Domain II, Topic C, Planning and Intervention Flashcards
_________ ____________ is a purposely planned action designed with the intent of changing a behavior, risk factor or condition, for an individual, group, or community. These _____________ influence the etiology or effects of a diagnosis. It is based on the nutrition diagnosis and provides the bases upon which outcomes are measured and evaluated.
Nutrition Intervention, Intervention
Four categories of Nutrition Intervention: ____ Delivery; _________, __________, ___________ of ____ with _____ __________
Food Delivery, Education, Counseling, Coordination of Care with Other Providers
________: prioritizing nutrition diagnoses, consult EAL and other practice guidelines, determine patient focused outcomes for each diagnosis, confer with caregivers, define time and frequency of care, identify resources needed
Planning
______________: Action phase involves communication of the care plan and carrying out the plan
Implementation
________ - _____ _________ ________ (EAL Evidence Analysis Library): systematically reviewed scientific evidence used in making food and nutrition pracice decision; integrate best available evidence with professional expertise practice decisions; integrate best available evidence with professional expertise and client values to improve outcome
Evidence Based Dietetics Practice
_______ Prevention Programs: reduced exposure to a promoter of disease (early screening for risk factors like diabetes). Health Promotion.
Primary
_________ Prevention Programs: Recruiting those with elevated risk factors into treatment program (setting up an employee’s gym). Risk Reduction.
Secondary
________ Prevention Programs: As disease progresses, intervention to reduce severity, manage complications, rehabilitation efforts
Tertiary
_______ _____ __________ (FTC) : Internet, TV, radio; bogus weight loss claims
Federal Trade Commission
________ _______ _______ ______ _____ (NCAHF)
National Council Against Health Fraud
When evaluating information in health claims, ask questions based on the CARS checklist:
C__________: check credential of author
A_______: info is current, factual and comprehensive
R_____________: is into fair, balanced and consistent
S______: is supporting documentation cited for scientific statements
Credibility, Accuracy, Reasonableness, Support
_______ ________ _______ ______ (POMR)
Problem Oriented Medical Record
_______ ________ ________ (PES)
Problem, Etiology, Symptoms
______ __________ ____ (SAP)
Screen, Assessment, Plan
______ _______ _________ _______ ________ (ADIME)
Assess, Diagnose, Intervene, Monitor, Evaluate
______ ________ ___________ and ______________ ___
Permanent legal document; entries written in black pen or typed; complete, clear, concise, objective, legible, accurate; sign, date all entries; entered at the time of actual date, time of entry and the date and time it should have been recorded
Health Insurance Portability and Accountability Act
___________ on HIPAA documents;
- Never use white out, thick markers, or remove an original and replace it with a copy
- At time an entry is in progress: draw single line through error, then enter the correction, initial date
- Omitted nformation: Beside original entry: “see addendum,” enter date and initial. Write the addendum in chart sequence, identify it as an addendum and reference the original entry. Sign.
- Correction performed some time after entry: correct minor errors (spelling, one word) with singl line drawn through, make correction, date, time, sign
Corrections
_________ plan begins on Day 1 of hospital stay
-_________ note includes summary of nutrition therapies and outcomes
Discharge
All _______ information is confidential
Patient
GI Disorder _____
- Eroded Mucosal lesion
- Treatment: Antacids, antibiotics to eradicate heliobacter pylori bacteria
- Drug therapy: Cietidine, Ranitidine (H2 blocker); prevents binding of histamine to receptor, decreses acid secretion
- diet: as tolerated, well balanced, avoid late night snacks
- omit: cayenne and black pepper, large amounts of chili powder, avoid excess caffeine and alcohol
Ulcer
GI Disorder ______ ______
- Protrusion of portion of the stomach above the diaphragm into the chest
- small, bland feedings; avoid late night snacks, caffeine, chili powder, black pepper
Hiatal Hernia
GI Disorder _______ ________
- Follows a gastrectomy (Billroth I, II)
- Cramps, rapid pulse, weakness, perspiration, dizziness
- When rapidly hydrolyzed carbohydrate enters the jejunum, water is drawn in to achieve osmotic balance. This causes a rapid decrease in the vascular fluid compartment and a decrease in peripheral vascular resistance. Blood pressure drops and signs of cardiac insufficiency appear. About two hours later, the CHO is digested and absorbed rapidly. Blood sugar rises, stimulating an overproduction of insulin, causing a drop in blood sugar below fasting. This is reactive or alimentary hypoglycemia.
- Gastric Surgery
Dumping Syndrome
________ _ (Gastroduodenostomy) attaches the remaining stomach to the duodenum
Billroth I
________ __ (Gastrojejunostomy) attaches the remaining stomach to the jejunum. When food bypasses the duodenum, the secretion of secretin and pancreozymin by the duodenum is reduced. These hormones normally stimulate the pancreas, so there is now little pancreatic secretion. Calcium (most rapid absorption in duodenum) and iron absorption (requires acid) are adversely affected
Billroth II
______ can be caused by both ___ or ______ deficiency
Anemia, B12, Folate
___ deficiency is caused by a lack of intrinsic factor and bacteria overgrowth in loop of intestine being bypassed interfere with ___ absorption (pernicious anemia diagnosed using the Schilling test)
B12, B12
______ deficiency: Needs B12 for transport inside the cell; also from poor ______ intake and low serum iron (cofactor in ______ metabolism)
Folate, folate, folate
After _______ _______: Frequent small, dry feedings, fluids before or after meals (to slow passage), restrict hypertonic concentrated sweets, give 50-60% complex CHO, protein at each meal, moderate fat, B12 injections may be needed. Lactose may be poorly tolerated due to rapid transport.
Gastric Surgery
_____________ is delayed gastric emptying can be caused by surgery, diabetes, viral infections, obstructions
- Moderate to severe hyperglycemia: detrimental effects on gastric nerves
- prokinetics (erythromycin, metoclopramide) increase stomach contractility
- Small, frequent meals; pureed foods, avoid high fiber, avoid high fat (liquid fat may be better tolerated)
- Bezoar formation may be due to undigested food or medications; treatment includes enzyme or endoscopic therapy
Gastroparesis
________ _____ (bacterial, viral, parasitic infection)
- chronic GI disease, intestinal lesions, may also affect stomach
- diarrhea, malnutrition, deficiencies of B12 and folate due to decreased HCL and intrinsic factor
- antibiotics, high calories, high protein, IM B12 and oral folate supplements
Tropical Sprue
___ - ________ _____, ______ Disease, ______ - _______ Enteropathy
- Gluten refers to storage proteins (prolamins: gliadin in wheat, secalin in rye, hordein in barley, avenin in oats)
- Reaction to gliadin: affects jejunum and ileum (proximal intestine)
- Malabsorption (leads to loss of fat - soluble vitamins), macrocytic anemia, weight loss diarrhea, steatorrhea, iron deficiency anemia
- Needs gluten restricted diet: NO wheat, rye, oats, barley, bran, graham, malt, bulgur, couscous, durum, orzo, thickening agents
- OK: corn, potato, rice, soybean, tapioca, arrowroot, carob bean, guar gum, flax
Non - tropiical sprue, Celiac disease, gluten induced enteropathy
___________ sometimes due to an atonic colon (weakened muscles)
-high fluid, high fiber diet, exercise
Constipation
______________ is the presence of diveticula
- Small mucosal sacs that protrude through the intestinal wall due to structural weakness. Related to constipation and lifelong intra - colonic pressures
- High fiber diet: increases volume and weight of residue, provides rapid transit
diverticulosis
______________: When diverticula become inflamed as a result of food and residue accumulation and bacterial action
-Clear liquids, low residue or elemental, gradual return to high fiber
Diveticulitis
_____ provides indigestible bulk, promotes intestinal function
-Dietary _____: Non - digestible CHOs and lignin, binds water, increases fecal bulk; found in legumes, wheat bran, fruits, vegetables, whole grains
Fiber, fiber
___ bran and _______ fibers decrease serum cholesterol by binding bile acids converting more cholesterol into bile
Oat, soluble
_______ fibers (pectins, gums) delay gastric emptying, absorb water, form soft gel in small intestine; this slows passage and delays or inhibits absorption of glucose and cholesterol; fruits vegetables, legumes, oats, barley, carrots, apples, citrus fruits, strawberries, bananas
Soluble
AI of Fiber: __g M, __g F
38, 25
A ____ fiber may increase the need for Ca, Mg, P, Cu, Se, Zn Fe
high
A ___ fiber diet may lead to ____________
low, constipation
_________: inflammation of stomach; anorexia, nausea, vomiting, diarrhea
-diet: clear liquids, advance as tolerated, avoid gastric irritants
Gastritis
____________ ____ _______ (IBD)
- Regional Enteritis (Chron’s disease)
- Chronic Ulcerative Colitis (UC)
Inflammatory Bowel Disease
________ ________ (Chron’s Disease: Affects terminal ileum; weight loss, anorexia, diarrhea
- B12 deficiency leads to megaloblastic anemia
- Iron deficiency anemia due to blood loss, decreased absorption
Regional Enteritis
_______ __________ _______ (UC)
- Ulcerative disease of the colon, begins in rectum
- Chronic bloody diarrhea, weight loss, anorexia, electrolyte (Na,K), disturbance, dehydration, anemia, fever, negative nitrogen balance
Chronic Ulcerative Colitis
Treatment for ____________ _____ _______
- Maintaoin fluid and electrolyte balance; antidiarrheal agent (sulfasalazine)
- Acute Chron’s flare ups: bowel rest, parenteral nutrition or minimal residue
- Acute UC: elemental diet may be needed to minimize fecal volume
- Energy needs according to current BMI, limit fat only if steatorrhea; water soluble and fat soluble vitamin; iron, folate; assess Ca, Mg, Zn; MCT oil, watch lactose, frequent feedings. High fat may improve energy balance
- Once ____________ _____ _______ is under control, high fiber to stimulate peristalsis
Inflammatory Bowel Disease, Inflammatory Bowel Disease
_________ _____ ________ (IBS)
- Chronic abdominal discomfort, altered intestinal motility, bloating
- Goals: adequate nutrient intake, tailor patter to specific GI issues
- Avoid large meals, excess caffeine, alcohol, sugars
- Use food diary to track intake, emotions, environment, symptoms
- identify food allergies and hypersensitivites
- work with client to alleviate stress during eating
Irritable Bowel Syndrome
_______ ___________ due to _______ deficiency
-Normally _______ splits _______ into glucose and galactose. In its absence _______ remains intact, exerting hyperosmolar pressure. Water is drawn into the intestine to dilute the load causing distension, cramps, and diarrhea. Bacteria then ferment the undigested lactose, releasing carbon dioxide gas.
