Nutrition is an indispensable component of care. It is from food intake that the body obtains the micro and macro nutrients needed to maintain and improve health. Diet is also an area of regulation for the management of chronic diseases such as diabetes. Care plans focused on nutrition necessarily must be individualized to take into account unique needs arising from specific medical conditions, the client’s developmental stage, and cultural preferences. Developing a care plan entails evaluating for nutritional risk, defining the goals of nutrition therapy, identifying interventions and expected outcomes, implementing the interventions, providing education, and promoting safety.
Evaluation of Nutritional Risk
The client is an 81-year old African American male diagnosed with type 2 diabetes mellitus (T2DM) and depression. He is living alone on a limited monthly pension and receiving home health services. On assessment, his waist circumference is 37 inches which falls within the normal range of ≤ 40 for males. His waist-to-hip ratio is .93, also a normal value as it is lower than .98. His height is 6 feet 1 inch and his weight is 170 lbs. so that his body mass index (BMI) is 22.4, a normal value. His blood glucose level is normal at 115 mg/dL and his glycosylated hemoglobin is 8.1 suggesting suboptimal control of his diabetes. His total cholesterol is 220 mg/dL and is above the normal as it is more than 200 mg/dL.
His blood pressure is 99/78 mm/Hg which is normal. His dentures are intact, the mouth is dry but with no other abnormalities, and he can swallow solid foods and liquids easily. He does not have any gastrointestinal problems. He appears weak but does not have functional limitations. He has been subsisting on sandwiches and burgers since his wife died five months ago. The wife cooked meals for both of them. The client eats twice or thrice a day, drinks coffee three times a day and some water. He reports that he often had no appetite and only manages to eat half of his meals at the most. He does not take any nutrient supplements or use complementary therapies. He is currently taking medications for diabetes, antihypertensive medications, and has recently been started on antidepressants.
Based on the assessment, what is concerning is the sudden decline in his weight from 191 lbs. four months ago. The patient is having unintentional weight loss defined as “an involuntary loss in total body weight over time and is associated with disease severity or undiagnosed illness” (Hartford Institute, 2006). He has lost nearly 11% of his body weight or 21 lbs. in the past four months which fulfills the criteria for acute unintentional weight loss. One nutritional diagnosis is inadequate oral intake related to lack of appetite as evidenced by the subjective report of the client and an intake of less than 50% of daily nutrient needs. Another nutritional diagnosis is an imbalance of nutrients related to the lack of variety in the client’s diet and food that is largely limited to carbohydrates and saturated fat. The client is therefore at risk for malnutrition. Older adults with poor nutrition and chronic conditions such as diabetes are also at risk for heart disease, impaired immune functioning, and osteoporosis (Stanley, 2014).
Interventions and Expected Outcomes
Nutritional interventions play a significant role in improving the client’s intake in terms of amount and nutrient content. Inadequate oral intake and the resulting weight loss are common among older adults especially among those who live alone (Rist, Miles & Karimi, 2012). Depression is a major etiology besides serious illness such as heart disease and cancer. Negative life events, usually the death of a spouse, followed by social isolation typically precipitates depression that manifests in a loss of appetite. Although the client’s BMI is currently within the normal range, sustained low food intake will result in continued weight loss and raises the risk of malnutrition. As such, increasing the client’s oral intake by improving his appetite is a multidisciplinary responsibility (Agarwal et al., 2013). Pharmacologic therapy is necessary to treat depression while the collaboration between nutritionists, nurses, and social workers facilitates non-pharmacologic interventions.
An imbalance of nutrients is especially important considering that the client has inadequately controlled diabetes. Type 2 diabetes is a major risk factor to the development of heart disease which has a greater incidence and prevalence among older adults. A diet high in saturated fat exacerbates this risk by increasing the levels of cholesterol in the bloodstream that contributes to atherosclerosis (Araki & Ito, 2009). In addition, diet is an important component in the management of hypertension and diabetes as these conditions relate to sodium and carbohydrate intake. A healthy diet assists in the achievement of an optimal body weight where excess weight sustains the metabolic imbalance underlying type 2 diabetes (Osher & Stern, 2009). At the same time, a healthy diet promotes general health and wellbeing that translates to an improved quality of life despite advancing age (Alfonso-Rosa et al., 2013).
While in the hospital, a nutrition planning session will be held with the patient to explain the need for medical nutrition therapy that includes diet modification, nutrition education, and non-pharmacologic strategies to improve his appetite and increase food intake (Stanley, 2014). A good understanding of his nutritional status promotes adherence to therapy. Education that provides the knowledge and skills to plan meals, understand food label data, prepare and/or access healthy foods, and monitor weight will enhance his efficacy in the self-management of diabetes following discharge (Strychar, Elisha & Schmitz, 2012). With regard to improving his appetite, the client’s food preferences that are often culturally determined will be taken into account. The staff will make sure that food presentation and temperature or the aesthetic aspect of food will stimulate appetite.
