Practice Behavior Skills Across the Curriculum

Practice Behavior Skills Across the Curriculum

After training, the learner will be able to:

History

• Take an appropriate patient medical history, including family, social, nutritional/dietary, physical activity, and weight histories; use of prescription medicines, over-the-counter medicines, dietary and herbal supplements; and consumption of alcohol and other recreational drugs. (Ch 1, Ch 3 objectives)

Physical

• Conduct an appropriate physical examination, including anthropometrics, evaluation of growth and development and signs of nutritional deficiency or excess. (Ch 1 Objectives)

Test Selection

• Select and interpret the results of screening measures, laboratory tests, and diagnostic procedures appropriate to assess and manage a patient's nutrition.

Evaluation

• Evaluate a patient's diet and current nutritional status based on the USDA Food Guide Pyramid.
• Identify individuals who require medical nutritional therapy and lifestyle modification.
• Integrate nutritional assessment information into an individualized nutritional management and physical activity plan for optimal health, risk factor reduction and common medical problems.

Counseling

• Effectively counsel patients to make informed nutritional decisions consistent with adopting and maintaining a healthy lifestyle and with establishing appropriate dietary, exercise and behavioral goals.
• Effectively communicate with patients in a culturally competent manner to provide accurate nutritional information and dispel misinformation.
• Employ effective counseling techniques matched to the patient's level of motivation and readiness for change, encouraging the use of goal setting, identification of barriers, problem solving, self-monitoring, self-reinforcement, and stimulus control.

Consultation and Referral

• Consult with or refer to a registered dietitian or other credentialed healthcare professionals and refer to community nutrition resources as appropriate.

Attitudes Across the Curriculum

After training, the learner will be able to:

Attitude Objectives

• Recognize that nutrition, physical activity, and health lifestyle behaviors can have direct, substantial, and long-term effects on growth and development, health maintenance, and disease prevention and treatment.
• Demonstrate a commitment to interact with patients in a culturally competent manner that appropriately acknowledges the unique characteristics and nutritional needs of each individual.
• Recognize how personal, environmental, and social factors interact and impact on eating behaviors and overall nutrition.
• Demonstrate sensitivity to biomedical and nutritional changes as well as psychological, social, and ethical issued that affect patient care.
• Recognize the importance of using a multi-disciplinary team approach in nutritional health care.
• Recognize the importance of patient autonomy and shared decision making in the nutritional management of patients.
• Encourage physicians to serve as positive role model for patients regarding nutrition and healthy lifestyles.
• Recognize the importance of attention to nutritional management to enhance a patient's quality of life
• Encourage physicians to be involved in public health initiatives that promote community health regarding nutrition and physical activity

OVERVIEW AND NUTRITION BASICS

Nutrition Principles (Ch 2)

Content Areas

• Fuels: Carbohydrates, proteins, and fats
• Energy balance, body composition, body weight
• Cholesterol and lipoprotein metabolism
• Vitamins, minerals, and trace elements (Ch 2 Objectives)
• Fiber: soluble and insoluble
• Fluid and electrolyte balance
• Food and nutrient deficiencies and excesses
• Free radical injury
• Food and nutrient requirements, recommendations and guidelines
• Inborn errors of metabolism

After training, the learner will be able to:

Knowledge Objectives

• Define a fuel; name the 3 classes of fuels in the human diet (carbohydrate, fat and protein). Distinguish among the classes according to their structural features and caloric content.
• Outline the metabolic pathways involved in the generation of energy from fuel oxidation and explain how each pathway is regulated in response to cellular energy demand.
• Describe crucial variation in the patterns of exogenous and endogenous fuel utilization among tissues.
• Outline the metabolic pathways involved in fuel interconversion, fuel storage and fuel mobilization. Specify the tissues involved in synthesis and storage of fuels, and trace the pathway of transport among tissues.
• Explain the concept of fuel homeostasis and use this concept to explain the changes of blood glucose, fatty acids and amino acid levels that occur in response to variations in timing, quantity, and type of dietary fuel intake and to variations in the intensity or duration of physical exercise.
• Describe the role of individual hormones in regulating fuel homeostasis in response to variations of dietary and physiologic state; describe the specific mechanisms by which hormones regulate the individual metabolic pathways involved, including nutrient regulation of gene expression.
• Define calorie, basal metabolic rate, respiratory quotient, and daily energy expenditure, and describe how these values are measured or calculated. Explain how each of these values is related to physical exercise, caloric balance, weight gain or loss, and the rate of fuel metabolism.
• Describe the physiological mechanisms that relate hunger, satiety, and appetite to diet and physical exercise.
• Define nitrogen balance and explain how it is affected by dietary intake and growth.
• Describe the structural feature of each of the following lipids: cholesterol, fatty acids (including saturated, mono-, polyunsaturated, omega-6 and omega-3; short-, medium, long-chain; odd and uneven chain, essential fatty acids), and eicosanoids. Describe the mechanism of absorption and tissue distribution
• Outline the pathways for synthesis and degradation of cholesterol, and explain the mechanisms that regulate these pathways in response to cholesterol intake, saturated fat, and other dietary components.
• Distinguish among the classes of lipoproteins involved in cholesterol and lipid transport in the blood, and explain how different genetic and dietary factors influence lipoprotein concentrations and composition.
• Name the vitamins and relate the essential structural features of each vitamin to its stability, lipid solubility, transport, coenzyme form, and role in metabolism. (Ch 2 objectives)
• Name the minerals required in the human diet, and explain how each is absorbed, transported, and stored and how its turnover is regulated. Distinguish among macrominerals, microminerals, and trace elements. (Ch 2 objectives)
• Describe the role of each required vitamin and mineral in molecular and systemic physiology. (Ch 2 objectives)
• Explain how a daily vitamin or mineral intake that is greater than or less than the DRI causes common clinical symptoms or pathology. (Ch 2 objectives)
• Distinguish between the two types of dietary fiber, and explain the potential contributions of fiber to health maintenance.
• Describe the pathways of alcohol metabolism in the liver in well individuals compared to chronic alcoholics.
• Define fluid and electrolyte balance and explain how they are maintained. Identify dietary components and common physiological or pathological conditions that create imbalances, and explain the consequences of these imbalances.
• Identify the major oxygen free radicals and reactive oxygen species (ROS) generated in human cells and explain how they are generated; describe the primary ways they injure cells.
• Describe the natural defense mechanisms present in cells to protect against ROS generation and injury.
• Define Recommended Dietary Allowance (RDA), Dietary Reference Intake (DRI), Adequate Intake (AI), Estimated Average Requirement (EAR); and Upper Limit (UL); explain how these values are established for different age groups; and identify the population groups to which they apply . (In Ch 2 objectives)
• Using the US Dietary Guidelines and the Food Pyramid, describe the general characteristics of a healthy diet, including the recommended contribution of various food groups, good common sources of individual nutrients, foods to be consumed in limited amounts, and the carbohydrate: fat: protein distribution.
• Identify types of individuals, populations or communities at risk for specific or general dietary vitamin and mineral deficiencies or imbalances as a result of genetic, environmental, or socio-cultural influences . (In Ch 1, Ch 2 Objectives)

