Domain 2 Flashcards
Subjective Global Assessment (SGA)
history, intake, GI symptoms, functional capacity, physical appearance, edema, weight changes
Mini Nutritional Assessment (MNA)
evaluates independence, medications, number of meals consumed each day- for those 65 years and older.
Nutrition Screen Initiative (NSI)
designed for the elderly to discover nutrition risk
Geriatric Nutritional Risk Index (GNRI)
tests serum albumin and weight changes
Malnutrition Screening Tool (MST)
acute hospitalized adult population- weight loss, recent poor dietary intake
Nutrition Risk Screening (NRS)
medical surgical hospitalized- % weight loss, BMI, intake, >70 years
Malnutrition Universal Screening Tool (MUST)
BMI, unintentional weight loss, effect of acute disease on intake for more than 5 days
What components are typically reviewed for a nutrition screening?
food/nutrition history, anthropometrics, lab/medical tests, nutrition-focused physical findings, client history
diet history
present patterns of eating
food record
food diary, record of everything eaten in a specific amount of time
24 hour recall
mental recall of everything eaten in pervious 24 hours. Quick tool to estimate a sample daily intake in the clinical setting
food frequency lists
how often an item is consumed in the community setting. best way to understand intake from a large amount of people
What formula estimates desirable body weight?
Hamwi formula:
Men- 106 lb for the first 5 ft, 6 lb for every inch above 5’
Women- 100 lb for first 5 ft, 5 lb for every inch above 5’
Small frame: -10%, Medium frame: +10%
Amputation adjustments for entire leg, lower leg with foot, entire arm, forearm with hand
entire leg: 16%
lower leg with foot: 6%
entire arm: 5%
forearm with hand: 2.3%
Adjusted IBW: (100-% amputation)/100 X IBW for original height
Adjusted IBW weight for spinal cord injury (quadriplegic; paraplegic)
quadriplegic: reduce IBW weight by 10-15%
paraplegic: reduce IBW weight by 5-10%
% weight change
[(usual weight - actual (current) weight) / usual weight] x100
What is considered significant weight loss?
10% weight loss within 6 months
Standards for triceps skinfold thickness (male;female)
Measures body fat reserves; measures calorie reserves
Male: 12.5 mm; Female: 16.5 mm
Standards for arm muscle area (male;female)
Measures skeletal muscle mass (somatic protein)
Male: 25.3 cm; Female: 23.2 cm
*important to measure in growing children
BMI formula
kg/m^2 or (lb/in^2) x 703
at risk waist circumference for men and women
men >40 in, women >35 in
at risk waist to hip ratio for men and women
men >1.0, women >0.8
Bioelectrical Impedance Analysis
used at bedside to evaluate fat free mass and total body water
Bod Pod
measures body composition by determining body density by measuring the amount of air displace.
