Nutrition Care for Individuals and Groups: Topic c - MNT - planning and intervention

Question 1

ulcer

Answer 1

a. eroded mucosal lesion
b. treatment: antacids, antibiotics to eradicate Helicobacter pylori bacteria
c. drug therapy: Cimetidine, Ranitidine - H2 blocker; prevents binding of histamine to receptor, decreases acid secretion
d. diet: as tolerated, well-balanced, avoid late night snacks
e. omit gastric irritants: cayenne and black pepper, large amounts of chili powder, avoid excess caffeine and alcohol

Question 2

hiatal hernia

Answer 2

a. protrusion of a portion of the stomach above the diaphragm into the chest
b. small, bland feedings; avoid late night snacks, caffeine, chili powder, black pepper

Question 3

dumping syndrome

Answer 3

a. follows a gastrectomy (Billroth I, II)
b. cramps, rapid pulse, weakness, perspiration, dizziness
c. 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.

Question 4

billroth I

Answer 4

(gastroduodenostomy) attaches the remaining stomach to the duodenum.

Question 5

billroth II

Answer 5

(gastrojejunostomy) attaches it 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.

Question 6

dumping syndrome - anemia

Answer 6

(1) B12 deficiency - lack of intrinsic factor and bacterial overgrowth in loop of
intestine being bypassed interfere with B12 absorption (pernicious anemia diagnosed
using the Schilling test)
(2) folate deficiency- needs B12 for transport inside the cell; poor folate intake
and low serum iron (cofactor in folate metabolism)
f. 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.
Following a complete gastrectomy, deficiencies of iron, B12, folate, calcium, vitamin D, B1 and copper may develop

Question 7

gastroparesis

Answer 7

a. delayed gastric emptying: surgery, diabetes, viral infections, obstructions
b. moderate to severe hyperglycemia: detrimental effects on gastric nerves
c. prokinetics (erythromycin, metoclopramide) increase stomach contractility
d. small, frequent meals; pureed foods, avoid high fiber, avoid high fat (liquid fat may be better tolerated), avoid caffeine, mint, alcohol (acidic), carbonation
e. bezoar formation may be due to undigested food or medications; treatment includes enzyme or endoscopic therapy

Question 8

tropical sprue

Answer 8

(bacterial, viral, parasitic infection)
a. chronic GI disease, intestinal lesions, may also affect stomach
b. diarrhea, malnutrition, deficiencies of B12 and folate due to decreased HCL and intrinsic factor
c. antibiotics, high calories, high protein, IM B12 and oral folate supplements

Question 9

Non-tropical sprue, Celiac disease, gluten-induced enteropathy

Answer 9

a. gluten refers to storage proteins (prolamins: gliadin in wheat, secalin in rye,
hordein in barley, avenin in oats)
b. reaction to gliadin - affects jejunum and ileum (proximal intestine)
c. malabsorption (leads to loss of fat-soluble vitamins), macrocytic anemia, weight
loss, diarrhea, steatorrhea, iron deficiency anemia
d. need (gliadin-free) gluten-restricted diet: NO wheat, rye, oats (if harvested and
milled with wheat), barley, (buckwheat may be contaminated with WROB); no
bran, graham, malt, bulgur, couscous, durum, orzo, thickening agents
e. OK: corn, potato, rice, soybean, tapioca, arrowroot, carob bean, guar gum, flax,
amaranth, millet, teff, quinoa

Question 10

constipation

Answer 10

a. sometimes due to an atonic colon (weakened muscles)
b. high fluid, high fiber diet, exercise

Question 11

Diverticular disease
a. diverticulosis

Answer 11

the presence of diverticula - small mucosal sacs that protrude
through the intestinal wall due to structural weakness. Related to constipation and lifelong intra-colonic pressures
(1) high fiber diet- increases volume and weight of residue, provides rapid transit

Question 12

Diverticular disease
b. diverticulitis

Answer 12

when diverticula become inflamed as a result of food and residue accumulation and bacterial action
(1) clear liquids, low-residue or elemental, gradual return to high fiber

Question 13

Diverticular disease
Fiber

Answer 13

• provides indigestible bulk, promotes intestinal function
  (1) dietary fiber- nondigestible CHOs and lignin, binds water, increases fecal bulk; found in legumes, wheat bran, fruits, vegetables, whole grains
  (2) oat bran and soluble fibers decrease serum cholesterol by binding bile acids converting more cholesterol into bile
  (3) 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
  (4) Al 38g M, 25g F fiber/ day recommended
  (5) a high fiber diet may increase the need for Ca, Mg, P, Cu, Se, Zn, Fe
  (6) a low fiber diet may lead to constipation

Question 14

Gastritis

Answer 14

a. inflammation of stomach; anorexia, nausea, vomiting, diarrhea
b. diet: clear liquids, advance as tolerated, avoid gastric irritants

Question 15

Inflammatory bowel disease (IBD)
a. Regional enteritis (Crohn’s disease)

Answer 15

(1) affects terminal ileum; weight loss, anorexia, diarrhea
(2) B12 deficiency leads to megaloblastic anemia
(3) iron deficiency anemia due to blood loss, decreased absorption

Question 16

Inflammatory bowel disease (IBD)
Chronic ulcerative colitis (UC)

Answer 16

(1) ulcerative disease of the colon, begins in the rectum
(2) chronic bloody diarrhea, weight loss, anorexia, electrolyte (Na,K) disturbance, dehydration, anemia, fever, negative nitrogen balance

Question 17

Inflammatory bowel disease (IBD)
treatment

Answer 17

(1) maintain fluid and electrolyte balance; antidiarrheal agent (sulfasalazine)
(2) acute Crohn’s flare-ups - bowel rest, parenteral nutrition or minimal residue
(3) acute UC, elemental diet may be needed to minimize fecal volume
(4) energy needs according to current BMI, limit fat only if steatorrhea; water soluble and fat-soluble vitamins; iron, folate; assess Ca, Mg, Zn; watch lactose, frequent feedings. High fat may improve energy balance.
Coconut oil derived MCT is an easy to oxidize source of energy and may improve bowel damage.
(5) protein at each meal, chewable MV
(6) when IBD is in remission or under control, high fiber to stimulate peristalsis

Question 18

Irritable bowel syndrome

Answer 18

a. chronic abdominal discomfort, altered intestinal motility, bloating
b. goals: adequate nutrient intake, tailor pattern to specific GI issues
c. avoid gas-forming foods and swallowing air during eating
d. use food diary to track intake, emotions, environment, symptoms
e. low FODMAP diet: eliminate possible sources of discomfort
f. work with client to alleviate stress during eating
g. peppermint (has menthol, smooth muscle relaxant) may relax lower esophageal sphincter, reducing reflux, cramping, pain

Question 19

Lactose intolerance - due to LACTASE deficiency

Answer 19

a. Normally lactase splits lactose into glucose and galactose. In its absence
lactose remains intact, exerting hyperosmolar pressure. Water is drawn into the
intestine to dilute the load causing distention, cramps, diarrhea. Bacteria then
ferment the undigested lactose, releasing carbon dioxide gas.
b. detected by breath hydrogen test - hydrogen is produced by colonic bacteria
on lactose, absorbed into bloodstream and exhaled in 60-90 minutes
c. lactose tolerance test - oral dose of lactose (up to 50 grams) after a fast. If
intolerant of lactose, blood glucose will rise< 25 mg/di above fasting (flat
curve). If tolerant of lactose, the rise would be above 25mg/dl (normal curve).
d. diet: lactose-free, no animal milk or milk products, no whey
(1) calcium and riboflavin supplements are recommended
(2) yogurt and small amounts of aged cheese may be tolerated
(3) OK: lactate, lactalbumin

Question 20

diarrhea - in infants and children

Answer 20

(1) acute - aggressive and immediate rehydration; replace fluids and
electrolytes lost in stool (WHO recommends glucose electrolyte solution)
(a) as effective as parenteral rehydration and much cheaper, ingredients
easily attainable; reintroduce oral intake within 24 hours
(2) chronic nonspecific infantile diarrhea - no significant malabsorption
(a) consider ratio of fat to CHO calories, volume of ingested liquids
(b) some are inadvertently placed on a low fat diet or consume too many
fluids or too many calories
(c) give 40% calories as fat, balanced with limited fluids; restrict or dilute
fruit juices with high osmolar loads - apple, grape

Question 21

diarrhea - in adults

Answer 21

(1) remove the cause; replace lost fluids and electrolytes especially those high
in sodium and potassium
(2) decrease gastric motility: avoid clear liquids and other foods high in lactose,
sucrose, fructose; avoid caffeine, alcohol, high fiber
(3) thicken consistency of stool: banana flakes, apple powder, pectin sources
(4) repopulate GI tract with normal flora
(a) prebiotic components (pectin, fructose, oats, whole grains) which
promote growth of healthy bacteria
FOS (fructooligosaccharides) onion, garlic, banana, artichoke,
asparagus, chicory
(b) probiotics - sources of bacteria used to reestablish bacterial gut flora
1. fermented dairy foods (yogurt, kefir, aged cheese)
2. fermented foods with beneficial live cultures (kimchi, miso, tempeh,
sauerkraut)
(5) stimulate GI tract with low fiber, low fat, lactose-free if needed

Question 22

steatorrhea

Answer 22

• consequence of malabsorption
  (1) normal stool fat 2 - 5 g; > 7 g is indicative of malabsorption
  (2) determine cause and treat
  (3) high protein, high complex CHO, fat as tolerated, vitamins (especially fatsoluble),
  minerals, MCT (rapidly hydrolyzed in GI tract)

Question 23

Short bowel syndrome SBS

Answer 23

a. consequences associated with significant resections of the small intestine
b. malabsorption, malnutrition, fluid and electrolyte imbalances, weight loss
c. severity reflects length and location of resection, age of patient, health of
remaining tract. Loss of ileum (especially distal 1/3), loss of ileocecal valve, loss
of colon are of particular concerns.
d. most digestion takes place in first 100cm of intestine (in duodenum,
and upper jejunum), what remains are small amounts of sugar, starches, fiber, lipids
e. jejunal resection - ileum can adapt and take over jejunal functions
f. ileal resection - significant resections produce major complications
(1) distal - absorption of B12, intrinsic factor, bile salts
(2) ileum normally absorbs major portion of fluid in GI tract
- patients have above average needs for water to compensate for excessive losses in the stool. Drink at least 1 liter more than their ostomy output daily.
(3) if ileum 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 leading to renal oxalate stones
- increased fluid and electrolyte secretion; increased colonic motility

Question 24

SBS - loss of colon

Answer 24

loss of water and electrolytes, loss of salvage absorption of
carbohydrates and other nutrients. Provide chewable vitamins.

