Domain II: Nutrition Care for Individuals and Groups: Medical Nutrition Therapy Flashcards
An ____ is an eroded mucosal lesion
Ulcer
What is the typical treatment for GI ulcers?
-Antacids
-Antibiotics to eradicate Helicobacter pylori bacteria
What are two examples of medications used for treatment of ulcers?
-Cimetidiine
-Ranitidine
Cimetidine and Ranitidine are what drug class?
H2 blockers
H2 blockers like Cimetidine and Ranitidine work by preventing the binding of ____ to its receptor, therefore decreasing acid secretion
Histamine
For someone with an ulcer, diet should be well-balanced and we should recommend avoiding ___-___ ____
Late-night snacking
For someone with an ulcer, we should also recommend avoiding gastric irritants such as…
-Cayenne
-Black pepper
-Large amounts of chili powder
-Avoid excess caffeine and alcohol
A ____ ____ is a protrusion of a portion of the stomach above the diaphragm into the chest
Hiatal hernia
MNT for a hiatal hernia:
-Small, bland feedings
-Avoid late-night snacks
-Caffeine
-Chili powder
-Black pepper
Dumping Syndrome commonly follows a _____ (Billroth I, II)
Gastrectomy
What symptoms does Dumping Syndrome cause when beginning to eat?
-Cramps
-Rapid pulse
-Weakness
-Perspiration
-Dizziness
Dumping Syndrome occurs when rapidly hydrolyzed carbohydrates enter the _____, and excess water is drawn in to achieve osmotic balance
Jejunum
The water in the jejunum causes rapid ____ in the vascular fluid compartment and a decrease in peripheral vascular resistant
Decrease
When this occurs during Dumping Syndrome, ____ ____ drops, and signs of cardiac insufficiency appear
Blood pressure
About 2 hours after signs of cardiac insufficiency occur, the carbohydrates are digested and absorbed rapidly, which causes blood sugar to rise, stimulating an ____ of insulin
Overproduction
The overproduction of insulin leads to blood sugars to fall below fasting, which is known as ____ or ____ ____
Reactive or alimentary hypoglycemia
A Billroth I, or a _______, attaches the remaining stomach to the duodenum
Gastroduodenostomy
A Billroth II, or a _______, attaches the remaining stomach to the jejunum
Gastrojejunostomy
With a Billroth II (gastrojejunostomy), food bypasses the _____
Duodenum
When food bypasses the duodenum, the secretion of ____ and ____ by the duodenum is reduced
Secretin, pancreozymin
Secretin and pancreozymin normally stimulate the ____, so after a Billroth II, there is little pancreatic secretion
Pancreas
Absorption of ____, which is most rapidly absorbed in the duodenum, and ____, which requires acid for absorption, are adversely affected after a Billroth II (gastrojejunostomy)
Calcium; iron
A Vitamin B12 (cobalamin) deficiency (common after gastric surgery) is caused by a lack of ____ ____, or ___ ___ in the loop of the intestine that is being bypassed
Intrinsic factor; bacterial overgrowth
_____ anemia is caused by B12 deficiency
Pernicious
Pernicious anemia is diagnosed using the ____ test, which looks for intrinsic factor levels
Schilling
____ deficiency is also common after gastric surgery and can also be caused by B12 deficiency because it needs B12 to be transported into the cell
Folate
Folate deficiency and low serum iron, which is a cofactor in folate metabolism, can lead to ____ anemia
Megaloblastic
MNT for s/p gastric surgery:
-Small, frequent meals
-Fluids before or after meals (not during) to slow passage
-Restrict hypertonic concentrated sweets
-50-60% complex carbohydrates
-Protein at each meal
-Moderate fat intake
-B12 injections may be needed
-Lactose may be poorly tolerated due to rapid transport
What deficiencies may develop after a complete gastrectomy?
-Iron
-B12
-Folate
-Calcium
-Vitamin D
-B1 (thiamin)
-Copper
____ is delayed gastric emptying
Gastroparesis
Gastroparesis can be caused by…
-Surgery
-Diabetes
-Viral infections
-Obstructions
Moderate to severe ____ can have detrimental effects of gastric nerves, and may lead to gastroparesis
Hyperglycemia
____ are a class of drug that work to increase stomach contractility and treat gastroparesis
Prokinetics
What are two examples of prokinetic drugs used for gastroparesis?
-Erythromycin
-Metoclopramide
MNT for gastroparesis:
-Small, frequent meals
-May need pureed foods
-Avoid high-fiber foods
-Avoid high-fat foods (liquid fat may be better tolerated)
-Avoid caffeine (acidic)
-Avoid mint (acidic)
-Avoid alcohol (acidic)
-Avoid carbonation
A _____ might occur with gastroparesis due to undigested food or medication
Bezoar
Treatment for a bezoar include ____ or ____ therapy
Enzyme or endoscopic
____ ____ is a rare digestive disease caused by either bacterial, viral, or parasitic infection
Tropical sprue
Tropical sprue is a chronic GI disease that cases ____ ____, and may affect the stomach as well
Intestinal lesions
Tropical sprue causes symptoms like…
-Diarrhea
-Malnutrition
Tropical sprue may also cause deficiencies of ____ and ____ due to decreased hydrochloric acid and intrinsic factor
Folate and B12
____ are typically used for medical treatment of tropical sprue
Antibiotics
MNT for tropical sprue:
-High kcal diet
-High protein diet
-IM B12 injections
-Oral folate supplements
Non-tropical sprue is similar in nature to ____ ____ or ____-___ ____
-Celiac disease
-Gluten-induced enteropathy
____ refers to storage proteins (prolamins)
Gluten
What are some examples of prolamins?
-Gliadin (wheat)
-Secalin (rye)
-Hordein (barley)
-Avenin (oats)
Celiac’s have a reaction to_____, which affects the jejunum and ileum (proximal intestine)
Gliadin
Celiac disease can cause…
-Malabsorption (leads to loss of fat-soluble vitamins)
-Macrocytic anemia
-Weight loss
-Diarrhea
-Steatorrhea
-Iron-deficiency anemia
Those with non-tropical sprue, Celiac, or gluten-induced enteropathy need a gluten (gliadin)-free diet which restricts…
-Wheat
-Rye
-Oats (if harvested and milled with wheat)
-Barley
-Buckwheat (may be contaminated)
-Bran
-Graham
-Malt
-Bulgur
-Couscous
-Durum
-Orzo
-Thickening agents
What things are acceptable for a gluten-free diet?
-Corn
-Potato
-Rice
-Soybean
-Tapioca
-Arrowroot
-Carbon bean
-Guar gum
-Flax
-Amaranth
-Millet
-Teff
-Quinoa
Constipation is sometimes due to an ____ colon (weakened muscles)
Atonic
MNT for constipation:
-High-fiber diet
-High fluid
-Exercise
____ is the presence of diverticula, or small sacs that protrude through the intestinal wall due to structural weakness
Diverticulosis
Diverticulosis is related to ____ and lifelong intra-colonic pressures
Constipation
MNT for diverticulosis is a ___-___ diet to increase volume and weight of residue and provide rapid transport
High-fiber
_____ is when diverticula become inflamed as a result of food and residue accumulation and bacterial action
Diverticulitis
MNT for diverticulitis:
-Clear liquids
-Low-residue or elemental
-Gradual return to high fiber
____ provides indigestible bulk and promotes intestinal function
Fiber
Dietary fiber includes non-digestible ___ and ___
Carbohydrates and lignans
Dietary fiber binds _____ and ____ fecal bulk
Water; increases
Dietary fiber is found in things like…
-Legumes
-Wheat bran
-Fruits
-Vegetables
-Whole grains
Oat bran and ____ fiber decrease serum cholesterol by binding bile acids, converting more cholesterol into bile
Soluble
Soluble fibers ____ gastric emptying, absorb water, and form a soft gel in the small intestine
Delay
Soluble fibers slow the passage of food through the GI tract and inhibit the absorption of ____ and _____
Glucose and cholesterol
What are sources of soluble fiber?
-Fruits
-Vegetables
-Legumes
-Oats
-Barley
-Carrots
-Applies
-Citrus fruits
-Strawberries
-Bananas
Adequate intake of fiber for men is ____ g, and for women, it is ____ g per day
38; 25
A high-fiber diet may increase needs for…
-Calcium
-Magnesium
-Phosphorus
-Copper
-Selenium
-Zinc
-Iron
A low-fiber diet may cause _____
Constipation
_____ is inflammation of the stomach
Gastritis
Gastritis may lead to…
-Anorexia
-Nausea
-Vomiting
-Diarrhea
MNT for gastritis:
-Clear liquids
-Advance diet as tolerated
-Avoid gastric irritants
What are two inflammatory bowel diseases?
-Crohn’s Disease
-Ulcerative colitis
Crohn’s Disease is also known as ____ ____
Regional enteritis
Crohn’s Disease affects the ____ ____
Terminal ileum
Crohn’s disease causes symptoms like…
-Weight loss
-Anorexia
-Diarrhea
Crohn’s disease can also cause B12 deficiency, which leads to ____ ____
Megaloblastic anemia
Crohn’s disease can also lead to ___-___ anemia due to blood loss and decreased absorption
Iron-deficiency
Ulcerative colitis is an ulcerative disease of the _____
Colon
Ulcerative colitis begins in the ____
Rectum
Ulcerative colitis causes symptoms like…
-Chronic bloody diarrhea
-Weight loss
-Anorexia
-Electrolyte (Na, K) disturbances
-Dehydration
-Anemia
-Fever
-Negative nitrogen balance
Treatment for IBD includes maintaining fluid and electrolyte balance, sometimes accomplished with ____-____ agents
Anti-diarrheal
One example of an anti-diarrheal is _____
Sulfasalazine
MNT for acute Crohn’s flare-ups:
-Bowel rest
-Parenteral nutrition or minimal residue
For acute Ulcerative Colitis, an ____ diet (EN) may be needed to minimize fecal volume
Elemental
For those with IBD, energy needs should be based on current ____
BMI
For those with IBD, fat only needs to be restricted for those experiencing _____
Steatorrhea
MNT for IBD:
-May need supplementation of water-soluble vitamins, as well as iron and folate
-Assess Calcium, Magnesium, and Zinc
-Watch lactose
-Small, frequent feedings
-High fat may improve energy imbalance
-Protein at each meal
-Chewable MVI
Coconut oil derived ____ ____ is an easy-to-oxidize source of energy and may improve bowel damage
MCT oil
When IBD is in remission or under control, a ___-___ diet should be initiated to stimulate peristalsis
High-fiber
____ ____ ____ causes chronic abdominal discomfort, altered intestinal motility, and bloating
Irritable bowel syndrome
The goals for treating IBS:
-Adequate nutrition intake
-Tailor patterns to specific GI issues
Those with IBS should avoid…
-Gas-forming foods
-Swallowing air during eating
It is recommended that those with IBS should use a ___ ___ to track intake, emotions, environment, and symptoms to determine any trigger foods
Food diary
A ____-____ diet may help eliminate possible sources of discomfort in those with IBS
Low-FODMAP
_____, which contains menthol, a smooth muscle relaxant, may relax the lower esophageal sphincter which can then reduce reflux, cramping, and pain for those with IBS
Peppermint
Lactose intolerance is due to a ____ deficiency
Lactase
Normally, lactase splits lactose into ____ and ____
Glucose and galactose
In the absence of lactase, lactose remains intact, exerting _____ _____
Hyperosmolar pressure
Due to the hyperosmolar pressure caused by lactose, ____ is drawn into the intestine to dilute the load
Water
The excess water drawn into the intestine causes…
-Distention
-Cramps
-Diarrhea
Bacteria then ferment the undigested lactose, releasing ____ ____ gas
Carbon dioxide
Lactose intolerance is detected by a ____ ____ test
Breath hydrogen
The breath hydrogen test works because hydrogen is produced by ____ ____ on lactose, absorbed into the bloodstream, and exhaled in 60-90 minutes
Colonic bacteria
The lactose tolerance is conducted by providing someone with an oral dose of lactose (up to 50 g) after a fast; if intolerant of lactose, blood glucose will rise < ____ mg/dl above fasting (flat curve), if tolerant, blood glucose will be above that much (normal curve)
25
MNT for lactose intolerance:
-Lactose-free
-No animal milk or milk products
-No whey
-Calcium and riboflavin supplements are recommended
-Yogurt and small amounts of aged cheese may be tolerated
What two products are okay in someone with lactose intolerance?
