Medical Nutrition Therapy Pocket Guide for Dietetic Internship by mcova002

Medical Nutrition Therapy Pocket Guide By: Mariana Covarrubias

Table Of Contents • Medical Abbreviations…………………………………….3-6 • Nutrition Care Process…………………………………….7-19 • Nutrition Assessment………………………………………20-36 • Laboratory………………………………………………………37-41 • Food Drug Interactions……………………………………42-55 • Aging………………………………………………………………56-69 • Dysphagia……………………………………………………….70-77 • Neurology……………………………………………………….78-89 • HTN………………………………………………………………..90-101 • CVD………………………………………………………………..102-118 • Diabetes…………………………………………………………119-142 • Obesity…………………………………………………………...143-163 • Other Charts……………………………………………………164-168

Abbreviations • ABG: Arterial Blood Gas

• CABG: coronary artery bypass graft

• a.c. : before meals

• CAD: coronary artery disease

• AD: right ear

• CAT: computed axial tomography

• ad lib. : as desired

• CBC: complete blood count

• ADHD: attention-deficit/hyperactivity disorder

• CC: chief complaint

• AKA: above knee amputation

• CF: cystic fibrosis

• Alb: albumin

• CHF: congestive heart failure

• APKD: adult polycystic kidney disease

• CMP: comprehensive metabolic panel

• AS: left ear

• CNS: central nervous system

• AU: both ears

• c/o: complains of

• AV: atrioventricular

• CO: cardiac output

• BCC: basal cell carcinoma

• COPD: chronic obstructive pulmonary disease

• BD: bipolar disorder

• CP: cerebral palsy/chest pain

• b.i.d: twice a day

• CSF: cerebrospinal fluid

• BKA: below knee amputation

• CT: computed tomography

• BM: bowel movement

• CVA: cerebrovascular accident

• BMP: basic metabolic panel

• DC: discharge

• BP: blood pressure

• DJD: degenerative joint disease

• BS: blood sugar

• DKA: diabetic ketoacidosis

• BUN: blood urea nitrogen

• DVT: deep vein thrombosis

• Bx: biopsy

• Dx: diagnosis

• c: with

• ECG: electrocardiogram

Abbreviations •

HGB or hbg: hemoglobin

•

hpf: high power field

•

HPI: history of present illness

•

HRT: hormone replacement therapy

• EKG: electrocardiogram

•

h.s.: hour of sleep

• ENT: ear, nose, and throat

•

HTN: hypertension

• ETOH: ethyl alcohol

•

Hx: history

• FH: family history

•

I&D: incision & drainage

• FSH: follicle stimulating hormone

•

IP: inpatient

• Fx: fracture

•

IUD: intrauterine device

• GERD: gastroesophageal reflux disease

•

IV: intravenous

• GH: growth hormone

•

JCAHO: Joint Commission on Accreditation of Healthcare Organizations

• gm: gram

•

KUB: kidney, ureters, bladder

• gr: grain

•

L&W: living and well

• gt: drop

•

LASIK: laser assisted in situ keratomileusis

• gtt: drops

•

LEEP: loop electrosurgical excision procedure

• GTT: glucose tolerance test

•

LH: luteinizing hormone

• H&P: history & physical

•

LLQ: left lower quadrant

• HAV: hepatitis A virus

•

LP: lumbar puncture

• HBV: hepatitis B virus

•

LUB: left upper quadrant

• HCV: hepatitis C virus

•

MCH: mean corpuscular hemoglobin

• ECU: emergency care unit • ED: erectile dysfuntion • EDD: estimated date of delivery • EEG: electroencephalogram

• HD: huntington disease

Abbreviations • MI: myocardial infarction

• PaCO2:partial pressure of carbon dioxide

• MRA: magnetic resonance angiography

• Pap: Papanicolau (smear)

• MS: multiple sclerosis

• PAR: post anesthetic recovery

• MVP: mitral valve prolapse

• p.c.: after meals

• NAD: no acute distress

• PD: panic disorder

• NG: nasogastric

• PE: physical examination

• NKDA: no known drug allergy

• PEFR: peak expiratory flow rate

• NPO: nothing by mouth

• Per: by or through

• NSAID: nonsteroidal antiinflammatory drug

• PET: positron- emission tomography

• OA: osteoarthritis

• PF: peak flow

• OB: obstetrics

• pH: potential of hydrogen

• OCD: obsessive compulsive disorder

• PH: past history

• OCP: oral contraceptive pill

• PI: present illness

• OD: right eye; doctor of optometry

• PIH: pregnancy-induced hypertension

• OH: occupational history

• p.m.: after noon

• OP: outpatient

• PMH: past medical history

• OR: operating room

• Post-op: postoperative

• OS: left eye

• P.r.n.: as needed

• OU: both eyes

• Pt: patient

• p: after

• PT: physical therapy

• P: plan, posterior, pulse

• PTH: parathyroid hormone

• PACU: post anesthetic care unit

• PTSD: post traumatic stress disorder

Abbreviations • Px: physical examination

• SA: sinoatrial

• q: every

• SCC: squamous cell carcinoma

• q.d.: every day

• SH: social history

• qh: every hour

• Sig: instruction to patient

• q2h: every 2 hours

• SH: social history

• q.i.d: four times a day

• SOB: shortness of breath

• q.o.d: every other day

• STAT: immediately

• R: respiration

• Sx: symptom

• RA: rheumatoid arthritis

• TIA: transient ischemic attack

• RBC: red blood count

• t.i.d: three times a day

• RLQ: right lower quadrant

• Tr: treatment

• R/O: rule out

• TSH: thyroid stimulating hormone

• ROS: review of symptoms • RTC: return to clinic • RTO: return to office • RUQ: right upper quadrant • Rx: recipe; prescription • s: without • S: subjective

• Tx: treatment • UCHD: usual childhood diseases • URI: upper respiratory infection • VC: vital capacity • w.a: while awake • WDWN: well developed, well nourished • WNL: within normal limits

Nutrition Care Process • NCP Steps: – Nutrition Assessment

– Nutrition Diagnosis

– Nutrition Interventions

– Nutrition Monitoring and Evaluation

NCP- Nutrition Assessment • Purpose – Initiated by referral or through screening – Is to obtain adequate information in order to identify nutrition related problems.

• Observing for cues during interview • Determining appropriate data to collect – Selecting assessment tools

– Involves anthropometrics, biochemical, clinical and dietary data

• Distinguishing relevant from irrelevant data

– Analyze and interpret with evidence based standards

• Determining if consultation is appropriate

NCP- Nutrition Diagnosis • Nutrition Diagnosis Domains: – Intake

• Purpose

– Excessive or inadequate intake compared with actual or estimated requirements

– to identify and label the nutrition problem

– Clinical

– nutrition diagnosis - NOT medical diagnosis

– Medical or physical conditions that are abnormal

– Behavioral-Environmental – Knowledge, beliefs, attitudes, access to food

– EXPLICIT statement of nutrition diagnosis

NCP-Nutrition Diagnosis • PES format – Problem: describes alterations in client’s nutritional status – Etiology: cause or contributing risk factors – Signs and symptoms: identifiable characteristics

• Problem—related to— Etiology—as evidenced by— Signs and Symptoms

• PROBLEM: • Statement describes alterations in pt nutritional status – Altered (GI function…) – Impaired (nutrient utilization…) – Ineffective – Increased/decreased – Acute – Chronic – Inadequate/excessive (calorie intake…) – Inappropriate (intake of types of carbohydrate) – Swallowing difficulty

NCP- Nutrition Diagnosis • ETIOLOGY: • Cause or contributing factors – Pathophysiological – Psychosocial – Situational – Developmental – Cultural – Environmental

• SIGNS & Sx: • Signs – Objective data

• Sx – Subjective data

• EXAMPLE: • Inadequate oral intake related to changes in taste and smell as evidenced by average daily intake 40% less than recommended daily requirements.

NCP- Nutrition Diagnosis

• Commonly Used Nutrition Dx: – Increased energy needs – Inadequate energy intake – Excessive energy intake – Inadequate fluid intake

– Evident protein energy malnutrition – Excessive fat intake – Inadequate protein intake

– Inadequate fiber intake – Underweight – Involuntary weight loss – Overweight/obesity – Food, nutrition and nutrition-related knowledge deficit – Not ready for diet/lifestyle change – Disordered eating pattern

 All the terms can/must be used as the “problem”  Some terms can also be used as the etiology (can also be free text)  Some terms can also be used as Signs/Symptoms as long as accompanied by actual data (can also be free text)

NCP- Nutrition Intervention • Purpose – Plan and implement purposeful actions to address the identified nutrition problem – Bring about change – Set goals and expected outcomes – Client-driven – Based on scientific principles and best available evidence

• Setting goals and prioritizing • Transferring knowledge from one situation to another • Defining the nutrition Rx or plan • Initiating interventions • Matching intervention with client needs, dx and values

NCP- Nutrition Intervention • Plan the Intervention – Must Prioritize needs – Must be Realistic and Specific

• Implement the Intervention – Must be Active

• Plans can change as the pt condition changes

• Intervention: Nutrition Rx: – This is the diet that you recommend that the pt/client follow – Example: 2g Na, low cholesterol diet

NCP- Nutrition Intervention Establish patient goals and expected outcomes – Goals are related to PES statement. – Goals communicate the expected outcome(s) for patient – Must have at least one goal for patients with a nutrition diagnosis

• Goals and Interventions go hand in hand • Interventions enable goals to be met • Last Intervention must be reassessment timeframe

 SAMPLE GOALS:

Maintain optimal nutritional status Meet nutrient needs

INTERVENTIONS: – Recommend calorie count – Boost BID – Add Prostat TID

NCP- Nutrition Intervention • General Nutrition Interventions:

• Food and/or Nutrient Delivery

– Rx of a diet or special supplement

– Meals and Snacks

– Rec for route and frequency of nutrient delivery

– Enteral and Parenteral Nutrition

– Rec for more comprehensive nutrition assessment, including labs and measures of food intake

– Feeding Assistance

– Nutrition education – Referrals to public aid, SW, or nutrition F/U

• Domains – Food and/or Nutrient Delivery

– Supplements – Feeding Environment – Nutrition-Related Medication

• Nutrition Education – Initial/brief nutrition education – Comprehensive nutrition education

• Nutrition Counseling – Nutrition-Related Behavior Modification Therapy

• Coordination of Nutrition Care

– Nutrition Education

– Coordination of other care during nutrition care

– Nutrition Counseling

– Discharge and transfer of nutrition care to new setting or provider

– Coordination of Nutrition Care

NCP- Nutrition Monitoring & Evaluation • Purpose – Determine the progress that is being made toward the client’s goals or desired outcomes.