Considerations for thin, dry hair
vitamin c or protein deficiency
considerations for pale, dry eyes and poor vision
vitamin a, zinc or riboflavin deficiency
considerations for swollen, red, dry, cracked lips
riboflavin, pyridoxine or niacin deficiency
considerations for smooth, slick, purple, white coating tongue
iron deficiency
considerations for sore, red, swollen, bleeding gums
vitamin c deficiency
considerations for missing, loose, teeth
calcium deficiency, poor intake
considerations for pale, dry, scaly skin
iron, folic acid, zinc deficiency
considerations for brittle, thin, spoon shaped nails
iron or protein deficiency
Normal range for serum albumin
3.5-5.0 g/dl
- levels above normal range likely due to dehydration
- low levels associated with edema or surgery
normal range for serum transferrin
> /= 200 mg/dl
- increases with iron deficiency, transports iron to bone marrrow
normal range for transthyretin/prealbumin
16-40 mg/dl
normal range for retinol-binding protein
3-6 mg/dl
- binds and transports retinol
normal range for hematocrit
men- 42-52%
women- 37-47%
pregnant women- 33%
newborn- 44-64%
- volume of packed cells in whole blood
normal range for hemoglobin
men- 14-17 g/dl
women- 12-15 g/dl
pregnant women </= 11 g/dl
-iron containing pigment of red blood cells
normal range for serum ferriton
men 12-300 ng/ml
women 10-150 ng/ml
-indicates size of iron storage pool
normal range for serum creatinine
0.6-1.4 mg/dl
-related to muscle mass; measures somatic protein
normal range for creatinine height index
normal = 80%
ratio of creatinine excreted/24 hours to height
normal range for blood urea nitrogen
10-20 mg/dl
- related to protein intake
normal range for BUN:creatinine ratio
10-15:1
normal range for urinary creatine clearance
115+/- 20 ml/minute
- measures glomerular filtration, renal function
normal range for total lymphocyte count
> 2700 cells/cu mm
-measures immunocompetency
define C-reactive protein
marker of acute inflammatory stress
- when elevated CRP decreases, PAB increases
define Free erythrocyte protoporphyrin
direct measure of toxic effects of lead on heme synthesis. Increased in lead poisoning. Lead depletes iron leading to anemia
define prothrombin time
evaluates clotting adequacy; change in vitamin K intake will alter rate (11.0-12.5 seconds)
define hair analysis
useful in measuring intake of toxic metals
activity factors for sedentary, active and stressed
1.2
1.3
1.5
Mifflin St Jeor Equation
Men: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) + 5
Women: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) - 161
megestrol acetate
appetite stimulant
dextroamphetamine
appetite suppressant, anorexia, nausea, weight loss
orlistate
decreased fat absorption by binding lipase, vitamin/mineral supp.
marinol
appetite stimulant
mythylphenidate (Ritalin)
anorexia,, weight loss, nausea
statins
decreased LDL, TG; increase HDL
chemotherapy
malabsorption
mineral oil, cholestyramine
decrease absorption of fat, fat soluble vitamins
glucocorticoids, antibiotics
protein deficits
oral contraceptives
decrease folate, B6, C
loop diuretics
deplete thiamin, potassium, magnesium, calcium, sodium
thiazide diuretics
decrease potassium, magnesium, calcium, sodium
antibiotics
decrease vitamin k
steroids
decrease bone growth, CHO intolerance
methotrexate
decrease folate
lithium carbonate (antidepressant)
increased appetite, weight gain; must maintain sodium and caffeine levels
anticoagulant (warfarin sodium)
antagonizes vitamin K; avoid Ginkgo biloba extract, garlic, ginger, vitamin A and E
propofol
sedative; 1.1 calories/ml, check TG
phenobarbital
decreased folic acid, vitamins B12, D, K B6
cyclosporine (immunosuppresant)
hyperlipidemia, hyperglycemia, hyperkalemia, hypertension
Isoniazid (treats TB)
depletes pyridoxine, peripheral neuropathy, don’t take with vitamin D, calcium or phosphorus
Elavil (antidepressant)
sedative effect, weight gain, increased appetite
vitamin B6 and protein
decreased effectiveness of levodopa which controls symptoms of parkinsons disease. Take in morning with limited protein
calcium
binds tetracycline
tyramine
hypertension if taken with monoamine oxidase inhibitor.
tumeric/curcumin
may reduce inflammation, antioxidant
Health Risk Appraisal (HRA)
survey categorizing a POPULATION’s general health status
Infant mortality rate
infant deaths under 1 year of age, expressed as the number of deaths per 1000 live births
incidence vs prevalence
incidence:
(number of NEW cases of a disease over a period of time/total number of people at risk) x 100,000
Prevalence:
(total number of people with a disease during a period of time/average number of people) x 100,000
Nutritional Surveillance
continuous collection of data
Nutrition Screening Initiative
Promote nutrition and improve nutritional care for the elderly to identify nutritional problems early.