Question 25

SBS - nutritional care

Answer 25

(1) parenteral nutrition initially to restore and maintain nutrient status
(2) enteral - start early to stimulate growth, increase over time; continuous drip
(3) may take weeks or months to transition to food
(4) jejunal - normal balance of carbohydrate, protein, fat; avoid lactose,
oxalates, large amounts of concentrated sweets; vitamin, mineral
supplements
(5) ileal - limit fat, use MCT (does not require bile salts, needs less intestinal
surface area), supplement fat-soluble vitamins (ADEK), Ca, Mg, Zn
Parenteral B12 followed by monthly injections if more than 100cm of terminal
ileum is removed.

Question 26

functions of liver

Answer 26

1. functions of liver - stores and releases blood, filters toxic elements, metabolizes
   and stores nutrients, regulates fluid and electrolyte balance
   a. enzyme profile - list of major enzymes found in organs and tissues; enzyme
   levels in blood are elevated when tissue damage causes them to leak into
   the circulation
   liver function tests:
   - ALP alkaline phosphatase; 30-120 U/L
   - AST, SGOT aspartate amino transferase; 0-35 U/L
   - ALT, SGPT alanine aminotransferase; 4-36 U/L

NOTE: in liver disease, enzymes levels are elevated

Question 27

Acute viral hepatitis

Answer 27

a. inflammation, necrosis, jaundice, anorexia, nausea, fatigue
(1) jaundice occurs when bile ducts are blocked
b. HAV: fecal - oral transmission (type most directly connected to food) - raw oysters are a concern
HBV: sexually transmitted, HCV: blood to blood contact
c. prescription
(1) increase fluids to prevent dehydration
(2) care varies according to symptoms and nutrition status
(3) 50-55% CHO to replenish liver glycogen and spare protein
(4) acute hepatitis: 1 - 1.2 g protein/kg: cell regeneration, provide lipotropic agents to convert fat into lipoproteins for removal from liver ** high protein intake helps prevent fatty liver
(5) moderate to liberal fat intake if tolerated; <30%cals if steatorrhea
(6) small, frequent feedings (4-6) because of the anorexia
(7) encourage coffee (antioxidant)
(8) multivitamin with B complex, C, K, zinc
(9) if fluid retention, 2 gm Na

Question 28

Cirrhosis

Answer 28

a. 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 liver is disrupted. Poor food intake leads to deficiencies.
b. protein deficiencies lead to ascites, fatty liver, impaired blood clotting
c. blood flow: esophageal, veins portal vein -> liver-> vena cava

Question 29

cirrhosis - ascites

Answer 29

d. ascites occurs when blood cannot leave the liver
(1) Connective tissue overgrowth blocks blood flow out of liver into vena cava.
The liver expands (can store a liter of extra 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.
(2) low serum albumin may be due to dilution factor

Question 30

cirrhosis - esophageal varices

Answer 30

e. esophageal varices occur when blood can’t enter the liver: portal hypertension
(1) 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.

Question 31

diet for cirrhosis

Answer 31

(1) adequate to high protein .8 - 1.2 g/kg; in stress at least 1.5 g/kg
(2) high calorie 25 - 35 cals/kg estimated dry weight or BEE+ 20%
(3) moderate to low fat 25 - 40% of calories, MCT if needed, <30 grams fat if
malabsorption. Fat is preferred fuel in cirrhosis. Include omega 3.
Decrease LCTs if steatorrhea develops.
(4) low fiber if varices are present, low sodium (<2gm) if edema or ascites
(5) with hyponatremia, fluid restriction of 1 - 1.5Uday depending on severity,
and moderate sodium intake
(6) B complex vitamins, C, Zn, Mg; monitor need for A and D
a. zinc involved in conversion of ammonia to urea, increased loss in urine

Question 32

Alcoholic liver disease - hepatic steatosis, alcoholic hepatitis, cirrhosis

Answer 32

a. liver injury due to alcohol and metabolic derangements it causes
b. alcohol is converted into acetaldehyde and excess hydrogen which disrupts
liver metabolism
(1) hydrogen replaces fat as fuel (in the Kreb’s cycle), so fat accumulates in liver,
leading to a fatty liver, and in blood, raising the TG level
(2) shift in NADH/NAD ratio inhibits beta-oxidation of fatty acids and promotes
triglyceride synthesis
c. associated malnutrition
(1) alcohol replaces food in diet
(2) alcohol causes inflammation of GI tract and interferes with absorption of
thiamin, 812, vitamin C, folic acid, supplement thiamin and folic acid
(3) alcohol interferes with vitamin activation
(4) increased need for B vitamins to metabolize alcohol
(5) increased need for magnesium; excreted after alcohol consumption
(6) malnutrition increases alcohol’s destructive effects
(7) folate and protein deficiencies - most responsible for malabsorption
(8) thiamin deficiency - Wernicke-Korsakoff syndrome

Question 33

Hepatic failure (ESLD)

Answer 33

• liver function decreased to 25% or less
  a. liver cannot convert ammonia (NH3) into urea - ammonia accumulates
  b. apathy, drowsiness, confusion, coma (PSE - portal systemic encephalopathy)
  c. asterixis (flapping, involuntary jerking motions): sign of impending coma
  d. treatment
  (1) If not comatose: moderate to high levels of protein, increase up to 1-1.5
  gram protein/KG as tolerated. Modest protein intake if protein-sensitive
  hepatic encephalopathy.
  (2) 30-35 calories/kg; 30-35% calories as fat with MCT if needed
  (3) low sodium if ascites; vitamin/mineral supplementation
  (4) altered neurotransmitter theory: BCAA decreased -(used by muscles for energy); AAA (aromatic amino acids) increased because damaged liver is unable to clear them.
• adding BCAA- adds calories and protein; may not reduce symptoms
• used when standard therapy does not work and when patient does
  not tolerate standard protein
  (5) standard treatment is lactulose (hyperosmotic laxative that removes nitrogen); neomycin (antibiotic that destroys bacterial flora that produce
  ammonia)

Question 34

NAFLD non-alcoholic fatty liver disease

Answer 34

a. steatosis, more common with BMI >=35, Type 2 diabetes, metabolic syndrome
b. excess fat buildup in liver unrelated to alcohol consumption
c. treatment: 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 sessions each week

Question 35

Gallbladder disease

Answer 35

a. cholecystitis - inflammation of gallbladder
(1) an infection causes excess water to be absorbed causing cholesterol to
precipitate out leading to gallstones - cholelithiasis
b. treatment
(1) low fat diet: acute 30-45 grams; chronic 25 - 30% of calories
(2) cholecystectomy - surgical removal of 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.

Question 36

Pancreatitis

Answer 36

a. inflammation with edema, cellular exudate and fat necrosis
b. may be due to blockage or reflux of the ductal system; premature activation
of enzymes within pancreas leads to autodigestion

Question 37

acute pancreatitis - what is it and nutrition tips?

Answer 37

c. acute - hypermetabolic, hyperdynamic state increasing BMR
(1) put pancreas at rest, withhold all feeding, maintain hydration (IV)
(2) progress as tolerated to easily digested foods with a low fat content
(3) elemental (pre-digested) enteral nutrition into jejunum may be tolerated

Question 38

chronic pancreatitis

Answer 38

d. chronic - recurrent attacks of epigastric pain of long duration
(1) PERT: pancreatic enzymes 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, parenteral
B12? (deficiency of pancreatic protease which splits off vitamin from carrier)
(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

Question 39

Cystic fibrosis - disease

Answer 39

a. disease of exocrine glands - secretion of thick mucus that obstructs glands and
ducts; chronic pulmonary disease, pancreatic enzyme deficiency, high
perspiration electrolyte levels, malabsorption. Affects transport of chloride
across the cell membrane.

