NUTRITION AND NUTRITIONAL
STATUS IN DISEASE
CM Viviers (RDSA)
Department of Human Nutrition
NUTRITION AND NUTRITIONAL
STATUS IN ILLNESS
ILLNESS
Altered
food intake
Altered
digestion
Altered
metabolism
MALNUTRITION
Altered
excretion
CHRONIC LUNG DISEASE
(e.g. cystic fibrosis)
Nutritional-related problems
● Increased energy needs (↑work of breathing, infections, fever)
● Increased nutrient losses (maldigestion & malabsorption of
protein/fat)
● Decreased food intake (infections, other illnesses, breathing, cramps)
● Impaired feeding skills
●Outcomes of malnutrition:
- Growth retardation (FTT, delayed puberty)
- Malabsorption (steattorrhoea)
- Poor immune status (recurrent infections)
- Increased lung disease
- More rapid progression of disease
- Increased morbidity
CHRONIC LUNG DISEASE
Dietary treatment
Goals:
● Improve growth, development, resistance to infection
● Reduce excessive losses from maldigestion/malabsorption
● Prevent progressive pulmonary disease/complications (glucose
intolerance, intestinal obstruction)
Strategies:
● Increase intake of energy and protein
- Supplement breast fed baby with high energy formula
- Regular and enjoyable mealtimes
- Larger food portions
- Extra snacks
- Select food with high nutrient density
- Fortify foods/beverages
CHRONIC LUNG DISEASE
Dietary treatment (cont)
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MCT oil
Ω-3 fatty acids
Nocturnal feeds
Regular re-evaluation of intake
Replace enzymes
Insufficient replacement → poor tolerance of starch & fat
Monitor
Tolerance of lactose, fats, gas forming foods, food consistency
Hydration status
Micronutrient status
Provide adequate micronutrients
Vitamins A, D, E, K
Zinc
Iron
Calcium
CANCER
Nutritional-related problems
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Altered energy expenditure
Alterations in REE → cachexia/weight gain
Tumor growth
Infections
Digestion and absorption of nutrients affected
Changes in CHO, fat, protein metabolism
Glucose intolerance
Body fat depletion, ↓ HDL, ↑ VLDL
Protein depletion, ↓ muscle mass, ↑ muscle breakdown, ↓ rates of
synthesis
● Decreased intake
- Alterations in taste and smell
- Position of tumor
- Side-effects of cancer treatment
CANCER
Nutritional-related problems
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Symptoms with a nutritional impact
Nausea and vomiting
Bowel changes (diarrhoea/constipation)
Dysphagia, dry mouth, chewing/swallowing difficulties, abdominal
gas
Anorexia/early satiety
Pain, fatigue
CANCER
Dietary treatment
Goals:
● Prevent/reverse nutrient deficiencies
● Sustain and promote normal growth and development
● Minimise nutrition-related side-effects
● Maximise quality of life
Strategies:
● Increase energy and protein intake
- Small frequent meals
- Energy dense foods
● Decide on route of feeding
- Oral, enteral, parenteral
● Individual food preferences/aversions
CANCER
Dietary treatment
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Prevent further weight loss
Control glucose intolerance
Complex carbohydrate, limit simple sugars
Regular meals
Provide adequate micronutrients
Vitamin B6, pantothenic acid, folic acid, Vitamins A, E, C, β-carotene
CANCER
Dietary treatment
● Treat side-effects of chemo-/radiation therapy
- Loss of appetite/early satiety: High protein, high energy supplements
Limit high fat foods
Avoid liquids with meals
- Nausea and vomiting:
Frequent, small meals
No strong odours
Cool/room temperature foods
- Sore mouth/throat: Increase fluid intake
Decrease fibre and roughage
Select soft, moist food, add gravy/sauces
- Abdominal gas:
Decrease fibre/roughage
Limit high fat foods
Exclude gasforming foods
HEART
(e.g. Heart failure)
Nutritional-related problems
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Stunted growth
Increased needs
Catabolic
Increased energy expenditure – rapid breathing
Decreased intake of food
Difficulty in breathing
Quickly tired
Insufficient/excessive weight gain (oedema)
Fluid retention/↓ circulation
Iron deficiency
HEART
Dietary treatment
Goals:
● Promote growth and development
● Reduce/eliminate oedema
● Avoid distention of diaphragm
● Correct nutrient deficits
Strategies:
● Increase energy, protein and fat intake
- HBV protein sources
- ↓ CHO and ↑ fat content to reduce RQ
- Energy dense meals (1T fat → 135 kcal/1T sugar → 60 kcal)
- Food with soft texture reduces chewing
HEART
Dietary treatment (cont)
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Restrict fluid and salt intake with fluid retention
Monitor input/output
Sodium restricted diet (↓ dietary sources of Na+)
1t salt → 2400 mg Na+
250 mL milk → 120 mg Na+
1 slice bread → 150 mg Na+
- Inclusion of K+ rich foods