Practice Behavior Skills

• Translate basic science information into clinically relevant principles that guide medical decision-making.

Attitudes

• Acknowledge that effective patient management requires an understanding of basic nutrition science principles/

Community and Population Health

Content Areas

• Population-based disease prevention and health promotion
• Epidemiological measures and tools
• Community health assessment Interaction of nutrition with lifestyle, environment, biology, and health care system
• Food insecurity

After training, the learner will be able to:

Knowledge Objectives

• Summarize the Dietary Guidelines for Americans and explain how they are important in patient care.
• Describe the role of nutrition in health promotion and disease prevention, particularly as related to chronic diseases.
• Identify the prevalence of individuals who are overweight, obese, or malnourished in the U.S. (Ch 1 Objective 2, 3)
• List the food categories in the Food Guide Pyramid and the recommended number of servings in each.

Practice Behavioral Skills

• Given a 24-hour dietary recall, assess the status of a patient's diet using the Food Guide Pyramid and Dietary Guidelines for Americans.
• Provide nutritional counseling and dietary recommendations that appropriately take into account the patient's health status, the Food Guide Pyramid, and Dietary Guidelines for Americans.

Attitude Objectives

• Recognize the importance of nutrition and community nutrition services in health promotion, disease prevention, and disease management.
• Demonstrate a personal commitment to the importance of prevention in health care.
• Exhibit a non-judgmental demeanor and sensitivity toward patients, families, and community members.

Behavioral Principles

Content Areas

• Social and cultural determinants of eating behavior
• Barriers to dietary change
• Behavioral theory in nutritional counseling
• Behavioral counseling
• Lifestyle modification
• Efficacy of behavioral treatments

After training, the learner will be able to:

Knowledge Objectives

• List at least three common barriers to dietary change, and identify effective strategies for overcoming these barriers.
• Describe common social, ethnic, cultural, and societal factors that contribute to the prevalence of nutritional problems and should be considered in their management.
• Explain how to apply the Brief Counseling Model in the context of patient nutrition management.

Practice Behavior Skills

• Effectively counsel patients, employing behavior theory principles and specific effective counseling techniques including: goal setting, barrier identification, problem solving, and relapse prevention techniques, including self-monitoring, self-reinforcement, and stimulus control.

Attitude Objectives

• Demonstrate a belief in his/her ability effectively to promote patient behavior change.
• Recognize the preeminence of the patient's taking responsibility for his/her own nutritional health.
• Recognize the importance of enabling patients to believe in their ability to change current behavior patterns.
• Demonstrate a commitment to promote behavior change through establishing the best possible physician-patient relationship.

Nutrition Assessment (Ch 1, 2, 3)

Content Areas

• Overweight and obesity (Ch 1 objective)
• Malnutrition
• Diet history
• Family, medical, and social histories
• Review of systems
• Physical examination
• Functional status
• Subjective global assessment
• Laboratory data
• Energy expenditure

After training, the learner will be able to:

Knowledge Objectives

• Describe the metabolic and medical consequences of varying degrees of over- and undernutrition. (Chapter 1 Objective 2; Ch 5 objectives)
• Compare and contrast the �ABCD's� (anthropometric, biochemical, clinical, and dietary intake measures) of nutrition assessment.
• Describe the impact of the altered nutritional status associated with five common acute and five common chronic diseases.
• List the laboratory measurements commonly used to assess the nutritional status of patients. (Ch 1 objectives)
• Describe the food pyramid, explain how it could be used as a nutrition assessment tool, and give functional definitions of portion size in each category of the pyramid.
• Outline a laboratory profile indicative of malnutrition, protein-energy malnutrition, iron deficiency anemia, or megaloblastic anemia.
• Identify the likely physical examination findings associated with over- and under-nutrition and vitamin/mineral deficiencies or toxicities. (Ch 1, Ch 2 objectives)

Practice Behavior Skills

• Take an appropriate patient medical history of a standardized patient, including dietary and social histories. (Ch 1 objectives)
• Give height and weight, calculate the BMI, and interpret the BMI according to published NIH guidelines.

Attitude Objectives

• Recognize the value of nutritional assessment in the comprehensive care of ambulatory and hospitalized patients. (Ch 1 Objectives)
• Recognize the importance of nutrition in health maintenance, disease prevention, and management.
• Demonstrate a commitment to utilizing a multidisciplinary approach to screening, assessing, and counseling individuals at nutritional risk.

