17.2 Factors Affecting Nutrition

Developmental Level

The human body is engineered to grow and develop through structured, organized, time-sensitive processes. These processes occur naturally within the body and follow predictable patterns for physiological and cognitive maturity. Across a person’s life span, nutritional requirements differ based on the unique developmental needs at each stage of development. For example, caloric needs are based on body weight, activity level, and metabolic demands. As growth and development occur, these factors change. For example, in utero body weight is low, but metabolic demands are high. At birth, growth measures, such as head circumference, length, and weight, help identify individual risk for malnutrition. As the child grows, body weight increases, activity levels vary, and metabolic demands continue.

Growth charts are tools for measuring healthy growth trends based on established height and weight norms. At each life stage, developmental markers can be tracked to help with early identification of developmental delays and abnormalities. Timely nursing intervention along the growth and development path can dramatically improve health outcomes and prevent long-term negative health effects associated with early nutritional deficits.

Age

If typical growth and development patterns occur, chronological age can predict generalized nutritional needs. Recommended DRIs provide guidelines for nutrient needs across an individual’s life span. Table 17.5 provides an example. Note that the recommendations are based on weight (kilograms) and age. Consider the needs of a child versus the needs of an adult. Protein, calories, and calcium are needed in greater amounts as children grow, then level off in adulthood. There are also unique recommendations for older adults, who experience loss of muscle and bone mass and lower activity levels due to declining mobility and thus require fewer calories than their younger counterparts. Older adults also have unique dietary needs due to their higher risk of chronic disease, development of poor dentition, and socioeconomic changes that affect the type and amount of nutrients consumed.

Sex

Nutritional needs differ between sexes largely due to hormone differences. A chemical mediator that circulates in the body and has a specific stimulating or inhibiting action on the target organs is called a hormone. Table 17.6 lists some of the hormones that control growth and development, metabolism, adrenal function, and stress. Sex hormones are responsible for the majority of differences between the biological sexes. These differences can result in distinctive caloric and other nutritional needs, particularly beginning in adolescence. For example, females require higher levels of iron during childbearing years due to the hormonal influences of menstruation and pregnancy. Pregnancy also changes caloric needs. More information regarding specific pregnancy-related nutritional needs is provided later in this chapter.

Pregnancy

Nutritional requirements increase during pregnancy and lactation. The growing fetus puts increased nutritional demands on the body. Increased caloric needs require a nutrient-dense diet to maximize nutrition. Prenatal vitamins are advised to meet increased requirements for micronutrients such as iron, folic acid, iodine, choline, and vitamin D. Optimal nutritional requirements continue during lactation, when the mammary glands produce and release milk for breastfeeding. Increasing intake of pasteurized dairy, eggs, and lean proteins is a healthy way of increasing these nutrients.

Health Status

An individual’s health status is greatly influenced by their overall nutritional status, and vice versa. Individuals in good health experience high levels of well-being and life satisfaction. Healthy people are physically active within their environment and engage in rewarding relationships. Physiologically, good nutrition and hydration balance lead to healthy growth and development patterns. The maintenance of a healthy body weight protects individuals by reducing the risk of chronic disease. Conversely, chronic disease states often present with significant nutritional demands that increase the risk of compromised nutritional health and negative outcomes.

Chronic illness and declining health impact nutritional status in various ways. Some chronic illnesses interfere with an individual’s ability to ingest food properly. For example, a child with a cleft palate may have trouble eating enough calories, or an older adult who suffers a stroke may develop dysphagia (difficulty swallowing) and be unable to swallow food. Some chronic illnesses affect absorption of nutrients within the body. A child with cystic fibrosis may develop pancreatic insufficiency and be unable to absorb fats and proteins. Inflammatory bowel disease can result in poor vitamin B12 absorption. Many chronic diseases cause metabolic dysfunction leading to poor utilization of nutrients. Diabetes, Addison disease, and chronic kidney disease are examples of chronic diseases with significant impact on nutrient metabolism and utilization.

Every chronic disease provides a nutritional challenge. Treatment for heart disease includes restrictions on sodium and fat. Increased calcium and vitamin D are needed to treat bone disorders such as osteoporosis. Treatment for gastroesophageal reflux disease includes limiting acidic foods, spicy foods, and alcohol. There is a nutritional aspect associated with the prevention or treatment of nearly every chronic disease. Avoiding excess calories is important to both the prevention and treatment of obesity and heart disease. Controlling fat consumption reduces the risk of obesity, stroke, and heart disease. Adequate fiber in the diet reduces the risk of colon cancer. Good nutrition, as prevention or treatment, leads to better health outcomes.

