7.3: Plan Nutritional Strategies to Impact Endocrine Wellness

Learning Objectives

By the end of this section, you should be able to:

• 7.2.1 Understand nutritional habits that optimize endocrine wellness.
• 7.2.2 Generate solutions to optimize endocrine wellness utilizing nutritional habits.

Planning Nutrition Goals

It is important to set nutritional goals with individuals with endocrine disorders as diet plays a crucial role in managing these conditions and promoting overall health and well-being. Research has shown that dietary modifications can significantly improve outcomes and reduce the risk for complications associated with various endocrine disorders, particularly diabetes. For example, research has shown that dietary interventions, including reducing simple carbohydrate and added sugar intake and increasing protein and fiber intake, can improve blood glucose control and reduce the risk for cardiovascular disease in individuals with type 2 diabetes (Gray & Threkeld, 2019).

The American Diabetes Association (2019) has identified a framework for nutrition therapy goals that reflect the importance of using a holistic approach to working with clients with diabetes. Their broad goals of nutrition therapy are to:

• Promote and support healthful eating patterns, emphasizing a variety of appropriately portioned nutrient-dense foods.
• Consider personal and cultural preferences, health literacy, willingness to change, and access to healthy foods.
• Not judge clients about their food choices so that their eating can continue to be enjoyable.
• Provide practical tools for developing good eating practices rather than focusing too much on a particular food item or food type.

Clients with diabetes should follow the prescribed diet which typically includes a limited number of calories and carbohydrates. General guidelines for meal planning with diabetes include (CDC, 2023b):

• Limiting added sugars and refined grains such as white bread, rice, and pasta
• Including more non-starchy vegetables
• Limiting intake of highly processed foods

Setting nutritional goals for clients with endocrine disorders can be difficult. Endocrine disorders are complex conditions that can seem overwhelming to the client to manage. In addition to considering the nutritional components of the diet, the nurse must consider cultural, socioeconomic, and psychological factors affecting food intake. The goal-setting process is only successful if it is collaborative. The nurse should encourage the client to explain how their family, culture, and beliefs influence how and what they eat. These influences should be incorporated into the goals set.

When setting nutritional goals, both short-term and long-term goals are needed. Short-term goals may be necessary to help stabilize and manage acute changes in hormone levels that have occurred. Short-term goals may require more stringent meal planning and food consumption that is not realistically sustainable over time. Long-term goals are necessary to help the client manage their condition on an ongoing basis. Ideally, these goals incorporate the changes needed to stabilize the client’s endocrine health in a realistic and practical manner. Table 7.4 lists common endocrine disorders and related nutritional goals.

Table 7.4 Examples of Endocrine Disorders and Abnormal Lab Values Associated with Nutritional Goals (sources: Brutsaert, 2022; Hoffman & Sullivan, 2020; Centers for Disease Control and Prevention, 2022b; Cushing syndrome, 2023; Kiani et al., 2022; National Institute of Diabetes and Digestive and Kidney Diseases, 2018b; National Institute of Diabetes and Digestive and Kidney Diseases, 2021c; National Institutes of Health, 2023; Xenou & Gourounti, 2021).

Endocrine Disorder or Lab Value	Nutritional Goals
Diabetes (high blood glucose)	Balance carbohydrate intake with insulin requirements, limit simple sugars and refined carbohydrates, increase fiber intake, promote weight management
Polycystic ovary syndrome (PCOS)	Promote weight loss if overweight or obese, reduce intake of refined carbohydrates and sugars, increase intake of fiber and omega-3 fatty acids, monitor iron and vitamin D levels
Thyroid disorders (e.g., hypothyroidism)	Monitor iodine and selenium intake, limit consumption of goitrogens (e.g., soy, cabbage), increase intake of iron and vitamin B12, promote weight management
Cushing’s disease/syndrome	Limit sodium intake, increase potassium and calcium intake, promote weight management
Adrenal insufficiency	Ensure adequate protein and carbohydrate intake, monitor sodium intake, increase potassium and calcium intake
Hypoglycemia	Balance carbohydrate intake with insulin requirements, eat frequent small meals throughout the day, avoid skipping meals or fasting
Low iron	Increase iron-rich foods such as lean red meat, poultry, fish, beans, and fortified cereals
Low vitamin D	Increase intake of vitamin D-rich foods such as fatty fish, egg yolks, and fortified foods; consider supplementation if necessary
Low vitamin B12	Increase intake of vitamin B12-rich foods such as lean meat, fish, poultry, and fortified foods; consider supplementation if necessary
Low potassium	Increase intake of potassium-rich foods such as bananas, potatoes, tomatoes, spinach, and avocado
Low calcium	Increase intake of calcium-rich foods such as low-fat dairy, leafy greens, and fortified foods

Adequate intake of vitamins and minerals is important for the endocrine system as they play a role in hormone synthesis, regulation, and metabolism (Hoffman & Sullivan, 2020; Kiani et al., 2022; Lewis, 2022; Shrimanker & Bhattarai, 2023). These include:

