Misc Domain II Flashcards
amputations - entire leg
16% of body weight
amputations - lower leg with foot
6% of body weight
amputations - entire arm
5% of body weight
amputations - forearm with hand
2.3% of body weight
adjusted IBW for amputations
(100 - % amputation) / 100 x IBW of original height
spinal cord injury - quadriplegic
reduce by 10-15% of table weight
spinal cord injury - paraplegic
reduce by 5-10% of table weight
tricep skinfold thickness - TSF
measures body fat reserves; measures calorie reserves
tricep skinfold thickness - TSF measurements
standard: male 12.5mm; female 16.5mm
arm muscle area AMA
- measures skeletal muscle mass (somatic protein)
- to determine use TSF and MAC (midarm circumference)
- important to measure in growing childdren
arm muscle area AMA measurements
standard: male 25.3cm; female: 23.2cm
waist/hip ratio - WHR
differentiates between android and gynoid obesity
gynecoid type adipose tissue is found predominantly in the lower part of the body (hips and thighs).
waist/hip ratio measurements
WHR of 1.0 or greater in man, 0.8 or greater in women is indicative of android obesity and an increased risk for obesity-related diseases (diabetes, hypertension)
hair assessment - thin, sparse, dull dry brittle, easily pluckable
vitamin C, protein deficiency
auscultation hypoactive bowel sounds
every 15-20 seconds, may indicate paralytic ileus or peritonitis
auscultation normal bowel sounds
are gurgling high-pitched sounds every 5-15 seconds
serum albumin range
3.5 - 5.0 g/dl
serum albumin
- maintains colloidal osmotic pressure
- visceral protein
- hypoalbuminemia
- levels above normal range likely due to dehydration
serum transferrin
- serum level controlled by iron storage pool; rises with iron deficiency
- can be determined from TIBC
serum transferrin range
> 200 mg/dl
TTHY transthyretin, PAB prealbumin range
- 16-40 mg/dl
TTHY transthyretin, PAB prealbumin
- during inflammation; liver synthesizes CRP at expense of PAB
- liminted usefulness in screening or assessment
RBP - retinol binding protein range
3-6 mg/dl
RBP - retinol binding protein
- circulates with prealbumin; shortest half-life
- binds and transports retinol
Hct hematocrit range
- men 42-52%
- women 36-48%
- pregnant women 33%
- newborn 44-64%
Hgb hemoglobin range
men 14-18 gm/dl
women 12-16 gm/dl
pregnant >=11
Hgb hemoglobin
iron containing pigment of red blood cells
erythrocytes are produced in bone marrow
serum ferritin range
10-150 ng/ml female
12-300 ng/ml men
serum ferritin
indicates size of iron storage pool
serum creatinine range
0.6-1.2 mg/dl M
0.5-1.1 mg/dl F
serum creatinine
- related to muscle mass; measures somatic protein
- may indicate renal disease, muscle wastage
CHI - creatinine height index
80% normal
60-80% mild muscle depletion
BUN blood urea nitrogen range
10-20 mg/dl
BUN blood urea nitrogen
- related to protein intake
- indicator of renal disease
- BUN: creatinine ratio - normal 10-15:1
urinary creatinine clearance range
115 +- 20 ml/minute
urinary creatinine clearance
measures GFR - glomerular filtration, renal function
- estimate includes body surface area
TLC total lymphocyte count range
> = 2700 cells/cu mm
depletion 900-1800
severe depletion <900
TLC total lymphocyte count
decreased in protein-kcal malnutrition
measures immunocompetency
CRP c-reactive protein
marker of acute inflammatory stress
- as it declines, indicates when nutritional therapy would be beneifical
- when elevated CRP decreases, PAB increases
FEP free erythrocyte protoporphyrin
direct measure of toxic effects of lead on heme synthesis (leading to anemia). increased in lead poisoning. lead and calcium compete at plasma membrane for transport
PT prothrombin time
11-12.5 second; 85-100% of normal
anticoagulants prolong PT
PPFPs
prepared and perishable food programs - nonprofit programs that link sources of unused, cooked and fresh foods with social service agencies that serve the hungry
NNMRRP
National nutrition monitoring and related research program
PedNSS
pediatric Nutrition Surveillance System
PNSS
pregnancy nutrition surveillance system
NFCS
USDA nationwide food consumption surveys
NFNS
National food and nutrition survey
WWEIA - what we eat in america - dietary intake component of NHANES
BRFSS
behavior risk factor surveillance system
YRBSS
youth risk behavior surveillance system
FSANS
food safety and nutrition survey - FDA
TANF
temprorary assistance for needy families
CFDP
commodity food donation/distribution program
CSFP
commodity supplemental food program
TEFAP
the emergency food assistance program
NSLP
national school lunch program
NSBP
national school bfast program
ASP
