dieth therapy final

DIET THERAPY OF DIFFERENT DISEASE

Presented by: Dave Jay S. Manriquez RN.

DIET THERAPY IN NURSING

Nutrition Index

Mr. Tucker’s (actual) weight is 3% less than his admission wt.

LIQUID DIETSINDICATIONS FOR CLEAR LIQUID DIEToProvide oral fluids; before/after surgery; prepare bowel for diagnostic tests (colono scopic examination, barium enema, and other procedures); minimize stimulation of GI tract; promote recovery from partial paralytic ileus (early refeeding); minimize residue in the GI tract; transition feeding from < IV feeding to solid foods; acute GI disturbances; diarrhea .CONTRA INDICATIONS FOR CLEAR LIQUID DIETo Should not be used more than 24 hours; inadequate GI function; nutrient needs requiring parenteral nutritionINDICATIONS FOR FULL LIQUID DIETo Provide oral fluids; after surgery; transition between clear liquids and solid food; oral or plastic surgery to the face and neck; mandibular fractures; patients who have chewing or swallowing difficulties; esophageal or GI strictures; diarrhea CONTRA INDICATIONS FOR FULL LIQUID DIET: Dysphagia

Types Of Diets

PUREED, MECHANICAL, OR SOFT DIETS INDICATIONS FOR PUREED DIETo Neurologic changes; inflammation or ulcerations of the oral cavity and/or esophagus; edentulous patients; fractured jaw; head and neck abnormalities; cerebrovascular accident .CONTRA INDICATIONS FOR PUREED DIEToSituations where ground or chopped foods are appropriateINDICATIONS FOR MECHANICAL SOFT DIET IoPoorly fitting dentures; edentulous patients; limited chewing or swallowing ability; dysphagia; strictures of intestinal tract; radiation treatment to oral cavity; progression from enteral tube feedings or parenteral nutrition to solid foodsCONTRA INDICATIONS FOR MECHANICAL SOFT DIETo Situations where regular foods are appropriate INDICATIONS FOR SOFT DIETDebilitated patients unable to consume a-regular diet; mild GI problemsCONTRAlNDICATIONS FOR SOFT DIET oSituations where regular-foods are appropriate

Indicators of Potential Nutritional Problems Clear or full liquid diets for more than three days without nutrient supplementation or with inappropriate or insufficient nutrient supplementation. Intravenous feeding (dextrose or saline) or NPO for more than 3 days without supplementation. Low intakes of prescribed diet or tube feedings Inconsistent growth or weight for height, above or below norms in children.

Pregnancy weight gain deviating from normal patterns

Diagnoses that increase nutritional needs or decrease nutrient intake (or both):cancer,malabsoprption, diarrhea, hyperthyroidism, excessive inflammation, postoperative status, hemorrhage, wounds (large, draining, or infected wounds), burns, infection, sepsis, major trauma (or multi system injury)

Chronic use of drugs, especially alcohol, that affects nutritional statusAlterations in chewing, swallowing, appetite, taste, and

smellTemperature consistently above 37o C (98.6 Fo) for more

than 2-daysHematocrit: <43% in men, <37% in womenHemoglobin: <14 g/dl in men, <12 g/dl in women;

accompanied by mean cell volume <82 cu or >100 cuAbsolute decrease in lymphocyte count (<1500

cells/mm3)Elevated (>250mg/dl) or decreased (<130 mg/dl) total

plasma cholesterol Serum albumin, <30 g/dl in patients without renal disease, liver

disease, generalized dermatitis,overhydration.

Dysphagia Position the patient in a comfortable with the head in an

upright position, slightly tilted forward Textured foods that require chewing stimulate a better

swallow, e.g. toast instead of bread or boiled potato instead of mashed potatoes.

Offer juices diluted with water at first, and use flexible straws if the patient has suckling capabilities

Mildly sweetened and salted foods are generally favored. Foods should be close to room temperature. Avoid acid or bitter flavors and sticky foods (e.g. soft bread, bananas, or peanut butter).

Make consistency adjustments according to the patient’s tolerance. Liquids can be used to moisten foods for individuals with decreased saliva production

Adapt the diet to the patients’ need and gradually upgrade it as feeding skills improve.

Gastroesophageal Reflux

Achieve and maintain ideal body weight to improve mechanical and postural status (except pregnant women, who should not try to lose weight).

