|Nursing's Role in Nutrition
|MICHAEL HENNING MSN, RN, ANP-C
||CIN: Computers, Informatics, Nursing
Volume 27 Number 5
Pages 301 - 306
There are not enough dietitians and nutritionists available to serve the entire healthcare industry. That means that nurses often fill the role of nutrition counselors. Nurses do not receive extensive education about nutrition, but there are great opportunities for nurses in nutrition, both as educators and researchers. One way this can happen is through the use of nutrition assessment tools. This article introduces a freeware nutritional assessment tool for use on Windows-based computers (available at http://nursing.jmu.edu ). Unlike currently available tools, the Nutrition Analyzer is a stand-alone, Web-independent product, which builds a database of client data that can be manipulated for analysis and research.
In our society, we often seek healthcare to get a pill for a medical problem. We take that pill hoping that it will change the way that our body works and help us feel better. On the other hand, by the same route, with impunity, we eat food that may not be good for us. The path for both is the same, but we expect two totally different outcomes. In the case of the pill, we want correction for the medical problem; in the case of the meal, we do not expect harm to come from the high-fat, high-calorie, and poor nutritional intake. Public perception is often misguided because of media reports on nutrition that do not give complete information in the sound bites.1
Proper nutrition is important for staying healthy and is particularly vital for the elderly. The nutritional state of a patient often affects patient outcomes during illness and recovery.2 In the United States, nutrition screening is a part of inpatient admission.3 Dinsdale4 asks if this is really soon enough to be screening the community for nutrition problems. Recovering from frailty or from the complications of obesity cannot be effectively treated in a few days of hospitalization. The conclusion that must be made is that we need to effectively treat nutrition before illness or hospitalization occurs. By treating nutrition proactively, illness and hospitalizations may be prevented.
The nurse is the logical person to provide nutritional information because nurses are the primary interface between the patient and the healthcare system.5 In 2004, there were about 50 000 dietitians and nutritionists employed primarily in inpatient settings.6 Dietitians and nutritionists are available in outpatient settings, but lack of medical orders and the cost of consultation create an environment where these resources are not generally available to patients. The onus for nutritional education then falls on the 2.4 million registered nurses, 40% of whom work in clinics or offices to fill the role of nutrition educator.7 Unfortunately, there are few tools available for nurses to enable them to become that resource. In-depth nutrition education in nursing curricula is not particularly common. Generally, nutrition is included only as a small part of a broader nursing education. Adams et al8 found that in medical schools, nutrition education is generally included in a problem-based curriculum and not as stand-alone courses. While no recent studies have been done in nursing curricula, a 1987 survey concluded that nutrition education in undergraduate and graduate nursing schools was inadequate.9 Ironically, a recent survey of school nurses in Florida ranked nutrition counseling as the number one research topic to be pursued in nursing.10 On-the-job training will not substitute for the years of formal education and clinical experience that nutritionists have, but basic healthy eating tools can be used by nurses to augment their nutrition education and transform them into competent nutrition counselors.
The purpose of this article is twofold. The first part of this article will look at the role of nursing in nutrition education and nutrition research. The second part of this article will introduce a Windows software program that can aid nurses in fulfilling the role of nutrition counselor. The program is freeware and available from the James Madison University (JMU) Department of Nursing Web site (http://www.nursing.jmu.edu /msn/index.html click on helpful links).
At some point in man's history, we progressed from eating to stay alive to developing an exotic palate that makes food not just necessary for survival but has transformed eating into an enjoyable experience. The food that we eat provides the "tinker toys" allowing our bodies to perform all of the intricate processes that are required for life. Because our bodies process both the good and the bad components of our diets, it is important to know the nutritional content and food grouping of the foods that we eat.11
Nursing plays a key role in nutrition education because nutrition is a part of patient outcomes.12 The healing of the body can take place only when the nutrients that provide the building blocks for repair are present. The nurse as a nutrition educator is a vital role in the overall healthcare system. Prehospital nursing has the opportunity to provide nutrition education that can help to preserve the health of all populations and particularly of older adults.13 Much has been written about eating dysfunction in the geriatric population. In the role of nutrition educator, nurses can work to prevent frailty in the older population.
Having reliable data on which to base healthy eating decisions is important.14 One source of data is food labeling. Survey data state that 83% of consumers read the food labels on products to provide healthy food choices for themselves and their families.15 Often, that is not enough though. Food labeling contains some of the basic information, but it is often hard to interpret how that fits into an overall healthy eating program. The manufacturer who is labeling the food is more concerned with selling the product than providing nutrition counseling, so the role of the nurse educator can be defined as the person who recommends not only healthy food selection criteria but also an overall healthy eating program for his/her patients and how to interpret nutrition information.