Lactose intolerance, lactase, lactase, lactose, lactase
_______ __________ can be detected with a hydrogen breath test
-hydrogen is produced by colonic bacteria on lactose, absorbed into the bloodstream and exhaled in 60 - 90 minutes
Lactose Intolerance
In a _______ ________ test an oral dose of _______ is given after a fast. If intolerant, blood glucose will rise < 25mg/dL above fasting (flat curve) If tolerant, the rise would be above 25 mg/dL (normal curve)
Lactose intolerance, lactose
On a _______ free diet, calcium and riboflavin supplements are recommended; yogurt and small amounts of aged cheese may be tolerated; lactate and lactalbumin are OK
lactose
_____ diarrhea in infants requires aggressive and immediate rehydration; replace fluids and electrolytes lost in stool (WHO recommends glucose electrolyte solution)
-as effective as parenteral rehydration and much cheaper; ingredients easily attainable; reintroduce oral intake within 24 hours
Acute
In _______ nonspecifc diarrhea in infants:
- Consider ratio of fat to CHO calories, volume of ingested liquids
- Some are inadvertently placed on a low fat diet or consume too many fluids or too many calories
- give 40% calories as fat, balance with limited fluids; restrict or dilute fruit juices with high osmolar loads (apple, grape)
Chronic
In _____ diarrhea:
- remove the cause; bowel rest; replace lost fluids and electrolytes, especially those high in sodium and potassium
- when diarrhea stops, begin with low fiber foods, followed by protein foods, fat need not be limited
- avoid lactose at first
- foods or supplements that contain prebiotic components (pectin, fructose, oats, banana flakes) which favor friendly bacteria
- probiotics: sources of bacteria used to reestablish bacterial gut flora
Adult
__________ (consequence of malabsorption
- normal stool fat 2 - 5 g; > 7 g is indicative of malabsorption
- determine cause and treat
- high protein, high complex CHO, fat as tolerated, vitamin (especially fat soluble), minerals, MCT (rapidly hydrolyzed in GI tract)
Steatorrhea`
_____ _____ ________ (SBS)
- Consequences associated with significant restricions of the small intestine
- malabsorption,, malnutrition, fluid and electrolyte imbalances, weight loss
- severity reflects length and location of resection, age of patient, health of remaining tract. Loss of ileum (especially distal 11/3), loss of ileocecal valve, loss of colon are of particular concern; most digestion takes place in the first 100 cm of the intestine (in duodenum and upper jejunum) what remains - small amounts of sugar, starches, fiber, lipids
Short Bowel Syndrome
_____ _________ significant resections that produce major complications
-distal: absorption of B12, intrinsic factor, bile salts
-_____ normally absorbs major portion of fluid in GI tract
-Patients have above average needs for water to compensate for excessive losses in stool. Drink at least 1 liter more than their ostomy output
-If _____ cannot recycle bile salts; lipids are not emulsified, leads to malabsorption of fat soluble vitamins; malabsorbed fats combine with Ca, Zn, Mg, leading to soaps;
Colonic absorption of oxalate increases; renal oxalate stones
-Increased fluid and electrolyte secretion; increased colonic motility
Ileal resection, ileum, ileum,
Loss of _____: water and electrolyte loss, loss of salvage absorption of CHO and other nutrients
colon
Nutritional care after SBS
1) _________ nutrition initially to restore and maintain nutrient status
2) _______ - start early to stimulate growth, increase over time; continuous drip
3) May take weeks or months to transition to food
4) _______ - normal balance of CHO, protein, fat; avoid lactose, oxalates, large amounts of concentrated sweets; vitamin, mineral supplements
5) _____ - 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
Parenteral, enteral, jejunal, ileal
Functions of the _____ - stores and releases blood, filters toxic elements, metabolizes and stores nutrients, regulates fluid and electrolyte balance
Liver
______ profile - list of major enzymes found in organs and tissues; enzyme levels in blood are elevated when tissue damage causes them to leak into circulation
Enzyme
________ ___________ (ALP) 30 - 120 U/L
- Increases with liver disease
- Decreases with scurvy
Alkaline phosphatase
\_\_\_\_\_\_ \_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ (LDH) Increased with: -Hepatitis -Myocardial Infarction -Muscle Malignancies
Lactic Acid Dehydrogenase
_________ _____ __________ (AST, SGOT) 0 - 35 U/L
- Increased with hepatitis
- Decreased with uncontrolled diabetes with acidosis
Alanine Aminotransferase
In _____ disease, enzyme levels are elevated. SGOT is decreased in uncontrolled diabetes
Liver
Symptoms of _____ _____ hepatitis
-Inflammation, necrosis, jaundice, anorexia, nausea, fatigue (1) Jaundice occurs when bile ducts are blocked
Acute Viral
HAV transmitted through _____ matter - oral transmission (type most directly connected to food)
fecal
HBV ________ transmitted
sexually
HCV ____ to ____ contact
blood to blood
Nutrition intervention for _____ _____ hepatitis:
- Increase fluids to prevent dehydration
- care varies according to symptoms and nutrition status
- 50 -55% CHO to replenish liver glycogen and spare protein
- acute hepatitis: 1 - 1.2g protein/kg: cell regeneration, provide lipotropic agents to convert fat into lipoproteins for removal from liver
- Moderate to liberal fat intake if tolerated; limit fat if steatorrhea
- Encourage coffee (antioxidant)
- multivitamin with B complex, C, K, zinc
Acute viral
In _________ damaged liver tissue is replaced by bands of connective tissue which divides liver into clumps and reroutes many of the veins and capillaries. Blood flow through the liver is disrupted. Poor food intake leads to deficiencies
-Protein deficiencies lead to ascites, fatty liver, impaired blood clotting
Cirrhosis
Normal blood flow runs from the _________, __________, or __________ veins to the ______ vein, to the _____, to the ____ ____
abdominal, esophageal, collateral, portal, liver, vena cava
_______ occurs when blood cannot leave the live
Ascites
_________ tissue overgrowth blocks blood flow out of liver into the vena cava. The liver expands (can store a 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. This fluid is almost pure plasma with a high osmolar load, pulling more fluid in to dilute the load, leading to sodium and water retention.
-Low serum albumin may be due to dilution factor
Ascites
__________ varices occur when blood can’t enter the liver.
- Connective tissue overgrowth causes resistance to blood entering from portal vein. The increased pressure forces blood back into collateral veins that offer less resistance. Esophageal, abdominal, collateral veins enlarge.
- Due to portal hypertension
Esophageal
Diet for _________.
- High protein 0.8 - 1.0 g/kg; in stress at least 1.5 g/kg
- High calorie 25 - 35 cals/kg estimated dry weight or 1.2 - 1.5 x BEE
- moderate to low fat 25 - 40% of calories, MCT if needed, less than 40 grams of fat if malabsorption. Fat is prefered fuel in cirrhois. Include omega 3. Decrease LCTs if steatorrhea develops.
- Low fiber if varices are present, low sodium iif edema or ascites
- With hyponatremia, fluid restriction of 1 - 1.5 L/day depending on severity, and moderate sodium intake
- B complex vitamins, C, K Zn, Mg; monitor need for A and D
- Zinc involved in the conversion of ammonia to urea, increased loss in urine
Cirrhosis
_________ liver disease - hepatic steatosis, alcoholic hepatitis, cirrhosis
Alcoholic
_____ injury is due to the alcohol and metabolic derangement it causes
Liver
_______ is converted into acetaldehyde and excess hydrogen which disrupts liver metabolism
alcohol
In alcoholic liver disease, _______ replaces fat as fuel in the Kreb’s cycle, so fat accumulates in liver, leading to fatty liver, and in blood, raising the TG level
Shift in ____/___ ratio inhibits beta-oxidation of fatty acids and promotes TG synthesis
Hydrogen, NADH/NAD
_______ causes inflammation of GI tract and interfeeres with absorption of thiamin, B12, vitamin C, and folic acid
Alcohol
_______ interferes with vitamin activation
Alcohol
Increased need for _ vitamins to metabolize alcohol
B
Increased need for _________; excreted after alcohol consumption
magnesium
Malnutrition increases _______ destructive effects
alcohol’s
_____ and _______ deficiencies are most responsible for malabsorption in alcoholic liver disease
Folate and protein
_______ deficiency in Wernicke - Korsakoff
Thiamin
_______ _______ (ESLD)
- liver function decreases to 25% or less
- liver cannot convert ammonia into uream ammonia accumulates
- apathy, drowsiness, confusion, coma (PSE - portal systemic encephalopathy)
- Asterisix (flapping, invoulantary jerking motions) sign of impending coma
Hepatic Failure
Nutrition treatment for _______ failure
- If not comatose: moderate to high levels of protein, increase up to 1 - 1.5 gran protein/kg as tolerated
- 30 - 35 calories/kg; 30-35% calories as fat with MCT if needed
- Low sodium if ascites; vitamin/mineral supplementation
Hepatic
_______ ________________ Theory is designed for hepatic failure: BCAA levels decrease (used by muscles for energy); AAA (aromatic amino acids) increase because damaged liver is unable to clear them
- adding BCAA adds calories and protein; may nt reduce symptoms
- used when standard therapy does not work and when patient does not tolerate standard protein
Altered Neurotransmitter Theory
Standard treatment for _______ failure is lactulose (hyperosmotic laxative that removes nitrogen); neomycin (antibiotic that destroys bacterial flora that produce ammonia)
lactulose
___ - _________ _____ liver disease
- Steatosis, more common with BMI greater than 35, type 2 diabetes, metabolic syndrome
- excess fat buildup in liver unrelated to alcohol consumption
- Can be managed with lifestyle changes
1) weight loss (7-10% of starting weight). NO rapid weight loss: greater flux of fatty acids to liver may worsen inflammation and accelerate disease progression
2) Healthful eating: mediterranean diet, moderate alcohol, avoid sugar sweetened beverages, coffee may help (antioxidant)
3) Physical activity: at least 150 minutes of moderate intensity aerobic activity, plus two strength training session each week
Non - alcoholic fatty
___________ disease
- Cholecystitis - inflammation of the ___________
1) An infection causes excess water to be absorbed causing cholesterol to precipitate out leading to gallstones - cholelithiasis