• Selecting appropriate indicators • Using appropriate reference std for comparison

Monitoring: review and measurement of status at scheduled times

• Defining where pt is now

Evaluation: systematic comparison with previous status, intervention goals, reference standard

• Deciding between discontinuing or continuing with nutrition care

• Determining factors that help or hinder progress

NCP- Nutrition Monitoring & Evaluation • Step 1: Monitor progress – Check pt adherence to intervention – Check if being implemented as prescribed – Monitor change in status – Gather other negative or positive outcomes

• Step 2: Measure Outcomes – Select outcome indicators that are relevant – Use standardized measures to – Increase validity and reliability of measurements – Facilitate electronic charting, coding, outcomes management

– Support conclusions with evidenceOutcomes Step 3: Evaluate

Compare current findings with previous status, goals or reference standards

Nutrition Care Process • 1st set measurable goals so evaluation is simple • If not meeting goals, re-evaluate, change goals • Process is ONGOING until stable

Nutrition Assessment • NUTRITION SCREENING: • Identifies those pt who are at nutritional risk • Every pt is screened within 24 hours of admission – Tech or RN can refer

• NUTRITION ASSESSMENT: • Completed when someone is determined to be at nutritional risk –

i.e. after screen, pt reports a 15% unintentional weight loss

• Data is interpreted by RD • Nutritional Intervention is established and outcomes are monitored

• Info. Obtained: • All facilities have various – All points covered in Nutr Screen policies regarding screen criteria

– Examples Screening Tools: – SGA – PG-SGA – Mini Nutritional Assessment

– In depth nutritional hx – Social hx – Physical exam

– Anthropometric measurements – Medical data – Laboratory data

& INTERPRETATION of all points

Nutrition Assessment

Nutrition Assessment CLINICAL DATA

• ANTHROPOMETRICS

Look at your pt!

• Height

• Hair

–

Sitting height, recumbent length in peds

–

Arm span

–

Knee height • Female ht cm)

• Skin

• Teeth

84.88-(.24 X age) + (1.83 X knee

• Male 64.19 – (.04 X age) + (2.02 X knee ht cm)

• Eyes • Lips

1 in= 2.54cm

• Weight 1 kg= 2.2 # –

Use bedscales

–

IBW

Nutrition Assessment • HAMWI METHOD est. IBW: • Females: 100# for first 5’ 5# per inch above 5’ • Males:

106# for first 5’

6# per inch above 5’

• ADJUSTED BODY WEIGHT: • Used for obesity > 120% IBW • Has limitations, use with caution

+/- 10% for frame size

(Actual- IBW) X .25 + IBW

Nutrition Assessment • IBW FOR AMPUTEES: • Foot 1.8% • AKA 13%

Body Part

• BKA 6%

Entire arm 6.5entire leg

18.5

Upper arm 3.5upper leg

11.6

• Entire leg

18.5%

% Body Part

Forearm 2.3lower leg 5.3

adj wt = current weight X 100 100- % of amp

Hand 0.8foot 1.8

Nutrition Assessment • Est. Frame Size:

• Get measurements and compare to standards

• Frame Index= Body height (cm)

• Lower and upper ends of the curve are associated with risk

Wrist circumference (cm)

Percentile Fat Status < 5th lean 5th – 15th below average

• Elbow Breadth • Compare to standards

15.1-75th

average

75.1-85th

above average

>85th

excess fat

Nutrition Assessment • BODY MASS INDEX (BMI): •

Defines the level of adiposity based on the comparison of height to weight. BMI = Weight (lb) x 703 Height (in)2

•

Interpretation: < 18.5 Underweight 18.5-24.9 Healthy Range 25-29.9

Overweight, Grade I

30-39.9

Moderately Obese, Grade II

>40

Morbidly Obese, Grade III

Nutrition Assessment

•ARM MUSCLE AREA: •cAMA (corrected AMA) –Males: [MAC (cm) – (3.14 X TSF(cm)]2 - 10 4 X 3.14

–Females: [MAC (cm) – (3.14 X TSF(cm)]2 - 6.5 4 X 3.14 Percentile Muscle Status < 5th wasted 5th – 15th below average 15.1-85th average 85.1-95th above average >95th high muscle

Nutrition Assessment CREATININE HT. INDEX: % creatinine ht index = 24o urine creatinine X 100 expected 24o cr excretion Compare to standards

• WAIST HIP RATIO: • Ratio of circumference of waist and the hips R= W H

Interpretation of skeletal muscle loss Mild depletion 60-80% Moderate depletion 40-59% Severe loss of muscle <40%

• CVD risk with ratio > 1 Men > 0.8 women

Nutrition Assessment • % IBW: • Used to determine whether a pt is obese, underweight or WNL. %IBW=Actual Body Weight x 100 Ideal Body Weight

• Interpretation: > 200 = morbidly obese > 150 = obese > 120 = overweight 80-90% = mild malnutrition 70-79% = moderate <69% = severe malnutrition

Nutrition Assessment • % UBW: • Compares what the pt usually weighs with what their weight is now. %UBW = Actual Body Weight x 100 Usual Body Weight • Interpretation: 85-90% UBW = mildly malnourished 75-80% UBW = moderately malnourished <74% UBW = severely malnourished

Nutrition Assessment • % Weight Change: • Determines whether a significant weight loss has occurred within a specific time frame. %wt ∆ = UBW – Actual Body Weight x 100 UBW • Interpretation: Significant 1 week1-2%

Severe >2%

1 month 5% >5% 3 months 7.5%

>7.5%

6 months 10%

>10%

Nutrition Assessment • Calculations: • % usual = actual weight

X 100

usual weight • % ideal = actual weight

X 100

IBW • % loss = usual- actual

X 100

usual

• ALBUMIN: 3.5-5.0 mg/dL • 21day half life •  levels associated with mortality and morbidity • Not as sensitive indicator of nutritional status • Widely used in hospitals • Only useful at admission

3.2-2.8 2.7-2.2 <2.1

mild depletion moderate depletion severe depletion

Nutrition Assessment

HARRIS BENEDICT EQUATION: wt= kg, ht= cm, a= age Males: BEE= 66.47 + 13.75 (wt) + 5 (ht) – 6.76 (A) Females: BEE= 655.1 + 9.56 (wt) + 1.85 (ht) – 4.68 (A) BMR = BEE X SF or AF Use “clinical judgment”

Stress Factors Activity Factors Surgery Minor 1.0-1.2 Confined to bed 1.2 Surgery Major 1.1-1.3 Out of bed 1.3 Skeletal or blunt trauma1.1-1.6 Normal ADL’s1.5 Head trauma 1.6-1.8 Infection mild 1.0-1.2 moderate 1.2-1.4 severe 1.4-1.8 Burns (% Body Surface Area) <20% BSA 1.2-1.5 20-40% BSA 1.5-1.8 >40% BSA 1.8-2.0

Nutrition Assessment • Estimating Kcal Needs:

• MIFFLIN ST. JEOR:

• Kcal/Kg

Female:

– 20 kcal/kg – 25 kcal/kg

REE= 10 X wt (kg)+6.25 X ht (cm)- 4.92 X age (yrs) – 161

– 30 kcal/kg – 35 kcal/kg

• Tight ranges are best • i.e.: 30-32 kcal/kg

Male: REE= 10 X wt (kg)+6.25 X ht (cm)- 4.92 X age (yrs) + 5

Nutrition Assessment • IRETON JONES:

Where…

SPONTANEOUSLY BREATHING PATIENTS

IJEE = kcal/day:

IJEE(s) =

v = ventilator-dependent;

629 - 11(A) + 25(W) - 609(O)

A = age (years); W = actual body weight (kg);

s = spontaneously breathing

S = sex (male=1, female=0);

VENTILATOR-DEPENDENT PATIENTS

IJEE (v) = 1784 - 11(A) + 5(W) + 244(S) + 239(T) + 804(B)

T = dx of trauma (present=1, absent=0) B = diagnosis of burn (present=1, absent=0 O= obesity >30% above IBW from 1959 Metropolitan Life Insurance tables or BMI >27 (present=1, absent=0)

Nutrition Assessment • EST. PRO Needs:

• FLUID NEEDS:

– grams protein/ kg

• Ranges:

– Normal adult :0.8g/kg

16-30yo, active

40ml/kg

– Geriatric/Hospitalized: 0.8-1.2g/kg

25-55yo, adult

35ml/kg

56-65yo, older

30-35ml/kg

– Moderately stressed: 1.2-1.8g/kg

>65yo, elderly 30ml/kg

– Stressed: 1.6-2.2g/kg

• Can also use 1ml/kcal

Labs • ICF:

• ECF:

• K++ is found in this fluid

• Na++ is found in this fluid • 3 compartments – Intra Vascular Compartment (IVC)

• Largest, 2/3 of body fluids

– Contains fluid found within the blood – Depletion results in  intravascular volume

– Interstitial Fluid (ISF)

• Fluid of the cells

– Holds lymph – “3rd spacing” or edema occurs here

– Transcellular Fluid (TCF)

• Helps important metabolic reactions

– Fluid in pericardial, CSF, pleural, synovial, digestive

Labs

• Semipermiable membranes allow fluid to move freely between the different compartments – Directed by osmolality and volume

– Na+/Cl concentration in ECF is the major determinant of serum osmolality – Change in total body Na+ = change in ECF – Plasma volume major determinant of CV pressures

• Osmolality is the measure of the osmoles of solute per kilogram of solvent (H2O) – Dominated by small molecules (ie. Na+, K, Cl, HCO3 etc…) Together make up over 95% of total osmolality