-Lactate
-Lactalbumin
Treatment for acute diarrhea in infants and children requires aggressive and immediate _____ (replace fluids and electrolytes lost in stool)
Rehydration
For infants and children with acute diarrhea, WHO recommends a ____ ____ solution
Glucose electrolyte
A glucose electrolyte solution is as effective as _____ rehydration and much cheaper and ingredients are easily attainable (reintroduce oral intake within 24 hours)
Parenteral
Chronic nonspecific infantile diarrhea causes no significant _____
Malabsorption
For an infant with chronic nonspecific infantile diarrhea, consider the ratio of ____ to ____ calories as well as the volume of ingested liquids (some are inadvertently put on a low fat diet or consume too many fluids or too many calories)
Fat to carbohydrate
MNT for chronic nonspecific infantile diarrhea:
-Provide 40% of calories from fat
-Limit fluids
-Restrict or dilute fruit juices with high osmolar loads (gapes, apple)
No fruit juice up to age ____, those up to 6 should be limited to 4 ounces per day
1
For adults with diarrhea, remove the cause and replace lost ___ and ____, especially those high in sodium and potassium
Fluid and electrolytes
In order to decrease diarrhea, ___ ___ needs to be decreased
Gastric motility
MNT for reducing gastric motility:
-Avoid clear liquids
-Avoid foods high in lactose, sucrose, and fructose
-Avoid caffeine and alcohol
-Avoid high-fiber foods
Another way to decrease diarrhea is to _____ the consistency of stool
Thicken
MNT for thickening the consistency of stool:
-Banana flakes
-Apple powder
-Pectin sources
If an adult is having diarrhea, it is important to repopulate the GI tract with normal ____
Flora
_____ are food components (pectin, fructose, oats, whole grains) that promote the growth of healthy bacteria
Prebiotics
Prebiotics exist in _____
Fructooligosaccharides
Examples of prebiotic foods:
-Onion
-Garlic
-Banana
-Artichoke
-Asparagus
-Chicory
_____ are sources of bacteria that are used to reestablish bacterial gut flora
Probiotics
Probiotics can be found in ____ dairy foods like yogurt, kefir, and aged cheese
Fermented
Probiotics can also be found in other fermented foods with beneficial live cultures, like…
-Kimchi
-Miso
-Tempeh
-Sauerkraut
If needed, adults with diarrhea can stimulate the GI tract with a diet…
-Low in fiber
-Low in fat
-Lactose-free
Steatorrhea is a consequence of ____
Malabsorption
Normal stool has between 2-5 grams of fat, stool with over ___ g is indicative of malabsorption
7
MNT for steatorrhea:
-High protein
-High complex carbohydrates
-Fat as tolerated
-Vitamins (especially fat-soluble)
-Minerals
-MCT (rapidly hydrolyzed in the GI tract)
The consequences of ____ ____ ____ are associated with significant resections of the small intestine
Short bowel syndrome
Short bowel syndrome can cause things like…
-Malabsorption
-Malnutrition
-Fluid and electrolyte imbalances
-Weight loss
The severity of short bowel syndrome reflects the…
-Length and location of resection
-Age of patient
-Health of remaining tract
The loss of the ____ (especially the distal 1/3), the ___ ____, and the ____ are of particular concerns with short bowel syndrome
Ileum, ileocecal valve, colon
Most digestion takes place in the first ____ cm of the intestine (in the duodenum and upper jejunum); what remains are small amounts of sugar, starches, fiber, and lipids
100
If someone has a jejunal resection, the ____ can adapt and take over the jejunal functions
Ileum
Significant resections of _____ produce major complications
Ileum
The distal ileum is responsible for the absorption of…
-Vitamin B12
-Intrinsic factor
-Bile salts
The ileum normally absorbs a major portion of ____ in the GI tract
Fluid
Patients with ileal resection have above-average needs for ____ to compensate for excessive losses in the stool
Water
Those with ileal resection should drink at least ___ ___ more than their ostomy output daily
1 Liter
If the ileum cannot recycle bile salts, lipids are not emulsified; this leads to malabsorption of ___-___ ____
Fat-soluble vitamins
Malabsorbed fats combine with calcium, zinc, and magnesium, leading to the production of ____, which impairs absorption
Soaps
Ileal resection may also increase colonic absorption of ____, leading to kidney stones
Oxalates
Those with ileal resections have ____ fluid and electrolyte secretions as well as increased colonic motility
Increased
Loss of the colon causes loss of…
-Water
-Electrolytes
-Salvage absorption of carbohydrates and other nutrients
If someone has loss of the colon, provide ___ ___
Chewable vitamins
Someone with short bowel syndrome might initially receive ____ ____ to restore and maintain nutrition status
Parenteral nutrition
In someone with short bowel syndrome, ____ nutrition should be started early to stimulate growth and be increased over time (continuous)
Enteral
It may take ___ or ____ for someone with short bowel syndrome to transition to oral feedings
Weeks, months
MNT for s/p jejunal resection:
-Normal balance of carbohydrates, protein, and fat
-Avoid lactose
-Avoid oxalates
-Avoid large amounts of concentrated sweets
-Vitamin and mineral supplements
MNT for s/p ileal resection:
-Limit fat
-Use MCT (does not require bile salts, needs less intestinal surface area)
-Supplement fat-soluble vitamins, Ca, Mg, Zn
-Parenteral B12 followed by monthly injections if more than 100 cm of terminal ileum is removed
Functions of the liver:
-Stores and releases blood
-Filters toxic elements
-Metabolizes and stores nutrients
-Regulates fluid and electrolyte balance
____ ____ is a list of major enzymes found in organs and tissues; enzyme levels in the blood are elevated when tissue damage causes them to leak into the circulation
Enzyme profile
What are 4 liver function tests?
-Alkaline phosphatase (ALP)
-Lactic acid dehydrogenase (LDH)
-Aspartate amino transferase (AST, SGOT)
-Alanine aminotransferase (ALT, SGPT)
Normal range for alkaline phosphatase (ALP) is ____-____ U/L
30-120
Alkaline phosphatase (ALP) is elevated in what conditions?
-Liver disease
-Bone disease
Alkaline phosphatase (ALP) is decreased in what conditions?
-Scurvy
-Malnutrition
Lactic acid dehydrogenase (LDH) is increased in what conditions?
-Hepatitis
-Myocardial infarction
-Muscle malignancies
Aspartate aminotransferase (AST) is increased in ____
Hepatitis
Alanine aminotransferase (ALT) is increased in ___ ___
Liver disease
In liver disease, liver enzymes are _____
Elevated
Acute viral hepatitis can cause symptoms like…
-Inflammation
-Necrosis of liver
-Jaundice
-Anorexia
-Nausea
-Fatigue
-Jaundice
Jaundice occurs when ____ ____ are blocked
Bile ducts
Hepatitis A is contracted through the ____-____ route of transmission (this is the type more directly connected to food)
Fecal-oral
Hepatitis B is ____ transmitted
Sexually
Hepatitis C is contracted through ___-___ contact
Blood-blood
Those with acute viral hepatitis should increase their ____ intake to prevent dehydration
Fluid
Care for acute viral hepatitis varies depending on ____ and ____ ____
Symptoms and nutrition status
Those with acute viral hepatitis should get ___-___% of kcal from carbohydrates in order to replenish liver glycogen and spare protein
50-55
Those with acute viral hepatitis should get ___-___ g of protein per kg for cell regeneration and to provide lipotropic agents to convert fat into lipoprotein for removal from the liver
1-1.2
Those with acute viral hepatitis should have ___ to ____ fat intake if tolerated, but those with steatorrhea should get under ____% of kcals from fat
Moderate to liberal; 30
Those with acute viral hepatitis should have small, frequent meals (____-___) because of anorexia
4-6
____ intake should be encouraged for those with acute viral hepatitis due to its antioxidant content
Coffee
Those with acute viral hepatitis should take a ____ with B complex, C, K, and zinc
Multivitamin
If someone with acute viral hepatitis has fluids retention, they should not exceed ___ grams of sodium per day
2
_____ is damaged liver tissue that is replaced by bands of connective tissue which divide the liver into clumps and reroutes many of the veins and capillaries; blood flow through the liver is disrupted
Cirrhosis
With cirrhosis, a protein deficiency may lead to…
-Ascites
-Fatty liver
-Impaired blood clotting
What is the normal route of blood flow?
-Esophageal
-Veins
-Portal vein
-Liver
-Vena cava
Ascites occurs when blood cannot leave the _____
Liver
With ascites, connective tissue overgrowth blocks blood flow out of the liver into the ___ ___
Vena cava
Since blood flow is backed up, the liver expands (can hold an extra liter of blood); when storage capacity has been exceeded, pressure caused by increased blood volume forces fluid to sweat through the liver into the ____ ____
Peritoneal cavity
The fluid that leaks into the peritoneal cavity is almost pure ____ with a high osmolar load, pulling more fluid in to dilute this load; this leads to ___ and ____ retention
Plasma; sodium and water
Low serum ____ may be due to the dilution factor
Albumin
____ ____ occur when blood can’t enter the liver
Esophageal varices
When blood can’t enter the liver, it causes ____ ____
Portal hypertension
Connective tissue overgrowth causes resistance to blood entering the portal vein; the increased pressure forces blood back into ____ veins that offer less resistance; esophageal, abdominal, and collateral veins enlarge
Collateral
Someone with cirrhosis needs adequate to high protein; they should get ___-___ g/kg or ___ g/kg when in stress
0.8-1.2; 1.5
Someone with cirrhosis needs a high calorie intake of ____-____ kcal/kg estimated dry weight or basal energy expenditure + 20%
25-35
Someone with cirrhosis should have a moderate to low-fat diet, with fat making up ____-____% of calories
25-40
_____ oil might be needed for someone with cirrhosis
MCT
For someone with cirrhosis who is experiencing malabsorption, they should get under ____ g of fat per day
30
____ is the preferred fuel in cirrhosis (should include omega 3)
Fat
For someone with cirrhosis, decrease ___ ____ ____ if steatorrhea develops
Long chain triglycerides
If varices are present, someone should follow a ___-___ diet
Low-fiber
If someone has edema or ascites, someone should follow a ___-____ diet (under 2 g)
Low-sodium
With ____, someone should follow a fluid restriction of 1-1.5 L/day depending on severity as well as a moderate sodium intake
Hyponatremia
What vitamins should be supplemented in someone with cirrhosis?
-B complex
-Vitamin C
-Zinc
-Magnesium
-Monitor need for vitamin A and D
____ is involved in the conversion of ammonia to urea; in someone with cirrhosis, there is increased loss in urine
Zinc
What is the progression of alcoholic liver disease?
- Hepatic steatosis
- Alcoholic hepatitis
- Cirrhosis
Alcoholic liver disease is liver injury due to alcohol and the ____ derangements it causes
Metabolic
Alcohol is converted into _____ and excess _____ which disrupts liver metabolism
Acetaldehyde; hydrogen
With alcoholic liver disease, hydrogen replaces ___ as fuel in the Kreb’s Cycle, so fat accumulates in the liver which then leads to fatty liver and increases triglyceride levels
Fat
The shift in the NADH/NAD ratio with alcoholic liver disease inhibits ___-___ of fatty acids and promotes triglyceride synthesis
Beta-oxidation
In what ways does alcohol/alcoholic liver disease cause malnutrition?
-Alcohol replaces food in the diet
-Alcohol causes inflammation of the GI tract and interferes with absorption of B12, vitamin C, folic acid
-Interferes with vitamin activation
-Increases need for B vitamins in order to metabolize alcohol
-Increases needs for magnesium (excreted after alcohol consumption)
-Malnutrition increases alcohol’s destructive effects
You must supplement ____ and ____ ____ for someone with alcoholic liver disease
Thiamin; folic acid
____ and ____ deficiencies in alcoholic liver disease are most responsible for malabsorption
Protein and folate
A thiamin deficiency with alcoholic liver disease causes ____-____ ____
Wernicke-Korsakoff Syndrome
With hepatic failure (ESLD), liver function is decreased to ____% or less
25
With hepatic failure (ESLD), the liver cannot convert ____ into urea, so it accumulates
Ammonia
Symptoms of hepatic failure include…
-Apathy
-Drowsiness
-Confusion
-Coma
Coma caused by hepatic failure is called ____ ____ ____
Portal systemic encephalopathy
____, or involuntary jerking motions, is a sign of impending coma in someone with ESLD
Asterixis
Someone with hepatic failure (non-comatose) should have moderate to high protein diet, up to ____-____ g/kg as tolerated
1-1.5
If someone with ESLD should have _____ protein intake if they have protein-sensitive hepatic encephalopathy
Modest
Someone with end-stage liver disease should get ___-___ kcal/kg
30-35
Someone with ESLD should get ___-___% of their kcal from fat, with MCT if needed
30-35
Someone with ESLD should have a ___ ___ diet if they have ascites and should also get vitamin/mineral supplementation as needed
Low sodium
The altered neurotransmitter theory says that with ESLD, ____ are decreased (they are used for energy), and _____ are increased because the damaged liver is unable to clear them
Branched-chain amino acids (BCAAs); (Aromatic amino acids) AAA
Adding ____ to the diet of someone with end-stage liver disease will add calories and protein, but may not reduce symptoms; they are used when standard treatment is not working and when the patient does not tolerate standard protein
BCAAs
Standard treatment for end-stage liver disease is _____, which is a hyperosmolar laxative that removes nitrogen, along with _____, which is an antibiotic that destroys bacterial flora that produce ammonia
Lactulose; Neomycin
Non-alcoholic fatty liver disease causes _____, or fat build-up in the liver that is not related to alcohol consumption
Steatosis
Non-alcoholic fatty liver disease is most common in what populations?
-BMI 35 or over
-Type 2 diabetics
-Those with metabolic syndrome
Non-alcoholic fatty liver disease can be managed with _____ changes
Lifestyle
What lifestyle changes can be used to treat non-alcoholic fatty liver disease?