afterschool snack programs
SMP
special milk program
SFSP
summer food service program
CACFP
child and adult care food program
FFVP
fresh fruit and vegetable program
EFNEP
expanded food and nutrition education program
NSIP
nutrition services incentive program
OAA
older americans act nutrition program
NETP
nutrition education and training program
SFMNP
senior farmers’ market nutrition program
FAO
food and agricultural organization
clinical diagnosis (NC)
nutritional findings/problems that relate to medical/physical condition
clinical - functional balance
physical or mechanical change that interferes/prevents desired nutritional results; swallowing difficulty, altered GI function
clinical - biochemical balance
change in capacity to metabolize nutrients due to medications, surgery, or indicated by lab values
clinical - weight balance
chronic or changed wt status when compared with UBW: underweight, involuntary wt loss, overwt
intake diagnosis NI
actual problems related to intake
intake - caloric energy balance
actual or estimated changes in energy (hypermetabolism, hypometabolism, increased energy expenditure)
intake - oral or nutrition support intake
inadequate or excessive compared with goal
intake - fluid intake balance
inadequate or excessive compared with goal
intake - bioactive substances
supplements, alcohol, functional foods
intake - nutrient balance
intake of nutrients compared with desired levels
behavioral-environmental diagnosis (NB)
problems related to knowledge, access to food and food safety
behavioral-environmental - knowledge and beliefs
knowledge deficit, harmful beliefs, disordered eating pattern, undesirable food choices
behavioral-environmental - physical activity balance and function
inactivity, excessive exercise, impaired ability to prepare foods
behavioral-environmental - food safety
and access
primary prevention programs
reduced exposure to a promoter of disease (early screening for risk factors like diabetes). health promotion
secondary prevention program
recruiting those with elevated risk factors into treatment program (setting up an employee’s gym), reduce impact of a condition that has already occurred. risk reduction, slow process to restore health
tertiary prevention program
as disease progresses, intervention to reduce severity, manage complications (cardiac/stroke programs). rehabilitation efforts.
FTC - health care fraud
federal trade commission: internet, TV, radio; bogus wt loss claims
Ulcer drug therapy
cimetidine, ranitidine - H2 blockers which prevent the binding of histamine to receptor, decreases acid secretion
what vitamins/minerals are adversely affected by billroth II
calcium - most rapid absorption in duodenum and iron absorption (requires acid) are adversely affected
- B12 deficiency, folate deficiency
following a complete gastrectomy what deficiencies happen?
iron, B12, folate, calcium, vitamin D, B1, and copper may develop
gastroparesis
delayed gastric emptying due to surgery, diabetes, viral infections, obstructions
gastroparesis medications
prokinetics (erythromycin, metoclopramide) which increase stomach contractility
MNT for tropical sprue
antibiotics, high kcal, high protein, IM b12, oral folate supplements
non tropical sprue what not to eat
need gliadin-free - gluten-restricted diet: NO wheat, rye, certain oats, barley, bran, graham, malt, bulgur, couscous, durum, orzo, thickening agents
high fiber diet may increase the need for what minerals
Ca, Mg, P, Cu, Se, Zn, Fe
vitamin/mineral deficiencies with Crohn’s disease
B12, iron deficiciency
vitamin/mineral deficiencies with UC
electrolyte disturbance (Na, K)
negative nitrogen blanace
iron, folate, assess Ca, Mg, Zn
antidiarrheal agent - sulfasalazine
lactose intolerance test
if lactose intolerant blood glucose will be <25 mg/dl
supplement with calcium and riboflavin
acute diarrhea in infants and children
aggressive and immediate rehydration
reintroduce oral intake within 24 hrs
chronic nonspecific infantile diarrhea
no significant malabsoprtion
consider ratio of fat to CHO calories, volume of ingested liquids
give 40% kcal as fat, balanced with limited fluids; restrict or dilute fruit juices with high osmolar loads - apple, grape
ileal resection SBS
significant resections produce major complications
distal - absorption of B12, intrinsic factor, bile salts
need more fluids
malabsorption of fat soluble vitamins along with Ca, Zn, Mg leading to “soaps”
colonic absorption of oxalate increases leading to renal oxalate stones
loss of colon SBS
loss of water and electrolytes, loss of salvage absorption of carbs and other nutrients. provide chewable vitamins.
