Professional Documents
Culture Documents
Nutrition and Dietetics
Nutrition and Dietetics
Role of Nurses
ROLE OF DIETICIAN
1. Obtain history and usual diet prior to admission (difficulty in chewing, swallowing or self-feeding; chief
complaint; medications, and living situations)
2. Nutrition History – current habits, changes in appetite, food allergies and intolerance, cultural or religious
diet
3. Calculate calorie and protein requirement based on data
4. Determine nutritional diagnosis
5. Nutritional interventions – diet order change, requesting laboratory tests, performing nutrition counselling
or education
NURSING PROCESS
ASSESSMENT
● MALNUTRITION
- Impaired function that results from a prolonged nutrition deficiency
Anorexia and Bulimia Nervosa – Psychological
Rickets – Vitamin D deficiency
Scurvy – Vitamin C deficiency
Anemia – RBC
Goiter – Iodine deficiency
● NUTRITIONAL SCREENING
- Quick look at a few variables to judge a client’s risk for nutritional items;
✔ Height
✔ Weight
✔ Diet
✔ Albumin, haematocrit- (determines the hydration of the cells)
✔ Nausea and Vomiting
✔ Significant weight loss
✔ Change in appetite
✔ Difficulty eating
✔ Use of enteral or parenteral nutrition
ASSESSMENT
BIOCHEMICAL DATA
CLINICAL DATA
DIETARY DATA
𝐶𝑢𝑟𝑟𝑒𝑛𝑡 𝑤𝑒𝑖𝑔ℎ𝑡
%𝐼𝐵𝑊 = × 100
𝐼𝐵𝑊
BIOCHEMICAL DATA
CLINICAL DATA
DIETARY DATA
MEDICAL-PSYCHOLOSIAL HISTORY
o MEDICAL
✔ Medications
✔ Acute and Chronic disease
o PSYCHOLOGICAL FACTORS
✔ Depression
✔ Eating DO
✔ Psychosis
o SOCIAL
✔ Illiteracy
✔ Language barriers
✔ Limited knowledge on food
✔ Cultural
✔ Social isolation
✔ Cooking arrangements
✔ Low income
✔ Elderly
✔ Lack/extreme activity
✔ Use of tobacco or drugs
DIAGNOSIS
PLANNING
● GUIDELINES IN PLANNING
1. Patient-centered outcomes
2. SMART
3. Commitment/Compliance
4. Short-term goals – alleviate symptoms, prevent complications
INTERVENTIONS
NURSING RESPONSIBILITIES
✔ Check intake
✔ Document appetite
✔ Order supplements if intake is low or needs are high
✔ Nutritional consult
✔ Assess tolerance
✔ Assess weight
✔ Monitor progression of restrictive diets (NPO, clear liquid, soft diet, Diabetic Diet)
✔ Monitor comprehensive of information and motivation to change
MACRONUTRIENTS
- Carbohydrates (CHO)
- Proteins (CHON)
- Fats
MICRONUTRIENTS
- Vitamins
- Minerals
● CARBOHYDRATES (CHO)
- A class of energy-yielding nutrients that contain CARBOHYDRATES, HYDROGEN, OXYGEN
- 45% - 65% of our food should come from carbohydrates
- > carbohydrates intake > use = storage in the liver or in the tissues as fat
FUNCTION:
1. Gives the body energy
2. Best source of fuel for the body
3. Helps digest proteins and fats
- 1 sugar molecule
MONOSACCHARIDES DISACCHARIDES POLYSACCHARIDES
- Absorbed without undergoing
* GLUCOSE * SUCROSE * STARCH digestion
* FRUCTOSE * MALTOSE GLYCOGEN
* GALACTOSE * LACTOSE FIBRE
● GLUCOSE
- Circulates through the blood to provide energy for body cells
- “dextrose”
SOURCES
● FRUCTOSE
- Fat sugar
- Sweetest of all sugar
- Often added to food because it is both cheap and enhances taste
SOURCES:
✔ Fruit shake
✔ Dried cranberry
✔ Yogurt
✔ Pasta sauce
✔ Salad dressing
✔ Fruit pie
● GALACTOSE
- Galactose + Glucose = disaccharide or LACTOSE
- Doesn’t appear in appreciable amount in foods
- Added to glucose
DISACCHARIDE
● MALTOSE
- Glucose + Glucose
- Not found naturally in foods
- Adde for flavouring
● LACTOSE
- Glucose + Galactose = “MILK SUGAR”
- Found naturally in milk
- Enhances absorption of calcium and promotes the growth of GI Flora
- Also enhances the production of vitamin K
- The least sweet of all sugar
- Produces RBC, calcium
- Animal source
SOURCES:
TYPES OF SUGAR
NEGATIVE OUTPUT
● STARCH
● GLYCOGEN
- Storage form of glucose in animals and humans
- Animals (we usually eat, mainly the protein not the sugar content) No dietary source
- Are easily converted to lactic acid
- Miniscule amount only – shellfish (scallops and oysters)
STORAGE:
✔ Liver
✔ Muscles
GLYCEMIC RESPONSE
✔ How quick
✔ How high
✔ How long to return
Factors:
10 | N u t r i t i o n a n d d i e t e t i c s
GLYCEMIC LOAD
GLYCEMIC GLYCEMIC
INDEX LOAD
WHITE SPAGHETTI 58 28
WATERMELON 72 4
PEANUTS 17 1
SNEAKERS BAR 68 23
RECOMMENDATIONS
1. Eat less foods with added sugar.
2. Choose fiber-rich fruits, vegetables and whole grains more often.
3. Eat beans several times a week.
4. Brush teeth after eating foods with sugar and starch.
PROTEIN
11 | N u t r i t i o n a n d d i e t e t i c s
AMINO ACIDS
9 ESSENTIALS OR 11 NONESSENTIAL OR
INDISPENSIBLE DISPENSIBLE
HISTIDINE ALANINE
ISOLEUCINE ASPARAGINE
METHIONINE SERINE
PHENYLALANINE *ARGININE
THREONINE *CYSTEIN
TRYPTOPHAN *GLUTAMINE,
*TYROSINE
VALINE *GLYCINE, *PROLINE
FUNCTION OF PROTEINS
2. Enzymes
- Protein that facilitate chemical reactions w/o changing themselves.