Increase protein and reduce fat intake to increase sphincter pressure.

Avoid foods like chocolate, alcohol, peppermint, coffee, and carbonated drinks.

Avoid foods that may irritate and cause spasms; citrus juices, tomatoes, and tomato sauce.

Stop smoking, if that is a habit. Eat small meals four times a day. Eat large meal at noon with a lighter meal in the

evening. Finish the evening meal at least two to four hours before bedtime. Avoid late evening snacks.

Peptic Ulcer Trend in nutritional therapy of peptic ulcer- individualized approach, i.e. based on the individual patient’s tolerance for specific foods.To reduce or neutralize gastric acid secretion:Eat three meals daily; avoid skipping meals.Avoid stomach distention with large quantities of food at a meal.Avoid drinking milk frequently.Limit caffeine intake by reducing consumption of coffee, tea, cola, chocolate and other foods and beverages that contain caffeine.Limit alcohol intake and avoid drinking on any empty stomach.

. Limit intake of spicy, fatty or otherwise bothersome foods and beverages.

Some fibers, especially the soluble forms, are beneficial.

Citric acid juices may induce gastric reflux and discomfort in some patients.

Avoid bedtime snacks to prevent acid secretion if symptoms often occur in the middle of the night.Avoid cigarette smoking, which may increase gastric acid secretion and delay the healing process and is also associated with an increased frequency of duodenal ulcers.

GASTRITIS

The aim is to rest the stomach and reduce further irritation of the mucosa.

Acute type: NPO for 24 to 48 hours: give glucose

parenterally, followed by liquids, then soft to full diet as tolerated.

Chronic type: Bland, low fiber diet. Correct faulty food habits.

Intestinal Malabsorption

Decreased Absorption

Increased Absorption

Diet specific to etiology

Diarrhea

Clinical Implications Fluids must be replaced to avoid dehydration, solids should

be gradually added as tolerated. A low-residue diet may be in order to decrease the intake of fibrous materials.

Evaluate the use of foods that may contribute to diarrhea, especially those high in fiber, caffeine, and alcohol.

Encourage juices high in potassium Remove milk products from the diet if there is a possibility

of lactose intolerance. Bananas, grated raw apples, or cooked apple-sauce contain

pectin, which helps bind the fluid and retard its transit time. Extremely hot or cold foods increase peristalsis and may

aggravate diarrhea.

Constipation

Clinical ImplicationsAsk patients about their use of cathartics or laxatives. Gradually increase the amount of fiber or bulk in the diet

(raw vegetables and fruits, whole-grain breads, and cereals).

Force fluid intake; drink at least the equivalent of six to eight glasses of water a day.

Dried fruits, especially prunes, contain natural laxatives. Any hot beverage upon arising, such as coffee, tea, or

lemon water, may stimulate peristalsis because duodenal-ileal or gastric colic is strongest in the morning. Breakfast is also important and should contain some fiber.

Encourage activity and relaxation as much as possible allow sufficient time for bowel habits

Flatus

Clinical Implications Discourage drinking with straws. Avoid foods that produce gas (This is highly individual

matter, one which the patient must be observant). In many persons, dried beans, peas, and foods from the cabbage family (broccoli and Brussels sprouts) cause problems.

Decrease the amount of fat in the diet. Encourage the patient to chew food slowly, closing the

mouth. Malabsorption syndrome, peptic ulcers, and cholelithiasis

are disorders that cause excessive flatulence; these treatable disorders must be excluded by conventional means (Van Ness & Cattau, 1985)

Crohn’s Disease (Regional Enteritis)

Clinical Implications

During bouts with diarrhea, sources of potassium intake should be increased.

Multivitamin and mineral supplements are frequently recommended.

Ulcerative Colitis

Clinical Implications Patients with severe diarrhea or steatorrhea should

be monitored for magnesium, which is usually deficient in chronic inflammatory bowel disease (Philips & Garnys, 1981).

Low serum zinc levels are prevalent among children with chronic inflammatory bowel disease. Response to zinc intake is abnormal and growth is retarded (Nishl et al, 1980).

The use of azulfidine requires a daily intake of eight to ten cups of fluid.

Irritable Bowel Syndrom (IBS)

Clinical Implications

Patients with irritable bowel syndrome must be tested for lactose intolerance or malabsorption before further treatment (Goldsmith & Patterson, 1985).

Hydrophilic mucilloids necessitate large amounts of fluid intake.