Gallbladder,gallbladder
Treatment for ___________ disease
1) low fat diet: acute 30 - 45 grams; chronic 25 - 30% of calories
2) cholecystectomy - surgical removal of the gallbladder; bile now secreted from liver directly into intestine
- limit fat intake for several months to allow liver to compensate
- slowly increase fiber to help normalize bowel movements
Gallbladder
____________ inflammation with edema, cellular exudate and fat necrosis
-may be due to a blockage or reflux of the ductal system; premature activation of enzymes within pancreas leads to auto-digestion
Pancreatitis
_____ - pancreatitis
- put pancreas at rest, withhld all feeding, maintain hydration (IV)
1) progress as tolerated to easily digested foods with a low fat content
2) elemental (predigested) enteral nutrition into jejunum may be tolerated
Acute
_______ - pancreatitis
- Recurrent attacks of epigastric pain of a long duration
1) PER: Pancreatic enzyme orally with meals and snacks to minimize fat malabsorption from lack of pancreatic lipase. MCTs do not require pancreatic lipase. Add to mixed dishes, jams, jellies
2) To promote weight gain, give maximum level of fat tolerated without an increase in steatorrhea or pain
3) If malabsorbing fat soluble vitamins give water soluble forms
4) Pancreatic bicarbonate secretion may be defective; may need antacids so PERT therapy will work
5) In severe prolonged cases, parenteral nutrition may be needed
6) To avoid pain: avoid large meals with fatty foods, alcohol
Chronic
______ ________
-Disease of exocine glands: secretion of thick mucus that obstructs glands and ducts; chronic pulmonary diseases, pancreatic enzyme deficiency, high perspiration electrolyte levels, malabsorption
Cystic Fibrosis
Nutrition treatment for ______ ________
1) PERT- pancreatic enzyme replacment therapywith meals and snacks
2) High protein, high calorie, unrestriced fat, liberal in salt
- if growing normally and steatorrhea is contolled: calories to cover RDA for age and sex; if fails to grow - BEE x activity factors plus disease
- Protein 15 -20% calories: malabsorption due to pancreatic deficiency
- CHO 45 - 55% total calories
- Liberal fat to compensate for high energy needs - 35-40% of calories
- Additional 2 - 4 grams salt/day in hot weather, with heavy perspiration
- age appropriate doses of water soluble vitamins and minerals
- Supplement water soluble forms of fat soluble vitamin A and E
Cystic Fibrosis
______________ disease (CVD), ________ ______ disease (CAD), ________ ____ disease (HD)
Cardiovascular, coronary artery, ischemic heart
____________ - systolic >140 or diastolic >90 or both
- Systolic, contraction, greatest pressure; diastolic, relaxation, least pressure
- May be primary (essential) or secondary due to another disease
- classified in stages based on risk of developing coronary heart disease
- Obesity is a major factor in the cause and treatment
- Optimal BP with repect to cardiovascular isk is <120/80 mm Hg
Hypertension
Management of ____________
- Thiazide diuretics may induce hypokalemia
- four modifiable factors in primary prevention and treatment: overweight, high salt intake, alcohol consumption, physical activity
- salt restriction less than or equal to 2400 mg of Na (6 g salt); decrease weight if needed
- DASH diet - dietary approach to stop hypertension; whole grains, fruits, vegetables, low fat dairy, poultry, fish, moderate sodium, limit alcohol, decrease sweets, calcium to meet DRI (not supplements)
Hypertension
_____________ diet
- Rich in alpha linoleic acid, high in monounsaturates fats
- olive, canola, soybean pils, walnuts, almonds, pecan, peanuts, pistachios
- fish, poultry and egggs rather than beef, breads, fruits, and vegetables in abundance, beans, legumes, yogurt and cheese
- revetsatrol, in skin of red grapes, may lower blood pressure
Mediterranean
_______________: accumulation of lipids; structural and compositional changes in the intimal layer of the large arteries
Atherosclerosis
Risks for _______________: Hypertension, obesity, smokin, elevated blood lipids, hereditary
Atherosclerosis
_______________ is a form of ________ ______ disease (CAD) where the arteries harden and narrow from the buildup of plaque
Athersclerosis, coronary artery disease
________ is a deficiency of blood due to obstruction
Ischemia
________________ is characterized by a loss of elasticity of blood vessel walls
Arteriosclerosis
_________ __________ reduction of coronary flow to myocardium due to blood clot blocking a narrowed coronary artery
1) angina pectoris - chest pain
2) Heparin - blood clots
Myocardial Infarction
___________ includes high TG and low HDL
Dyslipidemia
___________ - transports dietary TG from gut to adiose cells; synthesized in intestine from dietary fat; lowest density due to smallest amount off protein
Chylomicron
____ (pre-beta)- Transports endogenous TG from liver to adipose cell
VLDL
___ (beta) - transports cholesterol from diet and liver to all cells
- small dense LDL - C associated with increased risk responsive to diet
- larger buoyant LDL not associated with increased risk
LDL
___ (alpha) - reverse cholesterol transport; moves cholesterol from cells to liver excretion
HDL
___ (pre - beta to beta) - LDL precursor; found in circulation secondary to catabolism of other lipoproteins
IDL
_________ ________ - three or more of the following risk factors are linked to insulin resistance which often increase risk for coronary events
1) elevated blood pressure which often increases risk for coronary events
2) elevated TG greater than or equal to 150 mg/dL
3) fasting serum glucose greater than or equal to 100 mg/dL
4) waist measurement greater than or equal to 102 cm (40”) men; greater than or equal to 88cm (35”) women
5) Low HDL < 40 mg/dL (men), < 50 mg/dL (women)
Metabolic syndrome
________ ___________ _________ ________ (NCEP) National heart, lung and blood institute, endorsed by American Heart Association
National Cholesterol Education Program
LDL - C < ___ optimal
Total cholesterol < ___ desirable
HDL - C < __ (M) < __ (F); >= __ high
100, 200, 40, 50, 60
High ____________ (Hcy) levels are independent risk factors for CHD
Homocystine
Normal triglyceride levels
150
___________ _________ ______ (TLC) for CVD from Adult Treatment Panel III
- up to 35% calories from total fat, <7% saturated fat, 5 - 10% PUFA, up to 20% MUFA, <200 mg cholesterol
- 25 - 30 grams fiber (half soluble)
- Stanols and sterols inhibit cholesterol absorption (2-3g)
- Maintain DBW, prevent weight gain
- Increase physical activity to at least 30 mintes of moderate intensity most days (expend at least 200 calories
Therapeutic Lifestyle Change
_____ _________ _____ (ATP) IV: does not focus on specific target levels for LDL, but defines groups for whom lowering LDL would be most beneficial. Recommend a heart healthy lifestyle.
Adult Treatment Panel
___ __ therapy recommended for:
- Patients who have cardiovascular disease
- Patients with an LDL of 190 mg/dL 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 percent or higher who are between 40 and 75 years of age
ATP IV
Etiology of _____ _______
1) weakened heart fails to maintain adequate output, resulting in diminished blood flow so fluid is held in tissues (edema); dyspnea (shortness of breath)
2) REduced blood flow to kidneys causes secretion of hormones that hold in sodium and fluid leading to weight gain
Heart Failure
Treatment for _____ _______:
1) Digitalis increases strength of heart contraction
2) low sodium (2-3 grams), DASH diet, 1-2 L fluid
3) 1.1 - 1.4g protein/kg ABW for normally nourished and malnourished
4) Energy needs: RMR x physical activity factor
5) Evaluate thiamin status (loss with loop diuretics). without thiamin, pyruvate cannot be converted into acetyl CoA for energy, so heart muscle is deprived.
6) DRI for folate, Mg; MV with B12
7) Encourage individualized regular physical activity
Heart Failure
Physical activity factors: \_\_\_\_\_\_\_\_\_ 1.0 - <1.4 \_\_\_ \_\_\_\_\_\_ 1.4 - < 1.6 \_\_\_\_\_\_ 1.6 - < 1.9 \_\_\_\_ \_\_\_\_\_\_ 1.9 - < 2.5
Sedentary, Low Active, Active, Very Active
_______ ________: Unintended weight loss, blood backs up into liver and intestines causing nausesa and decreased appetite Arginine and glutamine may help. Low saturated fat, low cholesterol, low trans fat, <2 grams sodium, high calorie
Cardiac Cachexia
Structure of the _______
a) __________ - tuft of capillaries held closely by Bowman’s capsule - produces ultrafiltrate which then passes through tubules. Capsule blocks passage of red blood cells and larg molecules like protein
b) ________ __________ ______ - Major nutrient reabsorption
c) ____ of _____ - water and sodium balance
d) ______ ______ - acid base balance
Nephron, glomerulus, proximal convoluted tubule, loop of henle, distal tubule
_____ functions:
__________ - red blood cells, protein stay in blood; all else filters through tubules
__________ - 100% glucose, amino acids; 85% water, sodium, potassium
_________ - wastes, urea, excess ketones
_________ - secretes hormones that control blood pressure, blood components; secretes ions that maintain acid - base balance
Renal, filtration, absorption, excretion, secretion
________ involved in renal function
a) ___________ (ADH) - from hypothalamus (stored inpituitary)
b) _____ - vasoconstrictor
C) _____________ (EPO)
Hormones, vasopressin, renin, erythropoietin
___________ (ADH)
1) exerts pressor effect; elevates blood pressure
2) Increases water reabsorption from distal and collecting tubules
3) SIADH - Syndrome of Inappropriate Antidiuretic Hormone
a) Hyponatremia caused by hemoodilution, treated with fluid restricion
Vassopressin
_____ (vasoconstrictor)
1) Secreted by glomerulus when blood volume decreases
2) Stimulates aldosterone to increase sodium absorption and return blood pressure to normal
Renin
_______________ (EPO)
1) Produced by kidney; stimulates bone marrow to produce RBC
Erythropoietin
Lab tests in _____ disease
a) Decrease glomerular filtration rate, creatinine clearance
b) Increase serum creatinine, BUN
c) BUN:creatinine ratio of >20:1
d) renal solute load
Renal
BUN:creatinine ratio of > 20:1 indicates a “___-_____ state” in which BUN reabsorption is increased due to acute kidney damage (may be reversible and may not require dialysis)
pre renal
BUN:creatinine ratio of < __:_ suggests reduced BUN reabsorption due to renal damage (may need dialysis)
10:1
_____ ______ load - solutes excreted in 1 L urine; daily fixed load of 600 mOsm
1) Mainly measures nitrogen (60%) and electrolytes (sodium)
