member of the
Academy of Medical-Surgical Nurses (AMSN) and has served on multiple volunteer committees, including the
Legislative Committee, where she advocates for changes in laws for the advancement of nursing and betterment of
the care and safety of clients. She is a member of the National League for Nursing (NLN), a charter member of the
Omega Upsilon Chapter of the Sigma Theta Tau International Honor Society of Nursing, and a peer reviewer for the
Accreditation Commission for Education in Nursing (ACEN).
Dr. Jody Vogelzang, Grand Valley State University. Dr. Vogelzang holds a BS in dietetics from Michigan State
University, an MS in Health Science from Grand Valley State University, an MA in Biology from Miami University of
Ohio, and a PhD in Health Services specializing in community health from Walden University. Dr. Vogelzang is a
registered dietitian and health education specialist and an expert in community health who has spent the last two
decades teaching in higher education. As a practitioner, Dr. Vogelzang is especially well-rounded, working in the
community setting with infants, children, pregnant women, and chronically ill adults and older adults and in
palliative and hospice care. In 2016, Dr. Vogelzang was the founding director of a coordinated graduate program in
clinical dietetics. She is a nationally recognized speaker and researcher. Her peers have formally recognized her for
excellence in professional practice—Excellence in Public Health Nutrition (AND) and Achievements in Public Health
Nutrition (APA). Dr. Vogelzang has also been recognized for her dedication to the high standards of the nutrition and
dietetics profession through active participation, leadership, and devotion to serving others in nutrition and dietetics
as well as allied health fields (AND Medallion Award). She regularly volunteers in professional and community
organizations locally, nationally, and internationally.
Dr. Kelli Whittington, Southern Illinois University. Dr. Whittington holds a BS in Nursing from Middle Tennessee
University, an MS in Nursing from Southern Illinois University, and a PhD in Workforce Education from Southern
Illinois University. She is Program Director of Nursing, School of Health Science, at Southern Illinois University. Dr.
Whittington’s nursing career spans more than 30 years, with practice in the acute care setting. Her nursing
experience includes ICU, oncology, management, and administration. Her nursing education career began in 1993
with an adjunct clinical position at the community college level. Throughout her nursing education experience, she
has taught nurses across all academic levels, from certified nurse assistants through bachelor’s-prepared registered
nurses, culminating with doctorally prepared registered nurses. She currently teaches nutrition courses to
accelerated, traditional, and RN-to-BSN students. Dr. Whittington is a member of the Illinois Nurses Association,
Illinois Organization of Nurse Leaders, Registered Nurse Education League, and Sigma Theta Tau International
Honor Society of Nursing. She is the recipient of the Emerson Excellence in Teaching Award (2019), the visiting
scholar award from Michigan State University (2009), and an Illinois Nurse Educator Fellowship (2023). Dr.
Whittington is a Certified Nurse Educator.
The senior contributing authors would like to particularly thank nursing consultants Amy B. Britt, Bon Secours Mercy
Health, and Marcy Caplin, Associate Professor, Kent State University College of Nursing, for their expertise and
assistance with content review and development. Thank you also to Dr. Allison Mann, PharmD, Clinical Associate
Professor of Pharmacy Practice, University of Wyoming.
Contributing Authors
Amy B. Britt, Bon Secours Mercy Health
Millie Hepburn, Sacred Heart University
Lisa R. McDonald, Capella University
Lee Anne Oliver, Beaufort County Community College
Marygrace Piskorowski, SUNY at Buffalo
Sharon R. Simon, Shenandoah University
Miranda Smith, The University of Alabama in Huntsville

Preface 5
Nicole M. Stephens, Galveston College
Cynthia Wagner, University of North Georgia
Reviewers
Oluwakemi Lois Adeola, Howard University
Jennifer M. Bell, Ball State University
Jocelyn D. Betts, Chicago State University
Amy B. Britt, Bon Secours Mercy Health
Ximena Burgos, University of Texas – El Paso
Marcy Caplin, Kent State University
Karen Crosby, Endicott College
Amanda N. DiEugenio-Swift, Eastern University
Stacha Hayes, Emory University
Veela Hughes, Albany State University
Karen D. Joris, Professor Emeritus, Lorain County Community College
Barbara Ludwig, Rockhurst University
Amy Mersiovsky, Texas A&M University – Central Texas
Jennifer Nickell, Portland Community College
Lee Anne Oliver, Beaufort County Community College (Retired)
Anita Ramani, Gurnick Academy of Medical Arts
Margaret Riley, Nurse Educate
Ellen Schoen, Vanderbilt University School of Nursing
Miranda Smith, The University of Alabama in Huntsville
Nicole M. Stephens, Galveston College
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end, OpenStax has created an interactive to aid with academic integrity discussions in your course.
6 Preface
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(https://openstax.org/r/academicintegrityabc).
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Special Thanks
The Division of Digital Learning at the Texas Higher Education Coordinating Board (THECB) has a history of dedicated
research initiatives, services, and programs that have advanced open education in Texas by providing support,
advocacy, and resources to Texas institutions in their OER efforts. The Division maintains a diverse OER portfolio
including OERTX, a digital library and community space for open education work. The leadership and collaboration
of the Division of Digital Learning staff made the OER Nursing Essentials (ONE) project possible, throughout
research, planning, and development phases of the eight-textbook series.
This work was supported in whole or in part by the THECB. The opinions and conclusions expressed in this
document are those of the author(s) and do not necessarily represent the opinions or policies of the THECB.

CHAPTER 1
Introduction to Nutrition for Nurses
FIGURE 1.1 Good nutrition, including fruits, is the foundation of good health. (credit: modification of work “Culinary fruits front view” by Bill
Ebbesen/Wikimedia Commons, CC BY 3.0)
CHAPTER OUTLINE
1.1 What Is Nutrition?
1.2 Interdisciplinary Teams and Nutrition in Nursing Practice
1.3 Nutrition and Population Health
1.4 Vulnerable Populations
1.5 Evidence-Based Practice and Nutrition
INTRODUCTION Good nutrition is fundamental to improving and maintaining health regardless of age or current
health status (Centers for Disease Control and Prevention [CDC], 2021). Accordingly, nurses must be knowledgeable
and prepared to incorporate nutrition science into their practice. Traditionally, the science of nutrition had focused
on nutrient intake and biochemical processing only. However, food intake serves other various purposes, from
celebrating milestones to providing comfort when stressed or grieving. Over time, food and food preparation has
evolved to center around pleasure and convenience rather than simply a means of sustenance. Consequently,
nurses must integrate these social and cultural factors with evidence-based nutritional guidelines to help their
clients meet their physical, psychological, and social needs.
1.1 What Is Nutrition?

LEARNING OUTCOMES
By the end of this section, you should be able to:
• 1.1.1 Define nutrition.
• 1.1.2 Identify key events in the history of nutrition.
8 1 • Introduction to Nutrition for Nurses
A Basic Definition of Nutrition

Nutrition is the intake of food to meet the needs of the body. Accordingly, nutrients are substances found in foods
and beverages that are essential for survival. Nurses must understand the components of nutrition and its impact on
bodily functions to provide effective nursing care.
Several food-related concepts are fundamental to understanding how nutrition affects the body. The term food
refers to edible substances made of protein, carbohydrates, fat, or other nutrients. Food is comprised of
macronutrients and/or micronutrients. Macronutrients are water and energy-yielding nutrients (carbohydrates, fats,
and proteins) needed in large amounts by the body. Micronutrients include vitamins and minerals. Food is the
building block of the diet, which describes the quantity and quality of food and drinks consumed.
Nutrition in Foods
Understanding calories is essential to understanding how the body uses nutrients for fuel. Calories, which measure
the amount of heat it takes to raise 1 kg of water by 1ºC, are used to indicate the amount of energy needed or
ingested daily. Human bodies need calories to function, digest food, grow, and move. The 2020-2025 Dietary
Guidelines issued jointly by the U.S. Department of Agriculture and the U.S. Department of Health and Human
Services recommend adult women consume an estimated 1,600 to 2,400 calories daily and adult men 2,000 to
3,000 calories daily based on age and activity level (USDA & USHHS, 2020).
The number of calories found in food varies based on food type. Table 1.1 lists the number of calories found in
macronutrients. Food preparation can modify the number of calories present. For example, a raw tomato has fewer
calories than a fried tomato. Water is classified as a macronutrient. Although it serves a vital role, it does not provide
energy to the body.
Macronutrient Calories per Gram Recommended Daily Intake

Carbohydrate 4 45–65%
Fat 9 20–35%
Protein 4 10–35%
TABLE 1.1 Macronutrients Energy Yield and Recommended Daily Intake (source: USDA & USHHS, 2020)
CALORIE CALCULATOR
Counting calories is one way to determine if clients are consuming an appropriate amount of food to meet their
needs. Calorie needs vary based upon client age, sex, and level of physical activity. Use this calorie calculator
(https://openstax.org/r/calculnet) when working with clients to determine their individual caloric needs.
The History of Nutrition in the Provision of Client Care

Modern nutrition science advanced significantly during the 20th century (Mozaffarian, Rosenberg & Uauy, 2018).
The identification of essential vitamins and minerals in the early 1900s launched the quest to identify and treat
vitamin-deficient medical conditions such as beriberi. Subsequent nutritional discoveries led to the practice of
fortifying certain foods to prevent deficiencies and setting the first recommended dietary allowances (RDAs).
During this same time frame, the federal government began to oversee and manage the food supply. In 1906, the
Pure Food and Drugs Act was passed, which launched the federal regulation of foods by the agency later known as
the U.S. Food and Drug Administration (FDA, 2018). The FDA was initially established to oversee how food was
prepared for consumers. This became necessary because as more people moved from rural to urban areas, they
depended on others to grow and produce the food they needed.
In 1938, the Food, Drug, and Cosmetic Act (FDCA) of 1938 was passed, significantly enhancing labeling
requirements. The FDCA required food labels to include the product’s recognizable name and standardized
information related to the identity, quality, and amount in the container (Lam & Patel, 2022).
Later, in the second half of the 20th century, the focus of nutrition shifted toward nutrition and its relationship to
health (USDA & USHHS, n.d.). In 1977, the first-ever federal guidance related to diet quality was published in
Dietary Goals for the United States. These goals were intended to improve the typical American diet to decrease the

1.1 • What Is Nutrition? 9
incidence of heart disease. The development of these goals prompted pushback from some members of the food
industry. For example, the goals originally recommended to reduce the intake of red meat in the diet. However,
groups such as the National Cattlemen’s Beef Association opposed this recommendation since it would negatively
affect the beef industry. Consequently, the language in the federal guidelines was changed from minimizing red
meat to selecting foods that will minimize saturated fat intake (Stillerman, 2019).
Continuing this new shift in perspective, in 1982 the Committee on Diet, Nutrition, and Cancer, National Research
Council presented their findings on the relationship between diet and cancer. These findings served as a foundation
to promote nutritional factors and dietary needs that decrease the incidence of cancer. Not only did the report
discuss foods linked to the potential development of cancer, but it also identified foods that supported cancer
prevention. This study specifically mentioned macronutrients and micronutrients found in the diet and their impact
on cancer development and/or prevention. This introduction of macronutrients and micronutrients to the public
facilitated several agencies to take active roles in promoting dietary agendas. For example, the Nutrition Labeling
and Education Act of 1990 prompted all food packaging entities to label foods with nutritional information and
serving sizes.
Through the years, visual displays of government food guides have been modified to reflect the changing
perspectives. The first guide, released in the 1940s, divided foods into seven groups and encouraged people to eat
foods from all groups as well as food not included in the seven groups without specifying amounts. The widely
recognized Food Guide Pyramid was first introduced in the 1990s and underwent several revisions until it was
replaced by MyPlate in 2011 (Davis & Saltos, n.d.; USDA, 2021). The most recent dietary guidelines for Americans,
2020–2025, uses the original MyPlate visual guide to recommend small, simple changes to improve diet quality.
Nutrition for Wellness

The Global Wellness Institute defines wellness as pursuing activities, choices, and lifestyles leading to holistic
health. Multiple factors influence a person’s health, including nutrition. Good nutrition is essential for keeping the
population healthy (CDC, 2021).
Origin of Nutrition Related to Wellness

The ancient Greek physician who influenced much of modern medicine, Hippocrates, is credited with saying, “Let
food be thy medicine and medicine be thy food” (King, 2019). This appears to be one of the earliest statements
acknowledging the role of nutrition in maintaining health. In 1948, the World Health Organization (WHO) defined
health as “a state of complete physical, mental and social well-being and not merely the absence of disease or
infirmity” (WHO, n.d.). This definition reflected a growing emphasis on a holistic perspective of health.
Weight Versus Body Mass Index

Several measurements are recognized and used to assess a person’s nutritional status and identify individuals at
risk for illness or disease. These indicators go beyond simply measuring a person’s weight to assess body
composition and weight distribution. Body mass index (BMI) is a formula that calculates the ratio of weight and
height to classify individuals as underweight, healthy weight, overweight, or obese. The waist-to-hip ratio (WHR)
calculates the ratio of the circumferences of the waist to the hip. Evidence has shown that individuals with excess
weight around their midsection may be at higher risk for certain health conditions. These assessments can be done
at home or with a health care provider to gain important information about an individual’s dietary-related health.
SPECIAL CONSIDERATIONS
BMI and Diverse Populations
Recently, the routine use of BMI as a lone indicator of obesity has been scrutinized as a result of research that
shows BMI may not be a reliable indicator for diverse populations. The American Medical Association (AMA) has
adopted a new policy clarifying the use of BMI as one means of identifying obesity. The policy states that BMI
should not be used exclusively to identify obesity; instead, it should be used in conjunction with other
assessment tools. The policy acknowledges the BMI assessment is based on data from non-Hispanic White
populations and does not consider differences in body shape and composition across different race/ethnic
groups, sexes, or age groups (AMA, 2023).
CALCULATING BMI
BMI is a screening tool used to identify clients who are overweight or obese. Considering the recent policy
change by the AMA, nurses should stay abreast of new research to determine how to incorporate BMI
measurements when working with diverse client populations. BMI does not measure body fat directly but
correlates with other more direct measures of body fat such as skinfold thickness measurements. High BMI can
be correlated with obesity-linked adverse health outcomes. To determine BMI, input the client’s height and
weight into the Adult BMI Calculator (https://openstax.org/r/cdchealthyweight). Use Table 1.2 to interpret the
results.
BMI Weight Status

< 18.5 Underweight
18.5 to < 25 Heathy weight
25.0 to < 30 Overweight
30.0 to < 35.0 Class 1 obesity
35.0 to < 40.0 Class 2 obesity
> 40.0 Class 3 obesity
TABLE 1.2 BMI Weight Classifications (source: CDC, 2022a)
MEASURING WHR
Clients may be self-conscious about having body measurements taken. Provide privacy for your client when
taking these measurements. To determine WHR, with the client standing upright, use a tape measure to measure
the distance around the smallest part of the client’s waist (waist circumference) and then the largest part of the
client’s hip (hip circumference). Then divide the waist circumference by the hip circumference or use this online
calculator (https://openstax.org/r/thecalculatorsite) to determine the WHR. The result is determined using Table
1.3.
Health Risk Women Men

Low ≤ 0.80 ≤ 0.95
Moderate 0.81–0.85 0.96–1.0
High ≥ 0.86 > 1.0
TABLE 1.3 WHR Health Risk Classifications (source: Van De Walle, 2019)
Health Promotion
Healthy People 2030 is a framework of U.S. public health objectives designed to improve the health and well-being
of the population (USHHS, ODPHP, n.d.). Since its initial release in 1980, it has been updated each decade to shape
health promotion and disease prevention strategies in the U.S. (CDC, 2023). In terms of nutrition, Healthy People
2030 aims to help people get the recommended amounts of healthy foods to reduce their risk for long-term
diseases and improve their health (USHHS, ODPHP, n.d.)
1.2 Interdisciplinary Teams and Nutrition in Nursing Practice

LEARNING OUTCOMES
• 1.2.1 Discuss the interdisciplinary nature of nutrition and client care.
• 1.2.2 Approach nutrition in nursing practice using the National Council of State Boards of Nursing
(NCSBN) Clinical Judgment Model.
An Interdisciplinary Team Approach to Meeting Client’s Nutritional Needs

The nurse is one part of an interdisciplinary team caring for the client. Nutrition affects all aspects of a person’s care.

1.2 • Interdisciplinary Teams and Nutrition in Nursing Practice 11
Decisions made by each practitioner affect the client’s nutritional status and influence decisions by other team
members. A coordinated, interdisciplinary approach can improve health care quality and outcomes (Bendowska &
Baum, 2023).
Although the primary health care provider (PCP) typically orders a specific diet for clients to follow, the PCP will
often have a dietitian meet with the client to review their history, physical examination, and lab values to determine
a nutrition care plan for the client. Additional input regarding nutrition may be obtained from other members of the
team based upon their area of expertise and the client’s needs. The nurse can work with the client and family to
identify preferences and likelihood of adherence to a specific diet regime. The nurse can assist the client in
understanding specific benefits of nutritional recommendations, as well as develop a plan for the client to adopt
healthy eating into their lifestyle.
Interdisciplinary Team Introduction

Dietary evaluation can begin in either the acute care setting or outpatient setting. When started in the acute care
setting, a nutritional plan (meal plan) is generally developed to address a specific need with a short-term goal. For
example, a client with chronic congestive heart failure experiencing an acute exacerbation would need to decrease
sodium consumption to decrease fluid retention. Dietary evaluation in the outpatient setting can help develop a plan
that focuses on steps that yield long-term goals. For example, a client diagnosed with Class 1 obesity could benefit
from weight reduction to decrease the risk of developing type 2 diabetes. Or, a patient already diagnosed with type 2
diabetes could benefit from dietary counseling as an intervention to manage the condition. See Table 1.4 for an
example of the roles of an interdisciplinary team.
Client and Health Care Dietitian Nurse Speech Other Specialists

Family Provider Therapist
Shares Makes initial Assesses Assesses Assesses Occupational therapist,
personal dietary order client’s client’s client’s physical therapist, mental
preferences, based on nutritional understanding ability to health counselor—for
ability to history and needs and of proposed swallow example, occupational
obtain and physical exam, develops nutritional plan therapists can assess self-
prepare laboratory nutritional plan and provides feeding skills and the
specific results, and based on ongoing need for adaptive
foods/ client client’s assessment of equipment
nutritional interaction preferences eating habits
supplements and budget
TABLE 1.4 Roles of an Interdisciplinary Team as They Relate to Clients’ Nutritional Needs
Integrative Nutritional Essentials and Evidence-Based Practice

Integrative nutrition combines medical nutritional therapy with functional medicine and other disciplines to
provide education and guidance for a personalized diet based on whole foods and lifestyle recommendations
(Center for Integrative Nutrition, n.d.). The integrative nutrition approach supports a multidisciplinary approach to
managing nutrition. Evidence-based practice (EBP) involves using the best evidence to deliver health care (Chien,
2019). Nutritional interventions should be based on evidence to improve patient outcomes.
Clinical Nursing Practice and Integrative Nutritional Essentials

Nursing practice has always had a holistic focus (Thornton, 2019). With this perspective, the nurse should view the
client’s physical and nutritional status in concert with other factors, consistent with the framework of integrative
nutrition. In a holistic practice, psychological, social, and cultural factors should be addressed when working with
clients to develop a nutritional plan (meal plan).
The National Council of State Boards of Nursing Clinical Judgment Model

The NCSBN developed the NCSBN Clinical Judgment Measurement Model (NCJMM) in conjunction with the updated
National Council Licensure Examination (NCLEX). This model is an evidence-based tool for NCLEX testing and pre-
licensure preparation. The model is used to evaluate prospective entry-level nurses’ clinical judgment and decision-
making ability (NCSBN, 2023).
NCJMM OVERVIEW
The NCJMM adds complexity and clinical context to NCLEX testing items to better simulate real-world practice
(NCSBN, 2019). This NCJMM video (https://openstax.org/r/ncsbnorgvideo) provides an overview of the model.
Understanding the model can better prepare nurses to take the NCLEX and apply what was learned in school to
post-graduate work.
Nursing Process
The nursing process represents a five-step approach to client-centered care: assessment, diagnosis, planning,
implementation, and evaluation (Toney-Butler & Thayer, 2023). During the assessment phase, most health and
medical history questions are relevant to the client’s nutritional status. Questions specifically related to nutrition are
those asking for a dietary recall (record of what the client has eaten during a specified time frame) or asking about
food frequency (how much of a food is consumed and how often). Other relevant questions include questions about
food preferences, food preparation ability and concerns, how the client accesses food, and cultural and religious
concerns related to nutrition. Again, many aspects of the physical assessment are related to nutrition. However, the
nurse can easily collect assessment findings directly related to nutrition: height, weight, and other body
measurements such as waist-hip measurements.
NCSBN Clinical Judgment Model Identification

The NCJMM has expanded the traditional nursing process model to focus on clinical judgment and to align more
closely with real-world nursing practice (Ignatavicius & Silvestri, 2023).
This educational resource will use the NCJMM as the framework to drive nursing care. The NCJMM provides a
systematic approach to assess the client, analyze their situation, and form a plan of care incorporating best EBP.
NCJMM AND NCLEX EXAM
The NCJMM is an evidence-based framework that outlines the clinical decision-making process for nursing
students and new graduates. Visit this NCLEX website (https://openstax.org/r/nclexclinical) to learn more about
this model and how it relates to the traditional nursing process. This model is the foundation for designing the
NCLEX exam that all nursing students must pass to become registered nurses.
1.3 Nutrition and Population Health

LEARNING OUTCOMES
• 1.3.1 Identify the roles that government agencies and nonprofit organizations play in the creation,
implementation, and enforcement of nutritional regulations.
• 1.3.2 Describe current USDA dietary guidelines, including MyPlate.
• 1.3.3 Analyze the primary sources of consumer nutrition information.
• 1.3.4 Assess the importance of client education for promoting healthy nutritional habits.
The U.S. Department of Agriculture

It is difficult to separate an individual from the community when assessing personal ability to meet nutritional
needs. Factors such as food accessibility, ability to prepare foods, and traditional dietary preferences play a role in
how a client can adopt a dietary lifestyle conducive to health and wellness. Government regulations and programs
and the availability of appropriate consumer nutritional education can influence these factors.
The USDA leads 29 agencies that oversee food production and consumption. The USDA (n.d.) recognizes poor
nutrition as a substantial factor in illness in the U.S.—poor nutrition is linked to diabetes, obesity, and heart disease.
These illnesses impact the nation more broadly by decreasing productivity and increasing health care costs. To
foster health, the USDA promotes research to build support and collaboration to provide all Americans equitable
access to healthy foods. The USDA’s Food and Nutrition Service works to address food insecurity and provide
evidence-based nutritional guidance to consumers (USDA Food and Nutrition Service, n.d.).

1.3 • Nutrition and Population Health 13
As part of the USDA’s commitment to connecting all Americans with access to affordable, healthy food, the USDA
manages programs designed to provide Americans of limited income or with special needs with healthy food. For
example, the Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides a monthly allotment
for enrollees to purchase certain nutrient-dense foods. The National School Lunch Program (NSLP) provides
nutritional, low-cost or free lunches to eligible school-age children. Table 1.5 lists food assistance programs
available through the USDA for qualified individuals.
Program Website
Supplemental Nutrition Program for Women, Infants, https://www.fns.usda.gov/wic (https://openstax.org/r/
and Children (WIC) fnsusdagov)
Farmers Market Nutrition Program (FNMP) https://www.fns.usda.gov/fmnp/wic-farmers-market-
nutrition-program (https://openstax.org/r/fmnp)
Fresh Fruit and Vegetable Program (FFVP) https://www.fns.usda.gov/ffvp/fresh-fruit-and-
vegetable-program (https://openstax.org/r/ffvp)
Supplemental Nutrition Assistance Program (SNAP) https://www.ers.usda.gov/topics/food-nutrition-
assistance/supplemental-nutrition-assistance-
program-snap/ (https://openstax.org/r/ers)
Farmers Market Grant Program administered jointly https://www.fns.usda.gov/snap/farmer-producer/
with the National Association of Farmers Market farmers-market-grant-program (https://openstax.org/
Nutrition Programs (NAFMNP) r/snap)
Healthy Fluid Milk Incentives (HFMI) https://www.fns.usda.gov/snap/healthy-fluid-milk-
incentive (https://openstax.org/r/snaphealthy)
The Emergency Food Assistance Program (TEFAP) https://www.fns.usda.gov/tefap/emergency-food-
assistance-program (https://openstax.org/r/tefap)
National School Lunch Program (NSLP) https://www.fns.usda.gov/cn (https://openstax.org/r/
School Breakfast Program (SBP) fns)
Special Milk Program (SMP)
Child and Adult Care Food Program (CACFP)
Summer Food Service Program (SFSP)
Team Nutrition
The Patrick Leahy Farm to School Program
TABLE 1.5 USDA Resources for Food Assistance Programs
The USDA also plays an essential role in regulating food production and distribution to ensure food quality and
safety. The Food Safety and Inspection Service is the primary USDA agency that enforces safe processing and
packing regulations of meat, poultry, and egg products.
The USDA actively promotes nutrition through educational materials. From the provision of curricula available for
school-age children in both English and Spanish, Team Nutrition—an initiative to support child nutrition—utilizes
visually appealing materials to promote nutrition various ways.
The Dietary Guidelines for Americans 2020-2025 are designed for policymakers and health professionals to assist
in their efforts to promote a healthy, nutritious diet (USDA & USHHS, 2020). MyPlate, a resource directed towards
consumers and based on the Guidelines, provides practical information on nutritious foods for consumers to use
daily. The MyPlate campaign uses the image of a plate colorfully sectioned into recommended proportions of food
for a nutritious meal. Fruits and vegetables comprise half of the plate, grains are approximately one-fourth of the
plate, and protein occupies the remaining section. Low-fat or fat-free dairy is represented by a glass next to the
plate. The MyPlate website encourages everyone to “start simple with MyPlate” and “make every bite count” (USDA,
n.d.).
Cultural Food Traditions
The USDA recognizes the importance of incorporating cultural food traditions when planning a healthy diet. The
Dietary Guidelines for Americans 2020–2025 are meant to be a framework for individuals to use to plan meals
that are nutritious yet reflective of their culture/ethnic food preferences. To assist with educating clients from
diverse backgrounds, MyPlate educational materials are available in many different languages.
The U.S. Food and Drug Administration

One of the oldest U.S. government agencies is the FDA, which has been the driving force behind labeling. Earlier
versions of food labels focused solely on listing accurate ingredients. In recent years, labels have evolved to provide
more detailed nutritional information to consumers. The FDA recently updated the Nutrition Facts label on packaged
food and drinks to incorporate current research and public input (Figure 1.2). The changes were designed to make it
easier for consumers to make good food choices to improve health and wellness. In addition to the new changes,
the FDA also engaged in a campaign to strategically support consumer education to decrease poor nutrition that
contributes to disease and death.
NEW NUTRITION FACTS LABEL
Access multimedia content (https://openstax.org/books/nutrition/pages/1-3-nutrition-and-population-health)

This is a 30-second “commercial” designed to highlight key changes in the new Nutrition Facts label. Watch the
new nutrition facts label video to see how nutrition information can be presented in an entertaining format.
FIGURE 1.2 The FDA updated the Nutrition Facts label in 2016. (credit: “On May 20, 2016, the FDA announced the new Nutrition Facts
label for packaged foods to reflect new scientific information, including the link between diet and chronic diseases such as obesity and
heart disease”/U.S. Food and Drug Administration, Public Domain)
EDUCATION ON THE NEW NUTRITION FACTS LABEL
Learn more about the FDA’s new Nutrition Facts label using this interactive resource: Interactive Nutrition Facts

1.3 • Nutrition and Population Health 15
Label (https://openstax.org//r/accessdatafda). Select different label components to learn more about each one
and how each appears on the new label. Then, test your knowledge of the new label by taking a brief quiz.
In addition to consumer education, the FDA offers professional continuing education on the new Nutrition Facts
label. Visit Healthcare Professionals | FDA (https://openstax.org/r/fdafood) to access educational materials
designed to help health care professionals understand the new label and how to incorporate it into their practice.
U.S. Nonprofit Organizations

Nonprofit organizations work to advance good nutrition through advocacy for pro-nutrition policies and by providing
consumer education and wellness promotion. These organizations may focus solely on nutrition or on reducing the
effects of illness and disease. For example, in 2006, the American Heart Association promoted health via nutrition
by presenting the Diet and Lifestyle Goals for Cardiovascular Disease Risk Reduction. These guidelines, reviewed
and updated in 2021, recommend the following nutritional recommendations as part of a comprehensive plan to
decrease the risk of cardiovascular disease:
• A variety of fruits and vegetables

• Whole grains
• Healthy sources of protein (mostly plants, nuts, fish and seafood, low-fat or nonfat dairy, and lean unprocessed
meat and poultry)
• Liquid non-tropical vegetable oils
• Minimally processed foods
• Minimal added sugar intake
• Foods prepared with little or no salt
• Limited or preferably no alcohol intake (AHA, 2023)
Health care organizations also provide free nutritional resources. For example, Johns Hopkins Medicine offers
Health, a vast online resource discussing healthy eating, vitamin use, diets for specific illnesses, and consumer tips.
Table 1.6 lists nonprofit websites to explore available information related to nutrition, health, and wellness.
Organization Website
Action for Healthy Kids https://www.actionforhealthykids.org/
(https://openstax.org/r/actionforhealthykids)
American Diabetes Association https://diabetes.org/healthy-living/recipes-nutrition/
healthy-food-choices-made-easy
(https://openstax.org/r/diabeteshealthy)
American Heart Association https://www.heart.org/en/healthy-living/healthy-
eating/eat-smart/nutrition-basics
(https://openstax.org/r/hearthealthy)
Johns Hopkins Medicine https://www.hopkinsmedicine.org/health/wellness-
and-prevention/food-and-nutrition
(https://openstax.org/r/hopkinsmedicine)
Mayo Clinic https://www.mayoclinic.org/healthy-lifestyle
(https://openstax.org/r/mayoclinic)
Meals on Wheels America https://www.mealsonwheelsamerica.org/
(https://openstax.org/r/mealsonwheelsamerica)
National Alliance for Nutrition and Activity https://www.cspinet.org/protecting-our-health/
nutrition/national-alliance-nutrition-and-activity
(https://openstax.org/r/cspinet)
TABLE 1.6 Nonprofit Websites Providing Nutritional Information
Consumer Health Information

The trend toward consumer awareness and personal responsibility has dramatically affected how food and nutrition
are currently promoted. Nurses can use the wealth of available resources to promote a healthy relationship with
food for individuals, families, and populations.
Consumer health information is widely available through the Internet and other media sources (television, podcasts,
magazines, etc.). When using consumer health resources, first assess the scientific validity of the information (North
Dakota State University, 2019). For all media sources, the author or speaker should be qualified to write or speak on
the topic, and the research sources supporting the material should be clearly identified. Online information should
come from a reputable website. Government websites (ending in .gov), educational organization websites (ending in
.edu), and nonprofit agencies (ending in .org) are considered the most reliable sources of online information.
The nurse should instruct clients to review nutritional information with a questioning attitude. Clients should be
wary of nutritional information that includes any of the following:
• Strategies that sound too good to be true

• Nutritional recommendations that are too simplistic or dramatic, and unlikely to be supported by scientific
evidence
• Identifying specific foods as “good” or “bad”
• Nutritional guidance that is promoted by nonscience-based testimonials or celebrities or that has supporting
research “underway”
• Guidance not supported by more than one study and not recommended by reputable scientific organizations
(North Dakota State University, 2019).
Of course, even the most accurate information may not be appropriate for a particular client. The nurse should use
clinical judgment to determine whether the nutritional information applies to the client’s situation. Additionally, the
nurse should consider the client’s literacy level and ability to understand what is being explained.
Health Literacy
An essential factor in the effectiveness of labeling or any health education is the ability of the client to read and
understand the information. Health literacy is the ability to “obtain, process, and understand basic health
information and services needed to make appropriate health decisions” (USHHS, ODPHP, 2021). In 2010, the
USHHS released a National Action Plan to Improve Health Literacy. Fundamental to this plan is the belief that all
people have the right to make informed decisions and that health services should be delivered in ways that support
this right. Services should be provided in ways that are easy to understand and that promote healthy living (USHHS,
ODPHP, 2021). Accordingly, limited health literacy is linked to poor health outcomes (USHHS, ODPHP, 2021).
CLINICAL TIP
Improve Communication with Health Professionals

Helping clients communicate with the health care professionals they work with will improve their care and
health-related outcomes. Encourage clients to use these strategies to promote good communication:
• Recommend the client write down or record information during their visit.
• Encourage the client to ask questions if something is not clear. Have the client confirm who to call if
questions arise later.
• Advise the client to let the health care team know if the client does not understand what is being said. If the
information is confusing or complicated, provide materials written in plain language that does not include
medical terminology.
• Suggest that someone accompanies the client to their next appointment (if appropriate). This person can
help take notes and ask questions. If the client does not speak the same language as the health care
provider, an interpreter credentialed for health care services is needed. Family members should not be
expected to act as medical interpreters. (U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion, 2010)
Client Readiness to Learn and Client Teaching Strategies

Nurses should ensure clients have the skills and knowledge they need to participate effectively in their health care
(Hendler, 2022). However, attempting to teach clients when they are not interested in learning is challenging.

1.4 • Vulnerable Populations 17
Accordingly, the nurse’s overall client assessment involves determining the client’s readiness to learn. The following
questions can help the nurse identify cues relevant to learning readiness:
• Does the client express an interest in the subject?

• Does the client ask relevant questions?
• Is the client’s body language consistent with someone who is paying attention?
• Does the client appear distracted and disinterested?
To try to increase the client’s interest in learning, the nurse should take time to establish rapport. The nurse should
ask the client questions to learn more about the client’s preferences and needs and explain the benefits of learning
the material.
Assessing readiness to learn is part of a more extensive assessment that should occur when preparing to teach
clients. Hendler (2022) summarizes an approach to effective teaching:
• Assess the client’s learning style.

• Determine the client’s strengths and weaknesses.
• Identify the client’s learning needs.
• Identify any relevant cultural or religious considerations.
During the teaching session the nurse should:
• Use appropriate resources for the client’s situation and literacy level. Obtain an interpreter who is credentialed
in medical interpretation if needed.
• Involve family or close friends in the session when possible since they are involved in the client’s health care
and daily living.
• Communicate using plain language that minimizes the use of medical jargon.
• If possible, teach the content over multiple sessions.
Evaluation of Effectiveness of Client Teaching

The nurse should evaluate client teaching to determine if the client has understood the information and applied it to
their life. Most frequently, client teaching is evaluated using feedback from the client. This can be verbal feedback.
For example, can the client answer relevant questions correctly? The nurse could have the client explain in their own
words what the nurse has said; the nurse could also demonstrate the material taught, if applicable. If possible, the
nurse should check in with the client later to monitor progress and answer any additional questions. Also, the nurse
should monitor any relevant client outcomes. For example, have blood glucose levels or hemoglobin A1C (HbA1c)
levels improved after instructing a client with newly diagnosed diabetes on diet management of the condition?
Holistic Assessment of Cultural Considerations

A client’s culture is intertwined with their health, requiring providers to continually learn more about their values,
beliefs, and ways of life (Gbareen, Barnoy & Theilla, 2021). A cultural assessment involves more than identifying any
language barriers. The nurse should seek to understand the client’s perspective, preferences, or social norms that
are part of the client’s life and affect the client’s food preparation and consumption.
1.4 Vulnerable Populations

LEARNING OUTCOMES
• 1.4.1 Assess the impact of food insecurity on health and food choices.
• 1.4.2 Describe ways to promote food security.
Social Determinants of Health

Nurses must consider that clients’ health problems can be affected by nonmedical factors. Individual clients are
part of larger groups whose health is affected by social, demographic, and environmental forces. Unfortunately,
certain populations are more likely to experience negative health outcomes related to these influences.
Social determinants of health (SDOH) are nonmedical factors that affect individuals’ health (USHHS, 2021;
ODNPHP, n.d.). Examples of SDOH include the following:
• Safe housing, transportation, and neighborhoods

• Racism, discrimination, and violence
• Education, job opportunities, and income
• Access to nutritious foods and physical activity opportunities
• Polluted air and water
• Language and literacy skills
One of the goals of Healthy People 2030 is to address SDOH and create social, physical, and economic conditions
that promote health and well-being for all.
Food Insecurity
Food insecurity is access to nutritious foods that is limited or uncertain because of social or economic factors
(National Institute on Minority Health and Health Disparities [NIMHHD], n.d.). Clients with food insecurity do not
have consistent, reliable sources of nutrient-dense foods. Poverty, long-term health conditions, and racial
discrimination are some of the factors that can lead to food insecurity (Feeding America, 2023). In 2020, almost
15% of U.S. households experienced food insecurity at some point in time (NIMHHD, n.d.). Nurses should screen
clients for food insecurity as part of a nutritional assessment.
Food Insecurity
As part of a nutrition assessment, clients should be screened for food insecurity. The USDA has a Household
Food Security Survey (HFSS) that can be used. However, researchers have developed a brief two-question tool
based upon the HFSS that can be used to quickly screen clients. The Hunger Vital Sign includes two statements
that can be read during a client interview; the client should respond to each statement as “often true,”
“sometimes true,” or “never true” for their household in the last 12 months. If the client responds “often true” or
“sometimes true” to either question, the screening for food insecurity is positive.
1. “We worried whether our food would run out before we got money to buy more.”
2. “The food we bought just didn’t last, and we didn’t have money to get more.”
The Hunger Vital Sign screening is easy to use and is increasingly being built into electronic health record
systems (Gattu et al., 2019).
Impact on Health and Food Choices

Local environments influence food insecurity significantly (NIMHHD, n.d.). For example, food deserts are geographic
areas that lack access to affordable, healthy food. These can be rural or urban areas that lack grocery stores with
healthy food options. In some areas, there may be stores that sell food, but the food is not nutritious. Food swamps
are areas with stores that sell food, but the food is high in calories, sugar, sodium, and/or fat—often referred to as
junk food.
When people do not have reliable, nutritious food sources, they cannot follow recommended diets. As such, food
insecurity is associated with poor health outcomes. People with food insecurity are at increased risk for long-term
health conditions, including diabetes, obesity, and heart disease (NIMHHD, n.d.).
Promoting Food Security

Food security means having enough food for an active, healthy life (NIMHHD, n.d.). Promoting food security
necessitates educating and referring clients to additional resources (Hunger + Health, 2023). Food
literacy—understanding labels and making good food choices—is critical to improving food security (Devine &
Lawlis, 2019). Sometimes the client can access adequate quantities of food, but it is not quality, nutrient-dense
food. For example, the client may eat a lot of fast food or junk food from a convenience store. Although education is
essential to improving the client’s diet, education alone is not enough. The client needs access to the types of foods
recommended through client teaching. Nurse referrals to community agencies for food and other financial
assistance are essential.

1.5 • Evidence-Based Practice and Nutrition 19
Vulnerable Populations
Some groups in the U.S. are considered vulnerable populations because nonmedical factors limit their ability to
achieve health and wellness (CDC, 2022b). Examples of vulnerable populations include racial or ethnic minority
groups, low-income groups, migrants, older adults, and children. When assessing clients, nurses should consider
whether they are part of a vulnerable population and plan interventions accordingly.
The County Health Rankings & Roadmaps (CHR&R) provide data to raise awareness of factors that influence health
in a community. This information is available for anyone to access. Nurses can use this information to learn more
about the clients they treat. Communities can use the information obtained from these rankings to promote health
equity and improve the overall health of their citizens. The CHR&R model identifies SDOH and how they relate to
citizens’ health factors. Communities can develop policies and programs to influence these health factors that
influence health outcomes.
Connect Health Literacy and Health Equity
Teaching nutrition using resources and strategies that address health literacy needs also promotes health
equity. Teach clients in a way that matches their cultural, language, and environmental needs, so they are more
likely to understand and accept what is being taught (USHHS, 2021). Health literacy can make information
easier to understand and health equity can make the information more inclusive.
COUNTY HEALTH RANKINGS
How healthy is your community? Review health data for any county in the U.S.—visit the County Health Rankings
& Roadmap website (https://openstax.org/r/countyhealthrankings) and search by state, county, or zip code to
obtain health data for a community of interest. Compare health-related metrics in a location of interest with
metrics from other locations. The database includes several nutrition-related metrics, including obesity rates,
food environment index, excessive drinking, access to health care, and other SDOH.
1.5 Evidence-Based Practice and Nutrition

LEARNING OUTCOMES
• 1.5.1 Apply EBP to client nutrition education and care.
• 1.5.2 Use EBP to evaluate trending nutritional views.
• 1.5.3 Use EBP to evaluate trending social media influencers.
Applying Evidence-Based Practice

Health information is readily available via the Internet. Unfortunately, only some of this information is vetted for
appropriateness and validity. Nurses should steer clients toward reliable sources of evidence-based information.
EBP is fundamental to nursing practice—whether collaborating with an interdisciplinary team or working individually
with clients directly. Throughout the remainder of this educational resource, the nurse will have opportunities to
apply EBP to various nutritionally based client scenarios. Working through these scenarios, via unfolding client case
studies, will require the nursing student to apply concepts of clinical judgment (introduced from the NCJMM) to
foster health and well-being to clients across all body systems and the lifespan. Unfolding case studies will build on
prior knowledge and scenarios. When using EBP to navigate the case studies, an understanding of nutrition and
body system disorders will be used to develop the best plan of care for the client.
Diversity Implications
Research on nutrition has traditionally focused on biological relationships between diet and health. Although
this is important, researchers must consider other factors. SDOH, health disparities, and health inequities all
affect clients’ nutritional intake and need to be addressed in research. Doing this will help researchers shift their
nutritional recommendations from a “one size fits all approach” to evidence-based recommendations that can
be utilized by diverse populations (Mattes et al., 2022).
Evaluating Trending Nutritional Views

As mentioned earlier, an overwhelming amount of information is available to the consumer through the Internet.
Consumers use the Internet to search health-related issues, find health care providers, and explore available
resources. New (and sometimes not so new) nutrition trends are always appearing. Table 1.7 lists some of the more
prevalent trends in recent years. Encourage clients to use the approaches previously described in Nutrition and
Population Health to review and discuss with their health care provider any trends that they are considering.
Trend Description
South Beach Consume nutrient-rich carbohydrates and fats
Diet
Raw foods Eat unprocessed/organic foods at a certain temperature
Fasting/ Consume liquids designed to eliminate toxins
cleanse
Organic Consume food certified as grown without chemical pesticides
NonGMO Consume food certified as having no genetic modifications
Vegan/ Eliminate animal-source protein/products from the diet either completely or selectively
vegetarian depending on specific type of vegetarian diet
Gluten free Minimize or eliminate the ingestion of gluten found in wheat, barley, and rye
Paleo Eliminate modern processed foods to focus on vegetables, fruits, nuts, eggs, fish, and lean
meats
Atkins/Keto Consume high-protein, low-carb foods
Calorie Track food intake using calories; lose weight by eating fewer calories than required
counting
Whole 30 Avoid inflammatory foods for better gut health
Probiotics Eat foods containing probiotics to enhance gut and digestive health
Weight Track food intake using point system; lose weight by eating a certain level of points
Watchers
Diet apps MyFitnessPal, for example, to quantify exercise and macronutrients
Mediterranean Focus on fruit, vegetables, beans, nuts, lean meats, fish, and olive oil
Intermittent Focus on when to eat, not necessarily what to eat
fasting
TABLE 1.7 Nutritional Trends from 2000 to the Present
Evaluating Social Media Sources for Nutrition Information

Over 4 billion social media users view information on social media sites. Social media can provide 24/7 support from
other users or support groups, instant communication, and cost-effective health care options. Social media and
other Internet sites also pose security risks, provide false information, promote inappropriate sharing of research
findings, and promote self-diagnosis without the benefit of an assessment from a trained, experienced health care
provider. A recent study of nutritional information on Instagram found the quality of the content to be extremely low

1.5 • Evidence-Based Practice and Nutrition 21
(Kabata et al, 2022). When looking at social media posts, consumers should consider (Johns Hopkins Sheridan
Libraries, 2023):
• The poster—Is this person qualified to post on this topic?

• Network—Do other credible people or organizations follow this account?
• Content—Can other sources validate the information?
• Contextual updates—Is this material they usually post about?
• Age—Is this an established account, or recently created?
• Reliability—Is the information source reliable?
As the American Academy of Nutrition and Dietetics noted, EBP uses scientific evidence rather than anecdotal
evidence. This fundamental difference informs the nurse who evaluates trends in nutrition, especially those found
on social media, and makes trusted recommendations to clients.
Benefits of Social Media Sources

Several sources channel the benefits of using social media to influence nutrition and nutritional education positively.
Food Hero, an online nutrition resource provided by Oregon State University through funding from the USDA,
provides an excellent format for social media sources to use. From the inclusion of several cultural resources to
videos on demand and gardening tips, their site provides information in a dynamic format. Food Hero is found on
Snapchat, YouTube, Twitter, Facebook, and Pinterest and serves as a great example for best practices on social
media. Several other examples can be found by following the links in Table 1.8.
Website URL
Clem & Thyme https://clemandthyme.com/# (https://openstax.org/r/clemandthyme)
Nutrition
kaelyrd https://www.kaelyrd.com/about (https://openstax.org/r/kaelyrdabout)
Gathered Nutrition https://gatherednutrition.com/ (https://openstax.org/r/gatherednutrition)
no food rules https://colleenchristensennutrition.com/course/ (https://openstax.org/r/
colleenchristensennutrition)
Christy Harrison https://christyharrison.com/foodpsych (https://openstax.org/r/christyharrison)
TABLE 1.8 Registered Dietitians with Social Medial Platforms
Pitfalls of Social Media Sources

As mentioned earlier, the Internet is full of conflicting information. The nurse should encourage clients to evaluate
nutrition information on social media sites in the same way information from websites and the media is scrutinized.
Much of the nutrition advice on social media is based on anecdotal findings and experiences rather than scientific
inquiry. Non-scientific social media content can promote eating disorders, distorted views of body image, and an
unrealistic promotion of diet culture, all of which negatively impact nutrition and wellness.
22 1 • Chapter Summary
Chapter Summary
• Nutrition is the intake of food to meet the body’s interventions for clients. The client must be ready
needs. Analyzing the quantity of food intake is not to learn, and the nurse must use an individualized
sufficient; the food consumed must be nutritional. approach to teaching. Evaluate the effectiveness
• Several noninvasive body measurements are of client education by receiving feedback from the
needed for a nutritional assessment: weight, BMI, client and tracking health outcomes.
and WHR. • SDOH are nonmedical factors that affect
• Nutrition is vital to health promotion, and nutrition individuals’ health and contribute to food
plays a prominent role in Healthy People 2030. insecurity. The nurse can address food insecurity
• The nurse is but one member of the through client education and referrals to
interdisciplinary team caring for the client. The community resources.
team must work together to manage the client’s • Vulnerable populations are at risk for poor health.
nutrition. Community health needs assessments and
• Based on the nursing process, the NCJMM community health rankings provide valuable
incorporates clinical judgment to make decisions information to address nonmedical factors
required in current nursing practice. influencing health.
• The USDA and the FDA are the federal agencies • EBP is essential to select interventions that can
that oversee food production, labeling, and lead to good health outcomes.
consumption. Nonprofit organizations also play an • Consumer nutrition information is abundant on the
essential role in promoting nutrition. Internet, but not necessarily reliable or accurate.
• Education is an integral part of nutrition-related
Key Terms
body mass index (BMI) a tool using weight and appropriate health decisions
height to screen and classify individuals as integrative nutrition combines medical nutritional
underweight, healthy weight, overweight, or obese therapy with functional medicine and other
calories the units used to measure the amount of disciplines to provide education and guidance for a
energy needed or ingested daily personalized diet based on whole foods and lifestyle
diet the quantity and quality of food and drinks recommendations
consumed macronutrients water and the energy-yielding
evidence-based practice (EBP) using critically nutrients (carbohydrates, fats, and proteins) needed
reviewed, scientifically proven evidence to deliver in large amounts by the body
nursing care micronutrients vitamins and minerals
food edible substances made of protein, MyPlate a resource directed towards consumers,
carbohydrates, fat, or other nutrients provides practical information for consumers to use
food deserts areas that lack access to affordable, daily to consume nutritious foods
healthy foods nutrients substances found in foods that can
food insecurity limited or uncertain access to promote health and minimize illness
adequate and affordable nutritious foods because of nutrition the intake of food to meet the needs of the
social or economic factors body
food literacy the ability to understand labels and how social determinants of health (SDOH) nonmedical
to make good food choices factors that affect individuals’ health
food security having access to enough food for an vulnerable population a group of people whose
active, healthy life health is negatively impacted by nonmedical factors
food swamps areas that have stores that only sell waist-to-hip ratio (WHR) the ratio of waist-to-hip
calorie-dense, non-nutritive food circumferences
health literacy how much a person obtains, wellness the pursuit of activities, choices, and
processes, and understands basic health lifestyles leading to holistic health
information and services needed to make
Review Questions
1. While instructing a client on how to read and interpret a food label, which of the following would suggest the
food is not a healthy choice?

1 • Review Questions 23
a. 1 gram saturated fat

b. 10 grams added sugars
c. 4 grams dietary fiber
d. 3 grams protein
2. According to the MyPlate model, which macronutrient comprises the largest part of the plate for an adult?
a. Protein
b. Fruits and vegetables
c. Grains
d. Dairy
3. Which of the following clients should be prioritized for referral to a multidisciplinary team to manage an acute
nutritional concern?
a. A new mother who wants guidance on losing weight postpartum
b. An adult whose blood glucose levels have increased over the past 6 months
c. A client being discharged from the hospital after a myocardial infarction
d. A client with a history of colon cancer
4. A new mother needs financial assistance securing nutritious food options for her infant. Which federal agency
is the most appropriate resource for this client?
a. TEFAP
b. WIC
c. HFMI
d. SNAP
5. The nurse is analyzing a popular diet plan with a client. Which of the following information would cause the
nurse to question the validity of the presented diet?
a. It specifies a target calorie range the client is expected to follow.
b. The diet’s supporting evidence comes from a single physician affiliated with the required meal plan.
c. Following it necessitates keeping a detailed journal describing food intake.
d. Different nutrients must be consumed in prescribed amounts.
6. Which of the following client statements should prompt the nurse to screen the client for food insecurity?
a. “I don’t have a steady income.”
b. “My oven does not work well.”
c. “Sometimes my food expires before I can eat it.”
d. “I don’t know any heart-healthy recipes.”
7. Which of the following actions by the nurse would occur during the outcome evaluation phase of the NCJMM?
a. Educating the client who wants to drastically limit caloric intake
b. Recording the client’s food intake for the past 24 hours
c. Reviewing the client’s prescribed diet with a dietician
d. Measuring the client’s WHR at a follow-up visit
8. Which of the following is a social determinant of health?

a. Family history of a disease
b. Age
c. Employment status
d. Number of children
9. The nurse is helping an adult, English-speaking client understand a newly prescribed diet. What is the best
approach when selecting appropriate educational materials for the client?
a. Provide materials designed to accommodate various reading abilities.
24 1 • Suggested Reading
b. Find as many materials as possible related to the diet.

c. Provide written materials in a variety of languages.
d. Ask the client whether or not they need supplemental materials.
10. A client reports feeling overwhelmed by all the nutrition advice showing up on the client’s social media
account feed. How should the nurse respond?
a. “Show me what you are looking at on social media.”
b. “You cannot believe most of what you see online. You should rely on your health care providers for
nutrition information.”
c. “Try not to spend so much time on social media as it is a sedentary activity.”
d. “It can be overwhelming. Let’s talk about what you should look for to determine if the information is valid
and reliable.”
Suggested Reading
Impactful Ninja. (2023). 9 Best Charities That Promote Health and Well-Being (Complete 2023 List).
https://impactful.ninja/best-charities-for-health-and-well-being/
U.S. Department of Agriculture. Dietary Guidelines for Americans. https://www.dietaryguidelines.gov/
U.S. Department of Agriculture. Healthy Food. https://www.usda.gov/nutrition-security/healthy-food
U.S. Food and Drug Administration. Food. https://www.fda.gov/food
World Health Organization. (2023). Nutrition. https://www.who.int/health-topics/nutrition#tab=tab_1

CHAPTER 2
A Holistic View of Macronutrients
FIGURE 2.1 A Hawaiian spirulina bowl is an excellent source of the macronutrient protein. (credit: modification of work “Hawaiian Spirulina
Smoothie Bowl” by Jennifer Johnston; NRCS Pacific Islands Area/Flickr, Public Domain)
CHAPTER OUTLINE
2.1 Carbohydrates
2.2 Fats
2.3 Protein
2.4 Hydration
INTRODUCTION Macronutrients, or nutrients needed in large amounts, include carbohydrates, fats, and proteins
and are critical for cells, tissues, and organs. These macronutrients power cellular energy, prevent disease, and
facilitate optimal body function. Without macronutrients, life would cease.
2.1 Carbohydrates
LEARNING OUTCOMES
• 2.1.1 Describe the nutritional function of carbohydrates.
• 2.1.2 Identify the impact of carbohydrates on wellness promotion and illness prevention.
Carbohydrate Function and Metabolism

Carbohydrates are a large food category containing starches, cellulose, and sugars. They are composed of organic
carbon, hydrogen, and oxygen molecules and are found naturally in fruits, vegetables, legumes, grains, and dairy
products. The term carbohydrate refers to both simple and complex carbohydrates.
Converting carbohydrates found in food to cellular energy begins with enzyme action in the mouth and is completed
26 2 • A Holistic View of Macronutrients
by enzymes formed in the small intestine and auxiliary organs. Table 2.1 lists some enzymes and their breakdown
products. The end product of carbohydrate metabolism is a simple sugar; the three main ones involved in human
nutrition are glucose, galactose, and fructose. Glucose, a simple sugar, provides energy to cells and is the preferred
fuel for the brain and nervous system. It is a monosaccharide, which is a sugar molecule that cannot be further
metabolized.
Enzyme Produced By Site of Action Substrate Acted Breakdown Product

Upon
Salivary amylase Salivary Mouth Starch • Disaccharides
glands (maltose)
• Oligosaccharides
Pancreatic Pancreas Small Starch • Disaccharides

amylase intestine (maltose)
• Monosaccharides
Oligosaccharides Small Small Disaccharides • Monosaccharides

intestine intestine
TABLE 2.1 Some Enzymes and Their Breakdown Products
Monosaccharides link with each other in different formations to create disaccharides, compounds made up of two
monosaccharide molecules. The disaccharide sucrose is formed from one glucose molecule and one fructose
molecule; lactose is formed from glucose and galactose, and maltose is formed from two glucose molecules.
Disaccharides are present in a wide variety of foods: lactose in milk products, maltose in molasses and other
fermented foods, and sucrose in a variety of foods as table sugar. Once a disaccharide is broken into
monosaccharides, a rise in blood glucose can be seen in 10–15 min. These rapid spikes in blood glucose can be
dangerous for individuals with diabetes.
Complex Carbohydrates and Fiber

Complex carbohydrates, also called polysaccharides, comprise long chains of glucose molecules, creating starch or
fiber. The chains of glucose molecules in starch are digestible and are slowly metabolized to a monosaccharide.
Fiber is made up of plant substances, such as cellulose, and moves through the digestive system in an undigested
form. Fiber is best known for its gastrointestinal health benefits. Research shows that fiber protects against
colorectal cancer, diabetes, diverticulitis, heart disease, inflammatory bowel syndrome, and obesity (Precker, 2022;
USDA, 2022). Although the recommended fiber amount varies with age and sex, an estimated 95% of American
adults and children do not consume recommended amounts of fiber (Quagliani & Felt-Gunderson, 2016). The most
prudent advice on increasing dietary fiber is to increase high-fiber foods gradually to avoid cramping, gas, and
bloating, while ensuring adequate fluid intake. Table 2.2 lists some common foods and their fiber content.
Food Item Standard Portion Size Fiber Content (Grams)

Guava 1 cup 8.9
Pinto beans ½ cup 7.7
Brussels sprouts, cooked ½ cup 6.4
Sweet potato, cooked 1 cup 6.3
Pumpkin seeds, whole 1 oz 5.2
Green peas, cooked ½ cup 4.4
Spinach, cooked 1 cup 4.3
Baked potato with skin 1 medium 3.9
Orange 1 medium 3.7
Ready-to-eat cereal, toasted oat 1 cup 3.0
TABLE 2.2 Common Foods and the Amount of Fiber in Standard Portion Sizes (source: USDA, 2022)

2.1 • Carbohydrates 27
Food Item Standard Portion Size Fiber Content (Grams)

Crackers, whole wheat 1 oz 2.9
Edamame, cooked ¼ cup 2.1
TABLE 2.2 Common Foods and the Amount of Fiber in Standard Portion Sizes (source: USDA, 2022)
Ultraprocessed Foods
Food not eaten in its original state is considered processed. Processed foods can include something as minimally
processed as wheat milled into flour or as complex as a hot dog made from five or more ingredients. It is estimated
that ultraprocessed foods (UPFs), commercially produced food products with a long shelf life and usually high in
sodium and fat, provide 50–60% of individuals’ total daily energy consumption in some high-income countries
(Beslay et al., 2020). During ultraprocessing of grains, they are refined, thereby losing essential nutrients, and sugar
and salt are added. Therefore, UPFs are much more likely to have lower amounts of fiber and higher amounts of
sugar and salt than their unrefined versions, as well as chemical preservatives, such as nitrates and sulfides, to
extend shelf life. Table 2.3 includes examples of how whole foods, or foods in their natural state, are transitioned
into UPFs. Research studies on UPFs and type 2 diabetes have found that participants with the highest UPF
consumption had a higher risk for type 2 diabetes, with a statistically significant dose–response relationship
(Llavero-Valero et al., 2021; Seal et al., 2021; Wood et al., 2023).
Whole Food Item Minimally Processed Food Item Ultraprocessed Food Item
Peanuts Natural peanut butter Peanut butter pretzels
Apple Natural applesauce Apple danish
Soybeans Tofu Soy-based meat alternatives
Corn Old-fashioned grits Corn chips
Grapes 100% grape juice Grape jelly
Wheat 100% whole wheat bread White bread

TABLE 2.3 Some Whole Foods and Their Transition to Ultraprocessed Foods
Nurses can help increase food literacy by holding meaningful discussions with clients about where food comes from
and how it is changed as it enters the consumer marketplace. Clients should be able to identify UPFs and
understand their relationship to health issues such as obesity, hypertension, and cancer (Fiolet et al., 2018).
Creating meal plans with whole and minimally processed foods ensures the consumption of more complex
carbohydrates instead of simple sugars.
Carbohydrates and Nutrition-Related Disease

When discussing carbohydrate-related diseases with clients, the nurse should always consider the type of
carbohydrate and the amount of sugar, fat, and salt added to carbohydrate-rich foods during processing.
Carbohydrates should make up 50–65% of caloric intake. However, there is a significant difference in health impact
if 50% of carbohydrates come from sugar-sweetened beverages and salty snacks instead of whole grains, fruits, and
vegetables. Individuals with a plant-forward philosophy typically consume less meat and more fresh and minimally
processed grains, fruits, and vegetables. A plant-forward meal plan provides more fiber, less sodium, and,
consequently, lower spikes in blood glucose. Research suggests that carbohydrates found in whole foods, especially
fiber, promotes health by contributing to good gut microbiota (Clemente-Suarez, 2022). Overconsumption of any
macronutrient can contribute to weight gain. A regular diet of ultraprocessed carbohydrates has been associated
with overweight, obesity, heart disease, and type 2 diabetes (Wood et al., 2023).
Two diets rich in fruits, vegetables, whole grains, and lean meats are the Mediterranean diet and the Dietary
Approaches to Stop Hypertension diet (DASH). The Mediterranean diet is an excellent example of a diet high in
complex carbohydrates because it is rich in fruits, vegetables, beans, legumes, nuts, and seeds. The diet also
includes fish, seafood, and poultry, as well as dairy products in moderate amounts. This diet is high in omega-3 fatty
acids (from fish) and low in fat. The Mediterranean diet can be beneficial because it reduces heart disease, improves
serum lipid profiles, and decreases hypertension (Hauser et al., 2022).
Research has shown that the DASH diet can substantially lower blood pressure (Hauser et al., 2022). The DASH diet
includes minimally processed foods, and sugary beverages, sweets, and red and processed meats are discouraged.
Other research has found that rates of diabetes, cancer, metabolic syndrome, and obesity are lower in individuals
following diets like the Mediterranean and DASH diets (Shoaibinobarian et al., 2023).
Carbohydrates and Athletes
Athletes need increased molecular energy in the form of carbohydrates to sustain their energy supply during
exercise. When someone is exercising, circulating glucose is the first source of energy. This energy source is
quickly depleted, and the body then relies on stored glycogen, a large polysaccharide stored in limited amounts
in the skeletal muscle and liver. When these stores are depleted, the body metabolizes fat for additional energy.
Fat releases energy slower than carbohydrates do and requires over twice as much oxygen to complete the
breakdown. Recent research indicates that manipulating fat intake before an athletic event may further increase
endurance (Iwayama et al., 2023). Endurance athletes have practiced “carbohydrate loading” since the 1960s,
which means they deliberately maximize the amount of carbohydrate in their diet approximately three days
before a competition (Thomas et al., 2016), thereby enlarging their glycogen stores. A diet higher in
carbohydrates than usual, coupled with days of no exercise, allows for the maximum buildup of stored energy.
Milk Carbohydrate and Lactose Intolerance

People are often surprised to discover that dairy products contain sugar. Lactose, often called “milk sugar,” is a
disaccharide composed of galactose and glucose. Breaking down lactose into a monosaccharide requires the
enzyme lactase. Lactase peaks at birth so that infants can digest breast milk. If lactose intolerance is diagnosed, it is
not recommended to change to a completely dairy-free diet, as many intolerant patients can tolerate up to 12–15 g
of lactose per day without side effects (Catanzaro et al., 2021). Some people do not have this enzyme due to injury
or a defect in the small intestine. Lactose intolerance appears to occur more frequently in Africa and Asia, while
northern Europeans show better tolerance of lactose-containing foods. In the United States, it is estimated that
about 33% of the population has lactose intolerance (Alzahrani et al., 2022).
Without lactase, individuals will develop lactose intolerance symptoms such as bloating, gas, and diarrhea. They can
take steps to help minimize discomfort and still consume milk-based foods by consuming lactose-free dairy
products or taking lactase enzymes before meals to aid digestion. Additional calcium and vitamin D sources should
be pursued if clients limit their dairy intake. A possible replacement for these nutrients is plant-based dairy
products such as calcium- and vitamin D-fortified almond, rice, soy, hemp, and coconut milk if food allergies are not
a concern (Katoch et al., 2022).
Carbohydrates and Blood Glucose

For individuals attempting to stabilize their blood sugar, intentional monitoring of food intake is critical, as sugars,
starches, and fiber can affect blood glucose levels. Monosaccharides can cause spikes in blood glucose, requiring
the hormone insulin to move it into the cells. Starch and fiber cause a less dramatic rise in blood glucose. For
healthy adults, whole or minimally processed carbohydrates should supply 50–65% of daily calories. The American
Diabetes Association (ADA, 2019) recommends that the percentage of daily carbohydrates be individualized for
those with diabetes. Current recommendations include a focus on self-management of diabetes, including
individualization of carbohydrate levels based on food preferences and metabolic goals.
The glycemic index is a tool for better understanding the impact of certain foods on blood glucose. More than 4,000
foods have been ranked based on the availability of highly absorbable monosaccharides (Atkinson et al., 2021). For
example, processed foods made with refined flour and sugar, including cookies, cakes, and candy, have a high
glycemic index, whereas whole foods, such as unrefined grains and nonstarchy vegetables, have a lower glycemic

2.2 • Fats 29
index. It is important to note that the glycemic index evaluates only individual foods, not entire meals, and no
nutrient qualities are included in the glycemic index rankings (Charles, 2022).
The glycemic load is a newer and more comprehensive approach for assessing the impact of carbohydrates on
blood glucose. The glycemic load uses the glycemic index and the number of total carbohydrates in a food serving to
predict the timing and rise of blood glucose. It is a more accurate assessment of healthy food intake than the
glycemic index alone (Charles, 2022).
2.2 Fats
LEARNING OUTCOMES
• 2.2.1 Describe the nutritional function of fats.
• 2.2.2 Identify the impact of fats on wellness promotion and illness prevention.
• 2.2.3 Examine special considerations for individuals who face challenges securing adequate fat intake.
Fat Function and Metabolism

Fats are found primarily in animal foods such as meat, high-fat dairy products, and fried food, although plants are
also sources of fat in the form of oils. Fat is a concentrated energy source, supplying more than double the caloric
energy of carbohydrates or protein. See Table 2.4 for the comparison of energy in macronutrients. (Note that alcohol
also provides calories, but unlike the macronutrients, it does not provide vitamins, minerals, or fiber. Its calories are
commonly referred to as “empty” because they have no nutritional value.)
Fat helps maintain body temperature, is a critical part of fat-soluble vitamin transport, protects body organs by
cushioning them, and is an essential component of cell membranes. Hormones secreted by accessory organs assist
in fat metabolism. Although an enzyme, lingual lipase, exists in the mouth, the bulk of fat digestion occurs in the
small intestine, where ingested triglycerides (fats composed of three fatty acids and one glycerol molecule) break
down into monoglycerides and glycerol.
Macronutrient Calories (Energy) per Gram Primary Food Source

Carbohydrate 4 Grains, fruits, vegetables
Fat 9 Meat and dairy products
Protein 4 Meats, nuts, legumes
Water 0 Municipal supply, well, bottled
Alcohol 7 Beer, wine, hard liquor
TABLE 2.4 Energy Contribution of Carbohydrates, Fat, Proteins, Water, and Alcohol
Fat adds a smooth taste to foods and contributes to satiety. For instance, fat contributes to the flavor of a well-
marbled steak, a loaded baked potato, chicken cooked with skin, cereal with whole milk, coffee with cream, and
deep-fried fish with french fries. These foods are high in calories and saturated fats and may take twice as long to
digest as carbohydrates, remaining in the stomach and intestine longer and staving off hunger pangs. During fat
digestion, the intestinal cells secrete the hormone cholecystokinin, which slows pancreatic function and causes
longer gastric emptying, making the person feel full (Borer, 2023).
The fat-soluble vitamins A, D, E, and K are found only in fat-containing foods. They travel through the blood with fat
molecules from the small intestine and are stored in the liver until needed. Because the fat-soluble vitamins are
stored in the body, there is no need for daily ingestion. The storage mechanism makes deficiencies rare in the United
States except for vitamin D deficiency, which has seen a large uptick globally over the last decade. According to
Guilbeau and Watson (2022), an estimated 18% of people in the United States have inadequate levels of vitamin D
and 5% have vitamin D deficiency. Fat-soluble vitamin deficiencies may occur when fat is restricted or when a client
receives total parental nutrition without lipids.
According to the U.S. Dietary Guidelines for Americans for 2020–2025, no more than 20–35% of daily calories
should come from fat; the exception is toddlers aged 2–3 years, for whom the goal is 30–40% (U.S. Department of
Agriculture & U.S. Department of Health and Human Services, 2020). Fat is an essential nutrient critical for
metabolic functions including vitamin synthesis, long-term energy storage, and the production of essential fatty
acids. However, given its caloric density, too much fat, like too much carbohydrate or protein, can raise caloric intake
above caloric output, causing weight gain.
Saturated Fat
A saturated fat is usually solid at room temperature and is found in animal-based foods and some plant oils.
Saturated fat was first linked with heart disease in the 1950s by Ancel Keys, who proposed the diet–heart
hypothesis (Teicholz, 2023). It has been widely accepted that a decrease in saturated fats is protective against the
development of cardiovascular disease (MacDonald et al., 2022). The U.S. Dietary Guidelines for Americans
2020–2025 continue to include the recommendation to lower the intake of saturated fat. The American Heart
Association recommends a dietary pattern that achieves 5–6% of calories from saturated fat. For example, if an
individual needs about 2,000 calories a day, 120 calories at most should come from saturated fat, or approximately
13 g/day (American Heart Association, 2021). Table 2.5 lists amounts of saturated fat in some everyday foods.
Food Item Measure of Edible Portion Saturated Fat Content (Grams)

Dried coconut, raw 1 piece, about 2" x 2" 13.4
Trail mix, tropical 1 cup 11.9
Chimichanga with beef 1 chimichanga 8.5
Butter 1 Tbsp 7.2
Cheddar cheese, cut pieces 1 oz 6.0
Milk, whole (3.3% fat) 1 cup 5.1
Pork salami, dry type 2 3⅛" x ¹⁄₁₆" slices 2.4
Chicken thigh, roasted 1 thigh 1.6
TABLE 2.5 Common Foods and Their Saturated Fat Content (source: Gebhardt & Thomas, 2022)
Monounsaturated Fats
Monounsaturated fats (MUFAs) such as olive oil have become the “go-to” fat, replacing polyunsaturated fats, which
received much of the attention in the 1980s. Table 2.6 lists some common oils and their monounsaturated fat
content. All fats have the same number of calories per gram (9 g), whether saturated or not.
Oil Monounsaturated Fat Content (Grams per 1 Tbsp)

Safflower 10.2
Olive 9.9
Almond 9.5
Canola 8.2
Peanut 6.2
Soybean, hydrogenated 5.8
Sesame 5.4
Palm 5.0
Corn 3.3
Sunflower 2.7
Coconut 0.9
TABLE 2.6 Various Oils and Their Monounsaturated Fat Content (sources: Gebhardt & Thomas, 2022; USDA, 2019)
There is a difference between animal monounsaturated and plant monounsaturated fats. Animal-based mono-
unsaturated fats are present in eggs, poultry, red meat, fish, and full-fat dairy. Evidence demonstrates that research
subjects who had “a higher intake of monounsaturated fatty acids from animals had a 21% higher risk of death from
any cause” (American Heart Association, 2018). A decrease in mortality was observed when monounsaturated fats
such as olive oil were substituted for saturated fats (Guasch-Ferre et al., 2019).
Polyunsaturated Fats
Two well-known polyunsaturated fats are omega-3 and omega-6 fatty acids. Omega-3 fats play a role in heart

2.2 • Fats 31
health and are found in eggs, soybeans, flaxseed, canola oil, and fatty fish such as salmon. The role of omega-6 fatty
acid in heart health is more complex than that of omega-3. Its greatest effect appears to be strengthening of the
immune system. Omega-6 fatty acids are found in sunflower, safflower, soy, sesame, and corn oils.
Polyunsaturated fatty acids are known for their health properties and anti-inflammatory action (Currenti et al.,
2022). Polyunsaturated fats should make up no more than about 11% of the 20–35% of daily calories from fat (Liu
et al., 2016). Table 2.7 presents a comparison of the polyunsaturated content of common cooking oils.
The majority of daily fat consumption should come from unsaturated sources, i.e., monounsaturated and
polyunsaturated fats (Schweichler, 2022).
Oil Percentage of Polyunsaturated Fats

Flaxseed 73
Soybean 55–58
Corn 59
Cottonseed 52
Peanut 32
Sunflower 29
Canola 32
Safflower 13
Olive* 11
Butter** 3
Coconut** 2
*High in monounsaturated fat (71%)
**High in saturated fat (butter: 63%, coconut: 87%)
TABLE 2.7 Percentage of Polyunsaturated Fats in Common Oils (source: Gebhardt & Thomas, 2022; USDA, 2019)
Trans Fats
Artificially produced trans fats have been used as food stabilizers in baked goods, snacks, and fried fast foods for
more than 100 years (Amico et al, 2021). Trans fats make potato chips crisp and margarine spreadable, and they
add texture to peanut butter. Trans fats also appear on food labels as partially hydrogenated oils, which are created
when food manufacturers take unsaturated oils and mechanically add hydrogen ions, thereby making the liquid oil
more saturated and partially firm.
Decades of research associating trans fats with elevated low-density lipoprotein (LDL), a significant cholesterol-
carrying molecule in the blood, and lowered high-density lipoprotein (HDL), a protein/lipid molecule that removes
cholesterol from the blood, coupled with much grassroots advocacy, resulted in mandated food labeling of trans fat
in 2006. Yet, it took more than 25 years to enact a ban on artificial trans fats in food products from the time they
were first noted to be harmful (Amico et al., 2021). Small amounts of naturally occurring trans fats are found in meat
and dairy products. However, they do not appear to have the same negative impact as artificial trans fats and are not
harmful if consumed in moderation (Bendsen et al., 2011).
Cooking and Food Preparation Techniques

Fat adds flavor to food, but most Americans consume more daily fat than recommended for heart health. Fat is an
essential nutrient, and in a varied meal plan of whole grains, lean meats, and fresh fruits and vegetables, excessive
dietary fat is not usually an issue. However, cooking techniques can take the healthiest of foods and add unneeded
fat. A common example of a cooking technique that adds fat is deep frying, which can increase a food’s caloric
content by 50% or more. Vegetables are low in fat, but when breaded and fried, the caloric and fat content climb,
significantly reducing the health benefits. For example, battering and frying mushrooms, onion rings, and cauliflower
change the nutrition profile by adding a significant amount of fat to a food group with negligible fat.
Alternatives to deep frying have emerged with the widespread marketing of countertop air fryers. This innovative
cooking tool “fries” food with hot air and can save 70–80% of calories (Watson, 2021). Other more conventional
ways to eliminate fat include grilling, baking, roasting, or boiling food items and adding flavor with seasonings or
with low-fat rather than full-fat sauces. In baking, a 50% reduction of fat can be accomplished by substituting
applesauce, canned pumpkin, pureed prunes, or mashed bananas for butter. (Using low-fat margarine in baking is
not recommended because these products have added water and will affect the texture of the baked item.) Fat in
the form of monounsaturated fatty acids can be added by sautéing vegetables in olive oil or by adding avocado or
minimally processed peanut butter to toast.
Food preparation techniques, such as adding heavy dressing to a green salad, can also alter a food’s nutrition
profile. Loading a baked potato with butter, sour cream, cheese, and bacon can increase its calories dramatically.
Eating simple foods without high-fat enhancements is a real starting point for better health.
Special Considerations for Individuals Who Face Challenges Securing Adequate Fat Intake
Fat intake is a challenge for many people who consume a Western diet. However, the challenge is not securing
adequate fat but controlling the overconsumption of fat. For more than 100 years, scientists and researchers have
believed that fat plays a role in heart disease. Researchers are widely convinced that saturated fat increases LDL
cholesterol and is a significant causal factor in the development of heart disease (Kris-Etherton & Krauss, 2020).
The lack of enzymes or emulsifying agents (i.e., bile) that help digest fat impacts dietary guidance on fat intake.
Clients who have their gallbladder removed are encouraged to avoid high-fat, fried, and greasy foods, such as fatty
sauces and gravies (Rajan, 2021), for at least a week after surgery.
Today, a “food replacement message” is this: Replacing saturated fat with polyunsaturated fat, or monounsaturated
fat, and trading ultra-processed foods for a diet rich in whole, minimally processed foods may lower heart disease.
This food replacement message resonates with the U.S. dietary guidelines and the U.S. Department of Agriculture’s
MyPlate food guide and should be at the core of food literacy.
2.3 Protein
LEARNING OUTCOMES
• 2.3.1 Describe the nutritional function of proteins.
• 2.3.2 Identify the impact of proteins on wellness promotion and illness prevention.
• 2.3.3 Examine special considerations for individuals who face challenges securing adequate protein
intake.
Nutritional Function of Proteins

Proteins are found in every cell and perform various functions in the human body. The digestion of proteins begins in
the stomach with the enzyme pepsin and hydrochloric acid. The acidic environment denatures the proteins, and the
enzyme divides the protein into smaller polypeptides, which are linear organic molecules consisting of many amino
acid residues bonded together in a chain, forming part or all of a protein. The small intestine also releases digestive
hormones, including secretin and cholecystokinin, which stimulate the enzymes to break down the proteins into
individual amino acids. Accessory organs release additional enzymes and contribute to the breaking of complex
proteins into smaller individual amino acids, which are transported across the intestinal mucosa.
In the final stages of metabolism, amino acids remain in the amino acid pool, a total number of essential amino
acids and nonessential amino acids available for building proteins, which is regulated by the liver. Circulating amino
acids recombine to form every protein required for maintenance and growth. In contrast, excess protein is
converted to glucose or triglycerides depending on the body’s need for energy. The sequence of the amino acids and
folding of the protein molecule determines the function (Figure 2.2).

2.3 • Protein 33
FIGURE 2.2 The structure of a protein determines its function. (credit: modification of work from Biology 2e. attribution: Copyright Rice
University, OpenStax, under CC BY 4.0 license)
Amino acids are classified as essential if they come from food and nonessential if the body can synthesize them. See
Table 2.8 for a list of amino acids and their classification. Amino acids are continually needed to replace normal cell
breakdown. Each protein has a specific sequencing of amino acids; when one is missing, protein synthesis stops
until the muscle breaks down to free up the needed amino acids for the amino acid pool. The intricate folding of the
protein molecule is based on the function required. For example, the proteins in nails, when compared to those in
the eyes, are very different in structure because the functions are highly diverse.
Amino Acid Essential/Nonessential

Alanine Nonessential
Arginine Nonessential
Asparagine Nonessential
Aspartic acid Nonessential
Cysteine Nonessential
Glutamic acid Nonessential
Glutamine Nonessential
Glycine Nonessential
Histidine Essential
Isoleucine Essential
Leucine Essential
Lysine Essential
TABLE 2.8 Essential and Nonessential Amino Acids and Their Classification
Amino Acid Essential/Nonessential

Methionine Essential
Phenylalanine Essential
Proline Nonessential
Serine Nonessential
Threonine Essential
Tryptophan Essential
Tyrosine Nonessential
Valine Essential
TABLE 2.8 Essential and Nonessential Amino Acids and Their Classification
Protein Intake for Wellness Promotion and Illness Prevention

Protein is essential for all tissues, and regular protein intake is essential to prevent proteolysis, a breakdown of
proteins that causes loss of lean muscle mass. Because protein is essential for all tissues, it is a superstar of dietary
intake. However, protein myths have elevated this macronutrient to an extreme level. High-protein diets, protein
powder, and amino acid supplements are popular as individuals pursue well-muscled bodies. Most adults require
only 1–1.2 g of protein per kilogram of body weight daily. For example, a person who weighs 165 lb (75 kg), should
consume 75–90 g of protein daily. Protein is not stockpiled in the body. Therefore, a diet high in protein will not
make for larger muscles or longer hair and nails, but an excessive amount of protein can contribute to weight gain.
Unneeded protein is stripped of its amino group, the nitrogen is excreted in the urine, and the carbon remnant is
converted to either glucose or triglyceride for use as energy.
Proteins from animal sources provide the highest quality proteins or “complete proteins” because they contain all
the essential amino acids. Meat, fish, poultry, and eggs are complete proteins. However, individuals following a
plant-based diet can achieve complete proteins by eating various legumes, grains, and nuts. Interestingly, soy is the
only legume classed as “complete” because it contains all the essential amino acids (Metropulos, 2019). However, it
is less digestible than animal protein, as humans cannot digest cellulose in the plant cell structure.
All animal proteins contain cholesterol, so a high-protein diet of beef, pork, poultry, and eggs will also be higher in
fat and cholesterol. Lean meats cooked without added fat, poultry without skin, and egg whites instead of whole
eggs will help control fat and cholesterol and provide adequate, high-quality protein.
Protein supplements are unnecessary if an individual is in good health, moderately active, and knowledgeable about
nutrition. A well-balanced diet with lean proteins and necessary fat, carbohydrate, and micronutrients can provide
adequate nutrients without purchased supplements. The bioavailability (the way food is absorbed) of the
macronutrients and micronutrients is better for whole foods. For example, chocolate milk is a “close to perfect”
postexercise supplement (Amiri et al., 2019). It contains the ideal ratio of carbohydrates to protein and includes the
milk proteins casein and whey, which metabolize at different rates for replenishment in the short and long term
(Garden-Robinson & Christenson, 2019).
Nitrogen balance is widely used as an indicator to assess protein loss or gain. This indicator can be especially useful
following trauma or prolonged illness (Dickerson, 2016). If dietary nitrogen intake in the form of protein is greater
than what is lost, a positive nitrogen balance is achieved, reflecting a gain of total body protein. Positive nitrogen
balance is essential for growth and healing.
Conversely, a negative nitrogen balance reflects protein degradation, with protein loss higher than protein retention.
A negative protein balance in acute care substantially impacts survival (Dupuis et al., 2022). Healthy adults achieve
nitrogen balance when protein intake is the same as protein degradation. Table 2.9 lists the protein content of
animal- and plant-based foods.

2.3 • Protein 35
Food Item Measure of Edible Portion Grams of Protein

Beef, lean only (braised, simmered, or pot roasted) 3 oz 26
Chicken, roasted (meat only) 1 cup (diced) 35
Edamame (cooked) 1 cup 19
Egg (scrambled, in margarine with whole milk) 1 large 7
Halibut (baked or broiled) 3 oz 23
Hummus 1 Tbsp 1
Leg of lamb, lean only 3 oz 22
Lentils, dry (cooked) 1 cup 18
Peanut butter (regular, smooth) 1 Tbsp 8
Pork chop loin, lean only (fresh, cooked) 3 oz 27
Quinoa (cooked) 1 cup 8
Skim milk 1 cup 8
Yogurt, plain (made with lowfat milk) 8 oz 12
TABLE 2.9 Protein Content of Selected Foods (sources: Gebhardt & Thomas, 2022; USDA, 2019)
Special Considerations for Individuals Who Face Challenges Securing Adequate Protein
Intake
Negative nitrogen balance occurs in several disease states, ranging from poor protein intake, which can be related to
eating disorders or bariatric surgery, to hypermetabolic states requiring increased protein. Concurrently,
carbohydrates and fats must meet energy needs to channel proteins specifically for tissue repair and restoration
(Munoz & Posthauer, 2022). For example, more calories and protein are needed to repair and restore function during
burn or wound healing, especially in children, in whom protein needs can be as high as 2.5–4.0 g/kg/day (Clark et
al., 2017). Enteral nutrition within 24 hours of hospital admission is optimal, as oral meals cannot usually meet
these metabolic requirements.
Metabolic-associated fatty liver disease has been traditionally treated with protein restriction, resulting in improved
liver function. However, malnutrition has been noted in more than 50% of clients following a low-protein diet,
contributing to low survival rates. Protein ingestion in liver disease must be individualized because although some
clients with cirrhosis may tolerate normal protein intake, others may require targeted amino acid therapy to reduce
the breakdown of lean muscle mass (Ampong et al., 2020).
Individuals with chronic renal disease also require protein in lower amounts. The kidneys eliminate protein waste
products, so when an individual consumes less protein, the kidneys do not have to work as hard in filtering
metabolites. The amount of prescribed protein in clients with chronic renal disease depends on their glomerular
filtration rate (GFR). If the client progresses to dialysis, protein should be increased because of protein loss in the
dialysate. Table 2.10 illustrates the decrease in recommended protein intake as the GFR decreases. When the GFR
level drops below 15, the decision to begin dialysis depends on individual symptoms.
Stages of Kidney Clinical Indicators Amount of Protein (g/kg of Ideal

Disease Body Weight)
Stage 1 GFR ≥ 90 (normal); abnormal level of protein No more than 0.8
detected in urine
Stage 2 GFR 60–89 No more than 0.8
Stage 3a GFR 45–59 0.55–0.60
Stage 3b GFR 30–44 0.55–0.60
Stage 4 GFR 15–29 0.55–0.60
TABLE 2.10 Protein Needs in Kidney Disease and Dialysis (sources: American Kidney Fund, 2022; National Kidney Foundation of Hawaii,
n.d.)
Stages of Kidney Clinical Indicators Amount of Protein (g/kg of Ideal

Disease Body Weight)
Stage 5 GFR < 15 0.55–0.60
Dialysis 1.0–1.2
TABLE 2.10 Protein Needs in Kidney Disease and Dialysis (sources: American Kidney Fund, 2022; National Kidney Foundation of Hawaii,
n.d.)
2.4 Hydration
LEARNING OUTCOMES
• 2.4.1 Describe the nutritional function of hydration.
• 2.4.2 Identify the impact of hydration on wellness promotion and illness prevention.
• 2.4.3 Examine special considerations for individuals who face challenges securing adequate hydration.
Hydration Function
Water is the universal solvent; every cell, tissue, and organ requires water to transport essential substances.
Molecules dissolve into the watery blood environment and move through the body, providing cellular support. Blood
also carries breakdown products for elimination. Staying hydrated is essential to good health and can be
accomplished by responding to thirst and intentionally monitoring fluid intake. See Figure 2.3 for the use of urine
concentration as an indicator of hydration status.
FIGURE 2.3 A color chart indicates the hydration level of urine. A very pale color indicates overhydration, whereas darker colors indicate
underhydration. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC
BY 4.0 license)
Water has zero calories and is readily available. Plain water is best; tea, coffee, and sodas also provide fluids but
often contain caffeine and sugar. How much water or other fluids are needed daily depends on body size, disease
state, and activity level. According to the Academy of Nutrition and Dietetics, the recommended amount of water
consumed per day is about 11.5 cups for women and 15.5 cups for men. This includes fluids consumed from both
foods and beverages. Approximately 20% of this water comes from food consumption, which brings the fluid
recommendations to about 9 cups per day for women and 13 cups per day for men (Gordon & Klemm, 2022).

2.4 • Hydration 37
Hydration and Older Adults
Older adults are at risk for dehydration because of diminished thirst and may cut back their fluid intake to avoid
trips to the bathroom. Encouraging fluids can help mitigate poor fluid intake.
Both food and fluids help an individual stay hydrated, enabling all body functions to perform optimally.
Commercially bottled water is convenient, but given the problem with plastic waste, as well as the lack of fluoride in
most bottled water, the use of refillable water bottles is an eco-friendly and bone-healthy alternative. The Centers
for Disease Control and Prevention (2020) reports that that bottled water may lack a sufficient amount of fluoride,
which is important for oral health and preventing tooth decay.
Other highly advertised beverages include hydration drinks containing electrolytes, sugar, and caffeine. These
drinks, sometimes referred to as sports drinks, may be helpful after intense exercise in adults but are not typically
needed for children unless they are experiencing nausea and vomiting and require electrolyte replacement (Munoz-
Urtuba et al., 2023). The more vigorous and longer the duration of the exercise, the more support research has
provided for rehydration beverages containing both carbohydrates and electrolytes (McDermott et al., 2017).
Two simple ways the nurse can check for hydration status include tenting of the skin and the color of urine. The
darker the urine, the greater the need for fluid (Figure 2.3).
Water Safety
Drinking water piped into homes may come from municipal water supplies or originate from a private well. Whereas
municipal water supplies are monitored by the U.S. Environmental Protection Agency, well water is considered
“private water,” and the safety is in the hands of the well owner (U.S. Environmental Protection Agency, 2023). Safe
drinking water does not receive much attention until a public health emergency occurs. Natural disasters such as
hurricanes, floods, and tornadoes can introduce microorganisms or chemicals to municipal water supplies, making it
unsafe. The county or state health departments issue notifications for unsafe water. Usually, boiling water can kill
microorganisms (Centers for Disease Control and Prevention, 2021); however, a water filter is needed to remove
chemicals and heavy metals (Centers for Disease Control and Prevention, 2022).
HEALTHY WATER
Healthy water is usually taken for granted until sanitation or safety concerns make it a public health issue. The
Centers for Disease Control and Prevention (2022) provide education on a vast array of healthy water topics
(https://openstax.org/r/cdcgovhealthywater).
Chapter Summary
• Carbohydrates, fats, protein, and water are • Fats play many essential roles in the body, but
essential for all body systems. because of their caloric density, they can
• Helping clients manipulate proper energy intake contribute to obesity and cardiovascular disease.
while maintaining dietary recommendations and • Protein is critical to cell development; complete
satisfying personal tastes requires a basic proteins (providing all of the essential amino acids)
understanding of nutrition. are regularly needed. Protein can contribute to a
• Carbohydrates provide easily metabolized sugars diet higher in fat.
contributed by grains, legumes, dairy products, • Water guidelines cover normal fluid losses but may
fruits, and vegetables. need to be altered for certain conditions.
Key Terms
amino acid pool molecules of essential and and proteins; it removes cholesterol from the blood
nonessential amino acids regulated by the liver and low-density lipoprotein molecule comprising lipids
available for use by the body and proteins; it transports cholesterol throughout
bioavailability the ability of an organic substance to the bloodstream
enter the circulation and produce an active effect monosaccharide sugar molecule that cannot be
carbohydrates large food category that includes further metabolized
starches, cellulose, and sugars polypeptides linear organic molecules consisting of
complex carbohydrates long chains of many amino acid residues bonded together in a
monosaccharides such as those found in starch chain, forming part or all of a protein
disaccharides compounds containing two proteolysis enzymatic breakdown of proteins or
monosaccharide molecules peptides into amino acids
glucose simple monosaccharide that is an important triglycerides compounds formed from glycerol and
energy source and is found in carbohydrates three fatty acid groups; the main constituents of
glycemic index system that ranks foods on a scale natural fats and oils
from 1 to 100 based on their effect on blood glucose ultraprocessed foods foods altered by commercial
levels techniques, usually by adding five or more artificial
glycemic load method of indicating the amount of substances
carbohydrate contained in a specified serving of a whole foods foods that have been processed or
particular food and its impact on blood glucose refined as little as possible and are free from
glycogen stored form of glucose additives and other artificial substances
high-density lipoprotein molecule comprising lipids
Review Questions
1. Amber County has issued a public health warning because arsenic was found in the drinking water. What is
the safest way for community members to address this contamination?
a. Obtain water from a neighboring county.
b. Boil the water.
c. Buy a water softener.
d. Purchase bottled water.
2. The nurse is assisting a client to calculate their daily caloric intake. How many calories per gram should the
nurse advise the client to assign for water?
a. 0
b. 4
c. 5
d. 7
3. The nurse is teaching the client about the Mediterranean diet. Which instruction will the nurse give the client?
a. Decrease consumption of complex carbohydrates.
b. Increase intake of fish.

c. Avoid eating legumes.

d. Increase intake of dairy products.
4. Which instruction would the nurse give to a client who is lactose intolerant?
a. Eat lactose-free dairy products.
b. Drink milk in small amounts.
c. Take a lactase enzyme after consuming a dairy product.
d. Drink milk fortified with vitamin D.
5. The nurse is teaching the client about dietary sources of omega-3 fatty acids. Which food source will the
nurse include?
a. Meat
b. Poultry
c. Vegetables
d. Salmon
6. The nurse is assessing a client who describes the color of their urine as pale yellow. Which statement would
the nurse give to the client?
a. “You probably have a urinary tract infection.”
b. “You need to drink more fluids.”
c. “You need to decrease your water intake.”
d. “You are well hydrated.”
7. The nurse instructs a client who has been following a vegetarian diet and has asked questions about the
quality of protein in grains. After explaining about complete proteins that provide all of the essential amino
acids in one food, the nurse presents the following list and asks the client to choose the one that is a
complete protein. Which food choice, selected by the client, indicates to the nurse that the client understands
the instruction?
a. Oats
b. Barley
c. Soy
d. Wheat
8. Which food choice indicates to the nurse that a client understands postoperative dietary guidelines for
gallbladder surgery?
a. Fried grouper
b. Ribeye steak
c. Pasta with marinara sauce
d. Green salad with cheese, ham cubes, and ranch dressing
9. The nurse is providing dietary instruction to a team of college athletes. Which source of energy does the nurse
explain is used first during exercise?
a. Circulating glucose
b. Stored glycogen
c. Skeletal muscle
d. Fat stores
10. The nurse is caring for a client with stage 3 chronic kidney disease. What is the maximum protein intake for
this client who weighs 75 kg?
a. 40 g
b. 45 g
c. 50 g
d. 55 g
Suggested Reading
Blum, D. (2023, January 7). The Mediterranean diet really is that good for you. Here’s why. The New York Times.
https://www.nytimes.com/2023/01/06/well/eat/mediterranean-diet-health.html
Cafasso, J. (2019, August 3). Everything you need to know about lactose intolerance. Healthline.
https://www.healthline.com/health/lactose-intolerance Kandola, A. (2019, May 14). What to know about simple
and complex carbs. Medical News Today. https://www.medicalnewstoday.com/articles/325171#complex-
carbohydrates
National Heart, Lung, and Blood Institute. (2021, December 29). DASH eating plan. https://www.nhlbi.nih.gov/
education/dash-eating-plan
Newman, T. (2023, May 30). Types of fat: Can fat be good for you? Medical News Today.
https://www.medicalnewstoday.com/articles/141442#unsaturated-fats
Tinsley, G. (2023, July 5). Carb loading: How to do it plus common mistakes. Healthline.
https://www.healthline.com/nutrition/carb-loading#TOC_TITLE_HDR_3

CHAPTER 3
A Holistic View of Micronutrients
FIGURE 3.1 Vitamins and minerals are found in vegetables and fruits such as strawberries, which are high in vitamin C and antioxidants.
(credit: modification of work “Pike Place Farmers Market Express June 25” by Seattle City Council/Flickr, Public Domain)
CHAPTER OUTLINE
3.1 Vitamins
3.2 Minerals
3.3 Supplements
INTRODUCTION Vitamins and minerals are essential for good health yet cannot be isolated from the food that
contains these vital substances. When studying the science of nutrition, academics tend to present vitamins and
minerals in tidy packages, although stepping back and looking at the bigger picture of food and dietary patterns is
quite important. Viewing nutrition holistically can bring focus to the more advantageous practice of consuming
minimally processed foods.
Consider this case: Curtis is an elementary school-aged child living in a large generational family home in an urban
neighborhood where food choices are limited and higher priced. Curtis’s primary caregiver is his aunt, due to his
parents' unpredictable work hours. Curtis was a selective eater as a toddler, and it was easier to adhere to his
preferences than to negotiate and battle at mealtime (Taylor & Emmett, 2019). Now, in third grade and after years of
poor food variety, Curtis’s parents have growing concerns about his health and nutritional status.
42 3 • A Holistic View of Micronutrients
3.1 Vitamins
LEARNING OUTCOMES
• 3.1.1 Describe the nutritional function of vitamins.
• 3.1.2 Identify the impact of vitamins on wellness promotion and illness prevention.
• 3.1.3 Examine special considerations for populations that face challenges securing adequate vitamin
intake.
Vitamin Function
The human body obtains vitamins—nutrients the body needs in small amounts to function and stay healthy—in two
ways: food and supplementation. Vitamins were first referred to as “accessory factors” that were present in food in
small amounts but essential for health. It was not until the start of the 20th century that these factors were named
vitamins and, at the beginning of the 21st century, became a multibillion-dollar industry, with over 50% of
Americans saying they regularly take vitamins of some variety (Mishra et al., 2021).
Vitamins are separated into two classes: fat-soluble and water-soluble. Fat-soluble vitamins (A, D, E, and K) are
absorbed along with fats in the diet and are stored in the body’s fatty tissue and liver. These vitamins play critical
roles in vision, bone health, immune function, and coagulation. Water-soluble vitamins (all other vitamins besides
A, D, E, and K) are dissolved in water. Excess intake of water-soluble vitamins is excreted in the urine.
All vitamins are found naturally in foods and have specific functions. In general, vitamins play the following essential
roles (Fletcher, 2019):
• Boost the immune system

• Decrease the risk for certain cancers
• Strengthen teeth and bones
• Maintain healthy skin
• Help the body metabolize proteins and carbohydrates
• Support healthy blood
• Aid brain and nervous system functions
Vitamins A, D, E, and K
Fat-soluble vitamins include vitamins A, D, E, and K. Fat-soluble vitamins play essential roles in many physiological
processes, such as vision, bone health, immune function, and blood clotting (Reddy & Jialal, 2022). Fat-soluble
vitamins, like dietary fat, are absorbed through the lymphatic system and then released into the blood, carried by
transport proteins. Because these vitamins are stored, daily intake is not required. Excess intake of fat-soluble
vitamins, as found with some supplements, can cause toxicity—side effects from taking large doses of supplements
or medications.
Absorption of fat-soluble vitamins occurs in the small intestine where they are mixed with bile salts, fatty acids, and
phospholipids; absorbed by chylomicrons (microproteins); and carried to the lymphatic system. Since all vitamins
require carrier proteins for transportation across the lipid bi-layer, absorption can be affected adversely by a genetic
abnormality in the transport molecules (Ofoedu et al., 2021).
Vitamin A is active in the genetic development of retinol pigments and contributes to healthy bones, teeth, and soft
tissue. Vitamin A also plays a role in reproduction, facilitating semen production and cell differentiation in fetal
development. Vitamin A is critical in immune function, helping to grow the cells that produce the mucus that lines
the gastrointestinal tracts, sinuses, and genitourinary tract. This mucus traps and protects the human body from the
myriad bacteria it encounters daily. Beta-carotene—a precursor to vitamin A—is an antioxidant that protects against
certain cancers and aging by stabilizing free radicals; a free radical is an unstable molecule made during normal cell
metabolism that has one unpaired electron (Figure 3.2).

3.1 • Vitamins 43
FIGURE 3.2 An antioxidant stabilizes a free radical by donating an electron to the unpaired electron of the free radical. (attribution:
Copyright Rice University, OpenStax, under CC BY 4.0 license)
Vitamin D is a fat-soluble vitamin that closely resembles a hormone’s functions. This vitamin can trigger effects in
tissue throughout the body, turning on and off the production of proteins. Vitamin D, like vitamin A, plays a role in
immunity by promoting the secretion of infection-fighting substances found in white blood cells (Dimitrov et al.,
2021).
Vitamin D naturally occurs in some foods (fatty fish and egg yolks), is added to others (like milk and orange juice),
and is available as a vitamin supplement. Vitamin D is unusual because the body can synthesize it from a cholesterol
precursor—7-dehydrocholesterol (7-DHC)—in the epidermis with the help of ultraviolet light. In addition, vitamin D
assists in promoting calcium uptake in the gut and ensures adequate calcium and phosphorus for bone
mineralization. Bones can become thin, fragile, and deformed without sufficient vitamin D. Vitamin D prevents
rickets, the softening of the bones, which results in bowed legs, and protects against osteoporosis, the loss of bone
density, which leads to porous structure (National Institutes of Health [NIH], 2023e).
Vitamin E, a fat-soluble vitamin, acts as an antioxidant and stops the development of free radicals during fat
oxidation. Fat oxidation is a chemical reaction in which a healthy molecule loses or is robbed of one of its electrons,
which then produces an unhealthy free radical. In addition to protecting the cell from reactive oxygen species (ROS)
(reactive species capable of causing damage to biomolecules), vitamin E helps establish a robust immune system
and improves the endothelial cells on the surface of blood vessels, making them more resistant to the adherence of
clots (NIH, 2021c).
Many other claims about vitamin E exist; however, due to the difficulty in establishing biomarkers and correlating
them with clinical outcomes, recommendations for vitamin E intake continues to emerge (Institute of Medicine [U.S.]
Panel on Dietary Antioxidants and Related Compounds, 2000). Recently, the Food and Nutrition Board suggested
that vitamin E intake among healthy adults is probably higher than the Recommended Dietary Allowance (RDA) but
warns that those following a low-fat diet could experience a deficiency (NIH, 2021c).
Vitamin K, a fat-soluble vitamin, is a coenzyme required for blood clotting and bone metabolism. Vitamin K is
present in the liver and other body tissues, including the brain, heart, pancreas, and bone. Compared with other fat-
soluble vitamins, minimal amounts of vitamin K circulate in the blood due to rapid metabolism and excretion (NIH,
2021d). The clinical status of vitamin K should be regularly evaluated in individuals who take anticoagulants or have
bleeding disorders. Infants are injected with vitamin K at birth to decrease the risk of a hemorrhagic event (Hand et
al., 2022).
Because fat-soluble vitamins are stored in tissue, higher amounts of these vitamins result in toxicity. In some water-
soluble vitamins, high-potency supplementation can also result in adverse health issues (Table 3.1).
Vitamin Toxicity Symptoms*

Vitamin A • Acute Toxicity: Nausea, vomiting, anorexia, altered mental status, and muscle
pain and weakness
• Chronic Toxicity: Anorexia, hair loss, dry mucous membranes, fever, fatigue,
hyperlipidemia, hypercalcemia, bone and joint pain, and epistaxis
• Note: Isotretinoin has closely related symptoms to that of vitamin A toxicity
Vitamin D • Acute Toxicity: Anorexia, muscle weakness, headache, apathy, bone pain,
nausea, and vomiting
• Chronic Toxicity: Polydipsia, abdominal cramping, polyuria, and back pain
Vitamin E • High doses of vitamin E are usually related to vitamin supplementation

• Acute Toxicity: Headaches, tiredness, double vision, diarrhea, easy bruising,
and muscle weakness
Vitamin K • Toxicity: Jaundice in newborns, hemolytic anemia, and hyperbilirubinemia;

toxicity also inhibits the effects of oral anticoagulants
Thiamine (B1) • Toxicity: Tachycardia, hypotension, vasodilation, weakness, convulsion, and

anaphylaxis
Niacin • Acute Toxicity: Flushing, pruritus, vasodilation, headache, diarrhea, and

vomiting
• Chronic Toxicity: Jaundice, abnormal liver function, and liver toxicity
Vitamin B6 • Toxicity: Tachypnea, sensory neuropathies, and diminished tendon reflexes
Vitamin C • Toxicity: Nephrolithiasis, diarrhea, nausea, increased estrogen levels
*Not intended to be comprehensive

TABLE 3.1 Vitamin Toxicity Symptoms (source: Rosenbloom, 2023)
B Vitamins
This section outlines water-soluble vitamins, which includes the family of B vitamins and vitamin C. There are eight
B vitamins (at times referred to as B complex): thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5),
pyridoxine (B6), biotin (B7), folate (B9), and cobalamin (B12).
All B vitamins act as coenzymes for catalytic activity and several processes that support every aspect of cellular
function, including brain and nervous system functions (Hanna et al., 2022). Although almost all the B vitamins are
involved in metabolism, one cannot be substituted for another. Therefore, a specific B vitamin deficiency is
associated with a specific disease. In general, deficiency diseases related to B vitamins are rare, partly because of
the wide availability of these vitamins in everyday food items, but also because B vitamins that are commonly lost in
food processing are added back into the food. For example, when the bran and germ are removed from grains,
leaving only the endosperm, B vitamins and vitamin E are also removed (Figure 3.3). Food manufacturers add back
the vitamins during food processing. This process is called food enrichment and is subject to government oversight
by the U.S. Food and Drug Administration (FDA) (Institute of Medicine [U.S.] Committee on Use of Dietary Reference
Intakes in Nutrition Labeling [IOM], 2003; Newman et al., 2020).

3.1 • Vitamins 45
FIGURE 3.3 Food processing strips the whole grain of bran and germ and results in a refined grain. (attribution: Copyright Rice University,
OpenStax, under CC BY 4.0 license)
Table 3.2 illustrates the function of B vitamins as coenzymes, assisting in metabolizing carbohydrates, fat, and
proteins, thus producing energy for body cells via the citric acid cycle. The citric acid cycle occurs in the cell
mitochondria, also known as the cell’s powerhouse—this is where the final breakdown for carbohydrates, amino
acids, and fatty acids occurs.
Macronutrient B Vitamin Catalysts Metabolic Pathway

Carbohydrate Niacin, vitamins B1 and B2, pantothenic acid Citric acid cycle in the mitochondria of each
cell
Fat Vitamin B2, niacin, pantothenic acid Citric acid cycle in the mitochondria of each
cell
Protein Vitamins B2, B6, and B12; biotin; pantothenic Citric acid cycle in the mitochondria of each
acid cell
TABLE 3.2 Energy Production from the Metabolism of Macronutrients with B Vitamin Catalysts
B vitamins must have macronutrients (carbohydrates, fat, and protein) available for energy production. Taking a
vitamin supplement instead of a balanced meal does not provide a substrate for coenzyme action. Instead,
obtaining vitamins through foods is preferred. Remember that none of the other B vitamins can cover a deficiency of
another.
Choline, Biotin, and Folate

Other water-soluble substances that are less known include choline, biotin, and folate. Choline is an essential
nutrient, not classified as a vitamin or a mineral, and is naturally present in food. Choline is often grouped with the B
vitamins because it has similar functions. Vitamin research continues to improve classification, and in 2022 for the
first time, a set amount, or Daily Value, for choline intake was included in the Daily Values (DVs), the list of all
vitamins and minerals needed (FDA, 2022a). This nutrient is a source of methyl groups needed for many steps in
lipid metabolism and is required to generate the neurotransmitter acetylcholine. Although the body produces some
choline endogenously in the liver, the amount is sometimes insufficient; additional choline must be ingested through
food sources. Most people in the U.S. consume less than the recommended choline intake, yet a deficiency in
healthy, nonpregnant individuals is rare, possibly because of the contribution of self-synthesized choline (NIH,
2022b).
Biotin is a water-soluble vitamin that works as a cofactor that catalyzes the metabolism of fatty acids, glucose, and
amino acids. Biotin is found in many animal and plant foods. There has never been a reported case of biotin
deficiency in a healthy individual consuming a Western diet (NIH, 2022a).
Folate (B9) functions as a coenzyme in synthesizing ribonucleic acid (RNA) and deoxyribonucleic acid (DNA). Folate
is also critical in the metabolism of amino acids required for normal cell division. A lack of folate will result in large
red blood cells, which is associated with megaloblastic anemia—a condition in which the bone marrow produces
unusually large, structurally abnormal, immature red blood cells (NIH, 2022c). Large doses of folate can result in
kidney damage.
The chemical structure of folate differs from the more commonly known folic acid. Folates are naturally found in
foods, although folic acid is the fully oxidized form of the vitamin used in fortified foods and most dietary
supplements. Since 1998, the FDA has mandated that food manufacturers add folic acid to “enriched breads,
cereals, flours, corn meals, pasta, rice, and other grain products to reduce the risk of neural tube defects (NTDs)”
(NIH, 2022c). NTDs result from a developmental error in the closure of the neural tube early in pregnancy and are
one of the most common congenital disabilities in North America (National Center on Birth Defects and
Developmental Disabilities, Centers for Disease Control and Prevention, 2023). The fortification program is
estimated to have increased mean folic acid intakes in the U.S. by about 200 mcg/day, a substantial increase. An
unintentional consequence of folate fortification is that people consuming the folate-fortified foods receive extra
folate, not just women of childbearing age. However, in the older adult, the consumption of folic acid from fortified
foods increases the risk of masking megaloblastic anemia caused by a vitamin B12 deficiency (van Gool et al.,
2020).
Vitamin C (Ascorbic Acid)

Vitamin C or ascorbic acid, a water-soluble vitamin, is best known for its coenzyme and antioxidant properties (Abiri
& Vafa, 2021). Vitamin C protects cells from premature aging caused by free radicals. Vitamin C stabilizes the cell by
accepting or donating an electron. The body is constantly moving electrons around, so vitamin C is used in almost
every tissue in the body. Free radicals are the leading cause of disease and inflammation, so vitamin C’s ability to
neutralize those free radicals (acting as an antioxidant) is central to lowering heart disease and cancer risk.
Vitamin C also promotes collagen synthesis. Although collagen synthesis is required for maintaining normal vascular
function, it also provides metabolic substrates for new blood vessel development (angiogenesis), enhancing blood
supply, and bringing more oxygen to the tissues. Vitamin C is necessary for a healthy immune system and increases
the absorption of non-heme iron.
The body tightly monitors the plasma concentration of vitamin C. Approximately 70–90% of vitamin C is absorbed in
moderate intakes of 30–180 mg/day. Absorption becomes less efficient at doses above 1000 mg/day, with about
50% of the excess excreted in the urine (NIH, 2021b). Most healthy, non-smoking Americans consume enough
vitamin C-rich foods to meet the daily requirements of 90 mg/day for males and 75 mg/day for females. According
to national nutrition studies, the average vitamin C intake is about 95 mg/day without vitamin supplementation. See
Table 3.3 for common fruits and vegetables containing vitamin C.
Food and Serving Size Milligrams of Vitamin C % Daily Value

Red pepper (fresh), ½ cup 95 106
Medium orange, 1 70 78
Medium kiwi, 1 64 71
Strawberries, ½ cup 49 54
Broccoli, ½ cup 39 43
Cantaloupe, ½ cup 29 32
Baked potato, 1 17 19
TABLE 3.3 Vitamin C Levels in Common Foods (source: NIH, 2021a)
Large doses of vitamin C can have an adverse effect in people with a family history of kidney or gallstones.
Supplementing vitamin C at a level three times or more of the RDA (approximately 3000 mg) can double the amount
of oxalate filtering through the kidney and greatly increases the chance of stone formation.
Most water-soluble vitamins are absorbed in the small intestine through the process of diffusion. Riboflavin,
however, requires the assistance of a carrier molecule for it to enter the bloodstream. Many water-soluble vitamins
function as coenzymes in other cellular reactions and may require additional chemical action before tissues use
them. Differences in ease of absorption or food bioavailability, dosage, and chemical form of the vitamin all influence
the amount of the vitamin absorbed in the small intestine (Ofoedu et al., 2021).

3.1 • Vitamins 47
SAFETY ALERT
Smoking and Increased Vitamin C Needs

Clients who smoke should increase their vitamin C by 35 mg/day. They have decreased plasma concentrations of
this antioxidant due to an increase in free radicals. According to Lykkesfeldt and Tveden-Nyborg (2019), “Active
smoking typically depletes the vitamin C pool by 25–50% compared to never-smokers.”
Certain populations or disease states require vitamin supplementation. In most cases, this is due to an increased
need related to disease, aging, pregnancy, and breastfeeding. Table 3.4 displays the water- and fat-soluble vitamins
and gives situations where vitamin supplementation may need to occur.
Vitamin Special Considerations/Reference

Water-Soluble
Thiamin (B1) • Chronic alcohol exposure (increase)
• Older adults (increase)
• HIV/AIDS (increase)
• Bariatric surgery (increase)
• Diabetes (increase)
Riboflavin (B2) • Vegan (increase) and vegetarian athletes (increase)

• Genetic mutation: riboflavin transporter deficiency (increase upon the emergence of
symptoms, not effective with long onset)
Niacin (B3) • Hartnup disease—caused by the body’s inability to absorb amino acids from the
diet results in the inability to produce vitamins and proteins—(increase)
• Carcinoid syndrome (increase)
• Undernutrition (increase)
• Inadequate riboflavin, pyridoxine, and/or iron intakes (increase)
Pantothenic acid (B5) • Genetic pantothenate kinase-associated neurodegeneration 2 mutation (unclear if

supplementation is helpful)
Pyridoxine (B6) • Rheumatoid arthritis (increase)

• End-stage renal disease (increase)
• People with alcohol dependencies (increase)
• Celiac disease
• Crohn’s disease
• Ulcerative colitis, inflammatory bowel disease, and other malabsorptive
autoimmune disorders (increase)
Biotin (B7) • Pregnant and breastfeeding (increase)

• Genetic mutation resulting in biotin enzyme deficiency (increase)
• Chronic alcohol exposure (increase)
Folate (B9) • Chronic alcohol exposure (increase)

• Pregnant and all women of childbearing age (increase)
• People with malabsorptive disorders, including tropical sprue, celiac disease,
inflammatory bowel disease (increase), genetic mutation that reduces the ability to
convert folate to one of its active forms (increase)
TABLE 3.4 Recommended Vitamin Supplementation for Various Diseases (sources: NIH, 2021a—d; 2022a—f; 2023a—d)
Vitamin Special Considerations/Reference

Cobalamin (B12) • Vegetarians (increase)
• Surgery of gastrointestinal tract such as in weight loss (increase), pernicious anemia
(injections), older adults (increase), breastfed infants of vegan mothers (increase)
Choline • Pregnant women (increase)

• Genetic alterations (increase)
• Long-term total parenteral nutrition (increase)
Vitamin C • Smokers and passive “smokers” (increase)

• Limited food variety (increase)
• Infants fed evaporated or boiled milk (increase)
• End-stage renal disease on chronic hemodialysis (increase)
Fat-Soluble
Vitamin A • Premature infants (increase)
• Cystic fibrosis (increase)
• Females and children in lower resourced countries (increase)
• Long-standing Crohn’s disease and ulcerative colitis (unclear as to the benefit of
increase)
Vitamin D • Breastfed infants (increase)

• Older adults (increase)
• Reduced sunlight exposure (increase)
• Darker skin tones (increase)
• Gastric bypass surgery (increase)
• Fat malabsorption as found in liver disease, cystic fibrosis, celiac disease, Crohn’s
disease, and ulcerative colitis (increase)
Vitamin E • Abetalipoproteinemia (large increase), fat malabsorption (increase)
Vitamin K • Newborns not treated with vitamin K at birth (intramuscular injection)

• Fat malabsorption as found in cystic fibrosis, celiac disease, ulcerative colitis, and
short bowel syndrome (increase)
TABLE 3.4 Recommended Vitamin Supplementation for Various Diseases (sources: NIH, 2021a—d; 2022a—f; 2023a—d)
Vitamin Intake for Wellness

To help consumers make healthy food choices and consume adequate amounts of vitamins, the FDA mandates that
foods carry a nutrition facts food label. Although the label does not display every vitamin or mineral, Figure 3.4 is an
example nutrition food label, outlining the most important nutrient information deemed by the FDA (2022a).

3.1 • Vitamins 49
FIGURE 3.4 This nutrition facts food label shows percent DVs of one serving (1 cup) of a food item. (credit: “Sample Label for Frozen
Lasagna”/U.S. Food and Drug Administration, Public Domain)
The nutrition facts food label in Figure 3.4 indicates that this food item is low in added sugars and vitamin D and is
considered high in saturated fat, calcium, and sodium. Restated more simply, one serving of this food item provides
one-quarter of the daily calcium and saturated fat requirements and over one-third of the daily allowance for
sodium, if consuming approximately 2,000 calories daily. Usually, a meal consists of more than one food item, so
adding naturally low-sodium and low-fat foods like fresh fruit or vegetables will help to balance this food
nutritionally.
Individual food manufacturers create nutrition facts labels based on the amount of nutrients in a standard serving
size of that food. The percent Daily Value (DV) is the percentage of the nutrient the food item provides for an adult
consuming about 2,000 calories daily. FDA guidance states that 5% DV or less of a nutrient per serving is considered
low, and 20% DV or more of a nutrient per serving is considered high (FDA, 2022). Note that reaching 100% of the
DV for sugar, fat, saturated fat, and sodium should not be a target or goal.
NUTRIENT DAILY VALUES REFERENCE GUIDE
The FDA recently updated their reference guide of DVs. A review of the U.S. Food and Drug Administration
website (https://openstax.org/r/fdagovfood) shows how nutrient recommendations increased or decreased since
the last review.
UNFOLDING CASE STUDY
Part A
Read the following clinical scenario and then answer the questions that follow. This case study will evolve
throughout the chapter.
Curtis, a third grader who has a long history of being a picky eater, does not like getting up early, so most days he
does not eat breakfast before leaving for school. He also does not like the school-provided lunch, so his aunt sends
him to school with a commercially packaged and processed lunch of cheese and meat with crackers. After school,
Curtis has a two-pack of toaster pastries with a glass of water, and his aunt usually makes him a box of macaroni and
cheese for supper—they know he will eat it without a complaint. During his last visit to the pediatrician, Curtis’s
caregivers voiced frustration with Curtis’s eating habits and wondered if he was getting all his vitamins and minerals.
After checking Curtis’s height and weight, the pediatrician explained that Curtis was at the 95th percentile for weight
and advised his family to serve more fruits and vegetables and monitor his weight.
To answer the following questions, search the Internet for food label information on a combo lunch pack (such as
Lunchables), boxed macaroni and cheese, and toaster pastries.
1. What micronutrient does the nurse assess is over the recommended amount in Curtis’s diet?
a. Folate
b. Vitamin D
c. Biotin
d. Sodium
2. What micronutrients would be increased with the addition of the fruits and vegetables as advised by the
nurse?
a. Vitamins B1 and B2
b. Vitamins B6 and niacin
c. Vitamins A and C
d. Biotin and pantothenic acid
Meal Planning
Cooking techniques can impact the retention of water-soluble vitamins. The best cooking techniques for preserving
water-soluble vitamins in vegetables include stir-frying, microwaving, and steaming. Each of these limits the amount
of water and shortens cooking time, which decreases lost vitamins.
Vitamins B1, B2, and folate are sensitive to heat or light. Exposure to heat for as few as 5 minutes can decrease the
content of the vitamin by as much as 90%. Vitamin C is degraded by heat and can begin to decrease within 5
minutes of exposure to a high temperature. For the best retention of a vitamin, cook for a shorter time, use less
water, and lower the temperature.
Another way of maximizing vitamin intake is through intentional meal planning. MyPlate from the U.S. Department of
Agriculture (USDA) is a simple tool for building a meal rich in vitamins and minerals that focuses on nuts, legumes,
fruits, vegetables, complex carbohydrates, lean meat, and dairy. Another effective way to present a balanced and
nutrient-rich meal is to create a plate of one-quarter protein, one-quarter high carbohydrate or starchy food, and
one-half fruits and vegetables.
3.2 Minerals
LEARNING OUTCOMES
• 3.2.1 Describe the nutritional function of minerals.
• 3.2.2 Identify the impact of minerals on wellness promotion and illness prevention.
• 3.2.3 Examine special considerations for populations that face challenges securing adequate mineral
intake.
Mineral Function
Minerals are common in cereals, bread, meat, fish, milk, dairy, nuts, fruit (especially in dried form), and vegetables.
About 20 minerals are essential for body function, all in varying amounts depending on their role. The
macrominerals are needed at levels higher than 100 mg/day, and trace minerals are needed in amounts less than
100 mg/day (Farag et al., 2023). Table 3.5 lists the macro (M) and trace (T) minerals and their functions.

3.2 • Minerals 51
Mineral Function
Calcium (M) Contributes to the structure of bones and teeth and controls blood vessel contraction and
dilation, muscle function, blood clotting, nerve transmission, and hormone secretion
Phosphorus (M) Contributes to the structure of bones and teeth and to the genetic material of DNA and RNA
Potassium (M) Maintains intracellular fluid volume and is important for muscle contraction, specifically heart
contractions
Sodium (M) Maintains extracellular fluid volume and plays a crucial role in normal nerve and muscle
function
Chloride (M) Plays a role in acid–base homeostasis, contributes to maintenance of urine and plasma
electroneutrality, and may even effect neurohormonal activation (Soliman et al., 2022)
Magnesium (M) Responsible for activation of enzymes, membrane function, intracellular signaling, and
muscle contraction
Sulfur (M) Operates as a cofactor involved in regulating oxidative processes and is an endogenous
metabolite of the amino acid, methionine
Iron (T) Helps develop red blood cells, metabolize cellular energy metabolism, and develop the
immune system
Zinc (T) Performs the role of antioxidant by protecting cell membranes from free radical damage as a
coenzyme of more than 300 enzymes
Iodine (T) Serves as a necessary component of thyroid hormones
Chromium (T) May facilitate the metabolism of carbohydrates, lipids, and proteins by increasing the
effectiveness of insulin—the precise mechanism for this activity has yet to be identified
Copper (T) Operates as a cofactor in the process of cellular oxidation and is required for the oxidation of
iron
Fluoride (T) Promotes remineralization of bones and teeth
Molybdenum (T) Aids in the metabolism of sulfur-containing amino acids and is an enzyme cofactor
Manganese (T) Serves as a cofactor for enzyme productions related to protein, fat, and carbohydrate
metabolism; functions as antioxidant
Selenium (T) Removes excess hydrogen peroxide from thyroid and is also needed for DNA synthesis
TABLE 3.5 Essential Minerals and Their Functions
Minerals work synergistically. For example, the sodium-to-potassium ratio is essential in maintaining normal blood
pressure and impacts blood pressure more than sodium or potassium alone. Likewise, the proper relationship
between calcium and phosphorus is vital in maintaining normal bone structure. As with vitamins, one mineral
cannot assume the function of another mineral, and a shortage or deficiency of any mineral will impact body
function.
Mineral absorption takes place primarily in the small intestine. For some minerals, absorption efficiency depends on
specific needs such as calcium absorption in pregnancy. During pregnancy, calcium absorption takes place actively,
which requires energy to transport across the cell membrane. In times of plentiful serum calcium, the body switches
to a passive diffusion method of absorption.
Mineral absorption can be helped or hindered by other dietary components that occur naturally in food. For
example, iron is best absorbed in an acid environment, so health professionals recommend taking an iron
supplement with orange juice. Juxtaposed is the absorption of minerals in the presence of phytates (found in whole
grains) that interfere with calcium, iron, magnesium, and zinc absorption.
NATIONAL INSTITUTES OF HEALTH
The NIH provides thorough information on their website (https://openstax.org/r/odsod) about dietary
supplements, herbs, vitamins, probiotics, and more.
Mineral Intake for Wellness

Minerals play an essential role in various metabolic and physiologic processes. A deeper dive into cellular nutrition
reveals that minerals are critical for the metabolism of every cell in the body. A well-balanced mineral intake is
essential throughout the human life cycle, although specific needs may vary based on age and sex (Farag, et al.,
2023). For example, the iron needs of premenopausal clients are higher than postmenopausal clients because of
the iron loss during menstruation. A diet comprised of vegetables, legumes, nuts, lean meats, and seafood provides
all the essential minerals needed throughout a person’s life.
Food fortification (the practice of intentionally increasing the content of one or more micronutrients) makes
meeting the required mineral DV easier. For example, in the mid-1920s, in response to an increase in goiter, iodine
was added to table salt (Leung, Braverman, and Pearce, 2012). Goiter is an increase in thyroid size resulting from
either iodine deficiency or hyperthyroidism. Vitamin D was first added to milk in 1933 in response to the presence of
childhood rickets (IOM, 2003; United Nations, 2019). Today, food fortification continues. Two more current
examples are the addition of calcium to orange juice and iron and folate to breakfast cereals. Even though some
breakfast cereals are fortified with essential vitamins and minerals, many should not be considered nutritionally
sound because they are high in added sugar. Fortification does not guarantee nutritional excellence.
MINERAL DAILY VALUES
As with vitamins, there are also mineral DV percentages. You can find vitamin and mineral information
(https://openstax.org/r/factsheets) on the NIH website, which contains a list of vitamins and minerals with
hyperlinks to more detailed information on each (select the mineral of interest and then proceed to the option of
health professional).
TRENDING TODAY
Micronutrients
As you work through this Trending Today feature, recall that nurses should rely on evidence-based practice
(EBP), which uses scientific evidence rather than anecdotal evidence, to inform their practice and care of clients.
Nurses should encourage clients to evaluate nutritional information on social media with the same scrutiny.
Research indicates an increasing use of micronutrient supplements, specifically single-nutrient supplements

(Cowan et al, 2020). Is it better to take a supplement to ensure you have an adequate supply of micronutrients,
or is it possible to get the micronutrients your body needs via food sources?
On social media, influencers promote awareness of micronutrient consumption in a person’s diet as a way to
assess their individual levels. TikToker @TheWellnessPharm suggests that individuals use a micronutrient testing
kit to help determine if they have consistently low levels of specific nutrients. Similarly, Instagram hosts several
forums dedicated to the discussion of obtaining daily micronutrient requirements from specific foods, often
promoting intuitive or mindful eating practice.
Take some time to review the following social media content and think critically about the information provided
and its appeal to clients:
• @TheWellnessPharm (https://openstax.org/r/tiktok) (TikTok)

• Any Instagram forum dedicated to the discussion of obtaining daily micronutrient requirements from specific
foods (Instagram)
• Nutrition for Resilience – Micronutrient Forum (https://openstax.org/r/mnforum) (Website)
Now answer the following questions:
1. Which account did you prefer when viewing or reading? Explain.

2. What is the purpose of the content you viewed or read?
3. How would you evaluate these sources for use of EBP, and which sources used EBP?
4. If a client came to you with this information, how would you educate them to critically use these sources?

3.3 • Supplements 53
5. What alternative sources would you recommend to clients to educate them about this topic?
3.3 Supplements
LEARNING OUTCOMES
• 3.3.1 Describe vitamin and mineral supplements’ role in nutrition and wellness.
• 3.3.2 Evaluate vitamin and mineral supplements as part of a nutritional plan, including the potential for
interactions.
• 3.3.3 Examine special considerations for the nutritional needs associated with vulnerable populations
and across the lifespan.
Regulations and Recommendations for the Use of Supplements

Eating a diet with fresh and minimally processed foods is the best source of vitamins and minerals. However, even
people with healthy eating habits sometimes need help to bridge occasional nutrient gaps, and supplements may
help.
Deciding on the right vitamin-mineral supplement can be difficult, considering that hundreds of different types are
available and no real guidance is provided at the point of sale (NIH, 2018). With almost 60% (Mishra et al., 2021) of
the population taking multiple vitamin and mineral supplements, guidance is important. People who are more likely
to need a supplement include those with the following characteristics (Weyh et al., 2022):
• With restricted diets

• Who are pregnant
• With loss of appetite due to sickness, injury, or surgery—note that vitamin/mineral supplements alone do not
provide calories or protein needed for healing
• With severe food allergies resulting in a restricted diet
• With a depleted immune system
Broadly, vitamin-mineral supplements are divided into three main groups: basic, high-potency, and specialized
(Table 3.6). Examples of when each group would apply include:
• Basic—Individuals needing to bridge occasional vitamin and mineral gaps.

• High-potency—Pregnant women have higher iron and folate needs and need a diet formulated for prenatal care.
• Specialized—Clients with age-related macular degeneration (AMD) may need to supplement with specific
vitamins and minerals: vitamin C (500 mg), vitamin E (400 IU), beta-carotene (15 mg), zinc (80 mg), and copper
(2 mg), which is effective in slowing AMD (NIH-National Center for Complementary and Integrative Health,
2018; NIH, 2023).
Vitamin- Description
Mineral
Category
Basic These vitamins have a usual daily dosage and contain a variety of vitamins and minerals in
(broad amounts that do not exceed the DVs. Many of the vitamins in this group are developed for specific
spectrum) populations such as males, females, seniors, and children to better meet the unique needs of age
and sex.
High- These multivitamin/minerals (MVMs) contain amounts of some vitamins and minerals that are well
potency over 100% of the percent DV. They might also include other nutrients and botanical ingredients.
These high-potency vitamins may be marketed in multiple packages for convenience and daily
use.
Specialized These MVMs are used for different needs like immune function, eye health, or athletic
(condition- performance. They are often combinations of vitamins, minerals, botanicals, probiotics, and
specific) coenzymes. Some of these products include nutrients much higher than the percent DV.
TABLE 3.6 Categories of Vitamin and Mineral Supplements (source: NIH, 2023a)
Vitamin-mineral supplements fall under the regulatory powers of the FDA. However, the weak regulation and the
vast array of supplements can confuse the consumer. The Dietary Supplement Health and Education Act (DSHEA) of
1994 altered the FDA’s authority to regulate dietary supplements (NIH Office of Dietary Supplements, 1994). Under
DSHEA, the FDA does not authorize or evaluate dietary supplements for safety or effectiveness before reaching
store shelves; unfortunately, this makes a “buyer beware” situation. Vitamin manufacturers can lawfully introduce
dietary supplements without even notifying the FDA. Since DSHEA was enacted, the dietary supplement market has
exploded, with the number of products multiplying nearly 20 times since 1994 (FDA, 2022).
Supplements and Nutritional Plans

Nurses should take a food-first approach to vitamins and minerals as the most prudent advice for clients. Food has
multiple advantages over a manufactured pill by providing complex carbohydrates, fiber, protein, unsaturated fats,
and antioxidants.
Table 3.7 is an example of a food-first approach with a diet full of vitamins and minerals from dairy, legumes, lean
meat, nuts, fish, fruits, and vegetables. A vitamin- and mineral-rich daily menu could be as simple as the following
meals:
• Breakfast—cereal with 5 g or less of added sugar, low-fat animal or plant milk (fortified with calcium and
Vitamin D), and a banana
• Lunch—carrot sticks, a tuna sandwich on whole wheat bread, and orange sections
• Snack—roasted almonds
• Dinner—broiled pork chop, collards, and lightly salted sweet potato fries (air-fried)
Vitamin/Mineral Food Source/Serving Size

Vitamin A 1 small carrot provides 6000 IU of vitamin A (100% of DV)
Vitamin B3 (niacin) 3 oz of tuna has 11 mg of niacin (about 50% of DV)
Vitamin B6 1 medium banana contains about 0.4 mg vitamin B6 (about 25% of DV)
Vitamin E 1 oz of almonds has over 7 mg vitamin E (about 50% of DV)
Vitamin B1 1 3-oz pork chop provides 0.4 mg of thiamin (33% of DV)
Vitamin C 1 medium orange provides 70 mg of vitamin C (78% of DV)
Vitamin D 8 oz of fortified milk contains 100 IU vitamin D (25% of DV)
Selenium 1 slice of whole wheat bread contains 10 mcg of selenium (about 20% of DV)
Calcium 1 cup of boiled collard greens contains 266 mg of calcium (about 26% of DV)
Zinc 3 oz of lean beef contains 5 mg of zinc (about 50% of DV)
TABLE 3.7 Examples of Vitamins and Minerals Found in Common Food Sources (Note that all of the above-mentioned foods contain
multiple vitamins and minerals.)
According to the National Institutes of Health (NIH-National Center for Complementary and Integrative Health,
2018), supplement manufacturers can make three health-related claims on their labels:
• Health—describes a relationship between a food, food component, or dietary supplement ingredient and
reducing the risk of a specific disease or health-related condition
• Nutrient—describes the relative amount of a nutrient or dietary substance in a product
• Structure or function—describes how a product may affect the organs or systems of the body and cannot
mention any specific disease
The dosage of specific vitamin and mineral supplements a client should consume will vary because the
Recommended Dietary Allowance (RDA) differs based on age and sex. For example, note the differences in
recommended daily iron intake for each of these groups:
• Adolescent (age 12 to 18 years) female: 15 mg

• Adolescent (age 12 to 18 years) male: 11 mg
• Adult (age 18 plus years) female: 18 mg
• Adult (age 18 plus years) male: 8 mg

3.3 • Supplements 55
Because of specific needs, vitamin-mineral supplements are customized and marketed to population segments
based on activity and age. For example, vitamins for children sport bright and catchy labels, gummy textures, and
fruity tastes. Prenatal vitamins often have labels with pastel colors. Supplements for older adults are packaged in
silver labeled bottles. Vitamin-mineral supplements can also be found as liquid drinks, including water, milk, and
coffee.
Clients may ask if they need a vitamin-mineral supplement. There is little scientific support for taking a vitamin-
mineral supplement when no deficiency signs and symptom exist (Seres, 2023); foods provide many vitamins,
minerals, and phytochemicals and are more bioavailable than those found in supplements (Harguth, 2022). In some
situations, vitamin-mineral supplements are essential for good health, but promoting food as the first line of health
defense is strongly supported by science and health professionals.
Recommended Dietary Allowance

The RDAs are published by the Food and National Academies of Sciences every 5–10 years. RDAs were developed
during World War II for nutritional guidance in feeding soldiers and food relief in the U.S. and internationally. They
were set at the minimum level for good health and not every nutrient has an RDA (Murphy et al., 2016). The
nutrients listed in the RDA are used as a goal for healthy individuals at every age. They are preventative in nature
and not meant to be treatment for disease.
Dietary Guidelines are updated every 5 years; they help interpret and apply the RDAs to dietary patterns. In 1985,
the Dietary Guidelines scientific report supporting their recommendations totaled 19 pages. In the 2020 version,
the total was over 800 pages, demonstrating the prolific research occurring over the past 40 years on vitamins and
minerals, dietary patterns, and health. The 2020–2025 Dietary Guidelines’ call to action “Make Every Bite Count”
includes four overarching values:
• Follow a healthy dietary pattern at every life stage.

• Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural
traditions, and budgetary considerations.
• Focus on meeting food group needs with nutrient-dense foods and beverages and stay within calorie limits.
• Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages (U.S.
Department of Agriculture and U.S. Department of Health and Human Services, 2020).
These Dietary Guidelines are reflected throughout this chapter as nutrient-dense foods are emphasized over
supplements.
DIETARY GUIDELINES
Read more on the history of dietary guidelines from 1980–2020; of special note is the expansion in guidance
over the last 30 years and the incorporation of recommendations into the overarching guideline. Review this
website for a look (https://openstax.org/r/dietaryguidelines) at how the guidelines have emerged over the last
three decades and this website for free materials (https://openstax.org/r/dietaryguidelinesresources) related to
the Dietary Guidelines for Americans 2020–2025.
Part B
Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case
Study Part A.
After Curtis’s last visit to the pediatrician, his aunt tries to introduce Curtis to some of her favorite Haitian dishes,
such as rice with a pork sauce, beef and pumpkin soup, and banana fritters. Curtis refuses to taste any of the native
Haitian foods. His aunt is now watching several other children after school in addition to Curtis, and Curtis’s parents
continue to work rotating shifts and extra hours. Curtis spends most of the school year eating the same limited
number of foods for lunch, snacks, and dinner. He rejects all attempts to include fruits and vegetables in his diet; it is
cheaper, easier, and faster to adhere to Curtis’s food preferences.
Curtis is sick more often than his classmates, which causes him to miss many days of school and fall behind in his
work. His mom is concerned and asks the school nurse what she should do about his inability to fight infections. The
school nurse indicates Curtis’s picky eating habits were contributing to frequent illness.
3. How could Curtis “Make Every Bite” count?

a. Increase consumption of toaster pastries since they are vitamin B fortified.
b. Add another powdered cheese packet to his macaroni and cheese.
c. Provide a vitamin gummy daily.
d. Experiment with fruit and vegetable smoothies for an after school snack.
4. Which vitamins should the nurse recommend to help build Curtis’s immune system?
a. Vitamin C and vitamin E
b. Vitamin K and vitamin C
c. Choline and biotin
d. Vitamin D and vitamin K

3 • Chapter Summary 57
Chapter Summary
• A well-rounded, varied diet of mostly unprocessed sources.
foods will provide many of the DVs recommended • Vitamin-mineral supplements should be selected
by the FDA. based on age, sex, and specific need.
• High doses of water-soluble vitamins are excreted • Coenzyme and antioxidant properties are critical
in the urine, although fat-soluble vitamins are functions of vitamins and minerals.
stored in the tissues. High doses of fat-soluble • Nutrition facts food labels and MyPlate can assist
vitamins can lead to toxicity and even death. in choosing foods high in vitamins and minerals.
• Certain disease states require higher vitamin and • RDAs and DVs reflect current nutrient research.
mineral intake, supplemented beyond dietary
Key Terms
angiogenesis new blood vessel development proteins
antioxidant artificial or natural substances that may megaloblastic anemia a condition involving a vitamin
prevent or delay some types of cell damage B12 and/or folate deficiency in which the bone
citric acid cycle final oxidation of protein, fat, and marrow produces very large, structurally abnormal
carbohydrate red blood cells
coenzyme a non-protein compound that binds with osteoporosis loss of bone density resulting in porous,
an enzyme to speed up a cellular reaction fragile bone
Daily Value one value for each nutrient selected for oxidation a chemical reaction in which a “healthy”
the labels of dietary supplements and foods molecule loses or is robbed of one of its electrons,
Daily Values a list of the vitamins and minerals that producing an unhealthy free radical
an individual should consume each day percent Daily Value the contribution of a vitamin or
fat-soluble vitamins vitamins that are absorbed mineral in a food portion based on the standard
along with fats in the diet and are stored in the benchmark of a total daily 2,000-calorie diet
body’s fatty tissue and liver Recommended Dietary Allowance (RDA) average
food enrichment the practice of adding back daily nutrient intake level necessary to meet the
nutrients that were lost in food processing bodily requirements of nearly all (97–98%) healthy
food fortification the practice of intentionally individuals
increasing the content of one or more rickets softening of the bone due to vitamin D
micronutrients (i.e., vitamins and minerals) deficiency resulting in bowed legs
free radicals a type of unstable molecule that is toxicity side effects from taking large doses of
made during normal cell metabolism supplements or medications
goiter an increase in thyroid size resulting from either vitamins nutrients the body needs in small amounts
iodine deficiency or hyperthyroidism to function and stay healthy
Hartnup disease a condition caused by the body’s water-soluble vitamins vitamins that dissolve in
inability to absorb amino acids from the diet water
resulting in the inability to produce vitamins and
Review Questions
1. Which vitamin has the greatest chance of toxicity if taken in large doses?
a. Vitamin A
b. Riboflavin (B2)
c. Vitamin C
d. Pantothenic acid
2. The nurse provides dietary instruction to a client who is having difficulty controlling their blood glucose level.
Which mineral deficiency should the nurse anticipate?
a. Chromium
b. Calcium
c. Copper
d. Iron
58 3 • Review Questions
3. The nurse is teaching a client how to read a supplement label. Which of the following statements by the client
about what information can be included in a supplement label indicates additional instruction is needed?
a. “It will describe how the ingredients can affect my body.”
b. “It will list the amount of the ingredients in the supplement.”
c. “It will describe how much of the supplement I should take.”
d. “It will describe how the supplement will cure my high blood pressure.”
4. The nurse is assessing a child with bowed legs. Which vitamin deficiency should the nurse anticipate is
related to this disorder?
a. Vitamin C
b. Calcium
c. Vitamin D
d. Riboflavin
5. Which information should the nurse give to a client taking high doses of water-soluble vitamins?
a. Excess water-soluble vitamins are stored in fatty tissue.
b. Excess water-soluble vitamins are stored in the liver.
c. Excess water-soluble vitamins quickly reach toxic levels.
d. Excess water-soluble vitamins are excreted in the urine.
6. Which vitamin supplement should the nurse recommend to a client who is trying to conceive?
a. Thiamin
b. Niacin
c. Folate
d. Choline
7. Which minerals should the nurse instruct parents to include in the diet of preschool-aged children for the
development of healthy bones and teeth?
a. Phosphorus and potassium
b. Iron and zinc
c. Calcium and phosphorus
d. Chloride and calcium
8. Which mineral deficiency should the nurse anticipate in the client diagnosed with goiter?
a. Iron
b. Iodine
c. Potassium
d. Sodium
9. Which food preparation technique should the nurse advise a client to use to prevent loss of water-soluble
vitamins from the food?
a. Use less water in food preparation.
b. Cook food for a longer time.
c. Cook at a higher temperature.
d. Cut food into larger pieces.
10. Which vitamin deficiency should the nurse anticipate in the client with chronic alcohol use?
a. Riboflavin
b. Niacin
c. Vitamin C
d. Thiamin

3 • Suggested Reading 59
Suggested Reading
Choosing a vitamin/mineral supplement: https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=ud3713
Dietary Guidelines for Americans 2020-2025: https://www.dietaryguidelines.gov/resources/2020-2025-dietary-

guidelines-online-materials
Do you need a dietary supplement?: https://newsinhealth.nih.gov/2021/12/do-you-need-dietary-supplements
Evolution of Dietary Guidelines: https://www.dietaryguidelines.gov/media/799
My Plate: https://www.myplate.gov/
Vitamin and Mineral Supplement Fact Sheets: https://ods.od.nih.gov/factsheets/list-VitaminsMinerals/


CHAPTER 4
The Digestive Process
FIGURE 4.1 The digestive process breaks down food and fuels the body for function. (credit: modification of work “Chef Salad” by
Gesalbte/Wikimedia Commons, CC0 1.0)
CHAPTER OUTLINE
4.1 Digestion
4.2 Physical Assessment of Digestive Organs
4.3 The Function of Digestive Organs
4.4 The Nurse’s Role in the Promotion of Gut Health
INTRODUCTION Eating food can be enjoyable, but it is also necessary for survival. When food is consumed, the
body breaks it down, and it becomes the fuel for energy and function. The level of nutrition in food impacts the
amount of energy gained in the body. The greater the nutritional value of food, the better for the body. The chapter
will explore the digestive process and will review the role the nurse plays in promoting nutrition for gut health.
4.1 Digestion
LEARNING OUTCOMES
• 4.1.1 Describe the digestive process.
• 4.1.2 Describe the organs of digestion.
• 4.1.3 Identify congenital anomalies within digestive organs.
The Digestive Process

The digestive process includes four steps: ingestion, digestion, absorption, and metabolism. Ingestion is the first
step and involves the process of bringing food and liquids into the body through the mouth. Next is digestion, in
62 4 • The Digestive Process
which the body breaks down solid food through a process that includes both mechanical and chemical actions to
form smaller, more absorbable substances for the gastrointestinal tract (Patricia & Dhamoon, 2022). Absorption is
when cells take in the broken-down substances, and metabolism is when those absorbed substances are converted
to energy.
Digestion occurs as an integrated process between the body’s upper and lower gastrointestinal tract and accessory
organs. The body needs to have proper digestive processes to ensure correct function. Common end products of
digestion are amino acids, simple carbohydrates, lipids, vitamins, and minerals.
Digestive Organs
The main organs of digestion, known as the gastrointestinal system, begin at the mouth and end at the anus. This
system is divided into the upper gastrointestinal system, which starts at the mouth and ends at the duodenum (the
start of the small intestine), and the lower gastrointestinal system, which starts at the small intestine and includes
the large intestine (the colon, rectum, and anus). Other organs in the digestive system that aid in digestion but are
not part of the main gastrointestinal system and don’t come in direct contact with food are the accessory organs: the
pancreas, liver, and gallbladder (Figure 4.2).
FIGURE 4.2 The digestive system consists of the upper and lower gastrointestinal tract and accessory systems and is responsible for
processing food. The main digestive organs, known as the gastrointestinal system, begin at the mouth and end at the anus. (credit:
modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
The purpose of the digestive system, and all the systems that work in harmony with it, is to receive food, release
nutrients and water from the food, and transport these nutrients to the bloodstream for energy production. The
digestive system is also responsible for absorbing water from the colon and for excreting nondigestible solid waste
from the anus (National Institute of Diabetes and Digestive and Kidney Diseases, 2022).

4.1 • Digestion 63
Upper Gastrointestinal System

The upper gastrointestinal system comprises the mouth, esophagus, stomach, and duodenum. The teeth, tongue,
and salivary glands, which are all accessories for digestion, are in the mouth and facilitate the breakdown of food
through mechanical (chewing) and chemical (enzymes) digestive processes. All of these components are required
for the mouth to effectively complete its role in the digestive process.
After this initial breakdown, food then travels out of the mouth, through the upper esophageal sphincter, down the
esophagus, through the lower esophageal sphincter, into the stomach, out of the stomach through the pyloric
sphincter, and into the duodenum (Figure 4.3). The process of digestion through this upper gastrointestinal tract,
starting at the mouth and ending in gastric emptying, can take 2–5 hours to complete (Readman, 2022).
FIGURE 4.3 Food journeys from the esophagus to the duodenum. (credit: modification of work from Anatomy and Physiology 2e.
attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Lower Gastrointestinal System

The lower gastrointestinal system comprises the small intestine, large intestine, rectum, and anus. Food entering
the lower portion of the gastrointestinal system comes from the duodenum as chyme, a mixture of gastric juices and
digested food. After digestive processes are complete in the duodenum, chyme moves through the small intestine,
large intestine, and rectum, then out the body through the anus in the form of stool. Digestion through the lower
gastrointestinal tract can take from 12 to 65 hours (Readman, 2022).
Accessory Organs and Systems

The pancreas, liver, and gallbladder are organs outside of the main gastrointestinal tract but are part of the digestive
system (GI Associates and Endoscopy Center, 2022b). They directly aid in digestion by releasing enzymes and
digestive fluids. Cholecystokinin, a hormone produced by the small intestine, triggers the pancreas and gallbladder
to contract when fats and proteins enter. The pancreas, while also responsible for other body functions, produces
amylase, lipase, trypsinogen, chymotrypsinogen, elastase, carboxypeptidase, nucleases, and protease. These
enzymes break down sugars, fats, and starches (GI Associates and Endoscopy Center, 2022b). When sugar enters
the bloodstream, the pancreas produces insulin, a hormone that assists in the absorption of glucose into cells to
use for energy.
The liver produces bile, a digestive fluid that is stored in the gallbladder. When fatty foods enter the duodenum, the
gallbladder releases bile to break down the fat into fatty acids. If the gallbladder is removed, the bile will instead
travel directly from the liver to the small intestine.
Other accessory organs and tissues that assist in digestion include the salivary glands, tongue, nerves, and blood
(University of Rochester Medical Center, 2022). When food enters the mouth and chewing begins, teeth break down
the food into smaller parts, and saliva is released. Saliva is released by the sensory system, which is stimulated by
sight, smell, and taste. Glands and mucosal membranes of the intestinal walls secrete small amounts of digestive
enzymes and lubricating mucus to assist with waste movement and nutrient absorption.
Congenital Anomalies of the Gastrointestinal System

While rare, congenital anomalies can affect the digestive system. Most congenital anomalies result from
undeveloped or incorrectly positioned organs, causing blockages that prevent food passage or the exit of waste
products (Columbia University Irving Medical Center, n.d.).
Atresia, Stenosis, and Malformations

Congenital abnormalities include atresia, stenosis, and malformations. Some of these abnormalities can be
detected in utero or soon after birth, while others remain undetected through childhood until they cause physical
symptoms (Ludwig et al., 2022). Atresia is a condition in which a passage in the body is blocked. For example,
esophageal atresia is when a baby’s esophagus has not developed correctly, and aural atresia is when the ear canal
is underdeveloped. Stenosis, or narrowing, is a partial blockage of an area, and a malformation is an abnormal
formation of a specific body part.
Anorectal anomalies can include an anus that is very narrow or totally enclosed by a layer of tissue or skin, a rectum
that does not connect to the anus (imperforate anus), or a rectum that connects to a part of the urinary or
reproductive tract through a fistula, an abnormal connection (Boston Children’s Hospital, 2022). Depending on
which anomaly is present, the client may experience symptoms such as difficulty passing stool and constipation,
total inability to have a bowel movement, or stool that exits through the urinary system or another system in the
body, causing infection and incontinence (Boston Children’s Hospital, 2022).
Biliary anomalies affect the bile ducts. They can involve a progressive narrowing effect and/or a complete blockage,
cystic formations that result in blockages in the biliary system, or biliary ducts that are malformed and do not
properly connect to the pancreaticobiliary junction (Columbia University Irving Medical Center, n.d.; Stanford
Medicine Children’s Health, 2023b). These anomalies fall into two main types, cystic and non-cystic. Cystic
anomalies are caused by saclike structures filled with pus or other fluid that form and block different parts of the
biliary system, whereas non-cystic anomalies are actual structural defects of the biliary system (Stanford Medicine
Children’s Health, 2023). Common symptoms of these anomalies include jaundice, abdominal pain, pale or clay-
colored stools, dark urine, enlarged liver margins, hyperamylasemia, enlarged splenic margins, and difficulty gaining
weight.
Malrotation and Volvulus

Malrotation most often occurs in the small intestine and involves an incorrect rotation that happens during fetal
development (Columbia University Irving Medical Center, n.d.). Volvulus is a severe complication of a malrotation in
which blood flow is blocked to the digestive tract, causing ischemia, and/or to the intestines, causing stool blockage
(Columbia University Irving Medical Center, n.d.). While malrotation can be the cause of volvulus, it can also occur in
the absence of malrotation (Johns Hopkins Medicine, 2022).
Malrotations alone are usually asymptomatic. It is not until volvulus develops that a client experiences symptoms
(Johns Hopkins Medicine, 2022) such as sudden and severe nausea and vomiting, dark red or bloody stools, severe
constipation or difficulty expelling stools, abdominal distention, bilious vomiting (vomiting that contains bile), and
shock.
4.2 Physical Assessment of Digestive Organs

LEARNING OUTCOMES
• 4.2.1 Outline the assessment process of the digestive organs.
• 4.2.2 Analyze and prioritize assessment findings.
Mouth, Oropharynx, and Lips

Because digestion is responsible for fueling the body, proper assessment of the digestive system is imperative to
prevent disease, maintain wellness, and promote nutritional health. Both a physical assessment and a review of the
client’s health history should be completed. In reviewing the client’s health history, the nurse should inquire about

4.2 • Physical Assessment of Digestive Organs 65
dietary practices, dietary intolerances or allergies, eating and bowel patterns, changes in eating or bowel patterns,
recent unintentional weight loss or gain, and medical diagnoses or surgical history. The nurse should obtain the
client’s weight and height to calculate the client’s body mass index (BMI).
An assessment of the mouth and the oropharynx (the middle part of the throat) begins with the lips. The nurse
should begin with the outer lips to judge for symmetry, color, texture, and contouring. The client should be asked to
smile so that the nurse can judge lip symmetry. If the client is unable to lift both sides of the lips equally, they are
not symmetrical, and this should be reported.
SAFETY ALERT
Lip Asymmetry
If the client is exhibiting asymmetry in their lips that is new, especially in conjunction with new symptoms such as
facial drooping or asymmetry, arm weakness, numbness, paralysis, or speech difficulty such as slurring or
aphasia, the nurse should immediately alert the provider, as this could indicate an acute stroke (American Stroke
Association, n.d.).
Next, the inner lips and buccal mucosa (the inner lining of the cheeks) should be inspected for color, texture,
moisture, and presence of abnormalities. To best visualize these structures, the nurse should direct the client to
relax their mouth. The nurse should then pull the bottom lip outward and away from the client’s teeth by grasping
the lip between the thumb and index finger on each side and carefully pulling outward (Villa, 2022). Drooling may be
seen in young infants and toddlers up to age 2, but it should not be excessive.
Nurses should watch for numerous abnormalities, some more urgent than others. Assessment findings that the
nurse should report immediately include cyanosis, a bluish discoloration of the skin that can indicate low oxygen
levels, and new unilateral asymmetry with movement, as this could indicate a cerebrovascular accident.
Gums, Buccal Mucosa, Tongue, and Teeth

The inspection of the inside of the mouth will include the gums, buccal mucosa, tongue, and teeth. To begin, the
client should open their mouth. The nurse should then use a penlight and a tongue depressor or blade to retract
each cheek to complete a visual exam of all internal surfaces, looking for any abnormalities. To evaluate the teeth in
the back of the mouth, the nurse should place both index fingers into one side of the mouth to retract the cheek. The
client will then slowly open and close their mouth while the cheek is retracted so that tooth alignment can be
visualized. This should be completed on both sides of the mouth.
Nurses should inspect the gums in this same manner. If the client has dentures, bridges, or other removable dental
appliances, they should be removed if possible, and the nurse should repeat the evaluation for the gums separately.
Check gums for retraction or recession, color, reddened inflammation, soreness, bleeding, edema, or lesions
(Cleveland Clinic, 2022c).
SAFETY ALERT
Tongue Depressor or Blade Contradictions

If the epiglottis (the small cartilage that covers the windpipe) is swollen, the nurse should not examine with a
tongue depressor, blade, or flexible laryngoscope. Further, the nurse should not manipulate the oral cavity
because this could trigger laryngospasm and close off the client’s airway, causing a life-threatening emergency
(Guerra & Waseem, 2022). Symptoms of epiglottitis include hyperthermia, sore throat, stridor (noisy breathing),
dysphagia (trouble swallowing), and drooling (Mayo Clinic, 2022). Children may also act anxious and irritable and
may sit up or lean forward to ease breathing, while adults may also have a muffled or hoarse voice or difficulty
breathing.
To facilitate inspection of the tongue, the client should open their mouth and stick out their tongue to allow the
nurse to inspect for position, color, texture, and moisture. The nurse should ask the client to curl their tongue
upward and move it from side to side to assess mobility. Lastly, the nurse should instruct the client to push the tip of
their tongue to the roof of their mouth and should inspect the base of the tongue, the mouth floor, and the frenulum
(the small tissue beneath the tongue that provides support) for color, texture, bleeding, moisture, and lesions.
The hard and soft palates at the roof of the mouth should be inspected for color, shape, texture, and the presence of
bony prominences. The nurse should instruct the client to open their mouth widely while tilting their head backward.
The nurse should use a tongue depressor or blade to depress the tongue if needed and use a penlight to see the
structures. The nurse should then ask the client to say “ah” and should inspect the uvula, the fleshy extension that
hangs at the back of the throat and at the end of the soft palate, for position and mobility after inspecting the soft
palate.
Palates, Uvula, Oropharynx, and Tonsils

The final steps of the assessment cover the palates, uvula, oropharynx, and tonsils. To begin, the nurse should use a
tongue depressor or blade to push downward against the tongue halfway back on the same side of the tongue of the
oropharynx that is being inspected. While holding the tongue out of the way, the nurse should use a penlight to
examine the color, size, and discharge of the oropharynx and tonsils. The inspection should be repeated on the
opposite side. Lastly, the nurse should elicit the gag reflex by using the tongue depressor or blade to stimulate the
back of the throat (Sivakumar & Prabhu, 2023).
As with the teeth and gum assessment, abnormal findings that the nurse should report immediately include
cyanosis and any suspicious lesions. Additional findings that the nurse should immediately report include a uvula
that is not midline or freely movable (this could be a sign of a tumor, trauma, or nerve damage), a uvula in a newborn
that is forked or bifurcated (a possible indication of an undetected cleft palate), plaques or drainage in oropharynx
(this could indicate acute infection), or swelling or drainage of tonsils (possible sign of an acute infection).
Abdomen
The assessment of the abdomen includes the upper gastrointestinal system (stomach and duodenum), the
accessory organs of the digestive system (pancreas, liver, and gallbladder), and most of the lower gastrointestinal
system (large and small intestines). This assessment must occur in a specific order: inspection, auscultation,
percussion, and then palpation. This is important because auscultating before percussing and palpating ensures the
nurse is listening to undisturbed bowel sounds.
CLINICAL TIP
Positioning the Client for Abdominal Assessment

When preparing the client for abdominal assessment, position them so that their abdominal wall musculature is
relaxed. To achieve this, the nurse should have the client lie supine and support the client’s head and behind the
knees with pillows.
Step 1: Inspection
Inspection should be the first step in the abdominal assessment (Roscoe, 2022). The nurse should do this with the
client in a completely supine position with the abdomen exposed (Mealie, Ali, & Manthey, 2022). The nurse should
inspect the skin integrity, abdomen contour, symmetry, and vascular patterns and visually inspect the abdominal
movement associated with respirations, aortic blood flow, and peristalsis (the muscle contractions that move food
through the digestive tract).
Step 2: Auscultation
Auscultation is the process of listening to the sounds of the body using a stethoscope. The process of auscultating
the abdomen is to assess the bowel and vascular sounds and peritoneal friction rubs. To auscultate the abdomen,
the nurse should:
• With the diaphragm of the stethoscope, listen for bowel sounds in each of the four quadrants of the abdomen.
Calculate the amount of time in between bowel sounds after listening for at least two and no more than 5
minutes in each quadrant.
• With the bell of the stethoscope, listen for the absence of bruits (the sound of blood flowing through a narrowed
portion of an artery) in the aorta, renal arteries, femoral arteries, and iliac arteries in the abdomen. If the nurse

4.2 • Physical Assessment of Digestive Organs 67
suspects a delay in gastric emptying, place the stethoscope on the abdomen near the stomach, hold the client’s
hips, and gently shake them from side to side while listening to their abdomen for a succussion splash, a
sloshing or splashing sound caused by excessive fluid remaining in the stomach (Mealie, Ali, & Manthey, 2022).
This may be uncomfortable for the client, so the nurse should inform the client what to expect.
• With the diaphragm of the stethoscope, listen for the absence of peritoneal friction rubs over the spleen and
liver as the client breathes in deeply.
Step 3: Percussion
Percussion, or tapping, of the abdomen is an assessment technique to determine the presence of gas, fluid, or
masses. The systematic process of percussion is to start in the lower-right quadrant of the abdomen and proceed to
the upper-right quadrant, move to the upper-left quadrant, and finish in the lower-left quadrant. The nurse should
percuss several areas of each quadrant to listen to the quality of the sound. Tympany, or a resonant, hollow sound,
relates to gas, or flatus. Dullness, decrease, absence, or flatness of sound relates to fluid or solid masses.
Percussion is also used to best judge the size of the liver and may be helpful in identifying splenic enlargement
(Mealie, Ali, & Manthey, 2022). To percuss for splenic size, the nurse should percuss the most inferior interspace on
the left anterior axillary line, or the Castell’s point, as the client breathes in deeply, to listen for the start of dullness
from tympany to discover the splenic edge. On the right side, the nurse should percuss down from the lung and up
from the bowel to discover the change from tympany to dullness to locate the liver margins.
Step 4: Palpation
The last step in the abdominal assessment is palpation. There are three palpation stages: superficial or light
palpation, deep palpation, and organ palpation. For superficial palpation, the nurse should hold their palm slightly
above the client’s abdomen with their fingers parallel and then use their finger pads to depress the abdominal wall
lightly at only about 1 cm (0.39 in), which is about the level of the subcutaneous tissue (Mealie, Ali, & Manthey,
2022). The nurse should move their finger pads in a circular motion over all the quadrants while noting any areas of
tenderness, masses, crepitus (a grinding or crunching sound), irregularity in contour, or muscle guarding. If a known
area of pain is already present on the abdomen, start farthest from the area of maximal pain with any form of
palpation and end in that area last (Mealie, Ali, & Manthey, 2022).
After light palpation is complete, the nurse should move on to deep palpation. This is done slowly with the same
hand position and in the same manner, except the depth of pressing is increased with firmer and more steady
pressure to explore deeper. While palpating deeply in the periumbilical, inguinal, and suprapubic regions, the nurse
should have the client cough while feeling for a mass to ensure there is no hidden hernia.
After palpation of the abdomen, the nurse should palpate the digestive organs. To palpate the liver, the nurse should
place a hand below the lower-right rib margin and ask the client to exhale and then inhale deeply while the nurse
feels for the margins and any nodularity. The nurse should then palpate the gallbladder by placing their palpating
hand under the lower-right rib margin at the midclavicular line and asking the client to exhale deeply. The nurse then
pushes in deeper and slowly, asking the client to inhale while watching for a sudden cessation of inhalation due to
pain. The spleen is palpated by placing a hand in the lower-right quadrant and moving it toward the splenic flexure
until the hand reaches the lower-left rib margin, at which time the client should be asked to exhale and then inhale
deeply.
SAFETY ALERT
Deep Palpation Contraindications

The nurse should not do deep palpation on clients with suspected abdominal aortic aneurysm, appendicitis,
polycystic kidney disease, kidney transplant history, or a tender spleen because it could cause severe damage
(Roscoe, 2022). For example, deep palpation may rupture an aneurysm, the appendix, or a cyst, or it may
damage a newly transplanted kidney.
The nurse should report immediately abnormal findings that can indicate serious health problems within the lower
gastrointestinal tract and accessory organs. Refer to Table 4.1 for a summary of possible abnormal findings and
their causes.
Assessment Finding Abnormality Sign/Symptom/

Syndrome
Ecchymosis (discoloration) of flank and groin Pancreatic hemorrhage Grey Turner’s sign
Periumbilical ecchymosis Retroperitoneal and intra- Cullen’s sign
abdominal hemorrhage
Purple-pink striae in the absence of pregnancy Cushing’s syndrome “Stretch marks”
Visible vascular pattern Portal hypertension or vena Vein dilation
cava obstruction
Very marked aortic pulsations Aortic aneurysm Pulsations
(Shaw et al., 2023)
Surrounding erythema, induration, and tenderness Omphalitis (specific to Deviation in umbilical
infants) stump appearance
(Gantan & Wiedrich, 2022)
Combined with abdominal distention: jaundice and/ Cirrhosis and liver failure Abdominal distention
or caput medusae (swollen veins) (Mealie, Ali, & Manthey,
2022)
TABLE 4.1 Abnormal Abdominal Findings and Possible Causes
SAFETY ALERT
Follow-up Testing
While physical assessment can aid in identifying potential nutritional deficiencies, it is not diagnostic, and other
follow-up testing is necessary to determine the best treatment needs and options.
Rectum and Anus

Assessment of the anus and rectum is the final step of the lower gastrointestinal system assessment. To assess the
anus, the nurse should visually evaluate the outer tissue for color, integrity, and absence of lesions. The nurse
should then ask the client to bear down as if defecating. With gloves on and the index finger lubricated, the nurse
should feel the rectal sphincter and slowly dilate it by sliding the lubricated finger into the rectum. Palpate inside the
rectum for masses, fissures, or other foreign bodies. After removal of the finger, inspect the finger for any signs of
bleeding or melena (dark, black, or sticky feces). If present, or if internal bleeding is suspected, the nurse should
perform a guaiac test, which will confirm if blood is present.
CLINICAL TIP
Important Newborn Assessment

For a newborn, the nurse should establish anal patency. This is done by two means: first, the nurse should insert
a lubricated rectal thermometer 1 cm to 2 cm (0.39 in to 0.78 in) into the newborn’s rectum to record
temperature, and second, the nurse should identify and document the passage of their first stool, called the
meconium (Gantan & Wiedrich, 2022).
4.3 The Function of Digestive Organs

LEARNING OUTCOMES
• 4.3.1 Describe the function of digestive organs in ingestion, digestion, absorption, and elimination.
• 4.3.2 Describe the pathophysiology associated with digestive organs.
• 4.3.3 Identify the impact of aging on digestive organs.

4.3 • The Function of Digestive Organs 69
Normal Function of the Digestive Organs

Before food ever enters the body, the sensory system starts the digestive process. The sight, smell, feel, and taste of
food influences the desire to eat. These senses trigger the salivary glands to begin releasing saliva in the
anticipation of eating, which helps break down food once it enters the oral cavity. When food enters the mouth,
chewing, also known as mastication, starts the breakdown of food. The tongue secretes mucins and lingual lipase
to help break down lipids. At the same time, the parotid, sublingual, and submandibular salivary glands release a
mixture of buffers, glycoproteins known as mucins, and salivary amylase to lubricate the food for swallowing and to
begin the digestion of complex carbohydrates and starches (National Institute of Diabetes and Digestive and Kidney
Diseases, 2022; Ogobuiro, Gonzales, & Tuma, 2022).
Food then passes to the pharynx. To swallow food into the esophagus and not the trachea, the swallowing center in
the brain stem of the central nervous system triggers certain actions:
• The nasopharynx is closed off by the rise of the soft palate when the tongue initiates swallowing by pushing
food to the back of the mouth.
• The larynx is closed in the pharynx to prevent food from entering the trachea (Mealie, Ali, & Manthey, 2022;
Ogobuiro, Gonzales, & Tuma, 2022).
• Once this swallowing reflex is initiated, it cannot be stopped until completed.
Once food is swallowed, it enters the esophagus by passing through the upper esophageal sphincter. The food
travels down the esophagus body involuntarily by way of a series of muscular contractions known as peristalsis. It
then exits the esophagus through the lower esophageal sphincter into the stomach (National Institute of Diabetes
and Digestive and Kidney Diseases, 2022).
While in the stomach, food is temporarily stored while mechanical and chemical processes break it down further
into chyme. The stomach uses its three muscular layers (the inner oblique, middle circular, and external longitudinal
layers) to contract and relax in a mixing and churning action to help mechanically break down food. To assist with
the chemical breakdown of food, the stomach releases hydrochloric acid secreted by its parietal cells, enzymes
such as pepsin, and hormones such as somatostatin and gastrin (Ogobuiro, Gonzales, & Tuma, 2022). The stomach
is also responsible for secreting an intrinsic factor (a glycoprotein that is necessary for the absorption of vitamin
B12) from the parietal cells.
The food, in the form of chyme, exits the stomach through the pyloric sphincter into the first of the three segments
of the small intestine, the duodenum. While in the duodenum, the pancreas (by way of the pancreatic duct) and liver
(by way of the gallbladder and biliary tree) empty enzymes into the duodenum through the sphincter of Oddi. The
liver secretes bile that is stored and concentrated in the gallbladder before it is released to aid in digestion (National
Institute of Diabetes and Digestive and Kidney Diseases, 2022; Ogobuiro, Gonzales, & Tuma, 2022). The pancreas’s
exocrine glands generate various enzyme precursors and enzymes that play a crucial role in the process of digestion
(Ogobuiro, Gonzales, & Tuma, 2022).
The food continues to the second segment of the small intestine, the jejunum, by way of peristalsis. This is where
the bulk of chemical digestion and nutrient absorption will occur before it moves into the last segment, the ileum,
which has some digestive and absorptive duties as well (Ogobuiro, Gonzales, & Tuma, 2022). Absorption in the
small intestine is done through nutrient exchange in extensive capillary networks that are located on the walls of the
small intestine. The surface area of the small intestine is increased to promote increased absorption through the use
of villi and microvilli that cover the walls and are home to the extensive capillary networks. There are also multiple
exocrine and endocrine glands that assist in the absorptive process by producing and releasing hormones, alkaline
mucinous materials, and enzymes.
Undigested food materials that pass through to the end of the small intestine through the ileocecal valve end up as
feces in the cecum, which is the first of the five segments of the large intestine (Ogobuiro, Gonzales, & Tuma, 2022).
While peristalsis moves the food through the large intestine, water and electrolytes are absorbed from the feces.
Final digestion of undigested food particles in the feces is completed by microbes that live in the large intestine.
Nutrients like vitamin K are produced and absorbed in the large intestine as well (Cleveland Clinic, 2022a; Ogobuiro,
Gonzales, & Tuma, 2022). The feces travel through the cecum, ascending colon, transverse colon, descending colon,
and sigmoid colon before moving into the rectum, where stretch receptors signal the brain to defecate.
From the rectum, the stool exits the body through the anal canal by passing through the internal and then external
anal sphincters. Relaxation of the internal anal sphincter is a reflexive action in response to the activation of the
stretch receptors, and the relaxation of the external anal sphincter is a conscious process that allows for stool to exit
the anus (Ogobuiro, Gonzales, & Tuma, 2022).
Pathophysiology Associated with Digestive Organs and Function

Many causes of diseases and disorders that impact the gastrointestinal system are linked with nutrition, as are many
of their treatments. Table 4.2 lists several organs impacted by nutritional deficit and the corresponding disease(s).
Organ Nutritional Link Disease or Disorder

Salivary gland Deficiency of vitamin B12 (cobalamin) Salivary gland tumors
Gums Deficiency of vitamin B12 Gingivitis
Mouth Deficiency of vitamin B12 Periodontal disease/cancers
Lips Maternal deficiency of vitamin B12 Cleft lip
Oral palate Maternal deficiency of vitamin B12 Cleft palate
Esophagus Food allergies Eosinophilic esophagitis
Stomach Deficiency of vitamin B12/lack of intrinsic factor Pernicious anemia
Intestine Low fiber intake, low water intake, and high dairy intake Constipation
Anus/rectum Low fiber intake, low water intake, and high dairy intake Hemorrhoids, fissures, and
fistulas
Gastrointestinal Low fiber intake, low water intake, high fat intake, and high Cancers
system cholesterol intake
Intestine Gluten Celiac disease
Stomach/ Worsened by food that contains caffeine, spicy foods, acidic Gastroesophageal reflux
esophagus foods, and dairy products disease (GERD)
TABLE 4.2 Diseases and Disorders of the Gastrointestinal System Linked with Nutrition (sources: Cleveland Clinic, 2022b; Cochran,
2022a–f; Munger et al., 2021; Ogobuiro, Gonzales, & Tuma, 2022)
Aging of the Digestive System

The nurse should be aware of considerations for aging clients in connection with the digestive system and the role of
nutrition. Older adults tend to have a decrease in appetite over younger adults due to comorbidities and/or
medications that decrease the desire to eat, cause nausea, or create dietary food restrictions due to drug
interactions. Older adults may experience the following issues:
• Appetite can decrease due to a loss in smell or taste or changes in the release of the hormones that control
appetite (e.g., ghrelin, peptide tyrosine, tyrosine, cholecystokinin, insulin, and leptin) (Nigam & Knight, 2017).
• Food may appear less attractive or appetizing due to changes made to food consistency for safety reasons
(Bartel, 2022; Nigam & Knight, 2017).
• The feeling of being full may happen faster or last longer due to the stomach wall losing elasticity, resulting in a
loss of hydrochloric acid secretion into the stomach, making food accommodation more difficult and gastric
emptying slower.
• Esophageal reflux may occur, and food may backflow more easily into the esophagus (Austin Gastroenterology,
2019).
• Hyposecretion of hydrochloric acid and protective mucus that occurs with age can result in chronic atrophic
gastritis, increased peptic ulcer disease, and decreased vitamin B12 absorption.
• An increase in the bacterial populations in the small intestine may lead to increased bloating and abdominal
pain as well as decreased absorption of calcium, folic acid, and iron (Bartel, 2022; Nigam & Knight, 2017).
• Decreases in digestive enzymes from the pancreas result in a reduction in the digestion of proteins and fats.
• The liver decreases bile production, rate of protein synthesis and metabolism, and its ability to detoxify
substances (Nigam & Knight, 2017).
• Risk for constipation increases because in the large intestine, there are reductions in neurotransmitters and

4.4 • The Nurse’s Role in the Promotion of Gut Health 71
neuroreceptors, atrophies of mucosa and muscle layers, formations of diverticula, declines in the rate of cell
division in the digestive epithelium, and increases in inflammatory conditions due to the increase in facultative
anaerobes. The increase in constipation increases the risk for hemorrhoid development.
Biological changes due to age make it important for an older client to be educated so that they eat nutrient-dense
options for adequate nutritional intake. With a lower caloric intake demand due to a slower metabolic rate from
aging, older adults’ need for calories will likely decrease, so the nutritional value of the foods they ingest is
important.
4.4 The Nurse’s Role in the Promotion of Gut Health

LEARNING OUTCOMES
• 4.4.1 Describe the homeostasis of gut health.
• 4.4.2 Describe the impact of diet on gut health.
• 4.4.3 Identify the impact of pharmacology on gut health.
• 4.4.4 Identify pathophysiology and gut health.
Gut Health Homeostasis

For healthy digestion and absorption of food and nutritional health, the gut must maintain a healthy homeostasis,
the equilibrium maintained in the body through physiological processes and evidenced by intestinal microbiota
growth. The nurse plays an important role in client education that leads to optimal nutritional health.
The composition of the gut’s microbial growth has a strong impact on the homeostasis of the gut. When the gut is
not in a state of homeostasis, the imbalance that results can cause dysbiosis, a disruption to the gut microbiome.
Many diseases have been linked to dysbiosis, including anxiety, depression, hypertension, cardiovascular disease,
cancer, inflammatory bowel disease, obesity, and diabetes, so the impact of an unhealthy gut surpasses just
gastrointestinal health (Afzaal et al., 2022).
To maintain proper gut homeostasis, bacterial growth requires energy in the form of adenosine triphosphate and
oxygen (Lee et al., 2022). Dietary factors, antibiotics, and underlying host conditions can reduce oxygen
consumption in the colonic epithelium, thereby reducing the available oxygen to the indigenous microbes.
The microbiota of the gut has many functions in the body. These bacterial residents help control nutrient
metabolism, defend against pathogens, contribute to carbohydrate digestion, synthesize methane from hydrogen
processed by bacterial metabolism, neutralize carcinogens, and synthesize biotin, folate, and vitamin K (Afzaal et
al., 2022).
Diet and Gut Health

Diet directly impacts the health of microbial growth (Lee et al., 2022). There are numerous foods that have a positive
impact on gut health. For example, fiber, water intake, fruits and vegetables, whole grains, and an overall well-
balanced diet have shown positive effects. Yogurt is known to have a positive impact because it contains active
bacterial cultures, which have been shown to be supportive of the gut microbiome environment (Stanford Medicine
Children’s Health, 2023a). High-fat diets, in contrast, have been shown to have a negative impact. They tend to
contribute to diabetes, obesity, metabolic syndrome, and colon cancer (Afzaal et al., 2022; Baton Rouge General,
2023). In addition, high sodium intake and alcohol use can contribute to dysbiosis and have been linked to
hypertension.
A nurse can make a direct impact on client health by educating clients on why diet, gut microbiota, and homeostasis
are important. The nurse should speak to the specific reasons why fiber, water, probiotics, and whole grains are
valuable in a diet and why saturated fats, alcohol, and sodium are areas of concern. The nurse should discuss with
the client so they understand which types of food to increase or decrease. Table 4.3 lists common foods and their
impact on the gastrointestinal system.
Food Impact on Gastrointestinal System

Fresh fruits and vegetables, lentils, kidney These foods are high in fiber and help maintain gut homeostasis,
beans, split peas, chickpeas, quinoa, oats, reduce cholesterol, promote healthy weight through satiety,
popcorn, almonds, chia seeds, sweet reduce constipation by adding bulk to stool, and possibly reduce
potatoes, and dark chocolate gastrointestinal cancer risks due to potential antioxidant
properties (Gunnars, 2020; Moffitt Cancer Center, 2023).
Water Increasing fiber requires increasing water in the diet to ensure
there is sufficient water in the stool to account for the added
bulk.
Saturated fats (found in fatty cuts of meat, Saturated fats can lead to gut imbalance (Afzaal et al, 2022),
pies, sausage, butter, lard, cheddar cheese, raise bad cholesterol levels (NHS, 2023), and increase colon
ice cream, sour cream, biscuits, cakes, cancer risks (Baton Rouge General, 2023).
pastries, milk chocolate confectionaries,
palm oil, coconut oil, and coconut cream)
High-sodium foods (breads; pizza; High amounts of sodium can upset the homeostasis of the gut by
sandwiches; deli meats and cured meats; increasing dehydration.
cheese; soups; burritos and tacos; snacks
like chips, popcorn, and pretzels; chicken;
and omelets)
TABLE 4.3 Common Foods and Liquids and the Gastrointestinal System
Pharmacology and Gut Health

Pharmacology and nutrition are interdependent because they rely on the same body processes. When the body
lacks nutrients, the body’s ability to utilize certain drugs is impacted (Bhupathiraju & Hu, 2023). A lack in nutrients
also impacts the body’s ability to properly dispose of toxins from drugs and digestion waste. The nutritional state of
a client greatly impacts the ability of their medications to be properly metabolized, used, and excreted.
Probiotics, such as Lactobacillus, are supplements that are known to have positive impacts on the gut microbiome.
These are useful in helping clients with dietary restrictions or who are taking certain medications that interfere with
gut health. These supplements should be taken in combination with a healthy diet because they do not prevent
gastrointestinal issues on their own but rather support healthy practices.
There are medications that can help and hurt the microbiota of the gut. Antibiotics are a well-known culprit for
altering microbial growth. Long-term antibiotic use has been linked to Clostridium difficile (C. diff) infection and
colon cancer. When a client needs antibiotics for longer than three days, it is common practice that they also be
given a probiotic to counteract some side effects and the possibility of infection.
There are other medications that are lesser known for being harmful. They include:
• Proton pump inhibitors to treat gastroesophageal reflux disease, which can cause enteric infections like C. diff
(Weersma et al., 2020)
• Metformin, used to treat diabetes, which can increase Escherichia coli (E. coli) in the intestines and lower other
bacteria, causing imbalances in the microbiome
• Statins to treat hyperlipidemia, which can cause constipation or diarrhea, upsetting the homeostasis in the gut
• Antidepressants, which can kill off beneficial gut bacteria and alter the normal microbiome of the gut
• Opioids to treat chronic pain, which can cause severe bouts of constipation, upsetting the microbiome and
preventing the excretion of wastes from the body
• Laxatives, which can cause disruption of the microbiome through electrolyte disturbances, dehydration, and
mineral deficiencies
Pathophysiology and Gut Health

Gut health and its impact on the body are often discussed in relation to bidirectional crosstalk at an axis point (the
two-way communication that is focused at a specific intersection) between body systems that regulate health
relative to one another (Tilg et al., 2022). The gut has many of these axes that connect it to the liver, brain, lung,

4.4 • The Nurse’s Role in the Promotion of Gut Health 73
nervous system, sensory system, etc. The following section will look at the gut and its connection with the liver,
brain, and lung.
Gut-Liver, Gut-Brain, and Gut-Lung Axis

Gut-liver axis communication happens between nutrients, metabolites, microbial antigens, and bile acids within a
microbial community (Ding et al., 2020; Tilg et al., 2022). A disturbance in this gut-liver network has been linked to
an increase in hepatic inflammation and hepatic encephalopathy and decompensation of liver cirrhosis (Klein,
2022).
The gut-brain axis has been shown to have many devastatingly negative effects. The gut has been shown to produce
neuroactive compounds that modulate metabolism and immunity (Benakis & Liesz, 2022), which are essential
components to healing after a stroke. Because a stroke leads to intestinal dysmotility and permeability of the
intestinal barrier, and thus decreased metabolism and depressed immunity, stroke victims often have impaired
healing. Table 4.4 outlines some other diseases connected to the gut-brain connection.
Disease Impact
Parkinson’s Overgrowth of intestinal bacteria results in an increase in opportunistic pathogens, causing the
disease neurotransmitter L-dopa to be decreased (Wallen et al., 2022). Parkinson’s disease is directly
impacted by the availability of L-dopa, and symptoms are worsened when the availability is
decreased.
Multiple Overgrowth of certain gut bacteria causes an imbalance in homeostasis; exacerbations and
sclerosis advancement of the disease can be affected (eBioMedicine, 2022; French, 2022).
Alzheimer’s Clients with Alzheimer’s disease are shown to demonstrate excessive production and
disease aggregation of amyloid-beta peptides that lead to extracellular plaque formation (Sidharthan,
2022). Gut microbiota health impacts the disease because when it is unbalanced, it releases
more of certain by-products that can alter inflammatory cytokine-signaling pathways, leading to
amyloid-beta peptide accumulation.
Mental A link has been found between systemic inflammations and anxiety, depression, and other
health mental illnesses (GI Associate and Endoscopy Center, 2022a). The health of the gut has a large
impact on the inflammatory state of the body. It also has a key function in the release of many
neurotransmitters, one of which is serotonin, an important mood neurotransmitter.
Huntington’s When the gut microbiota is unbalanced, there is an influence on mood, cognition, and sleep,
disease which are already negatively impacted by this disease (Wasser et al., 2020).
TABLE 4.4 Diseases Known to Be Linked to the Gut-Brain Axis Connection
Due to the recent COVID-19 pandemic, the gut-lung axis has been more recently explored. Overall, the gut’s role in
the health of the body’s overall immunity and the reduction of systemic inflammation has been applied to COVID-19
infection. The resulting acute respiratory distress syndrome that is a life-threatening effect of the virus is caused by
an autoimmune-response-mediated inflammation in the lungs. Overall rates of mortality with COVID-19 are
markedly higher for those admitted to the intensive care unit, and those who have gastrointestinal symptoms in
conjunction with their respiratory symptoms are much more likely to need intensive care, making gastrointestinal
issues a determinant of prognosis (Chen et al., 2020; Cleveland Clinic, 2022b; Ye et al., 2020; Ouali et al., 2021).
Long-haul COVID-19 has also become more prevalent. Because clients who have gastrointestinal symptoms with
COVID-19 infection have a longer detoxification time after infection, they are at a higher risk for developing long-
haul COVID than those without gastrointestinal symptoms.
Chapter Summary
• The gastrointestinal system contains the upper unintentional weight loss or gain, and any medical
gastrointestinal system (mouth, teeth, tongue, diagnoses or surgical history for proper
salivary glands, pharynx, esophagus, stomach, and assessment.
duodenum), the lower gastrointestinal system • Digestive organs ingest, digest, and absorb the
(small intestine, large intestine, rectum, anal food that is taken into the body to convert it to
canal, and anus), the accessory digestive organs usable energy.
(liver, gallbladder, and pancreas), and the • The body removes all usable nutrients and water
accessory systems (nervous and sensory from food intake and then eliminates the rest as a
systems). waste product, stool.
• While physical assessment of the client is • The nurse’s role is to educate the client on the
required, the nurse should also obtain a history of proper dietary practices that will help maintain gut
the client’s dietary practices, dietary intolerances homeostasis and to evaluate steps the client can
or allergies, typical eating and bowel patterns, take to prevent gut issues when they must take
changes in normal eating or bowel patterns, recent medications that can upset that homeostasis.
Key Terms
absorption the process of cells taking in digested homeostasis a balanced state in the body that allows
substances for proper function
amylase an enzyme that helps to break down ingestion the first step of the digestive process that
carbohydrates involves bringing food and liquids into the body
bile a fluid created in the liver that aids in digestion of through the mouth
food in the duodenum insulin a hormone that assists in the absorption of
carboxypeptidase an enzyme that helps to glucose into cells for energy usage
breakdown fats intrinsic factor a glycoprotein required for vitamin
cholecystokinin a hormone produced by the small B12 absorption in the small intestine
intestine that triggers the pancreas and gallbladder lipase an enzyme that helps to break down fats
to contract when fats and proteins enter mastication chewing action of the mouth
chyme a mix of gastric juices and digested food meconium the first stool passed by a newborn
chymotrypsinogen an enzyme that breaks down melena dark, black, or sticky feces
proteins into smaller particles metabolism the part of digestion in which the body
digestion the breakdown of solid food that includes converts absorbed substances into energy
both mechanical and chemical actions to form nucleases an enzyme that breaks down nucleic acid
smaller, more absorbable substances in the body’s chains
gastrointestinal tract pepsin an enzyme that begins to break down proteins
dysbiosis a disruption to the microbiome resulting in in the stomach
an imbalance in the microbiota of the intestines protease an enzyme that breaks down proteins
elastase an enzyme that helps break down fats, somatostatin a hormone that regulates stomach acid
proteins, and carbohydrates secretion during digestion
fistula a condition in which two body parts are succussion splash a sloshing or splashing sound
abnormally connected heard on auscultation of the abdomen due to
frenulum the small tissue beneath the tongue that excessive fluid remaining in the stomach
provides support trypsinogen an enzyme that helps break down fats
gastrin a peptide hormone that regulates gastric into amino acids
motility, gastric secretion of stomach acid, and tympany a resonant, hollow sound potentially heard
gastric mucosal growth during percussion
guaiac test a test that confirms the presence of blood uvula the fleshy extension that hangs at the back of
in stool the throat and at the end of the soft palate
Review Questions
1. The nurse is caring for a client with a small bowel obstruction. The client asks why they are experiencing
vomiting of stool. What response by the nurse is appropriate?

a. The gastrointestinal tract is one long tube, so a blockage will cause contents to move backward.
b. The pyloric valve prevents stool from flowing into the stomach when the intestines are blocked.
c. Peristaltic movement prevents the backflow of contents when the intestines are blocked.
d. Obstruction of the small bowel will not cause vomiting of stool.
2. The nurse is assessing a client who has flatus. What finding would the nurse expect to assess in this client?
a. Scaphoid abdomen
b. Jaundice of the abdomen
c. Tympany on percussion
d. Dullness on percussion
3. The nurse is assessing a 3-year-old client who has been brought in by their parents due to refusal to eat and
seems to choke on fluids easily. The nurse assesses that the client has uncontrolled drooling, is hyperthermic,
and has a very muffled cry. What precaution should the nurse take when assessing the gastrointestinal
system of this client?
a. Avoid use of tongue blade/depressor.
b. Avoid deep palpation of the abdomen.
c. Avoid percussion of the abdomen.
d. Avoid assessment of liver margins.
4. The nurse is educating a client on the normal function of the digestive system. The nurse teaches the client
that which organ is responsible for the most water absorption?
a. Esophagus
b. Stomach
c. Small intestine
d. Large intestine
5. The nurse is caring for a client with lower gastrointestinal bleeding. What test would the nurse anticipate
being ordered for this client?
a. Comprehensive metabolic panel
b. Guaiac test
c. Ovum and parasite stool test
d. White blood cell count
6. The nurse is assessing the nutritional status of a healthy older client. Which finding would the nurse
anticipate in this client?
a. Decreased stomach size
b. Decreased vitamin B12 absorption
c. Increased esophageal motility
d. Increased diarrhea
7. The nurse is educating a client on gut homeostasis. Which instruction would the nurse give the client?
a. Reduce intake of palm oil.
b. Increase sodium intake.
c. Limit fluids.
d. Reduce fiber intake.
8. The nurse is caring for a client on long-term antibiotic therapy. Which food should the nurse recommend the
client include in the diet to maintain gut homeostasis?
a. Fish
b. Yogurt
c. Broccoli
d. Carrots
9. The nurse is caring for a client taking multiple medications. Which should the nurse teach as supportive to the
microbiome of the gut?
a. Gentamycin
b. Pantoprazole
c. Lactobacillus
d. Lovastatin
10. The nurse is caring for a client with multiple health problems. Which finding in the client’s history supports
the client’s gut homeostasis?
a. Metformin use for type 2 diabetes
b. Increased intake of saturated fats
c. Regular use of laxatives
d. High intake of whole grains
Suggested Reading
Blonski, W., Slone, S., & Richter, J. (2022). Update on the Diagnosis and Treatment of Achalasia. Dysphagia. Online
ahead of print, https://pubmed.ncbi.nlm.nih.gov/35585208/. DOI: 10.1007/s00455-02210435-3
Bryce, C., Bucaj, M., & Gazda, R. (2022). Barrett Esophagus: Rapid Evidence Review. American Family Physician,
106(4), 383-387. https://www.aafp.org/pubs/afp/issues/2022/1000/barrett-esophagus.html
Friedman, A., Chen, A., Wu, R., Coe, N., Halpern, S., Hwang, U., Kelz, R., & Cappola, A. (2022). Evaluation and
Disposition of Older Adults Presenting to the Emergency Department with Abdominal Pain. Journal of the
American Geriatrics Society, 70(2), 501–511. DOI: 10.1111/jgs.17503
Katz, P., Dunbar, K., Schnoll-Sussman, F., Greer, K., Yadlapati, R., & Spechler, S. (2022). ACG Clinical Guideline for
the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology,
117(1), 27–56. DOI: 10.14309/ajg.0000000000001538
Thapar, N., Benninga, M., Crowell, M., Lorenzo, C., Mack, I., Nurko, S., Saps, M., Shulman, R., Szajewska, H., van
Tilberg, M., & Enck, P. (2020). Paediatric functional abdominal pain disorders. Nature Reviews Disease Primers
6(89). DOI: https://doi.org/10.1038/s41572-020-00222-5
Wolfe, C., Halsey-Nichols, M., Ritter, K., & McCoin, N. (2022). Abdominal Pain in the Emergency Department: How to
Select the Correct Imaging for Diagnosis. Dove Medical Press, 2022(14), 335–345. https://doi.org/10.2147/
OAEM.S342724

CHAPTER 5
Applying Clinical Judgment to Promote
Nutrition for Neurological Wellness
FIGURE 5.1 Nutrients from foods such as chili peppers impact brain function. (credit: modification of work “Chilli Pepper And Onion Mix
(https://openstax.org/r/wuestenigel)” by Marco Verch/Flickr, CC BY 2.0)
CHAPTER OUTLINE
5.1 Assess and Analyze the Impact of Nutrition on the Neurologic System
5.2 Plan Nutritional Strategies to Impact Neurologic Wellness
5.3 Implement Nutritional Strategies to Impact Neurologic Wellness
5.4 Evaluate Nutritional Strategies to Impact Neurologic Wellness
INTRODUCTION The neurologic system coordinates and manages nearly all activities of the human body in
response to internal and environmental influences by regulating specific cellular and tissue functions. Because of
the unique structure and functions within the brain, consideration of the specific nutrients that dramatically impact
normal operations is an important part of the nursing assessment.
Consider this case: Jamal Powell is a 68-year-old client being seen at the neurology care clinic. The client was
brought in by their spouse for evaluation of recent cognitive status changes. Jamal is concerned and fearful about
these cognitive changes because of the close family history of developing dementia in the middle to late 60s. The
client states that they smoked cigarettes for 3 years in their early 20s but quit and have not resumed smoking. There
is no history of toxic chemicals or other exposures and no history of head trauma, seizures, or stroke.
78 5 • Applying Clinical Judgment to Promote Nutrition for Neurological Wellness
5.1 Assess and Analyze the Impact of Nutrition on the Neurologic System
LEARNING OUTCOMES
• 5.1.1 Recognize the normal function of the neurologic system.
• 5.1.2 Recognize cues of nutritional impact on the neurologic system.
• 5.1.3 Analyze cues of nutritional impact on the neurologic system.
Normal Function of the Neurologic System

The neurologic system is defined by its two major components: the central nervous system (CNS), consisting of the
brain and the spinal cord, and the peripheral nervous system (PNS), consisting of all neurons outside of the CNS.
The PNS includes the somatic nervous system, which facilitates movement and muscle control in the body; the
neuromuscular junctions, which are located at the terminal end of motor nerves and conduct impulses to target
muscles; and the autonomic nervous system, which regulates involuntary body processes such as blood pressure,
heart rate, respiration, digestion, and sexual arousal.
The autonomic nervous system is composed of the sympathetic and parasympathetic nervous systems. The
sympathetic nervous system identifies impending danger and stimulates motor activity to either stay put and
defend against the danger or to run away from the danger, known as the fight-or-flight response. The
parasympathetic nervous system signals the body to rest and recover, as well as to digest food intake, known as
the “rest-and-digest” response.
While the CNS is responsible for regulating cardiac, skeletal, and visceral smooth muscle activity, the PNS relays
sensory input to the CNS for processing and then relays this information via motor responses to various effector
organs and cells of the body. The PNS has two components: The afferent (sensory) component transmits impulses
from peripheral organs to the CNS, and the efferent (motor) component transmits impulses from the CNS out to
peripheral organs to initiate an active response or action.
The brain requires approximately 20% of the body’s total oxygen delivery and about 15% of the cardiac output.
Because the brain cannot store glucose, it must rely on a constant supply of nutrients from the arterial blood flow, at
a rate of 50–55 mL/g/min (Norris, 2019).
Normal Brain Structure and Function

The brain conducts the most complex functions in the human body and is responsible for a person’s intelligence,
memory, speech, behavioral responses to stress, heart rate regulation, breathing rates, and movement. However, it
weighs approximately 3 lb (Figure 5.2). Approximately 60% of the brain is composed of fat, and the remaining 40%
is made up of water, carbohydrates, protein, and various salts. The brain contains nerves (neurons and glial cells) as
well as blood vessels, which supply the nutrients required for effective brain function. The tissue of the brain is
composed of cells referred to as white matter, located in the central part of the brain, and gray matter, located on
the external portion of the brain.

5.1 • Assess and Analyze the Impact of Nutrition on the Neurologic System 79
FIGURE 5.2 The regions of the brain are shown in lateral and anterior views. (credit: modification of work from Anatomy and Physiology 2e.
The internal white matter of the brain is composed of axons, the long slender projections of neurons, which conduct
electrical impulses across nerve cells. Axons are wrapped in myelin, a white fatty protein coating that protects and
insulates the axon and increases the speed of impulse conduction to other sensory and motor cells of the nervous
system. The gray matter is composed mainly of the round cell bodies (soma) of the neurons, which give it its grayish
color; it is responsible for interpreting and processing information as it is received. As information is processed, the
gray matter sends and receives chemical and electrical signals to control various processes such as movements and
sensations. The cerebrum is the largest part of the brain, weighing 1.5–3 lb or about 2% of the total body weight. It
is responsible for initiating, coordinating, and regulating movement, body temperature, speech, judgment, thinking,
learning, reasoning, and emotions, as well as functions of the senses, such as vision, hearing, and touch. The various
lobes of the cerebrum include the frontal, temporal, parietal, and occipital lobes, each controlling specific functions.
The protective outer layer of the cerebrum is the cerebral cortex. It facilitates memory, thinking, learning,
reasoning, problem-solving, emotions, consciousness, and sensory functions. It is divided into two hemispheres,
with the corpus callosum providing a pathway for communication between these two sides of the brain.
The brainstem has three components: the midbrain (responsible for hearing, movement, and other responses to the
environment), the pons (responsible for blinking, vision, balance, hearing, facial expression, chewing, and tear
production), and the medulla (responsible for heart rhythm, regulation of oxygen and carbon dioxide levels, blood
flow, and reflexive responses such as coughing, swallowing, sneezing, and vomiting). The spinal cord carries sensory
and motor messages to and from the brain to the effector organs to control bodily functions and environmental
responses.
The cerebellum is responsible for posture, equilibrium, and balance, as well as playing a role in emotions and social
behavior. The cerebellum may also have a role in addiction, autism, and some psychiatric conditions.
Neurotransmitters
The neurons (nerve cells) are the functional cells of the neurologic system and relay all sensory and motor
information via a complex system of chemicals produced by the body called neurotransmitters (Figure 5.3). They
can be categorized into three groups:
• Amino acids that function in the CNS synapses (gamma-aminobutyric acid [GABA], glycine, and glutamic acid)
• Peptides that perceive pain and various sensations (endorphins and enkephalins)
• Monoamines that transmit in the autonomic nervous system (epinephrine and norepinephrine)
Neurotransmitters allow neurons to communicate by relaying excitatory or inhibitory messages at the synapse of
the neuron to perform a wide range of functions via action potentials. Neurons have the capability to open the
sodium channels along the cell membranes, allowing sodium to move into the cell, thus creating cellular
depolarization, and subsequently moving potassium out of the cell in a process called the action potential. In turn,
the cell then repolarizes, producing a resting state called the resting membrane potential. These actions enable the
nervous system to rapidly transmit messages to and from the brain and tissues of the body, allowing changes for
adaptation to the external or internal environment.
FIGURE 5.3 Neurotransmitters communicate at designated receptors to allow sensory and motor responses. (credit: modification of work
from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Assessment of Nutrition and the Function of the Neurologic System

A comprehensive nutrition assessment is performed as a routine component of neurologic assessment during the
intake assessment. All clients require initial and ongoing screenings by nurses to determine any nutritional risk
factors related to proper functioning of the neurologic system. When performing a general neurologic assessment,
the nurse should begin by determining the client’s level of consciousness, mental status, motor abilities and
balance, and sensation. The nurse should take a detailed history of medical conditions directly affecting the client or
the client’s biological family. Any history of alcohol intake, medications, and dietary supplements, either prescribed
or over the counter, should be included. A history of pain, both recent and past, should be explored. Pain related to
chewing or swallowing, gastrointestinal pain, or pain that interferes with feeding may be pertinent to a nutritional
problem, and mealtime observations can provide information regarding overall nutritional risk. Any history of visual
disturbances, disequilibrium, dizziness, vertigo, vomiting, or changes in weight are significant and could be related
to dehydration or the quantity and quality of caloric and nutritional intake.
Guidelines for assessing weight, height, and body mass index (BMI) have been published by the National Heart,
Lung and Blood Institute (2023). A weight loss of more than 10% over the past year or 5% within the previous 6
months is significant and should be explored. Specifically, the nurse should ask for details of the client’s self-
management practices, including dietary, urinary, and bowel patterns; allergies; exercise and activities; and usual
sleep cycle. A BMI of 30 or higher is associated with greater risks for neurologic and cardiovascular diseases
(Centers for Disease Control and Prevention, 2022; Held et al., 2022). If the client is not critically ill, anthropometric
measurements, midarm muscle circumference, and skinfold thickness measurements should be recorded because
these may be helpful for estimating percentages of body fat and lean body muscle as a measure of nutritional status
and general health. For clients who are determined to be at nutritional risk, a referral should be established with a
registered dietitian.
An evaluation of mental health is an important component of neurologic health and should include an expression of

the client’s self-concept and perception, as well as a summary of patterns related to adaptation to daily life
stressors and relationships. This evaluation should also include specific beliefs or cultural norms as they relate to
nutritional health practices. A history of diseases, health conditions, and medications is extremely useful for
determining possible nutritional deficiencies. Given the sensitive nature of dietary habits, it is helpful for the nurse
to maintain a nonthreatening and consistent approach to nutritional screening as it relates to neurologic health.
CLINICAL TIP
Therapeutic Conversation
When performing evaluations, the nurse should conduct conversation using therapeutic conversation, such as
the five As (assess, advise, agree, assist, and arrange). Motivational interviewing is another strategy that is helpful
in engaging clients who may be hesitant.
Small changes are generally advised when considering behavioral changes that can seem overwhelming to the
client. Dietary changes such as reducing or increasing the intake of certain foods slowly can have a dramatic effect
over the long term. It is important to allow small substitutions that allow for individualized treats that satisfy food
cravings while reducing trans fats and ensuring adequate intake of vegetables and healthy foods. A nursing
assessment of nutrition should include a food diary that includes specific questions regarding the client’s dietary
habits over the previous few days and months—specifically, the number of meals and snacks consumed each day,
the amount of fruit consumed, fluid intake, and fat and sugar intake (Lee, 2022). Nutrition counseling cannot be
successfully completed in one meeting. The nurse should plan for subsequent meetings when adjusting a client’s
diet and should share the counseling efforts with other members of the health care team.
Controlling Nutrition Status Score

The Controlling Nutritional Status (CONUT) score is an instrument to measure nutrition (Ulíbarri, 2005). A CONUT
score is correlated to serum albumin level, the main protein in plasma. Albumin, which is synthesized in the liver,
transports hormones and enzymes throughout the body and maintains equilibrium by stabilizing the capillary
membrane. Albumin levels may be elevated in individuals who are dehydrated, consume a high-protein diet, or have
an acute infection. Albumin levels may also be elevated in clients taking certain medications, such as insulin,
steroids, or hormones. Individuals who are malnourished or have liver, kidney, or inflammatory diseases will have
low albumin levels. Fasting can rapidly diminish albumin levels by up to one-third within 24–48 hours. Low albumin
levels have been linked to increased mortality and longer hospital stay among clients with traumatic brain injury
(TBI) because of increased levels of stress, blood loss, and dysphagia (Wang et al., 2020).
The CONUT score presents albumin, lymphocyte, and cholesterol levels as an overall nutritional score (Table 5.1).
The formula for the CONUT score is a calculated value: 10 multiplied by the serum albumin value in g/dL, plus 0.005
multiplied by the total lymphocyte count in the peripheral blood in cubic milliliters, plus the total cholesterol score
(Wang et al., 2020). The CONUT score may be an indicator of in-hospital mortality and 90-day outcomes in persons
with traumatic brain injury (Wang et al., 2020). However, it is important to remember that among clients with acute
illness, infection or injury, albumin levels may be reduced due to the acute nature of these pathophysiologic events
rather than a nutritional problem. Relying solely on albumin as a marker of nutrition may be inaccurate (Smith,
2017).
Nutritional Levels Normal Light Deficiency Moderate Severe Deficiency

in Adults Deficiency
Serum albumin 3.5–4.5 3.0–3.49 2.5–2.99 < 2.5
(g/dL)
Score 0 2 4 6
Total lymphocytes/ > 1600 1200–1599 800–1199 < 800
mL ≥ 1.600×109/L 1.200–1.599×109/L 0.800–1.199×109/L < 0.800×109/L
Score 0 1 2 3
TABLE 5.1 Controlling Nutritional Status (CONUT) Score (source: Wang et al., 2020)
Nutritional Levels Normal Light Deficiency Moderate Severe Deficiency

in Adults Deficiency
Cholesterol (mg/ > 180 140–180 100–139 < 100
dL)
Score 0 1 2 3
Total score 0–1 2–4 5–8 9–12
TABLE 5.1 Controlling Nutritional Status (CONUT) Score (source: Wang et al., 2020)
Required Nutrients for Brain Function

The cells of the brain cannot store glucose or other nutrients; as a result, the brain can function for only
approximately 10 seconds without depleting the oxygen supply via the cerebral circulation. Glucose is considered a
macronutrient and is the main fuel for the brain. Because the neurons in the brain have no capability to store
glucose, a continuous supply is required to ensure adequate brain function. Death to brain cells begins when they
are deprived of oxygen for only 4–6 minutes. Any disruption in blood flow will lead to a buildup of toxic metabolic
byproducts that will damage vulnerable cells in the brain. Other macronutrients that supply the brain with fuel
include proteins and fats, which can also act as energy sources.
Micronutrients are vitamins and minerals that are critical for optimal brain function in very small amounts. They
include omega-3 fatty acids (important components of the membranes that surround the cells of the body),
polyphenols (micronutrients that have health-promoting properties and are found in many fruits and vegetables),
vitamins (especially certain B vitamins: B1 [thiamine], B6 [pyridoxine], B9 [folate], and B12), and minerals (zinc,
magnesium, iodine, iron).
Zinc is a trace metal ion that contributes to brain health by supporting the immune system and the function of the
pituitary hormones, such as the secretion of growth hormone. Zinc has also been shown to increase insulin-like
growth factor, which fosters the genesis of neural stem cells, and it has strong antioxidant properties that support
immune function (Choi et al., 2020). In addition, zinc accelerates the production of cells that provide nonspecific
immunity protection, such as neutrophils and natural killer cells (Choi et al., 2020).
Iodine is a vital mineral micronutrient that stimulates the production of thyroid hormones T3 and T4, which are
responsible for brain development and control of cellular metabolism. Iodine is critical to fetal development, as it
facilitates neuronal multiplication, migration, and organization; brain development; and nerve cell myelinization.
This process continues in the first few years of life. The effect of iodine on the brain continues throughout childhood
and adulthood, fostering the ability to learn and the desire and motivation to improve performance (Khattak et al.,
2017).
Vitamin B6 is known to reduce levels of homocysteine (an amino acid that can increase inflammation); it stimulates
the biosynthesis of certain neurotransmitters such as GABA, dopamine, and serotonin; and it is required for normal
development of the CNS during the perinatal period (Smith & Refsum, 2021). Ensuring that the body sustains
adequate blood levels of vitamins B6 and B12 has been shown to reduce feelings of stress and depression, improve
concentration and memory, and prevent stroke events (Berkins et al., 2021; Smith & Refsum, 2021).
Iron is another essential mineral micronutrient. It facilitates oxygen transportation, DNA synthesis, mitochondrial
respiration, myelin production, and the development and metabolism of various neurotransmitters. Iron is received
in the brain mainly bound to transferrin on endothelial cells. It crosses the blood–brain barrier and is then released
into the extracellular compartments in the brain (Ward et al., 2014).
Magnesium is a dietary micromineral with many roles in the body. A strong body of evidence supports its role in
supporting optimal nerve transmission and neuromuscular coordination (Kirkland et al., 2018). Moreover,
magnesium has a protective effect against the development of chronic pain, migraine headaches, depression,
anxiety, and stroke (Kirkland et al., 2018).
Selenium is a micronutrient that plays an important role as an antioxidant, protecting cells from damage. It is
involved in the production of immunoglobins that aid in cellular immunity, as it has anti-inflammatory effects (Farag
et al., 2021). During pregnancy, selenium is crucial to mitigate the stress associated with a growing fetus, and
selenium deficiency is associated with low birth weight because of restricted intrauterine growth. Clients who are

obese before becoming pregnant may have low levels of selenium during the first trimester of pregnancy. The risk of
hypertension during pregnancy is increased in clients with selenium deficiency.
Although micronutrients are required in smaller amounts than the macronutrients are, they are essential for most
metabolic, biochemical, and regulatory responses of the nervous system (Reddy et al., 2018). See Table 5.2.
Micronutrient Expected Effect Defined Level Significance of Recommended Daily

on Neurologic Abnormal Values Allowance and
System Treatment Dosages
Vitamin B1 • Myelin sheath • Indirect assay • Symptoms include • 10 mg/day for 7
(thiamine) maintenance of the loss of sensation in days, then 3–5
transketolase the hands, feet, mg/day for 6
enzyme and toes, weeks for mild
(0–15%) combined with deficiency
burning pain, • 50–100 mg/day
paresthesia, or may be provided
muscle weakness. in severe
• Deficiencies may deficiency among
occur in adults until
individuals with proper nutrition
chronic alcohol is delivered
use disorder, naturally.
Wernicke’s • Neurologic
encephalopathy, improvement in
or Korsakoff’s deficient
syndrome. individuals may
not be evident for
3–6 months.
Vitamin B3 • Carbohydrate • No reliable • Deficiency causes • 14–16 mg/day

(niacin) metabolism measure of neuropsychiatric
serum B3 symptoms such as
an apathetic,
inattentive, ill-
tempered, or
depressed affect;
left untreated,
coma or stupor
can result.
• Pellagra is a B3
deficiency that
causes dermatitis,
dementia, and
diarrhea.
TABLE 5.2 Micronutrients and Neurologic Function (source: National Institutes of Health, 2023a–j)

Vitamin B6 • Converts • 3.4–65.2 • Deficiencies are • 1.3–2 mg
(pyridoxine) pyridoxine into mcg/L seen with some (maximum) daily
pyridoxal medications
or
phosphate, a (isoniazid,
cofactor in • 13.76–263.81 phenelzine,
numerous nmol/L hydralazine, and
metabolic penicillamine) and
reactions in pregnancy,
chronic alcohol
use disorder, and
clients undergoing
hemodialysis.
• Deficiencies can
present as
numbness,
weakness, loss of
sensation,
paresthesia, or
foot, hand or leg
pain. An ataxic gait
and loss of or
decreased reflexes
may be present.
Deficiencies in
infants may
manifest as
seizures.
• Toxicity can occur
with excessive
supplementation
(≥ 100 mg/day).
Symptoms of
toxicity include
ataxic gait, loss of
reflexes, loss of
sensation, and
tingling or burning
sensations.


Vitamin B12 • Formation of • Serum level: • Deficiencies can • 8–12 mcg/day
(cobalamin) methionine > 200–250 manifest as • Adults older than
• Formation of pg/mL neuropathies 50 years may
the myelin (especially need to
sheath sensory problems supplement
in the feet), dietary
changes in affect consumption if
and behavior, or deficient.
peripheral and • If deficient: 1000
optic neuropathy. mcg orally daily
• Deficiencies may • In severe
be seen in deficiency,
individuals with injections may be
malabsorption recommended.
issues, pernicious
anemia,
gastrointestinal
surgeries, or past
weight-reduction
surgery.
Supplementation
is recommended
for individuals
eating vegan diets.
• Metformin and
proton pump
inhibitors can
worsen a
deficiency.
Vitamin E • Protein • Serum level: • Some people with • 15 mg/day

transport via not routinely rare lysosomal • Deficiency: 400
very low- assessed storage disorders units twice a day,
density will experience a with a gradual
lipoproteins; slowly progressing dose increase
stored in (5–10 years) until serum
adipose tissue degeneration of vitamin E level is
sensation, deep as expected.
tendon reflexes,
reduced
proprioception,
and ataxia.

Copper • Balances • Serum level: • Deficiencies can • 900 mcg/day
hormones that not routinely manifest as • Deficiency:
make nerve assessed neuropathies Intravenous
cells (upper and lower doses of 2–4 mg/
motor neuron day
signs).
• Excessive intake
can cause
headaches,
diarrhea, and
kidney failure and
can prevent
copper from
accumulating.
Chelation therapy
(as with the drugs
Cupramine,
Depen, and
Syprine) binds
copper into a
compound that
can effectively be
eliminated.
• Wilson’s disease, a
rare genetic
disorder, prevents
the elimination of
copper. Copper
excess is detected
via blood tests and
24-hour urine
collection.


Iodine • Synthesis of Urinary • A deficiency of • 150 mcg/day for
thyroid concentrations: iodine is a global persons ages 14
hormones T3 • Adults and concern, as it is years and older
and T4 children: the leading cause • Infants receive
• Fetal and 100–199 of intellectual adequate iodine
infant mcg/L deficits in the from formula,
development, • During world. Thyroid breast milk and
childhood pregnancy: deficiencies can food intake and
cognitive 150–249 result from a do not require
function mcg/L deficiency of supplementation.
• During iodine because it is • Acute poisoning
lactation: > required to is rare.
100 mcg/L produce thyroid
hormones. Goiter
and elevations of
thyroid-
stimulating
hormone (TSH)
may be signs of
deficit.
• Deficiency during
pregnancy and
infancy can cause
irreversible
effects.
• Excessive intake
can cause goiter in
adults, TSH
elevation,
thyroiditis, and
thyroid papillary
cancer.
• Iodine
supplementation
can interact with
certain
medications:
◦ Concurrent use
with antithyroid
medications
can cause
hypothyroidism.
◦ Concurrent use
with
angiotensin-
converting
enzyme (ACE)
inhibitors and

potassium-
sparing
diuretics
increases the
risk for
hyperkalemia.
Magnesium • Controls • Serum level: • Deficiencies are • Adult females:

oxidative 0.75–0.95 rare but may be 310–320 for
stress and mmol/L due to certain adult females
inflammation health conditions, (higher amounts
• Supports medications, or for pregnant/
adequate chronic alcohol lactating
blood flow use disorder. females)
• Essential role • Early signs of • Adult males:
in nerve deficiency may 400–420
transmission include anorexia, • Abundant in the
and nausea and diet: spinach,
neuromuscular vomiting, fatigue, nuts, seeds,
conduction weakness, whole grains,
numbness, lean meats,
tingling, muscle poultry, eggs,
contractions, seafood, beans,
cramps, seizures, peas, lentils,
personality other legumes,
changes, abnormal soy
heart rhythms, and
coronary spasm.
• Severe deficiency
may cause
hypocalcemia or
hypokalemia.
• Medication
interactions:
bisphosphonates,
antibiotics,
diuretics, and
proton pump
inhibitors.


Selenium • Essential role • Serum level: • Serum • 55–70 mcg/day
in Plasma or concentrations for persons 14
reproduction, serum drop with aging years and older
thyroid selenium and are related to including
hormone concentrations a decline in brain pregnant and
metabolism, of 8 mcg/dL function, possibly lactating clients
and DNA due to decreases • Supplementation:
synthesis in selenium’s 100 mcg
• Protection antioxidant • Food sources:
from oxidative activity. Brazil nuts,
damage and • Excessive intake seafood, organ
infection can cause hair and meats, muscle
nail loss or meats, cereals
brittleness, and other grains,
nausea, diarrhea, dairy products
skin rashes,
mottled teeth,
fatigue, irritability,
and CNS
abnormalities.

Zinc • Cellular • 80–120 mcg/ • Deficiency • 8–12 mg/day
metabolism, dL interrupts the • Food sources:
enhances senses of taste meat, fish, and
immune and smell. In older seafood (oysters
function, adults, deficiency contain the most
protein and can cause delays zinc of all foods);
DNA synthesis, in wound healing other foods such
wound and changes in as eggs, dairy,
healing, and cognitive and beans, nuts, and
cell signaling psychological whole grains
and division function. contain zinc but
• Can reduce the • Excessive intake are not fully
duration of the can cause nausea, metabolized.
common cold dizziness,
• Can delay age- headaches, gastric
related distress, vomiting,
macular and loss of
degeneration appetite.
• Doses of 50 mg or
more from
supplements or
excessive use of
denture adhesive
creams containing
zinc can interfere
with copper
absorption, reduce
immune function,
and lower high-
density lipoprotein
cholesterol levels.
• High doses from
supplements (142
mg/day) interfere
with magnesium
absorption.
Given that nearly 60% of brain tissue is composed of fat and that the omega-3 and omega-6 fatty acids account for
20% of the overall brain weight, it is important to understand the role of fats in brain function at all stages of human
life. These fatty acids promote cognition, preservation of neurons, and protection against neurodegeneration. This is
because omega-3 fatty acids facilitate production of oxyhemoglobin and hemoglobin in the blood, which improve
cerebral circulation and subsequently improve overall mental performance (Dighriri et al., 2022).
Another micronutrient group is the polyphenols, which are metabolites of plants. They are potent antioxidants and
have long been shown to reduce cardiovascular risk by providing antiplatelet and anti-inflammatory functions. In
addition, they may offer some protection from neurodegenerative diseases; recent evidence supports the theory
that cognitive decline may be prevented and Alzheimer’s disease may be slowed by the consistent intake of
polyphenols (D’Angelo, 2020; Luo et al., 2021). Most plant-based foods contain polyphenols, which can be found in
vegetables, fruits, legumes, olive oil, and nuts. Some of the richest sources are colored berries, nuts (especially

walnuts, almonds, and hazelnuts), seeds, vegetables, black and green tea, and certain spices. A polyphenol that has
received considerable attention over the past decade is curcumin, the root of the turmeric plant (used in many
Indian dishes, such as curry), which has shown a dramatic protective effect on the neurologic system. Red wine and
dark chocolate have also been shown to contain polyphenols and may be consumed in moderation (Fekete et al.,
2023). See Figure 5.4.
FIGURE 5.4 Polyphenols, which can be found in foods like almonds and pepitas (pumpkin seeds), may help prevent cognitive decline.
(credit: “This image is in a set called the 'Daily Picture Parade'" by Dennis Sylvester Hurd/Flickr, Public Domain)
Omega-3 Fatty Acids, Protein, and Cholesterol

Various nutrients are critical for ensuring brain health and cerebral blood flow; among the most important are
protein, omega-3 fatty acids, and cholesterol. The impact of these nutritional requirements on the neurologic
system begins during the prenatal period and extends throughout the lifespan. Omega-3 fatty acids are found in
fish, seafood, nuts, seeds, seaweed, spinach, broccoli, and avocados and other colorful fruits and vegetables, as
well as in fortified cereals and beverages. They are vital for brain function and can counteract some of the
deterioration that can result from brain or spinal cord injury. Recommendations for intake of omega-3 fatty acids
range from 0.5 g/day for infants to 1.1–1.6 g/day for persons 51 years of age and older.
Protein is a combination of linked amino acids and is the building block of skeletal muscle. In the neurologic system,
protein is required for the adequate function of mitochondria within the nerve cells. Protein deficiency results in
leakage of the cell membranes, creating electrolyte disturbances, and has been shown to contribute to
neurodegenerative diseases such as stroke, Alzheimer’s disease, and Parkinson’s disease. The current
recommendation for adult protein intake is 1.2–1.5 g/kg/day. In the presence of severe illness or injury, more
protein intake may be recommended. However, with specific regard to cognition, there are no absolute
recommendations for protein intake (Glenn et al., 2019). As mentioned earlier, protein levels in the body are
measured by albumin. Prealbumin is the precursor to albumin in the liver and is used by the body to produce other
proteins as well. With a half-life of 2–4 days, prealbumin is a highly sensitive indicator of nutritional status. Higher
serum levels of albumin have been associated with improved cognitive function in individuals with Parkinson’s
disease (Sun et al., 2022). However, stress and inflammation can reduce prealbumin levels and lead to poor
outcomes following various neurologic events such as TBI, especially in the presence of an active infection.
The brain maintains the highest level of cholesterol in the body, requiring approximately 20% of the body’s total
cholesterol, but the cholesterol level in the brain is independent of cholesterol levels in the peripheral tissues.
Cholesterol is a key building block for the creation of myelin. It is found in the astrocytes and other glia cells and is
taken up by the neurons as a critical building block to produce hormones (Li et al., 2022). Dietary intake of foods rich
in omega-3 fatty acids raise the high-density lipoprotein levels above 40 mg/dL and has been shown to be helpful in
preventing dementia, fatigue, “brain fog,” memory loss, depression, and other cognitive problems (Li et al., 2022).
Because of the independence of cholesterol metabolism in the brain, measurement of the cholesterol level
specifically inside the brain could be an important marker of neurologic health (Jin et al., 2019; Li et al., 2022). For
optimal brain health, the current general recommendation is to maintain a total cholesterol level of 160–200 mg/dL
(Lee & Siddiqui, 2023).
Assessment of Cerebral Perfusion and Nutrition

Cerebral blood flow is a measured volume of blood flowing per unit of mass over time through the vertebral arteries
and internal carotid arteries and is measured as an indirect marker of neuronal function. Although the brain requires
a continuous supply of nutrients, it does not have the ability to store them. Therefore, evaluating how well the brain
is perfused is an important way to determine brain health. Cerebral perfusion is measured with positron emission
tomography (PET) technology to determine the adequacy of blood flow (Chugani, 2021).
Analysis of Nutrition and the Neurologic System

Neuroplasticity, or “the ability of the nervous system to change its activity in response to intrinsic or extrinsic
stimuli by reorganizing its structure, functions, or connections” (Mateos-Aparicio & Rodríguez-Moreno, 2019), refers
to the brain’s ability to adapt to threats such as brain injury following traumatic or atraumatic injuries and to repair
itself. This has led to an increase in studies to explore dietary modifications in neurologic conditions, with a focus on
whole foods or food-derivative supplements in the diet.
Although various diet trends—such as paleo, keto, gluten-free, low-carbohydrate, low-cholesterol, pescatarian, low-
fat, and vegan diets—have shown benefits in reducing the development of neurologic conditions, these options are
discussed less than 12% of the time with health care professionals (Bhat et al., 2019; Roser et al., 2022). Also,
because obesity is not considered a disease, many insurance plans do not cover charges for obesity medications or
counseling for clients with a BMI of 30 or greater (Dowis & Banga, 2021; Roser et al., 2022).
The adequacy and frequency of dietary nutrition can also affect the blood supply to the brain. For example, the
sensation of hunger has been shown to increase cerebral blood flow (CBF) in the hypothalamus, thalamus,
amygdala, cerebellum, and other key areas of the brain (Wierenga et al., 2017). Conversely, food intake produces a
decrease in CBF in the thalamus, insula, temporal cortex, and cerebellum, but eating causes an increased CBF in the
prefrontal cortex, the area that signals satiety of hunger (Wierenga et al., 2017). Some foods have been shown to
increase cerebral blood flow in this region, as well as athletic performance, such as beets, red spinach, tart cherries,
pomegranate, citrus fruits, walnuts, berries, cinnamon, leafy green vegetables, and other nitrate-rich vegetables
(Morris et al., 2018).
Deficiencies of certain fats or toxic levels of some nutrients have been shown to have negative effects on brain
health, and dietary intake of trans fats—found in foods such as margarine, fried foods, and commercially prepared
cakes, pies, and cookies—has been shown to lead to hypertension and, ultimately, to negatively affect brain health
(Harlyjoy et al., 2019).
Nutritional Deficits of Protein, Albumin, and Prealbumin

Malnutrition results from an inadequacy of certain macronutrients and micronutrients and can delay neurologic
rehabilitation, leading to increased morbidity and mortality. The deleterious effect of malnutrition is inflammation,
which is a precursor to many diseases and conditions. Therefore, an important consideration in the nutritional
assessment of neurologic clients is the etiology of any inflammatory process due to any acute or chronic diseases.
An assessment of nutritional status of the neurologic system often includes anthropometric measurements, a
nutritional risk assessment, and biomarkers. Specific indicators of malnutrition, such as changes in weight, food
intake, loss of body fat or muscle, accumulation of body water, and strength are assessed. Malnutrition is likely if any
of these indicators is present. Although no specific nutritional screening tool has been recommended for clients with
neurologic disorders, several screening tools that have been successfully used for older clients are suggested for
use in persons with neurodegenerative conditions such as dementia, stroke, and Parkinson’s disease (Lee, 2022).
Among these tools, the Mini Nutritional Assessment-Short Form (MNA-SF) and the Controlling Nutritional Status
(CONUT) tool have been used to assess nutrition in clients with neurologic conditions (Power et al., 2018).
It is estimated that up to 60% of individuals who experience stroke show evidence of malnutrition (Yuan et al.,

2021), which contributes to challenges in rehabilitation and readmissions, as well as to overall morbidity and
mortality risk. Among clients with neurologic conditions, movement disorders, dysphagia, gastroparesis, cognitive
impairment, and depression can all contribute to malnutrition because of decreased oral intake despite an increase
in the body’s metabolic needs. Following a stroke or other neurologic event, dysphagia (swallowing difficulty) is
common and often results in a delay in resuming nutritional support as the client’s ability to protect their airway
during feedings is evaluated. In some cases, enteral feedings are provided via a nasogastric tube or an implanted
gastric tube 48–72 hours after the stroke. However, metabolic needs are often accelerated during this period, and
early identification of malnutrition can result in improved outcomes (Joundi et al., 2019).
The role of protein in the body is critical in the evaluation of neurologic disorders. The most abundant plasma
protein in the body is albumin, which has various antioxidant, anti-inflammatory, and neuroprotective effects.
Specifically, albumin has been shown to suppress amyloid formation. Amyloids are proteins that tend to
accumulate as tangles and clusters and are associated with a number of conditions, including Alzheimer’s disease.
As previously discussed, traditional laboratory markers of malnutrition include the measurement of visceral
proteins, namely prealbumin. Prealbumin is protein in the plasma and cerebrospinal fluid that is mainly
manufactured in the liver. Prealbumin is considered a transport protein because it carries thyroid hormone and
retinol to the liver. It is the precursor of albumin, a transport protein found in the serum, which helps remove small
molecules such as bilirubin, calcium, and progesterone in the blood and has a half-life of 20–22 days. Decreased
prealbumin levels are linked to protein–calorie malnutrition. Decreased prealbumin levels are often discovered in
association with infections and gastrointestinal hemorrhage. Low serum albumin levels in individuals experiencing
TBI and other neurologic conditions have been shown to be indicators of poor long-term outcomes, especially
among older adults (Liu et al., 2021).
Abnormal Findings Related to Nutrition

The deleterious effects of poor dietary patterns on human cognition continue to plague humans. Neurodegenerative
conditions are causing health care costs to soar; for instance, 6.5 million Americans are living with Alzheimer’s
disease, and the prevalence is expected to double over the next 30 years (Borshchev et al., 2019). Cognitive
deterioration is a concern in many diseases and conditions, and nutrition options, combined with exercise, have
been explored as noninvasive strategies to reduce the consequences of neuronal damage. Modifiable risk factors
account for 40% of risk factors for Alzheimer’s disease, and diet has been shown to be one of the predominant
factors in the development of cognitive decline (Borshchev et al., 2019). Avoidance of some foods, specifically those
rich in saturated fats and sugar (often referred to as junk foods), is recommended because they have been shown to
contribute to cognitive decline (Borshchev et al., 2019). Other nutritional factors, such as the number of calories
consumed per meal and the frequency of food consumption, have been shown to affect cognitive health.
Metabolic syndrome presents a major risk factor for neurologic compromise and is defined as the presence of
obesity, dyslipidemia, arterial hypertension, and diabetes. A person is considered obese if their BMI is greater than
30. Dyslipidemia is diagnosed if the total cholesterol level is greater than 200 mg/dL. A total cholesterol level
between 200 and 239 is considered borderline high, and a level greater than 240 mg/dL is considered high (CDC,
2022). Arterial hypertension (blood pressure greater than 130/80 mm Hg) has been shown to cause abnormal shifts
in cerebral autoregulation, which is the ability of the cerebral vessels to maintain stable blood flow to the brain
despite changes in arterial blood pressure (Borshchev, 2019). These shifting patterns seen in persons with
metabolic syndrome lead to hypoperfusion and reduced blood flow in the brain and can damage the brain’s white
matter (Borshchev, 2019). Although metabolic syndrome is well established as a precursor for diabetes and various
cardiovascular ischemic conditions, poor diet combined with obesity has also been associated with cognitive
impairment and increased risk for dementia as the individual ages.
Recent evidence has shown that even without metabolic dysfunction, adiposity alone has been shown to potentially
accelerate a decline in thought processes, such as attention, intelligence, memory, cognitive flexibility, processing
speed, and executive function (Farruggia & Small, 2019; Leigh et al., 2020). Adiposity may also result in reduced
brain volume and reduced white matter connectivity, especially in the temporal lobe structures (Leigh et al., 2020).
High intake of red meat, processed meat, and fried food and low intake of whole grains have been associated with a
reduced level of function in the temporal and frontal lobes, such as memory and executive functions (Leigh et al.,
2020). The traditional high-fat Western diet can trigger the advent of Alzheimer’s disease and vascular dementia by
triggering inflammation, the development of cerebral vascular atherosclerotic lesions, and a dismantling of the
blood–brain barrier (Borshchev et al., 2019; Więckowska-Gacek et al., 2021).
When abnormal cerebral blood flow (the volume of blood that moves through the blood vessels in the brain over a
given unit of time) is seen on PET scanning, this can signal overactive or underactive metabolism and can indicate
seizure activity, or it can be a marker of ischemic brain injury or degenerative conditions. Food supplementation with
polyphenols and omega-3 fatty acids in concert with a supervised nutrition program has been shown to improve
cerebral perfusion (Roberts et al., 2020).
Dietary patterns and stress can affect the immune system. As a result, the body may initiate an autoimmune process
in which the body perceives normal cells as foreign and attempts to rid the body of a perceived invading substance.
In the neurologic system, myelin-producing cells can become affected by this autoimmune process. Myelin can be
damaged when the body’s immune cells perceive myelin as a foreign substance and kill the cells that make myelin.
The most well-known condition in which myelin is destroyed is multiple sclerosis. Other conditions in which myelin
is attacked are optic neuritis and transverse myelitis. Myelin is attacked in the PNS of individuals with Guillain-Barré
syndrome, Charcot–Marie–Tooth disorder type 1 or type X, or copper or vitamin B12 deficiency, as well as individuals
with infectious processes, excessive alcohol consumption, or intake of certain drugs.
A diet high in saturated fat and sugar is known to produce changes in the gut microbiome, triggering inflammatory
processes that alter the immune system, and can lead to cognitive impairment (Leigh et al., 2020). These alterations
in the microbiome increase the permeability of the gut and lead to formation of bacterial amyloids (abnormal
proteins) and tangles of tau proteins. Tau proteins normally stabilize the tubelike internal skeleton of nerve cells,
but when the inflammatory process ignites in the gut, the tau proteins instead become tangled due to
phosphorylation in the gut. This phosphorylation then blocks the neuronal transport system and damages vital
communication between the neurons, eventually resulting in cell death (Więckowska-Gacek et al., 2021). The most
typical neuropathologic changes in the brains of persons with Alzheimer’s disease are these amyloid and tau protein
tangles.
Part A
The nurse completes a nutritional assessment of Jamal Powell. The client’s past medical history is positive for
hypertension, high cholesterol, and obesity.
Vital Signs Laboratory Values

Temperature: 98.5°F (36.94°C) Jamal had blood work drawn the week prior to this visit:
Blood pressure: 148/90 mm Hg • Total cholesterol: 240 mg/dL
• Low-density lipoprotein (LDL): 160 mg/dL
Heart rate: 97 beats/min
• High-density lipoprotein (HDL): 30 mg/dL
Respiratory rate: 14 breaths/min • Triglycerides: 250 mg/dL
Oxygen saturation: 97% on room air
Height: 5'9"
Weight: 230 lb (104.33 kg)
BMI: 34 (Class 1 obesity)
TABLE 5.3
1. The nurse is evaluating Jamal’s nutritional intake and symptoms. Which aspect of the client’s dietary intake
could be associated with these cognitive changes?
a. Increased vegetable intake
b. Increased whole grain intake
c. Increased dairy product intake

d. Increased intake of processed foods
2. When assessing the nutritional impact on cognitive function, what should the nurse anticipate the health care
provider to prescribe to evaluate the client further?
a. Spiral computed tomography
b. Positron emission tomography
c. Computed tomography of the head with contrast
d. Cerebral angiography
Alterations in Micronutrients and Neurologic Health

Deficiencies in micronutrients can contribute to neurologic deterioration. For example, deficiencies in ferrous sulfate
and zinc have been associated with ineffective sleep and neurobehavioral problems in young adolescents (Ji et al.,
2021). Zinc deficiencies have also been associated with epilepsy, seizures, and deficiency of growth hormone.
Alterations in other micronutrient levels can result in specific neurologic changes. For example, although
magnesium serves to promote optimal nerve transmission, low magnesium levels can lead to the death of neurons
and contribute to the development of psychiatric problems and other conditions, including depression, anxiety,
chronic pain, epilepsy, Alzheimer’s disease, Parkinson’s disease, and stroke.
Selenium improves immunity because of its antioxidant properties, and low levels are associated with tumors, skin
conditions, and cardiovascular, neuropsychiatric, and age-related diseases. Iodine deficiency can lead to
hypothyroidism, goiter, and mental developmental delays. An iron deficiency can result in worsening heart failure
symptoms because iron is key to erythropoietin production. A deficit of iron often results in fatigue and activity
intolerance. Copper is essential for maintaining the health of neurons, and an imbalance is associated with
neurodegeneration and a variety of neurologic disorders.
Toxic exposure to various substances can also lead to neurologic decline. In someone with a TBI, excessive zinc
accumulation can present in the postsynaptic neurons, and this can result in brain damage due to the death of
neurons. Therefore, modulation of zinc accumulation may be an important aspect of TBI treatment (Choi et al.,
2020).
Heavy metals are minerals with a high molecular weight and are natural elements found in the earth. Due to the
nature of these molecules, they cannot be destroyed or degraded. Some of these minerals (including mercury,
cadmium, arsenic, chromium, thallium, and lead) can enter the air and the human food and drinking water supply.
Heavy metals can accumulate in the body, causing deleterious neurologic effects over time (Choi et al., 2020). The
long-term effects of this accumulation can lead to Alzheimer’s disease, Parkinson’s disease, epilepsy, accelerated
cognitive decline, and behavioral problems. Mercury exposure can result from eating fish or shellfish that is
contaminated or from breathing air contaminated by toxic chemical spills, coal plants, industrial incinerators that
burn materials containing mercury, or natural sources such as volcanic eruptions. Exposure to toxic levels of
mercury can result in mood swings, tremors, headaches, motor dysfunction, and insomnia.
Cadmium is another heavy metal that may stay in the body for years, although it is eventually excreted. Cadmium
may be ingested by inhaling smoke from the burning of industrial metals, but cigarette smoke is also a main source
of cadmium inhalation and is the most harmful method of ingestion. Cadmium may also be found in coffee, tea, and
crop fertilizers. Neurologic effects of cadmium toxicity include the loss of smell, but a more significant effect is
anemia, which can contribute to cerebral hypoperfusion.
Aluminum can be harmful to the neurologic system because it accumulates in the body and can contribute to
cognitive impairment and memory loss. Aluminum can be found in food emulsifiers, antiperspirant deodorants, hair
spray, baking powder, toothpaste, and drinking water, as well as on cookware surfaces. Moreover, fluoride in
drinking water can make aluminum more bioavailable (Russ et al., 2020).
5.2 Plan Nutritional Strategies to Impact Neurologic Wellness

LEARNING OUTCOMES
• 5.2.1 Prioritize hypotheses of nutritional habits that optimize neurologic wellness.
• 5.2.2 Generate solutions to optimize neurologic wellness using nutritional habits.
Planning Nutritional Goals

For individuals with neurologic conditions, management of blood glucose, sodium, and protein is critical to promote
healing and cognitive performance. The brain requires a consistent supply of nutrients to function optimally, and any
deficiencies can affect the brain negatively as well as other parts of the neurologic system and cause illness. Illness
can also occur when these nutrients are at levels that are too high, so maintaining a healthy balance is important for
preventing neurologic illness.
Blood Glucose
Control of blood glucose is a key aspect of brain health. High blood glucose levels are associated with accelerated
cognitive decline compared with individuals who maintain normal blood glucose levels, independent of a diagnosis
of diabetes. High blood glucose is more common among individuals with excessive body fat because fat releases
hormones, proteins, and cytokines that ignite inflammation in the body, worsening brain function. Refined sugars
are highly processed, often derived from white sugar, brown sugar, coconut sugar, palm sugar, or high-fructose corn
syrup, and most Americans consume about 163 g (652 calories) of refined sugars each day. Refined sugars
contained in candies, baked goods, pastries, white bread, crackers, pasta, and white rice contain no nutrients and
can dramatically raise blood glucose. Therefore, foods containing processed sugar and other processed ingredients
should be limited or eliminated from the diet to ensure optimal long-term cognitive performance.
The dietary recommendations for neurologic health largely mirror those of the American Heart Association for heart
health. A normal blood glucose level after a period of fasting is generally between 70–100 mg/dL. An elevated level
(100–125 mg/dL) can indicate prediabetes, with higher levels (greater than 125 mg/dL) signaling a possible
diagnosis of diabetes. Blood glucose trends over a period of 2–3 months can be evaluated using the hemoglobin
A1c (HbA1c) test. The normal range for HbA1c is less than 6%, and 6.0–6.4% is considered prediabetes. A person is
considered to have diabetes if the HbA1c is 6.5% or greater.
A ketogenic diet has been shown to be beneficial for people with epilepsy (Kossoff, 2017). A ketogenic diet contains
a high percentage of fat and few carbohydrates and has been successfully used in children with seizures that are
intractable with medications alone. In this diet, ketones are formed as the body uses fat for energy rather than
carbohydrates. Although there are many theories regarding why this type of diet is beneficial for individuals with
seizures, the high levels of ketones in conjunction with antiseizure medications appear to increase the seizure
threshold, resulting in fewer seizures (Kossoff, 2017).
Complex carbohydrates contain more nutrients than simple refined sugars do. They are found in brown rice, oats,
quinoa, farro, barley, fruits, and vegetables, and they also contain more fiber, which slows the rise in blood glucose.
However, in the absence of a diabetes diagnosis, small doses of natural sugars (honey, maple syrup, or stevia) are
generally well tolerated and do not have a significant effect on brain function. Artificial sugars (such as aspartame,
saccharin, and sucralose) are not recommended for brain health because they affect the gut microbiome, leading to
insulin resistance and diabetes, and subsequently have been shown to contribute to decline in cognitive function
(Pase et al., 2017).
Sodium
Disruptions in sodium balance are a concern for clients with neurologic conditions, especially when they are
critically ill. The balance of water in the body is monitored by the osmoreceptors in the hypothalamus, as well as by
baroreceptors in the right atrium, great veins, and carotid sinus. The total water volume in the body is controlled by
regulation of sodium by the kidneys. Any change in sodium and water balance can dramatically affect the cells of the
brain. Sodium levels may be disrupted due to various conditions such as renal dysfunction, cirrhosis, lung disease,
certain cancers, congestive heart failure, diarrhea, vomiting, blood loss, or excessive sweating or can be the result of
diuretic medications. Neurospecific conditions, such as subarachnoid hemorrhage, TBI, meningitis, encephalitis,
and brain tumors, can disrupt sodium balance and result in hyponatremia, a serum sodium level less than 135

5.2 • Plan Nutritional Strategies to Impact Neurologic Wellness 97
mEq/L, which can cause various neurologic symptoms. Such disruptions are sometimes caused by failure in the
brain to release antidiuretic hormone (ADH), as is the case in central diabetes insipidus, or by urinary sodium loss
without water loss, as is the case in syndrome of inappropriate antidiuretic hormone secretion (SIADH). SIADH is
caused by an unsuppressed release of ADH from the pituitary gland or other nonpituitary sources that signals the
body to retain fluid (Yasir & Mechanic, 2023). Therefore, nurses should evaluate the sodium and water balance of all
clients with neurologic conditions as a routine part of the nutritional assessment.
Omega-3 Fatty Acids

Omega-3 fatty acids are specific unsaturated fatty acids that are often referred to as “good fats” because they have
a significant positive impact on brain function. However, many Americans consume a disproportionate quantity of
omega-6 fatty acids, found in corn and vegetable oils in processed foods. Although not routinely tested for, the
omega-3 index is a measure of the percentage of certain fatty acids in the red blood cell membranes:
eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The omega-3 index is an assessment of the
percentage of total fatty acids in the body and is a marker that identifies cardiovascular and cerebrovascular risk for
death (Swanson et al., 2012). An omega-3 index of less than 4% indicates a high risk for death, whereas a level
greater than 8% represents a low risk for stroke or other cardioembolic events in the future (Swanson et al., 2012;
von Schacky, 2020). Fatty fish, such as salmon, mackerel, and sardines, and wild meat, such as venison, buffalo, and
other hunted game animals, contain omega-3 fatty acids. They are abundant in many plant sources as well, such as
nuts, seeds (chia, pumpkin, sunflower), and flaxseed, olive, and canola oils.
Dietary Percentages of Carbohydrates, Fats, and Protein

The macronutrients (carbohydrates, fat, and protein) are the building blocks for optimal neurologic health. The
recommended dietary allowance for carbohydrates is approximately 45–65% of a person’s daily calories, whereas
protein should account for 10–35% of daily caloric intake, and fats should make up the remaining 20–35% of daily
food intake (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020).
For optimal brain health, current recommendations include daily intake of fresh vegetables, leafy green vegetables,
berries, fish and other seafood, healthy fats (virgin olive oil, whole eggs, avocados), as well as nuts and seeds. Other
foods that are recommended in moderate amounts are beans; legumes; whole fruits (in addition to berries); low-
sugar, low-fat dairy products (plain yogurt and cottage cheese); poultry; and whole grains.
To prevent cognitive decline, fried foods, pastries, sugary and processed foods, red meats and meat products, and
whole-fat dairy products (such as butter and full-fat cheese) should be limited or eliminated from the diet. Although
margarine was once touted as a healthy alternative to butter because it contains no cholesterol, it may contain
saturated fats, which have been shown to contribute to a decline in brain health. In one publication from the Nurses’
Health Study, replacing margarine or butter with the same quantity of olive oil resulted in a 5–7% lower risk for
cardiovascular and coronary heart disease, both of which are risk factors for stroke (Guasch-Ferré et al., 2020).
The Mediterranean diet is well established to prevent or reduce cardiovascular- and age-related cognitive decline
(Leight & Morris, 2020). It is low in saturated fat and plentiful in olive oil, legumes, broccoli, squash, whole grain
cereals, fruits, vegetables, and fish. It includes moderate consumption of dairy products and wine and low
consumption of nonfish meat products. The Mediterranean diet is recommended for neurologic health more than
any other diet strategy and is particularly recommended for neurologic conditions, including multiple sclerosis,
Alzheimer’s disease, and Parkinson’s disease (Leight & Morris, 2020).
An emphasis on fresh whole foods can also provide an effective path toward steady weight loss, as healthy eating
habits are formed over time. Because the plan focuses on choosing fruits, vegetables, legumes, and snacks such as
low-fat popcorn over potato chips, calorie-rich desserts, and other less healthy foods, and on choosing water over
sugary drinks, this diet generally reduces the caloric intake.
The foods included in the Mediterranean diet are largely plant based and include healthy fats. Because the foods are
filling, overall caloric intake generally decreases, although portion size remains a consideration if weight loss is
desired. The fiber in the foods results in a diversity of gut bacteria, which is beneficial because a healthy gut
microbiome has been shown to positively impact nutrient metabolism and energy expenditure. In some people,
especially those with irritable bowel syndrome, bowel discomfort may result from the high fiber content in this diet.
It is important to monitor potassium levels of clients with comorbid kidney disease because the Mediterranean diet
is often rich in potassium.
For reasons still unknown, maintaining low glucose levels can help reduce the number of seizures in people with
epilepsy. A ketogenic diet is sometimes recommended for these clients because it consists primarily of high-fat and
high-protein foods and includes few carbohydrates. This causes a breakdown of fats, rather than glucose, for energy,
which mimics a fasting state and has been shown to decrease seizure episodes. The ketogenic diet is commonly
recommended for children with epilepsy and some adults. The diet is rich in butter, mayonnaise, and heavy cream; it
includes small portions of fruit, cheese, and bacon, and other meats, fish, and poultry are allowed (Figure 5.5).
FIGURE 5.5 The macronutrients in the typical American diet compared with those in the Atkins diet, a classic ketogenic diet, and a
therapeutic medium-chain triacylglycerides (MCT) ketogenic diet. The therapeutic ketogenic diet is typically prescribed for clients with
epilepsy. (credit: “A series of pie charts depicting the calorific contributions from carbohydrate, protein and fat in four diets” by Colin,
vectorized by Fvasconcellos (talk contribs)/Wikimedia Commons, Public Domain)
SAFETY ALERT
Sugar and the Ketogenic Diet

Because even small amounts of sugar can reverse the effects of the ketogenic diet and lead to a seizure, sugar is
prohibited on this diet. When on this diet, clients must be aware of the potential addition of sugar or sugar
substitutes in some medications and supplements, such as gummy vitamins.
A modified Atkins diet is sometimes recommended for clients with epilepsy instead of a ketogenic diet. As with the
ketogenic diet, the Atkins diet contains foods that are high in fat (bacon, eggs, beef, mayonnaise, butter, heavy
cream, oil). Although some carbohydrates are allowed, the total amount of carbohydrates allowed is low (20–25 g/
day).
Daily Eating Patterns

Many Americans do not follow a healthy diet, and studies show that adherence to healthy eating guidelines occurs
only about 50–60% of the time across the lifespan (Wambogo et al., 2022). The appropriate amount of food to
consume each day is based on a person’s age, sex, height, weight, and physical activity level. A calculator is
available on the MyPlate website to assist in determining the appropriate number of calories that should be
consumed to maintain normal weight, based on activity level. One successful strategy to reduce overall caloric
intake among persons desiring to shed pounds is to use smaller plates.

5.3 • Implement Nutritional Strategies to Impact Neurologic Wellness 99
Identifying Challenges to Nutritional Goals

To maintain a brain-healthy diet, planning is required. Generally, the healthiest meals are those prepared at home
because they allow for control of portions and ingredients. In addition, using a cooking style that does not require
additional fat is preferred (e.g., slow cooking or sautéing is preferred over deep-frying foods). The process involved
in frying food generates chemicals that may create inflammation in the gut and facilitate limited cognitive function.
Unfortunately, many commercially made fast foods incorporate highly processed, high-calorie foods with artificial
ingredients and fried foods that are not in concert with brain health. The wide availability and low cost of these foods
can make it challenging to change eating habits. Supplements of fish oil have come under recent scrutiny, as some
studies show that these supplements may increase the risk for bleeding, diarrhea, and acid reflux and provide no
significant protective effect against cardiovascular disease or stroke (Manson et al., 2019).
The Difference Between Food and Supplements

Although many supplements are available over the counter, they are not meant to replace a healthy diet. Both the
macronutrients and micronutrients that are found in food are easier for the body to absorb than supplements.
Moreover, the variety of nutrients available in fresh foods has been shown to provide a higher nutritional value than
consuming an unhealthy diet and taking supplements.
The Difference Between Thirst and Hunger

There is a strong link between hydration status and cognitive ability and mood. Water is the body’s principal
component, making up 50–70% of total body weight (Tobias et al., 2022). The amount of daily water intake that the
body requires varies by age, body size, activity level, and environmental temperature. It is recommended that most
adults drink 6–8 8-oz glasses of water daily. The body loses water through urination, breathing, and sweating.
However, as a person ages, the ability to distinguish thirst from hunger diminishes. Because of this, dehydration
among older adults is a common problem. In many cases, by the time a person perceives thirst, moderate
dehydration has already occurred, and cognitive abilities may be slowed. Moderate dehydration has been shown to
cause headaches and can have a deleterious impact on mood, short-term memory, attention, focus, and numeric
and psychomotor function.
Because many older adults are chronically dehydrated, moderate intake of coffee and tea, in addition to hydration
from other liquids, can reduce cognitive decline and dementia because of the antioxidant effect of caffeine.
However, caffeine intake should be limited because it can impact sleep, especially if consumed late in the day.
Water is the best liquid to maintain hydration, and caffeinated liquids such as coffee and tea have a mild diuretic
effect. Although caffeine increases diuresis, the amount of fluid in the drink is thought to balance this diuretic effect.
Many people rely on drinking coffee or tea containing caffeine to increase alertness, as well as cognitive and athletic
performance. According to the U.S. Food and Drug Administration (FDA), adults should consume no more than 400
mg of caffeine per day, and no intake of caffeine is recommended for children. Very high daily doses of caffeine (750
mg) have been linked to serious health conditions such as chest pain, irregular heartbeat, and stroke, as well as
problems with sleep, loose stools, and gastrointestinal upset. The long-term effect of caffeine intake is not well
understood.
Alcohol is not a source of hydration but can have both positive and negative impact on brain function; however,
deleterious effects on brain function are more commonly reported for individuals consuming excessive amounts of
alcohol (Grant et al., 2017). Moderation in alcohol intake may be the key to optimal brain health. Current
recommendations cite safe alcohol use as only 1 drink/day for men and women. The type of alcohol intake may also
be considered. Red wine contains polyphenols, micronutrients that can positively impact blood pressure, and 1
glass/day may reduce stroke risk (Grant et al., 2017).
5.3 Implement Nutritional Strategies to Impact Neurologic Wellness

LEARNING OUTCOMES
• 5.3.1 Assess the client for readiness to learn.
• 5.3.2 Teach nutritional strategies to optimize neurologic wellness.
Holistic Nursing Assessment of the Client

When the nurse is considering changes to a client’s diet to facilitate adequate functioning of the neurologic system,
it is critical to evaluate how these changes will be affected by the client’s lifestyle and relevant socioeconomic
factors. The nurse must also consider the client’s culture, beliefs, attitudes, daily eating patterns, and health
conditions that may impact their approach to eating.
Daily Pattern of Food Intake and Sleep

The time of day that meals are taken can improve neurologic health. For example, recent studies suggest that
narrowing the window of time during which food is consumed during the day may positively impact cognitive
function (Gudden et al., 2021). Intermittent fasting, defined as either eating only between certain hours of the day
(e.g., between 11 a.m. and 5 p.m.) or consuming few calories on certain days and eating normally on other days, has
been shown to improve neurologic health among persons with Parkinson’s disease, ischemic stroke, mood and
anxiety disorders, and epilepsy (Gudden et al., 2021). Maintaining regular hours for meals and sleep has also been
associated with positive cognitive performance, and avoiding food intake in the hours before bedtime has been
shown to improve cognitive performance and sleep quality (Gudden et al., 2021).
Challenges in Healthy Nutrition

For many Americans, the availability and cost of healthy foods are major concerns. Soaring prices of weekly
groceries are concerning, and many Americans rely on food banks or other forms of public assistance to feed their
families than ever before. In addition, food preferences and dietary patterns are often influenced by cultural norms,
beliefs, family traditions, and long-term habits; therefore, changing one’s dietary intake is often challenging. Dietary
preferences are very personal for many people, so making changes may be fraught with high levels of resistance. It
is thus important for the nurse to ensure that changes in a client’s diet are feasible and in synergy with the client and
their family.
Client Teaching
Given the complexities of dietary habits, it is critical to first understand the client and family’s health state (cognitive
state and motivation, swallowing difficulties, mobility concerns), dietary history, allergies, or sensitivities to certain
foods, as well as food availability and financial concerns when planning a dietary lifestyle. Client teaching should be
part of an interprofessional plan of care involving the nurse, a registered dietitian, and the health care provider. The
health care team will be best able to create dietary adaptations that will meet specific criteria that will allow the
client to adhere to the plan of care.
Recommended Diet Plans for Comorbid Conditions

For many clients, comorbid conditions can complicate the ability to manifest a comprehensive diet plan. For
example, although the Mediterranean diet and ample fluid intake may improve cognitive status, for clients in heart
or kidney failure, specific modifications will be required to consider the effect of excess fluid or the correct
percentage of protein intake.
Part B
Study Part A.
Jamal Powell has a normal PET scan result and is advised to follow up with the clinic regularly. The client is referred
to a dietician but misses 6 separate appointments over 2 years.
Jamal is visiting the clinic today for a routine follow-up 2 years after the initial clinic visit. During this time, Jamal’s
memory has progressively worsened. Jamal believes these deficits have not been obvious to friends.
The client describes a recent problem of forgetting where they put things and confusing things in their memory.
However, the client’s relationship to time, as well as their skills in math and literacy, have not changed. Jamal is
independent with regard to basic activities of daily living, but complex tasks are becoming more challenging.

5.4 • Evaluate Nutritional Strategies to Impact Neurologic Wellness 101
The client states that they have started to feel less confident about driving over the past few months. Jamal appears
to be irritable and becomes distressed when discussing the symptoms and recent events they have been dealing
with. The client discusses their fears and frustrations surrounding these changes and feels they are becoming
depressed about the situation.
The nurse discusses Jamal’s diet and activity and plans to work with the client to improve their nutritional state.
Jamal’s diet is high in saturated fats and low in fresh vegetables and fruits. The client’s spouse mentions that they
read that polyphenols are good for brain health and asks which foods would be best to include in their diets.
Jamal also asks why everyone keeps saying that sugar in the diet is bad, stating that they have enjoyed sweets their
whole life. This is apparent with the recent HbA1c test result, which is 6.3%. (The expected range for nondiabetic
clients, such as Jamal, is less than 5.7%.)
The nurse explains that the combination of Jamal’s high BMI of 40, HbA1c of 6.3%, total cholesterol level of 250
mg/dL, and diagnosis of chronic hypertension (today’s blood pressure was 156/98 mm Hg) classifies them as having
a condition called metabolic syndrome. The nurse sets up another appointment with the dietitian to help Jamal
correct the nutritional issues identified. Because the dietitian’s earliest appointment is 2 months away, the nurse
teaches Jamal and their spouse about some basic nutritional changes they can make before the next appointment.
3. How much omega-3 fatty acid content should the nurse instruct Jamal to include in his diet each day?
a. 1.1–1.6 g
b. 3.5–6.6 g
c. 0.1–0.16 g
d. 11–16 g
4. The nurse is teaching Jamal and their spouse how to choose foods high in omega-3 fatty acids. Which food
choices would indicate understanding by the client?
a. Dairy and eggs
b. Fatty fish and oils
c. Colorful fruits and vegetables
d. Peanut butter and almond butter
5.4 Evaluate Nutritional Strategies to Impact Neurologic Wellness

LEARNING OUTCOMES
• 5.4.1 Evaluate a nutritional plan for its effect on neurologic wellness.
• 5.4.2 Modify a nutritional plan to promote neurologic wellness.
Evaluating the Client’s Adherence to the Nutritional Plan

Changing nutritional intake can be extremely challenging for clients because it often involves factors such as culture,
habits, and preferences that are formed over time. To ensure optimal health, the nurse should evaluate the
effectiveness of the plan. The nurse should not only review subjective data provided by the client but also
incorporate it with objective data to gain the entire picture. Data such as laboratory test results, weight loss or gain,
and vital signs can aid in evaluating the effectiveness of the plan and the client’s adherence to it.
Part C
Study Parts A and B.
Jamal and their spouse attended the appointment with the dietitian. Jamal is now back in the clinic 6 months after
the last visit. The nurse is evaluating the client’s adherence to the new nutritional plan (meal plan) that was
formulated with Jamal, their spouse, and the dietitian 3 months previously. The client has gained 10 lb (4.54 kg)
over this time.
Vital Signs Laboratory Values

Temperature: 98.6°F (37.0°C) Jamal had blood work drawn the previous week:
Blood pressure: 187/86 mm Hg • Total cholesterol: 254 mg/dL
• LDL cholesterol: 170 mg/dL
• HDL cholesterol: 30 mg/dL
Respiratory rate: 14 breaths/min • Triglycerides: 270 mg/dL
TABLE 5.4
Jamal’s spouse assisted the client in completing a 3-day diet history, which revealed an absence of fruits and
vegetables, a high intake of foods containing processed sugar, and a minimal amount of fiber. Even though the client
did not have an issue in any other prior visits, Jamal had become more depressed and started to drink alcohol. The
client’s alcohol intake for the 3-day diet history was approximately a 6-pack of beer daily and a couple of bottles of
wine over the 3 days.
As a follow-up study, the health care provider ordered an amyloid PET scan. The results revealed tau proteins
consistent with early Alzheimer’s disease.
To optimize all aspects of possible treatments for this diagnosis, the health care provider recommends a
Mediterranean diet and a weight loss regimen and prescribes donepezil 5 mg once by mouth daily at bedtime. The
nurse provides Jamal and their spouse educational materials about the medication, the Mediterranean diet, and
MyPlate recommendations. The nurse also advises the client to engage in a moderate exercise routine by walking
for 30 minutes at least 3 times a week.
5. Based on the assessment findings, which of the following clinical findings indicates compliance with the
prescribed nutritional plan?
a. Alcohol intake of 3 glasses wine per day
b. Total cholesterol level remains 240
c. Dietitian appointment scheduled
d. Body mass index > 35
6. The client’s spouse asks the nurse to explain a little more about tau proteins and why they are an issue. What
should the nurse say?
a. ”Jamal has too many tau proteins in his brain.”
b. “Tau proteins are genetic mutations that are causing dysfunction.”
c. “The tau proteins are tangled and accumulate in the brain, causing dysfunction.”
d. “There is no relationship between the tau proteins and Jamal’s symptoms.”
Evaluating the Effectiveness of the Nutritional Plan

When evaluating the effectiveness of a nutritional plan (meal plan), there are several considerations to evaluate
once the client is shown as being adherent. The ability to change dietary habits is gradual, and as such, subsequent
appointments with the health care provider, nurse, and dietitian will help the client continue adjusting strategies to
improve their health and change any negative habits. Setting goals for weight loss and for blood pressure and HBA1c
reduction as needed can provide later evidence as to the effectiveness of the nutritional plan. Discussing these
changes with the client and any appropriate family members will help ignite diet changes that can be permanently
employed and can help improve blood flow in the brain, which will slow cognitive decline.
Nutritional History
When obtaining a neurologic nutritional history, the nurse should evaluate specific considerations such as
availability, budget, cultural aspects of nutrition, and specific dietary practices. The nurse needs to identify which
resources are available to the client in terms of food availability and any limitations in food preparation practices, as
well as identify any food intolerances or preferences. A 3-day diet history is helpful to determine the adequacy of
the client’s current diet. The nurse should also determine any recent weight gain or loss, as well as the client’s

5.4 • Evaluate Nutritional Strategies to Impact Neurologic Wellness 103
typical bowel and urinary elimination patterns and any history of problems in the intestinal tract.
Physical Assessment
During the physical assessment of nutritional status, the nurse should identify the client’s hydration status and any
aspects of overnutrition or undernutrition. Skin tone and color should be evaluated, the mucosal membranes should
be assessed for hydration status, and the client should be weighed. An oral examination will identify any loose
teeth, oral pain, swallowing difficulty, or any other barriers to food intake. The nurse should assess the abdomen for
any pain, auscultate for bowel sounds, and complete a focused assessment based on information gleaned during
the history.
Part D
Study Parts A, B, and C.
Jamal returns for a follow-up appointment 2 months later so the nutritional plan can be evaluated and changed if
necessary. The check-in revealed a weight loss of 4 lb over the previous 2 months. Jamal states that they like and
are following the currently prescribed diet because it is easier than eating separate meals. However, Jamal and their
spouse still have some questions regarding food preparation and meal planning. Jamal has been very adherent but
is having a hard time giving up fried foods.
Jamal’s spouse reveals that the expense of groceries has risen recently, and they were trying to adjust their monthly
budget to accommodate this change. The client states that they have even decreased their alcohol intake to 1 glass
of red wine a day, not only for health reasons but also due to increases in grocery prices.
The nurse discusses the situation more with the client and their spouse to get all the data in order to best help them.
The nurse discovers that the client retired and is living on retirement income and Social Security. The client’s spouse
has not worked in 10 years and receives disability and Social Security checks each month as income.
The client has stopped driving because they felt it was unsafe, and the couple continues to live at home. Jamal’s
neurologist has ordered additional diagnostic exams to further evaluate the Alzheimer’s diagnosis, as well as
cognitive tests to evaluate the client’s safety.
7. When evaluating ways to help improve Jamal’s nutritional intake based on the information obtained, what is
the best suggestion to cost-effectively improve the nutritional plan?
a. Buy more fresh fruits and vegetables.
b. Use an air fryer to cook foods without breading.
c. Eat more microwaved meals to make meal preparation easier.
d. Increase the number of daily servings of fruit juice.
8. The nurse educates Jamal about abstaining from alcohol and suggests a few other nutritional modifications.
Based on the client’s case, what studies or tests should the nurse expect the health care provider to prescribe
to investigate other potential changes needed in treatment?
a. Magnetic resonance imaging of the head
b. PET scan
c. Computed tomography scan of the head with contrast
d. Cerebral angiogram
Chapter Summary
• The nurse plays a critical role across the spectrum • Micronutrients are essential for adequate
of care by assessing clients’ dietary habits to neurotransmission.
improve neurologic health. • Diet modifications can support brain health in
• The brain is composed of 60% fat, and the individuals of all ages.
remaining 40% is made up of water, • Metabolic syndrome can lead to cognitive decline.
carbohydrates, protein, and various salts. • Diet modifications can slow the decline of some
• The brain is responsible for all essential activities neurodegenerative conditions, including
of the body but cannot store energy. Parkinson’s disease, Alzheimer’s disease, and
• The traditional Western diet can promote gut multiple sclerosis.
inflammation, which can lead to cognitive decline. • Long-term effective diet modifications cannot be
• Adequate hydration is a key element of neurologic made in a single health care encounter.
health.
Key Terms
afferent transmits impulses from peripheral organs end of motor nerves, where action potential
to the central nervous system impulses are conducted to various muscles
albumin a common protein in plasma that carries neuroplasticity the ability of the nervous system to
hormones and helps maintain the integrity of the change its activity in response to intrinsic or
blood vessels. extrinsic stimuli by reorganizing its structure,
amyloids proteins that tend to accumulate in clusters functions, or connections
that are insoluble; amyloid proteins are associated neurotransmitters chemicals within the body that
with a number of conditions, including Alzheimer's allow neurons to communicate with each other to
disease enable the brain to execute a wide range of
autonomic nervous system regulates involuntary functions through the process of chemical synaptic
body processes such as blood pressure, heart rate, transmission
respiration, digestion, and sexual arousal omega-3 fatty acids a group of polyunsaturated fatty
axons the long slender projections of neurons that acids that the human body requires but does not
efficiently and rapidly conduct electrical synthesize
impulses across nerve cells parasympathetic nervous system the part of the
cerebral autoregulation the inherent ability of blood nervous system that relaxes the body after stress
vessels in the cerebrum to maintain homeostatic and danger and facilitates the body’s “rest-and-
cerebral blood flow despite a wide range of changes digest” response
in mean arterial pressure polyphenols micronutrients that have health-
cerebral blood flow the volume of blood that moves promoting properties and are present in many fruits
through the vessels in the brain and vegetables
cerebral cortex the protective outer layer of the prealbumin a protein synthesized by the liver that
cerebrum transports various thyroid hormones in the blood
dysphagia difficulty swallowing soma the body of a neuron
efferent carrying outward or away; in reference to the somatic nervous system facilitates movement and
nervous system, transmitting impulses from the muscle control in the body
central nervous system outward to peripheral sympathetic nervous system a division of the
organs to initiate an active response or action autonomic nervous sytem that is reponsible for the
hyponatremia a serum sodium level less than 135 body’s “fight or flight” response
mEq/L syndrome of inappropriate antidiuretic hormone
Mediterranean diet a diet low in saturated fat and release (SIADH) an unsuppressed release of
rich in other nutrients, commonly consumed Greece antidiuretic hormone from the pituitary gland or
and Southern Italy other nonpituitary sources that signals the body to
myelin the fatty protein membrane that provides a retain fluid
protective coating for nerve cells tau proteins present in nerve cells, proteins that
neuromuscular junctions locations at the terminal stabilize microtubules

Review Questions
1. The nurse is caring for a client who had a stroke 2 days ago and is experiencing continued dysphagia. Which
of the following nutritional therapies will likely be prescribed?
a. Nothing by mouth until the dysphagia subsides
b. Supplements given via a nasogastric tube
c. Initiation of total parenteral nutrition
d. Initiation of a soft diet
2. A client admitted with traumatic brain injury develops syndrome of inappropriate antidiuretic hormone
(SIADH). The nurse should prioritize which intervention to improve the client’s nutritional status?
a. Infuse intravenous fluids rapidly.
b. Perform a dysphagia screen.
c. Restrict fluids.
d. Check the client’s blood glucose level.
3. The nurse is caring for a client who is in the early stage of Alzheimer’s disease. The client and family inquire
about meal choices. Which food choice would be most appropriate for the nurse to discuss with the client?
a. Colored berries
b. Fried fish
c. Margarine
d. Zero-calorie sweeteners
4. A client with multiple sclerosis asks the nurse about the best foods to fight fatigue and enhance nerve cell
conduction. Which food choices would be appropriate for this client?
a. Nuts, seeds, and salmon
b. Cheese, milk, and margarine
c. Lean red meats, potatoes, and white bread
d. Eggs, lamb, and zero-calorie beverages
5. A child is diagnosed with epilepsy and is being seen for intractable seizures. Which diet(s) would the
interprofessional team potentially recommend?
a. Mediterranean diet
b. Ketogenic diet
c. DASH diet
d. Vegan diet
6. A 67-year-old woman presents to the urgent care center with a headache and dizziness following a 5-mile
running event for charity. Which of the following findings would be most concerning?
a. Seizure history
b. Limited fluid intake
c. History of kidney stones
d. Recent vaccination for influenza
7. A client asks the nurse about taking supplements for improving memory. Which would be the nurse’s best
response?
a. “You should start taking fish oil immediately to improve blood flow to your brain.”
b. “You should start taking a potassium supplement because this will help with nerve conduction.”
c. “You should start taking zinc because this will help regenerate myelin to help your nervous system.”
d. “You should review the content of your current diet with the nutritionist.”
8. A client with Parkinson’s disease asks the nurse about possible benefits of intermittent fasting. Which reply
would be appropriate?
a. “There is no clear evidence of a benefit of intermittent fasting with your condition.”

b. “Although evidence supports a benefit in people with epilepsy, there is no clear evidence of a benefit with
Parkinson disorder.”
c. “Yes, there is. Let’s talk with your health care provider to see if this is right for you.”
d. “You will need to discuss this issue with your health care provider.”
9. What is the recommendation for daily omega-3 fatty acid intake for a 52-year-old adult?
a. 0.5–1 mg
b. 1.1–1.6 mcg
c. 1.1–1.6 g
d. The daily recommendation is not yet established.
10. Nutrition can impact the development of neurofibrillary tangles that are found in individuals with Alzheimer’s
disease. Which of the following provides structural strength to microtubules in the neuron?
a. Beta-amyloid
b. Amyloid precursor protein
c. Tau protein
d. Microglia
Suggested Reading
Kahan, S., & Manson, J. E. (2017). Nutrition counseling in clinical practice: How clinicians can do better. Journal of
the American Medical Association, 318(12):1101–1102. https://doi.org/10.1001/jama.2017.10434
Yu, Y., Borshchev, Y., Uspensky, P, & Galagudza, M. (2019). Pathogenetic pathways of cognitive dysfunction and
dementia in metabolic syndrome. Life Sciences, 237, 116932. https://doi.org/10.1016/j.lfs.2019.116932

CHAPTER 6
Special Nutritional Considerations for
Neurological Health
FIGURE 6.1 Specific nutrients from healthy food, like green beans with almonds, support neurological health in a variety of special
conditions. (credit: modification of work “Yummy Green Beans with almonds” by Colorado State University Extension/Flickr, Public Domain)
CHAPTER OUTLINE
6.1 The Impact of Nutrition on Neurological Wellness Across the Lifespan
6.2 Nutrition and Chronic Neurological Illnesses
6.3 Neurologic Condition Treatments, Medications, and Nutrition
INTRODUCTION There are many specific nutritional requirements to consider across a client’s lifespan that affect
their neurologic health. This chapter highlights many of the nutritional considerations that promote optimal
neurologic function at various ages and developmental stages, as well as important nutritional considerations in
special situations, such as pregnancy, or among clients being treated with certain medications or receiving other
medical treatments. For clients being treated for a neurological disease or condition, nutritional considerations
should be included in the plan of care.
Consider this case: A nurse working at an internal medicine clinic is caring for a client suspected of having dementia.
In this chapter, key elements of neurological nutrition across the lifespan will be provided, as well as specific
recommendations for clients with neurologic conditions. These key elements will be utilized in the case study to
apply evidence-based practice care to the clients presented.
108 6 • Special Nutritional Considerations for Neurological Health
6.1 The Impact of Nutrition on Neurological Wellness Across the Lifespan

LEARNING OUTCOMES
• 6.1.1 Describe the impact of nutrition on the neurological system during pregnancy.
• 6.1.2 Describe the impact of nutrition on the neurological system during infancy.
• 6.1.3 Describe the impact of nutrition on the neurological system during childhood.
• 6.1.4 Describe the impact of nutrition on the neurological system during adolescence.
• 6.1.5 Describe the impact of nutrition on the neurological system during adulthood.
• 6.1.6 Describe the impact of nutrition on the neurological system during later adulthood.
Pregnancy
Diet during pregnancy has been shown to have a significant impact on fetal neurodevelopment in a number of ways.
Several nutrients and micronutrients have been shown to impact neural tube formation and other aspects of
neurological development (Cortés-Albornoz et al., 2021). The developing brain of the fetus consumes more than
half of the available nutrition delivered via the placenta, mainly in the form of glucose. The developing fetal brain is
vulnerable to insufficient macronutrients and micronutrients, especially in the first stages of pregnancy. Nutrition
during pregnancy is of critical importance to both the developing fetus and the mother. This section will discuss the
effect of specific nutrients on healthy brain function for both the mother and the developing fetus. Specific vitamins
and minerals, such as vitamins A, B9 (folate), B12 (cobalamin), D, E, and K, as well as certain minerals, such as
copper, iron, creatine, choline, zinc, and iodine, are required to prevent a host of neurological conditions in the fetus.
They can also impact rates of maternal preeclampsia and postpartum depression.
Table 6.1 outlines the recommended daily allowances for micronutrients for women and men.
Vitamin Recommended Daily Food Sources

Allowance (RDA)
Vitamin A 700–900 µg/day Sweet potato, cantaloupe, carrots, liver, eggs, mango, spinach,
pumpkin, butternut squash
Vitamin C Adult females: Citrus fruits, kiwi, broccoli, strawberries, Brussels sprouts,
(ascorbic acid) 75 mg/day cantaloupe, tomatoes, tomato juice
Adult males:
90 mg/day
Vitamin D 600 IU/day Fish liver oil, salmon, swordfish, tuna, fortified foods, sardines, beef
(calciferol) liver
Vitamin E 15 mg/day Red bell pepper, pumpkin, beets, collard greens, spinach, sunflower
(d-alpha- seeds and oil, almonds, peanut butter, peanuts
tocopherol)
Vitamin K 90–120 mg/day Canola and soybean oils, leafy green vegetables
(phylloquinone)
Biotin (vitamin 30 mcg/day Eggs, peanut butter, mushrooms, avocados, almonds
B7)
Calcium Adult females: Dairy (cheese, yogurt), winter squash, edamame, sardines, salmon,
1000–1200 mg/day almonds
Adult males:
1000–1200 mg/day
Chromium 10 µg/day Grape juice, meat, Brazil nuts, whole wheat, mussels, broccoli
TABLE 6.1 Micronutrient Daily Allowances and Sources for Adult Females and Males (sources: CDC 2020, CDC, 2021; CDC, 2022; NIH,
2021; NIH, 2022a; NIH, 2022b; USDA, 2019)

6.1 • The Impact of Nutrition on Neurological Wellness Across the Lifespan 109
Vitamin Recommended Daily Food Sources

Allowance (RDA)
Cobalamin 2.4 mg/day Dairy products, eggs, poultry, fish, meat, fortified cereals,
(vitamin B12) nutritional yeast
Copper 0.9 mg/day Organ meats, shellfish, fish, nuts, seeds, whole grains, chocolate
Folate 400 µg/day Fresh fruits, whole grain, peanuts, beans, dark green leafy
(vitamin B9) vegetables
Fluoride 3 mg/day Brewed tea, coffee, fluoridated water, shellfish, potatoes, oatmeal,
raisins
Iodine 220 µg/day Fish, dairy (milk, yogurt, cheese), iodized salt
Iron 18–8 mg/day Nuts, dried fruit, whole grain pasta, bread, legumes, tofu, oats,
various meat sources
Magnesium Adult females: Whole grains, dark green leafy vegetables, dried beans, legumes
310–320 mg/day
Adult males:
400–420 mg/day
Niacin (vitamin 14–16 mg/day Red meat, poultry, bananas, legumes, nuts, seeds, brown rice,
B3) fortified cereals, breads
Phosphorus 700 mg/day Dairy (milk, cheese, yogurt), fish, eggs, nuts legumes, vegetables,
grains
Pyridoxine 1.3 mg/day Salmon, avocado, chickpeas, dairy, milk, sunflower seeds, spinach,
(vitamin B6) beef, bananas
Riboflavin 1.1–1.3 mg/day Salmon, chicken breast, organ meats, lean beef, eggs, cheese,
(vitamin B2) yogurt, dairy, milk
Thiamin Adult females: Salmon, eggs, pork, fish, liver, sunflower seeds, beans, nutritional
(vitamin B1) 1.1 mg/day yeast
Adult males:
1.2 mg/day
Selenium 55 mg/day Brazil nuts, bananas, eggs
Zinc 8–11 mg/day Meat, seafood
TABLE 6.1 Micronutrient Daily Allowances and Sources for Adult Females and Males (sources: CDC 2020, CDC, 2021; CDC, 2022; NIH,
2021; NIH, 2022a; NIH, 2022b; USDA, 2019)
Nutrition and Fetal Neurologic Development

Undernutrition during pregnancy, especially too little protein (46–71 g of protein per day generally recommended
during the first and second trimesters of pregnancy), can result in miscarriage, poor fetal neuronal growth (Murphy
et al., 2021; Stean et al., 2023), and improper development of the hypothalamus (Sun, et al., 2020). Altered
nutritional states such as maternal obesity, high-fat diet, and undernutrition, as well as caffeine intake (less than
200 mg/day recommended) can have a substantial impact on the developing fetal neurological system and can
predispose the child to a variety of disorders not only in the early postpartum period, but also in adulthood. A
pregnant person's intake of approximately 650 mg of long-chain polyunsaturated fatty acids is essential for the
development of the fetal brain and retina, and an absence of these essential nutrients can lead to pregnancy
complications and compromised fetal outcomes (Duttaroy & Basak, 2020: Murphy et al., 2021).
Altered nutritional states among pregnant clients in low- and middle-income countries has been shown to increase
the risk for preterm and low-birth weight infants, perinatal infant death, and an increase in both mental and physical
developmental problems throughout the lifespan (Chea, et al., 2023). Undernutrition may result in impaired brain
growth, visual memory problems, and delayed speech, and possibly a lower IQ in the child (Georgieff, et al., 2018).
The health of the male parent can also impact fertility and fetal health. The quality and quantity of sperm produced,
as well as sperm mobility, can be related to the male parent’s general health, weight, and volume of alcohol
consumed.
Micronutrients
Several requirements for micronutrients increase during pregnancy, especially iron. The development of gray matter
in the brain, as well as the structure of dendrites, motor functioning, language ability, and academic performance,
are correlated to adequate iron intake (30–40 mg/day). Iron is available in meats (including organ meats such as
heart, liver, kidney, and tongue), poultry, fish, and eggs and generally requires maternal supplementation to reach
the recommended daily intake (Georgieff, et al., 2020). Choline, another micronutrient (450 mg/day is
recommended), plays an important role in cognitive function, especially neural tube development, intelligence, and
sensory gating ability. Choline is available in chicken, beef, eggs, and dairy (Steane, et al., 2023). Zinc (11 mg/day
recommended) is associated with appropriate movement, normal heart rate variability, and stability of autonomic
nervous system. It is available in red meat, shellfish, poultry, pork, and dairy, as well as in fortified cereal, beans,
and nuts. Because zinc is essential to carbohydrate and protein metabolism, a deficiency of zinc can be associated
with brain degeneration and a decrease in memory and learning, and can lead to a host of neurological disorders
(Choi, et al., 2020).
Vitamin A facilitates the patterning of neurons, the development of axons, and the development of the body’s main
organs. The pregnant client requires approximately 600 mg/day of vitamin A. Milk and yogurt are rich in vitamin A
(Figure 6.2), which is also found in eggs; oily fish; many orange and yellow fruits and vegetables, such sweet
potatoes; and leafy green vegetables, such as spinach (Carazo et al., 2021). Given the abundance of vitamin A in the
diet, and storage supply of about 4 months in the tissues, supplementation is generally not recommended, because
high doses of vitamin A can cause liver toxicity and increase the risk for birth abnormalities.
FIGURE 6.2 Yogurt is not only rich in vitamin A, but also is a source of calcium, iodine, phosphorus, and riboflavin. (credit: “Yogurt with
Blueberries and Granola” by Alabama Extension; ACES | Margaret Barse & Aimee Lewis/Flickr, Public Domain)
Several B vitamins are critical to the normal development of the fetal neural tube. For example, vitamin B12
(cobalamin) and vitamin B9 (folate) support the development of neurons and myelination of the axons, which carry
neurologic messages throughout the body. Folate is integral in fetal brain development, especially during periods of
rapid growth and development (Li et al., 2019). Requirements for the B vitamins increase by 50% during pregnancy.
For pregnant clients, the requirement is approximately 400 mcg/day of B vitamins.
Vitamin D has a role in regulating gene expression and brain development as well as several other functions, such as
the regulation of calcium, the development of dopamine, skeletal regulation, and language development (Larqué,
2018). The maternal requirement of vitamin D during pregnancy is approximately 1500–2000 UL and may be

consumed in the diet by eating fatty fish, eggs, beef, and fish liver oil (Chauhan et al., 2023). A deficiency of vitamin
D may result in attention deficit hyperactivity disorder and poor language development (Tous, et al., 2020).
Iodine plays an important role in thyroid hormone synthesis and is therefore essential for neurologic development of
the fetus. During the first half of pregnancy, a deficiency of thyroid hormone (specifically T4) can disrupt the
development of neurons, synapses, and myelin formation. A client with severe iodine deficiency is more likely give
birth to a baby with decreased IQ scores or possibly cretinism (altered intellectual disability, small stature, and
thickening of the facial features). Supplementing a normal diet with 250 mg/day of iodine is recommended for
pregnant clients. Clients contemplating pregnancy may be encouraged to begin iodine supplementation prior to
conception. Iodine is available in the diet in most sea fish, especially shellfish, and is fortified in many cereals and
grains, in addition to iodized salt. Prenatal supplementation with each of these micronutrients (except vitamin A) is
generally recommended. The requirements for each of these are met in daily intake of a prenatal vitamin, so
additional supplementation is not recommended.
The phospholipids (fats that contain phosphorus) in the plasma membrane, called gangliosides (lipids that carry
sialic acid residues), are essential for fetal brain maturation and can determine normal neural repair and apoptosis,
neurotransmitter release, and transmission of signals across cells (Sipione et al., 2023). Severe
neurodevelopmental and neurodegenerative problems can result from decreased levels of gangliosides. Clients who
carry a rare autosomal recessive gene mutation, such as Tay-Sachs disease (a rare disease that destroys nerve cells
in the brain and spinal cord), cannot synthesize gangliosides due to the deficiency of an enzyme (hexosaminidase A).
These clients will develop an accumulation of these fatty substances, primarily in the brain and spinal cord.
Symptoms include slowed development in the infant, and stiff muscles and seizures may manifest. A similar gene
mutation affecting gangliosides can result in spastic paraplegia and intellectual disabilities, due to a deficit of
gangliosides in the hippocampus (Okuda, 2019). Egg yolks, meat, and milk are the dietary sources of gangliosides
(Okuda, 2019).
While a deficiency of nutrients has been shown to have a negative impact on fetal brain development, a high-fat
maternal diet and obesity during pregnancy have been correlated to autism and attention deficit disorder among
newborns, behavioral disorders in children, and a propensity for obesity in adulthood (Cortés-Albornoz, et al.,
2021). Also, high consumption of sugar during pregnancy, especially fructose, has been associated with altered
development of the prefrontal cortex and subsequent autism spectrum disorder (Rivell, et al., 2019). Obesity among
pregnant clients has been associated with infants exhibiting altered immunity, higher rates of attention deficit
hyperactivity disorder, and autism or intellectual developmental delays than children born to mothers with a normal
weight (Sanchez et al., 2018). The nature of the maternal diet has been shown to impact the bacterial colonization
in the infant’s gut in the early postpartum period, which can impact subsequent neurodevelopment across the
lifespan (Al Rubaye, et al., 2020).
As shown in Applying Clinical Judgment to Promote Nutrition for Neurological Wellness, omega-3 fatty acids are
required for healthy brain function. A deficiency of these essential brain-building blocks results in brain
inflammation and possibly brain injury and stroke. Approximately 1 in every 3,500 full-term infants in the United
States will develop an ischemic stroke when expecting mothers do not consume adequate amounts, especially in
the first trimester of pregnancy (Dunbar & Kirton, 2018).
Prenatal alcohol intake in any amount has been shown to have a detrimental effect on congenital cognitive
impairment, including fetal alcohol spectrum disorder and, if severe, fetal alcohol syndrome (Oei, 2020). Maternal
caffeine intake crosses over to the placenta and is associated with altered sleep and movement as well as the ability
to learn, because the developing fetus does not possess the enzymes to metabolize caffeine. Maternal caffeine
intake of more than 200 mg/day has been associated with shorter stature in early childhood (Gleason et al., 2022).
Impact on the Client’s Health During Pregnancy

The impact of pregnancy on the neurological health of the client is of great concern. Pregnant people’s rates of
morbidity and mortality have risen dramatically in recent years, especially in non-Hispanic Black and Hispanic
individuals (Hoyert, 2023). Hormones change during pregnancy, and particularly the rise in progesterone can affect
maternal health. Current nutritional recommendations for neurologic health during pregnancy include a diet rich in
fresh fruits and vegetables, whole-grain cereals, milk, and dairy products, as well as meat, fish, and eggs as they are
rich in vitamins A, C, and D as well as calcium and phosphorus.
During the antepartum period, many people have an increased interest in eating carbohydrates, and if toothbrushing
does not occur as often, dental caries and plaque are more likely. Dental infections and caries have long been
associated with the development of a stroke, but dental inflammation has also been associated with premature
contractions, placing the fetus at risk for premature birth, low birth weight babies (Alrumayh et al., 2021). While
regular oral care during pregnancy (toothbrushing and flossing at least twice a day) require diligence during
pregnancy, dental procedures such as extractions and root canals, if required, are performed with caution during
pregnancy, and may be delayed until after the first trimester.
Sugars, dried fruits, and chewy candy should be avoided to promote optimal dental health, as this can also impact
the neurologic health of the pregnant client. Gingivitis and tooth decay are more likely during pregnancy, and this is
thought to be associated with hormonal changes, especially estrogen and progesterone. Those who develop
morning sickness with vomiting during pregnancy are more likely to have gingivitis, which can lead to an acidic
environment in the mouth and, consequently, tenderness and minor bleeding can occur, making toothbrushing
uncomfortable.
High levels of fat in the maternal diet and an inactive lifestyle are associated with high cholesterol and high blood
pressure. A significant portion of people who consume a high-fat diet and are inactive during pregnancy develop
preeclampsia, placing them at a five-times higher-than-average risk for stroke, not only in the peripartum period,
but also in later life (de Havenon et al., 2021). Pregnant clients who develop frequent migraine headaches are more
likely to develop preeclampsia during pregnancy (Zambrano & Miller, 2019). Clients who develop an infection such
as a urinary tract infection or sepsis during their pregnancy are more likely to be readmitted to the hospital for a
stroke after the delivery (Zambrano & Miller, 2019). Approximately 7.4% of maternal deaths are a result of stroke.
Stroke is now the second-leading cause of maternal death in Japan among women older than 40 years, and many of
these are considered preventable (Zambrano & Miller, 2019). A large percentage of maternal deaths in the United
States are associated with inadequate prenatal care and preeclampsia (Elgendy et al., 2021). In addition to
preeclampsia and stroke during pregnancy, Bell’s palsy can develop during delivery, and a temporary paralysis of
one side of the face can last up to 6 months postpartum.
Risk for Stroke During Pregnancy or Delivery
Black clients with a history of hypertensive disorders of pregnancy (HDOP) are at a 66% higher risk for
experiencing a stroke (Sheehy et al., 2023). Their risk for stroke during pregnancy or delivery is doubled due to
the possibility of a hypercoagulable state, eclampsia, or preeclampsia (Richardt et al., 2023), and this may be in
part related to poor prenatal nutrition.
The Client Without Neurological Illness

The consequences of chronic conditions may undermine pregnancy or aggravate the maternal condition, and
nutritional requirements may exceed the recommendations of a normal pregnancy. Demyelinating
polyneuropathies, inflammatory muscle disease, and myasthenia gravis may become more extreme during
pregnancy. Although there are no specific nutritional recommendations for these conditions during pregnancy, an
interprofessional approach of physicians, scientists, nurses, dieticians, and other specialists are often required to
best manage symptoms and to optimize nutritional support.
Although a variety of chronic conditions can impact maternal nutrition in pregnancy and lactation, type 1 diabetes,
type 2 diabetes, gestational diabetes, and systemic lupus erythematosus (SLE) can have a profound effect on
maternal and fetal health. These conditions are discussed next.
Type 1 Diabetes, Type 2 Diabetes, and Gestational Diabetes

Recent improvements in the monitoring of blood glucose have dramatically increased a pregnant client’s ability to
maintain normal blood glucose levels. Glucose is an osmotic diuretic and because of this effect, diabetic clients may
be subject to dehydration. Diabetic ketoacidosis is more common in type 1 diabetes than in other types of diabetes.
The dietary requirements for a pregnant or lactating client with type 1 diabetes are essentially the same as those for
a client without a chronic disease or condition, with a few recommendations. Normal blood sugar should always be
maintained. This can be managed using continuous blood glucose monitoring, and an insulin pump for type 1

diabetes may be recommended for type 2 diabetes and gestational diabetes as well. In some cases, metformin may
be used for gestational diabetes and type 2 diabetes. The effect of insulin type 1 diabetes and metformin type 2
diabetes are similar in that they both produce normoglycemia and optimize fetal neurologic outcomes. Although
metformin crosses the placental barrier, it was shown to be slightly superior in preventing maternal weight gain and
hypertension (Newman et al., 2023). Maternal weight gains of 11–18 kg (24.25–39.68 lb) are generally
recommended. Diet should consist of 50% unprocessed carbohydrates (no concentrated sweets), 20% protein, and
30% polyunsaturated fats (Newman et al., 2023). Although a short-term drop in blood glucose is generally well
tolerated by a developing fetus, long-term hypoglycemia can have devastating effects on fetal brain development.
Systemic Lupus Erythematosus (SLE)

Systemic lupus erythematosus (SLE) is associated with several pregnancy-related complications, especially during
delivery. Although diet alone is insufficient to manage SLE, the gut is affected by SLE. A diet that maintains a healthy
gut microbiome should include each of the food groups and food from all the colors of the rainbow, such as
blueberries, strawberries, corn, oranges, eggplant, broccoli, and tomatoes, to increase phytonutrients. The presence
of any allergies must be carefully considered when selecting foods. Antepartum clients are often advised to avoid
fatty red meats, refined sugar and flour, fried foods, alcohol, gluten, and processed foods. Bananas are
recommended because they are high in magnesium, which helps to protect the fetal brain, promotes normal fetal
growth, and helps prevent preeclampsia. Dark green vegetables, such as kale and spinach, are rich in iron and can
mitigate the side effect of anemia resulting from some anti-inflammatory medications that may be used for
maternal treatment of SLE.
Clients with Chronic Neurological Illness

Clients with neurologic conditions can generally experience a healthy pregnancy. However, research is ongoing to
study the impact of multiple sclerosis, migraines, aneurysms, myasthenia gravis, and epilepsy during pregnancy (Xu,
2019). Some medications to treat seizures can be successfully administered during pregnancy. Caution should be
employed when considering the effect of medications to treat the neurologic condition of the mother. Headaches
can be sign of preeclampsia, so the pregnant client with a history of migraines should be closely monitored.
Medications to treat headaches or other neurologic conditions must be carefully planned to avoid those that cross
the placental barrier. The risk for stroke is highest in clients with preeclampsia, so blood pressure must be carefully
monitored and treated.
Conditions such as Guillain-Barré syndrome can be potentially lethal. This nervous system condition presents with
acute ascending weakness and may progress to acute respiratory failure if left untreated with respiratory support.
Treatment of Guillain Barré syndrome is the same for pregnant and nonpregnant clients (Leonhard et al., 2019).
In terms of nutritional support, diets that are rich in macronutrients and micronutrients for a client without a
neurologic condition are considered safe for the pregnant client with a chronic neurologic condition.
Infancy
The development of the brain and nervous system is the most rapid in the first two years of life. Given the known
benefits of breastfeeding over infant formula, nutritional support with human breast milk is critical to neurological
development during infancy. Specifically, the development of visual function and other cognitive domains are
improved when babies are breastfed throughout infancy (Nieto-Ruiz, 2019). A deficiency of a host of macronutrients
and micronutrients, such as protein, carbohydrates, certain fats, iron, zinc, copper, iodine, selenium, vitamin A,
choline, folate, and vitamin B12 (cobalamin), have been shown to be essential in preventing certain neurologic
disorders, such as anorexia, irritability, growth retardation, and developmental regression (Nawaz, et al., 2020). Iron
deficiency alters myelin formation in infancy as well as the development of the hippocampus (brain structure
responsible for emotion, memory, and autonomic nervous system) and neurotransmitters. The impact of maternal
iron deficiency includes a reduction in memory, motor, and behavioral affect in the infant. A zinc deficiency
interferes with both hippocampal and cerebellar development. Polyunsaturated fatty acids also affect membrane
function and the development of appropriate synapses.
Lactating Clients
To ensure the adequacy of breast milk for infant nutrition, lactating clients should include protein-rich foods, such as
meat, poultry, fish, eggs, dairy, beans, nuts, and seeds, 2–3 times a day (CDC, 2023a). Three servings of vegetables
that include dark greens should also be consumed, as well as 2 servings of fruit. Whole-grain foods such as cereals,
breads, pastas, and oatmeal are also recommended. Seafood is recommended if it is low in mercury. A healthy diet
should include most of the macronutrients and micronutrients that are required for lactating clients, but a
multivitamin and mineral supplement may also be recommended to ensure adequate nutrition for both the mother
and infant. Caloric intake should increase by approximately 330–400 calories per day to produce high-quality breast
milk (CDC, 2023).
Childhood
The brain reaches 80% of its adult weight by age 3 (Bethlehem et al., 2022) and is exceptionally sensitive to any
nutritional deficiencies. Glucose metabolism in the brain continues to accelerate from birth to 4 years. At age 4
years, glucose metabolism occurs at approximately twice the rate as that of an adult. This accelerated metabolic
rate continues until age 9 or 10 years and then begins to slow to the adult level during late adolescence. Because
the brain cannot store glucose, a continuous supply of glucose by eating frequent meals is paramount. The effect of
overnight fasting can have an adverse effect on children; therefore, breakfast is an extremely important meal to
nourish the brain and improve cognitive function.
A breakfast that is rich in low glycemic carbohydrates is known to result in optimal cognitive performance. Different
types of breakfast may impact the development and performance of various gray and white matter in the brain
(Arora, 2022). The effect of long-chain polyunsaturated fatty acids (LCPUFA) is essential for brain function,
especially in the brain’s gray matter. Given the rapid brain development, especially in early childhood, it is critical to
ensure adequate micronutrients intake, which can be challenging. Deficiencies of micronutrients such as iron, folate,
and vitamin B12 may become evident around age 5–6 years, as deficiencies are associated with poor cognitive
performance, especially in the school setting (Arora, 2022).
Micronutrient deficiency may be more apparent among children whose mothers had experienced inflammatory
bowel diseases, celiac disease, or ulcerative colitis, as these vitamins are poorly absorbed in the intestines in these
conditions. For children who are deficient, dietary supplementation with micronutrients can improve cognitive
performance, especially if the breakfast is low in sugar (Arora, 2022).
The prevalence of pediatric obesity climbed to 19.7% between 2017 and 2020 in the U.S. (CDC, 2023b). Some
studies suggest that there is a biological link between childhood obesity and lower cognitive function and that this
effect is related to insulin resistance. However, these studies are inconclusive, especially when sociodemographic
factors are considered. For healthy children, the Mediterranean diet is an example of a diet that can provide the
essential nutrients required for the development of a healthy neurologic system.
Adolescence
Multiple studies of the diets of adolescents have shown that there is a direct relationship between diet and brain
development (Arora, 2022). Diet is associated with various aspects of mood, anxiety, depression, and other mental
health disorders. A disproportionate percentage of teens are known to have an eating disorder (i.e., anorexia
nervosa or bulimia), and this has a direct result on neurotransmission within the brain (Aurora, 2022). A poor diet
during adolescence can result in structural changes in the brain, causing poor cognitive function, mood changes, and
emotional imbalances. These structural changes may become permanent, as the brain is still developing in
adolescence, and the processes of neurotransmission in the brain is still evolving during this period. For example,
dopamine is a neurotransmitter in the brain that is responsible for pleasure and reward responses, and if the brain
interprets a message that a cheeseburger or ice cream is a reward, dopamine is released. This dopamine effect is
much more pronounced in an adolescent brain than in an adult, because adolescents have more dopamine
receptors than adults. When the adolescent brain is rewarded with poor diet choices, this impact carries over into
adulthood.
Healthy food choices, including a moderate intake of low-fat dairy and meats with low levels of refined sugars,
promote the development of healthy bacteria, acting as natural probiotics. Bacteria in the stomach influence the
production of serotonin and create a lining of the stomach that protects against harmful bacteria, limiting
inflammation and improving the absorption of nutrients. Serotonin is produced in the intestine and regulates sleep,
appetite, mood, and pain inhibition. The creation of healthy bacteria in the gut is critical, because bacteria activate
the pathway between the brain and GI tract.