nutritional care SBS
PN initially to restore and maintain nutrient status then move onto EN
liver function tests ALP
alkaline phosphatase
30-120 U/L
increased - liver, or bone disease
decreased - scurvy, malnutrition
liver function tests LDH
lactic acid dehydrogenase
increased in hepatitis, myocardial infarction, muscle malignancies
liver function tests - AST, SGOT
aspartate amino transferase
0-35 U/L
increased in hepatitis
liver function tests - ALT, SGPT
alanine aminotransferase
4-36 U/L
increased in liver disease
HAV
fecal oral transmission
HBV
sexually trasmitted
HCV
blood to blood contact
heptatitis MNT
1-1.2 g/pro/kg
50-55% CHO
mod to liberal fat intake if tolerated
small frequent feedings
coffee is okay
multivitamin with B complex, C, K, zinc
if fluid retention, 2 gm Na
MNT for cirrhosis
adequate to high pro .8-1.2 g/kg; in stress at least 1.5g/kg
high kcal 25-35 kcals/kg
mod to low fat 25-40% kcal - fat is the preferred fuel in cirrhosis
low fiber if varices are present, low sodium if edema or ascites
B complex vitamins, C, Zn, Mg; monitor need for A and D
alcoholic liver disease MNT
supplement thiamin and folic acid
need more B vitamins
increased need for magnesium
thiamin deficiency
protein deficiency
hepatic failure
liver cannot convert ammonia (NH3) to urea - ammonia accumulates
- asterixis (flapping, involuntary jerking motions): sign of impending coma
hepatic failure MNT
1-1.5 g pro/kg if not comatose and not protein-sensitive
30-35 kcal/kg, 30-35% kcal as fat with MCT if needed
low sodium if ascites; vit/mineral supplementation
increased BCAA
meds for hepatic failure
lactulose (hyperosmotic laxative that removes nitrogen); neomycin (antibiotic that destroys bacterial flora that produce ammonia)
MNT for NAFLD
wt loss 7-10%, not rapid
healthful eating through Med diet, moderate alcohol, avoiding sugar bevs, coffee may help
physical activity
gallbladder disease
low fat diet - acute 30-45 g; chronic 25-30% of kcal
if cholecystectomy - bile now secreted from liver directly to intestine so limit fat intake to allow liver to compensate. slowly increase fiber
acute pancreatitis MNT
hypermetabolic state increased BMR
withhold feeding, maintain hydration
progress as tolerated to easily digested foods with a low fat content
elemental (pre-digested) EN into the jejunum may be tolerated
chronic pancreatitis MNT
PERT therapy orally with meals and snacks to minimize fat malabsorption from lack of pancreatic lipase.
MCTs do not require pancreatic lipase
- avoid large meals with fatty foods, alcohol
CF MNT
use age-appropriate BMI to assess height and weight
PERT therapy with meals and snacks
high protein, high kcal, unrestricted fat, liberal in salt
age appropriate doses of water-soluble vitamins and minerals
supplement zinc, water-soluble forms of fat-soluble vitamins (A and E)
normal BP
< 120/80 mm Hg
elevated BP
systolic between 120-129 and diastolic less than 80
stage 1 HPN
systolic between 130-139 or diastolic between 80-89
stage 2 HPN
systolic between at least 140 or diastolic at least 90 mm Hg
HPN MNT
thiazide diuretics may induce hypokalemia
<2300 mg sodium/day
DASH diet
decrease wt
risks of atherosclerosis
hypertension, obesity, smoking, elevated blood lipids, heredity
chylomicron
synthesized in intestine from dietary fat, transports dietary triglycerides from gut to adipose, lowest density; smallest amount of protein
VLDL
transports endogenous triglyceride from liver to adipose
LDL
transports cholesterol from diet and liver to all cells
- small dense LDL-C associated with increased risk, responsive to diet
- larger buoyant LDL is not associated with increased risk
HDL
reverse cholesterol transport; moves cholesterol from cells to liver and excretion
IDL
LDL precursor; catabolism of other lipoproteins
metabolic syndrome risk factors
3 or more of:
elevated blood pressure >=130 and/or >= 85 diastolic
elevated TG >= 150 mg/dl
fasting serum glucose >=100 mg/dl
waist measurement >=40 in men and 35 in women
low HDL <40 for men and <50 women
desired labs for metabolic syndrome
<100 LDL-C
<200 cholesterol total
>= 60 HDL
<150 TG
heart healthy diet
saturated fat <7% kcal, <200 mg cholesterol, 2g sodium, no trans fats, include fiber, fruits, veg, low fat dairy, unsaturated fats
recommend a heart- healthy lifestyle and statin therapy for
pts who have ASCVD, patients with LDL of 190 or higher, pts with type 2 diabetes between the ages of 40 and 75, pts with an estimated 10-yr risk of CVD or 7.5% or higher who are between 40 and 75 yrs old