• Vitamin A is important for vision, immune function, and cell growth and differentiation. It also plays a role in regulating gene expression and hormone synthesis. Vitamin A is found in green, leafy vegetables and dairy products.
• B vitamins, including thiamin, riboflavin, niacin, pantothenic acid, pyridoxine, biotin, folic acid, and cobalamin, are important for energy metabolism and neurotransmitter synthesis. Vitamin B is found many foods including leafy green vegetables, enriched grains, and cereals.
• Vitamin C is an antioxidant that helps protect against oxidative stress and inflammation. It also plays a role in collagen synthesis and wound healing and has been linked to improved insulin sensitivity and glucose metabolism. Fruits and vegetables are important sources of Vitamin C.
• Vitamin D plays an essential role in calcium metabolism, which is critical for bone health. It also plays a role in regulating insulin secretion and glucose metabolism, and deficiency has been linked to an increased risk for type 2 diabetes. Sources for vitamin D include orange juice and dairy products fortified with vitamin D.
• Vitamin E is an antioxidant that helps protect against oxidative stress and inflammation, which are linked to the development of chronic diseases such as diabetes, heart disease, and cancer. Nuts and seeds are a key source of vitamin E.
• Calcium is important for bone health and muscle contraction, but it also plays a role in hormone secretion and metabolism. It is involved in the regulation of parathyroid hormone (PTH), which regulates calcium balance in the body. Dairy products are a primary source of calcium. For clients who do not eat dairy products, soy products and dark leafy green vegetables are also good sources of calcium.
• Chloride is an important electrolyte that plays a role in fluid balance and the regulation of pH. It is also involved in the production and secretion of gastric acid, which is important for digestion and the absorption of nutrients. It is found in food sources with salt.
• Magnesium is important for muscle and nerve function, but it also plays a role in hormone metabolism and signaling. It is involved in the regulation of PTH and insulin secretion, and deficiency has been linked to an increased risk for diabetes. Magnesium is found in whole grains and dark-green leafy vegetables.
• Phosphorus is important for bone health and mineralization, and it is a key component of hydroxyapatite, which is the mineral matrix of bones. Several hormones, including parathyroid hormone (PTH) and calcitonin, are involved in the regulation of phosphorus metabolism and bone mineralization. Also, involved in the regulation of glucose metabolism, and several hormones, including insulin and glucagon. Dairy products, meats, nuts, and whole grains are good sources of phosphorus.
• Potassium is an important electrolyte that is involved in muscle contraction and nerve function. It also plays a role in insulin secretion and glucose metabolism. Potassium is also found in leafy green vegetables as well as starchy vegetables.
• Sodium is an important electrolyte that plays a role in regulating blood pressure and fluid balance. It also plays a role in the regulation of hormone secretion, particularly in the renin-angiotensin-aldosterone system (RAAS), which regulates blood pressure and fluid balance. Sodium is readily found in processed foods including chips, pizza, and sandwiches.

Safety Alert: Managing Hypoglycemia

Hypoglycemia (a blood glucose level below 70 mg/dL) must be treated immediately to avoid serious complications. The 15-15 Rule can be used to treat mild hypoglycemia which occurs when blood glucose levels decrease to 55–69 mg/dL. Clients with blood glucose levels in this range should consume 15 g of carbohydrates and then recheck their blood glucose level after 15 minutes. Repeat these steps until their blood glucose is greater than 70 mg/dL. Examples of food items that have approximately 15 g of carbohydrates include:

• 4 oz of juice
• 1 tbsp of sugar, honey, or syrup
• Small portions of candy (hard candy, jellybeans, etc.)

Blood glucose levels that do not respond to these interventions require immediate attention at a health care facility (CDC, 2022b).

Identifying Challenges to Nutritional Goals

Developing and maintaining healthy eating practices can be difficult for any client. For the general population, a healthy diet involves eating nutrient-dense foods across all food groups while staying within calorie limits and minimizing intake of added sugars, saturated fat, and sodium (Departments of Agriculture and Health and Human Services, 2020). Meeting nutritional goals can be especially challenging for individuals with endocrine disorders as these conditions often require specific dietary modifications to manage these conditions.

For example, individuals with adrenal insufficiency may struggle with electrolyte balance and carbohydrate intake. Individuals with diabetes often struggle with carbohydrate intake and blood glucose management (American Diabetes Association, 2019). Additionally, there are different types of diabetes. Although the nutritional requirements for clients with diabetes are generally the same, clients with type 1 diabetes must take insulin to regulate their blood glucose levels. Clients with type 2 diabetes can manage their blood glucose levels through diet. Similarly named, but unrelated to diabetes is diabetes insipidus. Clients with this condition may be able to decrease urine output by eating a low-protein or a low-salt diet, but otherwise nutrition does not cause or prevent this condition (National Institute of Diabetes and Digestive and Kidney Diseases, 2021).