Disease of the Liver, Pancreas

and Gall Bladder

Hepatitis

During acute phase: 5-10% dextrose Intravenously and/or protein parenterally: To minimize protein losses, prevent ketosis, to replace fluids and electrolytes.

High calories: To counteract weight loss and for maximum protein utilization.

High CHO: To spare protein: Insure glycogen reserve and maintenance of hepatic function.

High protein: To repair hepatic cells; from cholic and other bile acids; to prevent hypothermia; supply lipotropic factors which mobilize liver fat.

Cirrhosis

Moderate fat, MCT preferred over LCT (Restrict fat if there is billiary obstruction): To meet high energy needs, at the same time preventing fatty liver.

High vitamins: To maintain liver function. Frequent small feeding in cases of anorexia: For better

tolerance. Consistency: liquid to soft in acute attacks; more liberal

in convalescence: Adjusted to patient’s tolerance. Low sodium: In cases of ascites. Alcohol prohibited: Detoxification function of the liver is

impaired by alcohol.

Hepatic Encephalopathy (Hepatic Coma)

Protein Intake Initially: non-protein diet (Borst Diet)

Progress to: 20-30 gm/day (Giordano-Giovanetti Diet) if condition improves until the normal protein allowance is tolerated: To eliminate completely a source of nitrogen for ammonia synthesis.

Calories: 1500 to 2000 a day to come mostly from CHO and fat: Minimize tissue protein breakdown which is a source of ammonia.

Liberal vitamins and minerals: For adequate nutrition. Low sodium: Prevent ascites. Tube feeding: when oral feeding is not possible.

Cholecystitis

IV fluids and electrolytes; progress to clear liquid: To rest inflamed gallbladder, prevent and correct dehydration, volume depletion and electrolyte abnormalities.

Low fat: Reduce discomfort by preventing stimulation of sphincter of Oddi, and contraction of GB.

Bland low fiber: Decrease mechanical and chemical stimulation.

Low calorie for obese patients: For weight loss, obesity is predisposing factor.

Small frequent feedings: To prevent dyspepsia.

Pancreatitis

Acute attack: NPO: To rest the organ. Low fat: To control steatorrhea and prevent

stimulation for bile production. Moderate CHO and protein: Prevention of

hypoglycemia and creatorrhea. Plus enzyme supplements: Utilization of nutrients. Six small feedings, bland: Avoid undue distention

and stimulation. Avoidance of alcohol: Alcohol may precipitate

attack. Supplements of fat-soluble vitamins and calcium:

To prevent deficiencies. MCT oil: Better absorbed than LCT.

DIETARY MANAGEMENT OF SURGICAL CONDITIONS

Pre-operative Post-operative

Dietary Management in General

Pre-Operative

To improve the nutriture of the patient.

To prepare the patient for nutrient losses during surgery.

To hasten post-operative recovery.

To build up glycogen reserves.

To strengthen bodily resistance to infections.

Pre-Operative Dietary Management in: Emergency Operation

If patient is in good nutritional status – NPO 8 hours prior to surgery

To avoid vomiting during anesthesia or recovery from anesthesia, and decrease the risk of post-operative gastric retention since peristalsis is stropped

If patient is in poor nutritional status (protein deficient) parenteral administration of whole blood or plasma.

For adequate stores of serum protein to prevent hypoproteinemia and shock.

In addition, 5% glucose in water, saline solution, vitamins and potassium.

For adequate nutrition

Pre-Operative Dietary Management in: Elective Surgery

High calorie for underweight

To build up any weight deficit

Low to adequate calories for others

if patient is overweight, weight reduction is indicated to reduce surgical risks.

High carbohydrates For glycogen stores and to spare protein for tissue synthesis. Stores of glycogen exert a protective action on the liver and help to prevent post-operative ketosis and vomiting.

High protein To build reserves for anticipated blood losses during surgery and increased tissue catabolism, to reduce the possibility of edema at the site of the wound which is a hindrance to wound healing.

Increased vitamins, especially ascorbic acid, vitamin K; B- complex

For wound healing and prevention of hemorrhage

increased minerals, especially phosphorus and potassium; Na and chloride

To replace electrolyte losses due to the break-down of body tissue; and due to vomiting, diarrhea, perspiration and diuresis.