Level 1: screen identifies those who need more comprehensive assessments
Level 2: screen provides more specific diagnostic info on nutritional status
National Nutrition Monitoring and Related Research Program (NNMRRP)
includes all data collection and analysis activities of the federal government attitudes about diet and health (jointly run by USDHHS and USDA
PedNSS Pediatric Nutrition Surveillance System
run by USDHHS
-low income, high risk children, birth-17 yo. (emphasis on birth-5 yo)
- height, weight, birth-weight, hematocrit, hemoglobin, cholesterol, breast feeding
- monitors growth and nutritional status, infant feeding practices
PNSS pregnancy Nutrition Surveillance System
run by USDHHS
-low income, high risk pregnant women
- maternal weight gain, anemia, pregnancy behavioral risk factors (smoking, alcohol) birth weight, countrs # of women who breast feed
-identify and reduce pregnancy-related health risks
NHANES National Health and Nutrition Examination Survey
-ongoing repeated survey
- evaluates clinical, chemical (hemoglobin, hematocrit, cholesterol), anthropometric, nutritional data
- NHANES III- oversampling of adults >/=65
- WWEIA (what we eat in america)- two days of 24 hour recall data. conducted by usda for adults >/=60 african americans and hispanics
NFCS- USDA Nationwide Food Consumption Surveys
-evaluates 7 nutrients: protein, calcium, iron, thiamin, riboflavin, vitamin C, A.
- diets are good if intake equals or is above RDA; rated poor if less than 2/3 of RDA for 1 or more nutrients
BRFSS Behavioral Risk Factor Surveillance System
run by USDHHS
- adults 18 yo and older residing in households with telephones
- telephone interviews collect info on height, weight, smoking, alcohol, food frequency for fat, fruits and vegetables, preventable health problems, diabetes
YRBSS youth risk behavior surveillance system
run by USDHHS
- Grades 9-12. smoking, alcohol use, weight control, exercise, eating habits
- prevalence of health risk behaviors among young people
Health and diet survey
run by FDA and USDHHS
- telephone survey of randomly selected adults
- tracks self-perception of relative nutrient intake levels, use of food labels, knowledge of fats and cholesterol, prevalence of supplement use and awareness of diet and disease
TANF temporary assistance to needy families
- states determine the eligibility and benefits and services provided
USDA commodity food donation / distribution program
-provides food to help meet nutritional needs of children and adults and strengthens agricultural market for products produced by American farmers
-food given to school lunch, elderly feeding, supplemental food programs
(CSFP) Commodity Supplemental Food program
- administered by state health agencies
- monthly commodity canned or packaged foods
- low income women (pregnant, breast feeding, post partum), infants, children up to 6 years old and some elderly at nutritional risk
(TEFAP) the emergency food assistance program
- quarterly distributions for commodity foods by local public or private non profit agencies, food banks, soup kitchens, homeless shelters
-supplements diets of low income households
National School Lunch Program
-run by USDA
- cash grants/food donations; dollars reimburse schools on basis of numbers of meals served
- lunch must provide on average over a school week: 1/3 recommended protein, vitamin A and C, iron and calcium
- grades 9-12: 2 oz meat serving; nuts must be combined and only used for half the requirement
- graham flour is considered whole grain
- K-5: 3/4 cup vegetables is one serving
- 100% full strength fruit juice may be used as 1/2 of weekly servings of fruit
National School Breakfast Program
-run by USDA
- entitlement program, meals must meet dietary guidelines
- breakfast must provide on average over each school week: 1/4 daily recommended levels for protein, calcium, iron, vitamin A and C
After School Snack Program ASP
-run by USDA
- provides healthy snacks
- cash subsides for each snack served. same eligibility as NSLP
Special Milk Program (SMP)
- run by USDA
- purpose is to encourage milk consumption in children
Summer Food Service Program (SFSP)
- run by USDA
- school lunch
- administered by FNS, state educational agencies, public or private nonprofit residential summer camps
Child and Adult Care Food Program (CACFP)
- run by USDA
- reimburses operators for meal costs, provides commodity food and nutrition education materials
- meals must meet guidelines; must offer free or reduced price to eligible
Fresh Fruit and Vegetable Program (FFVP)
- run by USDA
- introduces children to fresh fruits and vegetables
- free to children nationwide in selected schools
Special supplemental nutrition program for women, infants and children (WIC)
- run by USDA
-for pregnant women, postpartum, breast-feeding, infants and children up to 5 yo. - provides food for low income mothers at nutritional risk
- for infants at risk with weight, height, head circumference in infants, hemoglobin, hematocrit.