- DIGESTIVE ENZYMES – Some breakdown larger molecules
- ENZYMES FOR PROTEIN SYNTHESIS – Some combine molecules to form larger compounds
4. Fluid Balance
- Attracts water 🡪 osmotic pressure
- Circulating proteins like albumin – maintain proper balance (intracellular, intravascular, interstitial)
- Edema
12 | N u t r i t i o n a n d d i e t e t i c s
5. Acid-base Balance
- Act depending on the pH surrounding fluids
- Lipoproteins –transports fats, cholesterol, fat-soluble vitamins
- Hemoglobin
6. Transport Molecules
- Globular proteins transport through blood
7. Other compounds
- Opsin, light-sensitive visual pigment in the eye
NITROGEN BALANCE
- Reflects the state of balance between protein breakdown and protein synthesis
- Comparing nitrogen intake with nitrogen excretion over 24 hours
EXAMPLE:
Mary is 25 yo woman who was admitted due to multiple fractures and traumatic injuries from a car accident. A
nutritional intake study indicated a 24-hr protein intake of 64 g. A 24-hr Urinary Urea Nitrogen (UUN) collection
results was 19.8 g.
13 | N u t r i t i o n a n d d i e t e t i c s
1. Determine nitrogen intake by dividing protein intake by 6.25.
- 64 / 6.25 = 10.24 g of Nitrogen
4. Interpret results
Interpretation
● Neutral = balance
● (+) = synthesis > breakdown (growth, pregnancy, recovery from injury
● (-) = breakdown > synthesis (starvation or the catabolic phase after injury)
Example 1:
Adult male who weighs 154 pounds
= 56 g protein per day
Example 2:
Adult female who weighs 65 kgs
= 52 g protein per day
14 | N u t r i t i o n a n d d i e t e t i c s
- Protein-losing renal diseases
- Malabsorption – short bowel syndrome
PROTEIN RESTRICTION
PROTEIN DEFICIENCIES
KWASHIORKOR
CAUSE
- Acute, deficiency of protein or critical infections 🡪 loss of appetite
- Stressors: measles or gastroenteritis; American Adults – Trauma or sepsis
ONSET
- Rapid, acute; develop in weeks
APPEARANCE
- May look well nourished because of edema and enlarged liver
WEIGHT LOSS
- Some
MORTALITY
- HIGH
MARASMUS
CAUSE
- Severe deficiency or impaired absorption of calories, protein, Vitamins & Minerals
- Severe prolonged starvation
- Children – w/ chronic or recurring infections, marginal food intake
- Adults – secondary to chronic illness
15 | N u t r i t i o n a n d d i e t e t i c s
ONSET
- Slow, chronic, months to years to develop
APPEARANCE
- Skin and bones
WEIGHT LOSS
- Severe
MORTALITY
- Low, unless r/t underlying disease
PROTEIN EXCESS
- No potential adverse effects from a high protein intake from food or supplements (institute of
Medicine of the National Academics, 2005)
● According to the AHA and Heart and Stroke Foundation of Canada Emphasis on grains fruit and
vegetables
16 | N u t r i t i o n a n d d i e t e t i c s
- X processed meat (ham, salami, bacon, hotdogs, sausages) 🡪 increase risk of colorectal cancer
(AIRC, 2007)
VEGETARIAN DIETS
● Food sources
- Dried peas, beans, nut, nut butters, soy products,
veggie burgers
Vitamins
o Greek word which means “vital for life”
o Organic molecules essential for normal health and growth and they are required in small amounts,
Form no structures
No mass
o Deficiencies or excessive amounts can be dangerous
Water soluble- all vitamins b (b complex), c, and non-b complex (choline)
o Vitamins are responsible for the movements of the macronutrients.
o Hematopoiesis- regulation and maturity of blood cells in the bone marrow.
o Others- Heme synthesis
Fat soluble- Vitamins ADEK
17 | N u t r i t i o n a n d d i e t e t i c s
Difference of Water soluble and Fat soluble
Water soluble are easier to be excreted and absorbed; fat soluble have larger structures.