heart failure MNT
digitalis increases strength of heart contraction
low sodium 2-3 g
dash diet
1-2 L fluid
1.1-1.4 g protein/kg
use indirect calorimetry if available but if not, estimate RMR at 22kcal/kg for normally nourished, 24 kcal/kg for malnourished
- evaluate thiamin status
- DRI for folate, Mg, MV with b12
cardiac cachexia MNT
arginine and glutamine may help
low saturated fat, low cholesterol, low trans fat, <2 g sodium, high calorie
vasopressin
ADH, from hypothalamus stored in pituitary
exerts pressor effect; elevates BP
increases water reasborption
SIADH, hyponatremia caused by hemodilution, treated with fluid restriction
renin - vasoconstrictor
secreted by glomerulus when blood volume decreases
stimulates aldosterone to increase sodium absorption and return blood pressure to normal
erythropoietin EPO
produced by kidney; stimulates bone marrow to produce RBC
lab tests in renal disease
decreased GFR, creatinine clearance
increased serum creatinine, BUN
BUN/Cr ratio of >20:1 indicates a pre renal state in which BUN reabsorption is increased due to acute kidney damage
BUN/Cr ration of <10:1 suggests reduced BUN reabsorption due to renal damage - may need dialysis
renal calculi MNT
1.5-2L fluid to dilute urine with renal calculi
adequate calcium intake to bind oxalate and a low oxalate diet
alkaline / acid ash diet
alkaline ash/acid ash diets
minerals not oxidized in metabolism leave an ash (residue) in urine
to prevent acidic stones - create an alkaline ash: increase cations (Ca, Na, K, Mg), by adding veg, fruits, brown sugar, molasses
to prevent alkaline stones - create an acid ash: increase anions (Cl, Ph, Su) by adding meat, fish fowl eggs shellfish, cheese, corn, oats, rye
acute kidney injury or failure
oliguiria or azotemia
1-1.3 g/kg if non catabolic without dialysis
1.2-1.5 g/kg if catabolic and/or initiation of dialysis
25 -40 kcal/kg. energy expenditure increases as kidney function declines.
low sodium
8-15 mg/kg phos
2-3 g potassium
replace fluid output from previous day plus 500 ml
nephrotic syndrome MNT
0.8-1.0 g/kg; <30% fat, low sat fat, 200 mg cholesterol
35 kcal/kg
modest sodium restriction
calcium 1-1.5 g/day
vitamin D supp
may need fluid restriction
abnormalities in iron, copper, zinc, calcium related to protein loss
CKD MNT
25-35 kcals/kg
<2300 mg sodium
CKD levels 3-5 need 0.60 g protein/kg
phosphorus - adjust intake
calcium - 800-1000 mg total elemental
potassium generally not restructed
fluid generally unrestricted in CKD 1-4
consider supp of folate, b12, b complex; vit c and D
chronic renal failure - hemodialysis MNT
1-1.2 g pro/kg
25-35 kcal/kg
<2.3 g sodium
25-35% fat; <7% saturated; <200 mg cholesterol
fluid individualized
calcium, individualized with max 2g
potassium adjust intake
800-100 mg phos
vitamins B6, folate, b12, vit D, C supps
vitamin A and E supps are NOT recommended
chronic renal failure - peritoneal dialysis MNT
1-1.2 g protein/kg
25-35 kcal/kg
<2.3 g sodium
potassium generally unrestricted
calcium, individualized with max 2g
800-1000 mg phosphorus
1-3L fluid depending on output, cardiac status
risk factor for diabetes GADA
glutamic acid decarboxylase antibodies
normal blood glucose
70-100 mg/dl, 2hPG post-prandial <140 mg/dl
impaired fasting glucose FPG
100-125
impaired glucose tolerance
2hPG 140-199
diabetes fasting plasma glucose
FPG >=126
diabetes glucose tolerance test
GTT >= 200 or symptoms of diabetes plus casual plasma glucose >=200 mg/ddl
diabetes HgA1c
> =6.5%
normal A1c
<5.7%; over 65 yrs <7% in healthy, <=8% in frail
goal for A1C for diabetics
<7.0%
prediabetes A1c
5.7-6.4%f
foods with low glycemic index
legumes, milk, whole grains, fruits, veg
goal for diabetics blood glucose average
average pre-prandial goal 70-130; peak post-prandial average <180
gestational diabetes risk factors
BMI > 30, history of GDM
gestational diabetes screening
at 24-28 weeks of gestation, screen with 50g oral glucose load; glucose >=140 mg/dl indicates further testing
gestational diabetes MNT
40-45% CHO, 3 small medium sized meals and 2-4 snacks; DRI for CHO during preganancy is 175 g/day; 15-30g CHO at breakfast (less well tolerated); increases risk of fetal macrosomia (LGA) or fetal hypoglycemia at birth
food lists for diabetes - starch/bread
carbs - 15
pro - 3
fat - 1
kcal - 80
food lists for diabetes - fruit
carb - 15
food lists for diabetes - milk, fat free, low fat
carbs - 12
pro - 8
fat - 0-3
kcal - 100
food lists for diabetes - milk, reduced fat
carbs - 12
pro - 8
