Nutrition and Dietetics
Role of Nurses
1.
2.
3.
4.
Screening-in-patient to determine the risk
Liaison between the dietician and physician as well as with the other members of healthcare team
Nutrition resource when dieticians are not available
Basic Nutrition Counselling in hospitalized clients low to mid risk
ROLE OF DIETICIAN
1. Obtain history and usual diet prior to admission (difficulty in chewing, swallowing or self-feeding; chief
complaint; medications, and living situations)
2. Nutrition History – current habits, changes in appetite, food allergies and intolerance, cultural or religious
diet
3. Calculate calorie and protein requirement based on data
4. Determine nutritional diagnosis
5. Nutritional interventions – diet order change, requesting laboratory tests, performing nutrition counselling
or education
NURSING PROCESS
ASSESSMENT
MALNUTRITION
Impaired function that results from a prolonged nutrition deficiency
Anorexia and Bulimia Nervosa – Psychological
Rickets – Vitamin D deficiency
Scurvy – Vitamin C deficiency
Anemia – RBC
Goiter – Iodine deficiency
●
●
NUTRITIONAL SCREENING
Quick look at a few variables to judge a client’s risk for nutritional items;
✔ Height
✔ Weight
✔ Diet
✔ Albumin, haematocrit- (determines the hydration of the cells)
✔ Nausea and Vomiting
✔ Significant weight loss
✔ Change in appetite
✔ Difficulty eating
✔ Use of enteral or parenteral nutrition
1|Nutrition and dietetics
✔
✔
✔
Bowel habits
Diagnosis
*protein also releases Immunoglobulin
●
COMPREHENSIVE NUTRITIONAL ANALYSIS
An in depth analysis of nutritional status
Focus: moderate-high risk with suspected or confirmed protein-energy malnutrition
●
NUTRITIONAL CARE PROCESS – A B C D
ASSESSMENT
BIOCHEMICAL DATA
CLINICAL DATA
DIETARY DATA
●
HEIGHT AND WEIGHT
𝐵𝑀𝐼 =
𝑊𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)
𝐻𝑒𝑖𝑔ℎ𝑡 (𝑚)2
BMI – index of weight in relation to height
● PERCENTAGE OF “IDEAL” BODY WEIGHT (%IBW)
HAMWI METHOD
2|Nutrition and dietetics
For women: first 100 pounds – first 5ft of height
+ 5 pounds for each additional inch
For men: first 106 pounds – first 5ft of height
+ 6 pounds per additional inch
%𝐼𝐵𝑊 =
𝐶𝑢𝑟𝑟𝑒𝑛𝑡 𝑤𝑒𝑖𝑔ℎ𝑡
× 100
𝐼𝐵𝑊
DOES NOT MEASURE;
o Body composition
o Evaluation of body fat
o Oedema and dehydration
●
CALCULATING PERCENT WEIGHT CHANGE
(𝑈𝑠𝑢𝑎𝑙 𝑏𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 − 𝑐𝑢𝑟𝑟𝑒𝑛𝑡 𝑏𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡)
× 100 = % 𝑊𝑒𝑖𝑔ℎ𝑡 𝑐ℎ𝑎𝑛𝑔𝑒
𝑈𝑠𝑢𝑎𝑙 𝑏𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡
BIOCHEMICAL DATA
Urinalysis and blood test (albumin & pre-albumin)
Albumin – 3.5g/dL – 5.4g/dL
Pre-albumin or thyroxin-binding protein – more sensitive indicator not specific for malnutrition.
Affected by metabolic stress and other condition
3|Nutrition and dietetics
-
More expensive and usually not available
CLINICAL DATA
SIGNS AND SYMPTOMS OF MALNUTRITION
✔ Hair – dull, brittle, dry, falls out easily
✔ Swollen glands of the neck and cheeks
✔ Skin – dry, rough, spotty (sandpaper feel)
✔ Poor or delayed wound healing or sores
✔ Thin appearance, with lack of subcutaneous fat
✔ Muscle wasting
✔ Oedema – lower extremities
✔ Weakened hand grasp
DIETARY DATA
o
o
o
o
o
o
o
o
o
o
Do you avoid any particular foods?
Do you watch what you eat in any way?
How many meals and snacks do you eat in a 24-hour period?
Do you have any food allergies?
Do you drink vitamin, mineral, herbal or other supplements?
What concerns do you have about what or how you eat?
For acutely ill; how has illness affected your choice or tolerance of food?
Who prepares the meals?
Do you have enough food to eat?
How much alcohol do you consume daily?
MEDICAL-PSYCHOLOSIAL HISTORY
o
o
o
MEDICAL
✔ Medications
✔ Acute and Chronic disease
PSYCHOLOGICAL FACTORS
✔ Depression
✔ Eating DO
✔ Psychosis
SOCIAL
✔ Illiteracy
✔ Language barriers
✔ Limited knowledge on food
✔ Cultural
✔ Social isolation
✔ Cooking arrangements
✔ Low income
✔ Elderly
✔ Lack/extreme activity
✔ Use of tobacco or drugs
DIAGNOSIS
4|Nutrition and dietetics
OBVIOUS DIAGNOSES
LESS OBVIOUS (may be
part of the care plan)
Imbalanced Nutrition: Less
than body requirements
Adult failure to thrive
Imbalanced Nutrition: More
than body requirements
Acute/Chronic pain
Readiness
nutrition
Deficient knowledge (of
food /nutrition)
for
enhanced
Risk
for
Imbalanced
Nutrition: more than body
requirements
Feeding self-care deficit
Impaired
swallowing/detention
Risk
for
aspiration/constipation
Impaired oral mucous
membrane
PLANNING
●
GUIDELINES IN PLANNING
1. Patient-centered outcomes
2. SMART
3. Commitment/Compliance
4. Short-term goals – alleviate symptoms, prevent complications
INTERVENTIONS
WAYS TO PROMOTE ADEQUATE INTAKE
✔
✔
✔
✔
✔
✔
✔
Encourage a big breakfast if appetite deteriorates throughout the day
Advocate D/C of IV therapy (if feasible)
Replace meals withheld for diagnosis test
Out of bed when eating (if possible)
Encourage good oral hygiene
Solicit info on food preferences (cultural or religious)
Display a positive attitude – education or serving food
WAYS TO FACILITATE CLIENT AND FAMILY TEACHING
✔
✔
✔
✔
Listen to concerns and ideas
Family involvement (if appropriate)
Reinforce importance of nutrition
Help in selecting appropriate foods
5|Nutrition and dietetics
✔
✔
✔
✔
Counsel the client about drug-nutrient interation
Keep message simple, emphasize things “to do”, not “not to do”
Written hand outs
Avoid if not tolerated
MONITORING AND EVALUATION
NURSING RESPONSIBILITIES
✔
✔
✔
✔
✔
✔
✔
✔
Check intake
Document appetite
Order supplements if intake is low or needs are high
Nutritional consult
Assess tolerance
Assess weight
Monitor progression of restrictive diets (NPO, clear liquid, soft diet, Diabetic Diet)
Monitor comprehensive of information and motivation to change
MACRONUTRIENTS
-
Carbohydrates (CHO)
Proteins (CHON)
Fats
MICRONUTRIENTS
-
Vitamins
Minerals
-
● CARBOHYDRATES (CHO)
A class of energy-yielding nutrients that contain CARBOHYDRATES, HYDROGEN, OXYGEN
45% - 65% of our food should come from carbohydrates
> carbohydrates intake > use = storage in the liver or in the tissues as fat
FUNCTION:
1. Gives the body energy
2. Best source of fuel for the body
3. Helps digest proteins and fats
4. Glucose for energy – catabolism vs. anabolism
Catabolism – breaks down glucose for energy
Anabolism – builds up *amino acid
5. Protein sparing – 4cal/gram
6. Preventing lactosis/ lactic acidosis- a medical condition characterized by the build-up of lactate
in the body, with formation of excessively low pH in the bloodstream. Excessive acid accumulates
due to a problem with the body’s oxidative metabolism. BREAK DOWN OF FATS
7. Making other compounds (glycogen, nonessential amino acids, fats- building blocks of protein)
6|Nutrition and dietetics
SIMPLE SUGARS
CARBOHYDRAT
ES
SIMPLE
SUGARS
MONOSACCHARIDES
Quick energy sources
They came from sugar
They do not usually supply any other
nutrients or fibre
COMPLEX
SUGARS
DISACCHARIDES
POLYSACCHARIDES
* GLUCOSE
* SUCROSE
* STARCH
* FRUCTOSE
* MALTOSE
GLYCOGEN
* GALACTOSE
* LACTOSE
FIBRE
MONOSACCHARIDES
1 sugar molecule
Absorbed
without
digestion
undergoing
●
GLUCOSE
Circulates through the blood to provide energy for body cells
“dextrose”
SOURCES
● FRUCTOSE
Fat sugar
Sweetest of all sugar
Often added to food because it is both cheap and enhances taste
SOURCES:
✔ Fruit shake
✔ Dried cranberry
✔ Yogurt
✔ Pasta sauce
✔ Salad dressing
✔ Fruit pie
-
● GALACTOSE
Galactose + Glucose = disaccharide or LACTOSE
Doesn’t appear in appreciable amount in foods
Added to glucose
DISACCHARIDE
-
2 linked monosaccharide (at least 1 glucose)
Would split before being absorbed
7|Nutrition and dietetics
● SUCROSE
Glucose + Fructose = “ TABLE SUGAR or SUGAR”
SOURCE
✔ Sugar beets
✔ Sugar cane
-
● MALTOSE
Glucose + Glucose
Not found naturally in foods
Adde for flavouring
● LACTOSE
Glucose + Galactose = “MILK SUGAR”
Found naturally in milk
Enhances absorption of calcium and promotes the growth of GI Flora
Also enhances the production of vitamin K
The least sweet of all sugar
Produces RBC, calcium
Animal source
SOURCES:
TYPES OF SUGAR
SUGAR
OTHER NAME
FOOD
SOURCES
GLUCOSE
“BLOOD
SUGAR”
FRUIT,
VEGGIES,
GRAINS
8|Nutrition and dietetics
SUCROSE
“TABLE
SUGAR”
TABLE SUGAR,
SUGAR CANE
FRUCTOSE
“FRUIT SUGAR”
FRUIT
MALTOSE
“MALT
SUGAR”
“MILK SUGAR”
GRAINS
LACTOSE
MILK
NEGATIVE OUTPUT
Protein: Blood, Urea, Nitrogen
Fats: Ketones, Cholesterol, Creatinine
POLYSACCHARIDE | COMPLEX CARBOHYDRATES
-
100s – 1000s of glucose molecule linked together
(X) sweet but sense sweetness by receptors
Supply longer-lasting energy, as well as other nutrients and fibres that the body needs.
●
STARCH
● GLYCOGEN
Storage form of glucose in animals and humans
Animals (we usually eat, mainly the protein not the sugar content) No dietary source
Are easily converted to lactic acid
Miniscule amount only – shellfish (scallops and oysters)
STORAGE:
✔ Liver
✔ Muscles
9|Nutrition and dietetics
● FIBRE
“Roughage” – can’t be digested by human enzymes
Found only in plants/fruits
SOLUBLE – good for those who are having diarrhoea
INSOLUBLE – constipated, because it breaks own easily
How do you know if a food has added sugar?
✔
Check out the Food Label:
Total Carbohydrate (g): Dietary Fiber,
Sugars, Other Carbohydrates (Complex)
List of ingredients: sugar, brown sugar, juice
fruit juices, molasses, honey, syrup, malted
corn sweetener, corn syrup, maltose,
fructose, lactose, glucose, dextrose
GLYCEMIC RESPONSE
Effect a food has on the blood glucose concentration
✔
✔
✔
How quick
How high
How long to return
Factors:
●
●
●
●
●
●
Fat, fibre and acid In food
Method of preparation
Degree of processing
The amount eaten
Degree of ripeness
Combination with other food
GLYCEMIC INDEX (GI)
-
A numeric measure of the glycemic response of 50g of a food sample
The higher the number, the higher the glycemic response
10 | N u t r i t i o n a n d d i e t e t i c s
GLYCEMIC LOAD
-
GI X amount of carbs 🡪 impact on glucose level
Not reliable
GLYCEMIC
INDEX
GLYCEMIC
LOAD
WHITE SPAGHETTI
58
28
WATERMELON
72
4
LOW FAT ICE
CREAM
50
3
PEANUTS
17
1
SNEAKERS BAR
68
23
CHO IN HEALTH PROMOTION
●
●
●
●
Tips for Increasing whole grain Intake
Way to limit added sugar 🡪 X soda, “sweet tooth”, “read labels”
Sugar Alternatives 🡪 sugar alcohol, nonnutritive sweeteners
Steps to Avoid Dental Caries
RECOMMENDATIONS
1. Eat less foods with added sugar.
2. Choose fiber-rich fruits, vegetables and whole grains more often.
3. Eat beans several times a week.
4. Brush teeth after eating foods with sugar and starch.
PROTEIN
-
In Greek, “to take first place”
CHON
Adult – 20% of body weight
10% to 35 % of total calories/meal
Every tissue and fluid in the body contains some protein except bile and urine
11 | N u t r i t i o n a n d d i e t e t i c s
AMINO ACIDS
9 ESSENTIALS OR
11 NONESSENTIAL OR
INDISPENSIBLE
DISPENSIBLE
HISTIDINE
ALANINE
ISOLEUCINE
ASPARAGINE
LEUCINE
ASPARTIC ACID
LYSINE
GLUTAMIC ACID
METHIONINE
SERINE
PHENYLALANINE
*ARGININE
THREONINE
*CYSTEIN
TRYPTOPHAN
*GLUTAMINE,
*TYROSINE
*GLYCINE, *PROLINE
VALINE
-
Basic building blocks of protein and end product of protein digestion
10,000 -15, 000 vary in size, shape and function
Some dispensable 🡪 indispensable when metabolic need is great and endogenous synthesis is not
adequate.
FUNCTION OF PROTEINS
1. Body Structure and Framework
40% found in the skeletal muscle
15% in skin and blood
Tendons, membranes, organs and bones
2. Enzymes
Protein that facilitate chemical reactions w/o changing themselves.
DIGESTIVE ENZYMES – Some breakdown larger molecules
ENZYMES FOR PROTEIN SYNTHESIS – Some combine molecules to form larger compounds
3. Other body secretions and fluids
Neurotransmitters (serotonin, acetylcholine)
Antibodies
Some hormones (insulin, thyroxine, epinephrine)
Breast milk, mucus,
4. Fluid Balance
Attracts water 🡪 osmotic pressure
Circulating proteins like albumin – maintain proper balance (intracellular, intravascular, interstitial)
Edema
12 | N u t r i t i o n a n d d i e t e t i c s
5. Acid-base Balance
Act depending on the pH surrounding fluids
Lipoproteins –transports fats, cholesterol, fat-soluble vitamins
Hemoglobin
6. Transport Molecules
Globular proteins transport through blood
7. Other compounds
Opsin, light-sensitive visual pigment in the eye
-
Thrombin, normal blood clotting
8. Some has specific functions within the body
Tryptophan – precursor of the vit. Niacin; component of Serotonin
Tyrosine – precursor of melanin
9. Fueling the body
Not preferred fuel but source of energy if fat and CHO are inadequate
NITROGEN BALANCE
-
Reflects the state of balance between protein breakdown and protein synthesis
Comparing nitrogen intake with nitrogen excretion over 24 hours
EXAMPLE:
Mary is 25 yo woman who was admitted due to multiple fractures and traumatic injuries from a car accident. A
nutritional intake study indicated a 24-hr protein intake of 64 g. A 24-hr Urinary Urea Nitrogen (UUN) collection
results was 19.8 g.
13 | N u t r i t i o n a n d d i e t e t i c s
1. Determine nitrogen intake by dividing protein intake by 6.25.
64 / 6.25 = 10.24 g of Nitrogen
2. Determine Total Nitrogen Output by adding 4 to the UUN.
19.8 + 4 = 23.8 of Nitrogen
3. Calculate Nitrogen Balance by subtracting Nitrogen Output from intake.
10.24 – 23.8 = (-) 13.56g in 24 hours
4. Interpret results
Interpretation
●
●
●
Neutral = balance
(+) = synthesis > breakdown (growth, pregnancy, recovery from injury
(-) = breakdown > synthesis (starvation or the catabolic phase after injury)
RECOMMENDED FOR DIETARY ALLOWANCE
●
For Healthy adults (ONLY) is 0.8g/kg
Example 1:
Adult male who weighs 154 pounds
= 56 g protein per day
Example 2:
Adult female who weighs 65 kgs
= 52 g protein per day
CONDITIONS THAT NEED INCREASE PROTEIN
●
-
INADEQUATE CALORIE INTAKE
Very low calorie weight loss diets
Starvation
PEM
-
● WHEN BODY NEEDS TO HEAL ITSELF
Hypermetabolic conditions (burns, sepsis, major infection, major trauma)
Skin breakdown
Multiple fractures
Hepatitis
-
● REPLACE EXCESSIVE PROTEIN LOSS
Peritoneal dialysis
14 | N u t r i t i o n a n d d i e t e t i c s
-
Protein-losing renal diseases
Malabsorption – short bowel syndrome
-
● DURING PERIODS OF NORMAL TISSUE GROWTH
Pregnancy
Lactation
Infancy to adolescence
PROTEIN RESTRICTION
-
Severe liver diseases
Impaired renal function
PROTEIN DEFICIENCIES
KWASHIORKOR
CAUSE
Acute, deficiency of protein or critical infections 🡪 loss of appetite
Stressors: measles or gastroenteritis; American Adults – Trauma or sepsis
ONSET
Rapid, acute; develop in weeks
APPEARANCE
May look well nourished because of edema and enlarged liver
WEIGHT LOSS
Some
OTHER CLINICAL SYMPTOMS
Poor appetite
Irritability
Patchy and scaly skin
Hair loss / easy pluckability
MORTALITY
HIGH
MARASMUS
CAUSE
-
Severe deficiency or impaired absorption of calories, protein, Vitamins & Minerals
Severe prolonged starvation
Children – w/ chronic or recurring infections, marginal food intake
Adults – secondary to chronic illness
15 | N u t r i t i o n a n d d i e t e t i c s
ONSET
Slow, chronic, months to years to develop
APPEARANCE
Skin and bones
WEIGHT LOSS
Severe
OTHER CLINICAL SYMPTOMS
Hunger
MORTALITY
Low, unless r/t underlying disease
PROTEIN EXCESS
-
No potential adverse effects from a high protein intake from food or supplements (institute of
Medicine of the National Academics, 2005)
PROTEINS IN HEALTH PROMOTION
●
-
According to the AHA and Heart and Stroke Foundation of Canada Emphasis on grains fruit and
vegetables
● Accdg to American Institute for Cancer Research,
X eat > 18oz / week 🡪 red meats (pork, lamb, beef)
16 | N u t r i t i o n a n d d i e t e t i c s
-
X processed meat (ham, salami, bacon, hotdogs, sausages) 🡪 increase risk of colorectal cancer
(AIRC, 2007)
VEGETARIAN DIETS
● Complete elimination of animal products to simply
avoiding meat.
● Lower rate of obesity, CVD, HPN, DM II, Cancer,
dementia, renal disease, gallstones
● Food sources
Dried peas, beans, nut, nut butters, soy products,
veggie burgers
● If not planned properly 🡪 lack essential nutrients
(Iron, zinc, calcium, Vit D and alpha-linoleic acid &
excessive fat & cholesterol due to poor choices
Nutrition and Dietetics (Midterms)
Vitamins and Minerals
 Vitamins
o Greek word which means “vital for life”
o Organic molecules essential for normal health and growth and they are required in small amounts,
 Form no structures
 No mass
o Deficiencies or excessive amounts can be dangerous
 Water soluble- all vitamins b (b complex), c, and non-b complex (choline)
o Vitamins are responsible for the movements of the macronutrients.
o Hematopoiesis- regulation and maturity of blood cells in the bone marrow.
o Others- Heme synthesis
 Fat soluble- Vitamins ADEK
17 | N u t r i t i o n a n d d i e t e t i c s
Difference of Water soluble and Fat soluble
 Water soluble are easier to be excreted and absorbed; fat soluble have larger structures.
Important Terms
 Hypovitaminosis- insufficiency of one or more essential vitamins
 Hypervitaminosis- abnormally high storage levels of vitamins, which can lead to toxic symptoms.
Water soluble vitamins
Energy-yielding vitamins
 Vitamin B1: Thiamine
 RDA- Men-1.2 mg/day; Women- 1.1 mg/day
o Functions:
o Cofactor of alpha-ketoglutarate dehydrogenase (TCA)- tricarboxylic acid
o Easily destroyed by heat
o Alcoholic/ chronic alcoholic- Thiamine deficiency
o Decrease thiamine/ glucose level
o 70-100 mg/dL- normal glucose level
o Priority- increase thiamin
o Because if glucose= glycolysis= pyruvate (end product); needs thiamin to move in the spindle= no use;
build up that will cause lactic acidosis; causes damage in liver and kidney.
 From bread, milk, cereals, egg, cauliflower, flax seeds, potato.
 For emergencies; fast- thiamin injections
 Dry and wet beriberi
o Dry- peripheral neuropathy
o Wet- peripheral neuropathy and heart failure, pitting edema, and cardiomegaly- increase in cardiac size.
 Wernicke’s Korsakoff’s syndrome
o Stress/ alcoholic=brain alterations due to thiamin deficiency (brain tissue ischemia+cell death)
18 | N u t r i t i o n a n d d i e t e t i c s
o



