Question 40

cystic fibrosis - treatment

Answer 40

b. treatment: use age-appropriate BMI to assess height and weight
( 1) PERT - pancreatic enzyme replacement therapy with meals and snacks
(2) high protein, high calorie, unrestricted fat, liberal in salt
(a) if growing normally and steatorrhea is controlled - calories to cover RDA
for age and sex; if fails to grow - BEE X activity factors plus disease
coefficients; may need 110 - 200%of normal energy needs
(b) protein 15 - 20 % calories - malabsorption due to pancreatic deficiency
(c) carbohydrate 45-55% total calories
(d) liberal fat to compensate for high energy needs - 35-40% of calories
(e) additional 2-4 grams salt/day in hot weather, with heavy perspiration
(f) age-appropriate doses of water-soluble vitamins and minerals
(g) supplement zinc, water-soluble forms of fat-soluble vitamins (A and E)

Question 41

Hypertension

Answer 41

a. classification
(1) systolic - contraction, greatest pressure; diastolic - relaxation, least pressure
(2) may be primary (essential) or secondary due to another disease
(3) classified in stages based on risk of developing coronary heart disease
Normal <120/80 mm Hg
Elevated Systolic between 120-129 and diastolic less than 80
Stage 1 Systolic between 130-139 or diastolic between 80-89
Stage 2 Systolic at least 140 or diastolic at least 90 mm Hg
(4) obesity is a major factor in the cause and treatment
(5) optimal BP with respect to cardiovascular risk is <120/80 mm Hg

Question 42

hypertension - mangement

Answer 42

(1) thiazide diuretics may induce hypokalemia
(2) four modifiable factors in primary prevention and treatment: overweight,
high salt intake, alcohol consumption, physical inactivity
(3) salt restriction < 2300 mg sodium/day; decrease weight if needed
(4) DASH diet- Dietary Approaches to Stop Hypertension; whole grains, fruits,
vegetables, low fat dairy, poultry, fish, moderate sodium, limit alcohol,
decrease sweets, calcium to meet ORI (not supplements)

Question 43

hypertension - mediterranean diet

Answer 43

(1) rich in alpha linolenic acid, high in monounsaturated fats
(2) olive, canola, soybean oils; walnut, almonds, pecan, peanuts, pistachios
(3) fish, poultry and eggs rather than beef; breads, fruits and vegetables in
abundance; beans, legumes; yogurt, cheese, moderate consumption of
wine with meals
(4) resveratrol, in skin of red grapes, may lower blood pressure

Question 44

Atherosclerosis

Answer 44

a. risks: hypertension, obesity, smoking, elevated blood lipids, heredity
b. coronary artery disease (CAD): hard, narrow arteries from plaque buildup
c. ischemia: deficiency of blood due to obstruction
d. arteriosclerosis - loss of elasticity of blood vessel walls
e. myocardial infarction - reduction of coronary flow to myocardium due to
blood clot blocking a narrowed coronary artery
(1) angina pectoris - chest pain (2) heparin given for blood clots

Question 45

f. dyslipidemia & classification of lipoproteins

Answer 45

(includes high triglycerides and low HDL)
(1) classification of lipoproteins
(a) chylomicron - synthesized in intestine from dietary fat, transports dietary
triglycerides from gut to adipose, lowest density: smallest amount of protein
(b) VLDL (pre-beta) - transports endogenous triglyceride from liver to adipose
(c) LDL (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
(d) HDL (alpha) - reverse cholesterol transport; moves cholesterol from
cells to liver and excretion
(e) IDL (pre-beta to beta) - LDL precursor; catabolism of other lipoproteins

Question 46

metabolic syndrome

Answer 46

three or more of the following risk factors are linked to
insulin resistance which often increase risk for coronary events
(1) elevated blood pressure ~130 systolic, and/or ~85 diastolic
(2) elevated TG ~150 mg/di
(3) fasting serum glucose ~ 100 mg/di
(4) waist measurement ~102cm (40”) men; ~88cm (35”) women
(5) low HDL < 40 mg/di (men),< 50 mg/di (women)

Question 47

assessment of risk - lipoproteins

Answer 47

• LDL-C; <100 optimal
• total cholesterol; <200 desirable
• HDL-C; <40 low (M) <50 low (F) ~60 high
• Normal TG < 150
• High homocysteine (Hcy) levels are independent risk factors for CHD.

Question 48

Heart Healthy diet for prevention and treatment of cardiovascular disease

Answer 48

(1) Saturated fat <7% of total calories, <200 mg cholesterol, 2g sodium,
no trans fat
(2) Promote whole grains, fruits, vegetables, low fat or fat-free dairy, unsaturated
fats
(3) Includes 20- 30g fiber per day and 5-10g soluble fiber

Question 49

Heart failure
a. etiology

Answer 49

(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

Question 50

Heart failure
b. treatment

Answer 50

(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
Sedentary 1.0 - <1.4 Low active 1.4 - < 1.6 Active 1.6 - < 1.9 Very active 1.9 - < 2.5
Use indirect calorimetry if available. If not available, estimate RMR at 22callkg for
normally nourished, 24callkg for malnourished.
(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 812
(7) encourage individualized regular physical activity

Question 51

cardiac cachexia:

Answer 51

unintended weight loss, blood backs up into liver and intestines
causing nausea and decreased appetite. Arginine and glutamine may help.
Low saturated fat, low cholesterol, low trans fat, <2 grams sodium, high calorie

Question 52

The Renal System

Answer 52

1. the nephron
   a. glomerulus - tuft of capillaries held closely by Bowman’s capsule - produces
   ultrafiltrate which then passes through tubules. Capsule blocks passage of red
   blood cells and large molecules like protein.
   b. proximal convoluted tubule - major nutrient reabsorption
   c. Loop of Henle - water and sodium balance
   d. distal tubule - acid-base balance
2. renal functions
   a. filtration - red blood cells, protein stay in blood; all else filters through tubules
   b. absorption - 100% glucose, amino acids; 85% water, sodium, potassium
   c. excretion - wastes, urea, excess ketones
   d. secretion - secretes hormones that control blood pressure, blood components;
   secretes ions that maintain acid-base balance

Question 53

the renal system - hormones

Answer 53

a. vasopressin (ADH) - from hypothalamus (stored in pituitary)
(1) exerts presser effect; elevates blood pressure
(2) increases water reabsorption from distal and collecting tubules
(3) SIADH - syndrome of inappropriate antidiuretic hormone
(a) hyponatremia caused by hemodilution, treated with fluid restriction
b. renin - vasoconstrictor
(1) secreted by glomerulus when blood volume decreases
(2) stimulates aldosterone to increase sodium absorption and return blood
pressure to normal
c. erythropoietin EPO
(1) produced by kidney; stimulates bone marrow to produce RBC

Question 54

lab tests in renal disease

Answer 54

a. decreased glomerular filtration rate, creatinine clearance
b. increased serum creatinine, BUN
c. BUN: creatinine ratio of> 20:1 indicates a “pre-renal state” in which BUN
reabsorption is increased due to acute kidney damage (may be reversible and
may not require dialysis)
BUN: creatinine ratio of< 10:1 suggests reduced BUN reabsorption due to
renal damage (may need dialysis).
d. renal solute load - solutes excreted in 1 L urine; daily fixed load of 600mOsm
(1) mainly measures nitrogen (60%) and electrolytes (sodium)

Question 55

what happens to the body because of renal disease

Answer 55

a. anemia due to decreased production of erythropoietin
b. upset in blood pressure
c. decreased activation of vitamin D (kidney produces active form which
promotes efficient absorption of calcium by the gut)

Question 56

renal calculi:

Answer 56

1.5-2L fluid/day needed to dilute urine

Question 57

calcium oxalate stones

Answer 57

(a) adequate calcium intake (RDA from dairy or supplements with meals) to
bind oxalate and a low oxalate (40-50 mg) diet (dark leafy greens,
chocolate, strawberries, nuts, beets, tea)
(b) more stones are detected in diets deficient in calcium

Question 58

alkaline ash / acid ash diets

Answer 58

(a) minerals not oxidized in metabolism leave an ash (residue) in urine
(b) to prevent acidic stones - create an alkaline ash: increase cations (Ca,
Na, K, Mg), by adding vegetables, fruits, brown sugar, molasses
(c) to prevent alkaline stones - create an acid ash: increase anions (Cl, Ph,
Su) by adding meat, fish, fowl, eggs, shellfish, cheese, corn, oats, rye

Question 59

acute kidney injury, acute renal failure

Answer 59

(1) sudden shutdown with previously adequate capacity; decreased GFR,
inadequate pre-renal perfusion
(2) due to burns, accident, obstruction, severe dehydration
(3) symptoms - oliguria (<500 ml urine), azotemia (increased urea in blood)
(4) at first: IV glucose, lipids, protein
1-1.3 g/kg if non-catabolic without dialysis as GFR returns to normal.
1.2-1.5 g/kg if catabolic and/or initiation of dialysis
(5) 25-40 cals/kg, BEE x stress factor (1.2-1.3) during hypermetabolic
conditions. Energy expenditure increases as kidney function declines.
(6) low sodium (2-3 grams), replace losses in diuretic phase
(7) 8 - 15 mg/kg phosphorus. May need phosphate binders.
(8) 2 - 3 grams potassium based on output, serum potassium, dialysis
(9) replace fluid output from previous day plus 500

Question 60

nephrosis - nephrotic syndrome

Answer 60

(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 decrease clearance of VLDL)
(3) .8 - 1.0g/KG; 50% from HBV. Excess protein will be catabolized to urea and
excreted.
(4) <30% fat, low saturated fat, 200 mg cholesterol
(5) 35 calories/kg/day
(6) modest sodium restriction 2-3g/day - depends on hypertension, edema
(7) calcium 1 - 1.5 g/day, supplement vitamin D
(8) may need fluid restriction with edema
(9) abnormalities in iron, copper, zinc, calcium related to protein loss