fat - 5
kcal - 120
food lists for diabetes - milk, whole
carbs - 12
pro - 8
fat - 8
kcal - 160
food lists for diabetes - sweets, desserts, other CHO
carbs - 15
rest varies
food lists for diabetes - non-starchy veg
carbs - 5
pro - 2
kcal - 25
food lists for diabetes - lean protein
pro - 7
fat - 2
kcal - 45 (canadian bacon)
food lists for diabetes - medium fat protein
pro - 7
fat - 5
kcal - 75
food lists for diabetes - high fat protein
pro -7
fat - 8
kcal - 100
food lists for diabetes - plant based
pro - 7
rest varies
food lists for diabetes - fats
fat - 5
kcal - 45
food lists for diabetes - alcohol
kcal - 100
food lists for diabetes - free foods
<20 kcal and <5g CHO per serving
acute ketoacidosis
hyperglycemia due to insulin deficiency or excess carb intake, dehydration due to polyuria, increased pulse, fruity odor of ketones. treatment: insulin, rehydration
acute hypoglycemia
insulin reaction (shock); due to insulin excess or lack of eating, slow pulse, cool clammy skin, hungry, weak, shakiness, sweating
treatment: glucose
- begin with 15 g CHO, fruit juice (4-6oz), sugar
- wait 15 min; if still < 70 mg/dl, give another 15 grams
- repeat and treat until BG is normal
if unresponsive: administer glucagon
postprandial or reactive hypoglycemia
overstimulation of pancreas or increased insulin sensitivity; blood glucose falls below normal 2-5 hrs after eating <50mg/dl
- avoid simple sugar, 5-6 small meals per day, spread intake of CHO throughout the day
Addison’s disease
- decreased cortisol - glycogen depletion, hypoglycemia
- decreased aldosterone - sodium loss, potassium retention, dehydration
- decreased androgens - tissue wasting, wt loss
diet: high protein, frequent feedings, high salt
hyperthyroid
elevated T3 and T4
increased BMR leading to wt loss
increase kcal
hypothyroid
T4 low; T3 low or normal
decreased BMR leading to wt gain
wt reduction
goiter
enlargement of thyroid gland
inadequate iodine intake
gout
disorder of purine metabolism
increased serum uric acid - deposits in joints causing pain
gout MNT
mod pro, liberal carb, low to moderate fat, decrease alc, liberal fluid, avoid high purine foods (anchovies, sardines, organ meats, sweet breads, meat-based gravies & extracts)
meds - urate eliminant, colchicine, induce loss of nutrients
galactosemia
due to missing enzyme that would have converted galactose 1-PO4 into glucose 1-PO4
- treated solely by diet - galactose and lactose, no drugs
- NO: organ meats (naturally contain galactose), MSG extenders, milk, lactose, galactose, whey, casein, dry milk solids, curds, calcium or sodium caseinate, dates, bell pepper
urea cycle defects
unable to synthesize urea from ammonia resulting in ammonia accumulation
vomiting, lethargy, seizures, coma, anorexia, irritability
diet - protein restriction to lower ammonia; therapeutic formulas to adjust protein composition to limit ammonia production
example: OTC Ornithine transcarbamylase deficiency
phenylketonuria PKU
missing enzyme - phenylalanine hydroxylase - which would convert phenylalanine into tyrosine; phenylalanine and metabolites accumulate leading to poor intellectual function
detected w/ Guthrie blood test
diet
- restrict the substrate phenylalanine (PHE), supplement the product tyrosine (TYR), tyrosine becomes a conditional AA
- low in Phe, but provide enough to promote normal growth
- avoid aspartame
- need for phenylalanine decreases with age, infection
- low protein, high CHO intakes may lead to increased dental caries
glycogen storage disease
deficiency of glucose 6 phosphatase in liver; impairs gluconeogenesis and glycogenolysis
- liver can’t convert glycogen into glucose leading to hypoglycemia
- provide a consistent supply of exogenous glucose with raw cornstarch at regular intervals, and a high carb, low fat diet
homocystinurias
- treatable inherited disorder of AA metabolism
- characterized by severe elevations of methionine and homocysteine in plasma, and excessive excretion of homocystine in urine
- associated with low levels of folate, B6, B12
- newly diagnosed patients receive increased doses of folate, pyridoxine, B12
- if they don’t respond: low protein, low methionine diet
maple syrup urine disease MSUD
- inborn error or metabolism of the BCAA’s - leucine, isoleucine, valine
- poor sucking reflex, anorexia, FTT, irritability, sweet burnt maple syrup odor of sweat and urine
- restrict BCAA 45-62 mg/day
- provide adequate energy from CHO and fat to spare AA
- include small amounts of milk to support growth; gelatin may be used
