Bridgitte Carroll
KNH 413
Gretchen Matuszak
24 April 2014
2 g Sodium Diet
1. Purpose
a. To help decrease high blood pressure
b. High sodium intakes will cause fluid retention and vasoconstriction, increasing BP
2. Population
a. Assign diet to hypertensive patients, BP > 140/80
b. 5% of population is affected by a high sodium intake that will increase their BP
3. General Guidelines
a. 2 g Sodium per day
b. Should be paired with a weight loss plan to increase success of blood pressure reduction
c. Can also use DASH diet, which incorporates fresh fruits and vegetables, whole grains and has a
2,300 mg sodium intake
d. Aim to decrease blood pressure
4. Education Material
a. Educate on lower sodium options and substitutions
b. Mrs. Dash and spices to liven up food instead of salt
c. Teach patient how to read labels to determine amount of sodium and if it is high/low sodium
option
Tips for Reducing Sodium in Your Diet
o
o
o
o
Buy fresh, plain frozen, or canned "with no salt added" vegetables.
Use fresh poultry, fish, and lean meat, rather than canned or processed types.
Use herbs, spices, and salt-free seasoning blends in cooking and at the table.
Cook rice, pasta, and hot cereals without salt. Cut back on instant or flavored rice, pasta, and cereal mixes,
which
Meal
24-hour recall
Substitutions/Suggestions
Breakfast
2 Scrambled Eggs with Veggies
Hot Sauce
Eliminate or use Cayenne Pepper in
eggs
2 Slices of Bacon
Orange Juice
Lunch
Tomato Soup
Grilled Cheese –
1 whole wheat English muffin
Kraft American Cheese
Milk
Low-sodium variety
2 slices of lower sodium whole
wheat bread
Natural Cheese
Snack
Pretzels
Unsalted nuts or crackers
Dinner
Corn Tortillas
Chicken prepared with season
salt
Salsa & Hot Sauce
Corn, canned
Black beans, canned
Prepare with Mrs. Dash
Use Mrs. Dash to flavor, use fresh
tomatoes more than salsa
No salt added variety
No salt added variety, wash
thoroughly
o
o
o
o
usually have added salt.
Choose "convenience" foods that are lower in sodium. Cut back on frozen dinners, pizza, packaged mixes,
canned soups or broths, and salad dressings — these often have a lot of sodium.
Rinse canned foods, such as tuna, to remove some sodium.
When available, buy low- or reduced-sodium, or no-salt-added versions of foods.
Choose ready-to-eat breakfast cereals that are lower in sodium.
Top 10 Sources of Sodium in the American Diet
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Bread and rolls
Cold cuts/cured meats
Pizza
Fresh and processed poultry
Soups
Sandwiches like cheeseburgers
Cheese
Pasta dishes like spaghetti with meat sauce
Meat dishes like meatloaf with tomato sauce
Snacks, including chips, pretzels, popcorn and puffs
5. Samples Menu
a. Foods Recommended – Low- or reduced-sodium, or no-salt-added versions of foods such as
soup and vegetables, spices, lower sodium ready to eat breakfast cereals and frozen dinners,
natural cheeses, lower sodium breads
b. Foods Avoided – Condiments, processed cheeses, high sodium breads and rolls, cold cuts/cured
meats, high sodium snacks like pretzels and chips
c. Sample Menu
1 cup fresh mixed fruits, such as melons, banana, apple and berries, topped
with 1 cup fat-free, low-calorie vanilla-flavored yogurt and 1/3 cup walnuts
1 bran muffin
Breakfast
1 teaspoon trans-free margarine
1 cup fat-free milk
Herbal tea
Lunch
Curried chicken wrap made with:
 1 medium whole-wheat tortilla
 2/3 cup cooked, chopped chicken, about 3 ounces
 1/2 cup chopped apple
 2 tablespoons fat-free mayonnaise*
 1/2 teaspoon curry powder
1/2 cup, or about 8, raw baby carrots
1 cup fat-free milk
Dinner
1 cup cooked whole-wheat spaghetti with 1 cup marinara sauce, no added salt
2 cups mixed salad greens
1 tablespoon low-fat Caesar dressing
1 whole-wheat roll
1 teaspoon trans-free margarine
1 nectarine
Sparkling water
Trail mix made with:
 1/4 cup raisins
Snack (anytime)
 1 ounce, or about 22, unsalted mini twist pretzels
 2 tablespoons sunflower seeds
i. (N.A., 2011)
6. Websites
a. American Heart Association – www.heart.org/conditions/highbloodpressure
b. Mayo Clinic – Hypertension
c. National Heart, Lung and Blood Institute - http://www.nhlbi.nih.gov/health/healthtopics/topics/hbp/
d. Academy of Nutrition and Dietetics http://www.eatright.org/Public/content.aspx?id=6442469653&terms=hypertension
References
Mayo Clinic Staff. (2012) Hypertension. Mayo Clinic. Retrieved from: http://www.mayoclinic.org/diseasesconditions/high-blood-pressure/basics/definition/con-20019580
Nelms, M., Sucher, K. P., Lacey, K., & Long Roth, S. (2011). Nutrition therapy & pathophysiology. (2nd ed.
ed.). Belmont, CA: Wadsworth, Cengage Learning.
Carolyn Klempay
KNH 413
Diet Instruction
1 gram Sodium Diet
Patient History:
Darla is a 42-yr old wife and mother of three. She loves to cook and enjoys trying new foods and
recipes in the kitchen as she cooks meals for her entire family. Darla works full-time, volunteers with her
local church, and attends many games and recitals for her children who play soccer and instruments in
the school band. With such a full household and hectic schedule, Darla spends all of her time caring for
others and has sacrificed her own well-being in the process. With little time to exercise or focus on her
own health, she is 5’2” and weighs 160 lbs (72.7kg). Recently Darla went to her doctor’s office and was
told she was pre-hypertensive. The doctor said she should meet with a dietitian and ask specifically how
to decrease her salt intake.
BMI = wt (kg) / ht2 (m2)
BMI = 72.7 kg / (1.57m)2
BMI = 72.7/2.46
BMI = 29.5 kg/m2
24-hour Dietary Recall:
Breakfast
Lunch
2 eggs over-medium with salt and pepper, 2 slices bacon, one medium
plain bagel with butter
Deli sliced ham sandwich on white bread, Provolone cheese, lettuce,
and mustard. 1 medium pickle slice
Dinner
Snack
Spaghetti with pork sausage, Parmesan cheese, Italian bread, creamed
corn, salad with Italian dressing
Pretzels with 2 Tbsp peanut butter
24-hour Dietary Recall Analysis:
Food Item
Sodium Content
(mg)
2 eggs
140
1/16 tsp table salt
145
2 slices bacon
300
1 medium plain bagel
400
1 Tbsp salted butter
80
2 slices white bread
340
1 oz deli ham
750
1 oz low-fat provolone cheese
250
Lettuce
0
1 tsp mustard
55
1 medium pickle slice
370
3 oz Spaghetti pasta with ¼ cup
300
sauce
2 oz pork sausage
400
1 Tbsp Parmesan cheese
75
1 slice Italian bread
120
½ cup creamed corn
365
Salad with 1 Tbsp Italian dressing 242
1 oz pretzels
400
2 Tbsp peanut butter
150
Total
4,882 mg sodium
Diet Instruction:
1g (1,000 mg) Sodium Diet
Basic Information on Pre-Hypertension:
-Blood pressure is the force of blood against the walls of arteries
-When BP is elevated for an extended period of time, this is hypertension
-Hypertension makes the heart work too hard and contributes to atherosclerosis (hardening of the
arteries)
-Hypertension increases risk of heart attack, stroke, heart failure, kidney disease, and blindness
-Blood pressure between 120/80 and 139/89is pre-hypertension (don’t have high BP now, but likely in
the future)
-Above 140/90 is hypertension
-Systolic/Diastolic (BP when heart beats/BP when heart is at rest)
(National Institute of Health)
Basic Information on Sodium:
-Salt is commonly referred to as “Sodium”
-We need salt in our diets for proper functioning of nerves and muscles and correct balances of fluids in
our bodies
-Kidneys are responsible for helping regulate our sodium levels
-When we take in too much sodium, our kidneys can’t get rid of it all and it builds up in the blood
 This results in high blood pressure, or hypertension
-Typically, it is recommended to consume less than 2,400 mg sodium (2.4 g) per day (MedlinePlus)
24-hour Dietary Recall Modifications Analysis:
Food Item
Sodium Content
(mg)
2 eggs
140
1/16 tsp table salt
145
2 slices bacon
300
1 medium plain bagel
400
1 Tbsp salted butter
80
2 slices white bread
2 oz deli ham
1 oz low-fat provolone
cheese
Lettuce
1 tsp mustard
1 medium pickle slice
3 oz Spaghetti pasta with ¼
cup sauce
340
750
250
2 oz pork sausage
400
1 Tbsp Parmesan cheese
1 slice Italian bread
75
120
½ cup creamed corn
Salad with 1 Tbsp Italian
dressing
1 oz pretzels
365
242
2 Tbsp peanut butter
Total
0
55
370
300
Food Modifications
2 eggs
½ cup honeydew
8 oz yogurt
1 cup oatmeal
unsalted pecans &
raisins
2 slices wheat bread
3 oz turkey
1 oz Swiss cheese
Sodium Content
(mg)
140
30
100
10
0
260
60
55
0
55
10
10
150
Lettuce
1 tsp mustard
1 cup canned peaches
1 cup brown rice,
cooked tomatoes &
avocado
3 oz ground beef
meatballs
½ cup cauliflower
sweet potato baked in
skin
½ cup cooked broccoli
spinach with oil &
spices
3 cups air popped
popcorn
1 oz unsalted almonds
4,882 mg sodium
Total
935 mg sodium
400
60
10
40
30
65
0
0
Foods to Avoid:
-Salt
-Processed foods
-Canned, frozen foods
-Snack foods
-Packaged starchy foods (stuffing mix)
-Instant cooking foods (potatoes)
-Mixes (biscuits, cake)
-Certain meats and cheeses
-Deli/ lunch meats (ham, bologna)
-Cured/ smoked meats (sausage, bacon)
-Canned meats (Spam, Vienna sausage)
-Cheeses - avoid over 140mg sodium per
serving (American cheese, Velveeta)
-Condiments and Sauces
- Ketchup and salad dressings
-Worcestershire, pizza, barbeque, steak,
soy
-Pickles and Olives
Low Sodium Foods:
Fruit
-unsalted fresh, frozen, or canned
-fruit juices
Vegetables
-unsalted fresh, frozen, or canned
-vegetable juices, without salt added
-tomatoes
Protein
-plain meats
-fish
-poultry
-eggs
Starch
-shredded wheat
-plain pasta or rice
-homemade yeast breads, made without
salt
Dairy
-milk
-yogurt
-low sodium cheese
-hard cheeses (cheddar, Swiss)
Other
-ice cream
-unsalted nuts
-unsalted butter or margarine
Tips to lower Sodium in foods:
-Make foods homemade, you can control the amount of salt that is added
-Choose fresh, frozen, or canned items without added salt
-Snack on fresh fruits, vegetables, or unsalted nuts which are low in sodium
-Read the nutrition facts label!
-Use fresh or salt-free spices to add flavor to foods
-When eating out, ask for gravies and sauces on the side for better portion control
SUMMARY:
Goals:
-Begin 1 gram (1,000 mg) sodium dietary regimen
-Become educated on foods high and low in sodium
-Decrease BP to below 120/80, rid pre-hypertension
Closing Questions:
-Can you name 2 foods high in sodium?
-Can you name 2 foods low in sodium?
-Can you explain 2 changes you are going to implement this week to help reduce
your sodium intake?
**Here is my card and I think it would be good to have a follow-up
appointment in 2 weeks to see how things are coming along!!
Resources:
Academy of Nutrition and Dietetics. (2013, January). The Basics of the Nutrition
Facts Panel. A Guide on How to Read a Nutrition Facts Panel from the
Academy. Retrieved February 19, 2014, from
http://www.eatright.org/Public/content.aspx?id=10935
American Heart Association. (2013). Eat Less Salt. - book review by the Academy of
Nutrition and Dietetics. Retrieved February 19, 2014, from
http://www.eatright.org/Media/content.aspx?id=6442475958#.UwTliIWur
K
ClevelandClinic. (2013). Eat Right. Cleveland Clinic. Retrieved February 19, 2014,
from http://my.clevelandclinic.org/healthy_living/nutrition/hic_lowsodium_diet_guidelines.aspx
Columbia Edu. (2012). Sample Menus for the DASH Eating Plan. Mayo Clinic Source.
Retrieved February 19, 2014, from
http://www.cumc.columbia.edu/student/health/pdf/Sample%20menus%2
0for%20the%20D
Department of Health and Human Services. (2014, February 18). Low Sodium
Foods: Shopping list. Low Sodium Foods: Shopping list. Retrieved February
19, 2014, from http://healthfinder.gov/HealthTopics/Category/healthconditions-and-diseases/heart-health/low-sodium-foods-shopping-list
Dugdale, D. C. (2012, September 6). Low-salt diet : MedlinePlus Medical
Encyclopedia. U.S National Library of Medicine. Retrieved February 19, 2014,
from
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000109.ht
m
FDA. (2013, April 18). Food. Sodium in Your Diet: Using the Nutrition Facts Label to
Reduce Your Intake. Retrieved February 19, 2014, from
http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm315393.htm
MayoClinic Staff. (2013). Low-sodium recipes. - Healthy Recipes. Retrieved February
19, 2014, from http://www.mayoclinic.org/healthy-living/recipes/lowsodium-recipes/rcs-20077197
Nutrition Care Manual. (2014). NCM Nutrition Care Manual eat right. Public Home
Page. Retrieved February 19, 2014,
from.http://www.nutritioncaremanual.org/category.cfm?ncm_category_id=1
&ncm_heading=Meal%20Plans&client_ed=1
Zernel, M. B. (1997). McKinley Health Center - DASH Diet/1500, 1800, and 2000
calories per day - University of Illinois. McKinley Health Center - DASH
Diet/1500, 1800, and 2000 calories per day - University of Illinois. Retrieved
February 19, 2014, from http://www.mckinley.illinois.edu/handouts
Jessica Anderson
KNH 413
3/21/14
Diet Instruction: 50g Fat Restricted Diet
Patient Description and Diagnosis: Alex Reschke is an 18-year-old Caucasian
female, 5’8”, and 218 pounds. She is currently a senior at Mentor High school and a
member of the varsity track-and-field team, in which she participates in shot put
and discus. The other night, Alex could not sleep. She experienced severe right
upper quadrant pain and back pain between the shoulder blades that lasted for
hours. Immediately, her parents rushed her to the hospital. After Alex described her
symptoms and personal/family health history, the doctor performed an abdominal
ultrasound and computerized tomography (CT) scan to analyze and look for signs of
gallstones. The scan came back positive for cholelithiasis. Due to the presence of
gallstones, the doctor performed a test to check the bile ducts for gallstones. Using a
HIDA scan, a dye was used to highlight the bile ducts, determining that a gallstone
was blocking the bile duct pathway. Thus, Alex’s severe pain was a result of bilary
obstruction, in which the gallstone passed from the gallbladder through the cystic
duct and lodged itself into the common bile duct. Alex did not show signs of
inflammation. Due to her recent diagnosis of symptomatic cholelilthiasis, specifically
choleldocholithiasis (common bile duct stones), as well as her family history of
gallbladder cancer, she decided to undergo a cholecystectomy (removal of the
gallbladder laproscopically). In about 6-12 weeks, Alex will have undergone surgery.
In the meantime, Alex has been asked by her physician to see a Registered Dietitian
for instruction on a 50g fat restrictive diet to help relieve her symptoms prior to
surgery.
Etiology: Gallstones and bilary tract infections are known to affect 20 million
American’s each year. Gallstone related diseases are responsible for about 10,000
deaths per year in the United States. Interestingly, only 1 in 3% of the population
complains of symptoms during the course of a year, and fewer than half of these
people have symptoms that return. Women are at higher risk of developing
gallstones than men, occurring in nearly 25% of women in the US by the age of 60
and as many as 50% by the age of 75. Women are at an increased risk due to
estrogen, which stimulates the liver to remove more cholesterol from blood and
transfer it into bile. Other risk factors associated with cholelithiasis include being
overweight or obese, eating a high fat diet, having a family history of gallstones,
having diabetes, and much more. Gallstones may cause no signs or symptoms and
may last a few minutes to hours. Symptoms which may appear include sudden and
rapidly intensifying pain in upper right or center portion of abdomen, back pain
between shoulder blades, pain in the upper right shoulder, as well as high fever with
chills and possible yellowing of the skin and whites of eyes (Jaundice). When the
gallbladder is removed, the liver continues to make enough bile to digest food;
however, the bile drips continuously from the liver into the intestine. The causes of
the formation of gallstones is still unclear, but it is suggested that such formation
may occur due to bile containing too much cholesterol, bile too high in bilirubin or
the gallbladder does not empty correctly. In such abnormal conditions, cholesterol
precipitates as gallstones rather than remaining in the solution of bile salts and
lecithin in the form of micelles.
Diagnostic Measures: The challenge is diagnosing gallstones is verifying that the
abdominal pain is caused by the stones and not other conditions. Ultrasounds and
imaging techniques are commonly used in the detection of gallstones. Because
gallstones most often do not cause any symptoms, simply finding stones does not
necessarily explain a patient’s pain. In diagnosing gallstones, disorders should be
ruled out, such as if the patient’s pain lasts less than 15 minutes, frequently coming
and going, or not severe enough to limit activities. Disorders with similar symptoms
include IBS and Pancreatitis. In patient’s with known gallstones, the doctor can often
diagnosis acute cholecystitis based on classic symptoms of constant and severe pain
in the upper right quadrant of the abdomen and imaging techniques to confirm the
diagnosis. Blood tests can be used to identify abnormalities that may indicate
gallstones or complications: bilirubin and enzyme alkaline phosphatase levels
elevated, especially in choledocholithiasis; elevated levels of aspartate
aminotransferase and alanine when common bile duct stones are present.
Additionally, a high white blood cell count is common in many patients with
cholecystitis. Imaging and diagnostic techniques for gallstones may include
Ultrasonography, Endoscopic Ultrasound, Computed Tomography, Magnetic
Resonance Cholangiography, X-rays, HIDA scan (Gallbladder Radionuclide Scan),
Virtual Endoscopy, and Endoscopic Retrograde Cholangiopancreatography (ERCP).
Ultrasounds can help in the diagnosis of various conditions: accurately detect stones
as small as 2mm in diameter; indicate gangrene when air is present in the
gallbladder. In contrast, ultrasounds may not be helpful in the diagnosis of
cholecystitis when gallstones are not present in those with symptoms, and may not
be helpful in identifying common bile duct stones or imaging the cystic duct.
Additionally, X-rays of the abdomen may detect calcified gallstones and gas. An
HIDA scan is a nuclear imaging technique that is more sensitive than ultrasound for
diagnosing acute cholecystitis and is noninvasive. During this procedure, a tiny
amount of radioactive dye is injected intravenously and excreted into the bile. If the
dye does not enter the gallbladder, the cystic duct is obstructed, indicating acute
cholecystitis. False results are commonly found in alcoholics with liver disease or
patients who are fasting or receiving all their nutrition intravenously.
Treatment: Acute pain from gallstones and gallbladder disease is usually treated in
the hospital, where diagnostic procedures are performed in ruling out other
possible conditions and complications. There are three approaches to gallstone
treatment: expectant management (“wait and see”), nonsurgical removal of stones,
and surgical removal of gallbladder. For expectant management, a person has no
symptoms, the risks of both surgical and nonsurgical treatments for gallstones
outweigh the benefits. Those who show no signs of severe pain or complications
may be discharged from the hospital with oral antibiotics and pain relievers.
Exceptions to this policy are those who show risk for complications for gallstones,
including those at risk of gallbladder cancer, Pima Native Americans, and patients
with stones larger than 3cm. Because the presence of gallstones at an early age
increases ones risk for gallbladder cancer, young adults who do not have symptoms
may be recommended to have their gallbladder removed. When gallstones are
present without inflammation, patients have the following options: intravenous
painkillers for severe pain, elective gallbladder removal, lithotripsy, and drug
therapy. In regards to the presence of common bile duct stones, a laparoscopic
cholecysectomy has taken a role in the detection and removal of common bile duct
stones. Because the gallbladder is not an essential organ, its removal is one of the
most common surgical procedures performed on women. The advantage of surgical
treatment over the other methods is its ability to eliminate gallstones and prevent
gallbladder cancer. Cholecystectomy may be performed within days to weeks after
hospitalization for an acute attack, depending on the severity of the condition.
During a laparoscopic cholecystectomy, the surgeon separates the gallbladder from
the liver and other areas, and removes it through one of the 3 small incisions made
in the abdomen. Often times, patients will need to stay in the hospital overnight.
Although she does not show signs of inflammation, a laparoscopic cholecystectomy
was chosen for Alex. This is due to her family history of gallbladder cancer, her age,
the severity of her pain, as well as her ethnicity – Caucasian.
Medical Nutrition Therapy: For the next 6-12 weeks, prior to surgery, Alex will
follow a 50g fat restrictive diet. Doing so will assist in relieving her symptoms
associated with choledocholithiasis.
BMI: kg/m2
Ht. 5’8”  5’ x 12in/ft + 8in = 68in x 2.54cm/in = 172.72cm
 172.72cm x 1m/100cm = 1.7272m
~1.73m
Wt. 218lbs  218lbs x 1kg/2.2lb = 99.09kg
BMI = (99.09kg)/(1.73m2) = 33.1kg/m2d
Alex is classified as obese, according to BMI for children (>95th percentile). Such
status of health risk for a classification as obese is associated with further increased
risk of disease.
Although Alex is considered obese, weight loss at this time is not of primary focus.
The relieving of symptoms due to her recent diagnosis of choledocholithiasis, in
preparation for her laparoscopic cholecystectomy, is of greatest concern. Weight
maintenance and achievement of proper macronutrient ratios as well as a
consuming a well-balanced diet high in fiber, various vegetables and fruits as well as
nuts, with a decreased intake in sugar, alcoholic beverages and caffeine are
recommended to Alex at this time. In regards to fat, it is recommended for Alex to
consume foods containing monounsaturated fats – found in olive and canola oils, as
well as omega-3 fatty acids – found in canola, flaxseed and fish oil. Fish oil may be
beneficial in regards to Alex’s triglyceride levels, because it improves the emptying
action of the gallbladder.
The Total Energy Expenditure (TEE) was used in determining Alex’s estimated
energy needs at rest. With the re-addition of added physical activity, post surgery,
an estimation of Alex’s energy needs and estimated energy expenditure will need to
be reassessed and revised to best fit her overall health and wellness and nutrition
goals.
Total Energy Expenditure for Overweight and Obese Females Aged 3 through 18
Years:
TEE = 389 – 41.2 x age + PA x (15.0 x wt. + 701.6 x ht.)
PA Factor: 1.24 for active
Wt. = 99.09kg
Ht. = 172.72cm
Age = 18yrs
Prior to Operation, with caution, unless told doctor advises not to participate in
sport:
 TEE = 389 – 41.2 x 18 + 1.24 x (15.0 x 99.09kg + 701.6 x 1.7272m)
= 389 – 741.6 + 1.24 x (1486.35 + 1211.80352)
= 389 – 741.6 + 1.24 x (2698.15)
= 389 – 741.6 + 3345.706
= 2993.106 Kcal/d
~ 3000 – 3100Kcal/d with PA (active PA = 1.24)
Post Operation/No Activity:
No PA Factor (when PA = 1.0)
= 389 – 741.6 + 2698.15
= 2354.55 Kcal/d
~ 2350 – 2450 Kcal/d without PA (sedentary PA = 1.0)
Using the TEE for overweight and obese females aged 3 to 18 years, prior to
operation, Alex requires about 3000Kcal/d with physical activity. If the doctor
advises Alex not to participate in track and field for the next couple of weeks, she
should consume about 2350 to 2450Kcal/d. This requirement should be followed
post operation, when recovering. Prior and when recovering from surgery, it is best
for Alex to avoid fatty foods at first and slowly add them back into her diet. It is
important for her to consume the right fats – monounsaturated and omega-3’s,
while avoiding high consumption and foods high in saturated and trans fats as well
as foods that are high in cholesterol. Such foods can cause bilary irritation; thus,
resulting in symptoms of discomfort, cramping, and diarrhea.
Below are the calculations for Alex’s macronutrient ratio. In order to prevent
excessive diarrhea and symptoms related to choledocholithiasis, she should follow
this ratio daily.
Without physical activity:
Total Kcal: ~2400Kcal/d
Fat: 20% daily Kcal
2400kcal/d x 1g fat/9kcal = 266.7g fat x .20 = 53.34g fat/d
Protein: 25% daily Kcal
2400kcal/d x 1g protein/4kcal = 600g pro x .25 = 150g pro/d
Carbohydrate: 55% daily Kcal
2400Kcal/d x 1g carbohydrate/4kcal = 600 kcal CHO x .55 = 330g CHO/d
As the information above displays, it is advised for Alex to restrict her fat intake to
roughly 53g per day. That is, she should consume 20% of her calories from fat
sources. Because Alex is an athlete and her body is under stress, her protein needs
are increased. Increasing Alex’s protein content may assist in controlling symptoms
until surgery. Alex’s protein needs were calculated to be 150g/d, which makes up
about 25% of her daily calories. Lastly, Alex requires 330g of carbohydrate per day,
which is 55% of her total daily energy needs.
It is recommended for Alex to consume small and frequent meals, about 5-6 a day.
Due to poor absorption of fat, water-soluble form of vitamins A, D, E, and K may be
necessary. Such foods include dark leafy green vegetables, carrots, dairy products
fortified with vitamin D, sunflower seeds, almonds, as well as olive oil and soybean
oil. Post-surgery diarrhea may be managed through increased fiber intake to
increase fecal bulk, and patient avoidance of food that may cause diarrhea.
In helping to aid with digestion, it is advised for Alex to eat foods high in fiber.
Although this is important, it should be noted to up her total fiber intake slowly.
Increasing fiber intake too drastically may result in additional cramping and
discomfort. It is also important for Alex to drink plenty of fluids, especially water.
Because diarrhea frequently occurs for a few days post-operation, it is important for
Alex to stay well hydrated. In addition, fluid helps encourage the passage of waste
through the digestive system and helps to soften stools. Because Alex will be eating
foods with higher fiber content, constipation may occur. By drinking enough fluids
daily, she will be able to avoid such conditions. It is advised for Alex to drink at least
8 8oz glasses of fluid each day, at least 4 servings of fruits and vegetables, and at
least 4 servings of breads or cereals (2 of those servings being whole grain).
During counseling with Alex, it is important to review the macronutrient ratio
designed for her specific needs as well as obtaining adequate intake through a wellbalanced diet. The patient will be informed on the importance of obtaining her fat
intake from monounsaturated and omega-3 sources, increasing fluid intake to at
least 8 8oz glasses of water per day, as well as eating a diet rich in fiber. The
patient’s 24-hour recall will be reviewed. Additionally, Alex will receive suggestions
for improvement in her overall diet, based on the nutritional recommendations
determined. She will be educated and given handouts on specific foods to avoid –
causing the onset of symptoms, and those to consume as well as foods high in fatsoluble vitamins – A, D, E, and K. Alex will be given a list of food exchanges that she
can use to assist her in educating herself on energy contents of specific foods while
using it to easily swap out foods for one another throughout the week.
24-Hour Recall With Suggestions: for a 2400Kcal diet
If needed, patient may make meals into smaller, more frequent, meals.
Total: 53g fat
Fat per meal: ~ 12.3g fat
Fat per snack: ~ 8g
Foods Consumed
Breakfast:
2 slices of white toast (160kcal; 2g fat)
1T butter (135kcal; 15g fat)
3 eggs (225Kcal; 15g fat)
1tsp hot sauce
8 oz glass 2% milk (120Kcal; 5g fat)
Suggestions for Improvement
2 whole wheat slices of toast (160 Kcal; 1g
fat)
Total: 640Kcal and 37g fat
Snack:
½ cup Almonds (200Kcal; 16g fat)
Banana (60Kcal; 0g fat)
1 cup Greek Vanilla Yogurt, low-fat
(120Kcal; 4g fat)
1/3 cup granola (80Kcal; 1g fat)
485Kcal and 15.5g fat
Smoothie:
1 ½ cup nonfat vanilla Greek Yogurt
(180Kcal; 0g fat)
¼ cup Almonds (100Kcal; 8g fat)
Banana (60Kcal; 0g fat)
½ cup special K cereal (80Kcal; 1g fat)
½ cup Strawberries (60Kcal; 0g fat)
1T peanut butter (100Kcal; 8g fat)
Scrambled - 2 egg whites and 1 egg
(125Kcal; 5g fat)
2T mild salsa (10Kcal; 0g fat)
8 oz skim milk (90Kcal; 1.5g fat)
460Kcal and 21g fat
Lunch:
2 slices white bread (160Kcal; 2g fat)
1T mayonnaise (135Kcal; 15g fat)
2 slices provolone cheese (200Kcal; 16g
fat)
2oz luncheon meat – ham (200Kcal; 16g
fat)
2 leafs of lettuce – romaine (0Kcal; 0gfat)
½ cup diced pineapple (60Kcal; 0g fat)
755Kcal and 33g fat
420Kcal and 9g fat
2 slices whole wheat bread (160Kcal; 2g
fat)
1 slice skim American cheese (55Kcal; 3g
fat)
2oz grilled chicken breast (110Kcal; 6g
fat)
2 leafs of lettuce (0Kcal; 0g fat)
½ cup diced pineapple (60Kcal; 0g fat)
½ cup steamed broccoli (25Kcal; 0g fat)
8 oz glass skim milk (90Kcal; 1.5g fat)
500Kcal and 12.5g fat
Dinner:
1 ½ cup bow-tie pasta (240Kcal; 3gfat)
2 1oz beef meatballs (200Kcal; 16g fat)
¾ cup marinara (95Kcal; 0g fat)
1 oz parmesan cheese – regular (100Kcal;
8g fat)
2 breadsticks (160Kcal; 2g fat)
8 oz glass 2% milk (120Kcal; 5g fat)
1 cup whole wheat pasta (160kcal; 2g fat)
2oz grilled chicken breast (110Kcal; 6g
fat)
½ cup asparagus – steamed (25Kcal; 0g
fat)
1 oz red. Fat Kraft parmesan cheese
(55kcal; 3g fat)
1 breadstick (80Kcal; 1g fat)
8 oz glass skim milk (90Kcal; 1.5g fat)
915 Kcal and 34g fat
Snack:
1 oz plain cream cheese (100Kcal; 8g fat)
1 plain bagel (160Kcal; 2g fat)
260Kcal and 10g fat
520Kcal and 13.5g fat
Snack:
1oz low fat cream cheese (55Kcal; 3g fat)
1 whole wheat bagel – 2halves (160Kcal;
1g fat)
2Tbsp Jelly (60Kcal; 0g fat)
Snack:
½ cup blueberries (60Kcal; 0g fat)
½ cup raspberries (60Kcal; 0g fat)
1/2 cup special K cereal (80Kcal; 1g fat)
Total: 475Kcal and 5g fat
Total Kcal: 3030Kcal
Total g fat: 135g
Prognosis:
Total Kcal: 2400Kcal
Total g fat: 55.5g
Assessment:
A: presence of gallstones; choledocholithiasis; cholecystectomy in 6-12 weeks
B. No biochemical measures
C. BMI 33kg/m2 (categorizing as obese); height 5’8”; weight 218lbs; age 18yrs
D. 50g fat restrictive diet; high fiber and increased fluid intake; increase
consumption of fat-soluble vitamins and protein; obtain fat sources from mainly
monounsaturated and omega-3’s (avoid saturated and trans fats)
Less than optimal intake of types of fats (NI-5.6.3) R/T food and nutrition
knowledge deficit concerning type of fat and choledocholithiasis AEB patient 24hour recall, frequent consumption of fats that are undesirable for condition, BMI >
30kg/m2 (BMI of 33kg/m2), obesity, and family history of gallstones.
Inadequate fiber intake (NI-5.8.5) R/T food- and nutrition related knowledge deficit
concerning desirable quantities of fiber AEB patient 24-hour recall, diarrhea, and
choledocholithiasis.
Increased nutrient needs of protein, fat-soluble vitamins and fiber (NI-5.1) R/T
altered absorption of fat from cholecystectomy and comprise of organs related to GI
function AEB diarrhea, choledocholithiasis and patient 24-hour recall.
Intervention:
Provide patient with a 50g fat restrictive diet (20% Kcal/d). Change diet, increasing
fluid intake, fiber intake, protein intake, and fat-soluble vitamins. If unable to meet
fat-soluble vitamin recommendations, may provide patient with supplement.
Instruct patient on importance of increasing fiber intake gradually to avoid digestive
discomfort. Instruct patient on methods of obtaining a well-balanced diet, achieving
4 servings of grains/cereals (most whole grains), 4 servings of non-starchy fruits
and vegetables and at least 8 8oz glasses of water/fluid per day. Advise patient to
keep a daily food-log.
Monitoring and Evaluation:
Provide patient with knowledge of maintaining a food-log. Have patient state foods
that they should avoid and consume to see if they have obtained knowledge of the
diet.
Works Cited
Academy of Nutrition and Dietetics. (2013). Standardized Language for the Nutrition
Care Process:
Pocket Guide for International Dietetics & Nutritional Terminology (IDNT)
Reference Manual
(Fourth ed.). Chicago, IL: Academy of Nutrition and Dietetics.
Adams, M. (2013, September). Fat-Restricted Diet. Retrieved March 19, 2014, from
NYU Lagone Medical
Center website: http://www.med.nyu.edu/content?ChunkIID=196199
Fat-Soluble Vitamins: A, D, E, and K [PDF]. (n.d.). Retrieved from
http://www.ext.colostate.edu/pubs/
foodnut/09315.pdf
Gallbladder Diseases. (n.d.). Retrieved March 19, 2014, from Medline Plus website:
http://www.nlm.nih.gov/medlineplus/gallbladderdiseases.html
Gallstones and gallbladder disease. (2013, June 27). Retrieved March 19, 2014, from
University of
Maryland Medical Center website:
http://umm.edu/health/medical/reports/articles/
gallstones-and-gallbladder-disease
Good foods to help your digestion. (2012, June 21). Retrieved March 19, 2014, from
NHS Choices
website: http://www.nhs.uk/Livewell/digestive- health/Pages/stomachfriendly-foods.aspx
Health Information: Health Facts for You [Cholecystectomy Home Care] [Fact sheet].
(2013, October
15). Retrieved March 19, 2014, from UW Health website:
http://www.uwhealth.org/healthfacts/
surgery/4432.html
Low Fat Diet [Fact sheet]. (n.d.). Retrieved from Hartford Healthcare Medical Group
website:
http://www.hartfordhealthcaremedicalgroup.org/ed_guide_lowfat.php
Mayo Clinic Staff. (2013, July 25). Gallstones. Retrieved March 19, 2014, from Mayo
Clinic website:
http://www.mayoclinic.org/diseases-
conditions/gallstones/basics/symptoms/con-20020461
My Daily Food Plan [PDF]. (n.d.). Retrieved from http://myplate.gov/foodgroups/downloads/results/
MyDailyFoodPlan_2400_18plusyr.pdf
Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy for
Ischemic Heart Disease. In Nutrition Therapy & Pathophysiology (2nd ed., p.
319). Belmont, CAL/USA: Wadsworth Cengage Learning.
Annelise Chmelik
April 24, 2014
KNH 413
Diet Instruction: Bland Diet
1. Description of Patient and Diagnosis
a. Patient:
Client name: Anthony Cicero
DOB: 2/15
Age: 37
Sex: Male
Education: College Degree, Law Degree
Occupation: Lawyer
Hours of work: 70 hours/week
Household members: Lives with his wife Rosanna age 34, son Michael age 7, and
daughter Francesca age 3.
Ethnic background: Italian
Religious affiliation: Catholic
Referring physician: P. A. Rocco, MD
Chief complaint:
“For about 6 weeks now I have had horrible abdominal pain and a pretty consistent
burning sensation. My symptoms worsen every time I eat food, and are even worse
at night. My wife said that I am not eating as much as I used to, and I tell her it is
because I do not have much of an appetite.“
Patient history:
Mr. Cicero is a 37-yo male lawyer, who recently was assigned a very important case.
He has been working at the office at least 70 hours a week, and has been
significantly stressed. A majority of his meals have been fast food because he does
not have time to sit and eat a home cooked meal. Therefore, he has been picking up
McDonalds or Chipotle on a regular basis since those restaurants are down the block
from the firm he works at. Mrs. Cicero said that whenever he gets a chance to relax,
he indulges in a Scotch, sometimes two or three a night. Mrs. Cicero also noted that
her husband has lost about 7 pounds in the last month.
Onset of disease: 6 weeks
Meds: Aspirin for occasional backaches
Smoker: Yes. ½ pack per day
Anthropometric Data:
Height: 5’10”
Weight: 205 lbs
Vitals: Temp 97.6˚F, BP 135/90 mm Hg
Nutrition Hx:
General: Appetite has been poor.
Usual dietary intake:
Breakfast:
Black coffee – 2 cups
McDonalds Breakfast Burrito
Lunch:
Chipotle Burrito Bowl with white rice, steak, tomato salsa, corn salsa,
extra hot salsa, sour cream, cheese, and lettuce
Tortilla chips and guacamole
12 oz. Coca-Cola
PM snack:
Black coffee – 2 cups
Dinner:
Spaghetti and Meatballs with a vodka cream sauce
Side salad with vinagrette dressing
Scotch on the rocks with lemon
HS snack:
Slice of chocolate cake
24-hr recall:
Breakfast:
Black coffee – 2 cups
McDonalds Egg McMuffin
McDonalds Hasbrown
Lunch:
No appetite/time for lunch, just a 12 oz. Coca-Cola
PM Snack:
Black coffee
Dinner:
1 piece of Spicy Italian Sausage
Garlic bread
HS Snack:
2 glasses of Scotch on the rocks with lemon
Food allergies/intolerances/aversions (specify): None
Previous MNT? No
Food purchase/preparation: Self and wife
Vit/min intake: None
Diet order: Bland diet
Tx plan:
Antibiotic to kill H. pylori
Proton Pump Inhibitor (PPI): suppresses acid production by halting the mechanism
that pumps acid into the stomach
Nutrition consultation for education on Bland Diet, which will assist in the reduction
or elimination of symptoms
b. Diagnosis:
After Dr. Rocco listened to his symptoms, stress, and intake of caffeine, alcohol,
cigarettes, and high-fat foods, the physician decided to perform an endoscopy to
determine if an ulcer was present. The endoscopy revealed a peptic ulcer. The
physician also conducted a urea breath test to confirm the presence of H. pylori.
Peptic ulcer disease involves ulcerations of the mucosa of the gastrointestinal tract
and can occur in the esophagus, stomach, duodenum, and jejunum. This break in the
mucosa results in a crater surrounded by an acute and chronic inflammatory cell
infiltrate.
2. Discussion of Disease:
a. Etiology:
An ulceration can develop in the following conditions:
 The stomach produces excess amounts of pepsin and acid
 The lining of the stomach or duodenum is impaired and is more
susceptible to damage from gastric acid and pepsin
Factors that may affect the mucosal integrity include the following:
 Helicobacter pylori infection: Helicobacter pylori bacteria commonly live
in the mucous layer that covers and protects tissues that line the
stomach and small intestine. Often, H. pylori causes no problems, but it
can cause inflammation of the stomach’s inner layer, producing an ulcer
 Aspirin: aspirin or certain over-the-counter and prescription pain
medications can irritate or inflame the lining of your stomach and small
intestine.
 Nonsteroidal, anti-inflammatory drugs
 Alcohol: alcohol can irritate and erode the mucous lining of your
stomach, and it increases the amount of stomach acid that is produced.
 Steroids
Factors that decrease the blood supply to the gastric or duodenal mucosa
include the following:
 Smoking
 Stress
 Injury
Factors that increase acid secretion include the following:
 Foods:
o Pepper
o Alcohol
o Caffeine