Renal Solute
Manifestation of _____ disease
a) anemia due to decreased production of erythropoietin
b) upset in blood pressure
c) decreased activation of vitammin D (kidney produces active form which promotes efficient absorption of calcium by the gut)
Renal disease
_____ disorders include:
a) _____ calculi
b) acute _____ _______
c) _________ ________
d) chronic ______ _______
e) ___ _____ _____ _______ (ESRD)
f) chronic _____ _______
Renal, renal, kidney injury, nephrotic syndrome, kidney disease, End Stage Renal Disease, renal failure
_____ _______
1) 1.5 - 2 L fluid/day needed to dilute urine
2) calcium oxalate stones
a) Adequate calcium intake to bnd oxalate and a low oxalate (40 - 50 mg) diet
b) More stones are detected in diets deficient in calcium
3) Alkaline ash / acid ash diets
a) Minerals not oxidized in metabolism leave an ash (residue) in urine
b) Can change composition of diet to change pH of ash in urine
c) Now usually done with medication
d) To prevent acidic stones - create an alkaline ash: increase cations (Ca, Na, K, Mg), by adding vegetables, fruits, brown sugar, molasses
e) To prevent alkaline stones - create an acid rich ash: increase anions (Cl, Ph, Su) by adding meat, fish, fowl, eggs, shellfish, cheese, corn, oats, rye
Renal calculi (kidney stones)
_____ ______ ______
1) Sudden shutdown with previously adequate cpacity; decreased GFR, inadequate pre - renal perfusion
2) Due to burns, obstruction, severe dehydration
3) Symptons - oliguria (<500 mL urine), azotemia (increased urea in blood)
Acute kidney injury
Nutrition treatment for _____ ______ ______:
1) IV glucose, lipids, protein
- 1 - 1.3 g/kg if non catabolic and or initiation of dialysis
2) 25 - 40 cals/kg, BEE x stress factor (1.2 - 1.3) during hypermetabolic conditions. Energy expenditure increases as kidney function declines
3) Low sodium (2-3 grams), replace losses in diuretic phase
4) 8 - 15 mg/kg phosphorus (May need phosphate binders)
5) 2 - 3 grams potassium based on output, serum potassium, dialysis
6) Replace fluid output from previous day pluss 500 mL
Acute Kidney injury
_________ ________
1) Defect in capillary basement membrane of glomerulus which permits escape of large amounts of protein into the filtrate moving through the tubules
2) Albuminuria, edema, malnutrition, hyperlipidemia (increased synthesis and lower clearance of VLDL)
3) Abnormalities in iron, copper zinc, calcium related to protein loss
Nephrotic Syndrome
Nutrition treatment for _________ ________
1) Modest protein restriction: 0.8 - 1 g/kg; 50% from HBV. Excess protein will be catabolized to urea and excreted
2) <30% fat, low saturated fat, 200 mg cholesterol
3) 35 calories /kg/day
4) Modest sodium restriction (2-3 g /day)
5) Calcium 1 - 1.5 g/day, supplement vitamin D
6) May need fluid restriction with edema
Nephrotic Syndrome
_______ ______ _______
1) anorexia, weakness, weight loss, nausea, vomiting
2) anemia due to deficient production of hormone erythropoiein by kidney
Chronic Kidney Disease
_______ ______ _______
1) 25 - 25 kcal / kg or BEE x activity facto. adjust for weight gain or loss
2) <2400 mg/day sodium
3) Protein restricted when GF mL/minute falls
4) Supplement phosphorus
5) Potassium generally not restricted unless serum level is elevated and urine output is < 1 liter per day
6) Fluid generally unrestricted
Chronic Kidney Disease
\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_ Stage 1 GFR >=90 Stage 2 GFR 60 - 89 Stage 3 GFR 30 - 59 Stage 4 GFR 15 - 29 Stage 1-2 0.8-1.4 g protein/kg Stage 3-4 0.6-0.8 g protein/kg
Chronic Kidney Disease
_______ ______ _______
Stage 1-2 Supplement Phosphorus to maintain normal serum level
Stage 3-4 800-1000 mg/day or 10-12 mg/g protein
Chronic Kidney Disease
___ _____ _____ _______ (ESRD)
1) usually associated with a BUN >100 mg/dL and Cr 10-12 mg/dL
2) Retention of nitrogen metabolites - may use Giovanetti diet - 20 grams protein (HBV), increase calories; control edema, prevent deficiencies
End Stage Renal Disease
____________
a) 1.2 grams protein/kg SBW (standard body weight), at least 50% HBV
b) < 60 years 35 calories/kg
c) >= 60 years or obese 30 - 35 calories/kg
d) >= 1 liter fluid output: 2 - 4 grams sodium and 2 L fluid
e) < 1 liter fluid output: 2 grams sodium and 1 - 1.5 L fluid
f) Anuria: 2 grams sodium and 1 L fluid
g) 40 mg/kg IBW 2-3 grams) potassium
h) Calcium: individualized with maximum 2 grams elemental total
i) 800 - 1000 mg phosphorus or < 17 mg/kg IBW or SBW
j) vitamin C, B6, folate, B12 supplements: DRI for others
k) zinc DRI 8-11 mg/day, individualize for iron and vitamin D
Hemodialysis
__________ ________
a) 1.2-1.3 grams protein/kg SBW or adjusted BW; >=50% HBV
b) < 60 years of age 35 calories/kg including dialysate
>= 60 years of age 30 - 35 calories/kg
c) 2-3 grams sodium - based on blood pressure and weight
d)Potassium generally unrestricted (usually 2 - 4 grams)
e) =< 2000 mg total elemental calcium including diet and binders
f) 800 - 1000 mg phosphorus or 10 - 15 mg phosphorus / g protein
g) 1 - 3 L fluid depending on output, cardiac status
h) CAPD - continuous ambulatory pertioneal dialysis 4 - 5 x per dat
i) VM as for for hemodialysis except thiamin
Peritoneal dialysis
_______ ________
Type _ - Insulin deficient, depend on exogenous insulin
Type _ - Insulin resistance with relative insulin deficiency (may need insulin)
Risk factor: acanthosis nigricans (gray brown skin pigmentation in skin folds), GAD (glutamic acid decarboxylase antibodies)
Diabetes Mellitus, 1, 2
Normal blood glucose __ - 100 mg/dL
Impaired fasting glucose __ - 125
Impaired glucose tolerance ___ - 199
70, 100, 140
Diabetes Diagnosis Fasting Plasma glucose >= \_\_\_ Glucose tolerance test >= \_\_\_ Symptoms of diabetes plus casual plasma glucose >= \_\_\_ mg/dL HgbA1c >= \_\_\_ %
126, 200, 200, 6.5
____________ (glycated) __________ (HbA1c)
a) measures % of hemoglobin that has glucose attached
b) normal <5.7%; over 65 years
Glycosylated Hemoglobin
Goals for all diabetics
a) Maintain normal blood glucose (average pre - prandial goal __ - 130; peak post - prandial average < ___)
b) Optimal serum lipid levels: LDL < ___, TG < ___, HDL > __(M) >__ (F)
c) Blood pressure goals systolic < ___, diastolic
70, 180, 100, 150, 40, 50, 130 80
Strategies for Type _ diabetics
a) With fixed daily doses of insulin, consistency of CHO is recommended
b) Integrate insulin therapy with usual eating habits
c) Monitor blood glucose and adjust insulin doses for amount of food eaten
d) With intensive insulin therapy, adjust pre - meal insulin dosage based on total CHO content of each meal, usin an insulin to CHO ratioe
e) for planned exercise, reduction in insulin dosage may be best choice
f) Endurance athletes: 120 - 18 mg/dL is guideline during activity
1
Strategies for Type _ diabetes
a) Achieve glucose, lipid and blood pressure goals
b) Weight loss if necessary: improve food choices, space meals, exercise
2
General nutrition recommendations for _______:
- Macronutrient distribution based on DRI’s for healthy adults
- <7% total calories as saturated fat
- Trans fat intake should be minimized
- Encourage fiber intake
- sucrose may be substituted for other CHO
Diabetes
__________ ________ risk factors include BMI >30 and a history of GDM
Gestational diabetes
___________ _______
a) at 24 - 28 weeks of gestation, screen with 50 g oral glucose load; glucose >= 140 mg/dL indicates need for further testing
b) 40-45% CHO, 3 small medium sized meals and 2 - 4 snakcs
c) DRI for CHO during pregnancy is 175 g / day
d) 15 - 30g CHO at breakfast (less well tolerated), rest divided evenly
e) increases risk of fetal macrosomia (LGA large for gestational age), fetal hypoglycemia at birth
f) overweight/obese: modest energy restriction to slow weight gain
Gestational Diabetes
________ _____ compares blood glucose response of a food to a standard glucose load
1) Affected by cookin methods and processing of starch; as particle size decreases, the index increases
2) Foods with low index: legumes, milk, whole grains, fruits, vegetables
3) Glycemic load: weighted average of the glycemic indexes of all foods eaten
4) Use of index as a method fro weight loss or weight maintenance is not currently recommended
5) No significant effect on A1c with a low glycemic diet for longer than 12 weeks
Glycemic Index
1 serving bread contains __ g CHO, _ g Protein, _ g Fat, __ calories
15, 3, 1, 80
1 serving of fruit contains __ g CHO, _ g Protein, _ g Fat, __ calories
15, 0, 1, 60
1 serving of fat free milk contains __ g CHO, _ g Protein, _ g Fat, __ calories
12, 8, 0-3, 100
1 serving of reduced fat milk contains __ g CHO, _ g Protein, _ g Fat, __ calories
12, 8, 5, 120
1 serving of Whole milk contains __ g CHO, _ g Protein, _ g Fat, __ calories
12, 8, 8, 160
1 serving of sweets contains __ g CHO, _ g Protein, _ g Fat, __ calories
15, varies, varies, varies
1 serving of non starchy vegetables contains __ g CHO, _ g Protein, _ g Fat, __ calories
5, 2, 0, 25
1 serving of lean meat contains __ g CHO, _ g Protein, _ g Fat, __ calories
0, 7, 2, 45
1 serving of medium fat meat contains __ g CHO, _ g Protein, _ g Fat, __ calories
0, 7, 5, 75
1 serving of high fat meat contains __ g CHO, _ g Protein, _ g Fat, __ calories
0, 7, 8, 100
1 serving plant based proteins contains __ g CHO, _ g Protein, _ g Fat, __ calories
varies, 7, varies, varies
1 serving of fat contains __ g CHO, _ g Protein, _ g Fat, __ calories
0, 0, 5, 45
1 serving of alcohol contains __ g CHO, _ g Protein, _ g Fat, __ calories
varies, 0, 0, 100
Free foods for diabetics contain < __ calories and < _ g CHO per serving
20, 5
_____________ ________ gives flexibility in food choices
1) one choice from the starch, fruit or milk list - 15 grams CHO and each is a CHO choice; meal plan outlines the number of CHO choices to be selected for meals and snacks
Carbohydrate counting
Types of _______
1) Bolus (premeal or prandial
2) Basal (background)
Insulin
_____: Premeal or prandial insulin
a) Rapid acting: aspart (Noovolog), Lispro (Humalog); takes 5 - 15 minutes before eating, usual duration 4 hours
b) short - acting: regular (Humulin R); take 30 - 45 minutes before meal (burst of insulin to cover the meal just about to be eaten). One unit covers 10 - 15 grams CHO; duration 3 - 6 hours
Bolus
____, background insulin
a) intermediate acting: NPH (Humulin N, Novolin N, ReliOn) onset 2 - 4 hours, duration 10 - 16 hours, cloudy in appearance
b) long acting: Glargine (Lantus), Determir (Levemir) onset 2 - 4 hours, duration 18 - 24 hours
