Impact of MalnutritionSusceptibility to infectionWeakness and fatigueImpaired wound healingImpaired growth and development in
childrenEdemaAnemia
Nutritional ProductsLiquid 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 ProductsPancreatic 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 IntakesRDA—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
VitaminsA—vision, growth, bone development, skin
and mucous membranesE—antioxidant in destruction of certain fats,
may increase absorption, storage and duse of vitamin A
K—essential for normal clottingD—instrumental in bone health
VitaminsFat soluble==A, D, E, KWater soluble==B complex and CSupplements exert same physiologic effects
as fr. foodsNo Rx neededShould not exceed recommended amounts of
Vit. D, E, folic acid and vitamin ALarge doses of all minerals are toxicAntioxidants—may affect free radicals,
inconclusive studies regarding outcomes
VitaminsCyanocobalamin—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
VitaminsRiboflavin—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).
VitaminsVitamin 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--Electrolytes22 minerals necessary for human nutritionCalcium and phosphorus in bone developmentSodium (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 utilizationCobalt—component of B12Copper—component of enzymes, RBCsFluoride—bones and teethIodine—thyroidIron—enzymes, component of hemoglobinSelenium—function of myocardium and other
musclesZinc—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-ExchangeKayexalate (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.
ChelatorsCuprimine (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 preparationsOral ferrous salts include sulfate, gluconate
and fumarateAdverse effects include nausea, discolored
stools, constipationContraindicated in hemosiderosis,
hemochromatosis, multiple blood transfusions, anemias not iron deficiency in nature, PUD, inflammatory intestinal disorders
Iron dextran—IV. Anaphylaxis.
MagnesiumMagnesium oxide or hydroxide for mild
hypomagnesemiaMagnesium sulfate parenterally for
pronounced Mg++ Deficiency, convulsions associated with
pregnancy and prevention of low magnesium in TPN
Contraindicated in renal impairment or in comatose
PotassiumHypokalemiaCan be secondary to dietary problems,
diuretics, those receiving only IV fluidsContraindicated 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.
ZincZinc sulfate and gluconate are OTCComponent of multivitaminsMetabolized in liver and excreted in feces
Enteral feedingsMaintain GI tract and immune system
functioningNG, OGJejunostomyPercutaneous endoscopic gastrostomyNasointestinal tubesFor feedings into stomach—intermittent feedingsFor feedings into jejunum or duodenum,
continuous feedingPotential complication is aspiration
Enteral FeedingsPulmocareAmin-Aid for those in renal failureNepro for those on dialysisSuplena—lower in protein and some
electrolytes for renal patients not on dialysisHepatic Aid II—protein restricted in liver
failureFluid restrictin as in 1.5kcal/mL
Parenteral SupportCentral or peripheral administrationCan give 5-10% peripherallyFat emulsions can be given peripherally or
centrally; no filterVitamins, sometimes insulinAminosyn-RFHepatAmine—special form. of amino acidsCautious use of lipids r/t hypertriglyceridemiaLarge doses Vit. C can cause stonesMonitor fluid and electrolytesMonitor blood sugars
Parenteral SupportIn liver failure—need Vit. A, B6, folic,
riboflavin, B12, pantothenic acid and thiamine
Niacin is contraindicatedExtreme caution with iron dextran
Drugs to aid Weight Management
Overweight ==BMI of 25 to 29.9kg/sq. meterObesity==BMI of 30 or moreDesired BMI is 18.5 to 24.9 kg/sq. meterWaist size >35 inches in women and >40
inches for men is another risk factor
ObesityMore common in women, minority groups
and poor peopleAssociated with serious health risksCancer of breast, colon, endometrialCentral obesity greatly contributes to breast
cancer (androstenedione to estradiol)Cardiovascular disorders—hypertension,
insulin resistance, hyperlipidemia, central adiposity
ObesityDiabetes mellitus—impaired glucose
tolerance, insulin resistance. Hyperinsulinemia, impaired lipid metabolism, hypertension
ObesityOsteoarthritisSleep apneaNASHIncreased complications of pregnancyInfertility in menGestational diabetesMetabolic syndrome—HDL (40,50), BP
135/85 or higher, serum glucose >110, central adiposity
ObesityDecreased physical activitySedentary jobs and recreational activitiesLarge portion sizesFast foodsFast paceDepressionMedications can cause obesitychildren
Medications affecting weightAntihistamines such as loratadine and
diphenhydramine increase appetiteBeta blockers decrease BMR, increase fatigue
and decrease exericise toleranceStatins SteroidsPPIs may increase appetiteHormonal contraceptives—fluid and sodium
retentinMood stabilizing medication—lithium with
expected wt. gain up to 22#
Medications and weight gainAntiepileptics—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 obesityReserve for those with BMIs of 30 kg per sq.
meter or greaterSensible dietPhysical activityBehavioral modification
Drugs for weight reductionSide effects—phenylpropanolamine,
fenfluramine, ephedraCurrent meds-Adipex, Didrex, MeridiaAffect dopamine and norepinephrine in brain
Adipex--phentermineMost frequently prescribed adrenergic
anorexiantSchedule IVShort term use< 3 monthsContraindicated in hypertension, CV disease
or drug abuseCaution in anxiety or agitationAdverse effects: nervousness, dry mouth,
constipation, tachycardia and hypertension
Meridia--sibutramineSchedule IVInhibits reuptake of serotonin and
norepinephrineCauses increased satiety, decreased food
intake and faster metabolismMay be used for longer period of timeCautious use in glaucoma, impaired hepatic
function and a history of drug abuseContraindicated in CV disorders hypertensionCommon 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 ingestedImproves cholesterol levelsSide effects include oily spotting, fatty stools,
fecal incontinence and increased defecationPrevents absorption of fat-soluble vitamins
A,D, E, K
HerbalsFew studies to validate efficacyGlucomannan—”feel full”, laxative effect, can
cause hypoglycemiaGuarana—found in energy drinks, caffeine;
contraindicated in those with CV problems, worsens GERD
Laxative and diuretic herbs—aloe, rhubarb root, Super Dieter’s Tea
Neuroleptic Malignant Syndrome
Rare but potentially fatal reaction that can occur hours to months after initial drug use
S/S develop 24-72hCharacterized 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 HyperthermiaA 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 episodeMust watch liver functionsIncompatible with saline and D5W
Serotonin SyndromePotentially 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