7
Dietary Assessment and Guidance

Dietary assessment is one of several key elements of overall nutrition assessment. (The other elements include assessment of weight status, laboratory values, and clinical data.) Some approaches to the collection of dietary data are very easy for any practitioner; others require a high degree of skill.

Standard Approaches for Assessing Intake

In a diet or food recall, the woman is asked to recall everything she ate and drank within a specified period, usually 24 hours. Diet recalls are usually easy to obtain if only qualitative information is sought about foods eaten on the previous day. A few simple questions will usually help spark a flagging memory. Often there is no need to probe for accompaniments or portion size. These details are most important in relation to problems with weight or disease conditions. Because food intake fluctuates from day to day, it is important to try to ascertain whether the intakes on the day reported were typical or whether they reflected unusual intake because of illness, a party, or another infrequent event.

In a food frequency questionnaire, the woman is asked how often she ate the foods on the list over a specified period, usually one week or longer. Food frequency questionnaires help identify the core diet and how it can be built upon. For example, a woman who eats soup daily could be encouraged to add vegetables to it. The questionnaires also provide a summary of the foods used over a period of time. They can be used to identify women who seldom eat important nutrient sources, who never eat any



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7 Dietary Assessment and Guidance Dietary assessment is one of several key elements of overall nutrition assessment. (The other elements include assessment of weight status, laboratory values, and clinical data.) Some approaches to the collection of dietary data are very easy for any practitioner; others require a high degree of skill. Standard Approaches for Assessing Intake In a diet or food recall, the woman is asked to recall everything she ate and drank within a specified period, usually 24 hours. Diet recalls are usually easy to obtain if only qualitative information is sought about foods eaten on the previous day. A few simple questions will usually help spark a flagging memory. Often there is no need to probe for accompaniments or portion size. These details are most important in relation to problems with weight or disease conditions. Because food intake fluctuates from day to day, it is important to try to ascertain whether the intakes on the day reported were typical or whether they reflected unusual intake because of illness, a party, or another infrequent event. In a food frequency questionnaire, the woman is asked how often she ate the foods on the list over a specified period, usually one week or longer. Food frequency questionnaires help identify the core diet and how it can be built upon. For example, a woman who eats soup daily could be encouraged to add vegetables to it. The questionnaires also provide a summary of the foods used over a period of time. They can be used to identify women who seldom eat important nutrient sources, who never eat any

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foods from a food group, or who eat large amounts of foods high in calories and low in essential nutrients. Some can be scored readily by computer. Although some women appear to have difficulty understanding the concepts involved in a food frequency questionnaire and may grossly overreport their food intake, the questionnaire may be helpful in identifying foods that the woman is willing to eat and thus useful in diet counseling. For food or diet records, women are asked to record names and amounts of all the foods and beverages they consumed for a specified period (e.g., 1 day, 3 days, or 1 week). Food or diet records are potentially accurate sources of dietary information, especially if the woman has considerable writing and recording skill and has been trained in how to measure portion sizes and keep the records. Since recording food intake may lead to changes in eating behavior, the practice should be monitored to reinforce desirable behaviors and to avoid adverse effects (such as inadequate weight gain during pregnancy). Records may be most useful for obtaining quantitative information relative to modified diets or for identifying behaviors that might be improved. In a checklist, such as the one in the nutrition questionnaire, pages 7 and 8, the woman is asked to mark which of the listed foods she ate during a specified period. Checklists are easy for most people to complete, and they provide an informative glimpse of dietary practices. For illiterate women, realistic pictures or drawings can be used. It is desirable to supplement such forms by asking a few key questions and observing nonverbal communication, as well as by paying careful attention to the oral responses. Selecting an Approach for Dietary Assessment To select the appropriate method for a given woman and situation, the following questions may be useful:

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What is my objective in collecting the information? Possible objectives include finding out whether the woman has an energy deficit or whether her intake of folate is adequate. How will I use the information? In other words, how accurate and detailed does the food intake information need to be? Possible uses include determination of the woman's eligibility for participation in WIC, of the need either for counseling to improve diet quality or to take nutrient supplements, and of appropriate food choices or menu patterns. The latter can be used when developing a detailed plan for a modified diet to help with the management of a disease or an inborn error of metabolism. Avoid collecting information that you will not use. What is the standard to which the information collected should be compared—a predetermined number of servings of foods from various food groups or a nutrient standard such as the Recommended Dietary Allowances?19 Most often it is sufficient to direct attention to food use rather than to intake of specific nutrients. For example, three servings of milk or cheese daily ensures adequate calcium intake with few exceptions (such as the breastfeeding of twins). Attention to intake of specific nutrients is essential in the management of diabetes mellitus, renal disease, certain gastrointestinal diseases, and phenylketonuria. What resources do I have for collecting, analyzing, and interpreting dietary data? If there is a need for a detailed dietary assessment to serve as the basis for a modified diet or for intensive diet counseling, the services of a dietitian are highly desirable. For health care practices that do not include a dietitian, arrangements for consultation and referral are needed. A dietitian can assist in developing routine procedures for dietary assessment and can train other providers to use those procedures proficiently A dietitian might be

