1. HS-CPM-9. Students will evaluate the importance of nutrition in physical medicine.

2. Substandard a. Identify the six classes of nutrients and describe the functions of each

3. Essential Nutrients Carbohydrates: supply energy to the body in the form of sugar Fats: source of stored energy; provide and carry the fat soluble vitamins: A,D,E,K Proteins: important for growth, maintenance, repair of tissue Vitamins: aid in absorbing and using the nutrients. Each vitamin helps one or more specific functions in the body. Adam Freeman's notes on Nutrition

4. Essential Nutrients cont. Minerals: helps in activating numerous reactions in the body- building and regulating Water: regulates body temperature, moistens tissues like eyes, nose & mouth, lubricates joints, protects body organs & tissues, helps prevent constipation, carries nutrients & oxygen to cells, helps dissolve nutrients for use in body, flushes out waste products Adam Freeman's notes on Nutrition; MayoClinic

5. Substandard b. Identify the five food groups and list several food sources for each group

6. 5 Food Groups Vegetables Fruits Grains Dairy Proteins

7. 5 Food Groups Vegetables: may be fresh, frozen, canned or dried and may be eaten whole, cut-up, or mashed. You should eat a variety of dark green, red and orange vegetables, as well as beans and peas (which are also considered part of the protein group). Examples: broccoli, carrots, collard greens, split peas, green beans, black-eyed peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoes and kidney beans Centers for Disease Control & Prevention

8. 5 Food Groups cont. Fruits: may be fresh, canned, frozen or dried and may be eaten whole, cut-up, or pureed. Examples: apples, apricots, bananas, dates, grapes, oranges, grapefruit, mangoes, melons, peaches, pineapples, raisins, strawberries, tangerines, and 100% fruit juice Centers for Disease Control & Prevention

9. 5 Food Groups cont. Grains: At least half of the grains you eat should be whole grains, such as whole-wheat bread, whole-grain cereals and crackers, oatmeal, bulgur, and brown rice. Refined grains include white bread, white rice, enriched pasta, flour tortillas, and most noodles. Centers for Disease Control & Prevention

10. 5 Food Groups cont. Dairy: Most of your choices should be fat-free or low- fat milk and milk products, but all milks and calcium- containing milk products count in this category. Examples include milk, cheeses, and yogurt as well as lactose-free and lactose-reduced products and soy beverages. Centers for Disease Control & Prevention

11. 5 Food Groups cont. Proteins: Choose a variety of lean meats and poultry, seafood, beans and peas, eggs, processed soy products, unsalted nuts, and seeds. Make sure to eat at least 8 ounces of seafood each week. Centers for Disease Control & Prevention

12. Substandard c. Assess the nutritional status of patients in physical medicine

13. Assess Nutritional Status Influenced by food intake, quality & quantity, & physical health Good nutritional history should be obtained General clinical examination, with special attention to organs like hair, gums, nails, skin, eyes, tongue, muscles, bones & thyroid gland. Detection of relevant signs helps in establishing the nutritional diagnosis www.pitt.edu/~super7/19011-20001/19801.ppt ‎

14. Clinical signs of nutritional deficiency HAIR Protein, zinc, biotin deficiency Spare & thin Protein deficiencyEasy to pull out Vit C & Vit A deficiency Corkscrew Coiled hair www.pitt.edu/~super7/19011- 20001/19801.ppt ‎

15. Clinical signs of nutritional deficiency MOUTH Riboflavin, niacin, folic acid, B12 Glossitis (swollen tongue, often smooth look) Vit. C,A, K, folic acid & niacinBleeding & spongy gums B 2,6,& niacinAngular stomatitis (canker sores), cheilosis (painful cracking of corners of mouth) & fissured tongue Vit.A,B12, B-complex, folic acid & niacin Leukoplakia Vit B12,6,c, niacin,folic acid & iron Sore mouth & tongue www.pitt.edu/~super7/19011-20001/19801.ppt ‎

16. Clinical signs of nutritional deficiency EYES Vitamin A deficiencyNight blindness, exophthalmia (protruded eyeballs) Vit B2 & vit A deficiencies Photophobia- blurring, conjunctival inflammation www.pitt.edu/~super7/19011- 20001/19801.ppt ‎