Rapid gastric emptying
Stress
Other conditions such as Zollinger-Ellison syndrome

Tests for H. pylori:
o Blood: a blood sample is taken from the patient’s vein and tested
for H. pylori antibodies
o Urea Breath Test: the patient swallows a capsule, liquid, or
pudding that contains urea “labeled” with a special carbon atom.
After a few minutes, the patient breathes into a container,
exhaling carbon dioxide. If the carbon atom is found in the
exhaled breath, H. pylori is present, as this bacterium contains
large amounts of urease, a chemical that breaks urea down into
carbon dioxide
o Stool: the patient provides a stool sample, which is tested for H.
pylori antigens
Endoscopy of the gastrointestinal tract
o During an endoscopy, the physician passes a hollow tube
equipped with a lens down the throat and into the esophagus,
stomach, and small intestine. Using the endoscope, the physician
will look for ulcers. If the doctor detects an ulcer, small tissue
samples may be removed for examination in a lab. A biopsy can
also identify the presence of H. pylori in the stomach lining
o A doctor is more likely to recommend endoscopy if the patient is
older, having signs of bleeding, or have experienced recent
weight loss or difficulty eating and swallowing.
X-ray of upper digestive system
o This procedure is sometimes called a barium swallow or upper
gastrointestinal series. This series of X-rays creates images of
your esophagus, stomach, and small intestine. During the X-ray,
the patient swallows a white liquid, containing barium, which
coats the digestive tract and makes an ulcer more visible.
Tests to determine contributions from other conditions that may
contribute to hypersecretion (Zollinger-Ellison Syndrome) include the
following:
o Serum gastrin
o Secretin stimulation test
b. Diagnostic Measures



c. Treatment:
i. Medical, surgical, and/or psychological treatment
The treatment for peptic ulcers depends on the cause. Treatments can
include:
 Antibiotic medications to eliminate H. pylori: if H. pylori is found
within the digestive tract, the physician may recommend a
combination of antibiotics to kill the bacterium




Medications that block acid production and promote healing: proton
pump inhibitors reduce stomach acid by blocking the action of the
parts of cells that produce acid. These drugs include the prescription
and over-the-counter medications omeprazole (Prilosec),
lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole
(Nexium), and pantoprazole (Protonix).
Medications to reduce acid production: Acid blockers – also called
histamine (H-2) blockers – reduce the amount of stomach acid
released into your digestive tract, which relieves ulcer pain and
encourages healing. Available by prescription or over-the-counter,
acid blockers include the medications ranitidine (Zantac),
famotidine (Pepcid), cimetidine (Tagamet), and nizatidine (Axid).
Antacids that neutralize stomach acid: antacids neutralize existing
stomach acid and can provide rapid pain relief, but generally are not
used to heal the ulcer.
Medications that protect the lining of your stomach and small
intestine: in some cases, the physician may prescribe medications
called cytoprotective agents that help protect the tissues that line
your stomach and small intestine. Options include the prescription
medications sucralfate (Carafate) and misoprostol (Cytotec).
Another nonprescription cytoprotective agent is bismuth
subsalicylate (Pepto-Bismol)
ii. Medical Nutrition Therapy treatment for client
Nutrition therapy for peptic ulcer disease calls for the following:
 Optimize nutritional intake to correct any deficiencies and to meet
nutrition needs
 Avoid foods that potentially increase gastric acid secretion or can
damage the gastric mucosa
o Alcohol
o Pepper
o Caffeine
o Tea
o Coffee (including non-caffeinated)
o Chocolate
 Identify foods that directly irritate the gastric mucosa or are not
individually tolerated
 Avoid eating at least 2 hours before bedtime
Bland Diet:
 A bland diet is made up of foods that are soft, not very spicy, and low
in fiber
 Alcoholic and caffeinated beverages should be avoided
 Smoking should be ceased
iii. Prognosis
Treatment for peptic ulcers is often successful, leading to ulcer healing.
Along with the medication to kill the H. Pylori, the Bland diet will eliminate
any stimulating, irritating, and seasoned products from the diet. It is crucial
to take the prescribed medications according to the directions, cease
regular tobacco use, and discontinue use of pain relievers that increase the
risk of ulcers to ensure that the ulcer heals properly.
3. Client Instruction Materials
The purpose of a bland diet is to alleviate the gastric distress the patient is having.
Therefore, the foods included are limited to non-stimulating, non-irritating and
mildly seasoned products. This diet should be well balanced and individualized
according to the patient’s appetite and food tolerance. With time and recovery, the
patient may be able to expand this diet to their individual tolerances.
The following recommendations may help provide some relief:
 Avoid alcohol, cigarette smoking, aspirin, and other non-steroidal antiinflammatory agents
 Avoid frequent meals and or bedtime snacks to prevent increased acid
secretion, unless you note you gain relief from certain foods.
 Foods and seasonings that stimulate gastric acid secretion such as caffeine,
black pepper, garlic, cloves, and chili powder should be limited
 Do not eat within two hours of bedtime,
 Omit any particular foods that cause discomfort.
 Eat a well-balanced diet that includes a variety of foods
 Cook by baking, boiling, broiling, roasting, stewing, microwaving or creaming.
Avoid frying
Usual dietary intake:
Breakfast:
Lunch:
PM snack:
Dinner:
HS snack:
Black coffee – 2 cups
McDonalds Breakfast Burrito
Chipotle Burrito Bowl with white rice, steak, tomato salsa, corn salsa,
extra hot salsa, sour cream, cheese, and lettuce
Tortilla chips and guacamole
12 oz. Coca-Cola
Black coffee – 2 cups
Spaghetti and Meatballs with a vodka cream sauce
Side salad with vinaigrette dressing
Scotch on the rocks with lemon
Slice of chocolate cake
24-hr recall:
Breakfast:
Lunch:
PM Snack:
Dinner:
HS Snack:
Black coffee – 2 cups
McDonalds Egg McMuffin
McDonalds Hashbrown
No appetite/time for lunch, just a 12 oz. Coca-Cola
Black coffee
1 piece of Spicy Italian Sausage
Garlic bread
2 glasses of Scotch on the rocks with lemon
Sample Meal Plan:
Meal
Breakfast
Lunch
PM Snack
Food Choices
¾ cup of oatmeal
½ cup of canned peaches
8 oz skim milk
Chipotle Burrito Bowl with white rice,
chicken, cheese, and lettuce
12 oz. Orange Juice
Creamy peanut butter and crackers
Dinner
HS Snack
made with refined white flour
½ cup Spaghetti with red sauce, grilled
chicken
½ cup of cooked green beans
½ cup of applesauce
8 oz. skim milk
8 oz. water
------
Client Instructions
Breakfast:
Exchange McDonalds Breakfast Burrito for oatmeal
Exchange black coffee for skim milk
Include canned peaches
Lunch:
Eliminate tomato, corn, and hot salsa
Eliminate sour cream because of high fat content
Eliminate the guacamole
Eliminate Coca Cola for orange juice
PM Snack:
Eliminate coffee for water
Include creamy peanut butter and crackers
Dinner:
Exchange spicy/processed meats, e.g. sausage for grilled chicken
Exchange vodka sauce for red sauce
Exchange side salad for cooked green beans
Include apple sauce
Eliminate garlic bread
Exchange scotch for skim milk
HS Snack:
Eliminate chocolate cake
Eliminate scotch on the rocks
**Client should not consume any food stuff 2 hours prior to bed time
References:
Arizona Diet Manual. (1998). Bland Diet. Retrieved from
http://web.squ.edu.om/medlib/med_cd/e_cds/Griffith's%20Instructions%20Patients/pdf/Pg537.pdf
Dempsey DT & Harbison Sp. (2005). Peptic Ulcer Disease. 42(6): 346-454.
http://www.ncbi.nlm.nih.gov/pubmed/15988415?dopt=Abstract
FDA Diet Manual. (2014). Bland Diet. Retrieved from
http://www.medfusion.net/templates/groups/2328/3078/Bland%20Diet.pdf
Mayo Clinic. (2014). Peptic Ulcer. Retrieved from
http://www.mayoclinic.org/diseases-conditions/pepticulcer/basics/prevention/con-20028643
MedlinePlus. (2014). Bland Diet. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000068.htm
Myrtue Medical Center. (2008). Bland Diet Peptic Ulcer. Retrieved from
http://myrtuemedical.org/assets/pdf/dietary/bland-diet-for-peptic-ulcer.pdf
Nutrition Care Manual. (2014). Peptic Ulcer. Retrieved from
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2
=145083&ncm_toc_id=20009&ncm_heading=Nutrition%20Care
UC Davis. (2014). Nutritional Management of Gastrointestinal Diseases. Retrieved
from
http://nutrition.vetmed.ucdavis.edu/client_info_sheets/gastrointestinal_disease.cf
m
U.S. Department of Health and Human Services. (2014). H. pylori and Peptic Ulcers.
Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/hpylori/index.aspx
University of Maryland Medical Center. (2014). Gastritis. Retrieved from
http://umm.edu/health/medical/altmed/condition/gastritis
Kelsey Conrad
KNH 413 Spring 2014
Professor Matuszak
February 2, 2014
Diet Instruction: Celiac Disease
Patient and Diagnosis
The patient is a 22-year-old female collegiate tennis player at The Ohio State
University. At the age of 20, she sought medical treatment after experiencing several
bouts of gastrointestinal distress and was diagnosed with irritable bowel syndrome. Last
month, she began experiencing significant fatigue, joint pain, and muscle cramping.
These symptoms were initially attributed to the strenuous conditioning regimen that she
was participating in for her sport. When these symptoms did not subside and a skin rash
appeared she again sought medical treatment. She reported to the physician her diagnosis
of irritable bowel syndrome and, upon evaluation, the physician noted signs of
malnutrition. Due to all of these symptoms, he ordered a series of blood tests to identify
antibodies to gluten including anti-tissue transglutaminase (anti-tTG), endomysial IgA
(EMA), and anti-gliadin (AGA). The results of her tests were indicative of celiac disease
and the physician explained to her that the only current treatment for CD is nutrition
therapy consisting of a gluten-free diet. She was then referred to a registered dietitian to
educate her about a gluten-free diet and help aid her in adopting this new, challenging
diet.
Etiology
Celiac disease (CD) is an incredibly complex disease. Genetic, environmental,
and autoimmune factors triggered by the atypical reaction of the body to gluten
contribute to the etiology, but the exact cause of this condition is unknown (Nelms et al.,
2011). When an individual with this condition is exposed to the gliadin component of
gluten, the body produces an inflammatory response that results in damage to the
intestinal mucosa (Dugdale, 2012). The villi of the intestinal mucosa become shorter and
appear flat, resulting in reduced absorptive ability and malnutrition. Various
gastrointestinal symptoms are associated with CD, but other symptoms such as fatigue,
joint pain, depression, seizures, and skin rash also present themselves in CD patients
(Nelms et al., 2011). Because the symptoms of celiac disease vary person to person and
the GI symptoms of CD are common in various other conditions, the patient may initially
be misdiagnosed (Celiac Disease, 2011). Specific diagnostic criteria are being developed
and used to increase the rate of diagnosis. There is a genetic component associated with
the development of celiac disease. Additionally, women are more affected by this
condition than men (Celiac Disease, 2011).
Diagnostic Measures
The gold standard for diagnosing an individual with celiac disease is a biopsy of
the small intestine mucosa. This paired with subsequent indication of villous atrophy,
crypt hyperplasmia, andlymphocytic and plasma cell infiltration in the lamina propria
provides more evidence of the condition. Finally, the absence of symptoms upon the
removal of gluten from the diet results in diagnosis of CD. A more common diagnostic
measure is to perform blood tests to identify antibodies to gluten in the body. These
include anti-tissue transglutaminase (anti-tTG), endomysial IgA (EMA), and anti-gliadin
(AGA) with anti-tTG being the most commonly used to diagnose this disease (Nelms et
al., 2011). Genetic testing is also performed to identify individuals at a greater risk for its
development (Celiac Disease, 2012).
Treatment
There is currently no cure for celiac disease. There are no medical treatments or
surgical procedures that will cure this disease (Gluten Induced Conditions, 2011). The
only current treatment is medical nutrition therapy and the adoption of a gluten-free diet
(Understanding Celiac Disease, 2012). When gluten is removed from the diet, the
symptoms of the disease will subside and the villi of the intestinal mucosa will return to a
normal height and regular functionality (Celiac Disease Health Center, 2014). The
adoption of a gluten-free diet requires the individual to avoid all foods, beverages, and
medications that contain wheat, barley, rye, and possibly oats (Recommended Diet, 2012).
Individuals diagnosed with celiac disease should undergo nutrition assessment to
determine the extent of anthropometric changes and nutrient imbalances present. The
level of nutrition therapy administered to the patient depends on the condition of the
intestinal mucosa and the degree of malabsorption (Nelms et al., 2011). Typically, the
patient would be prescribed a gluten-free and lactose-free diet due to a lactase deficiency
commonly seen when the villi are damaged. As the villi regain their anatomical and
functional properties, lactose can slowly be added back into the diet (Nelms et al., 2011).
A gluten-free diet, however, is a life-long regimen. Individuals must be educated about
the food products and beverages containing gluten, as well as the medications, additives,
and ingredients that may contain gluten. Patients should be provided with a list of
allowed foods, foods to avoid, and foods to question. Educating the patient and
supporting the patient in this significant lifestyle change is crucial for the success and
health of the patient.
Being diagnosed with celiac disease as an athlete can be incredibly stressful.
Adopting a gluten-free diet while trying to compete at a high level can become very
complicated and challenging. Because of this, it is suggested that these athletes meet
with a registered dietitian as well as a sports psychologist (Mancini et al., 2011). Because
of the high demand for carbohydrate during athletic training, eliminating all sources of
wheat, rye, barley, and oats requires athletes to find alternative healthy sources of
carbohydrate to meet their energy needs. Some examples of these healthy sources of
carbohydrates include beans, rice, corn meal, corn flour, nuts, potatoes, tapioca, quinoa,
fruits, and vegetables. The athletes, coaches, and athletic training staff should all be
educated about the condition and what all it entails in order to best support the
individuals dealing with this condition. Another concern with individuals with celiac
disease is iron-deficiency anemia, and all athletes should be tested for this condition.
They should be advised to include iron-rich foods as a part of their gluten-free diet to
prevent complications associated with an iron deficiency. Additionally, vitamin D and
calcium deficiencies are commonly seen in individuals diagnosed with celiac disease.
Athletes, especially female athletes, should undergo assessment of bone mineral density
to identify these deficiencies and take measures to prevent injury during training.
Because celiac disease patients often experience lactose intolerance, athletes showing
signs of these deficiencies should add nondairy sources of calcium to the diet.
Multivitamin supplements, including vitamin D and calcium supplements are strongly
recommended for these athletes to resolve and prevent malnutrition and to ensure that
they are getting the nutrients they need to train and perform at their high level of
competition.
Prognosis
With the adoption of a gluten-free diet, the anatomy of the intestinal mucosa
returns to normal, malabsorption and maldigestion resolve, and the signs and symptoms
subside (Nelms et al., 2011). Unfortunately, some patients continue to experience
damage to the intestines despite the adoption of a gluten-free diet. This has been found to
be related to gluten contamination and cross-contamination, as well as the presence of
other diseases (Nelms et al., 2011). Most individuals, however, show significant
improvements with the restriction of gluten from the diet and can live essentially
symptom-free for a lifetime with the adoption of this lifestyle (Celiac Disease, 2013).
For athletes specifically, the adoption of a gluten-free diet may prevent some
additional challenges, but these athletes have the ability to perform at the highest level
despite the diet restrictions associated with this condition (Mancini et al., 2011). This
lifestyle change eliminates symptoms such as indigestion, abdominal pain, diarrhea, and
fatigue, improves energy levels during exercise, and helps to prevent complications such
as anemia, vitamin and mineral deficiencies, and bone mineral disturbances (Gluten
Sensitivity in Athletes, 2009). The elimination of these symptoms and the prevention of
these complications make athletic success possible for these individuals.
Celiac Disease Instruction Materials
The only treatment for celiac disease is the adoption of a gluten-free diet. The adoption
of this diet will alleviate symptoms associated with the condition and will allow the
intestines to regain their absorption and digestion ability. The principles of a gluten-free
diet include:

Avoid all foods made from or containing wheat, rye, and barley.