Iron To correct anemia

Increased fluids To replace losses due to vomiting and diuresis

Immediate Pre-operative Period – usually nothing is given by mouth for at least 8 hours before general surgery so that the stomach will have no retained food at the time of the operation

Post-operative Dietary Management in: Minor Surgery

LiquidsTolerated within a few hours; for maintenance or restoration of fluid and electrolyte balance.

Normal DietAs soon as activity of GIT is restored

Post-operative Dietary Management in: Major Surgery

NPO 24 - 48 Hours GI tract not yet functioning normally. To allow for recovery from anesthesia; prevent aspiration.

Nutrition support: type and duration depends on recovery of GIT function

As soon as activity of GIT is restored

Conventional intravenous administration of amino acid solution

Patient is expected to tolerate an enteral diet within a few days.

Total parenteral nutrition (TPN) To meet nutritional needs for extended periods when enteral feeding is not possible

Tube feeding. If there is GIT function, but patient cannot tolerate an oral diet.

To meet nutritional needs until patient can tolerate food by mouth.

To give patient a feeling of being “normal” and hasten recovery; also, less expensive.

Oral Diet – liquid to full, as tolerated

Specific Surgical Conditions

Surgery of the Mouth, Throat and Esophagus.

Gastrectomy

Dumping Syndrome

Intestinal Surgery

Diet following other abdominal Operations

Rectal Surgery

Surgery of the Mouth, Throat and Esophagus

The aim is to provide food that require little chewing, comfortable and prevent bleeding.

For tooth extraction: fluid diet progressing to soft until full diet is tolerated.

Surgery of the mouth: full fluid or pureed foods; or tube feeding.

Tonsillectomy: very cold or mild flavored foods the first few days. Avoid fibrous foods; then warm fluids and foods on the 2nd day, progress to a normal diet after a week.

Gastrectomy

NPO first 24-48 hours; intravenous feedings Day 2 to 4: iced water with intravenous feedings Day 5: 1 to 2 oz. Water every even hours, and 1 to 2 oz milk

every odd hour between. Day 6: Soft low fiber foods are used – eggs, custards,

thickened soups, cereals, crackers, milk and fruit purees are suitable.

Day 7: Tender meats, cottage cheese, and pureed vegetables are the next foods added to all the foods allowed in the previous days.

Meats are divided into 5 or 6 small feedings daily with emphasis on foods high in protein and fat. CHO is kept relatively low. If not liquids are taken with meals, and the diet continues to be low in CHO, especially the simple sugars, many patients progress satisfactorily.

Dumping Syndrome: Major Surgery

Small frequent feedings (5 or6) fed in supine position.

To prevent dumping of food into the intestines.

High protein Better tolerate because proteins are hydrolyzed into osmotically active substances more slowly; needed to rebuild tissues and gain strength.

High fat To meet energy needs

High calories For strength

Simple CHO (sugar, sweets or desserts, restricted)

Simple CHO increases osmolarity of jejunum contents * “dumping syndrome.”

Dry solid diet

Better than liquids as they enter the jejunum less rapidly.

Low fiber, low residue diet

To prevent rapid dumping of food into the intestines.

Avoid alcohol or sweet carbonated beverages

Intestinal Surgery: Major Surgery

Clear fluid Initial oral intake after surgery

Low residue, bland To promote healing of the stoma and to prevent irritation

HI calorie, HI PRO For weight recovery

VIT B12 supplemented To prevent possible macrocytic anemia in later years

Intestinal Surgery: Colostomy

Same for Ileostomy

Jejunoileostomy

Low fat, low CHO, low fiber To prevent from diarrhea

HI PRO To restore electrolyte balance and to provide for losses of K, Ca and Mg.

Diet following Other Abdominal Operations

Cholecystectomy

Low fat – for several weeks or months

To avoid pain since large amounts of fats cause contraction of the tissues irritated and inflamed by surgery

HI PRO For faster convalescense

Diet following Other Abdominal Operations

Peritonitis and intestinal obstruction

NPO – 1ST 24 to 48 hours, intravenous therapy

Gastrointestinal function has not yet returned and drainage of the stomach and upper intestine is essential until there is reduction of distention and passage of gas.

Clear liquids to low residue Better tolerated; transition to full diet

Rectal Surgery

Hemorrhoidectomy

NPO – 1ST 24 to 48 hours Due to anaesthesia

Clear liquid Initial Feeding

Low fiber-low residue: Fruits and vegetables are omitted except for strained fruit juices

To discourage early bowel movements

Allergy

Avoidance diet: An adequate diet which excludes the food(s) causing allergic reactions (e.g. milk-free, egg-free diet, wheat-free diet, etc.)