17. Clinical signs of nutritional deficiency NAILS Iron deficiencySpooning Protein deficiencyTransverse lines www.pitt.edu/~super7/19011-20001/19801.ppt ‎

18. Clinical signs of nutritional deficiency SKIN Folic acid, iron, B12Pallor Vitamin B & Vitamin C rough, cone-shaped, elevated papules, the openings of which are often closed with a white plug of encrusted sebum) Follicular hyperkeratosis (rough, cone-shaped, elevated papules, the openings of which are often closed with a white plug of encrusted sebum) Vit B2, Vitamin A, Zinc & Niacin Flaking dermatitis NiacinPigmentation, desquamation (shedding of outer layer of skin) Vit K,Vit C & folic acidBruising, purpura www.pitt.edu/~super7/19011-20001/19801.ppt ‎

19. Clinical signs of nutritional deficiency Thyroid gland In mountainous areas and far from sea places Goiter is a reliable sign of iodine deficiency. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

20. Clinical signs of nutritional deficiency Joints & bones Help detect signs of vitamin D deficiency (Rickets) & vitamin C deficiency (Scurvy) www.pitt.edu/~super7/19011-20001/19801.ppt ‎

21. Anthropometric Methods Anthropometry is the measurement of body height, weight & proportions. It is used to evaluate both under & over nutrition. The measured values reflects the current nutritional status & don ’ t differentiate between acute & chronic changes. Measurements: Mid-arm circumference Skin fold thickness Head circumference Head/chest ratio Hip/waist ratio www.pitt.edu/~super7/19011-20001/19801.ppt ‎

22. Anthropometry for Children Accurate measurement of height and weight is essential. The results can then be used to evaluate the physical growth of the child. http://www.cdc.gov/growthcharts/data/set1clinical/cj4 1c021.pdf Boys http://www.cdc.gov/growthcharts/data/set1clinical/cj4 1c021.pdf http://www.cdc.gov/growthcharts/data/set1clinical/cj4 1c022.pdf Girls http://www.cdc.gov/growthcharts/data/set1clinical/cj4 1c022.pdf www.pitt.edu/~super7/19011-20001/19801.ppt ‎

23. Measurement for Adults Height: The subject stands erect & bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault & height is recorded to the nearest ¼ inch. Weight: Use a regularly calibrated electronic or balanced- beam scale. Spring scales are less reliable. Weigh in light clothes, no shoes. Read to the nearest ½ pound. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

24. Body Mass Index The international standard for assessing body size in adults is the body mass index (BMI). BMI is computed using the following formula: BMI = Weight (kg)/ Height (m²) OR (weight (lb) / [height (in)] 2 x 703) See chart for conversion Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity & mortality www.cdc.gov/healthyweight/.../bmi/...bmi/childre ns_bmi_formula.html

25. BMI (WHO - Classification)  BMI < 18.5 = Under Weight  BMI 18.5-24.5= Healthy weight range  BMI 25-30 = Overweight (grade 1 obesity)  BMI >30-40 = Obese (grade 2 obesity)  BMI >40 =Very obese (morbid or grade 3 obesity) http://www.nhlbi.nih.gov/guidelines/obesity/b mi_tbl.pdf

27. Waist/Hip Ratio Waist circumference is measured at the level of the umbilicus to the nearest 0.5 inch. The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together. The measurement should be taken at the end of a normal expiration. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

28. Waist Circumference Waist circumference predicts mortality better than any other anthropometric measurement. It has been proposed that waist measurement alone can be used to assess obesity www.pitt.edu/~super7/19011-20001/19801.ppt ‎

29. Hip Circumference Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 inch. The subject should be standing and the measurer should squat beside him. Both measurement should taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

31. Dietary Assessment Nutritional intake of humans is assessed by five different methods. These are: 24 hours dietary recall Food frequency questionnaire Dietary history since early life Food diary technique Observed food consumption www.pitt.edu/~super7/19011-20001/19801.ppt ‎

32. 24 Hours Dietary Recall A trained interviewer asks the subject to recall all food & drink taken in the previous 24 hours. It is quick, easy, & depends on short-term memory, but may not be truly representative of the person’s usual intake www.pitt.edu/~super7/19011-20001/19801.ppt ‎