Physical Activity

Content Areas

• Energy expenditure, energy transfer
• Body composition
• Physiologic adaptation to physical activity
• Risks and benefits of physical activity
• Physical activity guidelines and recommendations throughout the lifecycle
• Pre-participation screening and risk stratification
• Social, behavioral, and attitudinal factors

After training, the learner will be able to:

Knowledge Objectives

• Describe the beneficial effects of physical activity and the detrimental effects of inactivity on the cardiovascular, musculoskeletal, pulmonary, neurological systems. (Ch 6, Ch7 objectives)
• Identify the relative contribution of basal and resting metabolism, dietary thermogenic influences, and physical activity to the total daily energy expenditure (TDEE). Differentiate between moderate and vigorous activity; classify various physical activities by their energy expenditure rates.
• List the four compartments of the body used to determine body composition. Identify different regional patterns of adipose tissue deposition and the influence of caloric intake on body fat.
• Describe the cardiovascular and metabolic responses to short-term and long-term physical activity. (Ch 6, Ch 7 objective)
• Explain how varying levels of physical activity influence an individual's nutritional requirements.

Practice Behavior Skills

• Conduct an appropriate exercise history (Objectives Ch 1)

Attitude Objectives

• Recognize that physicians can have a substantial positive impact on an individual's level of physical activity.
• Demonstrate a personal commitment to evaluate the physical activity needs of all patients and promote adequate levels of exercise to prevent disease and promote physical and mental health.
• Demonstrate a commitment to discourage sedentary lifestyles in patients as well as to encourage simple physical activity (e.g., walking, gardening) for patients who are not compliant or for whom vigorous activity is inappropriate.
• Demonstrate a personal commitment to serve as a positive role model for patients by maintaining a healthy personal lifestyle.

lifespan

Pediatrics (Ch 4, 5)

Content Areas

• Premature infants, infants, toddlers, children and adolescents (Ch 5 objectives)
• Growth and development
• Breast feeding versus formula feeding
• Introduction to solid foods
• Food preferences and feeding problems
• Vitamin and mineral requirements/deficiencies and recommendations (Ch 2 objectives)
• Failure to thrive, malnutrition
• Iron deficiency anemia
• Dental caries
• Overweight and obesity (Ch 1 objectives)
• Eating disorders (anorexia and bulimia)
• Special nutrition programs for children (Ch 5 objectives)
• Prevention and lifestyle modification
• Physical activity

After training, the learner will be able to:

Knowledge Objectives

• Identify the nutritional, metabolic, immunologic, social, economic, and long-term health benefits of breast-feeding.
• Describe at least one nutritional intervention effective for preventing each of the following pediatric diseases: dental caries, obesity, type 2 diabetes, and cardiovascular disease. (Ch 6, Ch 7 objectives)
• Summarize the short-term and long-term impacts of malnutrition on the physical and cognitive development of infants, children, and adolescents. Summarize the recommendations for healthy nutrition of infants, children, and adolescents by age, gender, and activity level as proposed by relevant medical societies and governmental agencies . (Ch 5 objectives)
• Compare and contrast the complete nutritional needs of adolescents of varying levels of physical activity, particularly teens engaged in vigorous sports . (Ch 5 objectives)

Practice Behavior Skills

• Take an appropriate pediatric medical history, including growth parameters, dietary intake, level of physical activity, and family/social history. (Ch 1 Objectives)
• Conduct a pediatric physical examination, including anthropometrics and evaluate the child for normal development and signs of nutritional deficiency or excess. (Ch 1 Objectives)
• Evaluate the length/height, head circumference, and Body Mass index (BMI) of an infant, child, or adolescent over time against the appropriate growth charts published by the US Centers for Disease Control and Prevention (CDC). (Ch 5 Objectives)

Attitude Objectives

• Actively support the mother who chooses breast-feeding and refer the mother to support programs and lactation consultants as appropriate. (Ch 4 objectives)
• Recognize the need to attend to the unique behavioral, psychosocial, and developmental characteristics of children and adolescents in the design of nutritional interventions for these patients. (Ch 5 objectives)
• Demonstrate a commitment to utilizing a multi-disciplinary team approach to managing the nutrition of infants, children, and adolescents as appropriate . (Ch 5 objectives)
• Recognize that childhood nutrition can have both short-term and long-term, and sometimes irreversible effects.
• Demonstrate a commitment to encourage adolescents to adopt a pattern of appropriate lifelong physical activity.
• Show sensitivity to the unique power of social influences on children and adolescents and to their special nutritional needs.
• Recognize the need to take the family context into account when managing the nutrition of children and adolescents.

Young Adulthood/Middle Age (Ch 5, 6)

Content Areas

• Food preparation
• Vitamin and mineral requirements/deficiencies and recommendations (Ch 2 objectives)
• Preconception nutrition counseling
• Nutrition counseling for the active adult
• Nutritional effects of smoking and alcohol use
• Prevention and lifestyle modification
• Physical activity

After training, the learner will be able to:

Knowledge Objectives

• Identify at least four chronic diseases common to young and middle-aged adults, and identify at least one effective nutritional modification used to prevent and/or treat each.
• Explain the metabolic and morphologic changes involved in growth and development during the transition from adolescence to adulthood.
• Summarize the current US Dietary Guidelines and the USDA Food Guide Pyramid.
• Cite the prevalence of alcohol and tobacco use among young adults, and describe the most common nutritional effects of tobacco and excessive alcohol use.
• Compare and contrast the components of the Dietary Reference Intake (DRI), including Recommended Dietary Allowance (RDA), Adequate Intake (AI), and Upper Limit (UL); describe the appropriate use for each. (Ch 2 objectives)

Practice Behavior Skills:

• Take an appropriate medical and dietary history of a healthy young adult; evaluate the patient's nutritional status and identify any nutritional concerns. (Ch 1 objectives)
• Take a 24-hour diet recall history, assessing the appropriateness of food intake using the USDA Food Guide Pyramid and the US Dietary Guidelines.
• Effectively demonstrate how to interpret a food label to a young or middle-aged patient.

Attitude Objectives

• Recognize that the influences of society during young adulthood (busy schedules, eating restaurant foods, etc.) have nutritional implications and may make optimum nutritional choices difficult.
• Demonstrate a commitment to answer patients' nutrition-related questions and counsel young and middle-aged adults about the impact that daily nutritional choices can have on their long-term health and/or the health of their unborn children.
• Recognize the importance of sound nutritional choices for both healthy and ill individuals.