- avoid eggs, meat, nuts, other dairy products
congenital sucrase isomaltase disease CSID
- diet modification of sucrose, starch and maltose
- if on Sacrosidase (oral enzyme replacement for sucrase), they do not need to restrict sucrose in their diet (just starch and maltose). enzyme is taken before and during meals and snacks
- diabetics on Sacrosidase need to check blood glucose levels. it converts sucrose into fructose and glucose
arthritis
normocytic anemia may develop
- inflammation of arthritis prevents reuse of iron
- antiinflammatory diet may help osteoarthritis
- methylprednisolone - steroid that may decrease inflammation
systemic lupus erythematosus
SLE
no specific dietary guidelines, tailor to needs
may have dietary deficiencies of iron, folate, calcium, fiber, b12
may have anemia but does not correlate with iron intake
may show symptoms of celiac disease
type I osteoporosis
potmenopausal within 15-20 yrs
type II osteoporosis
age associated > 70 yrs
osteoporosis MNT
HRT - hormone replacement therapy, wt bearing exercise, vitamin D, calcium, adequate pro, moderate to low sodium, 5 or more servings of fruit and veg
- take calcium carbonate with food; calcium citrate with or without food
epilepsy meds
phenobarbital and phenytoin (Dilantin) interfere with calcium absorption
epilepsy MNT
take 1 mg folate daily with drug
may need supplements of vitamin D, calcium, thiamin, provide phenytoin separate from meals and other supps
enteral feedings decrease bioavailability of phenytoin so hold tube feelings >=2 hrs
ketogenic diet
for epilepsy
mild dehydration needed to prevent dilution of ketones
need supps of Ca, D, folate, B6, B12 (spinach may aid in absorption)
cerebral palsy spastic form
difficult still movement; limited activity; obese
low kcal, high fluid, high fiber diet
cerebral palsy nonspastic form
athetoid form - involuntary wormlike movement, constant irregular motions leading to wt loss
high kcal, high pro, finger foods
traumatic brain injury
systemic inflammatory response: hypermetabolism, hyperglycemia, insulin resistance protein wasting
EN into small bowel
provide energy at 140% of estimated REE
1.5-2.0 g pro/kg
spinal cord injury
long term issues - obesity, CVD, pressure ulcers
acute phase: energy needs may be 10% below predicted, 2g pro/kg
rehabilitation - .8-1.0g pro/kg, 23 kcals/kg for quadriplegic pts, 28 kcals/kg for paraplegia
neurogenic bowel slows transit time: 1 ml fluid/kcal plus 500 ml/day
pressure injuries
30-35 kcals/kg if malnourished or at risk for malnutrition
stage 1 - 1.1-1.2 g/kg pro
stage 2 - 1.25-1.5 g/kg pro, adequate fluid
stage 3/4 1.5-2.0 g/kg pro
well balanced diet including good sources of vit A, C, zinc, copper
braden scale
stage I - upper layer of skin, red and warm to touch
II - broken skin, open sore
III - damage below skin surface into fat tissue
IV - large wound, may affect muscles and ligaments
ASD
autism spectrum disorder
- unnecessary food restrictions, possible food aversions, excessive supplementation can place children with ASD at risk
anomia
form of aphasia - lost words, unable to recall names of common items
nutrients associated with dementia
folate, B6, B12
microcytic hypochromic anemia RBC
RBC may be normal 4.7-6.1 M, 4.2-5.4 F
macrocytic anemia RBC
decreased <4.7 M, <4.2 F
microcytic hypochromic anemia hematocrit
low <42% M, <35% F
macrocytic anemia hematocrit
low <42% M, <35% F
MCV microcytic anemia (average cell size)
low <80
MCV macrocytic anemia (average cell size)
high >95
MCH microcytic anemia (average cell hemoglobin)
low <27 pg
MCH macrocytic anemia (average cell hemoglobin)
high >32 pg
MCHC microcytic anemia
low <31
MCHC macrocytic anemia
normal >31
32-36%
thalassemia
defective hemoglobin synthesis resulting in microcytic, hypochromic, short-lived RBC. may develop iron overload. do not avoid iron-rich foods. managed with transfusions and chelation therapy
provide high pro, B vitamins (especially folic acid), zinc
ag-ab reaction
when antigen enters body, antibody reactions
allergic to dust, spring, non food things
immunoglobumin E
(IgE) mediated reaction to normally harmless food protein
common allergens - peanuts, eggs, milk, soy, wheat, shellfish
CAP-FEIA
blood test is specific in identifying children with milk, egg, fish, peanut allergy
DBPCFC
double blind placebo-controlled food challenges - identify food induced symptoms for food borne allergies (gold standard for diagnosis)
RAST
alternative to skin test - serum is mixed with food on paper disk; measures specific IgE antibodies
