B
Nutritional Deficiency States
 Cancer
 AIDS
 Renal failure
 COPD
 Heart failure
Impact of Malnutrition
 Susceptibility to infection
 Weakness and fatigue
 Impaired wound healing
 Impaired growth and development in children
 Edema
 Anemia
Nutritional Products
 Liquid enteral products
 IV fluids
 Pancreatic enzymes
 Vitamins
 minerals
Nutritional Products
 Liquid enteral products--Variety of preparations for
nutritional supplementation and for those with special
conditions
 Enteral feedings are preferable to TPN due to
maintaining GI integrity, less risk for infection and less
expensive
 IV fluids used for hydration, specially prepared
intravenous products to meet all nutritional needs
Nutritional Products
 Pancreatic enzymes—amylase, protease, lipase are
required for absorption of CHO, protein, and fat
 Pancrelipase used as replacement therapy in
deficiency states incl. cystic fibrosis, chronic
pancreatitis, pancreatectomy, and pancreatic
obstruction
 Vitamins—insufficient dietary intake to meet
requirements
Dietary Reference Intakes
 RDA—recommended dietary allowance is the amount
estimated to meet the needs of approximately 98% of
healthy children and adults in a specific age and
gender group
 Tolerable Upper Intake Level—UL. Maximum intake
considered unlikely to pose a health risk in almost all
healthy persons in a specified age group
 With vitamins—D =50mg; E =1000mg; pyridoxine
=100mg
 With minerals—UL should not be exceeded due to
toxicity
Vitamins
 A—vision, growth, bone development, skin and
mucous membranes
 E—antioxidant in destruction of certain fats, may
increase absorption, storage and duse of vitamin A
 K—essential for normal clotting
 D—instrumental in bone health
Vitamins
 Fat soluble==A, D, E, K
 Water soluble==B complex and C
 Supplements exert same physiologic effects as fr. foods
 No Rx needed
 Should not exceed recommended amounts of Vit. D, E,
folic acid and vitamin A
 Large doses of all minerals are toxic
 Antioxidants—may affect free radicals, inconclusive
studies regarding outcomes
Vitamins
 Cyanocobalamin—B12—needed by all body cells incl. RBCs,
nerves, metabolism of CHO, proteins and fats. Pernicious
anemia.
 Folic acid—metabolism of all body cells, normal RBCs and
growth. Megaloblastic anemias, neural tube defects . Grains,
fresh green vegetables.
 Niacin—B3—coenzyme in many metabolic processes; fat
synthesis; tissue respiration. Grains, legumes. Pellagra (skin,
mucous membranes, asthenia, psychosis)
 Pyridoxine—B6—needed for conversion of tryptophan to niacin;
helps release glycogen from liver and muscle tissue; helps
maintain cellular immunity; functions in metabolism of CNS
Vitamins
 Riboflavin—B2—role in production of RBCs,
corticosteroids and gluconeogenesis. Milk products,
leafy green vegetables and dry yeast. Dermatoses,
glossitis, cheilitis.
 Thiamine—B1—coenzyme in CHO metabolism,
essential for energy production. Affects brain
utilization of glucose. Dry yeast, wheat germ, nuts,
legumes, vegetables. Beriberi (neurologic, cerebral and
CV abnormalities).
Vitamins
 Vitamin C—needed for formation of skin, bone, teeth,
cartilage, wound healing, metabolism of iron and folic
acid, resistance to infection. Found in fruits and
vegetables. Scurvy-bleeding of gums,joints, skin;
anemia, loosening of teeth
Mineral--Electrolytes
 22 minerals necessary for human nutrition
 Calcium and phosphorus in bone development
 Sodium (fluid balance), potassium (acid-base),
magnesium(nerve conduction), chlorine (fluid and
lyte balance, acid base balance) and sulfur (component
of proteins, insulin, B vitamins, some amino acids)
 Trace elements: chromium, cobalt, copper, fluoride,
iodine, iron, selenium and zinc—human nutrition
 Manganese, molybdenum, nickel, silicon, tin and
vanadium –normal growth and function of connective
tissue
Minerals cont.