Basal
Conventional _____ or _____ dose insulin regimen
1) Regular + NPH twice a day
- Pre breakfast - 1/3 reg, 2/3 NPH; pre supper - equal Reg + NPH
2) regular + NPH pre breakfast, regular pre supper, NPH bedtime (to control early AM surge)
Split, Mixed
_______ _____ __________ (MDI) Basal insulin once or twice daily and rapid acting bolus before meals
Multiple Daily Injections
__________ _________ _______ ________ (CSII) insulin pump therapy provides steady, measured continuous dose of basal, and a surge (bolus) dose of insulin before meals
Continuous Sustained Insulin Infusion
____ glucose lowering medication include
1) Insulin secretagogues
2) Biguanides
3) Thiazolidinediones
4) Alpha glucosidase inhibitors
5) Glucagon-like peptide - 1 (GLP - 1) agonist
6) Amylin agonist
7) DPP - 4 Inhibitors
8) SGLT - 2 inhibitors
Oral
_______ _____________ include sulfonylureas glipizide (glucotrol), meglitinides glinides (prandin)
Insulin secretagogues
__________ include metformin (glucophage) and suppress hepatic glucose production, as well as increase insulin uptake in muscles
Biguanides
__________________ (Actos) improve peripheral insulin sensitivity
Thiszolidinediones
_____ ___________ __________ include acarbose (precose) that inhibit enzymes that digest CHO, delaying absorption
Alpha glucosidase inhibitors
________ ____ _______ - 1 (GLP - 1) agonists like exenatide (Byetta) enhances insulin secretion, suppresses postprandial glucagon secretion
Glucagon - like peptide - 1
______ _______ include pramlintide (symlin) and decrease glucagon release, suppresses appetite
Amylin agonist
___ - 4 __________ include saxagliptin (Onglyza), often used with metformin, reduces glucose released by liver overnight and between meals
DPP - 4 Inhibitors
____ - 2 __________ include canagliflozin (Invokana), dapagliflozin (Farxiga), empaglyflocxin (Jardiance) target blood glucose lowering action in kidneys, by blocking a protein that returns glucose to the blood after it is filtered through the kidney
SGLT - 2 Inhibitors
____ __________ is a natural increase in early morning blood glucose and insulin requirements due to increased glucose production in liver after overnight fast
1) increased need for insulin at dawn
Dawn Phenomenon
Complications of uncontrolled ______
1) Acute ketoacidosis
2) Acute hypoglycemia
3) Neuropathy
4) Retinopathy
5) Nephropathy
Diabetes
_____ ____________: hyperglycemia due to insulin deficiency or excess carbohydrate intake, dehydration due to polyuria, increased pulse, fruity odor of ketones
Acute Ketoacidosis
_____ ____________: insulin reaction (shock) due to insulin excess or lack of eating, slow pulse, cool, clammy skin, hungry, weak, shakiness, sweating
1) begin with 15 g CHO from glucose tablets, fruit juice (4-6 oz), sugar
2) wait 15 minutes; if still < 70 mg/dL, give another 15 grams
3) Repeat and treat until blood glucose is normal
Acute hypoglucemia
__________ - peripheral and autonomic; astroparesis
neuropathy
___________ - leads to blindness
retinopathy
___________ - leads to decreased kidney function
nephropathy
________ hypoglycemia occurs when
a) overstimulation of pancreas or increased insulin sensitivity; blood glucose falls below normal 2 - 5 hours after eating (<50 mg/dL)
b) weak trembling, extreme hunger
c) goal is to prevent marked rise in blood glucose that would stimulate more insulin
d) avoid simple sugars, 5 - 6 small meals / day, spread intake of CHO throughou the da, protein at RDA levels
Reactive
_______ _____ Insufficiency, more commonly known as _________ disease
a) atrophy of adrenal cortex; symptoms due to absence of adrenal hormones
b) decreased cortisol (glycogen depletion, hypoglycemia), aldosterone (sodium loss, potassium retention, dehydration), and androgenic (tissue wasting, weight loss)
c) Dier - high protein, frequent feedings, high salt
Adrenal cortex, addison’s
_______ disorders include
_____ and ____ thyroidism
Thyroid, hyper, hypo
_______________ is excess secretion of thyroid hormone
1) elevated T3 and T4
2) Increased BMR leading to weight loss
3) Diet, increase calories
Hyperthyroidism
______________ is deficiency of thyroid hormone
1) T4 low, T3 low or normal
2) Decreased BMR leading to weight gain
3) Diet - weight reduction
Hypothyroidism
A ______ is an enlargement of the thyroid gland due to insufficient thyroid hormone
goiter
An _______ goiter is due to inadequate ______ intake
a) diet - _______ salt; free of goitrogens (contain goitrin which inhibits synthesis of thyroid hormone)
endemic, iodine, iodized
____ is a disorder of purine metabolism
a) Increased serum uric acid; deposit in joints causing pain, swelling
b) diet - low purine may not be effective; may need weight reduction
c) Mediations (urate eliminant, colchicine) induce loss of nutrients
Gout
Nutrition therapy for ____ includes: Moderate protein, liberal CHO, low to moderate fat, decrease alcohol, liberal fluid, avoid high purine foods (broth, anchovies, sardines, organ meats, sweetbreads, herring, mackerel)
Gout
___________ due to missing enzyme that would have converted galactose - 1 - PO4 into glucose - 1 - PO4
1) treated solely by diet - galactose and lactose free
2) NO organ meats, MSG extenders, milk, lactose, galactose, whey, casein, dry milk, curds, calcium or sodium caseinate, dates, bell peppers
3) OKAY soy, hydrolyzed casein, lactate, lactic acid, lactalbumin, pure MSG
Galactosemia
____ _____ _______
1) Unable to synthesize urea from ammonia resulting in ammonia accumulation
2) Vomiting, lethargy, seizures, coma, anorexia, irritability
3) diet - protein restriction (1.0, 1.5, 2.0 g/kg based on tolerance, age, projected growth rate) to lower ammonia; therapeutic formulas to adjust protein composition to limit ammonia production
4) Example: OTC Ornithine Transcarbamylase Deficiency
Urea Cycle Defects
_______________ (PKU) etiology
a) missing enzyme - phenylalanine hydroxylase - which would convert phenylalanine into tyrosine; phenylalanine and metabolites accumulate leading to poor intellectual function
b) detected with Guthrie blood test
Phenylketonuria
_______________ (PKU) diet
a) restrict the substrate phenylalanine (PHE), supplement the product tyrosine (TYR). Tyrosine becomes a conditional amino aci.
b) Low in phenyl alanine, but provide enough to promote normal growth (1. Phenex 1,2, Phenyl - Free 1,2 (low phenylalanine formulas))
c) avoid aspartame
Phenylketonuria
In _______________ (PKU) the need for phenylalanine decreases with age or infection. Low protein, high CHO intakes may lead to increased dental caries
Phenlketonuria
________ _______ _______
1) Deficiency of glucose - 6 - phosphate in liver; impairs gluconeogenesis and glycogenolysis
2) Liver can’t convert glycogen into glucose leading to hypoglycemia
3) Provide a consistent supply of exogenous glucose with raw cornstarch at regular intervals, anda high CHO, low fat diet
Glycogen storage disease
______________
1) treatable inherited disorder of amino acid metabolism
2) characterized by severe elevations of methionine and homocystine in plasma, and excessive excretion of homocystine in urine
3) associated with low levels of folate, B6, B12
4) Newly diagnosed patients receive increased doses of folate, pyridoxine (B6), B12
5) If they don’t respond: low protein, low methionine diet
Homocystinurias
_____ _____ _____ _______ (MSUD)
1) Inborn error of metabolism of the BCAAs leucine, isoleucine, valine
2) Poor sucking reflex, anorexia, FTT, irritability, sweet burtn maple syrup odor of sweat and urine
3) Restrict BCAA 45 - 62 mg/day (may use MSUD powder)
4) Provide adequate energy from CHO and fat to spare amino acids
5) Include small amounts of milk to support growth; gelatin may be used
6) avoid eggs, meat, nuts, and other dairy products
Maple Syrup Urine Disease
_________ - inflamation of peripheral joints
a) regular well balanced diet with vitamin intake at DRI
b) bed rest, aspirin, reduce overweight to decrease stress
c) normocytic anemia may develop
1) not diet related, inflammation of arthritis prevents reuse of iron
2) “Anti - inflammatory diet” may help osteoarthritis: fresh fruits and vegetables, resembles Mediterranean diet
Arthritis
________ _____ ____________ (SLE)
a) no specific dietary guidelines, tailor to needs
b) may have dietary deficiencies of iron, folate, calcium, fiber, B12
c) may have anemia but does not correlate with iron intake
d) may show symptoms of celiac disease
Systemic Lupus Erythematosus
___________ resorb and remove bone; ___________ reform bone
osteoclasts, osteoblasts
____________ - loss of bone tissue
1) Type 1 postmenopausal (within 15 - 20 years), Type II age associated >70
2) White and Asian women more than black or Hispanic
3) Causes: Malnutrition (especially protein), lack of exercise, decline in estrogen
4) Result is reduction in amount of bone due to defective calcium absorption (deossification)
Osteoporosis
Treatment for ____________; _______ ___________ _______ (HRT), weight bearing execise, Vitamin D (400 800 mg) and calcium (>= 1200 mg, don’t exceed 500 - 600 mg at one time) supplements, adequate protein, moderate to low sodium, 5 servings of fruit and vegetables
Osteoporosis, Hormone Replacement Therapy
____________ -adult rickets
1) Vitamin D deficiency - lack of sunlight or diet intake
2) Reduction in bone density - demineralization
3) Vitamin D, calcium supplements
Osteomalacia
________ - seizures, altered consciousness
Epilepsy
_______________ phenobarbitaql and phenytoin (Dilantin) intefere with calcium absorption
1) Take 1 mg folate daily with drug
2) may nneed supplements of vitamin D, calcium, thiamin
3) provide phenytoin separate from meals and other supplements
4) Enteral feedings decrease bioavailibility of pheytoin so hold tune feedings >=2 hours
Anticonvulsants
_________ diet - high fat, very low carbohydrate, _ grams fat : _ gram non fat
1) __% calories from fat, _ g protein /kg, remaining calories from CHO
2) Ketone bodies behave as inhibitory neurotransmitters; mild dehydration
3) Need supplements of Ca D, folate, B6, B12
4) MCTs are more ketogenic, more rapid metabolism and absorption
Ketogenic, 4:1, 90, 1
________ _____ is non hereditary, brain damage; inadequate control over voluntary muscles leading to spasms
Cerebral Palsy
In the _______ form of cerebral palsy:
a) difficult, stiff movement; limited activity; obese
1) low calorie, high fluid, high fiber diet
Spastic
In the ___ - _______ (athetoid) form:
Involuntary worm like movement, constant irregular motions leading to weight loss