food least likely to cause an allergy
rice
food intolerance non-IgE
abnormal physiologic response, GI, cutaneous, respiratory symptoms, but NO antibody production; intolerant
fever and infection MNT
excessive fluid loss may lead to dehydration (hyperglycemia, dry, loose inelastic skin); IV feedings of dextrose and water, then diet high in kcal and fluids
- BMR increases 7% for each degree rise in F temp; normal temp 98.6F
burns MNT
20-25% kcal as protein or 1.5-2 g protein/kg
1.2g/kg if burn <10% BSA
vitamin C 500 mg x 2, water soluble vitamins, vitamin K if on antibiotics
zinc for wound healing if zinc deficient, 220 mg zinc sulfate
burns - rule of 9s
arm including hand head and neck, genitalia 9% each
anterior trunk, posterior trunk, legs including feet 18% each
trauma
accelerated catabolism of lean body mass leading to neg. nitrogen balance as protein is catabolized to release glucose for energy
hyperglycemia, hyperinsulinemia, hypermetabolic
provide adequate but not excessive kcal - 25-30 kcal/kg ABW, 1.2 - 1.5 g pro/kg
stages of death - pre active
decreased intake of foods and liquids
stages of death - active stage
inability to swallow, abnormal breathing patterns
treatment cancer
radiation - moisten foods
mucositis - avoid fresh, raw, uncooked foods, offer cold and soft food
chemotherapy - methotraxate - antifolate drug
epidemiologic data
interrelationship between host, agent, environment in causing disease
marasmus
protein & kcal starvation
serum albumin normal, no edema
starved apperance
triceps skinfold, arm muscle circumference decreased
anorexia MNT
correct electrolyte imbalance
refeed slowly
recommended initial daily calorie levels range from 1000-1600
obesity MNT
3500 kcal / pound body fat; to lose 1 lb fat/week, reduce 500 kcal/day
obesity meds - orlistat
lipase inhibitor - take with diet 30% kcals as fat (fat restriction), vitamin supplements
obesity meds - lorcaserin
agonist of serotonin, enhances satiety
obesity meds - phentermine/topiramate
appetite suppressant, releases norepinephrine
bariatric surgery treatment can be done on individuals with
BMI 40 or greater, or BMI of 35 or greater with comorbidities
RYGB
roux en y gastric bypass
dumping syndrome may develop
- supplement calcium, vitamin D, iron, greater need for protein
vitamins for life: multivitamin, vitamin K, thiamin, biotin, folic acid, copper, zinc, iron. B12
SG
sleeve gastrectomy
vitamin supp: monitor iron, calcium, vit D
LAGB
laparoscopic adjustable gastric banding
deficiencies linked to decreased food intake and decreased food tolerance
eat slowly, sip drinks, no straws, no bubbles
low cariogenic potential foods
for dental caries
high protein, mod fat, minimal concentration of fermentable CHO, strong buffer; high mineral content (Ca, P), pH >6 stimulates saliva. low cariogenic: cheese, nut, meat
sugar alcohols (sorbitol, xylitol, mannitol)
do NOT promote tooth decay
toddler fluoride rec
fluoridated water, or oral supplements if prescribes
toothpaste should not be used until the child can spit it out
infant should not sleep with bottle - BBTD
stomatitis
inflammation of mouth
rinse with lukewarm water after meals
globus
lump in the throat
odynophagia
painful swallowing
achalasia
disorder of lower esophageal sphincter motility, does not relax and open upon swallowing
causes dypshagia
start with pureed moist thick foods, progress to thick liquids
level 0 white
thin, water - flow through straw
level 1 gray
slightly thick, thicker than water, can flow through straw
level 2 pink
mildly thick - sippable
level 3 yellow
liquidized, mod thick (liquid)
spoon or cup, no lumps (food begins)
spoon or drunk from cup, no lumps, effort with wide straw
level 4 green
extremely thick (liquid)
pureed (food)
spoon, not from cup or straw, not sticky, chewing not required
spoon, not sticky
level 5 orange
minced and moist
minimal chewing,biting not required, lumps mashed with tongue, avoid hard, dried, tough foods
level 6 blue
soft, bite-sized
able to chew bite-sized pieces, knife not required
level 7 black
regular, easy to chew
can bite off and chew soft, tender pieces
pregnancy induced hypertension
progresses from pre-eclampsia to eclampsia
more frequently found in women with lack of prenatal care, poor diets, poor protein and calcium intakes
sodium restriction is NOT recommended for prevention or treatment; sodium needed to maintain normal levels of sodium in plasma during large prenatal expansion of tissues and fluid.