Geriatrics (Ch 6)

Content Areas

• Physiologic changes in nutrient metabolism and absorption associated with aging Alterations in nutrient requirements with aging (Ch 6 objectives)
• Functional status
• Vitamin and mineral requirements deficiencies and recommendations
• DETERMINE Your Nutrition Health Checklist (Ch 2 objectives)
• Subjective Global Assessment
• Chronic diseases Malnutrition
• Obesity and overweight (Ch 1 objectives)
• Osteoporosis
• Prevention and lifestyle modification
• Physical activity
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Describe the physiologic changes associated with aging and the effects of these changes on nutrient requirements, absorption, and metabolism.
• Identify five common risk factors for poor nutritional status in older individuals. (Ch 6 objectives)
• List five pathophysiological conditions common among older individuals that affect nutritional status. (Ch 6 objectives)
• Describe the effects of malnutrition on physiologic function in geriatric patients.
• Describe how the process of aging alters the nutritional needs and the functioning of the gastrointestinal tract of older individuals, especially the absorption of essential vitamins. (Ch 2, Ch 6 objectives)

Practice Behavior Skills

• Take a thorough medical history and an assessment of functional status of an older patient, including alcohol use, abuse, and dependence. (Ch 1 Objectives) (Ch 6 objectives)
• Conduct a physical examination of an apparently healthy geriatric patient, employing instruments such as the �Mini Nutritional Assessment� (MNA), the �Subjective Global Assessment� (SGA), and the DETERMINE Your Nutritional Health Checklist. (Ch 1 Objectives)

Attitude Objectives

• Provide nutritional counseling that is sensitive to the physiologic, emotional, social, and monetary changes that occur with aging. (Ch 6 objectives)
• Demonstrate a commitment to identify malnutrition in older patients and to prescribe appropriate nutrition support. (Ch 6 objectives)
• Demonstrate a commitment to inquire about the nutritional health of older patients. (Ch 6 objectives)

Women's Health (Ch 1, 4)

Content Areas

• Lifespan: pediatrics, adulthood, and geriatrics
• Pregnancy, lactation, menopause (Ch 4 objectives)
• Immunology and breastfeeding
• Vitamin and mineral requirements and recommendations (Ch 2 objectives)
• Bone health
• Gender differences in common nutrition related diseases
• Effects of diabetes
• Gastrointestinal effects of female hormones
• Complementary and alternative therapies
• Prevention and lifestyle modification
• Physical activity

After training, the learner will be able to:

Knowledge Objectives

• Identify at least three common high-risk eating patterns (e.g., low calcium intake) that may negatively impact the growth and development of pediatric and adolescent females.
• Describe the potential metabolic, immunologic, social, economic, and health benefits of breast-feeding.
• Cite the current nutritional recommendations for adolescents and adult women during preconception, pregnancy, and lactation. Identify at least four types of foods or supplements that should be included or avoided in the diet during this period. (Ch 4 objectives)
• Describe how to assess the nutritional status of adolescent and adult women during preconception, pregnancy (including multiple gestations), post-partum, and lactation. (Ch 4 objectives)
• Summarize the physiological and biochemical changes that occur during and after menopause, and describe the nutrition effects of these changes.
• Compare and contrast the patterns of body fat distribution and weight gain in males and females.
• Differentiate between anorexia and bulimia as to etiology, signs, symptoms, effects on menstrual function and nutritional treatment.
• Cite the prevalence of overweight and obese individuals and those with eating disorders in the U.S. by age, gender, and ethnicity. (chapter 1 objectives)
• Identify six nutrient and immunologic components of human breast milk, and describe the immune benefits to the breast-fed child.
• Compare and contrast effective nutritional regimens for the prevention of chronic diseases in men vs. women.

Practice Behavior Skills

• Take an appropriate medical history and assess the nutritional status of an adolescent female or a pregnant and/or lactating woman, including family, social, nutritional/dietary, physical activity, and weight histories; use of prescription medicines, over-the-counter medicines and dietary supplements; and consumption of alcohol and other recreational drugs. (Ch, Ch 4 objectives)
• Given the pre-pregnancy height and weight, calculate a patient's Body mass Index (BMI) and identify appropriate weight gain goals for normal-weight, underweight, and overweight pregnant women. (Ch 4 objectives)
• Given a detailed medical, obstetric, dietary, and social history of a female of any age and weight, evaluate the patient's risk of developing chronic disease.
• Perform and appropriate history and physical examination of an overwieght or obese female child, adolescent, and/or adult, and accurately assess her nutritional status. (Ch 1 objective)

Attitude Objectives

• Maintain due vigilance to recognize any early signs and symptoms of eating disorders in females
• Actively support woman who choose to breast-feed.
• Demonstrate a commitment to consider a diagnosis of cardio vascular disease in both men and women equality.
• Demonstrate a commitment to counsel women of all ages about the impact of daily nutritional choices on heir long-term health and/or the health of their unborn children.
• Recognize the right of a pregnant woman to decide whether or not to breast-feed her infant. (Ch 4 objectives)
• Demonstrate sensitivity to the unique physiological and behavioral characteristics of each female in your medical practice.

cardiovascular system

Hyperlipidemia/Atherosclerosis (Ch 7, 9)