1) High calorie, high protein diet; finger foods
Non - spastic
In a ______ ____ injury
1) Energy needs are 10% below predicted
2) at least 1.5 L fluid per day
3) Pressure ulcers: 30 - 40 cal/kg
a) 1.2 - 1.5 protein/kg in stage I and II; 1.5 - 2g in stages III, IV
b) normal intake of calcium, adequate fluids
c) supplement vitamin C (500 - 1000 mgs with stage III or IV or if deficient)
d) Zn 15 mg (220 mg zinc sulfate) with stages III, IV for 2 - 3 weeks
e) Daily dietary source of vitamin A
Spinal Cord
_________ _______ ______________ ________ (ADHD)
a) Experimental treatment - feingold diet - no salicylates, artificial colors, artificial flavors. Efficacy not proven: positive result may be due to placebo effect
b) sugar does not cause hyperactivity
c) Provide wholesome foods at regular mealtimes with small servings followed by refills
d) Adderall side effects: lack of appetite, nausea, weight loss
e) If child is underweight, consider high calorie snacks at bedtime
Attention Deficit Hyperactivity Disorder
______ ________ _________
Unnecessary food restrictions, possible food aversions, excessive supplementation can place children with ASD at risk
Autism Spectrum Disorders
__________ _______
a) avoid distractions (no TV during meals); regular consistent mealtimes, encourage self-feeding, offer one course at a time, lower saturated fats, soft calming background music, finger foods may be helpful, avoid dehydration, may need verbal cues to chew and swallow
b) anomia, form of aphasia lost words, unable to recall names of common items
Alzheimer’s Disease
______
Decrease in total red cell ass due to fewer red blood cells or to smaller cells with less hemoglobin
Anemia
__________ ___________ ______
Small, pale cells; due to iron deficiency
a) associated with chonic infections, malignancies, renal disease
Microcytic, hypochromic anemia
__________ _____________ ______
FEW large cells, filled with hemglobin
a) due to deficiency of folate or vitamin B12; Schilling test for pernicious anemia
Macrocytic, megaloblastic anemia
In \_\_\_\_\_\_\_\_\_\_ or \_\_\_\_\_\_\_\_\_\_\_ anemia RBC: may be normal Hgb: low Hct: low MCV: low <80 MCH: low MCHC: low <31
Microcytic, hypochromic
In \_\_\_\_\_\_\_\_\_\_ anemia: RBC: decreased Hgb: low Hct: low MCV: high >95 MCH: high MCHC: Normal >31
Macrocytic
To supplement ____ in anemia, some foods high in ____ include: liver, kidney, beef, dried fruits, dried peas and beans, nuts, leafy green vegetables, fortified whole grain products
Iron, Iron
Typical American diet contains _ mg iron / 1000 calories
6
Ag - Ab reaction: when _______ enters the body, ________ reacts
Antigen, antibody
In allergies there is an ______________ E (IgE) mediated reaction to normally harmless food protein
a) common allergens - peanuts, eggs, milk soy, whet, shellfish
b) Cow’s milk protein is the most common single allergen for infants
c) introduce eggs at __ months of age; earliest age of peanut introduction 4 - 6 months of age
Immunoglobumin
_____ is a genetic predisposition to produce excessive IgE antibodies in response to an allergen
Atopy
_______ diagnosis include things like diet history, skin tests, elimination diet (omit suspected foods)
Allergy
___ - ____ blood test is specific in identifying children with milk, egg, fish, and peanut allergies
CAP - FEIA
______ - double blind, placebo - controlled food challenges, identify food induced symptoms (gold standard for diagnosis)
DBPCFC
____ (alternative to skin test) serum is mixed with food on paper disk; measures specific IgE antibodies
RAST
____ is food least likely to cause an allergy
Rice
____ ___________ (NON - IgE): Abnormal physiologic response, GI, cutaneous, respiratory symptoms, but NO antibody production
Food Intolerance
_____ and _________ excessive fluid loss may lead to dehydration (hyperglycemia, dry, loose inelastic ski); IV feedings of dextrose and water, then diet high in calories and fluids
-BMR increases 7% for each degree rise in F temp; normal temp 98.6 F
Fever and Infection
_____
A) Immediate shock period - catabolism; BMR rises 50 - 100%
1) replace fluids and electrolytes lost
2) Recovery period - increase calories (based on burn size)
3) Secondary period - 1.5 - 2 grams protein/kg (1.2 if ____ <10%BSA), high calories
a) vitamin C - wound healing, 500 mg x 2
b) water soluble vitamins 2x RDA, vitamin A 10000 IU
c) vitamin K if on antibiotics
d) zinc for wound healing if zinc deficient, 220 mg zinc sulfate
Burn, burn
___ and ____ response to injury - hypermetabolic, catabolic response following trauma (accelerated catabolism of lean body mass leading to negative nitrogen balance as protein is catabolized to release glucose for energy)
a) ___ phase: hypovolemia, shock, tissue hypoxia
b) ____ phase: follows fluid resuscitation and return of oxygen transport
c) Results of physiologic trauma: hyperglycemia, hyperinsulinemia, little or no ketosis, increased glucagon
Ebb, flow, ebb, flow
Hormones involved in __ and ____ response to injury
1) Catecholamines epinephrine, norepinephrine - hepatic glycogenolysis
2) ACTH - releases cortisol which metabolizes amino acids from muscle
3) aldosterone - Renal sodium retention, glucogenesis
4) ADH - renal water absorption
5) Hypovolemia, decreased cardiac output, drop in body temperature
6) Hyperglycemia - epinephrine suppresses insulin, insulin resistance (decreased cell uptake and use)
7) fluid and sodium retention, potassium excretion, loss of nitrogen, sulfur, zinc, phosphorus
Ebb and flow
__________ disease
1) Protein calorie malnutrition, malabsorption, fluid and electrolyte imbalances
a) altered taste acuity: add flavorings and seasonings
b) meat aversions may require elimination of red meat
c) thrush from oral infection: avoid spicy, acidic, strongly flavored foods
1) Provide bland liquids, soft foods, chilled or frozen foods
d) Throat or neck cancer - use PEG feeding
e) Cancer cachexia (generalized wasting) connected to cytokines and the tumor necrosis factor (TNF)
Neoplastic
Treatment for __________ disease (cancer)
a) Radiation - loss of taste, xerostomia (dry mouth, so moisten food), esophagitis, diarrhea, malabsorption
1) Mucositis - inflammation of mucosal lining of oropharynx and esophagus
- Avoid fresh, raw, uncooked foods, offer cold and soft food
b) Chemotherapy - chemical reagents which have toxic effects
1) nausea, vomitin, malabsorption, anorexia
2) stomatitis - crack in skin at mouth corners, riboflavin deficiency
3) Methotrexate - anti - folate drug
Neoplastic
_____________ data in __________ disease (cancer)
a) Interrelationship between host, agent, environment in causing disease
b) some evidence that fruits and vegetables are beneficial in overall cancer prevention (carotenoids, vitamin C)
c) some evidence that exercise in post menopausal women decreases risk of breast disease
Epidemiologic, neoplastic
________ is malnutrition typified by protein and calorie starvation
1) anthropometric diagnosis, serum albumin normal, no edema
2) severe fat and muscle wasting, starved appearance
3) triceps skinfold, arm and muscle circumference decreased
Marasmus
__________ malnutrition: protein calorie malnutrition
1) brought on by treatment, hospital, medications
Iatrogenic
________ _______
a) distorted body image, dramatic weight loss, preoccupation with food and weight gain
b) therapy is multidisciplinary; weight restoration and psychotherapy
Anorexia nervosa
Treatment for ________ _______
1) Correct electrolyte imbalance
2) Plan with patient, regular mealtimes, varied and moderate intake, gradually reintroduced feared foods
3) Focus on health benefits and life sustaining aspects of food (reason to eat)
4) Re-feeding increases cardiac load - go slowly
5) Recommend initial daily calorie levels range from 1000 - 1600 (30 - 40 cals/kg), but may need to be set 100 - 300 calories above the current level of intake to support adherence
Anorexia nervosa
_______
- Gorging and vomiting syndrome, usually close to normal weight
1) Damage to teeth, throat, esophagus, rectal bleeding, bruised knuckles from purgin with fingers, low potassium and chloride blood levels
Bulimia
Obesity BMIs
Class I __ - 34.9
Class II 35 - ____
Class III >= __
30, 39.9, 40
____ calories = to _ lbs body fat
3500, 1
For obesity weight loss reduce average caloric intake by ___ calories per day
500
_______ treatment - reduced caloric intake, exercise, behavior modification
1) Realistic weight loss goals: up to 2 lbs per week, up to 10% of baseline BW, or a total of 3% to 5% of baseline weight if cardiovascular risk factors are present
Obesity
_______ _________ strategies for _______
1) 1200 - 1500 cal/day for women; 1500 - 1800 cal/day for men
2) Energy deficit of approximately 500 - 750 calories / day
3) One of the evidence based diets restricting certain food types (high fat foods, high CHO foods) in order to create an energy deficit by reduced food intake
4) Small food based changes: changes in SSB, sugar sweetened beverages can assist with weight management
5) Meal replacements for weight loss may be recommended if the client has difficulty with portion control
Calorie Reduction, Obesity
Physical activity recommendations for obesity: ___ to ___ minutes per week for loss; for weight maintenance, ___ to ___ minutes per week
150, 420, 200, 300
_______ medication approved for long term use (up to 2 years)
1) Orlistat: lipase inhibitor, take with diet 30% cals as fat, vitamin supplements
2) Lorcaserin: aggonist of serotonin, enhances satiety
3) Phentermine / topiramate: Appetite suppressant, releases norepinephrine
Obesity
_________ __________ interventions: weight maintenance is usually recommended in overweight children 2 - 5 years of age with a multicommponent weight management intervention with active participation of the parent
- Weight loss may be recommended when the child has serious medical conditions
Pediatric Obesity
The ____ ______ ____ theory is the belief that localized exercise reduces fat stores in the active area - research does NOT support this notion
Spot weight loss theory
When a dieter reaches a plateau, ___ will drop to reflect the weight loss
BMR
Bariatric surgery treatment is provided to those with class ___ obesity with a BMI of __ or greater, or a BMI of __ or greater with comorbidities
III, 40, 35
_______ ______ permanently alters the anatomy of the GI tract
1) Reduces the amount of food that can be eaten at one time and produces early satiety
Gastric Bypass
____ - __ - _ (RYGB) reconstructs the small intestine to resemble the letter Y
1) Creates a small gastric pouch connected directly to the jejunum