-Weight loss (7-10% of starting weight; no rapid weight loss because greater flux of fatty acids to the liver may worsen inflammation and accelerate disease progression)
-Healthful eating (Mediterranean diet, moderate alcohol, avoid sugar-sweetened beverages, coffee may help due to antioxidants)
-Physical activity (150 minutes of moderate-intensity aerobic activity, plus two strength training sessions each week)
_____ is inflammation of the gallbladder
Cholecystitis
Cholecystitis can be caused by an infection, which causes excess water to be absorbed, causing _____ to precipitate out
Cholesterol
When cholesterol precipitates out, ____ can form
Gallstones
Another term for gallstones is _____
Cholelithiasis
Treatment for cholecystitis includes a ____-____ diet
Low-fat
Someone with acute cholecystitis should get ____-___ grams of fat per day
30-45
Someone with chronic cholecystitis should get ____-_____% of kcals from fat
25-30
A ____ is a surgical removal of the gallbladder
Cholecystectomy
After a cholecystectomy, ____ is secreted from the liver directly into the intestine
Bile
MNT for s/p cholecystectomy:
-Limit fat intake for several months to allow the liver to compensate
-Slowly increase fiber to help normalize bowel movement
Pancreatitis causes…
-Inflammation with edema
-Cellular exudate
-Fat necrosis
Pancreatitis may be due to a blockage or reflux of the ____ ____
Ductal system
Pancreatitis causes premature activation of enzymes within the pancreas, leading to _____
Autodigestion
Acute pancreatitis causes a hypermetabolic and hyperdynamic state, leading to increased ____ ____ ____
Basal metabolic rate
MNT for acute pancreatitis:
-Put pancreas at rest by withholding all feedings
-Maintain hydration (IV)
-Progress as tolerated to easily digested foods with low-fat content
-Elemental (pre-digested) enteral nutrition into the jejunum may be tolerated
Chronic pancreatitis causes recurrent attacks of ____ ____ of long duration
Epigastric pain
Someone with chronic pancreatitis should get ____ ____ _____ _____ which is taken orally with meals and snacks to minimize fat malabsorption from lack of pancreatic lipase
Pancreatic enzyme replacement therapy (PERT)
MCT oil can be used in someone with chronic pancreatitis because they do not require ____ ____ for digestion (can add it to mixed dishes, jams, jellies, etc)
Pancreatic lipase
To promote weight gain in someone with chronic pancreatitis, give maximum level of ____ tolerated without an increase in steatorrhea or pain
Fat
If someone with chronic pancreatitis is malabsorbing fat-soluble vitamins, give them in ___-___ form
Water soluble
Parenteral ____ may be provided to someone with chronic pancreatitis because pancreatic protease (which is low in pancreatitis) splits off the vitamin from the carrier
B12
In someone with chronic pancreatitis, pancreatic ____ secretion may be defective so an antiacid may be given to increase the efficiency of PERT
Bicarbonate
In severe, prolonged cases of chronic pancreatitis, ____ ____ may be needed
Parenteral nutrition
What can be done to avoid pain with chronic pancreatitis?
-Avoid large meals with fatty foods
-Avoid alcohol
Cystic fibrosis is a disease of ____ glands
Exocrine
Cystic fibrosis causes secretion of thick ____ that obstructs glands and ducts
Mucous
Cystic fibrosis causes ____ ____ deficiency
Pancreatic enzyme
Those with cystic fibrosis also have high perspiration _____ levels
Electrolyte
Cystic fibrosis can also cause _____ because it affects the transport of chloride across the cell membrane
Malabsorption
For those with CF, use age-appropriate ____ to assess height and weight
BMI
Those with CF may require ____ ___ ___ ____ at meals and snacks
Pancreatic enzyme replacement therapy
Diet for someone with CF should be…
-High protein
-High calorie
-Unrestricted in fat
-Liberal in salt
If someone with CF is growing normally and steatorrhea is controlled, provide calories to cover the ____ for age and sex
RDA
If someone with CF is failing to grow, use BEE x ____ ____ plus disease coefficients
Activity factor
Patients with CF who fail to grow may need ____-___% of normal energy needs
110-200
For those with CF, protein should make up ____-___% of calories because they experience malabsorption due to pancreatic deficiency
15-20
For someone with CF, carbohydrates should make up ___-___% of total calories
45-55
Those with CF need liberal fat intake to compensate for high energy needs; fat should make up ___-___% of total kcal
35-40
Those with CF require a high sodium intake; they need an additional ___-___ g/day in hot weather or with heavy perspiration
2-4
Those with CF should receive age-appropriate doses of ___-___ vitamins and minerals
Water-soluble
What supplements should be provided to someone with CF?
-Zinc
-Water soluble form of fat-soluble vitamins (A and E)
____ blood pressure is the greatest pressure and measures during the contraction; ____ is the least pressure and measures during relaxation
Systolic, diastolic
Hypertension may be ____ (essential), or ____ (due to another disease)
Primary, secondary
Hypertension is classified in stages based on risk of developing ____ ____ ____
Coronary artery disease
Normal blood pressure:
<120/80 mm Hg
Elevated blood pressure:
Systolic between 120-129 AND diastolic under 80
Stage 1 hypertension:
Systolic between 130-139 OR diastolic between 80-89
Stage 2 hypertension:
Systolic at least 140 OR diastolic at least 90
____ is a major factor in the cause and treatment of hypertension
Obesity
Thiazide diuretics may be used to treat hypertension; a common adverse effect is _____
Hypokalemia
What are the four modifiable risk factors in primary prevention and treatment of hypertension?
-Overweight
-High salt intake
-Alcohol consumption
-Physical inactivity
For the management of hypertension, salt restriction of under ____ mg/day should is recommended
2300
The DASH diet recommends…
-Whole grains
-Fruits
-Vegetables
-Low-fat dairy
-Poultry
-Fish
-Moderate sodium
-Limit alcohol
-Decrease sweets
-Calcium-rich foods to meet DRI
The _____ diet can also be used for the management of hypertension
Mediterranean
The Mediterranean diet is high in ___ ____ ____ and ____ fats
Alpha-linolenic acid (omega 3); monounsaturated
What are some types of fats that the Mediterranean diet promotes (high omega 3)?
-Olive oil
-Canola oil
-Soybean oil
-Walnuts
-Almonds
-Pecans
-Peanuts
-Pistachios
What else does the Mediterranean diet promote?
-Fish, poultry, and eggs rather than beef
-Breads
-Fruits and vegetables in abundance
-Beans and legumes
-Yogurt
-Cheese
-Moderate consumption of wine with meals
____, which is an antioxidant in the skin of red grapes, may help lower blood pressure
Reservatrol
What factors increase the risk of atherosclerosis?
-Hypertension
-Obesity
-Smoking
-Elevated blood lipids
-Heredity
Coronary artery disease causes hard, ____ arteries from plaque buildup
Narrow
____ is a deficiency of blood due to obstruction
Ischemia
_____ is the loss of elasticity of blood vessel walls
Arteriosclerosis
A ____ ____ is due to a reduction of coronary blood flow to the myocardium due to a blood clot blocking a narrowed coronary artery
Myocardial infarction
_____ ____ is another term for chest pain
Angina pectoris
____ is a medication that can be given for blood clots
Heparin (blood thinner)
Dyslipidemia describes both…
-High triglycerides
-Low HDL
____ are a type of lipoprotein synthesized in the intestine from dietary fat
Chylomicrons
Chylomicrons transport dietary triglyceride from the gut to the ____
Adipose
Chylomicrons are the ____ density lipoproteins and have the smallest amount of protein
Lowest
VLDL (pre-beta) transport ____ ____ from the liver to the adipose
Endogenous triglycerides
LDL (beta) transports ____ from the diet and liver to all cells
Cholesterol
Small dense LDL (LDL-C) is associated with increased risk; it is _____ to diet
Responsive
Larger buoyant LDL is ____ associated with an increased risk
Not
HDL (alpha) does reverse cholesterol transport; it moves cholesterol from the ____ to the ____ for excretion
Cells; liver
IDL (between pre-beta and beta) is an LDL precursor and causes ____ of other lipoproteins
Catabolism
____ ____ is diagnosed based on having 3 or more risk factors; diagnosis is linked to insulin resistance, which often increases risk for coronary events
Metabolic syndrome
What are the risk factors that the diagnosis of metabolic syndrome is made upon?
-Elevated blood pressure (130 or more systolic, and/or 85 or more diastolic)
-Elevated triglycerides 150 or more
-Fasting serum glucose 100 or more
-Waist measurement 40 inches or more in men or 35 inches or more in women
-Low HDL under 40 in men or under 50 in women
Optimal LDL level is under ____
100
Optimal total cholesterol level is under ____
200
Low HDL cholesterol for men is under ____ and for women it is under ____
40; 50
HDL cholesterol is high if it is ____ or above
60
High ____ levels are independent risk factors for CHD
Homocysteine
Normal triglyceride level is under ____
150
The ___ ___ diet is for the prevention and treatment of cardiovascular disease
Heart Healthy
The heart-healthy diet provides under ___% of total calories from saturated fat
7
The heart-healthy diet provides under ____ mg of cholesterol
200
The heart-healthy diet provides no more than ____ g of sodium
2
The heart-healthy diet promotes:
-Whole grains
-Fruits
-Vegetables
-Low-fat or fat-free dairy
-Unsaturated fats
The heart healthy diet promotes ___-___ g of fiber intake per day, with ___-___ g of soluble fiber
20-30; 5-10
The adult treatment panel (ATP IV) does not focus on specific target levels for LDL, but defines _____ for whom lowering LDL would be most beneficial
Groups
The adult treatment panel recommends a heart-healthy diet and statin therapy for…
-Patients who have atherosclerotic cardiovascular disease
-Patients with LDL of 190 or higher
-Patients with type 2 diabetes who are between 40 and 75 years of age
-Patients with an estimated 10-year risk of cardiovascular disease of 7.5% or higher who are between 40 and 75 years old
____ ____ is when a weakened heart fails to maintain adequate output, resulting in diminished blood flow so fluid is held in tissues (edema); causes dyspnea
Heart failure
With heart failure, there is reduced blood flow to the kidneys which causes secretion of hormones that hold in sodium and fluid, leading to ___ ___
Weight gain
____ is a medication used in heart failure to increase the strength of the heart contraction
Digitalis
Someone with heart failure should limit sodium intake to ___-___ g/day (DASH diet)
2-3
Those with heart failure should also limit fluid intake to ___-___ L/day
1-2
Those with heart failure should get ____-____ g/kg ABW of protein per day for both normally nourished and malnourished patients
1.1-1.4
Energy needs for heart failure is calculated by multiplying _____ by an activity factor
RMR
Activity factor for a sedentary patient with heart failure:
1-<1.4
Activity factor for a low-active patient with heart failure:
1.4-<1.6
Activity factor for an active patient with heart failure:
1.6-<1.9
Activity factor for a very active patient with heart failure:
1.9-<2.5
Use indirect calorimetry to determine RMR; if that is not available, estimate RMR at ____ kcal/kg for normally nourished or ____ kcal/kg for malnourished
22; 24
In someone with heart failure, evaluate ____ status (can be lost with loop diuretics; if low, pyruvate cannot be converted into acetyl CoA for energy, so the heart muscle becomes deprived
Thiamin
What should be supplemented in someone with heart failure?
-DRI for folate and magnesium
-MVI with B12
Those with heart failure should be encouraged to do regular ____ ____
Physical activity
____ ____ is unintended weight loss caused by blood that is backed up into the liver and intestines, causing nausea and decreased appetite
Cardiac cachexia
____ and ____ supplementation may help with cardiac cachexia
Arginine and glutamine
What is the MNT for cardiac cachexia?
-Low saturated fat
-Low cholesterol
-Low trans fat
-<2 g sodium
-High calorie
The _____ is a tuft of capillaries held closely by Bowman’s Capsule; it produces ultrafiltrate which then passes through the tubules
Glomerulus
Bowman’s capsule blocks the passage of ____ ____ ____ and large molecules like protein
Red blood cells
The proximal convoluted tubule is the site of major ____ ____
Nutrient reabsorption
The Loop of Henle maintains ____ and ____ balance
Water and sodium
The distal tubule is responsible for maintaining ____-___ balance
Acid-base
What are the 4 renal functions?
-Filtration
-Absorption
-Excretion
-Secretion
The kidneys make sure red blood cells and protein stay in the blood, all else filters through the ____
Tubules
The kidneys absorb ____% of glucose and amino acids, as well as ___% of water, sodium, and potassium
100; 85
The kidneys excrete…
-Wastes
-Urea
-Excess ketones
What types of things do the kidneys secrete?