Important Terms
Energy-yielding vitamins
Hematopoietic vitamins
19 | N u t r i t i o n a n d d i e t e t i c s
Anoncephaly- no skull
Vitamin B12: Cobalamin
RDA: 2.4 mcg/day
Absorbed in the ileum
Electrolytes
Minerals circulating in blood and other body fluids that carry an electrical charge
Effect on body: processes amount of water inside the body, blood ph, muscle action, and normal functioning of
the nerves and muscles
Sodium
Potassium
Chloride
20 | N u t r i t i o n a n d d i e t e t i c s
1300 mg, >50 yo-
upper limit- 2000 mg,
2300 mg >70- 1800
mg
Sources Table salt, Unprocessed Foods w/
processed foods, white Na- contain
food potatoes w/ Cl as well
skin, sweet
potatoes,
tomatoes,
bananas,
oranges,
dairy
products
and legumes
Deficiency FVD w/ Muscle Rare, same
headache, weakness, as Na
muscle confussion, deficiency
cramps, decreased
weakness, appetite,
decreased cardiac
concentration, dysrhythmia
appetite loss from
vomiting
Toxicity Na sensitive From diet or Due to
hypertension supplements dehydration
if (+) renal ---
disease imbalance
Energy balance
21 | N u t r i t i o n a n d d i e t e t i c s
Moderately active Walking about 1.5-3
miles/day
Active >3 miles/day
1.5 miles=1km
Factors for estimation according to level of physical activity for men and women
Basal metabolism- amount of energy needed to to maintain life-sustaining activities (breathing, circulation,
heartbeats, secretion of hormones)
Basal metabolic rate (BMR)- rate which the body spends energy to keep all these life-sustaining processes going
Thyroxine- key BMR regulator
o More thyroxine= higher BMR
Adaptive thermogenesis
Energy use by the body to adjust changing physical and biologic environment situations
o Physical and emotional trauma
o Too much eating, extreme temps, and extreme emotions
Healthy weight
Activation of drive to eat, some people may learn how to ignore the drive but they are vulnerable to
disinhibition= greater food intake
Adjustment of REE
Reducing food intake produces an immediate and significant depression of REE
23 | N u t r i t i o n a n d d i e t e t i c s
If reduction is not too great, the drop in REE may be sufficient to prevent weight loss; a successful defense of set
point
Normalizing eating
Use of food to express positive feelings, celebrate good fortune, reward hard work, and to create a sense of
companionship
Handling negative emotions such as boredome, frustrations, anger, or loneliness
Minimize emotional eating
Whatever pattern works best, it should be space food throughout active hours and should not produce
overwhelming hunger or the drive to consume excessively
o 3 main meals of small portion with snacks in between
24 | N u t r i t i o n a n d d i e t e t i c s
and retain
needed fluids
During exercise Weighing With
before and after electrolytes and
to determine CHO (carbs)
the amount of
fluid
replacement (1
lb= 2 cups of
h2O)
After exercise Consuming With Na
normal meals & (sodium)- helps
beverages speed recovery
restores by stimulating
average thirst and fluid
hydration retention
Water intoxication- water poisoning, hyperhydration, overhydration, or water toxemia is a potentially fatal disturbance
in brain functions that results when the normal balance of electrolytes in the body is pushed outside safe limits by
excessive water intake
Cheerios w/ milk
Flavoured yogurt
Pasta with meat sauce
25 | N u t r i t i o n a n d d i e t e t i c s
should be
in
moderation
Aerobic exercises
o Fast walking
o Jogging or running
o Cycling
o Dancing
o Swimming
o hiking
Muscle-strengthening activities
o Lifting weights
o hill walking
o Climbing stairs
o Push ups
o Sit ups
o squats
Bone strengthening activities
o Jumping rope
o Hopping
o Volleyball
o Gymnastics
o Running
o gymnastics
Balance and stretching activities
o Shoulder rolls
o Ankle rolls
o Heel-toe-walking
o Biceps curls
Role of nurses
In collaboration with
o Physicians, dietitians, behavior and exercise therapists
Metabolic changes
Recommendations
Alcohol
27 | N u t r i t i o n a n d d i e t e t i c s
Food borne illness
During pregnancy, women and their unborn children are more likely to become very ill form food poisoning.
Newborns are also at risk due to undeveloped immune system
Foods to avoid
Raw or undercooked foods, contain undercooked eggs, deli salads, unpasteurized milk, fruits, and vegetable
juices, refrigerated pate or meat spreads
Diabetes mellitus
Maternal phenylketonuria
28 | N u t r i t i o n a n d d i e t e t i c s
o Caffeine passes to the breast milk in small amounts
Adequate fluid intake is important
Food-related Issues
Dietary guidelines
Dietary modifications
Required to allow the body to heal, adjust to physical disability, or prepare for a diagnostic tests or
surgical procedures
Therapy may require texture changes (liquefy or pureed foods)
If a patient cannot or will not eat for a week or longer enteral (tube) feeding or parenteral (intravenous)
nourishment may be needed
Diet orders
Teaching tools
Problem Solution
Illiterate or too ill to Read menu items to
read or write, has the patient and marks
reduced visual abilities his/ her selections
or a low literacy level
Does not understand Clarify for patient or ask
the items used on for clarifications from
menu dietitian
Often must select foods Remind patients that
from menu a day in they are selecting
advance, often foods for the next day.
resulting too much or If they have not
too little food selected enough food
offer them foods kept
29 | N u t r i t i o n a n d d i e t e t i c s
in the nursing unit. If
they ordered to much
discard if not
consumed within 24
hours
Poor appetite Small frequent meals
and snacks every 2-3
hours. Choose energy
dense foods like meat,
dried fruits, buts, and
starches. Schedule
between-meal
supplement drinks
Does not understand Discuss dietary
why some of his/her concerns of the
favorite foods are not patient’s illness,
included on the menu, explaining why specific
why smaller amounts foods are not included
are served, or why or only limited amounts
textures are modified are allowed.