2) Dumping syndrome may develoo
3) Supplemental calcium in divided doses 1200 - 1500 mg, vitamin D 3000 IU, 45 - 60 mg iron taken apart from calcium, chewing of ice may be a sign of iron deficiency
- Greater need for protein
- multivitamin, multimineral supplement with 100% DRI for vitamin K, zinc, thiamine, folic acid, copper, biotin, iron
Roux - en -Y
______ ___________ (SG)
1) about 80% of stomach removed
2) food pathway not altered
3) vitamin supplementation, monitor iron, calcium, and vitamin D levels
Sleeve gastrectomy
____________ __________ ______ _______ (LAGB)
1) Small gastric pouch created using a fluid filled inflatable band
2) Adjusted to alter the size of the opening (fully reversible)
3) Restrics total amount of food eaten at one time
4) No surgery - induced malabsorption of nutrient. Deficiencies linked to decreased food intake and decreased food tolerance
Laparoscopic Adjustable Gastric Banding
______ _____ ________
1) Chromosome 15 deletion
2) Congential disorder, subnormal LBM, supra - normal body fat
3) Ghrelin levels are elevated which stimulates growth hormone secretion, appetite, intake, and fat mass deposition
4) do not sense satiety, decreased energy requirements
5) Obesity at 2 - 3 years of age, hypogonadism, muscle hypotonia, failure to thrive, short stature
6) Best treatment is to control food intake
Prader Willi syndrome
______ ______ bacterial enzymes ferment CHO deposits on plaque, enzymes produce acids that demineralize surface
Dental caries
Low __________ potential foods
-High protein, moderate fat, minimal concentration of fermentable CHO, strong buffer; high mineral content (Ca, P), PH >6, stimulates saliva
Cariogenic
_____ ________ (sorbitol, xylitol, mannitol) do NOT promote tooth decay
Sugar alcohols
________ can control caries, supplement starting at 6 months of age if level in water supply is < 0.3 ppm
1) Fluorosis (mottled teeth) with excessive fluoride
Fluorine
________ recommendations
1) Infants (birth - 6 months): oral supplementation NOT recommended. Use ___________ water if available
2) Infants (6 - 12 months) ___________ water; oral supplements ONLY if prescribed
3) Toddler (12 - 24 months) ___________ water, or oral supplements if prescribed
4) Children (2 - 3 years) ___________ water or supplements as recommended, ________ toothpaste (pea-size)
Fluoride, fluoridated, fluoridated, fluoridated, fluoridated, fluoride
Infant should not sleep with a ______ - ____ ______ _____ _____ (BBTD), _____ _________ ______ (ECC)
Bottle, Baby Bottle Tooth Decay, Early Childhood Caries
________ - Inflammation of the mouth (associated with riboflavin deficiency)
a) Avoid very hot, very cold foods, spices, sour/tart foods
b) rinse with lukewarm water after meals
Stomatitis
___________
a) Treat by decreasing gatric acidity, reflux
b) diet - small, low fat, bland, low fiber, weight reduction
Esophagitis
_________ - disorder of lower esophageal sphincter motility, does not relax upon swallowing
1) Causes dysphagia - difficulty swallowing
2) Start with pureed moist thick foods, progress to thick liquids
Achalasia
The ________ _________ ____ (NDD): Specifies diet consistency and liquid viscosity
National Dysphagia Diet
National Dysphagia Diet _
Pureed, moderate to severe
smoothe, pureed, homogenous, cohesive foods. “Pudding - like”. Blended, whipped, mashed. Avoid gelatin, fruited yogurt, hot cereal with lumps and soup with lumps, ice cream
1
_________ ____________ ______ (NDD2)
Mild to moderate
Moist, soft textured, easily formed into a bolus, moist, tender ground or diced meats, soft cooked vegetables, soft or canned fruits. Soft pancake okay. No bread, rice, cheese cubes
Dysphagia Mechanically Altered
\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_ (NDD3) Transition to regular Avoid very hard, sticky, crunchy foods, hard fruit and raw vegetables, nuts needs, dry bread and cereals
Dysphagia Advanced
______ Consistency Dysphagia
Spoon thick, Honey like, nectar like
Thin: includes all beverages: water, ice milk, juices, coffee, tea, gelatin
Liquid consistency
______ - __________ ______ disease (GERD)
1) Avoid eating before bed, soda, caffeine, acidic foods
2) small, low fat meals, liquids empty more rapidly
Gastro esophageal reflux disease
_________ _______ _____________ (PIH)
a) Progresses from pre-eclampsia to eclampsia
b) Hypertension, edema of face and hands, proteinuria, rapid weight gain after 20th week; may have convulsion
c) More frequently found in women wth lack of prenatal care, poor diets poor prootein and calcium intakes
d) sodium restriction is NOT recommended for prevention or treatment; sodim needed to maintain normal levels of sodium in plasma during large prenatal expansion of tissues and fluid
e) Proposed association between PIH and calcium deficiency
Pregnancy Induced Hypertension
___________ __________
- Severe nausea, vomitin, acidosis, weight loss
a) Bed rest, small amounts of frequent CHO
Hyperemesis Gravidarum
________ ______ __________ ________ (AIDS)
1) Virus debilitates immune system by attacking lymphocytes
2) diarrhea, malabsorption, nausea, vomiting, weight loss
3) Preserve lean body mass, prevent weight loss, prevent HIV wasting
Acquired Immune Deficiency Syndrome
Nutrition therapy for ____
1) Nutrient needs
a) Energy BEE x 1.3 for asymptomatic
b) Protein: asymptomatic 0.8 g/kg, up to 1.2 - 2.0 g/kg if wasted LBM
c) Vitamin/mineral supplements if needed to correct micronutrient deficiencies
AIDS
Nutrition Therapy for ____
1) Educate about food saftey
2) HIV infected women should be counseled NOT to breast feed
3) HIV employee - keep info confidential, suggest AIDS education program
4) Follow appropriate universal precaution; need not wear gloves, gowns or masks with general care unless respiratory or strict isolation indicated
AIDS
Nutrition therapy for ____
1) __________/__________ _______ _____________ __________ (NRTI) including Retrovir, Zidovudine can lead to anemia, loss of appetite, low vitamin B12, copper, zinc, carnitine
AIDS, Nucleotide/Nucleoside Reverse Transcriptase Inhibitors
Nutrition therapy for ____
Nutritional supplements should not be routinely recommended and herbal supplementation should be discouraged as adjunctive therapy to conventional care. Use of Vitamin C or St. John’s Wort could result in drug resistance. CAM (complementary alternative medicines) are not inert and may have profound consequences
AIDS
Pediatric ___
a) High protein, high calorie with supplements needed for weight gain
b) Energy needs: general guidelines plus appropriate stress factors
c) Multivitamins/minerals at doses 1 - 2 x RDA or DRI
d) Lactose restriction if intolerant
e) ___ - __________ _____________ ________ (HALS) may develop from therapy
1) High cholesterol, high TG, insulin resistance, changes in body fat distribution
f) Significant loss of lean body mass can be obscured by edema and HALS
HIV, HIV - Associated Lipodystophy Syndrome
_______ ___________ _________ _______ (COPD)
- persistent obstruction of airflow
a) Emphysema - air sacs (alveoli) lose elasticity; thin cachectic, often older
1) Difficulty exhaling; air pocket walls expand, thin out, collapse
b) Chronic bronchitis - Excess mucus production, chronic productive cough
c) symptoms - weight loss, emaciation, anorexia
Chronic Obstructive Pulmonary Disease
Nutrition Therapy for ____
1) Maintain stable weight - replete but do not overfeed: High calorie, high protein diet (1 - 1.5 g/kg dry weight, 15 - 20% cals), 30-45% as CHO
2) Small, frequent, mini meals and snacks, easy to prepare and eat, nutrient dense supplements (smoothies, meatloaf, muffins with cream cheese, tuna salad, cereal with fruit)
COPD
_____ ___________ ________ ________ (ARDS)
a) Lungs no longer able to exchange gases, hypermetabolism, increased energy needs; severely underweight
b) Meet basic nutritional requirements, maintain stable weight, facilitate weaning from mechanical ventilation, without exceeding capacity to clear carbon dioxide
c) Provide adequate but not excessive calories; avoid excess non - protein calories
d) Provide enteral formula containing EPA and GLA (gamma - linoleic acid), and enhanced levels of antioxidant vitamins
e) 1.5 - 2.0 protein/kg BW, maintain lean body mass
Acute Respiratory Distress Syndrome
Types of Enteral formulas
1) ________ polymeric
2) _________, chemically defined
3) __________
Standard polymeric, elemental, specialized
________ _______ Enteral Formula
1) Lecithin may be added as an emulsifier
2) Initiated at full strength at a rate of 10 - 40 mL/hour
3) Modular: ix individual components, adds flexibility
4) Blenderized: whole food, large bore tube, thick intact protein, high residue isotonic osmolality is close to that of blood)
Standard Polymeric
_________, __________ defined Enteral Formulas
1) Used with malabsorption
2) Pre-digested protein or amiino acids, glucoose or sucrose, small fat, vitamins, minerals, electrolytes
3) Absorbed in proximal intestine, low to no residue, don’t need pancreatic enzyme, high osmolality, poor taste
4) Used with compromised GI function, inability to digest and absorb
5) Alitraq, Peptamen, Vivonex
Elemental, chemically defined
___________ Enteral Formula
1) Nepro, Novasource Renal - renal
2) Nutre, Pulmocare, Respalor: High fat, low CHO - pulmonary
3) Hepatic Aid II, NutriHep - Liver
4) Glucerna, Diabetisource - diabetes
5) The more __________ the formula the greater the cost
Specialized, specialized
Tube ____ (opening)
1) Based on viscosity of feeding
2) Large #__ - Blenderized whole foods
3) Small #_ - Ready prepared formulas, more comfortable
16, 8
Guidelines for _______ Access
1) Anticipate length of time needed, risk of aspiration, patient’s anatomy, clinical status, normal or abnormal digestion and absorption
2) Hang time open systems 4 hours, closed system 24 - 48 hours
Enteral
Short Term ______ access (_ - _ weeks)
1) Nasogastric tube, normal GI function
2) Continuous Drip - constant, steady rate over 16 - 24 hours, usually with a feeding pump (for those with a compromised GI function or who do not tolerate large volume infusion)
3) Cyclic feeding - Delivered by continuous drip at an increased rate over 8 - 16 hours, often overnight, by pump (for under - nourished, especially older, ambulatory, malnourished patients)
4) Intermittent Drip (pump or gravity) - more mobility
5) Nasoduodenal or Nasojejunal if unable to tolerate gastric feedings
6) Transpyloric: passed by pyloric valve in stomach; used in comatose patients or ones with no gag reflex.