NUTRITION FOR THE GERIATRIC CLIENT
The Joint Commission on Accreditation of Healthcare Organizations requires a nutritional assessment on admission to the hospital.3 Is that soon enough to begin monitoring nutrition intake for the geriatric patient? There are several tools that help to give a quick assessment of nutritional status that can be used in the outpatient setting. In their study, Hays et al13 used eating inventory and found a good correlation for prediction of poor nutrition. In addition, there is the Mini Nutritional Assessment from Nestle Corporation.16 These tools are available to make the assessment, but having the assessment information means taking action to do something about poor nutrition.
Frailty is a syndrome marked by a reduction in functional reserve and other impairments that prevent the patient from returning to a homeostatic condition.17 Fried et al18 believe that frailty in the older person leads to a downward spiral and increases the mortality of those frail clients. In the geriatric population, there is a propensity for unintentional weight loss and a protein-deficient diet.19 Malnutrition leads to poor outcomes for geriatric patients. It is important to address the nutritional value of the geriatric diet before malnutrition and frailty impact the elderly.
Often, older adults suffer from comorbid conditions in addition to poor nutrition.20 Beyond the physical complaints, there is a tendency for depression.16 Treatment for depression can result in weight gain in the frail and prefrail patient, exposing the other end of the nutrition spectrum-obesity. In addition to malnutrition and frailty, obesity is also a problem in the elderly.13 Equally detrimental to elderly health, obesity is also an area that needs to be addressed through nutrition counseling.
In reviewing the literature, one can conclude that nutrition counseling seems to lean toward the older adult. In this population, nutritional problems are more obvious because the elderly have diminished functional reserves, and the effects of diet have a more profound result. Every nurse learns in school to "stay ahead of the pain" with regard to pain management. Nurses' role as nutritional expert is to stay ahead of the nutrition problems of their clients. Whether the nurse is dealing with obesity in a juvenile or frailty in an older person, the sooner the intervention, the better the possibility of success.
Beyond the role of nutrition educator, evidence-based practice demands that nursing substantiate its knowledge and suppositions with research. Nutrition guidelines require research to back up the claim.1 Higgins and Barkley2 state that there is a dearth of nutrition articles, and one of the reasons is that there is little nutrition research under way. Prospective benefits from nutrition research include the following: There could be economic and human resource savings from research and behavior change, quality of life could be improved, and health and productivity could be increased.
Nurses can become both expert nutrition educators and researchers. Reaching out to the patients in the community is vital to improve community health and is a harvest field of potential study subjects.5 Because nutrition experts are in short supply, nurses can fill the gap in both education and research and provide a valuable input to the health of the nation as the holes are filled in with evidence-based practice recommendations.
Nutrition analysis software is available online. Two current analysis tools that can be used without cost are Nutritional Analysis Tools and System (http://www.nat.uiuc.edu/mainnat.html ) and MyPyramid Tracker (http://www.mypyramidtracker.gov/ ) from the US Department of Agriculture Food and Nutrition Information Center (FNIC). Both of these tools are Web based and provide free analysis of entered data. The primary drawback of both tools is that they are Web based, making saving and manipulating data difficult. Both of these Web-based tools allow the creation of a data set for a single user logged into the Web site. Adding, modifying, and analyzing nutrition data using these tools require multiple screens and updates during the process, which become time-consuming, particularly with dial-up connection. In addition, they have limited offline functionality. Having used these tools for nutrition on a dial-up connection focused the need for a stand-alone tool, and the Nutrition Analyzer was born.
The Nutrition Analyzer is a Windows-based program that uses the FNIC SR-19 food component database. The software allows the user to enter a client's food history and then manipulate the data for analysis. The software allows looking at individual food items, specific meals, specific days, or all entered data. The values for 29 food components are calculated. An important part of the program is that the entire diet can be analyzed, which prevents the person doing the analysis from reductionism.21 In reductionism, a single element of the diet is considered, such as calcium, and only the item of interest is considered important. Because the Nutrition Analyzer software looks at many elements of the diet, the effect of a change in a single nutrient is shown on all nutrients of the diet. This is important because nutrition is not just eating potassium or selenium; it is intake of whole food items that contribute many things to the nutritional makeup of the meal.
Figure 1 shows the main screen of the software. The program is organized by tabs, with the first tab used to select or enter a client and then select food items for that client from a diet diary or diet recall. Food items are retrieved by searching a particular food group, searching the database for a key word, or using previously entered client food choices. The column box at the bottom of the window shows the food item and nutrients and dynamically changes as the number of servings of the item is changed, allowing the program user to see how servings change the nutrient levels.
||FIGURE 1. Nutrition Analyzer main screen.
