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