Question 61

chronic kidney disease

Answer 61

(1) anorexia, weakness, weight loss, nausea, vomiting
(2) anemia due to deficient production of hormone erythropoietin by kidney
(3) Mediterranean Diet, DASH, high fruit and vegetable intake
(4) 25 - 35 cals/kg
(5) <2300 mg/day sodium
(6) CKD 3-5: 0.55 - 0.60 g protein/kg, or 0.28 - 0.43 g/kg with keto acid analogs to meet 0.55 - 0.60 g protein/kg
(7) phosphorus: adjust1 intake to maintain normal serum level
(8) calcium: 800 - 1000 mg total elemental
(9) potassium generally not restricted unless serum level is elevated and urine output is <1 liter I day
(10) fluid generally unrestricted in CKD 1-4
(11) consider supplementation of folate, vitamin B12, B complex if needed; vitamin C and D supplementation if at risk of deficiency

Question 62

chronic renal failure - long term goal is to prevent malnutrition
Hemodialysis

Answer 62

(1) 1 - 1.2 g protein/kg SBW (standard body weight)
(2) 25 - 35 calories/kg
(3) < 2.3 g sodium
(4) 25-35% fat;< 7% saturated;< 200 mg cholesterol
(5) fluid individualized for body weight, urine output, residual kidney function
(6) potassium: adjust intake to maintain normal serum range
(7) calcium: individualized with maximum 2 g elemental total
(8) 800-1000 mg phosphorus or < 17mg/kg I BW or SBW
(9) vitamins B6, folate, B12 to correct deficiencies based on symptoms
(10) vitamin D and C supplements if deficient
(11) vitamin A and E supplements NOT recommended

Question 63

Peritoneal dialysis

Answer 63

(1) 1 - 1.2 g protein/kg SBW or adjusted BW
(2) 25 - 35 calories/kg
(3) < 2.3 grams sodium - based on blood pressure and weight
(4) potassium generally unrestricted (usually 2-4 grams)
(5) <= 2000 mg total elemental calcium including diet and binders
(6) 800 - 1000 mg phosphorus or 10-15 mg phosphorus/ g protein
(7) 1 - 3 L fluid depending on output, cardiac status
(8) CAPD - continuous ambulatory peritoneal dialysis 4-5X per day
(9) VM as for hemodialysis

Question 64

Diabetes mellitus

Answer 64

a. Type 1 - insulin deficient, depend on exogenous insulin
b. Type 2 - insulin-resistance with relative insulin deficiency (may need insulin)
c. risk factor: acanthosis nigricans (gray-brown skin pigmentations in skin folds)
from insulin resistance
d. risk factor: GADA glutamic acid decarboxylase antibodies

Question 65

indices of glycemic control

Answer 65

normal blood glucose 70-100 mg/di, 2hPG (post-prandial) <140mg/dl
impaired fasting glucose FPG 100 - 125
impaired glucose tolerance 2hPG 140 - 199
diabetes - fasting plasma glucose FPG >= 126 or glucose tolerance test GTT >= 200 or
symptoms of diabetes plus casual plasma glucose =>200m g/di
HgA1c >= 6.5%

Question 66

glycosylated (glycated) hemoglobin (Hb A1c)

Answer 66

(a) measures % of hemoglobin that has glucose attached
(b) normal < 5.7%; over 65 years <7% in healthy, <= 8% in frail elderly
(c) goal for diabetics < 7.0% (at risk for developing diabetes 5.7-6.4%)
(d) measure of long term blood glucose control (60-90 days)
(e) high concentration of glucose forms chemical bond with hemoglobin
-the longer the blood glucose is high, the higher the HbA1c

Question 67

glycemic index

Answer 67

• compares blood glucose response of a food to a standard glucose load
  (1) affected by cooking 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 for weight loss or weight maintenance is not
  currently recommended

Question 68

goals for all diabetics

Answer 68

(a) maintain normal blood glucose (average pre-prandial goal 70-130; peak
post-prandial average <180)
(b) optimal serum lipid levels: LDL <100, TG<150, HDL>40M, >50F
(c) blood pressure goals systolic <130, diastolic <80
(d) prevent and treat chronic complications

Question 69

strategies for Type 1 diabetes

Answer 69

(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 dosages based on total CHO content of each meal, using an insulin-to-CHO ratio
(e) For planned exercise, reduction in insulin dosage may be best choice
(f) Endurance athletes: 120-180mg/dl is guideline during activity

Question 70

strategies for Type 2 diabetes

Answer 70

healthy eating and physical activity
(a) Achieve glucose, lipid and blood pressure goals.
(b) Weight loss if necessary: improve food choices, space meals, exercise.

Question 71

gestational diabetes

Answer 71

risk factors BMI >30, history of GDM
(a) at 24-28 weeks of gestation, screen with 50g oral glucose load; glucose ~140mg/dl indicates need for further testing
(b) 40-45% CHO, 3 small-medium sized meals and 2-4 snacks
(c) ORI for CHO during pregnancy is 175g/day
(d) 15-309 CHO at breakfast (less well tolerated), rest divided evenly
(e) increases risk of fetal macrosomia (LGA large for gestational age, 4000-4500 grams}, fetal hypoglycemia at birth
(f) overweight/obese: modest energy restriction to slow weight gain

Question 72

There is no ideal amount of carbohydrate recommended for all individuals. The strategy selected should

Answer 72

be based on their abilities, preferences and treatment goals. Macronutrient distribution is based on DRl’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 carbohydrates.

Question 73

Carbohydrate management approaches include

Answer 73

carbohydrate counting, the plate method for portion control and carbohydrate exchange lists.

Question 74

Consistent Carbohydrate Diet

Answer 74

One choice from the starch, fruit or milk list= 15 grams CHO and each is a CHO choice. Foods with 6-10 g CHO provide 0.5 CHO serving. It provides a range of 3-5 carbohydrate servings (45-75 g) at each meal, along with 0-4 carbohydrate servings (0-30 g) during snacks.

Question 75

Bolus: premeal or prandial insulin

Answer 75

(a) rapid-acting : Aspart (Novolog), Lispro (Humalog)
take 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

Question 76

Basal, background insulin

Answer 76

(c) intermediate-acting: NPH (Humulin N, Novolin N, ReliOn) onset 2 - 4 hours, duration 10 - 16 hours, cloudy in appearance
(d) long-acting: Glargine (Lantus), Determir (Levemir)
onset 2 - 4 hours, duration 18 - 24 hours. Start at 1 0 units/day or 0.1 - 0.2 units/kg. Take around same time each day.

Question 77

Type 2 Diabetes Non-Insulin medications

Answer 77

(1) biguanides: Metformin (Glucophage) - suppress hepatic glucose production. First line therapy for most with T2D. Take with food. Check B12 levels. Deficiency can lead to anemia or peripheral neuropathy. Weight neutral. Low risk of hypoglycemia.
(2) DPP-4 inhibitors: saxagliptin (Onglyza), sitagliptin (Januvia), often used with Metformin. Allows endogenous GLP-1 to stay active longer, reduces glucose released by liver overnight and between meals. Weight neutral.
(3) SGLT-2 inhibitors: canagliflozin (lnvokana), dapagliflozin (Farxiga), empagliflozin (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. More glucose is excreted in urine and less reabsorbed. Monitor
kidney function. Weight Joss. Considered for patients with T2D and CKD,
(4) glucagon-like peptide-1 (GLP-1) receptor agonist: Exenatide (Byetta), dulaglutide (Trulicity), semaglutide (Ozempic) slows gastric emptying, enhances insulin secretion when glucose is high after eating, suppresses
postprandial glucagon secretion, promotes fullness and leads to weight loss.
(5) TZD Thiazolidinediones: (Actos) - increase insulin sensitivity in muscle. Weight gain.
(6) Sulfonylureas: glimepiride (Amaryl) secretagogue stimulates pancreas to release more insulin. May lead to hypoglycemia. Weight gain.

Question 78

Dawn phenomenon

Answer 78

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

Question 79

complications of uncontrolled diabetes - acute ketoacidosis

Answer 79

acute ketoacidosis - hyperglycemia due to insulin deficiency or excess carbohydrate intake, dehydration due to polyuria, increased pulse, fruity odor of ketones. Treatment: insulin, rehydration

Question 80

complications of uncontrolled diabetes - acute hypoglycemia

Answer 80

insulin reaction (shock); due to insulin excess or lack
of eating, slow pulse, cool, clammy skin, hungry, weak, shakiness, sweating
Treatment: glucose
1. begin with 15 g CHO from glucose tablets, fruit juice (4-6oz), sugar
2. wait 15 minutes; if still <70mg/dl, give another 15 grams
3. repeat and treat until blood glucose is normal
If unresponsive: administer glucagon, will mobilize glucose from liver

Question 81

complications of uncontrolled diabetes - long term

Answer 81

• neuropathy (peripheral and autonomic, gastroparesis),
  retinopathy (leads to blindness), nephropathy (decreased kidney function)

Question 82

Postprandial or reactive hypoglycemia

Answer 82

a. overstimulation of pancreas or increased insulin sensitivity; blood glucose falls below normal 2-5 hours after eating (<50 mg/di)
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 throughout the day, protein at RDA levels

Question 83

adrenal cortex insufficiency - Addison’s disease

Answer 83

a. atrophy of adrenal cortex; symptoms due to absence of adrenal hormones
b.
decreased cortisol - glycogen depletion, hypoglycemia
decreased aldosterone - sodium loss, potassium retention, dehydration
decreased androgenic tissue wasting, weight loss
c. diet - high protein, frequent feedings, high salt