1st stage- Wernicke’s
 wobbly and weird; confusional state; opthalmoplegia- weakeness of the eye muscles; still with
vision; ataxia- loss of control; muscle weakness
nd
o 2 stage- Korsakoff’s
 Amnesia; confabulation- altered reality; psychosis
Vitamin B2: Riboflavin
RDA- Men- 1.3 mg/day; Women- 1.1 mg/day
Functions:
o Precursor of 2 coenzymes: Flavin mononucleotide(FMN) and Flavin adenine dinucleotide(FAD)
Egg, tomatoes, cabbage, cereals, nuts, squash, lean meat, and milk.
Ariboflavinosis
o Oral: Angular stomatitis- singaw, inflammation of the mucous membranes, cheliosis- drying of the
corner of the lips, glossitis- inflammation of the tongue.
o Facial- Dermatitis of nasolabial region.
o Ocular-vascularization of the cornea.
Vitamin B3: Niacin
RDA- Men- 16 Niacin Equivalent/day; women- 14 NE/day; upper level of 35 mg/day for adults.
Functions
o For information of nicotinamide adenine dinucleotide(NAD) and nicotinamide adenine dinucleotide
phosphate(NADP) coenzymes.
Dairy products, lean meat, nuts, egg, poultry, fish, vitamin b complex, and supplements.
o Supplements is good- due to frying vitamins are reduced; very sensitive to heat and light.
The timed-release tablets and capsules- fewer side effects. However, the timed-release versions are more likely
to cause liver damage.
o Cannot be digested in the mouth but is also broken down when acidity is already high.
Deficient when corn is staple diet
Pellagra- can lead to death
o dermatitis- dryness of the skin; scaling,
o diarrhea
o demetia- starting point of Alzheimer’s
o Should have the triad (3Ds) to be diagnosed
o Rash when exposed to light
Vitamin B5: Pantothenic Acid
Functions:
o In order to synthesize coenzyme-A (COA)- metabolism of CHO, CHON, and fats.
Does not have a deficiency but is needed.
Vitamin B7: Biotin
RDA: 30 mcg/day
Deficiency of biotin= causes: Too many egg whites= alopecia
Tomatoes, carrots, almonds, onions, salmon, romaine lettuce, eggs, walnuts, sweet potato, cauliflower, vitamin
b complex, and supplements
Hematopoietic vitamins