A poor diet during adolescence creates a disruption in healthy gut bacteria, resulting in an inability to absorb
nutrients or produce serotonin. The neurologic impact of a poor diet during adolescence is a reduced attention span,
an inability to learn or remember new information, and an inability to regulate one’s mood. The typical teenage diet
in the U.S. often includes sugary drinks, processed sugars, fried foods, and an imbalance in healthy nutrients. A poor
diet in adolescence also contributes to the development of depression, sleep disturbances and mood disorders. It
can also contribute to an early development of heart disease, type 2 diabetes, memory disturbances, and brain
inflammation (Griebsch et al., 2023; Moscatelli et al., 2023). Some teens have tried to reduce processed sugar
intake by switching to sports drinks containing aspartame. However, aspartame contains phenylalanine, which
increases brain inflammation and can worsen brain function, increasing the risk for developing Alzheimer’s disease
and other forms of neurodegeneration (Czarnecka et al., 2021). Conversely, many children and adolescents have
moved toward a health-conscious lifestyle that includes vegetarian or vegan diets (Figure 6.3). Although nutritional
needs can generally be met with a plant-based diet, the nutrient requirements of adolescents are higher per
kilogram of body weight than adults, and this consideration is important in diet planning. Nutritional deficiencies,
especially of omega-3 fatty acids, iron, zinc, and B12, are more common among vegetarians and vegans, requiring
close monitoring by health care professionals (Rudloff et al., 2019).
FIGURE 6.3 Poor diet choices can be improved by replacing unhealthy ingredients, such as those found in all-meat pizzas, with healthier
plant-based options such as bell peppers or mushrooms. (credit: “Tonight’s Pizza” by Alan Levine/Flickr, Public Domain)
Adulthood
The needs of adults change as aging occurs. While adulthood begins at 18 years, the needs of adults change as a
person enters their 30s, 40s, 50s and 60s due to changes in metabolic rate, activity levels, the physical demands by
occupation, hormonal changes, and a wide range of other factors. Moreover, nutritional needs may vary based on a
person's sex. For example, health and nutrition for females must consider important factors across the lifespan,
such as pregnancy, breastfeeding, and menopause. As females age, they are at a higher risk than males of cardiac
disease, breast cancer, and osteoporosis.
Specific recommendations for macronutrients to maintain neurologic health can also vary depending on a range of
factors, including a person's sex, environment, and other characteristics or circumstances. The degree of physical
activity alters protein requirements. Physical body size and weight alter caloric needs. Carbohydrates provide the
main source of energy. In general, 130 g/day of carbohydrates are recommended, and these should be consumed
from high-fiber whole grains, fruits, vegetables, and legumes, as well as low-fat yogurt and other dairy products. A
dietary intake of polyunsaturated fats, which can be found in vegetable oils, nuts, seeds, and fish oil, should
comprise around 15% of the adult diet.
While caloric needs are higher in early adulthood, this need often declines as a person ages. Because many adults
do not adjust their diet as they age, overconsumption of calories coupled with a decline in physical activity often
results in adult-onset obesity, which can be associated with poor cognitive status. Some estimates report that
42.5% of adults in the U.S. are overweight or obese, and it varies by race and ethnicity (Fryar, et al. 2021). Due to
the inadequacies of the traditional Western diet, many adults are also nutrient deficient, especially in
micronutrients, even if their caloric intake exceeds the body’s needs.
Older Adults
The changing nutritional requirements in older adults are more relevant than ever before. In 2019, estimates show
that there were more than 703 million people globally over age 65, and more than 50 million were diagnosed with
dementia. By the year 2050, it is projected that 1.5 billion people will be over age 60, and 153 million will be living
with dementia (Alzheimer’s Disease International, 2023). Nutritional strategies, including the intake of specific
macronutrients and micronutrients, such as those rich in B vitamins, long-chain polyunsaturated fatty acids, and
flavonoids (foods that have antioxidant properties due to their variable phenolic composition, like fruits and
vegetables, tea, wine, and whole grains), have been shown to delay or slow the onset of age-related conditions.
Supplementing the diet with micronutrients has been shown to improve cognition in some studies of clients with
Alzheimer’s disease, but the best health benefits have been verified with a varied multinutrient-rich diet rather than
supplements alone (Fei et al., 2022).
The process of aging is associated with a loss of muscle mass. While a variety of food sources are recommended to
support brain health, those containing foods rich in iron, folate, calcium, and vitamins A, C, and D, are particularly
important for supporting muscle mass as well. Adequate intake of vitamin B12 among older adults is recommended
to maintain the integrity of nerve cells. Foods high in vitamin B12 include eggs, fortified breakfast cereal, and certain
fish, such as tuna. However, the absorption of some vitamins may be reduced due to both age-related and other
changes in the gut, as well as the effect of medications like metformin, proton pump inhibitors, vitamin C
supplements, colchicine, and medications that are used to treat peptic ulcers and other gastrointestinal problems.
The tendency of older adults to become dehydrated can also affect the ability to absorb nutrients, and an increase in
water intake as well as fresh fruits and vegetables can help to overcome dehydration. Special nutritional
considerations for older adults should include an understanding of maintaining adequate nutrient and fluid intake,
the client’s sensitivities to certain foods, and any challenges with chewing or swallowing.
Part A
A nurse working in an internal medicine clinic is assessing John Everett, a 77-year-old Black male. His daughter
accompanies him for this routine exam. The nurse asks about John’s appetite and recent food intake. He reports
that he eats “ok,” but his daughter says that he is not eating very well. The nurse reviews John’s record and notes
that he has lost 10 lbs since his last visit. John lives alone, and his daughter is concerned he is not eating enough
nutritious food.
1. Which of the following age-related findings is associated with older adults?

a. Increased appetite
b. Decreased muscle mass
c. Increased caloric intake
d. Decreased hydration requirements
2. Which of the following statements by the client indicates that he is at risk for impaired nutrient absorption?
a. “I don’t drink much water.”
b. “I eat canned vegetables.”
c. “I take my blood pressure medicine with food.”

6.2 • Nutrition and Chronic Neurological Illnesses 117
d. “I eat a lot of snacks and small meals.”
6.2 Nutrition and Chronic Neurological Illnesses

LEARNING OUTCOMES
• 6.2.1 Discuss the impact of nutrition on neurological illness.
• 6.2.2 Discuss the impact of nutrition on psychiatric illness.
Nutritional Requirement for Optimal Neurological Health

Although the development of neurologic conditions varies in process, there are several common threads in reduced
cognition and other neurologic functions. Neurologic chronic conditions are associated with a variety of factors, such
as increased oxidative stress, neuroinflammation, and a disruption in energy metabolism. Each of these factors can
be influenced and modified by dietary intake.
The nurse should screen all clients with neurologic illness for malnutrition in conjunction with the health care team,
using the tools described in Applying Clinical Judgment to Promote Nutrition for Neurological Wellness. This
screening is especially important because clients with neurological conditions may have difficulty chewing or
swallowing. Aphasia, apraxia, depression, or altered cognitive states may further challenge adequate intake. Key
nutritional recommendations for preventing neurologic deterioration in neurodegenerative conditions are provided
in this section.
The effect of specific diets (such as ketogenic and Mediterranean diet) among clients with neurologic conditions,
such as epilepsy, traumatic and atraumatic brain injury, multiple sclerosis, autism, and various neurodegenerative
conditions, such as Alzheimer’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis (ALS), have been
explored in various clinical trials and are described in this section. While the type of diet is important, it is
fundamental that the nurse assess the client’s physical ability to eat. The nurse should assess the client’s current
food intake, signs of fatigue, loss of movement, and evidence of dry mouth as these findings can make eating
challenging. Meeting the nutritional requirements of clients who have difficulty swallowing (dysphagia) secondary to
a stroke or other condition can be particularly challenging because these clients require additional diet
modifications so that foods can be consumed safely to decrease the risk for choking or aspiration.
Meeting the nutritional requirements of clients with a stroke can be challenging, given the potential for difficulty
swallowing (dysphagia). Although the ideal diet for a client who has had a stroke is generally similar to a cardiac diet
(low salt, low fat, high fiber), this may be challenging.
Ketogenic Diet
The ketogenic diet is high in fat and low in carbohydrates, and has been used to facilitate treatment for clients with
drug-resistant epilepsy. The impact of the ketogenic diet, as well as variations like a modified Atkins diet or low
glycemic diets is to promote the formation of ketone bodies. The brain uses ketones to generate energy, and this
type of diet reduces the magnitude of glycolysis. Although the science is still somewhat unclear, it is thought that
this generation of ketone bodies alters the metabolism of certain neurotransmitters and improves mitochondrial
function in a fashion that reduces oxidative stress, improves mitochondrial function, and activates certain signaling
pathways (Francis & Stevenson; Miller, et al., 2020).
The beneficial impact of ketogenic diets in clients with epilepsy is well known to be a reduction in seizures that have
been previously intractable to drug therapy. In addition, the impact of a ketogenic diet in children with epilepsy
often includes an improvement in cognitive function and a reduced rate of developmental delays, if initiated very
early. However, the impact on cognition may be directly related to the diet or to a brain injury associated with
uncontrolled seizures.
The ketogenic diet shows some promise in other conditions as well, such as multiple sclerosis, autism, and
Alzheimer’s disease (Li, 2021). In a study of clients with multiple sclerosis, a ketogenic diet may improve
concentration, attention, and memory (Francis & Stevenson, 2018). Although limited data exists due to small
sample sizes and difficulty with blinding procedures, a ketogenic diet has been shown to improve autistic behavior,
but individual food preferences and the gastrointestinal impact of this diet may impact feasibility (Francis &
Stevenson, 2018). The effect of the ketogenic diet is to produce a state of ketosis, and among individuals with
Alzheimer’s disease, a modest improvement of cognitive function occurs when ketosis is achieved. However, among
individuals with Alzheimer’s disease, cognitive improvement was observed only when clients engaged in a ketogenic
diet achieved ketosis, even among those with severe Alzheimer’s disease (Tabaie, et al., 2022). Among individuals
with ALS, a high-fat diet, such as the ketogenic diet, has been shown to slow disease progression, while a calorie-
restricted diet has been shown to reduce survival rates (Jiang et al., 2022).
Mediterranean Diet
While the Mediterranean diet (Figure 6.4) has shown effectiveness in preventing heart disease, the antioxidant and
anti-inflammatory benefit of this diet can help prevent stroke events and slow cognitive decline in clients with
Alzheimer’s disease, in part because of the long-chain polyunsaturated fatty acids and olive oil. Moreover, the
polyphenols obtained from fresh fruits and vegetables have been shown to mitigate the phosphorylation of tau
protein, preventing tangle formation, and to negate beta-amyloid aggregation in the brain. The net effect of reducing
oxidative stress and neuroinflammation is to enhance neurogenesis, improve transmission across synapses, and
reduce neuronal death (Román et al., 2019).
FIGURE 6.4 The long-chain polyunsaturated fatty acids and olive oil in the Mediterranean diet may help prevent stroke events and slow
cognitive decline in clients with Alzheimer’s disease. (credit: “photo of restaurant, dish, meal, food, salad, green, Greek, mediterranean,
pepper, produce, vegetable, menu, fresh, healthy, lunch, cuisine, delicious, dairy product, onion, lettuce, cheese, tomato, dinner, oil, diet,
olive, brunch, appetizer, sense, feta”/PxHere, Public Domain)
Alternative Food and Supplement Options

While the ketogenic and Mediterranean diets have shown promise in the prevention and management of neurologic
conditions, the metabolism of lipids in the brain are dramatically disrupted when there is an excessive intake of
carbohydrates, particularly those found in processed foods such as high-fructose corn syrup and artificial
sweeteners. However, complex carbohydrates, such as those found in fresh fruit, vegetables, and high-fiber cereal
grains, are recommended for the management of cognitive decline (Román et al., 2019).
Client Teaching
In general, a diet rich in fruits and vegetables, whole grains, nuts, seeds, fish, meats, eggs, dairy products, healthy
fats (olive oil, avocado, coconut, and flaxseed oils), and probiotic-rich foods (yogurt, kimchi, kefir, sauerkraut), as
well as fresh herbs and spices are neuroprotective.
For clients with neurologic conditions, preventing further brain inflammation can mitigate or slow degenerative
processes. Resveratrol is a polyphenolic compound that is present in grapes, mulberries, tea, seeds, some cereals,

6.3 • Neurologic Condition Treatments, Medications, and Nutrition 119
and red wine consumed in moderation. It can protect the body from developing increased levels of triglycerides and
cholesterol and can have a positive effect in the early stages of neurodegenerative disorders (Oppedisano et al.,
2020).
Ensuring optimal intake or supplementation of vitamins and certain minerals, such as magnesium, can prevent
acute episodes of brain fog and fatigue in persons with MS. When supplementing clients with deficiency of vitamins
A, B12, and D3, it is helpful to administer these supplements with magnesium, as they do not compete with one
another during for absorption. Reducing carbohydrate intake can also help to mitigate the fatigue of MS. Coenzyme
Q10 (CoQ10) has been shown to have a significant antioxidant effect to produce energy and is well known for the
prevention of heart disease, but it also has neuroprotective effects. CoQ10 is not available in foods but is
synthesized by the body. In clients who have experienced ataxia because of neurologic conditions, supplementation
of CoQ10 has been shown to improve both gait and posture (Oppedisano et al., 2020).
A diet high in antioxidants and fiber can help fight inflammation in clients with MS and will slow further
demyelination and prevent constipation. Some sources suggest that a ketogenic diet prevents or slows symptom to
manifest in clients with MS (Dynka et al., 2022).
Part B
Study Part A.
During John’s visit it becomes apparent that he is experiencing some cognitive decline. The health care provider is
recommending further neurological evaluation for possible dementia. The provider is also concerned about the
client’s weight loss and wants the nurse to work with John to improve his food intake.
3. Which of the following dietary recommendations should the nurse make to John?
a. Limit all carbohydrate intake.
b. Increase intake of complex carbohydrates.
c. Switch to drinking diet beverages with artificial sweeteners.
d. Limit fluid intake and focus on solid food intake.
4. John’s daughter asks why he can’t just take a vitamin to meet his nutritional needs. Which of the following is
the best response by the nurse?
a. Vitamins and supplements are used as a last resort.
b. Vitamins and supplements do not contain adequate amounts of needed nutrients.
c. Taking vitamins and supplements may be confusing for the client and difficult to remember to take.
d. Research shows that eating a nutrient-rich diet is the best source of micronutrients to support cognition.
6.3 Neurologic Condition Treatments, Medications, and Nutrition

LEARNING OUTCOMES
• 6.3.1 Identify drug–food interactions for their impact on treatments utilized for neurological disorders.
• 6.3.2 Identify treatments and medications that can cause nutritional deficiencies in clients with
neurological disorders.
Specific dietary needs change over the course of a client’s lifespan, and certain neurologic conditions may benefit
from a diet that contains specific key nutrients that promote health and delay symptoms. Anticonvulsants are
medications used to prevent or treat epileptic seizures and can also cause nutritional deficiencies (Table 6.2).
Clients who have experienced a stroke or who have Parkinson’s disease, myasthenia gravis, or ALS should be
screened for dysphagia before offering oral meals and then must be monitored when eating for symptoms of
choking, watery eyes, or coughing. While dysphagia symptoms among clients with ALS may present with slowly
progressive symptoms that lead to a malnourished state, clients with Parkinson’s disease or myasthenia gravis may
develop symptoms suddenly and may quickly develop exacerbations in which oral intake is not possible. The nurse
should assess the client, perform a dysphagia screen, and withhold any oral intake until oral intake is safe. The risk
for aspiration pneumonia can preclude oral feeding in clients with several neurologic conditions. If these symptoms
are present, the nurse should consult with a speech pathologist and dietitian for the best treatment plan. Liquids
may need to be thickened if dysphagia is present, and this can lead to dehydration. The nurse should follow fluid
intake and urinary output closely to ensure adequate fluid status. In some cases, supplemental nutrition may be
required temporarily or permanently via enteral feeding to ensure adequate nutrient and fluid intake.
Medication Nutritional Considerations

Anticonvulsant/Antiepileptic Medications (Alcohol should be avoided with all antiepileptic medications.)
• Phenytoin • Can cause deficiencies in vitamin D and biotin
• Barbiturates
• Carbamazepine
• Valproic acid • Can decrease L-carnitine, cause hypoglycemia in neonates, reduce zinc in the
(VPA) bloodstream, and cause hair loss
• Absorption of VPA diminished with soy
• Hepatotoxicity occurs when high-fat diet is consumed
• Gabapentin • Increase in body weight by increasing appetite

• Pregabalin
• Carbamazepine
Monoamine Oxidase Inhibitors

• Phenelzine • May block vitamin B12, cause an increase in body weight and appetite, and reduce
activity
Tricyclic Antidepressants
• Nortripgyline • Dietary high fiber, legumes, fish, meat, and vitamin C may decrease drug absorption
• Amitriptyline • May cause a decrease in plasma tryptophan serum concentration but an increase in
• Imipramine brain concentration of tryptophan and the risk for serotonin syndrome
• Desipramine • May increase body weight by stimulating hunger and carbohydrate intake
Antipsychotic Drugs
• Chlorpromazine • Can cause deficiency of riboflavin and vitamin B12
Sleep Medications (Do not take with alcohol.)

• Zolpidem • May interact with St. John’s wort
• Triazolam • May interact with grapefruit juice
TABLE 6.2 Common Food and Medication Interactions in Clients with Neurologic Conditions (source: FDA, 2020a–b)
Drug–Food Interactions with Treatments for Neurological Disorders

Many clients with neurologic conditions require treatments and medications that can affect their nutritional status.
It is important for the nurse to identify potential nutritional risks and help plan dietary adjustments with clients. This
section familiarizes the nurse with some of the more common treatments and medications used for these clients.
A person’s genetic background strongly influences food and drug interactions, and certain nutritional deficiencies
alter the gut microbiome, which can alter future medication absorption. Excessive intake of some vitamins can
reduce the effectiveness of certain drugs, especially those used to treat epilepsy. Understanding the interactions
between food and medications used for neurologic conditions among the health care team can ensure appropriate
use and promote efficacy and client safety.
Nurses must consistently monitor clients for drug–food interactions; this is a collaborative effort involving the client

reports, pharmacists, physicians, nurses, and dieticians. The ongoing assessment of clients receiving neurologic
medications is critical. For example, identifying changes in body weight or nutritional deficits is key in promoting
medication effectiveness and improving health (Table 6.3).
Increased Body Weight Decreased Body Weight

Antidepressants: Amphetamines:
• Mirtazapine • Phenifuramine
• Fluvoxamine • Phentermine
• Phenelzine
• Citalopram
• Amitriptyline
• Doxepin
• Imipramine
Neuroleptics: Antipsychotics:
• Clozapine • Phenothiazines
• Olanzapine
• Risperidone
• Quetiapine
• Haloperidol
Benzodiazepines: Psychostimulants:
• Alprazolam • Methylphenidate
• Diazepam • Glucagon-like protein-1 (GLP-1) receptor agonists
• Clonazepam
Antiepileptics:
• Valproic acid
• Gabapentin
TABLE 6.3 Neurologic Medications That Affect Body Weight (sources: FDA, 2022a; Verhaegen et al., 2019)
Medications Used to Treat Parkinson’s Disease

One of the main medications used to treat Parkinson’s disease is levodopa, a dopaminergic agent. As the body
metabolizes levodopa, elevated homocysteine levels (an amino acid) can present. This elevation can cause greater
stiffness of the aorta and a lower bioavailability of CoQ10, placing the individual at a higher risk for cardiovascular
events such as stroke. Therefore, due to the given the nature of the breakdown of levodopa, an adequate intake of
folate, niacin, and vitamins B6 and B12 is recommended to prevent increased homocysteine levels, mitigating an
increased cardiovascular risk. Alternatively, too much protein when taken with levodopa can inhibit its action, so
medication should be taken 30–60 minutes before a meal and is not recommended in conjunction with a high-
protein diet (Gezmen-Karadag, 2018). Sugar or fat can worsen Parkinson’s symptoms as these foods can inhibit
absorption of levodopa, while a high-carbohydrate diet will increase the effect of levodopa (Gezmen-Karadag,
2018). In addition, clients with Parkinson’s disease who have a high levodopa requirement will often present with
constipation and may require stool softeners.
Medications Used to Treat Epilepsy

Many of the anticonvulsant drugs (i.e., phenobarbital, carbamazepine) used to prevent seizures can also cause an
increase in vitamin D metabolism in the liver and reduced bioavailability of vitamin D, which decreases calcium
absorption in the intestine. This signals an increase in calcium uptake away from the bones. Low levels of vitamin D,
serum calcium, and serum phosphate have been seen among children with epilepsy who receive these medications
(Kija et al., 2019).
Other nutritional deficiencies that can result from taking antiepileptic drugs include low levels of biotin, an increase
in homocysteine levels, and a deficiency of several B vitamins (Samahan et al., 2020). Therefore, it is recommended
that clients taking anticonvulsant medications take calcium and vitamin D supplements. It was also noted that high
folate levels can increase homocysteine concentrations and, therefore, folate levels should be monitored (Safahani
et al., 2020). Hypocalcemia, reduced serum L-carnitine, zinc, and copper levels have been associated specifically
with administration of phenytoin or valproic acid, but the supplementation of calcium has been shown to improve
both cognition and function (Kija et al., 2019).
Nutrition education is recommended for clients prescribed valproic acid, as the intended action may be inhibited
among people who consume large amounts of soy, as seen in vegan and vegetarian diets. Moreover, while some
anticonvulsant medications, such as topiramate, may reduce total body weight, valproic acid has been associated
with weight gain because of decreased serum glucose levels, which increase appetite. Clients who receive valproic
acid should be closely monitored, as hepatotoxicity (injury to the liver or impaired liver function) may result. Clients
taking any anticonvulsant medications should not consume alcohol, because these medications weaken the
tolerance to alcohol, increasing the risk for intoxication. Table 6.4 provides a list of common medications used to
treat seizures.
Generic Name Nutritional Effect

Carbamazepine • Can cause deficiency in vitamins B and D
• Can cause bone loss, hyperhomocysteinemia
Clonazepam • Can decrease appetite but cause weight gain as it slows the metabolism
Diazepam • Do not take with grapefruit or grapefruit juice, kava, or St. John’s wort
Ethosuximide • Can cause loss of appetite and weight loss
Levetiracetam • Can deplete biotin, calcium, L-carnitine, and vitamins A, B12, D, and E
Midazolam • Do not take with grapefruit or grapefruit juice
Oxcarbazepine • Can increase appetite and cause weight gain

• Can reduce sodium levels and cause nausea, upset stomach, and indigestion
Phenobarbital • Causes vitamin D deficiency

• Can cause bone loss
• Increases biotin breakdown
• Can cause loss of appetite and weight loss
• Can deplete calcium and vitamins A, B9 (folate), and D
Phenytoin • Vitamins B and D deficiency

• Can cause bone loss
• Hyperhomocysteinemia
• Do not mix with enteral tube feedings
Pregabalin • Can increase appetite and cause weight gain

• Can lower vitamin B12 levels
Primidone • Can cause loss of appetite and weight loss

• Can lower vitamin B12 levels
Topiramate • Can suppress appetite, causing weight loss

• Can cause ketosis and increase risk for kidney stones
Valproic acid • Vitamin D deficiency

• Can cause bone loss, as well as hyperammonemia and L-carnitine deficiency
TABLE 6.4 Common Medications Used to Treat Seizures (sources: Dhaliwal et al., 2023; Epilepsy Foundation, 2023)

Medications Used to Treat Multiple Sclerosis (MS)

Several medications and treatments may be used to treat clients with MS, depending on the type and severity of the
condition and considering potential risks and benefits. One group of medications is immunomodulators. Interferon
beta-1a is an injectable immunomodulator that is often prescribed to clients with MS, as it acts to reduce
inflammation and halt nerve damage through the destruction of certain cells. While flu-like symptoms may be
common, liver damage is a critical side effect of this medication. A loss of appetite as well as nausea, clay-colored
stools, dark urine, and jaundice may indicate that the liver is failing and should be reported to the provider
immediately (Filipi & Jack, 2020). One of the newest medications that prevent MS relapses is ofatumumab, which
can also cause nausea, and if this occurs, the nurse should report it to the health care provider. A rare adverse and
potentially lethal effect of this medication is brain infection, which could cause speech, vision, or muscle movement
abnormalities. The ketogenic diet can reduce the need for medication in people with MS.
Medications Used to treat Depression, Psychosis, and Sleep

Several classes of medications are used routinely to treat depression, such as selective serotonin reuptake
inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs). One commonly prescribed
medication to treat depression is fluoxetine, which may be associated with increased insulin levels and subsequent
short-term weight gain in some individuals. Other common antidepressants, such as sertraline and paroxetine, have
been linked to high LDL cholesterol, and long-term use may increase the risk for cardiovascular disease. Some of the
tricyclic antidepressants, such as amitriptyline, may also cause weight gain, as they can increase appetite. A high
intake of fiber foods, such as legumes, fish, and meat, and foods rich in vitamin C, may decrease absorption of these
medications. Tyramine is a trace monoamine found in aged cheeses and cured meats and should be avoided if the
client is taking a monoamine oxidase inhibitor. Some antipsychotic medications, such as chlorpromazine and
clozapine, can cause a vitamin B12 deficiency and/or constipation. Therefore, supplemental B vitamins and minerals
are recommended, as well as adequate fluid and fiber intake.
For clients with sleep disturbances, medications like zolpidem rapidly decelerate brain activity and can help them
fall asleep and asleep. Clients taking sleeping medications should avoid caffeine and alcohol and should take them
on an empty stomach to ensure adequate absorption. Zolpidem interacts with St. John’s wort, and the two should
not be administered together. Another medication prescribed to treat insomnia, triazolam, should not be taken with
grapefruit juice, as this has been shown to increase blood levels of the drug, causing excessive drowsiness.
Chapter Summary
• For proper functioning of the neurologic system, macronutrients and micronutrients prevents
specific nutrients are required across the client’s cognitive decline.
lifespan. • Weight management is important throughout the
• The health of the client and fetus is optimized by client’s lifespan and can promote neurological
ensuring that the client consumes adequate health.
protein and has a diet is rich in micronutrients • Neurologic conditions and subsequent treatment
including vitamins A, B9 (folate), B12 (cobalamin), and medications can alter the client’s nutritional
D, E, and K as well as minerals such as copper, state.
iron, creatine, choline, zinc, and iodine. • Nurses should be aware of the potential nutritional
• Specific nutrients for infants, children, and challenges that could present and teach their
adolescents offer optimal neural development. clients about specific nutritional strategies to
• The nutrient needs for adults change with the prevent rapid declines related to neurologic
aging process; ensuring adequate intake of key diseases and conditions.
Key Terms
anticonvulsants medications used to prevent or treat emotion, memory, and the autonomic nervous
epileptic seizures; many anticonvulsants are also system
used to treat certain psychiatric conditions homocysteine an amino acid that can be found in
Coenzyme Q10 a nutrient that the body produces meat; high levels are associated with the
and can be found in many foods; CoQ10 facilitates development of heart and neurologic conditions
the conversion of food to energy and is a powerful ketogenic diet a diet that is high in fat with adequate
antioxidant that can promote health in protein and low in carbohydrates to produce
cardiovascular and neurologic conditions ketosis; has been used successfully to treat certain
cretinism altered intellectual disability, small stature, neurologic conditions, such as pediatric epilepsy
and thickening of the facial features Mediterranean diet a diet that emphasizes foods that
gangliosides glycosphingolipids that are highly are plant based and contain healthy fats, such as
available in a healthy nervous system and carry vegetables, fruits, whole grains, and olive oil as the
most of the sialic acid residues in the brain main source of fat
hepatotoxicity injury to the liver, or impaired liver oxidative stress an imbalance in the body’s
function, due to the exposure to certain drugs, food production of free radicals and antioxidant defense
additives, alcohol, solvents, some plants, and other that can set the stage for a variety of neurologic
environmental toxins conditions
hippocampus a brain structure located just below the phospholipids a type of fat (lipid) that also contains
ventricles of the brain that is a focal point for phosphorus
Review Questions
1. The nurse is providing dietary instruction to a client who is in the first trimester of pregnancy. Consuming
which of the following foods should the client prioritize to facilitate fetal neurological development?
a. Apples and grapes
b. Whole wheat bread
c. Fruit juice
d. Chicken and lentils
2. A 54-year-old client, recently diagnosed with multiple sclerosis, presents to the clinic for a follow-up
appointment The client asks the nurse if there is any special diet that might help their symptoms. The nurse
advises which diet as an option for the client to discuss with the neurologist?
a. Mediterranean diet
b. DASH diet
c. Ketogenic diet
d. Diabetic diet
3. A client is prescribed phenytoin for epilepsy. Which of the following nutritional deficiencies is the client at risk

for?
a. Vitamin D deficiency
b. Iron deficiency
c. Hypoglycemia
d. Hypercalcemia
4. A 15-year-old client has decided to try a vegetarian diet. Which of the following nutritional deficiencies is this
client at risk for developing?
a. Vitamin C
b. Omega-3 fatty acids
c. Calcium
d. Potassium
5. The patient care technician is assisting a client with Parkinson’s disease during mealtime and reports the
client began to drool and cough while eating. Which action is the most appropriate from the nurse?
a. Perform a bedside swallow evaluation.
b. Tell the patient care technician to watch the client carefully for the rest of the meal.
c. Show the patient care technician how to suction the mouth orally.
d. Place a nutrition consult for tomorrow morning to initiate tube feedings.
6. The nurse is educating a client’s family about the addition of polyphenols to the client’s diet. Which foods
should be recommended by the nurse?
a. Chicken
b. Fish
c. Whole-fat milk
d. Spinach
7. A client diagnosed with epilepsy asks the nurse if nutritional changes could potentially help control their
seizures. Which diet would the nurse tell the client about?
a. DASH diet
b. Ketogenic diet
c. Mediterranean diet
d. Vegetarian diet
8. The nurse is educating a client who is breastfeeding about maternal dietary habits that can promote the
infant’s health. Which of the following statements by the client indicates the need for additional instruction?
a. “I will be sure to eat some leafy green vegetables.”
b. “I will drink plenty of fluids throughout the day.”
c. “I need to eat fewer carbohydrates.”
d. “I need to eat 300–400 extra calories each day.”
9. A diet rich in flavonoids, which are found in tea, red wine, certain fruits, and vegetables is often recommended
in neurodegenerative conditions, due to which of the following benefit of flavonoids?
a. Antioxidant effect
b. They cross the placental barrier.
c. They cross the blood-brain barrier.
d. Anticoagulant effect
10. The nurse is providing discharge instructions to a client who has been prescribed an antidepressant. What
nutritional recommendations are appropriate for this client?
a. Drink a glass of orange juice when taking your medication.
b. Eat a high-fiber meal when taking your medication.
c. Switch to a high-carbohydrate diet to decrease the risk for weight loss.
d. Follow a balanced diet to decrease the risk for weight gain.
Suggested Reading
Alzheimer’s Disease International (2023, June 19). https://www.alzint.org/news-events/news/new-data-predicts-
the-number-of-people-living-with-alzheimers-disease-to-triple-by-2050/
Cortés-Albornoz, M. C., García-Guáqueta, D. P., Velez-van-Meerbeke, A., & Talero-Gutiérrez, C. (2021). Maternal
Nutrition and Neurodevelopment: A Scoping Review. Nutrients, 13(10), 3530. https://dx.doi.org/10.3390/
nu13103530
Gezmen-Karadag, M., Çelik, E., Kadayifçi, F., Yesildemir, Ö., Öztürk, Y. E., & Agagündüz, D. (2018). Role of food-drug
interactions in neurological and psychological diseases. Acta Neurobiologiae Experimentalis, 78(3), 187–197.
Zambrano, M., Miller, E. (2019). Maternal Stroke: An Update. Current atherosclerosis reports, 21(9), 33.
https://doi.org/10.1007/s11883-019-0798-2

CHAPTER 7
Nutrition for Endocrine Wellness
FIGURE 7.1 Endocrine wellness is connected to a healthy diet full of vegetables. (credit: modification of work “Vegetables” by Scott Bauer/
Wikimedia Commons, Public Domain)
CHAPTER OUTLINE
7.1 Assess and Analyze the Impact of Nutrition on the Endocrine System
7.2 Plan Nutritional Strategies to Impact Endocrine Wellness
7.3 Implement Nutritional Strategies to Impact Endocrine Wellness
7.4 Evaluate Nutritional Strategies to Impact Endocrine Wellness
INTRODUCTION Endocrine disorders, such as diabetes and thyroid disease, require careful diet and lifestyle
management. Accordingly, nurses play a critical role in promoting nutrition for endocrine wellness. For example,
nurses instructing clients with diabetes on proper nutrition can significantly improve their clients’ glycemic control
(Martos-Cabrera et al., 2021). Nurses can collaborate with other health care professionals to develop
comprehensive treatment plans for clients with endocrine disorders. Multidisciplinary interventions can improve
glycemic control and reduce hospitalizations in clients with type 2 diabetes (Ni et al., 2019).
Consider this case: Meena, a 44-year-old Indian American female was recently diagnosed with hypothyroidism and
type 2 diabetes. Meena develops some concerning symptoms and comes to the clinic for evaluation.
128 7 • Applying Clinical Judgment to Promote Nutrition for Endocrine Wellness
7.1 Assess and Analyze the Impact of Nutrition on the Endocrine System
LEARNING OUTCOMES
• 7.1.1 Recognize the normal function of the endocrine system.
• 7.1.2 Recognize cues of nutritional impact on the endocrine system.
• 7.1.3 Analyze cues of nutritional impact on the endocrine system.
Normal Function of the Endocrine System

The endocrine system is a network of cells, tissues, and organs that regulate and control all processes using
hormones. Hormones are secretions that help regulate organ function by exerting their effects on certain cells in the
organ. They coordinate biological functions like metabolism, sexual reproduction, blood pressure, body
temperature, heart rate, growth, development, and sleeping. Related to nutrition, the endocrine system regulates
appetite and how nutrients are used.
The hypothalamus is a region in the brain that regulates the endocrine system through its connection and
coordination with the nervous system. The pituitary gland, also located in the brain, regulates other glands like the
adrenal, thyroid, and testicles. These glands include the thyroid, parathyroid, adrenal, pineal, and pancreas which
play critical roles in regulating calcium levels in the body, metabolism, sexual development, and blood pressure, and
insulin production, respectively. Figure 7.2 shows the pituitary gland and other key parts of the endocrine system.
The goal of regulating hormone levels in the blood is to reach a state of balance or homeostasis. Imbalances can
lead to health problems like high blood pressure, changes in mood and behavior, and weight gain (Betts et al.,
2022).
FIGURE 7.2 The endocrine system is comprised of the central glands, found in the brain, and peripheral glands found in other parts of the
body. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0
license)
Nutrition plays a vital role in maintaining homeostasis and affecting hormone functions. Overall, a balanced diet with
limited ultra-processed food, a variety of fruits and vegetables, whole grains, and lean protein sources is important

7.1 • Assess and Analyze the Impact of Nutrition on the Endocrine System 129
for endocrine health. This diet helps individuals maintain a healthy weight and decrease the risk for hormonal
imbalances. Table 7.1 lists the glands that play a key role in secreting and regulating hormones and related
nutritional factors.
Gland Role Related Nutritional

Factors
Adrenal Release cortisol (steroid hormone) commonly referred to as Adequate protein intake
glands the “stress hormone” (5–7 oz eq/day for adults)
as part of a balanced diet
Hypothalamus Instructs the pituitary gland when to release hormones Diet low in ultra-processed
foods which decreases
inflammation
Ovaries Produces sex hormones including estrogen and progesterone Balanced diet with limited
red meat and poultry
Pancreas Controls the release of insulin and glucagon, which are involved Limited added sugar,
in regulating blood glucose levels and affecting digestion refined grains, overall
calories
Pineal gland Produces melatonin, which helps regulate sleep Foods containing melatonin
have not been found to
affect pineal gland function
Pituitary gland Known as the “master gland,” it influences many other (< 2300 mg/day); diet low
endocrine glands, including the thyroid. It affects various bodily in ultra-processed foods
functions such as blood pressure, metabolism, and growth. which decreases
inflammation
Testes Produces the sex hormone testosterone Foods or supplements
containing omega-3 fatty
acids
Thyroid Controls metabolism, heart and digestive function, mood, and Adequate iodine intake
muscle and bone development through iodized salt, fish,
shellfish, dairy, seaweed
TABLE 7.1 Key Endocrine Glands and Their Role in Regulating Hormones (sources: Betts et al., 2022; Salas-Huetos A., 2020; Samodien, E.
et al., 2019; Tan, D. X. et al., 2018; U.S. Department of Agriculture & U.S. Department of Health and Human Services, 2020; Xenou, M., &
Gourounti, K., 2021. )
Alterations in Endocrine System Function

Endocrine disorders develop in one of two ways. Primary endocrine disorders result from problems with the
peripheral glands, while secondary endocrine disorders result when the pituitary gland is either overstimulated or
understimulated by the hypothalamus causing an alteration in the peripheral gland’s function. The result of all
endocrine disorders is either hyper-functioning or hypo-functioning of the affected gland.
Alterations in Endocrine System Function – Diabetes

The most prevalent endocrine disorder is diabetes (Agency for Healthcare Research and Quality, n.d.). It is
estimated that 37.3 million Americans have diabetes, with approximately 8.5 million cases (23%) undiagnosed
(National Institute of Diabetes and Digestive and Kidney Diseases, 2023). Diabetes develops when the body is not
able to maintain adequate blood glucose control (Sapra & Bhandari, 2023). Type 1 diabetes typically develops early
in life and occurs when insulin producing cells (beta cells) are destroyed in the pancreas resulting in low to non-
existent levels of insulin. Type 2 diabetes results from insulin resistance that develops gradually from obesity and
aging. The insufficient amount of insulin (type 1 diabetes) and/or functionally ineffective amounts of insulin (type 2
diabetes) result in elevated blood glucose levels.
Glycemic control, which is the maintenance of optimal blood glucose levels, is essential to manage potential
complications of diabetes effectively. Poorly controlled blood glucose levels lead to vascular and neurological
complications including myocardial infarctions, cerebral vascular accidents, renal disease, neuropathies, and
retinopathy (Sapra & Bhandari, 2023). These complications result from several different mechanisms triggered by
elevated blood glucose levels that either cause buildup within vessels that impede blood flow, reduce the ability of
the vessels to autoregulate, or trigger altered biochemical processes that hinder the vessel’s functionality
(Brutsaert, 2022). The risk for these conditions developing is increased in clients who have co-morbid conditions.
Differences in Insulin Sensitivity Among Diverse Populations
Members of US racial/ethnic minority groups have higher rates of insulin resistance than non-Hispanic White
members of the population. This is most likely attributed to both genetic and lifestyle factors (Caballero, 2018).
Alterations in Endocrine System Function – Other Endocrine Disorders

Other endocrine disorders commonly seen are hypo/hyperthyroidism and adrenal disorders. Hypothyroidism results
from the decreased levels of thyroid hormones T4 and T3. Accordingly, thyroid stimulating hormone (TSH) is
increased, indicating that the thyroid gland is not functioning properly. It usually results from autoimmune causes,
but it could also occur after radioactive iodine therapy or surgery for hyperthyroidism or goiter (Braunstein, 2022).
Hyperthyroidism is caused by increased secretion of T4 and T3 caused by Graves’ disease, goiter, or thyroiditis.
Adrenal insufficiency is caused by Addison’s disease or a disorder regulating the pituitary gland and results in low
cortisol levels in the body (Grossman, 2022). In an effort to stimulate the adrenal glands, adrenocorticotropic
hormone (ACTH) is released. Conversely, Cushing’s disease/syndrome develops when corticosteroid levels in the
body are high either from taking corticosteroid medications or from overproduction by the adrenal glands.
Assessment of Nutrition and the Function of the Endocrine System

Endocrine disorders can be difficult to diagnose. Frequently these conditions develop over time, and clients present
with symptoms that are non-specific. A thorough history and physical is essential.
Health History and Physical Assessment

Taking a client’s health history is the first step when assessing the client’s endocrine system. In addition to general
health history questions, it is important to identify conditions for which the client may be at risk and to assess the
need for genetic testing (Bickley et al., 2021). When collecting information on the client’s nutritional status for
potential effects on the endocrine system, the nurse should ask about changes in appetite, thirst and fluid intake,
and bowel function. It is also important to know if the client has experienced any changes in weight or energy levels.
After obtaining a thorough health history, a physical assessment should be performed to look for signs of endocrine
dysfunction:
• Inspect the body, looking for abnormal hair growth, skin changes, and abnormal body proportions.
• Auscultate heart sounds for rate and rhythm as some endocrine disorders cause tachydysrhythmias. Also listen
over the carotid arteries and directly over the thyroid gland for any bruits.
• Palpate the thyroid gland (Figure 7.3), adrenal glands, and testes for tenderness, size, symmetry, and shape,
looking for any nodules, enlargement, or changes in texture.
• Assess weight, height, and body mass index (BMI) for any changes in body composition.
• Assess sexual development, including secondary sex characteristics, and menstrual cycles.
• Evaluate the client’s mood and behavior for any changes.
• Perform point-of-care blood glucose testing (Bickley et al., 2021).

FIGURE 7.3 As part of the physical assessment, the nurse should palpate the thyroid gland and adjacent structures, shown here in anterior
view. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0
license)
Laboratory Tests for Endocrine Functioning

Laboratory testing for endocrine disorders includes tests measuring hormones, vitamin levels, electrolytes, and
kidney function among others. Table 7.2 lists the commonly ordered laboratory tests specific to endocrine
disorders.
Laboratory Test Normal Range Indication

Adrenocorticotropic 9–52 pg/mL (picograms/ Elevated level consistent with Addison's disease
hormone (ACTH) milliliter)
Cortisol 8–20 mcg/dL (micrograms/ Decreased level consistent with Addison's disease
milliliter; drawn in am)
Glucose 70–105 mg/dL (milligrams/ Elevated level consistent with diabetes
deciliter; fasting)
Hemoglobin A1C 4.7–8.5% Elevated levels consistent with diabetes
(HbA1c)
T4 0.9–2.4 ng/dL (free; Increased level consistent with hyperthyroidism
nanograms/deciliter)
5–12 mcg/dL (total;
micrograms/deciliter)
Thyroid-stimulating 0.5–5.0 mcIU/mL Decreased level consistent with hypothyroidism;
hormone (TSH) (microinternational units per increased level consistent with hyperthyroidism
milliliter)
Urinary free cortisol < 90 mcg (micrograms)/24 Elevated levels consistent with Cushing’s syndrome
measurement hours
TABLE 7.2 Laboratory Tests for Endocrine Disorders (source: Merck Manual Professional Version, 2022)
Analysis of Nutrition and the Endocrine System

The endocrine system requires adequate nutrition to function. Nutritional deficits or imbalances can cause various
endocrine abnormalities. For example, the most common cause worldwide for goiter, or an enlarged thyroid (Figure
7.4), is iodine deficiency as iodized salt is not consistently used worldwide (Can & Rehman, 2023). However, in the
United States, its use has significantly reduced goiter development (Can & Rehman, 2023). Instead, goiter formation
in the United States is usually caused by Hashimoto’s thyroiditis or Graves’ disease. Clients who primarily consume
other types of salt (kosher, sea, etc.) need to obtain iodine in their diet through other means.
FIGURE 7.4 Iodine deficiencies can lead to goiter, an enlarged thyroid. (credit: “Goitre” by Almazi/ Wikimedia Commons, Public Domain)
A thorough analysis of the client’s nutrition status can help identify potential endocrine-related issues. The nurse
should review the nutritional assessment to identify any nutrient-related deficiencies. For example, a client with
limited fruit and vegetable consumption is at risk for vitamin C deficiency. Vitamin C deficiency is associated with
multiple health problems. Specifically related to the endocrine system, vitamin C affects the regulation of several
important hormones including insulin growth factor and sex steroids (Shi, Rath, & Niedzwiecki, 2021). Conversely,
when evaluating the client’s nutrition status, there is potential to find excessive intake of nutrients. For example, a
diet with excessive carbohydrate intake can increase blood glucose levels in individuals contributing to the
development of insulin resistance and diabetes. Once nutritional imbalances are identified, the nurse can work with
the client to make dietary changes and reduce the risk for developing endocrine disorders (Bickley et al., 2021).
Table 7.3 lists signs and symptoms of common endocrine disorders and their corresponding nutritional factors.
Endocrine Signs and Symptoms Related Nutritional Factors

Disorder
Diabetes Increased thirst and urination, Excessive intake of added sugar, refined
unexplained weight loss, increased hunger, grains, or overall calories can cause or worsen
blurred vision, slow-healing sores or this condition
infections, fatigue
Hypothyroidism Fatigue, weight gain, constipation, dry skin Deficient iodine intake can cause or worsen
and hair, sensitivity to cold, depression, this condition
joint pain
Hyperthyroidism Weight loss, increased appetite, rapid Excessive iodine intake can cause or worsen
(Graves’ heartbeat, trembling hands, nervousness this condition
disease) or anxiety, sweating, heat intolerance
Adrenal Fatigue, weakness, weight loss, nausea High sodium diet is beneficial for clients with
insufficiency and vomiting, low blood pressure, low aldosterone; adequate calcium and
(Addison’s darkening of the skin vitamin D intake is essential for clients taking
disease) corticosteroids
Cushing’s Weight gain, especially in the face, neck, Controlled sodium diet and low-carbohydrate
disease/ and abdomen, thinning skin, easy bruising, diet is beneficial
syndrome slow healing of wounds, muscle weakness,
fatigue
TABLE 7.3 Common Endocrine Disorders with Signs and Symptoms and Related Nutritional Factors (sources: Braunstein, 2022; Brutsaert,
2022; Grossman, 2022; Hoffman & Sullivan, 2020; National Institute of Diabetes and Digestive and Kidney Diseases, 2021a–c and 2-18
a–b)

Obtaining Adequate Iodine through Diet Sources
Dozens of countries, including the United States, add iodine to table salt. Despite this practice, there are still
groups who are at risk for iodine deficiency:
• People who do not use iodized salt including people in Southeast Asia, sub-Saharan Africa, and Eastern
Europe
• Pregnant women
• Vegans and people who eat few or no dairy products, seafood, and eggs
• People living in areas with iodine-deficient soils – primarily mountainous areas (Himalayas, Alps, and Andes
regions) or river valleys prone to flooding (South and Southeast Asia)
• People who consume foods that interfere with iodine uptake including soy, cassava, and cruciferous
vegetables
Alternative sources of dietary iodine for these groups include:
• Seaweed (kelp, nori, kombu, and wakame) (traditionally consumed in China, Japan, and Korea)
• Fish and other seafood
• Dairy products
Fruits and vegetables, although they have a lot of other health benefits, are not a good source of iodine.
(source: NIH, 2023)
Part A
Meena, a 44-year-old Indian American female was recently diagnosed with hypothyroidism and type 2 diabetes.
She has a history of class 1 obesity, with a BMI of 33. Meena lives alone and works as an office administrator. Her
hobbies include reading, watching movies, and cooking. Meena presents to the clinic complaining of fatigue and
feeling cold even in warm temperatures.
1. Which of the following assessment questions is the most important for the nurse to ask this client to obtain
more information about their nutritional status?
a. Have you experienced any changes in your weight or appetite?
b. Do you have trouble sleeping?
c. Are you able to track what you eat?
d. Do you like to cook?
2. Based on the client’s chief complaint, which of the following questions should you ask the client about her
diet?
a. How much protein do you eat?
b. Do you consume a lot of sugar?
c. What type of salt do you use on food?
d. Do you eat hot meals?
7.2 Plan Nutritional Strategies to Impact Endocrine Wellness

LEARNING OUTCOMES
• 7.2.1 Understand nutritional habits that optimize endocrine wellness.
• 7.2.2 Generate solutions to optimize endocrine wellness utilizing nutritional habits.
Planning Nutrition Goals

It is important to set nutritional goals with individuals with endocrine disorders as diet plays a crucial role in
managing these conditions and promoting overall health and well-being. Research has shown that dietary
modifications can significantly improve outcomes and reduce the risk for complications associated with various
endocrine disorders, particularly diabetes. For example, research has shown that dietary interventions, including
reducing simple carbohydrate and added sugar intake and increasing protein and fiber intake, can improve blood
glucose control and reduce the risk for cardiovascular disease in individuals with type 2 diabetes (Gray & Threkeld,
2019).
The American Diabetes Association (2019) has identified a framework for nutrition therapy goals that reflect the
importance of using a holistic approach to working with clients with diabetes. Their broad goals of nutrition therapy
are to:
• Promote and support healthful eating patterns, emphasizing a variety of appropriately portioned nutrient-dense
foods.
• Consider personal and cultural preferences, health literacy, willingness to change, and access to healthy foods.
• Not judge clients about their food choices so that their eating can continue to be enjoyable.
• Provide practical tools for developing good eating practices rather than focusing too much on a particular food
item or food type.
Clients with diabetes should follow the prescribed diet which typically includes a limited number of calories and
carbohydrates. General guidelines for meal planning with diabetes include (CDC, 2023b):
• Limiting added sugars and refined grains such as white bread, rice, and pasta
• Including more non-starchy vegetables
• Limiting intake of highly processed foods
Setting nutritional goals for clients with endocrine disorders can be difficult. Endocrine disorders are complex
conditions that can seem overwhelming to the client to manage. In addition to considering the nutritional
components of the diet, the nurse must consider cultural, socioeconomic, and psychological factors affecting food
intake. The goal-setting process is only successful if it is collaborative. The nurse should encourage the client to
explain how their family, culture, and beliefs influence how and what they eat. These influences should be
incorporated into the goals set.
When setting nutritional goals, both short-term and long-term goals are needed. Short-term goals may be necessary
to help stabilize and manage acute changes in hormone levels that have occurred. Short-term goals may require
more stringent meal planning and food consumption that is not realistically sustainable over time. Long-term goals
are necessary to help the client manage their condition on an ongoing basis. Ideally, these goals incorporate the
changes needed to stabilize the client’s endocrine health in a realistic and practical manner. Table 7.4 lists common
endocrine disorders and related nutritional goals.

7.2 • Plan Nutritional Strategies to Impact Endocrine Wellness 135
Endocrine Nutritional Goals

Disorder or Lab
Value
Diabetes (high Balance carbohydrate intake with insulin requirements, limit simple sugars and refined
blood glucose) carbohydrates, increase fiber intake, promote weight management
Polycystic ovary Promote weight loss if overweight or obese, reduce intake of refined carbohydrates and
syndrome (PCOS) sugars, increase intake of fiber and omega-3 fatty acids, monitor iron and vitamin D levels
Thyroid disorders Monitor iodine and selenium intake, limit consumption of goitrogens (e.g., soy, cabbage),
(e.g., increase intake of iron and vitamin B12, promote weight management
hypothyroidism)
Cushing’s disease/ Limit sodium intake, increase potassium and calcium intake, promote weight management
syndrome
Adrenal Ensure adequate protein and carbohydrate intake, monitor sodium intake, increase
insufficiency potassium and calcium intake
Hypoglycemia Balance carbohydrate intake with insulin requirements, eat frequent small meals
throughout the day, avoid skipping meals or fasting
Low iron Increase iron-rich foods such as lean red meat, poultry, fish, beans, and fortified cereals
Low vitamin D Increase intake of vitamin D-rich foods such as fatty fish, egg yolks, and fortified foods;
consider supplementation if necessary
Low vitamin B12 Increase intake of vitamin B12-rich foods such as lean meat, fish, poultry, and fortified
foods; consider supplementation if necessary
Low potassium Increase intake of potassium-rich foods such as bananas, potatoes, tomatoes, spinach,
and avocado
Low calcium Increase intake of calcium-rich foods such as low-fat dairy, leafy greens, and fortified
foods
TABLE 7.4 Examples of Endocrine Disorders and Abnormal Lab Values Associated with Nutritional Goals (sources: Brutsaert, 2022;
Hoffman & Sullivan, 2020; Centers for Disease Control and Prevention, 2022b; Cushing syndrome, 2023; Kiani et al., 2022; National
Institute of Diabetes and Digestive and Kidney Diseases, 2018b; National Institute of Diabetes and Digestive and Kidney Diseases, 2021c;
National Institutes of Health, 2023; Xenou & Gourounti, 2021).
Adequate intake of vitamins and minerals is important for the endocrine system as they play a role in hormone
synthesis, regulation, and metabolism (Hoffman & Sullivan, 2020; Kiani et al., 2022; Lewis, 2022; Shrimanker &
Bhattarai, 2023). These include:
• Vitamin A is important for vision, immune function, and cell growth and differentiation. It also plays a role in
regulating gene expression and hormone synthesis. Vitamin A is found in green, leafy vegetables and dairy
products.
• B vitamins, including thiamin, riboflavin, niacin, pantothenic acid, pyridoxine, biotin, folic acid, and cobalamin,
are important for energy metabolism and neurotransmitter synthesis. Vitamin B is found many foods including
leafy green vegetables, enriched grains, and cereals.
• Vitamin C is an antioxidant that helps protect against oxidative stress and inflammation. It also plays a role in
collagen synthesis and wound healing and has been linked to improved insulin sensitivity and glucose
metabolism. Fruits and vegetables are important sources of Vitamin C.
• Vitamin D plays an essential role in calcium metabolism, which is critical for bone health. It also plays a role in
regulating insulin secretion and glucose metabolism, and deficiency has been linked to an increased risk for
type 2 diabetes. Sources for vitamin D include orange juice and dairy products fortified with vitamin D.
• Vitamin E is an antioxidant that helps protect against oxidative stress and inflammation, which are linked to the
development of chronic diseases such as diabetes, heart disease, and cancer. Nuts and seeds are a key source
of vitamin E.
• Calcium is important for bone health and muscle contraction, but it also plays a role in hormone secretion and
metabolism. It is involved in the regulation of parathyroid hormone (PTH), which regulates calcium balance in
the body. Dairy products are a primary source of calcium. For clients who do not eat dairy products, soy
products and dark leafy green vegetables are also good sources of calcium.
• Chloride is an important electrolyte that plays a role in fluid balance and the regulation of pH. It is also involved
in the production and secretion of gastric acid, which is important for digestion and the absorption of nutrients.
It is found in food sources with salt.
• Magnesium is important for muscle and nerve function, but it also plays a role in hormone metabolism and
signaling. It is involved in the regulation of PTH and insulin secretion, and deficiency has been linked to an
increased risk for diabetes. Magnesium is found in whole grains and dark-green leafy vegetables.
• Phosphorus is important for bone health and mineralization, and it is a key component of hydroxyapatite, which
is the mineral matrix of bones. Several hormones, including parathyroid hormone (PTH) and calcitonin, are
involved in the regulation of phosphorus metabolism and bone mineralization. Also, involved in the regulation of
glucose metabolism, and several hormones, including insulin and glucagon. Dairy products, meats, nuts, and
whole grains are good sources of phosphorus.
• Potassium is an important electrolyte that is involved in muscle contraction and nerve function. It also plays a
role in insulin secretion and glucose metabolism. Potassium is also found in leafy green vegetables as well as
starchy vegetables.
• Sodium is an important electrolyte that plays a role in regulating blood pressure and fluid balance. It also plays
a role in the regulation of hormone secretion, particularly in the renin-angiotensin-aldosterone system
(RAAS), which regulates blood pressure and fluid balance. Sodium is readily found in processed foods including
chips, pizza, and sandwiches.
SAFETY ALERT
Managing Hypoglycemia
Hypoglycemia (a blood glucose level below 70 mg/dL) must be treated immediately to avoid serious
complications. The 15-15 Rule can be used to treat mild hypoglycemia which occurs when blood glucose levels
decrease to 55–69 mg/dL. Clients with blood glucose levels in this range should consume 15 g of carbohydrates
and then recheck their blood glucose level after 15 minutes. Repeat these steps until their blood glucose is
greater than 70 mg/dL. Examples of food items that have approximately 15 g of carbohydrates include:
• 4 oz of juice
• 1 tbsp of sugar, honey, or syrup
• Small portions of candy (hard candy, jellybeans, etc.)
Blood glucose levels that do not respond to these interventions require immediate attention at a health care
facility (CDC, 2022b).

Developing and maintaining healthy eating practices can be difficult for any client. For the general population, a
healthy diet involves eating nutrient-dense foods across all food groups while staying within calorie limits and
minimizing intake of added sugars, saturated fat, and sodium (Departments of Agriculture and Health and Human
Services, 2020). Meeting nutritional goals can be especially challenging for individuals with endocrine disorders as
these conditions often require specific dietary modifications to manage these conditions.
For example, individuals with adrenal insufficiency may struggle with electrolyte balance and carbohydrate intake.
Individuals with diabetes often struggle with carbohydrate intake and blood glucose management (American
Diabetes Association, 2019). Additionally, there are different types of diabetes. Although the nutritional
requirements for clients with diabetes are generally the same, clients with type 1 diabetes must take insulin to
regulate their blood glucose levels. Clients with type 2 diabetes can manage their blood glucose levels through diet.
Similarly named, but unrelated to diabetes is diabetes insipidus. Clients with this condition may be able to decrease
urine output by eating a low-protein or a low-salt diet, but otherwise nutrition does not cause or prevent this
condition (National Institute of Diabetes and Digestive and Kidney Diseases, 2021).
Following any dietary recommendations depends on more than just understanding them. Clients must also have
access and means to obtain and prepare nutritious foods. A client’s culture and norms can also affect dietary

7.2 • Plan Nutritional Strategies to Impact Endocrine Wellness 137
behaviors and subsequent health risks (Brown et al., 2022). The nurse should consider the client’s cultural
background when recommending food choices. Asking the client about their favorite foods and foods that are
typically served at family or community gatherings is one way to learn more about the client’s culture.
A recent study determined that overall diet quality has improved in the United States (Orr et al., 2019). However,
there are still disparities among socioeconomic groups. These health disparities can stem from lack of access to or
means to obtain healthy foods. For example, clients may live in rural or inner-city areas that have few grocery stores
and instead must purchase food primarily from convenience stores or fast-food restaurants. Clients with limited
incomes may have to choose lesser quality food to ensure they can purchase enough food. Accordingly, differences
in diet quality may also explain differences in diabetes health-related outcomes among socioeconomic groups (Orr
et al., 2019). The relationship between overnutrition and socioeconomic status is complex, as individuals from
lower socioeconomic groups may also develop obesity due to limited access to fresh and nutrient-dense food and
easy availability of energy-dense food.
TRADITIONAL FOODS PROJECT
One example of a population-health based approach to reducing the risk for diabetes is the Traditional Foods
Project. This was a 6-year cooperative project involving the CDC and 17 native U.S. tribal programs with the goals
of supporting cultural traditions that could decrease the risk for type 2 diabetes among Native American and
Alaska Native communities (CDC, 2022c). This project demonstrated how to incorporate culture and history into
current day health interventions. Brochures with examples of the traditional food stories they documented can
be found on their website (https://openstax.org/r/diabetesndwp).
Clients’ lifestyles also must be considered. Inadequate physical activity, poorly managed stress, and inadequate
sleep can interfere with healthy eating patterns (Kesari & Noel, 2022). Skipping meals and eating late at night has
been linked to hormone imbalances (Gherasim et al., 2020).
Eating disorders, mental illnesses, and unhealthy diet trends can also affect nutritional status and increase the risk
for malnutrition. Alcohol and substance use are significant factors that can affect a client’s nutritional status. In
addition to the physical damage caused by alcohol or substance use, the consumption of these substances can
affect dietary habits. Intake of both can alter client’s appetites and potentially displace the consumption of nutrient-
dense food. Frequently, overconsumption of alcohol or substances is associated with disrupted, sometimes chaotic
lifestyles that can further impact nutritional intake (Mahboub et al., 2021).
MANAGING DIABETES THROUGH NUTRITION
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impact-endocrine-wellness)
It can be challenging for clients with diabetes to incorporate all the nutritional changes needed to manage their
condition. To learn more about the principles of healthy eating with diabetes watch this video from the National
Institute of Diabetes and Digestive and Kidney Diseases.
Part B
Study Part A.
After the initial health history and assessment, further testing is performed. Meena’s vital signs are:
Vital Signs Laboratory Results

Temperature: 97.6°F • Elevated TSH level: 10.5 µIU/mL
Pulse: 90 beats/min • Decreased free T4 level: 0.5 ng/dL
• Elevated fasting blood glucose level: 210 mg/dL
Respiratory rate: 18 breaths/min
• Elevated HbA1c: 8.2%
Blood pressure: 145/95 mm Hg
TABLE 7.5
Meena expresses a strong desire to improve her “hormone health” through lifestyle changes, particularly focusing
on nutrition. However, she is feeling a little overwhelmed. Her diet recall includes foods with a lot of added sugar
and salt. She tries to cook at home whenever possible to save money. When cooking at home she uses kosher or sea
salt because she believes these types of salts “are healthier.” Her favorite dishes to prepare are Indian dishes she
enjoyed with her family growing up. She is concerned she will no longer be able to enjoy these foods.
3. Which of the following nutritional strategies should be included in the client education for Meena's
hypothyroidism management?
a. Recommend a low-protein, high-carbohydrate diet.
b. Encourage increased consumption of iodine-rich foods.
c. Advise her to avoid goitrogenic foods, such as cruciferous vegetables.
d. Promote a diet high in saturated fats and processed foods.
4. Which of the following actions would be most appropriate for the nurse to address Meena’s elevated blood
pressure?
a. Initiate a sodium-controlled diet and educate Meena on sodium reduction strategies.
b. Provide instruction on calcium sources in her diet.
c. Encourage her to increase her fluid intake.
d. Initiate a low-carbohydrate diet and instruct Meena on how to obtain adequate protein in her diet.
Incorporating Cultural Foods into a Diabetes Diet
Clients with diabetes may still be able to incorporate some of their favorite culture-specific foods into their diet.
For example, leafy greens including collards, kale, and spinach are a traditional part of African American diets.
Eating these foods can help control blood glucose levels (CDC, 2022a). The Latin American staple quinoa is a
good source of fiber. Lastly, legumes and lentils, commonly used in African American, Hispanic, and Latin dishes,
can also help manage cholesterol and glucose levels.
7.3 Implement Nutritional Strategies to Impact Endocrine Wellness

LEARNING OUTCOMES
• 7.3.2 Teach nutritional strategies to optimize endocrine wellness.
Holistic Nursing Assessment of the Client’s Readiness to Learn

A holistic nutritional evaluation of the client involves assessing not only the client's physical symptoms and medical
history, but also their educational, emotional, social, and spiritual needs. Socioeconomic conditions, cultural norms,
and religious beliefs affect a person’s nutritional intake and learning ability.
Assessing a client’s readiness to learn involves identifying the client’s strengths and barriers relative to learning as
well as their motivation to learn and receptiveness to the instruction. Health literacy is a fundamental consideration
when teaching clients. Health literacy refers to how well an individual can find, understand, and use information to
make informed health-related decisions (Centers for Disease Control and Prevention, 2023c). Education goals and
strategies should be formulated consistent with the client’s health literacy level.

7.4 • Evaluate Nutritional Strategies to Impact Endocrine Wellness 139
Client Teaching
Effective education helps clients improve their overall health, manage chronic diseases, and lower the risk for
complications (Ardoin, 2022). Teaching clients how to follow their prescribed diet requires time, client engagement,
and a variety of resources and strategies (Agency for Healthcare Research and Quality, 2023). Once the nurse has
assessed the client’s education needs, the nurse needs to work with the client to set learning goals and objectives
and select appropriate learning resources (National Library of Medicine, 2021). Client education should be
structured around the methods of learning best suited for the client. Examples of educational resources include
written materials, models, and videos. Be realistic regarding the amount of content that needs to be covered and
respect the client’s limits. Use an organized but flexible approach to be able to adjust to the client’s response. If
possible, involve family members or caregivers in the process as these individuals can provide additional support to
the client.
The nurse should cover the following items as part of monitoring carbohydrate intake for clients with diabetes (CDC,
2023a):
• Clients with diabetes should track their carbohydrate intake to better manage their blood glucose levels.
• Keeping blood glucose levels stable and as close to normal as possible will help the client feel well and prevent
or delay the development of diabetes-related complications.
• There are three types of carbohydrates:
◦ Sugars: naturally found in fruit or milk, or added to many foods (added sugars are identified on the food
label)
◦ Starches: grains and starchy vegetables such as corn or potatoes
◦ Fiber: indigestible part of plants that do not elevate blood glucose levels
• Carbohydrates are measured in grams and listed on food labels or found in resources listing nutritional
information for nonpackaged food items.
• One serving of carbohydrates = 15 g of carbohydrates.
• The client should follow their prescribed diet indicating how many servings of carbohydrates to consume.
• The client should try to consume a consistent amount of carbohydrates at each meal to maintain consistent
blood glucose levels.
MEASURING PORTION SIZES
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to-impact-endocrine-wellness)
The portion sizes of food served by restaurants have increased over time. This can make it difficult for clients to
accurately measure food servings and follow their prescribed diet. This video demonstrates how portion sizes
can be measured using your hands – no measuring tools required.
7.4 Evaluate Nutritional Strategies to Impact Endocrine Wellness

LEARNING OUTCOMES
• 7.4.1 Evaluate a nutritional plan for its effect on endocrine wellness.
• 7.4.2 Modify a nutritional plan to promote endocrine wellness.
Evaluating the Client’s Compliance with the Meal Plan

It is important to determine how well the client has followed the prescribed diet. Self-monitoring of food intake
through a food diary (either paper-based documentation or through an app) is one way to determine this. Diet
recalls and food frequency questionnaires are other diet assessment tools that rely upon self-reported data. The
nurse should consider that self-kept food records are not always accurate as self-reported food consumption is
likely to be misreported in some way (Ravelli & Scholeller, 2020). However, reviewing the food diary with the client is
still beneficial because it can encourage discussion and provide an opportunity for additional instruction on food
choices and portion control. For clients with diabetes, an additional method of monitoring compliance is maintaining
and reviewing home blood glucose checks to determine if they are within the recommended ranges for the client.
CLINICAL TIP
Food Journals
Despite potential inaccuracies, it is still helpful to review a client’s food journal as part of their assessment to
learn more about dietary patterns, food preferences, and issues. To promote consistency with the journaling task,
help the client select the method of journaling that is most feasible for them to use—either a paper journal
(notebook, diary, or single pages like the journal sample here developed by the CDC My Food Diary
(https://openstax.org/r/healthyweight) or electronic method (phone application, spreadsheet, or other software).
This will make the process easier for the client and increase the client’s likelihood of following through.
Evaluating the Effectiveness of the Nutritional Plan

The plan’s effectiveness is evaluated by measuring expected clinical outcomes. If the nutritional plan (meal plan)
has been effective, the client should report an improvement in their symptoms. There are objective measures that
can be evaluated as well. Clients with endocrine disorders typically have laboratory tests performed regularly to
measure the relevant electrolyte and hormone levels. For example, clients with diabetes will have HbA1c levels
drawn that indicate the client’s glucose control over time. Clients with thyroid conditions will have thyroid panel
drawn. A thyroid panel is a group of laboratory tests that measure hormones and proteins that indicate thyroid
functioning. Noninvasive means of measuring effectiveness include measuring the client’s weight and vital signs to
determine if there have been improvements. If the goals were not met, the plan needs to be adjusted. Perhaps the
plan was too difficult for the client to follow and involved too many dietary changes all at once. The updated plan
could focus on prioritizing and managing fewer nutrients initially and then expand as the client is able to manage the
changes. If the client followed the plan but did not see the expected outcomes, work with the health care provider
and dietician to adjust the plan.
CLINICAL TIP
Assessing Blood Glucose Levels

Measuring blood glucose levels is a routine part of evaluating the effectiveness of the treatment plan for a client
with diabetes. When measuring a client’s blood glucose level, either by performing a point-of-care fingerstick
glucose measurement or a venous lab drawn, always note the last time the client ate. This is important to know
when interpreting the result as glucose levels fluctuate with meals.
Part C
To improve her endocrine health, the nursing team encourages Meena to engage in regular physical activity and
provides education on a balanced diet and portion control. They also refer her to a registered dietitian for
personalized nutritional guidance. In addition to these lifestyle changes, Meena is advised to monitor her blood
glucose levels regularly to help manage her type 2 diabetes and maintain better glycemic control.
For her hypothyroidism management, the nursing team educates Meena about incorporating iodine-rich foods, such
as seafood, dairy products, and iodized salt, into her diet to support thyroid function. Meena is receptive to this but
is concerned because her family traditionally has not eaten much meat or seafood. She has eaten some fish, but
reports she has a limited grocery budget, and she does not think she can afford to eat it regularly. The team works
with Meena to identify budget-conscious ways to incorporate seafood consistent with her cultural practices into her
diet. They also collaborate with an endocrinologist to ensure that Meena receives appropriate thyroid hormone

7.4 • Evaluate Nutritional Strategies to Impact Endocrine Wellness 141
replacement therapy and ongoing monitoring.
Through this comprehensive care plan, Meena is supported in her efforts to improve her endocrine health and
overall well-being. The nursing team continues to follow up with Meena and assess her progress, adjusting the care
plan as needed.
5. Which of the following statements would indicate that Meena has successfully incorporated the
recommended dietary changes for her endocrine health?
a. “I've been eating more fruits and vegetables and have reduced my intake of processed foods.”
b. “I've started skipping breakfast to reduce my overall calorie intake.”
c. “I only eat low-fat foods now and have completely eliminated carbohydrates from my diet.”
d. “I drink diet soda instead of regular soda to reduce my sugar intake.”
6. Which of the following outcomes would indicate an improvement in Meena's endocrine health after
implementing the care plan?
a. Decreased TSH level and improved blood glucose control
b. Increased TSH level and decreased T4 level
c. Increased appetite and weight gain
d. Decreased heart rate and increased blood pressure
Chapter Summary
• The endocrine system plays a crucial role in physical needs, but psychological, social, and
regulating many bodily functions. Accordingly, cultural needs as well.
endocrine disorders can manifest themselves • Nutritional strategies should be realistic and
through a wide range of signs and symptoms. manageable for the client to follow.
• Proper nutrition is essential for its optimal • Evaluation of nutritional interventions is based
functioning of the endocrine system. Tailored meal upon subjective information from the client
plans can help minimize symptoms and facilitate regarding how well the client is adhering to the
disease management. diet and symptom improvement as well as
• Assessing client nutrition from a holistic laboratory values related to the specific endocrine
perspective is necessary to address not only disorder.
Key Terms
Addison’s disease inadequate secretion of hormones pituitary gland gland in the brain that regulates
by the adrenal glands causing low blood pressure, growth and development as well as the function of
weakness, and skin discoloration other glands
cortisol a steroid hormone that helps regulate the primary endocrine disorders caused by dysfunction
body’s response to stress in the affected peripheral endocrine gland
Cushing’s disease/syndrome weight gain, bruising, renin-angiotensin-aldosterone system (RAAS)
and weakness caused by excessive cortisol in the system of hormones that regulates blood pressure
body and fluid balance
endocrine system a network of glands that regulate secondary endocrine disorders develop when the
and control all body processes through hormones pituitary gland is either overstimulated or
glycemic control maintaining optimal blood glucose understimulated by the hypothalamus causing an
levels alteration in the peripheral gland’s function
goiter enlarged, abnormal growth of the thyroid gland T3 triiodothyronine hormones released by the thyroid
Graves’ disease hyperthyroidism causing eye gland to help regulate weight, energy levels, and
protrusion, heat intolerance, and anxiety metabolism
homeostasis state of balance in the body T4 tetraiodothyronine (thyroxine) long-acting
hormones body substances that coordinate biological hormone released by the thyroid gland that can be
functions like metabolism, sexual reproduction, converted to T3
blood pressure, body temperature, heart rate, type 1 diabetes develops when insulin producing
growth and development, and sleeping cells (beta cells) are destroyed in the pancreas
hypothalamus a critical gland found in the brain that resulting in low to non-existent levels of insulin
works with the nervous system to control the type 2 diabetes results from insulin resistance that
endocrine system develops gradually from obesity and aging
iodized salt table salt fortified with iodine
Review Questions
1. A client has been diagnosed with Cushing’s syndrome. Which of the following dietary recommendations are
appropriate for this client?
a. Low-protein diet with added salt
b. Low-fat diet with added potassium
c. Low-carbohydrate diet with limited salt
d. High-carbohydrate diet with limited salt
2. The nurse is providing diet instruction to a client with a vitamin D deficiency. Which of the following
statements by the client indicates the need for further instruction?
a. “I should avoid eating tuna and salmon.”
b. “I should eat fortified cereal for breakfast.”
c. “My diet plan may not be enough. I may need to take a vitamin D supplement.”
d. “I should try to eat more spinach.”

3. A nurse is caring for a client with diabetes. Which of the following nutritional habits would be most likely to
optimize endocrine wellness for this client?
a. Eating a diet high in saturated fats
b. Consuming complex carbohydrates
c. Eating a low-fiber diet
d. Consuming refined carbohydrates
4. A client presents with symptoms of polycystic ovary syndrome (PCOS). Which nutritional plan would be most
likely to optimize endocrine wellness for this client to regulate hormonal imbalances?
a. Consuming a diet high in refined carbohydrates
b. Limiting complex carbohydrates
c. Consuming a diet low in fiber
d. Eating a diet low in processed and packaged foods
5. A client presents with symptoms of hypoglycemia. Which nutritional strategy would be most effective in
optimizing endocrine wellness for this client to maintain blood sugar levels?
a. Consuming a low-fiber diet
b. Consistently eating refined carbohydrates
c. Consuming a diet high in protein and unsaturated fats
d. Eating a low-fat diet
6. Which nutritional strategy would be most beneficial for a client with Addison’s disease?
a. Limiting salt intake
b. Limiting potassium intake
c. Increasing calcium intake
d. Increasing vitamin C intake
7. A client with newly diagnosed diabetes presents for education on dietary modifications. Which of the
following is an appropriate method for the nurse to assess the client's readiness to learn?
a. Ask the client to recite the appropriate dietary modifications for diabetes.
b. Ask the client about their prior knowledge of diabetes and dietary modifications.
c. Provide the client with written materials on diabetes and dietary modifications.
d. Ask the client to demonstrate how to administer insulin.
8. Which of the following indicates the diet plan for the client with diabetes type 2 needs to be adjusted?
a. The client reports weight loss.
b. The client’s hemoglobin A1C level has remained at 5.2%.
c. The client’s hemoglobin A1C has increased to 9.5%.
d. The client has not experienced hypoglycemia.
9. The nurse is reviewing the dietary recall of a client recently diagnosed with hypothyroidism. Which of the
following foods the client documented they ate frequently indicates the need for additional diet instruction?
a. Shrimp
b. Low-fat milk
c. Nuts
d. Cabbage
10. A client with hyperthyroidism is prescribed a nutritional plan to optimize endocrine wellness. Which of the
following food choices align with the recommended diet?
a. Canned tuna
b. Canned meats
c. Shellfish
d. Unsalted nuts
Suggested Reading
Centers for Disease Control and Prevention. (2023). Diabetes. https://www.cdc.gov/diabetes/index.html
National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Diabetes for health professionals.
https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-management/diabetes
Office on Women’s Health. (2021). Thyroid disease. A-Z Health Topics. https://www.womenshealth.gov/a-z-topics/
thyroid-disease
Young, W. (2022). Overview of endocrine disorders. Merck Manual Professional Version.

https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/principles-of-endocrinology/
overview-of-endocrine-disorders

CHAPTER 8
Endocrine Health
FIGURE 8.1 Nutrition from colorful fruits and vegetables plays a role in endocrine function. (credit: modification of work “Colors and
vitamins!” by Julien Lehuen/Flickr, CC BY 2.0)
CHAPTER OUTLINE
8.1 The Impact of Nutrition on Endocrine Wellness Across the Lifespan
8.2 Nutrition and Chronic Endocrine Illnesses
8.3 Treatments and Nutrition
INTRODUCTION Eight major hormone-secreting glands make up the complex endocrine system. The hormones
control growth, development, metabolism, reproductive function, and state of mind. Because nurses are
responsible for assessing clients as part of the initial stages of the nursing process, an understanding of normal
endocrine physiology will alert the nurse to any deviations when assessing endocrine function during the head-to-
toe client assessment. The nurse must also understand how nutrition plays a role in reparative processes and
optimum endocrine function throughout the lifespan and when clients have chronic endocrine conditions.
Consider this case: Sarah Yellowhorse is a 30-year-old Native American woman beginning the third trimester of her
first pregnancy. She has arrived at the clinic for her 24–26-week checkup. Her vital signs are within defined limits,
and her weight gain is as expected for this stage of her pregnancy. She has no history of diabetes or significant
medical or surgical conditions. However, she has a family history of diabetes types 1 and 2. Her mother was
diagnosed at 3 years old with type 1 diabetes, and last year her father was diagnosed at age 56 with type 2
diabetes. Sarah is concerned about her risk for developing gestational diabetes due to her ethnicity and family
history. She consumes some vegetables, such as squash and corn, but she has been eating more potatoes and
processed foods.
146 8 • Special Nutritional Considerations for Endocrine Health
8.1 The Impact of Nutrition on Endocrine Wellness Across the Lifespan

LEARNING OUTCOMES
• 8.1.1 Describe the impact of nutrition on the endocrine system during pregnancy.
• 8.1.2 Describe the impact of nutrition on the endocrine system during infancy.
• 8.1.3 Describe the impact of nutrition on the endocrine system during childhood.
• 8.1.4 Describe the impact of nutrition on the endocrine system during adolescence.
• 8.1.5 Describe the impact of nutrition on the endocrine system during adulthood.
• 8.1.6 Describe the impact of nutrition on the endocrine system during later adulthood.
Pregnancy
A cascade of endocrine-related changes occurs during pregnancy. Many of these physiologic changes occur in the
endocrine system (Figure 8.2) to prepare the pregnant individual for fetal growth and bodily changes during
pregnancy. The placenta drives these changes by producing human chorionic gonadotropin (HCG) (Kepley et al.,
2023). This hormone stimulates the corpus luteum to produce the progesterone necessary for growing and
maintaining a fetus, and it changes the pregnant individual’s immune function to protect the fetus from immune
rejection. HCG also stimulates the ovaries to increase estrogen and progesterone production until weeks 10–12 of
pregnancy, when the maturation of the placenta is complete (Herrick & Bordoni, 2023). The placenta then takes
over the production of those hormones throughout the pregnancy. In addition, the pregnant individual’s
hypothalamus creates and releases thyrotropin-releasing hormone (TRH) to stimulate thyroid-stimulating hormone
and prolactin from the pituitary gland (sometimes called the master gland).

8.1 • The Impact of Nutrition on Endocrine Wellness Across the Lifespan 147
FIGURE 8.2 The endocrine system is made up of eight major glands: the adrenal glands, hypothalamus, pineal gland, pituitary gland,
pancreas, ovaries or testes, thyroid gland, and parathyroid glands. (credit: modification of work from Anatomy and Physiology 2e.
The placenta increases TRH, thus stimulating the pituitary gland, which then increases thyroid-stimulating
hormone (TSH), a hormone that triggers secretion of thyroid hormones by the thyroid gland. Thyroid hormone
production increases by 50% throughout pregnancy (Singh & Sandu, 2023). These hormones include
triiodothyronine (T3) and thyroxine (T4), which regulate weight, energy levels, and metabolism. The influx of
thyroid hormones is required for fetal brain development and thyroid function (Kepley et al., 2023). The parathyroid
gland (Figure 8.3) secretes parathyroid hormone (PTH) to generate and maintain sufficient calcium levels for fetal
growth (Hysaj et al., 2021). PTH allows adequate calcium absorption during pregnancy by maintaining ionized blood
calcium phosphate levels by monitoring extracellular calcium concentrations (a lower calcium concentration triggers
the release of PTH). Other functions of PTH include conserving calcium, decreasing phosphate reabsorption, and
stimulating vitamin D production needed for the intestinal absorption of calcium. Vitamin D deficiency in pregnant
clients is associated with elevated PTH levels (Hysaj et al., 2021). PTH concentration during the first trimester is in
the lower normal range, but during the pregnancy, PTH levels increase to reach mid-normal range by the third
trimester (Hysaj et al., 2021). The pituitary gland increases by approximately 136% because of lactotroph
hyperplasia, which results in an influx of prolactin (Nana & Williamson, 2022). Prolactin levels increase by 10 times
during pregnancy to promote breast tissue development for later milk production.
The corpus luteum and placenta release a peptide called relaxin, which affects the connective tissue in the body. It
has several effects in pregnancy (Kepley et al., 2023). Relaxin softens the birth canal, supports growth of mammary
glands, and prevents premature uterine contractions. Relaxin also facilitates the release of nitric oxide, which
promotes systemic vasodilation resulting in decreased maternal blood pressure. In addition to the changes caused
by relaxin, cortisol levels increase during pregnancy, which is vital for fetal brain development (Kepley et al., 2023).
However, excessively elevated glucocorticoid levels impair neurodevelopment in the fetus. To combat pain during
labor, endorphin and enkephalin levels increase.
FIGURE 8.3 The parathyroid glands are small oval glands located next to the thyroid gland in the neck. (credit: modification of work from
Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Impact of Nutrition on the Endocrine System During Pregnancy

Nutrition during pregnancy is vital for the health of both the pregnant client and the fetus. Normal hormonal changes
cause disruptions in the pregnant individual’s body, and nutritional requirements change throughout the pregnancy
with the need to support the nutrition of both the client and the fetus. A balanced diet, micronutrients, and intake of
omega-3 fatty acids promote a healthy pregnancy during hormonal changes. To prevent a vitamin D deficiency, the
National Institutes of Health (2022c) recommends a daily intake of 15 mcg during pregnancy and lactation.
Pregnancy requires proper nutrient-rich foods to support optimal endocrine function and ensure the health of both
the pregnant client and the fetus (Jouanne et al., 2021). The pregnant client needs carbohydrates to fuel the
increased energy demands of the growing fetus (U.S. Department of Agriculture, 2020). These carbohydrates
support proper hormone production, including insulin, which regulates blood glucose levels. The growing fetus
needs adequate protein to develop and to produce hormones. Healthy fats play a role in hormone synthesis, fetal
development, and absorption of fat-soluble vitamins (Jouanne et al., 2021). Table 8.1 lists macronutrient intake
ranges for the pregnant client. A registered dietitian specializing in prenatal nutrition can guide the pregnant client
to support the fetus, client, and the endocrine function of both.
Macronutrient Percentage of Total Daily Food Sources

Calories
Complex 45–65% Whole grains, fruits, and vegetables (preferred
carbohydrates carbohydrate source)
Protein 10–35% Lean meats, poultry, fish, eggs, legumes, and dairy
products
Healthy fats 20–35% Avocados, nuts, plant-based oils, fatty fish, flaxseed, and
walnuts
TABLE 8.1 Macronutrient Intake to Support Pregnant Client and Fetus (sources: Jouanne et al., 2021; U.S. Department of Agriculture,
2020)
Pregnancy Complications: Hyperemesis Gravidarum

Some pregnant clients experience hyperemesis gravidarum, a condition during pregnancy characterized by
extreme, persistent nausea and vomiting. Although the exact cause is unknown, genetic predisposition and
hormonal and gastrointestinal changes may play a part. The hormonal change theory involves the dramatic increase

in HCG because some correlational studies show elevations in HCG with hyperemesis gravidarum. Estrogen is also
believed to be a contributing factor. As estrogen levels rapidly increase, so does vomiting. Estrogen-containing
medications are known to cause nausea and vomiting as a side effect, which supports this theory. Lower esophageal
sphincter relaxation during pregnancy is the basis for the gastrointestinal change theory. Even though the basis for
this theory is structural, hormones still play a role. It is theorized that the increased levels of progesterone and
relaxin hormones circulating in the bloodstream contribute to the relaxation of the lower esophageal sphincter. The
lower esophageal sphincter closes to prevent acid from traveling back up the esophagus, as occurs during acid
reflux. However, the relaxin hormone limits the functionality of the esophageal sphincter, contributing to heartburn.
Hyperemesis gravidarum complicates pregnancy because it can prevent the client and fetus from absorbing vital
nutrients. Nutritional recommendations for a client with hyperemesis gravidarum include switching the prenatal
vitamins to folic acid supplements only and the inclusion of a ginger supplement. There is limited research on diets
changes that can minimize nausea and vomiting during pregnancy. One correlational study found fewer symptoms
among women who consumed vegetables, fruits, and beans or legumes. However, women with elevated HCG levels
in the same study who consumed increased amounts of processed white bread had a higher incidence of
hyperemesis gravidarum (Tan et al., 2021).
Pregnancy Complications: Gestational Diabetes

Pregnant clients may have preexisting diabetes (either type 1 or type 2) or may develop diabetes during pregnancy,
which is known as gestational diabetes (GD). GD is a disorder that occurs as the result of changes caused by
human placental lactogen, a hormone that helps regulate insulin secretion, which leads to dysfunction or delayed
response of the beta cells to blood glucose, thereby producing glucose intolerance (Quintanilla Rodriguez & Mahdy,
2022; Rasmussen et al., 2020). Other hormones associated with GD include corticotropin-releasing hormone and
progesterone because these hormones are associated with insulin resistance and elevated blood glucose levels.
These changes typically occur around the 24th to 28th week of pregnancy, with some individuals having complete
resolution after childbirth. However, clients who experience GD have an increased risk for type 2 diabetes later in
life.
Risk factors for GD include obesity, family history, a history of GD with previous pregnancy, polycystic ovary
syndrome, and high-risk race or ethnicity (Quintanilla Rodriguez & Mahdy, 2022). A recent study of live births in the
U.S. found that the rates of gestational diabetes among pregnant women with their first live birth increased across
all race and ethnicity groups between 2011 and 2019 (Shah et al, 2021). However, rates were significantly higher
among most non-Hispanic Asian and Hispanic/Latina subgroups compared to non-Hispanic White individuals.
Greater Risk for Gestational Diabetes
In the U.S., American Indian and Alaska Native (AI/AN) women have higher rates of GD compared to non-
Hispanic white women (Stotz et al., 2021). A recent study found AI/AN women were aware of the role of
nutrition for maintaining a healthy weight during pregnancy and decreasing the risk for type 2 diabetes, but they
were not aware that these principles could be applied to reduce their risk for GD. These findings highlight the
need for culturally relevant diet instruction and interventions to address this disparity.
Nutritional considerations are the main factors for glucose control (Rasmussen et al., 2020). Pregnant clients with
GD should receive recommendations from their obstetrician and counseling from a registered dietitian and diabetes
expert. The nurse maintains sacred relationships with their clients, and this opportunity gives the nurse an
advantage in educating them on the correct micronutrient and macronutrient consumption before diabetes
counseling occurs. Many clients believe that blood glucose is solely related to sugar consumption and do not
understand that the body breaks down carbohydrates to glucose, thus affecting blood glucose levels (Chen et al.,
2020; Rasmussen et al., 2020). In addition, when individuals consume insufficient carbohydrates and increase their
fat intake, they can develop elevated levels of serum fatty acids. This increase in serum fatty acids results in
increased insulin resistance as well as higher than expected fetal fat accumulation and infant adiposity (Rasmussen
et al., 2020).
Low-glycemic, high-fiber foods such as vegetables, legumes, nuts, fruits, and whole grains are recommended
(Rasmussen et al., 2020). Other healthy diet options include lean proteins such as chicken, turkey, and salmon
(which contains omega-3 fatty acids) and healthy fats such as avocados and nuts. Pregnant clients also need to
consider portion control when consuming carbohydrates. The California MyPlate for Gestational Diabetes provides a
visual example of recommendations for the pregnant client (California Department of Public Health, 2018).
Pregnant clients should consume the recommended amounts of folic acid, vitamin D, iron, and calcium. Currently,
there is no evidence to suggest that taking additional amounts of these micronutrients affects GD (Rasmussen et al.,
2020).
The glycemic index is a system that ranks carbohydrate-containing foods based on their ability to raise blood sugar
levels quickly or significantly (Rasmussen et al., 2020). Different carbohydrates vary in their ability to raise blood
sugar levels based on the chemical structure of the food and their digestibility and absorbability. The scale goes
from 0 to 100, with higher values indicating faster and higher blood sugar levels. Although this tool is valuable, it
does not consider the amount of carbohydrates consumed, only the number of carbohydrates per serving size. In
contrast, glycemic load considers a food item’s glycemic index and total carbohydrate content. It accurately
represents how specific foods in specific quantities affect blood sugar levels.
Nurses should instruct clients to consume foods on the lower end of the glycemic index spectrum because these
foods will help them manage their blood glucose properly. Nurses should also advise clients to check the glycemic
load before consuming a meal to know how those foods will impact their blood glucose. Pregnant clients with GD
also need to be advised on the frequency and consistency of meals. Three main meals and 2 or 3 smaller meals or
snacks eaten at the same time each day are recommended to avoid excessive food intake and ensure steady blood
glucose levels throughout the day. Rasmussen et al. (2020) suggest carbohydrate intake at breakfast of 30 g
maximum (equivalent to 2 slices of bread or 1 bowl of cereal), based on limited research that shows elevated blood
glucose levels in the morning.
Part A
Sarah goes to the laboratory before her 24–28-week check for her oral glucose tolerance test (OGTT). Her results
show an elevated level, indicating a need for further testing, so a second OGTT is ordered for confirmation. Following
the second OGTT, Sarah is diagnosed with GD. Sarah is referred to a registered dietitian who specializes in GD. Sarah
and the dietitian develop a personalized meal plan:
• Morning: 30 g of carbohydrates—2 slices of toast with poached eggs

• Snack: a serving of vegetables and hummus
• Lunch: 60 g of carbohydrates—sandwich on whole grain bread with lean shredded chicken and vegetables such
as lettuce; she eats a serving of fruit such as an apple, and drinks mainly water
• Snack: ¼ cup of almonds
• Dinner: Lean protein with vegetables and 60 g of brown rice
Sarah is taught to monitor her blood glucose levels and to engage in some physical activity. Her health care provider
started her on a low dose of 500 mg metformin twice daily. Her subsequent examination will occur at 32 weeks’
gestation. The nurse encourages Sarah to call the office if she has any questions or concerns before her next
appointment and to adhere to the treatment plan. The nurse also encourages her to communicate openly with her
health care team throughout the pregnancy.
1. The consumption of which nutrient should Sarah most closely monitor to manage her blood glucose levels?
a. Water
b. Fats
c. Proteins
d. Carbohydrates

2. The nurse asks Sarah about her protein intake. Sarah reports that she has been regularly craving and eating
cheeseburgers. Why should the nurse be concerned about this finding?
a. Sarah is not choosing lean protein sources.
b. Sarah is eating too much cheese.
c. Eating a lot of red meat can indicate anemia.
d. This is not a concerning finding as long as Sarah is consuming adequate amounts of food.
Chronic Pregnancy Complications: Thyroid Disease

Thyroid hormones change during pregnancy, especially when the pregnant individual already has a chronic thyroid
condition (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2017; Singh & Sandhu, 2023).
Long-term thyroid disorders such as hypothyroidism (the thyroid gland does not produce enough thyroid hormone)
or hyperthyroidism (the thyroid gland produces and excretes too much thyroid hormone) require careful
management and oversight during pregnancy to ensure proper fetal growth and overall well-being of both the
pregnant client and fetus. Proper thyroid hormone levels ensure the baby’s brain and nervous system develop
correctly. As previously discussed, during normal pregnancy T4 levels remain unchanged; during hypothyroidism, T4
levels register as low, and TSH levels elevate as the pituitary gland attempts to trigger the thyroid to release more
T4. Sometimes, T4 can remain within normal limits, and only TSH is elevated (NIDDK, 2017; Singh & Sandhu, 2023).
Some signs of hypothyroidism include exhaustion, cold intolerance, muscle cramps, constipation, and memory or
concentration problems.
The goal of treatment during pregnancy is to maintain maternal hyperthyroidism at the expected upper limits using
the lowest effective prescribed dose of medication while avoiding fetal hypothyroidism. The treatment modality
remains based on the etiology of hyperthyroidism. Graves’ disease is treated with antithyroid, beta blockers, and
surgical interventions while monitoring for gestational thyrotoxicosis during pregnancy.
Nurses must remain cognizant of nutritional recommendations as they develop teaching and discharge plans.
Nutritional recommendations for pregnant clients include sufficient iodine intake. Good nutritional sources of iodine
include dairy, seafood (watch out for elevated mercury–seafood options), eggs, meat, and poultry (NIDDK, 2017;
U.S. Food and Drug Administration, 2023). Iodine is added to table salt and to some prenatal vitamins. Nazeri et al.
(2021) found that iodine supplementation can improve iodine levels in pregnant individuals, but the effects on the
fetus have not yet been established.
SAFETY ALERT
Mercury Consumption
Pregnant individuals need to be aware of mercury consumption during pregnancy. Mercury is a toxic metal with
serious adverse effects for the developing nervous system. Fish containing high levels of mercury include shark,
swordfish, and king mackerel; fish with low levels mercury include salmon, trout, and shrimp (U.S. Food and Drug
Administration, 2023).
Part B
Study Part A.
Sarah delivers a baby girl at 38 weeks’ gestation weighing 9 lb 1 oz. Sarah followed the recommendations of her
nurse, dietitian, and health care provider, and her blood glucose levels are now at baseline pre-pregnancy levels.
Because Sarah is at increased risk for developing type 2 diabetes, her nurse needs to incorporate this information
into Sarah’s postpartum education.
3. Sarah asks if her diabetes will recur now that she is no longer pregnant. How should the nurse respond?
a. “You need to be monitored 6 weeks after delivery for the signs of diabetes.”
b. “Now that you are no longer pregnant, your diabetes has resolved and is no longer an issue.”
c. “Having gestational diabetes increases your risk for developing type 1 diabetes later.”
d. “Having gestational diabetes increases your risk for developing type 2 diabetes later.”
4. The nurse reviews diet strategies with Sarah to decrease her risk for developing type 2 diabetes. Which of the
following statements indicates additional instruction is needed?
a. “I will limit my intake of concentrated sweets.”
b. “I will avoid eating nuts.”
c. “I will try to eat different fruits and vegetables.”
d. “I will incorporate protein into my meals and snacks.”
Infancy
The endocrine system undergoes extensive development during infancy. The hypothalamus and pituitary gland’s
primary function encompasses controlling and releasing hormones that regulate growth and metabolism. These two
glands are in the brain and mature during infancy to allow for appropriate hormone secretion. Growth hormone
encourages growth and development. Growth hormone is at a high level during infancy and contributes to rapid
developmental alterations during the first year of life (Murray & Clayton, 2022). The thyroid gland produces the
hormones triiodothyronine (T3) and thyroxine (T4), which are required for cellular proliferation and differentiation,
energy balance, cardiovascular physiology, and overall growth and development.
During the first few weeks of life, infants use hormones acquired from their mothers via the placenta until their
thyroid gland takes over hormone production and secretion. The adrenal glands (located above the kidneys)
produce cortisol and aldosterone. Cortisol regulates metabolism, the stress response, and immune function, and
aldosterone maintains salt and fluid balance (Kiebzak et al., 2021). Insulin and glucose are hormones regulated by
the beta cells in the pancreas. Infants remain sensitive to insulin, which allows for glucose stability. As with the
other endocrine glands, the pancreas continues its development during infancy, and hormonal regulation and overall
control continue to mature throughout infancy.
Macrosomia refers to a newborn who is significantly larger than average for their gestational age (Akanmode &
Mahdy, 2023). This condition is seen more frequently in infants whose mothers are obese, had GD, or had a
postdate pregnancy (Akanmode & Mahdy, 2023). Sustained elevations in a pregnant client’s blood glucose levels
transfer through the placenta to the fetus, resulting in fetal hyperglycemia. This causes hyperplasia of the beta islet
cells in the infant’s pancreas, leading to overutilization of glucose and storage by the fetus, resulting in increased
fetal weight (Akanmode & Mahdy, 2023). Other factors affecting the fetus with fetal hyperglycemia include fetal
adiposity and hyperinsulinemia.
Impact of Nutrition on the Endocrine System During Infancy

Blood glucose problems take the form of neonatal hypoglycemia or hyperglycemia. The definition of hypoglycemia
is a blood glucose level at or below 40 mg/dL in the first 4 hours of life and a level below 45 mg/dL between the 4th
and 24th hours (target level is 90–100 mg/dL; Kurtoglu et al., 2019; Rozance, 2023). Clients experiencing
hypoglycemia during these time frames are categorized as having transient neonatal hypoglycemia. Hypoglycemia
that persists longer than 60 minutes despite medical interventions is referred to as prolonged hypoglycemia.
Hypoglycemic conditions can develop among infants in the following situations: small for gestational age, sepsis,
asphyxia, premature birth, transient hyperinsulinemia, diabetes during pregnancy, intrauterine growth restriction,
toxemia, and increased metabolic requirements. The signs and symptoms in a newborn include tremors, irritability,
diaphoresis, tachypnea, decreased sucking ability, and high-pitched cry leading to lethargy, hypertonicity,
convulsions, and coma.
When treating hypoglycemia, oral feedings are preferred. However, if the infant is unable to take an oral feeding, or if
no improvement occurs after 30 minutes, then 2 mL/kg 10% dextrose is given intravenously over 1 min; if the infant
has a seizure, 4 mL/kg should be given. Subsequently, glucose is given intravenously at 6–8 mg/kg/min (Kurtoglu et
al., 2019). Discontinue intravenous glucose supplementation and resume solely oral feedings after clearance by the
pediatrician or neonatologist.

Hyperglycemia in a newborn refers to a blood glucose level greater than 125 mg/dL or a plasma glucose level
greater than 150 mg/dL (Kurtoglu et al., 2019). Before the development of the pancreas and beta cells, the insulin
receptors are not mature, and insulin production and secretion remain low. Neonatal hyperglycemia may be seen in
preterm babies following bouts of hypoglycemia resulting from glucose and lipid infusion. Hyperglycemia increases
the preterm infant’s susceptibility to infection, oxidative stress, bronchopulmonary dysplasia, prolonged
hospitalization, retinopathy, and mortality (Kurtoglu et al., 2019). Continuous monitoring remains important during
this situation. Treatment includes decreasing the rate of glucose administration and adjusting the rate of insulin
administration to keep the plasma glucose level between 150 and 200 mg/dL (Kurtoglu et al., 2019).
CLINICAL TIP
Macrosomia
Infants with macrosomia require lab work and close monitoring after birth for respiratory and metabolic issues.
Clinical evaluation of the infant’s respiratory effort following delivery is vital because meconium aspiration (when
the newborn breathes in a mixture of stool and amniotic fluid during delivery) and transient tachypnea are more
frequently seen in infants with macrosomia. Blood work should also be drawn immediately after delivery. These
infants are at risk for hypoglycemia, hypocalcemia, hypomagnesemia, increased bilirubin (due to increased
hemolysis and inefficient enterohepatic circulation), and polycythemia.
Childhood
A child’s growth, health, and development depend on a functioning endocrine system. The hormones act as
chemical messengers to control physical functions and physiologic development, including growth, metabolism,
sexual development, and other physical functions. As children undergo critical and rapid alterations, the main
hormonal signals are sent from the hypothalamus and the pituitary gland. These two endocrine organs stimulate the
production and release of specific hormones that target the other endocrine glands.
A child’s endocrine system goes through many phases as it is stimulated during the growth and development of the
thyroid, adrenal glands, pancreas, and gonads (testes in males and ovaries in females). The hormones are necessary
for optimal development as the child prepares for puberty (a stage of development in which sexual maturation and
reproduction capabilities refine and mature). The pituitary gland produces growth hormone, which plays an integral
role in the child’s growth. Insulin-like growth factors (IGF) play a role in mediating growth hormones; both growth
hormone and IGF are peptide hormones that effect growth, maintain bone mass, and aid in cellular differentiation
(Caputo et al., 2021).
Growth hormone and IGF promote bone and tissue growth, adequate nutrients, and hormone balance, which all
play integral roles in overall growth and development across the lifespan (Caputo et al., 2021). Without IGF, the
utilization of nutrients at the cellular and tissue levels would be compromised. Growth hormone and IGF maintain a
correlational relationship with insulin secretion, leading to the possibility that growth hormone and IGF affect
carbohydrate metabolism (Caputo et al., 2021). IGF enhances insulin sensitivity because it prompts glucose uptake.
Dietary guidelines for this age group recommend plant-based fiber because it incorporates amino acids that impact
nutrient metabolism and absorption. Protein (lean meat and dairy products) and amino acids are essential for
healthy growth and development because they play an anabolic role similar to that of growth hormone and IGF. The
recommendation is 5–20% for children ages 2–3 and 10–30% for older children and adolescents (U.S. Department
of Agriculture, 2020).
Impact of Nutrition on the Endocrine System During Childhood

Children are not immune to endocrine dysfunction. The nurse must recognize that proper balanced nutrition is vital
in supporting optimal endocrine function and development in children and across the lifespan. Children require
balanced nutrition to support the production and regulation of hormones (Caputo et al., 2021; U.S. Department of
Agriculture, 2020). Proteins are the building blocks of neurotransmitters and hormones. Amino acids used to
construct proteins stimulate growth hormone and IGF secretion.
A balanced diet includes a wide selection of nutrient-rich foods. When children do not get the proper nutrition they
need, they may be diagnosed with failure to thrive, meaning their weight gain is significantly below that of other
children of the same age and sex. A mix of fruits and vegetables, whole grains, lean proteins, and healthy fats
encourages growth, development, and proper endocrine function (Caputo et al., 2021). The U.S. Department of
Agriculture recommends that children consume 2 or 3 servings of vegetables per day, 2 or 3 servings of fruit, 3
servings of dairy products, 4–6 oz of lean proteins per day, and limited sugary, processed, and fried foods (Figure
8.4). Fruits and vegetables provide many anti-inflammatory and vital vitamins and nutrients for proper endocrine
function. Diets high in protein increase growth hormone and IGF secretion levels, ensuring adequate growth (Caputo
et al, 2021). Protein comes from lean meats, poultry, fish, eggs, dairy, legumes, and plant-based protein sources
such as tofu.
FIGURE 8.4 A breakfast that includes fruits, whole grain, and dairy can be fun and encourage children to meet recommended daily
nutritional guidelines. (credit: “Breakfast for kids: ‘Berry Bears’” by Ritas Safo/Flickr, Public Domain)
Healthy fats include avocados, seeds, nuts, and plant-based oils. These fats aid in hormone production and remain a
supportive element of brain development.
Carbohydrates should be mainly whole grains, such as oats, brown rice, whole wheat bread, and quinoa. Refined
sugars and processed foods should be avoided. These recommended carbohydrate options allow for slower energy
release and limit blood glucose spikes while providing sustained energy. Children need micronutrients such as
calcium, vitamin D, iron, zinc, selenium, and iodine for proper endocrine health. These micronutrients are found in a
variety of fruits and vegetables. These recommendations are designed for the general population, but clients
diagnosed with a medical condition may need a referral to a registered dietitian. The National Institutes of Health
Office of Dietary Supplements provides recommendations on micronutrient intake by age (https://openstax.org/r/
odnihgovfact).
Childhood Obesity and Malnutrition

Obesity in childhood is common, occurring in approximately 17% of youth ages 10–17 (Robert Wood Johnson
Foundation, 2023). Although such children look overnourished, the opposite is true (Kobylinska et al., 2022).
Malnutrition occurs when the body either does not receive sufficient nutrients or is unable to absorb essential
nutrients. The individual’s body composition changes, and functions are impaired (Kobylinska et al., 2022). Obesity
and malnutrition share a paradoxical relationship. Although obese children receive an abundance of calories, these
calories may lack essential nutrients to promote daily performance, encourage proper growth and development, and
encourage overall bodily homeostasis. Moreover, the child with obesity cannot fully absorb the essential nutrients
because of systemic inflammation (Kobylinska et al., 2022).
Malnutrition in children with obesity may result from poor dietary choices (nutrient-poor foods), sedentary lifestyles,
socioeconomic factors (limited access to healthy and wholesome foods), or lack of nutritional education. These

children are at increased risk for developing chronic diseases such as type 2 diabetes, cardiovascular disease, and
metabolic syndrome. Addressing this condition requires the collective efforts of family, caregivers, health care
providers, nurses, dietitians, and communities.
Childhood: Precocious Puberty

Precocious puberty, also known as early development of secondary sexual characteristics, begins before the age of
8 years in females and 9 years in males (Breehl & Caban, 2023). Precocious puberty may be caused by many
different endocrine-related factors, including obesity (Soliman et al., 2022). Several correlational studies show high-
caloric intake with early puberty onset (Soliman et al., 2022). For example, excessive weight or obesity in childhood
has a correlational relationship with the development of precocious puberty (Chen et al., 2017). The mechanism of
the link between obesity and precocious puberty is still under investigation.
Adolescence
Many changes occur within the endocrine system during adolescence. As puberty progresses in adolescence, sexual
maturation and reproduction capabilities refine and mature; these capabilities define puberty (Breehl & Caban,
2023). The primary physiological function of puberty is the production of mature adults capable of sexual
reproduction. Hormonal changes trigger the onset of puberty, which occurs between the ages of 8 and 13 years in
females and 9 and 14 years in males. The physical changes associated with puberty in females include breast
development, menarche, and growth of pubic and axillary hair. In males, the changes include genitalia development,
voice deepening, increasing height, and growth of pubic hair.
The endocrine glands involved in puberty include the hypothalamus, pituitary gland, adrenal glands, ovaries, and
testes. All of the hormones affect nearly every organ system in the body. For example, in the musculoskeletal
system, the muscles grow; the circulatory and respiratory systems see rapid growth. The nervous system is
influenced by hormonal changes as well. The increase in estrogen and testosterone affects the limbic system
through receptor binding, stimulating the sex drive and increasing the emotional roller coaster (Breehl & Caba,
2023). Children might undergo these changes earlier in life (precocious puberty) or experience delayed puberty
(after age 13 in females or age 14 in males).
Impact of Nutrition on the Endocrine System During Adolescence

Nutritional recommendations are crucial for adolescents transitioning from childhood into sexual maturity (Soliman
et al., 2022). The rapid changes and increasing energy demand for protein and micronutrients remain necessary for
growth and development during this stage of life. Food insecurity, obesity, and body dysmorphia prevent this age
group from getting the necessary nutrients. Evidence-based data supporting dietary recommendations for
adolescents going through puberty are limited (Soliman et al., 2022). The Dietary Guidelines for Americans
2020–2025 recommend 3 servings of vegetables, 2–2½ servings of fruits, 7–10 servings of grains, 3 servings of
dairy products, and 5–7 oz of lean protein (such as chicken, poultry, and seafood) per day (U.S. Department of
Agriculture, 2020). The recommendations also include limiting fried, fatty, and processed foods.
TRENDING TODAY
Type 2 Diabetes on the Rise in Adolescents

Type 2 diabetes in children and adolescents is on the rise due to an increase in childhood obesity (Teska, 2023).
Nurses need to consider nutritional aspects to effectively impact childhood obesity.
On social media, adolescents may view numerous pop-up ads about food and nutrition, which may impact their
dietary choices. Research by Chung et al. (2021) addresses the impact of food advertisement via social media on
the dietary choices adolescents make.
First, read the report Adolescent Peer Influence on Eating Behaviors via Social Media: Scoping Review
(https://openstax.org/r/adolescent) (Chung et al., 2021).
Next, take some time to review the following social media content and think critically about the information
provided and its appeal to adolescent clients:
• @healthywellnesstips (https://openstax.org/r/healthywellnesstipsinsta) (Instagram)

• Kids Nutrition & Recipes (https://openstax.org/r/kidsnutrition) (Facebook)
• Mayo Clinic Minute: How to help overweight kids get healthier (https://openstax.org/r/mayo) (YouTube)
1. What is the purpose of the social media content you viewed or read?
2. How might this social media content influence the dietary choices of adolescents?
4. How does the social media content you reviewed support or refute the findings in the review by Chung et al.?
The nurse should perform a thorough nutritional assessment by asking the adolescent client about their favorite
foods, the foods they consume both at home and when they are with their peers, the number of servings of nutrient-
dense foods they eat each day, and ways that social media may be influencing their dietary habits. Adolescents who
do not consume enough nutrient-rich foods may be at risk for deficiencies of iron, folate, vitamin B6, and vitamin
B12, which might delay their growth and development, as well as puberty.
Adulthood
The human body in adulthood continues to rely on the homeostasis, metabolic requirements, development, and
reproduction function that the endocrine system provides through the secretion of hormones (Campbell & Jialal,
2022). Physiologic changes continue as adolescents transition into young adults and then into adulthood. These
changes include peak physical growth; sexual maturation; brain development; and reproductive, metabolism, and
hormonal stability. Women stop growing earlier than men do, between 20 and 35 years of age, whereas men
continue to grow into adulthood and reach peak physical strength and stamina between 30 and 40 years of age.
Adults also reach sexual maturation. Sexual maturation and reproductive system markers include regular menstrual
cycles for females and peak testosterone production for males. Secondary sexual characteristics such as breast
development in females and facial hair growth in males reach full development. Growth hormone continues to play a
role in adulthood, as male skeletal growth is typically completed during this stage of life. Growth hormone
contributes to muscle growth, repair, and maintenance. Thyroid hormones, including T4 and T3, play a role in
metabolism, heart function, and energy regulation. Insulin regulates blood glucose levels; during adulthood,
nondiabetic adults respond effectively to the insulin their bodies produce, allowing them to fully use the
carbohydrates consumed and aid in the metabolism process.
As in all stages of life, the body continuously attempts to achieve homeostasis. This hormonal balance is crucial for
overall health, reproductive function, mood regulation, and metabolism. Hormonal changes vary based on
individuals’ genetics, lifestyle, and overall health. Nutrition integrates within the system to help it reach
homeostasis.
Nutrition plays a pivotal role in the health of adults for optimal endocrine function and prevention of endocrine
dysfunction (Caputo et al., 2021). The role of healthy nutrients includes overall health and endocrine disorder
prevention; energy-based performance; weight management; bone, mental health, and cognitive function; healthy
aging; and disease management and healing. A balanced diet includes whole grains, lean protein, fruits, vegetables,
healthy fats, and water. Micronutrient foods include antioxidant-rich foods, containing vitamins A, C, D, zinc, iodine,
selenium, iron, and magnesium, which decrease inflammation and the inflammatory process, containing vitamins A,
C, D, zinc, iodine, selenium, iron, and magnesium. Foods that contain these important micronutrients include leafy
green vegetables, citrus fruits, berries, nuts, seeds, lean meats, fatty fish, dairy, and whole grains. The nurse should
advise individuals to avoid processed and refined sugary foods and beverages to encourage optimal endocrine
function. Heavily processed foods contribute to inflammation, insulin resistance, and hormonal imbalances.
Later Adulthood
Age-related changes affect every endocrine organ (van den Beld et al., 2018). As the function of the organ system

8.2 • Nutrition and Chronic Endocrine Illnesses 157
begins to decline with age, other factors, such as inflammation and caloric intake, play a role in endocrine function.
A study by van den Beld et al. (2018) found that regular aging changes were associated with an increase in the
concentration of serum thyroid-stimulating hormone (TSH); but alterations in TSH concentration remained
dependent on iodine status. T3 blood concentrations fluctuate depending on the individual. The overall decline in
thyroid hormone activity resulted from hormone metabolism changes, inflammation, and energy restriction. Further
research is needed to develop age-specific hormone reference ranges to guide health care providers in hormone
replacement therapy (van den Beld et al., 2018).
The hypothalamic–pituitary–somatotropic axis remains responsible for growth hormone secretion into the blood
from the pituitary gland (van den Beld et al., 2018). Average age-related growth hormone secretion decline is called
somatopause. Somatopause is associated with adipose tissue increase and leads to the decline of growth hormone
and insulin-like growth factor after puberty.
Undernutrition occurs as normal aging brings appetite suppression and limited food intake (Molfino et al., 2021; van
den Beld et al., 2018). The endocrine system plays a role in appetite suppression and anorexia. Hormonal changes
include increases in cholecystokinin, leptin, and cytokines and a decrease in ghrelin. Appetite suppression in older
adults revolves around the increase in levels of cholecystokinin. Nurses and health care providers combat
cholecystokinin with an antagonist to stimulate the appetite and increase nutritional consumption. Frail older adults
can experience diminished leptin levels, while healthy older adults can have increased concentration levels of
circulating leptin (van den Beld et al., 2018). Aging is also associated with glucose intolerance, elevated insulin
levels, and vitamin and mineral deficiencies.
For older adults, consuming enough protein to minimize age-associated loss in muscle mass is important. The
recommendation for protein intake includes 23–31 oz per week at the minimum or 35% of total calories (Molfino et
al., 2021; U.S. Department of Agriculture, 2020). Continuous anorexia in frail older adults negatively impacts their
body composition; to combat this problem, early nutritional intervention improves outcomes and quality of life
(Molfino et al., 2021). Like all age groups, older adults should strive to choose nutrient-rich foods. The ability to
absorb Vitamin B12 decreases with age and the use of certain medications, so ensuring adequate intake of this
vitamin is of particular concern (U.S. Department of Agriculture, 2020).
8.2 Nutrition and Chronic Endocrine Illnesses

LEARNING OUTCOMES
• 8.2.1 Discuss the impact of nutrition on endocrine illness.
• 8.2.2 Discuss the impact of nutrition on acute exacerbation of chronic endocrine illness.
Nutritional Requirements for Optimal Endocrine Health

When hormones are out of balance—either an excess or deficiency of a certain hormone—an endocrine disorder is to
blame, and such fluctuations can lead to various types of systemic dysfunction (Rodolico et al., 2020). Endocrine
disorders are categorized as either primary or secondary. Primary endocrine disorders occur due to an imbalance in
the hormone production from the original endocrine gland; for example, primary hyperthyroidism originates in the
thyroid gland. In addition, because the endocrine system has a master gland (the pituitary gland) that regulates
hormones based on blood levels, disrupted hormone levels can cause secondary endocrine disorders, meaning that
the disorder does not come from the original organ but from the pituitary gland. For example, secondary
hyperthyroidism results from a TSH-secreting pituitary adenoma.
Nutrition is a significant factor in the development, management, and progression of various endocrine-related
disorders. Nutrients may either aggravate or alleviate endocrine symptoms or conditions.
Diabetes
The pancreas is the endocrine gland responsible for the production and secretion of insulin and glucagon. The
pancreas contains islets of Langerhans, containing insulin-producing beta cells and glucagon-secreting alpha cells.
These hormones fluctuate based on blood glucose levels, and an imbalance can result in negative effects. The most
notable endocrine disorder is diabetes, which is one of the most common endocrine conditions in the United States
(Agency for Healthcare Research and Quality, n.d.; Sapra & Bhandari, 2023). The subclassifications for diabetes
clinically define each type of the disorder. The categories include type 1 diabetes (insulin-dependent diabetes),
type 2 diabetes (noninsulin-dependent diabetes), and gestational diabetes (Table 8.2).
Diabetes Metabolic Process Medical Insulin Type Medication Dietary

Type Treatment Recommendations
Gestational Pregnancy-related • Medication • Long- • Metformin • Fruits and
diabetes changes result in • Insulin acting and vegetables
dysfunction of short- • Lean proteins
beta cells and acting • Low glycemic
resistance to index foods
insulin by cells.
Type 1 Beta cells are • Insulin • Long- • Short-acting • Fruits and
destroyed and acting and insulin: vegetables
produce no insulin. short- ◦ Regular • Lean proteins
acting human • Low glycemic
insulin index foods
◦ Insulin
lispro
• Intermediate/
Long-acting
insulin:
◦ Insulin
NPH
◦ Insulin
glargine
◦ Insulin
determir
◦ Insulin
degludec
Type 2 • Beta cells • Medication • May or • Stimulate • Fruits and

produce may not insulin vegetables
insulin but need production • Lean proteins
with limited medication • Meglitinides • Low glycemic
production. • Dietary • Sulfonylureas index foods
• Beta cells do changes • Dipeptidyl-
not produce peptidase 4
enough insulin inhibitors
to meet • SGLT2
metabolic inhibitors
demand. • GLP-1
• Beta cells agonists
produce
enough
insulin, but
the cells
develop
resistance.
TABLE 8.2 Types of Diabetes, the Involved Metabolic Processes, and Possible Treatments
Any of the subcategories of diabetes lead to the same clinical objective finding of hyperglycemia, which is defined as
a fasting serum glucose level greater than 126 mg/dL, a random glucose level greater than 200 mg/dL, or a
hemoglobin A1C (HbA1c) greater than 6.5% (Agency for Healthcare Research and Quality, n.d.; Sapra & Bhandari,

2023). Many health care providers check clients’ HbA1c levels when monitoring blood glucose control and dietary
modifications. Continuously elevated levels impair the beta-cell function of the pancreas, resulting in further
impaired insulin secretion (Sapra & Bhandari, 2023).
Type 1 diabetes results from the destruction of beta cells in the pancreas that eliminate the production and
secretion of insulin (Sapra & Bhandari, 2023). This destruction of insulin-producing cells, usually secondary to an
autoimmune disease, results in a dramatic decrease of insulin and elevated glucose levels. The absence of insulin
puts the client at risk for complications involving vascular and neuropathic issues and death. Type 1 diabetes
requires both insulin injections and nutritional management.
Type 2 diabetes has a different etiology than type 1 diabetes and has more of an insidious onset, with layered causal
effects (Sapra & Bhandari, 2023). In contrast to type 1 diabetes, type 2 diabetes results from a sensitivity or
resistance to the insulin the body creates. The difference is that in type 1 diabetes, the pancreas no longer creates
insulin, so insulin injections are necessary for life, whereas insulin is still produced in type 2 diabetes. However, the
circulating insulin in type 2 diabetes does not respond as it should (attributed to fatty acids and proinflammatory
cytokines causing glucose transportation challenges). Long-term hyperglycemia results in continued damage to the
small blood vessels and the potential development of chronic complications such as kidney failure, blindness,
neuropathy, and amputation. Some risk factors for the development of type 2 diabetes include obesity and the
decline of organ function or receptor cells associated with aging. Other endocrinopathies, such as acromegaly and
Cushing’s syndrome, are associated with diabetes and glucose intolerance, so the health care provider must assess
for these in the client with diabetes.
Nutrition is the building block for disease management and care plans. Optimal diabetes management includes
strict monitoring of carbohydrate intake and blood glucose levels (Sapra & Bhandari, 2023). To ensure optimal
endocrine health, individuals should eat a balanced and nutrient-rich diet that includes complex carbohydrates,
fiber-rich foods, lean proteins, and healthy fats (Gray & Threlkeld, 2019; Pancheva et al., 2021; Sapra & Bhandari,
2023). Portion control and mindful eating guide weight management and overall glycemic control in this client
population.
Part C
Sarah delivered her baby 4 years ago. She has returned to the clinic for an annual exam. Before the examination, her
primary health care provider ordered blood work to check Sarah’s metabolic processes and endocrine function.
Sarah’s HbA1c result is 7.7%. Sarah weighs 167 lb and is 5 feet tall.
5. The nurse recognizes that the test result indicates which condition?
a. Hyperthyroidism
b. Type 1 diabetes
c. Type 2 diabetes
d. Hypoparathyroidism
6. Which of the following dietary recommendations should the nurse reinforce during this visit?
a. Lean proteins, fruits, vegetables, and plenty of starchy potatoes
b. Lean proteins, fruits, vegetables, and low glycemic index foods
c. High glycemic index foods with limited proteins, fruits, and vegetables
d. No dietary recommendations, just medications
Thyroid Disease
Thyroid disorders refer to abnormal function of the thyroid (Figure 8.5). The gland plays a vital role in regulating
metabolic functions in the body through the production and secretion of thyroid hormones. Thyroid disorders result
from insufficient or excessive production or secretion of thyroid hormones or the hormones that stimulate the
thyroid to perform those functions. Treatment options for thyroid disorders depend on the specific condition and the
etiology. Some medical interventions include hormone replacement therapy, antithyroid medications, radioactive
iodine therapy, or surgical removal of the gland. The nurse should have a basic comprehension of thyroid function
and the integral role of dietary factors.
FIGURE 8.5 The butterfly-shaped thyroid gland is located in the front of the neck. (credit: modification of work from Anatomy and
Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Hyperthyroidism is defined as a low or suppressed level of TSH alongside elevated levels of T3 and T4 (Mathew et
al., 2023). If the T3 level is high and the TSH level is low, but the T4 level is normal, the condition is known as T3
toxicosis. When TSH is low but the T3 and T4 levels are normal, the condition is known as subclinical
hyperthyroidism. The causes of hyperthyroidism include Graves’ disease, toxic multinodular goiter, toxic adenoma,
iodine-induced pituitary adenoma, and iatrogenic or drug-related causes. Graves’ disease is the most common
cause and is associated with autoimmune disease. Graves’ disease triggered by autoimmune causes is mostly likely
to develop in the younger population; it is more likely associated with iodine deficiency and toxic multinodular goiter
when seen in older adults. The condition is more common in women and is associated with micronutrient
deficiencies, including iodine and selenium. Iodine and selenium are involved in thyroid hormone development, so
inadequate amounts increase an individual’s risk for thyroid complications.
Hypothyroidism is categorized as primary or secondary (Patil et al., 2023). Primary hypothyroidism results when the
gland produces inadequate amounts of T4. Secondary hypothyroidism, or central hypothyroidism, results from
dysfunction at the pituitary or hypothalamus level. Iodine deficiency is the most common cause of primary
hypothyroidism in countries with insufficient iodine. Iodine is a vital mineral for the production of thyroid hormones.
Adequate intake of iodine allows the thyroid to function effectively and prevent thyroid dysfunction such as
hypothyroidism or goiter development.
In the United States, where iodine is in sufficient supply, Hashimoto’s thyroiditis, an autoimmune disease, is the
leading cause (Patil et al., 2023). Other causes include medications such as lithium and amiodarone, radioactive
iodine (treatment for Graves’ disease), surgical interventions, radiotherapeutics, pituitary tumors, hypothalamus-
compromising tumors, TRH resistance, brain radiation therapy, and cancer drugs. Postpartum thyroiditis, a transient
autoimmune condition similar to Hashimoto’s thyroiditis, affects approximately 8% of pregnant women the first year
after delivery (Rad & Deluxe, 2023). Optimal well-being and thyroid function can be maintained when clients strive
toward nutritional balance. A diet that includes iodine incorporates fish, dairy products, and iodized salt (Mathew et
al., 2023; National Institutes of Health, 2022a).