• Osmolarity is the measure of the osmoles of solute per liter of solution – Dependent on the # of molecules not the nature of the compounds – Closely related to osmotic pressure

Labs

• The kidneys are the primary organs responsible for fluid and Na+ homeostasis and are under hormonal control – Vasopressin/ADH Made in the hypothalamus

and released from the posterior pituitary gland in response to ↑ osmolality and/or ↓ ECF volume

– Acts on the kidneys to ↑ the reabsorption of H2O

– Aldosterone – Secreted by the adrenal cortex primarily in response to ACTH or Angiotensin II release (resulting from ↓ in plasma volume) – Promotes Na+ reabsorption→ water follows Na+ = ↑ ECF volume

• Renal absorption/excretion of Na+, Cl and H2O is the major control of ECF volume and osmolality – Na+ excreted = Na+ filtered – Na+ absorbed

• When osmolality is ↑ and volume is ↓… – Vasopressin stimulates the kidneys to reabsorb water thereby concentrating the urine

• When plasma volume is ↓… – Blood flow and pressure also ↓ leading to the production of renin – Renin → angiotensin I → angiotensin II → aldosterone secretion and vasoconstriction – Aldosterone stimulates the kidneys to reabsorb Na+ – “the kidney interprets Na concentration in renal blood flow as the barometer of volume status” NCP 23:5;2008

Labs • Dehydration – Water or fluid loss exceeds intake, is assoc with functional decline – Characterized by high plasma Na causing water shift from cells out to ECF – Depletion of the ICF causes cells to shrink

• Hypovolemia

• Hypervolemia – Fluid volume excess – Expansion of the ECF, may involve the ISF, IVC – Inability of kidneys to excrete excess water • Kidney dz, CHF, cirrhosis

– Shifts from Plasma (IVC) to ISF –  Oncotic pressure

– Fluid volume deficit as a result of loss from ECF

• Edema

– V/D, drainage, bleeding

• Ascites

– Can cause hypovolemic shock and  tissue perfusion

• Anasarca

– Malnutrition

Labs • Basal Metabolic Panel:

• Na :135-147mEq/dl

• Na

• K: 3.5-5.0 g/dl

• Cl

• Cl: 100-106 mEq/L

• K

• CO2: 24-30 mEq/L

• CO2

• BUN: 8-25 mg/dl

• BUN

• Cr: 0.6-1.5 mg/dl

• Cr

• Glu: <126 mg/dl

• Glu

• Ca: 8.5-10.5 mg/dl

• Ca

• Phos: 3.0-4.5 mg/dl

Food & Drug Interactions •

Drug-Induced Nutdtfonal and Metabolic Alt: •

Altered Taste:

•

Chemotherapeutic agents (carboplatin, cisplatin, etoposide,

•

interferon alpha. teniposide)

•

.M etallic taste: captopril, mcmnidazole (Flagyi) .S ulfonylureas Disulhram •

Appetite Changes

•

ncreased: Steroids, megestrol, androgens, benzodiazcpines.

•

antihistamines, insulin, phenothiarines, sulfonylureas

•

Decreased: Antibiotics, antineoplastics. anticonvulsanu, levodopa,

•

thiazides. fluaxetine, amphetaniines, weight loss productsiappetite

•

suppressants

•

• Antibiotics, thiazidcs, chemotherapeutic agents •

Dry Mouth

•

Radiation therapy. diuretics. antihistamines. Iricyclic antidepressants,

•

atropinolike drugs

Diarrhea

• Antibiotics, magnesium-containing medications, hyperosmolar • medications, sorbitol-containing medications, prokinetic • agents, cathartics, cholinergics, lactulose, nwmycin •

Constipation

• Barbiturates, vecuronium, opiates (morphine, codeine) •

•

NauseaIEmesis

Hyperglycemia

• Steroids, theophyllinc, chemotherapeutic agents (Lasparaginase, • interferon, methowexate) •

Hypoglycemia

• Pentamidme, insulin, oral hypoglycemic agents

Food & Drug Interactions •

Drug Induced & Nutritional and Metabolic Alterations:

• Altered Fat MetabolismlAbsorptiou . Cyclosporine, androgens, estrogen, pmgestin, cholcstyramine. • aluminum-containing antacids • Sodium Alterations • Loss: Laxatives, diuretics, probenecid • Exc.35: Penicillin G sodium, increased amounts of normal • saline • Potassium Alterations • Loss: Diuretics, laxatives, probcnecid. amphotericin B • Ercers: Spironolactone, penicillin G potassium • Phosphorus Loss

• Binders (sucralfate, aluminum, calcium, magnesium sevelamer • [renagel]), corticosreroids, fumsemide, rhiazides • Magnesium Loss • Diuretics. amphotericin B, ciprofloxacin, cyclosporine. • pmbenecid, carbenicillin, pcntamidine, cisplatin • Calcium Loss • Fumsemide; Iriamterene, probenecid, corticostcroids, cisplatin. • amphotericin B, calcitonin, phcnytoin, pentamidinc. • mithramycin

Food & Drug Interactions • Low Serum Alb affects highly protein bound drugs by allowing more unbound drug to  action

• Intestinal tract and liver are important sites of drug metabolism • Food and drugs can compete for first pass metabolism in liver • Grapefruit and cardiac meds

–

Phenytoin

– Cytochrome P 450 3A4 is inhibited – Serum drug levels may become toxic

–

Warfarin

Food & Drug Interactions

Food & Drug Interactions • Excretion:

• Absorption:

• Food may alter renal reabsorption or excretion of drugs and affect blood levels of drugs

• Chelation of di- and trivalent ions

• Lithium and Na – High Na = Na excretion and Li excretion – Low Na = Na retention and Li retention

• Questran and Vit A, D, E, K • Drug alters gastric acidity – Anti GERD meds – Zantac, Protonix and Fe

B12, thiamin

• Drug damages mucosal surface causing malabsorption – Antineoplastics

Food & Drug Interactions • Metabolism: • Drug affects metabolism of nutrient – Phenobarbital and Phenytoin cause Fe, Vit D and K def – Methotrexate and folate def

• Drug causes vitamin antagonism – Isoniazid inhibits conversion to active form of Vit B6

• Excretion: • Drug  urinary loss of nutrients – Lasix and K

• Drug  urinary excretion of nutrients – Thiazide diuretics  excretion of electrolytes but  excretion of Ca

Food & Drug Interactions • Med Action: • Enhancing the effects or toxicity of drug – Theophylline and caffeine – MAOI’s and tyramine

• Antagonizing effects of drug – Vit K opposing Coumadin – High fat diet counteracts Pravachol, Lipitor, Tricor

Food & Drug Interactions

Food & Drug Interactions • GI Effects: • Drug may impair salivary flow – Tricyclic antidepressants

• Drug may cause candidiasis – Abx

• Drug may cause dysguesia – Flagyl, Lunesta, Biaxin

• Drug may affect intestinal peristalsis – Narcotics, antipsychotics

• Drug may damage rapidly proliferating cells causing stomatitis, esophagitis – Antineoplastics

• Drug may irritate stomach mucosa – NSAIDs, ASA

• Drug may destroy intestinal bacteria – Abx and diarrhea – Cleocin

C. Diff overgrowth

Food & Drug Interactions • Appetite/Wt Changes: • Some meds are prescribed to stimulate food intake and weight gain – Megace

• Some meds reduce appetite – Anti-ADD, Restoril

• Some meds produce unintentional weight gain – antipsychotics, antidepressants, corticosteroids

• Meds prescribed for obesity to suppress appetite and promote weight loss

• Metabolic Effects: • Drug may cause glucose intolerance – Corticosteroids, Decardron

• Drug may lead to lipid abnormalities – Thorazine

Food & Drug Interactions • Calcium Abs: • Enhanced by – Vit D – Multiple dosing

• Inhibited by – Phytates – Tannins

• Iron Abs: • Enhanced by – Vit C – Heme sources

• Inhibited by – Phytates – Tannins

Food & Drug Interactions

Aging • Sarcopenia – Normal, age related loss of muscle – Begins at 30-40y and diminishes at a steady rate – Healthy 80yo can lose ~40% of LBM as compared to when they were 30yo

• Atrophy – Older adults who are bedridden – Hip fx • Polypharmacy: • Ψ therapeutic agents – Altered taste, dry mouth

• Diuretics – ↓ Na, K, Mg, Ca, Zn

• H2 Blockers/ antacids – ↓Ca, Fe, Zn, B12, C & D

• Laxatives – ↓ K, Fat Sol Vit

• Antibiotics

Aging • DETERMINE

• Assessment:

• Disease

• Require thorough interview

• Eating Poorly

• Medical Hx

• Tooth Loss/Mouth Pain

– Nutritionally relevant dz states

• Economic Hardship

– Medications

• Reduced Social Contact

• Social Hx

• Multiple Medications

– Financial status

• Involuntary Weight Loss/Gain

– ADL’s

• Needs Assistance in Self-Care

– Activities of Daily Living

• Elder Years Above 80

• Nutrition Hx

Aging • Physical Exam – LBM – Height, weight, BMI, UBW

• Labs – Alb, pre alb – H/H – SMA 7

• Protein 1-1.2g/kg – May be affected by dz or stress

• Energy

20-25kcal/kg

– Usually lower due to BMR

• This is dependent on other comorbidities

Aging • Micronutrient needs: • Minerals – Ca – Zinc – Fe

• Vitamins – B6, Folate, B12 – Vit D, C,E, betacarotene, and K

• Fluid Needs: • 30 ml/kg • 1 - 1.5 ml/kcal or 100 mL/kg for the first 10 kg body wt 50 mL/kg for the next 10 kg body wt 20 mL/kg for the remaining kg body wt • Minimum of 1500ml/d + 900ml from food

Aging Classification

ng/mL

Supplementation & Repletion

Deficient

<20

Rx supplement containing 50,000 IU of Vitamin D2 per wk for at least 8 wks. After 8 wks retest blood levels to determine if supplementation needs to be sustained.