Vitamin B9: Folic acid
RDA: Adult: 400 mcg/day; Pregnant: 600 mcg/day (to ensure fetal development)
Absorbed in the jejunum
Beans and legumes, citrus fruits, whole grain, shell fish, poultry, and dark green leafy vegetables
Spina bifida- accumulation of fluid in the spinal cord
19 | N u t r i t i o n a n d d i e t e t i c s




Anoncephaly- no skull
Vitamin B12: Cobalamin
RDA: 2.4 mcg/day
Absorbed in the ileum
Electrolytes


Minerals circulating in blood and other body fluids that carry an electrical charge
Effect on body: processes amount of water inside the body, blood ph, muscle action, and normal functioning of
the nerves and muscles
Sodium





Major extracellular cation
Transmission of nerve impulses
Regulate water in intracellular and extracellular
1,500 mg/day- RDA; 1,300 mg/day (51-70 years old)
Hyponatremia-low blood sodium
Potassium






Cation; maintains levels extracellularly
Primary intercellular cation
Muscle function
Contractility of muscle (e.g: heart)
Nerve impulses
4,700 mg/day- RDA
Chloride





Key anion of extracellular fluids
Maintain fluid balance inside and outside the cell
A component of hydrochloric acid, an indispensable gastric juice produced by the stomach
o Reacts with hydrogen ions—acid breakdown of food
Acid- base balance
2,300 mg/day; 2000 mg/day (>50 years old)
Electrolytes mEq/L (milliequivalent)
Sodium (Na)
Normal
range
RDA
135-145
mEq/L
Hyponatremia
(decreased
sodium in
blood)
Adult- 1500
mg, 51-70 yo-
Potassium
(K)
3.5-5 mEq/L
Chloride
(Cl)
96-106
mEq/L
4700
mg/day
Adult- 2300
mg/day,
20 | N u t r i t i o n a n d d i e t e t i c s
1300 mg,
upper limit2300 mg
Sources
Deficiency
Toxicity



>50 yo2000 mg,
>70- 1800
mg
Table salt,
Unprocessed Foods w/
processed
foods, white Na- contain
food
potatoes w/ Cl as well
skin, sweet
potatoes,
tomatoes,
bananas,
oranges,
dairy
products
and legumes
FVD w/
Muscle
Rare, same
headache,
weakness,
as Na
muscle
confussion,
deficiency
cramps,
decreased
weakness,
appetite,
decreased
cardiac
concentration, dysrhythmia
appetite loss
from
vomiting
Na sensitive
From diet or Due to
hypertension
supplements dehydration
if (+) renal
--disease
imbalance
Fluid volume deficit/deficiency- vascular, cellular, or intracellular dehydration
o Occurs with diarrhea, vomiting, or high fever
o Other causes of excessive fluid loss- sweating, diuretics, and polyuria (excessive urination)
o Person with FVD less able to maintain blood pressure immediately= orthostatic hypotension
Fluid volume excess-increased fluid retention and edema due to compromised regulatory mechanisms, or excess
fluid and sodium intake
o When there is increase in sodium intake= hypertension may occur
Kwashiorkor- low protein levels
o Accumulation of fluids in the face, stomach, and extremities
Energy balance




Consummation and expenditure of energy should be equal
Ill patients= increase; due to the physiologic changes that needs adaptation
For energy needs a more active person or of larger or smaller body size, further adjustments must be made
Estimated calorie needs/day by age, gender, and physical activity level
Type of lifestyle
Sedentary
Activities done
Light physical
acitivity+ADL (activities of
daily living)
21 | N u t r i t i o n a n d d i e t e t i c s
Moderately active

Active
1.5 miles=1km
Walking about 1.5-3
miles/day
>3 miles/day
Factors for estimation according to level of physical activity for men and women
Level of activity
Very light
Men
Women
Light
Men
Women
Moderate
Men
Women
Heavy
Men
Women
Exceptional
Men
Women
Activity factor
(xREE)
Energy
expenditure
(kcal/kg/day)
1.3
1.3
31
30
1.6
1.5
38
35
1.7
1.6
41
37
2.1
1.9
50
44
2.4
2.2
58
51
Components of total energy expenditure



Basal metabolism- amount of energy needed to to maintain life-sustaining activities (breathing, circulation,
heartbeats, secretion of hormones)
Basal metabolic rate (BMR)- rate which the body spends energy to keep all these life-sustaining processes going
Thyroxine- key BMR regulator
o More thyroxine= higher BMR
Breakdown of human energy expenditure



Resting energy expenditure (breathing, circulation etc)- 70.0%
o Energy spent on normal life situations while at rest
Physical activity- 20.0%
o Body movement produced by the skeletal muscles
Thermic effect of food (digest, absorb, metabolize, store food)- 10.0%
o Increase in cellular activity due to eating
Adaptive thermogenesis

Energy use by the body to adjust changing physical and biologic environment situations
o Physical and emotional trauma
o Too much eating, extreme temps, and extreme emotions
Healthy weight

Measuring body fatness
22 | N u t r i t i o n a n d d i e t e t i c s
o
o
o



Lean body mass- bone, muscle, and other nonfat tissues
Sometimes not a good measurement of fatness
Due to fluctuations in body fluids; fluid retention occurs before menstruation or during hot weatherinterpreted as fat gain, and losses in a sauna may appear to be fat losses
o Determine body composition (lean body mass+body fat)
Interpreting BMI
o Weight-to-height ratios considered normal but levels of body fat are beyond what is recommended vice
versa
Body fat distribution
o Differences are related to gender, age, and stage of development
o Fat that is visceral in the abdomen are more dangerous than subcutaneous fat
o Visceral fat- quickly lost and gained
o Subcutaneous- slowly lost and gained
Determine your body shape
o Good estimate- compare waist to hip circumference
o Divide your waist measurement by your hip measurement
o Apple-man: >0.9-1
o Woman >0.8
o Pear-woman <0.8
Essential body fat and healthy level of total body fat

Essential fats are healthy fats
o Men 3-8% of their body weight; needed: 15-20%
o Women 12-14%; needed 25%-30
Regulation of body fat levels




Changes in body fatness
Genetic influenes on body siz and shape- hormones leptin and ghrelin
Leptins- produced by adipocytes/ cells in adipose tissue
o Function is to decrease appetite; inhibits hunger
Ghrelins- produced in stomach
o prohibits hunger and eating
Set point and body fatness



Set point is the neutral stage; usual or natural level
o How the body sways to maintain to the usual or natural levels
May adjust or get higher or lower to return to the set point- defending the set point
Can be physically adjusted (lifestyle, diet, activity, behavioral and emotional factors)
Food intake adjustments

Activation of drive to eat, some people may learn how to ignore the drive but they are vulnerable to
disinhibition= greater food intake
Adjustments in energy use


Adjustment of REE
Reducing food intake produces an immediate and significant depression of REE
23 | N u t r i t i o n a n d d i e t e t i c s

If reduction is not too great, the drop in REE may be sufficient to prevent weight loss; a successful defense of set
point
Restricted dietary patterns




Moderate restriction of kcal -<500 kcal; not lesser than 1200kcal
Very low calorie diets- for BMI >30 – 200 to 800 kcal
Formula diets-900kcal+vits and minerals
o Protein shakes, osteorized feeding
Pharmacotherapy- BMI >30 or patients with co-morbidities + BMI >27
o Supplements that boosts the appetite
Gaining, loosing, or maintaining: A wellness (non-diet) approach
Establishing realistic goals



Assess the tolerance of food, time
Changing behavior- due to external factors
Food preparation, availability of food, fresh produce
Normalizing eating


Enjoying eating – striving to retain the enjoyment of process
Letting hunger and satiety guide eating- eating when hungry even if it is not a traditional mealtime
Minimizing the use of food to meet emotional need



Use of food to express positive feelings, celebrate good fortune, reward hard work, and to create a sense of
companionship
Handling negative emotions such as boredome, frustrations, anger, or loneliness
Minimize emotional eating
Eating regularly and frequently

Whatever pattern works best, it should be space food throughout active hours and should not produce
overwhelming hunger or the drive to consume excessively
o 3 main meals of small portion with snacks in between
Adopting an active lifestyle

Maintaining a healthy body composition
o 30 mins of walking (maintain weight)
o More than 30 mins (weight loss)
Recommendations for adequate fluid replacement
What to do
Before exercise
Hydrating
What to eat and
drink
Drink Na
(sodium) and/
or salted
snacks- helps
stimulate thirst
24 | N u t r i t i o n a n d d i e t e t i c s
During exercise
After exercise
Weighing
before and after
to determine
the amount of
fluid
replacement (1
lb= 2 cups of
h2O)
Consuming
normal meals &
beverages
restores
average
hydration
and retain
needed fluids
With
electrolytes and
CHO (carbs)
With Na
(sodium)- helps
speed recovery
by stimulating
thirst and fluid
retention
Water intoxication- water poisoning, hyperhydration, overhydration, or water toxemia is a potentially fatal disturbance
in brain functions that results when the normal balance of electrolytes in the body is pushed outside safe limits by
excessive water intake
Recovery fluids and foods



Cheerios w/ milk
Flavoured yogurt
Pasta with meat sauce
Recommendations of macronutrient intake
CHO
Sedentary < 1 hr
exercise
5g x kg
Do not
carb
load
CHON
0.8g x kg
1.5-2g x
kg
FATS
None
None
90 mins
Sources
60-70 %
of intake
(450 g in
3000
kcal/
day
1.5-2g x
kg
As
discussed
20-25%
of intake
Lean
meats, fish,
poultry and
low-fat
dairy fried
and highfat snacks
Animal
food, vegan
athletes
should plan
more
carefully
25 | N u t r i t i o n a n d d i e t e t i c s
should be
in
moderation
Why exercise is important?