Moreover, food will be provided in small but frequent meals and liquids will be limited during mealtimes to boost the likelihood of the client achieving his goal of consuming 90-100% of his meals (Nieuwenhuizen et al., 2010). Coffee will be given only after mealtimes for the same reason. Achievement is a positive occurrence that helps improve the client’s mood as compared to failure. Mood and appetite can also be improved by increasing physical activity (Meyer & Gullotta, 2012). Moreover, eating is a social event and coordination with the nursing staff will ensure that the client will be in the company of others during mealtimes to improve appetite and food intake (Stanley, 2014). Progress will be monitored during hospitalization and after discharge. The results will be communicated with the other members of the health care team for additional or alternative treatment and management strategies when the interventions in the initial nutrition care plan fail. A list of the interventions and expected outcomes are listed in Table 1.
Goals of Medical Nutrition Therapy
Medical nutrition therapy is the “diagnostic, therapeutic and counseling services offered by a dietician for the management of any disease, condition, illness or disorder” (Agarwal et al., 2013). In order to be effective, therapy goals must be individualized. In the case of Andy, his nutritional needs arising from his medical condition and social situation should shape these goals to ensure relevance and applicability. The specific goals for medical nutrition therapy for this particular client are listed below.
1. Achieve and maintain optimal blood glucose and cholesterol levels within three months after the implementation of diet modification and nutritional education.
2. Modify the client’s energy and nutrient intake to prevent malnutrition on one hand and excessive weight gain on the other, as well as the complications associated with both diabetes and hypercholesterolemia.
3. Promote health by improving the client’s knowledge and skills about healthy eating, namely consuming the right kind and amount of food.
4. Guarantee that the client’s nutrient requirements are sufficiently met in relation to nutrition needs and personal preferences.
The Need for Diet Modification
The need for diet modification is evident in the client’s nutritional and medical status. Current type 2 diabetes, hypertension, and hypercholesterolemia require an appropriate diet for the management of signs and symptoms and the reduction of risks for heart disease. The risk for osteoporosis also requires more calcium in the diet. To prevent further weight loss, his present diet must further be modified to meet the minimum number of calories appropriate for his age and level of physical activity. These needs cannot be met by the client’s current diet and eating patterns because it provides less than the necessary calories. It also does not provide a wide range of vitamins and minerals in sufficient amounts to meet the recommended daily needs among older adults. In fact, it is high in fat that heightens the client’s present risks for disease. The client also consumes foods with a high glycemic index that makes it difficult to achieve predictable blood glucose levels.
Suggested Diet
A low-fat, low-sugar, low-salt, high-calcium diet that includes foods rich in vitamins and minerals is recommended for the client. This type of diet is heart friendly and appropriate for diabetics as well as older adults who may be experiencing a decline in bone mass density. This type of diet is best achieved by adhering to the MyPlate version for older adults (Tufts University, 2012). About half of the meal should be vegetables and fruits with the best choices being those with deeply-colored interiors. About a quarter of the meal should be carbohydrates, preferably fortified whole grain bread and cereals (Tufts University, 2012). Proteins should also be about a quarter and must include fish, lean meat, eggs, nuts, beans, and tofu. The latter is particularly high in calcium.
Fats must compose a very small portion of the diet while herbs and spices can replace salt as food flavoring (Tufts University, 2012). Lastly, fluid intake should include calcium-containing yogurt and low fat milk preferably fortified with vitamin D or low-sugar fruit juices. In relation to diabetes, carbohydrates must be distributed throughout the day in consistent amounts and timing to stabilize blood glucose levels (Arathuzik, 2014). Carbohydrate choices should be those with a low glycemic index such as the high-fiber foods suggested above to prevent fluctuations in blood glucose that make optimal management more difficult to achieve (Mayo Clinic Staff, 2013; Franz et al., 2010). The client can use the food exchange system for diabetics to fulfill personal food preferences during meals.
Nutrition Education
Preventing Food-Medication Interactions
Another component of client education is the prevention of food-medication interactions that may lead to adverse effects and harm. One strategy that can be recommended to the client is reading drug labels thoroughly especially sections on contraindications, warnings, and directions for taking (Yaheya & Ismail, 2009). In addition, the client can inquire with his physician, pharmacist, nurse or dietician about the possible food-drug interactions associated with the medications prescribed. Another strategy is for the client to read food labels carefully not just for nutrient content but also ingredients to make sure the food does not contain anything that will interact with his medications (FDA, 2008).
Conclusion
Nutrition is a key component of health promotion as well as disease prevention and management. Effective medical nutrition therapy is planned and implemented following assessment and diagnosis. It employs therapeutic interventions and client education to effect diet and behavioral modifications appropriate for meeting identified nutritional needs. Managing diabetes, unintentional weight loss, and other co-morbid conditions in an elderly patient through nutrition requires individualized interventions that address the etiology of actual and potential nutritional problems. It also warrants client education and training to enable self-management that includes adherence to a healthy diet and other health-promoting behaviors. It must further include the necessary precautions to prevent harmful food-drug interactions.
References
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