Learning Outcomes
By the end of this section, you should be able to:
- 20.1.1 Describe the impact of nutrition on the musculoskeletal and integumentary systems during pregnancy.
- 20.1.2 Describe the impact of nutrition on the musculoskeletal and integumentary systems during infancy.
- 20.1.3 Describe the impact of nutrition on the musculoskeletal and integumentary systems during childhood.
- 20.1.4 Describe the impact of nutrition on the musculoskeletal and integumentary systems during adolescence.
- 20.1.5 Describe the impact of nutrition on the musculoskeletal and integumentary systems during 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 the Fetus | Explanation |
|---|---|
| Collagen production | Water is essential to produce collagen, a protein needed for the development of skin and bones. |
| Nutrient transport | Proper hydration enables efficient transport of essential nutrients to the growing fetus. Adequate 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 fluid production | The amniotic fluid is responsible for thermoregulation in utero, and a stable temperature ensures appropriate fetal growth and development. Additionally, amniotic fluid cushions the growing fetus, allowing for essential movements that allow the fetus to develop strong bones and muscles. |
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).
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.
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.
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.
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 |
|---|---|---|
| Musculoskeletal System | ||
| Diastasis recti | The growing uterus can put pressure on the abdominal muscles, leading to separation and a visible bulge in the abdomen. The client is who pregnant client may experience weakness and back pain and may have difficulty regaining physical strength following delivery. | The pregnant client may wear an abdominal binder for support. |
| Carpal tunnel syndrome | Hormonal changes and fluid retention in the pregnant client can lead to overly stretchy joints and tendons, swelling, and compression of the median nerve in the wrist. This often manifests as numbness, tingling, or pain in the hands and fingers. | This condition usually resolves after delivery, but the pregnant client may wear a hand and wrist brace for support. |
| Lower back and pelvic girdle pain | Weight gain, changes in posture, and hormonal shifts can lead to lower back pain and stretching of the pubic symphysis. | The pregnant client may wear a pelvic and abdominal support belt and rest whenever necessary but should avoid NSAIDs for pain relief. |
| Integumentary System | ||
| Pruritic urticarial papules and plaques of pregnancy (PUPPP) | PUPPP is a skin condition of unknown origin that occurs in some pregnant clients, most commonly during the third trimester. It is characterized by itchy, red, raised bumps and hives that most commonly appear on the abdomen, thighs, buttocks, and arms. | There is no significant health risk for the pregnant client or the fetus, so treatment is supportive and may include creams and emollients, corticosteroids, antihistamines, and cool compresses. |
| Stretch marks | Because the skin naturally stretches to accommodate weight gain and the growing breasts and abdomen, stretch marks often develop. | Stretch marks appear as purplish-red lines that, with time, fade to silvery-white lines. They are permanent. |
| Linea nigra | Hormonal changes in some pregnant clients cause a benign dark line to form down the center of the abdomen from the umbilicus to the pubis symphysis (Figure 20.2). | During the postpartum period, the linea nigra will disappear slowly over a few months as the hormones of pregnancy exit the individual’s system. |
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 development | Adequate calcium intake during pregnancy is essential for the developing fetus’s bones. |
| Prevention of birth abnormalities | Folic acid may prevent neural tube abnormalities in the fetus. |
| Maternal calcium stores | If maternal calcium stores are low during pregnancy, the fetus may draw calcium from maternal calcium stores, further exacerbating hypocalcemia in the pregnant client and increasing the risk 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. |
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).
Unfolding Case Study
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.
Maria’s infant, Jose, is now 6 months old and is still being breastfed.
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 |
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. |
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).
Unfolding Case Study
Part C
Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Parts A and B.
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.
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).
Special Considerations
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, substance misuse, and smoking | Avoiding alcohol, drugs, and smoking can prevent many illnesses associated with the musculoskeletal and integumentary systems and may decrease the risk for some cancers. |
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.
| Action | Result |
|---|---|
| Manage chronic conditions. | Many chronic conditions can lead to a sedentary lifestyle, which, in turn, can lead to muscle loss. By managing these conditions, the older adult may be able to become more active. |
| Spread protein intake throughout the day. | Spreading protein intake throughout the day may stimulate muscle protein synthesis more efficiently. |
| Incorporate leucine-rich foods. | Leucine is an essential amino acid and stimulates muscle synthesis. Soy products, dairy products, turkey, fish, and chicken are leucine-rich foods. |
| Drink protein shakes. | Protein shakes can be a convenient way to increase protein consumption. However, they should be part of a comprehensive plan for sarcopenia and not the only treatment. |
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.
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 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).