Insufficient

20-30

Provide 2000IU/day of Vitamin D3

Sufficient

>30

Provide 2000IU/day of Vitamin D3

Optimal

50-80

Provide 1000IU/day of Vitamin D3 to maintain

Excess

>150

Not common

Aging • Osteoporosis: • Contributing Factors – nl ↓ in bone mass with age – Family hx – Premature menopause – Short stature/small bones – Sedentary lifestyle – Cigarette smoking – ETOH abuse – Caucasian/ Asian – Diets ↓ Ca/ Vit D • Others

• Prevention – Diet adequate in kcal, pro, Ca, Vit D – Supplemental Ca, Vit D – Weight bearing exercise – Hormonal therapy

– Steroid use – Anticonvulsant drugs – Hyperthyroidism – Renal osteodystrophy – Conditions – Anorexia, malabsorption, COPD

Calcium- 1500mg/d

Aging • Hip & Knee Replacements:

• Nutritional Intervention:

• Likely 2° osteoporosis • Tx: usually sgy, rehab therapy • Nutritional Concerns: – ↓ independence

– Adequate kcal to maintain IBW – ↑ pro to 1.2g/kg

– Depression – Bed ridden for long period of time

– Adequate micronutrients esp. Ca/ Vit D

Aging • Pneumonia: • Pulmonary congestion • Microorganism overgrowth leads to infection

• Tx: – Antibiotics – Ventilator

• Labs: SMA, CBC, WBC • Sx: – Difficulty breathing – Wheezing

• Nutrition Intervention: – Adequate kcal to maintain IBW

– Cough

– ↑ pro to ~1.2 g/kg

– ↓ appetite

– Monitor appetite and weight status

– SOB – edema

Aging • Alzheimer’s: • Shrinkage of size and wt of brain

• Pressure Ulcers: • Develop as a result of poor movement, circulation and nutrition

• Effects memory and cognition • Terminal AD involves atrophy and damage through the entire brain

• Generally pt with ulcers are already nutritionally compromised

• Familial AD associated with abnormal apo-E

• Nutritional Assessment:

• Labs: no specific

• Nutritional Recommendations

• Tx: – ACTH inhibitors: Aricept, Exelon, Reminyl – Glutamate Receptor Inhibitor: Namenda

– Adequate po/ pro intake

– KCAL 30-35 kcal/kg body weight – PRO

1.25-1.5 g/kg body weight

– Fluid

1 ml/kcal/day

– Vit A

multivitamin, higher with steroid

– Vit C

500-1000 mg if def or Stg III or IV

– ZnSo4

220mg BID for 2 weeks

use

Aging • Wound Healing: • Provide adequate energy to maximize nitrogen retention and facilitate wound healing • Provide adequate protein for positive nitrogen balance • Provide 100% of the RDA or adequate intake for vitamins and minerals daily • Treat suspected or confirmed vitamin and mineral deficiencies, especially zinc, vitamins A and C. • Monitor outcomes of food and supplements above the tolerable upper intake limits to avoid nutrient toxicity

• Maintain optimal hydration status and perfusion to wounded tissues • Maintain glycemic control • Monitor adequacy of nutrient intake • Monitor actual vs desired outcomes from nutrition interventions

Aging • Supplementation:

• Geriatric FTT:

• Arginine

• Causes

– Increases collagen production, N balance

• Glutamine – Improved N balance

• B-Hydroxy methylbutyrate – Increases collagen production

– Poor po intake 2° – Social – Economic – Physical – Medical

• Nutritional Assessment – Labs: Visceral Proteins, H/H – Weight hx

Aging • Geriatric FTT: • Assessment cont’d – Calculate rate of loss – 5% unintentional weight loss requires immediate intervention

– Prevent further weight loss – Reason for weight loss?

• Constipation: • Causes – Lack of movement – Fluids – Fiber

• Nutrition Inventions: – Encourage fiber and fluid with nutrition education – Stool softeners – Monitor closely

• Dehydration: • Causes – Body water content

• Nutrition Intervention: – Supplements, modification of diet – Appetite stimulant and/or anabolic agent may be indicated – May require nutrition support

– Thirst response – Renal changes – Loss of cognitive skills – Physical barriers – Fear of incontinence – Drugs & Laxatives

• Effects – Weight status – Cognition – UTI – Constipation

Aging • DEHYDRATION: • S&S – Weight loss – heart rate –  BP – skin turgor

• Sources of Fluid – Jell-O, juices and other beverages – Moisture in foods – Foods that are fluid at Room temp – Oxidative metabolism

• Nutrition Intervention: – Add liquid in form of foods – Assure safety of swallowing – Be sure to thicken liquids properly

Aging • NUTRITION INTERVENTIONS: • Liberalize Diet • Manage sensory Δ sx • Supplements – Protein Supplements – Vitamin Supplements

• Encourage fiber and fluids • Modify consistency • Check labs for progress • Assistance with fdgs

• Multi vitamin supplement • Education • Referral to SW

Dysphagia • Swallowing Function: • Initial Stage –

Under voluntary control

–

food and drink are put into mouth and the jaw closes to seal the mouth

• Oral Stage –

Under voluntary control

–

Food is chewed and mixed with saliva

–

A bolus is delivered by voluntary tongue movements to the back of the mouth into pharynx

• Pharyngeal Stage –

Soft palate closes the nasopharynx and the larynx moves upwards to prevent any food or liquid from passing into airways, which is aided by the backward tilt of the epiglottis

• Esophageal Stage –

Involuntary mechanism

–

Begins with the relaxation of the upper esophageal sphincter followed by peristalsis, which pushes food down into stomach

Dysphagia • Sx: • Anorexia

• Sx Oral Phase: • Drooling, excessive secretions • Pocketing of food in cheeks or under tongue

• Weight loss

• Spitting out food

• Food sticking in throat

• Excessive tongue movements

• Choking on food, liquid or saliva • Discomfort when swallowing • Heartburn or acid reflux

• Poor control of tongue movements • Unable to move tongue in all planes • Poor lip closure • Slowed oral transit time • Decreased oral sensation • Facial weakness • Slurred speech

Dysphagia • Sx Pharyngeal Phase: • Coughing before, during, or after swallowing food or liquid • Choking

• Sx Esophageal Phase:

• Nasal regurgitation

• Complaints of food getting stuck in throat

• Wet “gurgly” voice after swallowing food and liquid • Hoarse or breathy voice • Absent swallow reflex • Delay or absence of laryngeal elevation

Dysphasia • Diagnosis Dysphagia:

• Subj. Data:

• Physical examination

• Have you had swallowing or chewing problems in the past?

• Endoscopy

• Is food getting stuck? If yes, where?

• Flexible esophagoscopy • Modified Barium Swallow with video

• Is it difficult to initiate a swallow? • Which types of foods are problematic? Solids, pureed, or liquids? • Is the difficulty getting progressively worse or does it happen intermittently? • Are you avoiding certain foods? • Have you lost weight unintentionally?

• BSE

• Do you cough or choke when trying to swallow?

• pH monitoring or Bernstein test

• Do you wear dentures? Partial or full? Do they fit properly?

• Do you have a history of reflux or heartburn?

Dysphasia • Effects of Dysphasia:



Malnutrition



Dehydration

Aspiration and Pneumonia

• Speech Therapy: – Lip exercises – Posture – Tongue exercises – Thermal stimulation – Double swallow – Supraglottic swallow

• Nutrition Therapy: Goal: To optimize nutritional status and prevent dehydration • Nutrient Dense foods • Modify texture • Modify consistency of liquids

Dysphasia • Pureed Diet:

• Mechanical Soft diet:

• Minimal chewing/swallowing involved

• Mechanically altered foods that are easy to chew

• Blenderized foods – Meats, breads, vegetables, fruits pureed

• No raw fruits or vegetables

– Soups strained

• No tough meats

• Food to Avoid in Pureed Diet:

Food to Avoid:

• Hard cheeses

• Tough meats

• Raw eggs

• Raw vegetables/ corn on the cob

• No nuts, coconut and seeds

• Raw fruits except bananas

• Whole breads, uncooked cereals, whole rice and pasta • Whole fruits or vegetables cooked or raw • Bacon

• Bacon • No coconut or anything containing nuts/seeds

Dysphasia • Dysphasia Diet: • Includes foods that are easier to swallow • Consists of moist foods that are mechanically altered • Eliminates dry, raw or stringy items • Excludes foods that fall apart or do not form a cohesive bolus • Positioning of pt important as well

• Foods to Avoid: • Fruited yogurt • Fried foods, whole or dry meats, raw stringy fruits and vegetables • Peanut butter, refried or dried beans, peas • Hard rolls • Nuts, coconuts, seeds and raisins • Thick, sticky cooked cereals, grits • Corn, peas, leaf spinach, okra, rice • Popcorn, pickles, chili peppers, olives, horseradish

Dysphasia • Nutrition Intervention: • Modify consistency and educate – If liquids must be thickened, don’t forget about soups

• Supplements – If dysphagia present, cannot recommend Liquid supplement

• Consult SLP

Neurology • Sx:

• CVA/TIA: • Hemorrhagic

– Sensory loss

– ICH

– Taste changes

– SAH

– Hemiparesis

• Ischemic – Thrombi – Atheromas: blocking or travelling

• Risks – HTN

– DMLVH – obesity

– Aphasia

• Labs:

CAD

– Hyperlipidemia

– Dysphagia

smoking

– BMP – PT/PTT

Lipid Profile

• CVA/TIA:

Neurology

• Tx: – Medications – Anticoagulation- warfarin – Anti-platelet-asprin – tPA- tissue plasminogen activator with thrombolytic agent – Vitamin K, clotting factors

– Sgy – Endarterectomy – Insertion of shunt to relieve ICP – Coiling of aneurysm

– Rehabilitation – PT, OT, ST

Neurology • CVA/TIA:

• Brain Tumors:

• Diet

• Sx:

– Modified consistency and liquids until dysphagia resolves

– Anorexia

– Enteral nutrition common

– Lethargy

• Kcal 25-30 kcal/kg BEE X 1.3 maintain IBW –

• Pro

Dependent on Sx

1 g/kg

– Any neuro changes – Gait, cognitive ability, personality, motor skills

• Dx – CT, MRI, Bx

Neurology • Brain Tumors:

• MS:

• Tx:

• Remission/recurrence Dz, autoimmune

– Medications steroids, chemotherapy – Surgery

lobectomy, cranitomy

ventriculostomy – Radiation

• Diet: Regular – Kcal

greatly ↑ ↑

– Pro1.2-1.5 g/kg with sgy 1-1.2 g/kg with chemo – Monitor Na/Fluid

• Etiology unknown, some links to prior infection • Destruction of myelin sheaths • Sx: – Partial weakness tingling sensation – Paralysis spasticity of limbs – Involuntary contractions tremors – Flaccid muscles

visual impairment

– Dysphagia dysarthria – Neurogenic bladder

Neurology • MS: • Tx: – Steroids and ACTH, plasmapheresis, dz modifiers: Interferon

• Diet: Regular, modified as needed – Kcal: to maintain IBW – Pro: 0.8-1.0 g/kg – Concerns with self feeding, dysphagia – Some research shows a benefit of ω6 FA supp

• ALS: • Amylotrophic Lateral Sclerosis – AKA Lou Gehrig’s Dz – Destruction of neurons involved in controlling muscles – Etiology: possibly problems with glutamate

• Sx: – Progressive weakness dysphagia – Muscle atrophy

dysarthria

– Mobility problems – Respiratory muscle strength (end stage)

• Tx: Riluzole • Diet: Depends on sx – Mouth ↑ risk of dysphagia – Motor assistance with meals – Respiratory

may need TF

– Concerns with drooling, dry mouth, constipation – Kcal

BEE X 1.5-2.0 35-40 kcal/kg

– Pro1.5g/kg

Neurology • Parkinson’s Dz: • Death of nerve cells that produce dopamine causing an imbalance of excitatory and inhibitory neurotransmitters • Sx:

• Tx: medications – Levodopa/ Carbidopa – Sinimet

– Rigidity of extremitiestremors – Bradykinesia pain

–

– Expressionless face slowness – ↓ voluntary movements stooped posture

– Cogentin (Benzotropine mesylate)

• Diet: – Protein redistribution to  L-Dopa metabolism – Protein competes with med for transport in small intestine

– B6 is a cofactor in L-dopa

dopamine

– Anticholinergic drugs – COMT Inhibitors – Comtan (Entacapone) – Tasmar (Tolcapone)

– Dopamine antagonists

– Suppl < 15g

– Miranpex (Pramiexiole )

– Fdg issues and dysphagia present in Late PD

– Requip (Ropinirole )

– Kcal

BEE X 1.3 25 kcal/kg maintain IBW

– Pro0.8 g/kg

– MAO-B Inhibitors – Eldepryl – Selegiline

Neurology

• Epilepsy:

• Ketogenic Diet:

• Sx: Sz, partial or generalized

– Designed to induce a state of ketosis

• Tx: Medications

– 70% of kcals from fat and the remaining from PRO and CHO

– Depakene (valproic acid) Gabitril – Phenobarbital

Keppra

Zonegran

• Guillan Barre Syndrome:

– Tegretol (carbamazepine) Trileptal – Dilantin (phenytoin)

Lamictal

– Phenobarbital (barbiturates)

Neurontin

– Zarontin (ethosuximide)

Lyrica

– Klonopin (Clonazepam)

Topamex

– Must watch folate levels, megaloblastic anemia

• Diet: Ketogenic diet, Regular – Kcal IBW

BEE X 1.3 25kcal/kg maintain

– Pro0.8 g/kg

– Proposed mechanism of action is in the effect of ketones on neurotransmitters – Rapid progressive weakness which ascends to whole body and results in paralysis – Autoimmune, preceded by bacterial, viral infection – Tx: Respiratory support, mechanical ventilation, plasmapheresis, IV immunoglobins – Diet: – Enteral nutrition support until able to eat – Kcal

BEE X 1.3 maintain IBW

– Pro0.8 g/kg

Neurology • Myasthenia Gravis: • Sx: muscular weakness, crisis periods –

Limbs, respiratory system, larynx, pharynx, eyes, face

– Etiology: autoimmune rxc damages receptors for acetylcholine which disrupts nerve to muscle transmission

• Tx: medications – Immunosuppressant drugs – Anti cholinesterse agents: Pyridostigmine – Corticosteroids: prednisone – Surgery: thymectomy – Plasmapheresis

• Diet: Regular, modified consistency as needed – Kcal BEE X 1.3 maintain IBW – Pro0.8 g/kg

• Huntington’s Dz: • Genetic disorder, loss of basal ganglia cells – ↓ cognitive ability

impaired speech

– ↓ emotional control change in movement – Dysphagia

• Tx: Medications – depend on sx, anxiety, depression, psy – Tetrabenazine approved in 2008

• Diet: Regular, modified consistency as needed – Kcals BEE X 1.3

maintain IBW

– Pro1-1.5 g/kg – Folic Acid and B Vitamins

• Spinal Cord Injury: • Generally as a result of auto accidents • Extent of injury dep. on area of spinal cord – Paraplegia: 2 limbs paralyzed – Quadraplegia: all 4 limbs paralyzed

• Cervical, thoracic, lumbar, and sacral vertebrae

Neurology

Neurology • Spinal Cord Injury: • Initial needs are similar to metabolic stress or TBI – Kcal: 30-35 kcal/kg – Pro: 1.5-2g/kg • During Rehab, Kcal needs to maintain IBW are  • Protein needs still somewhat due to preservation of LBM – Kcal: 22-28 kcal/kg – Pro: 0.8-1g/kg • Nutritional Goals: – Maintain IBW – Avoid Pressure Ulcers – Prevent constipation

• Traumatic Brain Injury: • Open bleeding skull fracture • Closed lethargy/HA sleepiness confusion • Effects: hypermetabolism hypercatabolism ↓ immune function altered GI function • Labs: generally ↑ glucose abnormal Na, K, Cl UUN

Neurology • Systemic inflammatory response • Pt not aggressively tx may lose as much as 15% body weight • Early feeding indicated within 48 hours with high protein formula • N balance generally not achieved until week 3

• TBI: • Tx: Medication – Paralytics, coma inducing drugs – Pain medications: demerol, morphine – Steroids: decadron (to ↓ ICP) – Antihypertensives

• Diet: enteral support in early stages – Kcal

BEE X 1.5-2.0 35-40 kcal/kg

– Pro 1.5-2.2 g/kg

(maybe even higher)

– Fat 30-40% of total kcal

Neurology • TBI:

• Nutritional Assesment:

• Nutritional Intervention:

• Assess for dysphagia

– Determine feeding route and Rx – Monitor fluid status – Monitor weight

– ST – MBS

– UUN to make sure in + N balance

• Weight ∆’s

– Indirect calorimetry desired

• Nutritional hx

– Transition to oral fdgs

• Feeding issues • Medical hx

Hypertension Category Normal

SBP <120

and

DBP <80

Pre HTN

120-139

80-89

Stage 1 HTN

140-159

90-99

Stage 2 HTN

>160

>100

Hypertension • Types of HTN: • 1° HTN – Idiopathic

• 2° HTN – Endocrine disorders – Neurological disease – Renal artery stenosis

• Sx: usually none – HA – Vertigo – Syncope

Hypertension • Causes: • Cushing’s syndrome • Steroid tx • Thyroid/parathyroid dz • Renovascular dz • Sleep apnea • Drug induced • CKD • Primary aldosteronism

• Target Organ Damage: • Heart – LVH – CAD – CHF

• Cerebrovascular – TIA or CVA – Aneurysm

• Peripheral Artery Dz • Renal – Proteinuria – Microalbuminuria

• Retinopathy

Hypertension

• Compensatory Mechanisms:

• Sympathetic Nervous System –

Responds immediately; vasomotor center in brain

–

SNS innervated tissues contract or dilate vascular bed

• Renin Angiotensin System –

Constricts blood vessels; increases aldosterone release from adrenal cortex

• Kidneys –

Respond to vasopressin and aldosterone by retaining or excreting water and Na

↓ NaCl (total volume) Increase Vasoconstriction Increase Catecholamines ↑ Blood Pressure

Hypertension • ↑ Na +

• ↑ Ca ++

– Increase in urinary K

– Lose Na + – Decrease volume

– Hypokalemia results

– ↓ Blood Pressure

– Vasoconstriction – ↑ Blood Pressure

• ↑K+ – Increase in urinary Na – Decrease total volume – ↓ Blood Pressure

• ↑ Na + – Lose Ca ++ – Trigger Ca ++ conserving hormones – Vasoconstriction – ↑ Blood Pressure * Studies show more in ↓ BP when Ca intake is inadequate

• Meds:

Hypertension

• Diuretics

• ACE inhibitors

– Inhibit conversion of AI AII and less Na/H2O is reabsorbed which prevents constriction of arteries

– Promote excretion of salt and water through kidneys to decrease volume in bloodstream

– Vasotec

– Thiazides

– Lotensin

– Loop

– Altace

• Lasix • Bumex

– K-sparing • Aldactone

• β blockers – Decrease the vigor of heart’s contractions by blocking catecholamines – Lopressor – Toporol – Bystolic (new) – Cogard – Levatol

• Aldosterone Receptor Blockers

– Zestril

– Capoten

• Angiotensin II antagonists – Blocks the action of AII – Cozaar – Benicar – Diovan

• Renin Inhibitors – Inhibits renin production thereby reducing AI and AII production – Tekturna (Aliskiren)

• Ca-channel blockers – Blocks Ca from myocardial muscle which  contractility and dilates arteries – Cardizem

– Prevents the retention of Na and water

– Norvasc

– Aldactone

– Procardia

Hypertension • Centrally Acting (antiandrenergics) – Lower the heart rate – Catapres

• Direct vasodilators – Nitroglycerine

• COMBO MEDS: • ACEI & CCB • BB & Diuretics • ACEI & Diuretics

Hypertension • Lifestyle Modifications: • Weight reduction

• Nutrition Interventions: • Modifying Na in Diet

• Adopt DASH eating plan

– Generally to NAS or 2gm Na

• Dietary Na reduction

– Blanket restrictions not warranted

• Physical Activity • Moderation of ETOH consumption

• Nutrition Education – DASH diet – Weight reduction

Hypertension • NAS:

• 2 g NA:

• Generally 3-4g Na

• No canned vegetables, vegetable juices, soups or broths

• No salt added during preparation and at table • No cured meats • No tomato or vegetable juice in a can • No breads with salt on top

• No cured or smoked meats • No breads with salt on top • No commercially prepared rice, potato, or pasta mixes • No salad dressings with pork • No regular or processed cheese or spread

Hypertension • Dietary Approaches to Stop Hypertension • DASH: • Incorporates more fiber, K, Ca, Mg • Less total fat and sat fat – Low fat dairy – Low fat salad dressing, mayo, cheese

• Promotes weight loss

• LABELS: • SODIUM FREE (no sodium) = less than 5 mg of sodium per serving. • VERY LOW SODIUM = 35 mg or less of sodium per serving. • LOW SODIUM = 140 mg or less of sodium per serving. • REDUCED SODIUM = 25% less sodium than the original version of the product. • NO ADDED SALT or UNSALTED = no salt is added during processing (but this does not guarantee the food product is low in sodium).

