临床实践指南：加拿大女性营养共识（二）
前情提要
第一章 引言
经常摄入多样化、均衡的饮食是健康生活方式的重要组成部分。女性每天吃的食物当供给量恰当时，可提供必需营养素和能量的来源，能促进青春期、妊娠期和哺乳期的健康，维持身体功能，降低以后生活中许多慢性疾病的风险【1】。重要的是要了解各个年龄和生理阶段女性所做的食物选择受许多因素影响，共同构成了“饮食环境”，包括在童年时期建立的饮食习惯、食物的可获得/可用性、种族和文化、地理、教育程度、收入、食品消费趋势、媒体宣传和公共政策【2】。当前加拿大饮食环境的方方面面给想要摄入平衡、营养丰富、能量适当的饮食的女性提出挑战，因为高钠、能量密度高的加工食品和含糖甜饮料现在到处都是并经常食用【3-9】。生活在偏远地区的女性和那些在社会底层挣扎的女性在获取营养丰富的食物上都面临着许多挑战。
拜访医疗卫生专业人士，无论是常规或为了特定疾病，提供了进行营养对话的机会，筛选健康饮食的基本要素，并提出具体的建议，以改善饮食选择或营养相关的健康行为或为更全面的营养评估作出适当转诊。在繁忙的临床工作中完成一个全面的营养评估并使之发生改变是个艰巨的任务。但女性常规健康保健应包括基础筛查以评估其饮食摄入充足性、是否保持健康的生活方式和体重及可能限制其保持健康生活方式和体重的任何因素。在简短门诊就诊时讨论适当行为改变策略，如减少筛查时间间隔和快餐店就餐频率或增加在家吃饭频率和加强阅读食品标签的重要性，可以帮助促进改变不健康的饮食模式，并为正在进行的讨论提供基础。这些讨论有助于将其转诊给其他卫生保健提供者，如营养师。动机访谈是一项有助于促进以患者为中心行为变化的有效的临床技术【10】。另外，由于受欢迎的媒体经常重点报道关于促进营养的补充剂和饮食的研究，医学专业人员应该掌握当前的饮食趋势，并能分辨可能是有害的营养选择（包括补充剂）。
本共识旨在向加拿大医疗卫生专业人士提供女性从青春期到生育期、绝经期及之后营养指导的基本知识和工具。这些资料旨在帮助未接受正式营养培训但希望开始将循证营养元素结合到实践工作者。该指南首先对所有生命阶段的女性进行营养指导概述（见第二章），然后扩展到青春期、孕前期、妊娠期、产后期、绝经期及其之后独特的营养考虑。为已诊断患急性或慢性疾病、营养需求发生改变（如妊娠糖尿病、肾衰竭）的女性提供营养疗法，这超出了该指南的范围。已公开发表的文献、政府和医疗机构报告、临床实践指南、灰色文献、教科书都作为制定本文件的证据来源。分级推荐建议旨在帮助医疗卫生专业人士从新手成长为照顾患者的营养专家。
参考文献
Health Canada. Eating Well with Canada's Food Guide. 2011. http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php
Chan C. Food Environment, Health, and Chronic Disease. Green Paper Prepared for the Alberta Institute of Agrologists. 2015. http://www.albertaagrologists.ca/document/1911/Mar30_Green%20PaperFinal.pdf
Danyliw AD, Vatanparast H, Nikpartow N, Whiting SJ. Beverage intake patterns of Canadian children and adolescents. Public Health Nutr. 2011;14:1961-9.
Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-processed foods and likely impact on human health. Evidence from Canada. Public Health Nutr. 2013;16:2240-8.
Moubarac JC, Receveur O, Cargo M, Daniel M. Consumption patterns of sweetened food and drink products in a Catholic Middle Eastern Canadian community. Public Health Nutr. 2014;17:471-8.
Nikpartow N, Danyliw AD, Whiting SJ, Lim HJ, Vatanparast H. Beverage consumption patterns of Canadian adults aged 19 to 65 years. Public Health Nutr. 2012;15:2175-84.
Tanase CM, Koski KG, Laffey PJ, Cooper MJ, Cockell KA. Canadians continue to consume too much sodium and not enough potassium. Can J Public Health. 2011;102:164-8.
Black JL, Billette JM. Fast food intake in Canada: differences among Canadians with diverse demographic, socio-economic and lifestyle characteristics. Can J Public Health. 2015;106:e52-8.
Garriguet D. Canadians' eating habits. Health Rep. 2007;18:17-32.
American College of Obstetricians and Gynecologists. Motivational interviewing: a tool for behavior change. ACOG Committee Opinion No. 423. Obstet Gynecol. 2009;113:243-6.
