Chapter 070. Nutritional Requirements and Dietary Assessment (Part 6) Acute Care Settings Acute care settings, anorexia, various diseases, test procedures, and medications can compromise dietary intake. Under such circumstances, the goal is to identify and avoid inadequate intake and ensure appropriate alimentation. Dietary assessment focuses on what patients are currently eating, whether they are able and willing to eat, and whether they experience any problems with eating. Dietary intake assessment is based on information from observed intakes; medical record; history; clinical examination; and anthropometric, biochemical, and functional status. The objective is to gather enough information to establish the likelihood of malnutrition due to poor dietary intake or other causes and to assess whether nutritional therapy is indicated. Simple observations may suffice to suggest inadequate oral intake. These include dietitians' and nurses' notes, the amount of food eaten on trays, frequent tests and procedures that are likely to cause meals to be skipped, nutritionally inadequate diet orders such as clear liquids or full liquids for more than a few days, fever, gastrointestinal distress, vomiting, diarrhea, a comatose state, and diseases or treatments that involve any part of the alimentary tract. Acutely ill patients with diet-related diseases such as diabetes require assessment because an inappropriate diet may exacerbate these conditions and adversely affect other therapies. Abnormal biochemical values [serum albumin levels <35 g/L (<3.5 mg/dL); serum cholesterol levels <3.9 mmol/L (<150 mg/dL)] are nonspecific but may also indicate a need for further nutritional assessment. Most therapeutic diets offered in hospitals are calculated to meet individual nutrient requirements and the RDA. However, there are exceptions including clear liquids, some full liquid diets, and test diets, which are inadequate for several nutrients and should not be used, if possible, for more than 24 h. As much as half of the food served to hospitalized patients is not eaten, so it cannot be assumed that the intakes of hospitalized patients are adequate. Dietary assessment should compare how much and what food the patient has consumed with the diet that has been provided. Major deviations in intakes of energy, protein, fluids, or other nutrients of special concern for the patient's illness should be noted and corrected. Nutritional monitoring is especially important for patients who are very ill and who have extended lengths of stay. Patients who are fed by special enteral and parenteral routes also require special nutritional assessment and monitoring by physicians with training in nutrition support and/or dietitians with certification in nutrition support (Chap. 73). Ambulatory Settings The aim of dietary assessment in the outpatient setting is to determine whether the patient's usual diet is a health risk in itself or if it contributes to existing chronic disease-related problems. Dietary assessment also provides the basis for planning a diet that fulfills therapeutic goals while ensuring patient adherence. The outpatient dietary assessment should review the adequacy of present and usual food intakes, including vitamin and mineral supplements, medications, and alcohol, as all of these may affect the patient's nutritional status. The assessment should focus on the dietary constituents that are most likely to be involved or compromised by a specific diagnosis, as well as any comorbidities that are present. More than one day's intake should be reviewed to provide a better representation of the usual diet. There are many ways to assess the adequacy of the patient's habitual diet. These include a food guide, a food exchange list, a diet history, or a food frequency questionnaire. A commonly used food guide for healthy persons is the USDA's food pyramid, which is useful as a basis for identifying inadequate intakes of essential nutrients, as well as likely excesses in fat, saturated fat, sodium, sugar, and alcohol (Table 70-3). The guide is available online (www.MyPyramid.gov) and can be tailored to the needs of persons of different ages and life stages by varying the number of servings. The process of reviewing the guide with patients helps to identify food groups eaten in excess of recommendations or in insufficient quantities and helps them to transition to healthier dietary patterns. For those prescribed therapeutic diets, assessment against prescriptions stated as food exchange lists may be useful. These include, for example, the American Diabetes Association food exchange lists for diabetes, or the American Dietetic Association food exchange lists for renal disease. Table 70-3 My Pyramid: The USDA Food Guide Pyramid for Healthy Persons Servings and Examples of Standard Portion Sizes Lower: 1600 kcal Moderate: 2200 kcal Higher: 2800 kcal Fruits, cups 1.5 2 2.5 Servings and Examples of Standard Portion Sizes Lower: 1600 kcal Moderate: 2200 kcal Higher: 2800 kcal Vegetables, cups 2 3 3.5 Grains, oz eq 5 7 10 (1 slice bread, 1 cup ready to eat cereal, 0.5 cup co oked rice, pasta, cooked cereal) Meat and beans, oz eq 5 6 7 (1 oz lean meat, poultry, or fish; 1 egg, 1 Tbsp. peanut butter, 0.25 cup cooked dry beans, or 0.5 oz nuts or seeds) Servings and Examples of Standard Portion Sizes Lower: 1600 kcal Moderate: 2200 kcal Higher: 2800 kcal Milk, cups 3 3 3 (1 cup milk or yogurt, 1.5 oz natural or 2 oz processed cheese) Oils, tsp 5 6 8 Discretionary calorie allowance, kcal (remaining calories after accounting for all of the above) 132 290 426 Abbreviation: oz eq, ounce equivalent. Source: Data from United States Department of Agriculture. http://www.MyPyramid.com . Chapter 070. Nutritional Requirements and Dietary Assessment (Part 6) Acute Care Settings Acute care settings, anorexia, various diseases, test procedures, and medications. medications can compromise dietary intake. Under such circumstances, the goal is to identify and avoid inadequate intake and ensure appropriate alimentation. Dietary assessment focuses on what. adequacy of present and usual food intakes, including vitamin and mineral supplements, medications, and alcohol, as all of these may affect the patient's nutritional status. The assessment should