 Chromium—affects glucose utilization
 Cobalt—component of B12
 Copper—component of enzymes, RBCs
 Fluoride—bones and teeth
 Iodine—thyroid
 Iron—enzymes, component of hemoglobin
 Selenium—function of myocardium and other
muscles
 Zinc—enzymes, necessary for cell growth, for use of
vitamin A
Electrolyte—mineral
imbalances
 Deficiencies usually related to inadequate intake or
unusual losses (vomiting, diarrhea, gastric suction,
laxative abuse)
 Most excesses r/t excessive intake or impaired renal
excretion
Cation-Exchange
 Kayexalate (sodium polystyrene sulfate) to treat
hyperkalemia. Orally or rectally, combines with
potassium in the colon.
Chelating Agents (metal
antagonists)
 Exjade (deferasirox) oral iron chelator for those who
require frequent blood transfusions. Untreated iron
accumulation from the transfusions can lead to heart
failure and liver failure. 2007 warning of renal failure,
neutropenia, thrombocytopenia.
 Desferal (deferoxamine) parenteral to remove excess
iron from storage sites. Combines with iron and is
excreted by kidneys. Hemachromatosis, hemosiderosis
due to hemolytic anemias.
Chelators
 Cuprimine (penicillamine) chelataes copper, zinc,
mercury and lead which form soluble complexes and
are excreted in urine. Use in Wilson’s Disease;
cystinuria (AA) metabolic disorder resulting in calculi;
to lead poisoning and RA
 Chemet (succimer) for binding with lead in children.
Iron preparations
 Oral ferrous salts include sulfate, gluconate and
fumarate
 Adverse effects include nausea, discolored stools,
constipation
 Contraindicated in hemosiderosis, hemochromatosis,
multiple blood transfusions, anemias not iron
deficiency in nature, PUD, inflammatory intestinal
disorders
 Iron dextran—IV. Anaphylaxis.
Magnesium
 Magnesium oxide or hydroxide for mild
hypomagnesemia
 Magnesium sulfate parenterally for pronounced Mg++
Deficiency, convulsions associated with pregnancy
and prevention of low magnesium in TPN
 Contraindicated in renal impairment or in comatose
Potassium
 Hypokalemia
 Can be secondary to dietary problems, diuretics, those
receiving only IV fluids
 Contraindicated in renal failure and in those on
potassium sparing diuretics and spironolactone
 IV must be diluted well, infused slowly (often at 10
mEq/hour) to prevent cardiotoxicity. Monitor EKG.
Zinc
 Zinc sulfate and gluconate are OTC
 Component of multivitamins
 Metabolized in liver and excreted in feces
Enteral feedings
 Maintain GI tract and immune system functioning
 NG, OG
 Jejunostomy
 Percutaneous endoscopic gastrostomy
 Nasointestinal tubes
 For feedings into stomach—intermittent feedings
 For feedings into jejunum or duodenum, continuous
feeding
 Potential complication is aspiration
Enteral Feedings
 Pulmocare
 Amin-Aid for those in renal failure
 Nepro for those on dialysis
 Suplena—lower in protein and some electrolytes for
renal patients not on dialysis
 Hepatic Aid II—protein restricted in liver failure
 Fluid restrictin as in 1.5kcal/mL
Parenteral Support
 Central or peripheral administration
 Can give 5-10% peripherally
 Fat emulsions can be given peripherally or centrally; no
filter
 Vitamins, sometimes insulin
 Aminosyn-RF
 HepatAmine—special form. of amino acids
 Cautious use of lipids r/t hypertriglyceridemia
 Large doses Vit. C can cause stones
 Monitor fluid and electrolytes
 Monitor blood sugars
Parenteral Support
 In liver failure—need Vit. A, B6, folic, riboflavin, B12,
pantothenic acid and thiamine
 Niacin is contraindicated
 Extreme caution with iron dextran
Drugs to aid Weight
Management
 Overweight ==BMI of 25 to 29.9kg/sq. meter
 Obesity==BMI of 30 or more
 Desired BMI is 18.5 to 24.9 kg/sq. meter
 Waist size >35 inches in women and >40 inches for
men is another risk factor
Obesity
 More common in women, minority groups and poor
people
 Associated with serious health risks
 Cancer of breast, colon, endometrial
 Central obesity greatly contributes to breast cancer
(androstenedione to estradiol)
 Cardiovascular disorders—hypertension, insulin
resistance, hyperlipidemia, central adiposity
Obesity
 Diabetes mellitus—impaired glucose tolerance, insulin
resistance. Hyperinsulinemia, impaired lipid
metabolism, hypertension
Obesity
 Osteoarthritis
 Sleep apnea
 NASH
 Increased complications of pregnancy
 Infertility in men
 Gestational diabetes
 Metabolic syndrome—HDL (40,50), BP 135/85 or
higher, serum glucose >110, central adiposity
Obesity
 Decreased physical activity
 Sedentary jobs and recreational activities
 Large portion sizes
 Fast foods
 Fast pace
 Depression
 Medications can cause obesity
 children
Medications affecting weight
 Antihistamines such as loratadine and
diphenhydramine increase appetite
 Beta blockers decrease BMR, increase fatigue and
decrease exericise tolerance
 Statins
 Steroids
 PPIs may increase appetite
 Hormonal contraceptives—fluid and sodium retentin
 Mood stabilizing medication—lithium with expected
wt. gain up to 22#
Medications and weight gain
 Antiepileptics—phenytoin, valproic acid,
carbamazepine, gabapentin, lamotrigine. Slow
metabolism and increases appetite.