Avoid oats or only consume oats in small quantities.

Refer to food labels of processed foods because many of these products contain
gluten.

Beware of tablets, capsules, and vitamin products because many fillers in these
products contain gluten.

Avoid beer because it is made from barley.

If lactose intolerance is present, avoid milk and other dairy products that contain
lactose. Once the intestinal mucosa regains functionality, lactose intolerance may
no longer be a problem and lactose can be slowly added back to the diet.

Consume a daily multivitamin due to the vitamin and mineral deficiencies that
commonly result from the damage to the intestinal mucosa.

Supplement with iron, folic acid, vitamin B12, vitamin K, calcium, or vitamin D
if deficiencies are present.

Take measures to avoid gluten cross-contamination.

Understand the inconsistency in the amount of gluten allowed to be in foods
labeled “gluten free”.
(Gluten Free Diet, 2008)
Client 24-Hour Recall
Breakfast
Lunch
Dinner
2 Slices Whole Wheat
1 Whole Wheat Bun
¼ Cup Brown Rice
4 oz Luncheon Turkey
4 oz Marinated Chicken
Toast
1 Medium Banana
1 Cup Skim Milk
Lettuce
Tomato
1 Slice American Cheese
Breast
1 Cup Fresh Broccoli
1 Medium Sweet Potato
2 Tablespoons Mayo
1 Medium Apple
1 Cup Pretzels
Snacks/Miscellaneous
½ Cup Dry Roasted Peanuts
2 Beers
Reported Symptoms
Indigestion, abdominal pain, diarrhea, fatigue, joint pain, muscle cramping, skin
rash
Client Instructions
Breakfast:
Exchange whole-wheat toast for puffed rice cereal or grits
Exchange skim milk for lactose-free milk
Lunch:
Exchange whole-wheat bun for corn tortilla
Exchange luncheon meat for fresh meat
Exchange American cheese for cheddar or Swiss cheese
Ensure that the mayonnaise is pure
Exchange pretzels for popcorn
Dinner:
Use pure spices and herbs instead of marinade
Snacks/Miscellaneous:
Exchange dry-roasted nuts for raw nuts
Exchange beer for wine
Resources
Celiac Disease. (2011). In National Foundation for Celiac Awareness. Retrieved from
http://www.celiaccentral.org/Celiac-Disease/Diagnosis-Treatment/33/
Celiac Disease. (2012). In National Digestive Diseases Information Clearinghouse.
Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/index.aspx
Celiac Disease. (2013). In Celiac Disease Foundation. Retrieved from http://celiac.org/
Celiac Disease Educational Materials and Resources. (2013). In Celiac Disease
Awareness Campaign of the National Institutes of Health. Retrieved from
http://www.celiac.nih.gov/
Celiac Disease Health Center. (2014). In WebMD. Retrieved from
http://www.webmd.com/digestive-disorders/celiac-disease/celiac-disease
Dugdale, D.C. (2010). In MedlinePlus. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000233.htm
Gluten Free Diet. (2008). In Massachusetts General Hospital. Retrieved from
http://www.massgeneral.org/digestive/assets/pdf/gluten_free_diet.pdf
Gluten Induced Conditions. (2011). In Celiac Support Association. Retrieved from
http://www.csaceliacs.info/gluten_induced_conditions.jsp
Gluten Sensitivity in Athletes. (2009). In Sports, Cardiovascular, and Wellness Nutrition
(SCAN). Retrieved from http://www.scandpg.org/local/resources/files/2009/SDUSA_Fact_Sheet_Gluten_Sensitivity_In_Athletes_Oct%2009.pdf
Mancini, L.A., Trojian, T., & Mancini, A.C. (2011). Celiac disease and the athlete.
Current Sports Medicine Reports (American College of Sports Medicine), 10(2),
105-108.
Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L. (2011). Nutrition therapy &
pathophysiology: Second edition. Belmont, CA: Wadsworth, Cengage Learning.
Recommended Diet. (2012). In American Celiac Society Dietary Support Coalition.
Retrieved from http://www.americanceliacsociety.org/index.html
Understanding Celiac Disease. (2012). In Academy of Nutrition and Dietetics. Retrieved
from http://www.eatright.org/Public/content.aspx?id=5542
Maria Chambers
February 27, 2014
Diet Instruction: Clear Liquids
Patient History
Josie is a 32-year-old female living in Chicago, Illinois. She’s 5’5” (165.1 cm) and
weighs 250 lbs (113.64) with a BMI of 41.6 classifying her as obese. She has been
overweight her whole life and has spent a good portion of it following fad diets and
weight loss plans only to put the weight back on and even more than before her
dieting. About one year ago after her last attempt to lose weight and putting on an
additional 15 pounds, Josie made the decision to consult her doctor about bariatric
surgery. She is currently on step nine of the ten-step program. The first step
involves seeing if the patient qualifies for bariatric surgery. This includes having a
BMI greater than 40, over 18 years of age, and overweight for more than 5 years.
The patient should also make sure their insurance policy covers such surgery. The
second step is to attend an information session. During the information session, the
patient can meet the medical team and hear of a patient’s success story. The third
step is to schedule and attend the first appointment. During this appointment
patients can view an informational video about the procedure, meet the medical
team, and have the medical history reviewed. A dietitian will speak with the patient
about the patient’s current diet as well as how to improve the diet prior to the
surgery. A set of goals will be given that must be met before the surgery. A
psychologist will also meet with the patient to make sure there aren’t any mental
health concerns that need to be treated prior to the surgery. The fourth step is to
start an exercise program and lose some weight before surgery. The fifth step is to
come to the preoperative appointments and complete preoperative testing. The
sixth step is to meet with your surgeon. This is done once the appropriate changes
in the patient’s eating and exercise behaviors are seen. This is when the
appointment for the surgery will be assigned. The surgery will typically happen 2
months after the initial visit. The seventh step is to attend the pre-surgery skills
groups and an optional support group. These classes help establish lifestyle changes.
Step eight is to final pre-surgical appointments. During this appointment, the patient
will meet with the dietitian speaking about how to prepare for the surgery, what
will happen during the surgery and hospital stay, and postoperative
recommendations (Lahey Hospital and Medical Center, 2014). This is the current
meeting that we are in with Josie. During this meeting the dietitian will discuss a
clear liquid diet for Josie after her operation.
Discussion of the disease
Obesity is seen to be the result of an imbalance of energy between the calories
consumed and the calories expended. From a global perspective, there has been an
increased intake of energy-dense foods that are high in fat. There has also been an
increased amount of physical inactivity due to a multitude of reasons such as the
sedentary nature of work, various modes of transportation, and increasing
urbanization (WHO, 2013).
Obesity contributes as a major risk factor for many diseases including
cardiovascular diseases, diabetes, musculoskeletal disorders, and some cancers.
This disease can be prevented by having supportive environments and communities
that can positively shape people’s lifestyle choices. This includes healthier foods and
regular physical activity. Moreover, individuals can limit his or her intake of fats and
sugars, increase consumption of fruits and vegetables, whole grains, and nuts, and
participate in 150 minutes of physical activity per week (WHO, 2013).
Etiology
Obesity is developed when more energy is consumed than is expended. Factors
contributing to obesity include medical and psychiatric disorders, genetics, and an
obesigenic environment. Medical disorders that can result in obesity include
Cushing’s syndrome, hypothroidism, or Prader-Willi syndrome. Some
pharmacological treatments can cause weight gain as well. Eating patterns that can
contribute to obesity include night eating and binge eating. Genetics plays a role in
obesity because it affects body weight and body composition by increasing appetite,
taste preferences, energy intake, resting energy expenditure, the thermic effect of
food, and the efficiency the body has in storing energy (Nelms, 2011). It remains to
be difficult to differentiate the difference between genetics and the impact a
person’s environment has on body weight. An obesigenic environment is described
as that of low-cost energy dense foods and the availability of large portion sizes in
North America (Nelms, 2011).
A clear liquid diet is prescribed for patients right before a medical test or procedure,
specific types of surgery, or if certain digestive problems have occurred (Medline
Plus, 2012). It can also be recommended if certain digestive issues are present such
as nausea, vomiting, or diarrhea (Mayo Clinic Staff, 2011). In this case, a clear liquid
diet was prescribed for a post-bariatric surgery. A clear liquid diet is necessary to
maintain vital body fluids, salts, and minerals. It can provide some of the necessary
energy when normal and solid foods cannot be consumed. The reason this is
recommended the day before surgery is because the body can easily absorb clear
liquids. Clear liquids don’t stimulate the digestive system that normal foods would
and therefore do not leave any residue in the intestinal tract (UCLA). They require
very little digestion. A clear liquid diet does not provide adequate energy and
nutrients and therefore should not be maintained for a long time unless highprotein gelatin and other low-residue supplements are consumed along with the
clear liquids (Stanford). It should be limited to 24 to 48 hours unless supplements
are added (Nelms, 2011).
Diagnostic Measures
Obesity is classified as having a body mass index (BMI) of 30 kg/m2 or higher. This
is calculated by dividing the body weight of the individual (kg) by the height (m2).
Obesity is a risk factor for a multitude of health conditions including diabetes,
cardiovascular diseases, and cancer (WHO, 2013).
Treatment
Treatment for obesity includes assessment and management. The assessment
portion includes calculating the person’s BMI, measuring the waist circumference of
the individual, evaluating the person’s dietary and exercise habits, and also
determining the person’s readiness to lose weight. The management portion of
treatment includes using therapies to lose and maintain weight loss and using the
therapies to control disease risk factors. For some patients, pharmacologic
treatment and bariatric surgery are appropriate (Nelms, 2011). Bariatric surgeries
are recommended for those who have a BMI over 40 kg/m2 and have not lost
weight by other less invasive ways. There are four different types of bariatric
surgeries including adjustable gastric banding, vertical sleeve gastrectomy, Rouxen-Y gastric bypass, and biliopancreatic diversion with duodenal switch (Nelms,
2011).
Medical, surgical and/or psychological treatment
Josie is getting the Roux-en-Y gastric bypass surgery (RYGB). This surgical
treatment creates a small pouch located at the top of the stomach. This pouch
restricts food intake, and induces satiety quickly. The food bypasses the remainder
of the stomach, the duodenum, and the beginning part of the jejunum. With the
bypassing of these parts, this reduces the amount of food digestion and nutrient
absorption. The procedure will be performed laproscopically (Nelms, 2011).
Medical Nutrition Therapy
After the bariatric surgery, Josie should be on a clear liquid diet for one to two days.
From there she will have liquids or pureed foods for at least three to six weeks after
the surgery. Soft food and then regular food will then be added slowly back into the
diet at least one month after the surgery (Johns Hopkins Medicine Health Library).
Today I will be instructing Josie on a clear liquid diet that she should consume for 24
to 48 hours after her surgery.
Recommended clear liquids include: water, tea, or coffee (plan without milk or
cream), strained fruit juices without pulp (lemonade and apple juice), soft drinks
and sports drinks (ginger ale, Sprite, Gatorade), chicken/beef bouillon/broth – low
sodium and fat free, gelatin (Jell-o – no fruit or toppings, stick with lemon, lime, or
orange), popsicles (no fruit bars or sherbets), and hard candies (Stanford). The goal
and suggested amount of fluid is around 2-4 ounces of fluid per hour totaling to 64
ounces per day (Saint Clares).
Avoid: anything with red or purple coloring –this can leave a residue that resembles
blood in the bowel, no solid food, and no milk or milk products (Stanford Medicine,
2014).
Prognosis
Josie’s clear liquid diet is intended to provide her with fluid and some energy
without causing a lot of stimulation of the gastrointestinal tract. A full liquid diet is
then prescribed which is a good transition between clear liquid and solid food. A full
liquid diet includes all clear liquids, cream soups, milk, ice cream, pudding, and
yogurt (Nelms, 2011). From this diet, Josie can progress on to soft foods and then
normal foods. There is considered to be three phases after bariatric surgery in
regard to nutrition therapy. The first phase is a clear liquid diet for the first 48 hours.
The second phase is a full liquid diet. The patient should consume 3 to 4 ounces at
one time over a 20 to 30 minute period and consume 3 meals each day. The third
phase should take place about one month after the procedure and continue
throughout the person’s life. This phase includes a solid food diet consisting of 3 to 4
ounces of low fat and low sugar choices (Saint Clares).
Instruction Materials
Foods Allowed
Plain water
Fruit juices without pulp
Strained lemonade or fruit punch
Clear, fat-free broth
Clear sodas
Plain gelatin
Honey
Ice pops (no bits of fruit or fruit pulp)
Tea or coffee (no milk or cream)
Foods to avoid
Avoid liquids or gelatin with red or
purple coloring
Dairy products
**Anything not on the list should be
avoided
References
Clear liquid diet guidelines (2014). Stanford Medicine. Retrieved from
http://cancer.stanford.edu/surgery/colorectal/clearLiquidDiet.html
A clear liquid diet (N.D.). UCLA. Retrieved from
http://pancreas.ucla.edu/workfiles/For_Patients/Clear_Liquid_Diet.pdf
Clear liquid diet (2014). Saint Vincent Health. Retrieved from
http://www.saintvincenthealth.com/Services/Colon-and-Rectal-Surgery/PatientEducation/Clear-Liquid-Diet/Default.aspx
Diet-clear liquid (2012). Medline Plus. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000205.htm
Gastric Banding Progression Diet (N.D.). Saint Clares. Retrieved from
http://www.saintclares.org/assets/Uploads/Bariatrics_Images/Gastric-BandingProgression-Diet-Booklet.pdf
Mayo Clinic Staff (2011). Clear liquid diet. Retrieved from
http://www.mayoclinic.org/clear-liquid-diet/art-20048505?pg=1
Nelms, Sucher, Lacey, Long Roth. (2011). Nutrition Therapy & Pathophysiology.
Belmont, CA: Brook/Cole Cengage Learning.
Roux-en-Y Gastric Bypass Weight-Loss Surgery | Johns Hopkins Medicine Health
Library. (n.d.). Retrieved from
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology
/roux-en-y_gastric_bypass_weight-loss_surgery_135,65/
Step-by-step guide to surgical weight loss (2014). Lahey Hospital and Medical
Center. Retrieved from
http://www.lahey.org/Departments_and_Locations/Departments/Medical_and_Sur
gical_Weight_Loss_Center/Step-By-Step_Guide_to_Surgical_Weight_Loss.aspx
WHO: Obesity and overweight. (2013). Retrieved from
http://www.who.int/mediacentre/factsheets/fs311/en/
Medical Nutrition Therapy Diet
1. Purpose
a. Nutrition indicators
Assessment by a registered dietitian is required to establish
appropriate nutrient
and energy intake and to determine meal plans
b. Criteria to assign the Diet
Two consecutive measurements of an A1C level of >7 or a fasting
blood glucose of >126 is diagnosed as type 2 diabetes and meets the
criteria for a diabetic diet involving regulation of carbohydrate
consumption.
c. Rationale for Diet
MNT is recommended for individuals with Type 2 diabetes to instruct
them in managing carbohydrate intake to maintain glycemic control.
Individuals should also be presented with information on best types
of carbohydrates, adequate intake of fiber, better fat choices and
adding exercise. This information will help them control their blood
sugar and alleviate potential diabetic complications such as
neuropathy, retinopathy and cardiovascular disease.
2. Population
a. Overview
Type 2 diabetes accounts for 90-95% of all diagnosed diabetes cases.
It is progressive disease. Symptoms develop gradually and may not
be severe enough for the individual to recognize them as such.
Individuals with Type 2 diabetes typically do not develop ketoacidosis,
but are at risk for macrovascular and microvascular complications
Type 2 diabetes has a genetic predisposition and the risks increase
with age, obesity and lack of physical activity. Typically, persons
diagnosed are over 40, but it is currently being seen in young adults,
adolescents and children
Type 2 diabetes has two major pathophysiological abnormalities:
insulin resistance (associated with increased hepatic glucose
production and reduced glucose clearance) and insulin deficiency
(impaired beta cell secretion). Insulin resistance can be present
many years before the development of diabetes, but as long as the
beta cells of the pancreas can secrete adequate insulin, blood glucose
will remain normal. Once the beta cells cannot produce adequate
insulin, insulin deficiency develops and hyperglycemia results.
Therapy to lower blood glucose is required as soon as possible to
prevent the negative effects of hyperglycemia on the body.
b. Disease Process
Type 2 diabetes results from a combination of insulin resistance and
beta cell failure. Insulin levels may be depressed, normal or elevated,
but are inadequate to overcome the decreased tissue responsiveness
to insulin. This results in hyperglycemia. Hyperglycemia is first noted
by an elevation of postprandial blood glucose and then by elevated
fasting blood glucose levels.
Insulin resistance is first seen in muscle and liver tissues and in fat
cells. Initially, insulin levels increase to compensate for this
resistance, but eventually, insulin production declines as the disease
progresses. As insulin decreases and the cells are receiving less
glucose, hepatic production of glucose increases which leads to
hyperglycemia or glucotoxicity.
Insulin resistance is seen at the adipocyte level which can lead to
lipolysis and elevated levels of free fatty acids in circulation.
Increased free fatty acids can result in decreased insulin sensitivity,
impaired pancreatic insulin secretion and increased hepatic glucose
production. This results in a condition called lipotoxicity which arises
from insulin resistance of the adipose cells.
Viscera, or abdominal fat, in particular, releases excessive free fatty
acid. The increase in free fatty acid reduces glucose utilization by
skeletal muscle, insulin secretion by the pancreas and increases
glucose production in the liver.
c. Biochemical and Nutrient Needs
A client with Type 2 diabetes can consume a ‘normal’ diet, but must
monitor carbohydrate intake to insure that it is even distributed
throughout the day. The client should also consume less than 5% of
their calories in saturated fats, choosing mono and poly unsaturated
fats instead. The client may follow the standard 50-55%
carbohydrate, 15-20% protein and 20-30% fat guidelines stated for a
non diabetic population.
3. General Guidelines
a. Nutrition Rx
Determine individual energy needs, manage and schedule
carbohydrate intake to maintain stable blood glucose levels, maintain
or reduce weight and reduce risk of diabetic complications (especially
hypertension and hyperlipidemia) while meeting nutritional DRI.
b. Adequacy of nutrition Rx
A diabetic diet is nutritionally sound, incorporating adequate energy,
carbohydrates, fats, fiber and protein.
c. Goals
The goals of the diabetic diet are :
1) maintain blood glucose levels as close to normal as possible
2) maintain cardiovascular health
3) maintain or reduce weight
4) prevent diabetic complications
5) increase physical activity to improve health and assist with blood
glucose management
d. Does it Meet DRI
A carefully planned diabetic diet meets DRI.
4. Educational Material
Diabetes and Diet,
http://www.eatright.org/Public/content.aspx?id=6813
Eating Right with Diabetes,
http://www.eatright.org/Public/content.aspx?id=10748
What Can I eat? http://www.diabetes.org/food-andfitness/food/what-can-i-eat/
Tips for compliance
Use a scale and measuring tools to insure that you are consuming the
correct portion sizes!
5. Sample Menu
a. Foods Recommended
Although all foods can be part of a diabetic diet, whole grains, fresh
fruits and vegetables, dairy and lean proteins are especially
recommended to maintain healthy levels of blood glucose.
b. Foods to avoid
As with any diet, foods with high caloric content and little nutritional
value should be avoided. Some examples of these would be regular
soda, cakes and/or cookies and high fat, processed meats. These can
be consumed occasionally if they are included in the carbohydrate
count for the day.
c. Example of a meal plan
Carbohydrates should make up 50-55% of total calories. A diet of
1500 calories would consist of between 187g and 206g of
carbohydrates. A carb unit is the equivalent of 15g of carbohydrates,
so this is equivalent to between 12.5 and 13.75 carb units per day.
This is a sample menu based on 12.5 units
Meal
Amount
Grams of
Carbohydrate
High fiber
1C
30
breakfast cereal
Skim milk
1C
12
Banana
½
15
Lunch
Turkey and Swiss
sandwich
Carrot sticks, grape
tomatoes, celery
Low fat ranch
dressing
Large apple
Skim milk
Dinner
Butternut squash
Whole wheat
dinner roll with
margarine
Broccoli, steamed
Tossed salad
Low fat Italian
dressing
Baked Tilapia with
lemon
Snack
Fruit flavored fat
free sugar free
yogurt
Carb unit
2
1
1
2 slices whole
wheat bread
2 oz turkey
1oz low fat Swiss
1T low fat mayo
1t mustard
½ c each
30
2
0
0
0
0
5
0
0
0
0
Free *
2T
0
1
1C
30
12
2
1
1C
1 small
2t
15
15
1
1
½C
1C
1T
5
5
Free*
Free*
3 oz
0
0
6 oz
12
1
Total
186
* 3 ‘free’ carb units is the equivalent of one carb unit.
13
6. Websites
a. Organizations with Websites
American Diabetes Association, http://www.diabetes.org/
Academy of Nutrition and Dietetics, www.eatright.org
b. Government Websites
National Institutes of Health, Medline Plus;
http://www.nlm.nih.gov/medlineplus/diabetes.html
US Department of Health and Human Services;
http://diabetes.niddk.nih.gov/dm/pubs/overview/
7. References
a. Journal Articles References
Martins, M.R,; Ambrosio A.C.T,; Nery M.;Aquino, R dC,; Queiroz, M.S., 2014,
Assessment guidance of carbohydrate counting method in patients with type 2
diagetes mellitus; Primary Care Diabetes, Volume 8, issue 1, p. 39-42
Kulkarni, K; 2005, Carbohydrate counting; a practical meal planning option for
people with diabetes, Clinical Diabetes, Volume 23, issue 3 p. 120-124
Type 2 Diabetes, 2014, retrieved from Nutrition Care Manual,
http://www.nutritioncaremanual.org
Zach Pfirrman
KNH 413
3/16/14
Diet Instruction: Burn Victim, High Protein Diet
Patient Description & Diagnosis:
Client's Name: Julian Dickens
DOB: February 4th, 1984 (30 y/o)
Sex: Male
Weight: 210 lb.
Height: 6' 1''
Occupation: Construction Worker
Julian was admitted to the UC Hospital Burn Center after suffering from severe
burns in a fire that started at the construction site he works at. Julian suffered
superficial partial-thickness and some deep partial-thickness burns to his legs,
calculated at 20% of his skin area. He has underwent procedures to clean, debride,
and dress his wounds. He also needed to have skin grafting done on a few areas
where he was severely burned. He is getting silver nitrate cream applied between
dressings to prevent infection. His doctor has placed Julian on a High Energy, High
Protein Diet. Julian has already had a discussion with a RD about the prescribed diet.
Diet Recall
Julian's latest calorie count is lower than it should be. He had taken in 125g of
protein, which is low for what he was prescribed to take in. Also his nitrogen
balance measurements show that his nitrogen losses have decreased since Julian's
admission, but nitrogen losses are indicating that Julian is not taking in enough
protein for proper wound healing.
Etiology:
Burns can result from many different sources, the most common being thermal
exposure, such as direct contact with a heat source like fire or steam. Other types of
burns include chemical, electrical, and radiation exposure. Chemical burns are
suffered when the skin comes in direct contact with and acidic or alkaline
substances. Electrical Burns occur when an electrical current passes through the
body, damaging the skin, muscles, and even bone. Sun burns would be considered a
radiation burn.
Diagnostic Measures:
Burn injuries are diagnosed by determining the extent of the burn injury. The extent
of the burn is measured with two factors: the depth of the burn and the Body
Surface Area (BSA) affected. The depth of the burn is characterized in four main
classifications: Superficial burns, Superficial Partial-thickness burns, Deep Partialthickness burns, and Full-thickness burns. Superficial burns are caused by very
short exposure to high heats that burn the top layer of the epidermis or can be
caused by long exposure to ultra-violet light, causing a sun burn. These types of
burns are painful, but heal within one week. Superficial Partial-thickness burns can
be caused by short exposures to extremely hot sources like fire of boiling water.
They are very painful and may produce blistering, weeping wounds. These tend to
heal within a 1-3 weeks. When Deep Partial-thickness burns occur, the epidermis
and some, if not most, of the dermis layer of skin is destroyed. This is usually not as
painful because of the destruction to nerve endings. Grafting may be required for
this type of burn and it takes usually 21+ days to recover from these burns. Fullthickness burns destroy all layers of the skin and may do some damage to muscle,
organs, or bone. Skin grafting is almost always necessary and there is a severe risk
of contracture, which is when the burn scars thicken and tighten, preventing
movement.
The method of measuring the BSA affected is called the Rule of Nines. The
body is divided into sections that have a percentage value of nine or a derivative of
nine. The head and neck have a value of 9, measured by the front of the head at 4.5
and the back at 4.5. Each arm is valued at 9 with the front and back of each arm
having a value of 4.5. The chest and abdomen are scored separate, each having a
value of 9. Just the same, the upper and lower back have separate values of 9. The
genital area holds a value of 1. Each leg is scored with the front and back being 9, so
the legs total value is 36.
Protein catabolism declines with wound coverage and healing. Adequacy of
protein intake can be evaluated by following:
 Wound healing of burn and donor sites
 Adherence of skin grafts
 Nitrogen balance
Treatment:
For severe burns, patients will go through procedures that keep the wound sites
clean to prevent the possibility of infection. Sometimes the top layers of skin are
destroyed in a burn, but the dead skin tissue remains attached the body. In these
cases, a procedure known as Debridement is done. Debridement is the medical and
manually removal of all the layers of dead skin from a burn area. When burns are
deep enough, such as in full-thickness burns, skin grafting becomes necessary. Skin
grafting is done by a piece of skin is surgically sewn over the burn after dead tissue
is removed. After such procedures, the application of topical agents such as silver
sulfadiazine cream and silver nitrate to prevent infection, followed by dressing the
wound with sterile dressings.
Medical Nutrition Therapy
First thing to do is to calculate Mr. Dickens' energy needs and from that we can find
out how much Protein he should be receiving. I decided to use the Curreri formula
which is specifically used to find the energy needs of burn victims.
The Curreri formula:
(25 kcal x kg of body weight) + (40 kcal x %TBSA)
25 x 95.5 + 40 x 20 = 3187.5 rounded to 3200 kcal/day
Burn victims should be receiving more protein than is usually prescribed to the
average patient because their wounds quickly sap any protein in the body. It has
been estimated that as much a 20% of body protein can be lost within the first two
weeks of a burn injury. It is recommended that a burn patient with severe burns
should receive 20-25% of total kilocalories in protein alone.
Protein:
3200kcal x 20-25% = 640-800kcal of PRO / 4kcal/g = 160-200g PRO/day
Julian's diet recall shows that he only took in 125g of protein. That is 35g under the
minimum amount he should be taking in. So my plan is to have a discussion with
him about how to ensure that he receives enough protein. I will have him receive his
normal 3 meals, but include two Ensure High Protein shakes, one between breakfast
and lunch, and one between lunch and dinner. This will boost his protein intake by
50g. I will also discuss with him what foods are the best sources of protein and how
to hide extra protein into his meals.
Prognosis
If we can get Julian to regularly take in 160-200g of protein a day, the nitrogen
losses would decrease which will optimize wound healing. By keeping up with this
diet he will better maintain weight and strength and should have a normal recovery.
Foods Recommended

Eat 3 meals and at least 3 snacks every day.

