NUTRITION AND IMMUNIZATION OF CHILDREN AND
ADULTS
5 A’s for Organizational Construct
for Clinical Counseling
• Ask about risky health behaviors (lifestyles) and
consider factors such as age, gender, ethnicity,
presence or absence of co-morbidities, literacy,
etc. that would impact the choice of behavioral
change goals/methods.
• Advise Provide clear, specific, individualized
behavior-change advice including personalized
information about the risk/benefit of lifestyle
change. Advice messages from the physician can
be brief (30– 60 seconds), especially if provided
in a team care context.
5 A’s for Organizational Construct
for Clinical Counseling
• Arrange Regularly scheduled follow-up in person
or by phone/fax/email offers continual support
and allows for adjustment of the treatment plan,
as the patient’s condition, interest, and
motivation level changes. After initial follow-up,
contact is spaced based on intervention
outcomes/patient need for reinforcement.
Referral to more intensive/specialized treatment
may be indicated as co-morbidities develop or
environmental/support systems change.
5 A’sFor Organizational Construct
for Clinical Counseling
• Agree Treatment goals are mutually negotiated and
selected based on the patient’s interest in and readiness to
change problem behaviors, and after consideration of
treatment options, probable outcomes, and patient
preference.
• Assist The physician, either directly, via office staff or by
referral ensures that self-management skills are taught and
problem-solving/coping skills development is encouraged
to facilitate skills advancement, maintenance, and relapse
prevention
For patients not ready to commit to a specific behavioral
change in the immediate future, assistance in the form of
strategies that explore ambivalence can help to move
patients along the change continuum.
Stages of Change
• Precontemplation No intention to change behavior in
the foreseeable future
• Contemplation Aware that a problem exists and are
seriously thinking about overcoming it but have not yet
made a commitment to take action
• Preparation Intending to take action in the next month
• Action Modifying behavior, experiences, or
environment in order to overcome their problems
• Maintenance Working to prevent relapse and
consolidate the gains attained during action. This stage
extends from six months to an indeterminate period
past the initial action.
Encouraging Healthy Eating Habits
in Preschool Chidren
• Try to dine as a family whenever possible.
• Limit TV/computer time to less than 2 hours/day.
• Encourage your child to be physically active
(children need at least one hour of activity/day).
• Offer family activities to promote exercise.
Encouraging Healthy Eating Habits
in Preschool Chidren
• Do not use dessert as a reward ( ‘ finish your vegetables or
you won’t have dessert’)-dessert is part of the meal and
should be no more desired than the meal itself.
• Serve healthy desserts when possible.
• When a child says they have finished, allow them to take
their plate to the sink and return to the table while parents
finish. Appropriate activities or books will allow the child to
enjoy this time.
• Keep a cabinet full of healthy snacks for the child’s choosing
at snack time.
Encouraging Healthy Eating Habits
in Preschool Chidren
• Serve fruits and vegetables every day at meals and snacks.
Keep canned fruit such as pineapple, peaches and mandarin
oranges in their own juice on hand for quick snacks.
• Provide milk (low-fat for children over 2 years) and water for
meals or snacks. Limit juice to 100-160 g/ day.
• Do not be afraid to say no to junk food, chips, soda, candy or
sweets.
• Serve small portions on small plates and small cups. Let the
child regulate his or her own intake. Serving large portions
and insisting on a ‘ clean plate’ can lead to overeating and
the loss of self-regulation.
• .
Energy and Protein Requirements
Energy(kcal/day)
•
•
•
•
•
•
•
Age
0-6 mon
7-12 mon
1-2 yrs
3-8 yrs
9-13 yrs
14-18 yrs
Males
570
743
1046
1742
2279
3152
Females
520
676
992
1642
2071
2368
Protein(g/day)
Males
9.1
11.0
13
19
34
52
Females
9.1
11.0
13
19
34
46
Recommendations for Weight and Length Gain in Healthy Children
Weight
•
•
•
•
•
•
Length
Age
(g/day)
(cm/month)
3 months
25-35
2.6-3.5
3-6 months
6-12 months
1-3 years
4-6 years
7-10 years
15-21
10-13
4-10
5-8
5-12
1.6-2.5
1.2-1.7
0.7-1.1
0.5-0.8
0.4-0.6
Effectiveness of Medical Nutrition Therapy
Endpoint
•
•
Glycemic control
A1C
Plasma fasting
glucose
Lipids
T.Cholesterol
LDL cholesterol
Triglycerides
HDL cholesterol
Blood pressure
Expected outcome
1-2 unit(15-22%) decrease
50-100 mg/dL decrease
24-32 mg/dL(10-16%)
When to evaluate
6 weeks to 3 mon.