 Antidiabetic drugs—insulin, sulfonylureas, glitazones.
 Antidepressants—SSRIs and TCAs.
 Antipsychotics-Zyprexa and Clozaril cause gain in
40%. Risperdal less and Seroquel even less. Can even
affect glucose tolerance.
Drugs for treating obesity
 Reserve for those with BMIs of 30 kg per sq. meter or
greater
 Sensible diet
 Physical activity
 Behavioral modification
Drugs for weight reduction
 Side effects—phenylpropanolamine, fenfluramine,
ephedra
 Current meds-Adipex, Didrex, Meridia
 Affect dopamine and norepinephrine in brain
Adipex--phentermine
 Most frequently prescribed adrenergic anorexiant
 Schedule IV
 Short term use< 3 months
 Contraindicated in hypertension, CV disease or drug
abuse
 Caution in anxiety or agitation
 Adverse effects: nervousness, dry mouth, constipation,
tachycardia and hypertension
Meridia--sibutramine
 Schedule IV
 Inhibits reuptake of serotonin and norepinephrine
 Causes increased satiety, decreased food intake and
faster metabolism
 May be used for longer period of time
 Cautious use in glaucoma, impaired hepatic function
and a history of drug abuse
 Contraindicated in CV disorders hypertension
 Common SE: HA, insomnia, htn, tachy, anxiety
Xenical—Alli (orlistat)
 Decreases absorption of dietary fat (binds to gastric
and pancreatic lipases making them unavailable to
break down fat)
 Blocks 30% of fat ingested
 Improves cholesterol levels
 Side effects include oily spotting, fatty stools, fecal
incontinence and increased defecation
 Prevents absorption of fat-soluble vitamins A,D, E, K
Herbals
 Few studies to validate efficacy
 Glucomannan—”feel full”, laxative effect, can cause
hypoglycemia
 Guarana—found in energy drinks, caffeine;
contraindicated in those with CV problems, worsens
GERD
 Laxative and diuretic herbs—aloe, rhubarb root, Super
Dieter’s Tea
Weight loss programs
 Atkins
 South Beach
 Weight watchers
 Jenny Craig
 Serotonin syndrome
 Neuroleptic syndrome
 Malignant hyperthermia
Neuroleptic Malignant
Syndrome
 Rare but potentially fatal reaction that can occur hours
to months after initial drug use
 S/S develop 24-72h
 Characterized by fever, muscle rigidity, agitation,
confusion, tachycardia, delirium, respiratory failure
and acute renal failure
 Associated with antipsychotic meds such as Haldol,
Geodon, Abilify, Seroquel, Thorazine
 Treatment: stop antipsychotic, give dantrolene
(muscle relaxant) and amantadine or bromocriptine
(dopamine stimulators)
Malignant Hyperthermia
 A severe form of pyrexia that occurs during the use of
muscle relaxants and general inhalation anesthesia in
persons with an inherited autosomal dominant trait.
 Characterized by skeletal muscle rigidity, fever,
hypercarbia, metabolic acidosis, and cyanosis.
 Fatal in 70% of patients.
 Treat with Dantrium (dantrolene)—IV during acute
episode
 Must watch liver functions
 Incompatible with saline and D5W
Serotonin Syndrome
 Potentially serious drug-related condition seen in
patients taking two or more drugs that increase CNS
serotonin levels; the most common combinations
involve MAO inhibitors, SSRIs , SNRIs and TCAs. Also
can be caused by demerol, dextromethophan, and
Zofran
 Presents with muscle rigidity, tremors,fever, nausea,
rapid heart rate, agitation and seizures.
 Stop drugs, supportive care