Desensitization: The allergenic food is given in gradually increasing amounts over a long period of time.

Most Common Food Allergens

Chicken

Cow’s milk

Wheat

Peanuts/nuts

Soy products

Fish, shellfish

Diabetes Mellitus (DM)

Dietary Modification

Current concepts

There is no one “diabetic diet” that will suit the individual and special needs of a person with diabetes.

The diet for an individual with diabetes can only be defined as a “dietary prescription” based on nutrition assessment and treatment goals.

Goals of Nutrition Therapy of DM Maintenance of as near-normal blood

glucose levels as possible Achievement of optimal serum lipid

levels Provision of adequate energy to

maintain/achieve reasonable body weight

Prevention and treatment of the acute complications and of long-term complications

Improvement of overall health through optimal nutrition

Recommended Dietary ModificationTotal calories – sufficient to maintain/achieve

reasonable weight in adults, or meet increased needs of children, adolescents, pregnant and lactating women and individuals recovering from catabolic illness.

Caloric distribution:Carbohydrates : 50 – 70%Protein : 10 – 20%Fat : 20 – 30%

Cholesterol – limit to 300 mg/day or less Carbohydrates sweeteners are permissible

Low-Glycemic Index Foods: Less Than 50

Intermediate-Glycemic IndexFoods: 50 to 70

High-Glycemic Index Foods:More Than 70

* Eat foods printed in red sparingly; these are high in empty calories.

* Eat foods printed in red sparingly; these are high in empty calories.

* Don't avoid or even limit high-glycemic index foods printed in green; these are low-calorie and very nutritious foods.