Repetition and monotony will influence a patient’s acceptance of foods and meals served
Types of diets
Diet Indications Contraindications Sample
foods
Liquid diet Oral fluids before/after (x) >24 hours, Broths,
surgery, prepare bowel inadequate GI bouillon,
for diagnostic function, nutrient apple juice,
colonoscopy needs requiring grape juice,
examination, barium parenteral gelatin
enema, acute GI nutrition without fruit
disturbances
Full liquid After surgery, transition Dysphagia, wired Milk,
between clear and solid jaw icecream,
food, oral or plastic cooked
surgery to the face and eggs,
neck, mandibular eggnog, oral
fractures, chewing or supplements,
swallowing difficulties or milkshakes
Pureed diet Neurologic changes, Situations which Any food
inflammation/ulcerations ground or that can be
of the oral cavity, chopped foods blended
edentulous patients, are appropriate and served
fractured jaw, head, without
and neck abnormalities, particles
CVA
Mechanical Poor fitting dentures, Situations which Foods that
soft diet limited swallowing, regular foods are can be
chewing abilities, appropriate easily cut
stricture of the intestinal with a fork,
tract, radiation chopped, or
treatment of the oral blended
30 | N u t r i t i o n a n d d i e t e t i c s
cavity, progression from (x) hard,
enteral or parenteral stringy,
nutrition to solid foods tough
foods=
choking
Soft diet Debilitated patients Situations where All foods
unable to consume a regular diet is served on
regular diet, mild GI appropriate general diet
problems except for
highly fibrous
fruits and
vegetables
Biologically-based therapies- materials found in nature, include functional foods, botanicals, and herbs
Functional foods- physiologically active (bioactive) substances, marketed as dietary supplements
Dietary supplements- considered as foods not drugs
o Consumed orally as tablets, liquids, capsules, extracts, powders, gel caps,
Non-oral feeding
When patient cannot eat for more than few days, non-oral method must be used
Teaching tool
Was hands for at least 20 seconds
Flush feeing with 1-5 ml of water before and after
feeding to prevent feeding tube from clogging
31 | N u t r i t i o n a n d d i e t e t i c s
Never add new formula to formula already in the
feeding container
Change entire feeding setup every 24 hours
Place formulas: breast milk (4 hours), formula (8
hours) in containers
Make sure infant has pleasant sensations during
feeding; hold your child, allow him to suck a
pacifier
Head of the bed 30-45 degrees if child cannot be
held
When GI tract is functional, accessible, and safe to use, enteral feedings are preferred over parenteral
feeding
o Physiologically beneficial in maintaining integrity and function of gut
Severe dysphagia, major burns, short bowel syndrome after resection, and intestinal fistulas- warrant
tube feedings
Types of formulas
Standard formula- polymeric; composed of intact nutrients that require a functioning GI tract for
digestion and absorption of nutrients
Hypercaloric formula- (1.5-2 kcal/ml) designed to meet kcal protein demands in a reduced volume and
have moderate to high osmolality
Elemental formula- (1-1.3 kcal/ml) partially or fully hydrolyzed nutrients that can be used for the patient
with partially functioning GI tract, impaired capacity to digest foods or absorb nutrients, pancreatic
insufficiency, or bile salt deficiency
Formula selection
Feeding routes
Parenteral nutrition
32 | N u t r i t i o n a n d d i e t e t i c s
Intake
Lipogenesis
Glucagon- stimulate glucose production
Ketogenesis
Diabetes mellitus- relative or complete lack of insulin secretions by the beta cells of the pancreas or by
defects of cell insulin receptors
Diagnosed by elevated fasting blood glucose values (>126 mg/dl on at least two occasions)
Vitamins D homeostasis
o Maintains normal release of insulin from the beta cells
o Maintains epigenome, lowers inflammation= insulin resistance
o Protects betal cells against destruction
Blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes
o 70-110 normal glucose levels
o >110 mg/dl
Insulin resistance
o Muscles, fat, and liver cells do not respond properly to insulin and cannot easily absorb glucose
from bloodstream
o Excess body fats increases risk
Macrovascular effects- increase risk of coronary artery disease, peripheral vascular disease, and stroke
Microvascular effects- include nephropathy, retinopathy, and neuropathy
o Nephropathy- Chronic kidney disease (CKD)
o Retinopathy- leading cause of blindness
o Neuropathy- decreased sensation in the extremities
Impaired healing- effect of diabetes to the circulatory system= gangrene may develop
33 | N u t r i t i o n a n d d i e t e t i c s
Autonomic effects- orthostatic hypotension, persistent tachycardia, gastroparesis, neurogenic bladder
(urinary bladder dysfunction due to neurologic damage), impotence, and impairment of visceral pain
sensation
o Impairment of visceral sensation may obscure symptoms of angina pectoris or myocardial
infarction
Classifications of diabetes
T1DM, T2DM, latent autoimmune diabetes of adults (LADA), gestational diabetes mellitus (GDM), and
impaired glucose tolerance (IGT)
Type 1 DM
3Ps of T1DM
34 | N u t r i t i o n a n d d i e t e t i c s
Body will send signals to
eat because cells are Glucose cannot enter
hungry; consume large cells; builds up in
amounts of food bloodstream
(polyphagia)
Treatment of T1DM
Insulin- requires exogenous insulin to maintain normal blood glucose levels and to survive
Insulin with nutrition therapy and exercise= mimic physiologic insulin delivery
Types of insulin
o Classified into three groups
o Conventional or standard insulin therapy- constant dose of intermediate acting insulin combined
with short or rapid acting insulin or mixed dose of insulin