Include at least one of the following at each meal:
◦ Meat
◦ Eggs
◦ Peanut butter
◦ Tofu
◦ Dried beans
◦ Lentils
◦ Milk
◦ Yogurt
◦ Cheese

Eat a variety of fruits and vegetables.

Eat a variety of breads, cereals, pasta, potatoes, and rice.
Sample of a meal plan
Breakfast
2 well-cooked eggs (prepared any way)
2 oz sausage
1/2 cup yogurt
12 cup banana
1 slice whole-wheat toast
1 cup milk
Snack
½ cup nuts
Lunch
Tuna salad sandwich
2 slices whole-wheat bread
1/2 cup carrots
1 peach
1 cup milk
Snack
1/2 cup yogurt
Evening Meal
4 oz chicken breast
1 medium potato
1/2 cup mixed vegetables
1 apple
1 slice whole-wheat bread
1/2 cup ice cream
1 cup milk
High Protein Shake
References
Snack
Burns. (2013, February 14). University of Maryland Medical Center. Retrieved March
19, 2014, from http://umm.edu/health/medical/altmed/condition/burns
Burns Part 2 (Early Excision of the Burn Wound) . (2011, November 4). Short Notes
in Plastic Surgery. Retrieved March 16, 2014, from
http://shortnotesinplasticsurgery.wordpress.com/2011/11/04/18-burnspart-2-early-excision-of-the-burn-wound/
Burns: Nutrition Prescription. (n.d.). NCM Nutrition Care Manual eat right. Retrieved
March 17, 2014, from
http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=92068&highlig
ht=burns
Burns: Nutritional Considerations. (n.d.). NutritionMD.org ::. Retrieved March 16,
2014, from
http://www.nutritionmd.org/health_care_providers/integumentary/burns_
nutrition.html
Medical Student LC. (n.d.). Classification of Burn Depths. Retrieved March 16, 2014,
from http://www.medstudentlc.com/page.php?id=84
Nelms, M. N. (2011). Metabolic Stress and the Critically Ill. Nutrition therapy and
pathophysiology (2nd ed., pp. 692-696). Belmont, CA: Wadsworth, Cengage
Learning.
University of Rochester Medical Center. (n.d.). University of Rochester Medical Center.
Retrieved March 14, 2014, from
http://www.urmc.rochester.edu/Encyclopedia/Content.aspx?ContentTypeI
D=90&ContentID=P01754
Ellen Swary
Diet Instruction: High-Iron Diet
March 13, 2014
Description of Patient and Diagnosis
Allie is a 21 year-old female who is 5 feet 5 inches (165 cm) and weighs 124
pounds (56 kg). Allie is a college student who is active in her studies and loves to
run and has recently been diagnosed with iron deficient anemia due to her Celiac’s
Disease. Because she is always on the go, Allie tends to consume lots of prepackaged, fast-food meals and lacks fruits and vegetables in her diet.
Allie has recently been feeling very fatigued and occasionally is short of
breath, dizzy or has headaches. After doing a physical exam as well as running some
blood tests, her doctor found her hemoglobin level to be at 8.0 g/dL, indicating
moderate anemia, and a hematocrit level below 36%, which is an indicator of
anemia. Her doctor has referred her to a Registered Dietitian in order to help her
improve her eating habits and anemia status.
Discussion of the Disease
A. Etiology- Causation or origination of disease
Anemia is a disease, which occurs when an individual’s blood does not have
enough healthy red blood cells. Anemia can be temporary, or long term, and can
range from mild to severe cases. This can occur in a few circumstances, including
when the body does not make enough red blood cells, bleeding causes loss of red
blood cells more quickly than the body can replace them, or when the body destroys
red blood cells.
Red blood cells are contained within hemoglobin, which is the red, iron-rich
protein that gives blood its red color. Hemoglobin allows red blood cells to carry
oxygen to the lungs and carry carbon dioxide from other parts of the body to the
lungs to be expelled from the body. In order for the body to make enough blood cells,
certain vitamins, minerals and nutrients are needed for proper function. Three
important vitamins and minerals to consider are iron, vitamin B12, and folic acid.
Essentially, without these three components, the body can’t effectively carry oxygen
throughout the body, making it difficult for individuals to live their daily life.
Individuals with Celiac’s Disease are prone to inflammation and damage to
the lining of the intestine, which can prevent the absorption of iron, vitamin B12 and
folic acid. Additionally, poor diet (where there is a lack of vegetables and fruits rich
in vitamins, minerals and iron) and blood loss (heavy menstrual periods) can also
contribute to symptoms of anemia.
B. Diagnostic Measures
Suspicion of anemia may result due to general findings in a physical
examination and medical history, which may include tiring easily, pale skin and lips,
or a fast heartbeat. Additionally, it can be detected through medical examination and
blood tests that measure the concentration of hemoglobin and the number of red
blood cells. A complete blood count (CBC) should be conducted in order to measure
the red blood cells, white blood cells and platelets, this will include measurements of
hemoglobin, hematocrit and mean corpuscular volume, which can help indicate
whether a patient is anemic or not. Other blood tests can indicate the status of iron
levels, including the serum ferritin, serum iron, and total iron binding capacity,
which are also indicators for anemia. Below are the lab values summarized, which
would indicate an individual to be anemic:
Severity of anemia can be measured through hemoglobin levels:
Severity
Hemoglobin Concentration
Mild Anemia
9.5-13.0 g/dL
Moderate Anemia
8.0-9.5 g/dL
Severe Anemia
<8.0 g/dL
A diagnosis of anemia can be clarified if hematocrit levels fall below:
 39% for adult men
 36% for adult non-pregnant women
 33% for adult pregnant women
The following chart summarizes iron levels that would be normal, but if lower or
higher may indicate anemia (depending on the specific type)
Test
Serum Ferritin
Serum Iron
Total Iron Binding Capacity
Level (for women)
12-150 ng/mL
High- hemolytic anemia
Low- iron deficient anemia
60-170 mcg/dL
High- hemolytic anemia or Vitamin B12
Low- iron deficient anemia or anemia of
chronic disease
High- iron deficient anemia
Low- anemia of chronic disease
C. Treatment
i. Medical, surgical and/or psychological treatment
The status of Allie’s anemia is not harmful enough for surgical treatment, but
medical treatment may be necessary. Oral iron supplements are often
recommended for anemic patients. Depending on the severity, age, and weight, the
doctor can prescribe a oral supplement in doses ranging from 60-200mg. Oral iron
supplementation is the best way to restore iron levels for people who are iron
deficient, but this should only be used when dietary measures have failed. In
extreme cases, procedures including blood transfusions and blood and marrow stem
cell transplants may be needed. Evaluating Allie’s diet and making adjustments
where necessary would be beneficial for beginning her treatment plan.
ii. Medical Nutrition Therapy
Using a nutrient calculator while reviewing Allie’s 24-hour recall, it is evident
that she is lacking in her iron intake as well as her total caloric needs. With someone
who always on the go and busy in school, it is important that she consumes the right
balance of foods in order to receive the proper amount of calories on a daily basis.
The following calculations show Allie’s energy needs based on her height, weight,
age and activity level:
Harris Benedict:
Women: 655+ (9.56 x kg) + (1.85 x cm) – (4.68 x age)
655+ (9.56 x 56) + (1.85 x 165) – (4.68 x 21)
= 1400 kcalories
Physical Activity Level: 1.4
1400 x 1.4 = 2,000 kcalories
Additionally, it is recommended that someone Allie’s age should consume at
least 18 mg of iron daily in their diet. It is also important to consider that due to her
Celiac condition, consuming more than 18 mg of iron would be beneficial to Allie’s
health, due to complications with absorption of iron in relation to this disease.
Setting an initial goal of receiving 18 mg of iron through her diet would be helpful.
It is necessary for Allie to increase her consumption of fruits and vegetables
as well as consider combining certain food choices to optimize the iron absorption
for her body. While the RDA for someone’s Allie’s age is 18mg, consuming more iron
would be beneficial in her case. Iron overload would likely only be of concern if
supplementation were to be implemented into her daily intake. It is vital that Allie
learn some key factors that will influence the absorption of her iron, as well.
Meat proteins and vitamin C will improve the absorption of nonheme iron,
which is found in plant sources. Allie should get about 75mg or more of vitamin C
per day. To put that into perspective, 1 medium sized orange has about 70 mg of
vitamin C. Additionally, tannins, calcium, polyphenols and phytates (found in
legumes and whole grains) can decrease the absorption of nonheme iron. Heme iron
comes from animal sources, is more readily absorbed than nonheme, and is not
significantly affected by other foods in the diet.
24-Hour Recall
2 scrambled eggs
Chobani Greek Yogurt
Mcdonald’s Chicken Nuggets
Mcdonald’s Medium French Fries
Gluten free penne pasta
Tomato Basil pasta sauce
Kashi Peanut Butter Granola Bar
Naked Strawberry Banana Fruit
Smoothie
Total Calories: 1,780 Kcalories
Total Iron: 3 grams
Assessment
 Age: 21
 Height: 165 centimeters
 Weight: 56 kilograms
 Previously diagnosed with Crohn’s Disease
 Hemoglobin level to be at 8.0 g/dL - indicating moderate anemia
 Hematocrit level below 36% (anemic)
Diagnosis
 Inadequate iron intake related to food choices as evidence by 24-hour recall.
 Inadequate energy intake related to food choices as evidence by a 24-hour
recall.
Intervention
 Goal: Increase iron intake to a minimum of 18 grams (RDA) by incorporating
iron rich foods into the client’s diet. Educate them on good food
combinations and food choices to allow for proper iron intake and
absorption.
 Goal: Increase caloric intake to around 2000 kcalories per day and balance of
nutrients to allow for adequate energy needs. Educate the client on proper
caloric needs and provide menu ideas.
Monitor & Evaluate
 Monitor client compliance with new food suggestions and evaluate changes
in energy level. Continue regular check-ups in order to assess whether
adjustments in the diet or oral supplements are necessary.
iii. Prognosis
Although the outcome of anemia depends on the cause, if treated and cared
for appropriately through diet and supplementation, if necessary, then the outcomes
are likely to be good. In Allie’s case, however, other complications may result due to
her status of Celiac’s Disease.
References
Anemia and Iron-rich Foods. (2010, May). Retrieved from
http://my.clevelandclinic.org/disorders/anemia/hic-anemia-and-iron-richfoods.aspx
Anemia : Diagnostic Procedures | Florida Hospital. (2013). Retrieved from
https://www.floridahospital.com/anemia/diagnostic-procedures
Anemia: MedlinePlus Medical Encyclopedia. (2011). Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000560.htm
Anemia | University of Maryland Medical Center. (2013, September 18). Retrieved
from http://umm.edu/health/medical/reports/articles/anemia
Celiac disease - sprue: MedlinePlus Medical Encyclopedia. (2012, February 19).
Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000233.htm
Dietary Supplement Fact Sheet: Iron — Health Professional Fact Sheet. (2007, August
24). Retrieved from http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/
Iron deficiency anemia: MedlinePlus Medical Encyclopedia. (2013, March 3).
Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000584.htm
Nahikian-Nelms, M. (2011). Nutrition therapy and pathophysiology. Belmont, CA:
Wadsworth, Cengage Learning.
Vitamin C — Health Professional Fact Sheet. (2013, June). Retrieved from
http://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/#h2
What Are the Signs and Symptoms of Anemia? - NHLBI, NIH. (2012, May 18).
Retrieved from
http://www.nhlbi.nih.gov/health/healthtopics/topics/anemia/signs.html
Good Sources of Iron
Good Heme Sources: animal sources that are better absorbed in the body
 Beef (chuck roast, lean ground beef)
 Turkey
 Tuna
 Eggs
 Shrimp
 Lamb
Good Nonheme Sources (from plants):
 Cereals (check labels for enrichment)
 Beans (kidney, lima, Navy)
 Tofu
 Lentils
 Spinach
 Quinoa
 Peanut butter
 Brown rice
 Dried Fruit
 Beans: White, Lima, Soy
Combining nonheme iron sources with a source of vitamin C will help with
absorption, for example, it would be good to consume an orange at breakfast with
iron fortified breakfast cereal.
Good Sources of Vitamin C
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Citrus fruit: oranges, grapefruit, Clementine’s
Kiwi
Canataloupe
Orange Juice
Green & Red Peppers
Strawberries
Broccoli
Tomato juice
Spinach (cooked)
Additional education on reading a nutrition facts panel may also be helpful
for Allie to monitor the amount of calories she is consuming and knowing the iron
content of some of her foods. An example nutrition facts panel (below) could be
used for demonstration:
Rachael Hunt
KNH 413
Diet Instruction
Weight Reduction
Patient:
Patient: G.M
Age: 36
Sex: female
Weight: 183
Ht: 5’3’
Occupation: receptionist
Medical Concerns:
Obesity, SOB, sleep apnea, HTN, BMI 36
Diagnosis:
Obesity Stage 2 as evidence by B=36
24-hour recall:
Breakfast- 3 pieces of French toast with butter 2 tablespoons maple syrup
3 sausage patties
½ cup hash browns
1 cup coffee with ½ cup 2% milk
1 cup orange juice
Lunch- 2 grilled cheese sandwiches made with 4 slices of white bread and ½ cup
shredded cheddar
12-ounce coca-cola
½ cup chocolate ice cream
Snack- 2 peanut butter sandwiches
1-cup water
Dinner- Fried chicken (2 thighs an 1 leg)
½ cup Mac and cheese
1 baked potato with 1-tablespoon butter
2 sweet rolls with butter
1-cup water
Snack- 1/3-cup popcorn and 5 Oreo cookies
1 cup 2% milk
Calories: 3,000kcals
Fat: 120g
Protein: 115g
Etiology:
Although there are genetic and hormonal influences on body weight, obesity occurs
when you take in more calories than you burn through exercise and normal daily
activities. Your body stores these excess calories as fat. Obesity usually results from
a combination of causes and contributing factors, including:
 Inactivity. If you're not very active, you don't burn as many calories. With a
sedentary lifestyle, you can easily take in more calories every day than you
use through exercise and normal daily activities.
 Unhealthy diet and eating habits. Having a diet that's high in calories,
eating fast food, skipping breakfast, eating most of your calories at night,
drinking high-calorie beverages and eating oversized portions all contribute
to weight gain.
 Pregnancy. During pregnancy, a woman's weight necessarily increases.
Some women find this weight difficult to lose after the baby is born. This
weight gain may contribute to the development of obesity in women.
 Lack of sleep. Getting less than seven hours of sleep a night can cause
changes in hormones that increase your appetite. You may also crave foods
high in calories and carbohydrates, which can contribute to weight gain.
 Certain medications. Some medications can lead to weight gain if you don't
compensate through diet or activity. These medications include some
antidepressants, anti-seizure medications, diabetes medications,
antipsychotic medications, steroids and beta-blockers.
 Medical problems. Obesity can sometimes be traced to a medical cause,
such as Prader-Willi syndrome, Cushing's syndrome, polycystic ovary
syndrome, and other diseases and conditions. Some medical problems, such
as arthritis, can lead to decreased activity, which may result in weight gain. A
low metabolism is unlikely to cause obesity, as is having low thyroid function.
Risk Factors:
Obesity occurs when you eat and drink more calories than you burn through
exercise and normal daily activities. Your body stores these extra calories as fat.
Obesity usually results from a combination of causes and contributing factors,
including:
 Genetics. Your genes may affect the amount of body fat you store and where
that fat is distributed. Genetics may also play a role in how efficiently your
body converts food into energy and how your body burns calories during
exercise. Even when someone has a genetic predisposition, environmental
factors ultimately make you gain more weight.
 Inactivity. If you're not very active, you don't burn as many calories. With a
sedentary lifestyle, you can easily take in more calories every day than you
burn off through exercise and normal daily activities.
 Unhealthy diet and eating habits. Having a diet that's high in calories,
eating fast food, skipping breakfast, consuming high-calorie drinks and
eating oversized portions all contribute to weight gain.
 Family lifestyle. Obesity tends to run in families. That's not just because of
genetics. Family members tend to have similar eating, lifestyle and activity
habits. If one or both of your parents are obese, your risk of being obese is
increased.
 Quitting smoking. Quitting smoking is often associated with weight gain.
And for some, it can lead to a weight gain of as much as several pounds a
week for several months, which can result in obesity. In the long run,
however, quitting smoking is still a greater benefit to your health than
continuing to smoke.
 Pregnancy. During pregnancy a woman's weight necessarily increases. Some
women find this weight difficult to lose after the baby is born. This weight
gain may contribute to the development of obesity in women.
 Lack of sleep. Not getting enough sleep at night can cause changes in
hormones that increase your appetite. You may also crave foods high in
calories and carbohydrates, which can contribute to weight gain.
 Certain medications. Some medications can lead to weight gain if you don't
compensate through diet or activity. These medications include some
antidepressants, anti-seizure medications, diabetes medications,
antipsychotic medications, steroids and beta-blockers.
 Age. Obesity can occur at any age, even in young children. But as you age,
hormonal changes and a less active lifestyle increase your risk of obesity. In
addition, the amount of muscle in your body tends to decrease with age. This
lower muscle mass leads to a decrease in metabolism. These changes also
reduce calorie needs and can make it harder to keep off excess weight. If you
don't control what you eat as you age, you'll likely gain weight.
Social and economic issues. Certain social and economic issues may be
linked to obesity. You may not have safe areas to exercise, you may not have
been taught healthy ways of cooking, or you may not have money to buy
healthier foods. In addition, the people you spend time with may influence
your weight — you're more likely to become obese if you have obese friends
or relatives.
 Medical problems. Obesity can rarely be traced to a medical cause, such as
Prader-Willi syndrome, Cushing's syndrome, polycystic ovary syndrome, and
other diseases and conditions. Some medical problems, such as arthritis, can
lead to decreased activity, which may result in weight gain. A low metabolism
is unlikely to cause obesity, as is having low thyroid function.
Even if you have one or more of these risk factors, it doesn't mean that you're
destined to become obese. You can counteract most risk factors through diet,
physical activity and exercise, and behavior changes.
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Complications:
With obesity, you're more likely to develop a number of potentially serious health
problems, including:
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High cholesterol and triglycerides
Type 2 diabetes
High blood pressure
Metabolic syndrome — a combination of high blood sugar, high blood
pressure, high triglycerides and high cholesterol
Heart disease
Stroke
Cancer, including cancer of the uterus, cervix, ovaries, breast, colon, rectum
and prostate
Sleep apnea, a potentially serious sleep disorder in which breathing
repeatedly stops and starts
Depression
Gallbladder disease
Gynecologic problems, such as infertility and irregular periods
Erectile dysfunction and sexual health issues, due to deposits of fat blocking
or narrowing the arteries to the genitals
Nonalcoholic fatty liver disease, a condition in which fat builds up in the liver
and can cause inflammation or scarring
Osteoarthritis
Skin problems, such as poor wound healing
Depression
Disability
Physical discomfort
Sexual problems
Shame
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Social isolation
Diagnostic Measures:
These exams and tests generally include:
 Taking your health history. Your doctor may review your weight history,
weight-loss efforts, exercise habits, eating patterns, what other conditions
you've had, medications, stress levels and other issues about your health.
Your doctor may also review your family's health history to see if you may be
predisposed to certain conditions.
 Checking for other health problems. If you have known health problems,
your doctor will evaluate them. Your doctor will also check for other possible
health problems in the examination and laboratory tests, such as high blood
pressure and diabetes.
 Calculating your BMI. Your doctor will check your body mass index (BMI) to
determine your level of obesity. Your BMI also helps determine your overall
health risk and what treatment may be appropriate.
 Measuring your waist circumference. Fat stored around your waist,
sometimes called visceral fat or abdominal fat, may further increase your risk
of diseases such as diabetes and heart disease. Women with a waist
measurement (circumference) of more than 35 inches and men with a waist
measurement of more than 40 inches may have more health risks than do
people with smaller waist measurements.
 A general physical exam. This includes measuring your height, checking
vital signs, such as heart rate, blood pressure and temperature, listening to
your heart and lungs, and examining your abdomen.
 Blood tests. What tests you have depend on your health and risk factors.
They may include a cholesterol test, liver function tests, fasting glucose, a
thyroid test and others, depending on your health situation. Your doctor may
also recommend certain heart tests, such as an electrocardiogram.
Gathering all this information helps you and your doctor determine how much
weight you need to lose and what health conditions or risks you have. And this will
shape what treatment options are right for you.
Treatments:
You can start feeling better and seeing improvements in your health by just
introducing better eating and activity habits. The initial goal is a modest weight loss
— 5 to 10 percent of your total weight. That means that if you weigh 200 pounds
(91 kg) and are obese by BMI standards, you would need to lose only about 10 to 20
pounds (4.5 to 9.1 kg) to start seeing benefits.
All weight-loss programs require changes in your eating habits and increased
physical activity. The treatment methods those are right for you depend on your
level of obesity, your overall health and your willingness to participate in your
weight-loss plan. Other treatment tools include:
Dietary changes
Exercise and activity
Behavior change
Prescription weight-loss medications
Weight-loss surgery
Dietary changes
Reducing calories and eating healthier are vital to overcoming obesity. Although you
may lose weight quickly at first, slow and steady weight loss of 1 or 2 pounds (1/2
to 1 kilogram) a week over the long term is considered the safest way to lose weight
and the best way to keep it off permanently. Avoid drastic and unrealistic diet
changes, such as crash diets, because they're unlikely to help you keep excess weight
off for the long term.
Dietary ways to overcome obesity include:
 A low-calorie diet. The key to weight loss is reducing how many calories
you take in. You and your health care providers can review your typical
eating and drinking habits to see how many calories you normally consume
and where you can cut back. You and your doctor can decide how many
calories you need to take in each day to lose weight, but a typical amount is
1,000 to 1,600 calories.
 Feeling full on less. The concept of energy density can help you satisfy your
hunger with fewer calories. All foods have a certain number of calories
within a given amount (volume). Some foods, such as desserts, candies, fats
and processed foods, are high in energy density. This means that a small
volume of that food has a large number of calories. In contrast, other foods,
such as fruits and vegetables, have low energy density. These foods provide a
larger portion size with a fewer number of calories. By eating larger portions
of foods less packed with calories, you reduce hunger pangs, take in fewer
calories and feel better about your meal, which contributes to how satisfied
you feel overall.
 Adopting a healthy-eating plan. To make your overall diet healthier, eat
more plant-based foods, such as fruits, vegetables and whole-grain
carbohydrates. Also emphasize lean sources of protein, such as beans, lentils
and soy, and lean meats. Try to include fish twice a week. Limit salt and
added sugar. Stick with low-fat dairy products. Eat small amounts of fats, and
make sure they come from heart-healthy sources, such as nuts and olive,
canola and nut oils.
 Meal replacements. These plans suggest that you replace one or two meals
with their products — such as low-calorie shakes or meal bars — and eat
healthy snacks and a healthy, balanced third meal that's low in fat and
calories. In the short term, this type of diet can help you lose weight. Keep in
mind that these diets likely won't teach you how to change your overall
lifestyle, though, so you may have to keep this up if you want to keep your
weight off.
 Be wary of quick fixes. You may be tempted by fad diets that promise fast
and easy weight loss. The reality, however, is that there are no magic foods or
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quick fixes. Fad diets may help in the short term, but the long-term results
don't appear to be any better than other diets. Similarly, you may lose weight
on a crash diet, but you're likely to regain it when you stop the diet. To lose
weight — and keep it off — you have to adopt healthy-eating habits that you
can maintain over time.
Exercise and activity:
Increased physical activity or exercise also is an essential part of obesity treatment.
Most people who are able to maintain their weight loss for more than a year get
regular exercise, even simply walking.
To boost your activity level:
 Exercise. The American College of Sports Medicine recommends that people
who are overweight or obese get at least 150 minutes a week of moderateintensity physical activity to prevent further weight gain or to lose a modest
amount of weight. But to achieve significant weight loss, you may need to get
as much as 250 to 300 minutes of exercise a week. You probably will need to
gradually increase the amount you exercise as your endurance and fitness
improve. To make your own exercise goal more doable, break it up into
several sessions throughout the day, doing just five or six minutes at a time.
 Increase your daily activity. Even though regular aerobic exercise is the
most efficient way to burn calories and shed excess weight, any extra
movement helps burn calories. Making simple changes throughout your day
can add up to big benefits. Park farther from store entrances, rev up your
household chores, garden, get up and move around periodically, and wear a
pedometer to track how many steps you actually take over the course of a
day.
Behavior changes:
A behavior modification program can help you make lifestyle changes, lose weight
and keep it off. Steps to take include examining your current habits to find out what
factors, stresses or situations may have contributed to your obesity.
Behavior modification, sometimes called behavior therapy, can include:
 Counseling. Therapy or interventions with trained mental health or other
professionals can help you address emotional and behavioral issues related
to eating. Therapy can help you understand why you overeat and learn
healthy ways to cope with anxiety. You can also learn how to monitor your
diet and activity, understand eating triggers, and cope with food cravings.
Counseling may be available by telephone, email or Internet-based programs
if travel is difficult. Therapy can take place on both an individual and group
basis.
 Support groups. You can find camaraderie and understanding in support
groups where others share similar challenges with obesity. Check with your
doctor, local hospitals or commercial weight-loss programs for support
groups in your area, such as Weight Watchers.
Prescription weight-loss medication:
Losing weight requires a healthy diet and regular exercise. But in certain situations,
prescription weight-loss medication may help. Keep in mind, though, that weight-
loss medication is meant to be used along with diet, exercise and behavior changes,
not instead of them. If you don't make these other changes in your life, medication is
unlikely to work.
Your doctor may recommend weight-loss medication if other methods of weight
loss haven't worked for you and you meet one of the following criteria:
 Other methods of weight loss haven't worked for you
 Your body mass index (BMI) is 30 or greater
 Your body mass index (BMI) is greater than 27 and you also have medical
complications of obesity, such as diabetes, high blood pressure or sleep
apnea
Examples of Prescription weight-loss medications your doctor may prescribe
include:
 Orlistat (Xenical). Orlistat is a weight-loss medication that has been
approved by the Food and Drug Administration (FDA) for long-term use in
adults and children 12 and older. This medication blocks the digestion and
absorption of fat in your stomach and intestines. Unabsorbed fat is
eliminated in the stool. Average weight loss with orlistat is about 5 to 7
pounds (2.3 to 3.2 kilograms) more than you can get from diet and exercise
after one or two years of taking the medication.
Side effects associated with orlistat include oily and frequent bowel
movements, bowel urgency, and gas. These side effects can be minimized as
you reduce fat in your diet. Because orlistat blocks absorption of some
nutrients, take a multivitamin while taking orlistat to prevent nutritional
deficiencies.
The FDA has also approved a reduced-strength version of orlistat (Alli) that's
sold over-the-counter, without a prescription. Alli is not approved for
children. This medication works the same as prescription-strength orlistat
and is meant only to supplement — not replace — a healthy diet and regular
exercise.
 Lorcaserin (Belviq). Lorcaserin is a long-term weight-loss drug approved
by the FDA for adults in 2012. It works by affecting chemicals in your brain
that help decrease your appetite and make you feel full, so you eat less. Your
doctor will carefully monitor your weight loss while taking lorcaserin. If you
don't lose about 5 percent of your total body weight within 12 weeks of
taking lorcaserin, it's unlikely the drug will work for you and the medication
should be stopped.
Side effects of lorcaserin include headaches, dizziness, fatigue, nausea, dry
mouth and constipation. Rare but serious side effects include a chemical
imbalance (serotonin syndrome), suicidal thoughts, psychiatric problems,
and problems with memory or comprehension. Pregnant women shouldn't
take lorcaserin.
 Phentermine-topiramate (Qsymia). This weight-loss medication is a
combination drug approved by the FDA for long-term use in adults. Qsymia
combines phentermine, a weight-loss drug prescribed for short-term use,
with topiramate, a medication that's used to control seizures. Your doctor
will monitor your weight loss while taking the drug. If you don't lose at least
3 percent of your body weight within 12 weeks of starting treatment, your
doctor may suggest either stopping use of Qsymia or increasing your dose,
depending on your condition.
Side effects include increased heart rate, tingling of hands and feet, insomnia,
dizziness, dry mouth and constipation. Serious but rare side effects include
suicidal thoughts, problems with memory or comprehension, sleep disorders
and changes to your vision. Pregnant women shouldn't take Qsymia. Qsymia
increases the risk of birth defects.
 Phentermine (Adipex-P, Suprenza). Phentermine is a weight-loss medication
for short-term use (three months) in adults. Using weight-loss medications
short-term doesn't usually lead to long-term weight loss. While some health
care providers prescribe phentermine for long-term use, few studies have
evaluated its safety and weight-loss results long term.
Weight-loss surgery
In some cases, weight-loss surgery, also called bariatric surgery, is an option.
Weight-loss surgery offers the best chance of losing the most weight, but it can pose
serious risks. Weight-loss surgery limits the amount of food you're able to
comfortably eat or decreases the absorption of food and calories, or both.
Weight-loss surgery for obesity may be considered if:
 You have extreme obesity, with a body mass index (BMI) of 40 or higher
 Your BMI is 35 to 39.9, and you also have a serious weight-related health
problem, such as diabetes or high blood pressure
 You're committed to making the lifestyle changes that are necessary for
surgery to work
Weight-loss surgery can often help you lose as much as 50 percent or more of your
excess body weight. But weight-loss surgery isn't a miracle obesity cure. It doesn't
guarantee that you'll lose all of your excess weight or that you'll keep it off long
term. Weight-loss success after surgery depends on your commitment to making
lifelong changes in your eating and exercise habits.
Common weight-loss surgeries include:
 Gastric bypass surgery. This is the favored weight-loss surgery in the
United States because it has shown relatively good long-term results. In
gastric bypass (Roux-en-Y gastric bypass), the surgeon creates a small pouch
at the top of your stomach. The small intestine is then cut a short distance
below the main stomach and connected to the new pouch. Food and liquid
flow directly from the pouch into this part of the intestine, bypassing most of
your stomach.
 Laparoscopic adjustable gastric banding (LAGB). In this procedure, your
stomach is separated into two pouches with an inflatable band. Pulling the
band tight, like a belt, the surgeon creates a tiny channel between the two
pouches. The band keeps the opening from expanding and is generally
designed to stay in place permanently. LAGB is popular because it is less
invasive, generally causes slow, steady weight loss and the band can be
adjusted if needed. However, as with other procedures, this won't work