Question 84

hyperthyroidism

Answer 84

• excess secretion of thyroid hormone
  (1) elevated T3 and T4 increased BMR leading to weight loss
  (2) increase calories

Question 85

hypothyroidism

Answer 85

• deficiency of thyroid hormone
  (1) T4 low; T3 low or normal, decreased BMR leading to weight gain
  (2) weight reduction

Question 86

Goiter

Answer 86

• enlargement of thyroid gland due to insufficient thyroid hormone
  a. endemic goiter - inadequate iodine intake
  (1) diet- iodized salt; free of goitrogens (contain goitrin which inhibits synthesis
  of thyroid hormone)

Question 87

Gout

Answer 87

• disorder of purine metabolism
  a. increased serum uric acid; deposit in joints causing pain, swelling
  b. achieve and maintain healthy body weight
  c. moderate protein, liberal carbohydrate, low to moderate fat, decrease alcohol, liberal fluid, avoid high purine foods (anchovies, sardines, organ meats, sweetbreads, meat-based gravies and extracts)
  d. medications (urate eliminant, colchicine) induce loss of nutrients

Question 88

Inborn errors of metabolism - galactosemia

Answer 88

• 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 (naturally contain galactose), MSG extenders, milk,
  lactose, galactose, whey, casein, dry milk solids, curds, calcium or sodium
  caseinate, dates, bell peppers
  (3) OKAY: soy, hydrolyzed casein, lactate, lactic acid, lactalbumin, pure MSG

Question 89

Inborn errors of metabolism - urea cycle defects

Answer 89

(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

Question 90

Inborn errors of metabolism - PKU

Answer 90

(1) missing enzyme - phenylalanine hydroxylase - which would convert phenylalanine into tyrosine; phenylalanine and metabolites accumulate leading to poor intellectual function
(a) detected with Guthrie blood test
(2) diet
(a) restrict the substrate phenylalanine (PHE), supplement the product
tyrosine (TYR). Tyrosine becomes a conditional amino acid.
(b) low in phenylalanine, but provide enough to promote normal growth
1.Phenex-1,2, Phenyl-Free 1,2 (low phenylalanine formulas)
(c) avoid aspartame
(3) need for phenylalanine decreases with age, infection
(4) low protein, high CHO intakes may lead to increased dental caries

Question 91

Inborn errors of metabolism - glycogen storage disease

Answer 91

(1) deficiency of glucose-6-phosphatase 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, and a high carbohydrate, low fat diet

Question 92

Inborn errors of metabolism - homocystinurias

Answer 92

(1) treatable inherited disorder of amino acid metabolism
(2) characterized by severe elevations of methionine and homocysteine in plasma, and excessive excretion of homocystine in urine
(3) associated with low levels of folate, Be, 812
(4) newly diagnosed patients receive increased doses of folate, pyridoxine (Be), B12
(5) if they don’t respond: low protein, low methionine diet

Question 93

Inborn errors of metabolism - maple syrup urine disease (MSUD)

Answer 93

(1) inborn error of metabolism of the BCAAs leucine, isoleucine, valine
(2) poor sucking reflex, anorexia, FTT, irritability, sweet burnt 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, other dairy products

Question 94

Inborn errors of metabolism - congenital sucrase isomaltase disease (CSID)

Answer 94

(1) diet modification of sucrose, starch and maltose
(2) If on Sacrosidase (oral enzyme replacement for sucrase), they do not need to restrict sucrose in their diet Uust starch and maltose). Enzyme is taken before and during meals and snacks.
(3) Diabetics on Sacrosidase need to check blood glucose levels. It converts sucrose into fructose and glucose

Question 95

Arthritis

Answer 95

• inflammation of peripheral joints
  a. regular, well-balanced diet with vitamin intake to at least DRl’s
  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
  d. methylprednisolone: steroid that may decrease inflammation

Question 96

Systemic lupus erythematosus (SLE)

Answer 96

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

is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels.

Question 97

osteoclasts / osteoblasts

Answer 97

osteoclasts resorb and remove bone; osteoblasts reform bone

Question 98

osteoporosis

Answer 98

• loss of bone tissue
  (1) Type I postmenopausal (within 15-20 years), Type II age-associated> 70
  (2) white and Asian women: more osteoporotic fractures 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)
  (5) treatment: HRT - hormone replacement therapy, weight-bearing exercise, vitamin D(400-800mg) and calcium (~1200mg, don’t exceed 500-600 mg at
  one time) supplements, adequate protein, moderate to low sodium, 5 or more servings of fruits and vegetables
  (6) take calcium carbonate with food; calcium citrate with or without food
  (7) spread calcium throughout the day to maximize absorption

Question 99

osteomalacia

Answer 99

• reduction in bone density - demineralization
  (1) vitamin D deficiency - lack of sunlight or diet intake
  (2) vitamin D, calcium supplements

Question 100

epilepsy

Answer 100

• seizures, altered consciousness
  a. anticonvulsants phenobarbital and phenytoin (Dilantin) interfere with calcium absorption
  (1) take 1 mg folate daily with drug
  (2) may need supplements of vitamin D, calcium, thiamin
  (3) provide phenytoin separate from meals and other supplements
  (4) enteral feedings decrease bioavailability of phenytoin so hold tube feedings ~ 2 hours.

Question 101

epilepsy nutrition intervention

Answer 101

ketogenic diet - high fat, very low carbohydrate, 4 grams fat:1 gram non-fat
(1) 90% calories from fat, 1gram protein/kg, remaining calories from CHO
(2) ketone bodies behave as inhibitory neurotransmitters; mild dehydration needed to prevent dilution of ketones
(3) need supplements of Ca, D, folate, B6, B12 (spinach may aid in absorption)
(4) MCTs are more ketogenic, more rapid metabolism and absorption

Question 102

cerebral palsy

Answer 102

• non-hereditary, brain damage; inadequate control over voluntary muscles leading to spasms
  a. spastic form - difficult, stiff movement; limited activity; obese
  (1) low calorie, high fluid, high fiber diet
  b. non-spastic (athetoid) form - involuntary wormlike movement, constant irregular motions leading to weight loss
  (1) high calorie, high protein diet; finger foods

Question 103

traumatic brain injury

Answer 103

a. systemic inflammatory response: hypermetabolism, hyperglycemia, insulin resistance and protein wasting
b. enteral feeding into small bowel is often best option
c. provide energy at 140% of estimated REE
d. 1.5 - 2.0 g protein/kg

Question 104

spinal cord injury

Answer 104

a. long term issues: obesity, cardiovascular disease, pressure ulcers
b. acute phase: energy needs may be 10% below predicted, 2g protein/kg
c. rehabilitation: .8 -1.0g protein/kg, 23cals/kg for quadriplegic patients, 28 cals/kg for paraplegia
d. neurogenic bowel slows transit time: 1 ml fluid/calorie plus 500 ml/day

Question 105

pressure injuries

Answer 105

a. 30 - 35 cals/kg if malnourished or at risk for malnutrition
b. Stage I 1.1 - 1.2 g/kg protein
c. Stage II 1.25 - 1.5 g/kg protein, adequate fluid
d. Stage Ill/IV pressure injury 1.5 - 2.0 g/kg protein depending on size of injury and protein loss from draining wounds
e. well-balanced diet including good sources of vitamins A, C, zinc, copper
f. Braden scale Stage
I upper layer of skin, red and warm to touch
II broken skin, open sore
Ill damage below skin surface into fat tissue
IV large wound, may affect muscles and ligaments

Question 106

ADHD Attention Deficit Hyperactivity Disorder

Answer 106

a. provide wholesome foods at regular mealtimes with small servings followed by refills
b. sugar does not cause hyperactivity
c. Adderall side effects: lack of appetite, nausea, weight loss
d. if child is underweight, consider high calorie snacks at bedtime

Question 107

ASD Autism Spectrum Disorder

Answer 107

a. unnecessary food restrictions, possible food aversions, excessive supplementation can place children with ASD at risk

Question 108

Alzheimer’s disease

Answer 108

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, nutrient dense foods, may need verbal cues to chew and swallow
b. anomia, form of aphasia: lost words, unable to recall names of common items
c. nutrients associated with dementia: folate, B6, B12

Question 109

Anemia

Answer 109

1. decrease in total red cell mass due to fewer red blood cells or to smaller cells with
   less hemoglobin
2. microcytic, hypochromic anemia: small, pale cells; due to iron deficiency
   a. associated with chronic infections, malignancies, renal disease
3. macrocytic, megaloblastic anemia: FEW large cells, filled with hemoglobin
   a. due to deficiency of folate or vitamin B12; Schilling test for pernicious anemia
4. thalassemia: defective hemoglobin synthesis resulting in microcytic, hypochromic,
   short-lived R8C. May develop iron overload. Do not avoid iron-rich foods. Managed
   with transfusions and chelation therapy. Provide high protein, B vitamins (especially
   folic acid), zinc.
5. foods high in iron: liver, kidney, beef, dried fruits, dried peas and beans, nuts
   leafy green vegetables, fortified whole grain products
6. typical American diet contains 6 mg iron / 1000 calories