Content Areas

• Cholesterol
• Lipoproteins
• Hyperlipidemia
• Metabolic Syndrome
• Dietary fatty acids
• Antioxidants (Ch 2 objectives)
• Vitamin and methionine influences on homocyst(e)ine levels
• Fiber: soluble and insoluble
• Complex carbohydrate
• Alcohol
• Plant sterols and stanol ester
• Sodium
• National Cholesterol Education Program and American Heart Association dietary guidelines
• Prevention and lifestyle modification
• Physical activity
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Describe how fatty acids and cholesterol are absorbed in the intestine and how the body controls cholesterol absorption, including the role of the ABC protein.
• Outline the pathways of cholesterol and triglyceride transport between tissues and identify sites of regulation that influence VLDL, LDL, and HDL levels.
• Describe the role of the three major lipoprotein classes in atherogenesis. Identify the effects of saturated, monounsaturated and polyunsaturated fatty acids on plasma LDL and cholesterol levels.
• Identify at least three common foods that are high in cholesterol, saturated, monounsaturated and polyunsaturated fatty acids.
• Compare and contrast the structure of saturated fatty acids and trans fatty acids and their differential effects on atherogenesis.
• Identify at least three common foods high in n-3 fatty acids.
• Evaluate the utility of lowering homocyst(e)ine levels to prevent atherosclerosis. (Ch 7 objectives)
• Outline homocyst(e)ine metabolism and the roles of folate, B 6 and B12.
• List at least two common foods high in folate, B 6, B12, or methionine.
• Distinguish between soluble and insoluble fiber.
• Identify at least three common foods that are high in soluble and insoluble fiber.
• Describe the effects of soluble and insoluble fiber on LDL and triglyceride levels. Identify the effects of soluble and insoluble fiber on the absorption of bile acids and simple sugars.
• Compare and contrast the effects of complex carbohydrates and simple sugars on plasma glucose and triglyceride levels.
• Identify at least five common foods that are high in complex carbohydrates.
• Describe the effect of the level of alcohol consumption on VLDL and HDL in normal and hypertriglyceridemic persons and any subsequent effect on atherosclerosis. (Ch 7 objectives)
• Describe how plant sterols and stanols influence cholesterol absorption and LDL levels.
• Identify at least three common foods that are high in dietary sodium, calcium, and potassium.
• Identify NCEP ATP-III criteria defining the metabolic syndrome. (Ch 7 objectives)
• Explain how weight loss affects LDL and HDL levels, insulin resistance, abdominal obesity, glucose intolerance, hypertriglyceridemia, and the risk of diabetes.
• Summarize the Therapeutic Lifestyle Change (TLC) diet recommendation of the National Cholesterol Education Program (NCEP). Compare the TLC Diet with diets advocating extremely low or high fat intakes and the expected effects on levels of the major classes of lipoproteins. (Ch 7 objectives)
• Food examples for some of knowledge objectives
  • Foods high in Cholesterol: egg yolks, shrimp, liver, kidney Saturated fat: Palm oil, coconut oil, whole milk and cheese, fatty red meat Monounsaturated fat: olive oil, avocado, canola oil, nuts Polyunsaturated fat: safflower oil, corn oil, soybean oil, sunflower oil N-3 fatty acids: salmon, herring, halibut, flax seed, nuts Folate: brewers yeast, orange juice, liver, legumes, leafy vegetables, fortified grain products Vitamin B 6: Meat, poultry, fish, green leafy vegetables, whole grains, legumes Vitamin B 12: Meat, poultry, fish, eggs, dairy products Methionine: whole grains, sesame seeds, sunflower seeds, brewer's yeast Sodium: canned, frozen and dehydrated foods, chips, restaurant food Potassium: Fruits and vegetables, milk, potatoes Calcium: dairy products, calcium-fortified foods (e.g. orange juice, cereals)
• Examples of genetic variations/control of cholesterol levels:
  • 2 examples Apo E4: raises LDL Apo A-IV polymorphisms: may reduce response to dietary cholesterol

Hypertension (Ch 7)

Content Areas

• Insulin resistance syndrome
• Sodium
• Potassium
• Calcium
• Magnesium
• Alcohol Prevention and lifestyle modification
• Physical activity
• Dietary Approaches to Stop Hypertension (DASH) Diet (Ch 7 objectives)
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Explain the effects of abdominal obesity, insulin resistance, lack of physical activity, high sodium intake, and high alcohol consumption on blood pressure control in both hypertensive and non-hypertensive individuals; explain possible mechanisms for each effect.
• Summarize the recommendations of the DASH-sodium diet. (Ch 6, Ch7 Objectives)
• Describe the metabolic and pathophysiologic consequences of hypertension including cardiovascular, cerebrovascular, and peripheral vascular disease. Identify those forms of hypertension that are responsive to nutritional management. (Ch 6 objectives) (Ch 7 objectives)
• Explain how high intake of sodium and low intake of calcium, potassium, and magnesium affect the control of blood pressure in normal and hypertensive individuals.
• List at least five common foods that contain large amounts of each of the following: sodium, calcium, potassium, and magnesium.

Practice Behavior Skills

• Take an appropriate medical history that includes family history of hypertension; duration of hypertension; recent weight change; sequelae of co-morbid conditions including cardiovascular, cerebrovascular, and renal diseases; and use of prescribed and over-the-counter medications and nutritional supplements. (Ch 1, Ch 6, Ch7 objectives)
• Based on the current Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 6), differentiate between patients who, in addition to lifestyle modification, require medication and/or dietary modification for the control of blood pressure.
• Take an appropriate social and dietary history, including an assessment of the patient's diet, exercise patterns, and weekly alcohol consumption, and identify areas of concern. (Ch1 1 objectives)

Attitudes Objectives

• Recognize the value of a healthy diet and lifestyle in the prevention and treatment of patients with hypertension. (Ch 7 objectives)
• Demonstrate a commitment to utilize a multi-disciplinary team approach in medical care, seeking consultation with and referring patients to registered dietitians and other credentialed healthcare professionals as appropriate.

Heart Failure and Cardiomyopathy (Ch 7)

Content Areas

• Nutritional causes of cardiac failure
• Pathophysiology of cardiac cachexia
• Exercise regimens and restrictions
• Herbal supplement-nutrient/drug interactions (Ch 3 objectives) (Ch 6 objectives)
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• List at least eight physical signs and symptoms of congestive heart failure.
• Summarize the dietary and hygienic modifications that should be recommended to patients with congestive heart failure.