-Hormones that control blood pressure
-Blood components
-Ions that maintain acid-base balance
Vasopressin, also known as ____ ____, is secreted from the hypothalamus and stored in the pituitary gland
Antidiuretic hormone
Vasopressin (ADH) exerts a ____ effect and elevates blood pressure
Pressor
Vasopressin (ADH) increases ____ ____ from the distal and collecting tubules
Water resorption
The syndrome of inappropriate antidiuretic hormone causes (too much vasopressin) causes ______ caused by hemodilution
Hyponatremia
Hyponatremia is treated with a ____ ____
Fluid restriction
Renin is a hormone that causes ____ and elevates blood pressure
Vasoconstriction
Renin stimulates ____ to increase sodium absorption and return blood pressure to normal
Aldosterone
Erythropoietin is a hormone produced by the kidney; it stimulates the bone marrow to produce ___ ___ ___
Red blood cells
In renal disease, someone has decreased ____ and ____ ____
GFR; creatinine clearance
In renal disease, someone has increased serum ____ and ___
Creatinine and BUN
A BUN: Creatinine ratio of over ___indicates a “pre-renal state” in which BUN reabsorption is increased due to acute kidney damage (may be reversible and may not require dialysis)
20:1
A BUN: Creatinine ratio of under ____ suggested reduced BUN reabsorption due to renal damage (may need dialysis)
10:1
Renal ___ ____ describes solutes excreted in 1 L urine; daily fixed load of 600 mOsm
Solute load
Renal solute load mainly measures ___ (60%) and electrolytes (____)
Nitrogen; sodium
Manifestations of renal disease:
-Anemia due to decreased production of erythropoietin
-Upset in blood pressure
-Decreased activation of vitamin D
The kidneys produce the active form of vitamin D which promotes efficient absorption of ____ by the gut
Calcium
Renal ____ can be prevented by drinking 1.5-2 L of fluid in order to dilute the urine
Calculi
Calcium oxalate stones can be prevented with…
-Adequate calcium intake (RDA from dairy or supplements with meals) to bind oxalates
-Low oxalate diet (40-50 mg)
Founds high in oxalates:
-Dark leafy greens
-Chocolate
-Strawberries
-Nuts
-Beets
-Tea
More calcium oxalate stones are seen in patients with diets that are low in ____
Calcium
Minerals that are not oxidized in metabolism leave an ____ (residue) in the urine
Ash
To prevent acidic kidney stones, create an alkaline ash by increasing cations like calcium, sodium, potassium, and magnesium by adding to the diet things like…
-Vegetables
-Fruits
-Brown sugar
-Molasses
To prevent alkaline stones, create an acidic ash by increasing anions like chloride, phosphorus, and sulfur by adding into the diet things like…
-Meat
-Fish
-Fowl
-Eggs
-Shellfish
-Cheese
-Corn
-Oats
-Rye
___ ____ ____ is a sudden shutdown of the kidney with previously adequate capacity; causes decreased GFR and inadequate pre-renal perfusion
Acute kidney injury
Acute kidney injury can result from…
-Burns
-Accidents
-Obstructions
-Severe dehydration
Symptoms of acute kidney injury:
-Oliguria (<500 ml urine)
-Azotemia (increased urea in blood)
With acute kidney injury, at first we should provide…
IV glucose, lipids, protein
Someone with an AKI should get ___-___ g/kg of protein if they are non-catabolic without dialysis as GFR returns to normal
1-1.3
Someone with an AKI should get ___-___ g/kg of protein if they are catabolic and/or if dialysis is initiated
1.2-1.5
Those with AKI should get ____-____ kcals/kg or BEE x ___-___ during hypermetabolic conditions
25-40; 1.2-1.3
Energy expenditure ____ as kidney function declines
Increases
Those with AKI should have a low-sodium diet of no more than ___-___g; must replace loses during diuretic phase
2-3
Those with AKI should get ___-___ mg/kg phosphorus; they made need phosphorus binders
8-15
Those with AKI should get ___-___ grams of potassium based on output, serum potassium, and dialysis
2-3
For someone with AKI, replace fluid output from the previous day plus ____ ml
500
Nephrotic syndrome is also known as ____
Nephrosis
With nephrotic syndrome, there is increased ____ and decreased ____ of VLDL
Synthesis; clearance
Nephrotic syndrome is caused by a defect in the capillary basement membrane of the glomerulus which permits the escape of large amounts of ____ into the filtrate moving through the tubules
Protein
Nephrotic syndrome causes…
-Albuminuria
-Edema
-Malnutrition
-Hyperlipidemia
Those with nephrotic syndrome should get ___-___ g/kg of protein with 50% from high-biological value protein
0.8-1
In someone with nephrotic syndrome, excess protein will be catabolized to ____ and excreted
Urea
Those with nephrotic syndrome should get under ____% of total kcal from fat (low saturated fat)
30
Those with nephrotic syndrome should get no more than ____ mg of cholesterol
200
Someone with nephrotic syndrome should get ____ kcal/kg per day
35
Someone with nephrotic syndrome should have a modest sodium restriction of ___-___ g/day, depending on hypertension and edema
2-3
Those with nephrotic syndrome should get ___-___ g/day of calcium, and supplement with vitamin D as well
1-1.5 (1000-1500 mg)
Those with nephrotic syndrome might need ____ restriction if they have edema
Fluid
People with nephrotic syndrome may have abnormalities in what vitamins/minerals, related to protein loss?
-Iron
-Copper
-Zinc
-Calcium
Chronic kidney disease causes…
-Anemia
-Weakness
-Weight loss
-Nausea
-Vomiting
Anemia with CKD is due to deficient production of the hormone ____ by the kidney
Erythropoietin
What types of diets are recommended for those with CKD?
-Mediterranean diet
-DASH diet
-High fruit and vegetable intake
Those with CKD should get ___-___ kcal/kg per day
25-35
Those with CKD should get under ____ mg of sodium per day
2300
For CKD stages 3-5, we should recommend ___-___ g/protein per kg or 0.28-0.43 g/kg with keto acid to meet goal
0.55-0.6
In those with CKD, adjust ____ intake to maintain normal serum levels
Phosphorus
Those with CKD should get ___-___ mg of total elemental calcium per day
800-1000
____ is generally not restricted in CKD unless serum level is elevated and urine output is under 1 L/day
Potassium
____ is generally unrestricted for CKD stages 1-4
Fluid
What types of supplements should be considered in those with CKD?
-Folate
-B12
-B complex
-Vitamin C
-Vitamin D
The long-term goal of chronic renal failure is to prevent ____
Malnutrition
Those on hemodialysis should get ___-___ g/kg SBW of protein per day
1-1.2
Those on hemodialysis should get ___-___ kcal/kg
25-35
Those on hemodialysis should get under ____ g of sodium per day
2.3
Those on hemodialysis should get ___-___% of their calories from fat, with under ___% from saturated fat
25-35; 7
Those on hemodialysis should get under ____ mg of cholesterol per day
200
Fluid intake for someone on hemodialysis should be based on…
-Body weight
-Urine output
-Residual kidney function
For those on hemodialysis, adjust ____ intake to maintain normal serum range
Potassium
Calcium intake for those on hemodialysis should also be individualized with a maximum of ____ grams of total elemental calcium
2
Those on hemodialysis should get ____-____ mg of phosphorus per day or under ____ mg/kg IBW or SWB
800-100; 17
Those on hemodialysis might need supplementation of what vitamins/minerals to correct deficiencies?
-B6 (pyridoxine)
-Folate
-B12
In someone on hemodialysis, supplement vitamin ___ and ___ if deficient
C and D
Vitamin ___ and ___ supplements are not recommended for those with ESRD
A and E
Those on peritoneal dialysis should get ___-___ g/kg SBW/ABW of protein
1-1.2
Those on peritoneal dialysis should get ___-___ kcal/kg
25-35
Those on peritoneal dialysis should get under ____ g of sodium per day
2.3
____ is generally restricted for those on peritoneal dialysis (generally 2-4 grams)
Potassium
Those on peritoneal dialysis should get under ____ mg of total elemental calcium, including diet and binders
2000
Those on peritoneal dialysis should get ___-___ mg of phosphorus of ___-___ mg phosphorus per g of protein
800-1000; 10-15
Those on peritoneal dialysis should get ___-___ L of fluid depending on output and cardiac status
1-3
___ ____ ____ ____ takes place 4-5x per day
Continuous ambulatory peritoneal dialysis
Vitamins and minerals for those on peritoneal dialysis are the same as for those on ____
Hemodialysis
Type 1 diabetics are insulin ____, and depend on exogenous insulin
Deficient
Type 2 diabetics are insulin ____ with relative insulin deficiency (may or may not need exogenous insulin)
Resistant
One risk factor for diabetes in ____ ____ which causes gray-brown pigmentation in skin folds due to insulin resistance
Acanthosis nigracans
Another risk factor is the presence of ___ ___ ___ antibodies
Glutamic acid decarboxylase
Normal blood glucose is ___-___ mg/dl, or under ____ 2 hours post-prandial
70-100; 140
Impaired fasting blood glucose is between ____-____
100-125
Impaired glucose tolerance is indicated by a 2-hour post-prandial glucose of ___-___
140-199
Diabetes can be diagnosed based on…
-Fasting plasma glucose 126 or over, OR
-Glucose tolerance test of 200 or over, OR
-Symptoms of diabetes plus casual plasma glucose 200 or more
-HgA1C of 6.5 or over
Glycosylated hemoglobin A1C measures the percent of ____ that has ____ attached
Hemoglobin; glucose
Normal A1C is under ___%
5.7
Healthy adults over 65 should have an A1C under ___%; frail elderly under ___% and under
7; 8
The A1C goal for those with diabetics is ____%
7%
Those at risk for diabetes have an A1C of ____-____%
5.7-6.4
A1C is a measure of ___-___ blood glucose control (60-90) days
Long-term
When there is a high concentration of ____, it forms chemical bonds with hemoglobin; the longer blood glucose is high, the higher the A1C
Glucose
____ ____ compares the blood glucose response of a food to a standard glucose load
Glycemic index
The glycemic index is affected by cooking methods and the processing of ____
Starch
As particle size of starch decreases, the glycemic index ____
Increases
What are examples of foods with low glycemic indexes?
-Legumes
-Milk
-Whole grains
-Fruits
-Vegetables
Glycemic ____ is the weighted average of the glycemic indexes of all foods eaten
Load
The use of ___ ___ as a method for weight loss or weight maintenance is not currently recommended
Glycemic index
What are the treatment goals for all diabetics?
-Maintain normal blood glucose (average pre-prandial goal is 70-130, peak post-prandial average <180)
-Optimal serum lipid levels (LDL <100, TG<150, HDL >40M and >50W)
-Blood pressure goal of <130 over <80
-Prevent and treat chronic complications
For type 1 diabetics, along with daily doses of insulin, they should have a ___-___ diet
Carbohydrate-consistent
Those with T1D should integrate ____ therapy with their usual eating habits
Insulin
Monitor blood glucose and adult insulin dose for the amount of ____ eaten
Food
With intensive insulin therapy for T1D, adjust pre-meal insulin dosages based on the total ____ content of each meal, using an insulin-carbohydrate ratio
Carbohydrate
For those with T1D, it might be a good choice to ____ insulin dosage for planned exercise
Reduce
For endurance athletes with T1D, maintaining blood glucose of ___-___ mg/dl is the guideline during activity
120-180
For T2D, strategies focus on…
-Healthy eating
-Physical activity
Goal for T2D is to achieve ___, ___, and ___ ___ goals
Glucose, lipid, blood pressure
Those with T2D should achieve ___ ___ is needed by improving food choices, spacing meals, and exercise
Weight loss
What are two risk factors for the development of gestational diabetes?
-BMI >30
-History of gestational diabetes
At 24-28 weeks of gestation, screen women with a 50-gram oral glucose load; a blood glucose of ____ or over indicates the need for further testing
140
Those with gestational diabetes should get ___-___% of kcals from carbohydrates through 3 small-medium sized meals and 2-4 snacks
40-45
The DRI for carbohydrates during pregnancy is ____ g/day
175
Those with gestational diabetes should get ___-___ grams of carbohydrates at breakfast (less well tolerated), with the rest of the 175 divided evenly throughout the rest of the day
15-30
Gestational diabetes increases the risk of…
-Fetal macrosomia (LGA, 4000-4500 grams)
-Fetal hypoglycemia at birth
Overweight or obese pregnant woman should have a modest ____ ____ to slow weight gain
Calorie restriction
There is no ideal amount of carbohydrates recommended for all individuals with diabetes; the strategy selected should be based on their abilities, preferences, and ____ goals
Treatment
Macronutrient distribution for those with diabetes should be based on ____ for healthy adults (<7% total kcals as saturated fat, trans fat minimized, encourage fiber intake, etc)
DRIs
In diabetics, ____ may be substituted for other carbohydrates
Sucrose
Carbohydrate management approaches include…
-Carbohydrate counting
-Plate method for portion control
-Carbohydrate exchange list
One choice from the starch, fruit, or milk list is equal to ___ grams of carbohydrates and one carb choice
15
Foods with ___-___ grams of carbohydrate count as 0.5 carbohydrate serving/choice
6-10
The consistent carb diet provides ___-___ carbohydrate choices per meal, along with ___-___ carbohydrate choices during snacks
3-5; 0-4
Food lists for diabetes macros for starch/bread choice:
-15 g carbs
-3 g protein
-1 g fat
-80 kcal
Food lists for diabetes macros for a fruit choice:
-15 g carbs
-60 kcal
Food lists for diabetes macros for a fat-free, low-fat milk choice (1%):
-15 g carbs
-8 g protein
-0-3 g fat
-100 kcal
Food lists for diabetes macros for a reduced-fat (2% milk choice:
-15 g carbs
-8 g protein
-5 g fat
-120 kcal
Food lists for diabetes macros for a whole milk choice:
-15 g carbs
-8 g fat
-8 g protein
Food lists for diabetes macros for a non-starchy vegetable:
-5 g carbs
-2 g protein
-25 kcal
Food lists for diabetes macros for 1 oz lean protein source (example: Canadian bacon, poultry, fish, lunch meat):
-7 g protein
-2 g fat
-45 kcal
Food lists for diabetes macros for 1 oz medium-fat protein source (pork, beef, ricotta, mozzarella, eggs, tofu):
-7 g protein
-5 g fat
-75 kcal
Food lists for diabetes macros for 1 oz high-fat protein source (peanut butter, cheese, corned beef):
-7 g protein
-8 g fat
-100 kcal
1 oz/1 choice of plant-based protein provides ____ grams of protein
7
One fat choice provides ____ grams of fat per serving
5
One choice of alcohol provides ____ kcal
100
“Free foods” in terms of the food list for diabetes have under ___ grams of carbohydrates and under ___ calories
5; 20
Bolus insulin is taken _____
Premeal (prandial)
What are examples of rapid-acting insulin?
-Aspart (Novolog)
-Lispro (Humalog)
Rapid-acting insulin (aspart, lispro) should be taken ___-____ minutes before eating
5-15
The usual duration of rapid-acting insulin is ___ hours
4
What is one example of a short-acting insulin:
Humulin R
Short-acting insulin (Humulin R) should be taken ___-___ minutes before a meal (it gives a burst of insulin to cover the meal just about to be eaten)
30-45
One unit of short-acting insulin covers ___-___ grams of carbohydrates
10-15
The duration of short-acting insulin is ___-___ hours
3-6
What are three examples of intermediate-acting insulin?
-NPH
-Humulin N
-Novolin N
-ReliOn
The onset of intermediate-acting insulin (humulin N, Novolin N, reliOn) is ___-___ hours
2-4
The duration of intermediate-acting insulin is ___-___ hours
10-16
Intermediate-acting insulin looks ____ in appearance
Cloudy
What are two examples of long-acting insulin?
-Glargine (Lantus)
-Determir (Levemir)
The onset of long-acting insulin is ___-___ hours
2-4
The duration of long-acting insulin is ___-___ hours
18-24
Long-acting insulin should be started at ___-___ units/kg and should be taken at the same time each day
0.1-0.2
Fixed or conventional insulin therapies used a premixed or fixed insulin plan; ___ or ___ insulin is combined with ___ or ___ acting insulin
Basal (long acting) or intermediate and short or rapid
With multiple daily injections of insulin, ____ insulin is used once or twice daily as well as ___-___ insulin before meals (more common)
Basal (long-acting); rapid-acting
Continuous sustained insulin infusion requires an ____ ____ that provides steady, measured continuous doses of basal, and a surge (bolus) of insulin before meals
Insulin pump
What is an example of a Biguanide medication used for T2D?