Chapter 1: Introduction
Regular consumption of a varied and balanced diet is a key component of a healthy lifestyle. The foods women eat each day provide a source of essential nutrients and energy which, when provided in the correct amounts, facilitate healthy development during adolescence, pregnancy, and lactation; maintain body functions; and reduce the risk of many chronic diseases later in life. [1] It is important to understand that individual food choices made by females of all ages and physiological stages are influenced by a number of factors that collectively constitute the “food environment,” including food habits established during childhood, accessibility/availability of foods, ethnicity and culture, geography, education, income, food trends, media, and public policy. [2] Aspects of the current Canadian food environment can present a challenge to women aiming to consume a balanced, nutritious, energy-appropriate diet because energy-dense processed foods high in sodium and sugar-sweetened beverages are now widely available and frequently consumed. [3-9] Women living in remote areas and those with social struggles face many challenges in accessing nutritious food.
A visit with a health care professional, whether routine or for a specific medical concern, provides an opportunity to initiate a dialogue about nutrition, screen for the basic elements of a healthy diet, and offer specific advice to improve dietary choices or nutrition-related health behaviours or make an appropriate referral for a more comprehensive nutritional assessment. Completing a comprehensive nutritional assessment and effecting change can be daunting tasks in a busy clinical practice. However, routine health care of a woman should include a basic screen to assess the adequacy of her diet, whether she is maintaining a healthy lifestyle and body weight, and any factors that may be restricting her ability to maintain a healthy lifestyle and body weight. Discussing behaviour change strategies as appropriate, such as reducing screen time and the frequency of eating at fast food restaurants or increasing the frequency of family meals and importance of reading food labels, in a short clinic visit can help facilitate change in unhealthy eating patterns and provide a basis for ongoing discussion. These discussions may facilitate referral to other health care providers, such as a dietitian. Motivational interviewing is an effective clinical technique to faciliate patient-centered behavioural change. [10] In addition, because popular media often highlight research promoting nutritional supplements and diets, medical professionals should have current knowledge of dietary trends and identify nutritional choices (including supplements) that may be harmful.
The aim of this consensus document is to provide health care professionals in Canada with the basic knowledge and tools to provide nutrition guidance to females from adolescence through their reproductive years to menopause and beyond. The information is intended to be useful to those without formal training in nutrition but who wish to begin to incorporate elements of evidence based nutrition into their practice. This guideline begins by providing general guidance for all women, regardless of life stage (see Chapter 2), and then expands on unique nutrition considerations during adolescence, preconception, pregnancy, postpartum, menopause, and beyond. It is beyond the scope of this guideline to provide nutritional therapies for women diagnosed with an acute or chronic medical condition who may have altered nutritional requirements (e.g., gestational diabetes, kidney failure). Published literature, governmental and health agency reports, clinical practice guidelines, grey literature, and textbook sources were used in the preparation of this document. The graded recommendations are intended to be useful to health care professionals from novice to nutrition experts in caring for their patients.
References
Health Canada. Eating Well with Canada's Food Guide. 2011. http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php
Chan C. Food Environment, Health, and Chronic Disease. Green Paper Prepared for the Alberta Institute of Agrologists. 2015. http://www.albertaagrologists.ca/document/1911/Mar30_Green%20PaperFinal.pdf
Danyliw AD, Vatanparast H, Nikpartow N, Whiting SJ. Beverage intake patterns of Canadian children and adolescents. Public Health Nutr. 2011;14:1961-9.
Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-processed foods and likely impact on human health. Evidence from Canada. Public Health Nutr. 2013;16:2240-8.
Moubarac JC, Receveur O, Cargo M, Daniel M. Consumption patterns of sweetened food and drink products in a Catholic Middle Eastern Canadian community. Public Health Nutr. 2014;17:471-8.
Nikpartow N, Danyliw AD, Whiting SJ, Lim HJ, Vatanparast H. Beverage consumption patterns of Canadian adults aged 19 to 65 years. Public Health Nutr. 2012;15:2175-84.
Tanase CM, Koski KG, Laffey PJ, Cooper MJ, Cockell KA. Canadians continue to consume too much sodium and not enough potassium. Can J Public Health. 2011;102:164-8.
Black JL, Billette JM. Fast food intake in Canada: differences among Canadians with diverse demographic, socio-economic and lifestyle characteristics. Can J Public Health. 2015;106:e52-8.
Garriguet D. Canadians' eating habits. Health Rep. 2007;18:17-32.
American College of Obstetricians and Gynecologists. Motivational interviewing: a tool for behavior change. ACOG Committee Opinion No. 423. Obstet Gynecol. 2009;113:243-6.
翻译：肖慧娟（天津市第三中心医院营养科）
