NUTRITION AND NUTRITIONAL STATUS IN DISEASE

CM Viviers (RDSA)Department of Human Nutrition

NUTRITION AND NUTRITIONAL STATUS IN ILLNESS

ILLNESS

Altered food intake

Altered digestion

Altered metabolism

Altered excretion

MALNUTRITION

CHRONIC LUNG DISEASE (e.g. cystic fibrosis)

Nutritional-related problems

● Increased energy needs (↑work of breathing, infections, fever)● Increased nutrient losses (maldigestion & malabsorption of

protein/fat)● Decreased food intake (infections, other illnesses, breathing, cramps)● Impaired feeding skills●Outcomes of malnutrition:- Growth retardation (FTT, delayed puberty)- Malabsorption (steattorrhoea)- Poor immune status (recurrent infections)- Increased lung disease- More rapid progression of disease- Increased morbidity

CHRONIC LUNG DISEASEDietary treatment

Goals:● Improve growth, development, resistance to infection● Reduce excessive losses from maldigestion/malabsorption● Prevent progressive pulmonary disease/complications (glucose

intolerance, intestinal obstruction)

Strategies:● Increase intake of energy and protein- Supplement breast fed baby with high energy formula- Regular and enjoyable mealtimes- Larger food portions- Extra snacks- Select food with high nutrient density- Fortify foods/beverages

CHRONIC LUNG DISEASEDietary treatment (cont)

- MCT oil- Ω-3 fatty acids- Nocturnal feeds- Regular re-evaluation of intake● Replace enzymes- Insufficient replacement → poor tolerance of starch & fat● Monitor - Tolerance of lactose, fats, gas forming foods, food consistency- Hydration status- Micronutrient status● Provide adequate micronutrients- Vitamins A, D, E, K- Zinc- Iron- Calcium

CANCERNutritional-related problems

● Altered energy expenditure- Alterations in REE → cachexia/weight gain- Tumor growth- Infections● Digestion and absorption of nutrients affected● Changes in CHO, fat, protein metabolism- Glucose intolerance- Body fat depletion, ↓ HDL, ↑ VLDL- Protein depletion, ↓ muscle mass, ↑ muscle breakdown, ↓ rates of

synthesis● Decreased intake- Alterations in taste and smell- Position of tumor- Side-effects of cancer treatment

CANCERNutritional-related problems

● Symptoms with a nutritional impact- Nausea and vomiting- Bowel changes (diarrhoea/constipation)- Dysphagia, dry mouth, chewing/swallowing difficulties, abdominal

gas- Anorexia/early satiety- Pain, fatigue

CANCERDietary treatment

Goals:● Prevent/reverse nutrient deficiencies● Sustain and promote normal growth and development● Minimise nutrition-related side-effects● Maximise quality of life

Strategies:● Increase energy and protein intake- Small frequent meals- Energy dense foods● Decide on route of feeding- Oral, enteral, parenteral● Individual food preferences/aversions

CANCERDietary treatment

● Prevent further weight loss

● Control glucose intolerance- Complex carbohydrate, limit simple sugars- Regular meals

● Provide adequate micronutrients

- Vitamin B6, pantothenic acid, folic acid, Vitamins A, E, C, β-carotene

CANCERDietary treatment

● Treat side-effects of chemo-/radiation therapy- Loss of appetite/early satiety: High protein, high energy

supplementsLimit high fat foodsAvoid liquids with meals

- Nausea and vomiting: Frequent, small mealsNo strong odoursCool/room temperature foods

- Sore mouth/throat: Increase fluid intakeDecrease fibre and roughageSelect soft, moist food, add gravy/sauces

- Abdominal gas: Decrease fibre/roughageLimit high fat foodsExclude gasforming foods

HEART (e.g. Heart failure)

Nutritional-related problems● Stunted growth- Increased needs- Catabolic● Increased energy expenditure – rapid breathing● Decreased intake of food- Difficulty in breathing- Quickly tired● Insufficient/excessive weight gain (oedema)- Fluid retention/↓ circulation● Iron deficiency

HEARTDietary treatment

Goals:● Promote growth and development● Reduce/eliminate oedema● Avoid distention of diaphragm● Correct nutrient deficits

Strategies:● Increase energy, protein and fat intake- HBV protein sources- ↓ CHO and ↑ fat content to reduce RQ- Energy dense meals (1T fat → 135 kcal/1T sugar → 60 kcal)- Food with soft texture reduces chewing

HEARTDietary treatment (cont)

● Restrict fluid and salt intake with fluid retention- Monitor input/output- Sodium restricted diet (↓ dietary sources of Na+) - 1t salt → 2400 mg Na+

