Presented by: Dave Jay S. Manriquez, RN.

Types Of DietsLIQUID DIETS

INDICATIONS FOR CLEAR LIQUID DIEToProvide oral fluids; before/after surgery; prepare bowel for diagnostic tests (colonoscopic 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

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 ProblemsClear 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 smell

Temperature 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.

DysphagiaPosition the patient in a comfortable with the head in an upright position, slightly tilted forwardTextured 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 productionAdapt the diet to the patients’ need and gradually upgrade it as feeding skills improve.

Gastroesophageal RefluxAchieve 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 UlcerTrend 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.

GASTRITISThe 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 MalabsorptionDecreased AbsorptionIncreased Absorption

Diet specific to etiology

DiarrheaClinical 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 potassiumRemove 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.

ConstipationClinical Implications

Ask 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

FLATUSClinical 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 ColitisClinical 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

HepatitisDuring 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.

CirrhosisModerate 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 IntakeInitially: 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.

CholecystitisIV 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.

PancreatitisAcute 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

Dietary Management in GeneralPre-operativePost-operative

Pre-OperativeTo 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 OperationIf 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 stroppedIf 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 anemiaIncreased 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 SurgeryLiquids

>Tolerated within a few hours; for maintenance or restoration of fluid and electrolyte balance.Normal Diet>As 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 restoredConventional 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.Oral Diet – liquid to full, as tolerated>To give patient a feeling of being “normal” and hasten recovery; also, less expensive.

Specific Surgical ConditionsSurgery of the Mouth, Throat and Esophagus.GastrectomyDumping SyndromeIntestinal SurgeryDiet following other abdominal OperationsRectal 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 feedingsDay 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 needsHigh calories>For strengthSimple 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 rapidlyLow 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 irritationHI calorie, HI PRO

>For weight recoveryVIT 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 OperationsCholecystectomyLow 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 OperationsPeritonitis and intestinal obstructionNPO – 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

HemorrhoidectomyNPO – 1ST 24 to 48 hours>Due to anesthesiaClear liquid

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

>To discourage early bowel movements

AllergyAvoidance 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 AllergensChickenCow’s milkWheat Peanuts/nutsSoy productsFish, 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 DMMaintenance of as near-normal blood glucose levels as possible Achievement of optimal serum lipid levelsProvision of adequate energy to maintain/achieve

reasonable body weightPrevention and treatment of the acute complications and

of long-term complicationsImprovement 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 lessCarbohydrates sweeteners are permissible

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/ObeseLow 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 lossModerate 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.

UnderweightHigh calorie diet: For storage of fat in the adipose tissue, to restore DBWGradual increases: To avoid gastric upsets and spells of discouragement.High protein: For replacement and repair of body tissueHigh 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.

HyperthyroidismHigh 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.

HypothyroidismIodine supplementationLow calorie: To minimize weight gain due to lowered BMR

HyperinsulinismFunctional 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

HyperinsulinismFastingHigh CHO: To provide constant sucrose of available glucose.

HypertensionCalorie 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

TriglyceridesRecent data suggest that elevated triglycerides are an independent risk factor for CHDNormal triglyceride levels: < 150 mg/dlBorderline-high triglycerides: 150 to 199 mg/dlHigh triglycerides: 200 to 499 mg/dl

Very high triglycerides: (> 500 mg/dl) increase pancreatitis riskInitial aim of therapy is prevention of acute pancreatitis.

CHDTotal 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 contractilityLong 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 cholesterolSodium – moderate intake: -control blood pressureCarbohydrates – type and amount depends on lipid abnormalityAlcohol – 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 ThrombosisAcute 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 dietRestriction 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 levelSoft, low fiber, free of gastric irritants

* To avoid indigestion and flatusSodium restriction

* To prevent /correct edemaSmall 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 balanceSodium restriction – 500 mg initially, 1000 mg later

- to control edema.Small frequent feedings

- decreased circulatory loadFluid as desired

Nutritional AnemiasIron 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 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 IronImpaired 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 alterationsLoss of excretory functionImpaired metabolic action, resulting in altered nutrient, metabolic and hormone levelsAdaptive changes in metabolic feedback loops involving hormones, enzymes and reaction products.Reduced food intake

Effects of these abnormalitiesBlood levels – amines, phenols and indoles and other nitrogenous substancesEnzymes 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 somatostatin

Serum erythropoietin and 1, 25 dihydroxycholecalciferol

Serum Renin – normal, increased or reducedDeficiencies 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 PRINCIPLESObjectives of nutritional therapy in chronic failureTo maintain nutritional statusTo minimize uremic toxicityTo prevent net protein catabolismTo stimulate patient’s well-beingTo retard progression of renal failureTo postpone initiation of dialysis

DIETARY PRINCIPLESNutritional treatment of CRFJudicious regulation of protein intakeRegulation of fluid intake to balance fluid output and insensible water lossRegulation of sodium to balance fluid outputRestriction of potassium and phosphateInsistence on an adequate calorie intake

Supplementation with appropriate vitamins

Renal Disorders-1Acute or chronic glomerulonephritis

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

NephritisTreat symptomatically when there is significant uremia,

hyperkalemia or edema. Replace all lost fluids

Renal Disorders-2UremiaAdequate calories and controlled protein, fluid and electrolytes according to laboratory data and renal functionNephrotic Syndrome

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

Kcal - increased kcal to spare proteinSodium - low sodium (2 grams) to reduce edema

Renal Disorders-3

Acute Renal Failure

Protein - not restricted below 1.0 – 2.0 g/kg DBWKcal - 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-4Chronic 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 CONDITIONSAcne Low fatAcute gastroenterities (diarrhea) Clear liquidAcute glomerulonephritis Low Na, Low proteinAddisons’ disease Hi Na, Low KAngina pectoris Low cholesterolArthritis, gout Purine restrictedADHD Finger foodsBipolar disorder Finger foodsBurn High calorie, hi pro

THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS

Celiac’s disease Gluten freeCholecystitis Hi pro, hi CHO, low fatCongestive heart failure Low Na, low cholesterolCretinism Hi pro, hi CaCrohn’s dse. Hi pro, hi CHO, low fatCushings’ dse. Hi K,low NaCystic fibrosis Hi calorie, high NaCystitis Acid Ash (for alkaline stones)Calculi Alkaline Ash (for acid stones)Decubitus ulcer (bedsore) High protein, High vit. C.

THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS

Diabetes mellitus Well balancedDiarrhea Hi K, high NaDiverticulitis Low residueDiverticulosis Hi residue with no seedsDumping syndrome Hi fat, high protein, dryHepatic encephalopathy Low proteinHepatitis Hi protein, high calorie

Hirschprungs’ dse. Hi calorie, low residue, hi proHyperparathyroidism Low calciumHypothyroidism Low cal, low cholesterol, low sat fat

THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS

Kawasaki’s dse. Clear liquidLiver cirrhosis Average proteinMeniere’s dse. Low sodiumMyocardial infarction Low fat, low Chol, low NaNephrotic syndrome Low Na, hi pro, hi calOsteoporosis Hi cal, Hi vit. DPancreatitis Low fatPeptic ulcer Hi fat, hi Cho, low proPhenylketonuria Low pro/phenylalaninePIH Hi pro

THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONSRenal colic Low Na, low proARF: Low pro, hi Cho, Low Na (Oliguric phase), Hi pro, hi Cal, & restricted fluid (diuretic phase)CRF Low pro, low Na, low KTonsillitis Clear liquid; cold diet