Metformin (Glucophage)
Biguanides (Metformin) suppress ____ ____ production
Hepatic glucose
Biguanides (Metformin) are ___-___ therapy for those with T2D
First-line
Biguanides (Metformin) should be taken with ____
Food
When taking Biguanides (Metformin), check ____ levels; deficiency could lead to anemia or peripheral neuropathy
B12
Biguanides (Metformin) are weight ____
Neutral
There is a ____ risk of hypoglycemia with Biguanides (Metformin)
Low
What are two examples of DPP-4 inhibitors:
-Saxagliptin (Onglyza)
-Sitagliptin (Januvia)
DPP-4 inhibitors (Saxagliptin, Sitagliptin) are often used concurrently with ____
Metformin (Biguanide)
DPP-4 inhibitors (saxagliptin, sitagliptin) allow endogenous ____ to stay active longer, which reduces glucose released by the liver overnight and between meals
GLP-1
DPP-4 inhibits like (saxagliptin and sitagliptin) are weight ____
Neutral
What are three examples of SGLT-2 Inhibitors?
-Canagliflozin (Invokana)
-Dapagliflozin (Farxiga)
-Empagliflozin (Jardiance)
SGLT-2 Inhibitors (-agliflozin) target blood glucose-lowering action in the ____ by blocking a protein that returns glucose to the blood after it is filtered
Kidneys
SGLT-2 Inhibitors (-agliflozin) causes more glucose to be excreted in the ____ and less to be reabsorbed
Urine
Monitor ____ function in those on SGLT-2 inhibitors (-agliflozin)
Kidney
SGLT-2 Inhibitors (-agliflozin) may aid in ____ ____
Weight loss
SGLT-2 inhibitors (-agliflozin) can be considered in patients with ____ and ____
Type 2 diabetes, CKD
What are three examples of GLP-1 receptor agonists?
-Exenatide (Byetta)
-Dulaglutide (Trulicity)
-Semaglutide (Ozempic)
GLP-1 receptor agonists (-glutide) slow ____ ___
Gastric emptying
GLP-1 receptor agonists (-glutide) enhance ____ secretion when glucose is high after eating
Insulin
GLP-1 receptor agonists (-glutide) suppresses postprandial ____ secretion
Glucagon
GLP-1 receptor agonists (-glutide) promote fullness and lead to ____ ____
Weight loss
What is one example of a Thiazolidinedione drug?
-Pioglitazone (Actos)
Thiazolidinediones (Actos) increase ____ ____ in muscle
Insulin sensitivity
Thiazolidinediones (Actos) may cause weight ____
Gain
What are two examples of sulfonylurea medication?
-Glimepiride (Amaryl)
-Glyburide
Sulfonylureas (Glimepiride, Glyburide) are secretagogues that stimulate the ____ to release more insulin
Pancreas
Sulfonylureas (Glimepiride, Glyburide) may cause ____ and ___ ___
Hypoglycemia and weight gain
The _____ phenomenon explains the natural increased in early morning blood glucose and insulin requirements due to increased glucose production in the liver after an overnight fast
Dawn
Due to the dawn phenomenon, there is increased need for ____ at dawn
Insulin
Acute ketoacidosis causes ____ due to insulin deficiency or excess carbohydrate intake
Hyperglycemia
Acute ketoacidosis also causes ____ due to polyuria, as well as increased pulse
Dehydration
Acute ketoacidosis causes a ____ odor on the breath due to ketones
Fruity
Treatment for acute ketoacidosis:
-Rehydration
-Insulin
Acute hypoglycemia is due to insulin ____ or lack of ____
Excess; eating
Hypoglycemia causes symptoms like…
-Slow pulse
-Cool, clammy skin
-Hunger
-Weakness
-Shakiness
-Sweating
The treatment for acute hypoglycemia is ____
Glucose
Protocol for treating hypoglycemia:
-Begin with 15 g carbohydrates from glucose tablets to fruit juice (4-5 oz), sugar
-Wait 15 minutes, if still under 70 mg/dl, give another 15 grams of carbohydrates
-Repeat and treat until blood glucose is normal
If hypoglycemic and unresponsible, administer ____ which will mobilize glucose from the liver
Glucagon
Long term complications of uncontrolled diabetes:
-Neuropathy (peripheral and autonomic, gastroparesis)
-Retinopathy (leads to blindness)
-Nephropathy (decreased kidney function)
Postpradial or reactive hypoglycermia is caused by either…
-Overstimulation of the pancreas
-Increased insulin sensitivity
With reactive hypoglycemia, blood glucose falls below normal ___-___ hours after eating (<50 mg/dl)
2-5
Symptoms of reactive hypoglycemia:
-Weakness
-Trembling
-Extreme hunger
The goal with reactive hypoglycemia is to prevent a marked rise in blood sugar that would stimulate more ____
Insulin
To prevent reactive hypoglycemia…
-Avoid simple sugars
-Eat 5-6 small meals per day
-Spread intake of carbohydrates throughout the day
-Protein at RDA levels
Adreanal cortex insufficiency is also known as ____ ____
Addison’s Disease
Addison’s disease causes ____ of the adrenal cortex; symptoms are due to the absence of adrenal hormones
Atrophy
What three hormones are low with Addison’s disease?
-Cortisol
-Aldosterone
-Androgenic
Low cortisol levels cause…
-Glycogen depletion
-Hypoglycemia
Low aldosterone causes…
-Sodium loss
-Potassium retention
-Dehydration
Low androgenic hormones causes…
-Tissue wasting
-Weight loss
MNT for Addison’s disease (low adrenal hormones):
-High protein
-Frequent feedings
-High salt
_____ is the excess secretion of thyroid hormone
Hyperthyroidism
With hyperthyroidism, elevated T3 and T4 causes increased ___ ___ ___, leading to weight loss
Basal metabolic rate
Those with hyperthyroidism have increased ____ needs
Calorie
_____ is the deficiency of thyroid hormone
Hypothyroidism
Those with hypothyroidism have decreased ___ with either normal or low ___; they have decreased basal metabolic rate which leads to weight gain
T4; T3
Those with hypothyroidism might need weight ____
Reduction
A ____ is an enlargement of the thyroid gland due to insufficient thyroid hormone
Goiter
An endemic goiter is caused by inadequate ____ intake
Iodine
MNT for someone with a goiter:
-Iodized salt
-Diet free of goitrogens (cruciferous vegetables)
Gout is a disorder of ____ metabolism
Purine
Gout causes increased serum ____ ____, which then deposits in joints and causes pain and swelling
Uric acid
MNT for gout:
-Achieve and maintain healthy body weight
-Moderate protein intake
-Liberal carbohydrate intake
-Low to moderate fat
-Decrease alcohol
-Liberal fluid
-Avoid high purine foods
What are examples of high-purine foods that should be avoided in someone with gout?
-Anchovies
-Sardines
-Organ meats
-Sweetbreads
-Meat-based gravies and extracts (vegemite, marmite)
Medications used for gout, such as ___ ___ and ____ induce the loss of nutrients
Urate eliminant, colchicine
____ is the lack of an enzyme that normally would have converted galactose-1-phosphate to glucose-1-phosphate
Galactosemia
Galactosemia is treated solely by diet- ____ and ____ free
Galactose and lactose
What is restricted on a galactosemia diet?
-Organ meats (naturally contain galactose)
-MSG extenders
-Milk
-Lactose
-Galactose
-Whey
-Casein
-Dry milk solids
-Curds
-Calcium or sodium caseinate
-Dates
-Bell peppers
What is okay on a galactosemia diet?
-Soy
-Hydrolyzed casein
-Lactate
-Lactic acid
-Lactalbumin
-Pure MSG
A urea cycle defects make the body unable to synthesize ___ from ammonia, resulting in ammonia accumulation
Urea
Symptoms of urea cycle defects:
-Vomiting
-Lethargy
-Seizures
-Coma
-Anorexia
-Irritability
Someone with urea cycle defects should have a ____ restriction (1, 1.5, 2 g/kg) based on tolerance, age, and projected growth rate in order to lower ammonia
Protein
Those with urea cycle defects can use therapeutic formulas to adjust protein composition to limit ____ production
Ammonia
What is one specific example of a urea cycle defect?
-Ornithine transcarbamylase (OTC) deficiency
____ is caused by a missing enzyme, phenylalanine hydroxylase, which would convert phenylalanine to tyrosine
Phenylketonuria (PKU)
PKU causes ____ and its metabolites to accumulate, leading to poor intellectual function
Phenylalanine
PKU is detected with a ____ blood test
Guthrie
For someone with PKU, restrict the substrate _____ and supplement with ____
Phenylalanine; tyrosine
With PKU, tyrosine becomes a ____ amino acid
Conditional
The PKU diet is low in phenylalanine, but still provides enough to promote normal ____
Growth
What are examples of low phenylalanine formulas?
-Phenex-1,2
-Phenyl-free 1,2
Those with PKU should avoid the artificial sweetener, ____
Aspartame
The need for phenylalanine decreases with…
-Increased age
-Infection
A low protein, high carbohydrate diet in those with PKU may lead to ___ ___
Dental caries
Glycogen storage disease is the deficiency of ___-__-___ in the liver
Glucose-6-phosphatase
Glycogen storage disease impairs ____ and ____
Gluconeogenesis and glycogenolysis
With glycogen storage disease, the liver can’t convert ____ into ____, leading to hypoglycemia
Glycogen into glucose
For someone with glycogen storage disease, provide a consistent supply of exogenous glucose with ___ ____ at regular intervals
Raw cornstarch
Those with glycogen storage disorders should have a high ____, low ____ diet
Carbohydrate, fat
Homocystinurias is a treatable inherited disorder of ___ ___ metabolism
Amino acid
Homocystinurias is characterized by severe elevations of ____ and ____ in plasma, and excessive excretion of ____ in urine
Methionine, homocysteine, homocysteine
Homocystinurias is associated with low levels of…
-Folate
-B6 (pyridoxine)
-B12 (cobalamin)
Patients newly diagnosed with homocystinurias receive ____ doses of folate, pyridoxine, and B12
Increased
If someone with homocystinurias does not respond to folate, pyridoxine, and B12, they should be on a low ____, low ____ diet
Protein, methionine
Maple Syrup Urine Disease is an inborn error of metabolism of the ____, which include…
BCAAs; valine, leucine, isoleucine
Symptoms of Maple Syrup Urine Disease:
-Poor sucking reflex
-Anorexia
-Failure to thrive
-Irritability
-Sweet burnt maple syrup odor of sweat and urine
With Maple Syrup Urine Disease, restrict BCAAs to ___-___ mg/day (may use MSUD powder)
45-62
For those with Maple Syrup Urine Disease, provide adequate energy from ___ and ____ to spare amino acids
Carbohydrates and fat
With Maple Syrup Urine Disease, you should include small amounts of ____ to support growth (gelatin may be used)
Milk
What should be avoided in someone with Maple Syrup Urine Disease?
-Eggs
-Meat
-Nuts
-Dairy products
Those with Congenital Sucrase Isomaltase Disease require diet modification of…
-Sucrose
-Starch
-Maltose
Those with Congenital Sucrase Isomaltase Disease can take ____, which is an oral enzyme replacement for sucrase that is taken before and during meals and snacks
Sucrosidase
Those with Congenital Sucrase Isomaltase Disease who take sucrosidase do not need to restrict sucrose in their diet, just ___ and ____
Starch and maltose
Diabetics on sucrosidase need to check blood sugar levels because it converts sucrose into ___ and ___
Fructose and glucose
____ is a condition of inflammation of peripheral joints
Arthritis
Those with arthritis should follow a regular, well-balanced diet with vitamin intake to at least ____
DRIs
Those with arthritis might need to be on bed rest, take aspirin, and reduce weight to decrease ____
Stress
____ anemia may develop in those with arthritis because the inflammation of arthritis prevents the reuse of iron
Normocytic
A ___-___ diet may help those with osteoarthritis; it includes fresh fruits and vegetables and is similar to the Mediterranean diet
Anti-inflammatory
____ is a steroid that may reduce inflammation in those with arthritis
Methylprednisone
There are no specific dietary ____ for those with systemic lupus erythematosus; diet should be tailored to needs
Guidelines
Those with Lupus may have deficiencies of…
-Iron
-Folate
-Calcium
-Fiber
-B12
Those with Lupus may have anemia, but it is not correlated to ____ intake
Iron
Those with Lupus may show symptoms of ____ ____
Celiac disease
____ resorb and remove bone
Osteoclasts
____ reform bone
Osteoblasts
____ is the loss of bone tissue
Osteoporosis
Type I osteoporosis is ____ (within 15-20 years)
Postmenopausal
Type II osteoporosis is ___-___ (>70)
Age-associated
___ and ___ women have more osteoporotic fractures than Black and Hispanic women
Asian and white
Possible causes of osteoporosis:
-Malnutrition (especially protein)
-Lack of exercise
-Decline in estrogen
The result of osteoporosis is a reduction in the amount of bone due to defective ____ absorption (deossification)
Calcium
What are some possible treatments for osteoporosis?
-Hormone replacement therapy
-Weight-bearing exercise
-Vitamin D supplements (400-800 mg)
-Calcium supplements (1200 or more mg; don’t exceed 500-600 mg at one time)
-Adequate protein
-Moderate to low sodium
-5 or more servings of fruits and vegetables
Calcium carbonate should be taken ___ ___, while calcium citrate can be taken with or without food
With food
Spread calcium throughout the day to maximize ____
Absorption
_____ is a reduction in bone density (demineralization)
Osteomalacia
Osteomalacia can be caused by a ___ ___ deficiency
Vitamin D
Treatment for osteomalacia includes…
-Vitamin D supplements
-Calcium supplements
____ causes seizures and altered consciousness
Epilepsy
What are two examples of anticonvulsants used for epilepsy?