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located by contacting a local hospital, public health agency, or the state dietetic association. Some dietary analysis computer software is targeted for use by health care providers, whereas some is targeted for use by clients. If a self-administered program is easy to use and a computer is available, this can be an efficient mechanism for collecting and summarizing dietary data. However, since the outputs from dietary analysis programs can be seriously misinterpreted, it is advisable to consult with a dietitian before obtaining dietary analysis software and implementing its use. Tips for Dietary Guidance For the Woman: Examples of Nutritious Snacks and Fast Foods Cheeseburger with lettuce and tomato Lean roast beef on a bun Grilled chicken sandwich Peanut butter sandwich Pizza with green peppers or other vegetables Cheese sandwich with sliced tomato Chef's salad, tossed salad, coleslaw, carrot sticks Soft taco with chicken or beef and vegetables Bean burrito Chinese vegetables and meat with plain rice Hard cooked egg Milk, low-fat milk, chocolate milk, milkshakes Flavored yogurt Fresh fruit Fruit juice Dried fruit and nuts

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For the Health Professional: Increasing the Calcium Intake of Women with Lactose Intolerance Encourage attempts to consume milk products, at least on a trial basis, since lactose tolerance often improves during pregnancy If milk is not tolerated, be sure to check on the woman's vitamin D status by asking about exposure to sunlight. Try small servings (for example, a small [4 oz] juice glass)of milk several times daily. Whole milk may be tolerated better than low-fat or skim milk, and taking milk with other foods often helps avoid symptoms. Try yogurt containing active, live cultures. To save money, buy a large container of plain yogurt and stir in fruit and sugar or jam or other flavorings to taste. Try aged hard cheese such as cheddar cheese. Try taking lactase tablets or drops when drinking milk. Follow the directions on the package. Try lactase-treated milk and milk products. These are more expensive than untreated products. Women who participate in WIC may be able to obtain them through WIC. Try cultured buttermilk for drinking or baking. If these strategies are unsuccessful, explore ways to increase calcium intake from foods that contain no milk products such as those listed on the next page. Consider recommending a calcium supplement.

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For the Woman Ways to Increase Your Calcium Intake If You Avoid Most Milk Products Choose more foods that provide calcium, such as the following. Foods equal to about 1 cup of milk in calcium content: 3 oz. of sardines (if the bones are eaten) Foods equal to about 1/2 cup of milk in calcium content: 3 oz. of canned salmon (if the bones are eaten) 4 oz. of tofu (if it has been processed with calcium sulfate) 4 oz. of collards 1 waffle* (7 inches in diameter) 4 corn tortillas (if processed with calcium salts) Foods equal to about 1/3 cup of milk in calcium content: 1 cup of cooked dried beans 4 oz. of bok choy or turnip greens or kale 1 medium square of cornbread* (21/2 x 21/2 x 11/2 inches) 2 pancakes* (4 inches in diameter) 7 to 9 oysters 3 oz. of shrimp Foods that can be made high in calcium: Soups made from bones cooked with vinegar or tomato Macaroni and cheese* and other combination foods made with good sources of calcium Ask your health care provider about taking a calcium supplement. *   A dairy product is a major contributor to the calcium content of this food.

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For the Woman: Boosting Your Nutrient Intake Substitute similar foods that provide more nutrients for the calories, for example: Foods That Are Low in Vitamins and Minerals Foods That Are Higher in Vitamins and Minerals Bologna Sliced chicken Bacon Ham Cake Ice milk, pudding Fruit drinks Fruit juices Jello® Fresh fruit Choose lower-calorie versions of the same foods to make room for good nutrient sources, for example: Commonly Eaten Food Lower-Calorie Version Ice cream Ice milk or frozen yogurt Whole milk Low-fat or skim milk Fried chicken Grilled chicken or fried chicken without the skin American cheese Low-fat cheese Cream soup Vegetable soup Choice or prime beef Lean beef Chips Unbuttered popcorn, pretzels Cut back on foods high in calories, such as those listed below, to make room for foods that are better sources of vitamins and minerals. High-Calorie Foods That Are Low in Essential Nutrients Most deep-fried foods and fat-rich foods (such as onion rings, fried taco shells, chips, doughnuts, bacon, and sausages) Soft drinks, Kool-Aid®, and fruit punch. Salad dressings and mayonnaise Most desserts (such as cookies, cakes, and pies) Fats and oils Most sweets (such as candy, sugar, and honey)

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For the Health Professional: Special Concerns for Some Low-Income Women Problem Possible Short-Term Solutions Local water tastes bad Encourage the women to bring water jugs to the clinic to fill. Discuss bottled water. No refrigeration Explore the possibility of using a cooler with ice or of making a cold box. Suggest nutritious foods that don't require refrigeration, such as peanut butter, bread, fruit, vegetables, and canned foods. No cooking facilities, homeless If the woman is on WIC, ask about the special food package for women without cooking facilities; explore potential for use of hot plate; caution against indoor use of charcoal against indoor use of charcoal grills. No money or food stamps to buy food Recommend food pantries, soup kitchens, or shelters to get meals until food stamps are issued. Assist the woman with obtaining expedited processing of her application for food stamps or for WIC or applying for other assistance programs. Dependent on home-grown vegetables or wild foods (seasonal) Explore the possibility of creating an indoor greenhouse; offer information about food preservation and safe food storage or refer to Cooperative Extension.