o Flexible or intensive insulin therapy- multiples daily injections (MDI); short or rapid-acting insulin
before meals; intermediate-acting insulins once or twice daily
o Continuous or subcutaneous insulin infusion- intensive therapy; rapid or short-acting is pumped
continuously in micro-amounts through an insulin catheter; boluses of rapid or short-acting
insulins are given before meals
Exercise- lowers blood glucose levels, assists in maintaining normal lipid levels, and increases circulation
Do not exercise when fasting glucose levels are > or equal to 250 mg/dl
Avoid exercise if ketosis is present (presence of ketones in urine)
T1DM; should not exercise when insulin is at its peak
Exercise when blood glucose levels are between 100-200 mg/dl or about 30-60 minutes after meals
Food intake: 15 g of CHO only
o Consume CHO to avoid hypoglycemia
Type 2 DM
Can be controlled
Primary metabolic problem is insulin resistance or defect in insulin secretion
Gradual onset of polyuria and polydipsia, easily fatigue, and have frequent infections
Oral glucose lowering medications- when diet and exercise alone cannot control hyperglycemia
35 | N u t r i t i o n a n d d i e t e t i c s
o Metformin- first line of therapy
Vitamin D supplementation= improve glycemic control and 𝐻𝐵𝐴1𝑐 levels
Metabolic goals in diabetes management
Goal
Glycemic control <0.7%
Hemoglobin 𝐴1𝑐
Preprandial capillary 90-130
plasma glucose
(mg/dl)
Peak postprandial <180
capillary plasma
Cardiovascular
Blood pressure <139/80
(mmHg)
Triglycerides <150
Low density <100
lipoprotein cholesterol
(mg/dl)
High density
lipoprotein cholesterol
Males >40
Females >50
Hypoglycemia
Diabetic ketoacidosis
Other guidelines
37 | N u t r i t i o n a n d d i e t e t i c s
Role of nurses
Help patient become aware and assess knowledge of, understanding of, and adherence to prescribed
diet
Observing meals and food choices
Monitoring glucose levels
Special considerations
Metabolic syndrome
Cluster of metabolic abnormalities along with
chronic low-grade inflammation and oxidative
stress
Pregnancy
Some hormones produced by the placenta during pregnancy are antagonistic to insulin
o Reduced effectivity
38 | N u t r i t i o n a n d d i e t e t i c s
Insulin does not cross the maternal placenta but glucose does
o > glucose= fetal pancreas increases insulin production= macrosomia= large for gestational age
o LGA= experience respiratory difficulties, hypocalcemia, hypoglycemia, hypokalemia, or
jaundice
Adequate calorie intake and nutrients must meet needs of pregnancy
Minimal SMBG 4x/day
o For pregnancy, 8x/day
Blood glucose goals during pregnancy:
o Fasting: <95mg/dl
o 1 hour postprandial- <140 mg/dl
o 2 hours postprandial- <120 mg/dl
Desired weight goals are based on prepregnancy BMI and should be steady and progressive
No calorie adjustments on the 1st trimester, but in the 2nd and 3rd trimester increased energy intake of
approximately 100-300 kcal/day
High quality protein increased by 10 g/day
o Supplied easily by consuming 1 or 2 extra glasses of nonfat or skim milk. Or 2 ounces of meat or
meat substitute
400 mcg of folic acid is recommended
o Prevent neural tube defects
Minimum of 1,700-1,800 kcal/day from carefully selected foods
o Intake less than this is not advised
Women with preexisting diabetes who become pregnant are vulnerable to complications
Optimal period of care is before conception
Glycosylated hemoglobin levels should be normal or close to the normal range before conception
Requirements increases during the 2nd-3rd trimester because of higher blood glucose levels
o Due to increased production of pregnancy hormones that are insulin antagonists
Goals of preconception care programs:
o Before meals: capillary whole-blood glucose 70-100 mg/dl or capillary plasma glucose 80-110
mg/dl
o 2 hours postprandial- capillary whole-blood glucose <140 mg/dl or capillary plasma glucose
<155 mg/dl
Three meals and three snacks are usually recommended
Use of frequent blood glucose monitoring is necessary
Gestational diabetes
39 | N u t r i t i o n a n d d i e t e t i c s
Girls are more susceptible than boys to T2DM
Due to poor glycemic control
Nutritional therapy and exercise are first line treatments but most children diagnosed with T2DM will also
require drug therapy—oral agents
Children with T2DM should receive comprehensive management education, including SMBG
Fasting can be a problem for muslims especially during the long month of Ramadan
o Possible hypoglycemia, hyperglycemia, or diabetic ketoacidosis, and dehydration
Pregnant women, children, and elderly who have diabetes should not be expected to fast
Morbidly obese individuals who have prediabetes or T2DM may elect to have bariatric surgery
Adolescents, in severe progressive form of diabetes with complications; in these patients bariatric
surgery is controversial
Ketogenic diets which are very low in carbohydrates and high in fats and proteins are not totally safe
and may be associated with nonalcoholic fatty liver disease or insulin resistance
o Not currently promoted for diabetes management
Liver disorders
Hep. A virus – transmitted through the fecal-oral route, but occasionally can be spread by transfusion of
infected blood. Onset of HAV is rapid, 4-6 weeks. Treatment for HAV is usually supportive, no antiviral
therapy. Is asymptomatic.
Hep. B virus – exceptionally resistant virus of surviving extreme temperatures and humidity. HBV is
transmitted via blood, semen, vaginal mucus, saliva, and tears, IV drug users, patients with hemophilia,
etc. HBV vaccination is recommended. Incubation for HBV is 12 weeks. Is asymptomatic, no cure.
Hep. C virus – can be transmitted through contaminated saliva and semen, but is predominantly
associated with blood exposure. Can develop into chronic liver disease and is a risk factor for liver
cancer. Are asymptomatic and infrequently detected.