Aerobic exercises
o Fast walking
o Jogging or running
o Cycling
o Dancing
o Swimming
o hiking
Muscle-strengthening activities
o Lifting weights
o hill walking
o Climbing stairs
o Push ups
o Sit ups
o squats
Bone strengthening activities
o Jumping rope
o Hopping
o Volleyball
o Gymnastics
o Running
o gymnastics
Balance and stretching activities
o Shoulder rolls
o Ankle rolls
o Heel-toe-walking
o Biceps curls
Role of nurses

In collaboration with
o Physicians, dietitians, behavior and exercise therapists
Nutrition across the lifespan


Progesterone- develops endometrium and relaxes
Estrogen- downside: slowing GI; slow absorption of calcium in the body and Fe causing constipation and
increased renal sodium
Metabolic changes


BMR increase 15-20% during pregnancy
Fat is the primary source of a mother’s fuel permitting glucose to be available to the fetus
26 | N u t r i t i o n a n d d i e t e t i c s

Increased macronutrient and micronutrient intake by the mother during pregnancy ensures the these higher
metabolic needs are met
Anatomic and physiologic changes




Plasma volume doubles during pregnancy, beginning in the second trimester
o Failure to achieve plasma expansion may result to spontaneous abortion, stillbirth, or a low-birth-weight
infant
o Hemodilution effect- result of the increased plasma volume; measure components in the plasma such
as hemoglobin, serum proteins and vitamins will appear to be at lower levels during pregnancy because
there is greater solvent (plasma) in relation to the solutes (components)
o Cardiac hypertrophy occurs to accommodate increased blood volume, accompanied by an increased
ventilatory rate
Glomerular filtration rates
o Increases to accommodate the expanded maternal blood volume being filtered and to carry away fetal
products
Amino acids, water, and soluble vitamins
Fetus use glucose as primary source; mother uses fats
Failure to gain weight may lead to:


Small for gestational age- short in terms of
Low birth weight- 2.5 g to 3 g
Recommendations













Increased macro and micro nutrients
Obese, minorities and low-oncome women, pcx who had gastric bypass (1-year post op)
Increase all except vitiamins D, E, and K, phosphorus, fluoride, vitamin C, and biotin
Increase extra 340 kcal/day- 2nd trimester; 452 kcal during 3rd trimester
Do not eat for 2 people- instead extra sandwich, fruits, glass of milk
Table 10.1- customizing of diet
o MyPlate an accessible source of information for pregnant and breastfeeding women
Do not take supplements
Consume small amounts of high-quality protein as tolerated; small-frequent feeding of protein
o Due to constipation
Vitamins and minerals
Vitamin A- 750-770 mcg; UL-2800-3000 mcg
Folate- 600 mg/day and iron intake- 27 mg/day= ferrous daily 2nd tri prevent iron deficiency anemia
Calcium-1000 mg/day- adult 1300 mg/day- adolescent: MOST IMPORTANT
Pica
o Hunger and appetite for nonfood substances
o Ice, cornstarch, clay, and dirt
Nutrition related concerns
Alcohol


NO ALCOHOL during pregnancy
Factor: alcohol; fetal alcohol syndrome; no intake- effects: low nasal bridge, short nose, flat midface, and short
palpebral fissures
27 | N u t r i t i o n a n d d i e t e t i c s
Food borne illness


During pregnancy, women and their unborn children are more likely to become very ill form food poisoning.
Newborns are also at risk due to undeveloped immune system
Foods to avoid

Raw or undercooked foods, contain undercooked eggs, deli salads, unpasteurized milk, fruits, and vegetable
juices, refrigerated pate or meat spreads
Diabetes mellitus


Pregnancy significantly affects insulin requirements
Complications: macrosomia, hypoglycemia, erythremia, hyperbilirubinemia
Maternal phenylketonuria



Inborn error of metabolism
Extremely low levels of phenylalanine hydroxylase- catalyzes conversion of phenylalanine to tyrosine
Failure to detect the disease or lack or compliance with dietary therapy causes irreversible mental retardation
HIV (Human immunodeficiency virus)

Additional strain to already fragile immune system
o Estrogen, progesterone, HCG, alpha fetoprotein, corticosteroids, prolactin, and a-globulin has
immunosuppressive effects
Common nutrition-related discomforts of pregnancy



Nausea and vomiting
o Morning sickness
o 1st trimester
o Cause by hormonal factors such as rise in estrogen or placental hormone HCG
o Stress and fatigue may exacerbate the condition
o Hyperemesis gravidarum- severe and unrelenting vomiting
Heart burn
o Rapid growth of fetus; pushes to the stomach; action or progesterone= relaxation of smooth muscles=
acts on the gastroesophageal sphincter= reflux of gastric contents of the stomach to the lower
esophagus= heart burn
Constipation
o Common on the 1st and 3rd trimester
o Action of progesterone= slows GI motility may be responsible
o 3rd trimester- fetus crowds other internal organs
Nutrition during lactation







Breast feed up to 6 months
Ideally for 12 months with addition of weaning foods
Complementary foods may occur at 4-8 months of age
Protein- 71 g/day
500-800 kcal/day- energy expenditure on milk production
Avoid consumption of gas-producing vegetables such as cabbage, onions, and broccoli- infants become fussy
Coffee (caffeine) and cola should be avoided- acts as diuretics
28 | N u t r i t i o n a n d d i e t e t i c s

o Caffeine passes to the breast milk in small amounts
Adequate fluid intake is important
Nutrition during infancy
Nutrition and Diet therapy (Finals)
Food-related Issues
Dietary guidelines



Five key messages (office of disease prevention and health promotion)
o Follow a healthy eating pattern across the lifespan
o Focus on variety, nutrient density, and amount
o Limit calories from added sugars and saturated fats, and reduce sodium intake.
o Shift to healthier food and beverage choices
 Consider cultural and personal preferences
o Support a healthy eating pattern for all
Healthy eating patterns limits saturated fats and trans fat, added sugar, and sodium
One of the most important tools is the nutrition label
Dietary modifications



Required to allow the body to heal, adjust to physical disability, or prepare for a diagnostic tests or
surgical procedures
Therapy may require texture changes (liquefy or pureed foods)
If a patient cannot or will not eat for a week or longer enteral (tube) feeding or parenteral (intravenous)
nourishment may be needed
Diet orders



Specific disease or conditions require modification of the normal diet
o Normal diet: regular, general, and house
Regular diet- designed to attain optimal nutritional status in people who do not require dietary
alterations
o Adjusted according to gender, age, height, weight, and activity level
Quantitative and qualitative diets
o Qualitative diets- modification in the consistency, texture, or nutrients
o Quantitative diets- modification in number or size of meals served, or amounts of specific
nutrients
Teaching tools
Problem
Illiterate or too ill to
read or write, has
reduced visual abilities
or a low literacy level
Does not understand
the items used on
menu
Often must select foods
from menu a day in
advance, often
resulting too much or
too little food
Solution
Read menu items to
the patient and marks
his/ her selections
Clarify for patient or ask
for clarifications from
dietitian
Remind patients that
they are selecting
foods for the next day.
If they have not
selected enough food
offer them foods kept
29 | N u t r i t i o n a n d d i e t e t i c s
Poor appetite
Does not understand
why some of his/her
favorite foods are not
included on the menu,
why smaller amounts
are served, or why
textures are modified
in the nursing unit. If
they ordered to much
discard if not
consumed within 24
hours
Small frequent meals
and snacks every 2-3
hours. Choose energy
dense foods like meat,
dried fruits, buts, and
starches. Schedule
between-meal
supplement drinks
Discuss dietary
concerns of the
patient’s illness,
explaining why specific
foods are not included
or only limited amounts
are allowed.
Meals in long-term cared

Repetition and monotony will influence a patient’s acceptance of foods and meals served
Basic hospital diets
Types of diets
Contraindications
Diet
Indications
Liquid diet
Oral fluids before/after
surgery, prepare bowel
for diagnostic
colonoscopy
examination, barium
enema, acute GI
disturbances
After surgery, transition
between clear and solid
food, oral or plastic
surgery to the face and
neck, mandibular
fractures, chewing or
swallowing difficulties
Neurologic changes,
inflammation/ulcerations
of the oral cavity,
edentulous patients,
fractured jaw, head,
and neck abnormalities,
CVA
Poor fitting dentures,
limited swallowing,
chewing abilities,
stricture of the intestinal
tract, radiation
treatment of the oral
Full liquid
Pureed diet
Mechanical
soft diet
(x) >24 hours,
inadequate GI
function, nutrient
needs requiring
parenteral
nutrition
Dysphagia, wired
jaw
Situations which
ground or
chopped foods
are appropriate
Situations which
regular foods are
appropriate
Sample
foods
Broths,
bouillon,
apple juice,
grape juice,
gelatin
without fruit
Milk,
icecream,
cooked
eggs,
eggnog, oral
supplements,
or milkshakes
Any food
that can be
blended
and served
without
particles
Foods that
can be
easily cut
with a fork,
chopped, or
blended
30 | N u t r i t i o n a n d d i e t e t i c s
cavity, progression from
enteral or parenteral
nutrition to solid foods
Soft diet


Debilitated patients
unable to consume a
regular diet, mild GI
problems
Situations where
regular diet is
appropriate
(x) hard,
stringy,
tough
foods=
choking
All foods
served on
general diet
except for
highly fibrous
fruits and
vegetables
Diet as tolerated (DAT)- ordered post-operatively
Vegetarian diet- normal diet by does not include meat, poultry, fish or seafood
o Ovo-lacto- consumes some animal products such as egg and dairy
o Lacto-vegetarians- consumes dairy products only
Other food considerations


Food allergy- release of histamine and serotonin
o Most common symptoms: diarrhea, nausea, vomiting, cramping, abdominal distention, and
pain
o Major triggers: eggs, milk, wheat, soy, fish, shellfish, peanuts, and tree nuts
Food intolerance- non-allergic reaction; caused by toxins, drugs, or conditions such as lactose and
gluten intolerances
o Dose responsive
o Lactose intolerant patients can use lactaid (treated milk), cheeses, and yogurt
Food safety and sanitation








Food borne illness can occur in any setting
Personal hygiene and handwashing are the most important factors for prevention
Food temperature
o Maintained at <40°F or >140°F
Hot foods should be served as soon as possible
Protein-rich food should be discarded is left at room temperature longer than 2 hours
Items that are not consumed should be labeled, dated, refrigerated, then use within 24 hours
Prevent cross-contamination should not mix drugs, staff foods, and patient foods
Foodborne outbreak- two or more individuals have the same symptoms over the same period
Complementary-alternative medicine: herbs and botanicals



Biologically-based therapies- materials found in nature, include functional foods, botanicals, and herbs
Functional foods- physiologically active (bioactive) substances, marketed as dietary supplements
Dietary supplements- considered as foods not drugs
o Consumed orally as tablets, liquids, capsules, extracts, powders, gel caps,
Non-oral feeding

When patient cannot eat for more than few days, non-oral method must be used
Teaching tool
Was hands for at least 20 seconds
Flush feeing with 1-5 ml of water before and after
feeding to prevent feeding tube from clogging
31 | N u t r i t i o n a n d d i e t e t i c s
Never add new formula to formula already in the
feeding container
Change entire feeding setup every 24 hours
Place formulas: breast milk (4 hours), formula (8
hours) in containers
Make sure infant has pleasant sensations during
feeding; hold your child, allow him to suck a
pacifier
Head of the bed 30-45 degrees if child cannot be
held
 When GI tract is functional, accessible, and safe to use, enteral feedings are preferred over parenteral
feeding
o Physiologically beneficial in maintaining integrity and function of gut
 Severe dysphagia, major burns, short bowel syndrome after resection, and intestinal fistulas- warrant
tube feedings
Types of formulas



Standard formula- polymeric; composed of intact nutrients that require a functioning GI tract for
digestion and absorption of nutrients
Hypercaloric formula- (1.5-2 kcal/ml) designed to meet kcal protein demands in a reduced volume and
have moderate to high osmolality
Elemental formula- (1-1.3 kcal/ml) partially or fully hydrolyzed nutrients that can be used for the patient
with partially functioning GI tract, impaired capacity to digest foods or absorb nutrients, pancreatic
insufficiency, or bile salt deficiency
Formula selection


Based whether patient can digest and absorb nutrients
Individual nutrient requirements determine the type and amount of tube-feeding formulas
Feeding routes







Nasogastric- nose to the stomach
Nasoduodenal- nose to the duodenum
Nasojejunal- nose to the jejunum
Esophagostomy- neck and extends to the stomach
Gastrostomy- surgically inserted into the stomach
Jejunostomy- surgically inserted into the small intestine
Percutaneous endoscopic gastrostomy (PEG)
Parenteral nutrition