Attitude Objectives

• Recognize the importance of nutritional deficiencies as potential causes of heart failure.
• Demonstrate a commitment to promoting a healthy diet and lifestyle modification in patients with congestive heart failure.

metabolic / endocrine systems

Obesity (Ch 1, 5, 9)

Content Areas

• Diagnosis: BMI and waist circumference
• NHLBI Obesity Guidelines
• Metabolic and pathophysiology consequences
• Epidemiology
• Etiology
• Treatment: behavioral, pharmacological, surgical, dietary
• Fad diets
• Prevention and lifestyle modification
• Physical activity
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• State the National Heart Lung and Blood Institute (NHLBI) guidelines used to classify a person as overweight and/or obese.
• Describe the metabolic and pathologic consequences of being overweight or obese as associated with the following chronic disorders: hypertension, insulin resistance, and dyslipidemia. Explain the mechanism by which each disorder results in these effects. (Ch 7 objectives)
• Identify at least four effective changes to daily activity regimens that can be used to prevent excessive weight gain and at least two behavioral strategies for sustaining appropriate weight following weight reduction.
• Describe the risks and benefits of the following non-traditional weight loss interventions: pharmaceutical treatments, very low calorie diets, the protein sparing modified fast, and surgical treatment.
• Give at least four examples of specific changes in diet, exercise, and other behaviors (e.g., consuming smaller food portions) that promote optimal health, and explain how each change results in its specific effect.
• Identify those stages of life when becoming overweight or obese is most likely to occur, and identify effective strategies that medical professionals can use to help patients prevent excess body weight.
• Compare and contrast the clinical usefulness of each of the following measures in predicting morbidity and mortality: body weight and height, waist circumference, percent body fat, Body Mass Index (BMI), and body fat distribution.
• Cite the prevalence of persons who are overweight or obese in the U.S. by age, gender, and ethnicity. (May be chapter 1 objective)
• Identify at least three characteristics or behaviors of people who are most successful at maintaining appropriate weight after a weight loss regimen.

Practice Behavior Skills

• Take an appropriate dietary and social history including family history of being overweight or obese, develop an appropriate differential diagnosis, and design an effective nutritional management plan.(Ch 1 objectives)
• Perform an appropriate physical examination of an overweight and/or obese child, adolescent, or adult; measure the patient's body weight and waist circumference, determine the percent body fat, calculate the BMI, estimate the patients' body fat distribution, and evaluate the patient for other signs and symptoms or weight related morbidity.(Ch 1 objectives)
• Effectively educate patients about the goals they can realistically expect to achieve, as well as the potential complications of common therapies for over weight or obese individuals

Attitude Objectives

• Recognize that being overweight or obese has become a national epidemic of increasing prevalence in the United Sates, and appreciate the value of as little as a 10% decrease in weight on co-morbidities or even maintaining body weight for those likely to become more obese. (Ch 1 objective 3)
• Demonstrate a commitment to utilizing a multi-disciplinary team approach to the medical care of overweight and/or obese patients.
• Demonstrate sensitivity to the social, emotional, and physiological factors that may affect an individual's behavior and body image.
• Demonstrator a commitment to interact with overweight and/or obsess patients in a non-judmental manner.

Diabetes Mellitus (Ch 9)

Content Areas

• Glucose metabolism
• Insulin secretion and sensitivity
• Diagnostic criteria and classification
• Epidemiology
• Hyperlipidemia
• Prevention and lifestyle modification
• Physical activity
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Identify the minimum components of a healthy diet and lifestyle for the prevention of Type 2 diabetes.
• Describe the most common macrovascular, renal, retinal, and neural complications associated with diabetes mellitus and describe the role of glycemic control and diet in reducing the secondary complications of diabetes.
• Explain how endocrine system control of nutrient metabolism maintains energy balance in normal and diabetic individuals.
• Differentiate between the short-term and the long-term effects of macronutrients on insulin secretion and insulin sensitivity in diabetes mellitus.

Practice Behavior Skills

• Take a thorough nutritional and physical activity history of a person with diabetes, including an assessment of the (a) family history of diabetes mellitus, (b) onset and duration of diabetes symptoms, and (c) evidence of complications, as well as the patient's (a) weight history, (b) usual dietary intake, (c) frequency, intensity, and duration of physical activity, and (d) use of medications, and (e) alcohol consumption, and identify any problem areas. (Ch 1 objectives)
• Conduct an appropriate physical examination for a patient with diabetes including assessments of height, weight, Body Mass Index (BMI), body fat, fundus, feet, vascular sufficiency and peripheral neuropathy (Objectives Ch 1)

Attitude Objectives

• Demonstrate a personal commitment to the importance of diet and exercise in preventive medicine by serving as a positive role model for patients with diabetes.
• Recognize the central importance of nutrition in the maintenance of health, and demonstrate a commitment to support patient adherence to the Nutrition Recommendations and Principles for People with Diabetes Mellitus accepted by the American Diabetes Association.
• Recognize the importance of patient self-motivation and demonstrate a commitment to shared decision making with diabetic patients.
• Recognize the value of utilizing a team approach in the treatment of diabetes mellitus that includes registered dietitians, certified diabetes educators, exercise physiologists, clinical psychologists/behavioral medicine specialists, nurse practitioners, and clinical pharmacists.

other organ systems

Gastrointestinal Disease (Ch 8, 12, 13)

Content Areas

• Overview of function: digestion and absorption
• Peptic ulcer disease
• Gastroesophageal reflux disease
• Liver disease
• Short bowel syndrome
• Malabsorption
• Dumping syndrome Inflammatory bowel disease (Crohn's disease, ulcerative colitis, IBD)
• Diverticulitis/diverticulosis
• Pancreatitis
• Constipation
• Nutritional consequences of GI surgery
• Fiber: soluble and insoluble Prevention of colorectal cancer Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Explain how common GI diseases (Crohn's disease, ulcerative colitis, chronic pancreatitis, cystic fibrosis, and hepatic cirrhosis) affect a patient's nutrition health, including effects on appetite, digestion/absorption, weight loss, and vitamin and mineral levels. (Ch 2 objectives) (Chapter 8 objectives)
• Describe the processes of digestion and absorption of specific macro- and micronutrients,including the roles of different organs, regions, and cells in the GI tract, pancreatic and intestinal cell secretions, and the hepatobiliary circulation. (Chapter 8 objectives)
• Identify dietary components that interfere with or enhance the digestion/absorption of specific nutrients (including those that influence GI transit time, affect gastric acid secretion, or cause irritation of the mucosa), and explain how each component affects nutritional status.
• Describe the nutritional and metabolic consequences of small and large intestinal resection.
• Describe the relationship between dietary habits and the risk of colorectal cancer, and identify those dietary and physical activity changes that appear to be the more efficacious in preventing the type of cancer.