Following any dietary recommendations depends on more than just understanding them. Clients must also have access and means to obtain and prepare nutritious foods. A client’s culture and norms can also affect dietary behaviors and subsequent health risks (Brown et al., 2022). The nurse should consider the client’s cultural background when recommending food choices. Asking the client about their favorite foods and foods that are typically served at family or community gatherings is one way to learn more about the client’s culture.

A recent study determined that overall diet quality has improved in the United States (Orr et al., 2019). However, there are still disparities among socioeconomic groups. These health disparities can stem from lack of access to or means to obtain healthy foods. For example, clients may live in rural or inner-city areas that have few grocery stores and instead must purchase food primarily from convenience stores or fast-food restaurants. Clients with limited incomes may have to choose lesser quality food to ensure they can purchase enough food. Accordingly, differences in diet quality may also explain differences in diabetes health-related outcomes among socioeconomic groups (Orr et al., 2019). The relationship between overnutrition and socioeconomic status is complex, as individuals from lower socioeconomic groups may also develop obesity due to limited access to fresh and nutrient-dense food and easy availability of energy-dense food.

Traditional Foods Project

One example of a population-health based approach to reducing the risk for diabetes is the Traditional Foods Project. This was a 6-year cooperative project involving the CDC and 17 native U.S. tribal programs with the goals of supporting cultural traditions that could decrease the risk for type 2 diabetes among Native American and Alaska Native communities (CDC, 2022c). This project demonstrated how to incorporate culture and history into current day health interventions. Brochures with examples of the traditional food stories they documented can be found on their website.

Clients’ lifestyles also must be considered. Inadequate physical activity, poorly managed stress, and inadequate sleep can interfere with healthy eating patterns (Kesari & Noel, 2022). Skipping meals and eating late at night has been linked to hormone imbalances (Gherasim et al., 2020).

Eating disorders, mental illnesses, and unhealthy diet trends can also affect nutritional status and increase the risk for malnutrition. Alcohol and substance use are significant factors that can affect a client’s nutritional status. In addition to the physical damage caused by alcohol or substance use, the consumption of these substances can affect dietary habits. Intake of both can alter client’s appetites and potentially displace the consumption of nutrient-dense food. Frequently, overconsumption of alcohol or substances is associated with disrupted, sometimes chaotic lifestyles that can further impact nutritional intake (Mahboub et al., 2021).

Managing Diabetes Through Nutrition

Access multimedia content

It can be challenging for clients with diabetes to incorporate all the nutritional changes needed to manage their condition. To learn more about the principles of healthy eating with diabetes watch this video from the National Institute of Diabetes and Digestive and Kidney Diseases.

Unfolding Case Study: Part B

Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Part A.

After the initial health history and assessment, further testing is performed. Meena’s vital signs are:

Table 7.5

Vital Signs		Laboratory Results
Temperature:	97.6°F	Elevated TSH level: 10.5 µIU/mL Decreased free T4 level: 0.5 ng/dL Elevated fasting blood glucose level: 210 mg/dL Elevated HbA1c: 8.2%
Pulse:	90 beats/min
Respiratory rate:	18 breaths/min
Blood pressure:	145/95 mm Hg

Meena expresses a strong desire to improve her “hormone health” through lifestyle changes, particularly focusing on nutrition. However, she is feeling a little overwhelmed. Her diet recall includes foods with a lot of added sugar and salt. She tries to cook at home whenever possible to save money. When cooking at home she uses kosher or sea salt because she believes these types of salts “are healthier.” Her favorite dishes to prepare are Indian dishes she enjoyed with her family growing up. She is concerned she will no longer be able to enjoy these foods.

3

Which of the following nutritional strategies should be included in the client education for Meena's hypothyroidism management?

1. Recommend a low-protein, high-carbohydrate diet.
2. Encourage increased consumption of iodine-rich foods.
3. Advise her to avoid goitrogenic foods, such as cruciferous vegetables.
4. Promote a diet high in saturated fats and processed foods.

4

Which of the following actions would be most appropriate for the nurse to address Meena’s elevated blood pressure?

1. Initiate a sodium-controlled diet and educate Meena on sodium reduction strategies.
2. Provide instruction on calcium sources in her diet.
3. Encourage her to increase her fluid intake.
4. Initiate a low-carbohydrate diet and instruct Meena on how to obtain adequate protein in her diet.

Special Considerations: Incorporating Cultural Foods into a Diabetes Diet

Clients with diabetes may still be able to incorporate some of their favorite culture-specific foods into their diet. For example, leafy greens including collards, kale, and spinach are a traditional part of African American diets. Eating these foods can help control blood glucose levels (CDC, 2022a). The Latin American staple quinoa is a good source of fiber. Lastly, legumes and lentils, commonly used in African American, Hispanic, and Latin dishes, can also help manage cholesterol and glucose levels.