Hep. D virus – can only occur when an individual with HBV is subsequently exposed to HDV. Incubation
period is 21 to 45 days but may be shorter in cases of superinfection.
Hep. E virus – an enterically transmitted, self-limiting infection. Incubation 15-60 days. Once infection
occurs, therapy is limited to support.
Periods of nausea and vomiting in patients with hep. Needs hydration via IV fluids.
Afterwards oral feedings should be initiated asap
Diets should be frequent and high in energy and high-quality protein to minimize loss of muscle mass.
40 | N u t r i t i o n a n d d i e t e t i c s
Protein should be 1.0-1.2 g/kg of body weight
Dietary fats should not be limited unless they are not well tolerated.
Fluid intake should be adequate to accommodate the high protein intake unless otherwise
contraindicated.
Supplementation includes vitamin b complex (especially B12- cobalamin, due to decreased absorption
and hepatic uptake), vitamin K (to normalize bleeding tendency), vitamin C, zinc for poor appetite
Abstinence from alcohol is imperative.
Treatment goals
An early form of liver disease can be caused by alcoholism, obesity, complications of drug therapy
(corticosteroids and tetracyclines), excessive parenteral nutrition, pregnancy, DM, inadequate intake of
protein, infection, or malignancy
Thorough diet history is essential, and a nutrition plan should be developed according to the etiology of
the condition.
If the problem is related to DM, glucose management requires carbohydrate counting.
If it occurs after parenteral nutrition, the amount of administration should be altered.
In general, high-fat and high-fructose intakes are problematic.
Lifestyle interventions are the first line of treatment: vitamins, amino acids, prebiotics, probiotics,
polyunsaturated fatty acids, and polyphenols are often used and show great promise.
Weight loss may be needed, but meals should not be skipped
Choline, fiber, coffee, green tea, and light alcohol drinking might be protective.
o Antioxidants= digestion
Morbidly obese (BMI >40) bariatric surgery may be required
Adequate racking of glucose and lipid levels will be needed
41 | N u t r i t i o n a n d d i e t e t i c s
Assistance of a registered dietitian will
be needed to guide this nutrition care
plan successfully
Probiotics/prebiotics may be
beneficial. They affect gut flora;
certain forms may alleviate liver injury
Probiotics- live bacteria in foods e.g. lactobacillus
Prebiotics- serves as fertilizer for the healthy gut flora; special dietary fibers
Cirrhosis:
Individual nutritional needs must be addressed and are different per patient.
0.8 g protein per kg body weight per day is essential.
To promote positive nitrogen balance and avert breakdown of endogenous protein stores.
1.2 g protein/kg dry or appropriate body weight is recommended.
Protein restriction should be avoided, because it can worsen malnutrition
Patients with esophageal varices should eat soft, low-fiber foods.
For ascites, a dietary sodium restriction (2000 mg) is used, usually with fluid restriction.
Liver Transplantation:
Primary objective- provide enough calories and protein to decrease protein catabolism and correct
any nutritional deficiencies.
Immediately post-transplantation (4-8 weeks after surgery) – require individualization of nutritional
therapy according to patient’s needs.
Adequate calories and protein are necessary for the stresses that result from surgery and high doses of
glucocorticoids.
Early enteral nutrition with new immunomodulating diets enriched with hydrolyzed whey protein can
prevent post-transplant bacteremia and post-transplant hyperglycemia
Between meal feedings and supplements should be used in order to meet calorie and protein goals
Gallbladder Disorders:
42 | N u t r i t i o n a n d d i e t e t i c s
Gallstones & Cholecystitis:
Pancreatic Disorders:
Feeding into the lower small bowel, in the jejunum distal to the ligament of Treitz, bypasses the areas
associated with pancreatic stimulation.
Pancreatic stimulation should be decreased.
Low-fat, elemental formulas are recommended.
Patients with enteral feedings should be closely monitored for increases in pancreatic enzyme levels.
43 | N u t r i t i o n a n d d i e t e t i c s
Mediterranean diet – promotes EVOO, fruits, vegetables, whole grains, legumes, herbs, and spices. Also
recommends lean proteins from fish and poultry and red wine in moderate amounts.
Resveratrol – a phytochemical that promotes longevity and is seen in red wine and red grape skins.
Supraglottic swallow – appropriate for patients with reduced laryngeal function. Deep breath before
swallowing and coughing or exhaling after.
Mendelsoh maneuver – helpful for individuals with cricopharyngeal dysfunction. Elevate larynx
voluntarily to maximum level during swallowing to allow food to pass.
Safest eating position for client with dysphagia
o upright position
Damage of esophageal mucosa due to reflux of the acidic gastric contents results to esophagitis
Hiatal hernia- condition in which a part of the stomach bulges upward through the diaphragm.
o Patients with this disorder may experience pneumonitis, chronic bronchitis, and asthma
Stomach Disorders
Vomiting- reverse peristalsis, one way of the body protects itself from intruding viruses or toxins
o Dehydration - a concern when vomiting is continual; which causes a lot of fluid and electrolyte loss.
o Small cold meals are better tolerated when clients are experiencing nausea or vomiting.
o Examples of food to give clients with nausea and vomiting: crackers and cheese, gelatin, fruit, or
lemonade.
o Foods to avoid: Hot, fried spicy, strong-smelling foods.
o Offer small frequent meals at frequent intervals is a good place to start.
o Breathing exercises and repositioning may be helpful.
o Good oral health is important, and patients may be prescribed antiemetics, 30 to 60 mins. Before
meals
44 | N u t r i t i o n a n d d i e t e t i c s
Peptic Ulcer Disease:
Is the term used to describe a break or ulceration in the protective mucosal lining of the lower
esophagus, stomach, or duodenum
Heliobacter pylori & use of NSAIDs are a major cause of duodenal ulcers.