Involves the provision of energy and nutrients intravenously
Components: carbohydrates (dextrose monohydrate), amino acids (mixture of nonessential and
essential crystalline amino acids), fats (lipid emulsions), total nutrient admixture (lipid emulsions added to
dextrose and amino acid mixtures), electrolytes, trace elements (zinc, copper, manganese, chromium,
and selenium), vitamins, and bioactive substances (prebiotics and probiotics)
32 | N u t r i t i o n a n d d i e t e t i c s
Intake
CHON
Fats
CHO
Insulin- storing of glucose for energy
Glucagon
Glucose
Insulin
Glycogenolysis
Glycolysis
Gluconeogenesis
Glycogenesis
Ketogenesis
Lipogenesis



 Glycolysis- glucose= ATP
 Glycogenesis- storage of glucose- creation of
glycogens
o Store glucose in liver and muscles
o Used for short term only
 Lipogenesis- glucose stored in adipose tissues
o For long term use
Glucagon- stimulate glucose production
Glycogenolysis- related to glysogenesis, opens storage to release glucose
Gluconeogenesis- turns amino acids and other molecules into glucose
Ketogenesis- fats are broken down into ketones
o Sugar produced in this process are used by the brain and heart only
Nutrition for Diabetes Mellitus



Diabetes mellitus- relative or complete lack of insulin secretions by the beta cells of the pancreas or by
defects of cell insulin receptors
Diagnosed by elevated fasting blood glucose values (>126 mg/dl on at least two occasions)
Vitamins D homeostasis
o Maintains normal release of insulin from the beta cells
o Maintains epigenome, lowers inflammation= insulin resistance
o Protects betal cells against destruction
2 major classes of diabetes



T1DM- autoimmune disorder
T2DM- lifestyle diabetes
Fast 8-10 hour
Prediabetes and insulin resistance


Blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes
o 70-110 normal glucose levels
o >110 mg/dl
Insulin resistance
o Muscles, fat, and liver cells do not respond properly to insulin and cannot easily absorb glucose
from bloodstream
o Excess body fats increases risk
Effects of diabetes on systems



Macrovascular effects- increase risk of coronary artery disease, peripheral vascular disease, and stroke
Microvascular effects- include nephropathy, retinopathy, and neuropathy
o Nephropathy- Chronic kidney disease (CKD)
o Retinopathy- leading cause of blindness
o Neuropathy- decreased sensation in the extremities
Impaired healing- effect of diabetes to the circulatory system= gangrene may develop
33 | N u t r i t i o n a n d d i e t e t i c s

Autonomic effects- orthostatic hypotension, persistent tachycardia, gastroparesis, neurogenic bladder
(urinary bladder dysfunction due to neurologic damage), impotence, and impairment of visceral pain
sensation
o Impairment of visceral sensation may obscure symptoms of angina pectoris or myocardial
infarction
Classifications of diabetes

T1DM, T2DM, latent autoimmune diabetes of adults (LADA), gestational diabetes mellitus (GDM), and
impaired glucose tolerance (IGT)
Criteria for diagnosing diabetes and prediabetes
𝐴1𝑐
Diabetes
Prediabetes
Normal
6.5 or
above
5.7-6.4
About 5
Fasting
plasma
glucose
(mg/dl)
> 126
Oral
glucose
tolerance
test
>200
100-125
<99
140-199
<139
Type 1 DM





This type of diabetes is not curable
Autoimmune disease resulting in beta cell destruction
Autoantibodies to beta cell protein forms after autoimmune destruction of the beta cells
Rate of beta cell destruction are rapid for infants and children and slow in adults
T1DM usual in >20 years old
3Ps of T1DM

Polyphagia, polyuria, and polydipsia
34 | N u t r i t i o n a n d d i e t e t i c s
Body will send signals to
eat because cells are
hungry; consume large
amounts of food
(polyphagia)
Glucose cannot enter
cells; builds up in
bloodstream
Blood becomes
hypertonic
Body will try to get rid of
excess glucose
Increasing urine output
(polyuria)
Increased urine output
will increase thirst
(polydipsia) to replace
fluids
Treatment of T1DM




Insulin- requires exogenous insulin to maintain normal blood glucose levels and to survive
Insulin with nutrition therapy and exercise= mimic physiologic insulin delivery
Types of insulin
o Classified into three groups
o Conventional or standard insulin therapy- constant dose of intermediate acting insulin combined
with short or rapid acting insulin or mixed dose of insulin
o Flexible or intensive insulin therapy- multiples daily injections (MDI); short or rapid-acting insulin
before meals; intermediate-acting insulins once or twice daily
o Continuous or subcutaneous insulin infusion- intensive therapy; rapid or short-acting is pumped
continuously in micro-amounts through an insulin catheter; boluses of rapid or short-acting
insulins are given before meals
Exercise- lowers blood glucose levels, assists in maintaining normal lipid levels, and increases circulation
General guidelines for regulating glycemic response to exercise





Do not exercise when fasting glucose levels are > or equal to 250 mg/dl
Avoid exercise if ketosis is present (presence of ketones in urine)
T1DM; should not exercise when insulin is at its peak
Exercise when blood glucose levels are between 100-200 mg/dl or about 30-60 minutes after meals
Food intake: 15 g of CHO only
o Consume CHO to avoid hypoglycemia
Type 2 DM



Can be controlled
Primary metabolic problem is insulin resistance or defect in insulin secretion
Gradual onset of polyuria and polydipsia, easily fatigue, and have frequent infections
Treatment and management of T2DM

Oral glucose lowering medications- when diet and exercise alone cannot control hyperglycemia
35 | N u t r i t i o n a n d d i e t e t i c s


o Metformin- first line of therapy
Vitamin D supplementation= improve glycemic control and 𝐻𝐵𝐴1𝑐 levels
Metabolic goals in diabetes management
Goal
Glycemic control
<0.7%
 Hemoglobin 𝐴1𝑐
 Preprandial capillary
90-130
plasma glucose
(mg/dl)
 Peak postprandial
<180
capillary plasma
Cardiovascular
 Blood pressure
<139/80
(mmHg)
 Triglycerides
<150
 Low density
<100
lipoprotein cholesterol
(mg/dl)
 High density
lipoprotein cholesterol
 Males
>40
 Females
>50
Glycemic control can be monitored by measurement of glycosylated hemoglobin or hemoglobin 𝐴1𝑐
along with self-monitoring of blood glucose (SMBG)
 T1 DM
 Three times or
 Pregnant
more every day
women that are
taking insulin
 T2 DM
 BID, AC: 70-130
mg/dl
 Postprandial
(2hrs): <180
mg/dl
 Bedtime: 90-150
mg/dl
Hypoglycemia

Low blood sugar (<70 mg/dl)
o Signs and symptoms: cool, clammy, pale skin
o Confusion
o Erratic behavior
o Hunger
o Trembling and shaking
Diabetic ketoacidosis





Body cannot produce enough insulin
o Glucose cannot enter into the cells= breaks down fat for fuel= high levels of blood acids
(ketones)= ketoacidosis
Severe DKA is defined by a pH <7.15
Hyperglycemia causes osmotic diuresis, dehydration, and lactic acidosis
Lowered pH stimulates respiratory center= deep, rapid respirations (Kussmaul’s respiration)
> ketones in the body= fruity, acetone odor to breath= mistaken for inebriated (intoxicated)
36 | N u t r i t i o n a n d d i e t e t i c s
Is an initial presentation of T1DM
Best handled in the ICU for correction of fluid loss with IV fluids, hyperglycemia with insulin, and
electrolyte disturbances, and acid-base balance with appropriate solutions
Drinking low-calorie fluids is recommended to maintain hydration



Hyperglycemic Hyperosmolar Nonketotic Syndrome
Actual insulin deficiency resulting in severe hyperglycemia
Triggered by trauma or infection
o Increases body’s demand for insulin
If hyperglycemia is left untreated, serum becomes hyperosmolar
o Osmotic diuresis= significant loss of electrolytes via urine



Food and nutrition therapies
Diabetes self-management education (DSME)
o Involve a comprehensive nutritional assessment, a self-care treatment plan, client’s health
status, learning ability, readiness to change, and current lifestyle
Recommendations for total fat, saturated fat, cholesterol, fiber, vitamins, and mineral intakes are same
for individuals with diabetes as those for the general population
Carbohydrate recommendations are based on individual’s eating habits, blood glucose, and lipid
goals
Protein intake can range from 15%-20% of daily kcal from animal and vegetable protein sources
If blood glucose levels are not affected by moderate alcohol intake, it is ought to be regarded as
additional energy
o Consumed with food to reduce risk of hypoglycemia
No food should be omitted






Goals of nutrition therapy
Glucose levels in normal range or close to the normal range
Lipid or lipoprotein profile reduce risk for macrovascular diseases
Blood pressure levels reduce risk for vascular diseases














Strategies for metabolic control
Adequate meal plan; reduced total fat
especially saturated fats
Meals spaced throughout the day
Mild to moderate weight loss (5-10 kg)
Regular exercise
Monitoring of blood glucose levels, 𝐴1𝑐 ,
lipids, and blood pressure
Oral hypoglycemic insulin if preceding
does not work
Modify nutrient intake and lifestyle
Enhance health using healthy food choices and physical activities
Address individual nutritional needs
Take prescribed medications
Injection sites
Other guidelines



Non-nutritive sweeteners- saccharin, aspartame, and acesulfame K
o Safe for DM patients
Sucrose- occasional
Plate methods- is an app that is used for diabetes meal management
37 | N u t r i t i o n a n d d i e t e t i c s
Role of nurses



Help patient become aware and assess knowledge of, understanding of, and adherence to prescribed
diet
Observing meals and food choices
Monitoring glucose levels
Special considerations





Illness- infection, injury, or stress
o > blood glucose values= diabetes control worsens; caused by increased hepatic production of
glucose (RAAS)
o Hyperglycemia increases insulin requirements
o Increase need for insulin but decreased appetite and food intake are common
Gastroparesis- delayed gastrointestinal emptying
o Manifest as heartburn, nausea, abdominal pain, vomiting early satiety, and weight loss
o Occurs in vagal autonomic neuropathy and occurs more often in T1DM
o Treatment: gastric electric stimulation (GES)
o Carefully monitor intake
o Replace carbohydrates with foods that are soft or liquid consistency
o Six small meals are better tolerated then 3 large meals
o Low-fat diet= prevent delay in gastric emptying
o Metoclopramide (reglan)= increase gastric contractions and relax the pyloric sphincter
o Patients may experience dry mouth and nausea
 Increase fluids and moisten food with broth
o Match insulin with meals to regulate delayed absorption and glucose changes
o If constipation or diarrhea occurs alter fiber according to the needs of the patient
 Indigestible solid mass (bezoar)- after eating oranges, coconuts, green beans, apples,
figs, potato skin, Brussels sprouts, or sauerkraut
Eating disorders
o Insulin initiated= weight gain
o Diabulimia- disordered eating from body image problems
Metabolic disorders= DM2= disproportionate fat= excessive cytokinesis
Management: food intake
Metabolic syndrome
Cluster of metabolic abnormalities along with
chronic low-grade inflammation and oxidative
stress
Criteria for metabolic syndrome (MetS) consist of
the presence of any three of the following:
 Enlarges waist circumference
 Low serum HDL (high-density lipoprotein):
<40 mg/dl- men and <50 mg/dl- women
 Blood pressure: >130/85 mmHg
 Fasting glucose value: >100 mg/dl
 T2D, coronary artery disease, and stroke
quickly develops with MetS
Diabetes management throughout the lifespan
Pregnancy

Some hormones produced by the placenta during pregnancy are antagonistic to insulin
o Reduced effectivity
38 | N u t r i t i o n a n d d i e t e t i c s