Culture

Cultural competence is a hallmark of patient-centered care. Culture describes the unique patterns of behavior and thought belonging to an identified group or organization. Nutrition and dietary patterns are often an integral part of cultural identity. The United States is home to a vast number of cultures. Cultural beliefs affect types of food eaten and when they are eaten. Some foods may be restricted due to beliefs or religious rituals, whereas other foods may be viewed as part of the healing process or have significant meaning to the celebrations of life. It is essential to consider cultural food preferences when planning nursing care and encourage healthy habits within the context of these foods.

Religion

Religious practices can influence nutritional intake, often due to restrictions in specific foods or meal preparation. Both Jewish and Muslim laws prohibit the consumption of pork products, and Hindu scriptures promote a vegetarian diet. Restrictions may vary even within a given religion as people practice varying degrees of strictness to dietary doctrines. Some individuals may observe food restrictions in association with specific religious celebrations. For example, Catholics may observe dietary restrictions during Lent, while practicing Muslims may fast during Ramadan. Food preparation can also be influenced by religious beliefs. Some Jewish people observe Kosher laws which govern the preparation of certain foods (e.g., beef), the prohibition of certain foods (e.g., pork and gelatin), or the combination of some food (e.g., beef served with dairy products), while some Muslim people observe Halal (the Arabic word meaning "permissible" or "lawful") which restricts the consumption of pork, alcohol, and blood products, and and calls for minimal suffering when preparing animal products. Religious practices and beliefs can be complex. It is important to support the nutritional goals of the individual patient by understanding and respecting the religious dietary practices of every patient.

Economic Status

Economic status refers to a combination of economic and social indicators that describe an individual’s overall scale of wealth and status. Factors that contribute to economic status include income, educational level, occupation, and place of residence. Economic status predicts a person’s ability to obtain nutritious food on a routine basis. Individuals with lower incomes have less means to obtain and prepare nutritious foods. Some individuals may live in a food desert: a geographical area where fresh produce and foodstuffs are either too expensive or unavailable. Federal supplemental assistance programs are available to help meet the nutritional needs of underserved and marginalized low-income populations. These include the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). There are also private organizations such as Meals on Wheels America. Individuals with higher incomes are not immune from nutrition concerns. Excess calories and intake of nutrient-poor foods can lead to obesity and other metabolic disorders due to easy access to food, especially fast food.

Environment

Community environments have a large impact on nutritional health. As stated earlier, food deserts can create areas of food insecurity among at-risk populations. This has its greatest impact on infants, children, and older adults, who are often dependent on others for meal preparation and shopping. Urbanization and industrial effects can have detrimental consequences on clean water supplies and spaces for meal preparation. War zones and refugee camps often deal with undernutrition and lack of access to safe, quality food and water.

Along with geographical environments, family structures within communities have a profound effect on nutritional status. People in a state of food insecurity have limited access to adequate food, typically due to economic or social factors. People experiencing the uncertainty of food insecurity or family discord find it difficult to maintain healthy eating routines. School lunch programs are a helpful resource to families in low-income neighborhoods. Older adults often experience isolation, which leads to poor nutrition habits and negative health trends. As patient advocates, nurses must gain understanding of federal and local nutrition assistance programs and implement timely referrals for their at-risk patients.

Alcohol Use

Because alcohol is high in calories and low in nutrient value, it can negatively impact nutritional health even when consumed in acceptable levels. The use of alcohol can increase the risk of chronic disease and injury. Alcohol consumption is linked to elevated triglycerides. Excessive use of alcohol can lead to chronic nutrient deficiencies due to poor absorption of nutrients, fluid imbalance, gastrointestinal disorders, and liver disease. According to Healthy People 2030, binge drinking (consuming four or more drinks per day for females or five or more drinks per day for males) is a significant problem in the United States (CDC, 2022). The USDA recommends that males limit consumption to two drinks per day and females to one drink per day.

Overuse of Supplements

Supplementation of macronutrients and micronutrients has become increasingly popular due in part to marketing and fitness claims as well as easy access to over-the-counter supplements. Supplements are pills, capsules, and liquids that contain vitamins, minerals, amino acids, or other nutrients. The U.S. government does not require manufacturers of dietary supplements to prove their safety or efficacy, and thus the industry is poorly regulated. Even when supplements are accurately labeled and safely produced, their overuse can lead to toxicities, particularly in fat-soluble vitamins such as vitamin A and vitamin D. Large doses of vitamin C, vitamin B6, and niacin can also lead to toxicities. Performance-enhancing dietary supplements contain amino acids that in excess can cause liver and kidney impairment. It is important for nurses to be familiar with the RDI, RDA, and other standard nutrient recommendations and know how to assess for potential toxicities in patients taking supplements.