1 Artichoke <15 1 Brown Rice 55 1 Golden Grahams 71

2 Asparagus <15 2 Canned fruit cocktail 55 2 Bagel 72

3 Broccoli <15 3 Linguine 55 3 Corn chips 72

4 Cauliflower <15 4 Oatmeal cookies 55 4 * Watermelon 72

5 Celery <15 5 Popcorn 55 5 Honey 73

6 Cucumber <15 6 Sweet corn 55 6 Kaiser roll 73

7 Eggplant <15 7 Muesli 56 7 Mashed potatoes 73

8 Green beans <15 8 White rice 56 8 Bread stuffing mix 74

9 Lettuce, all varieties <15 9Orange juice from frozen concentrate 57

9 * Cheerios 74

10

Low-fat yogurt, artificially sweetened <15

10

Pita bread 5710

Cream of Wheat, instant 74

11

Peanuts <1511

Canned peaches, heavy syrup 58

11

Graham crackers 74

12

Peppers, all varieties <15

12

Mini shredded wheats 5812

Puffed wheat 74

13

Snow peas <1513

Bran Chex 5813

Doughnuts 75

14

Spinach <1514

Blueberry muffin 5914

French fries 76

15

Young summer squash <15

15

Bran muffin 6015

Frozen waffles 76

16

Zucchini <1516

Cheese pizza 6016

* Total cereal 76

17

Tomatoes 1517

Hamburger bun 6117

Vanilla wafers 77

18

Cherries 2218

* Ice cream 6118

Grape-Nuts Flakes 80

19

Peas, dried 2219

Kudos Whole Grain Bars (chocolate chip) 61

19

Jelly beans 80

20

Plum 2420

Beets 6420

Pretzels 81

21

Grapefruit 2521

Canned apricots, light syrup 64

21

* Rice cakes 82

22

Pearled barley 2522

Canned black bean soup 64

22

Rice Krispies 82

23

Peach 2823

Macaroni and cheese 6423

Corn Chex 83

24

Canned peaches, natural juice 30

24

Raisins 6424

Mashed potatoes, instant 83

25

Dried apricots 3125

Couscous 6525

Cornflakes 84

26

Soy milk 3026

Quick-cooking oatmeal 6526

* Baked potato 85

27

Baby lima beans, frozen 32

27

Rye crispbread 6527

Rice Chex 89

28

Fat-free milk 3228

* Table sugar (sucrose) 65

28

Rice, instant 91

29

Fettuccine 3229

Canned green pea soup 6629

French bread 95

30

* M&M's Chocolate Candies, Peanut 32

30

Instant oatmeal 6630

* Parsnips 97

31

Low-fat yogurt, sugar sweetened 33

31

Pineapple 6631

Dates 103

32

Apple 3632

Angel food cake 6732

Tofu frozen dessert 115

33 Pear 36 33 Grape-Nuts 67

34 Whole wheat spaghetti 37 34 Stoned Wheat Thins 67

35 Tomato soup 38 35 American rye bread 68

36 Carrots, cooked 39 36 Taco shells 68

37 * Mars Snickers Bar 40 37 Whole wheat bread 69

38 Apple juice 41 38 Life Savers 70

39 Spaghetti 41 39 Melba toast 70

40 All-Bran 42 40 White bread 70

Sodium –limit to about 3000 mg/day; less for people with hypertension or renal complications.

Alcohol – moderate amounts may be allowed, contingent on good metabolic control.

Vitamins and mineral supplement – not usually necessary, but may be given to individuals, on reduced calorie diets (1400 kcal/day or less).

Strategies for Diabetes Medical Nutrition Therapy

Type I DM Type II DMStrategy Obese Non-ObeseCalorie restriction * *** * Timing of meals *** ** **Meal spacing ** *** **Fat modification *** *** ***Sucrose limitation ** ** **Exercise ** *** ***Exercise snack *** * *Other nutrition variables ** ** **

Blood glucose monitoring *** *** ***_________________________________________* Low ** Moderate *** High

Overweight/Obese Low calorie: To enable the body to deplete adipose tissue

stores. High protein: For high safety value; exerts higher specific

dynamic action; to minimize tissue nitrogen loss Moderate fat: For safety value; emphasis on PUFA. Normal to low CHO: Close relation of glucose to fat

formation. Bulky, low calorie foods: To provide safety without

increasing calorie intake. Supplement of PUFA: Accelerates oxidation of body fat.

Underweight High calorie diet: For storage of fat in the adipose tissue,

to restore DBW Gradual increases: To avoid gastric upsets and spells of

discouragement. High protein: For replacement and repair of body tissue High CHO: For added calories; protein-sparer. Bulky, low calorie foods: To provide satiety without

increasing calorie intake. Supplement of PUFA: Accelerates oxidation of body fat.

Hyperthyroidism

High calories: to compensate for increased BMR

Adequate vitamins – thiamin, riboflavin, B12, ascorbic acid, pyridoxine and vitamin A, D, E.

- increased requirements for enhanced cellular metabolism- Degradation of vitamin is accelerated.

Increased iodine: Iodine is needed for thyroxine formation.

Adequate calcium: Correct Ca resorption from bone and prevent hypercalciuria.

Hypothyroidism

Iodine supplementation

Low calorie: To minimize weight gain due to lowered BMR

Hyperinsulinism

Functional TypeLow CHO (75-110 g/day): emphasis on complex CHO:

CHO serves as stimulus to insulin secretion. High protein, high fat. If obese emphasize MUFA: To

supply glucose in as slow even but continuous flow and to prevent marked rise of sugar at any one time.

Maintenance of DBW: To prevent oversecretion of insulin.

Restriction on coffee, tea and cola beverages: Caffeine stimulates the adrenals to cause glycogenolysis and gluconeogenesis * increased blood glucose * stimulation of pancreas * increased insulin.

Avoidance of alcohol: Alcohol has hypoglycemic

Hyperinsulinism

Fasting

High CHO: To provide constant sucrose of available glucose.

Hypertension

Calorie level, depends on weight status or weight goal: Weight loss of 5-6% in over-weight/obese can lower BP.

Sodium – restricted: Excess sodium may increase:

- cardiac output due to over-filling of vasculature

- peripheral resistance to blood flow

Fluids and roughage – adequate: Prevent constipation which hinders absorption of anti-hypertensive drugs.

Risk Factors for CHD

● Modifiable ● Nonmodifiable

● Dyslipidemia - Age- Sex- Family history of

CHD ● Smoking

● Hypertension● Diabetes mellitus● Obesity● Dietary factors● Thrombogenic factors● Sedentary lifestyle

HDL Cholesterol

Low HDL cholesterol is a strong independent predictor of CHD1

The lower the HDL cholesterol level the higher the risk for atherosclerosis and CHD2

Low HDL is defined categorically as a level < 40 mg/dl (a change from < 35 mg/dl in ATP II)1

HDL cholesterol tends to be low when triglycerides are high2

Triglycerides

Recent data suggest that elevated triglycerides are an independent risk factor for CHD

Normal triglyceride levels: < 150 mg/dl

Borderline-high triglycerides: 150 to 199 mg/dl

High triglycerides: 200 to 499 mg/dl

Very high triglycerides: (> 500 mg/dl) increase pancreatitis risk

Initial aim of therapy is prevention of acute pancreatitis.