without changes in your behavior. Results are usually not as good as with
other procedures. The LAP-BAND gastric banding device has also been
approved for use in people who have a BMI of 30 to 34 and have an
additional health condition related to their obesity.
Gastric sleeve. In this procedure, part of the stomach is removed, creating a
smaller reservoir for food. There are ongoing studies evaluating this
procedure.
Biliopancreatic diversion with duodenal switch. In this procedure, most
of your stomach is surgically removed. This weight-loss surgery offers
sustained weight loss, but it poses a greater risk of malnutrition and vitamin
deficiencies, and you require close monitoring for health problems. It's
generally used for people who have a body mass index of 50 or more.
Medical Nutrition Therapy:
Pt ideal weight: 115lbs
Pt. TER: 1,400-1,500kcals/day
Start pt. at 2,000kcals/day once pt. is adjusted to new diet begin finals goal of
1,500kcal/day diet.
50-60g Protein a day
Recommend 30 min a day of low impact activity like walking.
Pt. nutrition education resources provided
Menu Adjustments:
2,000- meal plan provided
1,500-meal plan provided
Patient Resources:
United States Department of Agriculture
http://www.usda.gov/wps/portal/usda/usdahome
Center For Disease Control
http://www.cdc.gov/obesity/
Obesity Action Coalition
http://www.obesityaction.org
Ohio Obesity and/or Health and Nutrition Programs
Ohio Department of Health
Bureau of Healthy Ohio
246 North High Street, 8th Floor
Columbus, OH 43215
Phone: 614-466-2144
Fax: 614-564-2409
healthyohioprogram.org/
Ohio Vocational Rehabilitation Program
The Ohio Rehabilitation Services Commission
400 E. Campus View Blvd
Columbus, OH 43235-4604
Phone: 1-800-282-4536
www.rsc.ohio.gov
Lauren Arnett
2-20-14
Diet Instruction
Discussion of the Disease:
Dysphagia is the difficulty of swallowing. This is a problem with the throat or
esophagus and the muscular tube moving food and liquids from the back of the
mouth to the stomach. This is most likely to occur in older adults and babies who
have brain or nervous system problems. Dysphagia is characterized by regular
difficulty swallowing and not just once or twice. There may be pain associated as
well as food getting stuck in through or chest, drooling, hoarseness, regurgitation,
frequent heartburn, weight loss, and coughing or gagging. For the regular difficulty
swallowing a person should go and see their doctor, and if there is an obstruction
interfering with breathing than emergency help is needed. Swallowing is made up of
50 pairs of muscles and nerves that accomplish this act and there are many issues
that can cause this not to function properly. Reasons for this muscular tube not
working properly include a stroke, brain or spinal cord injury, muscular dystrophy,
immune system problem causing swelling or weakness, esophageal spasm, or
scleroderma. Another reason for swallowing difficulty is that something is blocking
this area. This includes GERD, esophagitis, diverticula, esophageal tumors and
lymph nodes pressing on he esophagus.
Tests that will be conducted at the doctors include a barium x-ray to give a better
visual of muscular activity. A dynamic swallowing study may occur where a person
will swallow food at different consistencies coated with barium to see how certain
foods are traveling. An endoscopy which is an instrument that passes down the
throat to view the esophagus as well as an esophageal muscle test which is inserted
into the esophagus to measure muscle contractions during swallowing.
Treatment:
Treatment depends on the type or cause of difficult swallowing. Options include a
swallowing therapist to provide certain exercises that will stimulate the nerves, and
learning new ways to make swallowing easier by place food in certain positions.
Other treatments include esophageal dilation, surgery and medications. Severe
dysphagia leads to special liquid diets and tube feeding. Support groups are very
important to help the client from feeling lonely. Talking about how they feel
throughout there daily activities and expressing concerns as well as solving
problems together. Making the eating experience enjoyable is very important. A
general therapist may be a good idea to allow the client to open up about this
problem.
Medical Nutrition Therapy:
Lily will be put on a diet following the level 2 recommendations for food intake. This
is a diet that allows for mechanically altered food through blending, chopping,
grinding or mashing to consume food more easily. She is consuming a lot of hard to
eat items such as thin liquids, chunky additives and dry food products. Moistening
foods and making substitutions to her current meal choices will help her as well as
her continuation of Swallowing therapy. Training the muscles to allow for initial
swallowing function to occur as well as using tips such as eating slowly, small bites,
in an environment that is not distracting, sitting with good posture, and thickening
foods will contribute to a successful road ahead. Specifically, this type of dysphagia
is difficulty of moving food from the mouth to the throat and esophagus.
Prognosis:
If dysphagia is not treated complications such as malnutrition and dehydration as
well as respiratory problems can occur. By following the therapy plan and diet
instruction Lily has a good outlook. Many stroke patients phase out of swallowing
difficulty and will hopefully not need to move to thicker liquids and stricter diet
requirements. Surgery is rarely a solution for Oropharyngeal dysphagia.
Client:
52-year old Lily James (5’2” and 120#) went into the doctor because she has been
having trouble swallowing her food and has noticed that she is choking while eating
quite often. She has been eating less throughout the day due to her nervousness of
eating. This has caused her some weight loss. She had a stroke recently and has been
cautious about eating healthier as well as being active, but doesn’t know what could
be wrong. She likes to go on walks with her husband, but doesn’t want to do too
much. She likes to go out to eat with friends, but has been embarrassed because she
will cough a lot when trying to eat. She has been making most of her meals at home.
After seeing her doctor and running some tests it was concluded that she has
Oropharyngeal dysphagia and needs to go to a swallowing therapist as well as make
changes in her diet.
24 hour recall:
Breakfast:
1 cup of coffee with cream
1 cup oatmeal with raisins
1 slice of whole grain toast
1 over easy egg
Medium Banana
Snack:
1 cup fruit salad
½ cup yogurt with nuts
Lunch:
1 cup milk
1 cup tomato Soup with handful of crackers
Grilled cheese sandwich
Snack:
½ cup chocolate pudding
1 small muffin
Dinner:
1 medium baked potato with bacon
3 oz. roasted chicken
½ cup cooked vegetables
1/3 cup applesauce
1 cup milk
References
(2014). Communication facts: special populations: dysphagia. American SpeechLanguage-Hearing Association. Retrieved February 16, 2014 from
http://www.asha.org/research/reports/dysphagia/
(2013). Dysphagia mechanically advanced diet. Wexner Medical Center. Retrieved
February 16, 2014 from
https://patienteducation.osumc.edu/documents/dys-3.pdf
(2014). Dysphagia. MayoClinic. Retrieved February 16, 2014 from
http://www.mayoclinic.org/diseasesconditions/dysphagia/basics/definition/CON- 20033444
(2014). Dysphagia. National Stroke Association. Retrieved February 16, 2014 from
http://www.stroke.org/site/PageServer?pagename=dysphagia
(2014). Dysphagia. WebMD. Retrieved February 16, 2014 from
http://www.webmd.com/digestive-disorders/tc/difficulty-swallowingdysphagia- overview
Lembo, A.J. (2014). Oropharyngeal dysphagia: clinical features, diagnosis, and
management. UpToDate. Retrieved February 16, 2014 from
http://nutritioncaremanual.org/vault/editor/Docs/Level%202%20NT%20f
o
r%20Dysphagia_MechAltered.pdf
(2014). Level 2 nutrition therapy for dysphagia: mechanically altered foods.
American
Dietetic Association. Retrieved February 16, 2014 from
http://nutritioncaremanual.org/vault/editor/Docs/Level%202%20NT%20f
or%20D
ysphagia_MechAltered.pdf
McCullough, G., Pelletier, C., & Steele, C. (2014). National dysphagia diet: what to
swallow?. The ASA Leader. Retrieved February 16, 2014 from
http://www.asha.org/Publications/leader/2003/031104/f031104c/
(2014). Swallowing disorders. MedlinePlus. Retrieved February 16, 2014 from
http://www.nlm.nih.gov/medlineplus/swallowingdisorders.html
(2014). Swallowing support groups. National Foundation of Swallowing Disorders.
Retrieved February 16, 2014 from
http://www.swallowingdisorderfoundation.com/swallowing-supportgroups/
Oropharyngeal Dysphagia: Difficulty moving food from mouth to throat and
esophagus. We want to make it easier for you so that you are not in pain and are
able to enjoy food, and eat again.
Caffeine is not recommended
Drink thickeners
Don’t have sticky foods
Adding starch and flour
At a restaurant: sauces and softened noodles, moist rice, bring thickener packet for a
drink, nectar packets
Care plan: swallowing therapist, Mechanically altered food (nectar thick foods)
- due to weight loss and pain
What to have instead:
Breakfast:
BOOST drink: pack in protein
Oatmeal moistened with milk without raisins
Make sure the banana is ripe
Commercially softened bread dipped in egg
Pancakes with syrup
Pineapple juice
Snack:
Soft drained canned fruits, pudding,
Lunch:
Thickening tomato soup with dry milk powder
Roll dipped in soup
Soft mac n cheese
Dinner:
Moistened mashed potatoes- add milk, butter or gravy
Moistened chicken with sauces and cut up into small pieces
Rice with butter
Meatloaf with ketchup
Desserts:
Cookies moistened in milk
Gelatin
Ice cream
Diet Instruction: Enteral Tube Feeding
Etiology:
Enteral nutrition is used when a patient is severely underweight and/or
malnourished. It can only be prescribed if the patient has a fully or partially functioning
gastrointestinal tract. If not, the patient must be placed on parenteral nutrition. There are
three different types of feeding tubes for enteral nutrition. These include the nasogastric,
gastrostomy, and jejunostomy tubes. The type of tube that a patient receives depends on
if the tube will be temporary or permanent. It also depends on which part of the
gastrointestinal tract is functioning. Enteral tube feedings can be safely and effectively
performed at home if the patient is given instruction by a health professional
(www.nestle-nutrition.com).
Some health conditions that can require enteral nutrition are gastrointestinal
disorders, cardiopulmonary disorders, hyper-metabolism, and neuromuscular disorders
(www.nutritioncare.org). My patient has Dysphagia and she is placed on enteral tube
feedings to ensure that she is getting her necessary daily caloric and nutrient intakes.
Dysphagia is more prevalent in the elderly population (www.nidcd.nih.gov). It is
usually seen as a symptom caused by a variety of disorders instead of as a disease state
(Nelms 354-355). Dysphagia is defined as “any condition that weakens or damages the
muscles and nerves used for swallowing (www.nidcd.nih.gov). Diseases of the nervous
system such as cerebral palsy, multiple sclerosis, and Parkinson’s disease can cause
dysphagia (www.nlm.nih.gov). Stroke or head injury can affect the ability of the
necessary muscles for swallowing or they can reduce sensations in the individual’s mouth
or throat. Some forms of cancer and even some treatments of cancer can cause dysphagia
as well (www.nidcd.nih.gov).
Diagnostic Measures:
Dysphagia is first diagnosed with a clinical bedside evaluation and a bedside
swallowing assessment. A healthcare team usually performs the diagnosis. The team
typically consists of physicians, nurses, a speech language pathologist, a physical
therapist, and an occupational therapist. The diagnosis is confirmed by performing either
a videofluoroscopy swallowing study or a fiber optic endoscopic swallowing evaluation.
For either diagnostic procedure, barium is added to a range of foods and beverages with
differing textures. Barium can be viewed by fluoroscopy or x-ray. This makes it possible
to monitor the movement of the food or beverage with barium. Barium is used to pinpoint
the specific location of dysphagia. Knowing the location makes it possible for the
healthcare team to establish an appropriate treatment plan (Nelms 355-356).
In Rose’s case, she has been diagnosed with inadequate oral food and beverage
intake related to her dysphagia. She has also been diagnosed with difficulty swallowing
and malnutrition.
Treatment:
Medical, surgical and/or psychological treatment:
The patient had a gastrostomy to insert a permanent gastric tube. The gastric tube
is being used for enteral tube feedings. The patient could receive treatment from a variety
of health professionals. The patient can be referred to a psychiatrist since she is going
through depression due to her inability to swallow and chew food. She can see a speech
pathologist or an occupational therapist in order to improve her chewing and swallowing
abilities. This can sometimes be attained by practicing muscle exercises to strengthen
facial muscles or to improve muscle coordination (www.nidcd.nih.gov).
Medical Nutrition Therapy:
The medical nutrition treatment therapy for the patient with dysphagia depends on
the cause and the severity. In Rose’s case, her dysphagia is preventing her from receiving
adequate oral intake. In order to bypass the passage of foods or beverages through the
esophagus, Rose is placed on enteral tube feeding. She is placed on enteral nutrition
because she had severe weight loss in the past 6 months. Enteral nutrition is chosen
instead of parenteral nutrition because Rose has a functioning gastrointestinal tract. A
gastrostomy was performed because Rose will need to be on long-term enteral nutrition.
Gastric tube feeding will also allow for bolus feedings, which mimic a regular eating
schedule (Nelms 85).
Before determining Rose’s enteral prescription, her fluid and electrolyte balance
must be restored. Her poor skin turgor and dry skin are evidences of dehydration. Her
electrolyte values are all elevated and this is common in individuals with dehydration.
Her hydration status has to return to normal in order for the electrolyte level readings to
be accurate.
Enteral formulas are typically the primary source of water for patients so it is
important to maintain an adequate fluid intake (Nelms 87). It is also recommended that
the patient consumes 2 cups of water per day to make sure that she is getting enough fluid.
Her enteral formula has 85% free water. Rose will use Nutren 1.0 and she will give
herself 5 bolus feedings a day. She will use 6 ½ cans of formula each day; this is
approximately 1 can and 1/3 cup of formula per feeding. She will be instructed on the
syringe method for bolus feeding at home. In order to make sure that there are no
complications with enteral feeding at home, she will monitor her weight once a week, her
hydration status at least 3 times a week, and her vital signs at least 3 times a week. She
will have her blood glucose levels measured every 2 weeks (Nelms 91). She will be
monitored closely for aspiration because her unstable mental state puts her at a higher
risk of developing it.
Description of patient and diagnosis:
Patient name: Rose Bush
DOB: 07/10/1942
Age: 72 y/o
Height: 5’ 4”
Weight: 120 lbs.
Sex: Female
Education: Bachelor’s Degree
Occupation: Retired business owner
Household members: daughter age 40, son-in-law age 41, granddaughter age 10
Ethnic background: Caucasian/ white
Chief Complaints
Patient: “I am embarrassed to eat in front of my friends and family members because I
take a long time to chew my food and my food does not always make it into my mouth.
Sometimes I drool and I think it is impolite to do that.”
Patient’s mother: “Lately she pushes her food around on her plate more than she eats it.
She is getting very thin and she seems depressed. She is very quiet during meals.”
Patient History
Onset of disease: Rose is a 72 year old female who had a stroke 7 months ago. She has
recovered from the stroke, but she had severe weight loss. In 6 months, she dropped from
145 pounds to 120 pounds (17.2% weight loss). She was admitted to the hospital for tests.
Rose complained of pain while swallowing and difficulty chewing. She was diagnosed
with Dysphagia and the doctor recommended a gastrostomy to insert a permanent feeding
tube. Rose is recovering from the gastrostomy and she has been administered enteral tube
feedings. Rose will be released from the hospital tomorrow. She will continue enteral
tube feedings at home. She needs instruction from a R.D. on how to perform the tube
feedings at home.
Physical Exam Upon Admission
General appearance: tired-looking woman, c/o fatigue and difficulty swallowing
Vitals:
HEENT
Heart: tachycardia
Eyes: sunken, membranes dry
Ears: membranes dry
Nose: dry mucous membranes
Throat: dry, inflamed
Neurologic: irritable, confused
Skin: poor turgor, dry skin
Chest/lungs: deep, rapid respiration
Biochemical Lab Values
1 day post-op
Electrolyte
Current Serum Level
Normal Serum Level
Sodium
151 mEq/L
136-146 mEq/L
Potassium
5.5 mEq/L
3.5-5.0 mEq/L
Chloride
110 mEq/L
98-106 mEq/L
Glucose
160 mg/dL
70-120 mg/dL
Electrolyte
Current Serum Level
Normal Serum Level
Sodium
140 mEq/L
136-146 mEq/L
Potassium
4.0 mEq/L
3.5-5.0 mEq/L
Chloride
108 mEq/L
98-106 mEq/L
Glucose
122 mg/dL
70-120 mg/dL
5 days post-op
Patient 24- hour recall
breakfast: ½ mashed banana, 8 oz. whole milk, 1/3 c. instant oatmeal
snack: 1 c. applesauce
lunch: ¾ c. mashed potatoes with gravy, 16 oz. water, ½ c. creamed corn
snack: skipped because her throat was very sore
dinner: 3 oz. meatloaf with gravy, 8 oz. Coca-Cola, ¼ rolled biscuit
snack: ½ c. pudding, 8 oz. water
Enteral Nutrition Prescription
Adjusted Body Weight Calculation:
AdBW=.25 (120 lbs.-145 lbs.) + 145 lbs.
AdBW=139 lbs.
139 lbs./2.2=63.2 kg
“dosing wt.”=63.2 kg
Mifflin-St. Jeor calculation for women:
wt=63.2 kg
ht= 162.6 cm
age=72 yrs.
10 (63.2 kg) + 6.25 (162.6 cm) – 5 (72 yrs.) – 161
1,127 kcal/day
PAL=1.4 (some seated work)
1,127 kcal*1.4= 1,578 kcal/day
Protein Goal:
RDA for older adults is 1.0 g/kg so Rose needs 63 kg protein/ day
63 kg pro *4=252 kcal
252 kcal/1,580 kcal*100=16 % pro
Electrolyte Needs:
There are no abnormal electrolyte losses so electrolyte needs should follow the RDA for
adults over 70 years old.
Sodium: 1,200 mg
Potassium: 4,700 mg
Chloride: 1,800 mg
Vitamin and Mineral Needs:
DRIs for adults 70 years and older
Vit. A: 700 mcg/day
Vit. C: 75 mg/day
Vit D: 15 mg/day
Calcium: 1,200 mg/day
Iron: 8 mg/day
Fluid Needs:
Patient’s hydration status has been restored
1,580 kcal* 1 mL=1,580 mL
osmolality should be about 300 mOsm/kg water
Enteral Formula Prescription:
The patient will receive 1,580 mL or Nutren 1.0 daily
Nutren 1.0:
1.0 kcal/mL
16% pro
51% CHO
33% fat
osmolality=370 mOsm/kg water
meets 100% for 20 key micronutrients
Continuous Feeding:
1,580 kcal/24 hrs.=66 mL/hr.
Bolus feedings 5 times/day:
1,580 mL/4=316 mL
250 mL/can of Nutren 1.0
316 mL/250 mL=1.3 cans
1 can and 75 mL per bolus feeding (1.3 cans)
household measurements: approx. 1 can and 1/3 cup
Prognosis:
If the patient’s swallowing ability improves and her throat pain decreases, she will
be able to switch to a diet with partial oral intake (Nelms 358). The oral intake would
follow the NDD (National Dysphagia Diet) Level 1, which includes only pureed foods or
smooth foods with no lumps (www.anfponline.org). The food should have a “puddinglike consistency (Nelms 357).” The patient will be educated by a R.D. on her modified
enteral tube feedings and appropriate foods for NDD Level 1. If the patient has trouble
tolerating the NDD Level 1, she will return to a full enteral tube feeding diet.
(Educational Materials)
At-Home Gastric Tube Feeding Overview
*Patient will decide times for feedings; feedings should be at least 2-3 hours apart
Your Formula: Nutren 1.0
Cans per day: 6 ½
Amount per feeding: 1 can and 1/3 c.
Your feeding schedule: 5 bolus feedings daily (at least 15 min. per feeding)
Times
AM
AM
AM/PM
PM
Amount of formula
1 can and 1/3 cup
1 can and 1/3 cup
1 can and 1/3 cup
1 can and 1/3 cup
PM
1 can and 1/3 cup
Wash your hands thoroughly with soap and water then gather supplies:





formula
syringes
lukewarm water (1 cup)
feeding bag (if using)
feeding pump (if using)
Things to remember:

You must flush the tube before and after administration of formula or
medications.

if the tube becomes clogged, take immediate action to unclog it.

Store unopened cans of formula at room temperature.

When a can is opened, use immediately. Date and refrigerate the unused
portion, but it must be thrown away if it is not used within 24 hours.