Food Group

Daily Svgs

Svg Sizes

Significance

Grains

7-8

1 slice, ½ c cooked rice, pasta, cereal

fiber

Vegetables

4-5

1 c raw leafy, ½ c cooked, 6oz juice

K, Mg, Fiber

Fruits

4-5

6oz juice, 1 med, ¼ c dried, ½ c fresh, frozen

K, Mg, Fiber

Dairy

2-3

8oz milk, 1 c yogurt, 1 ½ oz cheese

Ca, protein

Meats

3 oz cooked

Protein, Mg

Nuts, beans

4-5

1/3 c nuts, ½ oz seeds ½ c cooked beans

Mg, K, Protein, fiber

Fats, oils

2-3

1 tsp margarine, 1 tbsp mayo, 2 tbsp salad dressing, 1 tsp veg oil

27% kcal as fat

Sweets

5/wk

1 tbsp sugar

Low in fat

CVD • Atherosclerosis: – Factors that initiate atherosclerosis either cause direct damage (physical) to the artery wall or allow lipid materials to penetrate its surface (functional).

∆ in membrane permeability  Circulating macrophages 

Smooth muscle cells

• Thickening of arterial wall due to lipid accumulation 2° – LDL – LDL oxidation – ↑ uptake oxidized LDL by monocytes/macrophages

(because they express receptors for oxidized

= FOAM CELL FORMATION LDL)

CVD

CVD • 5 Stages of Lesions: – Fatty streak – Fibrous plaque – Complicated lesion – Rupture (MI or angina) – Occlusive (ischemia) – Inflammation • C Reactive Protein

• Apolipoprotein B and  A-1 – Inhibits clot lysis, promotes chol uptake into arterial walls

• Obesity: • Independent risk factor for CVD –  BMI

• Central abdominal obesity – < 38” is assoc with  CVD risk in men and women

• Waist to hip ratio – < 1 men – < 0.8 women

CVD • Metabolic Syndrome: • Abdominal obesity • TC, TG, LDL • HDL • Elevated BP • Insulin resistance or glucose intolerance • Additional Criteria – Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood) – Proinflammatory state (e.g., elevated Creactive protein in the blood)

CVD

Total Cholesterol <200 mg/dL

Desirable

200-239 mg/dL

Borderline high

>240 mg/dL

High

<100 mg/dL

HDL Cholesterol < 40 mg/dL (men) < 50 mg/dL (women)

Low

> 60 mg/dL

High/Desirable

LDL Cholesterol Optimal

100-129 mg/dL

Near/ Above Optimal

130-159 mg/dL

Borderline High

160-189 mg/dL

High

>190 mg/dL

TG <150 mg/dL

Normal

150-199 mg/dL

Borderline High

200-499 mg/dL

High

â&#x2030;Ľ500 mg/dL

Very High

CVD •Very High Risk (subset of High) –Therapeutic option of tx to <70mg/dL •High Risk –Therapeutic option of tx to <100mg/dL •Moderately High Risk –Therapeutic option of tx to <100mg/dL •Clinical trials show that tx option reduces risk of CHD •Tx option should reduce LDL levels by 30-40%

Total Chol.

LDL

HDL

Satura ted Fat**



PUFA Ω6





PUFA Ω 3*



inconsi stent



 w/ high intake





MONO (when rep SFA) Trans Fats***



CVD

CVD STEP I DIET:

• STEP II DIET:

Fat

Fat 30% or less

Saturated Fat <10% PUFA

30% or less Saturated Fat <7%

up to 10%

MONO

PUFA

up to 10%

MONO

up to 15%

CHO

55%

CHO

55%

PRO

15%

PRO

15%

Chol

<300mg

Chol

<200mg

Kcal

to maintain IBW

Kcal

to maintain IBW

• TLC: Major Features

CVD

Soluble Fiber – Insoluble

• TLC Diet

– Whole grains

– Reduced intake of cholesterol-raising nutrients (same as previous Step II Diet)

– Rind of fruits and vegetables

– Saturated fats <7% of total calories

– Soluble

– Dietary cholesterol <200 mg per day

– Pectin

– LDL-lowering therapeutic options

– Psyllium

– Plant stanols/sterols (2 g per day)

– Oats

– Viscous (soluble) fiber (10–25 g per day)

– β-Glucans

– Fiber binds bile salts in the GI tract

• Weight reduction • Increased physical activity • Functional Foods on CVD:

– Cholesterol removed from serum for bile acid synthesis in an effort to restore bile acid pool

– Plant Sterols/ Stanols

–  LDL, TC

– Mechanism of Action

– Recommendations

– Block entry of most cholesterol into micelle because they are preferentially absorbed

– 25-35g/day total

– Recommendations • 1.3g/d sterols • 1.7g/d stanols or • 2-3 g/d of both

Fortified Foods

– 7-13g/day soluble

Soy – Decreases TC and LDL cholesterol (modest) – Minimum effect on raising HDL cholesterol

• Mechanism of Action

– Benecol

– May alter cholesterol metabolism, LDL uptake

– Granola bars

– Replacing animal for plant protein

– OJ – Promise activ

–  LDL and TC, no effect on HDL and TG

Omega 3 FA Alcohol Antioxidants

CVD Alcohol Benefits:

Alcohol Risks:

• Cardioprotection

• Breast Cancer

2 drinks/ day for men

• Liver Disease

1 drink/ day for women

• Hypertension

1 drink=

• Pancreatitis

5 oz of wine

• G.I. Malignancy

1.5 oz 80% liquor

• Stroke

12 oz beer

• Cardiomyopathy

CVD • Antioxidants: – Oxidation of LDL – Hypothesized in prevention of atherogenesis – Within the body – Superoxide dismutase – Glutathione peroxidase

– Within the diet

• Nutrition Intervention: – Changing Modifiable Risk Factors – Lose weight – Stop smoking – Control HTN

– Nutrition Education

– Vit A, C, E – Beta carotene – selenium

– Monitoring acute sx associated with dz

• Nutrition Education:

CVD

– Lower sat fat and cholesterol

• MI: – Etiology: atherosclerosis – Sx:

– Modifying or substituting nutrients

– Angina

– Adding functional foods

– Tx:

– Increasing fiber – Dietary Guidelines – Cooking methods – Increasing fruits and vegetables

– SOB – CHF/edema

– Morphine, coumadin

• Nutrition Intervention – Low fat/ low chol – Therapeutic Lifestyle Changes – Promote functional foods – Kcal

25-30 kcal/kg

BEE X 1.3 – Pro0.8g/kg

CVD

• CHF:

• CABG:

– Sx:

– Bypass blocked blood vessels

– Dyspnea – Orthopnea – Nausea – Fullness

– Nutrition Intervention

– Pulmonary edema – Cardiac edema

– Low fat/ low chol

Tx: Goal is to decrease work of heart

– ? Na – Kcal

– Cardiac cachexia

to meet IBW

•

Diet –

Na restriction

– Pro 1.2-1.5g/kg for wound healing

–

Monitor serum K, replete

–

Fluid restriction

– Complications in wound healing are common

–

No alcohol

–

No caffeine—can cause MI or cardiac arrhythmia

–

Nutrition support may be indicated

CVD • Cardiac Cachexia: – Increased workload of the heart leads to… – Anorexia – Increased metabolic rate – Increased nutrient loss – Impaired delivery of nutrients – Impaired removal of waste

• Nutrition Intervention – Provide adequate energy and protein to combat hypermetabolic state – Kcals BEE X 1.5 – Pro

1.0-1.5g/kg

– Na 1-2g/d

• Cachectic Heart: – A soft, flabby heart characterized by loss of myocardial mass as the result of extreme malnutrition

• Nutr Dx: – Small, frequent meals to prevent overload of macronutrients – Focus is on adequate intake at this time – Nutrition support may be indicated with nutrient dense low volume formula

CVD • Cardiac Transplantation:

• Nutrition Intervention

– For terminal CHF

– LOW Na diet required

– 69% five yr survival rate

– Kcals for IBW and to control underlying condition

– Meds – Corticosteroids – Immunosupressive drugs – Diuretics – Antihypertensives, antilipemics

– PRO

1.0-1.2g/ kg for healing

– Fluid 1 Liter restriction – No caffeine or alcohol – Adequate Ca, Mg, and fiber – Encourage use of healthy fats in diet

• Cardiac Procedures/Surgeries:

CVD

• Transmyocardial Revascularization – After incision is made, a laser is used to drill holes from the outside of the heart into the inner pumping chambers

Cardiac Catherization (also known as “cath”)

• Angioplasty – Catheter with balloon at tip is inserted into coronary artery and inflated to widen blocked area – Stent Procedure

•

– A stent is a wire mesh tube used to prop-open an artery during angioplasty – Permanent

• Laser Angioplasty – Similar to above except uses a laser to open blocked artery by vaporizing the plaque buildup

•

• Atherectomy – Similar to angioplasty except catheter has rotating shaver on tip to cut away plaque – May also be used in carotid arteries to remove plaque and ↓ risk of stroke