CHD

Total fat – not more than 30% of TER:

- avoid post-prandial hyperlipedemia and its possible adverse effect of coagulation.

- reduce plasma LDL cholesterol

SFA – approx 10% of TER period of time.

PUFA – approx. 10% of TER consisting of omega-6 PUFA (e.g linoleic acid), promotes prostaglandin synthesis, which in turn promotes arterial dilation and heart muscle contractility

Long chain PUFA or omega 3 fatty acids

MUFA – approx. 10% of TER. as effective as PUFA in lowering serum total cholesterol,

but has the advantages of not lowering HDL cholesterol, less susceptible to oxidation, less thrombogenic potential, does not raise serum triglycerides; also has less tumorigenic potential.

Cholesterol – not more than 300 mg/day reduce plasma LDL cholesterol Sodium – moderate intake: -control blood pressure Carbohydrates – type and amount depends on lipid

abnormality Alcohol – avoid high intake: control blood pressure

- reduce fibrinogen - exessive intake can produce hypertriglyceridemia,

elevated LDL cholesterol, arrythmia, cardiac enlargement and heart failure

Calories – sufficient to maintain/achieve desirable body weight.

- reduce insulin resistance

- reduce synthesis of cholesterol, esp. LDL, VLDL, triglycerides

- reduce risk of cholesterol gallstone formation

Acute MI or Coronary Occlusion or Thrombosis

Acute phase: 500 – 800 cal liquid diet for 2-3 days* to avoid gagging and aspiration of solid foods.

No extremes in temperature- To prevent possible precipitation of arrythmias.

No coffee or tea- maybe stimulating and increases heart rate.

Parenteral feeding- For those unwilling to consume liquid diet

Restriction of Na - to prevent/correct edema

Subacute phase* 1000 – 1200 cal: 20% Pro. 45% CHO 35% fat

- To meet resting metabolism requirements.

Cholesterol, 300 mg* To control blood cholesterol possible precipitation level

Soft, low fiber, free of gastric irritants* To avoid indigestion and flatus

Sodium restriction* To prevent /correct edema

Small frequent feeding* to reduce possibility of post prandial dyspnea or pain.

Congestive Heart Failure

Low calories- reduce weight; decrease work of heart

Moderate protein- maintenance of N balance

Sodium restriction – 500 mg initially, 1000 mg later- to control edema.

Small frequent feedings- decreased circulatory load

Fluid as desired

Nutritional Anemias

Iron Deficiency AnemiaIron supplementation

Adequate diet with emphasis on vitamin C to enhance iron absorption and utilization.

Megaloblastic anemiaVitamin B12 must be given by injection

because of the lack of intrinsic factor necessary for its absorption.

Nutrition in Renal DiseasesNutrition in Renal Diseases

Metabolic Abnormalities

Renal clearance or urea guanidines, other products of N metabolism, Na, K, Ca, Mg, trace elements and many medicines.

Impaired ability to conserve nutrients such as Na and sometimes protein.

Reduce intestinal absorption of Ca and Iron Impaired ability to synthesize or metabolize

Loss of excretory function• Impaired metabolic action, resulting in altered nutrient,

metabolic and hormone levels.• Synthesis of certain hormones (erythropoietin and 1, 25

dihydroxycholecalciferol) Altered synthesis or degradation of nutrients by other

tissues Intestinal formation of dimethylamine and trimethylamine

Metabolic clearance of pyridoxine.

Possible mechanism underlying these metabolic alterations

Loss of excretory function Impaired metabolic action, resulting in

altered nutrient, metabolic and hormone levels

Adaptive changes in metabolic feedback loops involving hormones, enzymes and reaction products.

Reduced food intake

Effects of these abnormalities

Blood levels – amines, phenols and indoles and other nitrogenous substances

Enzymes of amino acid metabolism, tricarboxylic acid enzyme and gluconeogenic enzyme.