Acromegaly
Acromegaly is a disorder caused by too much growth hormone (Adigun et al., 2023; NIDDK, 2020) and results in
overgrowth of bones in the face, hands, and feet in response to excessive levels. The primary causes relate to an
increase in growth hormone (GH), with the most common cause relating to a somatotroph GH-secreting adenoma of
the anterior pituitary gland. Other primary causes are related to familial conditions, such as multiple endocrine
neoplasia type 1, familial acromegaly, McCune-Albright syndrome, and the Carney complex (Adigun et al., 2023).
Secondary causes are related to lymphoma, pancreatic-islet cell tumors, and excess growth related to specific
tumors or cancers. Clients with acromegaly may have a prominent forehead (and crease), brow, prognathism
(mandibular enlargement), macroglossia, thick eyelids, a large nose, a large lower lip, and voice deepening (Adigun
et al., 2023).
Nutrient and dietary patterns impact the GH and IGF changes that occur with acromegaly. Caputo et al. (2021)
concluded in their study that diets low in carbohydrates, such as a ketogenic diet (35 g of carbohydrates per day),
were associated with a decrease in IGF while allowing levels of GH to remain stable. For appropriate management of
their disease process, individuals with acromegaly should seek the advice of a registered dietitian when changing to
a ketogenic diet.
Dwarfism
Dwarfism is the medical term for short stature (Jain & Saber, 2023). There are two types of dwarfism based on the
client’s physical appearance: proportionate short stature and disproportionate short stature. Proportionate stature
refers to the length of the client’s limbs and trunk, which are symmetrically small, whereas disproportionate stature
describes a difference in length between a client’s trunk or extremities. Dwarfism has many causes, including
familial inheritance, growth or puberty delay, bone disorders, systemic diseases, and idiopathic, endocrine, and
genetic causes.
When dwarfism results from an endocrine disorder, the growth hormones are deficient (Jain & Saber, 2023). The
hormones that promote chondrogenesis include GH, IGF, androgens, T3, and T4. Chondrogenesis impacts the
growth and development of vertebrae, cartilage, hyaline, fibrous, and elastic cartilage (Jain & Saber, 2023). The GH-
IGF-1 axis is the regulatory path for height. IGF is responsible for stimulation of bone elongation and soft tissue and
cartilage growth; low levels of IGF correlate with short stature.
Nutritional factors support the health and well-being of individuals with dwarfism. Calcium and vitamin D maintain
healthy bone growth. Because individuals with dwarfism have higher incidences of bone and joint issues, nurses
should educate these clients about adequate intake of calcium and vitamin D (Caputo et al., 2021; Jain & Saber
2023). Calcium and vitamin D sources include dairy and plant-based milk products, leafy green vegetables, and
fortified foods. Individuals can also obtain vitamin D through sun exposure and the intake of fatty fish.
Protein is necessary for growth and tissue repair and should make up 15% of an individual’s daily caloric intake
(Caputo et al., 2021).
Addison’s Disease
The adrenal glands have two parts, the cortex and the medulla, each producing different hormones (Allen & Sharma,
2023). The adrenal cortex releases cortisol, aldosterone, and androgenic steroids, and the medulla secretes
epinephrine and norepinephrine. The hypothalamus releases the corticotropin-releasing hormone, which stimulates
the anterior pituitary gland to release adrenocorticotropic hormone (ACTH) from the adrenal cortex located within
the adrenal glands. Aldosterone is a hormone produced by the zona glomerulosa in the adrenal cortex. It plays a
role in blood pressure regulation and electrolyte maintenance through the absorption of sodium into the
bloodstream and the release of potassium into the urine (Allen & Sharma, 2023). Cortisol is a glucocorticoid
hormone produced in the zona fasciculata within the adrenal cortex that regulates fats, proteins, and carbohydrates
used in the body while also playing a role in suppressing inflammation, blood pressure regulation, bone formation,
and increasing blood glucose. Androgenic steroids are hormones produced in the zona reticularis of the adrenal
cortex, and these hormones remain the precursor for estrogens in the ovaries and androgens in the testes. The
adrenal medulla remains responsible for the hormone’s epinephrine and norepinephrine, which work within the
body during stressful situations to stimulate the “fight-or-flight” response or the “rest-and-digest” response.
When the adrenal glands do not secrete enough (clinical definition less than 3 mcg/dL of cortisol levels with
elevated ACTH) adrenal hormones, the condition is known as adrenal insufficiency (Allen & Sharma, 2023; Munir et
al., 2023). Primary adrenal insufficiency is called Addison’s disease, which occurs as a result of an autoimmune
response that destroys the three layers of the adrenal cortex, limiting the production and excretion of hormones. If
adrenal insufficiency occurs due to too much glucocorticoid administration, the disease is secondary adrenal
insufficiency.
Dietary recommendations are vital in people with primary adrenal insufficiency. The effects of Addison’s disease can
lead to an imbalance of sodium, so these clients require instruction regarding salt and sodium-rich foods. If a client
reaches a state of adrenal crisis, they require hydrocortisone and intravenous saline infusions.
Cushing’s Syndrome
When the adrenal cortex produces an abundance of cortisol (primary hypercortisolism), the condition is known as
Cushing syndrome (Allen & Sharma, 2023; Chaudhry & Singh, 2023). Cortisol affects the transcription and
translation of enzyme proteins that metabolize fats, glycogen, protein synthesis, and Krebs cycle while elevating
blood glucose levels and increasing insulin resistance (Chaudhry & Singh, 2023). Clients with Cushing’s syndrome
often have comorbidities such as hypertension, peptic ulcer disease, or diabetes.
Low-carbohydrate diets are recommended because they improve related conditions such as hyperglycemia, weight
gain, hypertension, and insulin resistance (Dugandzic et al., 2022). Low-carbohydrate diets include 25–50 g of
carbohydrates daily or around 5–10% of daily caloric intake. Clients on low-carbohydrate diets should avoid sugars,
refined fats, and highly processed foods.

The endocrine system regulates bodily functions by producing and secreting varying hormones. A balanced diet
remains the general foundation for supporting endocrine function. Some specific foods and nutritional supplements
support the endocrine system and allow optimal function in individuals with endocrine disorders. Although many
nutrients and supplements support the endocrine system whether or not an endocrine disorder is present, there is
no one-size-fits-all plan. Individuals must tailor their nutritional needs based on factors such as health conditions.
Diabetes
The goals of nutrition in diabetes are to manage serum glucose levels, achieve or maintain body weight goals, and
delay or prevent complications (Gray & Threlkeld, 2019; Pancheva et al., 2021). Dietary adherence increases the
client’s quality of life and is the best preventive against potentially developing life-threatening complications. When
teaching clients with diabetes, counseling them about nutrient-rich foods is as important as teaching them which
foods to avoid. Clients are often taught to adjust insulin requirements to match consumption instead of focusing on
fundamental diet instruction (Gray & Threlkeld, 2019; Pancheva et al., 2021). Significant risks for complications
associated with diabetes arise from poor dietary choices.
Dietary intake for people with diabetes involves consideration of both macronutrients and micronutrients (Pancheva
et al., 2021). Increasing daily water intake helps regulate blood glucose levels, maintains kidney function, prevents
dehydration, and helps with weight loss (Sedaghat et al., 2021). Protein recommendations are 1–1.5 g/kg body
weight per day or 15–20% of total daily calories consumed (Gray & Threlkeld, 2019). The client’s kidney function or
the presence of kidney disease needs assessment because most renal diets include protein restrictions.
Fat recommendations include restricting saturated fats to less than 10% of daily intake and eating good fats such as
fatty fish that contain omega-3 fatty acids, avocado, nuts, and nut butters (Gray & Threlkeld, 2019; Pancheva et al.,
2021). Saturated fats maintain a correlational relationship to cardiovascular disease in individuals with diabetes and
are found in fast foods, red meat, and full-fat dairy foods. Saturated fat intake in the United States, including in
children, is much higher than recommended (Pancheva et al., 2021). Nurses should teach clients to avoid or limit
fried or fast foods, limit intake of saturated fats, use liquid vegetable oils, and consume 1 or more servings of
omega-3 fats every day, such as fatty fish, walnuts, soybean oil, ground flax seeds, or flaxseed oil.
Carbohydrate intake has the most substantial influence on glucose control (Gray & Threlkeld, 2019).
Recommendations for carbohydrate consumption sometimes fluctuate as differences of expert opinion do not agree
on low carbohydrate versus average carbohydrate intake for diabetes maintenance and weight loss. The definition of
low carbohydrate varies among experts and is not recommended for pregnant or lactating women. The current
carbohydrate recommendations include 45–50% of the daily intake of carbohydrates (Gray & Threlkeld, 2019;
Pancheva et al., 2021). Experts agree that people with diabetes should avoid consuming sucrose (table sugar) and

8.3 • Treatments and Nutrition 163
sugar-sweetened beverages (particularly those that include high-fructose corn syrup) because they provide “empty”
calories and can contribute to weight gain (Gray & Threlkeld, 2019). Another recommendation is to consume
fructose as a monosaccharide in the form of fruits, some vegetables, and honey. The daily fiber recommendation is
20–35 g/day. Fiber can be found in raw vegetables and minimally refined grain (Gray & Threlkeld, 2019; Pancheva et
al., 2021). Total fiber intake includes both dietary fiber and functional fiber. While dietary fiber is considered a
carbohydrate, the lignin found in plants is not readily digested by the stomach or absorbed within the
gastrointestinal tract. Functional fiber remains responsible for the physiologic benefits of fiber. Diets high in fiber are
beneficial for individuals with many chronic disorders, including diabetes.
Vitamins A, E, C, and D are not associated with glycemic control or prevention of complications. However, they do
limit oxidative stress and systemic inflammation in association with immune system benefits and inflammatory
response. Sodium should be limited to 2300 mg/day to prevent the known correlation between the development of
cardiovascular disease and hypertension associated with diabetes (Gray & Threlkeld, 2019).
Probiotics are “good” bacteria associated with fermented foods such as yogurt, kefir, and kimchi. Positive
correlational studies show that with probiotic consumption, some individuals saw improvement in glycemic and
serum lipid levels (Gray & Threlkeld, 2019).
Hyperthyroidism and Hypothyroidism

The National Institutes of Health [NIH] (2022a) recommends a varying dose of iodine that increases with age as well
as during pregnancy. Processed canned foods may be high in sodium but do not contain iodized salt. Some
multivitamins include iodine-containing kelp (seaweed). Some plant foods such as soy, cabbage, broccoli,
cauliflower, and Brussels sprouts contain iodine. Too much iodine leads to thyroid gland inflammation, so nurses
should monitor clients for nausea, vomiting, diarrhea, weak pulse, and coma (NIH, 2022a). Selenium deficiency or
inadequate consumption can lead to thyroid dysfunction (NIH, 2022b). Selenium is added to many dietary
supplements but is naturally present in Brazil nuts, seafood, organ meats, cereals, grains, and dairy products.
Selenium acts as a protective mechanism against autoimmune thyroid dysfunction. Antioxidants and other
micronutrients produce anti-inflammatory effects in the thyroid, and a diet high in fruits, vegetables, legumes, nuts,
fish, complex carbohydrates, extra virgin olive oil, and plant-based oils is recommended for thyroid health during
times of thyroid dysfunction (Bellastella et al., 2022; Osowiecka and Myskowska-Ryciak, 2023). Other micronutrient
recommendations include vitamin D, vitamin B complex, vitamin A, vitamin C, magnesium, folic acid, zinc, iron, and
selenium.
Nurses should also teach clients to limit saturated fatty acids, refined and processed foods, and sugar because
these induce inflammation (Bellastella et al., 2022; Mathew et al., 2023; Osowiecka & Myskowska-Ryciak, 2023).
Some foods cause goiter, or an enlarged thyroid gland, and thereby interfere with thyroid function (Can & Rehman,
2023). Cabbage, broccoli, and soy have been potentially linked to goiter development (Bellastella et al., 2022;
Mathew et al., 2023; Osowiecka & Myskowska-Ryciak, 2023). If thyroid disease is secondary to another condition,
dietary requirements should address both conditions. This emphasizes the importance of a thorough holistic
assessment that includes nutrition.

LEARNING OUTCOMES
• 8.3.1 Identify drug–food interactions for their impact on treatments used for endocrine disorders.
endocrine disorders.
Health Assessment Considerations

Not all foods are able to provide necessary nutrients, especially for individuals with endocrine disorders. Nutrition
education plays a direct role in optimal health and wellness as well as in the management of disease processes
because foods can either enhance or inhibit wellness in the endocrine system. Diet instruction requires careful
explanation of scientific concepts in the context of the client’s specific situation. These concepts can seem
overwhelming to the client who must balance evidence-based recommendations with real-world conditions. Clients’
food choices are not just by their knowledge of nutrition, but their ability to obtain and prepare nutritious foods that
align with their culture and lifestyle.
Drug–Food Interactions Associated with Treatments for Endocrine Disorders

Endocrine-related medical interventions and medications are used to manage various endocrine disorders and
conditions (Campbell & Jialal, 2022). These treatment options often involve the use of medications that interact
with nutrition. Certain medications used in endocrine care affect nutrient absorption, metabolism, and utilization.
These medications may also have specific recommendations regarding time frames with the food interaction.
Nurses must understand these interactions to educate clients to avoid complications, promote optimal treatment
outcomes, and ensure overall well-being.
Diabetes
Diabetes is an endocrine disorder that involves the amount of insulin the body creates, secretes, and utilizes (Sapra
& Bhandari, 2023). The medications used to manage diabetes, such as insulin and oral antidiabetic medications,
require careful observation, monitoring, and coordination with meals and carbohydrate intake to ensure proper
blood sugar levels (Chen et al., 2020; Gray & Threlkeld, 2019; Pancheva et al., 2021; Rasmussen et al., 2020). When
individuals take insulin incorrectly such that the dosage is not appropriate for the given amount of carbohydrates
consumed, the individual can enter a state of either hypoglycemia (low serum blood glucose level) or hyperglycemia
(high serum blood glucose level; Sapra & Bhandari, 2023). Health care providers may prescribe antidiabetic
medications such as metformin to manage type 2 diabetes (Sapra & Bhandari, 2023). These medications need to be
taken with meals to limit gastrointestinal adverse effects. Studies indicate that people who take metformin are at
risk for vitamin B12 deficiency (American Diabetes Association [ADA], n.d.). These individuals therefore need regular
laboratory testing for B12 deficiency.
Clients with diabetes need to understand how alcohol consumption affects their blood glucose levels. If an
individual with diabetes drinks alcohol on an empty stomach or in excess, the liver cannot release stored glucose,
resulting in hypoglycemia. Alcohol also impairs the body’s capability to indicate low blood glucose levels; for
example, the individual may not experience the usual signs and symptoms of low blood glucose, such as shakiness
or sweating. Alternatively, alcoholic drinks that contain sugary mixes potentially increase blood glucose levels. If
clients with diabetes choose to drink alcohol, strict glucose monitoring and moderate consumption are
recommended because excessive alcohol use is associated with increased liver, nerve, and heart damage. Some
antidiabetic medications, such as sulfonylureas or insulin, interact with alcohol and increase the blood
glucose–lowering effects of the medication, leading to hypoglycemia.
Some supplements, including chromium and niacin, may interact with diabetes medications and lead to
hyperglycemia or hypoglycemia (ADA, n.d.). Chromium deficiency can increase blood glucose levels. In a client with
kidney disease, chromium supplementation may further damage the kidneys (ADA, n.d.). Some individuals may take
niacin to increase their “good” cholesterol levels; nurses should be aware that niacin can raise fasting glucose levels
(ADA, n.d.). Individuals with diabetes should consult their health care provider before adding supplements to their
daily dietary intake.
Thyroid Disorders
Thyroid conditions require individuals to take thyroid medications. Some medications for treating thyroid conditions
are associated with potential nutritional interactions (Wiesner et al., 2021). Levothyroxine should be taken at a
consistent time in the morning on an empty stomach 1 hour before a meal. Foods that interfere with absorption
include soy, calcium supplements, and some fruit juices, including grapefruit, orange, and apple juice (Wiesner et
al., 2021). Some clients who are prescribed levothyroxine concurrently take calcium to avoid osteoporosis, so the
nurse should advise these clients to avoid taking calcium, as well as iron, supplements within 4 hours of taking
levothyroxine because these supplements also reduce absorption of the medication (DailyMed, 2023).
Parathyroid Disorder
Calcium and loop diuretics balance sodium levels (Ellison, 2019). Loop diuretics inhibit the
sodium–potassium–chloride transporter and increase calcium excretion. Furosemide increases calcium excretion
and plasma parathyroid hormone (PTH). This hormone is created in the four small parathyroid glands located near
the thyroid. It regulates the homeostasis of calcium, vitamin D, and phosphate in the bloodstream, maintaining bone
stability (Khan et al., 2022). PTH responds to low calcium levels detected in the blood and stimulates the production

of vitamin D and calcitriol. The increase in calcium excretion from loop diuretics leads to the parathyroid gland
decreasing the production of PTH. PTH, as the negative-feedback loop, signals the parathyroid glands to stop
releasing PTH. A correlation has been noted between furosemide users and increased risk for hip fractures in the
older adult female population (Mohn et al., 2018). Older adults absorb less calcium and are at an increased risk for
fractures.
Thiazide diuretics affect the distal tubules, leading to increased calcium reabsorption (Mohn et al., 2018). A
correlation study showed that individuals who took hydrochlorothiazide also had a decrease in urinary calcium in
hyperparathyroidism, with no change in PTH observed (Mohn et al., 2018). However, more research is
recommended in the field of thiazide diuretics and risk factors for fractures in the older population.
Chapter Summary
• Nutrition plays a fundamental role in human Clients with this condition must closely monitor
growth and development, beginning in utero and their diet to limit carbohydrates and manage their
extending throughout the lifespan. caloric intake to regulate their blood glucose
• Pregnancy-related conditions that can impact the levels.
pregnant client’s nutrition and affect the fetus • Clients with thyroid disorders must manage their
include hyperemesis gravidarum and gestational intake of iodine-rich foods, selenium, and other
diabetes. key micronutrients to help regulate their thyroid
• Appropriate nutrition and a properly functioning function.
endocrine system are essential for growth and • Clients with acromegaly may benefit from a
development through puberty for children and ketogenic diet.
adolescents. • Diet plays a significant role for individuals with
• During adulthood, the endocrine system works to endocrine disorders. However, some medications
maintain homeostasis but eventually begins to used to treat these conditions can affect nutrient
exhibit age-related declines. Adults must adjust absorption.
their nutritional intake accordingly to decrease the • Clients with diabetes must balance food intake
risk for developing diabetes and other endocrine with insulin or oral antidiabetic medication
disorders. administration to decrease the risk for
• During later adulthood, individuals must maintain hyperglycemia and hypoglycemia.
adequate nutritional intake to counteract • Clients taking levothyroxine for hypothyroidism
decreased appetite. must take the medication on an empty stomach
• Endocrine disorders develop either from and avoid certain foods that can inhibit its
malfunction of the endocrine gland responsible for absorption.
secreting a particular hormone (primary disorder) • Clients taking calcium and loop diuretics are at risk
or from pituitary gland malfunction (secondary for fractures because these medications decrease
disorder). calcium and parathyroid hormone levels.
• Diabetes is the most common endocrine disorder.
Key Terms
acromegaly a disorder that results in overgrowth of mg/dL
bones in the face, hands, and feet in response to hyperthyroidism a clinically abnormal, elevated level
abnormally high levels of growth hormone of thyroid hormone in the blood; characterized by an
dwarfism short stature secondary to a genetic or increased metabolic rate, excessive body heat and
medical condition sweating, diarrhea, weight loss, tremors, and
gestational diabetes a disorder that produces increased heart rate
glucose intolerance during pregnancy as the result hypoglycemia a blood glucose level at or less than 40
of dysfunction or delayed response of the beta cells mg/dL
to blood glucose hypothyroidism a clinically abnormal, low level of
glycemic index a system that ranks carbohydrate- thyroid hormone in the blood; characterized by low
containing foods on a scale from 1 to 100 based on metabolic rate, weight gain, cold extremities,
their ability to raise blood sugar levels quickly or constipation, reduced libido, menstrual
significantly irregularities, and reduced mental activity
human chorionic gonadotropin (HCG) a hormone insulin-like growth factor (IGF) a peptide hormone
that stimulates the corpus luteum to produce the that promotes bone and tissue growth
progesterone necessary for promoting and malnutrition occurs when the body either does not
maintaining a growing fetus; reduces the pregnant receive sufficient nutrients or is unable to absorb
individual’s immune function to protect the fetus essential nutrients, resulting in body composition
from immune rejection changes and impaired functions
hyperemesis gravidarum a condition during puberty a stage of development in which sexual
pregnancy characterized by extreme, persistent maturation and reproduction capabilities refine and
nausea and vomiting mature
hyperglycemia a blood glucose greater than 125 mg/ relaxin a hormone secreted by the corpus luteum and
dL or plasma blood glucose level greater than 150 then by the placenta to help prepare the body for

childbirth metabolism, weight, and energy levels

thyroid-stimulating hormone (TSH) a hormone that type 1 diabetes insulin-dependent diabetes;
triggers secretion of thyroid hormones by the develops when insulin producing cells (beta cells)
thyroid gland are destroyed in the pancreas, resulting in low to
thyroxine (T4) tetraiodothyronine (thyroxine) long- non-existent levels of insulin
acting hormone released by the thyroid gland that type 2 diabetes noninsulin-dependent diabetes;
can be converted to T3 results from insulin resistance that develops
triiodothyronine (T3) hormone released by the gradually from obesity and aging
thyroid gland to help regulate processes including
Review Questions
1. How does protein intake contribute to growth and development during childhood?
a. Maintains digestive function
b. Influences nutrient absorption
c. Plays an anabolic role similar to that of growth hormone
d. Mediates levels of growth hormone
2. Which of the following foods supplies micronutrients that decrease inflammation?

a. Kale
b. Sourdough bread
c. Beef
d. White rice
3. Medications given to older adults to stimulate appetite target which hormone?

a. Ghrelin
b. Thyroid-stimulating hormone
c. Insulin
d. Cholecystokinin
4. Which of the following is a good food choice for a client with Hashimoto’s thyroiditis who needs to consume
iodine-rich foods?
a. Leafy green vegetables
b. Fish
c. Citrus fruits
d. Whole grains
5. The nurse is providing dietary education for a client with diabetes. The client asks why their sodium intake
should be limited. What is the best response from the nurse?
a. “Lowering your sodium intake can decrease your blood glucose level.”
b. “A low-sodium diet can decrease inflammation in the body.”
c. “Sodium-controlled diets can lower your elevated risk for developing cardiovascular disease and
hypertension.”
d. “Adding less salt to your food can decrease the food’s glycemic index.”
6. What is the recommended daily intake of saturated fats for individuals with diabetes?
a. Less than 5%
b. Less than 10%
c. Less than 15%
d. Less than 20%
7. What should the nurse include in dietary instructions for a client with diabetes regarding alcohol
consumption?
a. Alcohol consumption can either raise or lower blood glucose levels.
b. Alcohol consumption does not affect blood glucose levels.

c. Drinking alcohol is acceptable if low-sugar or sugar-free ingredients are used in mixed drinks.
d. Drinking alcohol may worsen signs of hypoglycemia when it occurs.
8. Which of the following practices will help clients with diabetes decrease the risk for hypoglycemia after
insulin administration?
a. Administering less than the prescribed dose of insulin
b. Coordinating insulin administration with their meal schedule
c. Eating less than the prescribed amount of carbohydrates
d. Administering insulin between meals
9. Which of the following instructions should the nurse include when teaching a client about levothyroxine?
a. “You can take this medication at any time during the day.”
b. “You can take this medication at the same time you take vitamins and other supplements.”
c. “Take this medication at the same time every day with meals.”
d. “Take this medication on an empty stomach.”
10. The nurse is documenting a client’s medications during an admission assessment. Which of the following
medications can decrease parathyroid levels, thereby increasing the risk for bone fractures?
a. Levothyroxine
b. Metformin
c. Furosemide
d. Insulin
Suggested Reading
American Diabetes Association. (2023). Recipes & nutrition. https://diabetes.org/healthy-living/recipes-nutrition
American Thyroid Association. (2023). Iodine deficiency. https://www.thyroid.org/iodine-deficiency/
Babiker, A., Alawi, A., Al Atawi, M., & Al Alwan, I. (2020). The role of micronutrients in thyroid dysfunction. Sudanese
Journal of Paediatrics, 20(1), 13–19. https://doi.org/10.24911/SJP.106-1587138942
Centers for Disease Control and Prevention. (2022). Eat well. https://www.cdc.gov/diabetes/managing/eat-
well.html
Cleveland Clinic. (2023). Endocrine system. https://my.clevelandclinic.org/health/articles/21201-endocrine-system
Szczuko, M., Kikut, J., Szczuko, U., Szydłowska, I., Nawrocka-Rutkowska, J., Ziętek, M., Verbanac, D., & Saso, L.
(2021). Nutrition strategy and life style in polycystic ovary syndrome—Narrative review. Nutrients, 13(7), 2452.
https://doi.org/10.3390/nu13072452

CHAPTER 9
Nutrition for Hematologic Wellness
FIGURE 9.1 Nutritional deficiencies are known to cause hematologic changes that can impact quality of life. (credit: modification of work
“display of vegetables and one orange” by Baileynorwood/Wikimedia Commons, CC0 1.0)
CHAPTER OUTLINE
9.1 Assess and Analyze the Impact of Nutrition on the Hematological System
9.2 Plan Nutritional Strategies to Impact Hematological Wellness
9.3 Implement Nutritional Strategies to Impact Hematological Wellness
9.4 Evaluate Nutritional Strategies to Impact Hematological Wellness
INTRODUCTION Metabolic processes with high energy requirements are sensitive to nutrient deficiencies. The
production of blood cells, called hematopoiesis, is an energy-intensive metabolic process essential for oxygen and
nutrient transport and protects against invasion of pathogens while maintaining hemostasis. The appropriate
balance of water and cellular components—such as albumin, electrolytes, macronutrients, and micronutrients—is
necessary for blood to optimally function. In the bone marrow, where hematopoiesis occurs, amino acids build the
hemoglobin contained in each red blood cell. Red blood cells use only glucose as fuel, which must be in constant
supply to support red blood cell metabolism (American Society of Hematology, n.d.).
Consider this case: Grant is a nurse and Ms. Foster is a client. Ms. Foster was sent to the emergency department by
her primary care physician after receiving results of her annual laboratory testing that revealed severe anemia (a
reduction in circulating red blood cells). Ms. Foster is a 75-year-old widow from a senior living facility who prepares
her own meals and is independent in her activities of daily living (ADLs). She has a history of type 2 diabetes and
hypertension; she reports that she recently had an episode of fainting and is no longer able to walk to her building’s
elevator without stopping for rest.
170 9 • Applying Clinical Judgment to Promote Nutrition for Hematologic Wellness
9.1 Assess and Analyze the Impact of Nutrition on the Hematological System
LEARNING OUTCOMES
• 9.1.1 Recognize cues that indicate the impact of nutrition on the hematological system.
• 9.1.2 Analyze cues to determine the impact of nutrition on the hematological system.
Assessment of Nutrition and the Function of the Hematological System

Early recognition of hematologic abnormalities and micronutrient deficiency signs can lead to prompt interventions.
Nurses play a key role in assessment, delivery of age-appropriate intervention, and education aimed at restoration
and prevention of recurrence. Through a comprehensive client assessment, the nurse can apply the nursing process
specific to nutritional practices that impact hematologic function. Considering the client’s nutritional preferences,
the nurse can develop strategies to promote hematologic wellness.
Providing holistic care to clients is a core competency for nurses; however, the quality of nutritional assessments
and decision-making can be inconsistent due to variations in clinical experience and settings of practice (Lulloff et
al., 2019). Delays in diagnosing excessive or deficient nutritional intake can lead to hematologic abnormalities,
which can result in life-threatening complications and long-term disease consequences. Accurate assessment of
the client’s nutritional status with early intervention gives clients the best chance for recovery.
Nurses who provide continuity and consistency through frequent assessment are well-positioned to recognize
subtle changes and to work collaboratively with the health care team to develop a plan of care. Assessment of
nutritional impact on the hematological system crosses multiple domains of clients’ needs with emphasis on
physiological and psychosocial integrity and management of care.
Physiological and Psychosocial Assessment

The nurse should begin the assessment with a health history. The client’s age and sex are important to consider as
bone marrow function and immunity decrease with age, and sex influences specific risk factors for hematologic
changes (Márquez et al., 2020). The health history includes past medical and surgical history, with emphasis on
blood disorders and any past episodes of bleeding, autoimmune disease, and gastrointestinal disease that may
result in malabsorption. Surgical history should include the presence of postoperative complications such as poor
wound healing and excessive bleeding or bruising. The nurse should explore family medical history because
hereditary anemias and certain metabolic conditions can impact hematopoiesis. Also, because many medications
have known hematologic side effects, the nurse should obtain an accurate list of the client’s current medications,
including over-the-counter products, vitamins, herbs, and nutritional supplements that may provide cues to risk
factors when analyzing health data.
The purpose of a nutritional assessment is to identify risk factors and specific nutritional deficiencies, to determine
nutritional needs, and to identify the physiological, psychosocial, and socioeconomic factors that may affect
hematologic function (Serón-Arbeola, 2022). Dietary history, including the client’s eating and drinking habits, could
highlight specific nutrient deficiencies; however, obtaining accurate dietary intake is challenging. If time permits, the
use of a food diary actively completed by the client is helpful. Behavioral and emotional considerations and social
determinants of health also must be explored (Walker-Clarke et al., 2022). Specific themes to discuss include:
• Access to food
• Aversion to specific foods
• Mental health influences of eating, such as anxiety and depression
• Food preparation knowledge and skill
• Time constraints and family meal patterns
• Attitudes and beliefs surrounding food consumption
A physical assessment will include subjective and objective data (Table 9.1), be system-based, and include vital
signs and anthropometric measurements, specifically, height, weight, and body mass index (BMI). Of particular
importance is the amount of weight loss (percentage) experienced over a specific period of time. Rapid, unexpected
weight loss of 5–10% from baseline is a risk factor for systemic manifestations of nutritional deficiencies. Triceps
skinfold thickness (TSF) and midarm circumference (MAC) are used with increased frequency to further define

9.1 • Assess and Analyze the Impact of Nutrition on the Hematological System 171
nutritional status, particularly in clients with concerns of malnutrition. TSF correlates with fat mass and MAC with
protein composition (Serón-Arbeola et al., 2022).
Subjective and Objective Findings Related Nutritional Deficiency

Anemia: Iron, copper, vitamin B12, vitamin C, vitamin E, folate
• Pallor
• Fatigue
• Changes in energy level
• Dyspnea, tachypnea
• Tachycardia
• Hypotension
• Dizziness
• Fainting
• Difficulty sleeping
• Ability to maintain ADLs and recreational activities
• Unusual food cravings (pica)
• Electrocardiogram (ECG/EKG) abnormalities
Thrombocytopenia/Coagulopathy: Vitamin K, vitamin C, vitamin E, vitamin B12

• Gingival bleeding
• Easy bruising
• Petechiae (Figure 9.2)
• Prolonged bleeding
• Bloody stool
• Prolonged menstrual cycle
Neutropenia: Copper, vitamin D, vitamin B12, vitamin C

• Frequent fevers
• Frequent infections
• Delayed wound healing
TABLE 9.1 Assessment for Potential Nutritional Deficiencies (sources: Le, 2016; Yu, 2019)
CLINICAL TIP
Ask Open-ended Questions

Nurses should always ask clients open-ended questions to elicit a more informative history. For example, the
nurse could ask “How often do you eat red meat each month?” (instead of “Do you eat red meat?”).
FIGURE 9.2 Petechiae, a condition characterized by small nonblanching spots as a result of bleeding, may be caused by a vitamin C
deficiency. (credit: “This photograph depicts a close view of a patient’s skin revealing the presence of numerous perifollicular petechiae,
the etiology had yet to be determined”/Centers for Disease Control and Prevention, Public Domain)
Management of Care: Diagnostic Assessment

Blood analysis is the primary diagnostic method for evaluating concerns of hematologic changes impacted by
nutritional deficiencies; however, nutritional screening, often performed by a registered dietician, should be
completed first in a comprehensive assessment (Table 9.2).
Some laboratory results can determine the client’s nutritional status. Prealbumin levels can be used to evaluate the
client’s protein status. Transferrin is a protein that transports iron through the blood to different tissues and organs
and is often measured when iron deficiency is suspected as a cause of anemia. Complete blood count (CBC), serum
iron level, serum vitamin B12, and folate levels should also be checked. Blood tests for specific vitamin deficiencies
may be necessary for clients who have gastrointestinal malabsorption (Read et al., 2021; Socha et al., 2020).
When blood results fail to confirm a diagnosis in symptomatic clients, a bone marrow aspiration and/or biopsy may
be necessary to evaluate the production of hematologic stem cells and the bone marrow microenvironment for
evidence of malfunction.
Diagnostic Study Hematologic or Other Nursing Considerations

Manifestation
Nutritional Screening Tools • More than 5% weight • Age and population specific
loss over past 3 • Client language
months • Complete within 48 hours of admission
Nutritional Risk Screening • All hospitalized Not applicable

2002 (NRS2002) clients
Malnutrition Universal • Community clients Not applicable

Screening Tool (MUST)
Mini Nutritional Assessment • Older clients Not applicable
(MNA-SF)
Nutritional Risk in Critically Ill • Critically ill clients Not applicable
(NUTRIC)
TABLE 9.2 Diagnostic Studies

Diagnostic Study Hematologic or Other Nursing Considerations

Manifestation
CBC With Differential • Bruising, petechiae • Total volume of blood obtained in 24 hours;
Complete Metabolic Profile • Gingival bleeding check facility policy
• Dyspnea • Is there a fasting requirement?
• Tachycardia • Appropriate collection tube
• Handling requirements: specific days
Albumin, Prealbumin, Vitamin • Poor wound healing processed; temperature of sample once
D (25OHD) obtained
Haptoglobin, Lactate • Hemolytic anemia
Dehydrogenase (LDH), • Thrombocytosis
Reticulocyte,
Vitamin E
Ferritin, Iron, Transferrin • Microcytic anemia
(small red blood cell)
Folate, Vitamin B12 • Macrocytic anemia

(large red blood cell)
• Neutropenia
Vitamin C • Excessive bleeding

and bruising
• Brittle, spoon-shaped
nails
Vitamin K, PT/PTT • Prolonged bleeding

• Coagulopathy
Copper • Anemia (normocytic)

• Neutropenia
• Malabsorption
(diarrhea, failure to
thrive)
Bone Marrow Aspiration/ • Overlapping Does the client need sedation?

Biopsy hematologic
abnormalities
TABLE 9.2 Diagnostic Studies
Analysis of Nutrition and the Hematologic System

Developing clinical judgment requires the nurse to recognize laboratory abnormalities and associate significance to
the client’s history and physical assessment (NCSBN, 2022). Making connections between a client’s diet
history—such as lacking red meat, a critically low hemoglobin, and signs and symptoms of anemia—will result in
identification of potential complications and anticipation of medical intervention. See Table 9.3.
Among nutritional blood disorders, iron deficiency anemia is the most common with increased prevalence in young
children, pregnant women, and older adults (Burton et al., 2020). Iron deficiency anemia is characterized by a low
hemoglobin concentration with small (microcytic), pale (hypochromic) red blood cells. The nurse should consider
other nutrient-related hematologic disorders as well:
• Vitamin B12 deficiency

• Folate deficiency
• Vitamin K deficiency
• Vitamin C deficiency
• Vitamin D deficiency
Deficiency Conditions and Medical Management Nursing Considerations

Individuals at Risk
Iron deficiency • Infants • Ferrous sulfate • Take 1 hour before or
• Menstruating 100–200 mg/day for 2 hours after meals
females adults dosed on • Take with vitamin C
• Older adults over 65 severity of anemia to increase
years • Orally or absorption
• Vegans intravenously • Avoid antacids,
• Dose dependent on proton pump
age and hemoglobin inhibitors (may
level decrease iron
absorption)
• Common side effect:
constipation;
increase fiber in diet
• Food sources: red
meat, beans, dark
green leafy
vegetables, iron-
fortified foods
• Monitor labs every 3
weeks during first 2
months of therapy
Vitamin B12 • Autoimmune • Vitamin B12 • Clients with

gastritis intramuscularly or malabsorption
• Celiac disease high dose Vitamin syndrome or gastric
• Inflammatory bowel B12 orally daily resection require
• Gastric bypass or • Diet modification parenteral
ileal resection administration
• Strict vegans • Protect vials from
• Pancreatic light
insufficiency • Take with meals to
• Alcohol use disorder increase absorption
• Food sources: animal
meat, fish, eggs,
dairy
TABLE 9.3 Management of Common Nutrition-Related Blood Disorders (sources: Burton et al., 2020; Maxfield & Crane, 2022; Nemati et
al., 2022; Sizar et al., 2022; Socha et al., 2020)

Deficiency Conditions and Medical Management Nursing Considerations

Individuals at Risk
Folate • Pregnant clients • Folic acid, orally • Take antacids at
• Clients with alcohol once daily least 2 hours after
use disorder, • Dose dependent on folic acid
malabsorption, age • Take folic acid early
hemolytic anemia, in pregnancy for
eczema prevention of neural
tube defects
• May turn urine
intensely yellow
• Food sources: leafy
green vegetables,
fruits, nuts, eggs,
meats
Vitamin K • Newborns • Phytonadione may • Lab analysis

• Liver disease be given impacted by drugs:
• Cystic fibrosis intramuscularly, warfarin, antacids,
• Celiac disease subcutaneously, or antibiotics, aspirin
• Inflammatory bowel orally; dose is • Food sources:
disease dependent on cheese, green
condition and age vegetables, meat,
• Intravenously in life- eggs
threatening bleeding
Vitamin C • Food insecurity • Ascorbic acid • May decrease

(scurvy) • Infants only 100–300 mg/day for response to warfarin
receiving cow’s milk children and and antibiotics
• Alcohol use disorder 500–1000 mg/day • May interfere with
• Smoking for adults blood and urine
• Eating disorder • Diet modifications glucose test
• GI tract disorder • Food sources: citrus
• Type 1 diabetes fruits, tomatoes,
• Iron overload strawberries,
cantaloupe, peppers
Vitamin D • Residential/assisted • Vitamin D3 • Order lab as 25(OH)

living (cholecalciferol) • Laboratory analysis
• Dark skin tones orally daily or high impacted by
• Obesity dose orally weekly barbiturates and
• Chronic disease corticosteroids
• Decreased exposure • Food sources: fatty
to sunlight fish, liver, fortified
milk
TABLE 9.3 Management of Common Nutrition-Related Blood Disorders (sources: Burton et al., 2020; Maxfield & Crane, 2022; Nemati et
al., 2022; Sizar et al., 2022; Socha et al., 2020)
Nursing Considerations
As the client’s relevant information is identified, the nurse will apply the nursing process, determine related nursing
diagnoses, and prepare to implement evidence-based care. Potential nursing diagnoses for aiding the client in the
restoration of hematologic wellness include (Doenges et al., 2022):
• Imbalanced nutrition, undernutrition

• Fatigue, related to malnutrition

• Failure to thrive, related to nutritional deficiency
• Frail elderly syndrome, related to malnutrition
• Knowledge deficit, related to nutrients needed for hematologic wellness
• Decreased activity tolerance, related to fatigue
• Impaired skin integrity, related to anemia, nutritional deficiency
• Impaired memory, related to anemia
• Infection, delayed wound healing, related to nutritional deficiency
• Impaired gas exchange, related to anemia
• Risk for infection, related to nutritional deficiency
• Risk for bleeding, related to nutritional deficiency
• Risk for falls, related to anemia
• Risk for unstable blood pressure, related to anemia
• Risk for constipation, after iron supplementation
• Risk for ineffective tissue perfusion, related to anemia
• Risk for delayed child development, related to nutritional deficiencies
Part A
Grant continues with his assessment of Ms. Foster. She reports difficulty sleeping for the past several months and
poor concentration. Over the past 3 days, she has been short of breath with little exertion and lightheaded. As Grant
discusses her diet history and food preferences, Ms. Foster reports that she constantly craves ice; otherwise, her
diet consists of bread, chicken, and canned vegetables. While Grant continues to perform his assessment, her
primary care physician (PCP) calls to report Ms. Foster’s hemoglobin as 6.2 gm/dL from the morning labs and
requests additional diagnostic evaluation to determine the etiology of her severe anemia. Grant recognizes that
older adults are at risk for nutritional anemias and suspects this for Ms. Foster. He understands the importance of a
thorough history and assessment to avoid potentially life-threatening complications of anemia. Grant has completed
his assessment of Ms. Foster and has obtained the following blood samples as ordered by her PCP:
• CBC
• Serum iron
• Ferritin
• Folate
• Vitamin B12
Her CBC confirms severe microcytic anemia (hemoglobin 6.0 gm/dL with a low mean corpuscle volume). Since Ms.
Foster has symptomatic anemia with shortness of breath and lightheadedness, Grant notifies the emergency
department physician and requests an additional evaluation. An ECG and chest radiograph are performed; the
physician determines that the source of Ms. Foster’s symptoms is unlikely related to hemorrhage and is most likely
related to a nutritional deficiency. An order to transfuse 1 unit of packed red blood cells over 2–4 hours is received.
Grant recognizes that iron deficiency is the most common cause of nutritional microcytic anemia. He is also aware
that the turnaround time for laboratory iron studies is 24–48 hours. He updates Ms. Foster and her daughter with
the plan of care and determines the priority nursing diagnosis to be impaired gas exchange, related to anemia;
imbalanced nutrition, less than body requirements, related to iron deficiency.
1. Which nutritional screening tool should the nurse anticipate as part of Ms. Foster’s evaluation?
a. Nutritional Risk Screening 2002 (NRS2002)
b. Malnutrition Universal Screening Tool (MUST)
c. Mini Nutritional Assessment (MNA-SF)

9.2 • Plan Nutritional Strategies to Impact Hematological Wellness 177
d. Nutritional Risk in Critically Ill (NUTRIC)
2. Ms. Foster’s priority nursing diagnosis is impaired gas exchange, related to anemia; imbalanced nutrition, less
than body requirements, related to iron deficiency. What other nursing diagnosis should the nurse consider
addressing during this visit?
a. Knowledge deficit, related to nutrients needed for hematologic wellness
b. Impaired skin integrity, related to anemia, nutritional deficiency
c. Impaired memory, related to anemia
d. Infection, delayed wound healing, related to nutritional deficiency
9.2 Plan Nutritional Strategies to Impact Hematological Wellness

LEARNING OUTCOMES
• 9.2.1 Prioritize hypotheses of nutritional habits that optimize hematological wellness.
• 9.2.2 Generate solutions to optimize hematological wellness utilizing nutritional habits.

Once nutritional deficiencies impacting hematopoiesis have been discovered, the nurse should explore goals aimed
at restoration of wellness. Barriers to a client’s success can include physiological and psychosocial factors. Assisting
the client in determining which nutritional habits can be modified is challenging but essential at this stage of
planning. The nurse should consider both the setting (hospital, clinic, client’s home) and the audience for
discussion. Goals that consider cultural influences are more likely to guide the client toward a nutritional lifestyle
with a lasting positive impact (Walker-Clarke et al., 2022).
Physiological Factors
Most physical attributes are non-modifiable; however, understanding the impact of physiological factors on nutrition
is an important component of client education. Providing anticipatory guidance related to nutrient demands in
various stages of life can influence goal setting through the management of expectations. Although clients cannot
manipulate their family medical history and genetics, health promotion strategies can be applied using these factors
as motivators.
Typically, males have higher energy demands than females, as well as an increased trajectory for height and weight
compared. Nutritional needs increase during pregnancy because of physiological and hormonal changes and fetal
demand. Folate deficiency is common during pregnancy and can lead to serious hematologic deficits in both the
pregnant client and fetus (Grzymisławska et.al., 2020).
Neonates and infants have increased caloric and protein needs to support the rapid growth and development that
occurs during this time, as well as to prevent anemia and bleeding disorders. Breastfed infants are dependent on the
health and diet of the person feeding them. Research has discovered that genetic variations in both the parents and
child can affect the production and consumption of milk (Golan, 2020). With this knowledge, nurses can
intentionally explore breastfeeding habits and provide support and rationale if nutritional supplementation is
indicated.
As humans age, growth hormone and erythropoietin deficiencies occur, which contribute to decreased production of
red blood cells. Additionally, appetite and food intake decrease due to delayed gastric emptying and changes in
taste. Papillae (taste buds) density decreases in older adults that results in taste and smell alterations. Poor dental
health, ill-fitting dentures, and dry mouth further contribute to decreased food intake, leading to nutrient
deficiencies. Although energy needs decrease with age, protein and micronutrients requirements increase (Kaur et
al., 2019).
Disease comorbidities often result in increased caloric, protein, and micronutrient needs. Acute and long-term
illnesses such as trauma, burns, cancer, lung disease, and immune dysfunction require even higher protein and
micronutrient intake to restore homeostasis during the healing stage.
Psychosocial Factors
Psychological and social factors impact eating behaviors throughout the lifespan (Walker-Clarke et al., 2022). These
are often considered modifiable contributors and are a major target for interventional strategies to restore
hematologic wellness (Figure 9.3). Assisting clients in recognizing the presence of these factors is the first
step—requiring empathy, emotional intelligence, and therapeutic communication. For example, although eating
more beef or fresh spinach may help combat iron deficiency in the older adult, financial constraints may prevent this
intervention; therefore, the nurse is challenged to create a more realistic economical and culturally sensitive option
for the client.
FIGURE 9.3 Psychological and social factors influence nutritional goals. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0
license)

Understanding clients’ needs requires knowledge regarding their food preferences and choices. Accessing nutrient-
rich food lists for the client to review can facilitate a meal plan that is both desirable and feasible. Food preferences
often cross physical, psychological, social, and environmental domains. Common themes to explore include:
• Taste and food preferences of the client and their household

• Health concerns
• Convenience and time
• Cultural and religious traditions
• Social influences
• Physical environment
• Economics
• Availability and variety
Planning nutritional goals starts with the nurse determining what is reasonable to tackle during the time available
and in the current setting, considering both physiological and psychosocial influences. It is important to evaluate the
client’s immediate external constraints such as finances, knowledge level, and current well-being. For example, has
the client recently received medication with drowsiness as a side effect? Will the client be able to focus on the
education to actively participate in goal planning?
Part B
Study Part A.

9.3 • Implement Nutritional Strategies to Impact Hematological Wellness 179
Grant is planning a discharge for Ms. Foster as she completes her blood transfusion. He recognizes that Ms. Foster
may be experiencing fatigue or drowsiness from the medical interventions and anxiety and/or fear related to the
need for a major modification to her diet. Further, he is aware that the emergency department environment can be
distracting to learning. With these factors in mind, Grant determines that he will focus the discharge education on
iron replacement therapy, follow-up with her PCP, and referral to a dietician.
He develops the following goal for Ms. Foster’s discharge education: Provide oral and written information on iron
replacement therapy including dose, route, frequency, side effects, and administration considerations immediately
before discharge. Grant will include a list of food sources rich in iron and inform Ms. Foster that taking her iron
supplement with 4–6 oz of orange juice can improve iron absorption.
3. Which of the following psychosocial factors should be considered first as the nurse prepares a list of iron-rich
foods?
a. Cultural and religious preferences
b. Home-cooked or prepared meals
c. Social influences
d. Availability and variety
4. Which of Ms. Foster’s risk factors for worsening anemia is modifiable?

a. Hypertension
b. Diabetes
c. Decreased taste
d. Decreased food intake
Encouraging Change
To prevent client frustration that can derail nutritional goals, the nurse should anticipate obstacles to the first steps
of the plan. After creating a plan to restore hematologic wellness, asking open-ended questions regarding the plan’s
steps can proactively help identify solutions to barriers (Hooker et al., 2018). Use of motivational interviewing,
increasing knowledge, and assessing readiness for change are the first steps. Ultimately, the client needs to believe
that the nutritional change will improve their life. For example, in the case of Ms. Foster, Grant learns that Ms.
Foster’s grandson is getting married in 3 months, and she has been worried about her ability to walk the distance
required at the wedding venue. Grant uses this information as an influence of motivation, encouraging her to add
iron-rich foods to at least 2 meals daily, eat meals in the dining room with her friends as much as possible, and use a
daily pill container or set a reminder to take her daily iron replacement. Convenient foods containing iron, such as
canned or frozen spinach, iron-enriched bread and cereals, and canned white beans, are recommended staples to
have on hand. He informs Ms. Foster that with these strategies, she should see a significant improvement in her
anemia and energy level within 2–3 months, just in time to participate in the wedding festivities.
9.3 Implement Nutritional Strategies to Impact Hematological Wellness

LEARNING OUTCOMES
• 9.3.2 Teach nutritional strategies to optimize hematological wellness.

Assessing clients for nutritional influences on hematologic wellness must encompass the client and their support
circle. The nurse should consider the different realms the client may be impacted by in their nutritional choices
(Figure 9.4). For example, adolescents, who may be adequately knowledgeable about nutrient-rich food sources,
may choose less-healthy options at school due to peer influence. The nurse should help clients visualize potentially
challenging situations. Visualization of the situation—and how to respond to the situation—can empower clients to
improve their attitude and practice of healthy eating and is part of a holistic approach to fostering hematologic
wellness (Wiafe et al., 2023).
FIGURE 9.4 Holistic nutritional assessment domains are important in assessing clients for nutritional influences and must encompass the
client and their support circle. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Age-Specific Considerations
For infants, school-aged children, and adolescents, determining where children spend their time and with whom is
an important step in developing a holistic approach to nutritional interventions. The modern family is diverse, and
often consists of multigenerational members and different households influencing each other’s health practices.
Gaining the confidence of the family unit’s influencer(s) requires a nurse’s thoughtful approach and cultural
sensitivity (Barnes et al., 2020). For infants, family traditions regarding the addition of solid food and cow’s milk to
the diet can contradict current evidence-based recommendations and can result in nutritional anemias. Discussing
menstruation may be taboo for some female adolescents and thus result in undisclosed menorrhagia and secondary
iron-deficient anemia. Older adults are often uncomfortable discussing oral health issues and economic burdens
that may have led to late recognition of malnutrition. The nurse is in a unique situation to holistically assess clients
and their families utilizing active listening and therapeutic communication strategies.
Client Teaching
As the teaching session begins, the nurse should ask the client to describe what they already know about the health
concern and should be prepared to adjust their educational plan. If the client reports having nutrient-deficient
anemia but does not understand what anemia is, the educational plan should start with an overview of the function
of red blood cells and how they are produced in the body. Most clients will struggle with adherence to a nutritional
plan (meal plan) if they do not understand why the modification is necessary. This is a component of determining
the client’s health literacy. Other variables of health literacy to consider include:
• Language spoken and read

• Cultural considerations regarding who should be present for the educational session
• The learning style of the client and their significant other as applicable
• External constraints (time, state of health)
Learning Modalities
Taking advantage of technology and existing reputable resources can be a time saver for both the nurse and the
client. Reputable references may be available electronically and/or in writing. Determining access to a computer or
internet service is vital if relying on an electronic modality for content. Additionally, consideration of the material in
the client’s primary language cannot be overlooked. Potential options include:
• One-on-one teaching
• Group or family teaching
• Demonstration—including food preparation and shopping
• Printed materials
• Videos, podcasts, applications for smart phones
• Community resources

9.4 • Evaluate Nutritional Strategies to Impact Hematological Wellness 181
A list of client education resources is included at the end of this chapter.
Part C
Grant starts discharge education with Ms. Foster by sharing his intended goal and time frame for completion. Ms.
Foster’s daughter offers to retrieve the car to expedite discharge. Grant suggests that she stay for the education and
participate in identifying potential barriers to the plan. Ms. Foster reports that her anemia should be resolved since
she received a blood transfusion. Grant explains to Ms. Foster that the lifespan of transfused red blood cells is
approximately 60 days and that she will need to start oral iron replacement therapy as soon as possible to restore
her hematologic wellness. He then modifies his educational plan to include an overview of red blood cell production,
signs and symptoms of anemia, and the expected time for recovery of symptoms.
5. A holistic approach to client teaching includes consideration of which of the following?

a. Spiritual influences
b. Family presence
c. Medical diagnosis
d. Family medical history
6. Which of the following age-specific considerations should the nurse consider first before initiating the
educational session with Ms. Foster?
a. Hearing or vision changes
b. Cognitive function
c. Preferred spoken language
d. Level of alertness
9.4 Evaluate Nutritional Strategies to Impact Hematological Wellness

LEARNING OUTCOMES
• 9.4.1 Evaluate a nutritional plan for its effect on hematological wellness.
• 9.4.2 Modify a nutritional plan to promote hematological wellness.
Evaluating Client Readiness to Follow a Nutritional Plan

Assessing a client’s readiness to change their nutritional lifestyle requires a collaborative conversation. The nurse
should emphasize the direct link between iron-deficient anemia, their current eating habits (craving ice and lack of
iron-rich foods) and their recent symptoms. Evidence-based research has shown that clients are more likely to
engage in healthy behavior if they believe that their symptoms and complications will negatively affect their lifestyle
(Lee & Chung, 2021). Often the only motivator prompting change is the presence of unpleasant symptoms. The next
step is for the client to reflect on how they feel about change and what they need to be successful. At this point, the
focus should shift to providing additional nutritional knowledge, such as specific dietary needs, and establishing the
client’s desire to achieve change. The use of a scoring scale can be helpful, asking questions such as
• “How important is it to you to make this change, on a scale of 0 to 10 with 10 being extremely important?”
• “How confident are you that you can make this change, on a scale of 0 to 10 with 10 being extremely
confident?”
The nurse must keep in mind that this is not a static process, and the focus must remain on a shared decision-
making conversation (National Lipid Association, 2021).
Making Connections
As previously stated, the client who makes connections between food choices and hematologic wellness is more
likely to intentionally change nutritional habits. According to the Transtheoretical Model (TTM), change occurs as a
series of steps aligned with the client’s degree of motivation (Nakabayashi et al., 2020; Lee & Chung, 2021). This
model has been widely used for health education interventions and more recently applied to nutritional
interventions, specifically. The model includes five stages: precontemplation, contemplation, preparation, action,
and maintenance. Figure 9.5 depicts this model, applied to the scenario in this chapter’s unfolding case study.
FIGURE 9.5 The Transtheoretical Model is applied to the this chapter's unfolding case study to illustrate how the client (Ms. Foster) is
changing nutritional habits. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
The nurse’s role is to raise a consciousness that empowers the client to recognize there are more positive outcomes
than negative to this nutritional modification. The benefit of using the TTM in practice is its applicability in all
settings, adaptability to different nutritional needs, flexibility, and cost-effectiveness (Nakabayashi et al., 2020).
An important assumption to the effectiveness of the TTM is the client’s nutritional health literacy, as it relates to
hematological wellness. Clients with low-to-moderate nutritional literacy are likely to have poor self-management
skills and communication with health care providers (Zhong et al., 2020). Client education targeted at enhancing
nutritional knowledge is an important point for nursing intervention. In Ms. Foster’s case, she has identified a lack of
knowledge regarding iron-rich foods; therefore, the nurse should incorporate information about iron-rich foods into
the decision-making conversations with Ms. Foster.
Evaluating the Effectiveness of a Nutritional Plan

According to TTM, maintenance of the behavior change takes 6 months to achieve. In the case of a nutrition-related
hematologic disease, the client will need to be evaluated at more frequent intervals due to the serious potential
consequences of untreated blood disorders. The nurse should be aware that pharmacologic interventions vary in
their onset and duration of action. Correcting long-term nutritional deficiencies is a process. Some medications are
dosed according to the extent of the blood abnormality and require intermittent laboratory analysis for dose

9.4 • Evaluate Nutritional Strategies to Impact Hematological Wellness 183
modifications. For instance, ferrous sulfate has a dose range that is different for infants and children versus adults
and is based on the severity of anemia using hemoglobin and symptoms as determinants. It is recommended to
check hemoglobin every 3 weeks during the first month of treatment for potential dose modifications. The nurse
should provide anticipatory guidance to the client in terms of frequency of return visits, what will be evaluated at
each visit, and what changes or symptoms the client should expect. The client is likely to remain motivated if they
can identify signs of improvement, even outside of actual visits with their health care team.
Modification of the Nutritional Plan

The final phase of any change plan is to make modifications based on the evaluation outcome, remembering that
change is a dynamic, cyclic process. Use of motivational interviewing with open-ended questions will assist the
client in recognizing self-efficacy. Bringing the focus back to hematologic wellness and the potential consequences
the client faces if untreated, while praising the successful change, is key. The nurse should re-address the
previously established goals and look for opportunities for improvement. In Ms. Foster’s case, the nurse would
consider the following questions:
• What iron-rich foods have you incorporated into your diet?

• How often do you consume each food? What serving size do you consume?
• How do you rate your level of fatigue and shortness of breath over the past week, compared with before you
started iron replacement 3 weeks ago?
• What barriers do you have to obtaining access to iron supplements and food items?
Part D
Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up from
Case Study Parts A, B, and C.
After discussing Ms. Foster’s symptoms in relation to her anemia, Grant reviews iron replacement therapy, including
the importance of taking iron with a citrus beverage such as orange juice to aid in iron absorption. He informs Ms.
Foster that most insurance companies will not cover the cost of iron replacement as it can be purchased over the
counter. Grant further offers to search her local pharmacy website to determine the cost and formulations available.
He provides a written client education handout on iron deficiency anemia as well as instructions for Ms. Foster to
call her PCP for a follow-up appointment in 3 weeks. Grant then discusses several foods that are iron rich (Table 9.4)
and helps Ms. Foster identify 3 food items that she feels she can incorporate into her daily diet. Ms. Foster’s
daughter repeats the items needed to initiate this plan and offers to take her mother to the store before returning
home. Ms. Foster reminds her daughter that she has groceries delivered every other week but will increase to a
weekly delivery to ensure fresh or frozen spinach availability daily. At this point, Grant asks Ms. Foster the following:
“How confident are you that you can make this change, on a scale of 0 to 10, with 10 being extremely confident?”
Food Item Serving Size Iron Content

Tofu ½ cup 3 mg
Kidney beans ½ cup 2 mg
Beef liver 3 oz 5 mg
Canned white beans 1 cup 8 mg
Boiled lentils ½ cup 3 mg
Fortified breakfast cereal ½ cup 18 mg
Potato, baked, flesh and skin 1 medium size 2 mg
Tomatoes, canned, stewed ½ cup 2 mg
TABLE 9.4 Iron-Rich Foods (source: National Institutes of Health, 2023)
Ms. Foster reports a confidence level of 8, vocalizing her motivation to actively participate in her grandson’s wedding
in 3 months. Grant feels confident that he and Ms. Foster have developed a solid plan in a collaborative manner. He
provides Ms. Foster with a copy of the plan and educational materials and recommends she ask her PCP for a
referral to a registered dietitian to help with meal planning. He adds the nursing care plan to Ms. Foster’s electronic
medical record to ensure that her PCP’s office will have access during the follow-up appointment.
7. What stage of change is Ms. Foster in at the conclusion of the nurse’s teaching session?
a. Contemplative
b. Pre-contemplative
c. Preparative
d. Action
8. What should the nurse recognize first when modifying a nutritional plan for change?
a. Change is a cyclic process.
b. Motivational interviewing is the preferred method to determine success of the prior plan.
c. Goals of the initial plan for change are important.
d. Barriers to success of the initial nutritional change plan exist.

Chapter Summary
• Iron deficiency anemia, characterized by low burns, cancer, lung disease, and immune
hemoglobin concentration and microcytic red dysfunction require even higher protein and
blood cells, is the most common nutritional blood micronutrient intake to restore homeostasis during
disorder in young children, pregnant women, and the healing stage.
older adults. • Aging adults are susceptible to nutrient-deficient
• Nutrient-related hematologic disorders include blood abnormalities because of decreased
vitamin B12 deficiency, vitamins C, K, and D production of hormones and red blood cells and a
deficiency, and folate deficiency. decreased appetite/food intake related to delayed
• Delays in diagnosing excessive or deficient gastric emptying, changes in papillae, and
nutritional intake can lead to hematologic declining oral health.
abnormalities resulting in life-threatening • Use of the TTM for nutrition educational
conditions. Accurate assessment of the client’s interventions can provide clients a degree of
nutritional status with early intervention gives motivation for successful restoration of
clients the best chance for recovery. hematologic wellness.
• Acute and long-term illnesses such as trauma,
Key Terms
macrocytic anemia anemia that is marked by nutritional value such as ice, dirt, clay, and paper
abnormally large red blood cells. Example: Folate Transtheoretical Model (TTM) an integrative model
and vitamin B12 deficient anemia of behavior change that assesses an individual’s
microcytic anemia anemia that is marked by readiness to act on a healthier behavior and that
abnormally small red blood cells. Example: Iron- provides strategies, or processes of change, to guide
deficient anemia the individual
pica craving and chewing substances with no
Review Questions
1. Which nutritional deficiency listed increases the risk for bleeding?
a. Vitamin K
b. Iron
c. Vitamin B12
d. Folate
2. The nurse is providing nutritional counseling to a client planning pregnancy. The nurse should emphasize the
importance of consuming what micronutrients to avoid macrocytic anemia?
a. Vitamin D
b. Vitamin E
c. Folic acid
d. Vitamin C
3. A middle-aged client with a history of alcohol use disorder is admitted to an acute care setting with symptoms
of severe anemia. The nurse anticipates what nutrient(s) to be deficient?
a. Iron
b. Vitamin B12
c. Calcium
d. Copper
4. The nurse notices that a client has excessive bruising and brittle nails. The client reports frequent infections.
Which nutritional deficiency would the nurse expect for this client?
a. Iron
b. Protein
c. Vitamin C
d. Copper
5. A nurse is preparing discharge instructions for a client who has just been diagnosed with iron deficiency
anemia and will be starting oral iron replacement therapy. Which of the following is an important nursing
consideration to include in the teaching plan?
a. Hemoglobin should be checked in 6 months.
b. Always take iron with milk or food to increase absorption.
c. Always take iron with a citrus beverage, 1 hour before or 2 hours after meals, to increase absorption.
d. Increase diet in fatty fish.
6. Which nursing diagnosis is a priority for an older adult client just diagnosed with nutritional anemia?
a. Risk for falls
b. Risk for imbalanced nutrition, less than body requirements
c. Frail elderly syndrome, related to malnutrition
d. Risk for bleeding
7. The nurse is preparing discharge instructions for a client with anemia related to vitamin B12 deficiency. The
nurse suggests which of the following food items be increased in the client’s diet?
a. Animal meat, fish, eggs, and dairy
b. Beans, seeds, and nuts
c. Dark green leafy vegetables
d. Citrus fruits and acidic raw vegetables
8. Which of the following psychosocial influences impacting nutritional goals for hematologic wellness is the
best target for an initial nursing intervention?
a. Health literacy
b. Transportation
c. Social support
d. Cognitive function
9. Assessing a client’s readiness to learn about nutrition-related hematologic illness, utilizing a holistic
approach, should include all of the following except:
a. Providing written materials regarding vitamin C deficiency to the client immediately before discharge
b. Determining the client’s preferred language for learning
c. Discussing the client’s preferred learning style
d. Delaying discharge education until the client’s significant other is present
10. When evaluating the effectiveness of a nutritional plan for iron deficiency anemia, the nurse considers which
of the following factors?
a. Behavior change typically takes 6 months to achieve, according to the Transtheoretical Model (TTM).
b. Hemoglobin is expected to increase as a response to oral ferrous sulfate within 2 to 3 months of starting.
c. An early sign suggesting improved anemia may include the client’s report of sleeping more.
d. Shortness of breath may take several months to improve.
Suggested Reading
Centers for Disease Control and Prevention. (2021, November 16). Iron. Infant and Toddler Nutrition.
https://www.cdc.gov/nutrition/infantandtoddlernutrition/vitamins-minerals/iron.html
National Heart, Lung, and Blood Institute. (2022, March 24). Blood tests. https://www.nhlbi.nih.gov/health/blood-
tests
Nguyen, M., & Tadi, P. (2022). Iron supplementation. In StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/
NBK557376/

CHAPTER 10
Hematologic Health
FIGURE 10.1 A healthier version of nachos that contains sweet potatoes, which are high in vitamin C, and beans, which are high in iron, can
provide nutrients that promote hematologic wellness. (credit: modification of work “Good-For-You-Nachos” by Alabama Extension; ACES |
Janet Guynn/Flickr, Public Domain)
CHAPTER OUTLINE
10.1 The Impact of Nutrition on Hematologic Wellness Across the Lifespan
10.2 Nutrition and Chronic Hematologic Illness
INTRODUCTION Nutritional needs vary from one life stage to the next. Specific stages of life have increased needs,
such as during pregnancy and vulnerable times, including acute and chronic illness. Meeting nutritional needs from
infancy through older age builds a framework for health and well-being throughout life (Rodríguez-Mañas et al.,
2023).
Nutritional deficiencies impacting hematologic health occur at all ages and affect people of all backgrounds and
socioeconomic status. Specific comorbidities and lifestyles contribute to a higher chance of experiencing undesired
consequences of these deficiencies and require special consideration by the health care team.
Consider this case: Catalina is a 15-year-old Black female adolescent with no prior medical problems. She is in the
10th grade, is in the high school band, and previously made good grades. She reports to her primary care clinic
today with concerns of increasing fatigue, headaches, and shortness of breath when playing her trumpet in the
school band. Her mother reports that her academic performance has declined over the past 6 weeks. Her diet is
reported to be normal for her age, although she does not care for most fruits and vegetables and seldom eats red
meat.
188 10 • Special Nutritional Considerations for Hematologic Health
10.1 The Impact of Nutrition on Hematologic Wellness Across the Lifespan

LEARNING OUTCOMES
• 10.1.1 Describe the impact of nutrition on the hematologic system during pregnancy.
• 10.1.2 Describe the impact of nutrition on the hematologic system during infancy.
• 10.1.3 Describe the impact of nutrition on the hematologic system during childhood.
• 10.1.4 Describe the impact of nutrition on the hematologic system during adolescence.
• 10.1.5 Describe the impact of nutrition on the hematologic system during adulthood.
• 10.1.6 Describe the impact of nutrition on the hematologic system during later adulthood.
The most common hematologic consequence throughout the lifespan is anemia, affecting approximately 1.8 billion
individuals worldwide (Safiri et al., 2021). Although the specific nutrient responsible for nutritional anemia can vary,
the condition is characterized by a deficiency in healthy red blood cells. This can lead to various health conditions
and is a major public health issue with significant implications for quality of life, productivity, and mortality.
Less common than anemia, nutritional bleeding disorders are a group of conditions that can lead to problems
involving prolonged bleeding and thrombosis caused by a lack of nutrients in the diet, such as vitamin K, vitamin C,
or iron. Recognizing signs and symptoms related to these deficiencies is critical to avoid life-threatening
complications, particularly during health emergencies such as trauma or sepsis. Although seen less frequently,
macronutrient and micronutrient deficiencies can also impair immune system function and tissue healing, effects
that can be particularly problematic for individuals living with acute or chronic illnesses such as infections or
autoimmune diseases.
Controlling anemia requires an interdisciplinary team to prioritize the highest-risk groups, including young children
and clients of reproductive age. Despite the nature of the disease, dietary iron deficiency (ID) is the leading cause of
anemia in all regions (Safiri et al., 2021). Recent reports indicate an increased trend in anemia and iron deficiency
among pregnant clients and young children over the past two decades (National Center for Health Statistics, 2023).
According to the World Health Organization (WHO) criteria, anemia and iron deficiency among pregnant individuals
and U.S. children have reached the significance of mild and moderate public health problems, respectively (Jefferds
et al., 2022). More attention must therefore be paid to nutritional interventions for these high-risk groups.
Impact on Health During Pregnancy

Red blood cell production increases by 30% during pregnancy to support blood volume expansion and fetal growth
(Benson et al., 2022). Iron is preferentially used for erythropoiesis (production of red blood cells); therefore, iron
deficits can quickly occur, resulting in maternal and fetal anemia.
Anemia affects approximately 36% of pregnant people worldwide and approximately 12% of pregnant people in the
United States. The most common causes of anemia in pregnancy are iron deficiency and acute blood loss (Smith et
al., 2019; WHO, n.d.-a). Figure 10.2 is an image of human blood from a case of iron deficiency. If iron needs are not
met, there is an increased chance of maternal and fetal adverse outcomes. As the severity of anemia worsens, so do
the associated risks, which can result in prolonged hospitalization for postpartum clients (Smith et al., 2019;
Jefferds et al., 2022). Clients who have multiple births are twice as likely as those who have single births to develop
iron deficiency anemia (IDA) due to increased blood volume expansion and utilization of iron stores.

10.1 • The Impact of Nutrition on Hematologic Wellness Across the Lifespan 189
FIGURE 10.2 Human blood from a case of iron deficiency anemia. The red blood cells are pale and smaller than the larger white blood cells
shown in the image. (credit: “This photomicrograph of a Prussian blue stained bone marrow sample, revealed that there was a lack of iron
stores. Prussian blue staining for iron particles, which reveals little or no stainable iron in the bone marrow reticulum cells, and
normoblasts, is the definitive test for iron deficiency, in the case of iron deficiency anemia (IDA)” by CDC/Dr. Gordon D. McLaren, Public
Domain)
The third trimester of pregnancy is the highest risk period of gestation. If the pregnant client has anemia (any type)
during pregnancy, they will have a decreased tolerance of blood loss occurring during birth, increasing their risk for
hypovolemic shock, heart failure, infection, and the need for blood transfusion (Sharma et al., 2021; Smith et al.,
2019). See Table 10.1 for complications and risks associated with anemia in pregnancy.
Race disparities in nutritional anemia exist both globally and within the United States. According to data from the
National Health and Nutrition Examination Survey (NHANES), a program conducted by the National Center for
Health Statistics to assess the health and nutritional status of adults and children in the United States, non-Hispanic
Black pregnant women have the highest prevalence of IDA, particularly during the third trimester of pregnancy
(Sharma et al., 2021).
Maternal Risks for Developing Anemia in Maternal Complications of Fetal Complications of

Pregnancy Anemia Anemia
• Maternal age less than 20 years • Maternal death • Preterm birth
• Maternal age greater than 40 years • Cesarean delivery • Low birth weight
• Multiparous • Preeclampsia • Small for gestational
• Multiple pregnancy • Placenta previa with age
• In vitro fertilization hemorrhage • Fetal death
• Underweight before pregnancy • Placental abruption
• Prior cesarean delivery • Hypovolemic shock
• Hypertension
• Chronic disease
TABLE 10.1 Complications and Risks Associated with Anemia in Pregnancy
Screening for anemia and ID in pregnant clients to improve maternal and infant health outcomes is a secondary
health promotion intervention. The American College of Obstetricians and Gynecologists (2021) now recommends
screening for anemia in all pregnant clients at the first prenatal visit and, if detected, screening for iron deficiency.
However, current guidelines do not recommend prepregnancy iron screening. This decreases the chance of early
identification because individuals may not be aware they are pregnant until later in the pregnancy.
Iron deficiency and IDA are found equally often among pregnant individuals; however, ID alone doubles in the third
trimester and might go completely undetected if the client is asymptomatic (Cochrane et. al, 2022; Nour, 2022).
Iron requirements gradually increase during pregnancy from 0.8 mg/day to 7.5 mg/day by the third trimester. The
average Western diet includes 1–5 mg of iron daily from food sources; therefore, iron stores will be depleted quickly
from a pregnant client if not supplemented (Means, 2020). The Centers for Disease Control and Prevention (CDC)
recommends 30 mg/day of elemental iron at the start of pregnancy, and the WHO recommends 60 mg/day. If the
pregnant client is diagnosed with anemia during pregnancy, iron should be increased to 60–120 mg/day (National
Institutes of Health [NIH], 2023; WHO, n.d.-b).
CLINICAL TIP
Elemental vs. Nonelemental Iron

Elemental iron is a natural substance (heavy metal) directly used by erythrocytes in the body. Nonelemental iron
is a chemical compound of iron bound to salt, such as ferrous sulfate. Iron supplements contain an iron salt
compound because it is absorbed better than natural iron (Harvard T. H. Chan School of Public Health, 2023).
Various iron supplements are available over the counter, which is often confusing for patients and health care
professionals. Although health care providers often write prescriptions for iron supplementation, most
pharmacies do not carry a “prescription-strength” iron supplement, and clients are directed to over-the-counter
products. These product labels will contain two different amounts of iron, elemental and nonelemental;
therefore, when providing patient education, nurses must be aware of the amount of elemental iron prescribed
and teach clients how to read the labels.
Folate and Vitamin B12 Requirements

Before the United States FDA began mandating folate fortification in 1998, folate (vitamin B9) deficiency was a
common cause of anemia during pregnancy (Ismail et al., 2023). Folate demands increase during pregnancy to
support fetal and maternal tissue development (Ballestín et al., 2021). Both anemia and folic acid deficiency can
place the fetus at risk for neurologic compromise, including defects in brain development and in the myelination of
nerve fibers (Jefferds et al., 2022). Although not a common cause of anemia in most women, vitamin B12 deficiency
can cause serious maternal-fetal consequences for women with gastrointestinal malabsorption.
Folate and vitamin B12 deficiencies do not always result in macrocytic anemia during pregnancy; however, a
physiologic decline is expected (Achebe & Gafter-Gvili, 2017). Folate deficiency in pregnant clients can result in low
birth weight and small-for-gestational age (SGA) newborns. Adequate maternal intake of vitamin B12 is necessary to
support fetal growth and development. Signs and symptoms of vitamin B12 deficiency include fatigue, pallor,
tachycardia, poor exercise tolerance, and suboptimal work performance and should be considered in clients with a
history of malabsorption conditions (Achebe & Gafter-Gvili, 2017).
As a primary health promotion intervention, the WHO recommends 400 mcg daily of folic acid in pregnant clients
until 3 months postpartum. The CDC recommends 400 mcg/day of folic acid for all individuals of childbearing age to
prevent neural tube defects in the event of pregnancy. Prenatal vitamins generally contain 1 mg of folate; however,
doses of up to 5 mg/day are recommended for those with higher demands, such as during pregnancy in women who
have previously had a pregnancy affected by a neural tube defect (Khan, 2023).
Vitamin B12 Deficiency
Vitamin B12 is readily stored in excess in the liver, so most pregnant clients are not deficient. However, when
vitamin B12 cannot be obtained or absorbed, such as with dietary insufficiency or malabsorption, hepatic stores
are depleted, creating a deficiency (Ankar & Kumar, 2022). This includes pregnant clients with a history of a
strict vegan diet for the previous 3 years and those who have undergone bariatric surgery. The WHO and the NIH
recommend 2.6 mcg of vitamin B12 daily during pregnancy, increasing to 2.8 mcg postpartum if breastfeeding
(NIH, 2022).

The risk of developing vitamin B12 deficiency is higher for people who do not get vitamin B12 from their diet,
such as those who are vegetarian or vegan and those with health conditions or medication regimens that
interfere with absorption of the vitamin:
• Intestinal diseases
• Previous gastric or ileac resection
• History of celiac disease or inflammatory bowel disease
• Autoimmune disorders (Graves’ disease, thyroiditis, vitiligo)
• Prolonged use of proton pump inhibitors or H2 receptor antagonists
Clients with a proven deficiency will need higher doses of replacement therapy as follows:
• Deficiency from diet: 1000 mcg orally once daily

• Deficiency from malabsorption: 1000 mcg parenterally (intramuscular injection) once every 3–4 weeks
(Ankar & Kumar, 2022)
Infancy
Infancy, from birth to 12 months, is a period of intense physical and developmental growth. Hematopoiesis
(formation of blood cellular components) and hemostasis (usual reaction to a bleeding injury to stop blow flow) are
incomplete at birth, and micronutrient deficiencies can impair the child’s long-term potential. Requirements for
macronutrients and micronutrients are higher during infancy and childhood than other developmental stages and
are influenced by the rapid cell division occurring during growth (Physicians Committee for Responsible Medicine,
2020a). Research indicates that micronutrient deficiencies negatively affect the thymus, which can impact
lymphocyte function, increasing the risk of infection and inflammatory disease in children (Pai et al., 2018).
Infants receive passive immunity while in utero and through breast milk. This is partially the basis of the American
Academy of Pediatrics (AAP) recommendations for breast milk as the “sole source of nutrition for the first 6 months
of life, or as long as both mother and baby desire” (Meek et al., 2022). After 6 months, infants should be introduced
to supplemental solid foods, including iron-fortified infant cereal. Introducing supplemental foods can be
challenging for caregivers, leaving infants and toddlers at additional risk for nutritional deficiencies, especially if
food allergies or intolerances are identified. To ensure that infants and young children achieve desirable physical
and social milestones, nurses must be well versed in the nutritional considerations affecting this vulnerable
population. Educating potential and new parents regarding all health benefits for the breastfed infant is an essential
client-centered nursing intervention.
Infant Benefits of Breastfeeding
According to the AAP Section on Breastfeeding (Meek et al., 2022), exclusive breastfeeding for the first 6
months of an infant’s life can decrease risk for:
• Acute and chronic infections, including lower respiratory and ear infections and tooth decay
• Food allergies
• Sudden infant death syndrome (SIDS)
• Otitis media
• Eczema
• Asthma
• Childhood and adult obesity
• Types 1 and 2 diabetes
• Gastrointestinal discomfort, including vomiting, diarrhea, and colic
Anemia
According to the WHO, infantile and childhood anemia in the United States ranges from 6–18%, with higher rates
among low-income families. As with other age groups, ID is the most common cause of anemia, followed by other
nutritional anemias, vitamin B12, and folate (NIH, 2022).
Iron deficiency occurs in 12% of infants ages 6–11 months and 8% of toddlers in the United States. Among
toddlers, IDA ranges from 0.9–4.4%, depending on the racial and ethnic makeup and socioeconomics of the
household (NIH, 2023). During the first 2 years of life, iron needs are high to build iron stores and support the child’s
rapid physical and cognitive development rate. Premature infants, infants born to those with iron-deficiency, and
infants with low birth weight have been shown to have lifelong learning and memory deficits because of damage to
the hippocampus, the brain’s memory center. Accordingly, clinical consequences of ID and IDA in children include
(Benson et al., 2022; Drakesmith et al., 2021):
• Impaired psychomotor development and cognitive function

• Delayed attention skills
• Social withdrawal
• Decreased leukocyte and lymphocyte function
• Decreased response to childhood vaccines
• Increased neurotoxicity when ID is associated with high lead blood concentrations
Infant iron stores start to diminish at 6 months of age. After this time, breastfed infants are at greater risk for anemia
because the iron content of breast milk depends on the lactating person’s diet, whereas infant formula is fortified
with iron. Full-term infants are at the highest risk between ages 6 months and 9 months if they are not consuming
iron-fortified formula or successfully introduced to solid foods rich in iron (NIH, 2023). Additionally, children
younger than 2 years are more likely than older children to have IDA associated with a transition to solid foods.
Recommendations for preventing and treating ID and IDA are shown in Table 10.2.
Recommending Infant Considerations Iron Dosing Iron-Fortified Foods

Organization
Centers for Disease Less than 12 months old, Iron-fortified formula Label will indicate “with
Control and Prevention not exclusively breastfed iron”
Less than 12 months old, 2–4 mg/kg/day
preterm or small for elemental iron until 12
gestational age, months old
exclusively breastfed
Less than 12 months old, Consult health care • Infant rice cereal
full-term, and provider for • Commercially
appropriate for recommendations. prepared baby food:
gestational age, beef, turkey, pork,
exclusively breastfed *If eating iron-fortified lamb, spinach
foods starting at 6 • Mashed chickpeas,
months old, iron white beans, broccoli
supplement may be • Pureed or mashed
discontinued. sweet potatoes; soft,
cooked beans; green
peas
American Academy of 4–12 months old, full- 1 mg/kg/day elemental

Pediatrics term, exclusively iron until eating iron-
breastfed fortified solid foods
TABLE 10.2 Recommendations for Iron Supplementation in Infants

Recommending Infant Considerations Iron Dosing Iron-Fortified Foods

Organization
1–12 months old, 2 mg/kg/day elemental
preterm, exclusively iron until 12 months old
breastfed
World Health 6–23 months old if diet 2 mg/kg/day elemental
Organization does not include iron- iron until 24 months old
fortified foods, or if living
in a region where anemia
prevalence is greater
than 40%
TABLE 10.2 Recommendations for Iron Supplementation in Infants
Individuals living at high altitudes (greater than 1,500 m) are at increased risk for anemia secondary to increased
erythropoiesis. This is a compensatory response to a lower oxygen saturation of the blood, so health care
professionals must interpret hemoglobin carefully by using altitude-adjusted algorithms (Mairbäurl et al., 2023).
Children living at high altitudes may need a greater intake of iron and micronutrients to avoid growth and
development delays (Sharma et al., 2019).
Bleeding Risks
Vitamin K is an essential fat-soluble vitamin required for adequate blood clotting. Infants have minimal vitamin K
stored at birth because only small amounts pass through the placenta. Vitamin K comes from one of two sources:
diet or synthesis by anaerobic (relating to absence of oxygen) bacteria located in the stomach (Yan et al., 2022). A
newborn with a healthy gut will not have bacteria-producing vitamin K until approximately 1 week of life. In addition,
breast milk contains low quantities of vitamin K. All infants are therefore at high risk for vitamin K deficiency
bleeding (VKDB) until they start eating solid foods, which usually occurs at age 4–6 months (Araki & Shirahata,
2020). VKDB is a condition associated with uncontrolled bleeding due to lack of sufficient vitamin K to form blood
clots.
To prevent VKDB, the American Academy of Pediatrics (2022) recommends intramuscular (IM) vitamin K
prophylaxis as follows:
• Infant birth weight greater than 1500 g: 1 mg vitamin K IM within 6 hours of birth
• Infant birth weight less than 1500 g: 0.3–0.5 mg/kg IM within 6 hours of birth
This risk for VKDB is increased for the following infants:
• Premature infants
• Infants who did not receive vitamin K replacement shortly after birth
• Infants born to mothers with malabsorption or use of antiseizure drugs, antibiotics, warfarin, or antitubercular
medications
• Infants with malabsorption, cholestasis (slowing or halt of bile flow from the liver), or liver disease
Table 10.3 outlines the three types of VKDB according to the time of presentation. Early and classic VKDB occur in 1
in 60 to 1 in 250 newborns whereas late VKDB occurs in 1 in 14,000 to 1 in 25,000 infants. Newborns who do not
receive a vitamin K injection are 81 times more likely to develop late VKDB (Hand et al., 2022).
Type Timing Associated Factors

Early Within 24 hours after birth • Maternal malabsorption or maternal use of specific
medications
• A spectrum of symptoms from simple bruising to life-
threatening cranial hemorrhage
Classic Within 1 week after birth • No prophylaxis was received or poorly feeding
• Exclusively breastfed
Late Between 2 weeks and 6 • Peaks 2–8 weeks after birth

months after birth • No prophylaxis was received and infant exclusively breastfed
• Infant malabsorption or cholestasis
• Most life-threatening: cranial hemorrhage in 30–60%
TABLE 10.3 Types of Vitamin K Deficiency Bleeding (sources: Araki & Shirahata, 2020; CDC, 2023b)
Childhood
A variety of nutritional inadequacies exist among school-aged children (aged 5–12 years), ranging from overeating
(caloric excess) to undereating, often due to food insecurity. Children who overeat or undereat are at risk for
hematologic consequences from nutritional deficiencies. Iron deficiency is the most common micronutrient
deficiency in school-aged children, although this age group has the lowest prevalence overall among all children.
Anemia in school-aged children is highest among non-Hispanic Black children, and iron deficiency is explicitly
highest among Mexican American children. The etiology of deficiency is mostly diet related, apart from children with
malabsorption conditions (Jefferds et al., 2022).
Iron plays an essential role in brain metabolism and neurotransmitter function, and deficiencies can lead to
cognitive dysfunction (Pivina et al., 2019). School-aged children are undergoing steady linear growth and a high
amount of cognitive processing. Iron deficiency with or without anemia can cause decreased school performance
due to poor attention span, poor memory, and visual and auditory deficits, compromising “socioemotional
development” (Rodríguez-Mañas et al., 2023). Children participating in extracurricular activities may have low
energy, negatively impacting their physical performance. Signs and symptoms related to IDA often have a gradual
onset in school-aged children and may not be easily detected. Research has shown a positive link between children
with attention-deficit hyperactivity disorder (ADHD) and IDA. Therefore, children over 4 years of age demonstrating
poor attention or impulsivity should be evaluated for ID (Mattiello et al., 2020). If it is detected, treatment and
dietary changes are recommended to ensure intake of 3–6 mg/kg/day of elemental iron for 2–3 months.
Vitamin D Deficiency
Fat-soluble vitamin D is essential for calcium absorption, which takes place in the gastrointestinal tract. It is
necessary for optimal bone growth; in addition, vitamin D modulates adaptive immunity, and deficiency is
associated with an increased risk of infection (Giannini et al., 2022). The fortification of milk with vitamin D
significantly decreased the prevalence of rickets, a softening and weakening of bones that can result in bone
deformities. However, with fewer children playing outside and an increase in the use of sunscreen, vitamin D
deficiency is once again a public health problem, affecting 15% of children aged 1–11 years (Porto & Abu-Alreesh,
2022). Children at increased risk for vitamin D deficiency include those with:
• Decreased dietary intake of vitamin D

• Dark skin tones
• Excess weight
• Decreased sun exposure
• Malabsorption diseases, including celiac disease, cystic fibrosis, pancreatic insufficiency, and short bowel
syndrome
The AAP recommends that all infants younger than 12 months old receive 400 units of supplemental vitamin D daily
and that children older than 12 months old receive 600 units daily (Porto & Abu-Alreesh, 2022). Children with risks
for deficiency or known deficiency will need higher doses.

Zinc Deficiency
Zinc is a mineral that is essential for growth in children. Deficiencies can impact hematopoiesis, resulting in poor
immunity and poor wound healing. Zinc deficiency affects approximately 31% of toddlers 1–3 years old in the
United States and up to 80% globally, usually due to poor diet or situations of food insecurity (Vreugdenhil et al.,
2021). Zinc is naturally found in meats, poultry, fish, dairy, eggs, and dry legumes, and in the United States, grains
and infant cereals are fortified with zinc. Strict vegetarians are at high risk for zinc deficiency because the body does
not readily absorb the zinc found in fruits, vegetables, and bread.
Adolescence
Adolescence is the second time in childhood when rapid growth and development occur. Physically, socially, and
psychologically, the energy and micronutrient demands are high. However, parental influence on food choices
diminishes during this time, often leading to nutritional deficiencies, most commonly iron.
Adolescence is a time of increased iron needs because of the expansion of blood volume and increase in muscle
mass. There are sex differences in ID without anemia in adolescents: 9–20% in females but less than 1% in males.
The prevalence of IDA in adolescent females who are not menstruating is 3% (Mattiello et al., 2020). Young females
are at particular risk for developing iron deficiency because of menstruation. Approximately 7% of menstruating
adolescents have IDA, and those who experience menorrhagia (heavy menstrual bleeding) are at increased risk
(Eiduson et al., 2021; Mattiello et.al., 2020). It is difficult to quantify heavy menstrual bleeding outside of clinical
trials; however, excessive menstrual blood loss that affects quality of life requires further evaluation and treatment
(Mansour et al., 2021). Counting how often sanitary pads or tampons are changed can aid in estimating the amount
of blood loss; for example, changing sanitary pads or tampons every 1–2 hours is consistent with heavy menstrual
bleeding (Fulton, 2022). Common signs and symptoms of ID and IDA in adolescents include:
• Decreased psychomotor skills

• Poor concentration
• Decreased academic performance
• Shortness of breath
• Rapid heart rate
• Headaches
• Dizziness and fainting
• Restless leg syndrome
• Irritability
• Mild weakness
• Fatigue and the need to nap more frequently
Oral iron replacement is recommended as the first step for treating ID and IDA in adolescents, at a dosage of 3–6
mg/kg of elemental iron daily for 2–3 months (Miniero et al., 2019). Adolescents will also need counseling regarding
dietary modifications and ways to manage potential adverse effects of iron replacement. Long-term dietary changes
will be necessary for female adolescents with ID or IDA associated with menstruation. For therapy to be successful,
dietary modifications should reflect individual preferences. Vegetarian options may include legumes, beans, tofu,
rolled oats, and quinoa.
Part A
The nurse prepares to assess Catalina for more details about her past medical history and current health concerns.
Catalina reports that prior to the past few months, she had felt great and had managed her grades and social life
well. She does not take any medications regularly, including daily vitamins. Her mother confirms that she has no
significant past medical issues, which makes her current symptoms more concerning. Catalina never complains and
has always prioritized her grades. Catalina and her mother confirm that nothing has changed in their social
circumstances, and Catalina denies symptoms of depression.
The nurse is aware that adolescent females are at risk for anemia and ID once menstruation begins and therefore
takes a detailed menstrual bleeding history. Catalina reports that she has had regular menstrual cycles lasting 5–7
days since age 13 years but has noticed an increase in the heaviness of her flow this school year. She further says
that her use of sanitary pads has increased, and she must change her pad every 1–2 hours during the day and night.
The nurse recognizes this as a sign of heavy menstrual bleeding and notifies the health care provider of her concern
that Catalina may be anemic and iron deficient.
1. What is an expected dose of oral iron supplement for Catalina?

a. 3 mg/kg/dose twice daily for 3 months
b. 6 mg/kg/dose twice daily for 3 months
c. 3–6 mg/kg/day for 6 months
d. 3 mg/kg/day until anemia is resolved
2. Which of the following strategies would be most effective when providing diet instruction to Catalina?
a. Ask her to identify her food likes and dislikes.
b. List the foods she must eat each week.
c. Explain that she needs to make these changes on just a short-term basis until her anemia resolves.
d. Explain that the iron supplement has side effects that she will have to tolerate if she is prescribed that
medication.
The Adolescent Athlete
Adolescent athletes face unique challenges related to nutritional needs. They are already at risk for nutritional
deficiencies because of rapid growth, unhealthy food choices, and high-risk behaviors. Adolescent athletes have
a high nutritional demand due to the daily energy expenditure associated with training and having less time to
make healthy food choices. Additionally, many athletes strive for a lean body composition for a competitive
edge, setting them up for disordered eating patterns that can have lifelong effects on their overall health
(Kontele & Vassilakou, 2021). Adolescent athletes who limit their intake of meat products are at even higher risk
for iron imbalance. Because of increased iron needs combined with potentially low iron intake and increased
blood loss from menstruation, ID and IDA are common problems among adolescent female athletes and can
affect their physical endurance and cognitive performance. In males, ID is often associated with higher
physiologic needs from excessive training rather than from diet alone (Desbrow, 2021).
Iron deficiency can manifest as extreme fatigue, increased susceptibility to infection, impaired skeletal muscle
function, and poor decision-making (Berg, 2019). Assessment for ID and IDA should be considered for both
male and female athletes demonstrating these symptoms. Athletes at the highest risk for iron deficiency include
those who are female; are underweight or undernourished; are vegetarian or consume limited amounts of iron-
rich foods; have underlying malabsorption conditions; or compete in endurance sports.
Adulthood
As in other age groups, ID and IDA remain the highest cause of anemia in young and middle adults, although other
nutrient deficiencies such as folate and vitamin B12 contribute (NIH, 2023). In adults ages 19–50, males require
more zinc and vitamins C, K, and B complex, and menstruating females of the same age require more iron. Females
are twice as likely as males to have nutritional anemia, and moderate to severe anemia is five times more common
in nonpregnant females than in males. Race differences are prevalent, with the highest incidence in non-Hispanic
Black adults, followed by Hispanic and White individuals (Malek et.al, 2019; Physicians Committee for Responsible
Medicine, 2020a; Rodríguez-Mañas et al., 2023).
Modern health care relies on healthy adults to maintain the blood supply. However, 25–35% of frequent blood
donors will develop ID, which may not be detected if it is present without anemia (NIH, 2023). This raises concern
for the frequent blood donor’s health and the quality of blood they donate (Hod et al., 2022).

Folic acid, vitamin B12, and vitamin K deficiencies in adults can also be secondary to chronic liver disease and
excessive alcohol intake. Middle adults in the United States consume less than the recommended daily
requirements for most essential micronutrients, leading to deficiencies that increase the risk for certain chronic
conditions. Chronic diseases are now increasingly common among young adults, often because of poor nutrition,
lack of physical activity, and smoking (Rodríguez-Mañas et al., 2023). Sixty percent of adults with chronic heart
failure have ID, and 17% of those have IDA. The etiology of this is multifactorial and may be related to:
• Poor nutrition
• Malabsorption
• Defective mobilization of iron stores
• Cardiac cachexia (unintentional severe weight loss caused by heart failure)
• Use of aspirin or other anticoagulant medications that can lead to microscopic blood loss in the gastrointestinal
tract
The economic burden on adults with IDA includes reduced physical productivity and work capacity due to
associated symptoms such as fatigue, weakness, and shortness of breath (Jefferds et al., 2022).
Later Adulthood
Aging naturally impacts physical changes, even in the healthiest adults, but healthy aging depends on proper
nutrition (Kaur et al., 2019). Although energy needs decrease with age, specific micronutrient needs increase. As
they age, adults become susceptible to nutrient-deficient blood abnormalities secondary to a decreased production
of hormones and red blood cells, as well as decreased appetite and food intake related to delayed gastric emptying
and declining oral health. In addition, older clients may experience nutritional challenges due to age- or disease-
related conditions associated with chewing, swallowing, digestion, and absorption of nutrients (Physicians
Committee for Responsible Medicine, 2020a). Malnutrition in this phase of life can result in lower physical function,
poor quality of life, a greater risk for loss of muscle mass, and a shorter lifespan (Kaur et al., 2019; Rodríguez-Mañas
et al., 2023).
Zinc deficiency occurs in approximately 60% of adults older than 70 years, leading to an increased risk for infection.
Decreased dietary zinc intake and the physiologic decline in gastrointestinal absorption are the most likely reasons
for this deficiency (Kaur et al., 2019).
Iron Deficiency
Older adults have the greatest incidence of nutritional anemia overall, with those aged 80–85 years having the
highest. This is the only age group in which males have a greater incidence of anemia than females—as much as two
times more. Older adults with anemia have increased hospitalization rates and mortality. Approximately 25–30% of
older adults with congestive heart failure have anemia, worsening functional capacity, and are at increased risk of
death (Ambrosy et al., 2019). With advancing age, iron stores diminish. This, along with decreased dietary intake of
iron-rich foods and increased incidence of gastrointestinal malabsorption and occult blood loss, contributes to ID
and IDA in older adults (Burton et al., 2020; Kaur et al., 2019). The prevalence of IDA in older adults is detailed in
Table 10.4.
Age Male Female

65–75 years 11% 10.2%
76–85 years 15% 7–12%
Older than 85 years 30% 17%
TABLE 10.4 Prevalence of Iron Deficiency Anemia in Older Adults (Kaur et al., 2019)
Signs and symptoms of IDA in older adults may include:
• Depression
• Fatigue
• Loss of muscle strength
• Decreased cognitive function
Iron-rich foods, such as fortified grains and cereals, and oral replacement are the first step once a deficiency is
confirmed; however, parenteral iron replacement may be required due to the frequency of gastrointestinal
malabsorption in this population (Burton et al., 2020).
Folate and Vitamin B Deficiencies

Vitamin B12 and folate deficiencies among older adults remain a significant challenge. Approximately 10–30% of
older adults are affected by atrophic gastritis, which can interfere with the absorption of vitamin B12 and folate
(NIH, 2022). Additionally, the metabolic processes of each micronutrient are interconnected, so it is difficult to
distinguish the source of physical manifestations (Socha et al., 2020). Signs and symptoms include:
• Risk for cardiovascular disease

• Cognitive impairment
• Insomnia
• Impaired mood
• Decreased decision-making ability
• Decreased physical performance, leading to increased risk for falls and fractures
Folate deficiency is more likely to be related to decreased absorption and reduced dietary intake, whereas vitamin
B12 deficiency is more often associated with diseases of malabsorption and polypharmacy. Mild vitamin B12
deficiency occurs in 20% of adults older than 60, and severe deficiency occurs in 6% of adults older than 70 (NIH,
2022). Nonhematologic symptoms range from vague and nonspecific to severe neurologic and neuropsychiatric
disorders (Stauder et al., 2018). Folate deficiency is reported to occur in 5–20% of older adults and is more
common in those who smoke, consume excessive amounts of alcohol, are obese, or live alone (Rotstein et al.,
2022). Vitamin B12 deficiency anemia is more likely to be associated with neurologic symptoms not seen in
individuals with folate deficiency anemia (Stauder et al., 2018). Anemia associated with both of these deficiencies
can be distinguished from IDA based on the size of red blood cells; iron deficiency anemia is microcytic, whereas
folate and vitamin B12 deficiencies are macrocytic. Treatment is focused on nutrient replacement and diet
modification.
10.2 Nutrition and Chronic Hematologic Illness

LEARNING OUTCOMES
• 10.2.1 Discuss the impact of nutrition on congenital hematologic disorders.
• 10.2.2 Discuss the impact of nutrition on cancers.
Congenital Hematologic Disorders

Sickle cell disease (SCD), a genetic hemoglobinopathy with chronic anemia, is the most common inherited blood
disorder in the United States (McCaskill et al., 2018) and affects the shape of hemoglobin, resulting in blocked blood
flow. Individuals with SCD are more prone to micronutrient and macronutrient (carbohydrate, fat, and protein)
deficiencies related to hyperreactive hematopoiesis, the physiologic response caused by chronic anemia. Nutrient
deficiencies (Table 10.5) further increase systemic oxidative stress (disturbance in the balance between the
production of free radicals and antioxidant defenses) and contribute to severe and frequent sickle cell vaso-
occlusive crises. These deficiencies can cause the following in people with SCD (Umeakunne & Hibbert, 2019):
• Delayed growth and development

• Decreased quality of life
• Chronic inflammation
• Painful vaso-occlusive crises
• Increased occurrence of stroke, pulmonary hypertension, heart disease, and renal disease
As with SCD, thalassemia is a genetic hemoglobinopathy, characterized by less oxygen-carrying protein and fewer
red bloods cells. There are multiple genetic forms ranging in severity. Thalassemia carries the same nutritional risks
as SCD does.
Table 10.5 outlines additional micronutrient deficiencies and recommended interventions.

10.2 • Nutrition and Chronic Hematologic Illness 199
Micronutrient Deficiency Recommended Foods/Interventions

Vitamin D* Milk, yogurt, cheese
Vitamin A Carrots, sweet potatoes, kale, spinach
Vitamin C Kiwis, oranges
Vitamin E Mustard greens, sunflower seeds
Zinc Nuts, fish, whole grains, dairy products
Folic acid 1 mg daily supplement
Leafy green vegetables
Vitamin B12 Steamed shrimp, baked snapper, whole grain breads
Omega-3 fatty acids Meats, beans, nuts, seeds, vegetable oils
*Vitamin D deficiency is five times more likely to occur in children with SCD than in children without SCD and is
associated with increased hospitalizations (McCaskill et al, 2018).
TABLE 10.5 Common Nutrient Deficiencies in Congenital Hematologic Disorders (source: Sickle-Cell.com, 2023)
Genetic Hemochromatosis
Genetic hemochromatosis causes excessive absorption of dietary iron secondary to decreased expression of the
peptide hormone hepcidin. It is the most common autosomal recessive disorder in White individuals, affecting one
in 300–500 people of northern European descent (Porter & Prashanth, 2023). It is twice as common in males as
females and can result in multiple organ dysfunction. Excessive intestinal dietary intake of heme and nonheme iron
is primarily managed by dietary modifications (Milman, 2021). These modifications are extensive and require
nutritional counseling and reinforcement by health care professionals:
• Consider a vegetarian or semivegetarian diet.

• Consume 21 oz of fruit and vegetables daily; fresh is best.
• Avoid red meat from mammals; instead, choose lean, white poultry.
• Avoid processed meat. Consume no more than 7 oz of meat from poultry per week. Consider additional protein
sources such as fish, eggs, and legumes.
• Choose whole grains; avoid iron-enriched grains.
• Beverages should consist of water, green or black tea, coffee, and low-fat milk. Avoid alcoholic beverages.
Hemophilia
Hemophilia is an inherited X-linked blood disorder resulting in decreased levels of clotting factor VIII or IX.
Occurring in 1 in 5,000 male births, this deficiency results in spontaneous bleeding, often in joints, and severe
bleeding following injury or trauma (CDC, 2023a). Nutritional considerations include managing weight and
maintaining iron levels to avoid IDA. Obesity is common secondary to a sedentary lifestyle to avoid injury-induced
bleeding; however, consequences of decreased physical activity include more stress on the joints and muscle
strains that can result in musculoskeletal bleeding (Lim et al., 2020). A recommended diet includes iron-rich foods
such as lean red meat, leafy green vegetables, broccoli, dried beans, grains, and raisins. It is important to consume
foods containing vitamin C, such as orange juice, to enhance iron absorption.
EFFECT OF MISSHAPEN RED BLOOD CELLS ON BLOOD FLOW
Access multimedia content (https://openstax.org/books/nutrition/pages/10-2-nutrition-and-chronic-

hematologic-illness)
The American Society of Hematology (2009) offers a video that demonstrates how blood flow is affected by
misshapen red blood cells.
Impact of Cancer on Nutrition and Hematologic Function

Advanced age is a risk factor for nutritional deficiency; the addition of chronic diseases, including malignancy, can
quickly lead to malnourishment. These comorbidities can contribute to reduced tolerance of anticancer therapy,
impacting survival (Stauder et al., 2020).
The prevalence of anemia in cancer can exceed 90% across all ages and is generally considered to be related to
medications, infections, or disorders of hematopoiesis. Common concerns are alterations in activities of daily living
affecting quality of life, decreased productivity, and inability to work. Fatigue is reported as the most common
troubling symptom of cancer and is directly linked to anemia (Gilreath & Rodgers, 2020). Fatigue and lack of
appetite commonly coexist, resulting in an inability to prepare meals, further exacerbating anemia.
Anemia was traditionally believed to be primarily related to the adverse effects of anticancer therapy; however,
recent research has shown a direct correlation with chronic, low-grade inflammation. Functional iron deficiency
(state in which iron is insufficiently incorporated into erythroid precursors even though body iron stores are
apparently adequate), malnutrition, and anorexia contribute to cancer-associated anemia (Natalucci et al., 2021).
See Table 10.6 for types of IDA in cancer. In contrast, iron overload can occur in clients with symptomatic anemia
receiving red blood cell transfusions and can alter the function of effective hematopoiesis, contributing to anemia
(Gilreath & Rodgers, 2020). Other micronutrient deficiencies affecting hematologic function in individuals with
cancer include folate and vitamin B12.
Approximately 50% of adults with colon cancer have anemia due to chronic blood loss from the gastrointestinal
tract (Chardalias et al., 2023). The prevalence of anemia in other cancers ranges from 29–46%, mainly related to
chronic disease, chemotherapy-induced anemia, nutrient-related anemia, chronic anorexia, and gastrointestinal
adverse effects such as nausea, vomiting, and diarrhea (Busti et.al., 2018).
Iron Deficiency Etiology

Absolute iron deficiency anemia Associated with bleeding; total body iron stores diminish.
Iron sequestration* Inflammation results in iron being unavailable for erythropoiesis.
Iron-restricted erythropoiesis* Erythropoiesis therapy (epoetin) outpaces iron delivery from storage.
*Functional iron deficiency anemia
TABLE 10.6 Types of Iron Deficiency Anemia in Cancer
Nutritional Interventions
Chronic illness has a significant impact on nutrition and, consequently, hematologic wellness. Recommendations
have evolved due to more emphasis on a holistic approach to caring for those with hemoglobinopathies and cancer.
The Mediterranean diet has gained popularity in the United States as a way to manage weight, lower cholesterol,
and stabilize blood sugar. Close investigation of the constituents of this eating lifestyle reveals significant anti-
inflammatory properties that translate well to chronic hematologic illness. Extra-virgin olive oil is has been found to
block the proinflammatory cascade (Natalucci et al., 2021).
The following foods and substances rich in antioxidants contribute to anti-inflammatory and microbiota-modulating
properties:
• Phytochemical vitamins in red, orange, and yellow fruits and dark green leafy vegetables
• Ginger
• Green tea
• Garlic
• Black pepper
• Turmeric
To avoid severe nutritional deficiencies, a high-calorie, nutrient-rich diet is essential for people living with SCD and
thalassemia. Increased oral hydration is vital in SCD to decrease the frequency of painful vaso-occlusive events.
Additional recommendations include daily supplements of omega-3 fatty acids, folic acid, high-dose vitamin D, and
a multivitamin without iron. For clients with thalassemia specifically, drinking black tea may decrease the
gastrointestinal absorption of iron (Goldberg et al., 2018; Physicians Committee for Responsible Medicine, 2020b;
Srichairatanakool et al., 2020).
People with SCD and vitamin D deficiency consuming a diet rich in fish, milk, cheese, and eggs were found to have
decreased hospital and emergency department visits (McCaskill et al., 2018). High-dose vitamin D replacement
(greater than 3000 units per day) has been found to augment immune response and decrease the risk of respiratory

infections in SCD (Umeakunne & Hibbert, 2019). Recent literature strongly correlates that vitamin D and chronic
inflammation play an important role in regulating iron homeostasis, which can improve anemia (Natalucci et al.,
2021).
Adults living with hemoglobinopathies should avoid drinking alcohol because it potentiates the oxidative damage
caused by iron overload (Milman, 2021).

LEARNING OUTCOMES
• 10.3.1 Identify drug–food interactions for their impact on treatments used for hematologic disorders.
hematologic disorders.
Drug–Food Interactions with Treatments for Hematologic Disorders

Some treatments for hematologic disorders will not work as intended if taken with certain foods. Limiting groups of
foods during an already vulnerable state of nutritional need can lead to additional micronutrient deficiencies. For
example, individuals requiring iron replacement are instructed to avoid cereals, dietary fiber, tea, coffee, eggs, and
milk while taking iron supplements because these foods are known to decrease iron absorption (Moustarah, 2022).
Unlike individuals with other hematologic illnesses previously discussed, individuals with SCD and thalassemia are
at risk for iron overload rather than iron deficiency. The primary cause of iron overload is red blood cell transfusion
therapy. However, iron overload can occur in people with and without transfusion-dependent thalassemia because
of intestinal absorption of iron secondary to ineffective erythropoiesis (Srichairatanakool et al., 2020). These
individuals are therefore counseled to avoid iron-rich foods. The rate of iron accumulation varies and correlates with
the number of red blood cell transfusions received. Each unit of packed red blood cells contains 200–250 mg of
elemental iron, equating to 0.3–0.6 mg/kg/day of elemental iron, and most transfusion-dependent older children
and adults will receive 2–4 units of blood monthly. The symptoms and associated health risks from iron overload
depend on where the iron accumulates. The liver, heart, and endocrine glands are the most common initial sites
(Srichairatanakool et al., 2020). Frequent complications of iron overload in people living with hemoglobinopathies
include:
• Increased risk for thrombosis

• Pulmonary hypertension
• Hypothyroidism
• Hypogonadism
• Osteoporosis
Nurses should ensure client rights regarding medication administration, which includes understanding any
contraindications and drug–food interactions. Equally important is a nutritional evaluation prior to the start of
treatment for hematologic disorders and the development of a plan to avoid further nutritional deficiencies that can
impact the desired response of treatment.
Part B
Study Part A.
Catalina’s health care provider confirms that her physical exam is normal other than signs of pallor. A complete
blood count (CBC) and ferritin level are ordered to evaluate for ID and anemia. Catalina is also referred to a
gynecologist for further evaluation of her heavy menstrual bleeding.
Catalina’s laboratory test results reveal a hemoglobin level of 7 g/dL (expected range: 12–15 g/dL) and a ferritin
level of 9 ng/mL (expected range: 12–150 ng/mL), confirming IDA. She is started on oral iron replacement and
counseled on foods to avoid while taking oral iron for better absorption. She is also encouraged to add iron-rich
foods to her diet daily and to return in 6 weeks.
At her 6-week follow-up visit, Catalina reports that she is feeling less tired, and her shortness of breath has
resolved. Her hemoglobin level at this visit is 10 g/dL. She has also been evaluated by a gynecologist and started on
oral birth control pills to decrease her heavy menstrual bleeding. Catalina is instructed to continue oral iron therapy
for at least 2 more months and then return for follow-up.
3. The nurse should include which of the following in Catalina’s discharge instructions regarding taking oral iron?
a. Iron should be taken with milk or tea.
b. If stomach discomfort occurs, take the iron with an antacid.
c. If a dose is missed, double the dose for the next day.
d. Iron should be taken with orange juice to enhance absorption.
4. Which of the following may indicate that Catalina’s iron dosage is not adequate or that the iron is not being
fully absorbed?
a. Constipation
b. Increased appetite
c. Weakness and dizziness
d. Increased menstrual bleeding
Treatments and Medications That Can Cause Nutritional Deficiencies

Treatments for hematologic malignancies can lead to nutritional deficiencies due to decreased food intake that is
secondary to adverse treatment effects such as nausea, vomiting, diarrhea, mouth sores, and loss of appetite.
Traditional chemotherapy and novel targeted therapy can affect taste and saliva production, further affecting the
individual’s interest in food.
Several of the most frequent hematologic malignancies, such as myelodysplasia and multiple myeloma (a blood
cancer affecting plasma cells found in bone marrow), occur in older adults. The average age at diagnosis for
hematologic malignancies in adults is 70 years, and 40% already have reduced food intake. The prevalence of
malnutrition in these individuals is approximately 30% and is more common in male clients (Stauder et al., 2020).
Associated symptoms include a high systemic inflammatory score, alterations in mood and cognition, and moderate
to severe fatigue. Decreased food intake, weight loss, low body mass index, and laboratory evidence of
malnourishment have been associated with decreased survival rates in older adults with hematologic malignancies
(Stauder et al., 2020). A complete nutritional assessment, timely intervention with micronutrient and macronutrient
replacement, and dietary referral are essential.

Chapter Summary
• Common vitamin and mineral deficiencies that associated with training and less time available to
impact hematologic wellness across the lifespan make healthy food choices, putting them at high
include deficiencies of iron, vitamin B12, folate, risk for iron deficiency and anemia.
and vitamins A, C, D, and K. • Folic acid, vitamin B12, and vitamin K deficiencies
• Anemia affects approximately 1.8 billion in adults can occur secondary to chronic liver
individuals worldwide, most often affecting young disease and excessive alcohol intake.
children, pregnant individuals, and older adults. • Individuals with SCD and thalassemia are more
• Non-Hispanic Black pregnant clients have the prone to micronutrient and macronutrient
highest prevalence of IDA, particularly during their deficiencies related to hyperreactive
third trimester of pregnancy. hematopoiesis, the physiologic response to
• Adolescent athletes have a high nutritional chronic anemia.
demand due to daily energy expenditure
Key Terms
anaerobic relating to the absence of oxygen (NHANES) a health-related program conducted by
cardiac cachexia unintentional severe weight loss the Centers for Disease Control and Prevention’s
caused by heart failure National Center for Health Statistics designed to
cholestasis the slowing or halt of bile flow from the assess the health and nutritional status of adults
liver and children in the United States
erythropoiesis the production of red blood cells oxidative stress disturbance in the balance between
functional iron deficiency a state in which iron is the production of reactive oxygen species (free
insufficiently incorporated into erythroid precursors radicals) and antioxidant defenses
even though body iron stores are apparently passive immunity a type of immunity conferred when
adequate a person is given antibodies rather than making
hematopoiesis the formation of blood cellular them via their own immune system
components primary health promotion an intervention to prevent
hemoglobinopathy a group of disorders in which the disease or injury before it occurs
hemoglobin molecule has abnormal production or secondary health promotion an intervention that
structure emphasizes early disease detection through
hemostasis the usual reaction to a bleeding injury to screening
stop the blood flow sickle cell disease an inherited red blood cell
menorrhagia heavy menstrual bleeding lasting more disorder affecting the shape of hemoglobin,
than 7 days resulting in blocked blood flow
multiple myeloma a blood cancer affecting plasma thalassemia an inherited blood disorder
cells that are found in the bone marrow; abnormal characterized by less oxygen-carrying protein
plasma cells multiply rapidly, crowd out normal (hemoglobin) and fewer red blood cells in the body
blood-producing cells, and produce an abnormal vitamin K deficiency bleeding (VKDB) uncontrolled
protein that leaves the bone marrow and damages bleeding due to lack of sufficient vitamin K to form a
organs in the body blood clot
National Health and Nutrition Examination Survey
Review Questions
1. Which of the following nutritional deficiencies can impact hematologic wellness across the lifespan?
a. Vitamin C
b. Vitamin B12
c. Magnesium
d. Calcium
2. Anemia affects which population the most often?

a. Pregnant individuals
b. School-aged children
c. Male and female adolescents

d. Middle-aged females
3. Infants and young children are at high risk for iron-deficient anemia related to which of the following?
a. Inability to chew meat
b. Rapid growth
c. Frequent use of a bottle
d. Little interest in food
4. Which of the following statements by a parent can indicate that their child is at an increased risk for vitamin D
deficiency?
a. “My child prefers chocolate milk to plain milk.”
b. “I am careful to put sunscreen on my child every time we go outside.”
c. “My child has lost some weight since the last visit.”
d. “My child loves to eat tuna fish sandwiches.”
5. You are reviewing the chart of a 15-month-old toddler who was brought to the emergency department for
fever for the fourth time this month. The child’s father reports that the child was weaned off infant formula 3
months ago and is allergic to eggs and lactose. You suspect this child may have a deficiency of which
micronutrient?
a. Vitamin K
b. Zinc
c. Folate
d. Vitamin B12
6. The nurse is teaching a client about sickle cell disease. Which of the following dietary strategies can decrease
the risk of disease complications?
a. Eating several small meals throughout the day
b. Limiting carbohydrate intake
c. Consuming dairy products and other sources of vitamin D
d. Avoiding seafood
7. Folate deficiency is more common in older adults who:

a. Are underweight
b. Follow a vegetarian diet
c. Consume alcohol daily
d. Eat at restaurants several times a week
8. Which of the following blood disorders is associated with the most nutritional deficiencies?
a. Thalassemia
b. Sickle cell disease
c. Aplasia
d. Iron overload
9. A client with thalassemia is being discharged after receiving a transfusion of packed red blood cells. Which of
the following foods should the client be instructed to limit in their diet?
a. Nuts
b. Dairy products
c. Apples
d. Iron-fortified breakfast cereals
10. Which of the following diets can be beneficial for people living with chronic illness and nutritional anemia?
a. High-fat diet

b. High-protein diet
c. Mediterranean diet
d. Low-fat diet
Suggested Reading
Abdou, M. (September 29, 2019). Nutrition and Blood. https://askhematologist.com/nutrition-and-blood/
American Academy of Pediatrics Healthy Children Nutrition. (n.d.). Ages & Stages. https://www.healthychildren.org/
English/ages-stages/baby/feeding-nutrition/Pages/default.aspx
Centers for Disease Control and Prevention. (n.d.). What is Vitamin K Deficiency Bleeding? https://www.cdc.gov/
ncbddd/vitamink/facts.html
Harvard T.H. Chan School of Public Health. (March 2023). Iron. The Nutrition Source.
https://www.hsph.harvard.edu/nutritionsource/iron/
National Cancer Institute. (November 3, 2022). Side Effects of Cancer Treatment. https://www.cancer.gov/about-
cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq
National Institutes of Health (NIH) Office of Dietary Supplements (ODS). (October 4, 2022). Zinc.
https://ods.od.nih.gov/factsheets/Zinc-Consumer/#h3

CHAPTER 11
Nutrition for Cardiovascular Wellness
FIGURE 11.1 Adding spices like garlic or curry powder to foods may improve heart health by reducing cholesterol and improving blood flow.
(credit: modification of work “Yay, Spices!” by Dennis Sylvester Hurd/Flickr, Public Domain)
CHAPTER OUTLINE
11.1 Assess and Analyze the Impact of Nutrition on the Cardiovascular System
11.2 Plan Nutritional Strategies to Impact Cardiovascular Wellness
11.3 Implement Nutritional Strategies to Impact Cardiovascular Wellness
11.4 Evaluate Nutritional Strategies to Impact Cardiovascular Wellness
INTRODUCTION Nutrition plays a key role in the proper development and maintenance of the cardiovascular
system. When disease exists in a client’s cardiovascular system, the nurse should include nutritional considerations
in the client’s care plan.
Consider this case: Mr. Jack Thompson, a 65-year-old White male, has no history of cardiovascular disease and
skips annual exams with his primary care provider because he’s always felt healthy and takes good care of himself.
While he does have an extensive family history of heart disease, he watches his diet, exercises regularly, and has not
smoked in 20 years. He presents today with a personal problem that he refuses to discuss with anyone other than
the provider and nurse when he gets in the room.
208 11 • Applying Clinical Judgment to Promote Nutrition for Cardiovascular Wellness
11.1 Assess and Analyze the Impact of Nutrition on the Cardiovascular

System
LEARNING OUTCOMES
• 11.1.1 Recognize cues that indicate the impact of nutrition on the cardiovascular system.
• 11.1.2 Analyze cues to determine the impact of nutrition on the cardiovascular system.
Normal Function of the Cardiovascular System

The cardiovascular system includes the heart, blood, blood vessels, lymph, lymphatic vessels, and glands that
move blood and lymph through the body. Assessment of this system involves the mechanical and electrical
functions of the heart and blood vessels and their effectiveness at circulating blood throughout the body.
Assessment should also include an examination of a client’s nutritional status.
The cardiovascular system’s primary role is to circulate blood throughout the body. The components of this system
include the heart, known as the cardiac muscle, and blood vessels. The blood vessels include the arteries, which
carry oxygenated blood from the heart to other parts of the body; veins, which carry deoxygenated blood from the
body to the heart; and capillaries, tiny blood vessels with thin walls where arteries and veins exchange blood
supply.
The heart has two components—the electrical conduction system and the mechanical working component—that
work together to effectively pump blood and maintain proper perfusion, or movement of blood, oxygen, and
nutrients to tissues in the body. The electrical system sends an impulse to the excitable cardiac tissue cells and
triggers them to mechanically contract in a specific pattern to push blood throughout the body.
Nutrition can heavily impact the heart’s ability to complete the task of pumping blood. Like other muscles in the
body, the heart requires electrolytes to produce action-potential impulses in muscles. The electrical charge that
sends an impulse to the heart to trigger contraction is highly dependent on the involuntary process of potassium and
sodium ion exchange (Balchem, 2021). Likewise, muscles, including the heart, are dependent on calcium and
magnesium ion exchange for physical contraction or movement (Balchem, 2021). Low levels of these electrolytes
can result in dysrhythmias and ineffective cardiac output and perfusion.
For the mechanical working component of the heart to function properly, the cardiac muscle must be supplied with
oxygen and nutrients from the coronary arteries. The cardiac muscle must also be in good physical working
condition and able to receive impulses from the heart’s electrical conduction system. The mechanical working
component is not necessary for the electrical conduction system to function; but, without the mechanical working
component, no blood is pumped through the body—and if the electrical conduction system is functioning
independently, there will only be pulseless electrical activity (PEA), or electrical conduction throughout the heart
without physical movement of the heart muscle.
Another consideration is the vascular portion of the cardiovascular system. While the heart requires electrolytes to
create electrical impulses to trigger contractions strong enough to circulate blood throughout the body, it may still
be unable to adequately perfuse the body if the vessels are blocked or become hardened, as in arteriosclerosis. The
primary cause of this disease is a nutritional intake high in unhealthy fats and cholesterol. When low-density lipid
(LDL) cholesterol levels are chronically high, fatty deposits known as plaques form in artery walls and reduce blood
flow through that vessel (Icahn School of Medicine at Mount Sinai, 2023). When the heart is forced to push against
the increased pressure from the less-elastic and smaller diameter of the diseased vessels, it causes the heart
muscle to continually be overworked. The heart muscle can become damaged, and the eventual result can be heart
failure.
The other consideration in normal function of the heart is the pressure it exerts against the vessel walls when
contracting and relaxing, known as blood pressure. When blood pressure is chronically high, the client has an
increased risk of heart failure. Blood pressure is largely regulated in the body by the renin-angiotensin-aldosterone
system (RAAS) that utilizes fluid and electrolytes, especially sodium (Martyniak and Tomasik, 2022). This system
works to change the sodium concentration in the blood to raise or lower blood pressure as needed by the body
(Martyniak and Tomasik, 2022). When the concentration of sodium is chronically high due to excessive intake and is

11.1 • Assess and Analyze the Impact of Nutrition on the Cardiovascular System 209
not able to be excreted by the kidneys, the RAAS system is unable to adequately control blood pressure.
There are two main circulatory systems of interconnected blood vessels that flow through the body: the systemic
circulatory system and the pulmonary circulatory system. The systemic system provides blood to the body’s tissues,
organs, and cells, and the pulmonary system transports blood between the heart and lungs allowing for oxygen and
carbon dioxide exchange to occur (Sherrell, 2021).
Through the circulation of blood, the cardiovascular system performs several other functions. Blood is considered a
“fluid connective tissue” (Visible Body, 2023), and it supports, protects, and gives structure to the blood vessels.
Blood provides numerous other functions, including:
• Clotting for tissue repair

• Protection from infection
• Transportation of body wastes to the kidneys for excretion
• Exchange of oxygen and carbon dioxide between body tissues
• Regulating body temperature
• Transporting nutrients and hormones throughout the body for use and functional regulation (American Society
of Hematology, 2023)
Assessment of Nutrition and the Function of the Cardiovascular System

A thorough assessment of the nutritional status of a client’s cardiovascular system involves examining each
component. Many diseases are associated with poor nutrition or malnutrition. The most effective method of
determining whether nutrition is a contributing factor is to evaluate each component individually. Note that the
electrical conduction system and the mechanical working component should be assessed separately.
Assessing Electrical Conduction System of the Heart

The normal electrical pattern of the heart (Figure 11.2) starts with the initiation of an impulse at the sinoatrial node
(SA node), the pacemaker of the heart. The impulse then travels through the atria, the top two heart chambers,
causing atrial contraction, down to the atrioventricular node (AV node), an electrical gatekeeper that controls a
delay between the atrial and ventricular impulse, allowing blood to fill the ventricle. From the AV node, the impulse
travels to the bundle of His, a bundle of conducting fibers that branch to each ventricle, then down both bundle
branches to the Purkinje fibers, or terminal-conducting fibers in the ventricles. This action causes the ventricles, or
bottom chambers of the heart, to contract (Johns Hopkins Medicine, 2023b).
FIGURE 11.2 The heart muscle and systemic circulation are vital components that work together to deliver oxygen and nutrients to the
body’s tissues and organs while removing waste products. (credit: modification of work from Anatomy and Physiology 2e. attribution:
An Electrocardiogram (ECG/EKG) or telemetry can be used to evaluate the electrical conduction of the heart. An
ECG is a recording of a heart’s electrical activity through electrodes placed on the chest to capture signals.
Telemetry is the continual measurement of a heart’s ECG through a portable device that automatically transmits the
reading to a monitor.
A nurse should know several important measurement facts of a telemetry wave (Figure 11.3):
• Each small square on the telemetry strip represents 0.04 seconds.

• Each portion of the wave indicates a different part of the cardiac polarization (relaxation) and depolarization
(contraction) cycle.
• Each wave is expected to have a certain appearance or shape and specific deflection: positive being upward and
negative being downward.
FIGURE 11.3 Nurses are expected to be able to measure and interpret the points of a telemetry wave. (credit: modification of work from
Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
For the heart to be in optimal health, the electrical conductivity should be a normal sinus rhythm (NSR). An NSR is
a rhythm that originates from the sinus node and is characteristic of a healthy heart’s cardiac rhythm. With an NSR,
the wave tracing should be within normal measurements, and the deflections and appearances or shapes of all

wave components should have a pulse that is calculated between 60 and 100 beats per minute. In addition, the
waves should be consistent and resemble each other. Table 11.1 outlines the telemetry wave components, normal
measurement, existence in the cardiac cycle, and the expected shape and deflection.
Wave/ Normal Part of Cardiac Cycle Wave/Segment Appearance/Shape and

Segment Measurement Deflection
of Segment
P Atrial depolarization Positive deflection/smooth hill shape
Q Start of ventricular Negative deflection/sharp downstroke if
depolarization shown (Some normal telemetry readings do
not have a true Q wave.)
R Ventricular depolarization Positive deflection/sharp mountain peak
upward
S Ventricular depolarization Negative deflection/sharp downward end of
the mountain
T Ventricular repolarization Positive deflection/ smooth hill shape
U Atrial repolarization: not an Positive deflection/smooth hill shape (Most
expected finding on every normal telemetry readings do not have a U
client wave.)
QRS 0.06–0.12 Ventricular depolarization Cluster of QRS waves together
complex seconds
PR 0.12–0.20 Beginning of atrial P wave and segment between P wave and Q
interval seconds depolarization to beginning of wave
ventricular depolarization
QT 0.40–0.44 Beginning of ventricular QRS complex, ST segment, and to end of T
interval seconds depolarization through wave
ventricular repolarization
ST Isoelectric line, Time in-between ventricular End of ST segment to beginning of T
segment not measured depolarization and wave—must be on isoelectric line, no
separately repolarization deflection
TABLE 11.1 Normal Telemetry Parameters (source: UNC Eshelman School of Pharmacy, 2023)
There are certain telemetry changes in which nutritional issues and electrolyte abnormalities are often the primary
cause. Common examples include:
• Long QT syndrome—when the QT interval is greater than 0.47 seconds in males and 0.48 seconds in females.
This can lead to life-threatening dysrhythmias and can be caused by low levels of potassium, magnesium, or
calcium.
• Torsades de pointes—a life-threatening dysrhythmia known as a multifocal ventricular tachycardia, caused by
low levels of magnesium (Cohagan & Brandis, 2022).
• A peaked or mountain T wave illustrates hyperkalemia (high levels of potassium in the blood) (Bord, 2022).
Assessing the Mechanical Working Component of the Heart and the Blood Vessels
A healthy heart represents the flow of an adequate blood supply, proper stimulation through the electrical system,
and effectiveness at physically pumping blood through the body. Normal blood flow through the heart starts when
deoxygenated blood is returned to the heart from the body via the superior vena cava. It travels through the right
atrium, through the tricuspid valve, and into the right ventricle. The blood is then pumped through the pulmonary
valve and into the pulmonary artery to be re-oxygenated in the lungs (Figure 11.4). Once the blood has gone through
the exchanges needed and is oxygenated, it returns to the heart through the pulmonary veins into the left atrium. It
will then travel through the mitral valve into the left ventricle, through the aortic valve into the aorta, and out to the
body for use (Pediatric Heart Specialists, 2023).
FIGURE 11.4 Normal blood flow starts when deoxygenated blood is returned to the heart via the superior vena cava. It travels through the
right atrium, through the tricuspid valve, into the right ventricle, and is pumped through the pulmonary valve and into the pulmonary artery
to be re-oxygenated in the lungs. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University,
OpenStax, under CC BY 4.0 license)
The oxygenated blood is returned to the body through two types of arteries. Elastic arteries are located closer to the
heart and are more flexible than muscular arteries. Muscular arteries contain smoother muscle and are farther away
from the heart. Both types of arteries must have strong walls, because arteries handle higher pressures from the
blood being pumped out of the heart (Cleveland Clinic, 2023b). The main function of arteries is to distribute the
oxygenated blood to all body organs and tissues, including the heart itself, through the coronary arteries. Refer to
Figure 11.5 for a visual of the artery wall.
FIGURE 11.5 The walls of elastic and muscular arteries must be both strong and flexible to properly handle high-pressure blood flow.
(credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
As blood travels through the body via the arteries, the arteries get smaller in diameter until they terminate into
arterioles, the smallest arteries. These arterioles link with capillaries and then connect to venules, the smallest
veins (Gupta and Shea, 2022). Capillaries are thin-walled vessels that connect arterioles and venules. As shown in
Figure 11.6, they are the vehicle for the final exchange of oxygen and nutrients into tissues and wastes into the
blood (Gupta & Shea, 2022).

FIGURE 11.6 Capillaries connect arterioles and venules, and are the vehicle for the final exchange of oxygen and nutrients into tissues and
waste into the blood. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
After passing through the capillaries and venules, blood continues into the veins on the way back to the heart. Veins
have thinner walls than arteries, because pressures are lower in this portion of the cardiovascular system. Veins also
dilate in response to fluid. Some veins, like the large veins in the legs, have valves in them to prevent backflow of
blood (Gupta & Shea, 2022). Once blood has traveled through the veins, it ends up in the heart to start the cycle all
over again.
Assessment
The nurse should complete a client’s assessment by recording manual blood pressure and apical pulse (a pulse
point on the chest at the apex of the heart). In addition, the nurse should look for other signs and symptoms of
adequate perfusion, including:
• Quality and rate of peripheral pulses (carotid auscultation and palpation, brachial, radial, ulnar, femoral,
popliteal, and pedal)
• Skin color check for pallor or cyanosis
• Skin temperature for degree of warmth and presence of moisture (Malik & Goyal, 2022)
• Skin turgor (elasticity) to check for edema and venous stasis sores or discoloration
• Capillary refill, which should be less than 2 seconds
Abnormal findings and their relationship to specific nutritional deficiencies are discussed in the next section.
Part A
Mr. Thompson reports to the provider and nurse that he has had difficulty achieving and maintaining an erection and
has noticed worrisome leg swelling. He also states that he was told by a nurse at a health fair a month ago that he
should have his blood pressure checked, because it was 139/93 mm Hg. Today his blood pressure is 126/88 mm
Hg. The swelling in his legs appears to be dependent edema that is only present when his legs are downward for
periods of time and appears to be due to insufficiency of blood return in the lower extremities.
1. Based on these findings, what would the nurse expect the provider to conclude?
a. The client has an elevated blood pressure, peripheral arterial disease, and erectile dysfunction.
b. The client has hypertension, peripheral arterial disease, and erectile dysfunction.
c. The client has hypertension, peripheral vascular disease, and erectile dysfunction.
d. The client has elevated blood pressure, peripheral vascular disease, and erectile dysfunction.
2. Which of the following tests would the nurse expect the provider to order initially to evaluate heart function?
a. Electrocardiogram
b. Echocardiogram
c. Troponin
d. Chest X-ray
The provider orders an ECG that is done at bedside and shows no abnormalities. The provider also orders a fasting
lipid panel (serum cholesterol levels) to help determine the client’s risk for heart disease. Because Mr. Thompson is
not fasting, the provider instructs him to return in the morning for a blood draw and to return in one week for follow-
up. The provider also explains to Mr. Thompson that erectile dysfunction can be directly related to the decreased
blood flow caused by hypertension. The client’s hypertension will have to be managed before the erectile
dysfunction can be fully evaluated for cause.
(source: Antipolis, S. (2020). How to Treat High Blood Pressure Without Ruining Your Sex Life. European Society of
Cardiology. Retrieved from https://www.escardio.org/The-ESC/Press-Office/Press-releases/how-to-treat-high-
blood-pressure-without-ruining-your-sex-life)
Analysis of Nutrition and the Cardiovascular System

A client’s nutritional status and needs can be identified with a physical assessment and lab results. Potassium,
cholesterol, and sodium levels can be monitored to best track nutritional needs for cardiovascular health.
Nutritional Analysis and the Impact on the Cardiovascular System

Nutritional issues can lead to changes in the electrical conduction of the heart. As a result, the client’s telemetry
rhythm can become abnormal. Rhythm changes include atrial fibrillation, atrial flutter, T-wave abnormalities, ST
segment changes related to AMI, U-wave presence or prominence, torsades de pointes, prolonged QT interval, and
supraventricular tachycardia. Rhythm changes can relate to one or more deficiencies. See Table 11.2 for a list of
telemetry changes, the nutritional relation, and client symptoms.
Telemetry Nutritional Relation(s) Client Symptom(s)

Change
Atrial • Excessive caffeine or alcohol intake • Palpitations
fibrillation/atrial • High cholesterol levels • Lightheadedness
flutter • High blood pressure • Chest pain
• Extreme fatigue
• Shortness of
breath
Torsade de • Primarily magnesium deficiency • Can start with

pointes • Can be related to calcium deficiency syncope
• Can be related to magnesium deficiency (fainting),
• Can be related to potassium deficiency palpations, and
dizziness
• Cardiac arrest
TABLE 11.2 Nutritional Relationship to Rhythm Changes (sources: Akbar et al., 2022; Centers for Disease Control and Prevention, 2022;
Cleveland Clinic, 2022a; Cleveland Clinic, 2022c; Cohagan & Brandis, 2022; Kenny & Brown, 2022; Lee, et al., 2022; Mayo Clinic, 2023a–b;
Morales-Brown, 2020; Teymouri, et. al., 2022)


Change
Supraventricular • Excessive caffeine or alcohol intake • Palpitations
tachycardia • Heart disease (high cholesterol, obesity, or blood pressure) • Pounding
sensation in the
neck
• Weakness
• fatigue
• Chest pain
• Lightheadedness
• Shortness of
breath
• Sweating
• Dizziness
• Fainting
T-wave changes • Inverted T waves can relate to cardiac ischemia from heart • Symptomology
disease and/or past acute myocardial infarction (AMI) (triggered related to cause
by high cholesterol and high blood pressure) and type of
• Peaked T waves can indicate hyperkalemia change
U-wave • Hypokalemia (low potassium levels) can cause tachycardia and • No

presence/ U-wave prominence symptomology
prominence unless it
interferes with
perfusion
ST segment • AMI can result from high cholesterol, obesity, and old ischemia • Chest pain
changes/AMI damage to the heart • Cardiac arrest
• Diaphoresis
• Shock
• Radiating pain to
left jaw and
shoulder
• Shortness of
breath
• Weakness
• Lightheadedness
• Syncope
• Pain in one or
both arms and/
or shoulders

Change
QT interval • Shortened QT intervals can indicate hyperkalemia • Can trigger a
lethal heart
rhythm
Many other • Hyperkalemia can cause wide QRS complexes and hidden P • Symptomology
rhythm waves, prolonged PR interval, decreased P wave amplitude, related to cause
disturbances ventricular fibrillation, asystole, junctional rhythm, bradycardia, and type of
ST depression, atrial fibrillation, in addition to other issues change
listed
• Hypoalbuminemia can cause low-voltage wave measurements
and abnormal QT interval measurements and has been
identified as a factor to increase mortality in AMI, atrial
fibrillation events, and heart failure
Numerous nutritional factors create or impact cardiovascular diseases such as coronary heart disease,
cardiomyopathy (a disease of the heart muscle), and hypertension. Table 11.3 outlines a handful of cardiovascular
diseases, the impact of nutrition, and the effect on the body.
Disease Nutrition Impact Effects on the Body

Coronary artery disease (CAD) Dietary intake that is high Can lead to hypertension, cardiomyopathy,
in cholesterol, and AMI
Peripheral vascular disease (PVD) sodium, trans fats, added Slows return of blood to the heart, leading to
sugars, and low potassium pooling of deoxygenated blood in the lower
and high extremities
fluid intake (for CHF and
Peripheral arterial disease (PAD) Slows flow of blood to the body causing
cardiomyopathy
ischemia
and especially with
Chronic heart failure (CHF) increased sodium Causes weakening of the heart muscle
Cardiomyopathy specifically) Causes enlargement and weakening of the
heart muscle
Hypertension Increases workload on the heart leading to
cardiomyopathy and CHF
TABLE 11.3 Cardiovascular Diseases (sources: Albakri, 2019; Centers for Disease Control and Prevention, 2022; Harvard University, 2023;
Medline Plus, 2022)
11.2 Plan Nutritional Strategies to Impact Cardiovascular Wellness

LEARNING OUTCOMES
• 11.2.1 Prioritize hypotheses of nutritional habits that optimize cardiovascular wellness.
• 11.2.2 Generate solutions to optimize cardiovascular wellness through nutritional habits.