Insulin does not cross the maternal placenta but glucose does
o > glucose= fetal pancreas increases insulin production= macrosomia= large for gestational age
o LGA= experience respiratory difficulties, hypocalcemia, hypoglycemia, hypokalemia, or
jaundice
Adequate calorie intake and nutrients must meet needs of pregnancy
Minimal SMBG 4x/day
o For pregnancy, 8x/day
Blood glucose goals during pregnancy:
o Fasting: <95mg/dl
o 1 hour postprandial- <140 mg/dl
o 2 hours postprandial- <120 mg/dl
Desired weight goals are based on prepregnancy BMI and should be steady and progressive
No calorie adjustments on the 1st trimester, but in the 2nd and 3rd trimester increased energy intake of
approximately 100-300 kcal/day
High quality protein increased by 10 g/day
o Supplied easily by consuming 1 or 2 extra glasses of nonfat or skim milk. Or 2 ounces of meat or
meat substitute
400 mcg of folic acid is recommended
o Prevent neural tube defects
Minimum of 1,700-1,800 kcal/day from carefully selected foods
o Intake less than this is not advised
Preexisting diabetes and prepregnancy







Women with preexisting diabetes who become pregnant are vulnerable to complications
Optimal period of care is before conception
Glycosylated hemoglobin levels should be normal or close to the normal range before conception
Requirements increases during the 2nd-3rd trimester because of higher blood glucose levels
o Due to increased production of pregnancy hormones that are insulin antagonists
Goals of preconception care programs:
o Before meals: capillary whole-blood glucose 70-100 mg/dl or capillary plasma glucose 80-110
mg/dl
o 2 hours postprandial- capillary whole-blood glucose <140 mg/dl or capillary plasma glucose
<155 mg/dl
Three meals and three snacks are usually recommended
Use of frequent blood glucose monitoring is necessary
Gestational diabetes



Good glucose is accomplished by individualization of intake and graphing weight gain
Insulin is prescribed with MNT to reduce risks of fetal macrosomia, neonatal hyperglycemia, and
perinatal mortality
Treatment option: oral antidiabetic
Type 2 diabetes in the young




Caused by childhood obesity
BMIs >40 (morbidly obese) and >45
Those who are diagnosed are mostly 10 and 19 year-olds, have a strong family history of T2DM, and
have insulin resistance
Clinical signs:
o Acanthosis nigricans- hyperpigmentation and thickening of the skin into velvety irregular folds in
the neck and flexural areas- reflects chronic hyperinsulinemia
o Polycystic ovary syndrome (PCOS)- associated with insulin resistance and obesity
o Hypertension
39 | N u t r i t i o n a n d d i e t e t i c s




Girls are more susceptible than boys to T2DM
Due to poor glycemic control
Nutritional therapy and exercise are first line treatments but most children diagnosed with T2DM will also
require drug therapy—oral agents
Children with T2DM should receive comprehensive management education, including SMBG
Type 2 diabetes in the elderly



At risk for macrovascular and microvascular complications
Higher risk for cardiovascular diseases
Key factors to consider:
o Elderly patients who are capable of activities of daily living without assistance and those who
have no cognitive impairment should have 𝐴1𝑐 and blood sugar goals that are similar to younger
people
o Avoiding low sugar is of paramount importance, and blood sugar goals and 𝐴1𝑐 should be
adjusted along with careful pharmaceutical management
o 𝐴1𝑐 and blood sugar goals may be relaxed
o Treat cardiovascular factors- hypertension
o Depression screening is important
Miscellaneous issues: fasting, bariatric surgery, ketogenic diets





Fasting can be a problem for muslims especially during the long month of Ramadan
o Possible hypoglycemia, hyperglycemia, or diabetic ketoacidosis, and dehydration
Pregnant women, children, and elderly who have diabetes should not be expected to fast
Morbidly obese individuals who have prediabetes or T2DM may elect to have bariatric surgery
Adolescents, in severe progressive form of diabetes with complications; in these patients bariatric
surgery is controversial
Ketogenic diets which are very low in carbohydrates and high in fats and proteins are not totally safe
and may be associated with nonalcoholic fatty liver disease or insulin resistance
o Not currently promoted for diabetes management
Nutrition for Disorders of the Liver, Gallbladder, ad Pancreas:
Liver disorders
Hepatitis – Inflammation of the liver. Separated into 5 categories:





Hep. A virus – transmitted through the fecal-oral route, but occasionally can be spread by transfusion of
infected blood. Onset of HAV is rapid, 4-6 weeks. Treatment for HAV is usually supportive, no antiviral
therapy. Is asymptomatic.
Hep. B virus – exceptionally resistant virus of surviving extreme temperatures and humidity. HBV is
transmitted via blood, semen, vaginal mucus, saliva, and tears, IV drug users, patients with hemophilia,
etc. HBV vaccination is recommended. Incubation for HBV is 12 weeks. Is asymptomatic, no cure.
Hep. C virus – can be transmitted through contaminated saliva and semen, but is predominantly
associated with blood exposure. Can develop into chronic liver disease and is a risk factor for liver
cancer. Are asymptomatic and infrequently detected.
Hep. D virus – can only occur when an individual with HBV is subsequently exposed to HDV. Incubation
period is 21 to 45 days but may be shorter in cases of superinfection.
Hep. E virus – an enterically transmitted, self-limiting infection. Incubation 15-60 days. Once infection
occurs, therapy is limited to support.
Food and nutrition therapies for hepatitis:



Periods of nausea and vomiting in patients with hep. Needs hydration via IV fluids.
Afterwards oral feedings should be initiated asap
Diets should be frequent and high in energy and high-quality protein to minimize loss of muscle mass.
40 | N u t r i t i o n a n d d i e t e t i c s





Protein should be 1.0-1.2 g/kg of body weight
Dietary fats should not be limited unless they are not well tolerated.
Fluid intake should be adequate to accommodate the high protein intake unless otherwise
contraindicated.
Supplementation includes vitamin b complex (especially B12- cobalamin, due to decreased absorption
and hepatic uptake), vitamin K (to normalize bleeding tendency), vitamin C, zinc for poor appetite
Abstinence from alcohol is imperative.
Treatment goals





Decrease viral replication or eradicate the infection
Delay fibrosis and progression cirrhosis
Decrease incidence of liver cancer
Ameliorate fatigue and joint pain
Prevent hepatic decompensation and the need for liver transplantation
Coping with hepatitis
An adequate diet that excludes
alcohol is recommended
For many individuals, loss of appetite
weight loss, and fatigue are common
problems. Recommend rest periods
before and after meals
Offer guidance tips for increasing
proteins and calories without adding
more total volume. Sauces, gravies,
desserts, milkshakes, and similar
enhancements will help



Fatty Liver and Nonalcoholic Fatty Liver Disease (NAFLD):

An early form of liver disease can be caused by alcoholism, obesity, complications of drug therapy
(corticosteroids and tetracyclines), excessive parenteral nutrition, pregnancy, DM, inadequate intake of
protein, infection, or malignancy
Food and Nutrition Therapies:









Thorough diet history is essential, and a nutrition plan should be developed according to the etiology of
the condition.
If the problem is related to DM, glucose management requires carbohydrate counting.
If it occurs after parenteral nutrition, the amount of administration should be altered.
In general, high-fat and high-fructose intakes are problematic.
Lifestyle interventions are the first line of treatment: vitamins, amino acids, prebiotics, probiotics,
polyunsaturated fatty acids, and polyphenols are often used and show great promise.
Weight loss may be needed, but meals should not be skipped
Choline, fiber, coffee, green tea, and light alcohol drinking might be protective.
o Antioxidants= digestion
Morbidly obese (BMI >40) bariatric surgery may be required
Adequate racking of glucose and lipid levels will be needed
Coping with fatty liver or nonalcoholic
steatohepatitis (NASH))
 A balanced diet is important.
Eliminate alcohol and limit total fat
intake and fructose
41 | N u t r i t i o n a n d d i e t e t i c s
Assistance of a registered dietitian will
be needed to guide this nutrition care
plan successfully
 Probiotics/prebiotics may be
beneficial. They affect gut flora;
certain forms may alleviate liver injury
Probiotics- live bacteria in foods e.g. lactobacillus

Prebiotics- serves as fertilizer for the healthy gut flora; special dietary fibers
Cirrhosis:







Intestinal bacterial overgrowth and increased bacterial translocation of gut flor
Liver cells replaced by fibrous connective tissue and fat infiltration
Liver cell scarring may cause congestion of the hepatic circulation which results in further decline of liver
function and portal hypertension.
Esophageal varices can occur as a result of collateral circulation that develops around the esophagus
when normal blood flow through the liver is blocked
Ascites is the accumulation of fluid in the peritoneal cavity
o Blood is shunted from portal circulation to systemic circulation, causes blood to bypass the liver,
leading to hepatic coma
Hepatic encephalopathy- changes in the level of consciousness, concentration, and memory due to
ammonia
o Cerebral intoxication- intestinal contents have not been metabolized by the liver
o Thus, ammonia is not excreted
Neomycin- used to reduce the number of bacteria in the GI tract
Food and Nutrition therapies:







Individual nutritional needs must be addressed and are different per patient.
0.8 g protein per kg body weight per day is essential.
To promote positive nitrogen balance and avert breakdown of endogenous protein stores.
1.2 g protein/kg dry or appropriate body weight is recommended.
Protein restriction should be avoided, because it can worsen malnutrition
Patients with esophageal varices should eat soft, low-fiber foods.
For ascites, a dietary sodium restriction (2000 mg) is used, usually with fluid restriction.
Liver Transplantation:

For end-stage liver disease
Food and Nutrition therapies:





Primary objective- provide enough calories and protein to decrease protein catabolism and correct
any nutritional deficiencies.
Immediately post-transplantation (4-8 weeks after surgery) – require individualization of nutritional
therapy according to patient’s needs.
Adequate calories and protein are necessary for the stresses that result from surgery and high doses of
glucocorticoids.
Early enteral nutrition with new immunomodulating diets enriched with hydrolyzed whey protein can
prevent post-transplant bacteremia and post-transplant hyperglycemia
Between meal feedings and supplements should be used in order to meet calorie and protein goals
Gallbladder Disorders:
42 | N u t r i t i o n a n d d i e t e t i c s
Gallstones & Cholecystitis:


Mild, aching pain in the midepigastrium
Nausea, vomiting, tachycardia, and diaphoresis
Food and Nutrition therapies:




During acute attacks, nothing per Orem and is to receive IV fluids.
Intake of omega-3 polyunsaturated fatty acids influences bile composition, decreasing biliary
cholesterol saturation.
Avoiding fat is often advised, but no strong evidence supports this recommendation.
Increase intake of fatty fish such as salmon, herring, mackerel and tuna.
Pancreatic Disorders:

Pancreatitis- inflammatory process characterized by decrease production of digestive enzymes and
bicarbonate with malabsorption of fats and proteins
o Sodium bicarbonate (NaHCO3)- regulated the blood pH
o Has alkalotic effects
Food and nutrition therapies:




Feeding into the lower small bowel, in the jejunum distal to the ligament of Treitz, bypasses the areas
associated with pancreatic stimulation.
Pancreatic stimulation should be decreased.
Low-fat, elemental formulas are recommended.
Patients with enteral feedings should be closely monitored for increases in pancreatic enzyme levels.