Question 110

allergies

Answer 110

1. Ag-Ab reaction: when antigen enters body, antibody reacts
2. lmmunoglobumin E (lgE) mediated reaction to normally harmless food protein
   a. common allergens - peanuts, eggs, milk, soy, wheat, shellfish
   b. cow’s milk protein is the most common single allergen for infants
   c. Potentially allergenic foods, such as eggs and peanuts, should not be restricted beyond 4 to 6 months of age.
   d. atopy: genetic predisposition to produce excessive lgE antibodies in response to an allergen
3. diagnosis - diet history, skin tests, elimination diet (omit suspected foods),
   a. CAP-FEIA blood test is specific in identifying children with milk, egg, fish, peanut allergy
   b. DBPCFC - double-blind, placebo-controlled food challenges - identify foodinduced
   symptoms (gold standard for diagnosis)
   c. RAST (alternative to skin test) serum is mixed with food on paper disk;
   measures specific lgE antibodies
4. rice is food least likely to cause an allergy
5. food intolerance (Non-lgE): abnormal physiologic response, GI, cutaneous,
   respiratory symptoms, but NO antibody production

Question 111

Fever and infection

Answer 111

1. excessive fluid loss may lead to dehydration (hyperglycemia, dry, loose inelastic skin); IV feedings of dextrose and water, then diet high in calories and fluids
2. BMR increases 7% for each degree rise in F temp; normal temp 98.6’F

Question 112

Critical care and hypermetabolic states - goals

Answer 112

1. Goals: Improve outcomes regarding infection rates, days in critical care unit, days
   on ventilator. Minimize catabolic loss of body protein. Initiate nutrition support, enterally whenever possible, within 24-48 hours of admission. Avoid overfeeding.
   Control blood glucose: 140-180 mg/di.
   EAL recommends that average intake within the first week be greater than 60% of total
   energy need. Consider fish oil supplements and antioxidants with ARDS and acute lung injury

Question 113

burns

Answer 113

a. immediate shock period - catabolism; BMR rises 50-100%
(1) replace fluids and electrolytes lost
b. recovery period: increase calories (based on burn size estimated by Rule of Nines which divides the body surface area into percentages)
Arm including hand, head and neck, genitalia 9 % each Anterior trunk, posterior trunk, legs including feet 18% each
c. 20-25% calories as protein (1.5 - 2 grams protein/kg, 1.2g/kg if burn <10%BSA)
d. vitamin C 500 mg X 2, water soluble vitamins, vitamin K if on antibiotics
e. zinc for wound healing if zinc deficient, 220 mg zinc sulfate

Question 114

trauma

Answer 114

• hypermetabolic, flight or fight response
  a. accelerated catabolism of lean body mass leading to negative nitrogen balance
  as protein is catabolized to release glucose for energy
  b. Results of physiologic trauma: hyperglycemia, hyperinsulinemia,
  little or no ketosis, increased glucagon to increase glucose production from amino acids
  (1) catecholamines epinephrine, norepinephrine - hepatic glycogenolysis
  (2) ACTH - releases cortisol which mobilizes amino acids from muscle
  (3) aldosterone - renal sodium retention, gluconeogenesis
  (4) ADH - renal water reabsorption
  (5) hypovolemia, decreased cardiac output, drop in body temperature
  (6) fluid and sodium retention, potassium excretion, loss of nitrogen, sulfur, zinc, phosphorus
  c. provide adequate but not excessive calories 25-30cal/kg ABW, 1.2 - 1.5 g protein/kg,

Question 115

Stages of death

Answer 115

a. pre-active stage of dying: decreased intake of foods and liquids
b. active stage: inability to swallow, abnormal breathing patterns

Question 116

Neoplastic disease (cancer)

Answer 116

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 infections: avoid spicy, acidic, strongly flavored foods
   (1) provide bland liquids, soft foods, chilled or frozen foods
   d. throat or neck cancer - use PEG for feeding
   e. cancer cachexia (generalized wasting) connected to cytokines and the tumor- necrosis factor (TNF)
   f. hypercalcemia may be a sign of breast cancer, metastasis to the bone

Question 117

Neoplastic disease treatment

Answer 117

a. radiation - loss of taste, xerostomia (dry mouth, so moisten foods adding
water or milk, sauces, gravies), esophagitis, diarrhea, malabsorption,
(1) mucositis - inflammation of mucosa! 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, vomiting, malabsorption, anorexia
(2) stomatitis - cracks in skin at mouth corners, riboflavin deficiency
(3) methotrexate - anti-folate drug

Question 118

Neoplastic disease epidemiologic data

Answer 118

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

Question 119

malnutrition

Answer 119

a. marasmus - protein and calorie starvation
(1) anthropometric diagnosis, serum albumin normal, no edema
(2) severe fat and muscle wasting, starved appearance
(3) triceps skinfold, arm muscle circumference decreased
b. iatrogenic malnutrition - protein-calorie malnutrition
(1) harm brought on by treatment, hospital, medications

Question 120

Anorexia nervosa

Answer 120

a. distorted body image, dramatic weight loss, preoccupation with food and weight gain
b. therapy is multidisciplinary; weight restoration and psychotherapy
(1) immediate concern - correct electrolyte imbalance (K)
(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) recommended initial daily calorie levels range from 1000-1600 (30-40
cals/kg), but may need to be set 100 to 300 calories above the current level
of intake to support adherence

Question 121

Bulimia nervosa

Answer 121

• binge eating followed by purging syndrome
  a. may present at normal or above-normal weight
  b. damage to teeth, throat, esophagus, rectal bleeding, bruised knuckles from purging with fingers, low potassium and chloride blood levels
  c. encourage structured intake: 3 meals and 2-3 snacks daily; eat every 3-4 hours, recognizing hunger cues
  d. at each meal or snack include a protein source, a healthful fat source, and a
  complex carbohydrate source. All foods are acceptable.
  e. eat slowly, allow adequate time, drink adequate water and fluids

Question 122

Obesity

Answer 122

a. BMI Class I 30-34.9
Class II 35-39.9
Class Ill >= 40
Children: BMI for sex and age obese >=95th percentile
b. 3500 calories/ pound body fat; to lose 1 lb. fat /week, reduce 500 calories/ day
Early rapid weight loss during diet is water - as liver glycogen is utilized.

Question 123

Obesity - treatment

Answer 123

reduced caloric intake, exercise, behavior modification.
(1) realistic weight loss goals: up to 2 lbs./week, up to 10% of baseline BW, or a total of 3% to 5% of baseline weight if cardiovascular risk factors are present
(2) calorie reduction strategies
(a) 1200-1500 cal/day for women, 1500-1800 cal/day for men
(b) energy deficit of approximately 500 to 750 calories/day
(c) one of the evidence-based diets restricting certain food types (high fat foods, high carbohydrate foods) in order to create an energy deficit by reduced food intake
(d) small food-based changes: changes in SSB, sugar-sweetened
beverages, can assist with weight management
(e) meal replacements for weight loss may be recommended if the client has difficulty with portion control
(3) physical activity: 150 to 420 minutes or more per week; for weight
maintenance, 200 to 300 minutes per week

Question 124

obesity - medications

Answer 124

approved for long term use (up to 2 years)
(1) Orlistat: lipase inhibitor, take with diet 30% cals as fat, vitamin supplements
(2) Lorcaserin: agonist of serotonin, enhances satiety
(3) Phentermine / topiramate: appetite suppressant, releases norepinephrine
e. pediatric overweight interventions: Weight maintenance is usually
recommended in overweight children 2-5 years of age with a multicomponent
weight management intervention with active participation of the parent. Weight loss may be recommended when the child has serious medical conditions.
f. spot weight loss theory - belief that localized exercise reduces fat stores in the active area - research does NOT support this notion
g. when dieter reaches plateau - BMR has dropped to reflect loss
h. healthy obese - elevated LDL, normal to low HDL

Question 125

bariatric surgery classification

Answer 125

Class Ill obesity with a BMI of 40 or greater, or a
BMI of 35 or greater with co-morbidities

Question 126

gastric bypass

Answer 126

permanently alters the anatomy of the GI tract
(1) reduce the amount of food that can be eaten at one time and produce
early satiety

Question 127

RYGB Roux-en-Y

Answer 127

reconstructs the small intestine to resemble the letter Y
- creates a small gastric pouch connected directly to the jejunum
- the dumping syndrome may develop
- supplement calcium in divided doses 1200-1500 mg, vitamin D 3000 IU,
45-60mg iron taken apart from calcium, chewing of ice may be a sign of
iron deficiency
- greater need for protein
- for life: multivitamin, multimineral supplement with 100% ORI for
Vitamin K, zinc, thiamin, folic acid, copper, biotin, iron. May require
B12 supplementation in addition to that in the MVMM.