Several body metrics can help the nurse evaluate the potential for cardiovascular disease development or to
determine level of cardiovascular disease present. These metrics include food intake, body mass index (BMI), waist-
to-hip ratio, blood pressure, and cholesterol. The primary goal is to utilize the best nutritional practices to prevent
cardiovascular disease. If disease is present, nutrition is used to help control the condition and prevent worsening
and exacerbation periods.

11.2 • Plan Nutritional Strategies to Impact Cardiovascular Wellness 217
Preventative Care Nutritional Planning

Preventative nutritional planning should focus on a client who does not yet have cardiovascular disease. Prevention
is always the highest priority for clients with a known risk of cardiovascular disease but should also be routine
education for all clients, as it affects a large portion of the population. Planning for disease prevention includes
monitoring weight and BMI, cholesterol levels, waist circumference, and intake of sodium, potassium, magnesium,
calcium, fluid, and fiber.
When educating the client on proper nutritional practices to reduce the risks of developing cardiovascular disease,
the client must first understand how to properly manage cholesterol levels and the differences in the types of fats
they ingest in relation to these levels. Three main types of fat are most often discussed in relation to cardiovascular
disease and its prevention—unsaturated fats, saturated fats, and trans fats, which are a form of unsaturated fat.
Saturated fats and trans fats are in semi-solid form at room temperature. Like all fats, they are made up of carbon,
oxygen, and hydrogen, but they have more hydrogen molecules than other forms of fat (Moll, 2022). Saturated fats
and trans fats are more likely to form deposits inside arteries and harden as plaques, making them forms of fat that
the client should limit to less than 6% of their daily intake (Moll, 2022). High intake of saturated and trans fats can
increase the client’s levels of low-density lipid (LDL) cholesterol levels (Moll, 2022). This is typically referred to as
“bad” cholesterol in the body, as it is the type most likely to deposit and stick to artery walls. While not all LDL is
harmful and plaque forming, it still puts the client at higher risk when they consistently have higher LDL levels. High-
density lipid (HDL) cholesterol is referred to as “good” cholesterol because of its low risk of plaque depositing.
Unsaturated fats should make up the majority of the daily recommended 20–35% of daily fat intake (Moll, 2022).
Maintaining adequate fiber intake will help to prevent cardiovascular disease. Fiber has been shown to lower LDL
cholesterol levels, lower blood pressure, and create satiety (a feeling of fullness) to help in weight loss (Harvard
Health Publishing, 2020). When increasing fiber intake, it important to also increase fluid intake, particularly water
intake, to prevent constipation. Adequate fluid intake (particularly water) of at least 6–8 cups per day for women
and 8–12 cups per day for men is needed for many body processes, including proper blood vessel function, blood
circulation, effective cardiac pumping, and sodium level maintenance, which can help prevent heart disease risk if
maintained at 142 milliequivalents per liter (mEq/L) and below (Dmitrieva, Liu, Wu, & Boehm, 2022; National
Institutes of Health, 2022).
Another important piece of education for the client is the proper regulation of their daily sodium intake. Too much
daily intake can increase the risk of hypertension, which can lead to heart failure. Americans consume an average of
3400 mg/day of sodium, which is well above the recommended limit of 2300 mg/day for those without heart
disease (American Heart Association, 2023). This maximum is still not optimal as the AHA recommends that clients
without heart disease move toward a limit of 1500 mg/day and those with heart disease to 1000 mg/day. While this
is the current recommendation, there is some debate from new findings by the American College of Cardiology
(2023) that individuals with heart disease do not benefit from limiting their sodium any more than those without
heart disease.
The nurse should have a nutrition education discussion with the client that includes maintaining a proper diet for
healthy BMI, waist circumference, calcium, magnesium, and potassium levels. The nurse can discuss both the use
of the MyPlate and DASH diets to accomplish this. The nurse should keep in mind, however, that a fine balance must
be maintained between potassium, sodium, magnesium, and calcium for proper conduction and mechanic pumping
of the heart to take place. Most clients can maintain these three electrolytes through balanced nutrition, but if they
are deficient in any of these and are unable to regulate them through nutritional intake alone, supplementation
should be considered. The nurse should discuss types of foods the client should include and limit in their diet for
cardiovascular health (Table 11.4).
Nutrient Foods High in the Nutrient

Calcium • Soybeans (edamame)
• Collard greens
• Spinach
• Turnip greens
• Bok choy
• Kale
• Broccoli
• Breakfast cereal
• Tofu
• Plant-based milks
Potassium • Beans
• Lentils
• Potatoes
• Winter squash (acorn, butternut)
• Spinach
• Broccoli
• Artichoke
Sodium • Smoked, cured, salted, or canned meat, fish, or poultry

• Frozen breaded meats and dinners
• Canned entrees
• Salted nuts
• Beans, canned with salt added
Magnesium • Soy products

• Legumes and seeds
• Nuts, peanuts, and peanut butter
• Whole grain breads and cereals
• Fruit
• Vegetables, particularly dark green and leafy
• Dried beans
TABLE 11.4 Nutrient Education Table (sources: American Diabetes Association, 2023; Penn Medicine Lancaster General Health, 2023;
University of California San Francisco, 2023; University of Rochester Medical Center, 2023; University of Washington, 2023; U.S.
Department of Health and Human Services, 2023)

11.2 • Plan Nutritional Strategies to Impact Cardiovascular Wellness 219
Nutrient Foods High in the Nutrient

Fiber • Avocado
• Brussels sprouts
• Broccoli
• Split peas
• Artichokes
• Lentils
• Kale
• Turnip greens
Saturated fats • Processed foods such as potato chips

• Baked goods with hydrogenated oil or partially hydrogenated oil
• Margarines
• Shortening
• Lard
• Fatback and salt pork
• High-fat meats
• High-fat dairy products
• Butter
• Cream sauces
• Gravy made with meat drippings
• Poultry skin
TABLE 11.4 Nutrient Education Table (sources: American Diabetes Association, 2023; Penn Medicine Lancaster General Health, 2023;
University of California San Francisco, 2023; University of Rochester Medical Center, 2023; University of Washington, 2023; U.S.
Department of Health and Human Services, 2023)
Secondary Care Nutritional Planning

Two main diets have been shown to benefit clients with heart disease: the Dietary Approaches to Stop Hypertension
(DASH) diet and the Mediterranean diet. The intent of these diets is to control weight and reduce cholesterol levels
and hypertension. This approach needs to be balanced with the client’s need for protein, because malnourishment
and heart failure can lead to hypoalbuminemia, a condition in which the body does not produce enough albumin, a
protein that keeps fluids in blood vessels.
The nurse should consider BMI, which is calculated as weight in kilograms by height in meters squared (kg/m2) and
waist size values:
• BMI—A healthy BMI is 18–24.9 kg/m2;; an overweight BMI is 25–29.9 kg/m2; and obesity is a BMI of 30 kg/m2
or higher.
• Waist size—A person who has a large waist size has a higher chance of developing cardiovascular disease, even
with a normal BMI. Males should aim to keep their waist size below 40 inches (102 cm) and females should aim
to keep their waist size below 35 inches (88 cm) (Harvard University, 2023).
BMI MEASUREMENT
The nurse should know a client’s BMI before creating a nutritional plan because a high BMI increases
cardiovascular risks. For clients with a high BMI, weight loss should be included in the plan. Harvard Medical
School provides a useful BMI calculator (https://openstax.org/r/healthharvaed).
Another metric is blood pressure, which measures hypertension or the advancement of hypertension. Hypertension
is known as the silent killer, because many people often do not have symptoms. Blood pressure is measured in
millimeters of mercury, or mm Hg. A single high hypertension value may not indicate an issue, but two or more
consecutive high readings is considered hypertension (Mayo Clinic, 2023c). Blood pressure ranges and their
associated condition are listed in Table 11.5.
Blood Pressure Systolic Diastolic
Low < 90 mm Hg Or < 60 mm Hg
Normal < 120 mm Hg And < 80 mm Hg
Elevated 120–129 mm Hg Or < 80 mm Hg
Hypertensive > 129 mm Hg Or > 80 mm Hg

TABLE 11.5 Blood Pressure Ranges (source: National Institute on Aging, 2022)
Cholesterol levels are also critical. Excessive cholesterol levels can lead to the buildup of plaques along blood
vessels, resulting in restricted blood flow and leading to hypertension, peripheral vascular and artery disease, and
cardiomyopathies, and can cause embolizing events in the body. Table 11.6 outlines ranges of cholesterol
measurements and their meanings (Johns Hopkins Medicine, 2023a).
Cholesterol Measurement Near Optimal Normal Borderline High Very

Optimal mg/dL mg/dL High mg/dL High
mg/dL mg/dL mg/dL
Total cholesterol < 200 200–239 > 239
Low-density lipids (LDL) (“bad” 100–129 < 100 130–159 160–189 > 189
cholesterol)
Triglycerides < 150 150–199 200–499 > 499
High-density lipids (HDL) (“good” > 60 > 40

cholesterol)
TABLE 11.6 Cholesterol Levels (source: Johns Hopkins Medicine, 2023a)
Part B
Study Part A.
Mr. Thompson has returned for his one-week follow-up. His cholesterol values are:
• Total cholesterol: 269 mg/dL

• LDL: 139 mg/dL
• HDL: 130 mg/dL
His blood pressure is 133/87 mm Hg, and his weight has increased by 2 lb. The nurse calculates his BMI to be 21
kg/m2 and his waist size is 42 inches.
3. Based on these results, what recommendations should the nurse include in Mr. Thompson’s dietary
education?
a. Increase red meat intake.
b. Decrease caffeine intake.
c. Increase fiber intake.
d. Decrease dairy consumption.

11.3 • Implement Nutritional Strategies to Impact Cardiovascular Wellness 221
4. The nurse starts to discuss the diet and exercise recommendations with Mr. Thompson, but he insists he is
following a heart-healthy diet and that the tests are wrong. What food selection in Mr. Thompson’s 24-hour
diet recall illustrates inaccuracy in his statement?
a. Freshly squeezed orange juice
b. Steamed broccoli
c. Baked fish
d. Grilled beef cheeseburger
The nurse discusses the dietary choices that Mr. Thompson can recall eating in the last few days and discovers that
he is not eating a heart-healthy diet. The nurse makes suggestions for other food choices, and the provider refers Mr.
Thompson to a dietitian for further education and nutritional management. He is asked to schedule a follow-up
appointment in 3 months. At that time, the provider will determine if these changes have been effective enough or if
medications will need to be added to his treatment plan.

Motivation, food security, financial resources, disability, and comprehension are additional factors that impact
cardiovascular health. Motivation is a significant factor because behavior changes may be needed, and the client
may need help maintaining their health plan. For example, the client may need to learn a new diet that includes food
they feel is lacking in taste, start exercising, or quit smoking. The client will have to truly desire to make changes.
The second major factor that can impact nutritional goals is access to the foods required in the nutritional plan
(meal plan) created for the client. Healthy foods like fresh fruits and vegetables cost more and do not last as long as
processed unhealthy food. This can be difficult for a client who is already financially or geographically challenged.
Frozen fruits and vegetables are another potential healthy source that will last longer than fresh varieties, but they
are still more expensive. These also require the client to have storage for these that they may not have, depending
on their living situation. Canned fruits and vegetables are the least expensive options they could add to their diet,
but they are also the least healthy. They may be prepared with large amounts of salt and sugar, and this will
outweigh the benefits the client will obtain from eating them. Even low-sodium and low-sugar options are higher in
salt and sugar than fresh options are.
A third major factor is the client’s ability to understand the nutritional plan. The client must fully understand what
foods are on the diet plan, how to properly read food labels, and how to make appropriate substitutions and
measurements. If they do not have a firm understanding, they may struggle to follow the plan. It may be necessary
to refer the client to a registered dietician and follow up consistently to ensure the client both understands the
education given and is adhering to the recommendations.
Lastly, debilitating health can contribute to the challenge of cardiovascular health. In the later stages of many of
diseases, shortness of breath and fatigue can make eating very difficult. It also increases the difficulty level in food
preparation, making it easier for a client to revert to eating fast foods in favor of less effort. The registered dietician
can offer some solutions regarding food preparation to reduce fatigue, such as purchasing prechopped fruits and
vegetables, making sheet-pan meals, and using slow-cooker recipes. This will not alleviate the fatigue that clients
with breathing difficulties will have during the act of eating. The registered dietician can take this breathing issue
into account and help with the selection of more nutrient-dense foods, so that the client will have to eat less to meet
their needed requirements.
11.3 Implement Nutritional Strategies to Impact Cardiovascular Wellness

LEARNING OUTCOMES
• 11.3.2 Teach nutritional strategies to optimize cardiovascular wellness.

An implementation strategy is necessary for success. To solidify plan compliance, the nurse should involve the client
in the creation of the plan, ensure that the client has a clear comprehension of the plan, and evaluate the holistic
needs of the client.
Maintaining cardiovascular health when no disease is present is also critical. A first step to maintenance is to review
diet plans. The MyPlate, DASH, and Mediterranean diets are well known and can be utilized to maintain
cardiovascular health. In addition, reducing alcohol consumption, caffeine intake, red meats, saturated and trans
fats, processed food consumptions, refined carbohydrates, sugary foods and drinks, and sodium have all been
shown to be protective for cardiovascular health (Harvard University, 2023; Morales-Brown, 2020). Likewise,
increasing the intake of fruits and vegetables, whole grains, fish, nuts, and poultry and using monounsaturated or
polyunsaturated oils in place of saturated oils will help prevent cardiovascular disease (Harvard University, 2023).
If the client wishes to prescribe to one of the recommended diets, the nurse should educate them on inclusions,
exclusions, and reductions (Table 11.7).
Diet Type Inclusions or Increases Exclusions or Reductions

Mediterranean • High intake of olive oil, nuts, • Restrict red meats, processed meats,
vegetables, fruits, whole grains, and sweets, dairy products, and added sugars
cereals • Red wine consumed in moderation with
• Moderate intake of fish and poultry in meals
place of red meats
DASH • Increase vegetables, fruits, and whole • Decrease saturated fat, whole-fat dairy
grains products, and tropical oils such as coconut,
• Include fat-free or low-fat dairy palm kernel, and palm oils
products, fish, poultry, beans, nuts, and • Decrease sugary beverages and sweets
vegetable oils over other oils • Decrease trans fats
• Increase food rich in potassium, • Decrease sodium
calcium, magnesium, fiber, and protein
MyPlate • 2 cups fruit daily* • Decrease added sugars to < 50 g/day

• 2.5 cups vegetables daily* • Decrease saturated fats to < 22 g/day
• 5–10 oz of total grains (preferably half • Decrease sodium to < 2300 mg/day
of this being whole grains) daily*
• 5.5 oz lean protein/meat daily*
• 3 cups dairy per day—preferably low-
fat options*
* Note: These are averages, as sex
and age can change recommended
amounts.
TABLE 11.7 Mediterranean, DASH, and MyPlate Diet Plan Inclusions, Increases, Exclusions, and Reductions (sources: Harvard University,
2023; Hinzey & Chien, 2023; National Heart, Lung, and Blood Institute, 2021; U.S. Department of Agriculture, 2020)
Holistic care is critical to heart health and should include a review of other lifestyle habits that can contribute to
cardiovascular disease. For example, smoking cessation is extremely important, as nicotine constricts blood vessels
and reduces blood flow while increasing blood pressure (Srakocic, 2023).
Physical activity is also paramount when reducing cardiovascular risks. Exercise helps with weight control, BMI, and
waistline management, and reduces the risk for diabetes. Regular physical activity can also help manage stress and
improve mood (Harvard University, 2023).
Lastly, sleep is a key consideration. Maintaining an adequate sleep schedule contributes to cardiovascular risk
reduction. Sleep has been shown to have an impact on factors that relate to cardiovascular health, such as dietary
intake, weight, exercise, inflammation, and blood pressure (Harvard University, 2023).
Client Teaching
Teaching a client with cardiovascular disease can be challenging. Symptoms like chronic fatigue, weakness, chest
pain, and shortness of breath can make it difficult to motivate the client to learn. For these reasons, the nurse

11.4 • Evaluate Nutritional Strategies to Impact Cardiovascular Wellness 223
should include caretakers and family members whenever possible during education.
Teaching should include DASH, Mediterranean, and MyPlate diets. The nurse should help the client decide which
would be most appropriate for their lifestyle. The nurse may need to adjust the diet to accommodate specific
cultural and religious preferences and allergies, and to accommodate other comorbidities that require special
dietary considerations.
11.4 Evaluate Nutritional Strategies to Impact Cardiovascular Wellness

LEARNING OUTCOMES
• 11.4.1 Evaluate a nutritional plan for its effect on cardiovascular wellness.
• 11.4.2 Modify a nutritional plan to promote cardiovascular wellness.
Evaluating Client Readiness to Follow a Nutritional Plan

Client readiness is an important metric in their desire to make necessary life and nutritional changes. The nurse
needs to work with the client to evaluate their desire to change. Most changes involve significant lifestyle
adjustments, and if the client isn’t ready, diet changes alone may not be enough. If the client is willing to follow the
nutritional plan, the nurse should educate the client on diet modifications. This will help the client understand how
much needs to change and ensure they feel that they can follow the plan.
The nurse also needs to evaluate ableness. The nurse should evaluate the challenges and provide recommendations
on how to remove those challenges. The nurse must ensure the client is capable of comprehending the information
given to them and that they can make decisions on how best to follow the plan. One step to aid in this evaluation is
to ask that the client return with a documented meal plan and include appropriate substitutions for daily meals.

Continual monitoring of lab values and blood pressure is the most effective way to evaluate a nutritional plan. The
client’s LDL levels should trend downward along with total cholesterol levels, if they were not in normal or optimal
ranges. Their blood pressure reading should trend downward to a normal level if it was increased. Levels of
prealbumin (a protein produced by the liver) should increase to the normal range if they had been low. BMI should
trend downward if it was high. Overall, all values should slowly trend toward standard levels if the client adheres to
the nutritional plan and the plan is effective.
Part C
Mr. Thompson has returned for his 3-month follow-up. He claims to be compliant with all the required changes he
and the provider and nurse previously discussed, and he said he is feeling great. The nurse documents that his
blood pressure is 122/78 mm Hg, his BMI is 20 kg/m2 (a slight change), and his waist measurement is 38 inches.
5. Based on these results, what would the nurse conclude about the dietary and exercise changes?
a. They appear effective.
b. They appear ineffective.
c. They are not effective enough.
d. This is not enough information to determine.
6. When evaluating the client’s caloric intake versus their activity level, what would the nurse document based
on these findings?
a. The client appears to be compliant.
b. The client appears to be partially compliant.
c. The client is not compliant.
d. There is not enough information to determine.

Chapter Summary
• The nurse should assess the cardiovascular the cardiovascular system include cholesterol,
system, a life-sustaining system in the body potassium, trans fats, saturated fats, sugars,
containing the heart and blood vessels, by magnesium, calcium, and sodium.
checking both the mechanical (physical) function • Dietary changes need to be implemented with
and the electrical function of the heart, as well as healthy lifestyle changes to see adequate
assessing how effectively the vessels allow the outcomes from nutritional plans.
movement of blood around the body after it is • When evaluating risk factors for cardiovascular
pumped by the heart. disease, BMI, waist size, and blood pressure are
• If the electrical conduction of the heart is not major considerations, along with specific
working properly, the mechanical function will not comorbidities such as diabetes.
work at all. • Even those without cardiovascular disease should
• The biggest dietary considerations in the health of have a heart-healthy diet.
Key Terms
arteries blood vessels that carry oxygenated blood placed on the chest to capture signals
from the heart to the body hypoalbuminemia a condition where the body does
arterioles arteries shrink to this smallest form and not produce enough albumin, a protein that keeps
link with capillaries fluids in blood vessels
atria the top two heart chambers normal sinus rhythm (NSR) the heart’s cardiac
atrioventricular (AV) node a second node in the rhythm that originates from the sinus node
heart that creates a delay in the electrical impulse perfusion the movement of blood, oxygen, and
from the SA node to the bundle of His to allow time nutrients to tissues in the body
for ventricular filling pulseless electrical activity (PEA) electrical
bundle of His a bundle of conducting fibers that conduction throughout the heart without physical
branch to each ventricle of the heart movement of the heart muscle
capillaries the point at which arteries and veins Purkinje fibers terminal-conducting fibers in the
exchange blood supply ventricles
cardiovascular system a system within the body that sinoatrial (SA) node the pacemaker of the heart
includes the heart, blood vessels, blood, lymph, telemetry the measurement of a heart’s ECG through
lymphatic vessels, and glands that moves blood and a portable device that automatically transmits to a
lymph through the body monitor
circulatory systems interconnected blood vessels veins blood vessels that carry deoxygenated blood
that flow through the body from the body to the heart
electrocardiogram (ECG/EKG) a recording of a ventricles the bottom chambers of the heart
heart’s electrical activity in which electrodes are venules the smallest veins that link with capillaries
Review Questions
1. The nurse is educating a client with hypertension about the Dietary Approaches to Stop Hypertension (DASH)
diet. Which statement by the client indicates the need for further teaching?
a. “The DASH diet increases my sodium intake.”
b. “The DASH diet increases my vegetable intake.”
c. “The DASH diet increases my potassium intake.”
d. “The DASH diet decreases my sugar intake.”
2. The nurse is reviewing a client’s medical record and notes that the last two blood pressure readings were
130/81 mm Hg and 122/99 mm Hg. Which diagnosis does the nurse anticipate for this client?
a. Normal blood pressure
b. Elevated blood pressure
c. Low blood pressure
d. Hypertensive blood pressure
3. The nurse is educating a client on ways to promote heart health. Which food modification would the nurse
recommend for a heart-healthy diet?

a. Red meat at 2 meals a day
b. Prepackaged meat products
c. Pineapple slices
d. Caffeinated unsweetened tea
4. The nurse is evaluating a client at a follow-up appointment who reports following a heart-healthy nutritional
plan for 3 months. Which objective data should the nurse utilize to support the client’s statement?
a. BMI change from 30 to 29 kg/m2
b. LDL change from 100 to 110 mg/dL
c. Blood pressure from 142/88 to 144/86 mm Hg
d. Increased shortness of breath
5. The nurse in the outpatient cardiology clinic is assessing a client who had an acute myocardial infarction 6
months ago and has completed an outpatient cardiac rehabilitation program. Which cholesterol level
indicates to the nurse that the client has achieved a desired level?
a. Total cholesterol 202 mg/dL
b. LDL 130 mg/dL
c. HDL 48 mg/dL
d. Triglycerides 242 mg/dL
6. The nurse is caring for a client with newly diagnosed atrial fibrillation. Which food should the nurse educate
the client to avoid?
a. Coffee
b. Oranges
c. Milk
d. Fish
7. The nurse is caring for a client with a history of cardiac arrest due to torsades de pointes. Which laboratory
value is a priority for the nurse to monitor in this client?
a. Total cholesterol
b. Calcium levels
c. Magnesium levels
d. Potassium levels
8. The nurse notes a very high and peaked T-wave abnormality on a client’s electrocardiogram (ECG). Which
laboratory value should the nurse expect the provider to order?
a. Magnesium level
b. Sodium level
c. Calcium level
d. Potassium level
9. The nurse is caring for a client who has hyperlipidemia. Which food choice by the client is appropriate?
a. Cake
b. Oatmeal
c. Fried chicken
d. Hot dog
10. The nurse is caring for a client who is prescribed the DASH diet to manage their high cholesterol levels. What
food choice in the client’s 72-hour diet recall requires further teaching?
a. Whole milk
b. Potatoes
c. Oysters

d. Orange juice
Suggested Reading
American Heart Association. (2022). 2022 heart disease & stroke statistical update fact sheet: Global burden of
disease. https://professional.heart.org/-/media/PHD-Files-2/Science-News/2/2022-Heart-and-Stroke-Stat-
Update/2022-Stat-Update-factsheet-GIobal-Burden-of-Disease.pdf
American Heart Association. (2022). Diet change may make biggest impact on reducing heart risk in people with
hypertension. https://www.sciencedaily.com/releases/2022/09/220907105458.htm
American Heart Association. (2022). FAQ: Hands-only CPR. https://cpr.heart.org/-/media/CPR-Files/Courses-and-

Kits/Hands-Only-CPR/HandsOnly-CPR-FAQs-ucm_494175.pdf
American Heart Association. (2023). Hands-only CPR training. https://cpr.heart.org/en/cpr-courses-and-kits/hands-

only-cpr
Gupta, N., Elnour, A., Sadeq, A., & Gupta, R. (2022). Diabetes and the heart: Coronary artery disease. E-Journal of
Cardiology Practice, 22(10). https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-22/
diabetes-and-the-heart-coronary-artery-disease
LaMotte, S. (2022). Mediterranean diet named best for 2022. CNN. https://www.cnn.com/2022/01/04/health/
mediterranean-diet-2022-best-diet-wellness/index.html

CHAPTER 12
Cardiovascular Health
FIGURE 12.1 Fish is a good source of omega-3s and other nutrients that contribute to heart health. (credit: modification of work “Sashimi”
by Ocdp/Wikimedia Commons, CC0 1.0)
CHAPTER OUTLINE
12.1 The Impact of Nutrition on Cardiovascular Wellness Across the Lifespan
12.2 Nutrition and Long-Term Cardiovascular Illnesses
INTRODUCTION The cardiovascular system plays a significant role in the care of clients throughout their lifespan.
This chapter will look at important nutritional modifications that impact cardiac-related events.
Consider this case: Tara is a 42-year-old multigravida pregnant client who presents to her obstetrician’s office
complaining of a severe headache, blurry vision, and edema to her legs. She is gravida 6, para 3 abortion 2 (meaning
the client is pregnant for the 6th time, 3 pregnancies have resulted in live births, and 2 pregnancies ended without a
live birth). The client is 25 weeks pregnant and has a history of hypertension and obesity. She was taking lisinopril
for hypertension prior to finding out she was pregnant and then changed to labetalol. In the office, Tara’s blood
pressure is 220/115 mm Hg. The provider examines Tara and sends her to labor and delivery for laboratory work
and further monitoring.
230 12 • Special Nutritional Considerations for Cardiovascular Health
12.1 The Impact of Nutrition on Cardiovascular Wellness Across the Lifespan

LEARNING OUTCOMES
• 12.1.1 Describe the impact of nutrition on the cardiovascular system during pregnancy.
• 12.1.2 Describe the impact of nutrition on the cardiovascular system during infancy.
• 12.1.3 Describe the impact of nutrition on the cardiovascular system during childhood.
• 12.1.4 Describe the impact of nutrition on the cardiovascular system during adolescence.
• 12.1.5 Describe the impact of nutrition on the cardiovascular system during adulthood.
• 12.1.6 Describe the impact of nutrition on the cardiovascular system during later adulthood.
Pregnancy
During pregnancy, multiple changes occur within the cardiovascular system. As cardiac output increases, vascular
volume increases, and there is a decrease in systemic vascular resistance and subsequent blood pressure. The
vessels also dilate, which leads to lower blood pressure in the second trimester. After 20 weeks of gestation, blood
pressure increases but typically remains near pre-pregnancy levels. These changes are designed to provide
perfusion—the flow of blood to tissues and organs—to the fetus (Kepley, Bates, & Mohiuddin, 2023). To best support
this growth and development of the fetus, the cardiovascular system of the client needs to be properly supported.
The pregnant client should increase caloric intake by 340–450 calories daily during the second and third trimesters.
Increasing folic acid, iron, and choline are important as well. Pregnant clients should avoid all alcohol, decrease or
eliminate caffeine intake, and avoid uncooked meats and fish. Although for clients with a pre-existing condition such
as hypertension (high blood pressure) and obesity, other measures will need to be incorporated into the nutritional
plan (meal plan) to help prevent complications (Lu et al., 2018; Anderson-Villaluz & Quam, 2022).
The food that the expectant client eats can also affect the fetus’s growing organs. Nutritional recommendations
include consuming skim or low-fat milk, yogurt, and cheese; healthy, lean proteins including oily fish; fresh fruits
and vegetables; and whole grains to help the fetus’s heart grow healthy. Pregnant clients are encouraged to avoid
food high in fat, cholesterol, and sodium as this does not only affect the client, but the fetus as well (Advent Health,
2021).
Research shows that optimal nutrition during pregnancy is linked with other healthy behaviors such as an increase
in physical activity and avoidance of smoking and alcohol.
Impact on the Client’s Health During Pregnancy

The demands of pregnancy on the client significantly changes the physiological functioning of the cardiovascular
system (Kepley, Bates, & Mohiuddin, 2023). The increase in metabolic demand promotes optimal uteroplacental
circulation—the transfer of oxygen and nutrients from client to fetus through umbilical cord and placenta—that is
needed by the fetus for growth and development. The increase in the cardiac output affects the client and the fetus
by increasing pressure on the vena cava from the weight of the extra fluid within the placenta and the weight of the
fetus. Vasodilation begins early in pregnancy, with a decrease in systemic vascular resistance. Maternal heart rate
also increases. Other changes that occur to the cardiovascular system due to the developing fetus include rotation
of the heart due to the pressure on the diaphragm, increase in heart rate, and mild hypertrophy due to the increase
in vascular volume (Gersh, 2022).
Maintaining healthy nutrition for heart health during pregnancy is important because it allows the heart to cope with
the stress of pregnancy. Implementing healthy heart behaviors positively impacts pregnancy and can help during
delivery and the postpartum period. Healthful measures that can be taken are using added salt sparingly, increasing
water intake to at least 64 oz daily, increasing protein in the diet, decreasing the amount of fried foods, exercising,
avoiding alcohol and caffeine, and elevating the feet during the day (American Pregnancy Association, 2023).
Many symptoms—such as shortness of breath, increase in heart rate, and swelling—experienced during pregnancy
are linked to cardiovascular changes. Decreased venous return to the head can cause the pregnant client to
experience syncope in which the client loses consciousness for a brief time or near-syncope episodes where the
client feels like they may pass out or have some lightheadedness or dizziness. The nurse should advise the client to
change positions slowly to minimize the associated risks for falls if this happens. The client may experience

12.1 • The Impact of Nutrition on Cardiovascular Wellness Across the Lifespan 231
dyspnea or difficulty breathing with exertion and/or visible pulsations of the jugular veins, as well as edema of the
lower extremities. Research also shows that not only the mother’s health is affected during pregnancy, but also the
developing fetus. The choices the mother makes nutritionally can affect the fetus’s risk for heart disease, kidney
disease, and metabolic disease in adulthood (Cunningham & LaMarca, 2018). Consistent themes found in the
research to best promote cardiovascular health during pregnancy through nutrition focus on decreasing total
cholesterol levels, regulating fasting glucose levels, and maintaining normal blood pressure readings.
It is important to teach clients what food choices are best. Suggestions include educating clients on how to drink
water or milk and eat fresh fruits and vegetables. When choosing meats, choose meat that is grilled rather than fried
and avoid raw fish. Eating a plant-based or vegetarian diet during pregnancy has been associated with higher risks of
congenital heart defects in the neonate at birth (Yang et al., 2019). Salads are typically a good source of nutrition
but can have many hidden calories in the dressings and various toppings that can be included in the salad. Clients
should choose low-fat salad dressing and eat desserts sparingly (Howland, 2018).
The Client with Pre-existing Cardiovascular Disease

Cardiovascular disease is a leading cause of complications in pregnant females (Cleveland Clinic, 2022a). The
pregnant client may be unaware of previous cardiovascular issues until they become pregnant. People with
previously undiagnosed cardiac issues may experience new cardiovascular-related health concerns and diagnoses
due to the increase in cardiac output and decreased systemic resistance. Heart murmurs, chest pain, and
generalized swelling should be evaluated by a health care provider (Gersh, 2022).
Clients with congenital heart disease can experience an exacerbation of related cardiovascular issues from
pregnancy-related physiological and hormonal changes (Ifitkhar & Biswas, 2023). There is an increased risk for both
maternal and fetal death associated with cardiovascular disease and pregnancy. Clients who have pre-existing
cardiovascular diseases need to be counseled about the additional risk factors that they could potentially encounter
during pregnancy, and they need to be counseled on ways to help keep their heart and their fetus’s heart healthy.
The amount of weight that the client gains during pregnancy can impact cardiovascular health by increasing the
need for higher cardiac output. For the client who gains more weight than what is recommended, the baby can be
too big and lead to complications during delivery according to the Centers for Disease Control (CDC, 2022b). Studies
have shown that only about one-third of pregnant women gain the recommended weight during pregnancy. The
recommended weight gain varies according to the pre-pregnancy body mass index (BMI) and if the client is
pregnant with one or more fetuses (CDC, 2022). To help prevent cardiovascular disease, the client should try to
meet the expected weight gain during pregnancy by increasing calories during the second (340 additional calories)
and third trimester (450 additional calories). The nurse should track and monitor pregnancy weight gain and
encourage the client to eat a well-balanced diet to help prevent cardiovascular problems during pregnancy (CDC,
2022).
Part A
Upon arrival at the labor and delivery department, Tara is placed on a fetal monitor, blood work and urine are
collected, and her vital signs are obtained.

Temperature: 37.4ºC • Urine shows protein
Blood pressure: 224/200 mm Hg • Liver enzymes are slightly elevated

TABLE 12.1

TABLE 12.1
Tara is started on a labetalol drip for blood pressure control. The fetal monitor shows no distress to the fetus, so she
is transferred to the intensive care unit for blood pressure monitoring and labetalol infusion.
Tara spends 4 days in the intensive care unit to get her blood pressure under control and to monitor her liver
enzymes and kidney function. Her liver enzymes and kidney function normalize, and her blood pressure is now down
to 120/76 mm Hg. She is converted to oral labetalol and will be ready to discharge home in the next day or two for a
follow-up with the obstetrician within 3–4 days.
The nurse is providing nutritional education to Tara since she has a history of hypertension and developed pre-
eclampsia. They both understand that nutrition and lifestyle modifications play a significant role in controlling blood
pressure and helping prevent Tara’s blood pressure from spiking.
1. Which part of Tara’s assessment or history is concerning due to the possibility of complications during
pregnancy?
a. Respiratory rate of 22 per min
b. Hypertension
c. Heart rate of 92 beats per min
d. Temperature of 37.4ºC
2. Tara asks about going out to dinner since she has a busy schedule. Which foods would be the best for her to
choose for her diet?
a. Fried chicken fingers and fries
b. Well-grilled chicken salad with full-fat cheddar cheese and ranch dressing
c. Raw sushi and rice
d. Well-grilled steak and steamed broccoli
Impact on the Fetus

The fetus of a client with cardiovascular disease is at an increased risk for morbidity, cardiovascular
disorders—inherited and congenital—premature delivery, and a restriction in fetal growth and development (Russell,
2022). Fetal growth and development restriction, related to inadequate placental perfusion, also increases the risk
for fetal demise. Additionally, infants born to clients experiencing poorly controlled cardiovascular disease
complications during pregnancy were noted to experience small gestational weight measurements and extreme
prematurity. An infant who is preterm also has reduced cardiomyocyte proliferation, which affects the total number
of cardiac cells they have. The decrease in myocytes affects the heart’s ability to repair itself and can decrease the
function of the heart (Bensley et al., 2018). Some cardiac problems that infants can develop from prematurity
include, but are not limited to, patent ductus arteriosus (Figure 12.2) and low blood pressure (Mayo Clinic, 2023c).
FIGURE 12.2 Patent ductus arteriosus is a common cardiac effect seen in premature fetuses. (credit: modification of work from Anatomy &
Superior nutrition during pregnancy is important not only for the client but for the developing fetus. Those who have
a limited intake of fruits, vegetables, fish, meats, and dairy can have infants who are stillborn or have a low birth

weight; the fetus could also have developmental delays. Those who lack nutrients such as iodine, folate, calcium,
and zinc can have complications during pregnancy that could potentially result in material death (UNICEF, 2023).
Research shows that if a pregnant person has gestational diabetes, there are cellular changes that occur within the
developing heart of the fetus. It is important to monitor the client’s blood glucose and if they do have diabetes,
make sure the glucose is under control. Cellular changes that occur during the development of the heart of the fetus
have been linked to high glucose levels in the pregnant client (Garg, 2020).
Part B
Study Part A.
Tara is at an advanced maternal age. As an already busy mom and working full-time, she regularly has a very hectic
schedule. Meals are often whatever she can pick up quickly. Tara has gained more weight in the second trimester
than her obstetrician recommends; the doctor is concerned about her elevated blood pressure, cholesterol and
glucose levels, heartburn, and lower leg edema.
Upon examination, fundal height is appropriate for gestation and fetal heart tones are normal. Considering Tara’s
busy schedule and the three children she is already caring for, Tara is concerned about how to feed her family and
keep herself healthy.
3. While preparing education for Tara, which information does the nurse need to include in the educational
packet to help keep Tara and her fetus healthy?
a. Decrease food intake
b. Exercise 60 minutes daily
c. Increase fruits and vegetables
d. Increase salt in the diet
4. Which finding in Tara would be the most concerning for premature birth?
a. Busy schedule
b. High blood pressure
c. Fundal height
d. Pregnant with one fetus
Infancy
For healthy infants born without cardiovascular disorders, research data indicates that breastfeeding for the first 6
months is best because it provides the infant with optimal nutrition. The goal is to breastfeed infants for a full year
while introducing solid foods (CDC, 2023e). Infants who are breastfed have a decreased risk for subsequent
cardiovascular-related diseases such as obesity and type 1 diabetes. Commercially made formulas are developed to
mimic breast milk. Infant formulas must meet the nutritional requirements that are set by the federal government
(FDA, 2023). The FDA recommends that formula preparations include calcium, fats, folate, iron, protein and
carbohydrates in the appropriate amounts for infants. Additionally, micronutrients of zinc, vitamins A, C, D, E, K, and
B vitamins are included in the recommendations (Watson, 2022). To ensure the infant receives the correct amount
of these macro and micronutrients, it is important to provide the formula as prepared or reconstitute as directed.
Watering down the formula will not provide the infant with the nutrients needed to support growth and
development.
Complementary foods can be added to the diet after the infant is 6 months old. Complementary foods include iron-
fortified infant cereals, pureed vegetables, and fruits. As more food is introduced to the infant, food choices should
include fruits and vegetables, whole grains, and whole milks, such as pumpkin, apples, pears, carrots, peas, and
pureed lean meats. Commercially prepared infant foods are available in various stages of infant development.
Home-prepared foods should be pureed to a consistency that is easy for the baby to eat with all peelings and seeds
removed (Advent Health, 2021) or cut into small pieces to avoid choking.
Foods and Drinks to Avoid with Infants
Specific food items should be avoided until 12 months of age. Infants under 12 months should avoid honey, due
to the potential for botulism, unpasteurized drinks/foods, foods high in salt or sugar, caffeinated drinks, cow’s
milk, and fish high in mercury (CDC, 2023b). Other foods that should be avoided that could potentially cause
harm are nuts, sunflower seeds, cherries with pits, raw carrots, popcorn, hard candy, raw apples and pears,
grapes, cheese cubes, and hot dogs or sausage because these have the potential to lodge in the infant’s trachea
and block the airway. Peanut butter and chewing gum can also make the mouth sticky and get lodged in the
airway (Nemours Children’s Health, 2023).
Infants with congenital heart disease require additional calories to support growth and development (Royal
Brompton and Harefield Hospitals, 2021). Babies with congenital heart disease may experience fatigue and typically
require more calories daily than the average infant. Many of these babies cannot eat or drink enough to meet their
caloric needs. The pediatrician can recommend supplementing breast milk or prescribe a high calorie formula. Baby
foods that are higher in calories are bananas with tapioca, mango with tapioca, prunes and rice, mixed vegetables,
and sweet potatoes. Many others can be obtained from the grocery store in the baby food aisle (American Heart
Association, 2023; Royal Brompton and Harefield Hospitals, 2021). Formulas that the provider can prescribe
include Infatrini and Similac High Energy with 100 calories and 2.6 g of protein per 100 mLs, in comparison to the
standard formula, which has 70 calories and 1.5 g of protein per 100 mLs (Royal Brompton and Harefield Hospitals,
2021). Infants who have heart issues also may require nasogastric tube feeds to help keep up with their nutritional
needs.
Feeding during infancy is an opportunity to introduce infants to a heart-healthy diet and encourage food likes that
will extend throughout their lifecycle. Promoting a rainbow of foods and allowing the infant to explore a variety of
textures and consistencies will promote a healthy relationship with food as a fuel source that will encourage and
sustain growth and development. Limiting processed, high-fat, high-sugar, and high-sodium foods in infancy will
develop a pattern of utilizing nutrient-dense foods for fuel across the lifespan.
Childhood
The heart healthy eating behaviors of infancy should also be followed in childhood, including calorie consumption
that supports the growth and developmental needs of the child. As these needs fluctuate, children should take the
lead on how much food they consume; parents and caregivers can allow then to stop eating when they are full
rather than promoting a clean plate (American Heart Association, 2018). Foods low in added sugar, saturated fats,
cholesterol, and salt should be the focus of a healthy childhood diet. A childhood diet should be rich in a variety of
colorful foods; 30–35% of daily caloric intake should be mono- or polyunsaturated fats from olive oil or canola oil.
See Table 12.2 for the nutritional needs of an average 3-year-old.
Nutritional Needs Measurements

Dairy 2 cups
Lean meats and beans 2 oz
Vegetables 1 cup
Fruits 1 cup
Grains 3 oz (with half of that from whole grains)
TABLE 12.2 Daily Nutritional Needs for a 3-Year-Old (source: AHA, 2010)
Developing a meal-time routine as a family—where the child is involved in the meal preparation—helps to build life-
long healthy eating habits. Including children in the preparation of food and teaching them to make healthy
nutritional choices is something parents can incorporate into their meals each day. Kids can help by washing the
fruits and vegetables, setting the table, and helping prepare things that are at their cognitive and coordination levels.
Involving children in meal preparation makes them feel they have choices in what they eat, and with the parents’
help they are making healthier choices. When eating fast food children can learn to choose healthy options such as

carrot sticks instead of French fries, yogurt instead of hashbrowns or other sides that are fried in grease, and fresh
fruit instead of baked goods high in added sugar.
Childhood is the optimal time to develop and reinforce heart-healthy dietary eating behaviors that support growth
and development throughout life. Heart-healthy nutritional patterns such as watching portion sizes, eating low-fat
dairy, limiting saturated fats, and increasing fruits and vegetables in the diet can help decrease the likelihood of
obesity, hyperlipidemia, and hypertension in childhood and later as an adult (Cleveland Clinic, 2022c).
Part C
Tara’s 3-year-old son, Carter, attends preschool Monday through Friday from 7 a.m. until 5:30 p.m. Other than
several upper respiratory tract viral infections and several rounds of otitis media, Carter is relatively healthy. At his
latest well-child visit, the health care provider was concerned with Carter’s high weight due to subsequent health
issues related to childhood obesity.
When discussing a normal 24-hour diet for Carter, Tara shares that he typically eats breakfast, lunch, and a snack at
preschool. They typically pick up food for dinner on the way home from work/preschool. As Tara often works from
home on the weekends, she admits that Carter tends to get more screen time than she would like.
5. With Carter’s height charted at 36 inches and weight at 54 lb, calculate his BMI and indicate his BMI category.
You may use this BMI calculator: https://www.cdc.gov/healthyweight/bmi/calculator.html.
a. 29.3; severe obesity
b. 19.2; healthy weight
c. 16.2; underweight
d. 32.2; severe obesity
6. While teaching Tara about healthy food choices for Carter, which statement is most appropriate?
a. “Make sure Carter eats all of his food at each meal and that his plate is clean.”
b. “Let Carter help you prepare meals in the kitchen while you are cooking.”
c. “Since you are busy, Carter can have a cheeseburger and fries daily to help you.”
d. “Screen time is good for Carter since you work and need to keep him occupied.”
Adolescence
Some important modifiable risk factors for cardiovascular disease in adolescents include poor dietary quality and
obesity, which can lead to early-onset atherosclerosis (Raeside, 2019). Preventing the occurrence of cardiovascular
disease in adolescents reduces the risk for early death from cardiovascular disease in later life. Although the
information presented previously focuses on nutrient-dense, heart-healthy foods is equally applicable to
adolescents, it is also imperative to integrate teaching strategies in ways meaningful for this age group.
To decrease the risk for long-term cardiovascular disease, preventing or delaying the occurrence of negative,
modifiable risk factors is essential (Dahm et al., 2016). Promoting the high consumption of fruits and vegetables, as
well as whole grains, lean meats, and fish, while minimizing the intake of processed foods, sodium, and artificial
trans fats during adolescence has been shown to decrease the incidence of cardiovascular disease in adulthood.
Refer to Table 12.3 for the daily nutritional needs of adolescents.
Foods Female – 1,800 Calories Male – 2,200 Calories

Dairy 3 cups 3 cups
Lean meats and beans 5 oz 6 oz
Vegetables 2.5 cups 3 cups
TABLE 12.3 Daily Nutritional Needs for the Average, Healthy 15-Year-Old (source: AHA, 2018)
Foods Female – 1,800 Calories Male – 2,200 Calories

Fruits 1.5 cups 2 cups
Grains 6 oz (with half of that from whole grains) 7 oz (with half of that from whole grains)
TABLE 12.3 Daily Nutritional Needs for the Average, Healthy 15-Year-Old (source: AHA, 2018)
Although many aspects of social media are not viewed positively, social media can provide information about heart-
healthy behavior in a way that positively impacts adolescent behaviors (Mayo Clinic, 2022a). The use of digital
media has been noted to be effective in providing adolescents with information when and where they seek it (Mayo
Clinic, 2022a). Additionally, utilizing social media assists teens in establishing a feeling of connection with their
peers, which can foster healthy behaviors (Anderson et al., 2022). Social media also reduces barriers to information,
increasing the accessibility of heart-healthy information available to this age group. Parents and nurses can balance
the positive implications with an awareness of the negative implications of social media. Research has indicated one
of the best ways to help alleviate negative impacts that social media can play on the teen is for parents and
guardians to have open communication with their teens.
Eating disorders, such as purging, binging, or limiting food/not eating certain foods, are more prevalent among
female adolescents than males. In the U.S. it is estimated that 10 in 100 young women have an eating disorder
(American Academy of Child & Adolescent Psychiatry, 2018). Teens can become withdrawn, and family may
recognize weight loss in individuals suffering from eating disorders. Recognizing these symptoms is crucial to the
health of the teenager.
In addition to diminished mental health, eating disorders lead to diminished physical health: electrolyte imbalances,
such as hypokalemia and hyponatremia; increased liver enzymes; increased bilirubin levels; anemia; and
leukopenia. These changes can affect the electrocardiogram by prolonging QT intervals, causing bradycardia, and
ventricular tachycardia. The effects of these disorders can decrease the blood pressure and cause a higher risk for
heart problems, such as cardiomyopathy, by causing the larger walls of the heart to become thicker and lose their
ability to pump blood (Sarder et al., 2015). Clients with anorexia typically have an amino acid deficiency because
they do not consume enough protein, which is essential for bodily function. Without enough protein, the body will
use the available protein for vital functions and the other nonessential functions will shut down. Nails become
brittle, menstruation ceases, muscles begin to thin and waste, and the essential functions that help to regulate the
heart become altered. Heart abnormalities are commonly seen in severe anorexia due to cardiac muscle cell death
(Comprehensive Psychiatric Resources, 2023).
Adulthood
Cardiovascular disease is occurring in younger adults more often because other diseases that can cause
cardiovascular disease are happening at younger ages. Risk factors for developing heart disease include
hypertension, hyperlipidemia, smoking, obesity, diabetes, sedentary lifestyle, and poor dietary choices (CDC,
2023c).
Cardiovascular disease (CVD) is a broad category, but includes four subtypes: coronary heart disease, stroke,
peripheral artery disease, and aortic disease. Table 12.4 includes a complete description of each.
Disease Subtype Description

Coronary heart disease Plaque builds up on the walls of the arteries that supply blood to the heart, which
(CHD) decreases blood flow to the heart. This causes angina, which is chest pain from the
lack of oxygen delivery to the heart.
Transient ischemic The temporary period of symptoms that are like a stroke and is caused by the
attack (TIAs) occlusion of the arteries leading to the brain. TIAs typically only last a few minutes
and the client usually recovers without any permanent damage.
Stroke The vessels leading up to the brain are blocked, stopping blood from flowing to the
brain. Brain cells are damaged or possibly die, which can lead to long-term
disability.
TABLE 12.4 Subtypes of Cardiovascular Disease (sources: CDC, 2023f; Mayo Clinic, 2022c)

Disease Subtype Description

Peripheral artery disease A blockage in the arteries to the extremity, usually the leg. This can produce pain in
(PAD) the legs while walking.
Aortic disease This is a broad category for any condition that impacts the ability of the aorta to
function correctly. The most common type is aortic aneurysm.
TABLE 12.4 Subtypes of Cardiovascular Disease (sources: CDC, 2023f; Mayo Clinic, 2022c)
When arteries become built up with plaque, it causes a narrowing of the artery (National Heart, Lung, and Blood
Institute, 2022), which impacts blood flow away from the area of stenosis (narrowing). Nutritional intake, along with
lifestyle choices and heredity, can affect a client’s risk for developing atherosclerosis. See Figure 12.3 for a graphic
depiction of normal versus abnormal blood flow due to atherosclerosis.
FIGURE 12.3 Atherosclerosis is due to plaque buildup which causes a narrowing of the artery and impacts blood flow distal to the area of
stenosis. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Risks for heart disease include high cholesterol and high triglyceride levels, high blood pressure, and a diet high in
saturated fats (Mayo Clinic, 2023d). There are two types of blood cholesterol, low-density lipoprotein (LDL)
cholesterol and high-density lipoprotein (HDL) cholesterol. Health care providers commonly refer to LDL as bad
cholesterol because it contributes to the development of plaque deposits in arteries; HDL is referred to as good
cholesterol as it provides some protection against heart disease (CDC, 2023d). Table 12.5 outlines cholesterol
levels in the desirable, borderline, and high ranges.
Laboratory Test Desirable Borderline Risk High Risk

Total cholesterol < 200 mg/dL 200–239 mg/dL > 240 mg/dL
LDL cholesterol < 100 mg/dL 100–159 mg/dL > 160 mg/dL
HDL (varies dependent > 60 mg/dL 40–59 mg/dL < 40 mg/dL
on sex)
Triglycerides < 150 mg/dL 150–199 mg/dL 200–499 mg/dL
Blood pressure < 120/80 mm Hg 120–129/< 80 mm Hg > 130/80 mm Hg
TABLE 12.5 Normal Cholesterol Levels (sources: CDC, 2021; National Heart, Lung, and Blood Institute, 2023; National Library of Medicine,
2022)
The use of the heart-healthy diet has been shown to help lower bad cholesterol (LDL) and increase good cholesterol
(HDL). Additionally, avoiding or minimizing processed foods and high-sugar foods and drinks has a positive impact
on heart health. Foods, such as red meats and high-fat dairy products that are high in saturated fat, should be
reduced to help lower LDL levels. Adding whey protein to the diet can help decrease LDL and total cholesterol
(Amirani et al., 2020). Increasing intake of omega-3—by increasing foods such as salmon, mackerel, and
walnuts—can reduce blood pressure. Clients can increase soluble fiber in the diet by eating oatmeal, kidney beans,
and apples, which can help decrease the absorption of cholesterol in the body leading to overall changes in
cholesterol levels. Exercise and quitting smoking can also help improve HDL levels (Mayo Clinic, 2023b). Adhering to
these dietary patterns can impact individual cholesterol levels to decrease the risk for developing atherosclerosis
and further cardiovascular diseases.
Alcohol consumption has been shown to have negative effects on cardiovascular health, leading to hypertension,
heart failure, and stroke. Drinking excessively—women more than 4 drinks per day and men more than 5 drinks per
day—can also lead to cardiomyopathy, which affects the ability of the heart to pump effectively (Johns Hopkins
Medicine, 2023). An alcoholic drink is defined as 0.6 of fluid ethanol per drink (National Institute on Alcohol Abuse
and Alcoholism, 2022). In a study that consisted of 371,463 participants, Biddinger et al (2022), showed an
increased risk for hypertension and coronary artery disease with alcohol consumption.
In addition to educating clients on controlling cholesterol, triglyceride, and blood pressure levels and avoiding
alcohol, nurses should inform clients about appropriate nutritional plans to combat cardiovascular disease.
Nutritional plans should be low in processed food, sugary drinks, saturated fats, fatty dairy products, and sodium
(Mayo Clinic, 2023e). The Dietary Approaches to Stop Hypertension (DASH) diet is an appropriate recommendation
because it includes a diet high in fruits and vegetables, unsaturated fats, whole grains, fish, legumes, and low-fat
dairy. Refer to Table 12.6 for the daily nutritional needs of adults.
Food 1,800 Calories 2,200 Calories

Dairy 3 cups 3 cups
Lean meats and beans 5 oz 6 oz
Vegetables 2.5 cups 3 cups
Fruits 1.5 cups 2 cups
Grains 6 oz (with half of that from whole grains) 7 oz (with half of that from whole grains)
TABLE 12.6 Daily Nutritional Needs for the Average Healthy Adult (source: U.S. Department of Agriculture, n.d.)
Part D
Tara is a busy mother who typically does not like to cook. She does have 4 children ranging from ages 12 years to 2
weeks. While her husband’s parents help care for the children, it is typically Tara who cares for them daily. Tara’s
husband is usually away on business 3–4 nights a week leaving Tara to care for the children herself.
At her last annual physical, her blood pressure was 148/84 mm Hg; total cholesterol was 248 mg/dL and
triglycerides showed 173 mg/dL. Her health care provider discussed risk factors associated with cardiovascular
disease.
Because school provides breakfast, lunch and a snack for Carter, Tara typically drinks several cups of coffee for
breakfast, grabs lunch at work and picks up dinner on the way home from picking up her children from her in-law’s
house. She works at home on the weekends, but believes she has time to make positive changes in their normal
eating routine to include heart healthy meals.
7. Which would be the best choice for Tara to include in her dietary menu planning?
a. Macaroni and cheese
b. Fried chicken
c. Pork sausage
d. Apples
8. What are ways in which Tara could decrease her cholesterol instead of being placed on medication?
a. Increase fiber in her diet
b. Drink more sodas
c. Increase intake of fatty meats
d. Eat more processed foods
Later Adulthood
Later adulthood can be further broken down as youngest-old adults between 65 and 74, middle-old adults between
75 and 84, with oldest-old age 85 and older (Lee et al., 2018). Although preventative care fostering a healthy

12.2 • Nutrition and Long-Term Cardiovascular Illnesses 239
cardiovascular system is the optimal desire, research indicates that there is an increase in cardiovascular disease as
people age. The incidence of cardiovascular disease increases from approximately 40% in adults ages 40–59 to
75% from ages 60–79, and approximately 86% in those above age 80 (Rodgers et al., 2019). Depending on the
activity level of the client, the older adult typically needs about 2000 calories daily. Additionally, healthy older adults
need increased dietary fiber, calcium, vitamin D, and potassium; healthy older adults should decrease their
consumption of saturated fats, sodium, and added sugars (FDA, 2022a). See Table 12.7 for the recommended
nutritional needs for later adulthood.
Nutrient Recommended Daily Amount

Dietary fiber 28 g
Calcium 1000 mg
Vitamin D 600 IU
Potassium 3400 mg
Saturated fats < 10% daily caloric intake
Sodium < 2300 mg
Added sugars < 10% daily caloric intake
TABLE 12.7 Daily Nutritional Needs for Later Adulthood (source: U.S. Department of Agriculture, 2020a)
As people age, many age-related changes occur that can affect nutritional needs. Many adults experience heart
complications from coronary artery disease, valvular disease, high cholesterol, heart failure, and arrhythmias. These
clients are typically placed on multiple medications to treat their condition. However, the nurse can educate clients
on nutrition and other lifestyle strategies to help clients manage their symptoms. Nutritional needs for a healthy
heart include eating a variety of fruits and vegetables; eating whole grains; choosing healthy proteins such as nuts,
fish, and seafood; decreasing intake of highly processed foods; minimizing intake of added sugars; using herbs
instead of salt for seasoning or choosing low-sodium foods; and limiting alcohol intake. The nurse should also
instruct clients on the importance of smoking cessation (American Heart Association, 2021). Another consideration
is how nutrition can interact with medications clients take to treat their heart disease.
12.2 Nutrition and Long-Term Cardiovascular Illnesses

LEARNING OUTCOMES
• 12.2.1 Discuss the impact of nutrition on cardiovascular illness.
Cardiovascular Diseases
The American Heart Association defines cardiovascular disease as any disease of the heart and blood vessels, many
of which are related to atherosclerosis (2017). Although some cardiovascular problems are congenital, meaning the
client was born with it, most cardiovascular diseases develop over the lifespan. Cardiovascular diseases that
develop over the lifespan are often linked with atherosclerosis (National Heart, Lung and Blood Institute, 2022).
Cardiovascular heart disease indicates a decrease in the amount of blood, and therefore oxygen, available to the
heart muscle (American Heart Association, 2017). CVD is often the result of narrowed cardiovascular arteries due to
the buildup of cholesterol plaque or atherosclerosis. Lipids—LDL, HDL, and triglycerides—are components of cell
membranes; they assist with energy movement and storage, production of hormones, and vitamin absorption.
However, having too much LDL or triglycerides or too little HDL negatively impacts the body (Cleveland Clinic,
2022b). For this reason, a heart-healthy diet seeks to control high cholesterol (hyperlipidemia) (American Heart
Association, 2020).
When clients have hyperlipidemia, consider what happens in their vascular system over time. As the buildup of
cholesterol begins to form plaques, the vascular system becomes constricted or narrowed. This narrowing causes
the heart to pump more forcefully to push blood throughout the cardiovascular system, resulting in hypertension
and, potentially heart failure, if the cardiac muscle becomes fatigued. Additionally, when the plaque area leading to
the cardiovascular arteries supplying blood and oxygen to the heart muscle continues to narrow until it eventually
becomes too stenosed for blood to flow through it, a myocardial infarction will occur.
Optimally, individuals will adopt a heart-healthy diet early in life that minimizes hyperlipidemia. This eating style
provides the nutrients needed to fuel the body while minimizing foods and food preparation styles that increase
cholesterol levels. Heart-healthy diets reduce saturated and trans fat by limiting red meat and whole milk dairy
products. Additionally, food is prepared by grilling or baking instead of by frying; healthy oils, such as olive oil, are
used, when cooking. Heart-healthy diets focus on fruits, vegetables, poultry, fish—especially fish that contains
omega-3 such as salmon (Medical News Today, 2021)—whole grains, and nuts. Sodium intake for clients on a
healthy heart diet should be limited to 2300 mg/day (FDA, 2022b; American Heart Association, 2020).
Hypertension
Hypertension, or high blood pressure is when the pressure needed to push blood throughout the body’s circulation
is consistently high and reads over 130/80 mm Hg (CDC, 2023a). The formation of plaques can cause constriction or
narrowing of the arteries (Figure 12.4). If left untreated, hypertension can increase the risk for cardiovascular
diseases. Heart healthy diets are designed to decrease cholesterol levels, decrease blood pressure, and reduce risk
for developing congestive heart failure. In addition, hypertensive clients may also follow a low-sodium diet. One of
the most effective diets to lower blood pressure is the DASH diet (Mayo Clinic, 2021). In addition to limiting the
intake of sodium to 2300 mg/day, the DASH diet also includes foods high in potassium, calcium, and magnesium.
The DASH diet encourages limiting saturated fats and sugars (Table 12.8).
FIGURE 12.4 Atherosclerosis is a primary cause of hypertension. (credit: “Hypertension (High Blood Pressure)” by Blausen.com staff
(2014). “Medical gallery of Blausen Medical 2014”/Wikimedia Commons, CC BY 3.0)
Food Types Serving Size Recommended Foods

Grains 6–8 servings daily 1 slice of whole grain bread
1 oz of dry cereal
½ cup of cooked rice or pasta
Vegetables 4–5 servings daily 1 cup of raw leafy green vegetables
½ cup raw or cooked vegetables
½ cup vegetable juice
Fruits 4–5 servings daily 1 medium fruit
½ cup fresh
frozen or canned fruit
½ cup fruit juice
TABLE 12.8 DASH Diet Recommended Foods (source: Mayo Clinic, 2021)

12.2 • Nutrition and Long-Term Cardiovascular Illnesses 241
Food Types Serving Size Recommended Foods

Low-fat/no-fat dairy 2–3 servings daily 1 cup milk or yogurt
1½ oz cheese
Lean meat/poultry/fish 6 servings daily Each serving = 1 oz
Cooked meat, poultry, fish, or egg
Fats/oils 2–3 servings daily 1 tsp butter substitute or vegetable oil
1 tbsp mayonnaise
2 tbsp salad dressing
Nuts, seeds, legumes 4–5 servings weekly ⅓ cup nuts
2 tbsp nut butter
2 tbsp seeds
Sweets/added sugars 5 or fewer servings weekly 1 tbsp sugar, jelly, or jam
1 cup sweetened lemonade or tea
TABLE 12.8 DASH Diet Recommended Foods (source: Mayo Clinic, 2021)

A holistic assessment of the client extends beyond a physical assessment and a nutritional assessment. The nurse
should examine which individual characteristics, aspects of medical history, challenges to maintaining health,
interest in wellness promotion and family, community, and cultural aspects impact the client’s ability to develop and
adhere to a nutritional plan designed to optimize cardiovascular function. For the cardiovascular client, the nurse
should focus attention on providing education to decrease cholesterol levels and hypertension, while providing a
nutrient-dense eating plan that fuels the body.
What are the client’s personal characteristics related to food that may impact their ability to adhere to a healthy
heart eating plan? For example, the nurse should consider if there are issues related to food enjoyment, food
intolerances, and likes and dislikes of certain foods. The nurse can do the following to get a better picture of how to
help the client achieve success in developing and adhering to a heart-healthy meal plan:
• Determine if the client likes to engage in the cooking process—plan, prepare, and cook meals—in lieu of eating
ready-made processed meals.
• Consider aspects of the client’s overall health history, paying specific attention to cardiovascular-related issues.
• Identify if there are long-term cardiovascular issues or if the issue is an acute exacerbation. If the medical issue
is long-term, determine what issues in the past have helped or hindered the client to identify and maintain a
heart-healthy diet. Incorporate pertinent family members into this assessment.
Risks for Heart Disease Vary by Ethnicity
The risk for heart disease varies across different ethnic groups. Black women are more likely to have a heart
attack, whereas Black men are more likely to die from having a heart attack. Asian people typically have less
coronary artery disease than other ethnic groups, although Asian Indian men and Filipino men and women do
have a higher risk in comparison to White people. Hispanic women who are young and have a heart attack are at
greater risk for dying than young Hispanic men, young Black adults, and young White adults. (Cleveland Clinic,
2023). In the United States, heart disease is the leading cause of death for people in most ethnic groups (CDC,
2023d).
Planning a heart-healthy menu using the cuisines of diverse cultures can improve adherence as well as provide
variety. Table 12.9 outlines different cultures and food choices that would be appropriate for heart health.
Culture Healthy Food Choices

Mexican • Grilled shrimp, chicken, or fish
• Black or pinto beans
• Salsa, pico de gallo, cilantro, black olives, jalapeno peppers
• Guacamole, fat-free sour cream
• Onions, peppers, mushrooms, tomatoes
• Whole grain brown rice, corn tortillas
Asian • Steamed rice

(Chinese, Thai, Japanese) • Vegetables such as bok choy, napa cabbage, bean sprouts, daikon, bamboo
shoots, and watercress
• Mung bean
• Rice noodles
• Low-sodium soy sauce, chili sauce, oyster sauce, and fish sauce
• Curry paste
• Curry such as Thai, Japanese, Chinese, or Malaysian curries
• Lemongrass
• Rice vinegar
• Cilantro, mint, ginger, galangal, and green onion
• Tofu and bean curd
• Edamame
Indian • Berries such as strawberries, blackberries, and blueberries

• Avocado
• Fish and fish oil
• Whole grains such as whole wheat, barley, oats, millet, brown rice, and high
fiber cereal
• Legumes such as lentils, mung beans, and kidney beans
• Seeds and nuts
• Chia seeds
• Spinach
• Collard and mustard greens
• Curry
Italian • Chicken or turkey (grilled, or baked)

• Low-fat ricotta cheese
• Farro or whole grain rice
• Tomatoes and bell peppers
• Whole wheat pastas
• Olive oil
• Low-sodium marinara sauce
• Grilled vegetables such as zucchini, eggplant, and radicchio
• Mussels, octopus, squid
Soul food/traditional • Roasted vegetables such as okra and bell bepper

southern cooking • Berries and stone fruits
• Baked chicken without skin
• Baked sweet potato
• Roasted turkey or pork
• Brown rice
• Cauliflower pasta
• Collard, mustard, and turnip greens
TABLE 12.9 Culturally Appropriate Food Choices for a Heart Healthy Diet Among Cuisines Popular in the United States (sources: Cleveland
Clinic, 2020a; Cleveland Clinic, 2020b; Patiala Heart Institute, 2023; Martin, 2023; WebMD, 2022; National Lipid Association, 2020)


LEARNING OUTCOMES
• 12.3.1 Identify drug-food interactions for their impact on treatments utilized for cardiovascular disorders.
cardiovascular disorders.
Drug-Food Interactions with Treatments for Cardiovascular Disorders

Nurses should be aware of the drug and food interactions that can occur with cardiac medications. This section will
discuss some of the most common.
Warfarin and Vitamin K

Warfarin keeps blood from coagulating too quickly and is used for treatment of venous thromboembolism and for
stroke prevention for certain conditions like atrial fibrillation or mechanical heart valves. Vitamin K works to assist in
coagulation. Warfarin and vitamin K work in opposite ways, so the client must be aware that their normal, daily
consumption of vitamin K should be consistent. Women typically need about 90 mcg of vitamin K daily; men
typically need about 120 mcg. Green, leafy vegetables, Brussels sprouts, broccoli, asparagus, and green tea are all
high in vitamin K (Mayo Clinic, 2022b). The clients can eat leafy greens, but they need to eat them in a consistent
amount. When a client’s consumption of leafy greens fluctuates, it can cause fluctuations in the effects of warfarin.
Diuretics and Electrolytes

There are a variety of diuretics used for heart failure and a few for hypertension; the most common are the loop
diuretics such as furosemide. Diuretic medications decrease the workload of the heart muscle and rid the body of
excess fluid, which can cause fluctuations in electrolyte levels, particularly potassium. The nurse should assess the
client for (and instruct the client to note signs of) hypokalemia—potassium levels less than 3.5 mEq/L. Symptoms of
hypokalemia include constipation, muscle cramps, heart palpitations, and fatigue (Mayo Clinic, 2023a).
Although the loop diuretics are the most common diuretics that are associated with electrolyte imbalances, the
clients who are taking other types of diuretics such as potassium-sparing diuretics need to be aware of the risk for
hyperkalemia that can develop from the use of these medications (Knott, 2020). Hyperkalemia, or elevated
potassium levels, can cause muscle fatigue, paralysis, arrhythmias, and nausea.
Since diuretics help the body to get rid of excess water, there is a risk that sodium—also an electrolyte—can be
reduced too much and cause hyponatremia. The nurse should inform clients of signs and symptoms of
hyponatremia: nausea and vomiting, weakness, and changes in level of consciousness; extremely low levels of
sodium can cause seizures (Sterns, 2022).

Clients with cardiovascular disease frequently take one or more prescribed medications that can potentially cause
nutritional deficiencies. Diuretics, for example, are used by clients with hypertension, heart-failure, and other
cardiac-related conditions. Deficiencies of water-soluble vitamins are related to the use of diuretic therapy which
causes increased excretion of these nutrients (Lennie et al., 2018). Other cardiovascular medications associated
with nutrient deficiencies include statin medications used to treat hyperlipidemia. Studies have shown that levels of
serum CoQ10, important for converting food into energy, decrease with the use of atorvastatin and similar
medications (Chong et al., 2021).
Traditionally, sodium has been the focus of research examining the role of nutrition in the management of heart
failure (Lennie et al., 2018). However, recent research has expanded the search for nutritional factors that influence
the management of clients with heart failure and other cardiovascular diseases. Researchers have found that clients
with heart failure frequently experience calcium, folate, magnesium, zinc, and vitamins C, D, E, and K deficiencies
(Lennie et al., 2018). These deficiencies can be related not only to medication use, but also other factors. Another
related factor to nutritional deficiencies among clients with heart failure is the lack of diet variety (Lennie et al.,
2018). These clients frequently experience loss of appetite, feel full after eating only a small amount, and have
limited energy to prepare and eat food. They are more likely to eat the same foods repeatedly, limiting their
potential to consume a variety of needed nutrients (Lennie et al., 2018).
Part E
Case Study Parts A, B, C, and D.
Recently, Tara has noticed her legs are swelling and she has experienced some shortness of breath with activity, so
she schedules an appointment with her primary care provider.
At Tara’s appointment, her provider takes her vital signs and finds her blood pressure is 165/85 mm Hg and her
heart rate is 72 beats per minute. She is experiencing crackles in the base of her lungs and 2+ pitting edema to
bilateral lower extremities.
The provider is concerned that Tara has developed heart failure and wants the nurse to educate Tara on healthy food
choices. The provider places Tara on the diuretic furosemide to decrease Tara’s swelling and a potassium
supplement. The provider orders laboratory work that includes a comprehensive metabolic panel and B-type
natriuretic peptide.
9. The nurse is educating Tara on nutritional considerations related to her condition. Which education statement
would be appropriate for the nurse to tell Tara?
a. “You need to increase your intake of potassium-rich foods.”
b. “You need to increase the amount of sodium in your diet.”
c. “You need to identify a small list of foods that you can easily prepare and eat several times a week.”
d. “You may need a vitamin supplement if you are unable to eat a variety of foods.”
10. The nurse is giving Tara an example of a healthy meal for her heart. Which meal would be the most
appropriate for the nurse to share with Tara?
a. Fried chicken, green beans, and tea
b. Grilled fish, steamed vegetables, and water
c. Hamburger, chips, and water
d. Baked chicken, rice, and white roll

Chapter Summary
• Proper nutrition is essential for maintaining a • Childhood dietary habits can impact adult health,
healthy heart through the lifespan and is important so it is important to establish habits like eating
for overall health. whole grains, vegetables and fruits, utilizing low-
• Physical activity, at least 150 min weekly, is an fat or non-fat dairy foods, and selecting fish and
important aspect of all stages of life. lean meats, as well as avoiding or minimizing
• As a person ages, it is important to have routine processed foods and high-sugar foods and drinks.
checkups which include monitoring cholesterol, • Older adulthood diseases can affect heart health.
triglycerides, and blood pressure.
Key Terms
angina chest pain caused by inadequate blood supply near syncope feeling of loss of consciousness
to the heart plaque fatty deposits of cholesterol on inner lining of
atherosclerosis plaque buildup within the vascular artery
system stenosis narrowing and hardening in diameter
dyspnea difficult or labored breathing stroke loss of oxygen to cerebral tissue
heart failure inability of heart to pump blood syncope loss of consciousness for a short period of
effectively to keep up with body demands time
hyperlipidemia excess of lipids or fats in the blood transient ischemic attack (TIA) temporary loss of
hypertension consistent blood pressure readings oxygen to cerebral tissue without permanent
above 130/80 damage
lipids fatty acids insoluble in water; lipids in the triglycerides fatty substance circulating in the
blood are LDL, HDL, and triglycerides cardiovascular system
myocardial infarction death of heart muscle due to uteroplacental transfer of oxygen and nutrients from
lack of blood flow and oxygen client to fetus through umbilical cord and placenta
Review Questions
1. A client who has a pre-existing heart condition consults her provider to plan for her next pregnancy. Which
statement would the provider need to include in the teaching for a client who has a normal BMI?
a. “You are able to gain as much weight as you need.”
b. “You need to increase your caloric intake by 340 calories daily in the second trimester.”
c. “You need to drink whole milk to help the fetus’s bones develop.”
d. “You need to refrain from exercising.”
2. When educating a new client about nutrition for their child to promote heart health, which statement should
be included?
a. “Use only breast milk for the first 6 months of life.”
b. “At six months, pureed vegetables can be added to the infant’s diet.”
c. “You can give your infant 100% fruit juice.”
d. “Healthy eating habits cannot start until later.”
3. When teaching a client about healthy snack choices for their child to promote heart health, which snack
choice would be the most appropriate?
a. Fruit flavored snacks
b. Whole milk
c. Banana
d. Ice cream
4. For a client who is following a heart healthy diet, what is the recommended sodium intake?
a. < 1500 mg/day
b. < 2300 mg/day
c. < 3000 mg/day
d. < 4000 g/day
5. Which factor can influence teenagers’ nutritional intake but may not have as strong an influence in other age
groups?
a. Social media
b. Parental guidance
c. Income level
d. Availability of food
6. A teenager comes to the clinic with her parents for concerns about eating disorders. Which long-term
complication is associated with eating disorders?
a. Aortic stenosis
b. Diverticulitis
c. Hypokalemia and hyponatremia
d. Rheumatoid arthritis
7. A nurse is providing education to a client with a total cholesterol of 240 mg/dL. Which of the following diet
strategies needs to be included?
a. Continue to consume 5–7 alcoholic beverages each week
b. Decrease intake of red meat and full-fat dairy products
c. Decrease intake of oatmeal, lentils, and other sources of fiber
d. Continue the current diet plan— this cholesterol level is within the accepted range
8. Which of the following would be an example of a DASH diet meal?

a. Sliced ham, canned corn, and a cup of milk
b. Fried eggs, bacon, and coffee
c. Grilled shrimp with whole grain rice and mixed vegetables
d. Oatmeal, sausage, and apple juice
9. A client is taking warfarin for a valve replacement. Which food should the nurse include in the teaching that
the client should consistently consume?
a. Asparagus
b. Potatoes
c. Water
d. Protein
10. The nurse is educating a client on how to eat heart healthy. The client tells the nurse that their typical meal
consists of traditional Mexican foods. Which meal chosen would indicate the client understands the
instruction?
a. Beef enchilada with cheese sauce and refried beans
b. Nachos covered with grilled chicken, cheese, sour cream, and lettuce
c. Quesadilla with fried shrimp, black beans, and pico de gallo
d. Grilled chicken, onions, green peppers, and avocado with corn tortillas
Suggested Reading
National Heart, Lung, and Blood Institute. (2022, March 24). Choose Heart-Healthy Foods.
https://www.nhlbi.nih.gov/health/heart-healthy-living/healthy-foods
Nemours Children’s Health. (2018, June). Eating During Pregnancy. https://kidshealth.org/en/parents/eating-

pregnancy.html
Office of Disease Prevention and Healthy Promotion. (2023, September 19). Heart-Healthy Foods: Shopping List.
https://health.gov/myhealthfinder/health-conditions/heart-health/heart-healthy-foods-shopping-list

Pathways to Population Health Equity. https://www.publichealthequity.org/
Rice, A. (2023, November 16). 15 Incredibly Heart-Healthy Foods. Healthline. https://www.healthline.com/nutrition/

heart-healthy-foods
WebMD. (n.d.). 21 Foods That Can Save Your Heart. https://www.webmd.com/heart-disease/ss/slideshow-foods-to-

save-your-heart

CHAPTER 13
Nutrition for Pulmonary Wellness
FIGURE 13.1 Selection, portion, and balance of food choices leverage nutrition as a modifiable risk factor to improve pulmonary health.
(credit: modification of work “Cheese, wine and bread in Cafe Vavin, 18 Rue Vavin, 75006 Paris” by Joe deSousa/Wikimedia Commons, CC0
1.0)
CHAPTER OUTLINE
13.1 Assess and Analyze the Impact of Nutrition on the Pulmonary System
13.2 Plan Nutritional Strategies to Impact Pulmonary Wellness
13.3 Implement Nutritional Strategies to Impact Pulmonary Wellness
13.4 Evaluate Nutritional Strategies to Impact Pulmonary Wellness
INTRODUCTION The pulmonary system is a set of organs that, in conjunction with the cardiovascular system,
provide life to the rest of the body through oxygenation. Numerous nutritional factors support, or prevent, full
function of the pulmonary system. When the pulmonary system is impaired by acute disease (cold, flu, pneumonia,
etc.) or chronic conditions (chronic obstructive pulmonary disease [COPD], asthma, cystic fibrosis, etc.), nutritional
support and considerations assist clients in healing. Additionally, obesity and chronic inflammation increase risks for
and worsen outcomes in lung disease through altered surfactant function, impaired vascular homeostasis, and
increased susceptibility to acute injury (Kokoszynska et al., 2021). Nurses’ understanding of nutrition and their
ability to apply the nursing process creates nutritional impact for optimal client health.
Consider this case: Katrice is an 11-year-old Black female who is overweight but active in school activities and
sports. Her past medical history includes seasonal allergies and diagnosis of asthma 1 year ago. Family history
includes three older siblings with seasonal and food allergies, eczema, and asthma. Her parents report “trying to
ensure a healthy diet” despite the need to eat prepared meals and fast food frequently because of the family’s busy
250 13 • Applying Clinical Judgment to Promote Nutrition for Pulmonary Wellness
schedule. They present today for an asthma follow-up appointment for Katrice.
13.1 Assess and Analyze the Impact of Nutrition on the Pulmonary System
LEARNING OUTCOMES
• 13.1.1 Describe the normal function of the pulmonary system.
• 13.1.2 Identify cues of nutritional impact on the pulmonary system.
• 13.1.3 Analyze cues of nutritional impact on the pulmonary system.
Development of the pulmonary system spans from its initiation in the first trimester of pregnancy through to early
adulthood (Arigliani et al., 2018). To assess and analyze the impact of nutrition on the pulmonary system, the nurse
must understand the system’s normal function. The pulmonary or respiratory system comprises the upper and lower
airways (passageways through which air moves), along with the lungs and alveolar sacs. The primary function of the
pulmonary system is to ensure adequate oxygenation throughout the body. This occurs with gas exchange, which
involves transporting oxygen to the cells and transporting carbon dioxide away from the cells. This process happens
through ventilation, diffusion, and perfusion. Ventilation is the movement of atmospheric air that is higher in oxygen
into the lungs and the removal of carbon dioxide. Ventilation is the number-one function of the respiratory system.
Respiratory diffusion occurs when gases move down the concentration gradient across the alveolar sacs and
capillaries. Perfusion is the process of the arterial blood moving through the tissue to the entire body. Adequate gas
exchange is essential for all systems of the body. If the pulmonary system is inadequate, total health and well-being
can be affected (Norris, 2019).
Normal Function of the Pulmonary System

The normal function of the pulmonary system is best understood when divided into the upper and lower respiratory
tract. The respiratory system plays a significant role in ensuring all body systems adequately receive gas exchange
for tissue perfusion (Figure 13.2).
FIGURE 13.2 The major respiratory structures span from the nasal cavity to the diaphragm. (credit: modification of work from Anatomy and
Upper Respiratory Tract

The upper respiratory system is responsible for inhalation and exhalation and also influences speech and the sense
of smell. The upper respiratory tract is comprised of the:

13.1 • Assess and Analyze the Impact of Nutrition on the Pulmonary System 251
• Nose—responsible for smell, which occurs via receptors from the olfactory nerve located in the upper areas of
the nose
• Sinuses—give a fullness to speech and act as shock absorbers if facial trauma occurs
• Pharynx (throat)—a passageway for the respiratory and digestive tracts
• Larynx (voice box)—houses the vocal cords, which are responsible for speech
Lower Respiratory Tract

The lower respiratory tract is comprised of the airways, lungs, and accessory muscles of respiration. The lower
respiratory system is responsible for gas exchange and perfusion.
The lower respiratory tract consists of the trachea, bronchi, bronchioles, alveolar ducts, and alveoli. Gases move to
and from the lungs through the airways. The airways only allow for movement of gases, not gas exchange, because
the airways are too thick to allow for diffusion. The actual respiratory gas exchange occurs in alveolar sacs that arise
from the ducts and contain groups of alveoli. Surfactant is a fatty protein that lines the alveoli and reduces surface
tension. Without surfactant, atelectasis, which is the collapse of the alveolar, will occur and gas exchange cannot
happen, because the collapse causes a reduction of the alveolar area.
The lower airways consist of two elastic lungs located in the pleural cavity of the chest. The two lungs are not equal
in size or gas exchange. The right lung is larger and consists of three lobes; the left lung has two lobes. Most of the
function (55–60%) occurs in the right lung. If the client’s right lung is compromised, it will interfere with gas
exchange and perfusion to a greater extent than a compromised left lung.
Respirations occur when changes in size of and pressure within the chest cavity take place. The diaphragm and
chest muscles contract and relax to cause these changes. When the work of breathing is increased, back and
abdominal muscles may be used in addition to chest muscles. When back and abdominal muscles are used, the
client is said to be using accessory muscles to breathe.
Humans breath in and out approximately 22,000 times a day (Canadian Lung Association, n.d.). While environmental
or contaminant factors impact pulmonary function, a natural degradation of function over time also occurs. The
following Special Considerations box describes respiratory changes that occur with aging. Respiratory changes in
older adults can be related to normal aging or respiratory disease. Age-related changes in the muscles and the
cardiovascular system may also cause abnormal respirations (Schneider et al., 2021).
Age-Related Changes in the Respiratory System
As individuals age, changes to the musculoskeletal, vascular, and respiratory systems that alter function and
may require nursing interventions, as outlined in Table 13.1.
Changes Nursing Implications

• Alveolar surface area decreases. • Encourage vigorous pulmonary hygiene (i.e.,
• Diffusion capacity decreases. client to turn, cough, and deep breathe) and use
• Elastic recoil decreases. of incentive spirometry, especially if the client is
• Bronchioles calcify and become rigid. confined to bed or has had surgery, to reduce
• Alveolar ducts dilate. the risk for infectious respiratory or mechanical
• Ability to cough decreases. complications.
• Encourage upright position to minimize
ventilation-perfusion mismatching; slumped
and supine positioning allows the abdomen to
compress the diaphragm and may limit full lung
expansion.
• Residual volume increases. • Include inspection, palpation, percussion, and
• Vital capacity decreases. auscultation in lung assessments to detect
• Efficiency of oxygen and carbon dioxide normal age-related changes.
exchange decreases. • Assess client’s respirations for abnormal
• Elasticity decreases. breathing patterns; Cheyne-Stokes respiration
may occur in older adults without pathology.
• Encourage frequent oral hygiene to aid in the
removal of secretions.
• Help the client actively maintain health and
fitness to keep losses in respiratory functioning
to a minimum.
• Muscles atrophy. • Have face-to-face conversations with the client
• Laryngeal muscles lose elasticity. when possible because the client’s voice may be
• Vascular resistance in the pulmonary system soft and difficult to understand.
increases. • Assess a client’s level of consciousness and
• Pulmonary capillary blood volume decreases. cognition, because hypoxia from acute
• Risk for hypoxia increases. respiratory conditions can cause the client to
become confused.
• The body’s compensatory measures to avoid • Assess subtle manifestations of hypoxia to
hypoxia and hypercarbia decrease. prevent complications.
• Respiratory muscle strength, especially in the • Encourage pulmonary hygiene and help clients
diaphragm and intercostals, decreases. actively maintain health and fitness to promote
maximal respiratory system functioning and
prevent respiratory illnesses.
TABLE 13.1 Expected Changes in Respiratory Symptoms for Older Clients (sources: Dezube, R., 2023; Schneider et al., 2021; Sun et
al., 2021)

Changes Nursing Implications

• Effectiveness of the cilia decreases. • Encourage pulmonary hygiene and help clients
• Alveolar macrophages are altered. actively maintain health and fitness to promote
• Immunoglobulin A decreases. maximal functioning of the respiratory system
and prevent respiratory illnesses.
• Anteroposterior diameter increases. • Discuss the normal changes of aging to help
• Progressive kyphoscoliosis occurs. reduce anxiety about symptoms.
• Chest wall compliance (elasticity) decreases. • Discuss the need for increased rest periods
• Mobility of chest wall may decrease. during exercise, because exercise tolerance
decreases with age.
• Osteoporosis is possible, leading to chest wall
abnormalities.
• Encourage adequate calcium and vitamin D
intake (especially during a client’s
premenopausal phase) to help prevent or
reduce later osteoporosis.
TABLE 13.1 Expected Changes in Respiratory Symptoms for Older Clients (sources: Dezube, R., 2023; Schneider et al., 2021; Sun et
al., 2021)
Assessment of Nutrition and the Function of the Pulmonary System

The nurse should complete an accurate assessment of the pulmonary system to identify the type and severity of
breathing problems that may interfere with gas exchange and be positively impacted by nutritional support. This
assessment should include a nutritional history and habits, fluid assessment, and barriers to nutritional goals. This
assessment will provide cues to direct the client’s care and enable optimal nutritional intake.
Client History
Accurate client information is important to identify how food intake may interfere with pulmonary function. The
nurse should be aware that age, gender, and race may affect nutritional needs and risks related to the respiratory
system. The client history should include allergies (food and environment), dietary habits, special dietary needs and
food sensitivities, food access and/or insecurity, smoking (tobacco and vaping), alcohol, illegal drug use (particularly
inhaled substances), travel and environmental exposures, and residential conditions. The history should specifically
include:
• Allergies—Include documentation of food, dust, pollen, bee stings, and medications. Document the onset of
allergy and the specific allergic response, such as wheezing, difficulty breathing, cough, rhinitis, hives, swollen
lips, or anaphylaxis. If the client identifies allergies, inquire as to number of prior reactions, treatments utilized,
response to treatment, hospitalizations, and if the client has been prescribed and/or carries epinephrine. Food
allergies are a risk factor for asthma along with asthma morbidity (daytime symptoms, increased rescue
therapy, hospitalization, ventilator use, unplanned health care utilization) and mortality (Sherenian et al., 2018).
• Dietary habits—Assess initially with a 24-hour food recall, in which a client reports all their food and fluid
intake on the last day (Figure 13.3). The 24-hour recall is used most often in dietary surveys and has been
adapted and validated for use by adolescents and adults, as well as by adults in reporting their child’s intake
(Arsenault et al., 2020). While not completely accurate for micronutrient evaluation, the 24-hour food recall can
be reviewed and discussed to determine if the reported food intake is typical for the client’s normal routine. For
example, if a client typically skips breakfast, eats mostly processed foods or fast food, drinks sugary beverages,
and/or eats high-sodium food such as packaged and processed items, this information will assist the nurse in
identifying areas for nutrition education.
• Special dietary needs—Include specific dietary preferences, religious requirements, or medically indicated
restrictions, such as gluten free, diabetic diet, low salt, avoidance of tree nuts or peanuts, kosher, halal, or pork
free. Dietary restrictions may put clients at increased risk for nutrient deficiency (vitamin E, magnesium,
sodium, potassium, and calcium), resulting in increased presence of respiratory symptoms such as wheezing
and airway hyperreactivity (Sherenian et al., 2018).
• Social determinants of health (SDOH)—Include conditions in the home, school, work, place of worship, and
social environments that affect health, quality of life, and risks for illness (Office of Disease Prevention and
Health Promotion [ODPHP], 2020). Economic and social conditions may limit or create uncertain access to
adequate food, known as food insecurity. Restrictions may result from insufficient monetary resources, social
support (for example, lack of school lunch during school breaks), or shortage of full-service supermarkets. Food
insecurity is associated with increased obesity, asthma, COPD, and cancer(ODPHP, 2020).
• Smoking—Include status as a current smoker, having ever smoked, the age when the client started, and the
number of cigarettes smoked daily. This should be recorded as pack-years, calculated as the number of packs
smoked per day multiplied by number of years smoked. The nurse should also assess for use of chewing
tobacco, hookah smoking, and vaping, including the product the client uses, such as nicotine or
tetrahydrocannabinol (THC). For pediatric clients, any exposure to smokers should document relationship,
frequency, location (home, car, or other) and duration of smoke exposure. According to the CDC (2022a),
smoking is the leading cause of preventable death and is associated with increased risk for asthma, COPD, and
immune-system damage or dysfunction. It is the primary cause of lung cancer, with 9 out of 10 lung cancer
deaths caused by smoking or secondhand smoke exposure.
• Alcohol intake—Include the number of drinks in a single event in a day and the cumulative total per week. The
Centers for Disease Control (CDC) (2022b) recommends that women have no more than 1 drink per day and
that men have no more than 2 drinks per day; they further define binge drinking as consumption of 4 or more
drinks during a single event for women and 5 or more during a single event for men. Alcohol use disorder affects
the respiratory system and increases the incidence and associated risks of asthma, COPD, lung infection,
aspiration pneumonia, and acute respiratory distress syndrome (ARDS) (Arvers, 2018).
• Illegal drug use—Include questions regarding any substance the client inhales, snorts, chews (edibles), or
injects. This includes paint, markers, bleach, cleaning supplies, marijuana, cocaine, opioids (heroin and
fentanyl), methamphetamines, gamma-hydroxybutyric acid (GHB), hallucinogens (ketamine, LSD, PCP, magic
mushrooms), MDMA (ecstasy and Molly), and flunitrazepam (Rohypnol). Impact of drug use on the respiratory
system involves respiratory sedation, risk of respiratory arrest, and immune-system suppression, increasing the
potential for respiratory infections (Plein & Rittner, 2018).
• Prescription medications—Document the medication name, dose, frequency, and compliance; this will include
medications taken for breathing problems and all other conditions. The nurse should be aware that clients may
need prompting for the inclusion of medical cannabis in their medication list, as the number of states allowing
for medical prescribing is increasing. Also assess the use of over-the-counter medications and herbal remedies.
Certain medications may affect the respiratory system. For example, angiotensin-converting enzyme (ACE)
inhibitors to treat hypertension may cause a dry nighttime cough. Aspirin and other nonsteroidal anti-
inflammatory drugs (NSAIDs) induce bronchospasm and should be avoided in clients with a history of
sensitivity to these medications.
• Travel, geographic location, and environmental exposure—Assess to reveal exposure to diseases and
pathogens found in certain areas that increase the risk for infection. Environmental exposures such as forest
fires, pollution (often more common in lower socioeconomic or dense urban areas), gasoline fumes, or
aerosolized chemicals (i.e., chlorine) increase upper and lower respiratory tract irritation and may worsen
chronic respiratory conditions (Lee et al., 2021). Residential conditions influence the health of individuals; for
example, substandard housing materials and overcrowding, along with biologic (molds, mites, roaches),
chemical (lead, carbon monoxide), and physical (temperature, fine particles) hazards lead to respiratory
disease (OASH, 2020). The nurse should document type of housing (single-family home, apartment, mobile
home), setting (rural, suburban, urban), number of occupants, number of bedrooms, and any hazards or
contributors to disease.

FIGURE 13.3 A 24-hour food diary provides clues about nutrients and how they may be impacting wellness. (attribution: Copyright Rice
CLINICAL TIP
Allergies
The nurse should document any known allergies, especially to medications. The specific type of response the
client experienced and what was done to correct it should be documented in a prominent place in the client’s
medical record.
When conducting an assessment, the nurse should obtain a family history of respiratory disorders. This provides
information regarding diseases that have genetic components, such as cystic fibrosis or emphysema. A family
medical history of allergies is often present in clients with asthma. The nurse should ask about infectious diseases
such as tuberculosis, because families have similar environmental exposures.
A client’s complete medical history including current conditions and diagnoses that impact the client’s health should
be documented. In addition, the primary complaint or reason for the current health intervention (office visit or
hospitalization) is necessary; this is often collected using the acronym OLD CARTS, referring to:
• Onset
• Location
• Duration
• Character
• Associated symptoms or aggravating factors
• Relieving factors
• Timing
• Severity or scale
In pulmonary diagnoses, primary concerns may include cough, wheezing, chest tightness, or shortness of breath.
Examples include:
• Cough—A potential sign of lung disease. Questions that the nurse might ask include: Is it the same, better, or
worse than when it started? Is the cough dry or does it produce sputum? Does anyone else you spend time with
have a cough?
• Sputum—A large cue in the respiratory assessment. The nurse should note the color, consistency, and amount.
The nurse should also ask about a time of day when coughing is more prevalent (in the morning, during or after
meals, etc.). Sputum can indicate infection, pulmonary edema, or cancer.
• Wheezing—A sign of airway restriction. Does it occur with exercise or activity, or also at rest? Do you hear it
while breathing in, breathing out, or both?
• Shortness of breath—May indicate different types of lung problems. The nurse should note dyspnea, difficulty
breathing, or breathlessness. Another factor that should be determined is orthopnea, shortness of breath that
occurs when lying down and is relieved by sitting up. These findings often occur with chronic lung disease.
To assess further, the nurse should ask if the complaint or problem has ever occurred before, if there are known
triggers, and what treatments have been used to make it better (Dezube, 2023).
A client history provides awareness of risks and conditions that may shape nutritional interventions. This could
include:
• Childhood illnesses—asthma, pneumonia, communicable diseases, hay fever, allergies, eczema, frequent colds,
croup, and cystic fibrosis
• Adult illnesses—pneumonia, sinusitis, tuberculosis, HIV/AIDS, COPD, emphysema, sarcoidosis, obesity,
obstructive sleep apnea, diabetes, hypertension, heart disease, influenza, and COVID-19
• Vaccinations—pneumococcal vaccine (PCV 13, PCV 15, and PPSV 23) influenza vaccine, COVID-19 vaccine, and
bacille Calmette-Guérin (BCG) vaccine
• Past surgical history—surgeries of the upper or lower respiratory tract
• Injuries, hospitalizations, and tests—injuries to the upper or lower respiratory tract, hospitalizations related to
pulmonary conditions, and dates of last chest x-ray, pulmonary function test, tuberculin test, or other diagnostic
tests and their results
• Indications of infectious disease (tuberculosis)—recent weight loss, night sweats, sleep disturbances
• Travel, occupation, hobbies, and social history—geographic areas of risk for infection or pollutants, occupational
hazards (aerosols or chemicals), tobacco, vaping, or other inhalants (Dezube, 2023)
Part A
In this visit with Katrice and her parents, the health care team wants to collect a complete client history including
Katrice’s medical and social history, family history, and current asthma symptoms. Katrice reports utilizing her
asthma inhaler before exercise but has rarely needed the inhaler outside of exercise. They deny audible wheezing,
nighttime cough, or asthma attacks that have required hospitalization. They are pleased overall with her asthma
control. The provider notices on exam that Katrice’s body mass index (BMI) has increased since her last visit, taking
her from overweight to obese.
1. Which statement indicates Katrice and her parents understand the normal function of the pulmonary system?
a. “It’s ok if I wheeze every day; as long as I use the inhaler, my lung function will stay the same for my
whole life.”
b. “The pulmonary system goes from my mouth through to the bottom of my lungs; it’s how my body gets
oxygen.”
c. “Wheezing is a sign that my airways have expanded too much, and air is moving through them too fast.”
d. “Secondhand smoke doesn’t affect the lung tissue.”
2. What additional history information would signal the need for additional intervention by the nurse?
a. The family of five living in a four-bedroom single-family home
b. Wearing masks and playing inside when visiting family who live near a factory in a high-pollution area
c. Wheezing sometimes associated with taking NSAIDS before exercise
d. Having grandma smoke outside, away from the house, and covering her clothing with a “smoking jacket”
Physical Assessment
Physical assessment begins with vital signs. Blood pressure, heart rate, respiratory rate, pulse oximetry, height,

weight, and BMI provide foundational information regarding respiratory effort, cardiovascular workload,
oxygenation, and nutritional status (underweight or overweight). The respiratory tract exam should include the nose
and sinuses; pharynx, trachea, and larynx; and lungs and thorax. Pulmonary assessment should include:
• Skin for color (cyanosis), pallor, and nail clubbing. These signs may indicate poor oxygenation from respiratory
disorders.
• Visual inspection of the nose and sinuses for deformities, swelling, lesions, pain to palpation, and the presence
of drainage or bleeding.
• Visual inspection of the mouth and throat. The health care provider should note the size and condition of the
tonsils, erythema, postnasal drainage, symmetry of the neck, shape and size of the lymph nodes, and position
of the trachea. Specific measures that may be documented are Mallampati score (an airway assessment scale
to classify the visibility of the oropharyngeal structures) and neck circumference, both of which contribute to
evaluation for obstructive sleep apnea. A specialist should examine the larynx if continued hoarseness is noted.
• Inspection, palpation, percussion, and auscultation of the lungs and thorax.
CLINICAL TIP
Assessing Airway Sounds

If the client is having difficulty breathing with secretions present in the upper airway, respirations would be loud
and gurgling. Secretions may be present due to infection, allergies, or other issues. The nurse should instruct the
client to clear their throat before proceeding with the assessment.
With inspection of the thorax, the nurse should visually observe the rate, rhythm, depth of inspiration, and symmetry
of the chest. The adult respiratory rate at rest is 12–16 breaths per minute (Dezube, 2023). The nurse should also
note the type of breathing, intercostal retractions, and the use of accessory muscles. Also, the nurse should observe
the comparison of lateral or transverse diameter to anteroposterior diameter; the normal ratio is 2:1. These cues
indicate lung disease such as COPD and advanced aging.
With palpation, the nurse should examine by touch and note for any abnormalities found, such as tenderness or
swelling. The nurse might note crepitus (air trapped in and under the skin), which is typically felt as crackling. This
should be reported to the health care provider. The nurse should also note fremitus (a vibration in the chest wall as
the client speaks) during palpation.
Percussion is systematic tapping over the intercostal spaces, moving through the anterior, lateral, and posterior
thorax. With percussion, the presence of abnormal fluid or air in the lungs may be detected, as noted by different
sounds. Resonance is expected over lung areas; hyperresonance, dullness, or flat sounds may indicate concerning
respiratory findings (Dezube, 2023).
With auscultation, the nurse should listen with a stethoscope for normal breath sounds, abnormal sounds, and
voice sounds. These sounds provide information about the flow of air through the lungs and trachea, which help to
identify fluid, mucus, or obstruction in the respiratory system (Dezube, 2023). Figure 13.4 shows the proper
sequence for auscultation. The nurse should begin at the apex of the lung, moving from side to side in a systematic
approach ending at the long bases.
FIGURE 13.4 Auscultation should be done posterior and anterior. (credit: modification of work from Anatomy and Physiology 2e.
AUSCULTATING LUNGS
Access multimedia content (https://openstax.org/books/nutrition/pages/13-1-assess-and-analyze-the-impact-

of-nutrition-on-the-pulmonary-system)
The proper way to auscultate lungs, including the correct locations, can be seen in this video. This is of great
importance to ensure that respiratory issues will not be missed and will be effectively monitored throughout the
course of disease.
Psychosocial Assessment
A psychosocial assessment is important to determine how the client is coping with respiratory distress, either acute
or chronic. The client’s emotions and responses may be based on concerns for normalcy, fitting in, bullying, cost of
medications and health care, missed time from work or school, access to and cost of proper nutrition, safety, and
support systems. In addition, the physical manifestations of disease may cause psychosocial symptom
manifestation. A client with a high fever may be disorientated, a client with COPD may be depressed due to lack of
cure, or a client with breathing difficulty may have anxiety caused by the sensation of not getting enough air.
The nurse should encourage clients to express their feelings and fears, allowing the health care provider to address
their anxiety, depression, stress, or other concerns. The nurse should discuss coping mechanisms to enable the
client to better handle the emotions and promote optimum disease and symptom management. The nurse may
educate the client on coping mechanisms such as deep breathing, relaxation, and other techniques that decrease
anxiety. Referrals to social, financial, educational, occupational, or mental health resources may be appropriate.
Diagnostic Assessment
The diagnostic assessment should include a laboratory assessment, imaging, and other noninvasive diagnostic
tests. The laboratory assessment may include blood studies and arterial blood gases. Arterial blood gases are the
best way to determine adequate oxygenation in hospitalized or unstable clients. An initial evaluation of albumin may
indicate concern for dehydration or malnutrition. Prealbumin provides a valid evaluation of protein–calorie
malnutrition. The example laboratory profile in Table 13.2 shows normal ranges and possible reasons for abnormal
ranges.
Test Normal Ranges (SI Significance of Changes from Normal

Units)
Complete Blood Count
Red blood • 4.2–5.9 × 1012 • Elevated levels (polycythemia): excessive production of
cells cells/L erythropoietin in response to a chronic hypoxic state
• Decreased levels: possible anemia, hemorrhage, or hemolysis
Hemoglobin, • Females: • Same as for red blood cells

total 120–160g/dL • Based on hemoglobin and hematocrit levels, follow-up labs may
(12–16 g/dL include serum ferritin, iron, folate, and B12
conventional units)
• Males: 140–170 g/
dL (14–17 g/dL
conventional units)
Hematocrit • Females: 37–47% • Same as for red blood cells

(conventional units) • Based on hemoglobin and hematocrit levels, follow-up labs may
• Males: 41–51% include serum ferritin, iron, folate, and B12
(conventional units)
TABLE 13.2 Pulmonary Laboratory Assessment Indications of Nutritional Concerns (sources: Castro et al., 2022; Padilla & Abadie, 2022;
Pagana & Pagana, 2018)


Units)
WBC count • Total:4.5-11 × 109 • Elevated levels: possible acute infection or inflammation
(leukocyte cells/L) • Decreased levels: an overwhelming infection, an autoimmune
count, disorder, or immunosuppressant therapy
WBC count)
Differential White Blood Cell (Leukocyte) Count
Neutrophils • 2.6–8.5 × 109 • Elevated levels: possible acute bacterial infection (pneumonia),
cells/L COPD, or inflammatory conditions (smoking)
• Decreased levels: possible viral disease (influenza)
Eosinophils • 0–0.55 × 109 • Elevated levels: possible COPD, asthma, or allergies

cells/L • Decreased levels: pyogenic infections
Basophils • 0–0.22 × 109 • Elevated levels: possible inflammation; seen in chronic sinusitis
cells/L and hypersensitivity reactions
• Decreased levels: possible in an acute infection
Lymphocytes • 0.77–4.5 × 109 • Elevated levels: possible viral infection, pertussis, and infectious
cells/L mononucleosis
• Decreased levels: possible during corticosteroid therapy
Monocytes • 0.14–1.3 × 109 • Elevated levels: See lymphocytes; also may indicate active
cells/L tuberculosis
• Decreased levels: See lymphocytes
Albumin • 35–54 g/L (3.5–5.4 • Elevated levels: dehydration

g/dL • Decreased levels: chronic disease, malabsorption, malnutrition
conventional units) with low protein, or dilution by IV fluids
• Follow-up diagnostics: prealbumin, blood urea nitrogen, or zinc
(deficiency increases risk for pneumonia [Keller, 2019])
Prealbumin • 180–450 mg/L • Elevated levels: chronic kidney disease, steroid use, or alcohol
(18–45 mg/dL use disorder
conventional units) • Decreased levels: malnutrition, liver disease, infection, or
inflammation
• Follow-up diagnostics: nutritional assessment, hemoglobin, and
anemia evaluation (iron, transferrin, folate, and vitamin B12)
Arterial Blood Gases

PaO2 • 75–100 mm Hg • Older adults: Values may be lower
• Elevated levels: possible excessive oxygen administration
• Decreased levels: possible COPD, asthma, chronic bronchitis,
cancer of the bronchi and lungs, cystic fibrosis, respiratory
distress syndrome, anemias, atelectasis, or any other cause of
hypoxia
PaCO 2 • 35–45 mm Hg • Elevated levels: possible COPD, asthma, pneumonia, anesthesia

effects, or use of opioids (respiratory acidosis)
• Decreased levels: hyperventilation/respiratory alkalosis

Units)
pH • 7.35–7.45 • Elevated levels: metabolic or respiratory alkalosis
• Decreased levels: metabolic or respiratory acidosis
HCO3 • 22–26 mEq/L • Elevated levels: possible respiratory acidosis as compensation

for primary metabolic alkalosis
• Decreased levels: possible respiratory alkalosis as
compensation for a primary metabolic acidosis
SpO2 • 95–100% • Older adults: Values may be slightly lower

• Decreased levels: possible impaired ability of hemoglobin to
release oxygen to tissues
The imaging assessment should include a chest x-ray and possibly a computed tomography (CT) scan. Chest x-ray is
used to evaluate and assess the lungs. The x-ray may detect pneumonia, atelectasis, pneumothorax, and a tumor. If
further evaluation is needed, a CT can be ordered, used in cases where suspicious lesions or clots are thought to be
present. The CT will verify these findings.
Pulse oximetry, capnography, and pulmonary function tests are noninvasive tests that provide information about gas
exchange in the client (Wood, 2022). Pulse oximetry identifies hemoglobin saturation with oxygen; the range should
be 95–100%. A range below 91% in a client with no chronic respiratory problems is an emergency. The
capnography measures carbon dioxide, and the pulmonary function test assesses breathing problems and lung
function; they are utilized in both diagnosis and management of COPD and asthma.
Analysis of Nutrition and the Pulmonary System

With a complete pulmonary assessment, the provider must note any abnormal cues and analyze these findings. The
abnormal findings typically are related to nutritional requirements and deficits. Depending on the indications from
the initial 24-hour food recall, follow-up or repeated assessments would assist in determining any repeated calorie
excesses or deficits. A focus on types of food intake, portions, meal patterns, and knowledge of nutrient content
provide the initial clues for the physical exam findings that may be present in clients with pulmonary conditions.
A cursory consideration of weight and BMI may not be the best indication of the nutritional status and overall health
for a client. In fact, a low BMI is linked to increased mortality for COPD clients due to the physiologic consequences
of diaphragmatic weakness, decreased lung function, and systemic inflammation (McDonald et al., 2019).
Malnutrition may result in clients with COPD or other chronic diseases from their increased energy expenditures,
causing fatigue, less activity, muscle loss, and poor appetite. Weight loss can worsen with each exacerbation
(McDonald et al., 2019). Diminished muscle mass is a sign of exercise intolerance and sedentary lifestyle for clients
with chronic pulmonary disease. Malnutrition is a negative factor in the prognosis of COPD.
Obesity is a well-established health factor, recognized by the World Health Organization (2023) as a leading public
health issue, with estimates in the 2016 data that 41 million children under age 5 and 240 million children ages
5–19 are overweight or obese. These children typically remain overweight or obese in adulthood. Obesity is a factor
for increased asthma risk through its role in inflammation and pulmonary overreaction to environmental triggers
(Calcaterra et al., 2021). Obesity alters the mechanics of the pulmonary system, leading to dyspnea, wheezing, and
airway hyperresponsiveness (Dixon & Peters, 2018). Excessive weight reduces pulmonary and chest wall
compliance, contributing to increased work of breathing in adults and children, but the inflammatory
immunomodulatory impact of high-fat, high-sugar, and low-nutrient “Western” diets is the predominant obesity
impact in children with asthma (Calcaterra et al., 2021). These physiologic responses are exacerbated by the low
activity levels that are a natural consequence of pulmonary symptoms.
Table 13.3 lists key nutritional physical exam findings in clients with chronic pulmonary conditions.

13.2 • Plan Nutritional Strategies to Impact Pulmonary Wellness 261
Physical Exam Finding Effect

Generalized nutrient • Low BMI
deficiency • Obesity or central obesity
Protein energy malnutrition • Poor physical performance in activities

• Lack of muscle strength
• Dull/dry hair or hair loss
• Banding of nails
• Bilateral edema
Anemia • Fatigue
• Decreased activity/exercise tolerance
• Weakness
• Palpitations
• Irritability
• Headaches
• Paresthesia
• Sore tongue
• Brittle nails or spoon-shaped nails
• Pallor
• Pica (ice, starch, clay)
Dehydration • Dry skin and mucous membranes

• Poor turgor
• Sunken eyes
• Decreased urine output
• Change in neurologic status
Poor oxygenation • Muscle retractions

• Tripod breathing
• Clubbing of nails
Micronutrient deficiency • Dim-light vision (vitamin A)

• Glossitis or inflammation of the tongue (iron, zinc, or riboflavin)
• Poor tooth health
• Lack of muscle strength; falls or fractures (vitamin D, calcium,
magnesium)
• Excessive bruising or bleeding (vitamin K)
• Dermatitis and diarrhea (niacin)
• Muscle cramps (vitamin C or magnesium)
TABLE 13.3 Nutritional Physical Exam Findings in Clients with Chronic Pulmonary Conditions (sources: Esquivel, 2018; Gea et al., 2018;
Rolo; Silvestri et al., 2022)
13.2 Plan Nutritional Strategies to Impact Pulmonary Wellness

LEARNING OUTCOMES
• 13.2.1 Identify nutritional habits that optimize pulmonary wellness.
• 13.2.2 Generate solutions to optimize pulmonary wellness utilizing nutritional habits.
Poor dietary habits are a modifiable risk factor and treatment target for clients with both acute and chronic illness. A
client with a cold, influenza, or pneumonia may need immune support (vitamin C and zinc), while a client with
chronic conditions needs a comprehensive approach to nutritional intervention. Healthy People 2030, the U.S.
Department of Health and Human Services’ public health initiative, identifies health behaviors focused specifically
on nutrition and food. The healthy-eating objectives include increasing fruit, vegetable, and whole-grain
consumption, decreasing intake of sugary drinks and sodium, reducing food insecurity, increasing intake of vitamins
and minerals, increasing number of infants breastfeeding, and reductions in obesity. MyPlate utilizes evidence-
based data from the Dietary Guidelines for Americans 2020–2025 and is a pictorial representation of the types and
quantities of food that should be consumed at meals.
Table 13.4 identifies some specific nutrition recommendations to impact pulmonary health. These principles
designed to promote general health are particularly useful for clients with chronic pulmonary conditions. Additional
strategies may include a focus on protein-rich foods that are easily digested.
Nutrient Food Source Consideration

Antioxidants • Fruits and vegetables Reduce inflammation, strengthen the
(vitamin C, vitamin immune system, support lung function,
E, and beta and reduce asthma symptoms
carotene)
Vitamin D • Fortified foods such as cereal, orange Supports lung function and reduces
juice, and yogurt upper respiratory infections
• Naturally occurring in salmon, tuna,
mushrooms, egg yolks, and cheese
Antioxidants • Apples, berries, grapes, seafood, meat, Anti-inflammatory benefits and promote
(flavonoids) and and eggs normal lung tissue
selenium
Whole grains • Whole oats, whole-wheat pasta and May reduce asthma symptoms promote
bread, buckwheat, and bulgur wheat, in better asthma control
addition to being a part of a healthy diet
Sulfites • Dried fruits and vegetables, pickled May be an allergen for some clients and
(preservative) foods, shrimp, wine/beer trigger reactions or asthma attacks
TABLE 13.4 Nutrition Recommendations for Pulmonary Wellness (sources: Andrianasolo et al., 2018; Nutrition for lung health and COPD,
2023; Vezina & Cantin, 2018; Vlieg-Boerstra et al, 2021; Tinsley & Lewsley, 2023)
The following nutritional supports and actions are available to optimize function and health in pulmonary conditions
for infancy through adulthood:
• Infants–Breast milk (Figure 13.5) is best in the first year, supporting optimal nutrition (vitamin A) and
development of immune system, and is associated with less allergic disease and as a protective mechanism in
later childhood against illness (wheezing, asthma, and viral illness). As an alternative, formula in the first year is
acceptable, although not protective against atopic disease or asthma. Cow’s milk and soy milk should be
avoided in the first year (CDC, 2022c); they are difficult for an infant to digest, and cow’s milk can cause for iron
deficiency and iron deficiency anemia (Calcaterra et al., 2021).
• Children–Combine preferences with a balanced diet plan. Consider finger foods; establish an eating routine
(i.e., sitting for meals, focused mealtime, pleasant environment for eating); educate on nutrition content,
balanced diet, MyPlate, and reading labels; create games that make nutrition fun; avoid sugary drinks;
encourage exercise and active play. Apples, kiwi fruit, spinach, garlic, avocados, broccoli and bananas are easy
to eat or add to other dishes; these are excellent fruits and vegetables for children with asthma due to the
nutrient content (minerals, vitamin C, vitamin E, and antioxidants) and the anti-inflammatory properties.
• Adolescents–Combine preferences with balanced diet plan. Educate about nutritional needs for growth and on
how to choose healthy options when eating out. Convenience foods that are easy to grab on the go and may
appeal to adolescents but that also contain antioxidants include oranges, strawberries, carrots, nuts, and
sunflower seeds.
• Adults–Educate on the impact of diet on health conditions, meal planning, and use of Mediterranean diet,
MyPlate, or nutrient dense meals.

FIGURE 13.5 Breastfeeding in the first 12 months provides optimal nutrition for infants. (credit: U.S. Department of Agriculture/Flickr,
Public Domain)
Pulmonary rehabilitation assists in reducing respiratory symptoms, improving function, and increasing emotional
and physical participation in activities that promote quality of life. The rehabilitation team will vary based on the
facility but often includes physical therapist, occupational therapist, respiratory therapist, and dietitian along with
the client’s health care provider. Instruction on nutrition, breathing techniques, and exercise assist in maximizing
energy.
For clients with dyspnea, frequent coughing, or fatigue, the following additional instructions and guidance from the
American Lung Association (2023) may be useful in supporting the opportunity for improved nutrition:
• Take smaller bites of food and eat slowly.

• Sit upright while eating.
• Take a break between bites and practice deep breathing exercises.
• Eat more food early in the morning if too tired to eat later in the day.
• Avoid foods that cause gas or bloating, which tend to make breathing more difficult.
• Eat 4–6 small meals a day to enable the diaphragm to move freely and let the lungs fill with air and empty out
more easily.
• Limit liquids with meals or drink after meals if drinking liquids causes a feeling of fullness, but continue to strive
for 6–8 glasses of water daily.
• Consider adding a nutritional supplement at night to avoid feeling full during the day.

The goal of nutrition therapy for pulmonary wellness is to maintain adequate respiratory function to decrease or
prevent malnutrition and obesity. Avoiding malnutrition will help preserve muscle strength and help maintain the
integrity of the immune system. Adequate and proper nutrition is the primary goal in pulmonary wellness; this
involves achieving a total daily caloric intake that meets the client’s metabolic needs with foods from a variety of
food groups and an emphasis on including antioxidants. If mucus overproduction and/or retention is problematic, as
with COPD, chronic bronchitis, emphysema, cystic fibrosis, and asthma, reducing foods high in histamine (such as
processed meat, aged cheese, legumes) is advised. Clients should avoid empty calories (calories lacking nutritional
value).
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to wild cherry bark tea, can promote lung health year round but may be especially helpful during seasons that
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specific foods to minimize treatment side effects encountered by individuals diagnosed and living with lung
cancer.
and its appeal to clients.
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3. How would you evaluate these sources for use of EBP, and which sources used EBP?
Carbohydrates, Fiber, Proteins, and Fats

The nurse should advise clients to choose complex carbohydrates, such as whole-grain bread and pasta, fresh
fruits, and vegetables, and to limit simple carbohydrates such as table sugar, candy, cake, and soft drinks and sugary
beverages. Women should aim for about 25 g/day of fiber; men should aim for 38 g/day (or 14 g for every 1000
calories) (Larson, 2021). Fiber is contained in bread, pasta, nuts, seeds, fruits, and vegetables. For clients prone to
gas or bloating, it can make breathing more difficult, so avoiding beans, legumes, and gas-producing vegetables,
such as Brussels sprouts, broccoli, cauliflower, and cabbage, may be necessary.
Proteins play a major role in preventing malnutrition and the integrity of the immune system. Protein requirements
increase according to illness severity ranging from 0.8–1.2 g/kg of protein per day for mild or moderate illness up to
1.2–1.5 g/kg of protein per day for clients with severe illness (Deer & Volpi, 2018). Good sources of protein include
milk, eggs, cheese, meat, fish, poultry, nuts, and peas. Clients who are malnourished should choose protein with a
higher fat content, while clients who are overweight or obese should choose low-fat or leaner options. To increase
protein intake, add peanut butter, whey, or soy (vegan) protein powder during food preparation, or add a protein
drink or shake as a supplement.
The client should choose healthier unsaturated fats from plant sources such as canola and olive oils, which do not
contain cholesterol and are liquid at room temperature. To reduce inflammation and support cellular rebuilding, the
client should choose omega-3 fatty acids and other healthy fats that are found in nuts, eggs, avocados, and fish. The
client should avoid artificial trans fats and saturated fats. Adding healthy fats to protein-based meals is a way to add
extra calories to food for undernourished clients who need them. To lose weight, clients will want to limit fat intake.
Vitamins, Minerals, and Antioxidants

Multivitamins will likely help support overall nutrient balance. Additionally, older clients or those with chronic
pulmonary illness requiring corticosteroid use may also benefit from calcium carbonate or calcium citrate and
vitamin D supplements for general bone health and the prevention of osteoporosis. All use of supplements should
be discussed with the health care provider.
Too much sodium may cause edema and impact blood pressure and fluid volume (American Lung Association,
2023). Processed and prepared foods, such as food that comes in cans, bottles, jars, or frozen packaging, may have
high sodium content. Clients should look for packages marked as low sodium. During food preparation, spices and
herbs can season foods instead of additional salt. They should also avoid adding salt to food after it is prepared.

Clients with COPD and hypoxemia will benefit from a lycopene-enriched diet. Fruit, vegetables, whole grains, and
nuts are rich in antioxidants and encouraged.

The client will face numerous challenges that make achieving nutritional goals challenging, if not impossible.
Challenges based on normal physiologic changes occurring with age, such as decreased taste and smell, may be
improved by utilizing spices, herbs, colorful foods, and preferred foods or those with pleasant food memories.
Fatigue, particularly in clients with dyspnea or increased work in breathing, will be best addressed through small
frequent meals and increased functional status. The involvement of physical therapy, occupational therapy, and
opportunities for strength building is essential. Increased energy requirements for clients who are underweight or
malnourished will require frequent calorie-dense meals, snacks, and likely nutritional supplementation with whey or
soy (vegan) protein drinks. Protein drinks provide high protein amounts in low-volume portions and may provide the
nutritional components necessary for muscle synthesis and improved muscle strength (Ahmadi et al., 2020).
The health care provider must develop strategies to improve or overcome these challenges to ensure the client
consumes adequate and proper nutrition for pulmonary wellness. The involvement of a registered dietitian for a
consult and for maintenance support will emphasize the importance of nutrition. Continued nutritional support and
individualized nutritional intervention by a dietitian over the course of 6 months lowers mortality in polymorbid older
adults after hospital discharge (Gomes et al., 2018).
Clients with limited function and impaired health due to significant pulmonary disease, obesity, or lack of strength
and energy secondary to malnutrition may struggle with isolation, depression, and anxiety. These may produce fear,
food avoidance, reliance on highly processed foods due to convenience, or various other barriers to quality nutrition.
Optimum management of pulmonary conditions is an excellent initial step in managing the associated mental health
conditions. Additional nutritional considerations may be the Mediterranean-style diet and the Mediterranean-DASH
Intervention for Neurodegenerative Delay (MIND) diet, which have cognitive and neurotransmitter benefits, reduce
stress and anxiety, increase energy, and lower the change of depression and psychological distress (Grajek et al.,
2022).
Financial limitations, access to resources, and religious or cultural barriers may also exist. Clients may need
considerations for social support and referrals (government or charitable resources), such as financial assistance or
meal-delivery programs. The Congregate Nutrition Program and the Home-Delivered Nutrition Program provide
meals to low-income and older adults, while the Supplemental Nutrition Assistance Program (SNAP) is the largest
hunger safety net in the U.S., assisting with the purchase of food items. Unfortunately, additional barriers exist in
accessing these programs due to lack of awareness, confusion about eligibility, application challenges, lack of
transportation to a meal site, and stigma due to the desire for autonomy and independence (Burris et al., 2021).
Social services offices at the organizational, city, or county level, along with non-profits (senior centers and
community groups), provide some individualized support in addressing these barriers and accessing essential
resources.
Religious and cultural barriers may exist related to locating and understanding how to select nutritious items that
are kosher or halal. Maximizing nutrition in shorter periods of time may be a challenge that clients face during
periods of fasting observed by Muslims during Ramadan, and Catholics, Protestants, Greek Orthodox, or those of
Jewish faith during religious holidays or selected periods of spiritual discipline. Involvement of community groups,
specialized websites, and members of faith communities, as well as provider and dietitian support, can assist a
client to address these barriers.
Part B
Study Part A.
Katrice is in today for a routine asthma follow-up. The provider collects and reviews the 24-hour food recall with
Katrice and her parents, praising the few high-quality food choices and providing education about MyPlate as a
guide for the types and quantities of food that will better support Katrice’s nutrition. Katrice admits to having donuts
or other sweet items for breakfast because they are “easy to grab and have in the car.” She also has candy daily and
fast-food meals at least 4–5 times a week. The provider explains the physiologic changes associated with obesity
and increased BMI, which can worsen Katrice’s asthma and impact her health during sports and play. Katrice and
her parents verbalize understanding. They will implement the new knowledge over the next 2 weeks, and return for
follow-up, bringing a food log with them and any questions. The provider also discusses a referral to physical
therapy for assessment and post-exercise stretches to support less pain and need for medication. The provider
educates about the risks of bronchospasm with NSAID use and recommends acetaminophen instead. Katrice’s
parents verbalize understanding and are receptive to education.
3. Which of the following statements by the client indicates additional diet instruction is needed?
a. “I will try to cut back on the amount of fast food I eat.”
b. “I am going to get some deli meat so I can make sandwiches to eat at school.”
c. “I’m going to try to eat sandwiches made with whole grain tortillas.”
d. “I will try to eat baked chicken instead of fried.”
4. Which of the following breakfast options is the best choice for the client?
a. A whey protein shake
b. Two strawberry toaster tarts
c. Pancakes and bacon
d. Whole grain toast
13.3 Implement Nutritional Strategies to Impact Pulmonary Wellness

LEARNING OUTCOMES
• 13.3.2 Teach nutritional strategies to optimize pulmonary wellness.

Holistic assessment is should take into consideration the overall health of the client, including their physical,
psychological, social, and spiritual well-being.
Social
As described earlier, holistic nursing assessment must look at a client’s overall health. Discussed were physical and
psychological assessments that need to consider the impact of social engagement in clients related to nutrition and
pulmonary wellness. The fatigue and malnutrition caused by the disease process will impact the client’s ability to
continue to engage in their normal social settings. This causes the client to experience depression and anxiety. The
health care provider will need to educate the client on ways to conserve energy and increase their caloric intake so
they might continue their normal activities.
Spiritual Well-Being
The health care provider must assess the client’s spiritual beliefs in a holistic assessment. This is important in
understanding the client’s nutritional intake, because certain spiritual and cultural practices do not allow the client
to eat certain foods. This information will be important if the client is experiencing malnutrition and will enable the
health care provider to help the client select foods high in caloric intake and value that do not go against their
beliefs.
Client Teaching
The nurse should assess teaching needs and the client and family’s learning ability. Deficits that may interfere with
learning, such as language barriers, literacy, numeracy, hearing, and educational levels, must be determined.
Appropriate accommodation provides the best opportunity for success and will allow the client to be educated to
the fullest. A balanced diet, energy expenditure, adequate protein, higher intake of iron, and small meals are
important topics to add to the client’s education so nutritional goals are met. Key summative points for the client

13.3 • Implement Nutritional Strategies to Impact Pulmonary Wellness 267
include:
• During respiratory distress or illness exacerbation, small frequent meals support increased functional status.
• Dietary changes or supplementation is an important modifiable risk factor and treatment component for clients
with both acute and chronic illness.
• Obesity alters the mechanics of the pulmonary system, leading to dyspnea, wheezing, airway
hyperresponsiveness, and increased work of breathing.
• Energy expenditure is typically elevated in clients with COPD due to increased efforts to breathe; adequate
protein stimulates the ventilatory drive. Clients benefit from protein-rich meals. Foods that are high in protein
include milk, eggs, cheese, meat, fish, poultry, and nuts.
• A balanced diet with high protein, complex carbohydrates, and healthy fats is used with differing volumes and
portions to support both clients who are malnourished and those who need to reduce weight.
• A healthy diet will increase the client’s likelihood of access to vital nutrients. The need for supplemental drinks,
multivitamins, and micronutrient supplements should be discussed with a registered dietitian.
• Control sodium intake by choosing fresh versus packaged food. High sodium levels will cause edema and
interfere with breathing, increasing the workload and causing a greater risk of malnutrition.
Implementing the following ideas from the American Lung Association (2023) and the COPD Foundation (2021) can
make mealtimes easier and more nutritious by increasing energy and protein without increasing food volume:
• General principles:
◦ Consume small, frequent meals.
◦ Eat a large meal when well rested, such as the first meal of the day.
◦ Encourage the use of high-calorie, high-protein supplements.
◦ Swallow as little air as possible when eating.
◦ Use easily prepared or nutritious snacks (fruits, carrots, nuts, hard-boiled eggs) to decrease fatigue.
• Clinical and home health care settings:

◦ Eat high-calorie foods first.
◦ Try more frequent meals and snacks.
◦ Add low-sodium margarine or butter, mayonnaise, sauces, gravies, and peanut butter to foods.
◦ Limit liquids at mealtimes.
◦ Try cold foods, which give less sense of fullness than hot foods.
◦ Rest before meals.
• At home:
◦ Keep favorite, nutrient-dense foods and snacks on hand.
◦ Keep ready-prepared meals available for periods of increased shortness of breath.
◦ Eat larger meals when you are not as tired.
◦ Avoid foods that cause gas.
◦ Add skim milk powder (2 tbsp) or whey protein powder to regular milk (8 oz) to increase protein and calories.
◦ Use milk or half-and-half instead of water when making soups, cereals, instant puddings, cocoa, or canned
soups.
◦ Add low-sodium grated cheese to sauces, vegetables, soups, and casseroles.
◦ Choose dessert recipes that contain egg, such as sponge cake, angel food cake, egg custard, bread pudding,
and rice pudding.
Part C
Katrice and her mother return after 2 weeks, bringing the food log from the past 2 weeks. They report that they used
the MyPlate website and games to help the whole family understand a healthier diet. They have not been as
compliant with the healthy eating principles as they would like due to “already having food at home that still needed
to be eaten.” However, Katrice’s mother reports that during their grocery shopping yesterday, they used the MyPlate
guidelines to focus on fresh food, complex carbohydrates, high-protein snacks, and limiting nonwater beverages to
low-sugar or sugar-free options.
5. Which snack item demonstrates Katrice’s understanding of healthy eating when choosing food for pre-game
energy?
a. Low-fat string cheese and a handful of almonds
b. Canned peaches and crackers
c. Peanut butter cookies
d. Pudding and a bag of chips
6. Which statement explains the correlation of Katrice’s obesity and her pulmonary health?
a. Obesity is a nonmodifiable risk factor and shouldn’t be the focus for asthma clients.
b. Obesity increases a client’s likelihood of access to vital nutrients.
c. Obesity alters the mechanics of the pulmonary system, leading to wheezing and airway
hyperresponsiveness.
d. Obesity can be reversed by eating the largest meal of the day right before bed.
13.4 Evaluate Nutritional Strategies to Impact Pulmonary Wellness

LEARNING OUTCOMES
• 13.4.1 Evaluate a nutritional plan for its effect on pulmonary wellness.
• 13.4.2 Modify a nutritional plan to promote pulmonary wellness.

Evaluation of nutritional strategies is imperative to verify a meal plan’s effectiveness and help the client achieve
pulmonary wellness. An evaluation aims to measure understanding of the intervention and progress made for the
specific interventions. Many clients cannot process large volumes of new medical information on the first exposure,
and they only remember a minimal amount of what has been taught (Timmers et al., 2020). Clients and families will
likely have questions requiring additional education and interval evaluation of each nutrition intervention. Each time
the impact of a nutritional intervention is evaluated, education reinforcement should occur. Nursing nutrition
interventions and evaluations vary based on organizational protocols and often involve a multidisciplinary approach.
Frequent tools used in the approach to evaluation of nutritional interventions include screening and diagnostic tools
and anthropometric measures (skin-fold measurement, arm circumference, height, weight, BMI, and patterns of
loss/gain), nutritional plan outcomes (appetite, eating difficulties, self-management strategies, pain with eating,
oral/dental status, physical activity, and quality of life), diagnostics (labs and tests), and physical findings
(appearance, muscle strength and function, muscle or fat wasting, swallow function, and affect) (van den Berg et al.,
2021). When evaluating nutritional strategies and interventions with this approach, nurses can compare current
findings with the previously recorded status to evaluate the success of the intervention on the client’s health and
outcomes.
The Ability to Obtain Adequate Nutrition

The health care provider must determine the ability to adhere to a meal plan. Questions to consider:
• Can the client afford the recommended food items?

• Is nutritious food available and accessible to the client?
• Do the foods in the meal plan go against the client’s culture or religious beliefs?
These are all things that must be determined so the client can be adherent and avoid worsening obesity and
exacerbated pulmonary illness. If the client’s answers present barriers to adequate nutrition or a source of possible
nonadherence, attention must be given to supporting the client with adjusted recommendations, resources, or
referrals to enable the client to follow the dietary guidelines and meal plan.

13.4 • Evaluate Nutritional Strategies to Impact Pulmonary Wellness 269
Case Study Conclusion

As noted in the case study, the client’s BMI was increasing, and she had moved from overweight to obese. The client
needed instruction to achieve proper nutrition including:
• Understanding the physiologic changes associated with obesity that can worsen asthma and impact health
during sports and play
• Using MyPlate as a model for adjusting food intake
• Focusing on a low-fat and high-protein diet with teaching about what foods fall into each food category
• Keeping a food log for review and education
• Removing medication (NSAID) use that would worsen asthma
The health care provider can give these instructions, enabling the client to adhere with the meal plan and optimal
respiratory health.
Chapter Summary
• Nutrition is a key factor in promoting pulmonary • Any nutritional implementation by the client will
wellness and supporting the function of the likely have barriers or challenges. Recognition of
pulmonary system. the barriers and considering client preferences,
• A systematic approach to assessment, physical religious beliefs, cultural norms, and social
exam, diagnostic tests, and nutritional intervention determinants of health in the design of
is essential in supporting the nutritional needs of interventions provides a holistic approach when
clients with pulmonary disease. planning goals and implementation strategies.
• Dietary choices including high protein, complex • Education about and implementation of nutritional
carbs, and healthy fats give nutritional support to health require follow-up care and reinforcement to
clients and provide a mechanism for improved achieve the client’s desired benefits.
function despite chronic respiratory conditions.
Key Terms
airways passageways through which gases move to pack-years the number of cigarettes or other smoke
and from the lungs packs smoked per day multiplied by number of
atelectasis the collapse of the alveoli years smoked
auscultation listening with a stethoscope for normal percussion a systematic tapping over the intercostal
breath sounds, abnormal sounds, and voice sounds spaces, moving through the anterior, lateral, and
crepitus air trapped in and under the skin, typically posterior thorax
felt as crackling perfusion the process of the arterial blood moving
dyspnea difficulty breathing, or breathlessness through tissues throughout the entire body
fremitus a vibration in the chest wall as the client respiratory diffusion occurs when gases move down
speaks the concentration gradient across the alveolar sacs
gas exchange oxygen being transported to the cells and capillaries
and carbon dioxide being transported away from the surfactant a fatty protein that lines the alveoli and
cells reduces surface tension
Mallampati score an airway assessment scale to ventilation the movement of atmospheric air that is
classify the visibility of the oropharyngeal structures higher in oxygen into the lungs and removal of
orthopnea shortness of breath that occurs when lying carbon dioxide
down and is relieved by sitting up
Review Questions
1. Which disease-related alteration can potentially place an older client with chronic obstructive pulmonary
disease (COPD) at risk for altered nutrition?
a. Altered taste
b. Decreased energy requirements
c. Fatigue
d. Altered smell
2. On initial laboratory tests, an adult client’s albumin level is below 3.5 g/dL. Which additional test could
potentially be utilized to gather additional information about nutritional risk for malnutrition?
a. Hemoglobin A1C
b. Antinuclear antibodies (ANA)
c. Prealbumin
d. Chest x-ray
3. What is the process for carbon dioxide and oxygen exchange?

a. Ventilation
b. Gas exchange
c. Perfusion
d. Diffusion

4. The nurse is instructing an older client on the importance of adequate calcium and vitamin D intake. Which of
the following age-related changes would this intervention affect?
a. Decreased lung capacity
b. Increased muscle atrophy
c. Decreased elasticity
d. Increased vascular resistance
5. For the client with chronic obstructive pulmonary disease (COPD), which dietary teaching should be
incorporated?
a. High-fat food choices
b. Simple carbohydrates as primary food choice
c. High-protein, calorie-dense food choices
d. Low-fiber food choices
6. Which of the following is a primary goal of nutrition therapy for a client with chronic obstructive pulmonary
disease (COPD)?
a. Maintaining a healthy body weight
b. Improving oxygenation status
c. Preventing muscle wasting
d. Lowering CO2 levels
7. The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) on strategies to maximize
food intake. Which of the following responses by the client indicates additional education is needed?
a. “I will treat myself to cake or pudding for dessert.”
b. “I will eat add cheese to my food whenever possible.”
c. “I will eat more cold foods rather than hot meals.”
d. “I will try to eat as much as I can during the evening before I go to bed.”
8. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. With palpitation,
the nurse feels crackling. What does the crackling most likely indicate?
a. Fremitus
b. Orthopnea
c. Crepitus
d. Tuberculosis
9. Which of the following findings is the best indicator that the client has followed the prescribed nutritional plan
to maintain a healthy weight?
a. The client can verbalize why obesity is detrimental to pulmonary health.
b. The client can describe the MyPlate approach to food selection.
c. The client’s food log demonstrates adherence to healthy nutritional plan.
d. The client has reached their recommended weight range.
10. A client states that they are experiencing a nighttime cough. Which medication could explain this symptom?
a. Acetaminophen
b. Ibuprofen
c. Beta-2 agonist
d. Angiotensin-converting enzyme (ACE) inhibitors
Suggested Reading
American Lung Association. (2023). COPD Action plan & management tools. Lung health & disease.
https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/living-with-copd/copd-management-
tools
Berger, M. M., Shenkin, A., Schweinlin, A., Amrein, K., Augsburger, M., Biesalski, H. K., Bischoff, S. C., Casaer, M. P.,
Gundogan, K., Lepp, H. L., deMan, A. M., Muscogiuri, G., Pietka, M., Pironi, L., Rezzi, S., & Cuerda, C. (2022).
ESPEN micronutrient guideline. Clinical Nutrition, 41(6), 1357–1424.
Espirito Santo, C., Caseiro, C., Martins, M. J., Monteiro, R., & Brandão, I. (2021). Gut microbiota, in the halfway
between nutrition and lung function. Nutrients, 13(5), 1716.
Sørensen, D., Wieghorst, A. R., Elbek, J. A., & Mousing, C. A. (2020). Mealtime challenges in clients with chronic
obstructive pulmonary disease: Who is responsible? Journal of Clinical Nursing, 29(23–24), 4583–4593.
https://doi.org/10.1111/jocn.15491
Tramontano, A., & Palange, P. (2023). Nutritional State and COPD: Effects on dyspnoea and exercise tolerance.
Nutrients, 15(7), 1786.
Walker, J. (2019). Enabling good nutritional care for clients with COPD. Journal of Community Nursing, 33(4).