Practice Behavior Skills

• Given a patient complaining of constipation, identify the likely causes and make appropriate recommendations to correct the condition and prevent future episodes.

Attitude Objectives

• Recognize the central important of nutrition in the treatment and management of patients with GI disease and demonstrate a commitment to providing appropriate nutritional intervention (including dietary modifications and enteral or parenteral nutrition therapy). (Chapter 8 objectives)
• Recognize the importance of dietary lifestyle factors in the prevention of GI disease. (Chapter 8 objectives)

Hematology/Oncology (Ch 2, 12, 13)

Content Areas

• Nutritional epidemiology
• Malignancy-associated malnutrition
• Nutrition-related anemias
• Nutritional consequences of cancer chemotherapy and radiation
• Nutrition support in cancer patients
• Complementary and alternative therapies
• Prevention of cancer and anemia
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Distinguish among the various nutritional anemias, including those caused by deficiencies of iron, folate, Vitamin B 12, and pyridoxine.
• List the appropriate laboratory tests used to assess the nutritional status of malnourished patients, and identify tests that distinguish between nutritional anemias and hematopoetic disorders.
• Summarize the proposed mechanisms by which antioxidants protect against cancers. Identify the four antioxidants for which the evidence of efficacy is strongest. (Ch 2 objectives)
• Summarize the proposed mechanisms by which folate, fiber, and excess dietary fat increase or decrease the risk of specific cancers.
• Summarize the American Cancer Society's Dietary recommendations.
• Identify the vitamins and minerals that cause or ameliorate nutrition-related anemias, and explain how these effects arise. (Ch 2 objectives)
• List at least eight common foods that are high in bioavailable iron that are appropriate for inclusion in the diet of a patient with iron-deficiency anemia.

Practice Behavior Skills

• Take a thorough medical history that includes social and dietary history, family history of cancer, history of recent weight change, and use of nutritional supplements and herbal therapies. (Ch 1 objectives) (Ch 3 objectives)
• Given the height and weight of a patient with a common hematologic or oncologic disease, calculate the BMI, explain to the patient how their disease alters nutritional status, and make appropriate nutritional recommendations.

Attitude Objectives

• Recognize the value of early nutrition intervention during cancer treatment to reduce or delay the development of malnutrition.
• Demonstrate a commitment to include nutritional assessment and therapy in routine patient care to prevent cancer and anemia.
• Recognize the importance of nutrition and healthy lifestyle behaviors in the decreasing risk of cancer.
• Recognize the value of utilizing a team approach in the treatment of cancer that includes registered dietitians and other credentialed nutrition professionals, as well as exercise physiologists, clinical psychologists/behavioral medicine specialists, nurse practitioners, and clinical pharmacists.

Immunology (Ch 8, 10, 11)

Content Areas

• Effect of nutrition and nutritional status on host defense mechanisms
• Protein-energy malnutrition
• Food allergy and intolerance
• Protein, amino acids, and nucleic acids and immune function
• Lipid peroxidation
• Diet and HIV
• Breast milk
• Vitamins and minerals in immune function
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Explain how both protein and protein-energy malnutrition alter the rate of tissue repair and causes immunodeficiency.
• Identify the nutrient and immunologic components of human breast milk, and describe the effects of these components on immune response in the breast-fed child.
• Compare and contrast food allergies vs food intolerance, and describe two pathophysiological manifestations of each.
• Explain how caloric intake influences immune competence.
• Explain how antioxidants influence lipid peroxidation and thus immune function. (Ch 2 objectives)

Attitude Objectives

• Recognize the importance of nutrition and healthy lifestyle behaviors in maintaining a healthy immune system.
• Demonstrate a commitment to life-long learning about the effectiveness of nutritional supplements, natural products, and herbal supplements on immune function. (Ch 3 objectives)

Rheumatology (Ch 3, 6)

Content Areas

• Osteo and rheumatoid arthritis
• Physical activity limitations and/or interventions
• Herbal supplement-nutrient/drug interactions (Ch 3 objectives) (Ch 6 objectives) (Ch 6 objectives)
• Complementary and alternative therapies
• Physical activity Medical nutrition therapy

After training, the learner will be able to:

Attitude Objectives

• Demonstrate appropriate sensitivity to rheumatic disease patients with physical limitations.

Pulmonary Disease  (Ch 10)

Content Areas

• Respiratory quotient
• Chronic obstructive pulmonary disease
• Mechanical ventilation
• Obstructive sleep apnea syndrome
• Cystic fibrosis
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Explain the association between obesity and sleep apnea, and outline the nutritional regimen recommended for these patients.
• Explain how acute lung injury and chronic lung diseases alter a patient's nutritional requirements.
• Practice Behavior Skills
• Given a patient with pulmonary disease, take an appropriate medical, social, diet, and weight history that includes an evaluation of current nutritional status, and conduct a thorough physical examination. (Ch 1 objectives)

Attitude Objectives

• Recognize the importance of healthy lifestyle behaviors in the prevention and management of pulmonary disease.
• Demonstrate a commitment to utilizing a multi-disciplinary team approach to the treatment of pulmonary disease, consulting with registered dietitians, nurses, and clinical pharmacists as appropriate.