Any dietary modifications must be individualized to include avoidance of foods that a patient can
associate with symptoms.
Some individuals avoid: red and black pepper, chili pepper, coffee, other caffeinated beverages, and
alcohol.
Foods and spices that are irritants, cause superficial mucosal damage, or worsen existing disease should
be omitted.
Dumping syndrome:
Gastrectomy, can cause the impairment of the normal stomach reservoir which causes a large volume
of particles to be dumped rapidly into the small intestine.
Liquids should be consumed between meals rather than with meals.
Simple carbohydrates are limited because they may worsen the syndrome.
Intestinal Disorders:
Diarrhea:
Passing of loose, watery bowel movements that result when the contents of the GI tract move through
too quickly to allow water to be reabsorbed in the colon.
Adequate hydration is essential in the high-risk population.
Recommendations for managing diarrhea:
o Eat small frequent meals
o Chew with a closed mouth to avoid swallowing too much air
o Get plenty of rest – lie down for 30 to 60 min after meals
o Include foods that are low in fiber, such as, bananas, rice, applesauce, dry toast and crackers.
o Drink liquids 30 mins. Before or after meals.
Constipation:
Normal functioning ranges from 3 times a day to every 3 days. Constipation means having fewer than 3
stools per week.
Water helps lubricate the intestines, making bowel movements easier to pass.
Patient should use fiber-rich products such as whole-grain breads & cereals, fruits, and vegetables.
Recommendations for managing constipation:
o Listen to body’s signals and follow a schedule that allows time for bowel movement to occur.
o Exercise regularly
o Relax, stress tightens muscles throughout the body and may inhibit proper bowel functions
o Consume regular meals. Skipping meals should be avoided
45 | N u t r i t i o n a n d d i e t e t i c s
o A chronic autoimmune disorder in which the mucosa of the small intestine, especially the
duodenum and proximal jejunum, is damaged by dietary gluten
Remove gluten from diet
Lactose intolerance:
o Limit lactose-containing foods or in severe cases no lactose diet is indicated. This all depends on the
RDA of lactose for the person as it differs.
o Depending on the individual’s symptoms and food dairy, lactose, gluten, or sugars may be
eliminated from the diet
Nutrition management of a patient with SBS should take into consideration the individual’s digestive and
absorptive capabilities
Patients require parenteral nutrition, or IV fluids in the immediate postresection period
Diet and enteral nutrition should be reintroduced as soon as possible.
Complex carbohydrates from whole grains, fruits and vegetables should be used, but simple sugars
should not.
Patients with end-jejunostomies can tolerate a higher proportion of calories from dietary fat than
patients with a remnant colon.
Diverticular Disease:
Bowel walls are weakened, diverticula (pouchlike herniations protruding from the muscle layer of the
colon) develop.
When diverticula are inflamed, patients are given nothing by mouth and then progress to liquids. After
inflammation, a high-fiber diet is recommend to reduce straining during defecation.
46 | N u t r i t i o n a n d d i e t e t i c s
Nutrition for diseases of the kidney
Nephrotic syndrome
Complex of symptoms that can occur after damage to the capillary walls of the glomerulus
Often results from primary glomerular disease (glomerulonephritis), nephropathy secondary to
amyloidosis (accumulation of waxy starchlike glycoprotein)
Primary goal- control hypertension, minimize edema, decrease urinary albumin losses, prevent protein
malnutrition and muscle catabolism
Consume adequate proteins and energy- 1g/kg/day of protein and 35g/kg/day of energy
o Prevent malnutrition and catabolism of lean body tissue
Good sources of protein- lean meats, well-trimmed poultry, eggs (limit 2 per week), fish, shellfish, beans,
and nuts
Sodium intake should be limited
Intake of cheese, canned foods, dried pasta and rice mixes, and canned or dried soups should be
controlled
Fruits and vegetables are highly recommended
Monitor and document patient weights, intake and output should be recorded at least every shift
Abrupt loss of renal function, may or may not be accompanied by oliguria or anuria
Most common cause of ARF- acute tubular necrosis (ATN)- injury after decreased blood supply, or
nephrotic cause, such as certain medications
Reduction of urine output stages:
o Oliguric phase (24-48 hours after initial injury; lasts 1-3 weeks)- retention of excessive amounts of
nitrogenous compounds in the blood, acidosis, high serum potassium phosphorus levels,
hypertension, anorexia, edema, and risk of water intoxications
o Diuretic phase (lasts 2-3 weeks)- urinary output is gradually increased
o Recovery phase (lasts 3-12 monts)- kidney functions gradually improves
Nonprotein calories (30-40 kcal/kg) should be provided for weight maintenance and to meet extra
demands
Fats, oils, simple carbohydrates, and low-protein starches are given
When dialysis is not part of the treatment- 0.6-0.8 g of protein per kilogram of body weight is often
prescribed
If dialysis is part of the treatment- 1.0-1.4g/kg of protein is required
Supplements of niacin, riboflavin, thiamine, calcium, iron, vitamin B12, and zinc may be given due to
protein deficiency
During oliguric phase, sodium is restricted to 1000-2000 mg/day and potassium to 1000g/day
High phosphorus intake should be controlled
o High phosphorus levels disrupts the hormonal regulation of phosphate, calcium, and vitamin D,