- provides food, nutrition education and referrals
- health exam is REQUIRED
- foods provided include: iron-fortified formula, cereal, milk, cheese, fruit juice
- Not an entitlement program: cap on amount of federal dollars allocated
Expanded Food and Nutrition Education Program (EFNEP)
- run by USDA
- provides grants to universities that assist in community development
- trains nutrition aides to educate the public
- improves food practices of low income homemakers with young children
- works with small groups and teaches skills to obtain a health diet
Maternal and Child Health Block Grant
- run by USDHHS
- under Title V of social security act
- provides training, consultation, funding
- women of child-bearing age, infants, children; state eligibility requirements
Healthy Start
- run by USDHHS
- reduces infant mortality and improves health of low income women, infants, children and families
Nutrition Services Incentive program (NSIP)
-administration on aging
- developed services to foster independent living; cash and commodities to state agencies
- OOA older americans act run by USDHHS
- one hot meal each day, 5 days/week, provide 1/3 recommended intake
- eligibility: all aged 60 and older plus spouse, regardless of income
Supplemental Nutrition Assistance Program (SNAP)
- run by USDA
- largest food assistance program: entitlement
- assist low income with monthly benefits; net income must be at or below certain % of poverty level; income limits vary by household size and are adjusted to cost of living
- designed to increase their purchasing power
-no non food items
Centers for Medicare and Medicaid Services (CMS)
-run by USDHHS
- Medicare: health insurance program for people over 65 yo; of any age with stage renal disease. includes annual wellness visit provided by affordable care act (RD included)
- Medicaid: payment for medical care for all eligible needy: all ages, blind, disabled, dependent children
Children’s Health Insurance Program (CHIP)
- under social security act, partnership between federal and state governments
- expands health coverage to uninsured children whose families earn too much income to quality for medicaid but too little to afford private coverage.
Headstart
- run by USDHHS
- helps low income children (3-5 yo)
- introduces new foods, teaches good food habits
Nutrition Education Training Program (NETP)
- run buy USDA since 1977
- amendment to school lunch act
- provides nutrition education training to teachers and school foodservice employees
Senior Farmers Market Nutrition Program (SFMNP)
- run by USDA
- grants to states to provide low income seniors with coupons to be exchanged for eligible foods at farmer’s markets, roadside stands, community supported agriculture programs.
- may be limited to specific and locally grown food
- nutrition education and information is provided (how to select, store, prepare)
Quasi-governmental agencies
receive both federal and private funds
- american red cross
- national research council- food and nutrition board (developed RDA)
Non government agencies
-voluntary health agencies- private, non profit, chartered and licensed by a government agency, funded by contributions from citizens or organizations (e.g. american heart association)
- professional organizations- academy of nutrition and dietetics
- foundations, business, industry
international agencies
FAO- food and agricultural organization- increasing levels of nutrition globally by increasing efficiency of production /distribution of foods
What are the 3 domains of nutrition diagnostic labels
clinical, intake and behavioral-enironment
clinical diagnosis
nutritional findings/problems that relate to medical/physical condition
- functional balance: physical or mechanical change that interferes/prevents desired nutritional results; swallowing difficulty, altered GI function
- biochemical balance: change in capacity to metabolize nutrients due to medications, surgery or indicated lab values
- weight balance: chronic or changed weight status when compared with UBW: underweight, involuntary weight loss, overweight
Intake diagnosis
actual problems related to intake
- caloric energy imbalance
- oral or nutrition support intake
- fluid intake imbalance
- bioactive substances (supplements, alcohol, functional foods)
- nutrient balance
behavioral-environmental
problems related to knowledge, access to food and food safety
- knowledge and beliefs
- physical activity balance and faction
- food safety and access
PES statement
problem (diagnostic label)
etiology (cause/contributing factor)
signs/symptoms (objective data/changes)
Altered GI function NC 1.4 vs Impaired nutrient utilization NC 2.1
NC 1.4- looks at problems inside the GI tract
NC 2.1- looks at problems with the metabolism of nutrients once they have entered the circulatory system
Four categories of interventions
- food delivery
- education
- counseling
- coordination of care with other providers
primary prevention
reduced exposure to a promoter of disease. health promotion
secondary prevention
recruiting those with elevated risk factors into treatment programs. risk reduction
tertiary prevention
as disease progresses, intervention to reduce severity, manage complications. rehabilitation efforts
What is CARS checklist?