● Avoid abdominal distention
- Small frequent meals
- Use bland low roughage foods
● Ensure adequate intakes of food sources of vitamins E, B6, B12,
folic acid, riboflavin, thiamine, iron
GASTRO-INTESTINAL TRACT
Nutritional-related problems
● Medical conditions can affect functions in any part of the GIT –
intake of food, digestion, absorption of nutrients and excretion of
waste products
● Malnutrition affects digestion and absorption of nutrients
- Villi atrophy → ↓ absorptive area
- Enzyme deficiencies (lactase, sucrase, maltase)
● Intolerances
- Lactose
- Gluten
GASTRO-INTESTINAL TRACT
Nutritional-related problems (cont)
● Food-induced symptoms
- Carbohydrate-induced symptoms
Hypertonicity:
Bloating (Gastric surgery)
Diarrhoea (Antrectomy)
Poor absorption:
Gas (Malabsorption)
Bloating (Coeliac disease)
Diarrhoea (SBS)
Abdominal pain (Dietary fibre)
- Fat-induced symptoms
Dyspepsia (GERD)
Bloating, early satiety (Gastric surgery)
GASTRO-INTESTINAL TRACT
Nutritional-related problems (cont)
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Symptoms with a nutritional impact
Diarrhoea - ↑ nutrient loses
Nausea and vomiting - ↓ intake, ↑ losses
Pain, bloating – avoiding important foods, ↓ intake
GASTRO-INTESTINAL TRACT
Dietary treatment
Goals
● Correct malnutrition/nutritional deficits
● Provide sufficient nutrients for growth and development
● Monitor GI function (intolerances, malabsorption)
● Replace losses
Strategies
● Provide sufficient energy & protein
- Small frequent meals
- Energy dense foods
GASTRO-INTESTINAL TRACT
Dietary treatment
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Replace losses
ORT
Soluble fibre (apples, bananas, carrots)
Potassium
MCT
Vitamins and minerals
Adjust consistency of foods / preparation methods
Withheld foods leading to problem/discomfort (depends on disease
condition)
● Add foods to relieve problem
- Soluble fibre (apples, banana, carrots)
- Insoluble fibre (whole wheat, bran)
Liver
Nutritional-related problems
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Inadequate intake
Anorexia, nausea & vomiting (liver disease)
Early satiety (ascites, enlarged liver / spleen)
Restricted / unpalatable diets (low in fat / protein / salt)
Impaired nutrient digestion and absorption
Steatorrhoea (bile salt deficiency)
Essential fatty acid deficiency
All nutrients (malnutrition related villous atrophy)
Increased nutritional requirements
Hypermetabolism
Accelerated protein breakdown
Insufficient protein synthesis
Liver
Nutritional-related problems
● Altered nutrient metabolism
- Carbohydrate: glycogenesis, glycogenolysis, gluconeogenesis (low
glygogen stores, fasting hypoglycaemia)
- Protein: transamination & oxidative deamination (synthesis of serum
protein – low albumin levels, poor blood clotting)
- Fat: energy production & synthesis of lipoproteins (fatigue, catabolic)
● Vitamin & mineral deficiencies
- Storage of fat soluble vitamins, Vit B12, Zn, Fe, Cu, Mg
- Transport of Vit A, Fe, Zn, Cu
- Conversion of carotene, folate, Vit D
● Increased ammonia levels & risk of hepatic coma
LIVER
Dietary treatment
Goals
● Correct malnutrition/nutritional deficits
● Promote growth and development
● Support residual liver function
● Prevent fat stasis & steatorrhoea, bone disease, anaemia, coma
● Provide supportive treatment for complications
Strategies
● Provide sufficient energy
- Small frequent meals
- Energy dense foods
● Provide sufficient protein
- HBV protein
- ↑ BCAA and ↓ AAA
- Vegetable protein ↓ methionine & ammoniagenic AA and ↑ fibre
- Casein vs meat protein
LIVER
Dietary treatment (cont)
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Steatorrhoea
Modify fat intake
MCT vs LCT
monitor Ca++ & vit D
Ascites
Restrict fluid & salt intake
Renal insufficiency
Alter fluid, Na+, K+, PO4 intake
Adjust consistency of foods (oesophagaeal varices)
Withheld foods leading to problem / discomfort (depends on disease
condition)
TYPE 1DIABETES MELLITUS
Nutritional-related problems
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Under-/overweight
Energy not utilised
Obesity & insulin administration
Physical activity / exercise
Hyperglycaemia
Poor balance between amount of CHO / timing of eating & insulin
regimen
● Hypoglycaemia
- Brain development
- Illness / infection & food intake / absorption
● Dehydration (polyuria)
● Long-term complications
- Macrovascular
- Microvascular
TYPE 1DIABETES MELLITUS
Dietary treatment
Goals
● Provide appropriate energy and nutrients for optimal growth and
development
● Achieve and maintain ideal body weight
● Attain & maintain optimal metabolic outcomes on an individual basis
- Blood glucose
- Lipids
● Prevent hypo- and / or hyperglycaemia