6 weeks; if goals
not achieved,intensify
nutrition therapy and
evaluate again in 6 weeks
19-25 mg/dL(12-16%)
decrease
15-17mg/dL(8%) decrease
With no exercise:7% decrease
With exercise:No decrease
5mmHg decrease in systolic and
2mmHg decrease in diastolic
Measure at every visit
(in hypertensive patients)
Guidelines for Avoiding Hypoglycemic
Symptoms
1.Eat small meals, with snacks between meals and at bedtime.
2.Spread the intake of carbohydrate foods throughout the day.
Carbohydrate foods include starches,fruits and fruit juices,milk
and yogurt, and foods containing sugars.
3. Avoid foods that contain large amounts of carbohydrate.
4.Avoid foods and beverages containing caffeine.
Guidelines for Avoiding
Hypoglycemic Symptoms
• 5. Limit or avoid alcoholic beverages. If an individual chooses
to drink alcohol, it should be in moderation and food should
always be eaten along with the alcoholic beverage
• 6.Decrease fat intake. Decreasing fat intake also helps to
weight loss.Excess weight interferes with the body’s ability
to use insuline.
Medical Nutrition Therapy for
GERD
• Limit intake of high fat, high calorie meals.
• Eat smaller meals more frequently during the day.
• Drink most fluids between meals rather than with meals.
• Increase intake of high fiber foods, such as fruits and
vegetables,and whole grains.
Medical Nutrition Therapy for
GERD
• Sit up or take a walk after eating. Lying down
after a meal can worsen symptoms.
• Limit foods that worsen symptoms, such as
alcohol, chocolate, coffee, or caffeinecontaining beverages, mint, citrus fruits,
tomato products, spicy foods, or carbonated
beverages.
Medical Nutrition Therapy for
Peptic Ulcer Disease
• Limit intake of caffeine containing beverages
and foods including coffee like tea, iced teas,
colas, and chocolate.
• Avoid alcohol, especially on empty stomach.
• Eat three small meals per day.
Medical Nutrition Therapy for
Peptic Ulcer Disease
• Don’t skip meals.
• Avoid eating spicy foods, fried foods, and
citrus fruits as these foods may worsen
symotoms
• Avoid other foods or drinks that cause
discomfort.
Tips to Decrease Gas and Bloating
• Certain foods can produce excess gas during digestion.
Various foods effect people in different ways. The following
diet tips may improve symptoms.
• Foods that may cause gas:
• Beans, cabbage, cauliflower, brussel sprouts, broccoli,
asparagus, peppers, cucumbers, onions, garlic, radishes,
sauerkraut
• Raw apples, avocado, melon
• Eggs, fried and fatty foods, carbonated beverages
• Swallowing air may also cause excess gas:
• Eat slowly, avoid chewing gum, carbonated beverages,and
smoking.
Nutritional Recommendations for UTI
• 1) Maintain adequate fluid intake of 8 cups of water, juice,
milk, or other beverages. Tea and coffee can be considered
part of fluide intake.
• 2) Recommend two water glasses of cranberry juice every
day; 10-12 hours apart for UTI-susceptible individuals.
• 3) Increase intake of dairy products such as yogurt.
• 4) Improve overall quality of food intake by increasing fruits,
vegetables, whole grains, fish, poultry, olive or canola oil,
and nuts.
Dietary Counseling Issues by Age and
Diseases
•
•
•
•
•
•
•
•
•
•
•
Infants
Flouride,iron,calories for growth,development
Children Flouride,iron,Ca,calories for growth,development
Teenagers Iron,Ca,calories for pubertal devolopment
Pregnancy Folate,iron,Ca.appropriate weigth gain
Alcoholism Folate,thiamin,vit.B12,calories
Anemia
Iron,vit.B12,folate
Ascites
Sodium,protein,fluid
Beriberi
Thiamin
Cancer
Adequate calories and protein,vit.,minerals,fiber
COPD
Vit.D,Ca,weight loss,calories
Diabetes Carbohydrates,sat.fat,cholesterol,calories,fiber
Dietary Counseling Issues by Age and Disease
•
•
•
•
•
•
•
Hyperlipidemia
Hypertension
Kidney stone
Liver disease
Malabsorption
Obesity
Osteoporosis
Sat.fat,monounsat.fat,choles.,folate,fiber
Na,Ca,K,alcohol,total calories
Ca,oxalate,uric acid,protein,Na,fluid
Protein,Na,fluid
Vitamins A,D,E,K,fat
Total calories,saturated fat
Vitamin D and calcium
Dietary Counseling Issues by Age and Disease
•
•
•
•
•
Pellegra
Renal failure
Rickets
Scurvy
Vegetarian
Niacin
Protein,Na,K,phosphorus,fluid
Vitamin D,calcium
Vitamin C
Protein,Vitamin B12,iron,calcium
Key Diet History Questions for Brief
Intervention
• Questions for all patients
• How many meals and snacks do you eat everyday?