Coping with pacreatitis
Consume small meals in six
feedings may facilitate adequate
nutritional intake
Pancreatic enzymes taken orally
with meals to control maldigestion
and malabsorption
Complete abstinence from
alcohol is essential
Eat high-protein, nutrient-dense
that includes fruits, vegetables,
whole grain, low-fat dairy, and
other lean protein sources
Nutrition for disorders of the gastrointestinal tract






Anti-inflammatory Diets that has protective qualities
o Traditional Mediterranean diet
o DASH diet (Dietary Approaches to Stop Hypertension)
Both diets encourage the use of antioxidant foods rich in carotenes, vitamin C and E, and selenium.
Examples of foods rich in those mentioned above: Avocados, blueberries, cherries, green team coffee,
dark chocolate and cocoa powder, whole grains, strawberries, raspberries, etc.
Foods rich in zinc, copper, iron and manganese – protect against free radical damage from pollution,
radiation, burned food, or excessive sunlight.
Omega-3 fatty acids & eicosapentoic acid – anti-inflammatory; found in salmon, tuna, mackerel and
sardines.
Extra-virgin olive oil – reduces inflammation; is a fundamental food in the world’s healthiest diet
(Mediterranean diet).
43 | N u t r i t i o n a n d d i e t e t i c s





Mediterranean diet – promotes EVOO, fruits, vegetables, whole grains, legumes, herbs, and spices. Also
recommends lean proteins from fish and poultry and red wine in moderate amounts.
Resveratrol – a phytochemical that promotes longevity and is seen in red wine and red grape skins.
Supraglottic swallow – appropriate for patients with reduced laryngeal function. Deep breath before
swallowing and coughing or exhaling after.
Mendelsoh maneuver – helpful for individuals with cricopharyngeal dysfunction. Elevate larynx
voluntarily to maximum level during swallowing to allow food to pass.
Safest eating position for client with dysphagia
o upright position
Heartburn and gastroesophageal reflux disorder nutrition:



Patients with GERD should avoid large or high-fat meals.
Patients should avoid overeating.
Foods that can irritate the esophagus and cause heartburn include: chocolate, peppermint, alcohol,
spearmint, liqueurs, caffeine, etc.
Esophagitis and Hiatal hernia


Damage of esophageal mucosa due to reflux of the acidic gastric contents results to esophagitis
Hiatal hernia- condition in which a part of the stomach bulges upward through the diaphragm.
o Patients with this disorder may experience pneumonitis, chronic bronchitis, and asthma
Food therapies & nutrition:
o
Avoid high fat meals or foods
Stomach Disorders

Vomiting- reverse peristalsis, one way of the body protects itself from intruding viruses or toxins
o Dehydration - a concern when vomiting is continual; which causes a lot of fluid and electrolyte loss.
o Small cold meals are better tolerated when clients are experiencing nausea or vomiting.
o Examples of food to give clients with nausea and vomiting: crackers and cheese, gelatin, fruit, or
lemonade.
o Foods to avoid: Hot, fried spicy, strong-smelling foods.
o Offer small frequent meals at frequent intervals is a good place to start.
o Breathing exercises and repositioning may be helpful.
o Good oral health is important, and patients may be prescribed antiemetics, 30 to 60 mins. Before
meals
Recommendations for managing nausea and
vomiting
 Chew foods slowly and thoroughly
 Use ice chips
 Sip on cool, carbonated (allow to
become flat) beverages such as 7 up or
ginger ale
 Avoid the caffeine of colas unless
tolerated
 Limit or omit acidic fruit juices
 Rest before and after meals, but keep the
head elevated to avoid reflux
44 | N u t r i t i o n a n d d i e t e t i c s
Peptic Ulcer Disease:





Is the term used to describe a break or ulceration in the protective mucosal lining of the lower
esophagus, stomach, or duodenum
Heliobacter pylori & use of NSAIDs are a major cause of duodenal ulcers.
Any dietary modifications must be individualized to include avoidance of foods that a patient can
associate with symptoms.
Some individuals avoid: red and black pepper, chili pepper, coffee, other caffeinated beverages, and
alcohol.
Foods and spices that are irritants, cause superficial mucosal damage, or worsen existing disease should
be omitted.
Dumping syndrome:



Gastrectomy, can cause the impairment of the normal stomach reservoir which causes a large volume
of particles to be dumped rapidly into the small intestine.
Liquids should be consumed between meals rather than with meals.
Simple carbohydrates are limited because they may worsen the syndrome.
Intestinal Disorders:

Intestinal Gas (Flatus):
o Intestinal gas can be decreased through some simple changes of food-related behaviors. Increase
fluid intake, and consume sufficient amounts of fiber to prevent constipation.
o Patients should omit alcoholic beverages and products containing fructose as needed.
o If there are effects after drinking milk, drink small quantities over several weeks, working up to an 8ounce glass.
Diarrhea:



Passing of loose, watery bowel movements that result when the contents of the GI tract move through
too quickly to allow water to be reabsorbed in the colon.
Adequate hydration is essential in the high-risk population.
Recommendations for managing diarrhea:
o Eat small frequent meals
o Chew with a closed mouth to avoid swallowing too much air
o Get plenty of rest – lie down for 30 to 60 min after meals
o Include foods that are low in fiber, such as, bananas, rice, applesauce, dry toast and crackers.
o Drink liquids 30 mins. Before or after meals.
Constipation:




Normal functioning ranges from 3 times a day to every 3 days. Constipation means having fewer than 3
stools per week.
Water helps lubricate the intestines, making bowel movements easier to pass.
Patient should use fiber-rich products such as whole-grain breads & cereals, fruits, and vegetables.
Recommendations for managing constipation:
o Listen to body’s signals and follow a schedule that allows time for bowel movement to occur.
o Exercise regularly
o Relax, stress tightens muscles throughout the body and may inhibit proper bowel functions
o Consume regular meals. Skipping meals should be avoided
Celiac Disease and Gluten Sensitivity:
45 | N u t r i t i o n a n d d i e t e t i c s
A chronic autoimmune disorder in which the mucosa of the small intestine, especially the
duodenum and proximal jejunum, is damaged by dietary gluten
Remove gluten from diet
o

Lactose intolerance:
o
Limit lactose-containing foods or in severe cases no lactose diet is indicated. This all depends on the
RDA of lactose for the person as it differs.
Irritable bowel syndrome – FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and
polyols) diet is applied.
o
Depending on the individual’s symptoms and food dairy, lactose, gluten, or sugars may be
eliminated from the diet
Inflammatory bowel disease:








2 inflammatory conditions of the intestines:
o Ulcerative colitis – an inflammatory process confined to the mucosa of the large intestine.
o Chron’s disease – an inflammatory disorder that involves all layers of the intestinal wall and may
affect the small intestine, large intestine, or both.
Goal of nutrition therapy is to replace lost nutrients, correct deficits and achieve energy, nitrogen, fluid
and electrolyte balance.
Acute IBD has an individualized nutrition therapy based on food tolerance and affected portions of the
GI tract.
High protein diet divided into small frequent meals are often recommended.
Ileostomies and Colostomies:
Is done when a disease or obstruction cannot be resolved, all or a segment of the colon including the
rectum is removed
Appropriate nutrition therapy depends on the type of ostomy performed. Goals are related to the
liquidity of the effluent.
Ileostomy = more liquid effluent
Colostomy = depending on the length of the remaining bowel effluent is liquid
o Effluent = liquid waste
o Liquid stools have greater loss of fluid and electrolytes. Any restrictions placed on the patient should
be based solely on individual tolerance.
Short Bowel Syndrome:





Nutrition management of a patient with SBS should take into consideration the individual’s digestive and
absorptive capabilities
Patients require parenteral nutrition, or IV fluids in the immediate postresection period
Diet and enteral nutrition should be reintroduced as soon as possible.
Complex carbohydrates from whole grains, fruits and vegetables should be used, but simple sugars
should not.
Patients with end-jejunostomies can tolerate a higher proportion of calories from dietary fat than
patients with a remnant colon.
Diverticular Disease:


Bowel walls are weakened, diverticula (pouchlike herniations protruding from the muscle layer of the
colon) develop.
When diverticula are inflamed, patients are given nothing by mouth and then progress to liquids. After
inflammation, a high-fiber diet is recommend to reduce straining during defecation.
46 | N u t r i t i o n a n d d i e t e t i c s
Nutrition for diseases of the kidney
Nephrotic syndrome


Complex of symptoms that can occur after damage to the capillary walls of the glomerulus
Often results from primary glomerular disease (glomerulonephritis), nephropathy secondary to
amyloidosis (accumulation of waxy starchlike glycoprotein)
Food and nutrition therapies






Primary goal- control hypertension, minimize edema, decrease urinary albumin losses, prevent protein
malnutrition and muscle catabolism
Consume adequate proteins and energy- 1g/kg/day of protein and 35g/kg/day of energy
o Prevent malnutrition and catabolism of lean body tissue
Good sources of protein- lean meats, well-trimmed poultry, eggs (limit 2 per week), fish, shellfish, beans,
and nuts
Sodium intake should be limited
Intake of cheese, canned foods, dried pasta and rice mixes, and canned or dried soups should be
controlled
Fruits and vegetables are highly recommended
Hidden sources of sodium
Baking powder, drinking and cooking water,
medications (antacids, antibiotics, cough
medicines, laxatives, pain relievers, sedatives,
mouthwash, and toothpastes
Role of nurses


Monitor and document patient weights, intake and output should be recorded at least every shift
Acute renal failure



Abrupt loss of renal function, may or may not be accompanied by oliguria or anuria
Most common cause of ARF- acute tubular necrosis (ATN)- injury after decreased blood supply, or
nephrotic cause, such as certain medications
Reduction of urine output stages:
o Oliguric phase (24-48 hours after initial injury; lasts 1-3 weeks)- retention of excessive amounts of
nitrogenous compounds in the blood, acidosis, high serum potassium phosphorus levels,
hypertension, anorexia, edema, and risk of water intoxications
o Diuretic phase (lasts 2-3 weeks)- urinary output is gradually increased
o Recovery phase (lasts 3-12 monts)- kidney functions gradually improves
Food and nutrition therapies







Nonprotein calories (30-40 kcal/kg) should be provided for weight maintenance and to meet extra
demands
Fats, oils, simple carbohydrates, and low-protein starches are given
When dialysis is not part of the treatment- 0.6-0.8 g of protein per kilogram of body weight is often
prescribed
If dialysis is part of the treatment- 1.0-1.4g/kg of protein is required
Supplements of niacin, riboflavin, thiamine, calcium, iron, vitamin B12, and zinc may be given due to
protein deficiency
During oliguric phase, sodium is restricted to 1000-2000 mg/day and potassium to 1000g/day
High phosphorus intake should be controlled
o High phosphorus levels disrupts the hormonal regulation of phosphate, calcium, and vitamin D,
leading to impaired kidney function
Chronic kidney disease
47 | N u t r i t i o n a n d d i e t e t i c s

Progressive, irreversible loss of kidney function over days, months, or years
Food and nutrition therapies

Medical nutrition therapy (MNT)- goals is to slow or prevent progression to the need for dialysis
Treatments and major concerns for preend stage renal disease, hemodialysis,
and peritoneal dialysis
Pre- ESRD Hemodia Peritoneal
lysis
dialysis
Trea Diet+med Diet+me
Diet+medi
tme icaton
dication+ cation+peri
nt
hemodial toneal
mo
ysis,
dialysis,
dalit
dialysis
dialysis
ies
using
using
vascular
peritonela
access
membrane
for waste for waste
product
product or
removal
fluid
removal
Dur
Indefinit,
3-4
3-5
atio hypernte
hours/3
exchanges
n
nsion,
days/we
/7
con glycemic ek, bone days/week
cer
control in disease,
, bone
ns
patients
hyperten disease,
with DM,
sion
weight
glomerul
gain,
er
Amino
hyperlipide
hyperfiltra acid loss, mia,
tion, rise
interdialy glycemic,
in BUN,
tic
control in
bone
electrolyt patients
disease,
e and
with DM,
anemia,
fluid
protein loss
cardiovas changes, into
cular
anemia,
dialysate,
disease
cardiova glucose
scular
absorption
disease
form
dialysate,
anemia,
and
cardiovasc
ular
disease
Hemodialysis