Clients are entered originally by clicking on the "Create New Client" button. A client designator, age, sex, height, and weight complete the entry process. Clients who have already been entered are recalled with the drop-down selection box. After the client food items have been entered, the program user would go to the second tab, which is the "Analysis" tab (Figure 2).
||FIGURE 2. Nutrition Analyzer analysis tab.
The "Analysis" tab shows all of the items selected for the client, and the nutrient totals for the items that are checked are shown in the column box on the right. In addition, the daily percentage of the recommended dietary allowance (RDA) for those nutrients is also included in the box. At the bottom of the frame, the client's height and weight are computed to get the body mass index and the target calories, and the target dietary percentages of carbohydrate, fat, and protein can be entered. When these data have been entered, they are saved with the client information for recall, and they also then provide the basis for an overall look at the dietary intake with respect to carbohydrates, fats, and proteins.
The "RDA" tab shows the government RDAs for the nutrient based on age and can be modified by the user. The "Nutrient" tab provides a place where the program user can single out a nutrient and create a list in ascending or descending order by quantity of a specific nutrient. The "Activity" tab can be used to perform a basal calculation for the client and see how different activities affect caloric requirements.
Figure 3 shows the "Print" tab displaying the analysis report. The software uses the Crystal Reports add-in, which allows any of the program outputs to be exported in Adobe, Excel, or Word format in addition to being printed. The analysis report will print a page for each day being analyzed and then a final page with a tabulation of nutrients and graphic showing the goal carbohydrate, fat, and protein content and the actual dietary content. In addition, the "Print" tab allows the printing of food and activity diaries and printing of the items on the nutrient page.
||FIGURE 3. Nutrition Analyzer print tab.
The software comes with a tutorial and complete help system. The tutorial is invoked the first time the software is run and can be called up at anytime through the help system. The software uses tool tips, which are selectable to help the user and immediate assistance through context sensitive help activated by pressing F1 in the currently focused item.
Doing a single diet analysis is only one function of the software. Another significant feature of the Nutrition Analyzer is that multiple clients can be entered into the system. An Access database that allows the analysis of multiple clients is built, which makes the software suitable for nutrition research. The created database can be used by researchers in a stand-alone mode to do more complex nutritional research for a cohort.
Having a portable, modifiable database of client information allows anyone, who would like to use this software for research, additional computing capabilities in other compatible software products. In this capacity, the Nutrition Analyzer becomes a powerful tool for nutrition research, particularly in the emerging area of adolescent obesity.
The software requires a recent Windows XP or Windows 2000 operating system and approximately 70 MB of disk space. During the installation of the nutrition software, the free support tools NetFramework 2.0, MDAC 2.8, and Crystal Reports are also installed on the target computer, if not already present.
The Nutrition Analyzer is a freeware program, which means that it can be downloaded, used, and redistributed in its original form without payment. The software download is available on the JMU Department of Nursing's Web site at http://nursing.jmu.edu /msn/index.html. Click on Helpful Links in the left hand column.
As nurses and nurse practitioners become more involved with nutritional interventions, the health of patients will improve. Starting in the community, with meaningful nutrition interventions, patient outcomes and health can be changed.4 Much of the result depends on nursing's focus. In the busy lives of nurses, patients often get looked at as a disease; while that is not a nursing concept, it is often a fact of life. If instead we see clients as the complex individuals that they are, the advantage of early nutrition intervention becomes obvious.
Taking the step into the role of nutrition educator and researcher is a step forward in autonomy.22 Being a "go-to" person for nutrition education is a big responsibility, but it is also an area that is in great demand. In working on her high-level theory, a participant in the study of Skipper and Lewis22 postulated that it is not enough that we "first, do no harm"; our job is to make things better. As nurses take on the mantle of nutrition educator and researcher, we can make a positive change in the health of our clients and our nation.
Certainly, this is not a new concept, but it is difficult to implement. Nurses have the physiological knowledge and the education to understand nutrition. The Nutrition Analyzer aids the nutrition educator in recognizing diet deficiencies quickly and easily. Nurses can fill the gap as nutrition educators.
Using the Nutrition Analyzer tool requires that the nutrition educator evaluate the client's motivation for change. There is no amount of dietary information that will help a client unless the information is used to change behaviors. With the eclectic training that nursing education encompasses, nurses are equipped to ascertain a client's readiness for intervention and a path to better health. In the area of research, acting on a nursing assumption about nutrition,the nurse can use the Nutrition Analyzer as a research tool to produce evidence-based goals in nutrition.
The biggest problem for clients is in recognizing that everything entering our gastrointestinal tract affects our health for the good or bad. The Nutrition Analyzer is an important tool in the nursing medicine bag and will help nurses provide the counseling and research that are so desperately needed in healthcare today.
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