33. Food Frequency Questionnaire In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency & quantity) per day, per week & per month. Inexpensive, more representative & easy to use. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

34. Food Frequency Questionnaire cont. Limitations: Long Questionnaire Errors with estimating serving size. Needs updating with new commercial food products to keep pace with changing dietary habits. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

35. Dietary History It is an accurate method for assessing the nutritional status. The information should be collected by a trained interviewer. Details about usual intake, types, amount, frequency & timing needs to be obtained. Cross-checking to verify data is important. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

36. Food Diary Food intake (types & amounts) should be recorded by the subject at the time of consumption. The length of the collection period range between 1-7 days. Reliable but difficult to maintain. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

37. Observed Food Consumption The most unused method in clinical practice, but it is recommended for research purposes. The meal eaten by the individual is weighed and contents are exactly calculated. The method is characterized by having a high degree of accuracy but expensive & needs time & efforts. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

38. Interpretation of Dietary Data 1. Qualitative Method Using the food pyramid & the basic food groups method. Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat-fish-poultry, vegetables & fruits) Determine the number of servings from each group & compare it with minimum requirement. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

39. Interpretation of Dietary Data cont. 2. Quantitative Method The amount of energy & specific nutrients in each food consumed can be calculated using food composition tables & then compare it with the recommended daily intake. Evaluation by this method is expensive & time consuming, unless computing facilities are available. www.pitt.edu/~super7/19011-20001/19801.ppt ‎

40. Substandard d. Define calorie and explain the role of calories in weight maintenance, weight loss, and weight gain

41. Calorie A unit of heat used to indicate the amount of energy that foods will produce in the human body http://www.merriam-webster.com/dictionary/calorie

42. Weight Maintenance/Loss/Gain If you want to lose weight, subtract 500 calories per day for each pound you want to lose every week. Add 500 calories per day for each pound you want to gain every week. 1 pound of fat represents 3500 calories (500 calories per day multiplied by 7 days equals 3500 calories). Calorie levels of less than 1200 calories are not recommended and are too low to meet nutritional requirements. Weight loss of more than 2 pounds per week is not recommended. For a more balanced approach to a 1 pound per week weight loss, increase your activity. Consider cutting calorie intake by 250 calories per day and exercising to expend (use up) the other 250 calories. This approach prevents a decrease in your metabolic rate and promotes increased lean muscle mass. http://www.nutrition.com.sg/ha/hacalcal.asp

43. If you are...Your caloric balance status is... Maintaining your weight"in balance." You are eating roughly the same number of calories that your body is using. Your weight will remain stable. Gaining weight"in caloric excess." You are eating more calories than your body is using. You will store these extra calories as fat and you'll gain weight. Losing weight"in caloric deficit." You are eating fewer calories than you are using. Your body is pulling from its fat storage cells for energy, so your weight is decreasing. http://www.cdc.gov/healthyweight/calories/

46. Video Clips http://theweightofthenation.hbo.com/digital-assets/ Are all calories created equal? Why maintaining a healthy weight is so hard.

47. Substandard e. Distinguish between the signs, symptoms, and treatment of various eating disorders

48. Anorexia Nervosa Symptoms Resistance to maintaining body weight at or above a minimally normal weight for age and height. Intense fear of weight gain or being “fat,” even though underweight. Disturbance in the experience of body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of low body weight. Loss of menstrual periods in girls and women post- puberty. www.nationaleatingdisorders.org

49. Anorexia Nervosa cont. Warning Signs Dramatic weight loss. Preoccupation with weight, food, calories, fat grams, and dieting. Refusal to eat certain foods, progressing to restrictions against whole categories of food (e.g. no carbohydrates, etc.). Frequent comments about feeling “fat” or overweight despite weight loss. Anxiety about gaining weight or being “fat.” Denial of hunger. Development of food rituals (e.g. eating foods in certain orders, excessive chewing, rearranging food on a plate). Consistent excuses to avoid mealtimes or situations involving food. Excessive, rigid exercise regimen--despite weather, fatigue, illness, or injury, the need to “burn off” calories taken in. Withdrawal from usual friends and activities. In general, behaviors and attitudes indicating that weight loss, dieting, and control of food are becoming primary concerns. www.nationaleatingdisorders.org