● Reduce risk of long-term micro- and macrovascular complications
● Improve health through food choices & physical activity
● Address individual needs
- Personal / cultural preferences
- Lifestyle
- Willingness to change
TYPE 1DIABETES MELLITUS
Dietary treatment
Strategies
● Determine food & meal plan then integrate insulin regimen into
usual eating habits & physical activity schedule
● Issues regarding CHO
- Carbohydrate sources (fruits, grains, starchy vegetables, milk,
sugars)
- Consistency in timing (distribution) & amount (portion sizes)
- Glycaemic Index vs Glycaemic Load
- Sweeteners
- Blood glucose monitoring
- Adjustments for exercise
● Issues regarding protein
- Requirements
- Plant vs animal protein
TYPE 1DIABETES MELLITUS
Dietary treatment
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Issues regarding dietary fat
Saturated & trans fats
Unsaturated fats
Other dietary components
Salt
Vitamins & dietary antioxidants
Non-starch polysaccharides (fibre)
Diabetic products
CHRONIC RENAL DISEASE
Nutritional-related problems
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Growth retardation
Restrictive diets
Poor food intake (uraemia → ↓ appetite)
Increased losses (↑ permeability of basement membrane →
proteinuria)
Oedema
↓ Excretion
↓ Protein intake → ↓ albumin
Hyperkalemia
Hypertension
Renal bone disease
↑ PO4 → Ca++ resorption from bones & ↑ Ca++ absorption from GIT
secondary hyperthyroidism & renal osteodystrophy
↓ Activation of vit D
Anaemia
RENAL
Dietary treatment
Goals
● Provide adequate energy
● Regulate protein intake
● Manage fluid balance & electrolytes
● Regulate Ca++ & PO4 intakes
● Provide adequate micronutrient & iron intakes
Strategies
● High energy, low protein foods (CHO, PUFA/MUFA)
● Control protein intake
- Optimal growth
- HBV 65 – 70% total protein intake
- Blood urea
- PO4 content
RENAL
Dietary treatment
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Reduce Na+ intake if hypertensive
‘No added salt’/salt restriction
Fresh foods
K+ modified diet if hyperkalaemia occurs
Fluid restriction individualised if necessary
Limit dietary PO4 without compromising protein intake
Supplement Ca++
Provide foods rich in iron, folic acid, vit C & B12
Haem iron vs non-haem iron
Components affecting absorption (phytates, polyphenols, Ca++)
Modify dietary fats for prevention of cardiovascular disease
DIALYSIS
Nutritional-related problems
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↑ Protein losses
Electrolyte changes (K+)
Fluid retention
↑ Glucose intake (PD)
Steroid treatment
↑ Appetite
Weight gain
DIALYSIS
Dietary treatment
Strategies
● Monitor weight gain between dialysis sessions
● Monitor changes in urea / creatinine
● Monitor changes in electrolytes
● Monitor fluid intake & output
HIV and AIDS
Nutritional-related problems
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Underweight
Increased energy expenditure
Malabsorption
Altered macronutrient metabolism
Loss of lean body mass
↓ Dietary intake
Preferential loss of body protein
Opportunistic infections
Growth faltering
Gastrointestinal complications
Food intolerance, malabsorption, constipation, diarrhoea
Lipodystrophy syndrome
Insulin resistance
Impaired glucose tolerance
Dyslipidaemia
HIV and AIDS
Dietary treatment
Goals
● Provide optimal nutrition
● Support regeneration of immune system
● Maintain growth, development & activity
● Help adherence to medication
● Preserve lean body mass
● Prevent overweight & obesity
● Encourage cardioprotective diet
● Encourage healthy eating
● Provide advice on food safety & hygiene
Strategies
● Increase energy & protein intake
- Adjust energy intake for mobility, infection, weight loss,
malabsorption
- Energy & nutrient dense meals & snacks (full cream milk, cheese,
PUFA / MUFA, ω-3 fats, sugar, jam)
- HBV protein
HIV and AIDS
Dietary treatment
● Optimise food intake
- Delayed weaning: Appropriate milk intake for age
- Neuro-developmental delay: Modify food consistency, finger foods,
daily routine
- Eating difficulties: Soft non-acidic foods, avoid spicy food & drink,
straws to bypass lesions, suck ice lollies
- Growth faltering: Space drinks & snacks away from meals, avoid
excessive fluid intake
● Food intolerance
- Lactose-free
● Constipation / diarrhoea
● HAART: Interactions between drug & food, nutritional side effects
● Lipodystrophy syndrome
- Impaired glucose tolerance: CHO distribution
- ↑ Total cholestrol: ↓ SFA, ↑ PUFA / MUFA, ω-3 fatty acids
- ↑ TG: ↓ Refined CHO, ω-3 fatty acids, fruit & vegetables
● Hygienic storage, preparation, serving of food
Critically ill children
(ICU)
Nutritional-related problems
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