250 mL milk → 120 mg Na+ 1 slice bread → 150 mg Na+

- Inclusion of K+ rich foods● Avoid abdominal distention- Small frequent meals- Use bland low roughage foods● Ensure adequate intakes of food sources of vitamins E, B6, B12,

folic acid, riboflavin, thiamine, iron

GASTRO-INTESTINAL TRACTNutritional-related problems

● Medical conditions can affect functions in any part of the GIT – intake of food, digestion, absorption of nutrients and excretion of waste products

● Malnutrition affects digestion and absorption of nutrients- Villi atrophy → ↓ absorptive area- Enzyme deficiencies (lactase, sucrase, maltase)● Intolerances- Lactose- Gluten

GASTRO-INTESTINAL TRACTNutritional-related problems (cont)

● Food-induced symptoms- Carbohydrate-induced symptoms

Hypertonicity:Bloating (Gastric surgery)Diarrhoea (Antrectomy)

Poor absorption: Gas (Malabsorption)Bloating (Coeliac disease)Diarrhoea (SBS)Abdominal pain (Dietary fibre)

- Fat-induced symptomsDyspepsia (GERD)Bloating, early satiety (Gastric surgery)

GASTRO-INTESTINAL TRACTNutritional-related problems (cont)

● Symptoms with a nutritional impact

- Diarrhoea - ↑ nutrient loses- Nausea and vomiting - ↓ intake, ↑ losses- Pain, bloating – avoiding important foods, ↓ intake

GASTRO-INTESTINAL TRACTDietary treatment

Goals● Correct malnutrition/nutritional deficits● Provide sufficient nutrients for growth and development● Monitor GI function (intolerances, malabsorption)● Replace losses

Strategies● Provide sufficient energy & protein- Small frequent meals- Energy dense foods

GASTRO-INTESTINAL TRACTDietary treatment

● Replace losses- ORT- Soluble fibre (apples, bananas, carrots)- Potassium- MCT - Vitamins and minerals● Adjust consistency of foods / preparation methods● Withheld foods leading to problem/discomfort (depends on disease

condition)● Add foods to relieve problem- Soluble fibre (apples, banana, carrots)- Insoluble fibre (whole wheat, bran)

LiverNutritional-related problems

● Inadequate intake- Anorexia, nausea & vomiting (liver disease)- Early satiety (ascites, enlarged liver / spleen)- Restricted / unpalatable diets (low in fat / protein / salt)

● Impaired nutrient digestion and absorption- Steatorrhoea (bile salt deficiency)- Essential fatty acid deficiency- All nutrients (malnutrition related villous atrophy)

● Increased nutritional requirements- Hypermetabolism- Accelerated protein breakdown- Insufficient protein synthesis

LiverNutritional-related problems

● Altered nutrient metabolism - Carbohydrate: glycogenesis, glycogenolysis, gluconeogenesis (low

glygogen stores, fasting hypoglycaemia)- Protein: transamination & oxidative deamination (synthesis of serum

protein – low albumin levels, poor blood clotting)- Fat: energy production & synthesis of lipoproteins (fatigue,

catabolic)● Vitamin & mineral deficiencies - Storage of fat soluble vitamins, Vit B12, Zn, Fe, Cu, Mg- Transport of Vit A, Fe, Zn, Cu- Conversion of carotene, folate, Vit D ● Increased ammonia levels & risk of hepatic coma

LIVERDietary treatment

Goals● Correct malnutrition/nutritional deficits● Promote growth and development● Support residual liver function● Prevent fat stasis & steatorrhoea, bone disease, anaemia, coma ● Provide supportive treatment for complications

Strategies● Provide sufficient energy - Small frequent meals- Energy dense foods● Provide sufficient protein- HBV protein- ↑ BCAA and ↓ AAA- Vegetable protein ↓ methionine & ammoniagenic AA and ↑ fibre- Casein vs meat protein

LIVERDietary treatment (cont)

● Steatorrhoea- Modify fat intake- MCT vs LCT- monitor Ca++ & vit D● Ascites- Restrict fluid & salt intake● Renal insufficiency- Alter fluid, Na+, K+, PO4 intake● Adjust consistency of foods (oesophagaeal varices)● Withheld foods leading to problem / discomfort (depends on disease

condition)

TYPE 1DIABETES MELLITUSNutritional-related problems

● Under-/overweight- Energy not utilised- Obesity & insulin administration- Physical activity / exercise● Hyperglycaemia- Poor balance between amount of CHO / timing of eating & insulin

regimen● Hypoglycaemia- Brain development- Illness / infection & food intake / absorption● Dehydration (polyuria)● Long-term complications- Macrovascular- Microvascular

TYPE 1DIABETES MELLITUSDietary treatment

Goals● Provide appropriate energy and nutrients for optimal growth and

development● Achieve and maintain ideal body weight● Attain & maintain optimal metabolic outcomes on an individual basis- Blood glucose- Lipids● Prevent hypo- and / or hyperglycaemia● Reduce risk of long-term micro- and macrovascular complications● Improve health through food choices & physical activity● Address individual needs- Personal / cultural preferences- Lifestyle- Willingness to change