used to evaluate information
credibility (authors credentials)
accuracy (info is correct and factual)
reasonableness (info is fair, balanced and consistent)
support (has supporting citations)
Describe an ulcer
-eroded mucosal lesion
- treatment: antacids, antibiotics
-diet: as tolerated, well-balanced, avoid late night snacks
-omit: cayenne and black pepper, large amounts of chili powder, avoid excess caffeine and alcohol
Describe a hiatal hernia
-protrusion of a portion of the stomach above the diaphragm into the chest
- small, bland feedings; avoid late night snacks, caffeine, chili powder, black pepper
describe dumping syndrome
follows a gastrectomy (billroth 1 and 2)
- cramps, rapid pulse, weakness, perspiration, dizziness
- when rapidly hydrolyzed carbohydrates enter the jejunum, wanter is drawn in to achieve osmotic balance. this causes a rapid decrease in vascular fluid compartment and decrease in peripheral vascular resistance. Blood pressure drops. two hours later, carbs are digested and absorbed rapidly, blood sugar rises, stimulating an overproduction of insulin, causing a drop in blood sugar below fasting.
- can lead to anemia (B12 or folate deficiency)
- diet: frequent small meals, fluids before or after to slow passage. 50-60% complex carbs and protein at meals with limited fat
Billroth 1
gastroduodenostomy
-attaches the remaining stomach to the duodenum
Billroth 2
gastrojejunostomy
- attaches stomach to jejunum (secretion of secretin and pancreozymin is reduced- due to bypassing duodenum- these hormones stimulate the pancreas so there is little pancreatic secretion and calcium and iron absorption are affected)
describe gastroparesis
- delayed gastric emptying: surgery, diabetes, viral infections, obstructions
- moderate to severe hyperglycemia: detrimental effects on gastric nerves
- prokinetics (erythromycin, metoclopramide) increase stomach contractility
- small, frequent meals; pureed foods, avoid high fiber, avoid high fat (liquid fat may be better tolerated)
- bezoar formations may be due to digested food or medications; treatment includes enzyme or endoscopic therapy
describe tropical sprue
-bacterial, viral, parasitic infection
- chronic GI disease, intestinal lesions, may also affect stomach
- diarrhea, malnutrition, deficiencies of B12 and folate due to decreased HCL and intrinsic factor
- antibiotics, high calories, high protein, B1 and folate supplements
describe non tropical sprue
-celiac disease, gluten-induced enteropathy
- reaction to gliadin (affects ileum and jejunum- proximal intestine)
- malabsorption, macrocytic anemia, weight loss, diarrhea, steatorrhea, iron deficiency anemia
- need gluten free restricted diet (no wheat, rye, oats, barley, bran, graham, malt, couscous, durum, orzo, thickening agents)
describe constipation
- sometimes due to an atonic colon (weakened muscles)
- diet: high fluid, high fiber diet, exercise
describe diverticulosis
-presence of diverticula- small mucosal sacs that protrude through the intestinal wall due to structural weakness. Related to constipation and lifelong intra-colonic pressures
-diet: high fiber, increase volume and weight of residue, provides rapid transit
describe diverticulitis
-when diverticula become inflamed as a result of food and residue accumulation and bacterial action
- diet: clear liquids, low-residue, gradual return to high fiber
describe fiber
-provides indigestible bulk, promotes intestinal function
- dietary fiber: non-digestible carbs and lignin, binds water, increases fecal bulk
- soluble fiber decreases serum cholesterol by binding bile acids converting more cholesterol into bile
- soluble fibers (pectins, gums) delay gastric emptying, absorb water, form soft gel in the small intestine; slows passage and delays or inhibits absorption of glucose and cholesterol