Blood is shunted from the patient’s body by way of special vascular access or shunt, thinned with
heparin, cleansed form excess fluid and waste products through a semipermeable membrane, and
then returned to the patient’s circulation
Dialysate- is an electrolyte solution similar in composition to normal plasma
Food and nutrition therapies
48 | N u t r i t i o n a n d d i e t e t i c s









Protein- 1.2 g/kg/day, with at least 50% being of high biologic value (animal sources)
Energy- <60 years old and of standard body weight (35 kcal/kg), for obese and adults >60 years old (30
kcal/kg)
Fats- use fish oils and olive oil because it reduces damage from inflammatory cytokines
Sodium and fluids- recommended fluid gain between dialysis treatment is less than 5% of the patient’s
dry (nonedematous) weight.
o Fluid output >1 L/day- 2-4 g/day sodium and 2 L/day of fluid
o Fluid output <1 L/day- 2g/day sodium and 1-1.5 L/day of fluids
o Anuria: 2g/day of sodium and 1 L/day of fluids
Potassium- 2.5 g/day
Phosphorus and calcium- restricted in patients receiving hemodialysis
o Intake of 12 mg/kg/day is recommended
o Foods high in phosphorus such as milk, milk products, cheese, beef liver, nuts and legumes are
severely limited
Iron and trace minerals- adequate iron supply is needed due to anemia and is necessary for normal
erythropoiesis to take place
o Trace minerals are not necessary unless a deficiency is suspected
Vitamin D- due to loss of production of calcitriol, the active form off vitamin D. supplementations are
recommended
Other vitamins- water-soluble vitamins especially vitamin B6 and folic acid.
Peritoneal dialysis




Removal of excess fluid and waste products from the blood by using the lining of the abdominal cavity
as the dialysis membrane
Intermittent peritoneal dialysis- involves infusion of approximately 2L of dialysate over 20-30 minutes
Continuous ambulatory peritoneal dialysis- entails infusion of dialysate in four or five exchanges in to the
peritoneum over 24 hours
Continuous cycling peritoneal dialysis- combination of IPD and CAPD
Food and nutrition therapies






Daily vitamin supplements are recommended especially folic acid and vitamin D
Recombinant EPO and iron supplements to manage anemia
During PD- Na, K, an fluids are continually removed, making severe dietary restrictions unnecessary
Restriction of dietary phosphorus is critical to prevent osteodystrophy (defective bone development)
Restricting and eliminating dairy products will be necessary to control phosphorus intake
Calcium supplementation is recommended
Kidney transplantation

Best renal replacement option for people with ESRD
Food and nutrition therapies

Pretransplantation
Nutrition guidelines for chronic renal failure without
dialysis, CRF with hemodialysis, or peritoneal dialysis
Nutrient
CRF w/o
hemodialysis Peritoneal
dialysis
dialysis
Energy
30-35 kcal/kg
35 kcal/kg
30-35
(ideal body
IBW if <60;
kcal/kg IBW
weight)
30-35
kcal/kg IBW
if >60
49 | N u t r i t i o n a n d d i e t e t i c s
Protein
Sodium
Potassium
Phosphorus
Fluids

0.6-1.0 g/kg
IBW
Individualized,
2-3 g.day
Individualized
to cover
losses with
diuretics
8-12 mg/kg
IBW or 0.6-1.2
g/day
As desired
1.2 g/kg IBW
2-3 g/day
1.2-1.2 g/kg
IBW
2-4 g/day
2-3 g/day
3-4 g/day
0.8-1.2
g/day or
<17 mg/kg
IBW
750-1000 ml
+ urine
output/day
0.8-1,2
g/day
Unrestricted
if weight
and blood
pressure is
controlled
and
residual
renal
function is
2-3 L/day
Immediately after transplantation- energy needs are increased (30-35 kcal/kg)
o Saturated fats are limited if dyslipidemia occurs
o Increase intake in omega-3 fatty acids
o Fluids are generally unrestricted and limited only by graft function
Kidney stones

Renal calculi, formation of kidney stones (urolithiasis). Due to low urine volume from inadequate fluid
intake, alkaline urine ph, etc.
Food and nutrition therapies

Comprehensive diet history is essential to identify the necessary diet modifications
Dietary recommendations for kidney stones
 Tailor diet to specific metabolic
disturbance and individual dietary habits
 Include a high fluid intake to produce at
least 2 L/day of urine (2-3 L/day intake)
 Avoid dietary calcium restriction.
Consume calcium-rich foods instead of
supplements
 Limit oxalate- rich foods; spinach,
rhubarb, beets, nuts, chocolate, tea,
wheat bran, and strawberries
 Limit supplemental vitamin C and D to
recommended dietary allowance for
gender and age

Choose plant-based proteins over animal
proteins several times a week
 Limit salt intake
 Use 5 or more servings of fruits and
vegetables per day for potassium sources
 Calcium oxalate stones- too much calcium in the urine
 Uric acid stones- metabolic product of purines
o Key therapy- weight loss + urinary alkalization
50 | N u t r i t i o n a n d d i e t e t i c s

Cysteine stones- hereditary disorder that causes the kidneys to excrete excessive amount of amino acid
cysteine (cystenuria)
o Treatment- reduce urinary cysteine concentration
Nutrition for Cardiopulmonary Diseases:
Cardiovascular diseases:

1.
2.
3.






Coronary artery disease:
3 types of preventive strategies:
Primary prevention – a public health effort
Secondary prevention – behaviors to reduce the effects of heart disease.
Tertiary prevention – is designed to minimize further complications or to restore health.
For CVD, these efforts may involve significant lifestyle changes combined with medication.
Atherosclerosis:
Chronic inflammatory process in which damage to the arterial wall can lead to coronary artery disease.
This condition begins in early life.
Vitamin D deficiency is associated with an increased risk for CVD and HTN.
Cholesterol and Dyslipidemia:
Cholesterol is an essential component of cell membranes and a precursor of bile acids, steroid
hormones, and vitamin D.
Dyslipidemia is caused by unbalanced LDL and HDL levels.
Low HDL levels for men is less than 40 mg/dl and 50 mg/dl in women
Food nutrition therapies:
-
Intake of better types of fats, plant-based proteins, and soluble fiber.
Weight loss may also be needed.
Mediterranean diet is cardioprotective
Daily intake of 2 to 3 grams of plant stanols or sterol esters are an additional therapeutic action.
(isolated from soybean and tall pine tree oils.
Substitute plant-based proteins for animal proteins (legumes, dry beans, nuts, whole grains, etc.)
Myocardial Infarction:








Food and nutrition therapies:
Purpose of nutrition therapy for MI patients is to reduce workload of heart.
Sodium, saturated fats, fluid and calories are controlled according to patient’s needs.
Small frequent meals are better than 3 large meals.
Large meals raise myocardial oxygen demand by increasing visceral blood flow.
Mediterranean diet should be initiated as it can prevent further coronary events.
Omega-3 fatty acids appear to reduce the risk of blood clots (Tuna, salmon, halibut, sardines, mackerel,
and lake trout)
Whole grain intake lowers risk for future heart attacks (rye and oats)
Caffeine-containing beverages may be temporarily restricted to avoid myocardial stimulation.
Peripheral Artery Disease:
-
A healthy diet to prevent PAD includes unsaturated fats like fish, nuts, and seeds and excludes saturated
fats.
Sodium should be cut back
Hypertension:


Food and Nutrition Therapies:
Weight loss is the most effective means of lowering blood pressure.
Weight reduction facilitates lower blood pressure even when it is only a loss of 10 to 15 pounds.
51 | N u t r i t i o n a n d d i e t e t i c s









Weight reduction and sodium restriction also augment the effects of antihypertensive medication.
Diet for weight loss ad control should include an energy restriction and an aerobic exercise prescription.
Decrease alcohol consumption
Increase physical activity
Terminate cigarette smoking
Decrease sodium intake
Increase intake of potassium, magnesium, and calcium.
A diet rich in fruits, vegetables, and low-fat dairy products along with reduced saturated and total fats
has been found to significantly lower blood pressure.
DASH diet is recommended.
Heart Failure







Food and Nutrition Therapies:
Most dietary measures will not be effective.
If etiology saw excessive sodium intake, restriction of sodium should be focused on
Patients with mild to moderate HF are often prescribed a sodium restriction of 3000 mg/day
Incase of severe HF patient’s sodium restriction is brought to 2000 mg/day
Fluid restriction of 1 to 2 L is sometimes indicated with low serum sodium.
Include high fiber foods such as cooked dried peas and beans, whole-grain foods, bran, cereals, pasta,
rice and fresh fruits
High fiber foods contain antioxidants that are cardioprotective.
Cardiac Cachexia:




Food and Nutrition therapy:
Energy requirements are 20% to 30% greater than basal needs because of increased cardiac and
pulmonary energy demands and metabolic rate.
Protein and energy intake should be sufficient to maintain body weight.
Use volume-concentrated formulas if fluid restriction is necessary
Calorie-dense (1.5 kcal/mL) nutritional supplements help to increase energy and protein intake.
Pulmonary Diseases:










COPD:
Malnutrition of individuals with COPD is multifactorial.
Energy expenditure is usually elevated but will vary according to person’s level of physical activity.
Adequate protein stimulates the ventilatory drive.
Patients require 1.2 to 1.9 g protein per kg of body weight for maintenance and 1.6 to 2.5 g/kg for
repletion.
Offer foods such as milk, eggs, cheese, meat, fish, poultry, nuts, beans, and legumes.
Higher serum a-carotene and b-carotene concentrations, reflect greater intake of orange and dark
green leafy fruits and vegetables are associated with better pulmonary functions.
Include vitamin d and other antioxidants.
High fat and low carbohydrates are recommended.
Offer 4 to 6 small meals a day to reduce sodium intake.
Too much sodium may cause edema and discomfort.
Cystic Fibrosis:



Food and Nutrition therapies:
Primary goal of nutritional therapy for patients with CF is to exceed the Dietary reference intakes for kcal
and all other nutrients by 1.2 to 2 times.
Improvements in pancreatic enzyme replacement therapy now allow higher amounts of dietary fat
intake.
Sodium requirements may be considerably higher.
52 | N u t r i t i o n a n d d i e t e t i c s

Fat-soluble vitamins may be prescribed in a water-miscible form if fat malabsorption is severe.
Acute Respiratory Failure and Respiratory Distress Syndrome:
-
Most patients in ARF require mechanical ventilation, which is why nutrition support may be provided via
enteral or parenteral nutrition.
Nutrition support should be initiated as soon as possible to help wean the patient from the ventilator.
Nutritional recommendations re the same as COPD guidelines: high calorie, high protein, moderate to
high (50% nonprotein kcal) fa, with moderate (50% nonprotein kcal) carbohydrate.
Enteral nutrition is recommended in several guidelines for mechanically ventilated patients.
Commercial formulas that provide 40% to 50% of total kcal from fat are available.
Higher caloric density formulas may be necessary when fluids are restricted
Parenteral nutrition may be needed in the treatment of acute respiratory failure.
High glucoe concentration can lead to excess CO2 production, which should be avoided.
Asthma:
-
Oxidative stress plays a rolein asthma; antioxidant dietary approaches are suggested.
A variety of fruits, vegetables, and whole-grains other than wheat and rice provide dietary fibers,
iron,magnesium and phosphorus from natural sources and should be used often.
A healthy diet and avoidance of obesity during pregnancy, childhood and aging may reduce asthma
exacerbations.
Vitamin D, fish oil and vitamin C are important nutrients.
Tuberculosis:
-
-
Obesity and type-2 diabetes are risk factors for TB
No special diet for TB
A high calorie, high protein, nutrient rich meal plan is suggested with small, frequent feedings.
53 | N u t r i t i o n a n d d i e t e t i c s