TYPE 1DIABETES MELLITUSDietary treatment

Strategies● Determine food & meal plan then integrate insulin regimen into

usual eating habits & physical activity schedule● Issues regarding CHO- Carbohydrate sources (fruits, grains, starchy vegetables, milk,

sugars)- Consistency in timing (distribution) & amount (portion sizes)- Glycaemic Index vs Glycaemic Load- Sweeteners- Blood glucose monitoring- Adjustments for exercise● Issues regarding protein - Requirements- Plant vs animal protein

TYPE 1DIABETES MELLITUSDietary treatment

● Issues regarding dietary fat- Saturated & trans fats- Unsaturated fats

● Other dietary components- Salt- Vitamins & dietary antioxidants- Non-starch polysaccharides (fibre)

● Diabetic products

CHRONIC RENAL DISEASENutritional-related problems

● Growth retardation- Restrictive diets- Poor food intake (uraemia → ↓ appetite)- Increased losses (↑ permeability of basement membrane →

proteinuria)● Oedema- ↓ Excretion- ↓ Protein intake → ↓ albumin● Hyperkalemia● Hypertension● Renal bone disease- ↑ PO4 → Ca++ resorption from bones & ↑ Ca++ absorption from GIT- secondary hyperthyroidism & renal osteodystrophy- ↓ Activation of vit D● Anaemia

RENAL Dietary treatment

Goals● Provide adequate energy● Regulate protein intake● Manage fluid balance & electrolytes● Regulate Ca++ & PO4 intakes● Provide adequate micronutrient & iron intakes

Strategies● High energy, low protein foods (CHO, PUFA/MUFA)● Control protein intake - Optimal growth- HBV 65 – 70% total protein intake- Blood urea- PO4 content

RENAL Dietary treatment

● Reduce Na+ intake if hypertensive- ‘No added salt’/salt restriction- Fresh foods● K+ modified diet if hyperkalaemia occurs● Fluid restriction individualised if necessary● Limit dietary PO4 without compromising protein intake● Supplement Ca++

● Provide foods rich in iron, folic acid, vit C & B12

- Haem iron vs non-haem iron- Components affecting absorption (phytates, polyphenols, Ca++)● Modify dietary fats for prevention of cardiovascular disease

DIALYSISNutritional-related problems

● ↑ Protein losses

● Electrolyte changes (K+)

● Fluid retention

● ↑ Glucose intake (PD)

● Steroid treatment- ↑ Appetite- Weight gain

DIALYSIS Dietary treatment

Strategies● Monitor weight gain between dialysis sessions● Monitor changes in urea / creatinine● Monitor changes in electrolytes● Monitor fluid intake & output

HIV and AIDSNutritional-related problems

● Underweight- Increased energy expenditure- Malabsorption- Altered macronutrient metabolism● Loss of lean body mass- ↓ Dietary intake- Preferential loss of body protein- Opportunistic infections● Growth faltering● Gastrointestinal complications- Food intolerance, malabsorption, constipation, diarrhoea● Lipodystrophy syndrome- Insulin resistance- Impaired glucose tolerance- Dyslipidaemia

HIV and AIDSDietary treatment

Goals● Provide optimal nutrition● Support regeneration of immune system● Maintain growth, development & activity● Help adherence to medication● Preserve lean body mass● Prevent overweight & obesity● Encourage cardioprotective diet● Encourage healthy eating● Provide advice on food safety & hygiene

Strategies● Increase energy & protein intake- Adjust energy intake for mobility, infection, weight loss,

malabsorption- Energy & nutrient dense meals & snacks (full cream milk, cheese,

PUFA / MUFA, ω-3 fats, sugar, jam)- HBV protein

HIV and AIDSDietary treatment

● Optimise food intake- Delayed weaning: Appropriate milk intake for age- Neuro-developmental delay: Modify food consistency, finger foods,

daily routine- Eating difficulties: Soft non-acidic foods, avoid spicy food & drink,

straws to bypass lesions, suck ice lollies- Growth faltering: Space drinks & snacks away from meals, avoid

excessive fluid intake● Food intolerance- Lactose-free● Constipation / diarrhoea● HAART: Interactions between drug & food, nutritional side effects● Lipodystrophy syndrome- Impaired glucose tolerance: CHO distribution- ↑ Total cholestrol: ↓ SFA, ↑ PUFA / MUFA, ω-3 fatty acids- ↑ TG: ↓ Refined CHO, ω-3 fatty acids, fruit & vegetables● Hygienic storage, preparation, serving of food

Critically ill children (ICU)

Nutritional-related problems

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