need 2,300 mg sodium per day
hyperemesis gravidarum
severe nausea, vomiting, acidosis, wt loss,
need bed rest, small amounts frequent carbs, correct fluid and electrolyte imbalance
AIDS MNT
protein - asymptomatic 0.8 g/kg, up to 1.2-2.0 g/kg if wasted LBM
if diarrhea - soluble fiber, MCT oil, electrolyte replacement beverages
low bacteria diet (neutropenic), avoid raw foods
NRTI drugs
for aids
retrovir, zidovudine
can lead to anemia, loss of appetite, nausea, dysphagia
use of vit C or st john’s wort could result in drug resistance
HALS
hiv associated lipodystrophy syndrome may develop from therapy
high cholesterol, high triglycerides, insulin resistance, changes in body fat distribution
significant loss of lean body mass can be obscured by edema and HALS
increase in dietary fiber decreases insulin resistance, reducing risk of fat deposition
pediatric HIV
high protein, high kcal with supplements needed for wt gain
multivitamins at doses 1-2x rda
COPD MNT
avoid overfeeding more than 35 kcals/kg to avoid excessive CO2 production
routine use of high fat, low carb formula is not warranted
small frequent meals and snacks
vitamin D supp
ARDS MNT
increased energy needs
adequate kcal
provide EN containing EPA and GLA and enhanced levels of antioxidant vitamins
1.5-2 g pro/kg BW, maintain lean body mass
prescription for antipsychotics
clozapine, olanzapine, risperidone, quetiapine
determine history of usual wt and wt gain
MNT for drug addiction
group process
mod or discontinued sugar intake
mod or discontinued caffeine
increased complex carb, pro, fiber with mod to low fat
30-35 kcal/kg plus 1-2 g protein/kg, encourage fluid intake, esp water
EN formula standard polymeric
initiated full strength at a rate of 10-40 ml/hr, advance 10-20 ml every 8-12 hrs over the next 24-48 hrs until goal rate is achieved
elemental chemically defined En formula
used with malabsorption
pre-digested protein or AA, glucose or sucrose, LCT and MCT, vitamins, minerals, electrolytes
absorbed in proximal intestine, low to no residue, don’t need pancreatic enzymes, high osmolality, poor taste
large #16 tube bore
blenderized whole foods
small #8 tube bore
ready prepared formulas more comfortable
hang time open system
8 hrs
hang time closed system
24-48 hrs
bolus method
clinically stable with functional stomach
intermittent drip (pump or gravity)
more mobility
continuous drip
constant, steady rate over 16-24 hours, usually with a feeding pump. for those with compromised GI function or who do not tolerate large volume infusion. clinic feeding is delivered by continous drip at an increased rate over 8-16 hours, often overnight by pump
gastrostomy or jejunostomy feedings
if needed for more than 3-4 weeks
PEG inserts tube into stomach through abdominal wall
1cal/cc formulas
80-86% water
1.5cal/cc formulas
76-78% water
2cal/cc formulas
69-71% water
normal GRV
<=250.
EN should not be held for GRVs <500 ml in absence of other signs of intolerance
peripheral parenteral nutrition
small surface veins
short term therapy with minimum effect on nutrition status
indications post surgery, mild to mod malnutrition
solutions:
- IV dextrose - 3.4 kcal/g
- fat emulsion - 10% 1.1 kcal/cc, 20% 2.0 kcal/cc
solutions generally limited to 800-900 mOsm
PN
used to achieve an anabolic state when patients are unable to eat by mouth and EN is not possible
set tie frame of 7-10 days in which to achieve intake goals by the EN route before adding PN
PN PICC
peripherally inserted central catheter - used for short or mod term infusion
PN CVC
long term central access is through the cephalic, subclavian or internal jugular vein into the superior vena cava
PN solutions
protein - ratio for anabolism is 1 g nitrogen / 150 kcal
- 1-1.5 g pro/kg/day
energy
- 35-50 kcal/kg
max rate of dextrose infusion should not exceed 4-5 mg/kg/min to prevent hyperglycemia and other complications.
to prevent EFAD give 500cc of 10% fat emulsion 1-2x/week
transitional feeding
introduce a minimal amount of full-strength EN feeding at a low rate of 30-40 ml/hr to establish GI tolerance
begin tapering when EN feedings are providing 60% of their nutrient requirements
refeeding syndrome
results in hypokalemia
hypophosphatemia
hypomagnesemia
DRI
umbrella of nutrient guidelines
RDA
goals for healthy individuals to prevent nutritional deficiency diseases, includes gender, age, life phases
EAR
estimated average requirement for 50% of population, used in planning meals for healthy people, assesses group nutritional adequacy
AL
used when insufficient evidence exists for EAR, RDA
UL
not associated with adverse side effects in most individuals of a healthy population
dietary guidelines for Americans
USDA, DHHS
designed to promote health and prevent chronic disease
limit foods and bevs higher in added sugars, saturated fat, and sodium, and limit alcoholic bevs
healthy eating index
USDA’s overall measure of diet quality
myplate plan
shows essential food groups and offers recommendations on balancing kcal, foods to increase and foods to reduce
healthy people 2030
DHHS
national objectives to improve health and well-being over the next decade
steps in program planning
develop a mission statement
set goals
set objectives
develop plan
budget development
direct nutrition outcomes
clinical and health status outcomes
patient-centered outcomes
health care use and cost outcomes
health care outcomes
of interest to health care providers and payers
health and disease outcomes - reduced readmissions, changes in severity, duration or course of condition or disease
cost outcomes - changes in length of stay, ICU days, etc.
patient centered outcomes - changes in indicators that reflect functional level, QOL