•

– In some cases, is combined with bypass surgery Bypass Surgery – Use of arteries/veins from other parts of the body (grafts) to reroute blood around a blockage – Surgeries may include one or more grafts Minimally Invasive Heart Surgery – Alternative to CABG; small incisions (ports) made in the chest are used to attach veins from the legs to the heart Radiofrequency Ablation (Catheter Ablation) – Catheter with electrode is passed through a vein to the heart, energy is used to destroy cells responsible for abnormal heart rhythms Artificial Heart Valve Surgery – Replaces an abnormal or diseased heart valve with a healthy one Cardiomyoplasty – Experimental; skeletal muscles are taken from back or abdomen and wrapped around the heart, the added muscle helps increase heart’s pumping (aided by pacemaker)

Diabetes Click to edit Master text styles Second level

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Diabetes • Short Term Fasting:  BG ∆ insulin:glucagon Glucose utilization Glucose production 1st Glycogenolysis (limited) 2nd Gluconeogenesis begins 3rd

Lipolysis

ketones

• Prolonged Fasting (7-10 days): – Glucose dependent tissue: (Brain, Kidney)Use ketones for fuel

Diabetes

2째 OGTT 75g CHO oral intake

FPG

Diabetes Condition

Fasting

OGTT 2 째

Normal

<100

<140

Pre-DM

100-125

140-199

>126

>200

Diabetes • Type 1? – Genetic – Cold weather – Virus – Early diet

• Type 2? – Genetic – Western lifestyle – Obesity

• Pre-Diabetes: – Impaired Fasting Glucose (IFG): fasting glu levels ≥ 110 mg/dl but < 126 mg/dl – Impaired Glucose Tolerance (IGT): 2-hour OGTT values are ≥140 mg/dl but < 200 mg/dl – HgA1c of 5.7%-6.4% = pre DM

• Type 1:

Diabetes

• Usually dx in children and young adults • Destruction of pancreatic beta cells which produce insulin • Sx: – Hyperglycemia – Polydipsia – Polyuria – Polyphagia – With weight loss

– Visual changes – Fatigue and irritability

• Insulin regimens • Insulin pump CHO counting used!!

• Type 2:

Diabetes • Type 1 insulin regimen: • At least 3-4 daily injections are required for good glycemic control • TDD is 0.4-1.0 u/kg • 60% in AM and 40% in PM • Adjustments as necessary

– Basal: long acting insulin, helps control BG overnight and between meals, approximately 50% of TDD – Bolus: mealtime, rapid acting or short acting insulin given to cover effects of glucose consumed at meals

Diabetes • Short or rapid acting insulin throughout the day – Mimics normal pancreatic function

• TDD 50% basal and 50% bolus • Basal • Bolus – 1U => 15g CHO expected

• Complications with insulin: – Hypoglycemia – Lipodystrophies – Reaction with other meds – Allergies

Diabetes • Nutrition Related strategies for type 1: – Food/meal plan based on individual’s appetite, preferred foods, and usual schedule of food intake and activities – Individuals using flexible or intensive insulin regimens consisting of basal (background) insulin and bolus (mealtime) insulin doses have more flexibility in timing and frequency of meals and amount of CHO eaten at meals

– Individuals taking fixed doses of insulin (rapid-acting or short-acting insulin and NPH insulin) need to eat similar amounts of CHO at consistent times that are synchronized with the time of actions of their insulin – Improved glycemic control with intensive insulin therapy is often associated with increased body weight

Diabetes • CHO counting: – Utilized for insulin pump or those receiving insulin therapy

• Ex:

– Each CHO exchange = 15 g CHO

• Pt requires 2000 kcal diet

– CHO exchanges include starch, milk, fruit, veg – CHO exchanges can vary +/- 5 grams

2000/.50 = 1000 kcals from CHO

• Determine kcal level • Determine % of kcals from CHO • Divide % CHO kcals by 4 (4kcal=1g CHO) to determine grams of CHO in diet • Divide grams by 3 to get a starting point for dividing exchanges throughout the day

1000 kcals/ 4 kcals CHO / 3 meals 1 g CHO

/ 15 g

1 CHO ex

Diabetes • Individuals @ high risk for type 2 DM

• Type 2 DM: • Most common • β cells do not produce enough insulin or cells are not recognizing it • Associated with Metabolic Syndrome

– Lifestyle changes – Moderate weight loss (7% body weight) & regular physical activity (150 min/week)

– Dietary strategies: – Reduced calories & dietary fat – 14g fiber/1,000 kcal – Increase whole grains food consumption • Overweight and obese insulin-resistant individuals – Modest weight loss improves insulin resistance

• Weight-loss interventions – Either low-CHO or low-fat calorie-restricted diets may be effective in short term (<1 yr)

Diabetes • Wt-loss Intervention: • Weight-loss medications – May be considered in treatment of overweight & obese individuals w/ type 2 DM – Can help achieve a 5-10% weight loss – When combined w/ lifestyle interventions

• Bariatric surgery – May be considered for some individuals w/ type 2 DM and BMI ≥35 kg/m2 – Can result in marked improvements in glycemia

Diabetes • Pediatric Type II DM: – Average age:10-17 yo – Sx:

– Energy needs BMI growth pattern usual intake activity

– Few to none

 Kcals by 250-500 kcals/day

– Acanthosis nigricans (AN) – Hyperlipidemia

Encourage activity and behavior modification

– Hypertension

• Med tx:

– Polycystic ovarian syndrome (PCOS)

Tx: •

• Diet Tx:

– If diet therapy fails

Normalize BG –

which  risk of acute/chronic complications

•

Slow rate of weight gain

•

Achieve normal BP & lipids

•

Maintain normal growth

•

Support/maintain emotional health

– OHA – Insulin – Combo

• Monitor: – Daily BG: fasting and 2° post prandial – Hb A1c

Gestational Diabetes • Body not able to make and use all of the insulin it needs • Glucose crosses the placenta and leads to macrosomia, large fetus • Mom must monitor after preg so that DM does not persists

• Provide adequate kcal – 30-35 kcal/kg normal weight – 25-30 kcal/kg overweight Distribute kcal/nutrients throughout day nutrient composition • the Balance 3 small-med meals and 2-4 snacks – 35-45% CHOlevels and Morning meal limited to 15-30g CHO 2° hormone glu metabolism in AM – 20-30% PRO All meals and snacks should contain CHO/FAT/PRO…AVOID – 30-35% FAT KETOSIS! Ideal glycemic control FPG <95 1° post prandial <180 2 ° post prandial <155 3 ° post prandial <140

Diabetes • DKA: •

Type 1

•

Develops within hours or a few days

•

BG exceed 250 mg/dL and may rise above 1000 mg/dL

•

Causes breakdown of triglycerides in adipose tissue –

•

excessive release of fatty acids into blood stream

Increased production of ketone bodies –

blood pH typically falls below 7.3

• Etiology: – severe lack of insulin

• Clinical Manifestations:

• HHNS: • Type 2 • BG rises and body tries to excrete in urine • Develops slowly over days or weeks • Blood glucose levels typically exceed 600 mg/dL and may rise above 2000 mg/dL • Etiology: – Infection, illness or drug tx that impairs insulin action or secretion

• Clinical Manifestations:

– Acetone breath, fruity

– Dehydration

– Acidosis

– Decreased blood volume and electrolyte imbalances

– partially corrected by exhalation of carbon dioxide

– Dehydration – Electrolyte imbalances

– Hyperglycemia

– Mental state may vary (coma)

– Neurological abnormalities – Abnormal reflexes, motor, verbal

Diabetes • Special Issues w/ hypoglycemia: • Honeymoon phase – Remission of newly dx type 1

• Dawn phenomenon – hyperglycemia caused by early morning release of growth hormone, which counteracts insulin’s glucose-lowering effects

• Somogyi effect (rebound hyperglycemia) – hyperglycemia resulting from the release of counterregulatory hormones following nighttime hypoglycemia

**Treated with adjustment of the dosage or formulation of insulin

• Chronic complications: – Prolonged exposure to high glucose concentrations destroys cells and tissues – Glucose and glucose fragments react with proteins to form advanced glycation end products (AGE’s)

Diabetes • Retinopathy:

• Diabetic Neuropathy:

• Damage to small vessels in the retina – impair vision causing blindness

• About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including:

• 95% of patients with DM 1 develop retinopathy by 15 yrs. after dx • Intensive management substantially reduces risk.

–

Impaired sensation or pain in the feet or hands

–

Slowed digestion of food in the stomach

–

Carpal tunnel syndrome

–

Peripheral, GU, GI, CV

• Leads to amputations

• Gastroparesis:

Diabetes

• Def- delayed gastric emptying • Sx: – Nausea/vomiting – Fullness – Anorexia – Weight loss

• Dx: – Gastric emptying studies – Endoscopy

• Tx: – Meds: Reglan, Erythromycin – Diet

• 1st assess nutritional status – Achieve and maintain IBW – Kcal/pro dependent on nutritional status

• Low fiber, low fat – In cases of severe gastroparesis, may need TF or PN

• Pain Management Prevention lies in tight glycemic control

• HbA1c: • Glycated hemoglobin (HbA1c) – Assists health care providers to evaluate long-term glycemic control – Measures glycemic control during the preceding two to three months – HbA1c – < 6% for non-diabetic persons – HbA1c – DM patients < 7%

Diabetes • CHO: must be well distributed throughout the day and consistent day to day – total amount of CHO in meals and snacks is more important than source and type – Sugar and sugar substitutes do not have to be eliminated from diet – 50% of total calories

• FAT: – 30% of total calories – <10% saturated fat

• Factors to consider – IBW – Glycemic control – Long term complications – Further restrictions may be warranted

• PRO: – 20% of total calories

• Exceptions: – Pt with nephropathy –  protein intake to 0.6-0.8g/kg

Diabetes • Type 1 & Exercise: – Avoid exercise if FPG is >250 mg/dL and ketosis is present – Use caution if FPG is >300 mg/dL and no ketosis is present

• insulin •  counterregulatory hormones

– Consume carbohydrate if plasma glucose is <100 mg/dL – Monitor BG before and after exercise – Identify when changes in insulin or food intake are necessary – Learn the glycemic response to different exercise conditions – Carbohydrate-based foods should be readily available during and after exercise.