Renal Disease (Ch 3, 6, 11)

Content Areas

• Sodium
• Potassium
• Calcium
• Phosphorous
• Fluid and electrolytes
• Acute renal failure
• Chronic renal failure (pre-dialysis)
• Dialysis
• Renal Transplantation
• Nephrotic Syndrome
• Nephrolithiasis
• Herbal supplement-nutrient/drug interactions (Ch 3 objectives) (Ch 6 objectives)
• Dyslipidemia or (hyperlipidemia)
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• Describe the nutritional, metabolic, and clinical consequences of chronic renal failure.
• Explain the interrelationships of renal disease and dietary factors such as protein, sodium, potassium, calcium, magnesium, phosphorus, and water; identify which patients need to restrict these nutrients.
• List the three most useful laboratory tests used to recognize nutritional causes and consequences of renal impairment.
• Explain how protein restriction or other changes in the nutrient composition of the diet can alter the progression of renal disease in patients with chronic renal failure.
• List three common foods that are relatively high in each of the following: sodium, calcium, potassium, and phosphate; identify which patients with renal disease need to restrict these foods.

Practice Behavior Skills

• Take an appropriate medical history, including weight change, history of renal disease, co-morbid conditions that can impact renal disease, and use of prescribed and over-the-counter medications and nutritional supplements. (Ch 1 objectives)
• Take an appropriate social and dietary history, including an assessment of the patient's exercise patterns.
• Conduct an appropriate physical examination for a patient with renal disease, including height and weight; calculate the BMI and determine the fluid status. (Ch 1 objectives)

Attitude Objectives

• Demonstrate a commitment to utilizing a multi-disciplinary team approach to the treatment of renal disease consulting with registered dietitians, clinical psychologists/behavioral medicine specialists, nurse practitioners, physician assistants, and clinical pharmacists as appropriate.
• Demonstrate a commitment to promote appropriate nutrition and lifestyle modifications for patients with acute or chronic renal disease, nephritic syndrome, or nephrolithiasis.
• Recognize the importance of healthy lifestyle behaviors in the treatment and management of renal disease.
• Demonstrate and awareness of the impact of co-morbid conditions of patients with renal disease that may influence compliance with recommended changes in diet and lifestyle.

Bone Health (Ch 6)

Content Areas

• Bone mass
• Calcium
• Vitamin D
• Phosphate
• Magnesium
• Dietary supplements
• Osteoporosis and osteomalacia
• Rickets
• Prevention and lifestyle modification
• Physical activity
• Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives

• List at least three widely available dietary and supplemental sources of calcium and vitamin D. Compare and contrast the sources in terms of its bioavailability, convenience, and cost.
• Describe at least three lifestyle changes that can reduce the risk of osteoporosis.
• Identify the RDI for calcium and Vitamin D, the AI for calcium, the RDA for Vitamin D, and describe how an individual can meet these recommendations according to the USDA food guide pyramid, and the Dietary Guidelines for Americans.
• Identify at least four classes of individuals at risk for developing osteoporosis, and compare and contrast the rationales used to explain the relationship of each to osteoporosis.
• Explain the nutritional basis of the homeostatic mechanisms that maintain adequate bone mass, and describe three common pathophysiological conditions that reduce bone mass.
• List at least three medical conditions and at least three medications that typically result in secondary osteoporosis.
• Identify at least three good sources of dietary Vitamin D, and evaluate the limitations of sun exposure for meeting the Vitamin D requirement.
• Explain how physiological aging typically affects the intake and metabolism of nutrients related to bone health. (Ch 6 objectives)
• Identify at least three sources of calcium and Vitamin D appropriate for a patient with lactose intolerance.

Practice Behavior Skills

• Effectively counsel pre-and post-menopausal women to maintain a level of calcium in the diet adequate to reduce their risk of osteoporosis.

Attitude Objectives

• Identify at least one psychosocial factor that commonly affects the intake of nutrients related to bone health at each stage of the life cycle.
• Demonstrate a commitment to encourage patients of all ages, especially adolescents, to maintain a proper diet adequate to sustain normal bone growth and development and prevent bone loss.
• Identify the toxic dose of vitamin D and describe the biological consequences of a vitamin D overdose.
• Demonstrate a commitment to promote sound nutritional decision-making and appropriate levels of physical activity for all patients regardless of health status.

other areas

Nutrition Support (Ch 2, 3, 6, 7, 12, 13)

Content Areas

• Energy and substrate metabolism in health and disease
• Starvation and malnutrition
• Assessment of nutritional status
• Enteral nutrition
• Total parenteral nutrition
• Enteral feeding formulas and selection of products
• Routes of administration
• Indications and contraindications
• Monitoring and complications
• Drug-nutrient interactions (Ch 6 objectives)
• Refeeding syndrome
• Hypermetabolic injury response

After training, the learner will be able to:

Knowledge Objectives

• Compare and contrast energy and substrate metabolism in postprandial, well-fed, short-term and long-term starvation states.
• Define malnutrition; describe its environmental and biological causes and clinical consequences.

Attitude Objectives

• Recognize the adverse impacts of malnutrition on disease and the associated benefits of providing appropriate nutritional support.
• Recognize the importance of correcting any malnutrition in patients before surgery.
• Carefully attend to the ethical issues involved in the provision of nutritional support in palliative care and in settings where patients cannot provide consent.
• Demonstrate a commitment to utilizing a multi-disciplinary team approach to the management of patients receiving enteral or parenteral nutrition.

Contemporary Trends (Ch 2, 3, 7)

Content Areas

• Dietary guidelines
• Vitamins, minerals, and herbal supplements (Ch 2 objectives) (Ch 3 objectives)
• Food fads, fad diets, and weight loss
• Vegetarianism
• Dietary supplements
• Food safety

Knowledge Objectives

• Summarize the current American Heart Association (AHA), American Diabetes Association (ADA), National Cancer Institute (NCI), USDA, and USDHHS dietary guidelines for healthy Americans. (Ch 7 objectives)

Practice Behavior Skills

• Take an appropriate and culturally sensitive diet history that includes an assessment of use of fad foods and herbal and dietary supplements (Ch 1 objectives). (Ch 3 objectives)
• Attitude Objectives
• Demonstrate an accurate awareness of the limitations of his/her knowledge of nutrition.
• Demonstrate a wiliness to seek out the best available medical knowledge relevant to the nutrition of patients.