-Phenobarbitol
-Phenytoin
Anticonvulsants like phenobarbital and phenytoin (Dilantin) can interfere with ____ absorption (take them apart from food)
Calcium
Those on phenytoin (Dilantin) or phenobarbital should get 1mg of ____ while taking the drug
Folate
Those on phenytoin (Dilantin) or phenobarbital may need supplementation of…
-Vitamin D
-Calcium
-Thiamin (B1)
Provide ____ separate from meals and other supplements
Phenytoin
Enteral feedings decrease the bioavailability of phenytoin, so hold tube feeds for at least ___ hours
2
The ____ diet is high fat, very low carbohydrate (4 grams of fat to 1 gram of non-fat)
Ketogenic
____% of calories should come from fat on the ketogenic diet
90
Those on the ketogenic diet should also get ___g/kg of protein, with the remaining kcal needed for carbohydrates
1
____ ____ behave as inhibitory neurotransmitters
Ketone bodies
Mild ___ is needed to prevent the dilution of ketones with the ketogenic diet
Dehydration
Those on the ketogenic diet need supplementation of…
-Calcium
-Vitamin D
-Folate
-B6 (pyridoxine)
-B12
____ may aid in the absorption of vitamins and minerals for those on the ketogenic diet
Spinach
____ are more ketogenic, and have more rapid metabolism and absorption
MCTs
Cerebral palsy is non-hereditary and causes ____ damage
Brain
Those with cerebral palsy have inadequate control of voluntary muscles, leading to ____
Spasms
The ____ form of cerebral palsy causes difficult, stiff movements; patients have limited activity and are commonly obese
Spastic
MNT for patients with spastic cerebral palsy:
-Low calorie
-High fluid
-High fiber
The ____ (athetoid) form of cerebral palsy cause involuntary wormlike movements; constant, irregular motions lead to weight loss
Non-spastic
MNT for those with non-spastic (athetoid) cerebral palsy:
-High calorie
-High protein
-Finger foods
Traumatic brain injuries cause a systemic inflammatory response, which leads to…
-Hypermetabolism
-Hyperglycemia
-Insulin resistance
-Protein wasting
For those with a traumatic brain injury, enteral feedings into the ___ ___ is usually the best option
Small bowel
For those with traumatic brain injury, provide ___% of estimated resting energy expenditure (REE)
140
Those with traumatic brain injury need ___-___ g/kg of protein
1.5-2
What are some long-term effects of a spinal cord injury?
-Obesity
-Cardiovascular disease
-Pressure ulcers
In the acute phase of a spinal cord injury, energy needs may be ___% below predicted
10
In the acute phase of a spinal cord injury, protein needs are ____ g/kg
2
In the rehabilitation phase of a spinal cord injury, protein needs are ___-___ g/kg
0.8-1
Those in the rehabilitation phase of a spinal cord injury need ___ kcals/kg for quadriplegic and ____ kcal/kg for paraplegic
23; 28
Those with spinal cord injuries may develop ___ ____, which slows transit time
Neurogenic bowel
Those with neurogenic bowel should get 1 ml of fluid/kcal plus ____ ml/day
500
Those with pressure injuries who are also malnourished or at risk for malnutrition, provide ___-___ kcal/kg
30-35
Those with a stage I pressure ulcer should get ___-___ g/kg of protein
1.1-1.2
Those with a stage II pressure ulcer should get ___-___ g/kg of protein, along with adequate fluid
1.25-1.5
Those with a stage III/IV pressure ulcer should get ___-___ g/kg of protein depending on the size of the injury and protein loss from draining wound
1.5-2
Those with a pressure injury should have a well-balanced diet, including good sources of…
-Vitamin A
-Vitamin C
-Zinc
-Copper
The ____ scale is used to stage pressure ulcers
Braden
Classifications of each stage of the Braden scale:
-Stage I: upper layer of skin, red and warm to the touch
-Stage II: broken skin, open sore
-Stage III: damage below skin surface into fat tissue
-Stage IV: large wound, may affect muscles and ligaments
For those with ADHD, provide wholesome foods at ___ ____ with small servings followed by refills
Regular mealtimes
Sugar does not cause ____
Hyperactivity
One medication commonly used in those with ADHD is ___
Adderall
Side effects of Adderall:
-Loss of appetite
-Nausea
-Weight loss
If a child with ADHD is on is underweight, consider high-calorie snacks at ____
Bedtime
Unnecessary food restrictions, possible food aversions, and excessive supplementation can put a child with ___ ___ ___ at risk
Autism spectrum disorder
MNT for those with Alzheimer’s disease:
-Avoid distractions (no TV during meals)
-Regular, consistent mealtimes
-Encourage self-feeding
-Offer one course at a time
-Lower saturated fats
-Soft, calming music
-Finger foods may be helpful
-Avoid dehydration
-Nutrient-dense foods
-May need verbal cues to chew and swallow
Those with Alzheimer’s may have ____, which is a form of aphasia; causes lost words, unable to recall names of common items
Anomia
What nutrients are associated with dementia?
-Folate
-B6 (pyridoxine)
-B12
____ is the decrease in total red blood cell mass due to fewer red blood cells or to smaller cells with less hemoglobin
Anemia
____, ____ anemia causes small, pale red blood cells
Microcytic, hypochromic
Microcytic, hypochromic anemia is caused by ___ ___
Iron deficiency
Microcytic, hypochromic anemia is associated with…
-Chronic infections
-Malignancies
-Renal disease
___, ____ anemia leads to FEW large cells that are filled with hemoglobin
Macrocytic, megaloblastic
Macrocytic, megaloblastic anemia is caused by deficiency of ___ or ____
Folate (B9) or B12
The ____ test is used to test for Pernicious anemia
Schilling
Lab values for microcytic, hypochromic anemia:
-RBC may be normal
-Hemoglobin: Low
-Hematocrit: Low
-Mean corpuscular volume (cell size): Low (<80)
-Mean corpuscular hemoglobin (hgb/cell; color): Low
-Mean corpuscular hemoglobin concentration: Low (<31)
Lab values for macrocytic anemia (B12, folate):
-RBC: Decreased
-Hemoglobin: Low
-Hematocrit: Low
-Mean corpuscular volume (cell size): High (>95)
-Mean corpuscular hemoglobin (hgb/cell; color): High
-Mean corpuscular hemoglobin concentration: Normal (>31)
____ causes defective hemoglobin synthesis
Thalassemia
Thalassemia results in ____, ____, short-lived red blood cells
Microcytic, hypochromic
Those with thalassemia may develop ___ ___
Iron overload
Patients with thalassemia should not avoid ___-rich foods
Iron
Thalassemia is managed with…
-Transfusions
-Chelation therapy
MNT for thalassemia:
-High protein
-B vitamins (especially folic acid/B9)
What foods are high in iron?
-Liver
-Kidney
-Beef
-Dried fruit
-Dried peas and beans
-Nuts
-Leafy, green vegetables
-Fortified grain products
A typical American diet consists of ___ mg of iron per 1000 calories
6
An ___-___ allergic reaction occurs when an antigen enters the body and antibodies react
Ag-Ab
Allergies are an ____ (IgE) medicated reaction to normally harmless food protein
Immunoglobulin
What are the top 9 food allergens?
-Peanuts
-Tree nuts
-Fish
-Shellfish
-Wheat
-Soy
-Eggs
-Sesame
-Milk
What is the most common allergen in infants?
Cow’s milk protein
Potentially allergenic foods, such as eggs and peanuts, should not be ____ beyond 4-6 months of age
Restricted
____ is a genetic predisposition to produce excessive IgE antibodies in response to an allergen
Atopy
Diagnosis of a food allergy is done by…
-Diet history
-Skin tests
-Elimination diet
The ___-___ blood test is specific in identifying children with milk, eggs, fish, and peanut allergies
CAP-FEIA
Double-blind, placebo-controlled food challenges identify food-induced symptoms; this is the ___ ___ for diagnosis of food allergies
Gold Standard
The ____ is an alternative to the skin test; serum is mixed with food on a paper disk; this measures specific IgE antibodies
RAST
____ is a food that is least likely to cause an allergy
Rice
Food ____ are non-IgE mediated; abnormal physiological response, GI, cutaneous, respiratory symptoms; NO antibody production
Intolerances
With fever and infection, excess fluid loss may lead to dehydration which causes symptoms like…
-Hyperglycemia
-Dry, loose, inelastic skin
Treatment for someone with dehydration:
-IV feedings of dextrose and water, then
-Diet high in calories and fluids
Basal metabolic rate increases ___% for each degree F rise in body temperature (normal temp 98.6 F)
7
The goals for someone in critical care/hypermetabolic state:
-Improve outcomes regarding infection rates
-Decrease days in critical care
-Decrease days on ventilator
-Minimize catabolic loss of body protein
-Initiate nutrition support (generally) whenever possible
-Avoid overfeeding
-Control blood glucose (140-180 mg/dl)
Enteral feeding should be initiated for those in critical care within ___-___ hours of admission
24-48
EAL recommends that the average intake within the first week of someone in critical care should be over ___% of total energy needs; consider fish oil supplements and antioxidants with ARDS and acute lung injury
60
With severe burns, there an immediate shock periods with catabolism; basal metabolic rate increases ___-___%
50-100
The first goal with severe burns is to replace ___ and ___ that were lost
Fluid and electrolytes
During the recovery period from a burn, patients have increased calorie needs based on burn size, which is estimated using the ___ ___ ___ which divides the body surface area into percentages
Rule of Nines
The arm including the hand, the head and neck, and the genitalia each account for ___% of the body’s surface area according to the rule of nines
9
The anterior trunk, posterior trunk, and legs including feet each account for ___% of the body’s surface area according to the rule of nines
18
Those with severe burns should get ___-___% of their calories from protein
20-25
Those with severe burns should also get ___-___ g/kg of protein (___g/kg if burns cover less than 10% of body surface area)
1.5-2; 1.2
Those with severe burns should get ____ mg x 2 of vitamin C per day
500
Those with burns should also get supplementation of…
-Water-soluble vitamins
-Vitamin K if on antibiotics
-Zinc for wound healing if deficient
If someone with burns is zinc deficient, provide ___ mg of zinc sulfate
220
Trauma causes a ____, fight or flight response
Hypermetabolic
Those with trauma have accelerated catabolism of lean body mass, leading to negative ___ ___ as protein is catabolized to release glucose for energy
Nitrogen balance
What results from physiologic trauma?
-Hyperglycemia
-Hyperinsulinemia
-Little or no ketosis
-Increased glucagon to increase glucose production from amino acids
During trauma, catecholamines like epinephrine and norepinephrine stimulate hepatic ____
Glycogenolysis
Adrenocorticotropic hormone release during trauma causes the release of ____ which mobilizes amino acids from muscle
Cortisol
Aldosterone is also released during trauma, which causes…
-Renal sodium retention
-Gluconeogenesis
Anti-diuretic hormone released during trauma leads to renal ____ reabsorption
Water
What are other outcomes of trauma?
-Hypovolemia
-Decreased cardiac output
-Drop in body temperature
-Fluid and sodium retention
-Potassium excretion
What minerals are often lost due to trauma?
-Nitrogen
-Sulfur
-Zinc
-Phosphorus
Provide adequate, but not ____ calories for someone during/after trauma
Excessive
In the pre-active stage of dying, there is ____ intake of foods and fluids
Decreased
In the active stage of dying, someone may have an inability to ___, and may have abnormal breathing patterns
Swallow
What are common nutrition-related concerns with cancer patients?
-Protein-calorie malnutrition
-Malabsorption
-Fluid and electrolyte imbalances
For a cancer patient with altered taste acuity, add…
Flavors and seasonings
Cancer patients with meat aversions may require ____ of red meat
Elimination
MNT for oral thrush:
-Avoid spicy, acidic, or strongly flavored food
-Provide bland liquids, soft foods, and chilled/frozen foods
For those with throat and neck cancer, provide enteral feedings through a ____
PEG
Cancer ____, or generalized wasting, is connected to cytokines and tumor necrosis factor (TNF)
Cachexia
____ may be a sign of breast cancer or metastasis to the bone
Hypercalcemia
Radiation therapy can cause side effects such as…
-Loss of taste
-Xerostomia (helps to moisten food)
-Esophagitis
-Diarrhea
-Malabsorption
-Anorexia
____ is the inflammation of the mucosal lining of the oropharynx and the esophagus
Mucositis
With mucositis, avoid…
-Fresh, raw, uncooked foods (offer cold and soft food instead)
____ agents are chemical reagents that have toxic effects
Chemotherapy
What are some common side effects of chemotherapy?
-Nausea
-Vomiting
-Malabsorption
-Anorexia
-Stomatitis (cracks in the corners of the mouth)->caused by riboflavin deficiency
Methotrexate is an anti-_____ drug
Folate
_____ data is an interrelationship between the host, agent, and environment in causing disease
Epidemiological
There is some evidence that ___ and ___ are beneficial in overall cancer prevention (carotenoids, vitamin C)
Fruits and vegetables
There is some evidence that ____ in post-menopausal women decreases the risk of breast disease
Exercise
____ is a term for protein and calorie starvation
Marasmus
Marasmus is based on an ____ diagnosis as there is normal serum albumin and no edema with the condition
Anthropometric
Marasmus causes severe ___ and ___ wasting with a starved appearance
Muscle and fat
With marasmus, ___ ___ and ___ ___ ___ are decreased
Tricep skinfold and arm muscle circumference
____ malnutrition is protein-calorie malnutrition brought on by treatment, hospitalization, or medications
Iatrogenic
Anorexia nervosa causes…
-Distorted body image
-Dramatic weight loss
-Preoccupation with food and weight gain
Therapy for anorexia is ____ and includes weight restoration and psychotherapy
Multidisciplinary
The immediate concern with treating anorexia nervosa is to restore ____ imbalances
Electrolyte
For those with anorexia nervosa, focus on health benefits and ___-___ aspects of food
Life-sustaining
Re-feeding someone with anorexia nervosa increases ___ load (go slowly)
Cardiac
The recommended daily calorie intake for someone with anorexia nervosa ranges from ___-___ (__-__ kcal/kg), but may need to be set 100-300 calories above the current level of intake to support adherence
1000-1600; 30-40
___ ___ is characterized by binge eating followed by purging
Bulimia nervosa
What are some symptoms/consequences of bulimia nervosa?