- high fiber diet may increase need for Ca, Mg, P, Cu, Se, Zn, Fe
describe gastritis
-inflammation of stomach
- diet: clear liquids, avoid gastric irritants
describe inflammatory bowl disease
Crohn’s disease (regional enteritis)
- affects terminal ileum
- B12 and iron deficiency
Chronic ulcerative colitis
- begins in the rectum
- chronic bloody diarrhea, weight loss, electrolyte disturbance (Na,K), dehydration, anemia, negative nitrogen balance
Treatment:
- maintain fluid/electrolyte balance
- bowel rest, PN or minimal residue for CD, possibly elemental diet for UC.
- when IBD is under control/in remission, high fiber to stimulate peristalsis
describe irritable bowel syndrome
-chronic abdominal discomfort, altered intestinal motility, bloating
-goals: adequate nutrition intake, avoid large meals, excess caffeine, alcohol or sugars
describe lactose intolerance
- normally lactase splits lactose into glucose and galactose. Without lactase, there is high hyperosmolar pressure and water is drawn into the intestine to dilute the load. This causes distention, craps ,etc. Bacteria then ferment the undigested lactose, releasing CO2 gas.
- detected by breath hydrogen test. hydrogen is produced by colonic bacteria on lactose, absorbed into bloodstream and exhaled 60-90 min later.
- lactose tolerance test- oral dose of lactose (up to 50g) after a fast. if intolerant of lactose, blood glucose will rise <25 mg/ml above fasting. of tolerant, glucose will rise >25 mg/ml.
-diet: no animal milk or milk products, no whey. - calcium and riboflavin supplements are recommended
describe diarrhea in infants and children
- acute- aggressive and immediate rehydration (glucose electrolyte solution). reintroduce oral intake within 24 hours
- chronic- consider fat to CHO ratio, and volume of ingested liquids. Give 40% calories as fat, balanced with limited fluids. do not give fruits juices with high osmolar loads
describe diarrhea in adults
- remove the cause: bowel rest, replace lost fluids/electrolytes (Na/K)
- once diarrhea stops, start with low fiber food, followed by protein foods
- avoid lactose at first
- foods or supplements that contain prebiotic components (pectin, fructose, oats, banana flakes)
- probiotics- sources of bacteria to reestablish gut flora
describe steatorrhea
- consequence of malabsorption
- normal stool fat 2-5 g; >7g indicative of malabsorption
- dietL high protein, high complex carb, fat as tolerated, vitamins especially fat soluble, minerals, MCT rapidly hydrolyzed in GI tract
describe short bowel syndrome
- loss of ileum (especially distal 1/3), loss of ileocecal valve, loss of colon are off concern
- most digestion takes place in the first 100 cm of intestine (duodenum and 1/2 of jejunum) what remains- small amounts of sugars, starches, fibers, lipids
- nutrition care:
- PN initially to restore and maintain nutrient status
- enteral - start early to stimulate growth (may take weeks or months to transition to food)
- for ileum resection: use MCT, limit fat, supplement fat soluble vitamins, Ca, Mg, Zn, B12
- for jejunal resection: normal balance of carbs, proteins, fats. avoid lactose, oxalates and large numbers of concentrated sweets
describe jejunal resection
- ileum can adapt and take over jejunal functions
describe ileal resection
- distal: absorption of B12, intrinsic factor, bile salts
- ileum normally absorbs major portion of fluid in GI tract (patients with ostomy bags should be drinking +1 L in addition to baseline)
- if ileum cannot recycle bile salts. lipids are not emulsified, leads to malabsorption of fat soluble vitamins, Ca, Zn and Mg. Colonic absorption of oxalate increases- renal oxalate stones. Increased fluid and electrolyte secretion; increased colonic motility.