CHAPTER 14
Pulmonary Health
FIGURE 14.1 Red bell peppers contain vitamin E, which can help stop oxidative damage and lung inflammation. (credit: modification of
work “Chicken and rice wok, Mazatlán. Date: April 4,2023” by El Nuevo Doge/Wikimedia Commons, CC0 1.0)
CHAPTER OUTLINE
14.1 The Impact of Nutrition on Pulmonary Wellness Across the Lifespan
14.2 Nutrition and Chronic Pulmonary Illnesses
INTRODUCTION Nurses begin with assessments, including across-the-room (inspection) or head-to-toe

(palpation, percussion, and auscultation) assessments, as part of the nursing process. As breathing and oxygen are
vital to life, the pulmonary evaluation must take priority as it represents a significant initial part of every holistic
client assessment. Any dysfunction in the respiratory system compromises vital gas exchange and poses a potential
medical emergency and respiratory failure (National Institute of Health [NIH], 2022e). Respiratory problems lead to
life-threatening consequences if not identified and managed promptly.
Consider this case: Kai is a 55-year-old Pacific Islander with a 30-year history of smoking. Kai works as a
construction worker on the island of Kauai. He worked his way up to foreman and finds he works long hours, making
fast food his main food option in the morning and evenings. During his time on the construction sites, he picked up
the habit of smoking, which he has adamantly vowed to stop but has yet to succeed at. Kai is 6 feet tall and weighs
280 lb. When Kai was younger, he ate traditional Hawaiian foods that contained fish, rice, pork, and poultry with a
wide variety of fresh fruits and vegetables.
274 14 • Special Nutritional Considerations for Pulmonary Health
14.1 The Impact of Nutrition on Pulmonary Wellness Across the Lifespan

LEARNING OUTCOMES
• 14.1.1 Describe the impact of nutrition on the pulmonary system during pregnancy.
• 14.1.2 Describe the impact of nutrition on the pulmonary system during infancy.
• 14.1.3 Describe the impact of nutrition on the pulmonary system during childhood.
• 14.1.4 Describe the impact of nutrition on the pulmonary system during adolescence.
• 14.1.5 Describe the impact of nutrition on the pulmonary system during adulthood.
• 14.1.6 Describe the impact of nutrition on the pulmonary system during later adulthood.
Pregnancy
Nurses must be skilled in assessing the holistic aspects of client care across the lifespan. One of the critical aspects
often overlooked but of incredible value is the nutritional intake of clients. Nurses must comprehend the pulmonary
system from pregnancy and infancy to older age, as they assess the dietary aspect and provide education and
advocacy for the clients they treat.
As clients progress through the reactions and lifestyle modifications that occur during pregnancy, considering
nutrition and how it impacts the pulmonary system is yet another area of importance. Pregnancy elicits various
responses from the pregnant client (Dokuhaki et al., 2021). The body undergoes various physiological changes to
adapt to the introduction and adjusts to a growing fetus. The pregnant client’s nutritional needs transform to
accommodate the developing fetus and consider the client’s physiological changes (Widysanto & Mathew, 2022).
Maternal nutritional needs and deficiencies are vital to fetal lung development and prevention of fetal and childhood
complications (Arigliani et al., 2018; Baiz et al., 2019; Fandino et al., 2019; Rocha et al., 2021).
Physiological Changes to the Pulmonary System During Pregnancy

Upper-airway changes that occur during pregnancy include nasal congestion, called rhinitis, because of hyperemia,
edema, plasma leakage into the stroma, glandular hypersecretion, increased phagocytic activity, and increased
mucopolysaccharide content. Hyperemia occurs as a result of a higher-than-normal blood flow. The exact etiology
of rhinitis during pregnancy is unknown but is thought to be related to increased blood volume and hormonal
fluctuations. Complications of rhinitis in pregnancy include snoring and sleep-disordered breathing, both related to
hypertension and preeclampsia.
The chest wall structurally adapts in pregnancy to anticipate the growing uterus and maternal weight gain as the
subcostal angle of the rib cage widens between 68.5° and 103.5° and the circumference of the lower chest wall
increases by 5–7 cm in girth while the diaphragm shifts upward. With pregnancy, total body blood volume increases
40% (Sanghavi & Rutherford, 2014; Soma-Pillay et al., 2016). The rise in the relaxin hormone initiates relaxation
and loosening of ligament attachments in the lower ribs.
Nutritional Needs and Deficiencies Related to Pulmonary System During Pregnancy

Pregnant clients have additional specialized dietary needs that support the physiological changes of the client and
growth of the fetus. A balance in macronutrients such as protein are vital for healthy pregnancies and babies
(Herring et al., 2018). Baiz et al. (2019) recommend consuming eggs and raw or cooked vegetables to limit the
effects of allergic rhinitis during pregnancy.
Under- or overnutrition of a pregnant client causes imbalances of nutrients such as amino acids and increases blood
cortisol levels and oxidative stress (Herring et al., 2018). If malnutrition prevails during pregnancy, the results
equate to “impairment of offspring growth and development, maternal insulin resistance, cretinism, IUGR
[intrauterine growth restriction], birth defects, cognitive and behavioral defects, postpartum complications,
preeclampsia, eclampsia, anemia, preterm birth, maternal hemorrhaging, and additional long-term effects for both
mother and offspring” (Herring et al., 2018).
Maternal needs and nutritional deficiencies related to malnutrition negatively impact the pulmonary system during
pregnancy. Undernutrition in a pregnant client alters hormones that disrupt the lung maturation of the fetus
(Fandino et al., 2019). Macronutrient and micronutrient recommendations are discussed further in the next section.

14.1 • The Impact of Nutrition on Pulmonary Wellness Across the Lifespan 275
Maternal Nutritional Impact on the Fetus

Adequate maternal nutrition prevents intrauterine complications such as intrauterine growth restriction (IUGR) and
lung development in the growing fetus (Bendix et al., 2020; Fandino et al., 2019; Voraphani et al., 2022). See Figure
14.2 for the stages of lung development. IUGR results from below-average fetal development and equates to babies
that are small for gestational age and have an abnormal growth trajectory; it is linked with placental dysfunction and
malnutrition. The term IUGR is often interchanged with small for gestational age (SGA), but the terms vary in that
SGA means the fetus is small for gestational age but has an average growth trajectory. The clinical definition of IUGR
is a baby weighing less than two standard deviations below the mean or remaining below the tenth percentile at a
specified gestational age (Bendix et al., 2020). Infants with IUGR are at risk for complications such as asphyxia,
hypothermia, hypoglycemia, and polycythemia. Long-term complications include growth limitations,
neurodevelopmental handicaps, and disease processes linked to the cardiovascular, renal, and immunological
systems. Even if the growth occurs in incremental units, the fetus may experience IUGR or meet poor outcomes
from maternal malnutrition (Arigliani et al., 2018; Fandino et al., 2019; Rocha et al., 2021).
FIGURE 14.2 Fetal lung development occurs in distinct phases during different weeks of gestation. When development is complete the
fetus is prepared for breathing that takes place outside of the womb. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0
license)
If a pregnant client has inadequate nutrition, the infant with IUGR is at a higher risk for reduced nutrient availability
and oxygen related to placental insufficiency. Undernutrition during pregnancy leads to impaired alveolarization and
suppressed surfactant protein expression, diminished pulmonary vascular development, lower alveolar surface
area, increased extracellular matrix, and thickened blood-gas barrier, limiting compliance and capacity. Causes of
IUGR include severe maternal starvation and suppressed pregnancy weight gain, high altitude, maternal hypoxia,
diabetes, and infections such as tuberculosis. Inadequate protein intake during pregnancy leads to embryonic
losses, IUGR, and reduced postnatal growth, leading to a deficiency in amino acids critical for cellular metabolism
and function (Herring et al., 2018). In contrast, high protein intake during pregnancy may also cause IUGR and
embryonic death related to amino acid excess and ammonia toxicity (Herring et al., 2018). Nurses must assess and
educate the pregnant client on the importance of moderate protein consumption. The recommended protein intake
for the first trimester is 46 g/day and increases to 71 g/day during the second and final trimesters (Murphy et al.,
2021).
Infancy
Infancy is a stage that begins the lifespan. It follows pregnancy and birth and is characterized by rapid growth,
development, and adaptations. During infancy, the baby experiences rapid weight and height gains. Generally,
depending on the source, babies are considered infants from birth up to age 1. Cognitive development during
infancy includes exploration, attention, memory, inquisitiveness, and communication acquisition. An infant’s
milestones include holding their head up, rolling over, sitting with support, crawling, standing, and walking. Infants
form bonds with their caregivers that are shared through eye contact, touch, responsive care, and body language.
Infants rely on their parents or caregivers for full support.
The pulmonary system undergoes significant adaptations to support the transition between the in-utero and outside
world. The fundamental pulmonary changes include the lungs’ transition from fluid-filled to breathing outside air
(Arigliani et al., 2018; Fandino et al., 2019; Rocha et al., 2021). Surfactant production increases late in pregnancy
and continues through development and maturation during the first few weeks of life. The lungs can expand and
stretch, allowing for growing volume capacity. The airways continue to grow and mature. Infants obtain antibodies
through breast milk in colostrum (in the first few days of life) and immunoglobulin A (after the first few days) to help
infants fight infection and support their immune systems.
Nutritional Impact During Infancy

Nutrition is crucial in lung growth, development, and repair in fetuses, preterm infants, infants, and children
(Arigliani et al., 2018; Bendix et al., 2020; Fandino et al., 2019; Rocha et al., 2021). One of the primary systems to
develop in a fetus is the respiratory system, which begins on day 22 after conception. Although the process begins
early with the trachea, lungs, bronchi, and alveoli, complete development does not occur until around age 8
(Rehman & Bacha, 2022). If a child is born with IUGR or SGA, health care providers must assess nutritional aspects
to determine if undernutrition or malnutrition contributes to stunted growth. Micronutrients that play a role in lung
maturation include vitamins A, D, E, selenium, and omega-3 fatty acids (Arigliani et al., 2018).
Childhood
Alveolarization continues from infancy through approximately 8 years of age. Even if pulmonary development and
function is normal at birth, insulting exposures can cause setbacks. Some scientists have traced poor lung function
from infancy through childhood to identify potential events associated with decreasing optimal pulmonary
development and capacity. A child born without any difficulty in pulmonary function but exposed to second-hand
smoke may experience stunted growth (Schultz et al., 2018). According to Schultz et al. (2018), in the same study,
when individuals demonstrated limitations at age 8 in lung function, they maintained these lower levels of function
even when retested at age 16. When 8-year-old children have developmental limitations and are exposed to
second-hand smoke, their lung function diminishes. Maternal smoking habits throughout pregnancy also play a role
in decreased lung development. Schultz et al. (2018) study results further support the view that being born
prematurely increases the risk for diminished lung development and function as the child grows. These children do
not recover the lost development with age. They also are at an increased risk for developing asthma, wheezing, and
declination of lung function during respiratory infection season.
Nutritional Impact During Childhood

Nutrition plays a significant role in the development and function of the respiratory system throughout childhood.
Adequate nutritional intake during childhood maintains a healthy growth pattern, aids lung tissue repair, and
supports the immune system to prevent and treat infection (Gozzi-Silva et al., 2021). Intake of adequate amounts of
macronutrient protein and micronutrients vitamins A, C, E, omega-3 fatty acids, and zinc is important for lung
function. Inadequate consumption of the proper nutrients causes impaired lung function and respiratory problems.
Improper nutritional intake affects the immune system, which protects the lungs from infection and inflammation.
Malnutrition throughout childhood increases the risk for infection and exacerbates conditions like asthma.
Childhood obesity causes detrimental effects on lung capacity by reducing lung capacity, expiratory reserve, and
residual volume due to excessive adipose tissue increasing the intraabdominal pressure on the diaphragm, altering
full chest expansion (Ferreira et al., 2020).
Adolescence
Childhood progresses into the adolescence stage through physiological alterations (Han et al., 2019; Schultz et al.,
2018). These changes include increased lung volume, respiratory muscle strength, airway resistance, susceptibility
to respiratory tract infection (RTI), and decreased respiratory rate, as follows:
• Lung volume increases as the child grows. The lung capacity and volume continue to grow as long as there are

no underlying factors hindering growth (Schultz et al., 2018).

• Increased respiratory muscle strength continues, and muscles increase the ability to exchange air in the lungs.
• Increased airway resistance occurs because of functional and structural changes during adolescence.
• Increased susceptibility to respiratory infections occurs as changes to the immune system and lack of adequate
nutritional intake influence.
Overall, the physiological changes that occur during adolescence contribute to or deter from pulmonary capacity
and function. Although RTI susceptibility increases and asthma can be challenging during adolescence, the
pulmonary systems of most adolescents experience growth.
Nutritional intake during adolescence is crucial as the pulmonary system grows and develops (Gozzi-Silva et al.,
2021). Adequate macronutrient and micronutrient intake also aids in the immune system’s development. Protein
consumption should include 0.85–1.2 g of protein per kilogram of body weight per day (Hudson et al., 2021). Solid
recommended sources of protein include lean meats, poultry, fish, eggs, dairy products, beans, tofu, legumes, and
nuts.
Micronutrient intake for adolescents should focus on vitamins A, C, and E, omega-3 fatty acids, magnesium, and
water (Gozzi-Silva et al., 2021; Scoditti et al., 2019). Vitamins A, C, and E are essential antioxidants that protect the
lungs from oxidative stress and inflammation. See Table 14.1 for a list of vitamins and possible food sources. Finally,
adolescents must remain hydrated, which is essential for all life functions.
Micronutrient Food Source

Vitamin A • Carrots
• Liver
• Spinach
• Sweet potatoes
Vitamin C • Citrus fruits

• Kiwi
• Strawberries
• Tomatoes
Vitamin E • Leafy green vegetables

• Nuts
• Seeds
• Vegetable oils
Magnesium • Chia seeds

• Leafy green vegetables
• Legumes
• Nuts
• Seeds
• Whole grain
Omega-3 fatty acids • Chia seeds

• Flaxseeds
• Mackerel
• Salmon
• Sardines
• Walnuts
TABLE 14.1 Micronutrient Food Sources (source: Gozzi-Silva et al., 2021)
Diets full of fruits, vegetables, whole grains, lean proteins, and healthy fats all regulate the development of lung
tissue and repair, promoting a healthy immune system. In addition to these specified nutrients, adolescents need to
consume a balanced and varied diet (Gozzi-Silva et al., 2021) and exercise regularly to support proper pulmonary
function.
Part A
Unlike many other American adolescents, Kai grew up eating fresh fruits and vegetables. His family had fruit trees in
his yard, so he grew up picking fresh fruits from their source. His mother would obtain the rest of their food items
from the local food market, with everything being grown locally. Kai’s mother would cook all their meals at home,
and he would walk to school and play football to get plenty of exercise. No one in his family smoked, and they rarely
ate outside of the home.
1. What lifestyle choices in Kai’s adolescence might lead the nurse to believe that Kai comprehends the benefits
of good lifestyle choices?
a. His family growing their own fruit
b. His family’s history of eating fresh fruits and vegetables and his daily exercise
c. His screen time
d. His family not eating outside of the home
2. What information from Kai’s past can the nurse incorporate into the dietary client’s education plan?
a. Previous history of adolescent exercise and dietary selection
b. Smoking cessation
c. History of food sourcing
d. History of being a football star
Adulthood
Adulthood is a developmental stage after adolescence and typically lasts until later adulthood. During this period,
individuals reach physical and cognitive maturity and assume adult responsibilities, such as career development,
marriage, and parenthood. Fewer physiological changes occur as the state of health stabilizes, and fewer rapid
developmental changes occur. The body does gradually change in function and structure during the aging process.
Some of these changes occur in the pulmonary system, so it is vital for nurses to advocate for healthy lifestyle
modifications and perform regular health screenings to promote optimal pulmonary health throughout adulthood.
The physiological changes during this time include lung size and function, respiratory muscle strength, respiratory
diseases, immune function, and lifestyle habits (Han et al., 2019; Schultz et al., 2018; Rogers & Cismowski, 2018).
By adulthood, lung growth and development are maximized, and function begins to decline. Respiratory muscle
strength improves during adolescence but declines as one ages. In adulthood, respiratory disease risk increases
related to unhealthy lifestyle choices such as smoking, occupational exposure (chemical plant workers, construction
workers, and health care providers exposed to chemicals such as chemotherapy), and not exercising. The immune
system protects the respiratory system as one of its functions from infection and inflammation. When a client
reaches adulthood, immune function diminishes gradually, making individuals more susceptible to illnesses
throughout aging.
Part B
Study Part A.
When Kai moved out of his parent’s house at age 20, he found it difficult to get a job, so he started working with a
local construction company at age 24. Kai began smoking when he was 25 while working on the construction sites.
He stated, “Smoking used to help me decompress.” The local construction company required Kai to work long

hours, making healthy food choices and exercise incorporation challenging. Kai found himself relying on fast food
options and the hard work on the construction sites as his daily “exercise.” Kai moved through the ranks and is now
a foreman, where he supervises the employees under him at the job sites. He sits more frequently than he used to
and found himself putting on more weight, jumping from 255 lb to 280 lb.
3. What lifestyle choices occur during adulthood might lead Kai to an increased risk for respiratory disease later
in life?
a. Construction work, smoking, and eating fast foods
b. Smoking, drinking alcohol, and exercising
c. Eating fast foods, construction work, and drinking lots of water
d. Smoking, construction work, and working long hours
4. What lifestyle changes can Kai make early on to decrease his chance of developing a chronic respiratory
disease?
a. Working out
b. Smoking cessation and eating better
c. Different job
d. Go back to school
Nutritional Needs Related to Pulmonary System for the Adult

Nutritional support is essential throughout the lifespan in maintaining healthy lung function (Collins et al., 2019;
Scoditti et al., 2019; Sharifi-Rad et al., 2019; Vahid & Rahmani, 2021; Voraphai et al., 2022; Yuan et al., 2021). As
lung function and capacity decline as a client ages, the importance of healthy lifestyles and nutrient-rich dietary
choices cannot be overstated. The dietary choices include antioxidant-rich foods that protect the lungs from free
radical damage (discussed in the next section) and oxidative stress. Fruits and vegetables are excellent sources of
antioxidant-rich foods, especially berries, citrus fruits, leafy greens, and tomatoes. Omega-3 fatty acids hold anti-
inflammatory properties that reduce inflammation in the lungs. Excellent sources of omega-3 fatty acids include
salmon, mackerel, sardines, flaxseeds, chia seeds, and walnuts. Lean protein is an essential macronutrient to aid in
repairing lung tissue and is found in skinless chicken, fish, beans, and legumes. Avoiding harmful environmental
substances, not smoking, avoiding excessive alcohol intake, and getting regular exercise promotes lung function and
health.
Later Adulthood
As people age, their progression parallels their risk for chronic disease. The lungs experience physiological changes
as people age, leading to altered lung capacity and increased risk for infection. The lungs also suffer a barrage of
continuous assaults over their lifetime. These assaults are chemical, mechanical, biological, immunological, and
xenobiotic. These insults lead to oxidative stress in the lung tissue because of antioxidant capacity depletion.
Free radicals are unstable molecules that contain unpaired electrons in an atomic orbit that participate in
phagocytosis's cellular destruction mechanism through macrophages and granulocytes (Sharifi-Rad et al., 2020).
Phagocytosis is the process of phagocytes ingesting and eliminating larger particles. Free radicals are kept at bay by
the body’s antioxidant system. Adverse effects occur when homeostasis of the free radicals is not maintained.
Research studies indicate the free radicals of oxygen play a role in chronic disease and deoxyribonucleic acid (DNA)
damage (Sharifi-Rad et al., 2020). Increasing the amounts of free radicals cause cellular damage and apoptosis (the
death of cells). Antioxidants counteract the free radical destruction process.
Nutritional Needs Related to Pulmonary System for the Older Adult

The nurse treating older clients must recognize the need for antioxidant supplements. The current American diet is
high in processed foods and additives. These food choices increase the risk for oxidative stress in the body,
depleting the antioxidant capacity. The pulmonary system’s reaction to oxidative stress includes activating the
inflammatory response, which further compromises the lungs and cascades further oxidative stress. These oxidative
reactions to the stressors are directly linked to chronic diseases such as asthma, chronic obstructive pulmonary
disease (COPD), and lung cancer (Rogers & Cismowski, 2018).
14.2 Nutrition and Chronic Pulmonary Illnesses

LEARNING OUTCOMES
• 14.2.1 Discuss the impact of nutrition on pulmonary illness.
• 14.2.2 Discuss the impact of nutrition on chronic pulmonary illness.
Nutrition Requirement for Optimal Pulmonary Health

Lung disease is the umbrella term for several diseases and disorders of the pulmonary system that prohibit the
lungs from performing optimally (NIH, 2022b). Lung diseases inhibit and alter respiratory function, breathing
capabilities, and lung capacity. Lung diseases vary in etiology. Infectious microorganisms cause some, while others
maintain an environmental cause. Chronic pulmonary diseases cause long-term breathing problems, drastically
impacting a client’s quality of life. These conditions include symptoms of cough, wheezing, and shortness of breath.
Other common chronic pulmonary diseases include chronic obstructive pulmonary disease, asthma, pulmonary
fibrosis, and pneumonia. Pulmonary conditions that are not long term include respiratory tract infections and
pulmonary embolism.
Chronic Obstructive Pulmonary Disease (COPD)

Chronic or long-term lower pulmonary diseases are classified as chronic obstructive pulmonary disease (COPD).
The COPD categories include emphysema and chronic bronchitis (Gozzi-Silva et al., 2021; NIH, 2022b; NIH,
2022d). These obstructive diseases are progressive and limit the volume of air that flows into and out of the
airways, decreasing gas exchange and making it difficult to breathe (NIH, 2022d). See Figure 14.3. Emphysema
results in damage between the walls of the air sacs, or alveoli, that exchange gas in the lungs (NIH, 2022d; Pahal et
al., 2023). Without injury present, the alveoli easily expand and stretch with inhalation and deflate readily with
exhalation (Pahal et al., 2023). Emphysema leads to permanent dilation of the airspaces and decreases alveolar and
capillary surface area. For example, consider an overinflated balloon that does not maintain the same elasticity over
time. The common cause of emphysema is exposure to cigarette smoking and other noxious gases, such as sulfur
dioxide (Pahal et al., 2023). Chronic bronchitis is the result of continuous inflammation of the airway linings,
causing increasing mucus with clinical manifestations that include a productive cough of at least 2 months occurring
within a 2-year time frame (NIH, 2022b; Widysanto & Mathew, 2023). As with emphysema, cigarette smoking,
active or passively, or inhaling toxic chemicals and industrial pollutants is the leading causative factor in developing
chronic bronchitis.

14.2 • Nutrition and Chronic Pulmonary Illnesses 281
FIGURE 14.3 The COPD disease process begins as healthy lungs endure exposure to different noxious environmental exposures.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Chronic lung conditions such as COPD severely diminish the quality of life, so individuals should strive to consume
foods that promote lung function throughout the chronic diseases states to prevent exacerbations (Collins et al.,
2019; NIH, 2022b; NIH, 2022d; Pahal et al., 2023; Scoditti et al., 2019; Widysanto & Mathew, 2022). Exercise is
limited in clients with COPD, because they often suffer from dyspnea on exertion as a condition symptom. The lack
of exercise is attributed to muscle loss and dysfunction, resulting in fatigue. Even the act of eating might trigger
dyspnea, leading to anorexia. If a client is faced with the choice between breathing and eating, they will breathe to
survive, which why anorexia and malnutrition is a common finding in these clients. As anorexia is present, the risk
for significant malnutrition increases while vital vitamin and nutritional depletion continues. The lack of critical
nutritional components accelerates respiratory decline as respiratory muscles weaken and cough pressure
diminishes. As cough pressure declines, mucosal buildup threatens potential complications such as pneumonia.
Part C
Kai is in the clinic today for difficulty breathing upon walking. His current vital signs are listed on the left side of the
following table. Kai states that he has smoked for 30 years and frequently eats fast food because his job demands
long hours and he does not have time for grocery shopping. You notice a cough; Kai states he does not know when it
began exactly. He has noted a decrease in his weight, and he has a hard time working the long days his job demands
because he becomes short of breath. You look at his chart, shown on the right side of the following table, which
includes his vital signs and exam notes from his visit last year.
Today’s Vital Signs Last Year’s Vital Signs and Exam Notes
Temperature: 97.6ºF Temperature: 98.0ºF
Blood pressure: 128/89 mm Hg Blood pressure: 126/82 mm Hg
Heart rate: 99 beats/min Heart rate: 89 beats/min
Respiratory rate: 28 breaths/min Respiratory rate: 20 breaths/min
Oxygen saturation: 89% on room air Oxygen saturation: 92% on room air
(drops to 77% while walking) Height: 6'0"
Height: 6'0" Weight: 280 lb
Weight: 268 lb
The client presents with mild dry cough for 2 weeks.
Client’s chest x-ray shows enlarged lung air pockets.
The client does not have a history of respiratory
conditions but stated he has smoked for 30 years. The
client is a construction worker with a fluctuating
dietary history. Recommendations for client include
smoking cessation.
TABLE 14.2
5. Based on the documented visit history, which of the following issues requires follow-up by the nurse during
today’s visit?
a. Smoking
b. Hydration status
c. Dietary recommendations
d. Workplace safety
6. The nurse is constructing a teaching plan for Kai to address potential complications of COPD. Which of the
following conditions will the nurse include in the plan?
a. Asthma
b. Respiratory syncytial virus
c. Pulmonary fibrosis
d. Pneumonia
Asthma
Asthma is a chronic disease clinically characterized by recurrent inflammation and airway narrowing (Gozzi-Silva et
al., 2021; Hashmi et al., 2023; NIH, 2022a). These symptoms of chronic inflammation result from irritation from
correlated efforts between the respiratory epithelium and both the initial and the (later) adaptive immune
responses. Hyperresponsiveness is the reaction of the airway results from the activation of the granulocytes, such
as the eosinophils, lymphocytes, macrophages, and mast cells. The response of the granulocytes triggers the
smooth muscle in the airways to contract and secret mucus and also includes microvascular leakages. As the airway
swells, gas exchange is prevented, and symptoms such as shortness of breath, dyspnea, cough, and wheezing is
present. The disease process is associated with childhood and can carry into adulthood, or it might occur in
adulthood. The etiology of asthma relates to allergic and environmental factors such as hay fever, tobacco smoke,
particulate matter, pollen, mold, dust mites, food, and eczema. Asthma has no cure, affecting 1 in 13 people in the
United States (Centers for Disease Control and Prevention, 2022). Figure 14.4 provides a visual of a normal airway
with asthmatic and asthma attack airways.

FIGURE 14.4 During an asthma attack, chronic inflammation triggers an immune response that causes the smooth muscles in the airways
to tighten, preventing gas exchange and restricting the ability to breathe. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0
license)
Pulmonary Fibrosis
Like scars that develop on the skin, pulmonary fibrosis involves scarring of the lung tissue (Krishna et al., 2022).
Scar or fibrotic tissue does not function normally in gas exchange. The fibrotic tissue prevents oxygen flow from the
alveoli into the bloodstream, leading to low oxygen levels and compromised lung capacity as the scar tissue stiffens.
Pulmonary fibrosis etiology might be idiopathic or secondary to another illness, medication, radiation therapy, or
environmental exposure (Agarwal & Huda, 2022; Krishna et al., 2022).
Nutritional intake significantly impacts clinical outcomes for individuals with pulmonary fibrosis. Nutrients are in
high demand due to the increase in respiratory workload, activation of inflammatory mediators, hypoxemia, and lack
of physical exercise (Faverio et al., 2020). As with COPD, malnutrition remains prevalent for those with inadequate
nutrition intake. Some preferred treatment medications for pulmonary fibrosis cause diarrhea and other adverse
effects such as food malabsorption. Specific dietary counseling by a registered dietitian is recommended for those
who experience these effects.
Respiratory Tract Infections

Respiratory tract infections (RTIs) encompass a variety of microorganisms that cause respiratory symptoms in the
individuals that contract them (LaRocque & Ryan, 2019; Saleri & Ryan, 2019). RTIs are commonly acquired viral
infections. These infections manifest in either the lower tract as pneumonia or in the upper tract as bronchitis,
rhinitis, sinusitis, otitis, pharyngitis, epiglottitis, and tracheitis. Systemic manifestations include fever, headache,
sore throat, cough, chest pain, dyspnea, and myalgia (LaRocque & Ryan, 2019; Saleri & Ryan, 2019). Transmission
occurs through direct droplet contact or inhalation (Saleri & Ryan, 2019). While many upper respiratory tract
infections are short term, some may lead to pneumonia. Table 14.3 outlines several RTIs and their symptoms.
Respiratory Tract Symptoms Recommendations

Infections Type
Upper respiratory tract
Common cold Sneezing, stuffy nose, runny nose, sore throat, • Hot tea with lemon or hot soup
watery eyes, fever, cough for sore throat
Pharyngitis Sore throat, dry throat, pain with swallowing, pain • Gargle with warm salt water
with speaking • Cold liquids
• Popsicles made with all-natural
Acute rhinitis Sneezing, stuffy nose, runny nose, itchy nose,
fruit and fresh fruit juices
throat, eyes, clear drainage from ears
• Plenty of fluids (water)
Acute otitis media Fever, ear pain, loss of balance, hearing • Honey
difficulties • Elderberry
Laryngitis Hoarseness, raw and sore throat, dry cough • Increasing vegetables
Tonsillitis High fever, headache, earache, feeling tired, voice • Reducing dairy intake until
changes symptoms improve
• Ginger
• Chicken-noodle soup
Lower respiratory tract

Acute bronchitis Runny nose, low-grade fever, congestion, Same as for upper respiratory tract
wheezing, cough infections
Pneumonia Cough, difficulty breathing, rapid heartbeat, fever,
loss of appetite
TABLE 14.3 Respiratory Tract Infections, Their Symptoms, and Dietary Recommendations to Alleviate Symptoms (sources: Green et al.,
2020; Lucas et al., 2019; Saleri & Ryan, 2019; Thomas & Bomar, 2022)
Pneumonia
Pneumonia is a condition that leads to inflammation of lung parenchyma caused by infection, chronic pulmonary
diseases, ventilator use, or aspiration (NIH, 2022c; Sattar & Sharma, 2022; Sanivarapu & Gibson, 2022). When
germs migrate into the lungs, the immune system is activated, causing alveoli and lung parenchyma inflammation.
The inflammation causes the lungs to fill with fluid or pus. When an infection is a cause, the types of pneumonia are
classified by acquisition type: community (within 48 hours of hospital admission), hospital-acquired (nonintubated
person after 48 hours of hospital admission), ventilation (within 48 hours after intubation), or health
care–associated (hospitalization within last 3 months) pneumonia. Pneumonia can lead to further chronic
complications for some clients, such as lung fibrosis, damaged lung parenchyma, necrotizing pneumonia, cavitation,
empyema, abscess, and death (Sattar & Sharma, 2022; Sanivarapu & Gibson, 2022). When left untreated, the
mortality rate for pneumonia is 30%.
Pulmonary Embolism
A pulmonary embolism is a cease in blood flow to the pulmonary artery or its branches. A pulmonary embolism
Figure 14.5 causes decreased or no blood flow because a blood clot becomes dislodged and migrates to the lungs
(Vyas & Goyal, 2022). As lipid plaques accumulate on the arterial walls, the body’s inflammation systems activate
(Ashrobi et al., 2022). Initial lipid plaques evolve into fibrous plaques that activate the release of inflammatory
markers and procoagulating factors. The process is known as atherosclerosis, and the activation of the platelets
causes adhesion and aggregation that triggers clot formation. A thrombus is a clot formed in a blood vessel that
prevents the natural flow of blood within the vessel through this process (Ashorobi et al., 2022; Vyas & Goyal,
2022). A thrombus that breaks off becomes an embolus. When it travels to the lungs and prevents the natural flow
of blood within the lungs, it is known as a pulmonary embolism.

FIGURE 14.5 A pulmonary embolism stops the flow of blood within the lungs. (attribution: Copyright Rice University, OpenStax, under CC
BY 4.0 license)

A well-balanced diet is important for overall health and becomes especially important for the client who remains
predisposed to pulmonary conditions. Specific dietary recommendations vary depending on the type and severity of
the pulmonary disease. Certain foods have potential benefits for pulmonary disorders and should be included in the
overall management and treatment of clients with pulmonary conditions.
Chronic Obstructive Pulmonary Disease (COPD)

While eating becomes a complex and breathless chore for clients with COPD, the nurse should educate clients on
the proper nutritional intake to promote optimal pulmonary health and prevent COPD exacerbations. Clients who
comprehend the need for appropriate healthy balance are met with improvements in health. A diet with high anti-
inflammatory foods, such as fresh fruit and vegetables, with minimal consumption of processed sugar, salt, and fried
fatty foods, is a solid recommendation from leading government entities. Macronutrient portion intake includes
15–20% proteins, 30–35% fats, and 40–45% carbohydrates (Collins et al., 2019; Hancu, 2019; Scoditti et al.,
2019). Protein-required measurements equate to 1.2–1.5g protein/kg (Collins et al., 2019; Hancu, 2019).
Micronutrients from oral nutritional supplements that maintain antioxidant and anti-inflammatory qualities include
vitamins A, C, and E. These vitamins, within their function, protect and prevent the progression of COPD. Vitamin D
has been found to reduce COPD exacerbation rates (Collins et al., 2019). Individuals with COPD should include
vitamin C at 75 mg/day for females and 90 mg/day for males—vitamin D at 600 IU for adults and 800 IU for people
aged 70 or older (Hancu, 2019).
As nurses perform their assessments, the should use the information the gather in the client’s nutritional planning
and as client teaching opportunities. While completing the assessment of a client with COPD, the nurse should
consider:
• Some clients with COPD may appear overweight because of their free-fat mass index or visceral fat-area
measurements (Hancu, 2019).
• Malnutrition is still of concern in these clients (Hancu, 2019).
• Avoid any judgment toward clients who are overweight.
In addition, the nurse should teach the client to:
• Prepare and/or consume nutritionally dense meals.

• Eat small, frequent meals.
• Rest before mealtimes.
• Time meals when energy level is at its highest.
• Aim for a BMI between 20–24, maintain muscle mass, and include pulmonary rehabilitation.
• Choose food options that require minimal energy expenditure in preparation.
• Limit alcohol consumption.
Asthma
While some food triggers asthma and allergic symptoms, several foods and food groups have been shown to reduce
the risk for developing asthma (Alwarith et al., 2020). Recommendations include daily ingestion of one or more
servings of fruits and vegetables and whole grains, which may reduce the risk in children, adolescents, and adults.
These food groups have also been shown to make asthma symptoms more manageable and are inversely related to
wheezing in children because of the antioxidant effects and preventative oxidative damage. Fruit intake decreases
asthma symptoms and the sensitization by inhaled allergens. The anti-inflammatory results of flavonoids in raw
vegetables (lost during the cooking process) are believed to explain the association between raw vegetable
consumption and well-managed asthma (Alwarith et al., 2020). High-fat intake, commonly in Western dietary
preferences, is associated with worsening airway inflammation and lung function limitations. Clients with asthma
should consider a plant-based diet, vegetarian diet, or strictly vegan foods to reduce asthma risk and decreases the
need for as-needed asthma medication use. If the client decides on a plant-based diet, counseling by a registered
dietitian should be included to avoid nutritional deficiencies.
According to Alwarith et al. (2020), a positive relationship exists between dairy consumption and concurrent asthma
symptomology. Current dietary guidelines recommend 3 servings per day of dairy for clients with asthma, because it
supplies calcium and vitamin D. Consultation with an allergist is recommended if dairy intake must be avoided
(Comerford et al., 2021). The nurse should teach the clients who wish to avoid dairy products to seek plant-based
milks that are fortified with vitamin D. See Table 14.4 for the various supplements and their relationship to lung
anatomy and physiology.
Supplement Relationship with Pulmonary System Food Sources

Vitamin E • Stops oxidative damage and lung inflammation • Almonds
Sunflower, safflower, and soybean oil • Peanuts
• Pumpkin
• Red bell pepper
Vitamin C • Encourages airway hydration and decreases free • Citrus (oranges, lemon, and
radicals grapefruit)
• Controls immune-system cytokines • Bell pepper
• Stops oxidative damage • Strawberries
• Makes asthma symptoms more manageable • Tomatoes
• Cruciferous vegetables
(broccoli, Brussels sprouts,
cabbage)
Selenium • Protects against oxidative damage and lung • Pork

inflammation • Beef
• Turkey
• Fish
• Eggs
• Beans and nuts (Brazil nuts)
TABLE 14.4 Function of Micronutrients Within the Pulmonary System and Food Examples (sources: Allen & Sharma, 2023; Alwarith et al.,
2020)

Supplement Relationship with Pulmonary System Food Sources

Vitamin D • Aids the immune system and response • Cod liver oil
• Salmon
• Fortified foods such as (dairy
and plant milks, orange juice)
• Eggs
Magnesium • Relaxes smooth muscle, used in asthma • Pumpkin seeds

exacerbation; need monitoring to prevent • Chia seeds
hypermagnesemia • Almonds
• Boiled spinach
• Cashews
• Peanuts
• Soy milk
• Rolled oats
TABLE 14.4 Function of Micronutrients Within the Pulmonary System and Food Examples (sources: Allen & Sharma, 2023; Alwarith et al.,
2020)
Pulmonary Fibrosis
The adoption and continued consumption of unhealthy dietary selections increase and accelerate the risk for
chronic diseases. Diets high in saturated fats increase the risk for pulmonary fibrosis development in both idiopathic
and age-related cases (Mercader-Barcelo et al., 2020). In the same analysis, Mercader-Barcelo et al. (2020) state
that a diet high in unsaturated fats reduces the severity of pulmonary fibrosis and the development of pulmonary
fibrosis. A diet high in saturated fats and high fructose corn syrup (sodas, candy, processed foods) sped up the
development of pulmonary fibrosis, while a diet including plant-derived polysaccharides has shown antifibrotic
effects. Plant-based polysaccharides include coconut fiber, barley, oats, wheat bran, and chicory root. The amino
acids arginine, glycine, and L-norvaline have demonstrated protection against pulmonary fibrosis in animal studies
as they reduce the buildup of neutrophils and macrophages in peripheral blood. As with the chronic illnesses COPD
and asthma, including foods high in vitamins A, B, C, D, and E is recommended.
Respiratory Tract Infections and Pneumonia

A healthy, balanced food intake boosts the immune system and helps prevent respiratory tract infections. Meeting
optimal pulmonary health nutritional requirements moderates the body’s immune response, promoting lung health
and respiratory homeostasis (Gozzi-Silva et al., 2021; Scoditti et al., 2019). Nutritional requirements for respiratory
tract infections (RTI) and pneumonia are similar. Undernutrition is associated with an increased risk for frailty,
difficulty in healing, increased risk for infection and worsening condition, morbidity, and mortality. A decrease in
nutritional status predicts life expectancy in clients who begin with an RTI and develop pneumonia; becoming
winded from eating leads to further deterioration of the condition. Nurses should seek to promote healthy habits to
prevent and treat RTI with attention to vaccinations, adequate hydration, hand hygiene, smoking cessation, exercise,
and nutrition.
Vahid and Rahmani (2021) recommend an anti-inflammatory diet to prevent and manage RTI and pneumonia
associated with infections and COPD. Their definition of an anti-inflammatory diet includes using turmeric, ginger,
garlic, onion, saffron, vitamin C, vitamin D, zinc, and omega-3 fatty acids. They conclude that these supplements,
bulbs, and spices decrease symptoms, minimize the duration, and prevent future infections. Consumption of the
micronutrients vitamin C, vitamin D, and zinc play a role in strengthening and protecting the immune system.
Adequate protein intake also supports the immune system per Vahid and Rahmani (2021). They state that the anti-
inflammatory diet not only aids the immune system but also boosts lung function and decreases oxidation.
Turmeric is a spice hailed for its anti-inflammatory properties. Turmeric contains curcumin (Vahid & Rahmani,
2021), which inhibits the expression of cytokines, thus decreasing the inflammatory response. This inhibitor has
also been proposed as an antiviral intermediary for RTI (Vahid & Rahmani, 2021).
Ginger also belongs to the curcumin category, demonstrating similar antiviral and anti-inflammatory responses,
such as its classmate turmeric. Ginger is thought to act by diminishing lung inflammation. See Figure 14.6.
FIGURE 14.6 Ginger, which has been shown to have anti-inflammatory effects, can be added to dishes as an ingredient or a spice. (credit:
“English: Wild rice, ginger, carrots, peas, and celery - Massachusetts, USA” by Daderot/Wikimedia Commons, Public Domain)
Garlic has antioxidant, anti-inflammatory, and cholesterol-lowering effects. Garlic is high in folic acid, vitamin C,
calcium, iron, magnesium, potassium, zinc, vitamin B2, vitamin B1, and vitamin B3. Garlic is thought to have
antiviral, antibiotic, and antifungal effects on the body. See Table 14.5.
Source Role in the Body

Garlic • Aids the immune system by preventing biosynthesis of inflammatory markers
• Related to the deterrence of virus from attaching to its host cells
Onions • Anti-inflammatory properties because of organosulfur compounds with quercetin and

allicin
• Prohibit virus from attaching to its host cells
• Improves lung function as antioxidant, anti-inflammatory, and antiviral
Vitamin C • Neutralizes free radicals

• Minimizes anti-inflammatory markers
• Inactivates and interferes with virus proliferation
Vitamin D • Strengthens the immune system and helps to prevent RTI

• Anti-inflammatory properties by limiting inflammatory cytokine response
Zinc • Potentiates antioxidant and anti-inflammatory properties

• Strengthens the immune system by controlling inflammatory cytokines
Omega-3 fatty • Play a role in lung tissue remodeling

acids
TABLE 14.5 Micronutrients and Their Role in Pulmonary Health (source: Vahid & Rahmani, 2021)
Pulmonary Embolism
The American diet contains detrimental inflammation-causing triggers. Yuan et al. (2021) observed that a higher
intake of French fries increased the risk for thrombosis. The incidence of pulmonary embolism decreased with a diet
high in fresh fruits and vegetables. Pneumonia and pulmonary embolism have inflammatory response activation as
compensatory mechanisms to combat the triggers of the disease processes.


LEARNING OUTCOMES
• 14.3.1 Identify drug–food interactions for their impact on treatments utilized for pulmonary disorders.
pulmonary disorders.
Drug–Food Interactions with Treatments for Pulmonary Disorders

Medical interventions for pulmonary disorders may be associated with dietary interactions or adverse effects. Some
medications used to treat chronic pulmonary disorders require dietary modifications, while other foods and
supplements interact with the prescribed medications. When interactions do occur, harmful side effects can result,
or interaction may limit the efficacy of the drug used to treat the illness.
Chronic pulmonary diseases such as asthma, COPD, and pulmonary fibrosis affect millions of people worldwide
(NIH, 2022a; NIH, 2022b; NIH, 2022d). Treatment to manage these conditions includes a variety of medications in
certain combinations. Bronchodilators, corticosteroids, and immunosuppressants help manage condition
symptoms; however, these medications have the potential to interact with certain foods that may alter their
absorption ability, limit effectiveness, and jeopardize safety. This section will provide an overview of everyday drug-
food interactions associated with standard treatment options for pulmonary diseases.
Health care providers must discuss possible food and drug interactions with their clients to ensure that the
medications are being used effectively with maximum results and minimize side effects. The nurse and health care
provider should guide clients on the best ways to take prescribed medications and advise on potential dietary
restrictions.
Bronchodilators
Bronchodilators are beta-2 adrenergic receptor agonists used as first-line medications to treat asthma and COPD.
Foods such as caffeine enhance the efficacy of bronchodilators as a first-line treatment options (Wee et al., 2020),
because caffeine shares the same effects in the body as bronchodilators. Side effects include tremors, nervousness,
anxiety, and heart palpitations. On the other hand, meals high in dietary fat can prohibit the absorption of the
bronchodilator (Santo et al., 2021). When the absorption is delayed, the effect of a beta-2 adrenergic receptor is
diminished. So high-fat diets should be avoided in clients with asthma and COPD who use bronchodilators.
Corticosteroids
Corticosteroids are hormone mediators created in the adrenal cortex (Yasir et al., 2022). This medication class
decreases airway inflammation in acute and chronic pulmonary conditions. Corticosteroids are used in asthma and
exacerbation of COPD. Nurses should advise clients to take corticosteroids with food to prevent stomach irritation.
Some foods—grapefruit, for example—may increase corticosteroid volume amounts in the bloodstream and increase
the risk for adverse effects (Food and Drug Administration, 2021).
Antibiotics
Antibiotics are commonly used to treat lower RTI and while antibiotics, antivirals, and antifungals are common
medical interventions for pneumonia. Levofloxacin is commonly used to treat RTI and pneumonia (DailyMed, 2022).
Concurrently using levofloxacin with dairy products or calcium-fortified juices decreases the absorption of the
medication and thus should be avoided (DailyMed, 2022).
Fruits and vegetables have antioxidant, antifungal, antibiotic, and antiviral qualities, which support the immune
system (Vahid & Rahmani, 2021). These effects help the immune system combat the invader during the use of
antibiotics.
Treatments and Medication That Can Cause Nutritional Deficiencies

Certain medications and medical interventions can be lifesaving when discussing pulmonary disorders. However,
these life-saving treatment options sometimes unintentionally affect a client’s nutritional condition. These
treatment modalities might lead to deficiencies in vital nutrients that maintain, prevent, or improve pulmonary
function. It is crucial for health care providers to continuously monitor the clients they treat and educate them about
potential nutritional deficiencies and how to treat them. A balanced and nutrient-rich diet may help reduce
nutritional deficiencies and support and improve overall respiratory function.
Corticosteroids
As previously mentioned, corticosteroids are commonly used to decrease inflammation in the airways in conditions
such as asthma and COPD (Yasir et al., 2022). Long-term use of corticosteroids causes some nutritional
deficiencies. These deficiencies include decreased potassium, calcium, and vitamin D, which in turn increase the
risk for decreased bone density, fractures, diminished muscle mass, muscle weakness, and osteoporosis.
Oxygen Therapy
Sometimes, chronic pulmonary conditions such as COPD warrant long-term oxygen therapy. Long-term oxygen
therapy in COPD clients contributed to deficiencies of vital nutrients in clients already suffering from malnutrition
(Mekal et al., 2021). As the energy demand shifts during COPD, hypoxia (low oxygenation to tissues) causes
decreased oxygenation and decreased normal intestine function (Zheng et al., 2015). As the body works to
oxygenate, the decrease in intestine function causes a loss of nutrients (Zheng et al. 2015). Mekal et al. (2021)
noted deficiencies in calcium, vitamins A, C, D, and E, and folates in about 95% of their COPD clients. The lack of
vital nutrients impacts the pulmonary system's optimal functional capabilities by decreasing muscle strength and
respiratory function. Clients with deficiencies need to be closely monitored and taught about nutrient-rich dietary
options to select to minimize these insufficiencies in nutrients.
Mechanical Ventilation
If an acute or chronic respiratory disease exacerbates to the point of life-saving measurement requirements,
mechanical ventilation provides a break to the lungs to allow them time to rest (Kalaiselvan et al., 2021). According
to Kalaiselvan et al. (2021), clients on mechanical ventilators do not have appropriate dietary intake, anorexia, and
malabsorption of vital nutrients. The prolonged use of mechanical ventilation leads to vitamin D and calcium
deficiencies. These deficits contribute to respiratory problems secondary to muscle weakness and difficulty
weaning from the ventilator.
Antibiotics
Malabsorption of vital nutrients contributes to pulmonary problems, limited immunity, and increased risk for RTI.
Antibiotics are often used in the treatment plan for RTI and bacterial pneumonia (Sanivarapu & Gibson, 2023). Long-
term use of antibiotics disrupts gut bacteria and prevents nutrient absorption, leading to deficiencies. According to
Ramirez et al. (2020), healthy bacteria in the colon helps break down xenobiotics and other compounds that play a
role in amino acid and vitamin synthesis within the colon. When antibiotics are used, they remove the healthy
bacteria that helps vitamin synthesis in the colon, causing the deficiencies. Nurses should recommend probiotic-
rich sources such as kimchi, sauerkraut, kefir, yogurt, and drinks such as kombucha to counter the loss of good
bacteria with antibiotic use. These probiotic-rich interventions help combat the side effects of antibiotics that
include nausea, vomiting, and diarrhea. When the nurse develops a discharge plan that includes antibiotic use,
probiotic-rich foods and drinks should be included in the plan.

Chapter Summary
• Nutrition plays a vital role in the growth, lead to vitamin deficiencies. COPD is one of the
development, and maintenance of the pulmonary most prevalent conditions affected by this. The
system throughout the lifespan. Starting in utero, diminished respiratory capacity among clients with
maternal malnutrition can limit alveolarization and COPD can limit the amount of food they are able to
pulmonary vascular development in the fetus. eat, placing them at high risk for nutritional
• Lung development continues through childhood deficiencies.
and adolescence during which the child’s lung • Consuming a nutrient-rich diet boosts the immune
volume expands and respiratory muscle strength system and helps prevent respiratory tract
increases. By adulthood, respiratory growth and infections and pneumonia. An anti-inflammatory
development stabilizes and can begin to decline diet can also minimize the impact of infections.
secondary to aging and comorbidities. High-fat diets can exacerbate asthma and
• Pulmonary conditions limit nutritional intake and pulmonary fibrosis symptoms.
Key Terms
apoptosis cellular death the lung parenchyma caused by infection, chronic
asthma a chronic disease process clinically pulmonary diseases, ventilator use, or aspiration;
characterized by recurrent inflammation and airway pneumonia can lead to chronic damage, such as
narrowing, limiting gas exchange in the lungs lung fibrosis
chronic bronchitis when the airway lining pulmonary embolism a thrombus that becomes
experiences too much inflammation, leading to dislodged and travels to the lungs, preventing the
increased mucus production natural flow of blood within the pulmonary artery or
chronic obstructive pulmonary disease (COPD) its branches
chronic pulmonary diseases known as emphysema pulmonary fibrosis scarring of the lung tissues that
and chronic bronchitis causes stiffening, limiting lung function
emphysema damage between the walls in the alveoli respiratory tract infections (RTI) microorganisms
that exchange gas in the lungs that infect the upper and lower respiratory tract and
free radicals compounds that take part in the cellular lead to symptoms such as fever, sore throat, cough,
destruction mechanism of phagocytosis through chest pain, dyspnea, and myalgia
macrophages and granulocytes rhinitis inflammation that causes symptoms such as
hyperemia a condition that occurs as a result of a nasal congestion, runny nose, sneezing, and
higher-than-normal blood flow postnasal drip
pneumonia a condition that leads to inflammation of
Review Questions
1. Based on physiological changes that occur during pregnancy, which nutrients should the nurse encourage a
client to eat to support the pulmonary system and fetal development during pregnancy?
a. Carbohydrates
b. Vitamin C
c. Proteins
d. Vitamin B
2. Nutritional factors play a role in the development and function of the pulmonary system during infancy. Which
nutrient is essential for the development of the pulmonary system?
a. Iron
b. Protein
c. Vitamin C
d. Omega-3 fatty acids
3. The nurse is caring for a pregnant client who has nutritional deficits. How should the nurse describe the
potential fetal effects from maternal malnourishment?
a. The fetus will experience lower blood glucose levels.
b. The fetus will develop a slower-than-normal heart rate.

c. The fetus may develop cognitive and behavioral delays.
d. The fetus may experience hormone imbalances.
4. The nurse is working with a client who was recently diagnosed with asthma and is using a bronchodilator
inhaler. Which of the following foods should the nurse instruct the client to minimize or avoid?
a. Steak
b. Coffee
c. Grapefruit
d. Kale
5. The nurse is providing prenatal diet instruction for a pregnant client. Which nutrients should the nurse
encourage the client to consume to promote explain proper fetal lung function and development?
a. Proteins, vitamins A, D, and E, and omega-3 fatty acids
b. Carbohydrates and vitamins A, D, and E
c. Proteins and iron
d. Fats, vitamins B12 and B6, and calcium
6. The nurse is providing discharge teaching for a client with respiratory alterations. Which of the following
statements regarding the effects of nutrition on the immune system and lung health should be included in the
plan?
a. Good nutrition is important, although it does not prevent acute respiratory tract infections.
b. Nutrition only affects lung tissue repair, not the immune system.
c. Improper nutritional intake alters the immune system but does not impact lung health.
d. Nutrition plays a role in supporting the immune system to prevent and treat infection and repair lung
tissue.
7. The nurse is instructing the parent of a child recently diagnosed with asthma. Which of the following foods
should the nurse instruct the parent to include with the child’s meals to decrease the risk for an asthma
exacerbation?
a. Salmon or other fatty fish
b. A lean protein such as chicken
c. At least one serving of fruits and vegetables
d. A serving of red meat
8. The nurse is counseling a client experiencing worsening COPD symptoms on diet strategies to minimize the
impacts of the disease. Which dietary component is associated with worsening airway inflammation and lung
function limitations?
a. Saturated fats
b. Carbohydrates
c. Vitamins
d. Unsaturated fats
9. What is the goal of an anti-inflammatory diet for clients with RTI and pneumonia?
a. To limit the immune system’s response
b. To increase the immune system’s response
c. To decrease lung function and reduce coughing
d. To minimize the duration of and decrease the risk for infections
10. The nurse is instructing a client on long-term oxygen therapy at home on the role of nutrition in managing the
client’s condition. Which of the following statements by the client indicates the client understands the
instruction?
a. “I know my GI tract is not getting as much oxygen as it used to, so I need to make sure I get enough

vitamins and minerals in my body.”

b. “I need to eat whatever I feel like I can – calories are the most important thing.”
c. “I need to eat as much protein as possible.”
d. “I need to try to avoid foods high in calcium as these can affect my condition.”
Suggested Reading
Calcium NIH recommendations: https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/
Magnesium NIH recommendations: https://ods.od.nih.gov/factsheets/Magnesium-Consumer/
Selenium NIH recommendations: https://ods.od.nih.gov/factsheets/Selenium-HealthProfessional/
Vitamin A NIH recommendations: https://ods.od.nih.gov/factsheets/VitaminA-Consumer/
Vitamin C NIH recommendations: https://ods.od.nih.gov/factsheets/VitaminC-Consumer/
Vitamin D NIH recommendations: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/
Vitamin E NIH recommendations: https://ods.od.nih.gov/factsheets/VitaminE-Consumer/


CHAPTER 15
Nutrition for Renal Wellness
FIGURE 15.1 Complex carbohydrates, such as breads containing whole grains that are rich in fiber, can have positive effects on the renal
system, helping to effectively eliminate waste from the body. (credit: modification of work “Loaves of nice bread” by ProjectManhattan/
Wikimedia Commons, CC0 1.0)
CHAPTER OUTLINE
15.1 Assess and Analyze the Impact of Nutrition on the Renal System
15.2 Plan Nutritional Strategies to Impact Renal Wellness
15.3 Implement Nutritional Strategies to Impact Renal Wellness
15.4 Evaluate Nutritional Strategies to Impact Renal Wellness
INTRODUCTION The renal system, which comprises the kidneys, ureters, bladder, and urethra, works to eliminate
liquid wastes from the body, manage fluid and electrolyte balance, and regulate blood pH, volume, and pressure.
Nutrition markedly impacts this system and can affect morbidity and mortality of clients with abnormal or
malfunctioning renal systems. This chapter focuses on assessment of the renal system and analysis of abnormal
findings and potential illnesses. The chapter will illustrate how to use this knowledge to identify important
nutritional needs and deficiencies to best educate clients on ways to improve morbidity and mortality surrounding
renal system illnesses.
Consider this case: Jose Vasquez, a 55-year-old client in an outpatient care setting who returns frequently for
regular health evaluations. The client’s diagnoses include obesity, hypertension, diabetes mellitus type 2, and
chronic kidney disease (CKD) stage 2. The client receives routine education on dietary and lifestyle changes needed
to best preserve kidney function and prevent disease advancement.
296 15 • Applying Clinical Judgment to Promote Nutrition for Renal Wellness
15.1 Assess and Analyze the Impact of Nutrition on the Renal System
LEARNING OUTCOMES
• 15.1.1 Recognize the normal function of the renal system.
• 15.1.2 Recognize cues of nutritional impact on the renal system.
• 15.1.3 Analyze cues of nutritional impact on the renal system.
Normal Function of the Renal System

The renal system contains the kidneys, urinary bladder, ureters, and urethra (Figure 15.2) The kidneys (the primary
organs in this system) filter blood and remove serum wastes, excrete wastes from the body, maintain blood pressure
(National Institutes of Health, National Cancer Institute, n.d.), maintain acid-base balance, and balance fluids. The
kidneys are also responsible for reabsorption of glucose, amino acids, bicarbonate, water, and phosphate, as well as
chloride, sodium, magnesium, calcium, and potassium ions (Newman, 2023).
FIGURE 15.2 The major organs of the renal system are responsible for regulating the composition and volume of bodily fluids, as well as
eliminating waste products from the body. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice
There are two kidneys, each located between the twelfth thoracic and third lumbar vertebrae on either side of the
vertebral column. The right kidney is slightly lower than the left because of the liver. A fibrous connective tissue
known as the renal capsule covers the outermost layer of the kidneys (Figure 15.3).

15.1 • Assess and Analyze the Impact of Nutrition on the Renal System 297
FIGURE 15.3 The kidneys filter waste products and excess fluids from the blood, regulate fluid balance, and produce hormones that help
control blood pressure and stimulate production of red blood cells. (credit: modification of work from Anatomy and Physiology 2e.
Renal Cortex and Medulla

The next layer of the kidney is the renal cortex, followed by the renal medulla. The renal medulla consists of a
series of renal pyramids that contain straight tubular structures and blood vessels. The top point of these pyramid-
like structures, known as the renal papilla, points toward the innermost layer of the kidney, called the renal pelvis,
which is found within the renal sinus. The renal sinus (cavity) collects urine that is produced by the functioning layer
of the kidney, the parenchyma (the renal cortex and medulla together). Inside the parenchyma are the nephrons,
the basic functioning units of the kidney (Figure 15.4).
FIGURE 15.4 The nephron filters the blood and produces urine. (credit: modification of work from Anatomy and Physiology 2e. attribution:
Nephrons
Each kidney has roughly 1 million nephrons (Cleveland Clinic, 2023b, 2023c). A nephron is the functional unit of the
kidney and contains two parts: the glomerulus, which is a cluster of capillaries and nerve endings that cluster
around its second part, the renal tubule. Urine created in the nephrons will pass into collecting ducts and flow to the
minor calyxes, to the major calyxes, into the renal pelvis, and out of the kidney into the ureter.
The kidneys remove three primary wastes: urea, uric acid, and drugs and their metabolites. Urea are wastes from
protein breakdown, while uric acid is waste from the breakdown of nucleic acids (Newman, 2023).
Hormone Production
The kidneys also play a role in the production of certain hormones that support other body processes. For example,
they help balance blood pressure by retaining water and sodium in the body; they also produce renin that helps to
maintain appropriate blood pressure by managing water reabsorption (Merck Manuals, 2023). The kidneys assist
with red blood cell production: they create and release erythropoietin, a hormone that signals the bone marrow to
produce red blood cells. Another hormone, calcitriol, which is a form of vitamin D that helps the body absorb
calcium and regulates the parathyroid hormone, is produced by the kidneys. The kidneys also help to raise glucose
levels through employing gluconeogenesis—the formation of glucose from precursors—in the renal cortex.
Renal Artery, Renal Vein, and Ureters

Two other important kidney components are the renal artery and the renal vein. The renal artery controls blood flow
to the kidneys for both supply to the organ and for filtering purposes. Blood flows through this artery at a rate of 1.2
L/min (Dalal, Bruss, & Sehdev, 2022). The renal vein carries filtered blood back to the heart, away from the kidneys.
The ureters are small tubes that run from the renal pelvis to the urinary bladder, allowing for urine passage
(National Institutes of Health, National Cancer Institute, n.d.). The urine is moved by way of peristalsis, or the
involuntary constriction and relaxation of musculature that promotes movement. The layers of the ureters include
the fibrous coat (outer layer), the muscular coat (middle layer), and the mucosa (inner layer).
Bladder
The urine that passes down the ureters travels to the urinary bladder, a temporary storage area for urine located in
the pelvic cavity, posterior to the symphysis pubis. The layers of the bladder include the outer superior surface
layer, the parietal peritoneum, and the outer fibrous connective tissue. The detrusor muscle is made up of
interwoven smooth muscle fibers that control the contraction of the bladder during urination; the submucosa, which
supports the mucous membrane and is composed of connective tissue; and the innermost layer, the mucous
membrane, which is composed of transitional epithelium that runs continuous with the ureters.
To prevent backflow of urine into the ureters, small flaps of mucosa cover the opening of the ureters into the bladder
and act as valves; the internal urethral sphincter, located at the bottom of the bladder, is controlled by the detrusor
muscle to control exit of urine through the urethra.
Urethra
The urethra is a thin-walled, hollow tube-like duct that allows urine to pass from the bladder to the outside of the
body. The urine enters the urethra through the internal urethral sphincter; to exit the urethra, it passes through the
final controlled muscle, the external urethral sphincter, which is composed of striated muscle fibers. The urethra’s
layers include the fibroelastic connective tissue layer (outer layer), smooth muscle layer (middle layer), and
epithelial spongy submucosa (inner layer).
Adrenal Gland
Although adrenal glands are not part of the renal system, they are an extremely important accessory gland. One
adrenal gland, or suprarenal gland, sits atop each kidney. These glands release a hormone called aldosterone,
which helps to balance the blood pH and fluid balance by signaling the excretion of potassium and the reabsorption
of sodium by the kidneys; aldosterone is part of the renin-angiotensin-aldosterone system to help manage blood
pressure (Merck Manuals, 2023). The other major role adrenal glands play is in the release of cortisol. Cortisol has
several uses in the body such as helping to maintain blood pressure, increase glucose levels, reduce inflammation,
and control metabolism. The relationship to the kidneys comes into play when cortisol signals the kidneys to
reabsorb specific electrolytes and excrete others based on the function it is trying to accomplish in the body at a
given time.
Assessment of Nutrition and the Function of the Renal System

Assessment of the renal system starts with collecting subjective data about urinary symptoms the client is
experiencing. Assessing for fluid retention, over- or underproduction of urine, and fluid deficit is useful when
assessing renal function. Swelling, unexplained weight gain, difficulty breathing, and very clear urine are some

symptoms a client might report that are important to the assessment of the renal system. Additional symptoms
might include dysuria (painful or difficult urination) (Urology Care Foundation, 2023), urinary urgency, or urinary
frequency. Other information concerning urinary incontinence, passage of urinary stones, color and clarity of urine,
retention of urine, and nocturia (nighttime urinary frequency). Objective data collected to validate these subjective
findings can include assessment of limb edema, crackles in the lungs, intake and output measurements, and testing
of the urine directly.
After collecting subjective data, the nurse should complete a physical examination of the renal system. This can be
done through organ evaluation and measurement of function results. The physical assessment of the organs should
begin with the abdominal assessment procedure as described in The Digestive Process with some special
considerations to focus on the renal system during this assessment.
The first step is an inspection of the skin, during which the nurse should examine the color and look for masses,
bulging areas, or distention. Skin discoloration may indicate anemia, if pale or cyanotic; a bulging area above the
symphysis pubis may indicate urinary retention or a full bladder; and distention may indicate fluid build-up. Next,
during auscultation of the abdomen, hyperactive bowel sounds can indicate diarrhea, which can result from
hyperkalemia (Cleveland Clinic, 2023a), possibly related to renal issues. During palpation of the abdomen,
hyperkalemia may manifest as abdominal tenderness; severe skin dryness may mean dehydration; and an
overdistended bladder seen through palpation may indicate urinary retention issues. To palpate the right kidney, the
nurse should place one hand under the right flank of the client and press downward against the outer edge of the
right abdomen to “sandwich” the kidney, which should be smooth and firm (Roscoe, 2022). The left kidney cannot
normally be palpated—unless enlarged—due to its location behind the bowel (Roscoe, 2022). Abdominal palpation
can also identify urinary retention and a full bladder by identifying fluid in an enlarged bladder. During the final
step—percussion of the abdomen—a dullness above the symphysis pubis may indicate bladder distension
(Maddukuri, 2022b).
SAFETY ALERT
Contraindications for Deep Palpation

Deep palpation is contraindicated in clients with suspected abdominal aortic aneurysm, appendicitis, polycystic
kidney disease, kidney transplantation history, or a tender spleen, due to a risk for injury to the client and rupture
of organs (Roscoe, 2022).
Bladder Scanning
Bladder scanning is another way to evaluate the bladder and its ability to effectively empty. This scan can assist in
determining whether a client is retaining urine, indicated by bladder distention and abdominal fullness and
discomfort. Post void residual (PVR) volume can be measured with a bladder scan machine, which is a portable,
hand-held, non-invasive, ultrasound device. A wand is placed at the suprapubic area for examination immediately
after the client voids and attempts to fully empty their bladder (Ballstaedt & Woodbury, 2022). Results help to
determine if the bladder is being emptied adequately during micturition, or urination; determine if urine is being
produced in those with renal illness; and assess for any bladder tumors, diverticula, or stones that may be present.
For young and middle-aged adults (ages 18–65 years), a PVR of less than 50 mL is considered normal, over 200 mL
is considered inadequate; for older adults (over age 65), 50 to 100 mL is considered normal; and for children, more
than 20 mL is considered abnormal. A PVR over 500 mL, combined with identified neurologic findings, is highly
predictive of cauda equina syndrome, a dysfunction affecting the multiple lumbar and sacral nerve roots of the
cauda equina, which can cause a need to strain or an altered flow or altered awareness of the need to urinate.
SAFETY ALERT
Bladder Scanning During Pregnancy

Bladder scanning is not suitable on clients who are pregnant, those with uterine prolapse, or those with severe
abdominal scarring and abdominal ascites because these conditions may prompt false high results (Ballstaedt &
Woodbury, 2022).
Other Body Assessments

In assessing the renal system, the nurse should examine the chest, skin, costovertebral angle (the area on the back
flank at the bottom of the 12th rib forming a 90-degree angle to the spine, as shown in (Figure 15.5), rectum, groin
and genitals, and neurologic system. In examining these areas, the nurse should:
• Auscultate the chest for heart and lung sounds (Maddukuri, 2022a).
• Examine the skin for color, turgor, and temperature.
• Evaluate neurologic indicators such as level of consciousness, orientation, ability to speak and write clearly, and
movements of the hands.
• Review the costovertebral angle for pain (Maddukuri, 2022b).
• Determine if there is any prostate enlargement by completing a rectal examination. (Although the prostate has
no relation to the renal system itself as far as function, if it enlarges, it can press against the urethra, preventing
urine from exiting the body).
• Examine the groin and genitals for herniation, deviation from normal anatomy, especially of the urethra,
possible signs of infection, and any masses.
FIGURE 15.5 Pain or tenderness at the costovertebral angle, the angle formed by the intersection of the 12th rib and the vertebral column
on either side of the spine, should be evaluated for pain or tenderness, as it can indicate problems with the kidneys or urinary tract. (credit:
modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Glomerular Filtration Rate, Serum Creatinine, and Blood Urea Nitrogen Tests
In addition to physical assessment, several pertinent tests are used to determine the proper functioning of the renal
system and are the true indicators of health. The three major serum tests are the glomerular filtration rate (GFR),
serum creatinine, and blood urea nitrogen (BUN) (Centers for Disease Control and Prevention, 2022; National
Kidney Foundation, n.d.). The GFR measures how well the kidneys remove excess fluids and waste products from
the blood (factoring in age and sex). This test is related to the 24-hour creatinine clearance test, because it can also
identify how well the kidneys filter out wastes. The GFR can be used to evaluate the client for acute kidney injury
(AKI) as well as to determine the stage of CKD and when the kidneys have failed completely, requiring
transplantation or dialysis. Normal GFR for adults (18–69 years) is above 90 mL/min/1.73 m2; adults (70 years and
older) should be greater than 60 mL/min/1.73 m2; children and adolescents (3–17 years) should be greater than 80
mL/min/1.73 m2; and newborn to 2 years should be 40–60 mL/min/1.73 m2 (Mitchell, Strafford, & Tavares, 2022;
National Kidney Foundation, 2023a).
Serum creatinine is a measurement of the waste product from muscle energy consumption and muscle damage
from the kidneys, whereas BUN is a waste product that comes from ingested proteins excreted by the kidneys.
Serum creatinine levels should be 0.74–1.35 mg/dL for men 19 years and older, 0.59–1.04 mg/dL for women 19
years and older, and 0.5–1.0 mg/dL for children ages 2–18 years. Normal BUN levels for all ages are 6–24 mg/dL.
Urine
Testing urine can indicate how well the renal system maintains fluid balance by measuring hydration status and
volume produced. The 24-hour creatinine clearance test measures the amount of creatinine excreted directly into
the urine and is conducted through a urine sample collection process completed over 24 hours (Centers for Disease
Control and Prevention, 2022; National Kidney Foundation, n.d.). If the creatinine clearance amount is low, then the
kidneys are not filtering properly. A full urinalysis can test for pH, sodium, potassium, urea, creatinine, uric acid,

phosphorus, calcium, chloride, ammonia, water, ketones, nitrites, blood, glucose, protein, and leukocytes to
evaluate for infection and renal damage (Mitchell, Strafford, & Tavares, 2022). Most often, a urine dipstick test is
used, which can test for blood, urine specific gravity, urine pH, glucose, protein, nitrates, and leukocytes (Mitchell,
Strafford, & Tavares, 2022). A more specific dipstick urinalysis test, the albumin dipstick test, checks for
microalbuminuria that is caused by smaller protein amounts than the standard urine dipstick test can detect. This
test can help identify kidney disease in clients who have a negative test for excess protein in the urine in the regular
urinalysis testing but who are at high risk for kidney disease (National Kidney Foundation, n.d.). Another specific
urine test is the albumin-to-creatinine-ratio that uses the amount of albumin and creatinine levels to form a ratio,
which indicates the level of kidney function.
Image and Biopsy Tests

Imaging tests—such as ultrasound and computed tomography (CT) scans—and biopsies can also be conducted to
monitor the function of the kidneys. An ultrasound image of the kidneys can identify obstructions in the urinary tract
and evaluate the size and position of the kidneys. A CT scan of the kidneys can help identify obstructions, structural
abnormalities (National Kidney Foundation, n.d.), and kidney disease, which would present as abscesses, masses,
cystic masses, blockages, or lesions. A kidney biopsy is conducted by taking a sample of the kidney tissue, usually
through CT-guided or ultrasound-guided sharp needle aspiration. The tissue sample is then evaluated under the
microscope for irregularities like inflammation, protein deposits, or damage, such as scarring or cancerous
anomalies (National Kidney Foundation, 2023b).
Serum Electrolyte Testing

Serum electrolyte testing monitors fluid balance and electrolyte levels, both of which are regulated by the kidneys.
Irregular values can indicate issues with function. The major electrolytes—sodium, potassium, calcium, and
phosphorus— are monitored; however, bicarbonate, chloride, and magnesium are also important indicators of
kidney function. This list describes the importance of monitoring these nutrients:
• Sodium plays a significant role in maintaining fluid and acid-base balance and is primarily regulated by the
kidneys. If the kidneys are not functioning properly, sodium values can be impacted (Newman, 2023).
• Potassium, primarily regulated by the kidneys, is an important electrolyte to monitor because minor deviations
can cause a client to experience life-threatening problems such as cardiac dysrhythmias, also known as an
irregular heartbeat.
• Calcium and phosphorus have an inverse relationship—when one is high, the other is low. Calcium is extremely
important to body functions and the musculoskeletal system. If calcium levels get too low, bone structure can
break down and be life threatening for a client who has renal disease. Although calcium is not excreted through
the kidneys, increased phosphorus levels is a common issue in real failure. Phosphorus levels must be
restricted to prevent low calcium levels.
• Although the kidneys regulate bicarbonate levels, they are not as easily attributed to kidney function—other
pathologies in the body and compensatory mechanisms can impact these levels.
• Chloride is excreted and reabsorbed, along with sodium, from the blood. It is, however, found in higher amounts
in interstitial compartments and lymph fluid than in the blood, so monitoring sodium is more important than
monitoring chloride for fluid balance because most of these storage areas cannot be measured. It is still
important to ensure excessive intake in chloride is addressed, as this can lead to an increase in sodium levels,
fluid retention, and edema.
• Magnesium plays an important role when renal failure is present because excessive intake can lead to
hypermagnesemia and can exacerbate or cause hypocalcemia. Regular functioning kidneys remove excess
magnesium, but in the case of failure and an inability to filter, hypocalcemia can become a serious issue leading
to renal bone dysplasia, a life-threatening condition in which the body breaks down the bones to increase
blood calcium levels by releasing the calcium stored in bones.
COVID-19 and Renal Function
Clients who have a history of COVID-19 infection, particularly severe COVID-19 infection, should be evaluated
for renal damage and failure, despite prior history because “30% of clients who are hospitalized with COVID 19
develop AKI” and “more than 50% who are admitted to the intensive care unit with kidney injury require
dialysis.” This relationship is still being researched, but several hypotheses are currently being considered:
• COVID-19 directly targets renal cells.

• The decrease in oxygen from respiratory failure starves and damages the kidneys.
• COVID-19 causes a cytokine storm that destroys renal cells.
• COVID-19 causes clots that damage the small vessels in the kidneys (Sperati, 2022).
Analysis of Nutrition and the Renal System

Subjective and objective data should be collected, as previously discussed, to evaluate abnormal findings and the
possibility of malfunction in the renal system. The nurse should complete an analysis of the client’s nutritional
status through the client’s lab values and all assessment findings. A baseline of the renal system should then be
established and used to develop a nutritional plan.
When assessing the client, the nurse should ask about dysuria (Urology Care Foundation, 2023), urinary urgency,
urinary frequency, urinary incontinence, passage of renal stones, color and clarity of urine, retention of urine, and
any issues with nocturia. These findings can indicate several pathologies, including cystitis (inflammation of the
bladder caused by infection from bacteria). Cystitis is commonly referred to as a urinary tract infection (UTI).
Dysuria can also be related to pyelonephritis, an infection of the upper urinary tract that involves the parenchyma
and kidney pelvis. Pyelonephritis is also a UTI, but it is more serious and is usually accompanied by fever, flank pain,
nausea and vomiting, hematuria, and suprapubic tenderness, all of which can be subjective data that is also
objectively verifiable.
A report of nocturia, oliguria (low urine output), or anuria (absent urine output) with foamy quality urine can be
related to CKD. CKD will very often include many other subjective complaints that will be verifiable by objective data
as well. Other assessment data that could indicate CKD include lethargy, fatigue, headache, breathlessness, edema,
symptoms relating to anemia, anorexia, nausea, vomiting, weight loss, cramping muscles, hematuria (blood in the
urine), and pruritis (uncomfortable itching). Findings of colicky pain, hematuria, nausea, and vomiting can be an
indication of renal lithiasis, or kidney stones. Discharge from the penis or vagina, dysuria, frequency, and purulent
drainage from the penis all can be indicative of sexually transmitted infection.
When physical assessment findings indicate potential pathologies in the renal system, testing can assist in
diagnosing the issue. GFR will indicate if there is a decrease in the function of the kidneys when the results are less
than normal. Serum creatinine should be tested with the BUN results to evaluate kidney function. If the creatinine is
high and the BUN is high, kidney functioning is insufficient. Table 15.1 lists laboratory tests typically performed to
evaluate possible renal system issues and their relationship to the renal system.
Lab Test Results Relationship

White blood cell Elevated UTI
count
Potassium Elevated CKD
Sodium Decreased Fluid overload and edema from CKD
Calcium Decreased or CKD/hyperparathyroidism related to CKD/renal
elevated osteodystrophy
Bicarbonate Decreased CKD
Phosphorus Elevated CKD
Magnesium Elevated CKD or AKI
Chloride Decreased Fluid overload and edema from CKD
TABLE 15.1 Testing for Renal System Abnormalities and the Relationship to the Renal System

15.2 • Plan Nutritional Strategies to Impact Renal Wellness 303
15.2 Plan Nutritional Strategies to Impact Renal Wellness

LEARNING OUTCOMES
• 15.2.1 Prioritize the hypotheses of nutritional habits that optimize renal wellness.
• 15.2.2 Generate solutions to optimize renal wellness utilizing nutritional habits.
Planning Nutrition Goals

The nurse should consider a client’s current renal system when planning nutritional goals; therefore, plans will vary
accordingly. For the client with healthy kidneys, the goals of nutrition should focus more on dietary needs for
comorbidities, including limiting sodium, trans fats, saturated fats, and alcohol; eating appropriate amounts of
protein; and maintaining adequate fluid balance.
When creating nutritional plans for clients with compromised kidneys, the nurse should collaborate with a renal
dietician and consider all laboratory test values. The plans for these clients should focus on limiting fluid intake,
potassium, phosphorus, sodium, trans fat, saturated fats, magnesium, and proteins, while increasing calcium. Note
that at the start of dialysis, slightly different restrictions apply.
The Healthy Renal System Goals

The nurse should direct clients with a healthy renal system and no comorbidities to consider nutritional goals for
renal wellness. A good starting point is to use the MyPlate portioning method with every meal (de Bellefonds, 2021).
In addition, it is important to limit sodium intake to no more than 2300 mg/day. Because the majority of sodium
intake comes from processed foods and not table salt, encourage clients to avoid pre-processed foods or, at
minimum, choose no-sodium or low-sodium options.
MYPLATE
MyPlate (https://openstax.org/r/myplateg) pictorially represents healthy portion sizes of different food groups in
a nutritionally sound diet. This tool is useful as a good starting point for any healthy client trying to improve their
nutritional intake to maintain health.
Clients should also be aware of protein intake because protein byproducts are filtered through the kidneys. Clients
should eat enough protein to maintain overall health, but not consume too much because the kidneys will have to
work extra hard.
The nurse should encourage the client to choose complex carbohydrates such as whole grains, fruits, vegetables,
lentils, and beans over simple carbohydrates such as sweetened beverages, packaged foods, and desserts (de
Bellefonds, 2021). Heart health is important to kidney health, so limiting saturated fats and avoiding artificial trans
fat is recommended. The client should consider limiting, or even eliminating, their alcohol intake. Alcohol is a waste
product that the kidneys need to filter out, making it less efficient to filter out other things during this time; alcohol is
also dehydrating, which affects the kidneys’ ability to regulate the body’s hydration status.
Another factor the nurse should consider is any comorbidities a client has. For example, a client who has a healthy
renal system but has hypertension or diabetes is at much higher risk for developing CKD. Dietary goals should
include foods that will keep these pathologies under control, as well as include nutrients that support renal health
once a client has developed CKD.
Fads for Weight Loss—Dangers to Renal System Health
Diets that promote excessive or reduced intake of specific nutrients, such as protein or carbohydrates, can be
dangerous because they limit many nutrients and promote disease. For example, diets with excess red meats
and saturated fats may cause heart disease; diets high in protein can lead to intraglomerular hypertension that
may cause renal hyperfiltration, glomerular injury, and proteinuria, which could lead to CKD (Gang-Jee, et al.,
2020). Well-known diets that require extreme nutritional changes include Atkins, Keto, Dukan, Montignac,
Scarsdale, Stillman, and the Zone.
Goals for Clients with CKD

Clients with CKD need to follow the preceding guidelines, but they also have more restrictions. For clients who have
CKD and diabetes and/or hypertension, the following restrictions are also required in addition to their original
nutritional plan dictated by their comorbidity, categorized by stage Table 15.2.
Stage GFR Function Water Intake Nutrient Intake

1 ≥ 90 mL/ • Working well. • Increase water • Consume low-fat
min/ • Client is unaware of intake. and low-sodium diet.
1.73 m2 deficiencies.
2 60–89 mL/ • Still functioning. • High water intake. • Continue low-fat and
min/ • Client may be asymptomatic low-sodium diet.
1.73 m2 or show signs of • Add foods higher in
hypertension. calcium and
magnesium.
3A 45–59 mL/ • Decrease in function, with • Continue high • Continue with low-
min/ kidneys starting to decline. water only if no fat and low-sodium
1.73 m2 • Client will have edema or heart diet and food options
hypertension. failure present. that are high in
• Client may have anemia, • If client has heart calcium and
fatigue, anorexia, failure or edema, magnesium.
malnutrition, and bone pain. restrict fluids. • If heart failure or
edema is present,
restrict foods with
phosphorus,
potassium, and
protein, limiting
proteins that are
plant-based or from
lean meats.
3B 30–44 mL/
min/
1.73 m2
TABLE 15.2 Nutrient Intake for Clients with CKD, Dependent on Stage of Failure (source: National Kidney Foundation, 2023a)

15.2 • Plan Nutritional Strategies to Impact Renal Wellness 305
Stage GFR Function Water Intake Nutrient Intake

4 15–29 mL/ • Severe decline in kidney • Restrict fluids. • Restrict intake of fat,
min/ function; may need dialysis. sodium, potassium,
1.73 m2 • Client will have phosphorus, and
hypertension, anemia, magnesium.
malnutrition, altered bone • Increase intake of
metabolism, edema, calcium.
metabolic acidosis, • If not yet on dialysis,
hypocalcemia, an elevated restrict protein.
BUN and creatinine. Client • If dialysis has been
may have uremia and started, increase
azotemia. protein.
5 < 15 mL/ • End-stage renal disease • If on dialysis, • If on dialysis, follow

min/ (ESRD). follow stage 4 stage 4
1.73 m2 • Client will have complete recommendations. recommendations.
kidney failure in which all • If recipient of a • If recipient of a
other symptoms are present kidney kidney
and worsened. transplantation, transplantation,
• Client will have azotemia follow regular follow regular
with overt uremia and healthy diet. healthy diet.
require dialysis or renal
transplantation to survive.
TABLE 15.2 Nutrient Intake for Clients with CKD, Dependent on Stage of Failure (source: National Kidney Foundation, 2023a)

Many barriers exist for clients with CKD—the more advanced the disease, the higher the likelihood that a client will,
either deliberately or accidentally, not follow a nutritional plan. The nutritional plan for clients with CKD restricts
fluids, fat, sodium, phosphorus, protein, magnesium, and potassium and increases calcium, which presents many
challenges, especially before transplantation. The nurse should counsel the client on the following:
• Restricting fluids can be extremely difficult; the kidneys will excrete more urine if unable to concentrate solutes
in smaller urine amounts. The client will then become extremely thirsty because they are losing much more
water than they are permitted to drink each day.
• Sodium and phosphorus are not only found in certain fresh items but are also added to many processed foods
as preservatives. Processed foods are much cheaper and more readily available to clients with busy lives, so it
is more difficult to avoid these types of foods. Fast foods—prepared foods that are readily available—are not
only extremely high in both sodium and phosphorus, but also in fat content. The nurse should counsel the client
to limit their fast-food intake to only once or twice a week
• The client with CKD also needs to understand how to combine plant protein sources in the right amounts and
types to replace proteins easily found in meat. Although lean meat protein sources are acceptable, options tend
to be more expensive.
• The challenge faced when limiting magnesium is that many food sources high in magnesium are high in plant
proteins, which can replace meat proteins, making selections more limited. Another difficult balance to achieve
with magnesium is that many high calcium foods that need to be increased are also high in magnesium.
• Lastly, potassium is found naturally in a variety of fresh and healthy food choices. Many foods that the client
was taught to eat before they had CKD to manage hypertension, diabetes, or any number of other
comorbidities, will be ones they now have to avoid due to high potassium content. Potassium is the opposite of
most other foods on the list—it is high in fresh food options and low in processed food options.
15.3 Implement Nutritional Strategies to Impact Renal Wellness

LEARNING OUTCOMES
• 15.3.2 Teach nutritional strategies to optimize renal wellness.

When providing holistic care, the nurse should address potential barriers the client may face in accessing healthy
foods. According to the World Health Organization, 30–55% of health outcomes are influenced by social
determinant health disparities such as economic stability, food security, social context, and environment, among
others (Reinoso et al., 2022; World Health Organization, 2020). Many of the fresh foods recommended on a
customized nutritional plan for renal disease are often more expensive and harder to obtain than packaged or
processed foods. To set the client up for success in following the plan, the nurse should inquire about any food
security issues the client has. The nurse should create a plan that addresses the client’s insecurities and further
support the client by connecting them to the appropriate resources.
HELPFUL PROGRAMS
The nurse should refer clients to one of the multiple government programs (https://openstax.org/r/fnsusda)
available to help with food security issues.
Client Teaching
Client adherence to the nutritional plan may also be difficult if they are lacking education or fail to engage in a plan.
If the client does not understand diet restrictions or the need to follow them, they are not likely to follow the
prescribed diet. Client and family or caretaker engagement in the planning of their diet and in the active learning
process is considered essential to success—engaged clients are more likely to be proactive in the management of
their condition and they are more likely to make the needed behavior changes to improve their quality of life
(Kariuki, 2022).
The nurse should use multiple educational strategies to increase client confidence and compliance. Educational
strategies may include teach-back evaluation of understanding, programmed medication reminders, access to their
medical records, easy communication with their provider, and condition-specific educational resources in multiple
formats, including digital formats (Kariuki, 2022). The nurse should educate the client on some of the common
difficulties they will face when following the nutritional plan and provide specific strategies to address them. The
nurse should provide their client with some tips and tricks to help with some of the previously mentioned difficulties
Table 15.3.
Electrolyte/ Substitutions/Hacks
Restrictions
Fluids • Use small glasses at meals, or do not fill large glasses completely.
• Suck on hard, sugar-free candy, such as mints or sour balls, to help lubricate the mouth.
• Take sips and not gulps to savor liquids.
• Divide fluid intake into manageable amounts for each part of the day.
• If going out in the evening, take in less during the day to save intake.
• Use alcohol-free mouthwash and perform good oral hygiene.
Potassium • Avoid high-potassium foods.

• Use herbs, but not salt substitutes.
• Take diuretics or potassium binders when directed by the provider.
TABLE 15.3 Substitutions and Nutritional Hacks to Help with Nutritional Plan Adherence in CKD (sources: DaVita, 2023; National Kidney
Foundation, 2022)

15.3 • Implement Nutritional Strategies to Impact Renal Wellness 307
Electrolyte/ Substitutions/Hacks
Restrictions
Sodium • Use salt substitutions (not salt substitutes) such as garlic or onion.
• Make sauces, gravies, and snacks at home.
• Do food prep and freeze meals instead of buying store-bought microwave meals.
• Buy and cook fresh meats, not smoked, cured, luncheon, processed, or jerky meats.
Phosphorus • Use phosphorus binders when prescribed by the provider—take with meals.
• Limit foods that are especially high in phosphorus, like dark colas, chocolate, chocolate
drinks, cheese, milk, cream soups, ice cream, pudding, regular yogurt, oysters, beef liver,
organ meats, sardines, caramels, and processed meats and foods.
• Limit any store-bought food that contain phosphorus, phosphate, phosphoric, or
pyrophosphate.
Magnesium • Avoid milk of magnesia to treat for heartburn.

• Increase fiber intake, as it helps decrease magnesium absorption.
• Eat Greek yogurt as a healthy alternative to help lower magnesium levels, increase calcium,
and not raise phosphorus.
• Exercise to the point of sweating to lower magnesium.
Fat • Avoid trans fats and saturated fat.

• Avoid processed foods.
• Make food at home.
• Remove skin and fat from meat.
• Bake foods instead of frying.
• Use olive oil or avocado oil for cooking.
• Avoid sugary desserts.
• Read nutrition labels carefully to choose the least amount of trans fat and saturated fat.
Protein • Limit protein before dialysis—but eat enough to maintain health.

• Use plant sources high in protein first, such as quinoa, edamame, lentils, fava beans,
chickpeas, pinto beans, lima beans, mung beans, green peas, tofu, pumpkin seeds,
soybeans, chia seeds, almond milk, and mycoprotein.
• Use animal sources of protein sparingly, and choose lean sources such as skim milk, egg
whites, skinless chicken, and fish.
Calcium • Increase calcium; raising calcium will help lower phosphorus levels as well.
• Eat foods high in calcium and enriched with calcium; plant sources of calcium are a better
option than dairy sources, as dairy also contains higher levels of phosphorus.
TABLE 15.3 Substitutions and Nutritional Hacks to Help with Nutritional Plan Adherence in CKD (sources: DaVita, 2023; National Kidney
Foundation, 2022)
TRENDING TODAY
Advanced Nutritional Counseling for Nurses

To optimize renal health, it is imperative that clients with preexisting kidney disorders seek advanced nutritional
counseling. Nurses can meet this need and positively impact client outcomes by obtaining certifications in
nutrition science. As nursing roles expand, nurses continue to look for opportunities to positively impact client
care. Several strategies can enhance the nurse’s delivery of care, mastery of knowledge, and future job
opportunities.
In this Trending Today, explore opportunities that build upon a nursing license as a base to add skillsets to your
practice and certifications to your resumé. Evaluate one of the following to determine benefits and challenges of
these professional development areas:
• National Academy of Sports Medicine Certified Nutrition Coach at https://www.nasm.org/

(https://openstax.org/r/nasmo)
• Cornell Nutrition and Healthy Living Certificate at https://online.cornell.edu (https://openstax.org/r/
onlinecornelledu)
• National Board of Nutrition Support Certification at https://www.nutritioncare.org (https://openstax.org/r/
nutritioncareorg)
1. Which evidence-based practice certification did you view, and why?

2. How would obtaining this certification impact the care you provide?
3. How would obtaining this certification impact your practice potential?
4. As a nurse, how would you use a nutrition certification to help your client achieve their optimal level of
health?
Part A
Mr. Vasquez is in the clinic for a routine visit following his education session with the renal dietician 2 weeks prior.
The nurse reviews his food recall report for the last 3 days (72 hours) to evaluate the need for further education. The
client’s diagnoses include obesity, hypertension, diabetes mellitus type 2, and CKD stage 2, so his nutritional
education would have included all these issues.
1. Which dietary selection made by Mr. Vasquez suggests the need for further teaching by the nurse?
a. Lunch meats
b. Turkey off the bone
c. Apples
d. Hard-boiled eggs
2. Mr. Vasquez has an upcoming celebration and asks the nurse for a suggestion for a dessert that he could eat.
What suggestion is appropriate for the nurse to make?
a. Cupcakes
b. Fruit salad
c. Ice cream
d. Chocolate milk
15.4 Evaluate Nutritional Strategies to Impact Renal Wellness

LEARNING OUTCOMES
• 15.4.1 Evaluate a nutritional plan for its effects on renal wellness.
• 15.4.2 Modify a nutritional plan to promote renal wellness.
Evaluating the Effectiveness of a Nutritional Plan for Renal Wellness

Evaluation of the effectiveness of a nutritional plan involves evaluation of both client adherence to the plan and the
effectiveness of the plan to reach the intended outcomes. Mr. Vasquez’s nutritional plan is considered in the
following Unfolding Case Study feature. If the plan is ineffective in any way, the nurse should determine the
cause—adherence or general ineffectiveness—so that they can make appropriate changes.

15.4 • Evaluate Nutritional Strategies to Impact Renal Wellness 309
Part B
Study Part A.
At the last visit, Jose Vasquez was educated on nutritional changes that will help preserve kidney function and
manage comorbidities. At a recent physical examination, the following are noted:
Vital Signs Physical Examination

Temperature: 97.9°F (36.6°C) • No edema is present.
Blood pressure: 118/76 mm Hg • Lungs are clear to auscultation
in all fields.
Weight: Client has lost 3 lb (5.44 kg) since his last
visit 3 months ago
Finger stick glucose level: 100 mg/dL
TABLE 15.4
Mr. Vasquez reports following the nutritional guidelines strictly, and his food diary reflects this to be the case. Lastly,
the nurse receives the following lab results from the sample drawn 2 days ago as a preparation for this visit:
Lab Test Normal Range Mr. Vasquez’s Lab Results
GFR 90–120 mL/min/1.73 m2 52 mL/min/1.73 m2
Potassium 3.5–5.0 mEq/L 6.2 mEq/L
Sodium 135–145 mEq/L 122 mEq/L
Phosphorus 2.5–4.5 mg/dL 5.3 mg/dL

TABLE 15.5
3. Based on these assessment findings, what would the nurse document about the success of the nutritional
plan for Mr. Vasquez?
a. Plan is effective.
b. Plan is ineffective due to client nonadherence.
c. Plan is ineffective despite client adherence.
d. Unable to judge plan effectiveness with assessment presented.
4. Which dietary change would Mr. Vasquez need to make if he progressed to stage 3 CKD?
a. Increase calcium.
b. Restrict fluids.
c. Restrict magnesium.
d. Increase fats.
Modifying a Nutritional Plan to Promote Renal Wellness

Unfortunately, renal disease may still progress even when the client follows an appropriate nutritional plan; the
client’s nutritional plan may need to be modified.
Part C
It is determined that, despite Mr. Vasquez following the nutritional plan, his condition has worsened. Although this
disease process will progress regardless, it is still prudent to address the plan because the client’s disease is now in
an advanced stage; the plan requires modifications to prevent further injury.
5. Now that the client has advanced from stage 2 to 3 CKD, what assessment findings indicate a need to change
the current nutritional plan?
a. GFR of 51 mL/min/1.73 m2
b. Symptoms of heart failure
c. No dependent edema
d. Glucose levels that are low
6. Which selection is appropriate for the client to include in their diet?

a. Quinoa
b. Skin-on baked chicken
c. Sirloin steak, well-done
d. Fried fish

Chapter Summary
• The renal system comprises the kidneys, urinary sodium, calcium, magnesium, phosphorus,
bladder, ureters, and urethra, with the kidneys potassium, and protein.
being the primary organs. • Clients should engage in the planning of their diet
• The kidneys filter blood and remove serum wastes, and in an active learning process concerning their
balance fluids, maintain blood pressure, maintain health. Engagement is considered an essential
acid-base balance, and excrete wastes. The pillar for successful health management because
kidneys also reabsorb certain products including barriers to following the nutritional plan are more
glucose, amino acids, bicarbonate, water, likely to be identified. Engaged clients are more
phosphate, chloride, sodium, magnesium, and likely to be proactive and are more likely to make
potassium ions. the needed behavioral changes to improve their
• Heart health is important to kidney health, so quality of life.
making sure to limit saturated fats and avoid • The nurse should follow the four components of
artificial trans fat is important for both cardiac and the client education process—assessment,
renal health. planning, implementation, and
• Depending on the stage of renal disease, the client evaluation—holistically when providing client
will have to control their intake of fluids, fats, education.
Key Terms
adrenal gland the small glands sitting on top of the which the body breaks down the bones to increase
kidneys that release adrenaline, noradrenaline, blood calcium levels by releasing the calcium stored
cortisol, and aldosterone in bones
aldosterone a hormone that triggers the reabsorption renal capsule the outermost layer of the kidney
of sodium by the kidneys composed of fibrous connective tissue
cortisol a hormone released by the adrenal glands to renal cortex the outer layer of the kidney contained
help maintain blood pressure inside the capsule
costovertebral angle the area on the back flank at renal medulla the inner part of the kidney that
the bottom of the 12th rib forming a 90-degree contains working filtering units
angle to the spine renal papilla the apex of a renal pyramid
cystitis inflammation of the urinary bladder renal pelvis the top part of the ureter where the
erythropoietin a hormone released by the kidneys kidney tubules drain
that signals the bone marrow to produce red blood renin an enzyme secreted by the kidneys that
cells stimulates the production of angiotensin
glomerulus a cluster of capillaries around the end of symphysis pubis the joint consisting of a
a kidney tubule that filters waste products from the fibrocartilaginous disc sandwiched between the
blood surfaces of the pubic bones
gluconeogenesis the generation of glucose from non- urea the wastes from the breakdown of proteins
carbohydrate carbon substrates ureters two hollow tube-like ducts that allows
hematuria blood in the urine passage of urine from the kidneys to the urinary
kidneys a pair of bean-shaped organs that filter out bladder
blood wastes and excrete urine urethra the hollow tube-like duct that allows urine
micturition the act or urinating passage from the bladder to the outside of the body
nephron the functional unit of the kidney that uric acid the wastes from the breakdown of nucleic
contains the glomerulus and its tubule acids
parenchyma the renal cortex and medulla together urinary bladder a hollow organ posterior to the
pruritis uncomfortable itching symphysis pubis that acts as a storage reservoir for
pyelonephritis inflammation of the kidney urine before excretion
renal bone dysplasia a life-threatening condition in
Review Questions
1. The nurse provides dietary instruction to a client with kidney disease. The nurse informs the client which
nutrient is not directly absorbed by the kidney?
a. Calcium
b. Sodium
c. Magnesium
d. Potassium
2. Which laboratory value would indicate to the nurse that an adult male client has a potential renal problem?
a. Serum creatinine: 1.5 mg/dL
b. Blood urea nitrogen: 7 mg/dL
c. Glomerular filtration rate: 93 mL/min/1.73 m2
d. Potassium: 4.1 mg/dL
3. When should the nurse perform a bladder scan to determine a client’s PVR?
a. Before the client voids
b. Immediately after the client voids
c. One hour after the client voids
d. When the client has the urge to void
4. Which snack choice made by a client indicates to the nurse that the client understands the need to increase
complex carbohydrates in the diet?
a. Snack cakes
b. Crackers
c. Muffins
d. Fruits
5. Which nutritional instruction would the nurse give to a client with CKD who is not on dialysis?
a. Decrease calcium intake.
b. Use plant sources of protein before animal sources.
c. Increase intake of trans fat.
d. Reduce dietary fiber.
6. When developing a nutritional plan of care, which factor should the nurse consider for improving client
adherence to plan?
a. Level of engagement
b. Age
c. Gender
d. Comorbidities
7. Which assessment finding in a client on dialysis is of concern to the nurse?

a. Client is not restricting protein intake.
b. Client chooses foods that are low in potassium.
c. Client drinks large amounts of fluids.
d. Client has increased intake of calcium.
8. What instruction should the nurse give to a client on a fluid restriction secondary to kidney disease who
reports increased thirst?
a. Suck on hard, sweet candies.
b. Use large glasses for drinking.
c. Fill drinking glasses completely.
d. Sip fluids slowly.
9. Which food item on a 72-hour nutritional recall does the nurse identify as appropriate for a client who needs
to restrict phosphorous intake?
a. Vanilla ice cream

b. Potato chips
c. Hot dogs
d. Chocolate milk
10. Which food selection on a 72-hour recall indicates to the nurse that a client who must restrict potassium and
sodium intake requires more instruction?
a. Salt substitute
b. Cauliflower
c. Grapes
d. Apple
Suggested Reading
Amin, R., Thalluir, C., Docea, A., Sharifi-Rad, J., & Calina, D. (2022). Therapeutic potential of cranberry for kidney
health and diseases. eFood, 3(5), e33. https://doi.org/10.1002/efd2.33
Avesani, C., Cardozo, L., Wang, A., Lindholm, B., Stenvinkel, P., & Mafra, D. (2022, September 28). Planetary health,
nutrition, and chronic kidney disease: Connecting the dots for a sustainable future. Journal of Renal Nutrition,
S1051-2276(22)00161-3. https://doi.org/10.1053/j.jrn.2022.09.003
Bhattacharjee, R., Jackson, A., Ruthirakanthan, A., Juriasingani, S., Levine, M., Jiang, L., Patel, R., Richard-Mohamed,
M., Forrest, S., Ravichandran, S., Sener, A., & Luke, P. (2022). The impact of nutritional supplementation on donor
kidneys during oxygenated ex vivo subnormothermic preservation. Transplantation Direct, 8(10), e1382.
https://doi.org/10.1097/TXD.000000000000138
Caldiroli, L., Molinari, P., Abinti, M., Rusconi, C., Castellano, G., & Vettoretti, S. (2022). Can Mediterranean diet have a
positive impact on kidney health? A pending answer to a long-time question. Nutrients, 14, 4366. https://doi.org/
10.3390/nu14204366.
Ebrahim, Z., Glorieux, G., Moosa, M., & Blaauw, R. (2022). Effect of simplified dietary advice on nutritional status and
uremic toxins in chronic kidney disease participants. South African Journal of Clinical Nutrition, 35(4).
https://doi.org/10.1080/16070658.2021.2018788
Nagai, K., Kosaka, S., Kawate, Y., & Itsubo, N. (2022). Renal health benefits of sustainable diets in Japan: A review.
Renal Replacement Therapy, 8(25). https://doi.org/10.1186/s41100-022-00415-6

CHAPTER 16
Special Nutritional Considerations for Renal
Health
FIGURE 16.1 Renal health is impacted by nutrition and lifestyle choices. (credit: modification of work “dried-fruits” by www.Pixel.la Free
Stock Photos/Flickr, CC0 1.0)
CHAPTER OUTLINE
16.1 The Impact of Nutrition on Renal Wellness Across the Lifespan
16.2 Nutrition and Chronic Renal Illness
INTRODUCTION The renal system impacts many other systems in the body. Throughout the lifespan, nutrition and
other lifestyle decisions can impact the growth, development, and functioning of this system. The nutritional needs
of this system change not only with age but also with the current health status of the kidneys. It is the nurse’s role to
ensure that clients understand their nutritional needs based on their specific parameters such as age, renal health,
and comorbidity status.
Consider this case: Kayla Davis’ journey begins with the problems her mother encountered during pregnancy. We
will examine the various decisions for care in light of her disease and nutritional needs.
316 16 • Special Nutritional Considerations for Renal Health
16.1 The Impact of Nutrition on Renal Wellness Across the Lifespan

LEARNING OUTCOMES
• 16.1.1 Describe the impact of nutrition on the renal and urologic systems during pregnancy.
• 16.1.2 Describe the impact of nutrition on the renal and urologic systems during infancy.
• 16.1.3 Describe the impact of nutrition on the renal and urologic systems during childhood.
• 16.1.4 Describe the impact of nutrition on the renal and urologic systems during adolescence.
• 16.1.5 Describe the impact of nutrition on the renal and urologic systems during adulthood.
• 16.1.6 Describe the impact of nutrition on the renal and urologic systems during later adulthood.
Pregnancy
Nutrition plays a role in the development and function of every system in the body, including the renal system. This
role starts with the in utero development of a person and continues throughout their life. Nutrition combined with
lifestyle decisions can interact with normal and pathologic processes in the renal system, sometimes resulting in
system failure.
Poor nutrition during pregnancy can lead to fetal abnormalities that can cause kidney disease in the future (National
Kidney Foundation, 2022). Additionally, individuals with renal disease experience more problems during pregnancy
and must manage their nutritional intake differently. This section will cover these nutritional considerations and
their impact on the renal system during pregnancy.
The Healthy Pregnant Client

Pregnancy is accompanied by expected urinary and renal changes. Increased blood volume and cardiac output
result in increased glomerular filtration rate (GFR) and renal blood flow, which in turn causes increased excretion
and reduced blood levels of bicarbonate, urea, creatinine, and urate (Willacy, 2022). In increased GFR, the renal
tubules are unable to meet the increased fluid demands, resulting in mild glycosuria and proteinuria; fluid retention
increases, reducing plasma osmolality. The smooth muscle of the renal pelvis, ureters, and bladder relaxes and
dilates, causing the kidneys to increase in length; the ureters to lengthen, curve, and increase in residual urine
volume; and the bladder to increase its capacity. The uterus may also put pressure on the bladder and ureters as it
increases in size.
Good nutrition during pregnancy can prevent problems and support overall renal health for the pregnant client and
fetus. To achieve these aims, the client should:
• Increase caloric intake by 340 calories per day starting with the second trimester and 452 calories per day
starting with the third trimester (for a singleton pregnancy).
• Take a prenatal vitamin that includes iron or take a separate iron supplement in addition to a prenatal vitamin to
prevent iron-deficiency anemia.
• Avoid caffeine or limit it to less than 200 mg/day (Gleason, et al, 2022).
• Increase fluid intake, especially water.
(source: American College of Obstetricians and Gynecologists, 2023; Holcombe, 2022)
Because of the normal physiologic changes expected, specific renal issues that most commonly arise during
pregnancy include urinary tract infections (UTIs), pyelonephritis, and nephrolithiasis (kidney stones). Changes
make urine less acidic, and it contains more hormones and sugars, increasing risk for bacterial growth (Sissons,
2019). Signs and symptoms of UTI include dysuria, frequency of urination, hematuria (American College of
Obstetricians and Gynecologists, 2023b), abdominal cramps, and dyspareunia (pain during sexual intercourse).
If a UTI spreads from the lower urinary tract into the kidneys and develops into a more serious infection,
pyelonephritis, signs and symptoms may then also include fever of 38.0°C (100.4°F) or higher; flank pain;
costovertebral angle tenderness (American College of Obstetricians and Gynecologists, 2023b); chills; nausea;
vomiting; and back, side, or groin pain. Significant fetal and maternal morbidity and mortality have been associated
directly with pyelonephritis (Wing & Johnston, 2017). For instance, it has been linked to preterm delivery, in which
case all of the newborn’s systems will be underdeveloped; disseminated intravascular coagulation (DIC), which can
lead to hemorrhage and death of both mother and fetus; and maternal sepsis and respiratory distress, which can

16.1 • The Impact of Nutrition on Renal Wellness Across the Lifespan 317
lead to renal failure and maternal and fetal death (Wing & Johnston, 2017).
Prevention of UTIs, and subsequently pyelonephritis, is based on urinary hygiene and nutritional recommendations.
The nurse should instruct the client to drink 64–96 oz of water daily (American College of Obstetricians and
Gynecologists, 2020). Drinking 8–10 oz of unsweetened cranberry juice or taking cranberry supplements daily may
also help decrease the risk of UTI. Pregnant clients should also keep caffeine intake to 200 mg or less daily
(Holcombe, 2022) and eat an overall healthy diet that includes proper nutritional and caloric intake (Sissons, 2019).
Nephrolithiasis usually occurs in the second or third trimester, when there is greater pressure on the renal organs
from the growing uterus, and within the first year of giving birth (Furst, 2021; Urology Care Foundation, 2023). The
pressure and narrowing of the passages for urine flow can concentrate urine and thus increase the risk for stone
formation. Another factor that increases the risk for kidney stones is an elevated vitamin D level, which increases
calcium levels in the urine (Orlando Health, 2023). Signs and symptoms the pregnant client may experience include
nausea; vomiting; urgency and frequency of urination; hematuria (blood in the urine); and pain in the back, flank, or
upper abdomen. The nurse should provide the following nutritional recommendations for nephrolithiasis during
pregnancy:
• Get adequate daily amounts of vitamin B6 and magnesium (Weinberg, 2023).

• Avoid excessive vitamin C (Peerapen & Thongboonkerd, 2023).
• Limit sodium intake to less than 2.3 g/day (UT Southwestern Medical Center, 2023).
• Drink ten 10 oz glasses of water or other fluids daily (Urology Care Foundation, 2023).
• For calcium oxalate stones, maintain calcium intake at 1000–2000 mg/day and limit intake of oxalate-rich
foods (Peerapen & Thongboonkerd, 2023; UT Southwestern Medical Center, 2023).
• For uric acid stones, limit animal proteins and eat more plant proteins (Peerapen & Thongboonkerd, 2023).
A recent study has shown that healthy individuals who developed hypertension during pregnancy had twice the risk
of developing kidney disease within the first several years after the birth of their baby. Risks were even higher in
those who had hypertension before pregnancy and had worsening of their condition during the pregnancy (Malek et
al., 2022; Williamson, 2022). Nutritional recommendations for hypertension include limiting sodium intake to less
than 2 g/day, getting 4700 mg of potassium daily, limiting meats and saturated fats, eating 4–5 servings each of
fruits and vegetables, and following all other recommendations included in the Dietary Approaches to Stop
Hypertension (DASH) diet.
Disparity Implications—Pregnancy and Hypertension
Research evidence reveals a racial disparity exists showing that Black women were much more highly affected
than White women: Black women who had hypertension before and during pregnancy were three times more
likely to develop kidney disease (Malek et al., 2022).
The Pregnant Client with Preexisting Renal Disease

Pregnant clients with preexisting renal conditions will be more severely impacted by mild anemia, due to dilution of
the blood from fluid retention; an increased GFR, putting more work on the glomeruli; decreased serum sodium,
potassium, urea, creatinine, calcium, and albumin; mild glycosuria and proteinuria; reduced plasma osmolality;
increased urine retention in the system, which increases infection risks; decreased urine acidity; and increased
pressure in the system due to the growing uterus. Preexisting maternal renal conditions that can be affected by
pregnancy include polycystic kidney disease (PKD); post–renal transplant status; and chronic kidney disease
(CKD), a progressive disease of the kidneys that eventually ends in kidney failure.
Individuals with CKD are at much greater risk for experiencing adverse pregnancy outcomes, which can include
preeclampsia; acceleration in the loss of kidney function, thereby speeding the process of CKD to end-stage renal
disease (ESRD) or complete renal failure; fetal intrauterine growth restriction (IUGR); preterm delivery; the infant
being of low birthweight or/and small for gestational age (SGA); the need for the infant to receive care in the
neonatal intensive care unit (NICU); and maternal or fetal demise (Siligato et al., 2020; Wiles et al., 2019, 2020).
Kidney function declines as much in the 9 months of pregnancy as it does for a client living 1.7–4.9 years with
kidney disease. Therefore, pregnancy could lead the client with CKD to complete kidney failure and need for a
transplant or dialysis, purification of blood through means other than the kidneys, which can be extremely
dangerous for the mother and fetus (Wiles et al., 2020).
Clients with CKD who have problems with chronic anemia, hypertension, proteinuria, or fluid and electrolyte
imbalance before pregnancy will have continuation, and likely worsening, of these problems during pregnancy.
Nutritional modifications for these clients involve a delicate balance between the needs of the growing fetus and the
requirements of CKD. It has been found, however, that plant-based diets that are moderately restricted in protein
decrease risks for preterm delivery and SGA status resulting from IUGR (Attini et al., 2022).
The Fetus
Certain nutritional components have been found to be critical for renal development in utero, and the pregnant
person’s nutrition before and during pregnancy, as well as during early lactation, has been shown to have a
substantial impact on this system. Clients with severe iron deficiency anemia during pregnancy have been shown to
have elevated risks for preterm birth, placental abruption, and fetal malformation, which can include malformations
of the fetal renal system (Shi et al., 2022). Pregnant clients with various disease processes may need specific
dietary restrictions, but low-protein, low-carbohydrate, low-calorie, and low-sodium diets, as well as diets deficient
in the micronutrients folic acid, iron, zinc, and vitamin A, have all been shown to have potential long-term adverse
effects on the development of the renal system in the fetus (Nusken et al., 2020). High-fat, high-sodium, and high-
fructose diets have also been shown to be detrimental to renal system development. Depending on the exact timing
of the deficiency or the amount of exposure during development, adverse effects could include an altered number of
nephrons, blood pressure dysregulation, mitochondrial dysfunction, altered sodium handling, endothelial
dysfunction, inflammation, and oxidative stress of the kidney.
Studies have shown that increases in fetal growth and infant birth weight may be achieved by enhancing maternal
nutrition during pregnancy (Columbia University Irving Medical Center, n.d.). Inadequate maternal nutrition during
pregnancy is also a significant modifiable determinant for the development of chronic diseases in the child (Lee et
al., 2021). Nutritional intake that is not sufficiently supplied with key nutrients such as iodine, iron, folate, calcium,
and zinc can cause severe health problems in the mother (UNICEF, n.d.) that will directly affect fetal development
and the individual’s lifelong health. The nurse should instruct a pregnant client to take in 30 mg of iron, 220 mg of
iodine, 600 mcg of folate, 1000 mg of calcium, and 0.6 mg of zinc daily.
Infancy
Infants must receive proper nutrition for growth and development because all organs are impacted by malnutrition.
Well-balanced nutrition should provide enough calories for energy expenditure. Healthy, full-term infants require
around 100 kcal/kg/day (Patel & Rouster, 2022), whereas preterm infants require around 130 kcal/kg/day (Medical
Home Portal, n.d).
Other nutritional recommendations to consider in an infant’s diet concern micronutrients, including iron, zinc,
copper, chromium, manganese, and selenium (Patel & Rouster, 2022). Infants 7–12 months old should get 11 mg of
iron (Gavin, 2021), 3 mg of zinc (Stanford Medicine Children’s Health, n.d.), 220 mcg of copper (National Institutes
of Health, 2022a), 5.5 mcg of chromium (Duda, 2022), 0.6 mg of manganese (National Institutes of Health, 2021),
and 20 mcg of selenium daily (Lubeck, 2023). Infants can quickly become dehydrated, so proper fluid intake is
extremely important.
The preceding recommendations are for infants born without renal system defects. Those born with renal issues
may need nutritional alterations and fluid restrictions based on their level of kidney function. These restricted diets
may be in the form of a specially balanced formula that includes 2–4 mEq of sodium per 100 mL of formula and a
restriction of 1–3 mmol/kg/day of potassium (Nelms, 2018). Depending on the specific needs, restrictions may also
be in place for calcium, phosphorus, protein, calories, and fluids.
Oligohydramnios, a very low to almost absent amount of amniotic fluid, is a severe condition that must be managed
before birth and can be related to impaired or absent kidney function in the fetus (Keilman & Shanks, 2022). Starting
at 16 weeks’ gestation, around 90% of the amniotic fluid is made up of urine produced by the fetal kidneys.
Immediate treatment for oligohydramnios is imperative because the fetus’s lungs need this fluid to develop
properly.

Part A
Jennifer Davis had a difficult pregnancy. Prior to conceiving, she lived with type 2 diabetes, hypertension, chronic
moderate anemia, and stage 2 CKD. During the pregnancy, despite being very adherent, her kidney disease
advanced. She closely followed her nutritional restrictions for low sodium, low sugar, low carbohydrate, low fat, and
low protein, and as she progressed closer to kidney failure, she had to restrict fluids as well. Even though she
followed these dietary modifications, after delivery she was diagnosed with ESRD and was scheduled to have a
catheter placed to start hemodialysis (mechanical waste filtration).
Because of her health issues, she experienced preeclampsia that developed into eclampsia (seizures), requiring an
emergency cesarean birth of her infant at 32 weeks’ gestation. Her infant demonstrated effects from Jennifer’s
health issues as well. Due to Jennifer’s chronic anemia, nutritional restrictions, and preterm delivery, the infant was
of very low birth weight and small for gestational age (SGA) due to intrauterine growth restrictions. She required 8
weeks of care in the NICU after birth.
Kayla Davis is now 1 week old. She weighs 1 kg (2.2 lb) and is 33 cm (13 in.) long.
1. The nurse caring for Kayla is reviewing her nutritional plan, which is based on the highest normal calorie
range daily for a preterm infant. How many calories daily should Kayla receive to meet her nutritional needs?
a. 130 calories
b. 270 calories
c. 2,700 calories
d. 4,000 calories
2. The nurse is discussing Kayla’s need for energy sources in her nutritional intake. Which macronutrient is the
body’s primary energy source from nutrition?
a. Water
b. Proteins
c. Fats
d. Carbohydrate
Childhood
The U.S. Department of Agriculture (USDA) updated nutritional requirements in 2020, including recommendations
for infants and toddlers for the first time. It is recommended that children have no added sugar in their diet until age
2 years (USDA, 2020). They should eat a large selection of fruits, vegetables, and grains, preferably with at least half
of the grains being whole grains, and their proteins should come from lean meat sources or plant-based proteins
(McCarthy, 2021), with low-fat dairy products added after age 2 years. They should not receive the same portion
sizes as adults.
In children with altered kidney function, it may be difficult to ensure that they get enough calories and protein to
grow within the confines of their restrictive nutritional needs. To protect renal health in children who do not have
altered kidney function, sodium should be limited to less than 2 g/day because amounts greater than this can lead
to fluid retention and hypertension. Sugar intake should be limited to less than 25 g/day (American Heart
Association, n.d.) because it can lead to obesity, hypertension, and kidney hyperfiltration. Children should be
encouraged to eat fruits and vegetables because, in addition to their other benefits, the fiber will help prevent
constipation (Deshpande, n.d.) and keep cholesterol in check. Fruits also contain citrate, which helps prevent stone
formation (Deshpande, n.d.). Adequate water intake of 34–61 oz/day (1–1.8 L) can prevent urinary infections,
constipation, dehydration, and kidney stones and assist in weight control (Deshpande, n.d.).
Common conditions that can develop even if children are not born with renal problems are UTIs, enuresis (bladder
incontinence after the age of 3 years), and nephrolithiasis. Nutritional recommendations can help maintain optimal
renal health.
Nephrolithiasis has become more common than it once was in children and adolescents (American Academy of
Pediatrics, 2021) due to diets higher in processed foods, low vegetable intake, and lower physical activity levels.
Risk factors for developing kidney stones in children and adolescents include family history of nephrolithiasis; a diet
high in salt, meat, and processed foods; a diet low in fruits and vegetables; dehydration with low urine output;
inherited conditions such as cystinuria (a rare condition in which kidney stones form from an amino acid called
cysteine) and hyperoxaluria (excessive oxalate in the urine); some medications, including furosemide and
topiramate; blocked urine flow; bowel diseases; kidney infection; prolonged sedentary periods, especially bed rest;
weight loss surgery (American Academy of Pediatrics, 2021); and urinary tract infections (UTIs).
Enuresis may be diurnal (occurring in the daytime), nocturnal (occurring in the nighttime), primary (occurring in
someone who has never had total bladder control), or secondary (occurring in someone who previously could
control their bladder) (Johns Hopkins Medicine, n.d.). Enuresis has many psychological and physical causes. Renal
causes include bladder pressure from constipation, overactive bladder (OAB), small bladder, structural problems in
the urinary tract, inability to feel when the bladder is full (such as during sleep), UTI, and failure to urinate enough.
Many of these causes would need to be addressed with the child’s primary care provider. However, teaching the
child different hygiene habits can be helpful, and OAB can be helped by following special nutritional considerations,
discussed later in this chapter.
Children urinate more often than adults because they tend to drink more fluids in relation to their size, have smaller
bladders, and have less control over their urinary muscles, which results in feeling the need to “go” more often. UTIs
can be very common in this age group; therefore, young children need to be educated on proper urinary hygiene
(American Academy of Pediatrics, 2015). Females are more susceptible to UTIs than males because they have
shorter urethras, so bacteria can more readily enter the urinary tract (American Academy of Pediatrics, 2015).
General signs and symptoms of a UTI include vomiting, high temperature, lethargy, irritability, poor feeding, poor
weight gain, and jaundice (NHS Inform, 2023). More specific signs and symptoms include pain or burning with
urination; frequency or urgency of urination; deliberate holding of urine; change in toileting habits (such as
enuresis); pain in the side, back, or abdomen; bloody or cloudy urine; and foul-smelling urine.
Some nutritional measures can help prevent UTIs. Children should drink plenty of water to avoid constipation and to
maintain the kidneys’ function in eliminating waste products. Cranberry or blueberry juice can help create a more
acidic urinary environment that will discourage bacterial growth (American Academy of Pediatrics, 2015). Colas and
caffeinated beverages should be discouraged because these irritate the bladder and cause diuresis.
Certain foods are beneficial in preventing UTIs as well. Yogurts with live and active cultures and other fermented
products are recommended because they contain bacteria that help balance the body’s systems and can thereby
decrease the risk for UTIs (Norton Children’s, 2020; Urology Specialists, 2015). Foods high in vitamin C, including
oranges, lemons, strawberries, grapefruits, tomatoes, broccoli, and spinach, are beneficial to maintain a balanced
urine acidity level (Figure 16.2). Foods containing proanthocyanidins, including cranberries, raspberries, and
blueberries, are a good addition because these substances help prevent Escherichia coli infection, the number one
bacterial cause of common UTIs (Norton Children’s, 2020; Urology Specialists, 2015). High-fiber foods such as
whole grains, apples, bananas, and legumes are important to prevent constipation, which can block urine excretion
from the body and in turn cause urine stasis, which encourages bacterial growth (Norton Children’s, 2020). Sugar
intake should be limited because it provides a fuel source and breeding ground for bacteria to thrive (Urology
Specialists, 2015).

FIGURE 16.2 Blackberries, blueberries, and strawberries are nutrient-rich fruits that help promote urologic wellness. (credit: modification
of work “strawberries, blueberries, and blackberries” by Jonathan Cutrer/Flickr, Public Domain)
Part B
Study Part A.
Kayla was diagnosed with hydronephrosis (swollen kidney due to urine accumulation) related to uteropelvic junction
obstruction (blockage). This resolved on its own after 2 weeks of life. She was transferred from the NICU to the
regular pediatric floor for care at 8 weeks of age and was discharged home the following week. Her prematurity and
intrauterine growth restriction have resulted in ongoing effects on her development. She was diagnosed with type 1
diabetes because her pancreas is nonfunctioning, and one of her kidneys is nonfunctioning. The kidney is small and
undeveloped. The other kidney is functioning despite the hydronephrosis.
Unfortunately, by age 6, Kayla has developed CKD and is in stage 3 when diagnosed.
3. Which nutritional restrictions will pose the most problems for her growth and development at this stage?
a. Protein and calories
b. Fluid and potassium
c. Phosphorus and calcium
d. Magnesium and sodium
4. Because this client already has serious issues with their kidneys, the nurse educates the client’s parents on
nutritional measures to prevent further kidney issues that can exacerbate their other conditions. Which option
would necessitate the need for further education?
a. Broccoli
b. Whole grain bread
c. Cranberries
d. Ramen noodles
Adolescence
During adolescence, puberty, hormonal changes, and growth spurts occur. The body goes through many changes
that require healthy and supportive nutrition to ensure proper growth and maturity. Food should include high levels
of calcium, vitamin D, and iron for bone and muscle development (Castle, 2022). Iron for males and females aged
9–13 should be around 8 mg/day. Males aged 14–18 should receive 11 mg/day, whereas females in this age group
should receive 15 mg/day. The calcium recommendation for adolescents is 1300 mg/day, and the vitamin D
recommendation is 600 International Units daily. Caloric intake should range from 1800–3200 calories daily for
males and from 1600–2400 calories daily for females, depending on activity level (USDA, 2020).
Adolescents should follow the same nutritional guidelines as other age groups for urinary health. UTIs and
nephrolithiasis are the more common kidney-related issues in this age group. The same nutritional restrictions and
recommendations discussed elsewhere in this chapter for these conditions apply for adolescents as well.
UTIs have different causes in this group, necessitating additional educational points to discuss with the adolescent.
All of the earlier hygiene recommendations are still important, but an additional cause of UTIs in adolescents (as
well as in adults) is sexually transmitted infections (STIs). Chlamydia, gonorrhea, and trichomoniasis all can infect
the urethra and advance into the urinary system. Females also have increased risk for developing cross infections
from bacterial vaginosis (BV) and yeast infections.
Nutritional recommendations to help avoid BV and yeast infections include staying hydrated with plenty of water
and avoiding sugary, caffeinated, and carbonated beverages to help maintain a healthy pH balance. Probiotic and
prebiotic foods also help maintain the pH balance in the vagina and prevent yeast or bacterial overgrowth. Foods
that contain probiotics include yogurt with live cultures, sauerkraut, kimchi, pickles, miso, tempeh, and kombucha
(Sass, 2022). Prebiotics can be found in chicory root, leeks, garlic, asparagus, and onions.
Foods with a low glycemic index may also help prevent BV by helping maintain the pH balance; such foods include
whole grains, including oatmeal and barley; quinoa; yogurt; milk; nuts; legumes; beans; grapefruit; oranges; and
carrots (Sass, 2022). High-fiber foods support healthy bacterial growth and help prevent BV. Vitamin D has been
found to be important in overall vaginal health and pH balance). Foods that contain vitamin D include trout, cooked
salmon, sardines, eggs, cheddar cheese, and fortified milk (Sass, 2022). Another important addition to the diet is
apples, at least one daily, as these have been shown to improve vaginal lubrication (Sass, 2022; Tommaso et al.,
2014). Foods to restrict include white bread, high-sugar foods, white rice, honey, processed grains, and highly
processed foods (Sass, 2022).
Part C
Case Study Parts A and B.
Kayla and her mother have been managing her condition well, and her stage 3 CKD has remained stable. She is now
13 years old and has come into the clinic for a regular check-up. The nurse is planning to provide Kayla with
education on continued management of her CKD.
5. What would the nurse include when teaching a client Kayla’s age how to best promote renal health and slow
the progression of CKD?
a. Recommendation to increase fiber intake
b. STI prevention
c. Recommendation to increase fluids
d. Recommendation to decrease exercise
6. How many calories would be in the acceptable daily allowance range for Kayla?
a. 2,000 calories daily
b. 1,500 calories daily
c. 2,600 calories daily
d. 3,000 calories daily
Adulthood
Adults will not require as much from their nutritional intake for growth, although certain hormonal changes still
occur in adulthood. Individuals in this age group face more health risks that can impact the kidneys and their
functioning, including hypertension, diabetes types 1 and 2, CKD, PKD, benign prostatic hyperplasia (BPH),

nephrolithiasis, cardiovascular disease, and hyperlipidemia. Foods should be nutrient dense; low in sugars, sodium,
and saturated fats; high in fiber and calcium; and include vitamin D (USDA, 2020, p. 101). Nutritional
recommendations specific for renal health mentioned previously in the chapter apply to this age group as well.
Nephrolithiasis, UTIs, BPH, and CKD are more common in this age group due to the comorbidities that often
develop.
Part D
At age 18, Kayla becomes pregnant. Her GFR is 49 mL/min/1.73 m2, and she has hypertension, type 1 diabetes, and
chronic anemia. Despite the known risks to her and the fetus, she wants to go through with the pregnancy. She is
currently not restricting fluids, but she is restricting protein, potassium, phosphorus, sodium, sugar, and
carbohydrates. She is following all heart-healthy recommendations.
7. The nurse is educating Kayla about the potential problems in a pregnancy involving her unique health
conditions. What would the nurse include in this education?
a. Postterm delivery
b. Spina bifida
c. Multifetal pregnancy
d. Fetal intrauterine growth restriction
8. When Kayla is being monitored during her pregnancy, which lab value would be concerning and require
immediate treatment?
a. GFR 56 mL/min/1.73 m2
b. GFR 15 mL/min/1.73 m2
c. GFR 87 mL/min/1.73 m2
d. GFR 92 mL/min/1.73 m2
Kayla decides to continue with the pregnancy despite the risks. During her second trimester, the fetus is markedly
small due to intrauterine growth restriction, and Kayla has advanced to stage 4 CKD and is approaching the need for
dialysis. Because of Kayla’s rapid decline and the struggle to keep her potassium levels normal, her health care
provider orders a catheter to be placed for the impending need for dialysis and plans to deliver the baby as early as
safely possible. Unfortunately, 2 days before she is scheduled to have the catheter placed, Kayla goes into cardiac
arrest due to a dysrhythmia from hyperkalemia. She is unable to be revived, and her fetus is too premature to
survive.
Later Adulthood
For adults aged 60 years and older, the risk for chronic disease is highest. Such conditions include cardiovascular
disease, type 2 diabetes, obesity, hypertension, hyperlipidemia, CKD, congestive heart failure, cancers, and BPH.
Renal function also naturally declines in this age group, with defined GFR being less than 60 mL/min/1.73 m2
(National Kidney Foundation, 2023). Therefore, preserving kidney function is very important, and medication
dosages may need to be adjusted to ensure safety.
Nutritional intake should include nutrient-dense foods and be rich in whole grains, fruits, vegetables, and dairy, as
well as protein to prevent muscle loss. Older individuals should also increase their intake of vitamin B12 because the
ability to absorb this vitamin declines as people age (USDA, 2020, p. 128). Foods high in B12 include beef liver,
clams, cooked salmon, tuna, eggs, fortified breakfast cereal, spinach, and kidney beans (National Institutes of
Health, 2022b). Adults in this age group must also be sure to drink enough fluids, especially water, because the
sensation of thirst declines with age, increasing the risk for dehydration and UTIs (U.S. Department of Agriculture,
2020, p. 129).
16.2 Nutrition and Chronic Renal Illness

LEARNING OUTCOMES
• 16.2.1 Discuss the impact of nutrition on chronic renal disorders.
• 16.2.2 Discuss the impact of nutrition on acute exacerbation of chronic renal disorders.
Urologic Illnesses
Many different urologic and renal illnesses are impacted by nutrition. Some of the more common urologic
illnesses—illnesses that affect parts of the renal system other than the kidneys—that can be impacted by nutrition
include overactive bladder, interstitial cystitis, benign prostatic hyperplasia, and bladder cancer. Each of these has
different causes and different nutritional impact based on the pathophysiology of the disease.
Overactive Bladder
Overactive bladder (OAB), affecting more than 33 million Americans, causes urinary incontinence and urinary
urgency resulting from involuntary contraction of the detrusor muscle of the bladder (Mobley et al., 2020).
Anticholinergic medications and beta-3 adrenoceptor agonists are prescribed to treat this condition (Mobley et al.,
2020). Some individuals also take 2–4 g of sodium bicarbonate twice daily to alkalinize the urine and make it less
irritating to the bladder (Mobley et al., 2020).
Nutritional considerations for urologic illness center around reducing symptoms and avoiding medication
interactions. Anticholinergic drugs should not be taken with alcohol because this combination can increase the risk
for respiratory depression, unconsciousness, and death (Cafasso, 2023). Alcohol also acts as a diuretic, so clients
should avoid it to prevent increased urinary frequency (Stoppler, 2020). They should also avoid carbonated
beverages because they contain substances that can irritate a sensitive bladder and increase symptoms. Another
important nutritional modification is to eliminate caffeine. Coffee, tea, other caffeinated beverages such as energy
drinks, and brown chocolate all contain an acid that acts as a bladder irritant and aggravates OAB symptoms
(Mobley et al., 2020; Stoppler, 2020).
Citrus fruits, including oranges, grapefruits, lemons, limes, and clementines, are also acidic; they can alter the urine
pH and contribute to urgency and incontinence, so clients should avoid or reduce consumption of them (Mobley et
al., 2020; Stoppler, 2020). Pineapple, tomatoes, wasabi, chili, spicy salsa, and other spicy condiments are all acidic
foods, as are cranberries; although cranberries are beneficial for avoiding UTIs, they contain irritants that
exacerbate OAB (Mobley et al., 2020; Stoppler, 2020). Sugar, artificial sweeteners, honey, grapes, bananas, apples,
peaches, plums, strawberries, raw onions, dairy products (especially sour cream and aged cheeses), prunes,
ketchup, vinegar, soy sauce, and mayonnaise can all contribute to an increase in OAB symptoms (Mobley et al.,
2020; Stoppler, 2020). Nocturia can be decreased if individuals restrict their fluids during the day, especially after 6
p.m. (Mobley et al., 2020).
Nurses can encourage clients to try food substitutions. Dill, rosemary, thyme, and garlic are great substitutes for the
more irritating spices (Stoppler, 2020). White chocolate is recommended instead of regular chocolate because it
contains no caffeine, but clients should be cautioned not to eat too much because it contains sugar. Peas and
carrots, along with other high-fiber foods, are encouraged to keep bowel movements regular and prevent symptoms
resulting from increased pressure on the pelvic floor from constipation (Stoppler, 2020). In addition to estrogen
supplementation for women with OAB symptoms related to estrogen deficiency, these clients can benefit from
consuming vegetables that contain phytoestrogens, such as yams and carrots (Mobley et al., 2020). These clients
should also increase their intake of potassium, protein, and, especially, vitamin D, which works to reduce urinary
urgency at the site of the detrusor muscle (Mobley et al., 2020).
Another significant change clients can make is a lifestyle change, not a nutritional one: Clients who use tobacco
should stop, as its use is linked with OAB symptoms (Mobley et al., 2020).
Interstitial Cystitis
Interstitial cystitis, also known as chronic pelvic pain syndrome, causes pelvic pain and a persistent desire to
urinate, as well as nocturia, urinary frequency, and voiding of only small amounts at a time (Mobley et al., 2020).
These symptoms mimic those of UTI, but urine cultures will consistently show no infection. Pentosan polysulfate

16.2 • Nutrition and Chronic Renal Illness 325
sodium, sodium bicarbonate with calcium glycerophosphate, and dimethyl sulfoxide have all been used to treat this
condition, and dietary modifications to reduce bladder irritants can effectively supplement pharmacotherapy.
Nurses should give the same nutritional recommendations to clients with interstitial cystitis as for those with OAB.
Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is an enlargement of the prostate gland, affecting men (19 million in the United
States) as they age and as their testosterone levels decrease. Lower urinary tract symptoms (LUTS) include urinary
frequency and urgency, a weak urine stream, the feeling of being unable to empty the bladder, postmicturition
dribbling, and nocturia (Mobley et al., 2020). Nutrition has not been shown to directly affect testosterone levels, but
evidence indicates that the Mediterranean diet can be helpful in decreasing LUTS (Mobley et al., 2020). The
Mediterranean diet promotes daily consumption of plant-based foods to replace some meats and starches, and the
replacement of unhealthy fats, such as butter and margarine, with healthier fats (Modglin, 2022). This diet is rich in
olive oil, small amounts of fish and other seafood, and plant-based options.
Bladder Cancer
Bladder cancer is the seventh most common form of cancer diagnosed, with the highest incidence occurring in
White men (Mobley et al., 2020). Tobacco use is the greatest risk factor for the disease. Eating a diet high in
isothiocyanates, which are found in cruciferous vegetables such as cabbage and kale, and drinking tea have both
been linked to a decreased risk for developing bladder cancer.
Renal Illnesses
Renal illnesses are those that impact the kidney or any portion of the kidney. Many diseases can affect the kidney,
and although they may have different causes and initial signs and symptoms, they will also produce very similar
signs and symptoms because the diseases all impact the same organ. Common renal illnesses that can be affected
by nutrition include nephrolithiasis, CKD, and renal cancer.
Nephrolithiasis
Nephrolithiasis, commonly referred to as kidney stones, can occur as a single incident or as a chronic condition.
Kidney stones can cause a wide range of issues, from extreme pain to kidney failure due to hydronephrosis if they
block urine flow and are not treated in a timely manner. Nurses should instruct clients to drink at least 88 oz (2.5 L)
of fluids daily to help prevent stone formation (Mobley et al., 2022). Fruit juices are also recommended because
they contain citrate, which inhibits calcium oxalate and calcium phosphate stone formation (Dai & Pearle, 2022).
The type of nutritional modification required depends on the type of stone and its composition (Table 16.1).
Stone Type Composition Food Modifications

Calcium stones Calcium oxalate or • Avoid foods high in calcium: cheese, yogurt, edamame,
(oxalate or calcium phosphate calcium-fortified foods, canned sardines/salmon/tuna,
phosphate; 75% of tofu, almonds, leafy green vegetables.
stones) • Avoid foods high in oxalate: rhubarb, beets, potatoes.
• Increase consumption of green and black tea.
• Avoid high-fructose foods.
• Phosphate stones: Limit sodium intake and nondairy
animal protein.
Uric stones Uric acid • Avoid foods high in purines: red meat, shellfish, trout,
(up to 10% of scallops, alcohol, foods containing large amounts of
stones) high fructose corn syrup.
• Limit nondairy animal protein.
• Ensure that gout is treated effectively.
TABLE 16.1 Renal Stone Composition and Nutritional Recommendations (sources: Dai & Patel, 2022; Ferraro et al., 2020; Karki & Leslie,
2023; Leslie et al., 2023; Levtchencko et al., 2022; Mobley et al., 2020)
Stone Type Composition Food Modifications

Struvite stones Mixture of magnesium, • Restrict sodium: microwave meals, canned soups,
(5%–15% of ammonium, phosphate, canned meats, pizza, nuts, pickles, sandwich meats.
stones) and calcium carbonate • Limit intake of oxalate-rich foods.
Cysteine stones Cysteine • Increase consumption of fruits and vegetables.