Question 128

SG sleeve gastrectomy

Answer 128

(about 80% stomach removed)
(a) food pathway not altered
(b) vitamin supplementation, monitor iron, calcium and vitamin D levels

Question 129

LAGB laparoscopic adjustable gastric banding

Answer 129

(a) small gastric pouch created using a fluid-filled inflatable band
(b) adjusted to alter the size of the opening (fully reversible)
(c) restricts total amount of food eaten at one time
(d) no surgery-induced malabsorption of nutrients. Deficiencies linked to decreased food intake and decreased food tolerance.
(e) eat slowly, sip drinks, no straws, no bubbles

Question 130

Prader Willi syndrome

Answer 130

• chromosome 15 deletion
  a. congenital disorder, subnormal LBM, supra-normal body fat
  b. Ghrelin levels are elevated which stimulates growth hormone secretion, appetite, intake, and fat mass deposition
  c. does not sense satiety, decreased energy requirements
  d. obesity at 2-3 years of age, hypogonadism, muscle hypotonia, failure to thrive, short stature
  e. best treatment is to control food intake

Question 131

dental caries

Answer 131

• bacterial enzymes ferment carbohydrate deposits on plaque,
  enzymes produce acids that demineralize surface
  a. low cariogenic potential foods: high protein, moderate fat, minimal
  concentration of fermentable CHO, strong buffer; high mineral content (Ca, P), pH >6, stimulates saliva. Low cariogenic: cheese, nuts, meat
  b. sugar alcohols (sorbitol, xylitol, mannitol) do NOT promote tooth decay
  c. fluorine - 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

Question 132

Fluoride recommendations

Answer 132

1. Infants (birth - 6 months) oral supplementation NOT recommended. Use fluoridated water if available
2. Infants (6-12 months) fluoridated water; oral supplements ONLY if prescribed
3. Toddler (12-24 months) fluoridated water, or oral supplements if prescribed
   Toothpaste should not be used until the child can spit it out.
4. Children (2-3 years) fluoridated water or supplements as recommended, fluoride toothpaste (pea-size)
   d. infant should not sleep with a bottle - BBTD baby bottle tooth decay, ECC early childhood caries

Question 133

stomatitis

Answer 133

• inflammation of mouth
  a. avoid very hot, very cold foods, spices, sour/tart foods, alcohol
  b. rinse with lukewarm water after meals

Question 134

esophagitis

Answer 134

a. decreasing gastric acidity, reflux; small, low fat, bland, low fiber
b. odynophagia is painful swallowing; globus is a lump in the throat
c. achalasia - disorder of lower esophageal sphincter motility, does not relax and open upon swallowing
(1) causes dysphagia - difficulty in swallowing
(2) start with pureed moist thick foods, progress to thick liquids

Question 135

IDDSI International Dysphagia Diet Standardization Initiative

Answer 135

• Consistency is measured along 8 levels from 0 to 7
• Beverages are classified from levels 0 to 4, thin to extremely thick
• Foods are classified from levels 3 to 7, liquidized to regular
• Level O White thin, water flow through straw
• Level 1 Grey slightly thick thicker than water, can flow through straw
• Level 2 Pink mildly thick sippable
• Level 3 Yellow liquidized spoon or cup, no lumps
  moderately thick spoon or drunk from cup, no lumps, effort with wide straw
• Level 4 Green extremely thick spoon, not from cup or straw, not sticky, chewing not required
  Pureed 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 piece

Question 136

GERD

Answer 136

gastro-esophageal reflux disease
(1) avoid eating before bed, soda, caffeine, acidic foods
(2) small, low fat meals, liquids empty more rapidly

Question 137

pregnancy-induced hypertension (PIH)

Answer 137

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 with lack of prenatal care, poor diets, poor protein and calcium intakes
d. 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. Sodium intake should not be less than 2300 mg/day.
e. proposed association between PIH and calcium deficiency

Question 138

hyperemesis gravidarum

Answer 138

• severe nausea, vomiting, acidosis, weight loss
  a. bed rest, small amounts frequent carbohydrates, correct fluid and electrolyte imbalance

DURING PREGNANCY

Question 139

Acquired immune deficiency syndrome (HIV/AIDS)

Answer 139

1. diarrhea, malabsorption, nausea, vomiting, weight loss
2. preserve lean body mass, prevent weight loss, prevent HIV wasting
3. encourage physical activity 20min/day, 3X/week
4. nutrient needs: BEE X 1.3 for asymptomatic, based on ORI
   a. protein: asymptomatic 0.8g/kg, up to 1.2-2.0g/kg if wasted LBM
   b. standard doses of micronutrients if dietary intake is insufficient
   c. if diarrhea: soluble fiber, MCT oil, electrolyte replacement beverages
5. food and water safety - low bacteria diet (neutropenic), avoid raw foods
6. HIV infected women should be counseled NOT to breast-feed
7. NRTI drugs (nucleotide nucleoside reverse transcriptase inhibitors including Retrovir, zidovudine) can lead to anemia, loss of appetite, nausea, dysphagia
8. HALS (HIV - associated lipodystrophy syndrome) may develop from therapy
   a. high cholesterol, high triglycerides, insulin resistance, changes in body fat distribution
   b. significant loss of lean body mass can be obscured by edema and HALS
   c. increase in dietary fiber decreases insulin resistance, reducing risk of fat deposition
9. Nutritional supplementation 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 medicine) therapies are not inert and may have profound consequences.
10. Pediatric HIV
    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 1-2X RDA or ORI
    d. lactose restriction if intolerant

Question 140

COPD - chronic obstructive pulmonary disease

Answer 140

persistent obstruction of airflow
a. (1) emphysema - air sacs (alveoli) lose elasticity; thin, cachectic, often older
(a) difficulty exhaling; air pocket walls expand, thin out, collapse
(2) chronic bronchitis - excess mucus production, chronic productive cough
b. symptoms - weight loss, emaciation, anorexia
c. maintain appropriate body weight and composition
d. Avoid overfeeding (more than 35 cals/kg) to avoid excessive CO2 production. Routine use of high fat, low carbohydrate formula is not warranted.
d. 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)
e. Vitamin D supplementation improved exacerbation outcomes in those with
serum 25(0H) D levels 1 Ong/ml or lower,

Question 141

ARDS, acute respiratory distress syndrome

Answer 141

respiratory failure
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 g protein/kg BW, maintain lean body mass

Question 142

Mental/Behavioral health and addiction:
1. Factors that are cause for nutritional consult

Answer 142

a. Prescription for antipsychotics Clozapine, Olanzapine, Risperidone, Quetiapine:
(1) determine history of usual weight and weight gain
(2) Weight gain of 5% above baseline: recommend referral for weight management. Weight gain of 7%: clinically meaningful gain
b. BMI of 18 or below: possible inadequate intake
c. paranoia regarding food or resulting in severe food restriction
d. suspicion that functional level, social or financial factors are compromising food
intake
e. alcohol or drug abuse or eating disorder

Question 143

Malnutrition common among drug addicts

Answer 143

a. Prime concern is the next drug dose. Getting food may be secondary.
b. may be socially marginalized and impoverished (partly related to cost of drugs)
c. Injection drug use exerts stress on immune system, increasing need for nutritional antioxidants.
d. Bulimia and anorexia are not uncommon. Cocaine, amphetamines and ecstasy may be used to reduce appetite for desired weight loss or control.

Question 144

Nutrition intervention for drug addiction

Answer 144

a. Address person in a holistic manner with psychosocial support, including family
members. Group process is known to have positive outcomes for nutrition education.
b. Moderate or discontinued sugar intake: Sugar ingestion releases dopamine. Sugar
cravings may substitute for the dopamine release previously available from use of many drugs. This results in mood fluctuations and weight gain. Stable glucose levels are shown to decreased drug cravings and reduce relapse potential.
c. Moderate or discontinued caffeine. Caffeine reduces mood stability by inducing the
fight or flight response.
d. increased complex carbohydrate, protein and fiber with moderate to low fat intake.
e. regular 3 well-spaced meals and 1-3 healthy snacks
f. 30-35 cals/kg plus 1-2 grams protein/kg, encourage fluid intake, especially water,
between and with meals

Question 145

Enteral nutrition
1. formulas

Answer 145

a. standard polymeric - normal GI function, most provide 1-1.5 calories/ cc
(1) lecithin may be added as an emulsifier
(2) initiated full strength at a rate of 10-40 ml/hour, advance 10-20ml every 8
to 12 hours over the next 24 to 48 hours until goal rate is achieved
(3) modular: mix individual components, adds flexibility
(4) blenderized: whole food, large bore tube, thick intact protein, high residue
(5) least expensive formulas: intact protein (NOT pre-digested), and
isotonic (osmolality is close to that of blood)
(6) FOS fructooligosaccharides (prebiotics) and fiber may be added to
stimulate production of beneficial bacteria and may help resist Clostridium
difficile
b. elemental, chemically defined - used with malabsorption
(1) pre-digested protein or amino acids, glucose or sucrose, LCT and MCT,
vitamins, minerals, electrolytes
(2) absorbed in proximal intestine, low to no residue, don’t need pancreatic enzymes, high osmolality, poor taste
(3) used with compromised GI function, inability to digest and absorb
(4) Alitraq, Peptamen, Vivonex
c. specialized
(1) Nepro (renal), HepaticAid II (liver), Glucerna (diabetes)
(2) the more specialized the formula, the greater its cost

Question 146

Enteral nutrition
2. features

Answer 146

a. tube bore {opening) - based on viscosity of feeding
{1) large #16 - blenderized whole foods
{2) small #8 - ready prepared formulas, more comfortable

Question 147

enteral access

Answer 147

a. anticipate length of time needed, risk of aspiration, patient’s anatomy,
clinical status, normal or abnormal digestion and absorption
b. hang time open systems 8 hours, closed systems 24-48 hours
c. short term access 3-4 weeks, nasogastric tube, normal GI function
{1) bolus method - clinically stable with functional stomach
{2) intermittent drip {pump or gravity) - more mobility
(3) 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). Cyclic feeding is 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) nasoduodenal or nasojejunal if unable to tolerate gastric feedings
(5) transpyloric / post-pyloric: passed by pyloric valve in stomach; used in
comatose patients or ones with no gag reflex
(6) gastrostomy or jejunostomy feedings if needed for more than 3-4 weeks
(a) PEG inserts tube into stomach through abdominal wall
(7) do not use blue dye to check tube placement. Use X-ray confirmation of
tube tip location, or aspirate gastric contents

Question 148

1 cc water/ calorie ingested - enteral nutrition

Answer 148

1 cal/cc formulas are 80-86% water; 1.5 cals/cc are
76-78% water, 2 cals/cc formulas are 69-71 % water

Question 149

normal GRV - enteral nutrition

Answer 149

<= 250. Enteral nutrition should not be held for GRVs < 500ml in
absence of other signs of intolerance.