-Damage to teeth, throat, or esophagus
-Rectal bleeding (laxative abuse)
-Bruised knuckles from purging with fingers
-Low potassium and chloride levels
For those with bulimia, encourage ____ intake of three meals and 2-3 snacks daily; eat every 3-4 hours and recognize hunger cues
Structured
For those with bulimia, each meal should include a ___ source, a healthy ___ source, and a ___ ___ source
Protein; fat; complex carb
Those with bulimia should be encouraged to eat ___, and drink adequate water and fluids
Slowly
What are the three BMI classifications of obesity?
-Class I: 30-34.9
-Class II: 35-39.9
-Class III: 40+
In children, if BMI for sex and age is over at the ___ percentile or above, they are classified as obese
95th
There are ____ calories per pound of body weight
3500
To lose 1 lb of fat per week, reduce ____ calories per day
500
Early rapid weight loss during a diet is ___, as liver glycogen is utilized
Water
Treatment for obesity includes…
-Reduced caloric intake
-Exercise
-Behavior modification
A realistic weight loss goal can be…
-Up to 2 lb per week
-Up to 10% of baseline body weight
-Total reduction of 3-5% of baseline weight if cardiovascular risk factors are present
For women, calories can be restricted to ___-___ kcal/day, or ___-___ for men
1200-1500; 1500-1800
Calories can be restricted ___-___/day
500-750
Weight loss can also be achieved by following one of the evidence-based diets that restrict certain food types in order to create an ___ ___ by reduced food intake
Calorie deficit
Small, ___-___ changes can also help with weight loss such as changes in sugar-sweetened beverage intake
Food-based
Meal replacements for weight loss may be recommended if the client has difficulty with ___ ___
Portion control
For weight loss, ___-___ or more per week of phsyical activity is recommended; for weight maintenance, ___-___ is recommended
150-420; 200-300
Orlistat is a weight loss medication that works by inhibiting ____
Lipase
Orlistat should be taken with a diet with ___% of calories coming from fat
30
Those on Orlistat should take ___ supplements
Vitamin
Lorcaserin is a weight loss medication that is an agonist of ____
Serotonin
Lorcaserin works to enduce weight loss by enhancing ____
Satiety
Phentermine/Topiramate work as an ___ ____
Appetite-suppressant
Phentermine/Topiramate cause the release of ____
Norepinephrine
Weight ____ is usually recommended for overweight children 2-5 years of age with a multi-component weight loss management intervention with active participation of the parent
Maintenance
Weight loss may be recommended for children if a serious ____ ____ is present
Medical condition
Research does not support the _ weight loss theory which is the belief that localized exercise reduces fat stores in the active area
Spot
When a dieter reaches a plateau, ___ ___ ___ has dropped to reflect the loss
Basal metabolic rate
Someone is “healthy obese” if they have elevated ___ and normal to low ___
LDL; HDL
Bariatric surgery treatment is used for those with…
-Class III obesity with a BMI of 40 or more
-BMI of 35 or greater with co-morbidities
Gastric bypass permanently alters the ___ of the GI tract
Anatomy
Gastric bypass reduces the amount of food that can be eaten at one time and produces ___ ___
Early satiety
Roux-en-Y reconstructs the ___ ___ to resemble the letter Y
Small intestine
Roux-en-Y creates a small gastric pouch connected directly to the ___
Jejunum
___ ___ may develop in those with Roux-en-Y due to the lower portion of the stomach being removed
Dumping syndrome
What supplements should be taken by someone after Roux-en-Y?
-Calcium: 1200-1500 mg (divided doses)
-Vitamin D: 3000 IU
-Iron: 45-60 mg (taken apart from calcium)
What may be a sign of iron deficiency in those s/p Roux-en-Y?
Chewing ice
Patients who have a Roux-en-Y have increased ___ needs
Protein
What supplements must be taken for life in someone with a Roux-en-Y?
-Mulitvitamin/multimineral supplement with 100% DRI for vitamin K, zinc, thiamin, folic acid, copper, biotin, iron
-Many require B12 supplementation in addition to that in the MVMM
The sleeve gastrectomy removes ___% of the stomach
80%
With a sleeve gastrectomy, the ___ pathway is not altered
Food
Those with a sleeve gastrectomy should take vitamin supplements, monitor levels of…
-Iron
-Calcium
-Vitamin D
The laparoscopic adjustable gastric banding creates a small gastric pouch using a ___-___ inflatable band
Fluid-filled
The gastric band is adjusted to alter the size of the opening and is fully ____
Reversible
The gastric band restricts the amount of food eaten at ___ time
One
The gastric band causes no surgery-induced ____ of nutrients; deficiencies are linked to decreased food intake and decreased food tolerance
Malabsorption
Those with the gastric band should eat ____, sip drinks, not use straws, and avoid carbonation
Slowly
Prader-Willi syndrome is caused by a deletion of chromosome ___
15
Prader-Willi is a congenital disorder that causes subnormal ___ ____ ___ and supra-normal ___ ___
Lean body mass; body fat
With Prader-Willi, ____ levels are elevated which stimulates growth, hormone secretion, increased appetite and intake, and fat mass deposition
Ghrelin
Those with Prader-Willi do not sense ____ and also have decreased energy requirements
Satiety
Those with Prader-Willi may experience…
-Obesity at 2-3 years of age
-Hypogonadism
-Muscle hypotonia
-Failure to thrive
-Short stature
The best treatment for Prader-Willi is to control ___ ___
Food intake
Dental ___ are caused by bacterial enzymes that ferment carbohydrate deposits on plaque; enzymes produce acids that demineralize surface
Caries
What are some types of foods that have a low cariogenic potential?
-High protein, moderate fat, minimal concentration of fermentable carbohydrates
-Strong buffer
-High mineral content (Ca, P) and pH >6 stimulate saliva
Examples of low cariogenic foods:
-Cheese
-Nuts
-Meat
Sugar ____ (sorbitol, xylitol, mannitol) do not promote tooth decay
Alcohols
Flouride can control caries; supplement starting at 6 months of age if the level in the water supply is under ___ ppm
0.3
____ (mottled teeth) occurs when teeth are exposed to excessive fluoride
Fluorosis
For intants age 0-6 months, fluoride supplemented is ___ ___ ( use fluoridated water if available)
Not recommended
For infants/toddlers 6-24 months, use ___ water (only use oral supplements if prescribed)
Fluoridated
____ should not be used until the child can spit it out
Toothpaste
Children 2-3 years of age should use fluoridated water or supplements as recommended, as well as ___ ___ (pea-sized amount)
Fluoride toothpaste
Infants should not sleep with a bottle due to baby bottle ___ ___ (early childhood caries)
Tooth decay
____ is inflammation of the mouth
Stomatitis
Those with stomatitis should avoid…
-Very hot or very cold foods
-Spices
-Sour/tart foods
-Alcohol
Those with stomatitis should rinse their mouth with ___ ___ after meals
Lukewarm water
One way to deal with esophagitis is by decreasing ___ ___
Gastric acidity
Those that have esophagitis/reflux should have small meals that are…
-Low fat
-Bland
-Low fiber
____ is painful swallowing
Odynophagia
A ____ is a lump in the throat
Globus
____ is a disorder of lower esophageal sphincter motility (it does not relax and open upon swallowing)
Achalasia
Achalasia causes ___, or difficulty swallowing
Dysphagia
IDDSI categorizes dysphagia diets into 8 levels ranging from __-__
0-7
IDDSI Level 0 is…
Thin like water; can flow through a straw
IDDSI level 1 is…
Slightly thick; can still flow through a straw
IDDSI level 2 is…
-Mildly thick; sippable
IDDSI level 3 is…
-Liquidized: spoon or cup, no lumps
-Moderately thick: spoon or drunk from a cup, no lumps, effort with wide straw
IDDSI level 4 is…
-Extremely thick, pureed; eaten with a spoon (not out of cup or with a straw)
-Pureed: spoon, no sticky
IDDSI level 5 is…
-Minced and moist
-Minimal chewing, biting is not required
-Lumps able to be mashed with tongue
-Avoid hard, dried, tough food
IDDSI level 6 is…
-Soft, bite-sized
-Able to chew bite-sized pieces
-Knife is not required
IDDSI level 7 is…
-Regular, easy to chew
-Can bite off and chew soft, tender pieces
MNT for GERD:
-Avoid eating before bed
-Avoid soda
-Avoid caffeine
-Avoid acidic food
-Small, low-fat meals
-Liquids empty more rapidly
Pregnancy-induced hypertension progresses from ___ to ___
Pre-eclampsia, eclampsia
Eclampsia may cause…
-Hypertension
-Edema of the face and hands
-Proteinuria
-Rapid weight gain after the 20th week
-May have convulsions
Eclampsia is more frequently found in women with…
-Lack of prenatal care
-Poor diets
-Poor protein and calcium intakes
A ____ restriction is NOT recommended for prevention or treatment of pre-eclampsia/eclampsia; it is needed to maintain normal levels in plasma during large prenatal expansion of tissues of fluid
Sodium
Sodium intake during pregnancy should not be less than ___ mg/day
2300
There is a proposed association between pregnancy-induced hypertension and ____ deficiency
Calcium
Hyperemesis gravidarum causes…
-Severe nausea and vomiting
-Acidosis
-Weight loss
Treatment/management of hyperemesis gravidarum:
-Bed rest
-Frequent, small amounts of carbohydrates
-Correct fluid and electrolyte imbalance
What nutrition side effects can HIV/AIDS cause?
-Diarrhea
-Malabsorption
-Nausea/vomiting
-Weight loss
The nutrition goals for someone with HIV/AIDS include…
-Preserve lean body mass
-Prevent weight loss
-Prevent HIV wasting
Encourage those with HIV/AIDS to be physically active for ___ mins per day ___ days per week
20; 3
Nutrient needs for someone with HIV/AIDS should be BEE x ___ for those that are symptomatic (based on DRI)
1.3
Protein needs for someone with asymptomatic HIV/AIDS is ____ g/kg, or up to ___-___ if wasted lean body mass
0.8; 1.2-2
Those with HIV/AIDS should get standard doses of ____ if dietary intake is insufficient
Micronutrients
If someone with HIV/AIDS has diarrhea, what can be done?
-Increase soluble fiber
-MCT oil
-Electrolyte replacement beverages
Those with HIV/AIDS should follow a low-bacteria ____ diet and avoid raw foods
Neutropenic
HIV-infected women should be instructed not to ___-___
Breast-feed
What are 2 examples of nucleotide nucleoside reverse transcriptase inhibitor (NRTI) drugs?
-Retrovir
-Zidovudine
NRTI drugs used for HIV/AIDS have adverse effects like…
-Anemia
-Loss of appetite
-Nausea
-Dysphagia
HIV-associated ____ syndrome may develop from treatment
Lipodystrophy
HIV-associated lipodystrophy syndrome causes…
-High cholesterol
-High triglycerides
-Insulin resistance
-Changes in body fat distribution
HIV-associated lipodystrophy and edema can mask significant losses in ___ ___ ___ seen in those with HIV/AIDS
Lean body mass
Increasing dietary ____ can help decrease insulin resistance and reduce the risk of fat deposition
Fiber
Nutritional ____ should not be routinely recommended and herbal supplementation should be discouraged as adjuvant therapy to conventional treatment for HIV/AIDS
Supplementation
Use of Vitamin C or St. John’s Wort in someone with HIV/AIDS can result in ___ ___
Drug resistance
___ ___ medicine therapies are not inert and may have profound consequences
Complementary alternative
Those with pediatric HIV should have a diet that is…
-High protein
-High calorie with supplements needed for weight gain
Energy needs for those with pediatric HIV should be calculated using general guidelines plus appropriate ___ ___
Stress factors
Those with pediatric HIV should get multivitamins/minerals at doses __-__ times the RDA or DRI
1-2
What are two examples of COPD that cause persistent obstruction of airflow?
-Emphysema
-Chronic bronchitis
With emphysema, air sacs (alveoli) lose ____
Elasticity
Those with emphysema are often…
-Older
-Thin
-Cachectic
Those with emphysema have difficulty ____; air pocket walls expand, thin out, and collapse
Exhaling
With chronic bronchitis, there is excess ____ production and chronic productive cough
Mucous
Symptoms of COPD include…
-Weight loss
-Emaciation
-Anorexia
It is important for those with COPD to maintain appropriate ____ and ___
Bodyweight and composition
Those with COPD should avoid overfeeding (over ___ kcal/kg) to avoid excessive CO2 production (routine use of high fat, low carbohydrate formula is NOT warranted)
35
Those with COPD should get small, frequent meals that are easy to ____ and ____, along with nutrient-dense supplements
Prepare and eat
In those with COPD, supplementation with vitamin ___ improved exacerbation outcomes in those with serum 25(OH) D levels of 10 ng/ml or lower
D
With acute respiratory distress syndrome or respiratory failure, the lungs are no longer able to exchange ____
Gases
Acute respiratory distress syndrome or respiratory failure leads to ____ and increased energy needs
Hypermetabolism
Those with acute respiratory distress syndrome or respiratory failure are generally severely ____
Underweight
Goals for those with acute respiratory distress syndrome or respiratory failure include:
-Meet basic nutritional requirements
-Maintain stable weight
-Facilitate weaning from mechanical ventilation without exceeding capacity to clear carbon dioxide
For those with acute respiratory distress syndrome or respiratory failure, provide ___ but not excessive calories; avoid excess non-protein calories
Adequate
For those with acute respiratory distress syndrome or respiratory failure, provide enteral formula that contains ___ and ___, as well as enhanced levels of antioxidant vitamins
EPA, GLA
Protein needs for those with acute respiratory distress syndrome or respiratory failure are ___-___ g/kg in order to maintain lead body mass
1.5-2
What are factors related to mental/behavioral health and addiction that are cause for a nutritional consult?