describe loss of colon
water and electrolyte loss, loss of salvage absorption of carbs and other nutrients
functions of the liver
stores and releases blood, filters toxic elements, metabolizes and stores nutrients, regulates fluid and electrolyte balance
what are the liver function tests?
ALP - alkaline phosphatase (30-120 U/L)
elevated (liver/bone disease)
low (scurvy or malnutrition)
LDH - lactic acid hehydrogenase
elevated (hepatitis, myocardial infarction, muscle malignancies)
AST - aspartate amino transferace
elevated (hepatitis)
low (uncontrolled DM with acidosis)
ALT - alanine aminotransferance
elevated (liver disease)
describe acute viral hepatitis
- inflammation, necrosis, jaundice, anorexia, nausea, fatigue
- jaundice occurs when bile ducts are blocked
- treatment: increase fluids, 50-55% carbs to replenish liver glycogen and spare protein, 1-1.2 g/kg protein for cell regeneration, provide lipotropic agents to convert fat into lipoproteins for removal from liver, supplement with B vitamins, C, K and zinc
types of hepatitis
A: fecal-oral transmission
B: sexually transmitted
C: blood to blood contact
describe cirrhosis
-damaged liver tissue is replaced by bands of connective tissue which divides the liver into clumps and reroutes many of the veins and capillaries.
- protein deficiencies lead to ascites, fatty liver, impaired blood clotting
what is considered normal blood flow ?
abdominal/esophageal/collateral veins
to portal vein
to liver
to vena cava
esophageal varices
-occur when blood can’t enter the liver
- connective tissue overgrowth causes resistance to blood entering from portal vein. due to portal hypertension
diet for cirrhosis
- high protein (0.8g/kg); in stress (1.5 g/kg)
- high calorie (BEE x 1.2-1.5) or 25-35 cals/kg
- moderate to low fat
- low fiber if varices are present; low sodium if edema or ascites
- with hyponatremia, fluid restriction of 1-1.5 L/day and moderate sodium levels
- add B vitamins, C, K, Zn, Mg (maybe A and D)
describe alcoholic liver disease
- hepatic steatosis, alcoholic hepatitis, cirrhosis
- alcohol is converted into acetaldehyde and excess hydrogen which disrupts liver metabolism.
1. hydrogen replaces fat as fuel in the krebs cycle so fat accumulates in liver leading to fatty liver and high TG in blood. - malnutrition: alcohol replaces food, inflammation of GI tract interferes with absorption of thiamin, B12, vit C and folic acid, folate and protein deficiencies, thiamine deficiencies.
describe hepatic failure (ESLD)
- liver function decreased to 25% or less
- liver cannot convert ammonia (NH2) into urea- ammonia accumulates
- portal systemic encephalopathy
- asterix (flapping, involuntary jerking movements- signs of a impending coma)
- Treatment: moderate to high levels of protein (1-1.5 g/kg), 30-35 kcal/kg, 30-35% calories as fat with MCT, add lactulose- hyper osmotic laxative that removes nitrogen- and neomycin- an antibiotic that destroys bacterial flora that produce ammonia
*decreased BCAA and increased aromatic amino acids AAA because damaged liver cannot clear them. adding BCAA is used when stard therapy does not work and patient does not tolerate protein
describe cholecytitis
- inflammation of gallbladder
- an infection causes excess water to be absorbed causing cholesterol to precipitate out leading to gallstones- cholelithiasis
- treatment:
- low fat diet - 30–45 g, or 25-30% of calories
- cholecystectomy- surgical removal of gall bladder; bile now secreted from liver directly into intestine
describe pancreatitis
- inflammation with edema, cellular exudate and fat necrosis
- may be due to blockage or reflux of the ductal system; premature activation of enzymes within pancreas, leads to autodigestion
describe acute pancreatitis
- put pancreas at rest, withhold all feeding, maintain hydration (IV)
- progress as tolerated to easily digested foods with low fat
- elemental (pre digested) EN into jejunum may be tolerated
describe chronic pancreatitis
- recurrent attacks of epigastric pain of long duration
- take PERT (pancreatic enzymes orally with meals and snacks to minimize fat malabsorption from lack of pancreatic lipase.