Serum nitrogen-containing hormones (insulin, glucagon, PTH, growth hormones, gastrin, rolactin, leutinizing hormones, gastrin, prolactin, leutinizing hormones

Serum somatostatinSerum erythropoietin and 1, 25 dihydroxycholecalciferol

Serum Renin – normal, increased or reduced

Deficiencies of vit. D and folic acid and vit. B6 due to medicine.

Wasting syndrome:• Relative body weight, muscle mass and

body fat

• Slow growth rate in children

• Decreased serum concentration of total protein, albumin, transferin, C3 and other complement proteins

• Abnormal plasma amino acid concentration

DIETARY PRINCIPLES

Objectives of nutritional therapy in chronic failure To maintain nutritional status

To minimize uremic toxicity

To prevent net protein catabolism

To stimulate patient’s well-being

To retard progression of renal failure

To postpone initiation of dialysis

DIETARY PRINCIPLES

Nutritional treatment of CRF Judicious regulation of protein intake Regulation of fluid intake to balance fluid output and

insensible water loss Regulation of sodium to balance fluid output Restriction of potassium and phosphate Insistence on an adequate calorie intake Supplementation with appropriate vitamins

Renal Disorders-1

Acute or chronic glomerulonephritis

Controlled fluid intake = fluid outputKcalControlled protein -according to laboratory data & renal functionSodiumPotassium

Nephritis

Treat symptomatically when there is significant uremia, hyperkalemia or edema. Replace all lost fluids

Renal Disorders-2

Uremia Adequate calories and controlled protein, fluid and

electrolytes according to laboratory data and renal function

Nephrotic Syndrome

Protein - 1.5 g/kg/day + 1 g Protein for each gram protein lost in urine

Kcal - increased kcal to spare protein

Sodium - low sodium (2 grams) to reduce edema

Renal Disorders-3

Acute Renal Failure

Protein - not restricted below 1.0 – 2.0 g/kg DBW

Kcal - increased kcal to spare protein for a malnourished child, 1 ½ - 2 times normal requirements

Sodium - varies according to fluid retention and hydration states

Potassium - decreased due to hypercalcemia as a result of catabolic process

Renal Disorders-4

Chronic Renal Failure Regulation of protein intake

Balance of fluid intake and output

Adequate calorie intake

Regulation of sodium, potassium and phosphorus intake

Supplementation of appropriate vitamins and minerals

*Restriction is not fixed dependent on patient’s clinical and biochemical status

THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS

Acne Low fat Acute gastroenterities (diarrhea) Clear liquid Acute glomerulonephritis Low Na, Low protein Addisons’ disease Hi Na, Low K

Angina pectoris Low cholesterol

Arthritis, gout Purine restricted ADHD Finger foods Bipolar disorder Finger foods Burn High calorie, hi pro


Celiac’s disease Gluten free Cholecystitis Hi pro, hi CHO, low fat Congestive heart failure Low Na, low cholesterol Cretinism Hi pro, hi Ca Crohn’s dse. Hi pro, hi CHO, low fat Cushings’ dse. Hi K,low Na Cystic fibrosis Hi calorie, high Na Cystitis Acid Ash (for alkaline

stones) Calculi Alkaline Ash (for acid stones) Decubitus ulcer (bedsore) High protein, High vit. C.


Diabetes mellitus Well balanced Diarrhea Hi K, high Na Diverticulitis Low residue Diverticulosis Hi residue with no seeds Dumping syndrome Hi fat, high protein, dry Hepatic encephalopathy Low protein Hepatitis Hi protein, high calorie Hirschprungs’ dse. Hi calorie, low residue, hi pro Hyperparathyroidism Low calcium Hypothyroidism Low cal, low cholesterol, low sat fat


Kawasaki’s dse. Clear liquid Liver cirrhosis Average protein Meniere’s dse. Low sodium Myocardial infarction Low fat, low Chol, low

Na Nephrotic syndrome Low Na, hi pro, hi cal Osteoporosis Hi cal, Hi vit. D Pancreatitis Low fat Peptic ulcer Hi fat, hi Cho, low pro Phenylketonuria Low pro/phenylalanine PIH Hi pro


Renal colic Low Na, low pro ARF: Low pro, hi Cho, Low Na (Oliguric

phase), Hi pro, hi Cal, & restricted fluid (diuretic phase)

CRF Low pro, low Na, low K Tonsillitis Clear liquid; cold diet

dieth therapy final

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