50. Anorexia Nervosa cont. Health Consequences Abnormally slow heart rate and low blood pressure, which mean that the heart muscle is changing. The risk for heart failure rises as heart rate and blood pressure levels sink lower and lower. Reduction of bone density (osteoporosis), which results in dry, brittle bones. Muscle loss and weakness. Severe dehydration, which can result in kidney failure. Fainting, fatigue, and overall weakness. Dry hair and skin, hair loss is common. Growth of a downy layer of hair called lanugo all over the body, including the face, in an effort to keep the body warm. www.nationaleatingdisorders.org

51. Bulimia Nervosa Symptoms Regular intake of large amounts of food accompanied by a sense of loss of control over eating behavior. Regular use of inappropriate compensatory behaviors such as self-induced vomiting, laxative or diuretic abuse, fasting, and/or obsessive or compulsive exercise. Extreme concern with body weight and shape. www.nationaleatingdisorders.org

52. Bulimia Nervosa cont. Warning Signs Evidence of binge eating, including disappearance of large amounts of food in short periods of time or finding wrappers and containers indicating the consumption of large amounts of food. Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics. Excessive, rigid exercise regimen--despite weather, fatigue, illness, or injury, the compulsive need to “burn off” calories taken in. Unusual swelling of the cheeks or jaw area. Calluses on the back of the hands and knuckles from self-induced vomiting. Discoloration or staining of the teeth. Creation of lifestyle schedules or rituals to make time for binge-and-purge sessions. Withdrawal from usual friends and activities. In general, behaviors and attitudes indicating that weight loss, dieting, and control of food are becoming primary concerns. Continued exercise despite injury; overuse injuries. www.nationaleatingdisorders.org

53. Bulimia Nervosa cont. Health Consequences Electrolyte imbalances that can lead to irregular heartbeats and possibly heart failure and death. Electrolyte imbalance is caused by dehydration and loss of potassium and sodium from the body as a result of purging behaviors. Inflammation and possible rupture of the esophagus from frequent vomiting. Tooth decay and staining from stomach acids released during frequent vomiting. Chronic irregular bowel movements and constipation as a result of laxative abuse. Gastric rupture is an uncommon but possible side effect of binge eating. www.nationaleatingdisorders.org

54. Binge Eating Disorder Symptoms Frequent episodes of eating large quantities of food in short periods of time. Feeling out of control over eating behavior during the episode. Feeling depressed, guilty, or disgusted by the behavior. There are also several behavioral indicators of BED including eating when not hungry, eating alone because of embarrassment over quantities consumed, eating until uncomfortably full. www.nationaleatingdisorders.org

55. Binge Eating Disorder Health Consequences The health risks of BED are most commonly those associated with clinical obesity. Some of the potential health consequences of binge eating disorder include: High blood pressure High cholesterol levels Heart disease Diabetes mellitus Gallbladder disease Musculoskeletal problems www.nationaleatingdisorders.org

56. Eating Disorder Treatment Psychotherapy or counseling coupled with careful attention to medical & nutritional needs Some medications can help Must be tailored to the individual, depends upon severity of disorder & patient’s individual problems, needs & strengths Recommended care provided by multidisciplinary team, including a psychologist, psychiatrist, social worker, nutritional and/or primary care physician www.nationaleatingdisorders.org

57. Eating Disorder Treatment cont. Must address symptoms & medical consequences, as well as psychological, biological, interpersonal & cultural forces that contribute to the disorder Nutritional counseling is necessary & should incorporate education about nutritional needs, as well as planning for & monitoring rational choices by the individual treatment Many respond to outpatient therapy, including individual, group or family therapy & medical management by primary care provider www.nationaleatingdisorders.org

58. Eating Disorder Treatment cont. Support groups, nutrition counseling & psychiatric medications administered under careful medical supervision have proven helpful Inpatient care is necessary when the eating disorder has led to physical problems that may be life threatening, or when it is causing severe psychological or behavioral problems; typically requires a period of outpatient follow-up to address underlying issues Important to find a health professional they trust to help coordinate & oversee their care www.nationaleatingdisorders.org