Syringes need to be cleaned with warm, soapy water and left to air dry
between each use.
Bolus Feeding: Syringe Method
1. Draw up 60 ml of warm water in the syringe. Gently flush the water
through the tube to make sure the feeding tube is clean and open. Disconnect the
syringe. Recap the end of the feeding tube.
2. Remove the plunger from the syringe.
3. Uncap the feeding tube.
4. Attach the syringe directly to your feeding tube. Pour 1 can and 1/3 cup of
feeding into the syringe, allowing it to flow freely until all of the feeding is given.
5. Take the syringe and draw up 60 ml warm water. Gently flush the water through
the tube again to make sure the tube is clean and open. This water also helps keep
you hydrated.
6. Disconnect the syringe from the feeding tube.
7. Recap the feeding tube.
6. Repeat the procedure 4 more times. If you do not tolerate the prescribed amount
of formula, notify your dietitian.
Helpful Resources:
American Society for Parenteral and Enteral Nutrition (ASPEN)
Nestle Health Science: Medicare Coverage of Enteral Nutrition Therapy
References
Academy of Nutrition and Dietetics. (2014). Nutrition Care Manual. Retrieved from
http://www.nutritioncaremanual.org
American Gastroenterological Association. (1995). American gastroenterological
position statement: guidelines for the use of enteral nutrition. Retrieved from
http://www3.us.elsevierhealth.com/gastro/policy/v108n4p1280.html
American Society for Parenteral and Enteral Nutrition. (2013). What is enteral
nutrition? Retrieved from
http://www.nutritioncare.org/Information_for_Patients
Cleveland Clinic. (n.d.). Tube-feeding instructions for home. Retrieved from
www.my.clevelandclinic.org./home-enteral-nutrition-booklet.pdf
Dietary Manager. (2004).Understanding and implementing dysphagia diets.
Association of Nutrition & Foodservice Professionals. Retrieved from
http://www.anfponline.org/Publications/articles/2004_03_008Dysphagia
Fletcher, J. (2011). Nutrition: safe practice in adult enteral tube feeding. British
Journal Of Nursing, 20(19), 1234-1239. Retrieved from
http://eds.b.ebscohost.com.proxy.lib.muohio.edu
Lloyd, D. & Powell-Tuck, J. (2004). Artificial nutrition: Principles and practices of
enteral feeding. Clinics in Colon and Rectal Surgery, 17(2), 107–118.
doi: 10.1055/s-2004-828657
National Institutes of Health. (2010). Dysphagia. National Institute on Deafness and
Other Communication Disorders. Retrieved from
http://www.nidcd.nih.gov/health/voice/Pages/dysph.aspx
Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy &
pathophysiology 2/e. Belmont, CA: Wadsworth, Cengage Learning.
Nestle Health Science. (2013). Best practices in enteral feeding safety. Retrieved
from http://www.nestle-nutrition.com/Products
Katie Arlinghaus
KNH 413; Matuszak
MNT Diet
April 24, 2014
Medical Nutrition Therapy Diet: High Calorie, High Protein
1. Purpose
a. Nutrition Indicators
A high calorie, high protein diet is appropriate for those who need more
energy. This often occurs during healing or in times of increased metabolic
stress such as with cancer patients, HIV patients, burn victims, trauma cases,
etc. Weight loss is a major indicator that the patient is not receiving enough
calories.
b. Criteria to Assign the Diet
The patient should present with increased calorie and protein needs to be
assigned the diet. This need is commonly presented in cases of trauma, burn
victims, and cancer patients. The diet may be appropriate for an athlete as
well.
c. Rationale for Diet
The rational for the diet is to give the patient the proper amount of energy
and protein needed to heal and function properly.
2. Population
a. Overview
This diet is given to anyone who is not receiving the proper amounts of
energy and protein. This includes cancer patients, burn victims, and trauma
clients.
b. Disease Process
As mentioned previously, there are a variety of diseases that may require the
use of a high calorie, high protein diet. A case in which the diet is severely
needed is with cachexia. Cachexia is one of the most common causes of death
among patients with cancer and is present in almost 80% of cancer patients
that die. Cachexia has a much higher rate of incidence with lung and
gastrointestinal cancers than with breast and hematopoietic cancers. The
pathophysiology of cachexia is not understood fully, but is attributable to a
negative protein and energy balance driven by a variable combination of
reduced food intake and abnormal metabolism. It is believed that changes in
carbohydrate metabolism in cancer patients probably arise as a consequence
of meeting the metabolic demands of the tumor and may contribute to the
cachectic state. Amino acids are not spared in cancer cachexia and lean body
mass is depleted. This may occur due to hypercatabolism, decreased protein
synthesis, or both. Cachexia has been found to occur even when anorexia is
not present. The presence of malignancy often increases lipid metabolism,
decreases lipogenesis, and decreases the activity of lipoprotein lipase.
c. Biochemical and Nutrient Needs
An increase in macronutrients is a key component to the diet. Protein needs,
as the name of the diet suggests, are increased. Fat is also often increased as
an easy way to increase total calories because fat has 9 kcal/g versus 4kcal/g
found in protein and carbohydrates. Carbohydrates, however should also be
increased as part of the effort to increase the overall calorie consumption.
Protein status can be monitored through albumin levels. A nitrogen balance
may also be determined.
3. General Guidelines
a. Nutrition Rx
Increase protein and calorie intake. This can be done with diet or often
through enteral nutrition supplements or parental nutrition.
b. Adequacy of Nutrition Rx
The adequacy of the nutrition can be seen by monitoring weight, protein
status (albumin levels), nitrogen balance,
c. Goals
The goal of the diet is to increase caloric and protein intake to meet the
higher caloric and protein demands of a patient in metabolic stress with the
ultimate goal to promote healing and recovery. A measurable goal is to
increase or maintain weight
d. Does it Meet DRI
The diet meets, if not exceeds, DRI/RDA/AMDR recommendations for the
general population.
4. Education Material
a. Nutrition Therapy
Firstly the dietician should provide the client education on what are high
calorie and high protein foods. The dietician should also prescribe
appropriate enternal or parental nutrition supplements.
b. Ideas for Compliance
Noncompliance could occur for many reasons. Often symptoms of the
client’s disease or disease treatment cause the patient to not want to eat.
Managing these symptoms, and providing the client with alternatives specific
to his/her symptoms is key to encouraging the client to eat. For example, if
the smell of food makes the client nauseous, the client should stay away from
the cooking area, and opt for colder foods instead of hot foods (foods that are
cooked) and liquids. Noncompliance may also stem from a mental or
emotional issue. If this is the case, a psychologist may be helpful. Often, it is
just difficult to consume that many calories or that much protein for just diet
alone
5. Sample Menu
a. Foods Recommended
Enternal supplements, pre made or homemade shakes/smoothies
Add extra fat, for example: cook with butter, make oatmeal with milk instead
of water, drink whole milk instead of lowfat milk, etc
high protein foods: meats, cheese, milk, eggs, tofu, yogurt, nuts, legumes,
seeds, nut butters
Favorite foods
b. Foods to Avoid
foods that discourage the patient from eating
hated foods
low calorie foods
high fiber foods
low calorie fluids like water
c. Example of a meal plan
Breakfast (700-800 calories)
2 whole wheat tortillas each with 1⁄4 cup or 1 slice 2% cheese, 1 scrambled
egg and 2-3 oz lean Canadian bacon
1 fruit 8 oz 2% milk
Snack (350 calories)
1 whole wheat mini bagel with 2 Tbsp peanut butter and 2 Tbsp all-natural
jelly
Lunch (700-800 calories)
1 whole wheat pita w/ 6 oz chicken breast, 1⁄2 cup 2% grated cheese, lettuce,
tomato, and sauce 15 whole wheat crackers or baked chips 1 banana
16 oz low-fat chocolate milk or 100% juice
Snack (250-350 calories)
200-250 calorie energy/protein bar or shake
Dinner (700-800 calories)
6-8 oz meat, palm size (chicken, fish, beef, pork) 2 cups vegetables 2 cups
carbohydrate item (pasta, rice, potato, sweet potato, peas, crackers, beans,
corn, fruit) Side salad with dressing, if desired 16 oz 2% milk
Snack (200-250 calories)
Banana chocolate shake with protein powder and 2% milk
6. Websites
a. Organizations with Websites
American Cancer Society
Various medical centers and hospitals
ex: UCSF Medical Center
Academy of Nutrition and Dietetics
Abbot Nutrition
b. Government Websites
National Cancer Institute: http://www.cancer.gov/
Cancer Research UK: http://www.cancerresearchuk.org/
7. References
a. Journal Articles
Fearon, Kenneth C., Anne C. Voss, and Deborah S. Hustead. "Definition of cancer
cachexia: effect of weight loss, reduced food intake, and systemic
inflammation on functional status and prognosis." The American journal of
clinical nutrition 83.6 (2006): 1345-1350.
Kern, K. A., and J. A. Norton. "Cancer cachexia." Journal of Parenteral and Enteral
Nutrition 12.3 (1988): 286-298.
Julia Kaesberg
Counseling Session
KNH 413
February 27th, 2014
Patient Description and Diagnosis: Sarah Jones is a 50-year-old female, 5’4”, 131
pounds and her usual body weight is 125 pounds. Her %UBW is 104% (131/125 x
100). Sarah has been diagnosed with Stage 5 Kidney Disease and is beginning
hemodialysis. Sarah’s decline in kidney function is a result of her uncontrolled
hypertension. Currently, Sarah is presenting with edema in her legs and feet. She
has been asked by her physician to see a Registered Dietitian for instruction on a
hemodialysis diet, including fluid restriction. Sarah’s current urine output averages
about 0.7 L per day and brought a 24- hour recall with her to this session.
Etiology: The two leading causes of kidney failure in the United States are Type 2
Diabetes and high blood pressure. Effective treatment of these conditions can
prevent or slow down kidney disease. End stage kidney disease occurs when 90%
of kidney function has been lost and the patient may have symptoms such as nausea,
vomiting, weakness, fatigue, confusion, difficulty concentration and loss of appetite
(“Kidney disease: Causes,”).
Diagnostic Measures: There are three simple diagnostic measures that are
typically used to diagnosis kidney disease. The first is blood pressure. A blood
pressure of 140/90 or higher is considered high blood pressure and with kidney
disease 130/80 or less is recommended. The second diagnostic measure is
urinalysis. Protein and blood in the urine may indicate kidney disease, especially in
patients with diabetes. One test used to test for the presence of urine is the protein
to creatinine ratio and a value of 200 mg/gm is considered high. Another urine test
is the albumin to creatinine ratio and a value of 30 mg/gm per day or higher can be
a sign of early kidney disease. The third diagnostic test is the Glomerular filtration
rate (GFR), which is estimated from the results of a serum creatinine test. This
value indicates how well the kidneys are removing waste from the blood and a value
of 60 or lower may indicate kidney disease (“Three simple tests,”).
In addition to these simple diagnostic measures, physicians can also use renal
ultrasounds to determine the size and shape of the kidney to see any abnormalities.
A kidney biopsy can also be done to determine if cancerous or abnormal cells are
present. Finally, a CAT scan can be used (“End stage renal,”).
Medical Treatment: The first choice for medical treatment of End Stage Renal
Disease (ESRD) is hemodialysis. Hemodialysis cleans and filters the blood through a
machine that removes waste, extra salt and extra water. This helps to control blood
pressure and keep the proper balance of chemicals such as potassium, sodium,
calcium and bicarbonate in the body. Another choice is peritoneal dialysis, which
also removes waste, chemicals and water from your body using the linin of your
abdomen or belly. A third choice with ESRD is kidney transplantation where the
donated kidney does the work that the patient’s two failed kidneys used to do
(“Kidney failure: Choosing,”). For Sarah, hemodialysis was chosen as the best choice
of treatment for the current time. She will be receiving hemodialysis three times
per week.
Medical Nutrition Therapy:
Sarah’s protein needs are increased because of the hemodialysis and therefore
requires 1.2 g pro/kg (“Chronic kidney disease,”). Sarah needs about 71 grams of
protein per day. Using the Harris Benedict equation, Sarah requires about 1,800
calories per day. Based on the Nutrition Care Manual from the Academy of Nutrition
and Dietetics, Sarah must consume less than 2.4 g of sodium and potassium per day,
between 800-1000 mg of phosphorus per day and less than 2 g from protein per day.
Because the kidneys are not functioning properly, they cannot remove excess water
from the body, so Sarah must restrict her fluid intake to her urine output plus 1,000
cc of fluid per day. Her current urine output is an average of 400 cc per day, so she
can consume 1,400 cc of fluid in her diet daily (“Chronic kidney disease,”).
Calculations:
1.2 g pro/kg (59.5 kg) = 71 g protein/day
71 g pro x 4 kcal/g= 284 calories from protein
71 g pro/7 grams per ounce= 10 ounces of meat
Energy Requirements using Harris- Benedict equation:
655 + (9.56 x wt (kg)) + (1.85 x ht (cm)) – (4.68 x age)
655 + (9.56 x 59.5) + (1.85 x 163 cm) – (4.68 x 50)
655 + (569) + (302) – 234
1,292 x (1.4 PAL) = 1,808
1,750-1,850 calories per day
1,800 calories- 284 calories from protein= 1,516 calories from carbohydrate and fat.
1,800 x 0.55 = 990 calories from carbohydrate/4 kcal/g= 247 g carbohydrate
1,800 total calories -990 (kcal from CHO) -284 (kcal from PRO) = 526 calories from
fat/ 9 kcal/g= 58 g fat per day
During the counseling session, the patient will be informed on the importance of
restricting fluid, sodium, potassium, phosphorus and calcium. The patient’s 24hour recall will be reviewed and Sarah will be given tips on making food choices low
in these minerals and higher in protein. The patient will also be given lists of foods
that are low in potassium, sodium and phosphorous. In addition, Sarah will be
educated on sodium and foods that have added salt, with the recommendation of
choosing foods with 300 mg or less per serving.
Website:
The National Kidney Foundation
www. Kidney.org
Educational Material:
http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=157&a
ctionxm=ViewAll
References:
Chronic kidney disease (ckd) stage 5 dialysis . (n.d.). Retrieved from
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=55
37&lv2=255347&ncm_toc_id=255666&ncm_heading=Nutrition Care
End stage renal disease. (n.d.). Retrieved from
http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_uri
nary_system_disorders/end_stage_renal_disease_esrd_85,P01474/
Kidney disease: Causes. (n.d.). Retrieved from
http://www.kidney.org/atoz/content/kidneydiscauses.cfm
Kidney failure: Choosing a treatment that's right for you. (n.d.). Retrieved from
http://kidney.niddk.nih.gov/kudiseases/pubs/choosingtreatment/
Three simple tests to check for kidney disease. (n.d.). Retrieved from
http://www.kidney.org/kidneydisease/threesimpletests.cfm
Medical Nutrition Therapy Diet- NPO/Peripheral
Parenteral
Melissa Girgis
4/21/14
1. Purpose
a. Nutrition Indicators
An NPO (nothing by mouth)/ peripheral parenteral diet is required in clinical
situations in which patients are unable to meet their needs orally or with the
help of enteral nutrition products. Often, these patients do not have a
functioning gastrointestinal tract, so it is necessary to utilize a feeding route
that bypasses the digestive tract. Nutrition indications for PPN diet include
abdominal trauma, injury, or infection, impaired GI motility, GI tract
obstruction, excessive vomiting, or inability to digest/absorb nutrients as a
result of bowel resection, or short bowel syndrome.
b. Criteria to Assign the Diet
While total parenteral nutrition (administered through a large vein in the
center of the body, such as the jugular, subclavian, or femoral veins) is often
used for long periods of time, peripheral parenteral nutrition is not
sustainable for more than a few days. This feeding method delivers large
volumes of dilute nutrient solutions through veins of the back of the hand or
arm. Because large volumes are required to meet the nutritional needs of the
patient, patients with limited fluid intake would not use this feeding method.
c. Rationale for Diet
PPN is not used frequently. This diet is for patients whose gastrointestinal
tract requires a few days of rest to heal properly before transitioning to an
oral diet. This diet allows for healing while providing readily available
nutrients.
2. Population
a. Overview
Patients with Crohn’s disease, ulcerative colitis, or other conditions that may
require surgical interventions such as ileostomy or colostomy, would use a
PPN diet for a few days post-surgery to allow bowel rest and healing before
transitioning back to an oral diet. Surgical complications, other existing
medical conditions, or damage to the gastrointestinal tract due to accidents
or trauma may also require temporary disuse of the digestive tract.
b. Disease Process
Diseases of the gastrointestinal tract such as Crohn’s disease and ulcerative
colitis can have a severe effect on normal digestion and absorption of
nutrients. Patients typically do not meet their calorie, protein, and
fluid/electrolyte needs. Due to malabsorption these patients are at high risk
for deficiency of iron, magnesium, zinc, calcium, vitamin D, B12, folate, fatsoluble vitamins and water-soluble vitamins. If the disease continues to be
unresponsive to medication and diet therapy, surgical resection of the
gastrointestinal tract is indicated. Disease complications such as abscess,
obstruction, or perforation may also necessitate surgery. Post-surgery the
patient will use PPN to allow for intestinal adaptation and healing of the GI
tract, as well as delivery and supplementation of nutrients.
c. Biochemical and Nutrient Needs
For patients with malabsorption, trauma, infection, or other serious cases, a
very high amount of calories, protein, and nutrients will needs to be
delivered, often much higher than the general population. Most pharmacies
use multiple vitamin infusions rather adding vitamins individually. The levels
provided are often higher than those required by the general population
because it is assumed that the PPN patient is dealing with some type of stress.
Medications may also be delivered through parenteral nutrition. The
following vitamins and minerals and their dosing is provided in the table
below. Since vitamins are administered intravenously, absorption is not a
problem. If toxicity is a concern, supplements may be administered every
other day.
Vitamin/Mineral
Thiamin
Riboflavin
Niacin
Folic acid
Pantothenic acid
Pyridoxine (B6)
Cyanocobalamin (B12)
Biotin
Ascorbic acid
Vitamin A
Vitamin D
Vitamin E
Vitamin K
Chromium
Copper
Iron
Manganese
Selenium
Zinc
Requirement
6 mg
3.6 mg
40 mg
600mcg
15 mg
6 mg
5 mcg
60 mcg
200 mg
3300 IUs
200 IUs
10 IUs
150 mcg
10-15 mcg
0.3-0.3 mg
Not usually included
60-100 mcg
20-60 mcg
2.5-5 mg
3. General Guidelines
a. Nutrition Rx
A parenteral nutrition order form will be filled out for the patient based on
the recommendations of the dietitian, doctor, and pharmacist. Steps involved
in writing the nutrition prescription are (1) Consider dosing weight and
energy needs (2) establish protein goal (3) divide remaining kilocalories
between lipid and carbohydrate (4) consider electrolyte needs (5) evaluate
vitamin and mineral requirements (6) evaluate fluid needs (7) calculate final
parenteral prescription. An example order form is shown below.
http://jacquelinefarrallportfolio.files.wordpress.com/2012/12/parenteral-nutrition-3.jpg
b. Adequacy of Nutrition Rx
To check for tolerance and adequacy, patients will be monitored regularly.
Weight, and fluid input and output will be monitored daily, glucose will be
checked three times per day until consistently below 200mg/dL, blood work
will be done three times per week, triglycerides, CBC, PT, PTT will be checked
weekly, and nitrogen balance will be checked as needed.
c. Goals
1. Promote healing of illness, infection, injury, or disease state,
2. Deliver necessary fluids, vitamins, minerals, protein, calories, and fat
3. Avoid complications associated with inadequate intake such as weight loss,
muscle wasting, and malnutrition
d. Does it Meet DRI
PPN exceeds the DRI due to the assumption of increased needs in critically ill
or stressed patients.
4. Education Material
a. Nutrition Therapy
The patient will likely receive PPN for 1-5 days then progress to a clear liquid
diet. With toleration, patient can progress to all liquids, then to a low-residue
diet. Four to six smaller meals throughout the day are recommended.
Patients should eat slowly, drink plenty of fluids, chew food completely, and
avoid any foods that may not be completely digested such as fruit skins,
seeds, spinach, corn, peas, popcorn, and tough meats. The goal is for the
patient to be eating their usual diet by the eighth week post-operatively.
Enteral products may be used as necessary.
b. Ideas for Compliance
If a patient is determined to be in a healthy and stable condition they may be
given the option to continue PPN in the comfort of their own home. Home
care has proven to improve patient outlook and decrease health care costs.
Before approving this option it must be determined that the patient’s living
environment is appropriate, the patient possesses ability for self-care,
caregivers/friends/family are available, and insurance coverage is available.
5. Sample Menu
a. Foods Recommended/ b. Foods to Avoid
NPO means nothing by mouth. Patients on this diet who are receiving
peripheral parenteral nutrition will not eat or drink any food at all.
c. Example of a meal plan
The parenteral nutrition will be infused at a constant rate that is controlled
with a pump. Cyclic PN where the patient is fed at night and fasts during the
day is only used for patients receiving long-term PN to allow them freedom
from the pump during their waking hours.
6. Websites/ 7. References
Abbott Nutrition. (2014). http://abbottnutrition.com/
Academy of Nutrition and Dietetics-Nutrition Care Manual. (2014) Inflammatory
Bowel Disease Nutrition Therapy. Nutrition Therapy for Ileostomy.
http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=181
ACI. Parenteral Nutrition Pocketbook for Adults.
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/159805/aci_parent
eral_nutrition_pb.pdf
ASPEN. (2014). What is Parenteral Nutrition?
https://www.nutritioncare.org/wcontent.aspx?id=270
California State University. Parenteral Nutrition Tutorial.
http://www.csun.edu/~cjh78264/parenteral/cpn_vs_ppn/
Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition therapy &
pathophysiology. Belmont, CA: Wadsworth.
Parrish, Susan Rees, R.D., M.S.. (2006) The Hitchhiker’s Guide to Parenteral Nutrition
Management for Adult Patients.
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/diges
tive-health/nutrition-support-team/nutrition-articles/MadsenArticle.pdf
RX Kinetics (2014) TPN Tutorial. http://www.rxkinetics.com/tpntutorial/3_1.html
University Health Systems (2009) Parenteral and Peripheral Nutrition Support.
http://www.universityhealthsystem.com/files/01Guidelines%20for%20Creating%20TPN%20Orders.pdf
Lynne Roller
KNH 413
Medical Nutrition Therapy Diet- Pancreatitis Chronic
1. Purpose
a. Nutrition Indicators
A special should be used with pancreatitis patients. Since the pancreas is
inflamed, it cannot heal or produce enzymes such as insulin or glucagon. This
inflammation also causes the inability to digest food, especially fat.
b. Criteria to Assign the diet
A patient should be placed on a high carbohydrate, low fat diet if they are
experiencing any of the symptoms of pancreatitis, such as abdominal pain or
digestive problems. They should also show signs of high levels of triglycerides in the
blood.
c. Rationale for the diet
Since patients with pancreatitis cannot produce proper amounts of enzymes,
a high carbohydrate and low fat diet will help the body to digest foods and obtain
proper nutrients. Alcohol intake should also be minimal, since it has a high tendency
to increase symptoms.
2. Population
a. Overview
Chronic pancreatitis is an inflammation of the pancreas that does not heal or
get worse over time. This can lead to permanent damage. Inflammation can prevent
the pancreas from producing the enzymes insulin and glucagon. Inflammation
causes inability to digest food, especially fats.
b. Disease Process
The first sign of chronic pancreatitis usually occurs in 8-9 years into an
alcoholic’s drinking life. The first sign is usually maldigestion and can lead to fibrosis,
calcification of the pancreas, destruction of the glandular structure, and chronic
digestive issues.
c. Biochemical and Nutrient Needs
It is common to see deficiency in vitamins A, D, E, and K as symptoms
continue. There are also deficiencies in calcium, magnesium, thiamin, and folic acids.
3. General Guidelines
a. Nutrition Rx
Diet: high carbohydrate intake, low fat intake. Small meals throughout the
day, Creon 10 oral, 1 capsule per meal, avoid alcohol, multivitamin supplement,
smoking cessation.
b. Adequacy of Nutrition Rx
Depending on the severity of the patient’s symptoms, further diet instruction
may be needed. For example, if the patient is experiencing major pain eating and
digesting, a soft or NPO diet maybe needed.
c. Goals
Since chronic pancreatitis is not reversible, our main goal is to reduce the
patient’s symptoms by following the above nutrition guidelines.
d. Does It meet DRI
This diet will meet DRI for the most part. However, fat intake may be slightly
lower than guidelines, simply to reduce symptoms quickly.
4. Education Material
a. Nutrition therapy
Recommendations: High carbohydrate diet, low fat intake, small meals, high
fiber, maintain a healthy body weight, medium-chain triglyceride oils, vitamin B12
supplement, drink adequate amount of fluids. Concerns include : nausea, vomiting,
diarrhea, loss of appetite, steatorrhea, poor digestion of proteins, fats, and
carbohydrates, glucose intolerance
b. Ideas for Compliance
Creating meals that are well liked by the patient but also follow guidelines.
Working to educate family members to encourage patient.
5. Sample Menu
a. Foods recommended
Food Group
Protein
Dairy
Grains
Fruits
Vegetable
Beverages
Recommended Foods
Foods
Lean meats and poultry, fish, or eggs.
Low fat milk, cheese, yogurt, or ice
cream
Whole grains (pasta, cereal, bagels,
bread)
Fresh, frozen, or canned
Fresh, frozen, or cooked
Water, juice, tea
b. Foods to Avoid
c.
Food Group
Protein
Dairy
Grains
Fruits
Vegetables
Beverages
l
Foods
Fried, high fat meats and poultry, fried
eggs, processed meats
Whole fat dairy products, milkshakes,
half and half, cream, fried cheeses
White breads, croissants, biscuits, fried
potatoes, granola
Avocado
Fried vegetables
Creamed drinks or soda
d. Example of a meal plan
Breakfast: 1 slice of whole wheat bread, fruit smoothie made with skim milk.
Snack: apple
Lunch: pasta salad and skim milk
Snack: crackers
Dinner: Baked potato and broccoli and skim milk
Snack: low fat ice cream
6. Websites
a. Organizations with Websites
MayoClinic: http://www.mayoclinic.org/diseasesconditions/pancreatitis/basics/definition/con-20028421
University of Chicago Medicine:
http://www.uchospitals.edu/specialties/pancreas/pancreatitis/chronic.htm
b. Government Websites
http://www.nlm.nih.gov/medlineplus/
7. References
a. Journal articles references
Chronic Pancreatitis. Pancreatic Disease Center: University of Cincinnati.
http://www.ucpancreas.org/chronicpancreatitis.htm
Chronic Pancreatitis. The University of Chicago Medicine.
http://www.uchospitals.edu/specialties/pancreas/pancreatitis/chronic.html.
Chronic Pancreatitis. MedlinePlus. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000221.htm
Chronic Pancreatitis - Symptoms, Diagnosis, Treatment of Chronic Pancreatitis NY
Times Health Information. (n.d.). Health News - The New York Times. Retrieved
from
http://health.nytimes.com/health/guides/disease/chronicpancreatitis/overview.html
Huffman, MD, J. L. (2012, March 8). Chronic Pancreatitis. Medscape. Retrieved
from
http://emedicine.medscape.com/article/181554-overview
Longstreth, MD, G. F. (2010, January 20). Chronic pancreatitis - PubMed Health.
National Center for Biotechnology Information. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001268/
Nelms, M., Sucher, K., Lacey, K., Roth, S. Nutrition Therapy and Pathophysiology.
2/e.
Pancreatitis. (2013, September 7). Mayoclinic.
http://www.mayoclinic.org/diseasesconditions/pancreatitis/basics/definition/con-20028421.
Stevens, Tyler; Lee, Peter. Chronic pancreatitis. Cleveland
Clinic.http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement
/gastroenterology/chronic-pancreatitis/.
What is chronic pancreatitis. University of Southern California.
http://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web%20pages/P
ANCREATITIS/what%20is%20chronic%20pancreatit.html.
Emily Rohan
KNH413 – Diet Instruction
Hepatic Failure, Coma
1. Description of patient and diagnosis.
26-year old female, Cynthia Applebottom is admitted to McCullough Hyde
Hospital with increasing symptoms of liver disease 2 years after being diagnosed
with hepatitis C virus (chronic liver disease). A liver biopsy and CT scan
diagnose Cynthia with chronic liver failure, or Cirrhosis. A day after admittance,
Cynthia falls in to a coma and a liver transplant is immediately ordered. The
transplant was successful and Cynthia has been recovering for 4 days. She can
intake food orally but her chief complaint is that she doesn’t have a big appetite.
She has lost another 3 pounds since the surgery. She had lost 6 pounds
unintentionally prior to the surgery.
Temp: 96.5
Pulse: 80
Blood Pressure: 122/76
Height: 5’8”
Current Weight: 121 lbs
Usual Body Weight: 130 lbs (pre-surgery)
BMI: 18.5 (lower end of normal, almost underweight)
2. Discussion of the Disease
There are many types of liver disease and some are more serious/life
threatening than others. Jaundice, Portal Hypertension/Ascites, Hepatic
Encephalopathy, Hepatitis (A,B,C,D,E) , Cirrhosis are all diseases of the liver and
all can lead to liver failure and/or a coma if left untreated. The liver has many
functions including the removal of by-products from the digestion of food, the
absorption of food and proteins necessary for normal blood consistency and
clotting as well as other molecules involved in metabolism. Initial damage to the
liver can elevate certain enzymes in the blood due to leakage from the liver.
Measuring blood glucose, cholesterol, bilirubin, albumin, aminotransferases,
alkaline phosphatase, and prothrombin time will help evaluate liver function.
When the liver fails some or all of these substances can decrease. A bile acid test
may also be used to further test liver failure.
a. Etiology
The pathophysiology of hepatic encephalopathy (HE) is very similar
to the pathophysiology of liver failure because HE is a syndrome of
impaired mental status and abnormal neuromuscular function that
occurs from major liver failure. Ammonia is thought to be a direst toxin to
the brain that is generated from the catabolism of proteins, amino acids,
purines, and pyrimidines. Liver disease interferes with the detoxification
process and shifts ammonia metabolism to skeletal muscle and then used
to convert glutamate to glutamine instead of being synthesized, absorbed,
and transported in the intestinal venous blood to the lever and then
metabolized to urea. Mercaptans, ammonia, tyramine, octopamine, betaphenylethanolamines,
manganese, and gamma-aminobutyric acid also accumulate in liver
failure as well as in HE. The symptoms of hepatic coma are often
corrected by decreasing endogenous ammonia production. Aromatic
amino acids, such as tryptophan, tyrosine, and phenylalanine, are
elevated in the brains of patients with liver failure and HE.
Liver failure means that the liver is losing or has lost all of its function.
It is life threatening and demands urgent medical care. The first
symptoms usually seen in liver failure patients are nausea, loss of
appetite, fatigue, and diarrhea. As liver failure progresses, these
symptoms become more serious and severe to the point where the
patient may become disoriented or confused and the risk for coma or
death increases. If the liver is not responding to any treatment the only
option is a liver transplant. When liver failure occurs as a result of
cirrhosis, this essentially means the liver has been failing gradually for a
portion of time and is then termed Chronic Liver Failure (CLF). CLF can
also be caused by malnutrition. Cirrhosis represents the end of the
pathophysiology spectrum for a wide variety of chronic liver diseases in
which health tissue is replaced by scar tissue, blocking the blood flow
through the organ and resulting in the loss of liver function.
In comparison, acute liver failure is failure of the liver that occurs
suddenly, as little as 48 hours and is usually due to poisoning or a
medication overdose.
b. Diagnostic Measures
Diagnosing Hepatitis C Virus:
There are several blood laboratory tests that are used to diagnose
HCV infections, with the most common once being measurement of
antibodies to hepatitis C virus (anti-HCV), negative tests for
antibodies to HAV and HBV help confirm the diagnosis as well.
Diagnosing Cirrhosis:
No serologic or radiographic test can accurately diagnose cirrhosis
but a significant correlation has been demonstrated between
persistently elevating liver function tests and biopsy-proven
underlying hepatic disease. Symptoms of cirrhosis include fatigue,
weakness, nausea, poor appetite, jaundice, dark urine, light stools.
Steatorrhea, itching, abdominal pain, bloating, and malnutrition.
Vitamin and mineral deficiencies can cause or contribute to depressed
hematocrit and hemoglobin values. Decreased vitamin K values are
due to malabsorption and the inability of the liver to synthesize
protein clotting factors which can result in bleeding and bruising.
c. Treatment
i. Medical, surgical and/or psychological treatment
The primary medical treatments for cirrhosis are abstention from
alcohol, treatment of HCV, or other complications depending on patient, and
nutrition therapy.
The most common liver disorders that require a liver transplant
include chronic active hepatitis, cirrhosis, and biliary-related disorders. After
transplant, all patients require immunosuppressive drugs to prevent
rejection of the new liver.
ii. Medical Nutrition Therapy
Nutrition Concerns for patients with liver disease/liver failure:
-decreased abdominal room due to ascites, if present
-delayed gastric emptying
-decreased appetite
-poor nutrient absorption
-decreased bile production = low fat absorption
-diarrhea
-altered mental status/encephalopathy
The main goal for patients before transplant is to lessen the effects of
malnutrition and complications of liver disease.
Nutrition concerns post-operative liver transplant:
The risks for preoperative malnutrition, surgical stress, post-interventional
complications, post-operative protein catabolism, fasting periods, and side
effects of immunosuppressant medications suggest the need for early
nutrition support after the transplant. After recovery, patients are more
susceptible to food-borne infections as a result of the immune-suppressing
medications.
Nutrition concerns for post-liver transplant:
-increased energy expenditure
-inadequate energy intake
-inadequate oral food/beverage intake
-inadequate protein-energy intake
-malnutrition
-inadequate vitamin/mineral intake (thiamin)
-altered GI function
-impaired nutrient utilization
-underweight
-altered nutrition-related laboratory values
-food-medication interactions
-food and nutrition related knowledge deficit
-involuntary weight loss
Recommendations
After transplant, most nutritional deficiencies and metabolic disturbances
common in patients improve. The main goal is to meet the needs for healing
and preferred nutrition support should either oral or enteral.
Fluid Intake:
-avoid overhydration  6-8 cups a day is adequate
-avoid dehydration since it can lead to renal problems
Calorie Recommendations:
15-30% above basal needs
Cynthia’s Calorie Intake (Mifflin St. Jeor)
REE= 10 (55kg) + 6.25 (172.3cm) – 5 (26yrs) – 161
REE= 1336
REE x Activity Factor (1.2 for confined to bed) x Injury Factor (1.2 for
surgery)
Total Energy Requirements: 1336 x 1.2 x 1.2= 1924kcal
1924 x 15%= 288kcal extra
1924 x 30%= 577kcal extra
RANGE: 2210kcals to 2500kcals
Protein Recommendations:
1.5-2.0 g/kg
Cynthia’s needs:
55kg x 1.5g PRO= 82.5 grams
55kg x 2.0g PRO= 110 grams
RANGE: 82.5 – 110 grams of protein per day
Carbohydrate Recommendations:
To prevent/manage hyperglycemia it is recommended that the patient
decreases simple sugars and have carbohydrates provide 50-60% of total
kcal. It is also recommended to restrict sodium intake by 2-4grams.
Cynthia’s needs:
Cynthia is recovering well so I will use the lower value of kcal to calculate
CHO needs:
2210kcal x .50= 1105kcal from CHO / 4 grams per kcal= 276 grams CHO
2210kcal x .60= 1326kcal from CHO / 4 grams per kcal= 330 grams CHO
RANGE: 276-330 grams of Carbs per day
Fat Recommendations:
Some people with liver disease have problems digesting and absorbing fat.
The fat that is not digested is eliminated through bowel movements. Fat
present in the feces is a nutritional concern and the patient should be put on
a low-fat diet.
Other Nutrient Recommendations:
Calcium supplements along with a multivitamin may be recommended post
surgery to help maintain bone health and ensure overall nutritional needs
are being met. Patient should be educated on food safety because of their
increased susceptibility to food-borne illnesses.
iii. Prognosis- (supported by professional source)
Patients with cirrhosis, or any end-stage liver disease, average 1and 5- year survival rates are 80% - 50% respectively. The clinical
tools used to determine prognosis with patients with cirrhosis are the
Child-Turcotte-Pugh (CTP) classification and the prognostic model for
end-stage liver disease (MELD). MELD score is based on three blood
tests: international normalized ration (INR) which tests the clotting
tendency of the blood, bilirubin which tests the amount of bile
pigment in the blood, and finally creatinine which tests kidney
function. Essentially, the prognosis depends on the cause of the
hepatic failure and two main factors involved in determining
prognosis are etiology and coma grade upon admission.
After liver transplant, overall patient survival rates that were
at one and five years immediately increase to 86.4% and 72.9%
respectively.
PATIENT CHART
Patient: Cynthia Apple Bottom
Anthropometrics:
Temp: 96.5
Pulse: 80
Blood Pressure: 122/76
Height: 5’8”
Current Weight: 121 lbs
Usual Body Weight: 130 lbs (pre-surgery)
BMI: 18.5 (lower end of normal, almost underweight)
Chief complaints post-op:
The transplant was successful and Cynthia has been recovering for 4 days. She
can intake soft foods orally but her chief complaint is that she doesn’t have a big
appetite. She has lost another 3 pounds since the surgery. She had lost 6 pounds
unintentionally prior to the surgery.
Nutrition:
General: Poor appetite for the past 3 weeks. She drinks almond milk for
calcium supplement for breakfast everyday. Lunch is either a small salad or soup
with crackers and iced tea. Dinner is usually at home and consists of a piece of plain
chicken or fish with a vegetable and rice.
Current diet intake: ice chips or sips of orange juice. Breakfast: Soft scrambled eggs
with ½ slice of wheat toast. Mid day: Soft noodles with butter. Dinner: None- no
appetite.
Current diet order: mostly soft, 4 grams sodium restriction, high calorie, frequent
meals (4-6 x day)
Food purchase/prep: herself
Vitamin/Mineral Intake: 600 mg Calcium with 400 IU vitamin D,
multivitamin/mineral daily
Instruction Materials
Why is the liver important?
The liver is the second largest organ in your body and is located under your rib cage on the right side.
It weighs about three pounds and is shaped like a football that is flat on one side.
The liver performs many jobs in your body. It processes what you eat and drink into energy and
nutrients your body can use. The liver also removes harmful substances from your blood.
Why is nutrition important after liver transplantation?
Nutrition plays a key role in your recovery after liver transplantation. As with any surgery, adequate
calories, protein, vitamins, and minerals are needed for wound healing. Also, your nutrient and diet
needs may change if you have complications and/or side effects from your medications after your
transplant.
Once you have successfully recovered from the early stage after transplant (ex. your appetite is back
to normal, your weight is stable, and your wounds are healing well) then you should change to a diet
that is low in saturated fat and high in fiber, fruits, and vegetables. This type of diet will help reduce
risks for other chronic diseases including heart disease and diabetes. Always discuss your individual
dietary needs and concerns with your dietitian or doctor.
It is important to maintain a healthy weight. Obesity, gaining an unhealthy amount of excess fat,
increases your risk of chronic diseases and can damage your new liver.
Eating a healthy diet helps the liver to do its functions well and to do them for a long time.
Eating an unhealthy diet can lead to liver disease. For example, a person who eats a lot of fatty foods
is at higher risk of being overweight and having non-alcoholic fatty liver disease.
For people who have liver disease, eating a healthy diet makes it easier for the liver to do its jobs and
can help repair some liver damage. An unhealthy diet can make the liver work very hard and can
cause more damage to it.
Where should my calories come from?
You should eat enough calories to prevent muscle wasting and allow for gradual regaining of lean
body weight that is often lost with severe illness before transplant and during hospitalization (bedrest) after transplant. Choose nutrient dense foods (dairy, whole grains, plant foods) instead of foods
considered “empty calories” (ex. sodas, candy). If appetite is poor, broaden your scope of food
choices to allow for food preferences. Fruits and vegetables need to be part of your diet to provide
enough vitamins and minerals.
Where should my protein be coming from?
Protein is important to promote healing and muscle gain.
Suggestions of animal based high protein sources:
-fish
-poultry
-egg whites
-eggs with yolk no more than 4 times per week
-dairy products-milk, cheese, yogurt
-red meats- pork, beef, veal
Suggestions of plant based high protein sources:
-unsalted nuts
-peanut butter
-soy products
-dried beans, lentils
Choose lean protein foods more often and prepare them using lean cooking methonds like drilling or
baking rather than pan frying. Avoid using iron pans.
How can I avoid hyperglycemia?
Hyperglycemia is a side effect of the medications given after transplantation. To prevent or manage
this condition, foods high in simple sugars should be limited. These include:
-sugar
-molasses
-doughnuts, pastries, sweet rolls
-pies, cakes, cookies
-honey
-syrups
-jam, jelly, marmalade
-soft drinks (diet sodas are acceptable)
-candy, chocolate
-ice cream, frozen yogurt
-jell-o
-other sweetened beverages (juices, teas)
Blood sugar levels should be monitored and if you develop high blood sugar you diet may need to be
modified to the following guidelines:
-carbohydrates should be high in fiber- consume more whole grain products, legumes, vegetables
instead of refined white breads and cereals.
-Limit fruits to one serving per meal. One serving = ½ cup chopped or canned or one medium whole
-eat often, avoid skipping meals. Each meal and/or snack should include some high quality protein
How much sodium am I allowed?
Some medications such as prednisone can cause your body to retain sodium and water. This can then
cause increased blood pressure. To help avoid this, it is best to restrict salt intake. The “No Added Salt”
diet, which is usually recommended, suggests eating less than 3000 mg of sodium each day. To follow
these recommendations, you should:
1. limit salt when cooking, Use herbs and spices for flavor instead.
2. Do not add salt after food is prepared
3. Avoid or limit the following foods
a. High salt/canned soups, processed meats, fast food items, salted snacks (i.e. pretzels,
crackers, potato chips, etc.
4. Condiments
What else can help benefit my health after transplant?
EXERCISE.
Long periods of inactivity and/or bed rest causes loss of muscle mass and strength (including
strength of the heart) and limits your ability to perform exercise. A successful transplant does not
automatically return you to normal physical activity. For muscles to regain their function and
strength, they must be used regularly. Many people after transplant have high blood pressure, high
cholesterol, and gain fat weight. All of these increase your risk of heart attacks or stroke.
There is enough scientific evidence to say that regular physical activity:
•Decreases risk of death from heart disease.
•Prevents or delays the development of high blood pressure.
•Reduces blood pressure in people who already have high blood pressure.
•Keeps muscles and joints strong and functioning.
•Helps bones develop during childhood and helps adults prevent osteoporosis (thinning of the
bones).
FOOD SAFETY AND SANITATION
Post liver transplant surgery you are more susceptible to food borne illnesses so continuing food
safety practices is essential.
DRUG/NUTRIENT INTERACTIONS:
You are taking immunosuppressant medication. There are many potential food-drug
interactions that can occur. The following table will guide you:
Immunosuppressant Drug Generic Name
Possible food-drug interaction
Cyclosporine, tacrolimus
No Potassium supplement or salt substitute,
caution with grapefruit
Anorexia, diarrhea, increase glucose,
esophagitis, steatorrhea
Diarrhea, steatorrhea, negative nitrogen
balance
Increased cholesterol, hypertriglyceridemia
Take on empty stomach, anorexia, stomatitis,
dyspepsia, abdominal pain, colitis, diarrhea,
constipation
Azathioprine
Rapamune
Mycophenolate mofetil
Should I be worried about potassium toxicity?
If you are taking Cyclosporine or Tacrolimus, these can increase your blood potassium levels.
Abnormal blood potassium levels can cause problems with muscle and heart function. Below is a list
of food items that are high in potassium. If you are taking these medications you will be asked to limit
the intake of these items.
-Apricots, avocados, bananas, dried fruit, melons, oranges, nectarines, peaches
-leafy greens, pumpkins, potatoes, split peas, dried beans, lentils, tomatoes
-orange juice, prune juice, tomato juice, v-8 juices
-milk and dairy, peanut butter, nuts, chocolate
SAMPLE 1 DAY MENU
Breakfast
3 scrambled
egg whites
AM Snack
½ cup
Oatmeal
2 pieces soft
wheat bread
1 cup almond
milk
1 cup vanilla
greek yogurt
1 cup orange
juice
½ cup apple
sauce
Lunch
2 oz. turkey
breast
lunchmeat
(low sodium)
1 slice Swiss
Cheese
PM Snack
½ cup cottage
cheese
2 TBSP
hummus
Lettuce,
Tomato
2 slices whole
grain bread
8 crackers no
salt
Peanut butter
Fresh
fruit/berries
Dinner*
Whitefish with
Tomato
Mousse and
Fresh Herbs
Kale Blueberry
and
Pomegranate
Salad
Side Salad
with low fat
dressing
*recipes attached
RECIPES ADOPTED FROM “HEALTHY RECIPES” OF THE AMERICAN LIVER
FOUNDATION
Whitefish with Tomato Mousse and Herbs
Serves 4
1-pound White fish fillet (halibut, cod, etc.)
10 large, ripe tomatoes
1 clove of garlic
1⁄2 cup fresh or dried herbs (chervil, tarragon, basil, etc.) fine chopped
Salt and pepper to taste
DIRECTIONS:
-Cut the fish into four equal portions of 4 ounces each, season with salt and pepper,
keep refrigerated. -Cut tomatoes in half and remove seeds but save the juice. Using a
blender, puree the tomatoes and garlic. Place the tomato puree in a saucepan, and
simmer over medium heat for about 20 minutes.
-After cooking gently remove the red tomato mousse that is forming at the top and
reserve draining in a strainer lined with a coffee filter adding the additional liquid to
the rest and stain it though a coffee filter as well. What happens when the puree is
cooking it separates and forms a red thick puree on the top and a clear broth on the
bottom.
-Broil the fish under the oven broiler to desired doneness.
-Place the fish into a shallow bowl and pour tomato broth on top. Garnish with
tomato mousse, and fresh herbs.
KALE, BLUEBERRY AND POMEGRANATE SALAD
Kale is usually thought of as a green for cooking, but in this recipe, it’s used as a
salad green, one with a lot more texture than lettuce. Its hardiness means that the
leaves won’t wilt after the salad is dressed. Kale’s pleasant bitterness is nicely
balanced by the sweetness of the blueberries and the tartness of the pomegranate
seeds. This salad is rich in brain-boosting foods: Kale is an excellent source of
flavonoids and vitamin C, blueberries and pomegranates are high in antioxidants.
Serves 4
3 bunches Kale, stemmed and chopped
1 cup fresh blueberries
2 medium carrots, peeled and shredded
1⁄2 cup pomegranate seeds
1/3 cup pumpkin seeds, toasted
1/3 cup sliced almonds, toasted
1 tablespoon chopped fresh mint leaves
1⁄2 cup Soy-Seasame Vinaigrette
Salt and freshly ground black pepper
DIRECTIONS:
Combine the kale, blueberries, carrots, pomegranate seeds, pumpkin seeds, almonds,
and mint in a medium bowl and toss well.
Drizzle with the vinaigrette and toss again.
Season to taste with salt and pepper and serve right away.
WORKS CITED
Healthy Recipes. American Liver Foundation. July 2013. Retrieved from:
http://www.liverfoundation.org/downloads/alf_download_1068.pdf
Liver Transplant Patient Handbook. UCSF Medical Center. 2011. Retrieved from:
http://www.ucsfhealth.org/pdf/liver_transplant_manual.pdf
Liver Disease Diet. 2014. Retrieved from: http://www.drugs.com/cg/liver-diseasediet.html
Liver and Wellness. American Liver Foundation. 2009. Retrieved from:
http://www.liverfoundation.org/downloads/alf_download_729.pdf
Nutrition Therapy and Pathophysiology, Nelms, pages 447-460.
The Progression of Liver Disease. American Liver Foundation. October 2011.
Retrieved from: http://www.liverfoundation.org/abouttheliver/info/progression/
Renal Diet for Dialysis
Description of Patient and Diagnosis:
Client Name: Beth Anderson
DOB: 7/21/1946 (68 years old)
Sex: Female
Education: Bachelors Degree
Occupation: Secretary at a Real Estate Office
Hours of Work: 8:00 AM- 5:00 PM (sometimes 6:00PM)
Ethnic Background: Caucasian
Household Members: Husband- 69 years old
Patient History:
Beth is 68-year-old female who is 5’5’’ and weighs 134 pounds. She has
previously been diagnosed with kidney disease as a result of untreated high blood
pressure throughout most of her life. Even when she was diagnosed with kidney
disease she didn’t take into account the nutrition and medical therapy. Now that she
has reached stage five, kidney failure, she has realized how serious this is. She said
she is very busy throughout the day between work and taking care of her husband.
She has started hemodialysis at the hospital and will eventually go to a clinic that
specializes in dialysis once she gets used to the routine. Beth is educated about
kidney failure but she wants to start to meet with a dietitian to get educated on
healthier eating while dealing with dialysis. She is taking time off work and said she
will eventually work part time or retire at this point.
Nutrition History:
She considered herself to have a balance diet. Is not that picky about foods.
Loves to cook and is willing to try new recipes. She knows that she has to consume
more calories because she heard that meeting caloric needs is important while on
dialysis.
Main reason for coming in:
She knows that she has waited way to long to realize the severity of her
disease. She knows how serious kidney failure is and is embarrassed that she let her
kidney disease get to this point. She wants to start to meet with a dietitian to get her
eating on track as she is adjusting to dialysis. She likes to cook and is open to knew
ideas and recipes she can try
Discussion of the Disease:
Etiology:
There are many different factors associated with kidney failure, however the
most leading causes of this disease are Diabetes, hypertension, and
glomerulonephritis. Other factors that result in developing Kidney disease is ones,
ethnicity, family history, direct blow to the kidneys, and prolonged consumption of
over-the counter pain killers that combine aspirin and ibuprofen.
Diagnostic Measures:
Chronic kidney disease (CKD) progresses slowly over time and even times
when the kidney functions remain stable. Kidney function is assessed based on
glomerular filtration rate (GFR), which is reflected in clearance tests that measures
the rate at which substances are cleared from the plasma by the glomeruli. The
National Kidney Disease Education Program has defined CKD of less than 60
mL/min/1.73m2 for three months or longer and having an albuminuria of more
than 30 mg of unrinary albumin per gram of urinary creatinine. Stage 5 CKD is
defined as kidney function that is inadequate to sustain life and requires initiation of
renal replacement therapy.
Stage
Description
1
Kidney damage with normal GFC
2
Kidney damage with mild decrease in
GFR
3
Moderate decrease in GFR
4
Severe decrease in GFR
5
Kidney Failure
Treatment:
Hemodialysis: This is the most common method of medical treatment.
It requires access to the circulatory system; therefore patients need to have a
procedure done that allows continual access to the bloodstream. Patients
who decide to go with this method of treatment will have dialysis done three
times a week for about four hours in the hospital or a dialysis center. This
treatment can also be done at home, which allows the patient to be more
flexible with how long each cycle is and how often they do it.
Peritoneal Dialysis: This type of treatment is done by surgically
placing a catheter into the peritoneal cavity. Dialysate is the liquid that enters
the body through the catheter that is placed in the peritoneal cavity that
cleans out the blood in the system. There are two types of PD: continuous
ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal
dialysis (CCPD). CAPD is a method that requires no machine and can be done
in any clean and well lit location. It takes about four to six hours followed by
another 40 minutes to for draining of used dialysate and replacement of
fresh solution. Patients will usually sleep with the solution in the stomach
CCPD does require a machine called a cycler, which empties their stomach
three to five times during the night.
Renal Transplant: There are about 18,000 that are performed
annually and about 70,000 people are waiting for a transplant. For the
transplant to be successful the donor must match the recipients medical and
immunological characteristics.
Medical Nutrition Therapy:
Protein:
If a patient is receiving dialysis a protein level of 1.2 grams/kg is important
to maintain proper protein levels within the body. If the protein levels are too low
the patient will end up with a negative nitrogen balance indicating that aren’t
receiving adequate essential amino acids. It is recommended to eat high- quality
proteins, which are proteins that produce less waste than others. Some examples
are meat, fish, poultry and eggs.
Fluid:
Controlling fluid intake is important in dialysis pateints. Too much fluid
consumption can cause high blood pressure, interdialytic weight gain, presenece of
edema, and congestive heart failure. Most patients start with an allowance of 1 L per
day within the first 12 months. As output and input become more regular the 1 L
can be pushed up to 2 L depending on the individual situation.
Sodium: ~1,500-2,000 mg
It is important to monitor sodium intake so you can control the levels of fluid
within your system. Consuming foods high in sodium can cause you to drink more
fluids. The more fluids in your blood system the hard your heart pumps, which can
cause hypertension.
Potassium: ~2,000 mg
Potassium is an important mineral that is found in many foods such as fruits
and vegetables; however, it can affect heart rate. Healthy kidneys regulate the
amount of potassium within your system to keep a steady regular heart beat. High
levels of potassium in between dialysis can be dangerous. Avoiding foods such as
oranges, bananas, tomatoes, potatoes, and dried fruits.
Phosphorus: ~800- 1,000 mg
Phosphorus is a mineral that tends to pull calcium from the bones in our
body. This causes our bones to be brittle and weak allowing them to be perceptible
to fractures and breaks. People will take phosphate binders in between dialysis
sessions to absorb the phosphate within the system.
Supplements:
Monitor/ Evaluating
PrognosisSince Beth is just starting hemodialysis she has a little bit of time to get
adjusted to the treatment and adapting to the new eating habits. If she takes control
of her medical condition from this point on and follows the new eating plan she will
be able to live a somewhat normal life. Once she adapts to these changes going to
dialysis a few times a week will become part of her weekly activities. I have faith
that Beth is serious about these changes and is willing to do what it takes to allow
herself to be healthier. **FIX**
Medical Nutrition Therapy- treatment for client
HB= 655 + (9.56 X wt(kg)) + (1.85 X ht (cm))- (4.68 x age)
=655 + (9.56 X 61.24kg) + (1.85 X 165.1cm))- (4.68 x 68)
=655 + (585..45) + (305.44)- (318.24)
= 1,227 kcals/day
Stress Factor of 1.2-1.4
= 1.2 x 1,227 to 1.4 1,227
= 1,472 – 1,717 kcals/day
= ~1,550kcals/day
Protein:
=1.2 grams of protein/kg of body weight
=1.2 grams of protein X 61.24 kg
= 73 grams of protein/day
Carbohydrates:
= 1,550 kcals X .55
= 852 kcals/day
Fat:
= 1,500 kcals X .30
= 465 kcals/day
Helpful Resources:
American Association of Kidney Patients Nutrition Counter
National Kidney Foundation: Recipes
Healthy Eating for People on Hemodialysis- American Kidney Fund
24 Hour Recall:
Amount
Na +
(mg)
K+ (mg)
Phos
(mg)
Protein
(g)
kcal
Breakfast
Orange Juice
Scrambled Egg
Cheese
Whole Wheat
Toast
Banana
½ cup
1 egg
1 ounce
1 slice
1
71
461
132
248
69
78
69
21
99
146
57
.85
6.3
5.1
3.7
56
72
95
69
1 medium
1
422
26
1.3
105
Coffee
2% Milk
1 Cup
¼ cup in
coffee
7
29
54
86
5
56
.2
2
4
61
Sugar
Lunch
Whole Wheat
Bread
Deli MeatHam
Cheese
Lettuce
Tomato
Mayonnaise
Orange
Dinner
Steak
Brussels
Sprouts and
Asparagus
Mashed
Potatoes
Snack
Popcorn
About 1
packet
2 slices
264
138
114
7.4
138
2-3 slices
545
160
112
11
86
1 slice
¼ cup
2 medium
slices
1 tablespoon
1 medium
461
~2
4
78
~29
63
146
~4
9
5.1
0
~1
95
~2
7
105
1
1
232
4
32
.1
1.3
57
69
3 oz
½ cup
41
11/1
233
85.5/77 15/22
23.3
~1/~1
180
~10/~10
½ cup
349
245
59
2
119
1-2 cups
1
~61
~62
~2.5
79
2,486
1,0149
989
69
1.304
Instruction Materials
Instructions and Focus
Learn how to eat properly while going through dialysis. How to limit
amounts of sodium, potassium, and phosphorus but still eat adequate foods
throughout the day that will meet caloric needs.
Goal for appointment:
Start guiding Beth in the right direction for proper nutrition while she
adjusts to dialysis. Introduce foods that will help meet her caloric needs but low in
sodium, potassium, and phosphorus.
Nutrition Points to Cover
- Discuss calories, protein, fat, and carbohydrate
- Review sodium, potassium, and phosphorus
- Go over 24-hour recall
- Discuss goals that Beth would like to achieve throughout her experience
meeting with a dietitian
Weekly Tips:
Tips to Control…
Thirst:
o Consume foods that say low Sodium
o Drink out of smaller cups and glasses
o Freeze your drinks and eat them like popsicles
Potassium:
o Cut the food in half and only eat half one day and the other half the
next day
o Food such as potatoes dice or shred and boil in water to removed
the potassium
References
"Acute Kidney Failure ." MedlinePlus. N.p., 1 Feb. 2013. Web. 13 Apr.
2014. <http://www.nlm.nih.gov/medlineplus/ency/article/000501.htm>.
"Dialysis ." National Kidney Foundation . National Kidney Foundation, Inc.,
20 Jan. 2013. Web. 13 Apr. 2014.
<https://www.kidney.org/atoz/content/dialysisinfo.cfm>.
"Education ." American Association of Kidney Patients. N.p., 1 Jan. 2013.
Web. 13 Apr. 2014. <https://www.aakp.org/education.html>.
Kidney Failure . (n.d.). American Kidney Fund. Retrieved April 13, 2014,
from http://www.kidneyfund.org/kidney-health/kidney-failure/
"Kidney Failure: Eat Right to Feel Right on Hemodialysi." National Kidney
and Urologic Diseases Information Clearinghouse (NKUDIC). N.p., 20 Nov.
2013. Web. 13 Apr. 2014.
<http://kidney.niddk.nih.gov/KUDiseases/pubs/eatright/>.
"Kidney Failure ." MedlinePlus. N.p., 1 Feb. 2013. Web. 13 Apr. 2014.
<http://www.nlm.nih.gov/medlineplus/kidneyfailure.html>.
"Kidney (Renal) Failure ." Urology Care Foundation . N.p., 1 Mar. 2013.
Web. 13 Apr. 2014.
<http://www.urologyhealth.org/urology/index.cfm?article=20>.
Recipes . (n.d.). National Kidney Foundation . Retrieved April 13, 2014,
from http://www.kidney.org/patients/kidneykitchen/recipes.cfm
"The Renal Diet ." American Association of Kidney Patients. VCU Health
System MCV Hospitals and Physicians , 1 Jan. 2013. Web. 13 Apr. 2014.
<http://www.vcuhealth.org/transplant/docs/renal_diet.pdf>.
Resenius Medical Care . (n.d.). Meal Planning . Retrieved April 13, 2014,
from http://www.ultracaredialysis.com/HealthyLifestyles/EatHealthy/MealPlanning.aspx
Bryn Wilkin
KNH 413
Medical Nutrition Therapy Diet – Soft Diet
1. Purpose
a. Nutrition Indicators
A soft diet is used for patients who cannot tolerate a regular diet, and can be used as
a transition diet from full liquids to solid foods. Soft foods may be recommended for
patients who are unable to swallow normal food items due to a stroke, oral surgery,
metabolic stress, etc. A speech-language pathologist would accurately diagnose this
diet. However, a dietitian may recommend a soft diet prescription if they notice
difficulty chewing, swallowing, dental problems, weakness, stomach discomfort,
head or neck trauma, or a patient is taking chemotherapy.
b. Criteria to Assign the Diet
There are several criterions that are used to assign a soft diet. The patient must
show GI tolerance of a full liquid diet before transitioning to a soft diet. In addition,
a speech pathologist should test the patient in order to ensure that they are capable
of chewing and swallowing the foods in a soft diet. A dietitian should feel confident
that the patient will be compliant with a soft diet before prescribing it. Finally, the
patient’s GI tract should be tolerating a full liquid diet with no negative side effects
such as the presence of steatorrhea, diarrhea, or vomiting.
c. Rationale for Diet
This diet is most often used as a transition diet. The soft diet should be used to
increase a patient’s tolerance to solid foods. As a patient’s GI tract improves, a soft
diet can be used to slowly introduce solid food and the required digestion to the
body. This diet allows for some bowel rest as the patient begins to return to a
regular diet.
2. Population
a. Overview
A soft diet is most often used as a transition diet for people who are recovering from
surgery. Many times a soft diet will be used after an individual undergoes
gastrointestinal surgery or resection. The soft diet is part of a progression that
comes after a full liquid diet. Although there are many surgeries where a soft diet
may be prescribed, the following example covers how a soft diet would incorporated
into a patient’s recovery from a bowel resection, as the result of damage from
Crohn’s disease or ulcerative colitis.
b. Disease Process
Inflammatory bowel disease (IBD) is defined as an autoimmune, chronic
inflammatory condition of the gastrointestinal tract. It can be used as a general
term to describe one of two diseases: ulcerative colitis, and/or Crohn’s disease. The
complete etiologies for both inflammatory bowel diseases are not known. However,
it is clear that environmental factors play a part in causing an abnormal
inflammatory response. These factors include smoking, infectious agents, intestinal
flora, and physiological changes in the small intestine. There is also a strong
connection between IBD and family history. These genetic associations have been
connected within both the innate and acquired immune response. (Nelms, pg. 415417)
c. Biochemical and Nutrient Needs
Depending on what part of the bowel is removed, the patient will have different
biochemical and nutrient needs. If the jejunum is resected, it is very likely that the
ileum will be able to adapt to absorb nutrients typically absorbed in the jejunum.
The distal ileum is the only site for absorption of bile salts, vitamin B12 and also
absorbs a large volume of fluid. The ileocecal valve is crucial in maximizing nutrient
absorption. It controls the rate of passage of ileal contents into the colon. The colon
is also essential for reabsorbing electrolyte-rich fluid each day and helps to maintain
a person’s hydration status. Proper healing will require adequate protein and
energy needs. Therefore, it may be necessary to supplement a soft diet with
continued enteral feedings.
3. General Guidelines
a. Nutrition Rx
Diet Order: “Soft Diet”
Purpose: To decrease peristalsis and limit stimulation of the GI tract. Often used as
a transitional diet after surgery.
General Description & Priniciples: Includes easily digestible foods that are low fiber,
mildly seasoned, and tender. Omit caffeine and alcohol.
b. Adequacy of Nutrition Rx
A soft diet nutrition prescription would be written to cover 100% of the patient’s
energy needs via soft foods. However, depending on GI tolerance of the new diet, it
is possible that a soft diet alone will not supply the patient with adequate nutrition.
Therefore, it may be necessary to continue enteral feeding supplementation to
ensure that the patient is receiving enough calories, protein, and micronutrients.
c. Goals
Once the patient begins a soft diet, it would be important to monitor the patient’s
weight maintenance/gain to UBW, the redevelopment of bacterial flora in the GI
tract, and nutrient absorption in the remaining small intestine. The patient’s blood
panels should be evaluated, including levels of macro and micronutrients. In
addition, it would be important to see signs of diet tolerance from the patient. The
patient should not be experiencing excessive diarrhea or vomiting. In addition, the
patient should not feel GI discomfort in the stomach or intestines. It would be
important to monitor for signs and symptoms of steatorrhea or dumping syndrome.
The goal would be for the patient to experience a smooth transition to the soft diet,
with adequate energy and few negative clinical symptoms.
d. Does it Meet DRI
Yes, a soft diet will meet the recommended energy allowances as specified by the
DRIs. However, if patient compliance is low, or a new GI tract does not tolerate the
diet, enteral supplementation may be required for adequate nutrition.
4. Education Material
a. Nutrition Therapy
When an oral soft diet is first initiated, the patient should be given a low-residue,
lactose-free with small, frequent meals—as tolerated. As the patient tolerates the
mild diet, small amounts of fiber could be introduced. Foods that are considered to
be “gas-producing,” such as spicy/fried foods or caffeinated beverages should be
avoided. A multivitamin should be give throughout this time in order to ensure
delivery of complete nutrition to the patient. In addition, probiotics should be
incorporated into the diet in order to ensure that the patient’s new GI tract builds a
new bacterial flora. The patient should be asked to maintain a food and exercise
journal during their transition to the soft diet. In addition, the patient should note
any episodes of vomiting, diarrhea, or steatorrhea. Compliance and tolerance of the
diet should be evaluated during follow-up appointments.
b. Ideas for Compliance
Incorporating some of the patient’s favorite foods into the diet can increase patient
compliance. During an initial counseling session, the dietitian should try to modify
the patient’s pre-surgery usual food intake to fall within the restrictions of a soft
diet. In addition, the dietitian should involve a patient’s family in the counseling
sessions. Involving family members and receiving their support for the new diet can
greatly improve patient compliance – especially if the patient is an elderly client.
Finally, the dietitian should inform the patient of the prognosis for their recovery.
Inflammatory bowel disease can be managed by diet and exercise. A soft diet
prescription is not a lifetime prescription. The client will be able to return to a
regular diet if he or she is compliant with the current soft diet prescription.
5. Sample Menu
a. Foods Recommended
Food Group
Grains
Vegetables
Fruits
Recommended Foods
Breads, biscuits, muffins, pancakes,
waffles that have been well moistened
with syrup, jelly, margarine, or butter.
Well-moistened cooked or dry cereals.
All pasta and noodles, rice, wild rice, and
moist bread dressing.
Tender-fried potatoes. All cooked tender
vegetables. Shredded lettuce.
All canned and cooked fruits. Soft,
peeled fresh fruits such as peaches,
nectarines, kiwi, mangoes, cantaloupe,
honeydew, watermelon (without seeds).
Milk
Meat and Other Protein Products
b. Foods to Avoid
Food Group
Grains
Vegetables
Fruits
Milk
Meat and Other Protein Foods
Fats and Oils
Soft berries with small seeds such as
strawberries.
Milk, cream, half and half, pudding,
custard, ice cream, sherbet, malts, frozen
yogurt, and cottage cheese
Well-moistened, thin-sliced, tender, or
ground meat, poultry, or fish with gravy
or sauce. Eggs prepared in any way.
Yogurt without nuts or coconut.
Casseroles with small chunks of meat,
ground or tender meats.
Foods Not Recommended
Dry bread, toast, and crackers that have
not been moistened. Tough, crusty
breads such as French bread or
baguettes. Coarse or dry cereals such as
shredded wheat or All Bran. Dry bread
dressing. Dry cakes or cookies that are
chewy or very dry.
All raw vegetables expect shredded
lettuce. Cooked corn. Tough crisp-fried
potatoes, potato skins, or other fibrous,
tough, or stringy cooked vegetables.
Difficult to chew fresh fruits such as
apples or pears. Stringy, high-pulp fruits
such as papaya, pineapple, or mango.
Fresh fruits with difficult to chew peels
such as grapes. Uncooked dried fruits
such as prunes and apricots. Fruit
leather, fruit roll-ups, fruit snacks, dried
fruits.
None unless liquids are restricted.
Anything with nuts, seeds, dry fruits,
coconut, pineapple. Tough, dry meats
and poultry. Dry fish or fish with bones.
Chunky peanut butter. Yogurt with nuts
or coconut.
All fats with coarse, difficult to chew, or
chunky additives such as cream cheese
spread with nuts or pineapple.
c. Example of a meal plan
Meal
Menu
Breakfast
Lunch
Dinner
½ cup (4 ounces) orange juice – no pulp
½ cup well-moistened dry cereal with ¼
cup of milk
1 scrambled egg with cheese on a moist
biscuit
1 cup (8 ounces) milk
1 cup moist beef stew in small chunks
with a variety of well-cooked vegetables
1 slice moistened bread with butter or
margarine
½ cup canned fruit salad
½ cup pudding with a moist cookie
1 cup (8 ounces) milk
½ cup potato soup made with milk
1 slice moistened bread with butter or
margarine
3 ounces moist chicken on ½ cup softcooked rice
½ cup soft-cooked green beans
1 slice apple pie with a moist crust,
cheese wedge, and ice cream
1 cup (8 ounces) milk
6. Websites
a. Organizations with Websites
Digestive Healthcare of Georgia. (2013). Retrieved from:
http://www.digestivehealthcare.net/diets/soft_diet.html
Drugs.com: Know more. Be sure. (2013). Retrieved from:
http://www.drugs.com/cg/soft- diet.html
Fine, B. (2012). Nutrition Assessment. Retrieved from:
www.uic.edu/depts/mcam/nutrition/ppt/nutrition_assessment.ppt
Nutrition Care Manual. (2014). Soft Diet. Retrieved from:
http://www.nutritioncaremanual.org/
University of Minnesota Medical Center: Fairview. (2014). Retrieved from:
http://www.uofmmedicalcenter.org/healthlibrary/Article/86513
b. Government Websites
http://www.cdc.gov/nchs/data/nhanes/nhanes_07_08/DBQ_e_eng.pdf
http://www.nlm.nih.gov/medlineplus/
7. References
a. Journal articles references
NCBI Database. (2002). Short bowel syndrome: a nutritional and medical approach.
Retrieved
from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/
NCBI Database. (2009). Surgical therapy of recurrent Crohn’s disease. Retrieved
from:
http://www.ncbi.nlm.nih.gov/books/NBK6915/
Patient Description
Janice is a 50 year old female who has been diagnosed with Type II Diabetes
within the past six months. She is 61 inches (1.55m) tall and weighs 185lbs
(84.1kg) giving her a BMI of 35. Janice’s BMI classifies her as stage two obese. Her
mother was diagnosed with type II diabetes when she was 45 and her father died of
a heart attack when he was 67. Janice works in a high school as a classroom aid, a
job that requires some physical activity but does not meet the requirement of 30
minutes of moderate activity 5 days a week. Her job requires her to spend hours
every evening coming up with new lesson plans for the following day. Her busy
schedule does not allow her enough time to make regular visits to the gym. When
Janice was diagnosed with type II diabetes, her fasting serum glucose was 223
mg/dL and her total cholesterol was 335 mg/dL. Janis’s LDL-cholesterol levels were
140mg/dL, her HDL-cholesterol levels were 35 mg/dL, and her triglyceride levels
were 160 mg/dL. Her doctor proscribed her Januvia and Lipitor to manage her
blood glucose and cholesterol, respectively. Janice was screened again 2 weeks
prior to this visit and was told that these numbers had little to no change at all. Her
doctor recommended she schedule a nutrition management session with a dietician
to improve her glucose control and manage her dyslipidemia.
Family History
Mother: diagnosed with type II diabetes at age 45
Father: died of a myocardial infarction at age 67
Medications
Januvia: class- DPP-inhibitor
Lipitor: class- statin
24-hour Recall
Breakfast: 1 bacon, egg, and cheese sandwich on 1 bagel with 2 slices of bacon and 1
slice of American cheese with 8oz of 2% milk.
Snack: 1 glazed donut from the conference room with 1 cup of decaffeinated coffee
and 1 Tbsp of French vanilla flavoring
Lunch: from the cafeteria- 3 chicken tenders with ½ cup of fries, an 8oz fruit cup,
and water
Dinner: 4oz breaded pork chop pan fried in olive oil, ½ cup of mashed potatoes
with a tsp of butter, and a frosted cupcake for dessert
Snack: 1 cup of rich vanilla ice cream
Caloric breakdown provided by Fitday.com
Grams
Calories
Fat
Saturated Fat
Polyunsaturated Fat
Monounsaturated
Fat
Carbohydrates
Dietary Fiber
Protein
117.14
45.98
15.3
48.1
298.8
13.8
92.8
Calories
2584
1046.3
411.2
136.2
% Calories
429.5
1163.4
41
45
373.7
14.5
40.5
39.3
13
Cholesterol: 744mg
Type II diabetes is a disease where the body’s cells become resistant to
insulin and therefore cannot utilize the glucose in the blood resulting in abnormally
high blood glucose levels. The risk factors for diabetes are obesity, inactivity, fat
distribution, age, race, family history, pre-diabetes, and gestational diabetes.
Type II diabetes is diagnosed by three laboratory testing procedures:
hemoglobin A1c test, Fasting plasma glucose test, and the oral glucose tolerance test.
The hemoglobin A1c test analyses an individual’s average blood glucose levels over
a period of three months. A1c is represented as a percentage of the total blood and
any percentage greater than 6.5 is considered abnormally high. The Fasting plasma
glucose test is administered after eight hours of fasting and is most accurate in the
morning. Readings of 100 mg/dL-125mg/dL indicates the individual is glucose
intolerant and multiple reading of 200 mg/dL or higher means the individual has
diabetes. The oral glucose tolerance test measures an individual’s blood after a fast
period of eight hours and two hours after an individual has been given a solution
containing 75 grams of glucose dissolved in water. If after the two hours the
individual’s blood glucose levels are higher than 200 mg/dL the individual can be
diagnosed with diabetes.
Dyslipidemia is defined as having abnormal levels of lipids present in the
blood. Lipids found in the blood are LDL-cholesterol, HDL-cholesterol, and
triglycerides. These three components make up the total blood cholesterol of an
individual. Cholesterol is a waxy substance found in animal source foods. LDLcholesterol functions as a dietary cholesterol transport in the blood. High
concentrations of LDL-cholesterol is associated with high levels of cholesterol and is
often referred to as “bad cholesterol”. Abnormally increased levels of LDL-C are
greater than 130 mg/dL. HDL-cholesterol acts as a scavenger in the blood and
searches for cholesterol to bring back to the liver to be processed. HDL-C is called
the “good” or “happy” cholesterol and should be found in concentrations greater
than 40 mg/dL in the blood. Triglycerides are fats found in your blood that can be
stored and later used for energy. A normal level of triglycerides is less than 150
mg/dL in the blood.
Type II diabetes and dyslipidemia can be medically managed with the use of
medications. However, the MNT for Janice will be to initiate use of the TLC diet. The
TLC, or Therapeutic Lifestyle Changes diet, was designed by the National Cholesterol
Education Program (NCEP) and aims to lower cholesterol through an increase in
physical activity and weight reduction. The guidelines for the TLC diet are as
follows:
Less than 7% total calories from saturated fats
25-30% total calories from fat
less than 200mg of dietary cholesterol per day
20-30g of fiber per day.
Foods to stay away from include high amounts of animal source foods such as beef,
pork, milk, and cheeses. Foods that increase HDL-C and decrease LDL-C while also
working to lower blood glucose levels are fruits, vegetables, beans, and whole grains.
Resources
http://tlcdiet.org/
http://care.diabetesjournals.org/content/30/suppl_1/S48.full
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748661/
http://www.webmd.com/drugs/drug-3330Lipitor+oral.aspx?drugid=3330&drugname=Lipitor+oral&source=0
http://www.diabetes.org/living-with-diabetes/treatment-andcare/medication/oral-medications/what-are-my-options.html
http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/#3
Medical Nutrition Therapy Diet
Robertson
Haley
KNH 413- Spring 2014
1. Purpose
a. Nutrition Indicators There are several tests used to determine Wilson’s disease including:
examination for Kayser-Fleisher rings, serum ceruloplasmin test, 24hour urine copper test, liver biopsy, and genetic testing.
 Liver, nerurological, musculoskeletal and psychiatric areas of health
can also have indicators of Wilson’s disease helping to diagnose the
disease.
o These can include chronic active hepatitis, cirrhosis, jaundice,
hematemesis, difficulty speaking, excessive salivation, ataxia,
personality changes, dystonia, grand mal seizures, emptional
liability, compulsiveness, self-injurous behavior,
schizophrenic-like behavior, skeletal abnormalities, and
cardiac manifestations.
 Tests
o Serum ceruloplasmin levels < 20 mg/dL
o Urinary copper excretion rate > 100mcg/day
o Hepatic copper concentration (liver biopsy) > 250 mcg/g of
dry weight
b. Criteria to Assign the Diet:
If the patient has any of the above testing levels or multiple it is
recommended they follow a Wilson’s Disease diet.
c. Rationale for Diet:
The diet is recommended to decrease the levels of copper in the blood
by decreasing the amount of copper in the diet.
2. Population
a. Overview An autosomal recessive disease
 Occurs equally in men and women
 Both parents must carry the gene in order to inherit Wilson’s disease
 At least 1 in 20,000 people of all known rates and nationalities has the
disease
 The carrier frequency of the gene is 1 in around 100 people in the U.S.
o This gene is located on the 13th chromosome and is called
ATP7B
b. Disease Processo The genetic mutation located on chromosome 13 of the body is
responsible for Wilson’s disease.
o This gene contains the necessary information for making a
copper transport protein that is responsible for removing
copper from the liver, but mutations in the gene inhibit proper
removal of excess copper from the liver and allows copper to
accumulate in other organs and the liver.
o This excess build up of copper can lead to the symptoms
described above.
c. Biochemical and Nutrient Needs It is important to limit foods high in copper because the body is
not able to excrete the excess amounts from the organs, especially
during the beginning stages of the disease. The copper content of
drinking water must also be tested because it is possible for water
to contain copper as well so bottled water is recommended. It is
recommended also to be cautious of vitamins and supplements
containing copper.
 A zinc supplement, such as Zinc acetate prevents the absorption of
dietary copper in your body so a low copper diet can be tolerated.
3. General Guidelines
a. Nutrition Rx –
 Patients must avoid copper-rich foods and beverages and
restrict copper intake to < 1 mg/day. A Zinc supplement can be
added into the diet to help with copper excretion in addition.
b. Adequacy of Nutrition Rx
 This Nutrition Rx is an adequate Rx because it is focused on the
issue of the patients’ in ability to excrete copper. By decreasing
the intake of copper and increasing a supplement that will help
with the excretion of copper, the amount of excess copper in
the body should be able to be maintained.
c. Goals