(1–2% of all stones • Increase water intake to 4 L/day.
but 6–8% of all • Decrease sodium intake.
pediatric stones) • Limit nondairy animal protein.
TABLE 16.1 Renal Stone Composition and Nutritional Recommendations (sources: Dai & Patel, 2022; Ferraro et al., 2020; Karki & Leslie,
2023; Leslie et al., 2023; Levtchencko et al., 2022; Mobley et al., 2020)
Chronic Kidney Disease

Chronic kidney disease (CKD) affects more than 31 million Americans, but many remain undiagnosed because the
early stages are relatively asymptomatic (Mobley et al., 2020). Many things can cause CKD, but the most common
causes are diabetes types 1 and 2 and hypertension, conditions that need to be managed correctly to slow disease
progression. Nutrition plays a very important role in the health of clients with CKD, even if they advance to end-stage
renal disease (ESRD) and require dialysis treatment or a renal transplant to sustain life.
The stage of CKD is determined by GFR levels, which indicate how well the kidneys are filtering wastes from the
blood. (See Table 15.2 in Applying Clinical Judgment to Promote Nutrition for Renal Wellness.) Creatinine and blood
urea nitrogen (BUN) levels are also monitored closely and change more as the kidneys progress toward failure.
Nutritional restrictions are vital for clients with CKD. Referral to a certified renal dietician can ensure that clients are
properly educated and that their nutritional needs are individualized to improve their quality and length of life.
Foods high in calcium include cheese, yogurt, edamame, canned sardines, canned salmon, tofu, almonds, leafy
green vegetables, and calcium-fortified foods. Foods high in magnesium include dark chocolate, avocados, nuts,
legumes, tofu, seeds, whole grains, fatty fish, bananas, and leafy green vegetables.
Phosphorus should be restricted to less than 800–1000 mg/day, protein to 0.6–0.8 g/kg/day, and potassium to less
than 2000 mg/day (Mobley et al., 2020). Protein should come from lean sources as much as possible, which are
those that come from low-fat, high-protein foods such as eggs and skinless chicken.
For clients receiving dialysis treatments, strict fluid restriction is extremely important because gaining too much
weight due to fluid retention in between treatments can cause serious side effects. The average fluid restriction for a
client on dialysis is 32 oz daily (Fresenius Kidney Care, n.d.). Nurses should instruct clients that fluids are not just
beverages and substances that are liquid at room temperature; this category also includes gelatin, ice cream, ice,
ice chips, and soup.
SAFETY ALERT
Salt Substitutes
Nurses should be sure clients are aware that when a low-sodium diet is required and sodium substitution is
recommended, it is dangerous for them to use salt substitutes. These substitutes are made with potassium
chloride, which can raise potassium to life-threatening levels. Instead, clients should check food labels for added
sodium and flavor their food with herbs and other salt-free substitutes.
Renal Cancer
Renal cancer, or kidney cancer, occurs sporadically, but associations with aging, obesity, hypertension, smoking,
acquired cystic kidney disease, and exposure to asbestos, cadmium, or petroleum have been observed (Mas Que
Ideas Foundation, 2022). Most of the time, renal cancer is asymptomatic and found incidentally on an abdominal
scan performed for other medical purposes; however, on occasion, a client may experience hematuria, an
abdominal lump, or a symptom related to paraneoplastic syndrome, such as anemia, hypertension, weight loss,
anorexia, or muscle wasting. Renal cancer will not necessarily cause immediate or automatic kidney failure.

16.2 • Nutrition and Chronic Renal Illness 327
Proper nutrition and nutritional modifications can help lower the risk for renal cancer, prevent adverse effects of
cancer treatments and medications, support the highest level of renal function possible, and maintain a client's life
expectancy after cancer remission.
Preventing renal cancer is the first priority. Eating grilled and pan-fried foods as well as red meats increases the risk,
so nurses should instruct clients to restrict or avoid these (Richards, 2022). Increased intake of vegetables, with
special emphasis on cruciferous vegetables, and foods containing vitamin C, such as citrus fruits, strawberries, bell
peppers, tomatoes, and white potatoes, shows promise for decreasing the risk for developing renal cancer (Liao et
al., 2022). High-fiber foods; foods rich in antioxidants such as vitamin E and selenium; and foods containing
phytochemicals, such as whole grains, may also reduce the risk (Thompson, 2023). See Figure 16.3.
FIGURE 16.3 A diet rich in cruciferous vegetables (purple cabbage), phytochemicals (quinoa), antioxidants (carrots), and vitamin C (bell
peppers and peas) may lower the risk for developing renal cancer. (credit: “Asian Quinoa salad food” by Watts/Flicker, Public Domain)
Nutritional changes can address adverse effects of cancer treatment. Many side effects of chemotherapy—such as
nausea and vomiting, anorexia, diarrhea, constipation, flatus, bloating, weight loss, sore throat, gastrointestinal
problems, dysphagia, heartburn, dry mouth, mouth sores, and changes in taste and smell—make it difficult for the
individual to take in enough calories. Therefore, a nutrient-dense diet with sufficient calories, vitamins, and minerals
to ensure proper nutrition is important (Richards, 2022; Thompson, 2023). It should include whole foods, such as
fruits, vegetables, and whole grains, and limit foods high in salt and phosphorus (Richards, 2022). Fluid volume
status should be monitored because decreased kidney function may necessitate fluid restriction (Richards, 2022).
Nurses can suggest that clients with painful mouth sores avoid acidic or spicy foods, alcohol, and foods that are too
hot or too cold, and instead eat foods that are soft and easy to chew (Thompson, 2023).
Because of the eating issues that chemotherapy can cause, clients may better tolerate smaller, more frequent meals
and maybe even different food consistencies, such as soft, lightly mashed, or pureed foods (Richards, 2022). Brief
periods of fasting may even be beneficial during chemotherapy treatment because fasting can generate
environments in the body that make survival of cancer cells less likely and help normal cells resist the negative
effects of chemotherapy. These periods should be very short, and the client should eat calorie-rich, nutrient-dense
foods after fasting.
Another significant effect of chemotherapy is the risk for developing infection. Some nutritional precautions to lower
this risk include avoiding unpasteurized juice and dairy products as well as raw fish and raw meat (Richards, 2022).
Food preparation and storage are also important in infection prevention, so the nurse should educate the client on
appropriate methods.
In maintenance, a plant-based diet may improve survival after renal cancer (Richards, 2022). Because chronic
inflammation has been shown to play a major role in cancer, and fruits and vegetables have strong anti-
inflammatory properties, fruits and fiber-rich vegetables may have protective effects against renal cancer and its
reoccurrence (Thompson, 2023). Since whole grains are high in fiber and contain antioxidants such as selenium and
vitamin E as well as phytochemicals, they are also important nutritionally and may help prevent the occurrence and
reoccurrence of renal cancer.

Most long-term kidney disease management is focused on CKD. Care of CKD starts with nutritional restrictions and
treatment of any comorbidities to prevent disease progression, as the main goal is to prevent the need for dialysis
(Satellite Healthcare, 2022). Some religious beliefs involve more restrictions in nutritional allowances and prevent
the acceptance of dialysis or transplants, making it even more important for these clients to slow progression as
much as possible for as long as possible.
Nurses must be well versed in the nutritional and other care needs of these clients so they can properly educate
them to holistically care for their disease as well as live within the confines of their religious and cultural beliefs.
Treatment adherence, quality of life, and the self-care ability of clients with CKD and ESRD increase, and risks for
complications decrease, when nurses are actively involved in clients’ comprehensive care.
Promotion of Food Security

Food security must be addressed in all age groups to ensure renal health. The National Kidney Foundation has many
partnerships with other organizations that are working on initiatives to address food insecurity, especially for
individuals with special nutritional needs due to renal issues.
Economic status and the accessibility of grocery stores can affect people’s ability to obtain food. At least 33.2% of
low-income individuals live more than a mile from the nearest grocery store (Economic Research Service, 2022).
Older adults and individuals with mobility issues may have to rely on others to bring them food and therefore have
even more limited food options. Having insufficient ways to obtain food from grocery stores because of
transportation issues may lead some people to buy more fast food regardless of their health needs, as fast-food
restaurants are often more numerous and easily accessed than grocery stores.
Americans have access to a variety of government resources that can help them with food security issues. The Older
Americans Act authorizes meal services and related services for those aged 60 and older, as well as their spouses,
regardless of age. These services are provided in settings such as senior centers, churches, schools, and community
centers, and meals can be delivered to individuals’ homes if they have limited mobility (USDA, 2020, pp. 129–130).
The Supplemental Nutrition Assistance Program (SNAP), commonly called food stamps, is a federally funded
program that helps Americans with limited incomes obtain healthy foods and beverages during times of constrained
resources (USDA, 2020, pp. 68, 90, 105, 120, 129). These same groups of people can take advantage of the
Commodity Supplemental Food Program, which directly provides packaged food to older Americans with limited
income via federally funded resources and distribution help from nonprofit organizations (USDA, 2020, p. 130). The
Child and Adult Care Food Program is a federally funded program that provides reimbursement for food served to
children and older adults cared for in after-school programs and day care centers, including adult day care (USDA,
2020, pp. 68, 90, 130). The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
provides specific healthy foods for women who are pregnant, breastfeeding, or postpartum and for children aged
newborn to 5 years (USDA, 2020, pp. 68, 90, 120). The National School Lunch Program and the School Breakfast
Program provide low-income children with breakfast and lunch on school days, accounting for two-thirds of their
daily caloric needs for those days (USDA, 2020, p. 90).

Chapter Summary
• Nutrition plays a large role in the developmental promoting quality and length of life in clients with
process of every organ in the body, including the chronic renal illnesses.
renal system. • Many illnesses can be controlled or prevented with
• The importance of nutrition for the renal system proper nutritional modifications.
starts in utero and continues throughout the • The most significant nutritional considerations for
individual’s entire lifespan. the most serious diseases involving the renal
• Normal nutritional needs are altered when renal or system concern fluids, calories, protein,
urologic alterations exist. potassium, sodium, calcium, and phosphorus.
• Nutrition plays an extremely important role in
Key Terms
chronic kidney disease a progressive disease of the enuresis bladder incontinence after the age of 3
kidneys that eventually ends in kidney failure years
cysteine an amino acid that contains sulfur hyperoxaluria elevated amounts of oxalate in the
cystinuria a rare genetic condition in which urine
nephrolithiasis are made from cystine nephrolithiasis kidney stones
dialysis purification of blood through means other oligohydramnios very low to almost absent amniotic
than the kidneys fluid, which may be related to impaired or absent
dyspareunia painful sexual intercourse kidney function in the fetus
Review Questions
1. The nurse is caring for a client in the first trimester of pregnancy. Which assessment finding requires follow-
up by the nurse?
a. Decreased GFR
b. Increased fluid retention
c. Mild glycosuria
d. Proteinuria
2. Which instruction would the nurse give to a client about nutrition during pregnancy?
a. Eat 340 calories more each day in the first trimester.
b. Start prenatal vitamins in the second trimester.
c. Avoid or limit caffeine intake.
d. Reduce fluid intake.
3. The nurse provides nutrition counseling to the parents of a child with CKD. Which nutritional restriction is
most likely to affect growth and development?
a. Potassium
b. Sodium
c. Fluids
d. Protein
4. The nurse is educating a 14-year-old female adolescent with CKD and her parents about nutrition. Which
recommended daily intake for iron should the nurse teach the adolescent and her parents?
a. 7 mg/day
b. 9 mg/day
c. 12 mg/day
d. 15 mg/day
5. The nurse is teaching a client about nutritional interventions for an overactive bladder. Which instruction
should the nurse give the client?
a. Avoid cola drinks.
b. Use artificial sweeteners instead of sugar.

c. Reduce fiber intake.
d. Avoid foods high in potassium.
6. The nurse is providing discharge instructions to a client following the removal of a calcium kidney stone.
Which instruction will the nurse give this client to prevent future stone formation?
a. Avoid foods high in purine.
b. Avoid foods high in oxalate.
c. Restrict nondairy animal protein.
d. Increase sodium intake.
7. The nurse is completing a follow-up assessment of a client with a history of kidney stones. Which of the
following dietary habits reported by the client indicates the need for additional instruction related to their
kidney stone history?
a. Drinks at least 2 L of fluid daily
b. Eats a variety of fruits and vegetables
c. Consumes a high-protein diet
d. Drinks less than 6 oz of fruit juice each day
8. The nurse is working at a community health fair, providing information about risk reduction for renal cancer.
Which nutritional instruction will the nurse teach to reduce the risk for renal cancer?
a. Increase intake of cruciferous vegetables.
b. Increase intake of red meat.
c. Eat more pan-fried foods.
d. Cook meats on the grill.
9. The nurse is developing a teaching plan for a client who has just entered stage 4 CKD. Which instruction will
the nurse give the client?
a. There are no restrictions on fluid intake.
b. Reduce calcium intake.
c. Restrict potassium intake.
d. Increase magnesium intake.
10. Which instruction should the nurse give a client with benign prostatic hypertrophy to reduce lower urinary
tract symptoms?
a. Increase intake of fresh fruits.
b. Use butter rather than olive oil.
c. Reduce intake of whole grains.
d. Drink whole milk.
Suggested Reading
Allegaert, K., & Iacobelli, S. (2022). Editorial: The developing kidney: Perinatal aspects and relevance throughout
life. Frontiers in Pediatrics, 10, 990854. https://doi.org/10.3389/fped.2022.990854
Kovesdy, C. (2022). Epidemiology of chronic kidney disease: An update 2022. Kidney International Supplements,
12(1), 7–11. https://doi.org/10.1016/j.kisu.2021.11.003
National Kidney Foundation. (n.d.). Nutrition. https://www.kidney.org/nutrition
UNICEF. (2022, July 6). The state of food security and nutrition in the world 2022. Food and Agriculture
Organization of the United Nations, International Fund for Agricultural Development, United Nations Children’s
Fund, United Nations World Food Programme, World Health Organization. https://data.unicef.org/resources/
sofi-2022/
UPMC. (2022). What to Eat on a Renal Diet. https://share.upmc.com/2022/05/renal-diet/

Verbitsky, M., Krishnamurthy, S., Krithivasan, P., Hughes, D., Khan, A., Marasa, M., Vena, N., Kholasa, P., Zhang, J.,
Lim, T., Glessner, J., Weng, C., Shang, N., Shen, Y., Hripcsak, G., Hakonarson, H., Ionita-Laza, I., Levy, B., Kenny,
E., … Gharavi, A. (2023). Genomic disorders in CKD across the lifespan. Journal of the American Society of
Nephrology, 34(4), 607–618. https://doi.org/10.1681/ASN.2022060725

CHAPTER 17
Nutrition for Gastrointestinal Wellness
FIGURE 17.1 Food ingestion, breakdown, absorption, and metabolism are critical to fuel the body for proper function. (credit: modification
of work “Close-up, a glass of cocktail with green fruit and fresh mint (https://openstax.org/r/wuestenigela)” by Marco Verch/Flickr, CC BY
2.0)
CHAPTER OUTLINE
17.1 Assess and Analyze the Impact of Nutrition on the Gastrointestinal System
17.2 Plan Nutritional Strategies to Impact Gastrointestinal Wellness
17.3 Implement Nutritional Strategies to Impact Gastrointestinal Wellness
17.4 Evaluate Nutritional Strategies to Impact Gastrointestinal Wellness
INTRODUCTION To stay nourished, humans must ingest food, digest it into smaller usable substances, absorb
what is digested into the body cells, and metabolize what is absorbed into usable energy. This chapter covers the
expected overall normal findings, the meaning of abnormal findings, and the importance of nutrition in gut health.
For detail regarding these processes and the ways to assess the gastrointestinal system properly for appropriate
functioning, see The Digestive Process.
Consider this case: We will be following Zekia Azan, a 56-year-old Jamaican American woman with a history of
Crohn’s disease. She has an average of five or six watery stools daily despite therapy for her disease. She comes to
the outpatient clinic to be assessed after an exacerbation of her disease with increased diarrhea.
334 17 • Applying Clinical Judgment to Promote Nutrition for Gastrointestinal Wellness
17.1 Assess and Analyze the Impact of Nutrition on the Gastrointestinal

System
LEARNING OUTCOMES
• 17.1.1 Recognize the normal function of the gastrointestinal system.
• 17.1.2 Recognize cues of nutritional impact on the gastrointestinal system.
• 17.1.3 Analyze cues of nutritional impact on the gastrointestinal system.
Normal Function of the Gastrointestinal System

The gastrointestinal system comprises the organs in the upper gastrointestinal tract—the mouth, esophagus,
stomach, and duodenum—and the organs in lower gastrointestinal tract—the small intestine, large intestine (or
colon), rectum, and anus. The gastrointestinal system is aided by the teeth, tongue, salivary glands, and the
pancreas, liver, and gallbladder, which are also known as ancillary digestive organs. The sensory system, the
nervous system, the mucous membranes, and glands (digestive and adrenal) also have roles to play.
There are four main functions of the gastrointestinal system: ingestion, digestion, absorption, and metabolism.
Ingestion is the swallowing and absorbing of substances into the body. This process starts with the sensory organs
before food even enters the oral cavity: The smell or sight of appealing food can trigger the salivary glands to release
saliva. That process, combined with hunger, can increase the desire to ingest the food. Once the food is inside the
mouth, its taste, sensed through the papillae on the tongue, can either encourage or inhibit its further ingestion.
Foods that register an unappetizing taste encourage expulsion from the oral cavity.
Digestion occurs when the body breaks down what is ingested into absorbable substances. This, too, starts in the
oral cavity. The tongue and teeth start the digestion of food using mostly mechanical and some chemical processes
known collectively as mastication. Mastication employs the use of the tongue for mechanical compression,
abrasion, and distortion; secretion of mucins and lingual lipase, which assist in breaking down lipids; and
manipulation to assist with movement during chewing and swallowing (Ogobuiro et al., 2023). The teeth are used
strictly for mechanical processes during mastication as they cut, tear, grind, and chew food to break it down
physically into smaller pieces.
Chemical digestion and lubrication in the oral cavity to aid in food movement are accomplished by the tongue and
salivary glands. There are three pairs of salivary glands in the mouth: the parotid glands, which release salivary
amylase to break down complex carbohydrates; sublingual glands, which release a mucus secretion that acts as a
buffer and a lubricant; and the submandibular glands, which release a mixture of salivary amylase, buffers, and
glycoproteins called mucins (Figure 17.2) (Ogobuiro et al., 2023).
The food is broken down and lubricated enough during mastication to be swallowed and moved to the next phase of
digestion. The swallowing reflex is aided by the tongue, allowing food to travel down the esophagus via peristalsis
and empty into the stomach through the lower esophageal sphincter.

17.1 • Assess and Analyze the Impact of Nutrition on the Gastrointestinal System 335
FIGURE 17.2 The salivary glands aid in chemical breakdown of food in the oral cavity. (credit: modification of work from Anatomy and
Some digestion, both mechanical and chemical, occurs in the stomach, which also temporarily stores food. Food
exits the stomach as chyme, a blend of gastric juices and digested food particles. The stomach also synthesizes
proteins that are needed for vitamin absorption and microbial defenses, propagates the peristaltic reflex, and
releases intrinsic factor from the parietal cells, which enables the small intestine to absorb vitamin B12 (Hsu et al.,
2023). When chyme exits the stomach, simple carbohydrates have been digested. Larger molecules such as
complex carbohydrates, fats, and proteins have not yet been broken down.
The duodenum breaks down larger molecules. In the duodenum, at the sphincter of Oddi, there is a release of
digestive secretions by the ancillary organs (Ogobuiro et al., 2023), specifically from the gallbladder and the
pancreas. The pancreas releases active alpha-amylase, colipase, and lipase, and the gallbladder releases bile,
produced in the liver, to break down fats, proteins, and complex carbohydrates.
Absorption refers to the taking in of the broken-down substances into the cells. Very few substances are absorbed
by the stomach. The small intestine handles 90% of food absorption as food travels through its three segments, the
duodenum, jejunum, and ileum (Ogobuiro et al., 2023). The innermost layer of the mucosa of the small intestine is
composed of absorptive cells known as enterocytes, goblet cells, and enteroendocrine cells (Fish & Burns, 2022).
Enterocytes are effective at absorption because each one has around 3,000 microvilli that expand their available
surface area (Figure 17.3).
FIGURE 17.3 In the small intestine, goblet cells have microvilli to better absorb nutrients. (credit: modification of work from Anatomy and
The duodenum is the site for iron absorption and some vitamin B9 (folate) absorption, but the major site for vitamin
B9 absorption is the jejunum (Fish & Burns, 2022). Minerals and vitamins A, D, E, and K are absorbed through the
small intestine. The small intestine absorbs 90% of the water from digested food (Fish & Burns, 2022). The last
segment of the small intestine, the ileum, is responsible for the absorption of bile salts and vitamin B12 (cobalamin;)
(Fish and Burns, 2022). Each broken-down substance is now in a new, more usable form for use by the body's
metabolic processes (Table 17.1).
Macronutrient Before Digestion After Digestion
Carbohydrate: Amylose Monosaccharides

polysaccharides (starchy
foods)
Carbohydrate: disaccharides Lactose, sucrose, maltose, Glucose, fructose, galactose

trehalose
Protein Large-chain amino acids Separate amino acids and peptides

joined by peptide bonds (oligopeptides, dipeptides, tripeptides)
Fat Triglycerides Monoglycerides, fatty acids

TABLE 17.1 Nutrients Before and After Digestion for the Body’s Metabolic Use (source: Fish & Burns, 2022)
The last part of the absorption process takes place in the large intestine. It has three main functions in digestion:
absorption of the remaining water and electrolytes, absorption and production of vitamins, and formation and
movement of feces to the rectum for elimination. The first portion of the large intestine, the ascending colon,
removes any remaining water and key nutrients from the indigestible material passing through it while solidifying
this waste to form stool.
During this part of digestion, water osmosis causes absorption of the remaining water, sodium is absorbed via
sodium channels, potassium absorption is regulated by its concentration in the lumen, and chloride and bicarbonate
ions are exchanged. In addition, the large intestine houses trillions of bacteria, which produce many vitamins,
including vitamin K, B vitamins, and biotin, through fermentation (Azzouz & Sharma, 2023).

Metabolism refers to the chemical processes by which the body converts absorbed substances to energy. Catabolic
reactions release large amounts of protons, which are transported to mitochondria in the cells to produce adenosine
triphosphate (ATP), the body’s chemical carrier of energy (Sanchez Lopez de Nava & Raja, 2022). An imbalance
between energy spent and energy used, or between anabolism and catabolism, can result in obesity or cachexia
(Sanchez Lopez de Nava & Raja, 2022). Obesity is clinically defined as an excessive or abnormal accumulation of fat
in the body that can increase an individual’s health risks. Cachexia refers to muscle loss with or without fat mass
loss.
For these processes to take place effectively and provide balanced nutrition and appropriate energy, the individual
must first ingest the proper mix of the required nutrients and water.
Assessment of the Normal Gastrointestinal System

Assessment of the gastrointestinal organs and normal expected findings are explained in detail in The Digestive
Process. This section will cover expected physical assessment findings in clients who demonstrate normal
nutritional status. Overall normal physical assessment findings in addition to normal gastrointestinal organ–specific
findings can help confirm a fully functioning gastrointestinal system (Table 17.2).
Organ Assessed Expected Findings

Lips • Symmetric, soft, moist, smooth textured, uniform in color and with expected
color for race (pink for fairer-skinned and darker for darker-skinned
individuals), symmetrically contoured, symmetrically pursed when individual is
asked to purse the lips
Buccal mucosa and inner • Uniform pink or freckled brown in darker-skinned individuals, moist (may be
lips slightly drier in older clients because of decreased salivation), glistening,
smooth, elastic texture
Gums • Moist and firm without retraction from the teeth; older clients may show some
hyperpigmentation and receding of the gumline
Tongue • Central resting position in the mouth but able to move freely; no tenderness,
swelling, or lesions; smooth with lateral margins and raised papillae (taste
buds); base should be smooth and prominent with veins and no ulcerations
Oropharynx • Smooth and pink at the posterior wall; uvula midline at the back of the soft
palate and freely movable; tonsils (if present) smooth, colored appropriately for
race, of normal size (usually larger in children than in adults) or not visible,
without discharge; gag reflex present
Teeth • Smooth and white with shiny enamel; older adults may have teeth staining,
chipping, erosions, or abrasions due to the aging process and wearing of teeth;
older children and adults may have dental appliances; any dentures or bridges
should be smooth and intact
Expected number of teeth: adults, 32; children by the age of 3 years, 20;
children and young adults aged 6–20 years can have a varying number as they
lose primary teeth and gain permanent teeth; newborns should not have teeth
Soft palate and hard • Light>Light pink or colored appropriately for race; the soft palate should be
palate smooth and the hard palate more irregularly textured; newborns may have
Epstein pearls, Bohn nodules, or gingival cysts
TABLE 17.2 Expected Normal Findings During Physical Assessment of the Gastrointestinal System (sources: Diaz de Ortiz & Mendez, 2022;
Gantan & Wiedrich, 2022; Mealie et al., 2022)
Organ Assessed Expected Findings

Abdomen: inspection • Skin: intact, uniform in color and consistent with race, no ecchymosis or
jaundice, silver–white striae (stretch marks) may be present (may be
purple–pink in pregnant client), surgical scars may be present
Flat, rounded but not distended or scaphoid (sunken); no protrusions or
evidence of spleen or liver enlargement; no visible vascular patterns (except in
pregnancy); respirations should cause symmetric movements of the abdomen;
in very lean client, aortic pulsations may be visible at the epigastric area, and
peristalsis may also be visible; umbilical stump should be present in newborns
Abdomen: auscultation • Bowel sounds present in all quadrants, low pitched and gurgling and occurring
at a rate of 2–5 per minute, lasting from less than 1 second to several seconds
each; no bruits or friction rub; no succussion splash
Abdomen: percussion • Dull, flat, or decreased sounds over organs; more tympanitic (louder and higher
pitched) over areas of air or gas
Abdomen: palpation • No pain, crepitus, tenderness, bulging, masses, inflammation, or muscle

guarding; deep palpation should reveal normal-sized organs without masses,
nodules, or tenderness
Anus • Skin intact, hairless, and slightly moister, coarser, and more pigmented than
surrounding skin; patent anal canal
Rectum • No masses or fissures; prostate in male client should be firm, smooth, not
enlarged
TABLE 17.2 Expected Normal Findings During Physical Assessment of the Gastrointestinal System (sources: Diaz de Ortiz & Mendez, 2022;
Gantan & Wiedrich, 2022; Mealie et al., 2022)
In addition to assessing individual organs, the nurse should conduct a general physical assessment, being alert for
specific findings that indicate adequate nutrition (Table 17.3). Such findings also help demonstrate that the
gastrointestinal system is functioning correctly.
Feature Assessed Expected Findings

General appearance Alert, conscious, and ambulatory within the confines of client’s ability; no general
emaciation
Height, weight, and body Body mass index of 18.5–24.9 kg/m2; 30 and over is considered obesity, with Class
mass index 3 obesity being 40 or greater
Vital signs Vital signs that fall within expected ranges can indicate good nutritional status, but
many pathologies can affect vital signs without regard to nutrition. Blood pressure
and pulse can indicate hydration status; low blood pressure (less than 90/60 mm
Hg) and tachycardia (heart rate greater than 100 beats per minute) can indicate
hypovolemia
Eyes No pallor of the palpebral conjunctiva, icterus (yellowing) of the sclera, Bitot’s
spots (oval or triangular patches on the conjunctiva of built-up keratin), xerosis
(dryness) of the cornea, or xanthelasmas (yellow plaques on or near the eyelids)
Skin No xeroderma (dry skin), petechiae, purpura, ecchymosis, jaundice, carotenoderma
(yellow–orange skin discoloration), poorly healing wounds, pigmentation or rashes
in sun-exposed areas (such as around the neck or on the extremities, where
pigmentation might look like gloves or stockings), xanthomas (localized lipid
deposits), or loss of subcutaneous adipose tissue
TABLE 17.3 Expected Normal Findings During General Physical Assessment (sources: Castera & Borhade, 2022; Cleveland Clinic, n.d.-b;
Feroze & Kaufman, 2023; Johnson, 2021; Kesari & Noel, 2023; Rosenthal, 2020; Schneider & Gibbs, 2022; UPMC, n.d.)

Feature Assessed Expected Findings

Hair No dryness, brittleness, or unexpected discoloration; not easy to pluck; no patches
of baldness or extreme thinness
Nails No dryness, brittleness, discoloration, clubbing, or koilonychia (soft nails that are
concave in the center and appear to be “scooped out”)
Extremities No edema, weakness, paresthesia, sensation loss, bowing, ulcerations, poorly
healing wounds, neuropathies, or muscle atrophy or wasting
Odor No unusual odors; fruity acetone, musty, and sweet, burnt sugary odors can indicate
specific nutritional issues due to pathologies
Function Ability to perform functions at the client’s baseline for their age; deficits from
baseline or, in infants and children, delays in development, growth, or weight can
indicate poor nutritional status
TABLE 17.3 Expected Normal Findings During General Physical Assessment (sources: Castera & Borhade, 2022; Cleveland Clinic, n.d.-b;
Feroze & Kaufman, 2023; Johnson, 2021; Kesari & Noel, 2023; Rosenthal, 2020; Schneider & Gibbs, 2022; UPMC, n.d.)
Nutritional Deficiencies Related to Abnormal Assessment Findings in the Gastrointestinal

System
Abnormal findings in an assessment of the gastrointestinal system and other systems can indicate the presence of
disease or nutritional deficit. To best plan nutritional strategies for the client, the nurse should know what each
abnormal finding, in conjunction with laboratory results and dietary recall, could indicate. Some abnormal findings
and nutritional deficiencies and toxicities related to them are shown in Table 17.4.
Organ Abnormal Findings Nutritional Deficiency or Toxicity

Assessed
Lips Fissures, crusts, or scales on the lips or in the Deficiency of vitamin B1 (thiamine), vitamin
corners of the lips, cracked lips, angular cheilitis B12 (cobalamin), and/or iron
Tongue Inflammation of the tongue Deficiency of vitamin B2 (riboflavin) and/or
B3 (niacin)
Loss of taste Deficiency of zinc
Halitosis Deficiency of vitamin B12 (cobalamin)
Red, painful tongue that has a burning sensation Deficiency of iron
Gums/ Ulcerative gingivitis Deficiency of vitamin B2 (riboflavin) and/or
mouth B3 (niacin)
Hemorrhagic gingivitis, painful mouth ulcers Deficiency of vitamin B12 (cobalamin)
Bleeding gingivitis Deficiency of vitamin C
Stomatitis (mouth inflammation) Deficiency of vitamin B complex
Salivary gland dysfunction, dysphagia Deficiency of iron
Recurrent aphthous stomatitis (canker sores) Deficiency of zinc
Salivary Dry salivary glands Dehydration or iron deficiency
glands
Teeth Pits, grooves, or missing areas in enamel of the Deficiency of vitamin A
teeth, giving teeth a translucent appearance
Periodontal disease Deficiency of vitamin B6 (pyridoxine) and/or
B12 (cobalamin)
Abnormal bone patterns and shapes Deficiency of vitamin D
Dental caries (cavities) Deficiency of vitamin D and/or fluoride
TABLE 17.4 Relationship of Abnormal Assessment Findings and Nutritional Deficiencies or Toxicities (sources: American Dental
Association, 2023; Cleveland Clinic, n.d.-a; Gold & Schoenhaus, 2023; Hakes, 2021; Johnson, 2022; Kesari & Noel, 2023; Mount Sinai
Icahn School of Medicine, n.d.; Plewa & Chatterjee, 2022; Sawar et al., 2021; Stewart, n.d.)

Assessed
Oropharynx Recurrent tonsillitis Deficiency of vitamin D
Pharyngitis Deficiency of vitamin B2 (riboflavin)
Inflammation of the hard and soft palates Deficiency of iron, vitamin B2 (riboflavin), B6
(pyridoxine), B9 (folate), and/or B12
(cobalamin), D, and zinc
Abdomen Constipation (hypoactive bowel sounds, Deficiency of potassium, magnesium, vitamin
decreased frequency of bowel movements, hard B9 (folate), fiber, and/or fluid volume
stools, straining with bowel movements,
increased flatus, mild abdominal distention, mild
abdominal tenderness)
Diarrhea (hyperactive bowel sounds, increased Deficiency of vitamin B3 (niacin) or excessive
frequency of bowel movements, loose or watery intake of potassium
stools, increased flatus, abdominal tenderness,
symptoms of fluid volume deficit from losses)
Abdominal muscle pain and cramping Deficiency of magnesium, potassium,
sodium, vitamin B1 (thiamine), vitamin D,
and/or calcium
Anus Hemorrhoids and fissures (caused by chronic Deficiency of fiber and/or fluid volume
constipation and straining to pass stools)
General Loss of appetite Deficiency of zinc
appetite/ Weight loss Deficient caloric intake, protein deficiency, or
weight impaired absorption
Skin Skin discoloration Excessive intake of protein, carotene-
containing foods, or supplements (vitamin A),
causing diffuse hyperpigmentation, or
excessive intake of both protein and zinc,
causing carotenoderma
Ecchymosis Deficiency of vitamin C, vitamin K, or zinc
Muscle Muscle pain, cramps Deficiency of magnesium, potassium,
sodium, vitamin B1 (thiamine), vitamin D,
and/or calcium
Eyes Pallor Deficiency of iron, protein, or vitamin B6
(pyridoxine), B9 (folate), B12 (cobalamin), or
C
Bitot’s spots, xerosis Deficiency of vitamin A
Xanthelasmas Excessive caloric intake, obesity, or
hypercholesterolemia
Hair Dry hair Deficiency of vitamin A or E
Brittle hair Deficiency of vitamin B7 (biotin)
Discolored, easily pluckable hair; hair loss Deficiency of protein or iron; overall severe
malnutrition
Nails Dry and brittle nails Deficiency of vitamin B7 (biotin), zinc, or
protein
Nail discoloration Overall poor nutritional status

17.2 • Plan Nutritional Strategies to Impact Gastrointestinal Wellness 341

Assessed
Koilonychia Deficiency of iron, causing anemia
Extremities Edema Deficiency of vitamin B1 (thiamine) or
protein; excessive sodium
Paresthesia, muscle weakness Deficiency of vitamin B1 (thiamine), B6
(pyridoxine), B12 (cobalamin), or E
Loss of sensation Deficiency of vitamin B12 (cobalamin) or E
Muscle atrophy and wasting Severe malnutrition
Bowing of the legs (caused by rickets) Deficiency of vitamin D
Part A
Mrs. Azan tells the nurse that she has been having muscle weakness and cramping, abdominal pain, mouth and
tongue swelling, and sores in her mouth. When the nurse assesses Mrs. Azan, the nurse finds that she has angular
cheilitis, multiple canker sores in her buccal areas, a red and swollen tongue, and general pallor.
1. Based on both the objective and subjective assessment findings, what would the nurse rule out as a potential
deficiency being experienced by this client?
a. Potassium
b. Magnesium
c. Vitamin B12
d. Vitamin A
2. Based on Mrs. Azan’s presentation, which additional laboratory test should the nurse expect the health care
provider to order?
a. Iron
b. Vitamin D
c. Calcium
d. Vitamin E
17.2 Plan Nutritional Strategies to Impact Gastrointestinal Wellness

LEARNING OUTCOMES
• 17.2.1 Prioritize nutritional habits that optimize gastrointestinal wellness.
• 17.2.2 Generate solutions to optimize gastrointestinal wellness using nutritional habits.
Plan Nutritional Goals Based on Testing Results

Nutritional plans (meal plans) should be made with the client based on their specific signs and symptoms. This plan
may also include nutrient intake adjustments based on absorption requirements. Nutritional plans should include
any nutritional intake restrictions or additions for overall gastrointestinal health based on the client’s specific needs.
In addition to the nutrients needed to avoid the deficiencies outlined in Table 17.4, the plan should include foods
known to be beneficial for the overall wellness of the gut’s normal microbial growth and should be based on the
client’s food preferences and dietary restrictions.
A common vitamin deficiency that displays with abnormal assessment findings is vitamin B. Vitamin B deficiencies
that can be found, in order of most importance to the body for normal function, include:
• B12 (cobalamin)
• B1 (thiamine)
• B2 (riboflavin)
• B6 (pyridoxine)
• B3 (niacin)
• B9 (folate)
• B7 (biotin)
Several macro- and micronutrients can appear as abnormal assessment findings when deficient or toxic. They are
listed as follows in order of importance for normal gastrointestinal function:
• Iron
• Zinc (deficiency and toxicity)
• Vitamin D
• Protein (deficiency and toxicity)
• Vitamin C
• Vitamin A (retinol)
• Vitamin E
• Magnesium
• Potassium (deficiency and toxicity)
• Sodium (deficiency and toxicity)
• Fiber, calcium, fluids (water)
• Phosphorus
• Folate
• Vitamin K
• Fluoride
• Calories (underconsumption and overconsumption)
• Saturated fats (specifically for overconsumption only)
The client may require enzyme replacement for digestion in the absence of a functioning liver, gallbladder, or
pancreas.
When the nurse is evaluating the client’s diet to ensure healthy gut microbiota, dietary additions that might be
considered include fiber, additional water, yogurt with active bacterial cultures, whole grains, fruits and vegetables,
foods high in antioxidants, and probiotic and prebiotic foods (Afzaal et al., 2022; Gunnars, 2023; Lee et al., 2022;
Weersma et al., 2020). Substances that should be restricted include saturated fats and trans fats, sodium, and
alcohol (Afzaal et al., 2022).
CLINICAL TIP
Changes to a Client's Nutritional Intake

Before the dietitian or nurse makes any recommendations to add or restrict anything from the client’s nutritional
intake, laboratory tests should be done to confirm what the physical assessment indicates. Once that testing is
completed, the nutritional plan can be established.
Nurses must also understand the synergistic relationships between certain nutrients so they can plan interventions
to optimize nutritional progress. For example, if a client is iron deficient, an acidic environment will increase iron
absorption, which can be achieved by adding vitamin C to the diet (Academy of Nutrition and Dietetics, 2020a). An
inability to absorb iron could be directly related to a problem in the gastrointestinal system because most of the
body’s iron absorption occurs in the duodenum and proximal jejunum, so adding vitamin C to the client’s diet would
be crucial to correct their deficiency (Ems et al., 2023). There are also inhibitory effects to be aware of; calcium,
phytates, and polyphenols, for example, can reduce iron availability.

17.3 • Implement Nutritional Strategies to Impact Gastrointestinal Wellness 343
The inability to absorb nutrients is concerning when the client has gastrointestinal disease. Their nutritional plan will
include supplementation and higher nutritional intake levels than for a healthy client. A client with a gastrointestinal
disorder may eventually require injectable forms of vitamins to stay healthy if they cannot absorb them adequately
through oral ingestion. To best prepare a nutritional plan with the client, the nurse must consider the client’s food
preferences and cultural practices.
Identify Challenges to Nutritional Goals

A client may face several challenges when trying to achieve their nutritional goals for gastrointestinal health. The
first is malabsorption. Even when the client adheres to the nutritional plan of care, their body may be unable to
absorb the nutrients provided in their oral intake. Many gastrointestinal diseases can cause these issues (refer to
Special Nutritional Considerations for Gastrointestinal Health for greater detail on gastrointestinal diseases). To
address such deficiencies, the dietitian, nurse, and health care provider must work closely with the client to monitor
laboratory results and add supplementation in oral, enteral (feeding tube), and parenteral forms as needed to reach
nutritional goals.
Another challenge that may be encountered is the presence of food allergies or comorbidities. Many foods contain
allergens, such as eggs, milk, red meat, nuts, wheat/barley/rye (gluten), shellfish, and citrus fruits. Comorbidities
present a concern because if the client already has multiple nutritional restrictions due to other illnesses, such as
diabetes, hypertension, or chronic kidney disease, fewer food options may be available to them. In addition, the
client may be less motivated or able to follow a nutritional plan the more restrictive it becomes.
The final challenge to consider is the side effects of the gastrointestinal disease processes a client may be
experiencing. When a client has a gastrointestinal disease, they may be dealing with nausea, vomiting, anorexia,
and/or diarrhea. These issues may cause the client to be unable to consume food or to absorb enough nutrients
from what they do consume. For a client with these issues to be successful with their nutritional goals, the health
care provider, dietician, and nurse will need to address these issues, and the nutritional plan will need to include
foods that do not aggravate the client’s conditions.
17.3 Implement Nutritional Strategies to Impact Gastrointestinal Wellness

LEARNING OUTCOMES
• 17.3.2 Teach nutritional strategies to optimize gastrointestinal wellness.

The exact foods included in a nutritional plan should be personalized to each client. Caring for the client holistically
requires the nutritional plan to evolve based on the client’s dietary requirements. A holistic nutritional plan should
include food items that are appropriate based on the client’s religious, cultural, and personal beliefs. For example,
some religions forbid a single type of meat or all meat. In this case, the nutritional plan should include reasonable
meat and nonmeat options, such as quinoa or pumpkin seeds, as appropriate to ensure proper protein intake.
Client Teaching
Client teaching for gastrointestinal health should focus not only on general health but also on the specific nutrients
known to improve the health of the gastrointestinal system, as discussed in this chapter. Teaching should begin by
determining nutritional goals and setting a plan with the client. A registered dietician should be consulted to ensure
that the nutritional plan is appropriate for all the client’s needs, including any restrictions. The nurse should ensure
that the client understands the education and the plan developed with the dietician and should routinely follow up
to make sure the client is following this plan. The client must be an active part of this process so that the registered
dietician and nurse can determine if there is a lack of understanding. Active participation also gives the client a
chance to verbalize any specific food dislikes or barriers they may have in obtaining certain types of foods.
The nurse should ask the client to use the information they were taught to create a 3-day meal plan that includes
breakfast, lunch, dinner, snacks, and beverages. The client and the nurse can then sit down together and discuss
good choices and not-so-good choices the client may have made for each meal. This practice allows active learning
for the client and is one way to evaluate the client’s understanding of the nutritional plan.
17.4 Evaluate Nutritional Strategies to Impact Gastrointestinal Wellness

LEARNING OUTCOMES
• 17.4.1 Evaluate a nutritional plan for its effect on gastrointestinal wellness.
• 17.4.2 Modify a nutritional plan to promote gastrointestinal wellness.
Evaluation of the Client’s Adherence to the Meal Plan

After a nutritional plan has been in place for at least 3 months, its effectiveness should be evaluated. The client’s
ability to follow the plan must first be established before the plan is modified. If a client is not able to follow the plan
as prescribed, then changes need to be made based on the client’s unique reasons for nonadherence.
Part B
Study Part A.
Mrs. Azan returns to the clinic several months later after meeting with the registered dietician to make dietary
modifications. She has been taking her prescribed supplements. Although her previous signs and symptoms have
resolved, she is now presenting with unplanned weight loss; pallor; dry, brittle nails; hair loss; edema in the legs;
and muscle weakness.
3. What does the nurse recognize as a potential deficiency with these new presenting symptoms?
a. Vitamin C
b. Magnesium
c. Iron
d. Protein
4. Mrs. Azan states that she has decided to follow a vegetarian diet. Which of the following food choices can the
nurse recommend for this diet because it is a high-protein source?
a. Carrots
b. Quinoa
c. Corn
d. Whole grain bread
Evaluation of the Effectiveness of a Nutritional Plan

After it is established that the client is adhering to their nutritional plan, evaluating the effectiveness of the plan
requires checking laboratory results and watching trends as well as performing physical reassessments. If the plan
is not effective, adjustments should be made based on the cause of ineffectiveness.
Part C
Mrs. Azan has returned for her follow-up appointment. It has been 3 months since her last visit. Blood levels were
redrawn a week ago, and the results show that vitamin B12, magnesium, and potassium have stabilized to a low
normal range, but iron is still very low. The laboratory tests ordered also show that Mrs. Azan’s calcium and vitamin
D levels are low now despite being normal previously. The 72-hour recall the client reports is consistent with the

17.4 • Evaluate Nutritional Strategies to Impact Gastrointestinal Wellness 345
nutritional goals and education given, and she says she has been following the plan closely. Her food choices are
diverse enough to ensure that the calcium and vitamin D levels should not have decreased.
5. Given the results, what should the nurse conclude about the effectiveness of the nutritional plan?
a. It is effective, but the client is nonadherent.
b. It is effective, but the client is not documenting her food intake correctly.
c. It is ineffective because the client cannot comprehend the instructions well enough.
d. It is ineffective because the client’s Crohn’s disease is preventing absorption.
6. Based on the findings, how should the nurse expect the nutritional plan to be modified?
a. There will be no changes because the client has a chronic condition that cannot be cured.
b. The amount of food to be consumed will be increased.
c. Supplementation, either enteral (feeding tube) or parenteral, will be initiated.
d. There will be no changes; instead, the client will be reeducated about the current plan to improve its
effectiveness.
Chapter Summary
• The gastrointestinal system has four main of vitamins, and formation and movement of feces
functions: ingestion, digestion, absorption, and to the rectum for elimination.
metabolization. • The first portion of the large intestine, the
• The small intestine handles 90% of nutrient and ascending colon, removes any remaining water
water absorption. and key nutrients from the indigestible material
• The duodenum is the site for iron absorption and that passes through it, while solidifying this waste
some vitamin B9 (folate) absorption, but the major to form stool.
site for vitamin B9 absorption is the jejunum. • The nutritional plan for clients with
• Minerals and vitamins A, D, E, and K are absorbed gastrointestinal diseases will include
by the small intestine. supplementation and higher nutritional intake
• The last segment of the small intestine, the ileum, levels than for a healthy client.
is responsible for the absorption of bile salts and • Challenges to nutritional goals include
vitamin B12 (cobalamin). malabsorption, food allergies, comorbidities, and
• The large intestine has three main functions in side effects of the gastrointestinal disease
digestion overall: absorption of the remaining processes.
water and electrolytes, absorption and production
Key Terms
absorption the taking in of broken-down substances koilonychia soft nails with a concave indentation,
into the cells making them appear “scooped out”
Bitot’s spots oval or triangular patches on the mastication digestion of food using mostly
conjunctiva of built-up keratin mechanical and some chemical processes
chyme gastric juices and digested food particles metabolism the chemical processes in the body that
digestion the process by which the body breaks down convert absorbed substances to energy
what is ingested into absorbable substances xanthelasmas yellow plaques on or near the eyelids
icterus another word for jaundice, a yellowish xanthomas localized lipid deposits
pigmentation of the skin xeroderma dry skin
ingestion the taking in of substances into the body xerosis extreme dryness of skin or tissue; in corneal
through swallowing or transdermal absorption xerosis, the cornea may appear hazy
Review Questions
1. The nurse is assessing a client who has poor dentition. Which function of the gastrointestinal system will be
affected most by this?
a. Ingestion
b. Digestion
c. Absorption
d. Metabolism
2. The nurse is assessing a client for gastrointestinal wellness. Which action should the nurse complete to
assess the gastrointestinal system?
a. Auscultate the lungs.
b. Inspect the nares.
c. Palpate the abdomen.
d. Percuss the thorax.
3. The nurse is assessing a client for gastrointestinal wellness. Which finding could indicate a vitamin
deficiency?
a. Cyanotic lips
b. Angular cheilitis
c. Abdominal tenderness
d. Diaphoretic skin

4. The nurse prioritizes the nutritional content of clients’ meal options when planning their care. Which protein
option is best for clients of the Buddhist faith who are vegetarians?
a. Broccoli
b. Fish
c. Tofu
d. Whole wheat bread
5. The nurse is caring for a client with a protein and iron deficiency who is allergic to beef. Which is the best
alternative for the nurse to suggest?
a. Edamame
b. Milk
c. Cheese
d. Okra
6. The nurse is providing dietary instruction to a client who needs to eat foods that support the gut’s normal
microbial growth. Which of the following statements indicates that the client understands the education?
a. “I will drink at least a liter of water every day.”
b. “I will eat yogurt every morning with my breakfast.”
c. “I will make sure I eat protein at every meal.”
d. “I will drink an extra glass of milk every day.”
7. The nurse is working with a client with an iron deficiency. Which of the following foods would increase iron
absorption?
a. Whole milk
b. Whole grain toast
c. Scrambled eggs
d. Fresh orange
8. The nurse is preparing a client’s nutritional plan for increasing their iron intake. Which vitamin should the
nurse include?
a. Vitamin A
b. Vitamin C
c. Vitamin E
d. Vitamin D
9. The nurse is reviewing a client’s laboratory results and notices there has been little progress in raising the
client’s vitamin K level. Which assessment finding can the nurse directly relate to this continued deficiency?
a. Pharyngitis
b. Ecchymosis
c. Skin dryness
d. Weight loss
10. The nurse is caring for a vegan client who is having difficulty eating enough protein. Which food item is
appropriate for the nurse to recommend to this client?
a. Quinoa
b. Fish
c. Eggs
d. Carrots
Suggested Reading
Butts, M., Sundaram, V., Murughiyan, U., Borthakur, A., & Singh, S. (2023). The influence of alcohol consumption on
intestinal nutrient absorption: A comprehensive review. Nutrients, 15(7), 1571. https://doi.org/10.3390/
nu15071571
Codutti, A., Cremer, J., & Alim, K. (2022). Changing flows balance nutrient absorption and bacterial growth along the
gut. Physical Review Letters, 129, 138101. https://doi.org/10.1103/PhysRevLett.129.138101.
Kitchens, R. (2023, February 2). Health headlines: Researchers calling vitamin D deficiency “invisible epidemic.”
KPLC News. https://www.kplctv.com/2023/02/02/health-headlines-researchers-calling-vitamin-d-deficiency-
invisible-epidemic/
O’Connor, A. (2022, September 20). The best foods to feed your gut microbiome. The Washington Post.
https://www.washingtonpost.com/wellness/2022/09/20/gut-health-microbiome-best-foods/
Omprakash, T. A. (2023, February 24). Key takeaways from Crohn’s and Colitis Congress 2023. Crohn’s and Colitis
Foundation. https://www.crohnscolitisfoundation.org/blog/key-takeaways-crohns-colitis-congress-2023
World Health Organization. (2023). Micronutrients. https://www.who.int/health-topics/micronutrients#tab=tab_1

CHAPTER 18
Gastrointestinal Health
FIGURE 18.1 Nutritional intake starts with the gastrointestinal system, and the types of foods consumed have a direct impact on overall
health. (credit: modification of work “mushrooms with lentils-3” by jules/flickr, CC BY 2.0)
CHAPTER OUTLINE
18.1 The Impact of Nutrition on Gastrointestinal Wellness Across the Lifespan
18.2 Nutrition and Chronic Gastrointestinal Illnesses
INTRODUCTION The gastrointestinal system is vital to the overall health of the body. The ability of this system to
function optimally depends not only on the absence of illness but on the proper development of this system
throughout the lifespan. This chapter will examine the nutritional requirements needed at each stage of life to assist
this system in developing to its optimal capacity. It will also review illnesses that impact this system.
Consider this case: The client—unborn at the start of this chapter's case study—is Bao Nhung. The client’s mother,
Hien Nhung, is a 23-year-old first-generation Vietnamese American who works as a medical–surgical nurse on the
night shift at the local hospital. The client’s mother works long nights, and the pregnancy was unplanned. Hien has
not received any prenatal care during the pregnancy.
350 18 • Special Nutritional Considerations for Gastrointestinal Health
18.1 The Impact of Nutrition on Gastrointestinal Wellness Across the

Lifespan
LEARNING OUTCOMES
• 18.1.1 Describe the impact of nutrition on the gastrointestinal system during pregnancy.
• 18.1.2 Describe the impact of nutrition on the gastrointestinal system during infancy.
• 18.1.3 Describe the impact of nutrition on the gastrointestinal system during childhood.
• 18.1.4 Describe the impact of nutrition on the gastrointestinal system during adolescence.
• 18.1.5 Describe the impact of nutrition on the gastrointestinal system during adulthood.
• 18.1.6 Describe the impact of nutrition on the gastrointestinal system during later adulthood.
Pregnancy
Pregnancy adds nutritional needs to the pregnant client that were not required before conception, and the client’s
gastrointestinal health can impact the pregnancy even if they were healthy at the start. When a pregnant client has a
gastrointestinal system illness, the stress of the pregnancy only adds to their nutritional needs. It is important that
the expectant client maintain optimal nutrition during the pregnancy to ensure proper gastrointestinal development
of the fetus as well.
The Healthy Pregnant Client

The healthy pregnant client without gastrointestinal illness should maintain a healthy diet and increase their caloric
intake by 340 calories from their non-pregnant caloric intake amount daily starting the second trimester of a
singleton fetal pregnancy (American College of Obstetricians and Gynecologists, 2023). During the third trimester,
the caloric intake should increase by 450 calories from their non-pregnant caloric intake amount daily (Office of
Disease Prevention and Health Promotion, 2023). Other recommendations for pregnancy include increasing water
intake, decreasing caffeine intake, and adding a prenatal multivitamin with folic acid and iron (American College of
Obstetricians and Gynecologists, 2022). It is also recommended that the pregnant client consume food and drinks
that are low in added sugars, saturated fats, and sodium (Office of Disease Prevention and Health Promotion, 2023.
Pregnant clients can follow the recommendations found using My Pregnancy Plate to ensure that they are eating
well for their pregnancy (Oregon Health and Science University, 2023).
Specific recommendations can also be included to maintain the pregnant individual’s gastrointestinal health and
support fetal development. The microbiome, or collection of microorganisms that reside primarily in the
gastrointestinal tract, needs to be maintained during pregnancy to maintain overall gastrointestinal health. The gut
microbiome promotes immune function and intestinal homeostasis by reducing production of inflammatory
mediators (Tabani & Olendzki, 2019), which encourages normal mucosal functioning. Normal mucosal function is
needed to ensure optimal intestinal absorption of nutrients.
Additions to the diet that can be recommended by those caring for the client include prebiotic and probiotic foods.
Probiotic foods are nondigestible substances that stimulate the growth of “good” gut bacteria and include
fermented foods that contain live bacteria and yeast, such as yogurt, miso, kefir, kimchi, and honey (Tabani &
Olendzki, 2019). Prebiotic foods are foods that contain live microorganisms intended to maintain good gut bacteria
and include garlic, onions, asparagus, leeks, and bran. See Figure 18.2.

18.1 • The Impact of Nutrition on Gastrointestinal Wellness Across the Lifespan 351
FIGURE 18.2 Prebiotic foods like this grilled asparagus, which is also high in fiber, can promote gastrointestinal health during pregnancy.
(credit: “Ett par sparrisar och några bitar paprika på en klotgrill” By VisbyStar/Wikimedia Commons, Public Domain)
Another important addition for the gastrointestinal system during pregnancy is 25–35 g of fiber daily. Fiber, with
adequate water intake, helps to prevent constipation and hemorrhoid development, remove excess cholesterol in
the diet, and maintain the gut microbiome (Tabani & Olendzki, 2019). The pregnant client can obtain fiber from
barley, flaxseed, oats, lentils, and beans.
The microbiome can also be protected by limiting foods that contain lactose, wheat, corn, and refined sugars that
feed harmful bacteria in the gut (Tabani & Olendzki, 2019). These foods promote systemic inflammation and upset
the balance of the microbiome.
The fetus will develop their own microbiome based on the maternal microbiome during pregnancy, interaction with
the environment after birth, and the diet and lifestyle they develop after birth. Maternal dysbiosis, or an imbalance
in the microbiome that is associated with unhealthy conditions, can contribute to infant dysbiosis (Garcia-Montero
et al., 2023; Martinez et al., 2021). Reducing gluten-containing foods while pregnant can help increase the number
of Akkermansia muciniphila, Saccharibacteria (formerly known as TM7 bacteria), and Proteobacteria in the fetus,
reducing low-grade inflammation in the infant and the risk for developing diabetes (Tabani & Olendzki, 2019).
Infants exposed to unhealthy maternal microbiomes, especially in conjunction with unhealthy childhood diets, are
at increased risk for having lean (lower than optimal bacterial amounts), defective intestinal microbiota, which leads
to dysbiosis in the gut (Tabani & Olendzki, 2019). This can lead to dysfunction in genes that are active in both
glucose and lipid metabolism (Tabani & Olendzki, 2019). Infants exposed to an unhealthy maternal microbiome are
also more likely to have issues with immune system development, develop long-term health issues, and even be
predisposed to developing immune-modulated diseases and Crohn’s disease, a chronic inflammatory disease that
affects the intestines (UMass Chan Medical School, n.d.), particularly the colon and ileum, and can cause ulcerations
and fistulas.
The method of delivery can also affect the infant, regardless of the health of the mother’s microbiome. When
delivered vaginally, the newborn develops a microbiome higher in Lactobacillus and Prevotella, which is similar to
the vaginal flora (Tabani & Olendzki, 2019). Newborns born via cesarean section will have higher levels of
Staphylococcus, Corynebacterium, and Propionibacterium, more similar to the mother’s skin flora, which increases
risk for developing dairy allergies (Zhang, et al., 2021).
Promotion of a healthy maternal gut microbiome may also prevent preeclampsia as it has been shown to play a role
in preeclampsia and decrease the risk for premature birth (Jin et al., 2022). This is important for the overall health
of the infant’s gastrointestinal system because prematurity can result in immature development of this system.
The lactating client should continue to maintain their gut health to help prevent issues with their infant. Prebiotics in
foods such as kefir consumed by lactating women have been shown to reduce infant risks for developing colic,
allergies, and other gastrointestinal problems (Garcia-Montero et al., 2023).
The Pregnant Client With Preexisting Gastrointestinal illness

Diseases that can heavily affect the nutritional status of the pregnant client and fetus include Crohn’s disease;
ulcerative colitis (UC), an inflammatory disease that causes ulcerations in the superficial lining of the large
intestine; cholelithiasis; gastroesophageal reflux disease (GERD); pancreatic insufficiency; and diabetes types 1 and
2 (Balestrieri et al., 2020; Lifespan Health System, n.d.) .When the pregnant client already has a gastrointestinal
illness, eating properly for the health of the pregnancy becomes more difficult because intestinal absorption may
not be optimal.
Gastrointestinal issues that arise in an uncomplicated pregnancy can pose additional problems for these clients.
Conditions such as nausea, vomiting, constipation, heartburn, diarrhea, hemorrhoids, and hyperemesis gravidarum
(persistent and severe vomiting caused by pregnancy that can lead to weight loss and dehydration) can worsen
these clients’ ability to absorb and metabolize nutrients.
Managing gastrointestinal issues that commonly occur during pregnancy can help alleviate some of the additional
burden placed on these clients. Interventions commonly used during a healthy pregnancy include a healthy diet,
increased fluids, and exercise, with medications usually reserved as a last resort. However, the usual treatments will
not always address the underlying chronic issues in clients with preexisting conditions, who may need to be initially
treated with more advanced treatments, including medication.
These clients face will likely be advised to stop the suppressive medications they take to keep their chronic
condition under control. Clients with GERD may have to be switched to less effective medications such as calcium
carbonate to manage symptoms during pregnancy. Cholelithiasis can be manageable during pregnancy provided it
does not cause infection or cholecystitis. Even if the gallbladder loses the ability to release enough of the needed
digestive enzymes due to this condition, clients can be treated with supplemental enzymes.
The gastrointestinal issues that pose the greatest threat to the health of the pregnancy are Crohn’s disease and UC.
The medications used to treat these may be stopped due to fetal risks. Clients with these diseases are at higher risk
for iron (Mahadevan et al., 2019), vitamin D, and vitamin B12 (Mahadevan et al., 2019) deficiency during pregnancy
due to malabsorption, a digestive disorder that causes the body not to absorb nutrients from food effectively, which
occurs because of the inflammation process these illnesses cause. These clients will also be higher risk for folate
deficiency during exacerbation periods due to the need for a low-residue diet during this time, as well as the
potential for ileal involvement or the need to take medications that interfere with folic acid absorption (Mahadevan
et al., 2019). Due to these issues, supplementation is imperative, and serum levels should be monitored for iron,
vitamin D, and vitamin B12 (Balestrieri, 2020). Although iron supplementation is necessary, it can also increase the
risks for constipation and abdominal pain (Mahadevan et al., 2019). These clients should be educated about
increasing water intake and using acceptable laxatives during pregnancy.
During pregnancy, these clients should be followed closely by a gastroenterologist. There are significant risks to the
fetus because these diseases can impact fetal development. These clients have a greater risk for miscarriage,
preeclampsia, poor maternal weight gain, placenta abruption, premature delivery, cesarean delivery, birth of a
small-for-gestational-age newborn, and other delivery complications (Mahadevan et al., 2019).
Diet recommendations for clients with Crohn’s disease or UC are the same during pregnancy. These clients should
be educated about additional needs of the pregnancy in conjunction with the requirements for their diagnosis for
maintaining gut microbiome health. These clients need to avoid trigger foods. Although such foods may be different
for each individual, common triggers include (Crohn’s and Colitis Foundation, n.d.):
• Foods high in insoluble fiber (raw kale, apple skins, sunflower seeds)
• High-fiber foods (cabbage, asparagus, cauliflower)
• High-lactose foods (cow’s milk, ice cream, custard)
• Sugar alcohols and artificial sweeteners (sorbitol, saccharin, aspartame)
• Sugary foods and foods with added sugars (cookies, pastries, syrup)
• High-fat foods (butter, cheesy foods, fried foods)

• Spicy foods (sriracha, chili powder)

• Alcohol
• Caffeine (soda, tea, coffee)
• Sugar-sweetened beverages (soda, juices, drinks with syrup)
These clients should also avoid foods that can increase, or play a role in, intestinal inflammation (Crohn’s and Colitis
Foundation, n.d.):
• Red meat (beef, lamb, pork, bison)

• Processed meat (lunch/deli meat, bacon, hot dogs)
• Coconut oil, dairy fats, palm oil
• Processed foods containing the following additives may also play a role: carboxymethylcellulose,
polysorbate-80, carrageenan, maltodextrin, titanium dioxide, sulfates, guar gum
Some foods can be increased in the diet to decrease inflammation (Crohn’s and Colitis Foundation, n.d.):
• Fruits (bananas, raspberries, applesauce, blended fruit)

• Vegetables (squashes, green beans, fork-tender cooked carrots)
• Foods rich in omega-3 fatty acids (fatty fish [salmon, tuna, mackerel], walnut butter, chia seeds, flaxseed oil,
flaxseed meal)
• Cooked and cooled or reheated starches (potatoes, sweet potatoes, rice, oatmeal) to form retrograde starch
(Bedosky, 2022)
The Fetus
A pregnant client with preexisting gastrointestinal disease should closely follow the prescribed dietary
recommendations. Adherence will decrease the chances of fetal underdevelopment or premature delivery, which
can have lifelong effects for the child.
The fetus’s gastrointestinal system begins development at 3 weeks’ gestation and continues to mature through the
third trimester up to 32 weeks (Bhatia, Shatanof, and Bordoni, 2023). The pregnant client’s nutritional intake is the
sole source of fetal nutrition, so they should eat foods that are necessary for proper fetal development. Folic acid,
iron, calcium, vitamin D, DHEA, and iodine all play vital roles in this development (Getz, 2022). The nurse can
educate the pregnant client about specific foods to ensure that their fetus will get these needed nutrients (Table
18.1).
Nutrient Foods
Folic acid • Dark green leafy vegetables
• Beans
• Peanuts
• Sunflower seeds
• Fresh fruits, fruit juices
• Whole grains
• Liver
• Eggs
• Fortified foods
Iron • Red meats

• Fish and shellfish
• Eggs
• Nuts
• Dried fruit
• Whole-grain pasta and bread
• Iron-fortified bread and breakfast cereals
• Legumes
• Dark green leafy vegetables
• Oats
• Tofu
Calcium • Seeds
• Cheese
• Yogurt
• Sardines and canned salmon
• Beans and lentils
• Almonds
• Whey protein
Vitamin D • Cod liver oil

• Salmon
• Swordfish
• Tuna fish
• Orange juice fortified with vitamin D
• Dairy and plant milks fortified with vitamin D
• Sardines
• Beef liver
DHEA • Wild yams are the only food that contains anything similar to DHEA.
• DHEA is made naturally in the adrenal glands.
TABLE 18.1 Foods for Proper Development of the Fetal Gastrointestinal System (source: Getz, 2022)
Infancy
In infancy, nutrition needed for the health of the gastrointestinal tract depends on whether the infant has any
congenital abnormalities or early diagnosed illnesses related to the gastrointestinal system. Healthy eating patterns
that start with the introduction of solid foods constitute the best start a parent can give their child to ensure the
future of their gastrointestinal health because early eating patterns are often carried throughout an individual’s life.
This is true for all infants regardless of the presence or absence of gastrointestinal issues.
The Healthy Infant

It is extremely important to optimize nutrition during infancy for proper growth and development of the
gastrointestinal system because this period in life involves very rapid growth. Infants who were born prematurely or

had a low birth weight and have continued undernutrition, even in the absence of gastrointestinal illness or
abnormality, require additional nutrition to ensure proper growth and development because they are at much higher
risk for developing postnatal growth failure, failure to thrive, childhood obesity, and diabetes. They also have a
higher mortality risk in the future. These increased risks may be a result of having a low birth weight and rapidly
gaining weight as a compensatory measure (Patel & Rouster, 2023). For example, a healthy term infant requires 100
kcal/kg/day, but a preterm or low birth weight infant requires 110–135 kcal/kg/day to establish a healthy growth
and development pattern (Patel & Rouster, 2023). (Note: The use of “kcal” matches the wording in the source
material and, for the purpose of this chapter, is the same as “cal.”)
The nutrition infants receive comes primarily from breast milk or formula. Protein provided in their diet is needed for
proper growth and system development and should be 15% of their daily intake (Patel & Rouster, 2023). Breast milk
is a more nutritious option because the protein is more bioavailable than the cow’s milk or soy protein in infant
formula, allowing for greater absorption.
SAFETY ALERT
Infant Formula
Infant formula in concentrated forms (both powder and liquid forms) should be mixed as instructed, using the
appropriate measurements of formula concentrate and water. Adding additional water to formula concentrate
can be dangerous because the resulting diluted formula can lead to suboptimal caloric intake and electrolyte and
mineral imbalances. Suboptimal caloric intake can slow growth and development, and imbalances in electrolytes
and minerals can cause serious health problems, including seizures, and can also lead to death. (source: Abrams,
2022).
Carbohydrates should be 40–55% of an infant’s daily intake. Carbohydrates are used for energy and must be
provided in correct amounts because the body will use protein for energy when not enough carbohydrates are
available (Patel & Rouster, 2023). Another portion of daily intake comes from fats (lipids), which also provide energy
to the body. Low birth weight and premature infants may require higher amounts of carbohydrates and lipids
because they lack sufficient body fat stores. One reason breast milk has been shown to be a healthier option for
infants is because it contains higher levels of medium and short-chain triglycerides, which are easier to absorb
(Patel & Rouster, 2023) than long chain fatty acids found in formula. When infants are born too early to have
developed a proper sucking reflex, it may be necessary for the breastfeeding parent to pump breast milk for feeding
via nasogastric or orogastric tube.
Micronutrients are also needed to ensure the health of the gastrointestinal system. These trace elements, absorbed
in the gastrointestinal tract, require age-, weight-, and disease-specific adjustments to ensure proper nutrition
(Patel & Rouster, 2023). Of these micronutrients, preterm and low birth weight infants require higher levels of iron,
zinc, and copper than healthy full-term infants do.
The Infant with Gastrointestinal Abnormalities

Infants with gastrointestinal system illness or abnormality require individualized nutritional considerations to
ensure that they grow and develop properly. This is especially true when the gastrointestinal issue causes
malabsorption. These infants require similar amounts of macronutrients but may become deficient in micronutrients
more easily due to malabsorption.
Breast milk has a higher content of more easily absorbed, more bioavailable forms of proteins and fats, making it the
optimal choice for infants, especially those with gastrointestinal issues. If the absorption issues do not allow
nutritional needs to be met, the infant may require parenteral nutrition for healthy development until the issue can
be controlled. Parenteral nutrition does put the infant at higher risk for toxicity from micronutrients. This makes it
imperative that the infant be transitioned to enteral feedings as soon as possible and monitored closely for toxicity.
Iron is not needed in higher concentrations in infant with GI abnormalities unless they are preterm or are
specifically not absorbing the appropriate amounts, as absorption occurs in the duodenum and proximal jejunum
(Patel & Rouster, 2023). Infants with short bowel syndrome, a group of problems related to ineffective absorption
of nutrients, or with congenital abnormality of zinc absorption are at highest risk for zinc deficiency. They may
require higher amounts of zinc in their diet (Patel & Rouster, 2023).
Although large amounts of selenium are not recommended, it is important that premature infants and infants with
gastrointestinal issues receive optimal amounts. Selenium is an antioxidant that reduces a wide range of
inflammatory issues such as necrotizing enterocolitis (Patel & Rouster, 2023), an intestinal tract disease in which
the intestinal lining becomes inflamed and dies and then is sloughed off.
Breastfeeding is the optimal source of nutrients for infants, but it is even more important for infants with
gastrointestinal issues the first year of life. Breastfeeding reduces risks for diarrhea, food allergies, inflammatory
bowel disease, obesity, and diabetes (Patel & Rouster, 2023).
SAFETY ALERT
Contraindication for Breastfeeding

Breastfeeding is contraindicated in infants with galactosemia, a genetic disorder in which the
galactose-1-phosphate uridylyltransferase (GALT) enzyme is missing or does not function properly (Patel &
Rouster, 2023). This enzyme, produced in the liver, is needed to break down galactose, a sugar by-product of
lactose, into glucose. It is found in breast milk, cow’s milk, and other dairy foods. These infants must be on a
lactose-free diet. All infants born in the United States are tested for galactosemia through mandatory blood
testing soon after birth.
Part A
Hein Nhung has had a difficult pregnancy. She has experienced hyperemesis gravidarum and worsening of her
gastroesophageal reflux disease. Because of her inability to gain the recommended amount of weight and to
consume nutrient-rich foods during the pregnancy, Hein’s gut microbiome has severely changed. These difficulties
contributed to her baby, Bao Nhung, being delivered at 37 weeks’ gestation, with a low birth weight for age.
1. Which nutritional option would be best for the nurse to recommend to promote Bao’s gastrointestinal health?
a. Breastfeeding
b. Parenteral nutrition
c. High-calorie formula
d. Additional water to prevent constipation
2. During testing, Bao is found to have a deficiency in galactose-1-phosphate uridyltransferase. Which change
should the nurse expect in Bao’s diet?
a. None until later in life
b. An increase in the number of breastfeedings daily
c. A switch to a low-protein formula
d. A switch to a lactose-free formula
Childhood
Solid foods should be introduced into the diet at 6 months of age. After 1 year of age, most of the infant’s diet should
be solid foods. It is important to initiate healthy eating patterns because many of the habits started during this time
will continue throughout the lifespan. Proper nutritional practices will encourage healthy growth and development,
resulting in a healthy gastrointestinal system.
Young children tend to be extremely active and are growing, so they need high-energy foods, mostly from
carbohydrates (Thomas, 2023). Children aged 5–10 years old require 1500–2000 kcal/day (Thomas, 2023). Their

daily diet should contain appropriately sized portions of 5 or 6 servings of vegetables (in a mix of colors and
including both leafy and nonleafy vegetables) and fruits (of different varieties), 4–6 servings of whole grains, 1 or 2
servings of protein (lean meat, fish, nuts, seeds, tofu), and 2–4 servings of dairy products (Thomas, 2023). They
should receive whole milk until age 2 and then 2% or lower-fat milk daily, with plenty of water and very limited
added sugars and snacks (Ben-Joseph, 2023; Table 18.2).
Food Group Daily Servings Portion Size (Ages Portion Size (Ages Portion Size (Ages
1–3) 4–6) 7–10)
Meats/proteins 2 • 1 oz meat • 1 oz meat • 2–3 oz meat
• ½ egg • 1 egg • 1–2 eggs
• ¼ cup beans • ⅓ cup beans • ½ cup beans
Dairy 2–3 • ½ oz cheese • 1 oz cheese • 1 oz cheese

• ½ cup milk • ½ cup milk • 1 cup milk
• ⅓ cup yogurt • ½ cup yogurt • ¾–1 cup
yogurt
Fruits 2–3 • ¼ cup cooked, • ¼ cup cooked, • ⅓ cup cooked,

frozen, or frozen, or frozen, or
canned canned canned
• ½ piece fresh • ½ piece fresh • 1 piece fresh
• ¼ cup 100% • ⅓ cup 100% • ½ cup 100%
fruit juice fruit juice fruit juice
Vegetables 2–3 • ¼ cup cooked • ¼ cup cooked • ½ cup cooked

vegetables vegetables vegetables
• ½ cup salad • 1 cup salad
Grains 6–11 • ½ slice bread • ½ slice bread • 1 slice bread

• ¼ cup cooked • ⅓ cup cooked • ½ cup cooked
cereal, rice, or cereal, rice, or cereal, rice, or
pasta pasta pasta
• ⅓ cup dry • ½ cup dry • ¾–1 cup dry
cereal cereal cereal
TABLE 18.2 Examples of Recommended Portion Sizes for Children by Age Group. (sources: American Academy of Pediatrics, 2015; García-
Montero, et al., 2023)
An adequate amount of fiber is needed in the diet for gastrointestinal health (Thomas, 2023). Prebiotic and probiotic
foods should be introduced when solid foods are introduced. Some child-friendly foods containing probiotics are
yogurt with live cultures, pickles, kombucha, and cheese; child-friendly foods containing prebiotics include kiwi,
bananas, and apples (Garcia-Montero, et al., 2023). Processed and artificially sweetened foods should be avoided
(Stanford Medicine Children’s Health, n.d.). Another important consideration for gut health is to avoid unnecessary
antibiotics because they can damage and kill helpful bacteria in the gut.
Adolescence
Many expected body changes as well as a growth spurt occur during adolescence. These changes require an
increase in caloric intake to about 2200 kcal/day for females and 2500–3000 kcal/day for males, depending on
activity level such as participation in rigorous sporting activities (Nesta, 2019).
This age group has much more autonomy over their food choices and often eat fast foods because they do not like to
sit and eat but prefer fast convenience. Fast foods can contribute to constipation and need to be balanced with
nutrient-dense foods, high-fiber foods, prebiotics, probiotics, and high-calcium foods to support a healthy growth
and development pattern (Stanford Medicine Children’s Health, n.d.). A good addition to encourage gut health and
increase calcium are leafy green vegetables (Johns Hopkins Medicine, n.d.).
Part B
Study Part A.
Bao has adjusted well to the special diet at birth and transitioned well in late infancy and childhood to an altered
diet. At the age of 13, he begins having diarrhea, blood in the stool, fatigue, and abdominal pain and eventually is
diagnosed with Crohn’s disease. Bao is here today for a wellness visit with Hein.
3. Hein asks how Bao has gotten Crohn’s disease because it does not run in their family. Given Bao’s history,
what put him at increased risk for developing Crohn’s disease?
a. Inability to consume lactose
b. Hein’s pregnancy complications
c. Bao had no increased risk
d. Bao’s lack of adherence to the prescribed diet
4. The nurse is educating Hein and Bao about managing inflammatory periods. Which food should be avoided
during inflammatory periods?
a. Beans
b. Yogurt
c. White rice
d. Chicken
Adulthood
During adulthood, calorie requirements decrease. Current recommendations are 1800–2400 kcal/day for women
and 2400–3000 kcal/day for men, depending on activity level (U.S. Department of Agriculture and U.S. Department
of Health and Human Services, 2020). Gastrointestinal health requires more of a maintenance approach during
adulthood because this system is fully developed at this point in life. Prebiotics and probiotics are still
recommended to maintain gut microbiome health.
Clients should be educated to limit or avoid alcohol and to reduce fats and sodium in the diet for gut health (U.S.
Department of Agriculture and U.S. Department of Health and Human Services, 2020). Additions for nutritional
health include foods rich in iron and calcium (U.S. Department of Agriculture and U.S. Department of Health and
Human Services, 2020). People who smoke should be encouraged to stop because one of the negative effects of
smoking is decreased blood flow to the intestines, which can have a negative impact on gut health.
Later Adulthood
As in early life stages, prebiotic and probiotic foods should be continued in later adulthood, along with a low-sugar
diet. During this stage in the lifespan, men should consume 2000–2600 kcal/day, and women should consume
about 1600–2200 kcal/day because energy expenditure is less than in younger adulthood (U.S. Department of
Agriculture and U.S. Department of Health and Human Services, 2020). It is still important for clients in this age
group to continue a high-calcium diet for bone health.
For gut health, clients should eat a diet high in fiber and water and low in sodium (U.S. Department of Agriculture
and U.S. Department of Health and Human Services, 2020). During this stage in life, constipation may be common.
High fiber will help prevent it, and water is required for the fiber to work effectively. Eating adequate protein is
important in combination with physical exercise because muscle mass can decrease in older adults (U.S.
Department of Agriculture and U.S. Department of Health and Human Services, 2020). Blood flow is increased with
muscle mass and is important for gut health and intestinal health.

18.2 • Nutrition and Chronic Gastrointestinal Illnesses 359
18.2 Nutrition and Chronic Gastrointestinal Illnesses

LEARNING OUTCOMES
• 18.2.1 Discuss the impact of nutrition on chronic gastrointestinal disorders.
• 18.2.2 Discuss the impact of nutrition on acute exacerbation of chronic gastrointestinal disorders.
Nutritional Requirements for Optimal Health With Gastrointestinal Illness

When gastrointestinal illness is present, prebiotics and probiotics are still recommended; however, there are
additional recommendations to aid in gut health. High-fiber diets and high water intake are beneficial during
nonexacerbation periods in gastrointestinal disease. However,
SAFETY ALERT
Contraindications for High Fiber Intake

When a client is experiencing inflammation of the gastrointestinal tract due to illness such as ulcerative colitis,
Crohn’s disease, diverticulitis (inflammation of diverticula, which are bulging pouches that can form along the
intestines), or any other acute condition, high fiber intake is contraindicated because it can irritate the intestinal
lining and increase inflammation.
There are basic recommendations for gut health for individuals with gastrointestinal disease. Foods high in
saturated fats and trans fats should be avoided because they increase inflammation. Healthy fats, such as omega-3
fatty acids and monounsaturated fats, may help decrease inflammation and should be used in place of less healthy
fat (Nebraska Medicine, 2022). An anti-inflammatory diet is helpful overall in gastrointestinal illness. Antioxidants
found in foods such as avocados, broccoli, spinach, carrots, potatoes, and artichokes may help decrease
inflammation. Phytonutrients found in fruits and vegetables may help to protect against inflammation (Nebraska
Medicine, 2022). The Mediterranean diet follows the principles of anti-inflammatory nutrition.

Supplementation for gut health is often needed when gastrointestinal disease is exacerbated and in the
inflammatory phase because malabsorptive issues occur most often during this time. Supplementation adds higher
levels of needed nutrients to increase the chances of adequate absorption. In some severe cases, parenteral
supplementation may be required.
Food alternatives and simple replacements can be beneficial for promoting gut health, whether illness is present or
not (Table 18.3).
Food Replacement for Improved Gut Health

Milk Kefir
Sugary drinks Kombucha
Milk, cheese curd, Greek yogurt
mayonnaise
Red meats Fruits and vegetables, fish, chicken
Sugary cereals Oats
White bread Sourdough bread
Nonsprouting lentils Sprouting lentils
TABLE 18.3 Food Replacements to Improve Gut Health (sources: Crohn's and Colitis Foundation, n.d.; Johns Hopkins Medicine, n.d.;
Nebraska Medicine, 2022)

LEARNING OUTCOMES
• 18.3.1 Identify drug–food interactions for their impact on treatments used for gastrointestinal disorders.
gastrointestinal disorders.
Drug–Food Interactions Related to Treatments for Gastrointestinal Disorders

Medications used to treat Crohn’s disease and UC are in the anti-inflammatory and immunosuppressant classes.
The most frequently used medications for Crohn’s disease treatment are azathioprine and mercaptopurine. A client
with UC is most often prescribed balsalazide, mesalamine, olsalazine, or sulfasalazine. For diverticulitis, antibiotics
are needed; the most commonly used are ciprofloxacin plus metronidazole, trimethoprim-sulfamethoxazole plus
metronidazole, amoxicillin-clavulanate, and moxifloxacin.
Drug–food interactions are a concern when prescribing these drugs, so clients must be educated about specific
interactions to avoid adverse effects (Table 18.4).
Food Food Interaction

Azathioprine • Avoid raw or half-cooked foods (can cause foodborne illness).
Mercaptopurine • Take 1 hour before or 2 hours after ingestion of milk or dairy products (reduces
absorption when taken with food).
Balsalazide • Swallow right away if taken with food as an open capsule (mixing with food can cause
staining of the tooth enamel).
• Review medication insert for information on mixing medication with applesauce.
Mesalamine • Take this medication on an empty stomach—at least 1 hour before meals or 2 hours
after meals when taking specifically the Asacol HD version of this medication.
Olsalazine • Drink plenty of water with this medication to protect the kidneys.
• Avoid smoking (decreases medication effectiveness).
Sulfasalazine • Avoid alcohol and spicy foods (increases risk for indigestion).
Metronidazole • Avoid alcohol during and 24 hours before and after treatments (can cause serious
adverse effects).
Sulfamethoxazole- • Avoid alcohol (can cause serious adverse effects).

Trimethoprim
Amoxicillin- • No interactions.
Clavulanate
Moxifloxacin and • Avoid dairy products (can make less effective).
Ciprofloxacin • Avoid vitamins containing iron, magnesium, calcium, or zinc within 4 hours before and
after taking this medicine (can make the drug and the vitamins less effective).
TABLE 18.4 Foods to Avoid When Taking Certain Drugs (sources: Cancer Research UK, 2022; Mayo Clinic, n.d.; Mayo Clinic, 2023; NHS,
2021; Offices of Disease Prevention and Health Promotion, 2023; PeaceHealth, 2023)

Avoiding certain foods is not the only concern that needs to be addressed regarding treatments. Many of the
medications already described can also cause nutritional deficiencies. The client must know which foods they can
increase in their diet to prevent deficiency (Table 18.5).

Drug Nutrient Deficiency Foods to Replace Nutrients

Azathioprine • Niacin (vitamin B3) • Red meat, poultry, fish, brown rice, nuts, seeds,
legumes, bananas
Mercaptopurine • Hypoglycemia in • Complex carbohydrates, along with monitoring of

children younger than glucose levels
6 years old when
administered in a
liquid form
Balsalazide • Folic acid can reduce • Dark green leafy vegetables, beans, peanuts, sunflower
Olsalazine adverse effects of the seeds, whole grains, liver
Sulfasalazine medication
Mesalamine
Ciprofloxacin • Bifidobacterium • Kefir, sourdough bread, sauerkraut, kimchi, other
Moxifloxacin bifidum fermented vegetables
• Lactobacillus • Milk enriched with acidophilus, yogurt containing live L.
acidophilus acidophilus cultures, miso, tempeh
• Biotin • Legumes, egg yolks, organ meats, nuts, seeds,
• Folic acid mushrooms, avocados, sweet potatoes
• Inositol • Dark green leafy vegetables, beans, peanuts, sunflower
• Vitamin B1 (thiamin) seeds, whole grains, liver
• Vitamin B2 • Whole-grain bread and bran, prunes, cantaloupe, citrus
(riboflavin) fruits, beans, peas, almonds, peanut butter, liver
• Vitamin B3 (niacin) • Fortified breakfast cereals, pork, fish, beans, lentils,
• Vitamin B6 green peas, enriched cereals, breads, noodles, rice,
(pyridoxine) sunflower seeds, yogurt
• Vitamin B12 • Dairy milk, yogurt, cheese, eggs, lean beef and pork,
(cobalamin) organ meats (beef liver), chicken breast, salmon
• Vitamin K • Red meat, poultry, fish, brown rice, nuts, seeds,
legumes, bananas
• Fish, beef liver and other organ meats, potatoes and
other starchy vegetables
• Fish, meat, poultry, eggs, dairy products
• Kale, collard greens, broccoli, spinach, cabbage, lettuce
TABLE 18.5 Nutritional Deficiencies Caused by Pharmacologic Therapies and Foods to Replace Those Nutrients (sources: Kaiser
Permanente, 2015; Mayo Clinic, 2023; Naeini et al., 2021; Peace Health, 2015; Prescott et al., 2018; Ratajczak, et al., 2021)
Drug Nutrient Deficiency Foods to Replace Nutrients

Metronidazole • Calcium • Dairy products, soybeans, dark green leafy vegetables,
• Carbohydrates calcium-fortified foods, canned salmon, figs
• Beta-carotene • Grains, fruit, dairy products, legumes
• Fats • Yellow, orange, and green fruits and vegetables
• Folic acid • Fish, avocados, seeds, nuts, olive oil, eggs
• Iron • Dark green leafy vegetables, beans, peanuts, sunflower
• Magnesium seeds, whole grains, liver
• Potassium • Nuts, dried fruits, iron-fortified breads and cereals,
• Sodium legumes, oats, tofu
• Vitamin A • Smoked, cured, salted, or canned meat, fish, or poultry;
• Vitamin B12 frozen breaded meats; frozen processed foods such as
(cobalamin) burritos and pizza; canned entrees (like canned pasta in
• Vitamin D tomato sauce); salted nuts
• Vitamin K • Leafy green vegetables, orange and yellow vegetables,
tomatoes, red bell peppers, cantaloupes, mangos, beef
liver, fish oils, milk, eggs
• Cod liver oil, salmon, swordfish, tuna, sardines, beef
liver, vitamin D–fortified orange juice and dairy and plant
milks
Sulfamethoxazole- • Vitamin K • Kale, collard greens, broccoli, spinach, cabbage, lettuce

Trimethoprim • Calcium • Dairy products, soybeans, dark green leafy vegetables,
• Magnesium canned salmon, figs
• Vitamin B12 • Pumpkin seeds, chia seeds, almonds, boiled spinach,
(cobalamin) cashews, peanuts, soy milk
Amoxicillin- • Vitamin K • Kale, collard greens, broccoli, spinach, cabbage, lettuce

Clavulanate • Vitamin B12 • Fish, meat, poultry, eggs, dairy products
(cobalamin) • Dark green leafy vegetables, beans, peanuts, sunflower
• Folic acid seeds, whole grains, liver
• Potassium • Dried fruits, beans, lentils, potatoes, winter squash
• Vitamin B2 (acorn, butternut), spinach, broccoli, beet greens,
(riboflavin) avocados
• Milk, yogurt, cheese, eggs, lean beef and pork, organ
meats (beef liver), chicken breast, salmon
TABLE 18.5 Nutritional Deficiencies Caused by Pharmacologic Therapies and Foods to Replace Those Nutrients (sources: Kaiser
Permanente, 2015; Mayo Clinic, 2023; Naeini et al., 2021; Peace Health, 2015; Prescott et al., 2018; Ratajczak, et al., 2021)

Chapter Summary
• Gastrointestinal system health starts before birth affect the gastrointestinal system and the ability to
with the microbiome of the pregnant client. absorb nutrients properly.
• Prebiotic and probiotic foods are essential for • Individuals with chronic gastrointestinal illness
everyone because they support the gut have increased malabsorption risks and
microbiome. requirements.
• Supporting the gut microbiome is one of the most • Medications for gastrointestinal illnesses can
important ways to promote gastrointestinal health. cause nutrient deficiencies and interact with
• Events and changes that occur at each stage can different foods.
Key Terms
Crohn’s disease a chronic inflammatory disease that microbiome a collection of microorganisms that
can cause ulcerations and fistulas in the intestines, reside in the body, primarily in the gastrointestinal
particularly the colon and ileum tract
diverticulitis inflammation of diverticula, which are necrotizing enterocolitis a gastrointestinal tract
bulging pouches that can form along the intestines disease in which the intestinal lining becomes
dysbiosis imbalance of gut microbiota associated inflamed, dies, and is sloughed off
with an unhealthy outcome prebiotic nondigestible substances that stimulate
galactosemia a genetic disorder in which the growth of “good” gut bacteria
galactose-1-phosphate uridyltransferase (GALT) probiotic foods that contain live microorganisms
enzyme is missing or does not function properly intended to maintain “good” gut bacteria
hyperemesis gravidarum persistent and severe short bowel syndrome a group of problems related
vomiting caused by pregnancy; can lead to weight to ineffective absorption of nutrients
loss and dehydration ulcerative colitis (UC) an inflammatory disease that
malabsorption a digestive disorder that causes the affects the superficial lining of the large intestine,
body not to absorb nutrients from food effectively causing ulcerations
Review Questions
1. A nurse is educating a pregnant client about factors that affect the fetal microbiome. Which choice, when
asked what factors affect their fetus’s microbiome, indicate the need further teaching?
a. The father’s microbiome
b. The mother’s microbiome
c. The child’s diet
d. Interaction with the environment
2. What is the caloric intake a nurse should expect the provider to order for a premature infant?
a. 2000 kcal/day
b. 120 kcal/kg/day
c. 100 kcal/kg/day
d. 1500 kcal/day
3. The nurse is educating a group of pregnant clients about genetic diseases. Which disease should the nurse
explain will need lifelong management due to the individual’s inability to convert lactose into glucose?
a. Diverticulitis
b. Ulcerative colitis
c. Crohn’s disease
d. Galactosemia
4. The nurse is teaching a client about the nutritional needs of their adolescent child. Which information should
be included in the education?
a. Young males need fewer calories than young females do.
b. Adolescent females require 3000 kcal/day.
c. Fast foods need to be supplanted with healthier options.

d. Adolescents need less iron intake daily than other age groups.
5. The nurse is teaching an adult client how to maintain good gut bacteria. Which foods would be appropriate for
the client to include in their diet to maintain good gut bacteria?
a. Blueberries, strawberries, and kiwi
b. Salmon and tuna
c. Broccoli and cauliflower
d. Yogurt, kimchi, and honey
6. An older adult reports a problem with constipation. Which dietary recommendation is appropriate for this
client?
a. Decrease water intake.
b. Increase sodium intake.
c. Decrease calcium intake.
d. Increase fiber intake.
7. The nurse is providing teaching to a client with ulcerative colitis. Which nutritional component should be
adjusted when the client is in remission?
a. Water intake
b. Fiber intake
c. Iron intake
d. Potassium intake
8. The nurse is teaching a client about food substitutions to help improve gut health. Which substitution is
appropriate for milk?
a. Ice cream
b. Greek yogurt
c. Kefir
d. Kombucha
9. The nurse is working with a client who has diverticulitis and has been prescribed ciprofloxacin. Which food
should this client avoid while taking this medication?
a. Red meat
b. Milk
c. Tomatoes
d. Oatmeal
10. The nurse is providing discharge education to a client who has been prescribed amoxicillin. Which food
should the nurse instruct the client to incorporate into their diet to help prevent medication-related nutrient
depletion?
a. Beans
b. Whole grains
c. Sunflower seeds
d. Kale
Suggested Reading
Anderson-Haynes, S. (2021, April 21). Diet, disease, and the microbiome. https://www.health.harvard.edu/blog/
diet-disease-and-the-microbiome-2021042122400
de Vos W. M., Tilg H., Van Hul, M., & Cani, P. D. (2022). Gut microbiome and health: Mechanistic insights. Gut,
71,1020–1032. https://gut.bmj.com/content/71/5/1020.info
Holcombe, M. (2022, June 23). 3 ways to improve your health through your microbiome. https://www.cnn.com/

2022/06/23/health/microbiome-health-wellness/index.html
Hou, K., Wu, Z., Chen, X., Wang, J., Zhang, D., Xiao, C., Zhu, D., Koya, J., Wei, L., Li, J., & Chen, Z. (2022). Microbiota
in health and diseases. Signal Transduction and Targeted Therapy, 7(1), 135. https://doi.org/10.1038/
s41392-022-00974-4
Leonard, J. (2019). 10 ways to improve gut health. https://www.medicalnewstoday.com/articles/325293
Weaver, J. (2021, July 12). Fermented-food diet increases microbiome diversity, decreases inflammatory proteins,
study finds. https://med.stanford.edu/news/all-news/2021/07/fermented-food-diet-increases-microbiome-
diversity-lowers-inflammation

CHAPTER 19
Nutrition for Musculoskeletal and
Integumentary Wellness
FIGURE 19.1 Proper nutrition promotes a healthy integumentary and musculoskeletal system. (credit: modification of work “Balsamic
Roasted Turkey Salad Ingredients” by Alabama Extension; ACES | Janet Guynn/Flickr, Public Domain)
CHAPTER OUTLINE
19.1 Assess and Analyze the Impact of Nutrition on the Musculoskeletal and Integumentary Systems
19.2 Plan Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness
19.3 Implement Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness
19.4 Evaluate Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness
INTRODUCTION These two systems, musculoskeletal and integumentary, are considered together because they
are dependent upon one another to keep the body in homeostasis. The musculoskeletal system comprises bones,
muscles, ligaments, and tendons and is a part of the body’s internal environment that supports the muscles,
protects the organs, and aids in movement. The integumentary system encompasses the skin, hair, nails, sweat
glands, sebaceous glands, and nerves on the skin. The integumentary system serves as a barrier to protect the
musculoskeletal system and other systems from the external environment. Subcutaneous fat absorbs impact from
the external environment and protects the musculoskeletal system from trauma. The skin serves as a barrier against
germs that would attempt to invade the body and cause harm (Academic Master, Biology, 2018).
A good example of the relationship between the two systems is seen with pressure wounds. As the outer layer of the
skin suffers irritation and damage, there is potential risk for the progression of the wounds through the
subcutaneous fat, tendons, and even the bones. When this happens, bone inflammation from
368 19 • Applying Clinical Judgment to Promote Nutrition for Musculoskeletal and Integumentary Wellness
infection—osteomyelitis—occurs. With this relationship in mind, it is imperative that the skin integrity of the client
always be maintained. Adequate intake of proper nutrients is essential for the musculoskeletal system for bone
growth and bone health. The quality and amount of nutritional intake affects muscle mass, strength, and the ability
for muscles to repair themselves after injury. The integumentary system is also dependent on essential dietary
nutrients to maintain integrity and proper functioning. Many disease processes affect both the musculoskeletal and
the integumentary systems.
Consider this case: Mrs. Anne Wilson, a 70-year-old Black woman is referred by the primary care provider to a
rheumatologist for complaints of pain and swelling in both knees. Anne states that the ibuprofen that was earlier
prescribed is no longer treating the pain. The nurse at the rheumatologist’s office notices that Anne appears anxious
with a facial grimace and states that she is having 8/10 pain in both knees. The client states that she only got a few
hours of sleep last night due to the pain. Anne reports that she exercises daily by walking, but she admits that her
nutritional intake could improve.
19.1 Assess and Analyze the Impact of Nutrition on the Musculoskeletal and
Integumentary Systems
LEARNING OUTCOMES
• 19.1.1 Recognize the normal function of the musculoskeletal and integumentary systems.
• 19.1.2 Recognize cues of nutritional impact on the musculoskeletal and integumentary systems.
• 19.1.3 Analyze cues of nutritional impact on the musculoskeletal and integumentary systems.
Normal Function of the Neurological System

The impact of nutrition on the musculoskeletal and integumentary systems cannot be explained without first
reviewing the normal function of the neurological system. The neurological system and the musculoskeletal system
relate to one another in that the brain and nerves tell the voluntary muscles what to do. In response to the
messages sent to the brain through the nerve pathways, muscle fibers become tense and cause the muscles to
contract.
The brain is the most complex organ in the body. The brain is divided into lobes each having a specific function in the
neurological system. The frontal lobes are responsible for imagination, memory, and reasoning. Damage to a frontal
lobe is often manifested in memory loss and poor judgment and often follows a cerebrovascular accident (CVA).
When this lobe is not functioning properly, secondary issues related to the musculoskeletal and integumentary
systems emerge. For example, after injury to the frontal lobe, a client may not recognize the importance of mobility
and skin care. Therefore, damage to this area of the brain may have detrimental secondary consequences on the
musculoskeletal and integumentary systems (National Institute of Neurological Disorders and Stroke, 2023;
National Library of Medicine, 2022).
Important structures in the inner brain that play a part in musculoskeletal and integumentary function, like the
basal ganglia, initiate and coordinate movements. Diseases of the cells leading into the basal ganglia, such as
Parkinson’s disease, result in disturbance of movement as seen with tremors. The other important structures in the
inner brain include the hypothalamus, thalamus, and hippocampus, which do not directly affect the musculoskeletal
or integumentary systems (National Institute of Neurological Disorders and Stroke, 2023, National Library of
Medicine, 2022).
Assessment of Nutrition and the Function of the Musculoskeletal and Integumentary

Systems
Nutrition plays a key role in the development of a healthy musculoskeletal and integumentary system. Nurses are
taught to holistically view the client during the initial and ongoing assessment to reveal and relay any problems with
the client that may help the health care provider in diagnosing and treating the client. Delays in diagnosing and
treating the client with nutritional deficiencies can lead to muscle wasting, bone fractures, skin ulcerations, and so
much more. Many of the complications of inadequate nutrition are irreversible and even life threatening as related to
the musculoskeletal and integumentary systems. After surgery and at other times of stress on the body, the
importance of an accurate nutritional assessment cannot be underestimated.

19.1 • Assess and Analyze the Impact of Nutrition on the Musculoskeletal and Integumentary Systems 369
The benefits of eating properly for the musculoskeletal and integumentary systems include healthy skin, muscles,
bones, and teeth, as well as maintaining a healthy weight which, in turn, affects the cardiovascular system, the
endocrine system, and so on. Maintaining a proper body weight through good nutrition leads to healthier joints,
muscles, tendons, and bones because there is less stress on the musculoskeletal system. Musculoskeletal and joint
problems such as osteoarthritis are often worse for people who are overweight (Centers for Disease Control and
Prevention, 2022). Maintaining a healthy weight lowers the risk of heart disease, hypertension, stroke, and type 2
diabetes, breathing problems and sleep apnea, anxiety, and other conditions in other body systems.
With all the problems associated with inadequate nutritional intake on the musculoskeletal and integumentary
systems, the nurse has a priority of completing a full intake history of the client and proper follow-up assessment.
From there, the nurse can develop a plan of care for the client. This ensures that the client is assisted in maintaining
physiological and psychological integrity throughout the course of their treatment.
The health history should focus on past surgical history, including possible complications of previous surgeries and a
family medical history as many of the musculoskeletal and integumentary disorders have heredity tendencies. Some
of the most important medical history to obtain in these system categories include history of rheumatoid arthritis or
other autoimmune disorders (when the body’s immune system attacks and destroys healthy body tissue).
Osteoarthritis, osteoporosis, osteopenia, scleroderma, systemic lupus erythematous (SLE), and eczema are just
some of the genetically inherited diseases of the musculoskeletal and integumentary systems (Orthopedic
Oncology, 2023).
Normal Function of the Musculoskeletal and Integumentary Systems

Bones, muscles, tendons, ligaments, joints, and connective tissue hold the body together. The main function of the
musculoskeletal system is to support the body. This system also allows for movement of the body as well as
providing protection for internal organs. The bones that comprise the skeletal system store calcium and
phosphorus—minerals important to body function—blood components, and certain fats. The skeletal muscles
attached to bones are empowered by nerves with electrical current from the central nervous system. These nerves
located throughout the muscles allow for the contraction of the muscles. Only two types of muscles, the skeletal
muscles and the smooth muscles, are considered a part of the musculoskeletal system. The skeletal muscles
provide for the movement of the body and the smooth muscles are found in intestinal and vessel walls. Ligaments
and tendons help with body movement by connecting bones together to form joints (LibreTexts Medicine, 2019).
Aging influences the musculoskeletal system. As a person ages, height decreases because calcium, phosphorus,
and other minerals are lost. Fluid decreases between the disks in the vertebrae of the spine, which can cause pain
and deformity. Joints tend to lose cartilage contributing to stiff joints and joint pain. This contributes to
osteoarthritis and worsens its symptoms associated. Working to maintain a healthy musculoskeletal system is
important throughout the lifespan (Academic Senate for California Community Colleges (ASCCC) Open Educational
Resources Initiative, 2021).
TRENDING TODAY
Skin, Aging, and the Impact of Food

Research shows a link between aging skin and nutrition (Cao et al., 2020). From water to protein and specific
vitamins and trace elements, several elements play a crucial role not only in aging of the skin, but also in the
ability of the skin to remain intact and function as a first line of defense against microorganisms.
On social media, TikTok influencer Joy McCarthy (@joyoushealth) promotes the use of sprouts for detoxifying the
body, thus enhancing skin appearance. Similarly, Dr. Dray suggests the use of foods to promote collagen
production, which assists in delaying the aging process by maintaining skin elasticity and moisture.
and its appeal to clients:
• @joyoushealth (https://openstax.org/r/joyoushealth) (TikTok)

• The Best Foods for Collagen Production | Dr. Dray (https://openstax.org/r/collagen) (YouTube)

3. Do these sources adhere to EBP, and why are the recommendations realistic or unrealistic?
The integumentary system is made up of the skin and accessory structures—such as hair, nails, sweat glands, and
sebaceous glands—and is the largest organ system in the human body. The function of the integumentary system is
to protect the body from invading microorganisms, chemicals, and other environmental irritants. The skin helps to
control temperature and regulate electrolytes by preventing dehydration. The skin and its structures play a role in
storing fats and synthesizing vitamin D. The integumentary system is susceptible to diseases and injuries, many of
which are life threatening. Maintaining a healthy integumentary system is vital for maintaining good health.
Musculoskeletal tissue is especially vulnerable to injury (ASCCC Open Educational Resources Initiative, 2021).
Assessment of the Musculoskeletal and Integumentary Systems

Nursing assessment of the musculoskeletal system involves the collection of subjective and objective data.
Subjective data is gathered through a thorough interview of the client’s past medical and surgical history, family
medical history, current medical problems, lifestyle history, and nutritional history. The following interview
questions are good examples that focus on the musculoskeletal system:
• Are you experiencing any pain, weakness, swelling, or stiffness in any of your bones/joints?
• Have you ever been told that you have a long-term musculoskeletal disease such as osteoarthritis or
rheumatoid arthritis?
• Have you ever been diagnosed with nerve pain that affects the muscles of any of your extremities?
• Have you ever had any fractures, sprains, or strains that required medical treatment?
• Have you ever been told you had tendonitis or bursitis?
• Have you ever had any orthopedic surgeries?
• Have you ever had to undergo physical therapy for pain management?
• What is the list of your current medications including herbs and supplements?
Objective data is gathered as the nurse observes or inspects the client’s posture, movements, gait, deformities,
muscle tone, and range of motion. Range of motion reflects the client’s ability to move their joints actively or
passively.
General objective findings within the healthy musculoskeletal system are muscles with no wasting, no edema noted
over bones and joints, and skin color appropriate for skin tone over bones, joints, ligaments, and muscles.
Assessment findings should include posture that is well balanced with the head positioned over the shoulders, a
slight curve in the lower back, and a level pelvis. The knees are symmetrical, the toes face forward when standing,
and the shoulders and extremities are all symmetrical.
In healthy individuals, the movement of the musculoskeletal system is not restricted. There is full range of motion
(ROM), which is defined as the movement potential of the joints using flexion and extension. Movement is fluid and
smooth with no sounds heard from joints upon movement. There is full symmetrical muscle strength in all
extremities. The gait is balanced with no shuffling or limping. A center of gravity is maintained when standing—there
is no leaning or swaying, dragging feet, or waddling. Full ROM is evidenced by no pain.
The healthy musculoskeletal system is strong and symmetrical. Strong active movement is noted against gravity and
resistance. Muscle tone is a measure of a muscle’s resistance to stretching while at rest. Even when at rest, muscle
fibers are at least partially contracted, so muscle tone should have no flaccidity.

MUSCULOSKELETAL SYSTEM
Access multimedia content (https://openstax.org/books/nutrition/pages/19-1-assess-and-analyze-the-impact-

of-nutrition-on-the-musculoskeletal-and-integumentary-systems)
Nursing.com and Jon Haws, RN, provide a video review of how to perform a musculoskeletal assessment of the
spine and upper and lower extremities.
Nursing assessment of the integumentary system can often be done simultaneously with the musculoskeletal
system. If fact, observing for redness and swelling in the joints as already described relates both to the
musculoskeletal and integumentary systems. This is why these systems are grouped together. One system
influences the other and abnormal findings are typically related to both systems. Another example is for the sprain
and strain mentioned earlier—the skin will reflect bruising (ecchymosis) and swelling.
General objective findings within the healthy integumentary system includes normal skin, hair, and nails. Skin
should be distributed over the body in three tissue layers, all intact without any breaks in the skin. Healthy skin is
free of lesions, ulcers, irritations, skin tears, blisters, and sores. The color is appropriate for race with no
disturbances in pigmentation. Birthmarks and moles are smooth and consistent in color. Skin is warm and dry or
appropriate for present environmental factors. Skin temperature does not vary from one site on the body to another.
Normal moisture level is indicated by good skin turgor, with no tenting. To measure skin turgor, pinch up skin on the
back of the hand and observe for tenting (when the skin stands up like a tent).
The hair of a healthy integumentary system is equally distributed in places where hair should be growing. There is
no hair loss or hair growing where it does not belong. Texture is within normal limits for client per genetics,
hormones, and chemical use. There are sufficient oils to prevent breakage. No parasite infestation is noted, and
there is no fungus on the scalp.
The nails are translucent with pinkish tone. The base of the nail is about 160 degrees with normal sized fingertips.
There is no clubbing and no spoon-shaped nails. The nails should be smooth and firm. The nails are clean, with no
material growing under the nails. The cuticles are intact, and the surrounding skin is intact with no redness or
edema (Figure 19.2).
FIGURE 19.2 An assessment includes nail color and shape. (credit: “Fingernails, about 2 mm long, just the right length” by Kommissar/
Wikimedia Commons, Public Domain)
Tests Used in the Assessment of the Musculoskeletal and Integumentary Systems

During the assessment, nurses and providers use screening tests to determine objective findings in the
musculoskeletal and integumentary systems. The provider uses this information to determine the diagnostic tests
needed. The provider combines subjective data with these objective findings to help make a diagnosis. Refer to
Table 19.1 for screening and diagnostic tests used for the musculoskeletal system.
Screening Tests for Musculoskeletal System Diagnostic Tests for Musculoskeletal System
• Neuropathy impairment score (NIS) • Radiology and nerve studies
• Active and passive ROM ◦ X-ray
• Bilateral hand grip test ◦ Computerized tomography (CT) scan
• Bilateral foot push test ◦ Magnetic resonance imaging (MRI)
• Morse, or other, fall risk assessment ◦ Ultrasound
• Swollen joint count ◦ Arthroscopy
• Auscultation for crepitus ◦ Electromyography (EMG)
• Gait assessment ◦ Bone scan
• Use of ambulatory device ◦ Dual-energy x-ray absorptiometry (DXA)
• Use of prosthesis ◦ Ultrasound
• Labs
◦ Creatinine kinase
◦ Creatine Phosphokinase (CPK)
◦ Anti-cyclic citrullinated peptide (anti-CCP) antibody
◦ Erythrocyte sedimentation rate (ESR)
◦ Antinuclear antibody (ANA)
◦ Complete blood count (CBC)
◦ Serum calcium
◦ Rheumatoid factor
◦ C-reactive protein (CRP)
◦ Tissue biopsy
TABLE 19.1 Screening and Diagnostic Musculoskeletal Tests (sources: LibreTexts Musculoskeletal Assessment; 2022; Pagana & Pagana,
2023)
The nurse’s assessment of the integumentary system includes the skin, hair, and nails. Abnormalities found in this
system often reflect a dysfunction in other body systems. See Table 19.2 for screening tests and diagnostic tests for
the integumentary system.
Screening Tests for Integumentary System Diagnostic Tests for Integumentary System
• Capillary refill • Patch testing (a skin test for allergies)
• Skin turgor test • Biopsy
• Grading of edema test (pitting test seen in Figure 19.3) • Scraping (a test for obtaining superficial
• Staging of pressure ulcers dead skin for testing)
• Braden Scale (assessment tool using six categories to • Diascopy (a test for determining
determine risk for pressure injury) blanchability of the skin)
• Burn classification • Wood light test (a black light test used to
diagnose lesions)
• Tzanck testing (a test used to diagnose viral
disease with active vesicles)
• Culture and sensitivity
TABLE 19.2 Screening and Diagnostic Integumentary Tests (sources: Bendetti, 2021; Mazzasette, 2021)

FIGURE 19.3 A recurrent erysipelas is evident on an edematous leg. (credit: “Recurrent erysipelas on edematous leg” by Mikael
Häggström/Wikimedia Commons, Public Domain)
Part A
Anne Wilson, a 70-year-old Black woman is referred by the primary care provider to a rheumatologist for complaints
of pain and swelling in bilateral knees. Anne states that the ibuprofen that was earlier prescribed is no longer
treating the pain. The nurse at the rheumatologist’s office notices that Anne appears anxious with a facial grimace.
Anne states that she is having 8 out of 10 pain in both knees and that she only got a few hours of sleep last night due
to the pain. Anne reports that she exercises daily by walking, but she admits that her nutritional plan (meal plan)
could improve.
The provider enters the examination room to see Anne. On assessment, both knees are swollen with no redness or
discoloration noted. The client denies injury to the knees or legs and has no history of falls. The client is taking short,
tentative steps on observance of ambulation. The client admits that legs are stiff. No pain in both feet is reported.
Anne said her primary doctor thinks she has arthritis and needs to see a rheumatologist. Client vitals are listed in the
following table.
Vital Signs
Temperature: 98.4°F
Blood pressure: 142/88 mm Hg
TABLE 19.3
1. Based on these findings and client history, what screening tests should the nurse perform?
a. Morse fall risk assessment
b. NIS
c. Passive and active ROM
d. Braden scale
2. What diagnostic testing would the nurse expect the rheumatology provider to order?
a. X-ray of both knees
b. Vitamin D level
c. Tissue biopsy
d. Serum electrolyte panel
After x-rays, C-reactive protein, ESR, client history, and physical examination, the client was diagnosed with
osteoarthritis in both knees.
Anne is treated with ibuprofen 600 mg, 3 times daily, and instructed to follow up with the provider in 6 weeks for re-
evaluation to determine if the prescribed nonsteroidal anti-inflammatory drug (NSAID) is working. Anne is also
referred to physical therapy for strengthening and gait training. The nurse plans to provide nutritional education
before discharging the client.
Analysis of Nutrition and the Musculoskeletal and Integumentary Systems

A complete health history—including client dietary habits—is essential to any nursing assessment of the
musculoskeletal and integumentary systems. A person’s diet impacts how the body remains in a state of
homeostasis, how it heals, and how it helps to fight off diseases.
See Table 19.4 for abnormal objective assessment findings for the musculoskeletal system and nutritional factors
that are related to the abnormal assessment findings. Nutritional factors related to musculoskeletal disorders are
shown in Table 19.5.

Abnormal Objective Findings in the Musculoskeletal System

• Posture
◦ Kyphosis (an excessive outward curvature of the spine)
◦ Lordosis (an excessive inward curvature of the spine)
◦ Scoliosis (a sideways curvature of the spine)
◦ Intoeing (foot turned inward)
◦ Genu varum (bowing of legs)
• Asymmetry of shoulders and extremities
• Movement
◦ Limited ROM
◦ Crepitus (a grating sound produced by friction between bone and cartilage or bone and bone)
◦ Popping
◦ Limited muscle strength
◦ Balance disturbance
◦ Gait disturbance, including limping, leaning, falling or near falls, shuffling the feet, dragging the feet,
waddling, swaying
◦ Pain with movement
• Rheumatoid arthritis
• Osteoarthritis (a degenerative joint disease resulting in chronic pain and often edema)
• Scleroderma
• Psoriatic arthritis (a long-term inflammatory disease of the joints)
• SLE
• Inflammatory joint disease
• Cellulitis
• Sprains and strains
• Muscle soreness
• Strength
◦ Alterations in muscle tone
◦ Muscle atrophy, flaccid muscles
◦ Asymmetry of strength in extremities
◦ Fractures
◦ Osteoporosis
◦ Osteopenia
◦ Paget’s disease
• Observation
◦ Pressure injuries
◦ Skin tear
◦ Muscle tear
TABLE 19.4 Nutritional Relationship to Musculoskeletal Abnormalities (sources: Bendetti, 2021; Nursing Skills, 2023; Saeg, 2021)
Disorder Foods and Nutrients

Inflammation Anti-inflammatory foods:
• Tomatoes
• Olive oil
• Nuts
• Fatty fish
• Fruits
◦ Pineapple (contains a a group of enyzmes called bromelain)
Muscle and tissue Foods that aid in the repair of muscle and tissue:
damage • Protein-rich foods
◦ Lean turkey, chicken
◦ Fish
◦ Beans
◦ Peas
◦ Lentils
◦ Tofu
◦ Yogurt
◦ Eggs
◦ Cottage cheese
• Fiber-rich foods
◦ Fruits
◦ Vegetables
◦ Legumes
◦ Whole grains
• Vitamin C
◦ Citrus fruits
◦ Orange juice
• Omega-3 fatty acids

◦ Fatty fish (salmon, tuna)
• Zinc-rich foods
◦ Meat
◦ Poultry
◦ Seafood
◦ Liver
Bone disorders Foods that aid in bone growth and repair:

• Calcium-rich foods
◦ Milk
◦ Cheese
◦ Kale
◦ Yogurt
• Vitamin D
◦ Egg yolk
◦ Fatty fish
◦ Milk
TABLE 19.5 Nutritional and Musculoskeletal Relationship (sources: Bendetti, 2021; Meacham 2022; Saeg, 2021)
Pressure injuries must be treated with optimal nutrition for tissue healing. Using the guidelines from Johns Hopkins
Medicine (2023), pressure injury assessment and classification includes:

• Stage 1: A red, blue, or purplish area appears on the skin. This area, which looks like a bruise, may be warm to
the touch, burn, or itch.
• Stage 2: The area becomes an open sore that looks like an abrasion or blister and can be painful. The skin
around the wound may be discolored.
• Stage 3: The wound deepens, with a crater-like appearance, and often has dark patches of skin around its
edges.
• Stage 4: The wound extends even deeper to the muscle, bone, or joints. This can cause osteomyelitis, which is a
serious bone infection. It may also lead to sepsis (a life-threatening inflammatory response to a massive
infection).
An analysis of nutritional effects on abnormal findings within the integumentary system is listed in Table 19.6. The
nurse should understand the relationship between nutrition and abnormal findings in the integumentary system so
that the client can receive appropriate nutritional education.
Abnormal Objective Findings in the Related Nutritional Associated Foods

Integumentary System Factors
Hair
• Alopecia (hair loss) Overall hair health: • Liver, egg yolk, salmon, sweet
• Hirsutism (an abundance of hair in biotin potatoes, cauliflower
places where hair is normally
scarce or absent) Vitamin B12 (cobalamin) • Liver, salmon, tuna, yogurt, eggs
• Coarse texture
Folate • Asparagus, oranges, white beans
• Fine texture
• Breakage of hair Iron • Liver, beef, chicken, lamb, ham
Hair – Parasite Infections

• Lice, nits, scabies No related nutritional
• Scalp ringworm factors for parasite
infestations
Skin – Temperature
• Hot or warm, cold, or cool with No related nutritional
variations in temperature factors for skin
temperature
Skin – Color
• Skin discoloration: blue, gray, red, Pigmentation: vitamin C • Citrus fruits, strawberries, broccoli
white, yellow, darkened
• Presence of pigmentation
disturbance (vitiligo)
• Moles or birthmarks
Skin – Moisture Level

• Dry, cracked skin Zinc • Eggs, meat and poultry, seafood,
• Diaphoretic beans and lentils, whole grains, liver,
• Clammy potato with skin
• Leathery
Iron • Liver, beef, chicken, lamb, ham
Niacin • Liver, chicken, turkey, ground beef
Vitamin D • Egg yolks, fatty fish, milk
Vitamin A • Carrots, sweet potatoes, spinach
TABLE 19.6 Nutritional Relationship to Integumentary (sources: Marriott et al., 2020; White, 2022)

Skin – Tenting
• Tenting (when the skin remains Dehydration • Water and other liquids
raised when pinched on the back
of the hand)
Skin – Integrity
• Lesions (pustules, vesicles, hives, Vitamin A • Carrots, sweet potatoes
wheals, cyst) • Spinach
• Irritations
• Broken skin Vitamin B1 (thiamin) • Barley
• Pressure injuries
Vitamin B6 (pyridoxine) • Fish, organ meats, potatoes
• Skin ulcers
• Skin tears Vitamin B9 (folate) • Asparagus, beans, peas
• Blisters
Vitamin B12 (cobalamin) • Liver, salmon, tuna, yogurt, eggs
Vitamin C • Citrus fruits, orange juice
Vitamin D • Egg yolks, fatty fish, milk
Vitamin E • Olive oil, almonds, peanuts
Zinc • Eggs, meat and poultry, seafood

• Beans and lentils
Calcium • Cheese, milk, yogurt
Copper • Liver, oysters, nuts, seeds
Magnesium • Bananas, nuts, avocado, legumes
Selenium • Seafood, meat
Protein • Lean chicken, turkey, fish

• Beans, peas, lentils, tofu
• Nuts, peanut butter, seeds
• Cheese, yogurt, cottage cheese, eggs
• Milk or fortified soy
Nails
Overall nail health: biotin • Liver, egg yolk, salmon, sweet
potatoes, cauliflower
Nails – Discoloration
• Yellowing, blue, darkening, Vitamin B12 deficiency • Liver, salmon, tuna, yogurt, eggs
greenish black, white, reddish causes blue/black nails
brown Folate deficiency causes • Asparagus, oranges, white beans
pigmentation to change
in nails
Iron deficiency causes • Liver, beef, chicken, lamb, ham
pale nails

19.2 • Plan Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness 379

Nails – Shape
• Clubbing Low oxygen levels
• Spoon-shaped Iron deficiency • Liver, chicken, ham, lamb
Vitamin B deficiency • Legumes, nuts, dairy, fish, lean

meats
Nails – Texture
• Brittle • Brittle: vitamin A • Sweet potatoes, pumpkin, carrots
• Coarse deficiency • Liver, salmon, tuna, yogurt, eggs
• Notched • Ridges: vitamin B12
• Pitting deficiency
• Ridges
• Capillary refill: prolonged (more
than 3 seconds)
Nails – Condition
• Fungus, dirt, lack grooming No related nutritional
factors
Vitiligo
Vitiligo—a skin condition where the skin loses its pigmentation—physically affects all races and sexes equally,
about 1% of the population globally; however, the psychological impact on clients with darker skin tones is
much greater. Because this skin disease is more visible in darker skin tones, many clients struggle with self-
esteem and confidence after developing vitiligo (Cleveland Clinic, 2022). The nurse works to offer emotional
support by recommending support groups for their clients with vitiligo.
Vitamin B12 has been shown to be useful for repigmentation in clients with vitiligo. Meat, eggs, and dairy
products are good sources of Vitamin B12. Folic acid has also been proven to treat vitiligo. Although Vitamin D is
thought to play a role in vitiligo, there is insufficient evidence to indicate that a low Vitamin D could cause vitiligo.
Zinc is thought to inhibit melanocyte destruction and may be a useful mineral in the treatment of vitiligo.
19.2 Plan Nutritional Strategies to Impact Musculoskeletal and

LEARNING OUTCOMES
• 19.2.1 Prioritize hypotheses of nutritional habits that optimize musculoskeletal and integumentary
wellness.
• 19.2.2 Generate solutions to optimize musculoskeletal and integumentary wellness utilizing nutritional
habits.

The nurse is responsible for educating the client on nutritional strategies to impact musculoskeletal and
integumentary wellness. Based on the client’s history and current medical diagnosis, the nurse will prioritize
hypotheses of nutritional habits (or assess expected client responses of nutritional habits) to optimize the well-
being of the client. In doing so, the nurse will plan nutritional goals for the client and focus on assisting the client to
meet the goals.
Nutrition is an important lifestyle factor related to many long-term diseases. The musculoskeletal and
integumentary systems are no exception. Long-term consumption of low nutrient foods may contribute to
musculoskeletal pain and may also lead to obesity, homeostasis, inflammation, and sensitization of the central
nervous system. Therefore, it is essential that proper nutrition be a priority in planning for better health that is
related to the musculoskeletal and integumentary systems.
Calcium and vitamin D are essential to good bone health, and it is important that clients follow the recommended
daily allowances. Because more foods are being fortified with calcium and vitamin D, clients may not realize they are
consuming these micronutrients at unsafe levels. For example, a buildup of calcium can increase the risk for kidney
stones, cardiac issues, and prostate cancer.
For people over age 50, at least 1200 mg of calcium per day is recommended. Excess vitamin D can cause kidney
damage and dangerous serum calcium levels. Recommended vitamin D levels for adults to age 70 years is 600 IU
and above 70 years, 800 IU (Mayo Clinic, 2021). See Table 19.7 for calcium and vitamin D food sources.
Food Sources of Calcium Food Sources of Vitamin D

Milk Egg yolk
Yogurt Mushrooms
Fortified orange juice Oily fish (swordfish, herring)
Cheese Fortified milk
Sardines Fortified orange juice
Ice cream Fortified cereals
Tofu
Soy
Bread
Pudding
Broccoli
TABLE 19.7 Food Sources of Calcium and Vitamin D (source: Campbell, 2021)
Other vitamins and minerals essential to include in planning nutritional goals for the musculoskeletal system are
phosphorus, magnesium, vitamin K, vitamin C, and vitamin A. Phosphorus is a major mineral found in bone and
needed for bone health. It can be consumed through such foods as dairy products and meat, as well as shellfish,
beans, sunflower seeds, lentils, sardines, and cheese. Magnesium improves overall bone strength and is found in
spinach, bananas, nuts and seeds, avocado, and chickpeas. Vitamin K is essential to bone formation, and it channels
calcium into the bones. Foods containing vitamin K include leafy green vegetables, kiwi, and pumpkin. Vitamin C is
necessary in the synthesis of collagen, which is the main protein in bone. Vegetables, citrus fruits, and tomatoes are
high in vitamin C. Vitamin A is important for bone growth and can be found in liver, eggs, leafy green vegetables, and
carrots (Campbell, 2021).
Planning nutritional goals for integumentary health is very important as related to wound healing, inflammation, and
dermatologic disease processes. The primary focus is on protein because this is the important nutrient needed for
tissue repair. An important nutritional goal during wound healing is to stay well hydrated. Hydration helps skin
maintain its integrity; the loss of skin elasticity caused by dehydration makes the skin more susceptible to
infections, thus impeding the healing process (Campbell 2023). In setting nutritional goals that include protein,
these food items may be suggested:
• Salads (tuna, salmon, egg, and grilled chicken salad)

• Nuts
• Milk
• Cottage cheese
• Tuna and salmon
• Peanut butter

19.3 • Implement Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness 381
• Greek yogurt
• Whole grains
• Protein shakes (if food cannot be tolerated)

One big challenge to any nutritional plan is making sure the client can understand and follow the plan. Does the
client have financial means to purchase and prepare specific foods? Often, fast foods and non-nutritious foods are
more convenient and much less expensive. Is the client able to read nutrition labels? Is there a challenge to finding
necessary food items in the area in which the client lives? Does the client have transportation or internet services for
ordering food? If the client is unable to follow the plan for any of the reasons listed, the nurse should provide
information on assistance programs or make a referral to another agency to assist the client in these matters.
Motivation is also often a challenge for any nutritional goal. The client must understand how they will benefit from
the diet plan. The nurse should clearly identify potential complications the client ignores nutritional goals.
Maintaining a diet rich in vitamin D is challenging even if a client has the means and the motivation to follow the diet.
Our bodies naturally make vitamin D in our skin when it is exposed to sunlight. However, because of the importance
of protecting our skin by using sunscreen, we are blocking our skin’s ability to make vitamin D. Therefore, vitamin D
needs to come in the form of nutrition or added supplements for most people.
Consuming a diet with nutrient rich calories is often a challenge for the client during wound or tissue healing. The
client is often more immobile during such times, and the client may worry about gaining weight. The nurse can be a
vital resource for the client by educating them on the difference between consuming empty calories and nutrient-
rich calories. The client must understand the importance of nutrition and the positive impact that nutrient-rich
calories play in the tissue and wound healing process.
19.3 Implement Nutritional Strategies to Impact Musculoskeletal and

LEARNING OUTCOMES
• 19.3.2 Teach nutritional strategies to optimize musculoskeletal and integumentary wellness.

Maintaining overall health within the musculoskeletal and integumentary systems is critical to holistic health. One
way to attain this goal is to review specific nutritional plans with the client. Some plans, such as gluten free or
Mediterranean, are found to be helpful in decreasing the symptoms associated with musculoskeletal and
integumentary disorders. Some research suggests there is an inflammatory immune response related to gluten—a
protein found in wheat, barley, and rye grains. Some people may find that eating gluten makes their rheumatoid
arthritis symptoms flare up and that reducing or eliminating gluten helps relieve their symptoms. Another anti-
inflammatory nutritional plan, the Mediterranean diet, which emphasizes fresh fruits and vegetables, fish, whole
grains, nuts, and mono- and polyunsaturated fats, is helpful for reducing inflammation and works well to reduce
arthritis symptoms. This diet plan includes omega-3 fatty acids, vitamin C, fiber-rich foods, polyphenols, and other
known inflammation fighters. Polyphenols, found in various foods, are organic compounds that contribute to the
food’s color and smell. The nurse should ensure the client understands the premise behind the nutritional plan and
that they can read and interpret food labels and ingredients properly.
The client must also be assessed for readiness to learn. This can be accomplished through a holistic
assessment—an in-depth client assessment that delves into:
• Physiological health—Physical condition, physical limitations, medical conditions, past medical and surgical
history, and current medications
• Psychological health—Mental health condition, cognitive level, anxiety, stress
• Social and environmental—Support systems, living conditions, financial barriers, access to resources
• Cultural factors—Traditions, languages, set of beliefs
• Spiritual factors—Alcohol consumption, dietary choices, procedures allowed, advanced directives
By working with the client to establish holistic goals for good health, client/nurse communication is enhanced, and
trust is established. Holistic nursing provides a deeper respect for the client and helps them gain control over their
lifestyle changes.
As a part of the physiological health assessment, the nurse should determine the client’s list of medications. As a
part of client teaching, the nurse should educate the client about the medications that have been prescribed for
treatment. Some of the most ordered medications for musculoskeletal disorders include NSAIDS like ibuprofen,
diclofenac, naproxen, indomethacin, meloxicam, and others.
Client Teaching
When a client is hospitalized, teaching starts at admission and is an ongoing process throughout the stay until
discharge. Education should be provided in small segments for better client retention. Nurses should speak in a
language that the client can understand, refraining from using complex medical terminology. In some instances,
return demonstration is needed right before discharge. The nurse should educate according to the learning style of
the client and should include the caretakers who will be assisting the client once home (Morris, 2022).
Client teaching should always include nutritionally related teaching strategies. Too often at discharge, the nurse
focuses on the physical problem exclusively. Nutritional client education that focuses on the musculoskeletal and
integumentary system is a more holistic approach to treatment. See Table 19.8 for important nutritional teaching
concerning both the integumentary and musculoskeletal systems.

19.3 • Implement Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness 383
Function Nutritional Importance Nutrients to Support System

Integumentary System
• First line of • Unhealthy eating impacts the skin and leads • Foods high in water content
defense for the to malnutrition. This impacts the body’s such as fruits and
body against homeostasis in relation to protection, vegetables help to prevent
environmental thermoregulation, sensory, endocrine and dehydration and dry skin,
trauma and immune functions. promoting skin integrity
pathogens • A healthy diet helps to maintain and repair • Foods with anti-
• Skin has body tissue. inflammatory properties
thermoregulation ◦ Nuts
properties as well ◦ Fruits (blackberries,
as sensory, blueberries, avocados,
endocrine and grapes, cherries)
immune functions ◦ Turmeric
◦ Omega-3 fatty acids
(salmon)
◦ Green tea
◦ Olive oil
• Foods that promote wound

healing
◦ Proteins (cottage cheese,
beef, salmon, tuna,
chicken breast, beans,
nuts)
◦ Whole grains
◦ Vitamin C (citrus fruits,
broccoli)
◦ Vitamin A (carrots,
apricots)
◦ Zinc (shellfish, eggs,
poultry)
◦ Iron (red meat, dark
green leafy vegetables)
TABLE 19.8 Nutritional Teaching for Musculoskeletal and Integumentary Systems (sources: Campbell, 2023; Cleveland Clinic, 2023;
Opentextbc.ca 2013)
Function Nutritional Importance Nutrients to Support System

Musculoskeletal System
• Supports the • Malnutrition can severely impair the • Foods with anti-
body’s weight and musculoskeletal system. inflammatory properties:
provides stability • Proper nutrition is important to minimize ◦ Nuts
and movement normal bone loss that occurs over time. ◦ Fruits (blackberries,
• A healthy diet promotes healthy weight blueberries, avocados,
which decreases the strain on bones, joints, grapes, cherries)
muscles and ligaments. ◦ Turmeric
• Proper nutrition assists to decrease ◦ Omega-3 fatty acids
inflammation, promote bone marrow (salmon)
production, and maintain overall mobility. ◦ Green tea
◦ Olive oil
• Maintenance of bone and

muscle mass and
strengthens bones:
◦ Vitamin D (milk, cheese)
◦ Fruits
◦ Vegetables
◦ Zinc (pumpkin seeds,
lentils)
◦ Magnesium (bananas,
dark chocolate, whole
grains, leafy green
vegetables)
◦ Phosphorus (whole
wheat, cheese)
• Promotes bone formation:

◦ Proteins (cottage cheese,
beef, salmon, tuna,
chicken breast, beans)
◦ Greek yogurt
TABLE 19.8 Nutritional Teaching for Musculoskeletal and Integumentary Systems (sources: Campbell, 2023; Cleveland Clinic, 2023;
Opentextbc.ca 2013)
As seen in the table above, both the musculoskeletal and the integumentary systems are affected by inflammation.
Therefore, anti-inflammatory foods are important to consider for both systems. The muscles of the musculoskeletal
system can become inflamed due to injury, infection, or overuse. Likewise, the soft tissue and skin of the
integumentary system can become inflamed due to injury or infection. The injured muscle often involves the
surrounding tissue and skin. Bones that are injured (fractures) often manifest signs in the integumentary system,
such as bruising and discoloration. The injured tendons and ligaments of the musculoskeletal system manifest signs
in the integumentary system, such as ecchymosis and edema. These are just a few examples of how the
musculoskeletal system and the integumentary system are connected to one another.
Part B
Study Part A.
The nurse prepares to instruct the client on nutritional strategies to manage her arthritis. Client teaching for Anne

19.4 • Evaluate Nutritional Strategies to Impact Musculoskeletal and Integumentary Wellness 385
includes the reinforcement teaching of a nutritional plan that has anti-inflammatory properties for her osteoarthritis
with edema in the knees. Along with nutritional education, the nurse instructs the client to stay as active as
possible, doing stretching exercises daily as prescribed by the physical therapist to maintain or gain ROM in lower
extremities. The nurse instructs Anne to pay close attention to the skin surrounding her knees, observing for warmth
or redness. Anne is encouraged to report these integumentary symptoms if they occur because they could indicate
septic arthritis of the knees.
3. From what is known about nutrition and the impact that it has on the musculoskeletal system, which of the
following foods would you expect the nurse to include in dietary teaching for the client?
a. Leafy green vegetables
b. Dairy products
c. Red meat
d. Protein shakes
4. After the nurse finishes the instructions, which of the following statements by the client indicates additional
education is needed?
a. “I will try to incorporate more berries into my diet.”
b. “I will stop eating nuts.”
c. “I will try to eat more salmon and tuna.”
d. “I will eat fewer carbohydrates.”
19.4 Evaluate Nutritional Strategies to Impact Musculoskeletal and

LEARNING OUTCOMES
• 19.4.1 Evaluate a nutritional plan for its effectiveness on musculoskeletal and integumentary wellness.
• 19.4.2 Modify a nutritional plan to promote musculoskeletal and integumentary wellness.

Evaluation is an important part of the nursing process. After the client has integrated nutritional strategies into their
eating habits, the nurse should go back and evaluate the effectiveness of the plan. This is accomplished through
objective and subjective findings. Barriers to compliance may include a client’s inability to read, write, and perform
simple math. Finances, resources, transportation, and support are also barriers to client nutritional compliance.
A client’s compliance with the meal plan can, to some degree, be evaluated through their improvement of symptoms
related to the musculoskeletal and integumentary systems. Objective ways to evaluate compliance with a meal plan
are monitoring client weight and laboratory test results. Other objective findings include improvement in wounds,
fractures, injuries, and nail and hair quality. Radiology procedures showing regeneration of bone or no extension in
bone loss are also objective findings.
Subjective data from the client or caregivers must also be considered in determining client nutritional compliance.
In other words, the nurse needs to listen to the client and caregivers to determine if compliance is being met.

The effectiveness of a nutritional plan can be determined by many factors such as weight variance, changes in pain
and edema, alterations in muscle strength and tone, and absence or presence of fatigue. DEXA (dual x-ray
absorptiometry) scans that measure bone density can be used as a follow up to the initial scan to determine if bone
loss is stable or progressing. Continual monitoring of client labs is an effective way to evaluate whether the
nutritional plan is working. Labs for the musculoskeletal and integumentary systems are outlined in Table 19.9.
Labs for Musculoskeletal and Integumentary Indications

Systems
• White blood count (WBC) • Inflammation and infection
• Erythrocyte sedimentation rate (ESR) • Inflammation
• C-reactive protein (CRP) • Infection
• Culture and sensitivity
• Vitamins A and D, and calcium • Fractures

• Osteoporosis
• Osteopenia
• Paget’s disease
• Antinuclear antibody (ANA) • Autoimmune disorders

• Rheumatoid factor (RF)
• Anti-cyclic citrullinated peptide (CCP)
• Alanine aminotransferase (ALT)
• Aspartate aminotransferase (AST)
• Alkaline phosphatase (ALP) • Bone formation
• Plasma histamine • Immune disorders
TABLE 19.9 Labs for Musculoskeletal and Integumentary Systems (source: Pagana & Pagana, 2023)

Chapter Summary
• The musculoskeletal system includes the bones of bone formation, bone health, fracture healing,
the skeleton and the cartilage, ligaments, and wound healing, and hair and nail health.
other connective tissues and muscles. • Nurse assessment and screening tests for the
• The integumentary system includes the skin, hair, musculoskeletal and integumentary systems are
nails, sweat glands, sebaceous glands, and nerves essential for the overall success of client care.
on the skin. • Client teaching, including nutritional meal
• There is a relationship between the neurological planning, is important to the overall care of the
system and the musculoskeletal system in that the musculoskeletal and integumentary systems.
brain and nerves tell the voluntary muscles what • The client must be assessed for readiness to learn
to do. before educating the client about lifestyle changes
• Nutrition plays a key role in the development and including nutrition.
maintenance of a healthy musculoskeletal and • Evaluation of nutritional strategies include client
integumentary system. adherence. The nurse must be able to recognize
• Within the musculoskeletal and integumentary barriers to adherence with overall client health
systems, nutrition affects a person’s immune care.
system, inflammatory response, level of edema,
Key Terms
alopecia hair loss stretching while in a passive resting state
autoimmune disorder occurs when the body’s musculoskeletal system the bones of the skeleton
immune system attacks and destroys healthy body and the cartilages, ligaments, and other connective
tissue tissues and muscles
basal ganglia a part of the brain that starts and osteoarthritis a degenerative joint disease resulting
coordinate movements; diseases of the cells leading in chronic pain and often edema
into the basal ganglia include Parkinson’s disease patch testing a skin test for allergies
that results in tremors polyphenols beneficial plant compounds with
Braden scale an assessment tool using six categories antioxidant properties
to determine pressure injury risk psoriatic arthritis a long-term inflammatory disease
crepitus a grating sound produced by friction of the joints
between bone and cartilage or bone and bone range of motion (ROM) reflects the client’s ability to
diascopy a test for determining how quickly the skin move their joints actively or passively
blanches under pressure scoliosis a sideways curvature of the spine
genu varum bowing of legs scraping a technique for obtaining superficial dead
hirsutism an abundance of hair in places where hair skin for testing
is normally scarce or absent tenting when the skin remains raised after being
integumentary system the body system that pinched on the back of the hand
includes the skin, hair, nails, sweat glands, Tzanck testing a test used to diagnose viral disease
sebaceous glands, and nerves on the skin with active vesicles
intoeing foot turned inward vitiligo skin pigmentation disturbance
kyphosis an excessive outward curvature of the spine wood light test a black light test used to diagnose
lordosis an excessive inward curvature of the spine lesions
muscle tone a measure of a muscle’s resistance to
Review Questions
1. The nurse is educating a client on ways to promote bone health after the client suffered a stress fracture.
Foods containing which of the following vitamins are the priority for this client?
a. Vitamin D
b. Vitamin B12
c. Vitamin C
d. Vitamin E
2. During an assessment, the nurse notes the client has tenting. What does this indicate?
a. Poor muscle tone

b. Poor circulation
c. Poor skin integrity
d. Poor hydration
3. The nurse is educating the client with a torn bicep muscle on the effects of nutrition on musculoskeletal
health. What recommendation do you expect the nurse to make?
a. Increase protein intake
b. Increase vitamin D intake
c. Include foods high in biotin
d. Include foods high in iron
4. Which client would most likely benefit from consuming bromelain?

a. A 40-year-old marathon runner with sore muscles in legs
b. A 78-year-old client with a stage 3 pressure ulcer
c. An 83-year-old client with osteoporosis
d. A 65-year-old client with edema in their right knee due to osteoarthritis
5. A client with a stage 2 pressure injury was prescribed protein shakes twice daily. Upon return to the office for
a recheck, the pressure ulcer changed to stage 1. Which of the following findings supports the conclusion the
client has improved?
a. A blister has now formed at the site of the pressure injury.
b. The site of the pressure injury shows some healthy adipose tissue.
c. The site of the pressure injury is red but intact.
d. The pressure injury diameter is smaller but deeper.
6. The client has returned to the clinic for a follow-up appointment after being diagnosed with osteoporosis.
Which of the following statements by the client indicates they have followed the recommended diet to
manage their condition?
a. “I have been eating more fruit than I used to.”
b. “I try to eat several servings of dairy products each day.”
c. “I don’t like to eat fish.”
d. “I have switched from eating French fries to baked potatoes.”
7. The nurse is caring for a client who is prescribed a gluten-free diet to manage their dermatitis herpetiformis.
Which foods require modification when conforming to a gluten-free diet?
a. Fresh fruit and vegetables
b. Bread and pasta
c. Brown and wild rice
d. Fish and poultry
8. During an admission assessment, the nurse is assessing the client’s fingernails. Which of the following
findings would be concerning?
a. Capillary refill < 2 seconds
b. Smooth nails
c. Clubbing of nails
d. Translucent color with pinkish tone
9. The nurse is providing nutritional instruction to a client with a surgical wound that is slow to heal. Which of
the following statements by the client indicates the client understands the recommended diet strategies?
a. “I will eat smaller, more frequent meals.”
b. “I will drink water throughout the day.”
c. “I will limit my intake of dairy products.”

d. “I will eat several servings of fruits and vegetables each day.”
10. The nurse is working with a client who is experiencing alopecia. Which of the following nutrients, found in
liver and egg yolks, could the nurse recommend?
a. Folate
b. Zinc
c. Selenium
d. Biotin
Suggested Reading
Benedetti, J. (2021, December 16). Foods that Fight Inflammation. Harvard Health Publishing. Retrieved May 3,
2023, from https://www.health.harvard.edu/staying-healthy/foods-that-fight-inflammation
Campbell, B. (2021). Calcium Nutrition and Bone Health. Orthoinfo. https://orthoinfo.aaos.org/en/staying-healthy/

calcium-nutrition-and-bone-health/
Johns Hopkins Medicine (2023, May 13). Vitamin D and Calcium. https://www.hopkinsmedicine.org/health/
wellness-and-prevention/vitamin-d-and-calcium
Mayo Clinic. (2021, December 11). Nutrition and Healthy Eating. Retrieved May 13, 2023, from
https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gluten-free-diet/
art-20048530
Travers, J. (2020). The Bone Strength Plan. Welbeck Balance. London.