leading to impaired kidney function
Medical nutrition therapy (MNT)- goals is to slow or prevent progression to the need for dialysis
Treatments and major concerns for pre-
end stage renal disease, hemodialysis,
and peritoneal dialysis
Pre- ESRD Hemodia Peritoneal
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Hemodialysis
Blood is shunted from the patient’s body by way of special vascular access or shunt, thinned with
heparin, cleansed form excess fluid and waste products through a semipermeable membrane, and
then returned to the patient’s circulation
Dialysate- is an electrolyte solution similar in composition to normal plasma
Peritoneal dialysis
Removal of excess fluid and waste products from the blood by using the lining of the abdominal cavity
as the dialysis membrane
Intermittent peritoneal dialysis- involves infusion of approximately 2L of dialysate over 20-30 minutes
Continuous ambulatory peritoneal dialysis- entails infusion of dialysate in four or five exchanges in to the
peritoneum over 24 hours
Continuous cycling peritoneal dialysis- combination of IPD and CAPD
Daily vitamin supplements are recommended especially folic acid and vitamin D
Recombinant EPO and iron supplements to manage anemia
During PD- Na, K, an fluids are continually removed, making severe dietary restrictions unnecessary
Restriction of dietary phosphorus is critical to prevent osteodystrophy (defective bone development)
Restricting and eliminating dairy products will be necessary to control phosphorus intake
Calcium supplementation is recommended
Kidney transplantation
Pretransplantation
49 | N u t r i t i o n a n d d i e t e t i c s
Protein 0.6-1.0 g/kg 1.2 g/kg IBW 1.2-1.2 g/kg
IBW IBW
Sodium Individualized, 2-3 g/day 2-4 g/day
2-3 g.day
Potassium Individualized 2-3 g/day 3-4 g/day
to cover
losses with
diuretics
Phosphorus 8-12 mg/kg 0.8-1.2 0.8-1,2
IBW or 0.6-1.2 g/day or g/day
g/day <17 mg/kg
IBW
Fluids As desired 750-1000 ml Unrestricted
+ urine if weight
output/day and blood
pressure is
controlled
and
residual
renal
function is
2-3 L/day
Immediately after transplantation- energy needs are increased (30-35 kcal/kg)
o Saturated fats are limited if dyslipidemia occurs
o Increase intake in omega-3 fatty acids
o Fluids are generally unrestricted and limited only by graft function
Kidney stones
Renal calculi, formation of kidney stones (urolithiasis). Due to low urine volume from inadequate fluid
intake, alkaline urine ph, etc.
Cardiovascular diseases:
Myocardial Infarction:
- A healthy diet to prevent PAD includes unsaturated fats like fish, nuts, and seeds and excludes saturated
fats.
- Sodium should be cut back
Hypertension:
51 | N u t r i t i o n a n d d i e t e t i c s
Weight reduction and sodium restriction also augment the effects of antihypertensive medication.
Diet for weight loss ad control should include an energy restriction and an aerobic exercise prescription.
Decrease alcohol consumption
Increase physical activity
Terminate cigarette smoking
Decrease sodium intake
Increase intake of potassium, magnesium, and calcium.
A diet rich in fruits, vegetables, and low-fat dairy products along with reduced saturated and total fats
has been found to significantly lower blood pressure.
DASH diet is recommended.
Heart Failure
Cardiac Cachexia:
Pulmonary Diseases:
- COPD:
Malnutrition of individuals with COPD is multifactorial.
Energy expenditure is usually elevated but will vary according to person’s level of physical activity.
Adequate protein stimulates the ventilatory drive.
Patients require 1.2 to 1.9 g protein per kg of body weight for maintenance and 1.6 to 2.5 g/kg for
repletion.
Offer foods such as milk, eggs, cheese, meat, fish, poultry, nuts, beans, and legumes.
Higher serum a-carotene and b-carotene concentrations, reflect greater intake of orange and dark
green leafy fruits and vegetables are associated with better pulmonary functions.
Include vitamin d and other antioxidants.
High fat and low carbohydrates are recommended.
Offer 4 to 6 small meals a day to reduce sodium intake.
Too much sodium may cause edema and discomfort.
Cystic Fibrosis:
52 | N u t r i t i o n a n d d i e t e t i c s
Fat-soluble vitamins may be prescribed in a water-miscible form if fat malabsorption is severe.
- Most patients in ARF require mechanical ventilation, which is why nutrition support may be provided via
enteral or parenteral nutrition.
- Nutrition support should be initiated as soon as possible to help wean the patient from the ventilator.
- Nutritional recommendations re the same as COPD guidelines: high calorie, high protein, moderate to
high (50% nonprotein kcal) fa, with moderate (50% nonprotein kcal) carbohydrate.
- Enteral nutrition is recommended in several guidelines for mechanically ventilated patients.
- Commercial formulas that provide 40% to 50% of total kcal from fat are available.
- Higher caloric density formulas may be necessary when fluids are restricted
- Parenteral nutrition may be needed in the treatment of acute respiratory failure.
- High glucoe concentration can lead to excess CO2 production, which should be avoided.
Asthma:
- Oxidative stress plays a rolein asthma; antioxidant dietary approaches are suggested.
- A variety of fruits, vegetables, and whole-grains other than wheat and rice provide dietary fibers,
iron,magnesium and phosphorus from natural sources and should be used often.
- A healthy diet and avoidance of obesity during pregnancy, childhood and aging may reduce asthma
exacerbations.
- Vitamin D, fish oil and vitamin C are important nutrients.
Tuberculosis:
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