The goal of this diet is to ultimately decrease excess levels of
copper within the body and be able to maintain a balanced
level of copper intake with excretion through diet and
supplementation.
d. Does it Meet DRI
 The RDA for copper in an adult is 900 mcg or 0.9 mg. If a
patient follows the Wilson’s disease diet of low copper intake
they will meet the RDA for copper.
4. Education Material
a. Nutrition Therapy
 It is important for the client to fully understand the
implications of their disease from a nutrition and diet stand
point. Using nutrition handouts and nutrition education tools,
the client can gain a better understanding of high copper foods
they should avoid and low copper foods they are allowed to
include in their diet. By going through their typical day and
understanding their likes and dislikes it would be helpful in
order to advise them on slight changes they can make in their
eating plans in order to follow the diet successfully. Also,
keeping a food log and tracking the amount of copper in their
diet will also be a helpful tool in making sure they are following
the recommended diet.
b. Ideas for Compliance
 In order to increase compliance the patient should be fully
aware of the consequences of not accommodating to the low
copper diet and the health risks that are likely if non-compliant.
 Building a positive relationship with the client and using a
reward system can also be beneficial in compliance to the diet
so the patient knows the dietitian is invested in their health
and they should be as well.
5. Sample Menu
a. Foods Recommended
 Beef
 Eggs
 White meat turkey and chicken
 Cold cuts and frankfurters that do not contain pork, dark
turkey, dark chicken, or organ meats
 Most vegetables including fresh tomatoes
 Breads and pasta from refined flour
