CHAPTER 20
Musculoskeletal and Integumentary Health
FIGURE 20.1 Tomatoes contain essential micronutrients such as vitamin A, vitamin C, phosphorus, and potassium. (credit: modification of
work “Foods Vegetables in Bulacan displayed for sale in Baliuag, Bulacan Public Market” by Judgefloro/Wikimedia Commons, CC0 1.0)
CHAPTER OUTLINE
20.1 The Impact of Nutrition on Musculoskeletal and Integumentary Wellness Across the Lifespan
20.2 Nutrition and Chronic Musculoskeletal and Integumentary Illness
INTRODUCTION Musculoskeletal and integumentary changes can affect other organ systems, and they also
become evident as the body ages. Aging muscles and skin can cause changes in a person’s mobility and overall
wellness. Decreases in bone mass and density can result in fractures and illness. The chapter on Applying Clinical
Judgment to Promote Nutrition for Musculoskeletal and Integumentary Wellness covers the important role of
nutrition in musculoskeletal and integumentary health and wellness. This chapter will introduce special
considerations across the lifespan because nutritional needs change over time. Preventing and mitigating
complications of the musculoskeletal and integumentary systems, such as fractures, poor wound healing, physical
disability, disease progression, poor quality of life, and hospital admissions, can often be achieved through
implementing appropriate nutrition and adequate physical activity.
Consider this case: Meet Maria, a 20-year-old, and her newborn baby, Jose. To explore the concepts presented in
this chapter, the unfolding case study will follow Jose as he grows from a newborn to an older adult.
392 20 • Special Nutritional Considerations for Musculoskeletal and Integumentary Health
20.1 The Impact of Nutrition on Musculoskeletal and Integumentary Wellness

Across the Lifespan
LEARNING OUTCOMES
• 20.1.1 Describe the impact of nutrition on the musculoskeletal and integumentary systems during
pregnancy.
infancy.
childhood.
adolescence.
adulthood.
• 20.1.6 Describe the impact of nutrition on the musculoskeletal and integumentary systems during later
adulthood.
The Healthy Pregnant Client and Fetus

Pregnant clients are encouraged to eat a healthy, balanced diet, not just for their own health and well-being but also
for the health and well-being of the growing fetus. Nutrition plays a critical role in maintaining musculoskeletal and
integumentary health during pregnancy.
Adequate intake of calcium and vitamin D is essential for developing and maintaining healthy bones and teeth in
both the pregnant client and the developing fetus (Azzolino et al., 2021). During pregnancy, the demand for calcium
increases to support fetal skeletal development. Insufficient calcium intake may lead to decreased maternal bone
density as well as decreased bone density and teeth firmness of the child later in life (Tihtonen et al., 2021).
Protein is vital for the growth and repair of muscles and the development of the fetal musculoskeletal system.
Adequate protein intake is necessary to meet these demands for both the pregnant client and the fetus.
Maintaining proper hydration during pregnancy helps keep the skin hydrated, reducing the risk for dryness, itching,
and stretch marks. Moreover, sufficient water intake is crucial for fetal development. Table 20.1 highlights some of
the important ways staying hydrated during pregnancy benefits the growing fetus.
Benefit to Explanation
the Fetus
Collagen Water is essential to produce collagen, a protein needed for the development of skin and bones.
production
Nutrient Proper hydration enables efficient transport of essential nutrients to the growing fetus. Adequate
transport maternal blood volume and circulation to and from the placenta are necessary for nutrients to be
transported to the growing fetus and waste products removed.
Amniotic The amniotic fluid is responsible for thermoregulation in utero, and a stable temperature ensures
fluid appropriate fetal growth and development. Additionally, amniotic fluid cushions the growing fetus,
production allowing for essential movements that allow the fetus to develop strong bones and muscles.
TABLE 20.1 Hydration Benefits for the Fetus
Consuming a well-balanced diet rich in essential nutrients such as vitamins A, C, and E and the mineral zinc can
promote healthy skin during pregnancy. These nutrients play a role in collagen synthesis, essential for skin elasticity
and wound healing. Foods such as fruits, vegetables, whole grains, lean proteins, and healthy fats can provide these
necessary nutrients.
Omega-3 fatty acids, particularly docosahexaenoic acid (DHA), are crucial for developing the fetal skin and nervous
system. Including dietary sources of omega-3 fatty acids, such as fatty fish and flaxseed, can support the
integumentary health of both the pregnant client and the developing baby (American College of Obstetricians and
Gynecologists, 2023).

20.1 • The Impact of Nutrition on Musculoskeletal and Integumentary Wellness Across the Lifespan 393
The nurse should encourage pregnant clients to maintain a balanced and varied diet that includes a wide range of
nutrients. Referral to a registered dietitian may be recommended to ensure proper nutritional intake during
pregnancy.
Part A
Maria delivers a healthy baby and names him Jose. Maria’s diet was suboptimal during pregnancy because of
hyperemesis gravidarum and lack of appetite, and it lacked adequate folic acid, vitamin D, and calcium. Because of
her severe vomiting, Maria could not take her prenatal vitamin supplements. Maria has decided that she will
breastfeed.
1. What information might indicate that the baby is at increased risk for musculoskeletal and integumentary
issues later in infancy and throughout adulthood?
a. The baby will be breastfed.
b. The mother did not consume enough whole grains during the pregnancy.
c. The mother did not consume many dairy products during the pregnancy.
d. The baby is male.
2. Which body system might be most affected by suboptimal intake of vitamin D and calcium?
a. Musculoskeletal
b. Neurologic
c. Integumentary
d. Hematologic
Vitamin D
Approximately 99% of the calcium within the body is stored in bone (American Academy of Pediatrics, 2022).
Vitamin D mediates the storage and uptake of maternal calcium and, as such, is essential for fetal bone
development. Vitamin D is absorbed through the skin and ingested in various foods. There is a correlation between
low maternal vitamin D and osteopenia in newborns and decreased bone density in childhood (Azzolino et al.,
2021). Consequently, it is important to monitor vitamin D levels in the pregnant client. Supplementation may be
necessary when levels are not in the expected range.
The Pregnant Client with Integumentary or Musculoskeletal Illness

Table 20.2 outlines some of the musculoskeletal and integumentary conditions that can develop because of
physiologic changes during pregnancy.
Condition Manifestations Treatments

Diastasis The growing uterus can put pressure on the abdominal The pregnant client may wear an
recti muscles, leading to separation and a visible bulge in the abdominal binder for support.
abdomen. The client is who pregnant client may
experience weakness and back pain and may have
difficulty regaining physical strength following delivery.
Carpal Hormonal changes and fluid retention in the pregnant This condition usually resolves after
tunnel client can lead to overly stretchy joints and tendons, delivery, but the pregnant client may
syndrome swelling, and compression of the median nerve in the wear a hand and wrist brace for
wrist. This often manifests as numbness, tingling, or support.
pain in the hands and fingers.
TABLE 20.2 Musculoskeletal and Integumentary Conditions Resulting from Physiologic Changes During Pregnancy
Condition Manifestations Treatments

Lower back Weight gain, changes in posture, and hormonal shifts The pregnant client may wear a pelvic
and pelvic can lead to lower back pain and stretching of the pubic and abdominal support belt and rest
girdle pain symphysis. whenever necessary but should avoid
NSAIDs for pain relief.
Integumentary System
Pruritic PUPPP is a skin condition of unknown origin that occurs There is no significant health risk for
urticarial in some pregnant clients, most commonly during the the pregnant client or the fetus, so
papules third trimester. It is characterized by itchy, red, raised treatment is supportive and may
and bumps and hives that most commonly appear on the include creams and emollients,
plaques of abdomen, thighs, buttocks, and arms. corticosteroids, antihistamines, and
pregnancy cool compresses.
(PUPPP)
Stretch Because the skin naturally stretches to accommodate Stretch marks appear as purplish-red
marks weight gain and the growing breasts and abdomen, lines that, with time, fade to silvery-
stretch marks often develop. white lines. They are permanent.
Linea nigra Hormonal changes in some pregnant clients cause a During the postpartum period, the
benign dark line to form down the center of the linea nigra will disappear slowly over a
abdomen from the umbilicus to the pubis symphysis few months as the hormones of
(Figure 20.2). pregnancy exit the individual’s system.
TABLE 20.2 Musculoskeletal and Integumentary Conditions Resulting from Physiologic Changes During Pregnancy
FIGURE 20.2 This individual in third trimester exhibits a linea nigra, a dark line that appears on the abdomen from the umbilicus to the
pubis symphysis. (credit: “photo of hand, woman, round, trunk, female, leg, love, finger, child, arm, baby, muscle, chest, pregnancy,
maternity” by PxHere, CC0 Public Domain)
Impact of Maternal Health During Pregnancy

Proper nutrition in pregnancy is even more important for pregnant clients in poor health, which can result from
underlying medical conditions or malnutrition. A pregnant client in poor health may be at higher risk for nutrient
deficiencies, such as deficiencies of calcium or vitamin D, which can negatively affect bone strength and density.
Insufficient nutrient intake may increase the likelihood of conditions such as osteoporosis, fractures, or impaired
bone formation in the pregnant client and the developing fetus. Inadequate protein intake can lead to muscle
wasting, weakness, and reduced muscle function in pregnant clients with poor health, thereby affecting their overall
physical strength and ability to perform daily activities (Azzolino et al., 2021).

Poor health may also increase the risk for nutrient deficiencies, such as iron, folate, vitamin B12, or vitamin C. These
nutrients are essential for various processes, including red blood cell formation, collagen synthesis, and tissue
repair. Deficiencies in these nutrients can lead to anemia, impaired wound healing, weakened connective tissues,
and compromised overall musculoskeletal health.
Some important foods for musculoskeletal health in pregnancy that the nurse can recommend include beans, peas,
beef, pork, fish, poultry, milk, cheese, dairy products, nuts, and seeds (March of Dimes, 2020).
Prenatal vitamins play a key role in supporting the maternal and fetal musculoskeletal systems during pregnancy
and in the postpartum period. Table 20.3 highlights the importance of prenatal vitamins and their impact on the
musculoskeletal systems of the pregnant client and the fetus.
Benefit Explanation
Fetal bone Adequate calcium intake during pregnancy is essential for the developing fetus’s bones.
development
Prevention of Folic acid may prevent neural tube abnormalities in the fetus.
birth
abnormalities
Maternal If maternal calcium stores are low during pregnancy, the fetus may draw calcium from maternal
calcium calcium stores, further exacerbating hypocalcemia in the pregnant client and increasing the risk
stores for fractures. Additionally, maternal calcium levels drop during lactation. Continuing prenatal
vitamins in the postpartum period is one way to increase maternal calcium intake and stores.
TABLE 20.3 Prenatal Vitamin Benefits Related to the Musculoskeletal System
Infancy
Infancy is a time of rapid musculoskeletal and integumentary growth, so dietary considerations are critical to ensure
healthy bones, muscles, and skin. Breastfeeding does not provide an infant with enough vitamin D. To prevent
musculoskeletal disorders and to promote healthy skeletal growth, it is recommended that all breastfed infants
receive vitamin D supplementation. Supplementation with 400 IU of vitamin D per day should begin in the first few
days of life and should be provided to exclusively breastfed infants and breastfed infants supplemented with
commercial formula (Centers for Disease Control and Prevention, 2021). Vitamin D supplementation should
continue until the infant is weaned and has adequate intake of vitamin D–rich foods.
Regular dental checkups are important for the infant. The infant should see a dentist as soon as their first tooth
erupts, and some dentists recommend a visit even before this time to help them get used to the environment.
Regular fluoride supplementation becomes necessary through water or toothpaste when an infant begins to eat
solid foods. Standard formulas contain fluoride that a breastfed infant does not receive, so breastfed infants need
supplemental fluoride after 6 months of age. Nurses should encourage parents to begin brushing their infant’s teeth
as they erupt, using fluoride toothpaste according to their dentist’s recommendations (American Academy of
Pediatric Dentistry, 2023).
It is also important for infants to begin to “exercise” their muscles and bones as soon as possible for optimal growth
and development. As soon as a baby is born, a parent should encourage supervised “tummy time.” This activity
helps infants build the strength necessary for rolling over, crawling, and exploring the world. It also helps infants
strengthen their neck muscles and develop head control and can be introduced around 3–4 months old.
Osteopenia, or low bone density, is common in preterm newborns. It can also occur in newborns whose mothers
were deficient in calcium and vitamin D. Osteopenia is most likely in an infant born before 30 weeks’ gestation
because the majority of calcium uptake occurs during the third trimester of fetal life. A preterm newborn with
osteopenia may exhibit no symptoms but is at increased risk for fractures. Osteopenia and the risk for fracture
continue through the preterm infant’s first year of life.
Newborns identified as high risk for developing osteopenia or fractures, such as preterm infants, are monitored and
may receive fortifiers with their feedings to help them retain calcium and phosphorus (American Academy of
Pediatrics, 2022).
Part B
Study Part A.
Maria’s infant, Jose, is now 6 months old and is still being breastfed.
3. Which statement by the client indicates that further nursing education is necessary regarding the child’s
musculoskeletal health?
a. “My baby is now 6 months old and does not need to continue their vitamin D supplement.”
b. “My baby will not be walking for some time but putting them in a bouncer seat can help them develop the
skill.”
c. “I like to provide lots of opportunities for play for my baby, and they love to be on their tummy.”
d. “My baby doesn’t have any teeth yet, but I’ll make a dentist appointment as soon as they get them!”
4. The client asks the nurse if the baby needs vitamin D supplementation if the baby is given commercial
formula from time to time. How should the nurse respond?
a. “You will need to continue vitamin D supplementation until the baby is fully weaned and taking in
adequate vitamin D–rich foods regardless of whether or not you are supplementing.”
b. “Commercial formula contains adequate vitamin D, so you do not need to give the baby vitamin D on the
days you supplement with formula.”
c. “Commercial formula does not contain any vitamin D.”
d. “You should not supplement your baby with commercial formula and should exclusively breastfeed, as
that is what’s best for a growing infant.”
Childhood
During childhood, the bones and muscles grow and develop rapidly. The effect of malnutrition in these body systems
can have lifelong effects. Therefore, nurses should teach parents and caregivers about essential nutrients and ways
to ensure that their children receive adequate amounts for growth.
Vitamin D and Calcium

Vitamin D and calcium levels are not routinely monitored in children, so the nurse must assess for any signs of
deficiency and instruct parents on appropriate intake. Children with vitamin D deficiency can develop a condition
known as rickets, characterized by frequent fractures and weak bones, although this condition is rare. Children with
rickets are at increased risk for fractures (Chanchlani et al., 2020). Table 20.4 lists foods that are high in vitamin D
and calcium.
Foods High in Vitamin D Foods High in Calcium

Vitamin D–fortified foods, such as milk, orange juice, and cereal Dairy products
Fatty fish, such as salmon, trout, and sardines Sardines
Egg yolks Leafy green vegetables
Mushrooms Tofu
Cod liver oil Almonds
TABLE 20.4 Foods High in Vitamin D and Calcium
Fluoride
Fluoride is an important mineral for bone health and for dental health in particular because it stimulates new bone
formation and inhibits the progression of dental caries (cavities). It is naturally present in water and many foods.
However, since 1962 the U.S. Public Health Service has recommended that public water be supplemented with
fluoride to promote oral hygiene and tooth health in the overall U.S. population (Office of Dietary Supplements,
2022). Though fluoride occurs in water naturally, the fluoridation of public water supplies first began in 1945. Well

water may not contain adequate fluoride, which is important information for nurses to give clients who have private
well water as their main water source. Most bottled water does not contain fluoride. The American Academy of
Pediatric Dentistry (2023) recommends the use of fluoride for children and has determined that it is a safe and
effective way to reduce the incidence of dental caries.
Nurses should teach parents to begin brushing their child’s teeth twice a day as soon as a tooth erupts. Table 20.5
provides guidelines on the amount of toothpaste to use.
Age Range Amount of Toothpaste

Younger than 3 years old Use a small smear of fluoride toothpaste no larger than a grain of rice twice a day.
3–6 years old Use a pea-sized amount of fluoride toothpaste twice a day.
Older than 6 years old Use fluoride toothpaste according to the manufacturer’s recommendations.
TABLE 20.5 Amount of Toothpaste to Use According to Age (source: Thornton-Evans et al., 2019)
Protein and Iron

Protein, one of the body’s major tissue building blocks, is essential for muscle development, maintenance, and
repair. Children are constantly growing; therefore, ensuring a diet that includes adequate amounts of protein is
essential for adequate muscle growth. Meats, beans, tofu, and peanut butter all contain protein.
Protein also helps bones grow and develop. Collagen, for example, is a protein that provides bone strength and
flexibility. It is also important for healthy skin. Children need to consume foods that contain the building blocks of
collagen, such as fish, poultry, meat, eggs, dairy, legumes, and soy.
Iron is necessary to produce hemoglobin, which carries oxygen to all parts of the body. Muscles are vascular and
need an adequate oxygen supply during growth and development. Foods rich in iron include red meats, leafy green
vegetables, lentils, and iron-fortified cereals.
Obesity in Childhood
Obesity is on the rise across all populations and is especially dangerous in childhood because health habits are
established early in life. The development of obesity in childhood is complicated. Social determinants of health as
well as lifestyle choices have contributed to obesity in children.
Obesity leads to multisystemic issues, but two notable factors influence the healthy development of bones in obese
children. First, inactivity due to obesity can prevent a child from participating in healthy activities. This continuing
inactivity affects metabolism as well as the healthy development of bone during weight-bearing exercises. Second,
an overweight child may have an unbalanced diet and could be lacking in vitamin D, calcium, and other nutrients
essential for healthy bone development.
Children who are overweight or obese have additional stress on their skeletal system. In addition to increasing the
risk for acute injuries, the additional weight can lead to chronic musculoskeletal conditions in the bones and joints
and may increase the individual’s risk for early orthopedic surgery (Nowicki et al., 2019).
Part C
Jose is now 6 years old and has presented for a yearly checkup. Jose is overweight for their height. The nurse is
doing a diet review with Maria, and learns that Jose’s daily diet includes the following:
• Breakfast – toaster pastries

• Lunch – boxed macaroni and cheese, a juice box, and mandarin oranges from a can
• Dinner – chicken nuggets, french fries, and a juice box
Jose does not like to participate in gym class because the activities are “too hard” and prefers to play on a tablet for
about 2 hours a day.
5. Which of the following is the highest priority right now to promote the child’s musculoskeletal health?
a. The child should begin exercising twice daily.
b. The nurse should teach the mother about components of a healthy diet for children.
c. The child should be excused from gym class and referred to a specialist.
d. The child should drink whole milk instead of juice boxes with meals.
6. The mother asks the nurse to recommend foods that promote healthy bone development. Which of the
following foods would be the best choice?
a. Brown rice
b. Legumes
c. Red meats
d. Spinach
Adolescence
Adolescence is an important time for musculoskeletal development in an individual’s life. Maintaining an active
lifestyle during adolescence has been shown to positively influence skeletal development. During adolescence,
bone mass and density are especially receptive to exercise, making this period crucial for skeletal development.
Females achieve up to 90% of their peak bone mass by age 18 and males by age 20. Calcium, vitamin D, and vitamin
C are essential during these years. Musculoskeletal injuries are a leading cause of hospitalization for adolescents
and children. Both underlying conditions and sports injuries contribute to such injuries during adolescence
(American Academy of Orthopaedic Surgeons, 2016).
Adolescence is also thought to be a key time for muscle development. Leading an active lifestyle and avoiding
saturated fats and highly processed sugars during adolescence can promote healthy body mass distribution later in
life (Azzolino et al., 2021).
Increased Nutritional Needs for Adolescent Athletes
Adolescent athletes have increased nutritional needs because they are performing intense physical activity
while still growing and developing. As a result of their increased energy needs, they must consume adequate
amounts of carbohydrates, proteins, and fats. Carbohydrates come in a variety of forms, but it is important that
adolescent athletes avoid highly processed sugars, which increase risk for diabetes and obesity. For optimal
performance, they should strive to consume whole grains, fruits, legumes, and vegetables.
Protein helps restore muscle lost through exercise, so the athlete should consume adequate amounts of fish,
poultry, meat, and other protein sources. The protein needs of adolescent athletes can vary depending on factors
such as age, sex, body size, activity level, and training intensity. However, in general, the protein requirements for
adolescent athletes are higher than those of their more sedentary peers because of the increased demands of
physical activity and muscle development. Nurses can estimate the recommended daily protein intake for
adolescent athletes based on their body weight; adolescent athletes should consume approximately 10–30% of
their daily calories from protein (Klemm, 2020). Protein shakes are not necessary for healthy adolescent athletes,
and they should strive to get their protein from natural food sources.
Adulthood
Adulthood is a time for optimal health and health preservation. During adulthood, it is important to eat a variety of
nutrient-rich foods containing protein, calcium, and vitamin D and remain physically active to maintain bone density
and mass. Healthy adults have no special requirements for supplementation, but they should aim to ingest
adequate micronutrients and macronutrients to maintain healthy bones, muscles, and skin.
Barriers to physical activity during adulthood include increased pressures and time constraints, especially for
students, working adults, and those with families. The convenience of highly processed foods has contributed to a

rise in cancers and obesity throughout the world (Isaksen & Dankel, 2023; Hall et al., 2019). Choosing healthier
alternatives to fast food is a great way for adults to improve their overall nutrition and well-being and to set a
healthy example for children.
Many adults now reach for shakes and protein powders for convenience over whole foods. While protein powders
are convenient, they are unnecessary for most individuals (Gelsomin, 2020). Most individuals, even active athletes,
can obtain the necessary protein requirements for a healthy musculoskeletal system through diet alone. The risks
and disadvantages of using protein supplements are related to the actual content of the product (Harvard Health
Publishing, 2022). The FDA does not regulate the nutritional content of these products, so the actual ingredients
may vary from the label and may include contaminants. In addition to the protein, the supplements may contain a
lot of sugar and calories.
Table 20.6 lists ways that adults can strive to maintain optimal musculoskeletal and integumentary health and
prevent illness.
Action Rationale
Good posture Developing good posture helps keep core muscles toned and can prevent injury and
back and neck pain.
Workplace ergonomics The average adult who works full time spends many of their waking hours at work.
They should try to incorporate physical activity into their daily routine. Employers
should be encouraged to promote healthy practices, such as workstations that
promote proper posture.
Regular physical activity Regular physical activity, at any age, helps maintain strong muscles, which support
healthy bones, and prevent pain and injury associated with aging.
Use of sunscreen Using sunscreen helps keep the skin from prematurely aging and can help prevent
skin cancers associated with sun exposure.
Regular checkups Getting regular checkups by primary care providers and dermatologists can help
individuals ensure optimal health.
Weight management Maintaining a healthy weight prevents musculoskeletal injury due to
malnourishment or increased pressure of joints due to extra weight.
Avoidance of alcohol, Avoiding alcohol, drugs, and smoking can prevent many illnesses associated with
substance misuse, and the musculoskeletal and integumentary systems and may decrease the risk for
smoking some cancers.
TABLE 20.6 Actions for Optimal Musculoskeletal and Integumentary Health
Lactation
Dietary considerations for a client who is breastfeeding consist of increasing caloric intake by an additional 330–400
calories per day to a total of 2,000–2,800 calories per day (CDC, 2022). Additionally, clients who are lactating
women may need iodine and choline supplements because increased amounts of those nutrients are needed—290
mcg of iodine and 550 mg of choline (CDC, 2022). Maternal bone density temporarily decreases during lactation, but
bone loss is usually regained following weaning. Cases of osteoporosis are rare (National Institute of Arthritis and
Musculoskeletal and Skin Diseases, 2023b).
The impact of breastfeeding on the musculoskeletal system is highly individualized and depends on overall diet,
hydration, and physical activity. During lactation (and throughout the lifespan), individuals should strive for adequate
nutrition, including calcium and vitamin D, regular weight-bearing exercise, and a healthy lifestyle (CDC, 2021).
Menopause
Menopause occurs in middle adulthood and is associated with an increased risk for osteoporosis. During
menopause, estrogen, which helps prevent bone breakdown, decreases, which in turn leads to decreases in bone
density and bone mass. Some clients may develop fractures as a result. Therefore, the health care provider should
monitor bone density and encourage women to consume the recommended daily intake for calcium and vitamin D.
Weight-bearing exercise and maintenance of a healthy weight also help prevent age-related osteoporotic changes
during and after menopause. This is important because bone fractures are associated with significant decreases in
quality of life as well as increased mortality risk (Endocrine Society, 2022).
Later Adulthood
As the body ages, muscle mass progressively declines. This breakdown of skeletal muscle mass is known as
sarcopenia (Azzolino et al., 2021). The strength and functionality of the muscles begin to decline as well (Figure
20.3). Bone mass and density also begin to diminish, which can lead to increased risk for fractures and decreased
mobility (Azzolini, 2021). For older adults with sarcopenia, dietary interventions are effective for building muscle
mass. Table 20.7 highlights some effective ways the older adult with sarcopenia can increase muscle mass.
FIGURE 20.3 Muscle atrophy that occurs with aging can lead to joint problems because the muscles that stabilize bones and joints are
weakened. This can cause problems with locomotion and balance and can cause various injuries due to falls. (modification of work from
OpenStax: Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Action Result
Manage chronic Many chronic conditions can lead to a sedentary lifestyle, which, in turn, can lead to
conditions. muscle loss. By managing these conditions, the older adult may be able to become more
active.
Spread protein Spreading protein intake throughout the day may stimulate muscle protein synthesis more
intake throughout efficiently.
the day.
Incorporate Leucine is an essential amino acid and stimulates muscle synthesis. Soy products, dairy
leucine-rich foods. products, turkey, fish, and chicken are leucine-rich foods.
Drink protein Protein shakes can be a convenient way to increase protein consumption. However, they
shakes. should be part of a comprehensive plan for sarcopenia and not the only treatment.
TABLE 20.7 Interventions for Older Adults With Sarcopenia (source: Jang et al., 2023)
In addition to musculoskeletal breakdown, the skin becomes thinner and more fragile with age. When older adults
lack adequate protein intake, several factors can lead to the development of pressure ulcers: Because protein intake
is needed for the development of collagen, which is itself a protein that provides structural support to the skin,
insufficient protein can lead to skin that is thinner and more fragile, increasing the risk for shearing and wounds.
Older adults who are bedbound or use a wheelchair are at even greater risk for pressure ulcers and wounds. In
addition, protein plays an important role in skin regeneration and wound healing; if wounds and tissue are not
regenerating fast enough, pressure ulcers are more likely to develop. For these reasons, nurses should encourage
adequate protein intake to help promote integumentary health in this population.
Osteoporosis
Osteoporosis in older adults results from natural decreases in bone mass and bone mineral density. It develops
when the osteoclasts outpace the osteoblasts, resulting in more bone breakdown than buildup. These changes
increase the risk for fracture in the older adult. Osteoporosis is a silent disease in which symptoms typically do not
appear until an acute fracture occurs. Although it can occur in all people, osteoporosis is much more common in
older females, and the risk for fracture is higher in older females than in older males. Modifiable risk factors for
osteoporosis include vitamin D deficiency, low calcium intake, excessive consumption of alcohol, and smoking.

20.2 • Nutrition and Chronic Musculoskeletal and Integumentary Illness 401
Individuals with an average risk for fractures should perform 150–300 minutes of weight-bearing exercise a week,
and consume the recommended daily allowance of dietary calcium and vitamin D for bone health (The American
College of Obstetricians and Gynecologists, 2021). There is insufficient evidence to support the routine use of
calcium and vitamin D supplements for average-risk individuals. Clients at higher risk for fractures because of
comorbid conditions or medication regimens, should consult with their health care provider regarding their need for
supplementation. Combined calcium and vitamin D supplementation is recommended for individuals at high risk for
vitamin C and vitamin D insufficiency (Reid & Bolland, 2020).
Several tools are available for osteoporosis screening in older adults. One of the most common risk assessments is
the FRAX assessment, which is used to estimate a person’s risk for a bone fracture within 10 years. This
information can help the nurse and client plan care and implement strategies to help mitigate risks in the home and
other environments (University of Sheffield, n.d.).
FRAX ASSESSMENT
The FRAX assessment is a widely used tool (https://openstax.org/r/frax) to identify an individual’s risk for a major
fracture within 10 years. It is used together with bone mineral density testing. This tool was developed through a
collaborative effort led by the World Health Organization and the Centre for Metabolic Bone Diseases at the
University of Sheffield in the United Kingdom. It is continually updated to include current research and best
practices.
Osteoporosis in Males
Osteoporosis is more common in postmenopausal females, but following a fracture later in life, males statistically
experience more significant morbidity and mortality than females do (Burmeister et al., 2021). The increase in age-
related factures starts later in males because they start with greater bone mass and their rate of bone loss is slower
(National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2023a). The older adult male should strive to
consume 1200–1500 mg of calcium daily and between 800–2000 IU of vitamin D daily to help decrease their risk
for osteoporosis (Burmeister et al., 2021).
20.2 Nutrition and Chronic Musculoskeletal and Integumentary Illness

LEARNING OUTCOMES
• 20.2.1 Discuss the impact of nutrition on musculoskeletal and integumentary illness.
Nutritional Requirements for Optimal Musculoskeletal and Integumentary Health

Diet is an important factor to consider for preserving muscle mass. Protein and amino acids support muscle
synthesis and help maintain healthy muscle mass in all individuals. The nurse should teach the client with
decreased muscle mass the importance of maintaining adequate protein intake. Additionally, various studies have
shown that certain individuals experiencing low muscle mass due to malnutrition can benefit from oral nutritional
supplements (Prado et al., 2022). An assessment by a health care provider will allow them to help a client decide
which supplements are appropriate for their individualized needs.
One of the most important ways an individual of any age can maintain optimal musculoskeletal and integumentary
health is through a healthy diet and exercise and by maintaining a healthy body weight and composition. In addition
to monitoring a client’s weight, measuring body mass index (BMI) and waist-hip ratio (WHR) are examples of
noninvasive tools used to screen clients for obesity. Not only do underweight and overweight individuals have a
greater risk for musculoskeletal problems, but because adipose tissue is part of the integumentary system, weight is
intimately tied to this body system.
Nutrition and Skin Integrity

As explained previously, the relationship between pressure injuries (also known as pressure ulcer, pressure injury,
decubitus) and the aging process in the older adult is complex. Although aging results in thinner and more fragile
skin, other variables can add to an older adult’s increased risk for skin breakdown and wounds. Some older adults
live sedentary lifestyles that contribute not only to increased pressure on certain areas of the skin but also to
deconditioning of the muscles. Older adults may have unintended weight loss. In addition, older adults can
experience malnutrition for many reasons, leading to insufficient intake of macronutrients and micronutrients.
Because nutrition and adequate hydration are essential for wound healing, malnutrition can in turn increase the risk
for developing wounds and pressure injuries and may interfere with wound healing (Munoz, 2019).
Even small periods of malnutrition can cause delayed wound healing. Therefore, in addition to a healthy, balanced
diet, health care providers usually recommend oral nutritional supplements with added protein and amino acids for
clients with delayed wound healing due to malnutrition (Manley & Mitchell, 2022).
Nurses should encourage the use of a standardized nutritional risk assessment tool for older adults with wounds
in their care practice setting. These tools, such as the Mini Nutritional Assessment (MNA), can help the nurse
identify clients at risk for delayed wound healing and can help identify targeted areas of nutrition education for older
adults with delayed wound healing (Fulton et al., 2016).
The MNA has been validated and is highly sensitive; it has demonstrated good reliability and accuracy in identifying
older adults who are malnourished or at risk for malnutrition. It is typically administered by health care
professionals, and it can be used in various health care settings, including hospitals, nursing homes, and community
care settings. The assessment considers various factors that influence nutritional status, including dietary intake,
mobility, weight loss, and psychological factors. The MNA questionnaire portion consists of questions that cover a
range of topics, such as appetite, weight loss, mobility, and chronic diseases. The questions aim to gather
information about the individual’s dietary habits, recent weight changes, and ability to perform daily activities.
Additionally, the MNA includes anthropometric measurements such as BMI, calf circumference, and mid-arm
circumference, which provide objective data on muscle and fat stores.
Based on the responses to the MNA questionnaire and the measurements taken, individuals are categorized into
one of three groups:
• Well-nourished: Individuals who have good nutritional status and no apparent risk for malnutrition
• At risk for malnutrition: Individuals who show signs of poor nutritional status or have certain risk factors for
malnutrition
• Malnourished: Individuals who are already malnourished or have severe nutritional deficiencies
The MNA can help health care professionals make informed decisions regarding nutritional interventions for clients,
such as the need for dietary modifications, oral nutritional supplements, or referral to a dietitian for further
assessment and management.
MINI NUTRITIONAL ASSESSMENT
The MNA was developed more than two decades ago by the Nestlé Nutrition Institute. Nurses can use this tool in
a variety of settings to identify clients at risk for malnutrition or delayed wound healing and to implement
appropriate interventions. The short version of the assessment is available at this site (https://openstax.org/r/
whttps), which includes a video on its use.
Part D
Time flies! Jose is now 74 years old and has a pressure injury. Read through the following summary of Jose’s visit to
the wound clinic.

Vital Signs Nurse’s Note

Temperature: 98.6° F • 74-year-old presents for initial visit and evaluation of stage 2 pressure
Blood pressure: 122/68 ulcer on right hip. Reports that wound has been present for 4 months,
mm Hg that it causes severe pain, and that it started when bedbound due to a
right knee replacement in December. Over the past 4 months, reports
Heart rate: 80 beats/
occasional sadness due to loss of mobility. Is able to transfer from bed
min
to chair but cannot leave the house like they used to. Experiencing a
Respiratory rate: 14 decrease in appetite recently because they can no longer cook for
breaths/ themselves and don’t like the frozen meals their daughter buys.
min Estimates they have lost approximately 10 pounds in the last 4 months.
Pain: 6/10 in
right hip
decubitus
BMI: 18.5
Calf circumference: 29 cm
TABLE 20.8
7. Which of the following interventions would promote a healthy integumentary system and better wound-
healing outcomes?
a. Taking prescribed oral nutritional supplements
b. Repeating the MNA screening at regular intervals
c. Switching from skim milk to 2% milk
d. Eating less red meat
8. The nurse is preparing to complete the Mini Nutrition Assessment (MNA) for the client. Which of the following
is a potential classification based on the results?
a. Obese
b. Underweight
c. Overweight
d. Malnourished

LEARNING OUTCOMES
• 20.3.1 Identify drug–food interactions related to musculoskeletal and integumentary disorders.
musculoskeletal and integumentary disorders.
Drug-Food Interactions in Musculoskeletal and Integumentary System Disorders

Drug-food interactions can occur in individuals with musculoskeletal and integumentary system disorders. The most
common medications that often interact with food are bisphosphonates and tetracycline antibiotics.
Bisphosphonates are medications commonly used to treat osteoporosis and other bone-related conditions. Nurses
should instruct clients to take these medications on an empty stomach with a full glass of water; avoid consuming
any food, beverages (except water), or other medications for at least 30 minutes to an hour after taking the
medication; and remain upright for at least 30 minutes after taking these medications because they may irritate the
esophagus. Food, especially calcium-rich foods, can interfere with the absorption of bisphosphonates (Ganesan et
al., 2023).
Tetracycline antibiotics, such as doxycycline, can form insoluble complexes with calcium found in dairy products
and calcium supplements. These complexes reduce the absorption of the antibiotic and decrease its effectiveness.
To avoid this interaction, nurses should instruct clients to avoid taking tetracycline antibiotics within 2 hours of
ingesting calcium-rich foods or supplements. In addition, nurses should inform pregnant clients that tetracycline
staining of teeth may occur in the children of individuals who take this medication during pregnancy (DailyMed,
2018).
Medications That Can Cause Nutritional Deficiencies

Nurses should know that chronic use of certain medications can cause nutritional deficiencies and negatively affect
the musculoskeletal system. Not all individuals who take these drugs will develop nutritional deficiencies or
musculoskeletal problems, but the risk increases with long-term use. Table 20.9 outlines some of the most common
medications that can cause nutritional deficiencies related to the musculoskeletal system.
Medication/ Musculoskeletal Effect Considerations

Class
Corticosteroids Long-term use of corticosteroids, such as These medications can interfere with
prednisone, can lead to decreased calcium vitamin D metabolism, further affecting
absorption and increased calcium excretion, bone health.
which can result in bone loss and osteoporosis.
Antacids and Long-term use of antacids or PPIs can impair PPI use may lead to hypomagnesemia and
proton pump the absorption of calcium, magnesium, and hypocalcemia due to decreased absorption
inhibitors vitamin B12, which are important for of these minerals; therefore, magnesium
(PPIs) maintaining bone health. and calcium levels may need to be
monitored in some individuals.
Loop diuretics Loop diuretics (such as furosemide) can Electrolyte levels should be monitored in
increase urinary excretion of calcium, clients taking loop diuretics.
magnesium, and potassium. Prolonged use of
these medications may lead to electrolyte
imbalances and negatively affect bone density.
Anticonvulsant Some anticonvulsant drugs, including phenytoin Nurses should inform clients about the
medications and phenobarbital, may interfere with the increased risk for fractures and teach ways
metabolism of vitamin D and calcium, to modify activities as appropriate.
potentially leading to bone loss and an
increased risk for fractures.
TABLE 20.9 Medications That May Cause Nutritional Deficiencies
Medications That Increase the Risk for Osteoporosis
In addition to knowing which medications may cause vitamin and nutrient deficiencies, the nurse should be
aware that certain medications increase a person’s risk for osteoporosis. These medications include:
• Corticosteroids, which are used to treat inflammation

• Antiseizure medications, which are used to prevent seizures and treat other conditions such as neuropathic
pain
• Gonadotropin-releasing hormone agonists, which are used for cancers and some gender-affirming
treatments
• Depot medroxyprogesterone acetate, which is a contraceptive injection containing the hormone progestin
• Some medications used to treat cancer (American College of Obstetricians and Gynecologists, 2022)

Chapter Summary
• Clients who are pregnant should consume the progressive declines occur as part of the hormonal
recommended daily amounts of calcium and changes related to menopause.
vitamin D to support fetal skeletal development. • Clients with impaired skin integrity may need oral
• Infants who are breastfed should receive 400 IU supplements containing protein to promote
vitamin D daily to prevent musculoskeletal wound-healing.
disorders and promote healthy skeletal growth. • Bisphosphonates are a class of medications used
• Consuming calcium and vitamin D to promote to treat osteoporosis and other bone-related
bone growth continues to be important throughout conditions.
childhood as females achieve up to 90% of their • Some medications including corticosteroids,
peak bone mass by age 18 and males by age 20. antacids, proton pump inhibitors, and loop
• In adulthood, females have a higher risk for diuretics, and some anticonvulsant medications
osteoporosis and fractures. Temporary declines in can cause nutritional deficiencies that can
bone density occur during lactation, and negatively affect the musculoskeletal system.
Key Terms
bisphosphonates medications commonly used to osteopenia low bone density
treat osteoporosis and other bone-related pruritic urticarial papules and plaques of pregnancy
conditions (PUPPS) a skin condition of unknown origin that
fluoride an important mineral for bone health; it occurs most commonly during the third trimester of
stimulates new bone formation and inhibits the pregnancy and is characterized by itchy, red, raised
formation and progression of cavities bumps and hives that most commonly appear on
FRAX assessment a standardized assessment used the abdomen, thighs, buttocks, and arms
to estimate a person’s risk for a bone fracture within sarcopenia loss of skeletal muscle mass
10 years standardized nutritional risk assessment tool a
menopause a shift in hormones in a middle adult research-based tool used to assess clients’
woman’s life that results in physiologic changes, nutritional status
including cessation of the menstrual cycle
Review Questions
1. The nurse is educating a client about the FRAX assessment. Which statement by the client indicates the need
for further teaching?
a. “The FRAX will tell my doctor if I have osteoporosis.”
b. “The FRAX will tell my doctor if I’m at risk for a fracture.”
c. “The results of the FRAX will help the nurse develop my plan of care.”
d. “The FRAX is a risk assessment for osteoporosis.”
2. The nurse is reviewing a client’s chart and notes their current medications. Which classification of medication
increases the client’s risk for fracture?
a. Antibiotics
b. Antidepressants
c. NSAIDs
d. Corticosteroids
3. The nurse is teaching ways to promote healthy teeth in children. Which of the following practices is
recommended for children?
a. Brush teeth once a day in the morning.
b. Introduce fluoride toothpaste at 3 years of age.
c. Brush teeth with a fluoride toothpaste.
d. Schedule the first dental visit at 1 year of age.
4. The nurse is evaluating a client with PUPPP at a postpartum appointment. The client reports being very itchy.
Which objective data support the diagnosis of PUPPP?
a. Flat lesions in the vaginal area

b. No visible rash, but the client reports itchy skin
c. Silvery-white lines on the breasts
d. Raised hives on the torso
5. The nurse is caring for an adolescent client who participates in sports after school 4 or 5 times a week for 2–4
hours. The adolescent reports fatigue and sore muscles. What should the nurse suggest to this client?
a. “Drink a soda to increase your energy level after exercise.”
b. “Don’t exercise until your symptoms go away.”
c. “Try to eat a combination of protein and complex carbohydrates.”
d. “Avoid whole grains, fruits, legumes, and vegetables.”
6. The nurse is caring for a client with newly diagnosed osteoporosis who was prescribed bisphosphonate.
Which of the following should the nurse teach the client to avoid eating after taking the medication because it
can interfere with the medication’s absorption?
a. Coffee
b. Oranges
c. Milk
d. Grapefruit
7. The nurse is caring for a pregnant client who lives in a higher latitude part of the country that receives less
direct sunlight. Which laboratory value should the nurse expect the health care provider to be monitoring as a
priority of care with this client?
a. Albumin level
b. Calcium level
c. Magnesium level
d. Vitamin D level
8. The nurse is caring for a menopausal client who had a FRAX assessment that indicated a high risk for fracture
in the next 10 years. What should the nurse encourage the client to do now to help mitigate this risk?
a. Ask their health care provider to prescribe an estrogen supplement.
b. Ask their health care provider to check their calcium and vitamin D levels.
c. Include extra protein in their diet.
d. Get daily weight-bearing exercise such as walking.
9. The nurse is caring for an older adult client and recognizes which musculoskeletal manifestation is most likely
to benefit from increasing leucine consumption?
a. Osteomyelitis
b. Sarcopenia
c. Fractures
d. Osteopenia
10. The nurse is caring for a preterm newborn born at 28 weeks’ gestation. Which musculoskeletal manifestation
is most likely to be observed in this infant?
a. Osteoporosis
b. Osteopenia
c. Hip dysplasia
d. Club foot
Suggested Reading
Centers for Disease Control and Prevention. (n.d.). Cow’s milk and milk alternatives. https://www.cdc.gov/nutrition/
infantandtoddlernutrition/foods-and-drinks/cows-milk-and-milk-alternatives.html

Cleveland Clinic. (2022). Vitamin deficiency. https://my.clevelandclinic.org/health/diseases/15050-vitamin-d-

vitamin-d-deficiency
Cleveland Clinic. (2023, January 31). What to eat when you’re trying to heal. https://health.clevelandclinic.org/
foods-to-help-healing/
Nestlé Nutrition Institute. (n.d.). What is the MNA®? https://www.mna-elderly.com


A • Apps Frequently Used to Support Nutrition Wellness 409
APPENDIX A
Apps Frequently Used to Support Nutrition Wellness

The apps in Table A1 were identified by various sources, such as BuyersGuide.org, Medical News Today, and
Active.com. This table does not serve as an exhaustive list.
Overall Nutrition Apps

PlateJoy
Develops nutritionally sound meal plans with associated shopping lists based on
(https://openstax.org/r/
personal data input.
PlateJoy)
Yummly
(https://openstax.org/r/ Offers meal planning, recipes, and easy reads to introduce food exploration.
yummly)
Lifesum
Focuses on healthy weight through self-care and better food selection options;
tracks food and exercise and develops health goals. Recipes available.
lifesum)
Ate
Food journal that promotes mindful eating, exploring driving forces behind food
selection and consumption.
youate)
Weight-Loss Programs
NOOM Exploring the psychology behind what, when, and why certain foods are eaten.
(https://openstax.org/r/ Provides challenges to promote healthy weight and lifestyle with the goal of
noom) integration into consistent healthy decisions.
Nutrisystem
Provides meal and snack delivery based on healthy weight goal. Promotes healthy
food substitution.
nutrisystem)
Keto Cycle
Focus on weight loss via mindful integration of ketogenic diet. Meal prep included.
Keto-nutritional approaches are not appropriate for everyone.
ketocycle)
DoFasting Promotes intermittent fasting to lose weight, attain healthy BMI, and improve gut
(https://openstax.org/r/ health. Provides recipes, education, and workouts. Fasting nutritional approaches
dofasting) are not appropriate for everyone.
Recipes for Specific Pathologies
Diabetic App
(https://openstax.org/r/ Diabetic food recipes that assist with blood glucose stabilization.
playdiabetic)
Kidney Diet
(https://openstax.org/r/ Renal recipes focusing on tracking phosphorus, protein, and potassium.
playkidney)
Anti Inflammatory Diet
Recipes Anti-inflammatory recipes designed to maximize gut health as a precursor to
(https://openstax.org/r/ holistic health promotion.
playanti)
Meal Tracking
TABLE A1 Nutritional Wellness Apps and Websites
410 A • Apps Frequently Used to Support Nutrition Wellness
Weight Watchers
Provides personal, flexible, nutritionally sound meal plans while encouraging
lifestyle changes to promote health habits.
weightwatchers)
G-Plans
Meal tracking and planning with focus on metabolic body type, exercise tracking,
peer support, and artificial intelligence interactions.
gplanscom)
MyFitnessPal
Food diary that includes the ability to scan barcodes, provides recipes, tracks health
habits, and provides peer support.
myfitnesspal)
Other
BMI Calculator
(https://openstax.org/r/ Allows for quick BMI calculation.
healthharvardedu)
Water Reminder
(https://openstax.org/r/ Promotes mindfulness of hydration.
playgooglestore)
Quenza Designed for the personal nutrition coach, provides a digital format to share
(https://openstax.org/r/ exercises and track client progress; includes video support; and offers peer
quenzacomblog) inspiration. Offers a 30-day free trial.
Nutrition coaching
Provides virtual nutritional coaching from a registered dietician using a personalized
plan, coaching, and compliance monitoring.
heatherbauer)
Whisk
(https://openstax.org/r/ A free meal planner tool with recipes, meal planning, and grocery list creation tools.
whiskcom)
TABLE A1 Nutritional Wellness Apps and Websites

Answer Key 411
ANSWER KEY
Chapter 1
Review Questions
1. b. 10 grams of added sugars indicates this food has a significant amount of added sugar (20% of the
recommended amount). Current dietary guidelines recommend limiting sugar consumption.
2. b. According to MyPlate, carbohydrates (fruits and vegetables) comprise the largest portion of the plate.
3. c. Although all the clients have nutritional concerns, a client recently diagnosed with a myocardial infarction
(a “heart attack”) has an immediate need for diet instruction related to their new diagnosis.
4. b. WIC is designed to provide food assistance to low-income pregnant, breastfeeding, and non-breastfeeding
postpartum women and infants and children up to age 5 who are at nutritional risk.
5. b. Diets and nutritional counseling should reflect scientific findings supported by research.
6. a. Clients who do not have a steady income may not be able to get food when needed. These clients should
be screened for food insecurity.
7. d. Measuring the client’s WHR at a follow-up visit can provide objective data that reflects the client’s progress
toward a nutrition-related goal.
8. c. Employment status is a nonmedical factor that influences health.
9. a. Educational materials should be developed so that readers with lower literacy levels can understand the
content.
10. d. This response acknowledges the client’s feelings and initiates the process of educating the client on how to
evaluate nutrition information on social media.
Chapter 2
Review Questions
1. d. Arsenic is heavy metal and will not clear by boiling, so purchasing water is the best choice.
2. a. Water does not contain any energy and is calorie free.
3. b. The Mediterranean diet is high in complex carbohydrates (fruits, vegetables, beans, legumes, nuts, and
seeds) as well as fish, seafood, and poultry and includes moderate amounts of dairy products.
4. a. The individual who is lactose intolerant should consume lactose-free dairy products.
5. d. Omega-3 fatty acids play a role in heart health and are found in salmon, eggs, soybeans, flaxseed, and
canola oil.
6. d. The client who is well hydrated will have pale or light-colored urine.
7. c. Soy is the only complete protein listed. Oats, barley, and wheat are incomplete proteins and do not include
all essential amino acids.
8. c. Pasta with a plain red sauce is the lowest-fat item on the list and contains less than 3 g of fat per serving.
9. a. During exercise, circulating glucose is the first source of energy used. When this energy source is depleted,
glycogen stored in skeletal muscle is used, followed by fat.
10. b. The client with stage 3 chronic kidney disease should consume no more than 0.6 g/kg of body weight daily.
Therefore, of protein daily.
Chapter 3
Unfolding Case Study
1. d. The RDA for sodium is 2300 mg. The client’s diet consists of highly processed foods, all of which are high in
sodium.
2. c. Fruits and vegetables contain high amounts of vitamins A and C.
3. d. Fruit and vegetable smoothies provide a nutrient-dense alternative to a processed food (macaroni and
cheese and toaster pastries) without resorting to a supplement (gummy vitamin).
412 Answer Key
4. a. Vitamins C and E have direct influence on creating a robust immune system.
Review Questions
1. a. Vitamin A is the only fat-soluble vitamin listed and is stored in the tissue. It can result in toxicity.
2. a. Chromium may facilitate the metabolism of carbohydrates, lipids, and proteins by increasing the
effectiveness of insulin. The precise mechanism for this activity has yet to be identified.
3. d. Supplement labels are limited in the health claims they can make. They cannot mention a specific health
condition.
4. c. Vitamin D deficiency is related to rickets in young children.
5. d. Excess water-soluble vitamins are excreted in the urine; they are not stored in fatty tissue or the liver.
6. c. To reduce the risk for fetal neural tube defects in early pregnancy, clients of childbearing age and clients
who are pregnant should consume adequate amounts of folate.
7. c. Calcium and phosphorus contribute to the structure of healthy bones and teeth.
8. b. Iodine deficiency is the most common cause of goiter. Iodine is required to produce thyroid hormone,
without which the thyroid overworks and increases in size.
9. a. For the best retention of a vitamin, use less water, cook for a shorter time, and lower the temperature.
10. d. The client with chronic alcohol exposure is likely to have a thiamine deficiency.
Chapter 4
Review Questions
1. a. Because the gastrointestinal tract is a long, hollow tube, closing off the tube in any area causes any
contents to flow backward. Stool will backflow into the stomach because it cannot move forward to the anus
to exit the body.
2. c. Tympany on percussion signifies air, and emptiness in an area would indicate flatus.
3. a. The client’s symptoms are associated with epiglottitis, and using a tongue blade, depressor, or
laryngoscope to exam the throat or mouth could trigger a laryngospasm and respiratory distress.
4. d. The large intestine, or colon, is where the most water is absorbed.
5. b. The guaiac test detects blood in the stool.
6. b. Hyposecretion of hydrochloric acid and protective mucus occurs in older adults and decreases absorption
of vitamin B12.
7. a. Palm oil is a saturated fat that can cause gut imbalance, raise bad cholesterol, increase the risk for colon
cancer, and promote heart disease.
8. b. Yogurt with active yeast cultures has been shown to support the microbiome and prevent some of the side
effects related to long-term antibiotic use.
9. c. Lactobacillus has been shown to be supportive of the microbiome while the others are known to be
harmful.
10. d. Gut homeostasis is supported by eating whole grains, unless the person has a sensitivity to gluten.
Chapter 5
1. d. Diets high in processed foods, red meats, and refined sugars have all been shown to lead to cognitive
decline.
2. b. Cerebral blood flow should be evaluated with a PET scan to determine whether poor blood flow could be
contributing to changes in cognitive status.
3. a. Consuming 1.1–1.6 g of omega-3 fatty acids daily has been shown to optimize brain function in clients over
51 years of age.
4. c. Omega-3 fatty acids are found largely in colorful fruits and vegetables, as well as in fortified cereals and
beverages. Fruits, such as grapes, apples, pears, cherries, and berries; dark chocolate; legumes; red wine;
tea; and coffee are also good sources.
5. c. The client’s going to their dietitian appointment shows adherence to the prescribed plan. Signs of
nonadherence include alcohol use; increased BMI; increased total cholesterol; increased blood pressure; low

Answer Key 413
intake of fruits, vegetables, and fiber; and high intake of processed sugars.
6. c. Tau proteins can become tangled and accumulate in the brain and cause dysfunction.
7. b. Because of rising food costs, it may be helpful to use an air fryer to avoid deep-frying foods while
maintaining the client’s current food preferences, such as fried foods, and increasing adherence to the meal
plan.
8. b. Cerebral blood flow should be evaluated with a PET scan to determine whether poor blood flow could be
contributing to Jamal’s changes in cognitive status.
Review Questions
1. b. Supplements given via nasogastric tube can provide enteral nutrition for clients with dysphagia who are at
risk for aspiration.
2. c. The client is hyponatremic due to the head injury and is conserving fluids. In addition to fluid restriction,
medications may be administered to correct SIADH.
3. a. The progression of Alzheimer’s disease may be slowed by the consistent intake of polyphenols, and
colored berries are a rich source of polyphenols.
4. a. All other choices may result in inflammation and can cause further damage to the myelin sheath of nerve
cells.
5. b. The ketogenic diet is low in carbohydrates, and a low-carbohydrate diet has been shown to reduce the
incidence of seizures.
6. b. Dehydration is common among older adults because of a diminished sense of thirst; vigorous exercise can
cause rapid dehydration, and hydration is the priority to assess.
7. d. Although supplements may be beneficial in some cases, most nutrients are best absorbed when they are
consumed as regular food. Even though many Americans do not eat a healthy diet, it is best to evaluate
current dietary patterns and offer changes before recommending dietary supplements.
8. c. Evidence supports a cognitive benefit of intermittent fasting in Parkinson’s disease as well as epilepsy,
stroke, and Alzheimer’s disease.
9. c. The National Institutes of Health recommends 1.1–1.6 g of omega-3 fatty acids daily for a 52-year-old
adult.
10. c. Tau proteins provide structural support to the microtubules in the neuron but can become tangled due to
phosphorylation.
Chapter 6
1. b. Decreased muscle mass is associated with the aging process.
2. a. Older adults are at high risk for dehydration which can affect the body’s ability to absorb nutrients.
3. b. Complex carbohydrates, such as those found in fresh fruit, vegetables, and high-fiber cereal grains, are
recommended for the management of cognitive decline.
4. d. Supplementing the diet with micronutrients has been shown to improve cognition in some studies of
clients with Alzheimer’s disease, but the best health benefits have been verified with a varied multinutrient-
rich diet rather than with supplements alone.
Review Questions
1. d. Chicken and lentils are two sources of protein; 71 g of protein a day is often recommended during the first
trimester of pregnancy to promote fetal neurological development.
2. c. The ketogenic diet is low in carbohydrates, and carbohydrates are associated with increased symptoms
among clients with MS. A ketogenic diet may improve their concentration, attention, and memory.
3. a. Clients taking phenytoin are at risk for vitamin D and biotin deficiencies.
4. b. Nutritional deficiencies, especially of the omega-3 fatty acids, iron, zinc, and B12, are more common among
vegetarians and vegans.
5. a. Drooling and coughing are symptoms of dysphagia, and the client will require a dysphagia screening.
6. d. Polyphenols obtained from fresh fruits and vegetables have been shown to improve neurological function
and slow cognitive decline in clients with degenerative conditions including Alzheimer’s disease.
414 Answer Key
7. b. Ketogenic diets can reduce seizures that have not previously responded to drug therapy.
8. c. Lactating mothers should not restrict carbohydrate intake. They need to eat fruits, vegetables, and complex
carbohydrates including whole-grain foods, such as cereals, breads, pastas, and oatmeal.
9. a. Flavonoids inhibit growth of pathogens in the gut microbiome and have a strong antioxidant effect.
10. d. Follow a balanced diet to decrease the risk for weight gain. Taking antidepressants is associated with
weight gain.
Chapter 7
1. a. Although all these questions can provide information about the client’s nutrition, it is most important to
identify if the client has had changes in their weight or appetite which can directly reflect her current physical
health.
2. c. The client is presenting with symptoms of hypothyroidism. Sea salt, kosher salt, and other specialty salts
either do not contain iodine or contain only minimal amounts. Using iodized table salt is necessary to
maintain adequate iodine intake to promote thyroid health.
3. b. Although iodine deficiency is not the primary cause of the client’s hypothyroidism, ensuring adequate
iodine intake can still be beneficial for thyroid health. Educating the client about incorporating iodine-rich
foods, such as dairy products, and iodized salt into her diet can help support her thyroid function alongside
her medical treatment for hypothyroidism. Seafood is another good source of iodine, but the client’s cultural
background may limit the amount of seafood she consumes.
4. a. A low-sodium diet can help manage the client’s elevated blood pressure alongside other lifestyle changes.
Educating her on sodium reduction strategies, such as limiting processed foods and using herbs and spices
instead of salt, will empower her to make healthier choices.
5. a. Eating more fruits and vegetables while reducing processed food intake is a positive dietary change that
supports the client’s endocrine health. This statement indicates that she has successfully incorporated the
recommended changes to her diet to manage her hypothyroidism and type 2 diabetes.
6. a. A decrease in TSH level would indicate an improvement in the client’s hypothyroidism management, while
improved blood glucose control would reflect better management of her type 2 diabetes. These outcomes
would demonstrate the effectiveness of the care plan in addressing her endocrine health concerns.
Review Questions
1. c. Clients with Cushing’s syndrome should limit carbohydrate and salt intake. Increased salt intake can
worsen fluid retention and weight gain. Protein intake is recommended to promote structural integrity and
wound healing in these clients.
2. a. Tuna and salmon, and other fatty fish, are good sources of vitamin D. The client should try to incorporate
these foods into their diet.
3. b. Diabetes is a condition characterized by high blood glucose levels, and a diet high in fiber and complex
carbohydrates can help to regulate blood glucose levels and optimize endocrine wellness.
4. d. Eating a diet low in processed and packaged foods helps to optimize endocrine wellness. PCOS is a
condition characterized by hormonal imbalances, and a diet low in processed and packaged foods can help to
optimize endocrine wellness by reducing the intake of harmful additives and stabilizing blood glucose levels.
5. c. Hypoglycemia is characterized by low blood glucose levels, and a diet high in protein and healthy fats can
help to optimize endocrine wellness by stabilizing blood glucose levels.
6. c. Clients with Addison’s disease should increase their calcium and vitamin D intake to help decrease their
risk of osteoporosis secondary to corticosteroid use.
7. b. Assessing a client's prior knowledge of a condition and associated interventions is an appropriate method
to determine their readiness to learn.
8. c. Hemoglobin A1C is a lab test that measures how well the client’s glucose has been controlled over a
3-month period. An increased hemoglobin A1C level indicates that the client’s diet needs to be adjusted.
9. d. Cabbage and other cruciferous vegetables can interfere with the body’s ability to use iodine.
10. d. Unsalted nuts do not have iodized salt, making it a low-iodine food choice. Clients with hyperthyroidism
need to limit their sources of iodine.

Answer Key 415
Chapter 8
1. d. Blood glucose levels are heavily influenced by carbohydrate intake.
2. a. A healthy diet includes protein from lean sources such as chicken or seafood. Cheeseburgers are high in
saturated fat, which can worsen insulin resistance.
3. d. Having gestational diabetes increases a person’s risk for developing type 2 diabetes later in life.
4. b. Nuts include both healthy dietary fiber and healthy fats.
5. c. Sarah’s hemoglobin A1C result indicates that she may have developed diabetes.
6. b. Sarah will need to continue to eat lean proteins, fruits, vegetables, and high-fiber foods to manage her
Review Questions
1. c. Protein, in the form of lean meat and dairy products, is essential for growth and development. It plays an
anabolic role similar to that of growth hormone and insulin-like growth factor.
2. a. Kale is a leafy green vegetable that is a key source of anti-inflammatory micronutrients.
3. d. Clients can take antagonist medications to lower cholecystokinin levels to stimulate appetite.
4. b. Fish is an iodine-rich food and a good choice for a client with Hashimoto’s thyroiditis.
5. c. Sodium should be limited to 2300 mg/day to decrease the risk for cardiovascular disease and hypertension
associated with diabetes.
6. b. Clients with diabetes should restrict saturated fats to less than 10% of daily intake.
7. a. Alcohol consumption causes variability in blood glucose levels.
8. b. Insulin and other medications used to manage diabetes require coordination with meals to maintain proper
9. d. Levothyroxine should be taken on an empty stomach and timed to avoid interaction with certain foods and
supplements that can inhibit absorption.
10. c. Loop diuretics, such as furosemide, cause the parathyroid gland to decrease the production of parathyroid
hormone, which is important in maintaining bone stability.
Chapter 9
1. c. The Mini Nutritional Assessment is a nutritional screening tool for older clients.
2. a. The client will need education regarding foods rich in iron to consume at home.
3. b. Using Maslow’s hierarchy of needs framework, understanding the physical environment should be the first
consideration. It is essential to understand if the client will be cooking or eating prepared meals before
considering other options.
4. d. Eating smaller portions more frequently is a strategy that can overcome decreased food intake that occurs
due to getting full quickly. Although hypertension and diabetes are not risk factors for worsening anemia,
decreased taste is a physiological consequence of the change in density of taste buds that occurs with aging.
5. a. A holistic approach to client teaching includes spiritual influences, emotional influences, physical
influences, and social determinants of health.
6. b. The client’s cognitive functioning will determine if a caregiver needs to be present for the educational
session.
7. c. Ms. Foster is choosing food options and making plans for meals. She will be in the action stage of change
once she begins modifying her diet.
8. a. The nurse should recognize that change is a cyclic process and that successes and failures are expected.
Review Questions
1. a. Vitamin K is a fat-soluble vitamin necessary for the synthesis and activation of coagulation factors II
(prothrombin), VII, IX, and X.
2. c. Folate deficiency in pregnancy can lead to macrocytic anemia in mothers and neural tube defects in
fetuses.
416 Answer Key
3. b. Long-term alcohol use can cause the malabsorption of Vitamin B12.

4. c. These are all possible signs of scurvy, or vitamin C deficiency.
5. c. Iron is better absorbed when taken with vitamin C, found in orange juice, and on an empty stomach.
6. a. An older adult with anemia is likely to experience hypotension and/or lightheadedness, which is a
significant risk for falls.
7. a. Animal meat, fish, eggs, and dairy are sources of vitamin B12.
8. a. Health literacy is the only modifiable psychosocial factor listed.
9. a. Providing written material before determining the client’s preferred learning style, without assessing their
preference and without giving time to ask questions, is not consistent with holistic nursing care.
10. a. The nurse should consider that a change in behavior typically takes 6 months to achieve.
Chapter 10
1. a. The recommended dose is 3–6 mg/kg/day for 2–3 months; 3 mg/kg/dose twice daily is equal to 6 mg/kg/
day. Dividing the total daily dose will decrease gastrointestinal side effects.
2. a. Having the client identify their food likes and dislikes is a collaborative strategy the nurse can use to
develop a diet plan. Adolescents are more likely to adhere to diet modifications if they are partners in
developing their nutritional plan.
3. d. Taking iron with orange juice will increase gastrointestinal absorption. Taking iron with milk, tea, or coffee
can decrease its absorption. Antacids should be taken 2 hours before or 4 hours after taking iron for better
absorption because iron is better absorbed in an acidic environment. Missed doses of iron should not be
made up.
4. c. Feeling weak and dizzy may be a sign of low hemoglobin or worsening anemia. This can occur if oral iron is
not absorbed sufficiently by the body.
Review Questions
1. b. Common nutritional deficiencies affecting all ages include iron; vitamins B12, D, and K; and folate.
2. a. The groups most frequently affected by anemia are pregnant individuals, infants and toddlers, female
adolescents, and older adults.
3. b. Infants and children have increased nutrient demands due to rapid physical and cognitive growth, resulting
in rapid cell turnover.
4. b. Decreased sun exposure is one of several risk factors for vitamin D deficiency.
5. b. Zinc deficiency occurs in 31% of children between ages 1 and 3 years and can cause decreased immunity
and increased infections. Foods rich in zinc include eggs and dairy products, which the child is not consuming.
6. c. Clients with sickle cell disease are at high risk for vitamin D deficiency, which can increase their risk of
disease-related effects.
7. c. Older adults who consume excessive amounts of alcohol, live alone, smoke, or are obese are at risk for
folate deficiency.
8. b. Sickle cell disease is the most common inherited blood disorder in the United States. Clients with this
disease are prone to micronutrient and macronutrient deficiencies.
9. d. Iron-fortified foods such as breakfast cereals should be limited because this client is at risk for iron
overload after the transfusion.
10. c. The Mediterranean diet includes various foods and spices with anti-inflammatory and antioxidant
properties.
Chapter 11
1. c. The client’s blood pressure meets the criteria for hypertension, which is a systolic blood pressure greater
than or equal to 129 mm Hg and/or a diastolic blood pressure greater than or equal to 80 mm Hg. Peripheral
vascular disease causes blood return issues, while peripheral arterial disease will cause ischemia and blood
flow restrictions. This client has symptoms of erectile dysfunction which can be directly related to the

Answer Key 417
decreased blood flow caused by hypertension.

2. a. An electrocardiogram evaluates the electrical function of the heart and can provide initial indication of
heart disease or heart damage.
3. c. Increasing fiber intake has several health benefits. It lowers cholesterol and blood pressure and decreases
the risk of heart disease.
4. d. A cheeseburger contains red meat and cheese, both of which contain saturated fats that contribute to heart
disease.
5. a. It appears that the changes are effective, as the client’s blood pressure is coming down. The goal of the
diet is to reduce blood pressure and, secondarily, cholesterol levels. Cholesterol can be affected by much
more than just diet, and it may take more than 3 months for levels to decrease.
6. a. The client’s BMI was never an issue, so they do not have to lose a lot of weight. However, the client needed
to lessen their waist size and is currently on track with that goal.
Review Questions
1. a. The DASH diet has beneficial effects for clients with heart disease, including decreasing sodium intake to
control hypertension.
2. d. Hypertension is defined as a systolic blood pressure greater than 129 mm Hg and/or a diastolic blood
pressure greater than 80 mm Hg.
3. c. A heart-healthy diet, such as the DASH diet, promotes increasing intake of fruits, including pineapple.
4. a. The client’s body mass index (BMI) has decreased from 30 kg/m2, in the obese range, to 29 kg/m2, in the
overweight range.
5. c. The HDL level of 48 mg/dL falls within the normal range of greater than 40 mg/dL.
6. a. Coffee should be avoided because caffeine can trigger or aggravate atrial fibrillation.
7. c. Torsades de pointes is primarily caused by an extremely low magnesium level, so the priority of care with
this client is to monitor their serum magnesium level.
8. d. A high serum potassium level may cause peaked tall or high T-wave ECG.
9. b. Oatmeal is not only low in cholesterol but is high in fiber, which helps to lower LDL.
10. a. Whole milk is high in fat and cholesterol. The DASH diet promotes fat-free or low-fat dairy products.
Chapter 12
1. b. The client’s hypertension is concerning, because individuals who are already predisposed to high blood
pressure before pregnancy are at an increased risk for having more complications during pregnancy due to
the increase in vascular volume and increased stress on the body.
2. d. Tara needs to avoid fried foods, undercooked foods, and foods high in fat. The steak is cooked properly and
broccoli is a good source of nutrients.
3. c. To help with heart health in both the client and fetus, the best answer choice is to increase fruits and
vegetables.
4. b. High blood pressure is associated with pre-eclampsia, which can cause premature birth.
5. a. The client’s BMI places them in the severe obesity BMI category.
6. b. To help encourage good food choices, involve children in preparing meals.
7. d. Apples would be the best choice, because the other options are high in fat and sodium.
8. a. Foods high in fiber can help lower cholesterol levels.
9. d. The client is taking furosemide, which is a diuretic. Diuretics increase the risk for water-soluble vitamin
deficiencies particularly if the client is not able to eat a varied, nutrient-rich diet.
10. b. The choice for a healthy heart diet is to choose grilled or baked protein with vegetables and low to no sugar
substances.
Review Questions
1. b. The pregnant client who has a pre-existing heart condition will need to increase calories by 340 calories
daily to gain the necessary amount of weight but not an excessive amount that can strain their cardiovascular
system.
418 Answer Key
2. b. Infants can be introduced to pureed fruits and vegetables and infant cereals at 6 months.
3. c. The banana is the best choice for the snack as it is low in fat and sugar.
4. b. Adults should strive for an intake of less than 2300 mg of sodium daily.
5. a. Social media and peers can strongly influence adolescent eating habits.
6. c. Long-term complications of eating disorders cause electrolyte imbalances, prolong QT intervals, which can
cause arrhythmias, and can eventually lead to heart failure due to the stress on the heart.
7. b. Red meat and full-fat dairy products can elevate cholesterol levels.
8. c. Shrimp is a lean source of protein, whole grain rice is a complex carbohydrate, and vegetables are an
excellent source of nutrients.
9. a. Clients who are taking warfarin should be instructed to have a consistent intake of leafy green vegetables,
which can affect the clotting factors associated with the warfarin.
10. d. A meal of grilled chicken, onions, green peppers, and avocado with corn tortillas is lower in fat than the
other choices.
Chapter 13
1. b. The pulmonary or respiratory system comprises the upper airways, the lower airways, lungs, and alveolar
sacs. The primary function of the pulmonary system is to ensure adequate oxygenation throughout the body.
2. c. Aspirin and other nonsteroidal anti-inflammatory medications (NSAIDs) can induce bronchospasm in
clients who are sensitive and have had reactions to these medications in the past.
3. b. Processed meats and aged cheeses are high in histamines and can cause increased mucus production,
which can worsen asthma symptoms.
4. a. Protein drinks provide high protein amounts in low-volume portions to provide the nutritional components
necessary for muscle synthesis and improved muscle strength.
5. a. Eating protein, found in foods like cheese and nuts, at least twice daily will help with strong respiratory
muscles.
6. c. Obesity alters the mechanics of the pulmonary system leading to dyspnea, wheezing, airway
hyperresponsiveness, and increased work of breathing.
Review Questions
1. c. Fatigue is a common symptom of COPD that can make it difficult for the client to prepare and eat nutritious
foods.
2. c. Albumin is the primary protein of the body. Decreased levels may indicate chronic disease, malabsorption,
malnutrition with low protein, or dilution by IV fluids. Follow-on diagnostics would be pre-albumin and blood
urea nitrogen.
3. b. The process of gas exchange is when oxygen and carbon dioxide are exchanged in the alveoli of the lungs.
4. a. Calcium and vitamin D intake reduce the risk of osteoporosis and kyphoscoliosis that decrease the size and
diameter of the rib cage and reduce lung capacity.
5. c. The client should eat high-protein, calorie-dense meals to maintain nutritional status and prevent weight
loss that results from increased work of breathing.
6. a. A primary goal of nutrition therapy for pulmonary wellness is to maintain adequate respiratory function to
decrease or prevent malnutrition and obesity. Healthy body weight will help preserve muscle strength and
help maintain the integrity of the immune system.
7. d. The client should eat smaller, more frequent meals. Larger meals should be consumed earlier in the day
when the client is less tired.
8. c. Crackles indicate crepitus, or air trapped in and under the skin.
9. d. While all of these findings can indicate the client is knowledgeable of and is following the prescribed
nutritional plan, actually maintaining the recommended weight is an objective measure that indicates
adherence.
10. d. ACE inhibitors are known to induce nighttime coughing.

Answer Key 419
Chapter 14
1. b. The client grew up eating foods from their sources and cooking at home, and he participated in frequent
exercise that provided him with a solid foundation in healthy lifestyle choices.
2. a. The client grew up with the foundational knowledge of eating healthy food and exercising, so the nurse can
use this information in the dietary education plan.
3. a. Construction work, smoking, and selecting fast food are risk factors for chronic respiratory disease.
4. b. Smoking cessation and eating better improves pulmonary health.
5. c. The client’s note from last year indicates altered respiratory function and a low-quality diet, and since
nutritional counseling was not addressed during that visit, the nurse should instruct the client during this visit.
6. d. Pneumonia is a potential complication as the mucosal lining thickens and cough pressure declines in
clients with COPD.
Review Questions
1. c. Pregnant women should consume a balanced diet that includes protein to support the physiological
changes of the mother and the growth of the fetus.
2. d. Omega-3 fatty acids are essential to the development and function of the pulmonary system during
infancy.
3. c. Cognitive and behavioral defects may occur in the fetus whose mother is malnourished.
4. b. Foods containing caffeine, like coffee, can potentiate the effects of the bronchodilator leading to tremors,
nervousness, anxiety, and heart palpitation.
5. a. A pregnant client needs protein, vitamins A, D, E, and omega-3 fatty acids for proper lung function and
development of the fetus.
6. d. Nutrition plays a role in supporting the immune system, which prevents and treats infections while also
repairing lung tissue.
7. c. Consuming fruits and vegetable is linked to a decreased risk for developing asthma and a decreased risk for
experiencing asthma symptoms such as wheezing.
8. a. A diet high in saturated fats has been linked with worsening airway inflammation and lung function.
9. d. The main goal of an anti-inflammatory diet is to minimize the duration of and decrease the risk for
infection. An anti-inflammatory diet supports the immune system and lung function and decreases oxidation.
10. a. Long-term oxygen therapy in COPD clients causes nutritional deficiencies, because low oxygenation to the
gastrointestinal tract decreases its ability to function and absorb nutrients.
Chapter 15
1. a. Lunch meats are high in sodium and fat which should be avoided in clients with CKD stage 2, hypertension,
obesity, and diabetes.
2. b. Fruit salad has the lowest added sugar and carbohydrates. It also is better for the client’s weight.
3. c. Subjective and objective data illustrate that the client is doing what the plan requires, but the plan clearly is
not adequate for the client’s needs. The client has advanced from stage 2 CKD to stage 3 CKD despite having
lost weight, having blood pressure and blood sugar levels within defined limits, presenting no symptoms of
fluid overload even with the advancement in CKD stage, and using a food log to demonstrate dietary
adherence.
4. a. The client does not have symptoms of heart failure, fluid overload, or edema, and will need a diet high in
calcium and magnesium.
5. b. Symptoms of heart failure create a need to change the plan. In stage 3, if heart failure is present, additional
dietary measures are implemented. If they are not present, the same diet can be followed.
6. a. Proteins should be restricted to plant-based proteins and lean, low-fat meat sources.
Review Questions
1. a. Calcium levels are affected by the kidney through its relationship with the parathyroid gland and the
420 Answer Key
production of calcitriol, but not from direct reabsorption.

2. a. A serum creatinine level of 1.5 mg/dL is above the normal range of 0.74–1.35 mg/dL for adult males and
requires prompt attention. The other laboratory values are within normal range.
3. b. Since the PVR is the amount of urine left in the bladder after the client has urinated, the nurse should scan
the bladder immediately after the client has urinated.
4. d. Complex carbohydrates are found in foods such as whole grains, fruits, and vegetables.
5. b. The client with CKD should be instructed to use plant sources of protein before animal sources.
6. a. Engagement and participation in creating the plan is the single most important step toward client
adherence to the plan because if the client has no desire or motivation to follow the plan it will not matter if
they have the means to or not.
7. c. The client with CKD who is on dialysis should restrict fluid intake.
8. d. They should sip fluids slowly and savor them and not gulp them down quickly.
9. a. Vanilla ice cream is low in phosphorus.
10. a. Salt substitutes are dangerously high in potassium and should always be avoided when on a potassium
restricted diet. Salt substitutions are acceptable.
Chapter 16
1. a. 130 kcal/kg/day is the highest daily recommended amount for a preterm infant. 130 × 1 kg = 130 calories
daily
2. d. Carbohydrate is the preferred energy source for the body.
3. a. Protein and calories will be the biggest concerns at this age because she will need them to develop and
grow appropriately; however, she cannot take in so much that her kidneys will be overloaded and her glucose
out of range.
4. d. To prevent additional issues like UTIs, kidney stones, and hypertension, which can impact already-poor
kidney health, the client should eat a low-sodium, heart-healthy, high-fiber diet, and Ramen noodles are
extremely high in sodium.
5. b. Education on preventing STIs should start at age 10 to help ensure renal health. UTIs resulting from STIs
can spread silently and asymptomatically, depending on the cause, which could lead to pyelonephritis and
damage Kayla’s already weakened kidneys.
6. a. The requirement is 2,000 calories daily for an adolescent female.
7. d. Fetal intrauterine growth restriction (IUGR) is a risk for a client with these health conditions.
8. b. The client’s original CKD stage was stage 3, which is associated with the GFR range of 30 to 59 mL/min/
1.73 m2. During pregnancy, the range is expected to increase, so a lower range would be something to
address immediately. At 15 mL/min/1.73 m2, the client would require dialysis as an immediate intervention.
Review Questions
1. a. The GFR increases in early pregnancy, causing a hyperfiltrative state, so a decreased GFR would be
considered abnormal.
2. c. The pregnant client should avoid or limit caffeine intake to promote fetal health.
3. d. Protein is extremely important in growth and development and in repair of muscles and injury, but it is still
restricted in the diet of clients with CKD.
4. d. Females are at risk for anemia. The recommended daily iron intake for female adolescents aged 14 to 18
years, including those with CKD, is 15 mg.
5. a. Coffee, tea, colas, energy drinks, and brown chocolate all contain caffeine, which contains an acid that acts
as a bladder irritant and can aggravate OAB symptoms.
6. b. The client with calcium stones should avoid foods high in oxalate, such as rhubarb, beets, and potatoes.
7. c. Protein intake, particularly from red meat or canned sources, can increase the risk of kidney stone
development.
8. a. Increased intake of vegetables, especially cruciferous vegetables, decreases the risk of developing renal
cancer.
9. c. The client with stage 4 CKD should restrict intake of potassium as well as that of magnesium, phosphorus,

Answer Key 421
and sodium.
10. a. The Mediterranean diet, which includes an emphasis on fresh fruits, can decrease lower urinary tract
symptoms.
Chapter 17
1. a. Vitamin A deficiency is not associated with any of the client’s symptoms and could be ruled out based on
the assessment data. Based on the findings, the health care provider orders laboratory tests to determine the
client’s potassium, magnesium, and vitamin B12 levels.
2. a. The health care provider would be expected to check the client’s iron level. Iron deficiency can cause
tongue redness and inflammation and pallor. The provider decides to order a complete metabolic panel and
vitamin B12, iron, and magnesium levels.
3. d. Protein deficiency can cause weight loss, poor appetite, pallor, hair loss, and dry, brittle nails.
4. b. Quinoa is a seed grouped with whole grain that is high in protein and is a good protein option in a
vegetarian diet.
5. d. With Crohn’s disease, and when a client has many bowel movements daily, absorption becomes a problem.
In particular, iron, calcium, and vitamin D are not absorbed properly in this disease process.
6. c. The nurse should expect supplementation to be ordered. Enteral supplementation will likely be used, but if
that is not sufficient, parenteral supplementation may be considered.
Review Questions
1. b. Digestion includes mastication, which requires the teeth to be in working condition.
2. c. Palpating the abdomen can reveal any pain, guarding, or tenderness present in the gastrointestinal organs.
3. b. Angular cheilitis, or fissures and crusts in the corners of the lips, can indicate vitamin B1 (thiamine), vitamin
B12, or iron deficiency.
4. c. Tofu is a plant-based protein that can be an option in a vegetarian diet.
5. a. Edamame is a plant-based source of both protein and iron.
6. b. Eating yogurt and other probiotic foods supports the gut’s normal microbial growth.
7. d. Oranges have vitamin C and help create an acidic environment that increases iron absorption.
8. b. Vitamin C assists with iron absorption and should be included in the nutritional plan.
9. b. Ecchymosis, or bruising, is consistent with vitamin K deficiency because vitamin K is needed for adequate
blood clotting.
10. a. For vegan clients, protein options such as quinoa, tofu, and edamame are appropriate suggestions.
Chapter 18
1. a. Breastfeeding increases the chances that an infant will absorb the proper nutrients because the nutrients
provided in breast milk are more bioavailable than those in formula.
2. d. Children with galactosemia need to be on a lactose-free diet their entire lives to prevent life-threatening
problems.
3. b. The problems that Hein faced in pregnancy drastically altered her microbiome and contributed to her
infant’s low birth weight and birth at 37 weeks’ gestation. These complications all increased her infant’s risk
for Crohn’s disease.
4. a. High-fiber foods such as beans should be avoided during inflammatory phases of the disease because they
can irritate the inflamed intestinal lining.
Review Questions
1. a. The father’s microbiome is not shown to be a contributing factor to the child’s microbiome.
2. b. Premature newborns need more calories per kilogram of body weight than a full-term infant does and
should get 110–135 kcal/kg/day.
3. d. Galactosemia is a genetic disease in which the individual lacks the proper enzymes to convert lactose into
422 Answer Key
glucose.
4. c. Adolescents like to be autonomous, but many tend to prefer convenience foods such as fast food. Parents
should be instructed to provide a healthy diet whenever possible rather than simply incorporating healthy
items into unhealthy diet.
5. d. Consuming prebiotic or probiotic foods is conducive to maintaining good gut bacteria. Yogurt, kimchi, and
honey are examples of prebiotic foods.
6. d. Increasing water and fiber intake is important to prevent and manage constipation, a frequent problem
among older adults.
7. b. The client should be on a high-fiber diet when not in exacerbation but should be on a low-fiber diet due to
inflammatory cycles.
8. c. Kefir has anti-inflammatory properties that will help protect the microbiome.
9. b. Ciprofloxacin, frequently used for diverticulitis, should not be taken with calcium-rich or calcium-fortified
foods because the calcium can hinder ciprofloxacin’s absorption.
10. d. Kale can help prevent vitamin K deficiency. Amoxicillin is known to deplete vitamin K and vitamin B12.
Chapter 19
1. c. Often, a client with age-related degenerative disorders such as osteoarthritis will have limited ROM and
increased pain upon ROM of the joints. This simple screening provides valuable information for the diagnosis
of osteoarthritis as well as the treatment parameters for the client.
2. a. The provider would start with an x-ray of both knees to evaluate for any soft tissue changes and signs of
arthritis.
3. a. Leafy green vegetables have anti-inflammatory properties. Because the client has osteoarthritis with
edema in both knees, these nutrients should be included in the diet.
4. b. Nuts and seeds have anti-inflammatory properties that can be beneficial for clients with arthritis.
Review Questions
1. a. Adequate vitamin D intake is necessary for strong bones and the prevention and treatment of osteoporosis.
2. d. Good skin turgor indicates a normal moisture level in the skin. Tenting, when the skin remains stretched
out like a tent when pinched, is a sign of decreased moisture in the skin.
3. a. Protein aids in the repair of muscles and tissue.
4. d. Bromelain is a group of enzymes found in pineapples and is believed to reduce swelling and pain.
5. c. The pressure ulcer changed from a stage 2 ulcer to a stage 1 ulcer, which indicates improvement. Stage 1
pressure injuries are reddened, but not open.
6. b. Foods rich in calcium and vitamin D, such as dairy products, are important for bone health and the
treatment of osteoporosis.
7. b. Bread and pasta contain gluten and would not be included in a gluten-free diet.
8. c. Clubbing of nails, when nails look wider or swollen, is often seen with chronic obstructive pulmonary
disease (COPD).
9. b. The client understands hydration, like drinking water throughout the day, promotes skin integrity and
wound healing.
10. d. Biotin is found in foods such as liver and cooked egg yolks, and it is important in the promotion of hair and
nail health.
Chapter 20
1. c. Adequate intake of dairy products helps ensure that enough calcium is consumed, which is necessary to
support musculoskeletal and integumentary growth and development in the fetus.
2. a. Adequate intake of calcium and vitamin D is essential for developing and maintaining healthy bones and
teeth in both the pregnant client and the developing fetus.
3. a. Breastfed infants should continue vitamin D supplementation until they are taking in enough vitamin

Answer Key 423
D–fortified solids or vitamin D–rich foods.

4. a. Breastfeeding does not provide an infant with enough vitamin D. To prevent musculoskeletal disorders and
to promote healthy skeletal growth, experts recommend that all infants receive vitamin D supplementation.
5. b. The mother urgently needs to change this child’s diet so that they can achieve a healthy weight. Being
overweight places additional strain on a child’s skeletal system putting them at increased risk for injury and
may make them reluctant to participate in physical activity.
6. d. Leafy green vegetables are a good source of calcium, which promotes healthy bone development in the
growing child.
7. a. Oral nutritional supplements with added protein and amino acids are recommended for clients with
delayed wound healing due to malnutrition.
8. d. Based on the findings, the MNA classifies individuals as either well-nourished, at risk for malnutrition, or
malnourished.
Review Questions
1. a. The FRAX does not diagnose osteoporosis, but it can estimate a person’s risk for a bone fracture within 10
years. This information can help the nurse and client plan care and implement strategies to help mitigate
risks in the home and other environments.
2. d. Corticosteroids, as well as antacids, proton pump inhibitors, anticonvulsants, and loop diuretics, can affect
bone health with long-term use.
3. c. Starting in infancy, parents should brush their children’s teeth at least twice a day with a fluoride
toothpaste according to their dentist’s recommendations. The first dental visit should occur no later than the
eruption of the first tooth, which happens well before 1 year of age in most children.
4. d. Pruritic urticarial papules and plaques of pregnancy (PUPPP) is characterized by itchy, red, raised bumps
and hives that most commonly appear on the abdomen, thighs, buttocks, and arms.
5. c. Adolescent athletes have increased nutritional needs and should consume adequate amounts of complex
carbohydrates, proteins, and fats while avoiding processed sugars.
6. c. Food, especially calcium-rich foods, can interfere with the absorption of bisphosphonates.
7. d. There is a correlation between low maternal vitamin D and osteopenia in newborns and decreased bone
density in childhood. Consequently, it is important to monitor vitamin D levels in the pregnant client.
8. d. Weight-bearing exercise and maintenance of a healthy weight help prevent age-related osteoporotic
changes in menopausal individuals.
9. b. Older adults with sarcopenia, or low muscle mass, should incorporate leucine-rich foods to stimulate
muscle synthesis.
10. b. Osteopenia may be present in an infant born before 30 weeks’ gestation because the majority of calcium
uptake occurs during the third trimester of fetal life.
424 Answer Key

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Chapter 3 A Holistic View of Micronutrients

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Chapter 4 The Digestive Process

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480 References

Index 481
INDEX
Symbols albumin levels 81 anorexia 88, 157, 200, 236, 281

24-hour creatinine clearance albumin-to-creatinine-ratio 301 antepartum 112
test 300 alcohol 71, 99, 110, 122, 164, anti-inflammatory diet 287
24-hour food recall 253 214 Antibiotics 72, 88, 289, 290, 403
alcohol consumption 238 antibodies 276
A Alcohol intake 254 anticancer therapy 199
abdomen 66, 338
alcohol use 71 anticoagulant medications 197
abdominal assessment 66
aldosterone 152, 161, 298 anticonvulsant medications 122
abdominal distention 64, 68
allergies 253, 255 Anticonvulsant/Antiepileptic
abdominal pain 64, 70
Alopecia 377 Medications 120
Abdominal palpation 299
Alprazolam 121 Anticonvulsants 119
abnormal heart rhythm 88
ALS 118, 119 Antidepressants 72, 121, 123
Absolute iron deficiency anemia
altitude 275 antidiuretic hormone (ADH 97
200
aluminum 95 Antiepileptics 121
absorption 42, 46, 51, 62, 69,
Alveolar ducts 252 antioxidant 42
116, 148, 198, 198, 290, 335,
alveolar sacs 251 antioxidant properties 72
352, 355
alveolarization 275, 276 antioxidant supplements 279
accessory muscles 251
Alzheimer’s disease 73, 90, 95, Antioxidants 262, 277, 279
acid reflux 149
115, 117 antipsychotic medications 123
acid-base balance 301
American Diabetes Association Antipsychotics 121
acidic foods 70
15, 28 Antiseizure medications 404
Acromegaly 161
American Heart Association 15, anus 68, 70, 338
Action for Healthy Kids 15
15, 30 anxiety 95, 258, 266
action potential 79
amino acid pool 32 Aortic aneurysm 68
activities of daily living 200
amino acids 32, 79, 287 aortic disease 236
acute bacterial infection 259
amiodarone 160 aortic pulsations 68
Addison’s disease 130, 132, 162
Amitriptyline 120, 121, 123 Aphasia 117
adiposity 93, 149, 152
ammonia toxicity 275 apoptosis 279
adolescence 155, 357
Amoxicillin- Clavulanate 360, appetite 70, 122
Adrenal glands 129, 152, 161,
362 appetite suppression 157
298
Amphetamines 121 apraxia 117
Adrenal insufficiency 132, 135,
amputation 159 arterial blood gases 258
161
amylase 63 arteries 208, 212, 237
adrenocorticotropic hormone
Amyloids 93 arterioles 212
(ACTH) 161
anaerobic 193 arteriosclerosis 208
adult-onset obesity 116
androgenic steroids 161, 161 Artificial sugars 96
adulthood 278
anemia 113, 171, 188, 191, 196, ascorbic acid 46, 108
afferent 78
258, 259, 261, 317 aspartame 115
aging 116, 157, 197, 251, 369
angina 236 aspiration pneumonia 120
airway assessment scale 257
angiogenesis 46 aspirin 197
airway hyperreactivity 253
angiotensin-converting enzyme assessment 12
airway resistance 276
(ACE) inhibitors 254 assessment of the digestive
airways 250
animal-based foods 30 system 64
Akkermansia muciniphila 351
Anorectal anomalies 64 assessment of the renal system
albumin 81, 93, 173, 219, 258
482 Index
299 bicarbonate 301 brain fog 119

asthma 253, 260, 279, 282, 286 Bilateral edema 261 brain metabolism 194
astrocytes 91 bile 63 brain radiation therapy 160
ataxia 119 Biliary anomalies 64 breast milk 113, 191, 262, 355
ataxic gait 84 bilious vomiting 64 breast tissue development 147
atelectasis 251, 259 bilirubin 153 breastfeeding 177, 191, 233,
atherosclerosis 235, 284 bioavailability 34 395, 399
Athletes 28, 196, 398, 399 biotin 45, 47, 71, 108 breathing 265
Atkins diet 98 birth abnormalities 110 breathlessness 256
atorvastatin 243 birth weight 189, 190 Bronchioles 252
atresia 64 bisphosphonates 88, 403 bronchitis 259
atria 209 Bitot’s spots 338 bronchodilators 289
atrial fibrillation 214 bladder 298 bruising 171
atrial flutter 214 Bladder cancer 325 buccal mucosa 65, 337
atrioventricular node (AV node) Bladder scanning 299 BUN 302
209 bleeding 171, 199 bundle of His 209
atrophic gastritis 70 bleeding disorders 188 burning pain 83
attention deficit disorder 111 blindness 159
attention span 115 bloating 70, 263
C
cadmium 95
attention-deficit hyperactivity blood 96
caffeine 70, 99, 109, 111, 214,
disorder (ADHD) 194 blood abnormalities 197
289
aural atresia 64 Blood analysis 172
calciferol 108
Auscultation 66, 257 blood disorders 173, 182
calcitriol 165
autism 111, 117 blood flow 274, 284
Calcium 51, 70, 108, 121, 135,
autism spectrum disorder 111 blood glucose 26, 136, 139
164, 214, 301, 307, 392, 393,
Autoimmune disorders 191, 369 blood glucose levels 112, 140,
396
autonomic nervous system 78 149, 152
calcium concentrations 147
axons 79, 110 blood loss 188
Calcium stones 325
Azathioprine 360, 361 blood pressure 51, 148, 208,
California MyPlate for Gestational
219, 230, 240, 264
B blood sugar 28
Diabetes 150
B vitamins 44, 135 caloric intake 97, 357
blood transfusion 189
B12 164, 258 calories 8, 29, 71
blood urea nitrogen (BUN) 300
bacterial vaginosis (BV) 322 cancer drugs 160
blood volume 188, 274
bad cholesterol 72 cancer prevention 9
blood-gas barrier 275
Balsalazide 360, 361 cancer-associated anemia 200
Bloody stool 171
Banding of nails 261 cancers 70
BMI 10, 219, 260
Barbiturates 120 capillaries 208
Body mass index (BMI) 9
bariatric surgery 190 capnography 260
body measurements 10
basal ganglia 368 caput medusae 68
body weight 121, 369
Basophils 259 Carbamazepine 120, 120, 122
bone density 290, 393, 395, 399
behavioral disorders 111 carbohydrate loading 28
bone loss 385
Bell’s palsy 112 carbohydrates 8, 25, 27, 118,
Bone Marrow Aspiration/Biopsy
Benign prostatic hyperplasia 139, 148
173
(BPH) 325 carboxypeptidase 63
bones 369
Benzodiazepines 121 carcinogens 71
bowel sounds 66, 66
beta-2 adrenergic receptor Cardiac cachexia 197
Braden Scale 372
agonists 289 cardiac muscle 208
brain 78, 368
beta-amyloid aggregation 118 cardiac output 230
brain development 147
Beta-carotene 42 cardiomyopathy 216

Index 483
cardiovascular disease 216, 217, Disease (COPD) 285 congenital anomalies 64

231, 232, 239 chronic pain 95 congenital heart defects 231
cardiovascular system 208 chronic pelvic pain syndrome congenital heart disease 231,
cardiovascular workload 257 324 234
Carney complex 161 Chronic pulmonary diseases 280 congestive heart failure 197
cartilage 369 chyme 63, 69, 335 Congregate Nutrition Program
Celiac disease 70, 191, 194 chymotrypsinogen 63 265
cellular depolarization 79 Ciprofloxacin 361 constipation 64, 70, 70, 72, 151,
cellular metabolism 275 circulatory systems 209 358
cellulose 25 Cirrhosis 68, 73 Consumer health information 16
central diabetes insipidus 97 Citalopram 121 Controlling Nutritional Status
central hypothyroidism 160 citric acid cycle 45 (CONUT) 81, 92
central nervous system (CNS) 78 Cleft lip 70 cooking techniques 31, 50
cerebral autoregulation 93 Cleft palate 70 COPD 260
Cerebral blood flow 92, 94 Client education 139, 177 coping mechanisms 258
cerebral cortex 79 client questions 17 Copper 51, 86, 109, 171
cerebrum 79 client teaching 17, 382 CoQ10 119, 121
cesarean delivery 189 clinical judgment 173 coronary artery disease 241
cesarean section 351 Clonazepam 121, 122 coronary heart disease 216, 236
Charcot–Marie–Tooth disorder Clostridium difficile 72 corpus luteum 146
94 Clozapine 121, 123 corticosteroid therapy 259
Chelation therapy 86 clubbing 371 corticosteroids 289, 290
chemotherapy 327 Coagulopathy 171 corticotropin-releasing hormone
chest tightness 255 Cobalamin 48, 85, 109 149
chest wall 274 coenzyme 43 cortisol 129, 152, 161, 162, 298
chest x-ray 260 Coenzyme Q10 119 cortisol levels 274
chewing 117 cognitive decline 93 Corynebacterium 351
Cheyne-Stokes respiration 252 cognitive function 197 costovertebral angle 300
Child and Adult Care Food cognitive performance 114 cough 255, 280
Program 13, 328 cognitive processing 194 County Health Rankings &
childhood diet 234 colchicine 116 Roadmaps (CHR&R) 19
childhood obesity 114, 276 cold 261 COVID-19 73
Chloride 51, 136, 301 cold intolerance 151 COVID-19 infection 301
Chlorpromazine 120, 123 Collagen 397 cow’s milk 262
choking 233 collagen synthesis 46, 395 crackling 257
cholecystokinin 29, 63, 157 colon cancer 71, 72, 200 creatinine clearance 300
Cholelithiasis 352 colostrum 276 crepitus 257, 375
cholestasis 193 coma 83 cretinism 111
cholesterol 31, 34, 72, 91, 220 Commodity Supplemental Food Crohn’s disease 351, 360
cholesterol levels 217 Program 328 Cullen’s sign 68
choline 45, 48, 110 Common cold 284 cultural assessment 17
chondrogenesis 161 communication 16 cultural sensitivity 180
Chromium 51, 108, 164 comorbid conditions 100 curcumin 287
Chronic bronchitis 280 comorbidities 303 Cushing’s disease/syndrome
chronic hypoxic state 258 Complete Blood Count 258 130, 132, 135
chronic kidney disease 259, 317 Complex carbohydrates 26, 69, Cushing’s syndrome 68, 162
chronic obstructive pulmonary 264 cyanosis 65, 66, 257
disease 279, 280 computed tomography (CT) 260 cysteine 320
Chronic Obstructive Pulmonary concentration 82, 195 Cysteine stones 326
484 Index
Cystic anomalies 64 Dietary Guidelines for Americans EBP 19

cystic fibrosis 194, 259 2020-2025 13 Ecchymosis 68
cystinuria 320 Dietary history 170 edema 264, 372
cystitis 302 dietary recall 12 educational strategies 306
cytokines 157, 288 dietary recommendations 136 efferent 78
Dietary Supplement Health and eicosapentaenoic acid 97
D Education Act (DSHEA) 54 elastase 63
d-alpha-tocopherol 108
dietary supplements 54 Elastic recoil 252
Daily Value 45
Differential White Blood Cell elasticity 252
Daily Values 45
(Leukocyte) Count 259 Electrocardiogram (ECG/EKG)
dairy 70, 286
Diffusion 252 171, 210
dairy intake 70
digestion 32, 61, 63, 334 electrolyte disturbances 72
DASH diet 28
digestive enzymes 70 electrolyte levels 243, 301
deep palpation 67, 299
digestive organs 62 electrolytes 69
dehydrated 318
digestive process 61, 63, 69 elemental iron 190, 201
dehydration 37, 72, 80, 99, 116,
digestive system 62, 70 embolus 284
258, 259, 261, 380
Dim-light vision 261 Emphysema 280
delayed speech 109
disaccharides 26 endocrine disorders 131, 134
dementia 83, 116
disease management 159 endocrine glands 155
Demyelinating polyneuropathies
disease prevention 217 endocrine system 128
112
disequilibrium 80 endorphin 148
dental checkups 395
disproportionate short stature endothelial cells 82
dental health 112
161 Energy 29, 62, 356
denture adhesive 90
diuretics 88, 243 energy expenditure 358
Depot medroxyprogesterone
Diversity Implications 20 energy metabolism 117
acetate 404
diverticulitis 359 energy supply 28
depression 82, 95, 115, 117,
dizziness 80, 171, 195, 230 enkephalin 148
123, 197, 266
DNA synthesis 82 enteral feeding 120
dermatitis 83
docosahexaenoic acid 97 enteral feedings 93
Desipramine 120
docosahexaenoic acid (DHA) 392 Enteral nutrition 35
DEXA 385
dopamine 82, 114 enteral tube feedings 122
dextrose 152
Doxepin 121 enterocytes 335
diabetes 71, 72, 132, 157, 162,
drug use 254 enterohepatic circulation 153
164
Drug-food interactions 403 enuresis 319
diabetes insipidus 136
drug-resistant epilepsy 117 enzymes 26
diagnostic assessment 258
drug–food interactions 120, 360 Eosinophilic esophagitis 70
diagnostic tests 372, 372
drugs 72 Eosinophils 259
dialysis 35, 303, 318
duodenum 69, 335 epiglottis 65
diarrhea 72, 83
Dwarfism 161 epilepsy 95, 96, 98, 117, 120,
Diascopy 372
dysbiosis 71, 71, 351 121
Diazepam 121, 122
dyslipidemia 93 epinephrine 161
diet 8
dyspareunia 316 erythema 68
Diet recalls 139
dysphagia 93, 117, 119 erythropoiesis 188, 193, 200
Dietary Approaches to Stop
Dyspnea 171, 231, 256, 260, erythropoietin 258, 298
Hypertension 219
263, 281 erythropoietin deficiencies 177
Dietary Approaches to Stop
erythropoietin production 95
Hypertension diet (DASH) 27 E esophageal atresia 64
Dietary evaluation 11 eating behaviors 178, 234
Esophageal reflux 70
dietary fiber 163 eating disorder 114
esophagus 63, 70
Dietary Guidelines 55 eating disorders 236

Index 485
essential amino acids 32 fluid balance 152, 298, 300, 301 frontal lobes 368
estrogen 146, 155 fluid volume 264 fructose 111
estrogen levels 149 Fluids 306 functional fiber 163
Ethosuximide 122 Fluoride 51, 95, 109, 395, 396 Functional iron deficiency 200
Evaluation of nutritional fluoxetine 123 Furosemide 164, 243
strategies 268 Fluvoxamine 121
Evidence-based practice 11 folate 45, 47, 71, 110, 171, 175,
G
GABA 82
Exercise 222 190, 258
Gabapentin 120, 121
exhaustion 151 folate deficiencies 198
gait 119, 375
extracellular matrix 275 folate deficiency 352
galactose 26
Folate
F (vitamin B9) 109
galactosemia 356
failure to thrive 153 gallbladder 62, 63, 67, 69, 335
folic acid 46, 70
Fainting 171, 195 gamma-aminobutyric acid
folic acid deficiency 190
familial acromegaly 161 [GABA] 79
folic acid supplements 149
family history 255 gangliosides 111
food 8
family medical history 255, 369 gas exchange 250
Food allergies 70
Farmers Market Grant Program gastric emptying 63, 197
Food and Drug Administration 8
13 gastric or ileac resection 191
food and drug interactions 289
Farmers Market Nutrition Program gastrin 69
Food Assistance Programs 13
(FNMP) 13 Gastroesophageal reflux disease
food consistency 70
fasting serum glucose level 158 70, 72, 352
food cravings 171
Fat 8, 307 gastrointestinal change theory
food deserts 18
fat intake 70 149
food diary 139
fat-soluble vitamins 29, 42 gastrointestinal disease 359
food enrichment 44
fatigue 119, 171, 197, 200, 261, gastrointestinal health 350
Food fortification 52
266 gastrointestinal system 62, 70,
food frequency 12
Fats 29 334, 353
food frequency questionnaires
fatty acids 63 gene mutation 111
139
FDA 14, 48 Genetic hemochromatosis 199
Food Hero 21
fermented foods 26 Genu varum 375
Food insecurity 18, 328
ferritin 258 gestation 189
food journal 140
ferrous sulfate 95, 183 gestational diabetes 112, 149,
Food literacy 18
fertility 109 233
food packaging 9
fetal alcohol spectrum disorder gestational thyrotoxicosis 151
food preferences 178
111 ghrelin 157
food preparation 221
fetal alcohol syndrome 111 Gingivitis 70
food processing 44
fetal brain development 148 glia cells 91
Food security 18
fetal development 82, 352 glomerular filtration rate (GFR)
Food swamps 18
fetal health 109 35, 300, 316
Food, Drug, and Cosmetic Act 8
Fetal lung development 275 glomerulus 297
formula 233, 262, 355, 395
fetal skeletal development 392 Glossitis 261
fortified foods 46
fiber 26, 72, 217, 351 glucagon 157
fractures 165, 290, 399, 401
fiber intake 70 Glucagon-like protein-1 (GLP-1)
FRAX assessment 401
fibrotic tissue 283 receptor agonists 121
free radicals 42, 279
fibrous plaques 284 glucocorticoid levels 148
fremitus 257
fight-or-flight 161 gluconeogenesis 298
frenulum 66
fissures 70 Glucose 26, 63, 82, 112
Fresh Fruit and Vegetable Program
fistula 64 glucose control 162
(FFVP) 13
flavonoids 116, 262, 286 glucose intolerance 149
486 Index
glucose metabolism 114 Healthy People 2030 10 (HCG) 146

Glycemic control 129 healthy weight 369 hunger 92, 99
glycemic index 28, 150 heart 208 Hunger Vital Sign screening 18
glycemic load 29 heart attack 241 Huntington’s disease 73
glycogen 28 heart disease 30, 32 hydralazine 84
glycolysis 117 heart failure 189, 197, 237, 243 hydration 36, 99, 380, 392
glycoproteins 69 heart rate 195 hydrochlorothiazide 165
goiter 52, 87, 130, 163 heartburn 149 hydrogenated oils 31
Gonadotropin-releasing hormone Hematocrit 258 hyperamylasemia 64
agonists 404 hematologic disorders 173 hypercarbia 252
granulocytes 282 hematologic malignancies 202 hyperemesis gravidarum 148,
Graves’ disease 130, 132, 151, hematologic wellness 170 352
160, 191 Hematopoiesis 191 Hyperemia 274
gray matter 78, 114 hematuria 302 Hyperglycemia 153, 158, 164
Grey Turner’s sign 68 hemoglobin 90, 183, 258, 397 hyperhomocysteinemia 122
growth hormone 82, 152, 153, hemoglobin A1C 158 hyperinsulinemia 152
156, 161, 177 hemoglobinopathy 198 hyperkalemia 88, 243
guaiac test 68 hemolysis 153, 258 hyperlipidemia 72, 236
Guillain-Barré syndrome 94, 113 Hemophilia 199 hypermagnesemia 287
gums 65, 70, 337 Hemorrhoids 70 hyperoxaluria 320
gut bacteria 115, 350 hemostasis 191 hyperplasia 152
gut health 71, 72, 359 hepatic encephalopathy 73 hyperreactive hematopoiesis
gut homeostasis 71, 72 hepatic inflammation 73 198
gut microbiome 94, 113, 120 hepatic stores 190 hyperresonance 257
gut-brain axis 73 hepatotoxicity 122 hypersensitivity reactions 259
Gut-liver axis 73 hexosaminidase A 111 hypertension 68, 71, 189, 216,
high blood pressure 240 217, 219, 230, 240, 317
H High-density lipid (HDL) hypertensive disorders of
H2 receptor antagonists 191
cholesterol 217 pregnancy (HDOP) 112
hair 371
high-density lipoprotein 31, 237 Hyperthyroidism 132, 151, 160,
hair loss 261
High-fat diets 71 163
Haloperidol 121
hippocampus 113 hyperventilation 259
Haptoglobin 173
Hirsutism 377 hypoalbuminemia 219
hard palate 337
histamine 263 hypocalcemia 88, 122
Hartnup disease 47
holistic assessment 381 hypoglycemia 113, 135, 136,
Hashimoto’s thyroiditis 160
holistic care 170 152, 164
HCG 149
holistic health 381 Hypogonadism 201
HCO3 260
Holistic nutritional assessment hypokalemia 88, 243
headaches 86, 113, 195, 261
domains 180 hypomagnesemia 153
health 9
holistic practice 11 hyponatremia 96, 243
health disparities 137, 306
Home-Delivered Nutrition hypoperfusion 93
health education interventions
Program 265 Hypotension 171
182
homeostasis 71, 71, 128 hypothalamic–pituitary–somatotropic
health equity 19
homeostasis of the gut 71 157
health history 64, 130, 170, 369
homocysteine 82, 121, 121 hypothalamus 109, 128, 146
Health literacy 16, 19, 180, 182
hormones 128, 298 Hypothyroidism 132, 151, 163,
healthy diet 136
Household Food Security Survey 201
healthy eating patterns 356
(HFSS) 18 hypovolemic shock 189, 189
Healthy Fluid Milk Incentives
human chorionic gonadotropin hypoxemia 265
(HFMI) 13

Index 487
hypoxia 252, 259, 275, 290 Iodine 51, 82, 87, 109, 111, lactotroph hyperplasia 147
151, 160, 163 large intestine 336
I iodine deficiency 131, 133 Laryngitis 284
icterus 338
iodine-induced pituitary laryngoscope 65
Imipramine 120, 121
adenoma 160 laryngospasm 65
immune function 152
iodized salt 131 larynx 69, 251
immune system 31, 289
IQ 109 Laxatives 72
immunity 73
Iron 51, 70, 82, 109, 110, 171, lean muscle mass 34
immunoglobins 82
174, 192, 258, 342, 397 leptin 157
immunoglobulin A 276
iron deficiency 95, 113, 188, Levetiracetam 122
Immunoglobulin A 253
194 levodopa 121
immunomodulators 123
iron deficiency anemia 173, 318 Levofloxacin 289, 289
immunosuppressant therapy
iron overload 201 levothyroxine 164
259
Iron sequestration 200 life expectancy 287
In vitro fertilization 189
iron stores 188, 190, 200 lightheadedness 230
induration 68
iron supplement 51, 190, 201 lignin 163
infancy 152, 275
Iron-restricted erythropoiesis lingual lipase 29
Infant formula 233, 355
200 lipase 63
infection 189
Irritability 195 lipid infusion 153
inflammation 73, 119, 278, 351,
ischemia 64 lipid plaques 284
359, 381, 384
isoniazid 84 lipids 118, 239
inflammatory bowel disease 191
lips 65, 70, 337
inflammatory muscle disease J lithium 160
112 jaundice 64, 68
liver 62, 64, 67, 67, 69, 123, 190
inflammatory response 163 Johns Hopkins Medicine 15
liver disease 35, 259
influenza 259 joint pain 369
liver failure 68
Ingestion 61, 334 joints 199
liver toxicity 110
injury-induced bleeding 199
insomnia 123
K long chain fatty acids 355
ketogenic diet 96, 96, 98, 117, Long QT syndrome 211
Inspection 66
161 long-chain polyunsaturated fatty
insulin 63, 113, 157
ketosis 122 acids 114, 118
insulin resistance 130, 149
kidney cancer 326 loop diuretics 164
insulin-dependent diabetes 158
kidney disease 162 Lordosis 375
insulin-like growth factor 82,
Kidney Disease 35 loss of appetite 122
153
kidney failure 86, 159 loss of sensation 83
Integrative nutrition 11
kidney stones 122, 302, 316 low-density lipid (LDL) cholesterol
integumentary system 368, 370
kidneys 96, 296 levels 217
interdisciplinary team 10
koilonychia 339 low-density lipoprotein 31
Interferon beta-1a 123
Korsakoff’s syndrome 83 low-density lipoprotein (LDL)
Intermittent fasting 100
kyphoscoliosis 253 cholesterol 237
Interstitial cystitis, 324
Kyphosis 375 low-protein diet 35
intestinal microbiota 71
low-sodium diet 326
Intestine 70 L lower gastrointestinal system 62,
Intoeing 375 laboratory assessment 258
63
intramuscular (IM) vitamin K lactase 28
lower respiratory tract 251, 284
prophylaxis 193 lactation 399
lung cancer 254, 279
intrauterine growth restriction Lactobacillus 72, 351
lung capacity 279
275 lactose 26, 28
lung development 275
intrinsic factor 69, 70, 335 lactose intolerance 28
Lung disease 280
inversely related 286 lactose-free diet 356
488 Index
lung function 279 melena 68 mononucleosis 259

lung growth 276 memory 82, 110 monosaccharide 26
lung parenchyma inflammation Menopause 399 monounsaturated fats 30
284 menorrhagia 195 mood disorders 115
lung volume 276 menstruation 180, 195 morbidity 111
lycopene 265 Mental health 73 morning sickness 112
Lymphocytes 259 mental health disorders 114 motivation 182
Mercaptopurine 360, 361 motivational interviewing 183
M mercury 95, 95 Mouth 70, 257
Macrocytic anemia 173, 190
Mesalamine 360, 361 mouth floor 66
macroglossia 161
metabolic alkalosis 260 movement 368, 369
macrominerals 50
metabolic rate 114 movement potential 370
Macronutrients 8, 29, 115
metabolic syndrome 71, 93 Moxifloxacin 361
macrophages 287
Metabolic-associated fatty liver Moxifloxacin and Ciprofloxacin
Macrosomia 152
disease 35 360
Magnesium 51, 82, 88, 109,
metabolism 26, 29, 32, 44, 52, MS 119, 123
113, 119, 136, 214, 287, 301,
62, 70, 73, 135, 152, 169, 337 mucins 69
307, 380
Metformin 72, 85, 113, 116, 164 mucosal function 350
malabsorption 172, 198, 259,
Methylphenidate 121 mucus 263
343, 352
Metronidazole 360, 362 multidisciplinary approach 268
Mallampati score 257
microbial growth 72, 341 multiple births 188
malnutrition 35, 92, 154, 258,
microbiome 350 multiple endocrine neoplasia type
260, 266, 274, 402
microbiota 71 1 161
Malnutrition Universal Screening
Microcytic anemia 173 multiple myeloma 202
Tool (MUST) 172
micronutrient deficiencies 191, Multiple sclerosis 73, 117
malrotation 64
198 Multivitamins 264
maltose 26
Micronutrient deficiency 114, muscle cramps 151
Manganese 51
170, 261 muscle development 398
mastication 69, 334
micronutrient intake 154 muscle mass 116, 260, 290,
maternal death 112
Micronutrients 8, 318 400, 401
maternal nutrition during
micturition 299 muscle strength 197, 261
pregnancy 318
midarm circumference (MAC) muscle synthesis 265
Mayo Clinic 15
170 Muscle tone 370
McCune-Albright syndrome 161
Midazolam 122 muscle weakness 83, 290
meal plan 178, 268
midbrain 79 muscles 34, 368, 384
meal planning 50
migraine 82, 113 muscular arteries 212
meal preparation 234
mineral deficiencies 72 musculoskeletal system 368
Meals on Wheels America 15
minerals 50 Musculoskeletal tissue 370
mechanical ventilation 290
Mini Nutritional Assessment 92, myasthenia gravis 112, 119
meconium 68
172, 402 myelin 79, 94
meconium aspiration 153
Mirtazapine 121 myelin production 82
medical history 12
mitochondrial function 117 myelodysplasia 202
medications 72, 255
mitochondrial respiration 82 myocardial infarction 239
Mediterranean diet 27, 97, 114,
mobility 400 MyPlate 13, 50, 222, 303
219, 222, 381
Molybdenum 51
Mediterranean-DASH Intervention
monoamine oxidase inhibitors
N
for Neurodegenerative Delay nail clubbing 257
(MAOIs) 123
(MIND) diet 265 nails 261, 371
Monoamines 79
medulla 79 nasal congestion 274
Monocytes 259
megaloblastic anemia 45 nasopharynx 69

Index 489
National Action Plan to Improve non-cystic anomalies 64 omega-6 30

Health Literacy 16 Nonelemental iron 190 omega-6 fatty acids 90, 97
National Alliance for Nutrition and nonessential amino acids 32 Omphalitis 68
Activity 15 nonsteroidal anti-inflammatory Opioids 72
National Association of Farmers drug 254, 374 optic neuropathy 85
Market Nutrition Programs norepinephrine 161 oral health 197
(NAFMNP) 13 normal sinus rhythm (NSR) 210 oral hygiene 396
National Council Licensure Nortripgyline 120 Oral iron replacement 195
Examination (NCLEX) 11 Nose 251, 257 Oral palate 70
National Health and Nutrition NSAIDS 382 oropharynx 66, 337
Examination Survey (NHANES) nucleases 63 orthopedic surgery 397
189 numbness 84 orthopnea 256
National School Lunch Program nursing process 12 osteoarthritis 369, 375
13, 328 nutrient deficiencies 394 osteopenia 393, 395
nausea 88, 148 nutrient deficiency 253 osteoporosis 43, 201, 290, 400
NCSBN 11 nutrients 8 otitis media 284
NCSBN Clinical Judgment Nutrition 8 Ovaries 129
Measurement Model (NCJMM) nutrition facts food label 48 over-the-counter medications
11 Nutrition Facts label 14 254
near-syncope 230 Nutrition Labeling and Education Overactive bladder (OAB) 324
necrotizing enterocolitis 356 Act 9 overweight 260
nephrolithiasis 316, 325 nutritional assessment 170 Oxcarbazepine 122
nephron 297 nutritional deficiencies 68, 360 oxidation 43
nerve cells 79 nutritional evaluation 138 oxidative stress 117, 117, 163,
nerve transmission 82 nutritional goals 134, 136, 178 198, 274, 277, 279
neural tube defects 46 nutritional interventions 182 oxygen saturation 193
neurodegeneration 115 nutritional lifestyle 181 oxygen therapy 290
neurodevelopment 148 nutritional literacy 182 oxygenation 250, 257, 258, 261
neurogenesis 118 nutritional plan 140 oxyhemoglobin 90
neuroinflammation 117 Nutritional Risk in Critically Ill
Neuroleptics 121 (NUTRIC) 172
P
pack-years 254
neurologic assessment 80 Nutritional Risk Screening 2002
PaCO 2 259
neurological development 108, (NRS2002) 172
pain 80
113
neurological system 368
O palates 66
obesity 71, 154, 260, 397 Pallor 171, 257, 261
neuromuscular coordination 82
Objective data 370 palpation 67, 257, 299
neuromuscular junctions 78
obstructive sleep apnea 257 Palpitations 261
neurons 79, 110
ofatumumab 123 pancreas 62, 69, 129, 152, 157,
neuropathies 85
oils 31 335
neuropathy 159
Olanzapine 121 Pancreatic amylase 26
Neuroplasticity 92
older adults 71 Pancreatic hemorrhage 68
neurotransmission 114
Older Americans Act 328 pancreatic insufficiency 194
neurotransmitter function 194
Oligohydramnios 318 Pantothenic acid 47
neurotransmitters 79, 113
Oligosaccharides 26 PaO2 259
Neutropenia 171
Olsalazine 360, 361 parasympathetic nervous system
neutrophils 82, 259, 287
omega-3 30 78
newborn 68
omega-3 fatty acids 90, 97, 111, parathyroid gland 147
Niacin 47, 83, 109, 164
288, 392 parathyroid hormone (PTH) 147
Nitrogen balance 34
omega-3 index 97, 97 parenchyma 297
490 Index
parenteral iron replacement 198 222 prevent respiratory tract

parenteral nutrition 355 physiological factors on nutrition infections 287
parenteral supplementation 359 177 Prevotella 351
paresthesia 83, 261 pica 171, 261 Primary adrenal insufficiency
Parkinson’s disease 73, 91, 95, Pineal gland 129 162
119, 121, 368 pituitary adenoma 157 Primary endocrine disorders
parotid glands 334 pituitary gland 128, 146 129, 157
paroxetine 123 placenta 146 primary health promotion 190
passive immunity 191 Placenta previa 189 Primary hypothyroidism 160
Patch testing 372 Placental abruption 189 Primidone 122
patent ductus arteriosus 232 placental insufficiency 275 proanthocyanidins 320
pathogens 71 plant-based diet 115 probiotic 322, 350
pediatric obesity 114 plant-forward meal plan 27 probiotics 71, 163, 357
Pellagra 83 Plaque 236 Processed foods 27, 28, 118
penicillamine 84 plasma parathyroid hormone progesterone 111, 146, 149
pepsin 69 (PTH) 164 prognathism 161
peptic ulcer disease 70 pneumonia 259, 261, 284, 284, prolactin 146, 147
Peptides 79 287 prolonged hypoglycemia 152
percent Daily Value 49 Polycystic ovary syndrome 135 Propionibacterium 351
percussion 67, 257 polycythemia 153, 258 proportionate short stature 161
perfusion 208, 213, 250 polypeptides 32 proprioception 85
Periodontal disease 70 polypharmacy 198 protease 63
peripheral artery disease 236 polyphenols 82, 90, 118, 381 Protein 8, 32, 148, 172, 307,
peripheral nervous system (PNS) polysaccharides 26 355, 380, 397, 398
78 polyunsaturated fats 30 protein intake 91, 264, 303
peristalsis 69 pons 79 protein supplements 399
Periumbilical ecchymosis 68 portion sizes 139 protein–calorie malnutrition 258
Pernicious anemia 70, 85 postnatal growth 275 Proteobacteria 351
personality changes 88 Postpartum thyroiditis 160 proteolysis 34
pertussis 259 posture 119, 370 Proton pump inhibitors 72, 85,
Petechiae 171 Potassium 51, 136, 214, 301, 116, 191
pH 260 306 pruritis 302
pH balance 322 potassium chloride 326 Psoriatic arthritis 375
Pharmacology 72 Prealbumin 91, 93, 173, 258 psychomotor skills 195
Pharyngitis 284 Prebiotic 322, 350, 357 psychosocial assessment 258
Pharynx 251 Precocious puberty 155 Psychostimulants 121
phenelzine 84, 120, 121 preeclampsia 112, 189, 351 puberty 153, 155
Phenifuramine 121 prefrontal cortex 111 Pulmonary assessment 257
phenobarbital 121, 122 Pregabalin 120, 122 pulmonary embolism 284, 288
Phenothiazines 121 pregnancy 108, 146, 163, 177, pulmonary fibrosis 283, 287
Phentermine 121 188, 230, 274, 316, 350, 392 pulmonary function 276
phenylalanine 115 prenatal care 112 pulmonary hygiene 252
Phenytoin 120, 122 prenatal multivitamin 350 Pulmonary hypertension 201
phospholipids 111 Prenatal vitamins 55, 149, 190, Pulmonary rehabilitation 263
Phosphorus 51, 109, 136, 301, 395 pulmonary system 250
307, 380 Pressure injuries 376 Pulsations 68
phosphorylation 94 pressure ulcers 400 Pulse oximetry 260
phylloquinone 108 pressure wounds 367 pulseless electrical activity (PEA)
physical activity 115, 199, 222, preterm delivery 316 208

Index 491
Pure Food and Drugs Act 8 respiratory distress syndrome Secretions 257
Purkinje fibers 209 259 seizures 84, 96, 113, 117, 121
pyelonephritis 302, 316 respiratory effort 257 selective serotonin reuptake
pyogenic infections 259 Respiratory muscle strength inhibitors (SSRIs) 123
Pyridoxine 47, 84, 109 252, 276, 278 Selenium 51, 82, 89, 95, 109,
respiratory rate 257 160, 163, 262, 286, 356
Q respiratory system 250, 276 sepsis 112
Quetiapine 121
respiratory tract exam 257 serotonin 82, 114
R respiratory tract infection 276 sertraline 123
radioactive iodine 160 Respiratory tract infections serum creatinine 300, 302
radiotherapeutics 160 (RTIs) 283 Serum electrolyte testing 301
random glucose level 158 resting membrane potential 79 serum fatty acids 149
range of motion (ROM) 370 Restless leg syndrome 195 serum thyroid-stimulating
reabsorption 296 Resveratrol 118 hormone (TSH) 157
readiness to learn 17, 17, 138 Reticulocyte 173 sexual maturation 156
receptor cells 159 Retroperitoneal and intra- sexual reproduction 155
Recommended Dietary Allowance abdominal hemorrhage 68 sexually transmitted infections
(RDA) 54 Rheumatoid arthritis 375 (STIs) 322
rectum 68, 69, 338 rhinitis 274, 284 shock 64
red blood cell formation 395 Riboflavin 47, 109 short bowel syndrome 194, 355
red blood cell transfusions 200 rickets 43, 396 Shortness of breath 195, 255,
red blood cells 188, 258 Risperidone 121 280
Refined sugars 96 Sickle cell disease (SCD) 198
S sinoatrial node (SA node) 209
reflexes 84
Saccharibacteria 351
relaxin 147, 274 Sinuses 251, 257
saliva 63
renal artery 298 sinusitis 259
Salivary amylase 26, 69
renal bone dysplasia 301 skeletal development 398
Salivary gland tumors 70
Renal cancer 326 skeletal muscles 369
salivary glands 69, 334
renal capsule 296 Skin 257, 400
salt substitutes 326
renal cortex 297 skin turgor 371
sarcopenia 400
renal development 318 sleep 222
satiety 29, 72
renal disease 35 sleep disturbances 115, 123
saturated fat 71, 217
renal illnesses 325 sleep-disordered breathing 274
saturated fats 29, 30
renal medulla 297 small for gestational age (SGA)
scans 385
renal papilla 297 275
scarring 283
renal pelvis 297 small intestine 32, 69, 335
SCD 201
renal system 296 smell 90
School Breakfast Program 13,
renal vein 298 smoking 222, 254
328
renin 298 smooth muscles 369
Scoliosis 375
renin-angiotensin-aldosterone snoring 274
Scraping 372
system (RAAS) 136 Social determinants of health
screening tests 371
reproduction 155 (SDOH) 17, 253
Screening Tools 172
Residual volume 252 social media 20, 236
second-hand smoke 276
Resonance 257 Sodium 51, 71, 136, 217, 301,
secondary adrenal insufficiency
Respirations 251, 257 307
162
respiratory acidosis 260 sodium balance 96
secondary endocrine disorders
respiratory alkalosis 259 sodium intake 71
129, 157
Respiratory diffusion 250 sodium substitution 326
secondary health promotion 189
respiratory disease risk 278 sodium-to-potassium ratio 51
Secondary hypothyroidism 160
492 Index
sodium–potassium–chloride sucrose 26, 162 Telemetry 210, 214

transporter 164 Sulfamethoxazole-Trimethoprim tenderness 68
Soft palate 337 360, 362 tenting 371, 378
solid foods 356 Sulfasalazine 360, 361 Testes 129
soma 79 Sulfites 262 testosterone 155
somatic nervous system 78 Sulfur 51 tetracycline antibiotics 403
somatopause 157 Summer Food Service Program thalassemia 198, 200, 201
somatostatin 69 (SFSP) 13 The Emergency Food Assistance
soy milk 262 superficial palpation 67 Program (TEFAP) 13
spastic paraplegia 111 Supplemental Nutrition The Patrick Leahy Farm to School
Special Milk Program (SMP) 13 Assistance Program (SNAP) 13, Program 13
sperm 109 265, 328 therapeutic conversation 81
sphincter of Oddi 69 Supplemental Nutrition Program Thiamin 47, 109
spicy foods 70 for Women, Infants, and Children thiamine 83
spinal cord 79 (WIC) 13, 13, 328 Thiazide diuretics 165
spiritual and cultural practices supplements 53, 72, 99, 264 thirst 99
266 suprarenal gland 298 thorax 257
spirometry 252 Surfactant 251 throat 251, 257
spleen 67 Surfactant production 276 Thrombocytopenia 171
SpO2 260 surfactant protein expression thrombosis 201, 288
spoon-shaped nails 371 275 thrombus 284
Sputum 255 surgical history 369 thymus 191
ST segment changes 214 swallowing 69, 117 Thyroid 129
St. John’s wort 123 sympathetic nervous system 78 Thyroid deficiencies 87
standardized nutritional risk symphysis pubis 298 thyroid disorders 160
assessment tool 402 symptom management 258 thyroid hormone synthesis 111
Staphylococcus 351 syncope 230 Thyroid hormones 156
starches 25, 69 syndrome of inappropriate thyroid hormones T4 and T3 130
statin medications 243 antidiuretic hormone secretion thyroid medications 164
Statins 72 (SIADH) 97 thyroid panel 140
stenosis 64, 237 systemic inflammation 163 thyroid-stimulating hormone
steroid use 259 Systemic lupus erythematosus (TSH) 147
stiff joints 369 (SLE) 113 thyroiditis 191
stomach 63, 70, 335 thyrotropin-releasing hormone
stools 64
T (TRH) 146
T-wave abnormalities 214
stress 82 thyroxine (T4) 147, 152
T3 130
stress response 152 tingling 88
T3 toxicosis 160
Stretch marks 68 tissue growth 153
T4 130
striae 68 tissue healing 188
T4 levels 151
stroke 73, 92, 95, 112, 117, 119, tissue repair 395
Tachycardia 171
236 TM7 bacteria 351
tachypnea 171
Struvite stones 326 tongue 65, 66, 261, 337
tapping 67
stunted growth 276 tongue depressor 65
taste 90
stupor 83 Tonsillitis 284
tau protein 118
subclinical hyperthyroidism 160 tonsils 66
tau proteins 94
Subjective data 370 topiramate 122, 122
Tay-Sachs disease 111
sublingual glands 334 Torsades de pointes 211, 214
TBI 95
submandibular glands 334 toxic adenoma 160
Team Nutrition 13
succussion splash 67 toxic multinodular goiter 160
teeth 65, 337

Index 493
toxicity 42 urinalysis 301 287, 288, 380, 381, 392, 393,

trace minerals 50 urinary bladder 298 396
Traditional Foods Project 137 urinary tract infection 112, 316, vitamin D deficiency 148, 194
trans fats 31, 217 320 Vitamin D deficiency 147
transferrin 82, 172 urination 299 vitamin D metabolism 121
Transient ischemic attack (TIAs) urine 37, 64 vitamin D replacement 200
236 urologic illnesses 324 vitamin D supplementation 395
transient neonatal hypoglycemia USDA 12 vitamin E 43, 48, 85, 108, 135,
152 uteroplacental 230 171, 286
transient tachypnea 153 UTIs 320 vitamin K 43, 48, 69, 71, 108,
transport protein 93 uvula 66 171, 175, 243, 380
Transtheoretical Model 182 vitamin K deficiency bleeding
traumatic brain injury 81
V (VKDB) 193
Valproic acid 120, 121, 122, 122
tremors 368 vitamin K injection 193
vascular pattern 68
trends 20 vitamin-mineral supplement 53,
Vascular resistance 252
Triazolam 120, 123 55
vaso-occlusive crises 198
Triceps skinfold thickness (TSF) vitamins 42
vegan diet 115, 190
170 vitamins B6 82
vegetarian diets 122
tricyclic antidepressants 123 vitiligo 191, 377, 379
Vein dilation 68
triglycerides 29, 239, 355 voice box 251
veins 208
triiodothyronine (T3) 147, 152 volvulus 64
vena cava obstruction 68
Tripod breathing 261 vomiting 80, 88, 148
Ventilation 250, 290
trypsinogen 63 vulnerable populations 19
ventilation-perfusion
tuberculosis 259
Tympany 67
mismatching 252 W
ventricles 209 waist-to-hip ratio (WHR) 9
type 1 diabetes 112, 129, 136,
venules 212 warfarin 193, 243
158
vertigo 80 water 36, 69, 72, 99
type 2 diabetes 112, 129, 136,
visual memory 109 water balance 96
149, 158
Vital capacity 252 water intake 70, 116
Tyramine 123
vitamin A 42, 48, 108, 110, 135, water supplies 37
Tzanck testing 372
380 Water-soluble vitamins 42, 50,
U vitamin B1 109 243
U-wave 214 Vitamin B1 83 WBC count 259
U.S. Dietary Guidelines for vitamin B12 69, 70, 85, 109, weakness 84, 195
Americans for 2020–2025 29 110, 116, 157, 164, 171, 174, weight gain 30, 122
ulcerative colitis (UC) 352 190, 198 weight gain during pregnancy
ultraprocessed foods 27 vitamin B2 109 231
umbilical stump 68 vitamin B3 109 weight loss 122, 170
Undernutrition 109, 157, 274, Vitamin B3 83 weight-bearing exercise 401
287, 355 vitamin B6 109 well water 37
unsaturated fats 217 Vitamin B6 84 wellness 9
upper gastrointestinal system 62 vitamin B7 108 Wernicke’s encephalopathy 83
upper respiratory system 250 vitamin B9 110 Western diet 32
Upper respiratory tract 284 vitamin C 46, 48, 108, 135, 171, wheezing 253, 255, 260, 280
Urea 298 175, 286, 288, 342, 380 white matter 78, 114
ureters 298 vitamin C deficiency 132, 172 whole foods 27
urethra 298 vitamin C supplements 116 WHR 10
uric acid 298 vitamin D 29, 43, 48, 108, 110, Wilson’s disease 86
Uric stones 325 135, 161, 165, 171, 175, 262, Wood light test 372
494 Index
World Health Organization 306 xeroderma 338 Z

wound healing 90, 171, 380, xerosis 338 Zinc 51, 82, 90, 109, 110, 288
402 zinc accumulation 95
Y
Zinc deficiencies 95
X yeast infections 322
zinc deficiency 113, 195, 197
xanthelasmas 338
Zolpidem 120, 123
xanthomas 338

Index 495

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UNIT 1 NUTRITION BASICS FOR NURSES

UNIT 2 NUTRITION AND NEUROLOGICAL

UNIT 3 NUTRITION AND ENDOCRINE WELLNESS

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UNIT 4 NUTRITION AND HEMATOLOGICAL

UNIT 5 NUTRITION AND CARDIOVASCULAR

UNIT 6 NUTRITION AND PULMONARY WELLNESS

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UNIT 8 NUTRITION AND GASTROINTESTINAL

UNIT 9 NUTRITION AND MUSCULOSKELETAL

Appendix A Apps Frequently Used to Support Nutrition Wellness 409

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About OpenStax Resources

About Nutrition for Nurses

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About the Authors

Senior contributing authors: Emerald Charity Bilbrew (left),

Millie Hepburn, Sacred Heart University

Lisa R. McDonald, Capella University

Lee Anne Oliver, Beaufort County Community College

Marygrace Piskorowski, SUNY at Buffalo

Sharon R. Simon, Shenandoah University

Miranda Smith, The University of Alabama in Huntsville

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Nicole M. Stephens, Galveston College

Cynthia Wagner, University of North Georgia

Jennifer M. Bell, Ball State University

Jocelyn D. Betts, Chicago State University

Amy B. Britt, Bon Secours Mercy Health

Ximena Burgos, University of Texas – El Paso

Marcy Caplin, Kent State University

Karen Crosby, Endicott College

Amanda N. DiEugenio-Swift, Eastern University

Stacha Hayes, Emory University

Veela Hughes, Albany State University

Karen D. Joris, Professor Emeritus, Lorain County Community College

Barbara Ludwig, Rockhurst University