• How often do you eat out? What kind of restaurants?
• What do you like to drink during the day, including alcohol?
How many glasses? How often do you eat fruits and
vegetables?
• How often do you eat dairy products? Low fat or regular
type?
• Do you usually finish what is on your plate or leave food?
• How often do you exercise, including walking?
Key Diet History Questions for Brief
Intervention
• In addition to the questions above
• Questions for patients with dislipidemia
• How often do you eat fatty meats? (hot dogs, sausage,
salami, pastrami)
• How often do you eat fish? How is it prepared?
• What do you spread on your bread?
• What types of fats do you use in cooking?
• What types of snacks and desserts do you eat ?
Key Diet History Questions for Brief
Intervention
• Questions for patients with high blood pressure
• Do you use a salt shaker at the table or in cooking?
• Do you read food labels for sodium content?
(<400 mg/serving permitted)
• How often do you eat canned, smoked, frozen and prepared
foods?
Key Diet History Questions for Brief
Intervention
• Questions for patients with diabetes mellitus
• What time do you take your diabetes medication (including
insulin)?
• What time do you eat your meals and snacks?
• Do you ever skip meals during the day?
• How many servings of starchy foods such as breads, careals,
pastas, corn, peas, or beans do you eat during a typical day?
Dietary Triggers for Migraine Headaches
• Offending food or behavior Chemical trigger
• Cheese
Tyramine
• Chocolate
Phenylethyamine,
theobromine
• Citrus fruits
Phenolic amines,
octopamine
• Hot dogs,cured meats
Nitrites,nitric oxide
• Dairy foods
Allergenic proteins(casein)
Dietary Triggers for Migraine Headaches
•
•
•
•
•
•
•
•
Offending food or behavior
Fatty and fried foods
Food dyes,additives
Artificial sweetener
Wine,beer
Caffeineated beverages
Fasting,skipping meals
Inadequate sleep
Chemical trigger
Linoleic and oleic fatty acids
Tartrazine,sulfites
Aspartame
Histamine,tyramine,sulfites
Caffeine withdrawal
Hypoglycemia,stress hormone release
Treatment Protocols by Body Mass Index
• BMI
•
•
•
•
•
25-30
27-30 RF
30-40
35-40 RF
≥ 40
Diet
Exercise
Behavior
Pharm
Surgery
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Sources of Dietary Fat
1. More atherogenic: Saturated fatty acids
a) Beef, Pork, Veal,Lamb,
b) Hydrogenated vegetable oils
c) Cocoabutter, coconut oil, palm oil
Sources of Dietary Fat
• 2.Less atherogenic: Unsaturated fatty acids
• A) Polyunsaturated fatty acids
• a) omega-6 fatty acids: corn,safflower,
sunflower, soybean
• b) omega-3 fatty acids: fish, flaxseed,
soybean, marine vegetation
• B) Monounsaturated fatty acids: olive-oil,
canola oil, nuts, avocado
Immunization In Childhood
Birth
Hep B
I
1st
month
2nd
moth
4th
month
II
6th
month
18-24
month
1st
class
III
BCG
I
DaBTIPA-Hib
I
II
III
MMR
Rapel
I
Polio
Pneum
ococcal
12 th
month
I
I
II
III
I
Rapel
I
Immunization in Childhood
• DaBT-IPA-Hib :
Diphteria,tetanus,pertussis,inactivated
polio,Haemophilus influenza type B
• MMR :Measles, mumps, rubella
Immunization in Aduts
•
Age 19-26
27-49
50-59
60-64
≥65
Influenza
__________________ every year(1)
Tatanus,diphteria,
Pertussis
__________________ every 10 years(1)
Varicella
___2 dose(1)
HPV
__3 dose (women)(1)
Zoster __________________________________________1 dose(1)
MMR ________ 1 or 2 dose(1)_______________1 dose(2)
Pneumococcal__ 1 or 2 dose(2)___________________________________1 dose(1)
Hepatitis A_____ 2 dose(2)
Hepatitis B_____ 3 dose(2)
Meningococcus_ 1 or more(2)
Immunization in Aduts
• 1. All individuals in this age group who are not
immunized
• 2. Individuals with risk factors ( medical,
occupational)