Rice
Regular oatmeal
Cereals with <0.1 mg of copper per serving (check label)
Butter
Cream
Margarine
Mayonnaise
Non-dairy creamer
Sour cream
Oils
Salad dressings (made from allowed ingredients)
Most milk products
Milk flavored with carob
Cheeses
Cottage cheese
Jams, jellies, and candies made with allowed ingredients
Carob
Flavoring extracts
Coffee
Tea
Fruit juices
Fruit-flavored beverages
Lemonade
Soups made with allowed ingredients
b. Foods to Avoid
 Lamb
 Pork
 Pheasant
 Quail
 Duck
 Goose
 Squid
 Salmon
 Organ meats including liver, heart, kidney, and brain
 Shellfish including oysters, scallops, shrimp, lobster, clams,
and crab
 Soy protein meat substitutes
 Tofu
 Nuts and seeds
 Vegetable juice cocktail
 Mushrooms
 Nectarines
 Commercially dried fruits including raisins, dates, prunes





















Avocado
Dried beans including soy beans, lima beans, baked beans,
garbanzo beans, pinto beans
Dried peas
Lentils
Millet
Barley
Wheat germ
Bran breads
Cereals with >0.2 mg of copper per serving (check label)
Soy flour
Soy grits
Fresh sweet potatoes
Chocolate milk
Soy milk
Cocoa
Instant breakfast beverages
Mineral water
Soy-based beverages
Copper-fortified formulas
Brewer’s yeast
Multi-vitamins with copper or minerals
c. Example of a meal plan
Sample Menu
Breakfast
 1 C Oatmeal
 ½ C 2% Milk
 1 Scrambled Egg (with cheese)
 8 oz. Orange Juice
Snack
 Greek yogurt with Strawberries
Lunch
 Turkey Sandwich
o 2 oz. Turkey
o Refined white bread
o Mustard
o Lettuce
o Cheese
 1/2 C carrots chopped
 1 small apple

1 bottled water
Snack
 ½ PBJ Sandwich
o 1T PB
o 1 T Jelly
o 1 slice refined white bread
o 1 bottled water
Dinner
 Chicken 2 oz (baked)
 ½ C Green Beans
 ½ C Cooked Corn
 Salt/Pepper
 2 T Margarine
 ½ C 2% Milk
 2 Sugar cookies
Snack
 3 C Air-Popped Popcorn
 Smoothie 8 oz.
o Yogurt
o Fruit juice
o Strawberries
o Banana
6. Websites
a. Organizations with Websites
 Arizona Digestive Health
o http://www.arizonadigestivehealth.com/low-copper-dietfor-wilsons-disease/
 Wilson’s Disease Association
o http://www.wilsonsdisease.org/wilson-disease/
 Oregon State University (Linus Pauling Institute)
o http://lpi.oregonstate.edu/infocenter/minerals/copper/
b. Government Websites
 Center for Disease Control (CDC)
o http://www.cdc.gov/niosh/npg/npgd0151.html
 Genetics Home Reference
o http://ghr.nlm.nih.gov/condition/wilson-disease

Better Health Channel
o http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf
/pages/Wilson's_disease#
7. References
a. Journal articles references
http://www.wilsonsdisease.org/wilson-disease/wilsondiseasediet.php
a. Websites
o About Wilson Disease. (2009, January 1). Wilson Disease Association.
Retrieved , from http://www.wilsonsdisease.org/aboutwilsondisease.php
o Diseases and conditions: Wilson's Disease. (2011, September 23).
Mayo Clinic. Retrieved , from http://www.mayoclinic.org/diseasesconditions/wilsons-disease/basics/treatment/con-20043499
o Gilroy, R. (2013, October 1). Wilson Disease. Medscape. Retrieved ,
from http://emedicine.medscape.com/article/183456-overview
o Higdon, J., Delage, B., & Prohaska, J. (2014, January 1). Micronutrient
information center: Copper. Oregon State University Linus Pauling
Institute. Retrieved , from
http://lpi.oregonstate.edu/infocenter/minerals/copper/
o Low copper diet for Wilson's Disease. (2014, January 1). Arizona
Digestive Health. Retrieved , from
http://www.arizonadigestivehealth.com/low-copper-diet-forwilsons-disease/
Emily Hawley
KNH 413: TPN Diet
April 24, 2014
Purpose
The purpose of total parenteral nutrition (TPN) is to sustain life and promote
growth and healing to patients whose gastrointestinal tract has been altered to the
point where it is no longer able to metabolize and/or absorb nutrients for a
significant period of time. This may be due to a massive bowel resection or short
bowel syndrome, abdominal trauma or infection, or certain disease states. A
patient’s complete inability to consume their energy and nutrients orally is another
reason why TPN may be required. A patient may exert various signs that point to
needing TPN such as rapid weight loss, fatigue, hypoglycemia, or nutrient
deficiencies. A TPN solution is tailored to the patient’s individual energy, fluid,
protein, carbohydrate, lipid, and micronutrient needs and will drip through a needle
or catheter placed in the vein. TPN bypasses the normal way the body digests food
in the stomach. It supplies the fuels the body needs directly into the blood stream
through a central IV line. The body needs three kinds of fuel carbohydrates, protein
and fat. TPN also contains other nutrients, such as vitamins and minerals,
electrolytes and water.
Population
People of all ages have received parenteral nutrition. It may be given to infants and
children, as well as to adults. People can live very well on parenteral nutrition for as
long as it is needed. Many times, parenteral nutrition is used for a short time; then it
is removed when the person can begin to eat normally again. People would need
TPN if You have had surgery on your intestines or digestive tract, you have a
medical condition that prevents your intestines from working, such as a blockage,
Crohn disease, or short-bowel syndrome, you have other medical conditions, such as
cancer, AIDS (acquired immunodeficiency syndrome), pancreatitis, or hyperemesis
gravidarum, or you have severe burns or other trauma.
General Guidelines
TPN requires water (30 to 40 mL/kg/day), energy (30 to 45 kcal/kg/day, depending
on energy expenditure), amino acids (1.0 to 2.0 g/kg/day, depending on the degree
of catabolism), essential fatty acids, vitamins, and minerals. Children who need TPN
may have different fluid requirements and need more energy (up to 120
kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day).
Basic TPN solutions are prepared using sterile techniques, usually in liter batches
according to standard formulas. Normally, 2 L/day of the standard solution is
needed. Solutions may be modified based on laboratory results, underlying
disorders, hypermetabolism, or other factors. Most calories are supplied as
carbohydrate. Typically, about 4 to 5 mg/kg/min of dextrose is given. Standard
solutions contain up to about 25% dextrose, but the amount and concentration
depend on other factors, such as metabolic needs and the proportion of caloric
needs that are supplied by lipids. Commercially available lipid emulsions are often
added to supply essential fatty acids and triglycerides; 20 to 30% of total calories
are usually supplied as lipids.
Progress should be followed on a flowchart. An interdisciplinary nutrition team, if
available, should monitor patients. Weight, CBC, electrolytes, and BUN should be
monitored often. Plasma glucose should be monitored every 6 h until patients and
glucose levels become stable. Fluid intake and output should be monitored
continuously. When patients become stable, blood tests can be done much less often.
Liver function tests should be done. Plasma proteins (eg, serum albumin, possibly
transthyretin or retinol-binding protein), prothrombin time, plasma and urine
osmolality, and Ca, Mg, and phosphate should be measured twice a week. Changes in
transthyretin and retinol-binding protein reflect overall clinical status rather than
nutritional status alone. A full nutritional assessment should be done every 2 weeks.
Education Material
a. Nutrition Therapy: The specialized Registered Dietitian calculates the exact
nutritional needs for the patient. The needs are supposed to meet the
patients needs of energy, fat, carbohydrates, and protein by 100%. Vitamins,
minerals, and electrolytes are also taken into consideration.
b. Compliance: If the patients continue TPN on 12 hours cycles at home they are
required to be given education materials in order to properly administer the
formula as well as how to do so in a sanitary fashion to prevent infection at
the tube injection site or any other kind of TPN complication; this may
require a training session with a nurse or registered dietitian as well as
several check-ups once the patient is home. Educating a patient on
recognizing the specific signs of infection and complication is also critical.
Sample Menu
Patients on TPN do not have a set menu because they do not receive any food orally
due to bowel rest or another kind of malabsorption problem.
Websites
ASPEN:
http://www.nutritioncare.org/Information_for_Patients/What_is_Parenteral_Nutriti
on/
Canadian Cancer Society: http://www.cancer.ca/en/cancer-information/diagnosisand-treatment/managing-side-effects/tube-feeding-and-total-parenteralnutrition/?region=on
References
http://www.nutritioncare.org/Information_for_Patients/What_is_Parenteral_Nutriti
on/
http://www.drugs.com/cg/total-parenteral-nutrition.html
http://www.merckmanuals.com/professional/nutritional_disorders/nutritional_su
pport/total_parenteral_nutrition_tpn.html