59. Substandard f. Analyze the importance of water and describe signs of dehydration

60. Importance of Water For the human body, water is truly a vital resource. You can go weeks without food but only 5-7 days without water. When the water in your body is reduced by just 1 percent, you become thirsty. At 5 percent, muscle strength and endurance declines significantly and you become hot and tired. When the loss reaches 10 percent, delirium and blurred vision occur. A 20 percent reduction results in death. http://www.chem.duke.edu/~jds/cruise_chem/water/watdiet.html

61. Importance of Water cont. http://www.chem.duke.edu/~jds/cruise_chem/water/watdiet.html TissuePercent Water Blood83.0 Heart79.2 Muscle75.6 Brain74.8 Skin72.0 Bone22.0

62. Importance of Water cont. Blood (83% water) transports oxygen, carbon dioxide, nutrients & waste products Urine (mostly water) removes waste products from the body Keeps mouth moist & washes away dirt on your eyes, lubricates joints Assists in digestion, accesses stored energy for muscles & organs Maintains electrolyte balance within body Assists with temperature regulation http://www.chem.duke.edu/~jds/cruise_chem/water/watdiet.html

63. Signs of Dehydration Mild to moderate dehydration is likely to cause: Dry, sticky mouth Sleepiness or tiredness — children are likely to be less active than usual Thirst Decreased urine output — no wet diapers for three hours for infants and eight hours or more without urination for older children and teens Few or no tears when crying Dry skin Headache Constipation Dizziness or lightheadedness http://www.mayoclinic.com/health/dehydration/ DS00561/DSECTION=symptoms

64. Signs of Severe Dehydration Extreme thirst Extreme fussiness or sleepiness in infants and children; irritability and confusion in adults Very dry mouth, skin and mucous membranes Lack of sweating Little or no urination — any urine that is produced will be dark yellow or amber Sunken eyes Shriveled and dry skin that lacks elasticity and doesn't "bounce back" when pinched into a fold In infants, sunken fontanels — the soft spots on the top of a baby's head Low blood pressure Rapid heartbeat Rapid breathing No tears when crying Fever In the most serious cases, delirium or unconsciousness

65. Substandard g. Compare and contrast different methods of fluid replacement for the physically active person

66. Fluid Guidelines for Athletes http://blogs.harrisonhigh.org/adam_freeman/Fluid_G uidelines.pdf#page=1&zoom=auto,-91,702 http://blogs.harrisonhigh.org/adam_freeman/Fluid_G uidelines.pdf#page=1&zoom=auto,-91,702 Gatorade Sports Science Institute http://blogs.harrisonhigh.org/adam_freeman/Sports_ Drinks_vs_Water.pdf http://blogs.harrisonhigh.org/adam_freeman/Sports_ Drinks_vs_Water.pdf

69. Substandard h. Describe the components of a pre-event meal.

70. Pre-Event Meals Should be high in carbohydrates & fluids Carbs are easier to digest than fat & protein & can be converted into energy to be used immediately Should be eaten 3-4 hours before activity Water is the best liquid to drink Be sure to be well hydrated about an hour before competition Athletes that are anxious about the competition may use carb-loaded sport drinks because they are digested quickly, helping them avoid feelings of nausea Fundamentals of Athletic Training, 2011

71. Pre-Event Meals cont. When determining pre-event meals for an entire team, must consider diversity of team (specific food preferences or intolerances, religious holidays, ie. Meat restrictions, etc) and determine what types are acceptable before a competition Vegetarians have special protein needs Eat familiar foods; pre-event meal is no time to experiment Fundamentals of Athletic Training, 2011

72. Good Pre-Event Foods Pasta Fruit Plain crackers Rice cakes Cereal Vegetarian foods Potatoes Meatless lasagna Soup Rice Juice Bread Raisins Pancakes Waffles Fundamentals of Athletic Training, 2011

74. Carbohydrate Loading Athletes that participate in endurance events may benefit Ingest large amounts of carbohydrates for three days prior to an event Theory: if there is a large carbohydrate store, athlete is less likely to run out of energy Depleting the body of carbs prior to carb loading will cause the body to store more carbs Once carbs are used up, body begins to break down fat, which takes more energy than breaking down carbs, depleting the body of energy Fundamentals of Athletic Training, 2011