Medications

Some medications enhance metabolic processes and impact nutritional status in a variety of ways. For example, exogenous insulin brings needed glucose into body cells. Antiglycemic medications, such as sulfonylureas and bigaunides, assist in improving insulin sensitivity, thus improving utilization of blood glucose by the cells in the body. Thyroid hormone maintains thyroid function, which sets the body’s metabolic rate. Other medications affect gastric function by lowering levels of acid production. Still other medications, such as psyllium and glycolax, alter absorption of nutrients and water in the gut. Statin drugs lower lipids levels. It is important to know how medications are used within the body and how they directly influence metabolic processes.

Many medications have an indirect effect on nutritional status. For example, diuretics are used to increase elimination of water and thus will affect body water levels as well as sodium and potassium balance. Medications with gastric upset as a side effect can decrease nutrient intake and absorption. Some psychotropic medications interfere with appetite, leading to either weight gain or weight loss, depending on the drug. Nurses must be familiar with the side effects of all drugs administered to patients under their care, anticipating long-term effects on nutritional status.

Some nutrients interfere with the mechanism of action of different drugs. For example, vitamin K, found in green leafy vegetables, can decrease the effectiveness of some anticoagulants. In contrast, some drugs should be taken with food to increase absorption. For example, vitamin C improves the absorption of iron. The pharmacokinetics of a drug—the study of the drug’s absorption, metabolism, and distribution within the body—determine the probability of a food-drug interaction. Food and drug interactions can cause deficiencies or toxicities depending on the drug and the food. Nurses must always review administration requirements for each drug, noting whether the drug should be taken with or without food.

Food Meaning

Nutrition is a basic necessity of life. Maslow’s hierarchy of needs (Figure 1.6) lists food as an essential physiological need. It is important to note, however, that food consumption is highly influenced by cultural and environmental factors that have a profound effect on psychological well-being. Thus, food to most people is more than a nutrient. Food is tied to family traditions and celebrations in life. Americans traditionally celebrate Thanksgiving with turkey and pumpkin pie. Many Italian Americans celebrate the Feast of Seven Fishes on Christmas Eve, and Jewish tradition serves challah bread at the Sabbath and potato latkes at Hanukkah. Similarly, vegans avoid meat and other animal products due to personal beliefs related to animal cruelty and exploitation. Many cultures have food traditions that transcend nutritional science, giving food meaning beyond its chemical composition.

Emotional responses are invoked when food meaning goes beyond mere nutrition. Most celebrations that involve food evoke feelings of comfort, happiness, and belonging. Memories, both good and bad, are often tied to the sight and smell of specific foods. Associations with sadness and grief can lead to food aversions, while foods tied to comfort can lead to food excesses as the desire to re-create moments of comfort and celebration override judgment. This can lead to binge eating and obesity. It is important for nurses to identify and reinforce healthy patterns of eating and recognize nutritional risks related to emotional eating habits.

Self-Image

Nutritional status is tied to weight trends, weight trends are tied to body image, and body image is tied to self-image. A person’s body image is the perception that person has about their physical body, including any feelings associated with that perception, whereas self-image is broader, encompassing feelings about one’s whole self. Individuals who maintain a healthy body weight are more likely to have a positive self-image—particularly given cultural norms, reinforced by media, that stigmatize bodies perceived to be over- or underweight. Distorted perceptions of body image can lead to severe eating disorders, such as anorexia nervosa and bulimia.

Depression

As stated earlier, food often evokes an emotional response. It can provide feelings of comfort and belonging or feelings of sadness and grief. It is easy for food to become an emotional outlet for psychological discomfort, especially when the foods consumed promote feelings of comfort and belonging. Emotional eating is common among individuals who are depressed or stressed as they seek emotional responses they find lacking elsewhere in their life. The consumption of “comfort foods” is an emotional response to stress and is common among most individuals. When the dietary pattern includes a high degree of emotional eating, negative outcomes, such as binge eating and overeating that leads to obesity, are more likely to occur. It is important to assess the underlying emotional state of individuals experiencing nutritional impairment. A holistic approach to nursing care is needed.