- pancreatic bicarbonate secretion may be defective; may need antacids so PERT therapy will work
- in severe cases, PN may be needed
define cystic fibrosis
- sticky mucus that blocks ducts in the pancreas and prevents enzymes from reaching the small intestine to digest food
-disease of exocrine gland- secretion of thick mucus that obstructs glands and ducts; chronic pulmonary disease, pancreatic enzyme deficiency, high perspiration, electrolyte levels, malabsorption - treatment:
- PERT pancreatic enzyme replacement therapy with meals and snacks
- high protein, high calorie, unrestricted fat, liberal in salt
define hypertension
- systolic >140, or diastolic >90 or both
- systolic: contraction, greatest pressure
- diastolic: relaxation, least pressure
- may be primary (essential) or secondary due to another disease
- optimal blood pressure <120/80 mm Hg
- thiazide diuretics may induce hypokalemia
- primary causes: overweight, high salt intake, alcohol consumption, physical in activity
- salt restriction <2400 mg
- DASH diet or Mediterranean diet
define atherosclerosis
- accumulation of lipids; structural and compositional changes in the intimal layer of the large arteries
describe coronary heart disease
- hard, narrow arteries from plaque buildup
describe ischemia
deficiency of blood due to obstruction
descrive arteriosclerosis
loss of elasticity of blood vessel walls
describe myocardial infarction
reduction of coronary flow to myocardium due to blood clot blocking a narrowed coronary artery
- angina pectoris
- heparin (blood clots)
describe dyslipidemia
- high triglycerides and low HDL
Chylomicrons
- transports dietary triglycerides from gut to adipose cells; synthesized in intestine from dietary fat; lowest density due to smallest amount of protein
VLDL
-pre beta
- transports endogenous triglyceride from liver to adipose cells
LDL
- beta
- transports cholesterol from diet and liver to all cells
HDL
-alpha
- reverse cholesterol transport; moves cholesterol from cells to liver and excretion
IDL
- pre beta to beta
- LDL precursor; found in circulation secondary to catabolism of other lipoproteins
Metabolic syndrome
- 3 or more of the following risk factors are linked to insulin resistance which often increase risk for coronary events:
- elevated blood pressure >/= 135 systolic and or >/= 85 diastolic
- elevated TG >/= 150 mg/dl
- fasting serum glucose >/= 100 mg/dl
- waist measurements >/= 102 cm (40 in) in men and >/= 88 cm (25 in) in women
- low HDL <40 mg/dl in men and <50 mg/dl in women
describe heart failure
- weakened heart fails to maintain adequate output, resulting in diminished blood flow so fluid is held in tissues (Edema) ; dyspnea (shortness of breath)
- reduced blood flow to kidneys causes secretion of hormones that hold in sodium and fluid leading to weight gain
- digitalis increases strength of heart contraction
- diuretics- nutrient loss, glucose intolerance, increased serum uric acid
- diet: low sodium, DASH diet, low fluid
- evaluate thiamin status (loss with loop diuretics)- without thiamin, pyruvate cannot be converted into acetyl coA for energy so heart muscle is deprived
describe cardiac cachexia
-unintended weight loss, blood backs up into liver and intestines causing nausea and decreased appetite. arginine and glutamine may help. low saturated fat, low cholesterol, low trans fat, sodium restriction