Enteral, 3 - 4
____ Term Enteral feedings (needed for more than _ - _) weeks
a) PEG inserts tube into stomach through abdominal wall
Long, 3 -4
When checking for ______ tube placement do NOT use blue dye, use x ray confirmation of tube tip location, or aspirate gastric contents
enteral
_______ _____ recommendations
1) _ mL water / calorie ingested
2) 1cal/mL formulas are 80-86% water
3) 1.5 cals/mL are 76 - 78% water
4) 2 cals/mL formulas are 69–71% water
Enteral Water, 1
Check _______ __________ every _ hours during the first __ hours. Then decrease to 6 - 8 hours unless patient is critically ill. If the GRV is > 250 after the second check, consider a prmotility agent. If the GRV 500 mL , hold othe feeding and assess tolerance
gastric residual volume, 4, 24
Adverse effects of ______ nutrition include
1) Lactose intolerance
2) formula hyperosmolality
3) Rapid infusion causing influx of water into gut
4) Bacterial contamination
Enteral
mL of enteral formula needed per day = ________ needed / cal/mL
calories
Enteral formula protein content = __ of daily formula x grams of _______ per liter
mL, protein
Daily fluid need with enteral feeding = % water in formula x daily formula in __
Subtract formula water from total fluid requirements to determine water ______
mLs, flushes
Enteral feeding administration rate = Total __ of formula /day / 24 hours
mL
__________ __________ _________ (PPN)
1) Used with small surface veins
2) Indications - post surgery (when enteral feeding is expected to resume within 5 - 7 days), mild to moderate malnutrition, as supplement to enteral
Peripheral Parenteral Nutrition
__________ __________ Solutions
1) IV dextrose - 3.4 calories / gram
a) To figure calories (mL x % x 3.4)
b) Highest concentration of dextrose used in peripheral nutrition is 10%
2) Protein 3 - 15% amino acid solutions
3) ___________ ___ ________ (IVFE)
a) 10% 1.1 cqalories/mL
b) 20% 2.0 calories/mL
4) Solutions generally limited to 800 - 900 mOsm
Peripheral Parenteral Nutrition, Intravenous Fat Emulsion
__________ _________ (PN)
1) Infusion of a hypertonic solution delivered through a central venous catheter
2) Used to achieve an anabolic state when patients are unable to eat by mouth and enteral feeding is not possible
3) Subclavian vein minimizes risk of phlebitis
4) Typical Uses: Altered GI function, Impaired Nutrient Utilization
Parenteral Nutrition
Note for patients on __________ Nutrition
1) Moderately to severely malnoursihed patients expected to have prolonged periods of GI dysfunction
2) Critically ill hemodynamically stable with paralytic ileus, acute GI bleeds, bowel obstruction
3) Only malnourished cancer patients on therapy who are anticipated to be unable to ingest and absorb adequate nutrients for a period of 7 - 4 days
4) Peritonitis, fistulas
5) Critical care patients if hypermetabolism is expected to last for more than 5 days and enteral support is not possible
Parenteral Nutrition
A ____________ ________ _______ ________ (PICC) is a catheter used for short or moderate term infusion
Peripherally Inserted Central Catheter
A _______ ______ ________ (CVC) is a long term central access catheter through the cephalic, subclavian or internal jugular vein into the superior vena cava
Central Venous Catheter
One primary concern with __________ nutrition is the translocation of bacteria; not feeding through gut allow wall to break down, bacteria move out causing sepsis
Parenteral
___ __________ ________ ______ (GALT) occurs in some cases of parenteral nutrition or bowel rest. The gut provides 50% of total body immunity. 70 - 80% of toal body immunoglobulin production is secreted across the GI mucosa to defend against pathogenic substances in the GI lumen
Gut Associated Lymphoid Tissue
_________ Protein solution
1) Ratio for anabolism is _ g nitrogen / ___ calories; 1 - 1.5 g protein / kg / day
2) crystalline amino acids _ - __% solution
3) % = number of grams of protein in ___ mL of solution
a) A 3% solution has 3 grams of amino acids / 100 mL
Parenteral, 1, 150, 3 - 15, 100
__________ Energy Solution
a) __ - __ calories/kg; up to a 70% dextrose solution
1) a __% solution provides ___ g CHO/liter
2) To avoid overfeeding and hyperglycemia, start at =< __ - __ calories /kg
3) Maximum rate of dextrose infusion should not exceed _ to _ mg/kg/minute to prevent hyperglycemia and other complications. Increased blood glucose from excess dextrose increases RQ in ventilated patients and increases infectious complications
Parenteral, 35 - 50, 10, 100, 20 - 25, 4 to 5
__________ fat solution
a) fat needed for energy to prevent _________ _____ ____ __________ (EFAD)
1) To prevent EFAD give ___ mL of 10% fat emulsion 1 - 2 x week
2) Symptom of EFAD; petechiae (red spots)
Parenteral, Essential Fatty Acid Deficiency, 500
_____ ________ __________ (TNA) or three in one systems are __________ nutrition solutions that include dextrose, amino acids, and lipids
Total Nutrieny Admixures, Parenteral
Contraindications for __________ nutrition
1) If alimentary tract can be used
2) If needed only for short time in well nourished
3) During periods of cardiac instabillity
4) If risks inherent in process outweigh benefits
Parenteral
___________ _______
a) Introduce a minimal amount of FULL STRENGTH enteral feeding at a low rate of __ - __ mL/hour to establish GI tolerance
b) Begin tapering when enteral feedings are providing 33 - 50% of their nutrient requirements
c) Decreaase PN as you increase enteral rate by 25 - 30 mL/hour increments every 8 - 24 hurs to maintain prescribed nutrient levels
d) when patient can tolerate about __% of needs by enteral route, DC PN
Transitional Feeding, 30 - 40, 60
__ - ______ ________ occurs with aggressive administration of nutrition to the malnourished
a) At risk: anorexia, chronic alcoholism, prolonged fasting, unfed 7 - 10 days, significant weight loss, phosphorus - deficient PN
b) Starved cells take up nutrients, potassium and phosphorus shift into intracellular compartments
c) results in hypokalemia, hypophosphatemia and hypomagnesemia
d) overfeeding PN and dextrose > 5mg/kg/min may lead to hyperglycemia
Re - feeding syndrome
___________ ________ combines evidence based complementary therapies with conventional (allopathis) treatments to address the social, psychological and spiritual aspects of health and illness
Integrative Medicine
The ________ ______ for _____________ and ___________ _____ (NCCIH) provides yoga, meditation, herbs and botanicals, traditional healing practices
National Center for Complementary and Integrative Health
_____________ and ___________ ________ (CAM) fall into categories like mind - body medicine, alternative medical systems, acupuncture, oriental medicine, lifestyle and disease prevention, biologically based therapies, herbs and orthomolecular medicine, manipulative and body based systems, chiropractic medicine, biofield systems like therapeutic touch, bioelectric magnetics
Complementary and Alternative Medicine
__________ medicine addresses the whole person, not just the symptoms, and looks at the underlying cause of disease, engaging patient and practitioner in a partnership for therapy
Functional
________ health views mental, physical and spiritual aspects of life closely connected and equally important with regard to treatment
Holistic
_______ _________ _______ (DRI)
- Is an umbrella of nutrient guidelines
Dietary References Intakes
___________ _______ __________ (RDA)
-Goals for healthy individuals to prevent nutritional deficiency diseases, includes gender, age, life phases
Recommended Dietary Allowances
_________ ________ ____________ (EAR)
- For 50% of population, used in planning meals for healthy people, assesses group nutritional adequacy
Estimated Average Requirement
\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ (AI) - Used when insufficient evidence exists for EAR, RDA
Adequate Intake
\_\_\_\_\_ \_\_\_\_\_\_ (UL) - Tolerable upper level not associated with adverse side effects in most individuals of a healthy person
Upper Limits
_______ _________ for Americans - Revised every five years
1) Designed to prevent chronic disease, written by USDA and HHS
2) Community nutrition programs use the guidelines when developing
Dietary Guidelines
2015 - 2020 _______ _________
a) Healthy eating pattern across the lifespan: Vegetables from all sub - groups, fruits (especially whole), grains (half whole grains), fat - free or low fat dairy, variety of proteins, oils
b) Focus on variety, nutrient density, and amount
c) Limit calories from added sugars (<10% of calories) and saturated fats (<10% of calories) and trans fats, and reduce sodium intake (<2300 mg)
d) Shift to healthier food and beverage choices
e) Support healthy eating patterns for all (home, school, work, communities)
f) Adults need 150 minutes of moderate - intensity physical activity each week (include strengthening activities on 2 or more days). Double the activity time for additional an more extensive health benefits
Dietary Guidelines
_______ ______ _____ (HEI)
- USDA’s overall measure of diet quality
1) Measures how well Americans follow the guidelines
2) 5 food groups, 4 nutrients (fat, saturated fat, cholesterol, sodium), variety
Healthy Eating Index
_______ ____ Guidance System
1) Shows essential food groups, and offers recommendations on balancing calories, foods to increase and foods to reduce
2) Build a healthy plate: make half your plate fruits and vegetables, make at least half your grains whole, use skin of 1% milk, vary protein choices
3) Cut back on foods high in solid fats, added sugars, salt
MyPlate Food
_______ ______ ____
- National Health Program and Disease Prevention
1) Identified broad goals and specific objectives for improving
2) Focuses on disease prevention by changing behaviors
3) Targets healthy diet and healthy weight as critical goals
4) ____ goals address nutrition and weight, physical activity, heart disease and stroke, diabetes, oral health, cancer, food safety, and health for seniors
5) Example of objective
a) Increase the proportion of adults who meet the objectives for physical activity
Healthy People 2020
A _____ is an award of financial or direct assistance: anyone can apply; usually lasts over a few years
Grant
_____ ______ from the federal government are given to states or local communities for broad purposes as authorized by legislation. Recipients have great flexibility in distributing funds.
There are five federal block grant areas
1) Maternal and child health
2) Community services
3) Social services
4) Preventative health services
5) Primary care
Block Grants
___ _____ Major federal level grant; steps to a healthier US focused on community based health initiatives related to obesity. Directs funds to address asthma, obesity and diabetes prevention
CDC Steps
Steps in program planning
1) Develop a _______ ________ (philosophy) and _____ / _______ statement
2) Set _____
3) Set __________
Mission statement, needs/problem statement, goals, objectives
Areas to analyze when developing a _______ statement or a ____ / _______ statement
a) what nutrition services can contribute to the health and well being of the community; what population groups will be served; select and rank the most critical issues; what is the present situation; who says it is a problem; what will happen if nothing is done
Mission, needs/problem
To ___ _____ in program planning
- Develop a broad direction and a general purpose (increase quality and years of life)
a) What health problems have nutritional implications
b) Determine current nutritional high risk groups and the most critical needs
Set goals
To ___ __________ set specific measurable (tangible actions within a time frame
Example: Increase the number of women who can identify two risk factors for CHD by 25% in one year.
a) More defined than goals; contain specific target dates for completing specifc projects. Include expected results in quantitative and qualitative terms within a given time frame
b) SMART objectives: specific, measurable, achievable, relevant, time frame
c) Guidelines for writing
1) Include who what behavior (measurable or action verb), how much, by whom, when, where
2) Action verbs are measurable: Exercise, select, list, identify, count, produce
3) Not an action verb: appreciate, understand
Set objectives
To _______ a ____ in program planning
- Evaluate alternative strategies (cost/effective analysis): what are all the possible ways to solve the problem, what resources would be needed to do each alternative, which alternatives are the most feasible, who needs to be involved in choosing which way is best
Develop a plan
In plan development ______ ___________ controls and coordinates activities, indicates how and at what rate dollars are to be expended.
Budget Development
Consider the following in ______ preparation
-Expenditures of preceding period, present budget, changes in present budget period, expenditures of present period, budget requests for next period
budget
Phases of the ______ cycle include
- Prepare requests
- Evaluate revenue potential
- Formulate document
- Send to legislative body
- Legislative review and authorization
- Execute the Budget (run the program)
- Evaluation and review
budget
Functions of a __________ budget
-Summarizes program activities performed in terms of the cost of specified accomplishments
Ex: what it costs to screen 200 children for anemia
Performance
Budget _______
Public health departments derive a portion of their income from general revenue (taxes), and federal, local or foundation grants
Funding
Program ______________ requires administrative support
- Realistic budget, staff commitment, support of target population
- Areas include educating, enabling, and developing skills
Implementation
_________ in program implementation involves :
- Increasing awareness, knowledge and options
a) Scientifically sound information explained to client so they understand reasons for changes you are recommending
b) to reach large numbers: use media, hotlines, point of choice or point of purchase intervention
c) In health fairs, evaluate nutritional risk using BMI
Educating
________ in program implementation
- Reduces barriers that make it easier for people to act
a) Enabling interventions relate to the 4 “P’s” of marketing
b) The product should be acceptable, the place accessible, the price reasonable, and the promotion tailored to enable attention and acceptance
Enabling
_____ ___________ in program implementation works with competencies necessary to make and sustain new eating habits (psychomotor learning)
a) One on one counseling, small group sessions, school fitness programs, worksite cafeteria programs
b) Teaches how to: select appropriate foods, budget for healthful foods, how to obtain Food Stamps if needed, how to develop new eating behaviors
Skill development