• Improves cardiovascular health • Enhance Glu metabolism • Increased insulin sensitivity

Obesity BMI 25-29.9 Overweight • Etiology: BMI 30-34.9 Obese, Grade I BMI 35-39.9 Obese, Grade II BMI 40+ Morbidly Obese, Grade II

– Biology – Hormonal, endocrine

– Genetics – Environmental – Phys inactivity, portions, dining out, distorted body image

– Medications – Antipsychotropics

– Psychological status – depression

Obesity • Metabolic syndorme: – Also known as Syndrome X – Comprised of: – Abdominal obesity – Elevated serum glucose – Elevated triglycerides – Elevated serum cholesterol – Hypertension

• Insulin Resistance: – An impaired physiological response to insulin – Is positively associated with central abdominal obesity and glucose intolerance – Often a cause of Type 2 diabetes – Weight loss improves insulin sensitivity

Obesity • Calculating Calorie Needs: – The actual weight should be used in the HBE

• Calculating PRO needs:

– 21 kcal/kg BW in obese, critically ill pt

• 0.8-1.0g day

– Mifflin St Jeor Equation

• Once EE is calculated, an energy deficit should be incorporated in order to induce weight loss – Typical deficit is -250 to -500kcal/d

• The goal is to induce weight loss of approximately ½ to 2#/week

– Depends on dz and medical status

• Adj BW is not ideal for calculating pro needs in the stressed, obese pt • Monitor status • Fluid Needs: • Currently, no standard formula for fluid needs in obese patients • May be “safest” to use 1ml/kcal

Obesity • Goals of Wt Management: • Prevention of weight gain or stopping weight gains in the individual that has been seeing a steady increase in his or her weight • Varying degrees of improvements in physical and emotional health • Small maintainable weight losses or more extensive losses accomplished through sensible and tolerable eating and exercise behaviors • Improvements in eating, exercise, and other behaviors apart from weight loss

• Nutrition Interventions: – Diet and Lifestyle changes – Exercise – Pharmacotherapy – Surgery

Obesity Group Name

Trade Name

Sibutramine

Meridia

Orlistat

Xenical

Obesity • Sibutramine: • Appetite suppressant and antidepressant • Serotonin – norepinephrine reuptake inhibitor

• Should not be used if; –

Persons younger than 16

–

Pregnant or breastfeeding women

–

People taking an MAO inhibitor medication or an SSRI for depression (e.g Prozac, Zoloft, or Paxil)

–

Anyone taking other prescription or OTC diet aids

–

People taking prescription pain relievers such as Demerol, Duragesic, or Talwin.

• Causes tachycardia and ↑d BP – Not for pts w/ PMH of CHD, CHF, arrhythmia or stroke

• Studies have shown a 5-10% weight loss with LT use, on average

Obesity • Orlistat: • Inhibits pancreatic lipase which causes reduced absorption of dietary fat – Approximately 30% of dietary fat consumed is blocked – For a person consuming 2000 kcal, 30% of which are fat, they would lose 200 - 300 kcals/D

• Found to ↑ wt loss by 6 – 9 lbs • Only one that is not a controlled substance • Meals should be balanced • Taken with meals or up to 1 hour after meals • High fat meals/foods should be avoided – Leads to more GI side effects

• Orlistat is not absorbed, so side effects are actually caused by fat malabsorption • Side effects include fatty stools, oil spotting, soft or liquid stools and fecal urgency – This can be improved by limiting amount of fat eaten at a meal

• Malabsorption of fat soluble vitamins is also a problem – Vitamin supplements should be taken at night so they are able to be absorbed

• Should not be used if; – People with chronic problems absorbing food – Anyone with gallbladder problems – Pregnant or breastfeeding women

Obesity • Bariatric Surgery: • These procedures are both RESTRICTIVE and/or MALABSORPTIVE

• Candidates:

– Reduces the size of the stomach

• Must have tried all other conventional weight loss methods

– Decreased absorptive surface of SB, 60% is bypassed

• 100# over IBW, BMI > 40 or > 35 with co-morbidities

– Food going into SB where there is less mixing with bile and pancreatic enz

• Must have psychological and RD evaluation prior to surgery • Follow up with RD and labs

Obesity • Types of Surgery: • Roux-en-Y Gastric Bypass (RYGB) • Sleeve (vertical) Gastrectomy • Vertical Banded Gastroplasty • Laparoscopic Adjustable Gastric Banding

• Sleeve Gastrectomy: – Newer, easier procedure – Long term effects have not been evaluated – Reminiscent organ is removed – Portion of stomach that produces ghrelin

– For high risk super super obese pts – Can be 2 part sgy so pt can lose wt for a year and then have RYGB

• Lap Band: • A band is placed around the stomach making the stomach smaller. – The band is adjustable. The band can expand and contract like a balloon. – There is an access port beneath the skin through which saline can be injected or removed to allow for band adjustment

Obesity • GBP: Roue-en-Y: – Most common bariatric surgery – Greater weight loss and long term results – Gastric capacity reduced by 90% – 15-30ml

– Bypasses duodenum and part of jejunum – Initial pouch 1-2oz, mature pouch 6-9oz

• Impact: – Total weight loss 25-30% (some up to 66%) – 90% of patients improve disease control – 83-90% Remission of T2DM

Obesity • Post-op hormonal effects: • Adiponectin: – Produced solely in adipose tissue – Found lower in obese individuals – If decreased  develop insulin resistance – Plasma adiponectin levels rise after RYGB

• Ghrelin: – Gastric fundus plays a functional role in ghrelin secretion and regulation – Bypassing of the stomach, reduces ghrelin secretion thereby reducing hunger

• Leptin: – Leptin is released by adipocytes in response to nutrient supply and acts in the brain  to increase energy consumption – Obese pt have peripheral resistance to leptin – Levels are higher and there is insulin resistance

– Postop: – Leptin levels fall, correlated with weight loss

Obesity • Dumping Syndrome: – Sx – Abd cramping, N/V/D, hypotension, weakness

• RD (preop): – Pre-op weight loss of at least 5% – Lifestyle and behavior changes

– Prevention

– Repletion of vitamin and mineral deficits

– Pt should avoid high sugar foods or beverages

– B12, vit D, folate, Zn, Fe, Ca, Thiamin

– Nutrition education and counseling

Obesity • RD (post-op): – Education Continues! – Assess compliance with guidelines and adequacy of behavior – Compliance with multivitamin/mineral supplementation – Investigate “Early Plateau”/ Regain ??

• Post-op Immediate Goals: • Maintain integrity of pouch • Enhance compliance • Capitalize on “Rapid Weight Loss Phase” • Train patient to focus on high protein intake

Obesity • Post Surgery Diet: • Stage1 • Clear liquids (noncarbonated, no sugar) • Stage 2 ClearHigh Protein Liquids • Stage 3 – 10-14 days post-op: High Protein LiquidsPureed and very soft protein sources – 4-5 weeks post-op: Pureed, soft vegetables/peeled fruit as tolerated

• Stage 4 Healthy Solid Foods

• High Protein Liquid Diet Days 3-7: • Liquid Supplementation Guidelines: 150-200 kcal/serving 15-30g Prot/serving Goals: 60g Protein/day 48-64oz Fluid/day Sip Slowly: Max 8oz/hr Usual Duration: 4 weeks

Obesity • High Protein Diet with Solids Weeks 2-3 – Soft/Moist Protein Foods – No fruits/vegetables until protein is tolerated – No starch – 3oz of Protein each meal from a variety of sources eg. Tuna,cottage cheese,eggs, soy…

• Lifelong Diet: – Normal food consistency – All Food Groups – Three meals & 2-3 snacks daily – Use Low Glycemic Index fruits/vegetables – Use Protein Bars – Still avoid foods with High Caloric Value

Obesity • Problem Foods: – Bread – Rice

• Deficiencies: – Vitamin D – Thiamine – Iron

– Poultry

– B12

– Carbonated Beverages

– Folate

– Fried Foods – Spicy Foods – Citrus Fruits

– Calcium – Anemia – Osteoporosis, increased bone loss

– This affects ~30% of all surgery pts

Obesity • Malabsorptive Surgery (RYGB): • Common nutrients affected are protein, Ca, Fe, folate • Vitamin D – can lead to Ca malabsorption • Thiamine- Wernicke encephalopathy • Zinc- can contribute to Vit A deficiency

• Complications after surgery – Emesis, diarrhea, strictures

• Bypassing of absorption sites – Fe, Folate, Vit B12, Ca, Thiamine

• Diminished HCl secretions – Fe, Vitamin B12

• Decreased consumption of nutrient rich foods

Obesity • Est. Calorie Needs: * Diet should be hypocaloric with appropriate level of protein * Non-Pro Calories:15 –20 cal/kg AdjBW * 500 – 700 calories/day for the first few weeks after sx * 800-1000 kcal target, may eventually reach 1200-1500 kcal

• Est. PRO needs: – Based current weight may overestimate needs 2° fat mass not as metabolic active and % LBM is low compared with a person of normal body weight – 1.2 g Prot/kg IBW – no less than 60g/d

– Or estimate 1 –2g/kg AdjBW

Obesity • Est. Fat needs: – Consider needs of fat for satiety and prevention of EFAD – Monounsaturated preferred – Minimum 30g/day

• Est. Fluid Needs: – To prevent dehydration – Should not be taken with meals – Minimum of 64 oz/day

• Avoid ETOH intake – increase potency d/t lack of gastric alcohol dehydragenase and increased risk of liver damage

Obesity • Vit/Mineral Supp: – High potency Multivitamin/Mineral Suppl

• ADIME notes should include: – Compliance data

– Folate 400 µg/day

– Thorough nutrition hx

– B-12 350 µg/d, 500 µg/wk or 1000 µg IM/month

– Weight hx, labs

– Calcium Citrate 1200-1500 mg/day

– Protein >60g/d

– Vit D 1000-2000 IU /day – Fe 65-80 mg elemental/d

– Estimation of needs – Nutritional goals There are no standards set for assessment of these pt!

Obesity • Nutr Support for Bariatric Pt: • Enteral feeding is preferred – PEG or G-tube – TF via PEG in excluded stomach has been done – Reduces dumping

• Hypocaloric, high protein feedings – Kcals 13.5-22 kcals/kg IBW – Pro 2.0-2.2 g/kg IBW