-Prescription for antipsychotics (Clozapine, Olanzapine, Risperidone, Quetiapine)
-BMI of 18 or below (possible inadequate intake)
-Paranoia regarding food resulting in severe food restriction
-Suspicion that functional level, social or financial factors are compromising food intake
-Alcohol or drug abuse or eating disorder
With antipsychotic medications, determine history of usual weight and any weight grain; if weight gain is ___% above baseline, recommend referral for weight management; a weight gain above ___% is a clinically meaningful gain
5; 7
____ is common among drug addicts because their prime concern is their next drug dose; food may be secondary
Malnutrition
Injection drug use exerts stress on the ___ system, increasing needs for nutritional antioxidants
Immune
Drug addicts may be socially marginalized and ____ (partly due to the cost of drugs)
Impoverished
Cocaine, amphetamines, and ecstasy may be used in Bulimic patients to reduce ___ for desired weight loss or control
Appetite
Nutrition intervention for drug addiction should address the person in a ___ manner with psychosocial support, including family members; group process is known to have positive outcomes for nutrition education
Holistic
Those with a drug addiction should have a moderate or discontinued ____ intake; ingestion releases dopamine and may substitute for the dopamine release previously available from use of many drugs which results in mood fluctuations and weight gain
Sugar
Stable ____ levels are shown to decrease drug cravings and reduce relapse potential
Glucose
Those with a drug addiction should also have moderate or discontinued ____ intake; it reduces mood stability by inducing the fight or flight response
Caffeine
Those with a drug addiction should have a diet that is high in…
-Complex carbohydrates
-Protein
-Fiber
Those with a drug addiction should have a diet with moderate to low ___ intake
Fat
Those with a drug addiction should get ___ well-spaced meals per day with 1-3 healthy snacks
3
Energy needs for someone with a drug addiction are ___-___ kcal/kg
30-35
Protein needs for someone with a drug addiction are ___-___ g/kg
1-2
Encourage ____ intake, especially water, between and with meals for those with a drug addiction
Fluid
Standard ____ enteral nutrition formula is used for those with normal GI function
Polymeric
Most standard polymeric formula provides ___-___ kcal/cc
1-1.5
____ may be added to standard polymeric formula as an emulsifier
Lecithin
Standard polymeric formulas are initiated at full strength at a rate of ___-___ ml/hour
10-40
Advance standard polymeric ___-____ ml every 8-12 hours over the next 24-48 hours until goal rate is achieved
10-20
____ enteral products allow you to mix individual components and add flexibility
Modular
_____ formulas are made with whole foods
Blenderized
When using a blenderized formula, a large ___ tube must be used
Bore
Blenderized formulas have thick, intact protein and are high ____
Residue
The least expensive enteral formulas are…
-Intact protein (not pre-digested)
-Isotonic (osmolality is close to that of blood)
____ and ___ may be added to standard polymeric formulas to stimulate the production of beneficial bacteria and may help resist C. diff
Fructooligosaccharides (prebiotics) and fiber
____, chemically defined enteral formulas are used in those with malabsorption
Elemental
Elemental formulas contain ___-___ protein or amino acids, glucose or sucrose, LCT and MCT, vitamins, minerals, and electrolytes
Pre-digested
Elemental enteral formulas are absorbed in the ___ ____
Proximal intestine
Elemental formulas are ____ or no-residue
Low
Elemental formulas do not require ___ ___ for absorption
Pancreatic enzymes
Elemental formulas are ____ osmolality and generally have poor taste
High
Elemental formulas are used for those who…
-Have compromised GI function
-Have an inability to digest and absorb
What are three examples of elemental formulas?
-Alitraq
-Peptamen
-Vivonex
What are three examples of specialized enteral formulas?
-Nepro (renal)
-HepaticAid II (liver)
-Glucerna (diabetes)
The more specialized the formula, the greater the ____
Cost
The tube bore is adjusted based on the ____ of feeding
Viscosity
A large #____ bore tube would be used for blenderized formulas
16
A small #____ bore tube would be used for ready-prepared formulas; more comfortable
8
Enteral access should be based on…
-Anticipated length of time needed
-Risk of aspiration
-Patient’s anatomy
-Clinical status
-Normal or abnormal digestion and absorption
Hang time for open systems is ___ hours
8
Hang time for a closed system is ___-___ hours
24-48
For short-term enteral nutrition (3-4 weeks) in someone with normal GI function, what type of access should be used?
Nasogastric
The bolus tube feed method is used for clinically stable patients with functioning ___
Stomach
An intermittent drip of enteral feeding is done with either ____ or ____ and allows for more mobility
Pump or gravity
A continuous drip of tube feed uses a constant, steady rate over ___-___ hours, usually with a feeding pump
16-24
Continuous tube feeding is used for what patients?
-Those with compromised GI function
-Those who do not tolerate large volume infusion
____ feeding is delivered by continuous drip at an increased rate over 8-16 hours, over overnight, by pump
Cyclic
Cyclic feeding is used for what patients?
-Undernourished patients (especially those who are older, ambulatory, or malnourished)
Use ____ and _____ feedings if a patient is unable to tolerate gastric feedings
Nasoduodenal, nasojejunal
___-___ feedings are used in comatose patients or ones with no gag reflex to prevent aspiration (passed pyloric valve in the stomach)
Post-pyloric
Those who will need enteral nutrition for more than 3-4 weeks should get ____ or ____ feedings
Gastrostomy or jejunostomy
A ____ tube inserts tube into the stomach through the intestinal wall
PEG
Use ___-___ to confirm the tube tip is located in the correct place or aspirate gastric contents (do not use blue dye)
X-ray
Those on enteral feeding should get ____ cc of water per calorie ingested
1
Most 1 kcal/cc formulas are ___-___% water
80-86
Most 1.5 kcal/cc formulas are ___-___% water
76-78
Most 2 kcal.cc formulas are ____-____% water
69-71
Normal gastric residual volume is ____ ml or under
250
Enteral nutrition should NOT be held for gastric residual volume over ____ml or over in the absence of other signs of intolerance
500
Actual intake of enteral nutrition may be lower than prescribed because of ___ ___ and ADL interruptions
Medical procedures
What are common adverse effects of enteral nutrition?
-Lactose intolerance
-Formula hyperosmolality
-Rapid infusion causes influx of water into the gut
Steps for formula calculation:
-Select formula and determine calories needed
-Divide calories needed by cal/ml to determine mLs of formula needed per day
-Determine protein content: multiply mLs of daily formula by grams of protein per liter
-Determine fluid needs: multiply % water in formula x daily formula in mLs to determine water content contribution of enteral nutrition; subtract formula water from total fluid requirements to determine water flushes
-Determine administration rate: divide total mLs of formula per day by 24 hours to determine continuous feeding goal rate
____ parenteral nutrition uses small surface veins
Peripheral
Peripheral parenteral nutrition is used for ___-___ therapy and has minimal effect on nutritional status
Short-term
Indications of peripheral parenteral nutrition:
-Post-surgery (when enteral feeding is expected to resume within 5-7 days
-Mild to moderate malnutrition as a supplement to enteral feedings
IV dextrose in parenteral nutrition is ___ kcal/grams
3.4
The highest concentration of dextrose used in peripheral parenteral nutrition is ____%
10
Protein (amino acids) makes up between ___-___% of peripheral parenteral nutrition
3-15
Either ____% or ____% of peripheral parenteral nutrition is made up of fat (intravenous fat emulsion, intralipid)
10; 20
10% lipids are ____ kcal/cc
1.1
Generally, peripheral parenteral nutrition solutions are limited to ___-___ mOsm
800-900
Parenteral nutrition is the infusion of a hypertonic solution delivered through a ___ ___ ___
Central venous catheter
Parenteral nutrition is used for achieve an ____ state when patients are unable to eat by mouth and enteral feeding is not possible
Anabolic
ASPEN has set a time frame of ___-___ days in which to achieve intake goals by the enteral route before beginning parenteral nutrition
7-10
Use of parenteral nutrition in critically ill patients has been shown to…
-Increase infectious complications
-Increase duration of ICU stays
-Increase mechanical ventilation
A _____ line is used for short or moderate-term infusion of parenteral nutrition
PICC (peripherally inserted central catheter)
A central venous catheter is used for long-term central access and is through either the ___, ____, or ____ vein into the ___ ___ ___
Cephalic, subclavian, or internal jugular; superior vena cava
The main concern with central parenteral nutrition is the translocation of ____; not feeding through the gut allows walls to break down allowing bacteria to move out and cause sepsis
Bacteria
Gut-associated lymphoid tissue is compromised by ___ ___ or ___ ____
Bowel rest; parenteral nutrition
Gut-associated lymphoid tissue provides ___% of total body immunity
50
___-___% of total body immunoglobulin production is secreted across the GI mucosa to defend against pathogenic substances in the GI lumen
70-80
The protein ratio for anabolism is 1 gram of nitrogen / ____ calories
150
Those on parenteral nutrition should get ___-___ grams of protein/kg each day
1-1.5
____ amino acids make up 3-15% of parenteral nutrition solutions
Crystalline
The percentage of protein in parenteral nutrition is the number of grams of protein in ____ ml of solution
100
Those on central parenteral nutrition should get ___-___ kcal/kg
35-50
Those on central peripheral nutrition should get a solution that is up to ___% dextrose
70
A 10% dextrose solution provides ____ g of carbohydrates per liter
100
To avoid overfeeding and hyperglycemia, start parenteral nutrition at ___-___ kcal/kg or less
20-25
The maximum rate of dextrose infusion (glucose utilization rate) should not exceed ____-___ mg/kg/minute to prevent hyperglycemia and other complications
4-5
Increased blood glucose from excess dextrose increases ___ ___ in ventilated patients and increased ____ complications
Respiratory quotient; infectious
Fat is needed for energy and to prevent ______
EFAD (essential fatty acid deficiency)
To prevent essential fatty acid deficiency, give ____ cc of 10% fat emulsion 1-2x/week
500
One symptom of essential fatty acid deficiency is _____, or red spots on the skin
Petechiae
Provide ___, ___, and ___ to those on TPN as needed
Vitamins, electrolytes, water
___ ___ ___ (3-in-1) includes dextrose, amino acids, and lipids
Total nutrient admixture
Contraindications to parenteral nutrition:
-If alimentary tract can be used
-If needed for only a short time in someone who is well-nourished
-During periods of cardiac instability
-If risks inherent in the process outweigh benefits
For transitional feeding, introduce a minimal amount of full-strength enteral feeding at a low rate of ___-___ ml/hour to establish GI tolerance
30-40
Begin tapering parenteral nutrition when enteral feedings are providing ___-___% of their nutrition requirements
33-50
Decrease parenteral nutrition as you increase enteral rate by ___-___ ml/hour increments every 8-24 hours to maintain prescribed nutrient levels
25-30
When patients can tolerate about ___% of their needs by the enteral route, discontinue parenteral feedings
60
_____ _____ is a consequence of aggressive administration of nutrition to someone who is malnourished
Re-feeding Syndrome
What populations are most at risk for re-feeding syndrome?
-Those with anorexia nervosa
-Those with chronic alcoholism
-Those with prolonged fasting
-Those unfed for 7-10 days
-Those with significant weight loss
-Those who are phosphorus deficient/those who are getting phosphorus deficient parenteral nutrition
With re-feeding syndrome, starved cells take up nutrients and ___ and ___ shift into intracellular compartments
Potassium and phosphorus
Re-feeding syndrome results in…
-Hypokalemia
-Hypophosphatemia
-Hypomagnesemia
Hypokalemia affects…
-Cardiac
-Renal
-Carbohydrate metabolism
-Muscle weakness
Hypophosphatemia causes…
-Cardiac abnormalities
-Respiratory failure
-Seizures
Hypomagnesemia causes:
-Intracellular metabolism
-Cardiac arrhythmias
-Hypocalcemia
Those at risk for re-feeding syndrome should have tightly controlled blood sugar between ___-___ mg/dl
140-180
Overfeeding parenteral nutrition and dextrose over ____ mg/kg/min may lead to hyperglycemia
5
Glucose moves into the cell for oxidation and stimulates insulin which decreases ___ and ___ excreting, increasing the risk of cardiac and pulmonary complications
Salt and water
Upon initiation of parenteral nutrition to a malnourished person, monitor…
-Glucose
-Phosphorus
-Potassium
-Magnesium
____ medicine combined evidence-based complementary therapies with conventional (allopathic) treatments to address the social, psychological, and spiritual aspects of health and illness
Integrative
The National Center for Complementary and Integrative Health promotes things like…
-Yoga
-Meditation
-Herbs and botanicals
-Traditional healing practices
What are the NIH categories for complementary and alternative medicine (CAM)?
-Mind-body medicine
-Alternative medical systems like acupuncture and oriental medicine
-Lifestyle and disease prevention
-Biologically-based therapies including herbs and orthomolecular medicine
-Manipulative and body-based systems like chiropractic medicine
-Biofield systems like therapeutic touch and bioelectric magnets
Functional medicine addresses the ___ ___, not just the symptoms, and looks at the underlying cause of a disease, engaging the patient and practitioner in a partnership for therapy
Whole person
____ health views mental, physical, and spiritual aspects of life closely connected and equally as important with regard to treatment approaches
Holistic