Question 150

Actual intake - enteral nutrition

Answer 150

may be lower than prescribed because of medical procedures and
ADL interruptions ( activities of daily living)

Question 151

adverse effects - enteral nutrition

Answer 151

lactose intolerance, formula hyperosmolality, rapid infusion causes influx of water into gut

Question 152

formula calculation - enteral nutrition

Answer 152

a. Select formula and determine calories needed.
b. Divide calories needed by cal/ml to determine mls formula needed per day.
c. Determine protein content: Multiply mls of daily formula by grams of
protein per liter.
d. Determine daily fluid need: Multiply % water in formula x daily formula in mls to determine water contribution of enteral nutrition. Subtract formula water from total fluid requirements to determine water flushes.
e. Determine administration rate: Divide total mis of formula/day by 24 hours to
determine continuous feeding goal rate.

Question 153

Peripheral parenteral nutrition

Answer 153

• small surface veins
  1. short term therapy with minimum effect on nutritional status
  a. indications - post-surgery (when enteral feeding is expected to resume within
  5 - 7 days), mild to moderate malnutrition, as supplement to enteral
  2. solutions
  a. IV dextrose - 3.4 calories / gram
  (1) to figure calories (ml) (%) (3.4)
  (2) highest concentration of dextrose used in peripheral nutrition is 10%
  b. protein 3-15% amino acid solutions
  c. IVFE intravenous fat emulsion (lntralipid)
  ( 1) 10% 1.1 calories/cc
  20% 2.0 calories/cc
  d. solutions generally limited to 800-900 mOsm

Question 154

Parenteral nutrition PN

Answer 154

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. ASPEN: set time frame of 7-10 days in which to achieve intake goals by the
   enteral route before adding PN
4. use of PN in critically ill patients has been shown to increase infectious
   complications, longer ICU stays and increased mechanical ventilation
5. catheters
   a. PICC peripherally inserted central catheter - used for short or moderate
   term infusion
   b. CVC long term central access is through the cephalic, subclavian or internal jugular vein into the superior vena cava
6. concern - translocation of bacteria; not feeding through gut allows wall to
   break down, bacteria move out causing sepsis
   a. GALT (gut associated lymphoid tissue) is compromised by bowel rest or
   parenteral nutrition. Provides 50% of total body immunity. 70-80% of total body immunoglobulin production is secreted across the GI mucosa to defend against pathogenic substances in the GI lumen.

Question 155

Parenteral nutrition PN solutions

Answer 155

a. protein: ratio for anabolism is 1 gram nitrogen / 150 calories;
1-1.5 grams protein / kg / day
( 1) crystalline amino acids 3-15% solution
(2) % = number of grams of protein in 100 mls of solution
A 3% solution has 3 grams of amino acids / 100 ml.
b. energy 35-50 calories/KG; up to a 70% dextrose solution
( 1) a 10% solution provides 100g CHO/liter
(2) to avoid overfeeding and hyperglycemia, start at <= 20-25 calories/kg
(3) maximum rate of dextrose infusion (glucose utilization rate) should not
exceed 4 to 5 mg/kg/minute to prevent hyperglycemia and other complications. Increased blood glucose from excess dextrose increases RQ in ventilated patients and increases infectious complications.
c. fat: needed for energy and to prevent essential fatty acid deficiency (EFAD)
(1) to prevent EFAD give 500cc of 10% fat emulsion 1-2 X/week
(2) symptom of EFAD: petechiae (red spots)
d. vitamins, electrolytes, water as needed
e. TNA: total nutrient admixtures (three in one systems) include dextrose,
amino acids and lipids

Question 156

Parenteral nutrition PN contraindications:

Answer 156

if alimentary tract can be used, if needed only for short time in
well nourished, during periods of cardiac instability, if risks inherent in process outweigh benefits

Question 157

transitional feeding PN

Answer 157

a. introduce a minimal amount of full-strength enteral feeding at a low rate of 30-40 ml/hour to establish GI tolerance
b. begin tapering when enteral feedings are providing 33-50% of their nutrient requirements
c. decrease PN as you increase enteral rate by 25-30 ml/hour increments every 8-24 hours to maintain prescribed nutrient levels
d. when patient can tolerate about 60% of needs by enteral route, D/C PN

Question 158

re-feeding syndrome

Answer 158

• aggressive administration of nutrition to malnourished
  a. at risk: anorexia nervosa, 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
  (1) hypokalemia: cardiac, renal, carbohydrate metabolism, muscle weakness
  (2) hypophosphatemia: cardiac abnormalities, respiratory failure, seizures
  (3) hypomagnesemia: intracellular metabolism, cardiac arrhythmias,
  hypocalcemia
  d. tightly control blood glucose 140 -180 mg/di
  e. overfeeding PN and dextrose >5mg/kg/min may lead to hyperglycemia
  (1) glucose moves into cells for oxidation, stimulates insulin, which decreases salt and water excretion, increasing risk of cardiac and pulmonary complications. Upon initiation of PN to a malnourished person, monitor glucose, phosphorus, potassium and magnesium (avoid refeeding syndrome).

Question 159

Complementary and integrative therapies

Answer 159

1. Integrative medicine combines evidence-based complementary therapies with
   conventional (allopathic) treatments to address the social, psychological and
   spiritual aspects of health and illness.
2. NCCIH National Center for Complementary and Integrative Health.
   a. yoga, meditation, herbs and botanicals, traditional healing practices.
3. Complementary and alternative medicine CAM - NIH categories
   a. mind-body medicine, alternative medical systems like acupuncture and oriental
   medicine, lifestyle and disease prevention, biologically based therapies including herbs
   and orthomolecular medicine, manipulative and body-based systems like chiropractic
   medicine, biofield systems like therapeutic touch, bioelectric magnetics
4. Functional medicine addresses the whole person, not just symptoms, and looks at the underlying cause of disease, engaging patient and practitioner in a
   partnership for therapy.
5. Holistic health views mental, physical and spiritual aspects of life closely connected and equally important with regard to treatment approaches.

Question 160

Dietary Reference Intakes, DRI - umbrella of nutrient guidelines

Answer 160

1. RDA Recommended Dietary Allowances - goals for healthy individuals to prevent nutritional deficiency diseases, includes gender, age, life phases
2. EAR estimated average requirement for 50% of population, used in planning
   meals for healthy people, assesses group nutritional adequacy
3. Al adequate intake, used when insufficient evidence exists for EAR, RDA
4. UL tolerable upper level not associated with adverse side effects in most individuals of a healthy population

Question 161

Dietary Guidelines for Americans

Answer 161

• revised every five years, USDA, DHHS
  1. designed to promote health and prevent chronic disease
  2. community nutrition programs use these guidelines when developing plans
  3. 2020 - 2025 Dietary Guidelines
  a. Follow a healthy dietary pattern at every life stage.
  b. Customize and enjoy nutrient-dense food and beverage choices to reflect
  personal preferences, cultural traditions, and budgetary considerations.
  c. Focus on meeting food group needs with nutrient-dense foods and beverages, and stay within calorie limits.
  d. Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages.
  (1) Limiting added sugars to less than 10% of calories per day for ages 2 and older and to avoid added sugars for infants and toddlers
  (2) Limiting saturated fat to less than 10% of calories per day starting at age 2
  (3) Limiting sodium intake to less than 2,300mg per day (or even less if younger than 14)
  (4) Limiting alcoholic beverages* (if consumed) to 2 drinks or less a day for
  men and 1 drink or less a day for women

Question 162

Healthy Eating Index

Answer 162

• 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

Question 163

MyPlate Plan

Answer 163

• implementation of the Dietary Guidelines
  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 low fat or fat-free milk, vary protein choices
  3. choose foods and beverages with less added sugars, saturated fat, sodium

Question 164

Healthy People 2030

Answer 164

DHHS
1. data-driven national objectives to improve health and well-being over the next
decade
2. Core Objectives: measurable objectives that are associated with targets for the decade. Reflect high-priority public health issues and are associated with evidence-based interventions.
3. Leading Health Indicators (LHls) are a small subset of high-priority objectives selected to drive action toward improving health and well-being.
- Focus on upstream measures, such as risk factors and behaviors, rather than disease
outcomes, address issues of national importance, address high-priority public health issues that have a major impact on public health outcomes, are modifiable in
the short term (through evidence-based interventions and strategies to motivate
action at the national, state, local, and community level), address social determinants
of health, health disparities, and health equity, have new data available periodically, preferably annually

Question 165

Steps in program planning (1-4)

Answer 165

1. Develop a mission statement (philosophy) and needs/problem 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 statement: Clinic will work to enhance the health of its clients by reducing the risk of heart disease.
2. Set goals - broad direction, 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
   Goal: Increase the awareness of CHO risk factors.
3. Set objectives - specific measurable (tangible) actions within a time frame
   Objective: Increase the number of women who can identify two risk factors for CHO by 25% in one year.
   a. More defined than goals; contain specific target dates for completing specific
   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
4. Develop plan: 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

Question 166

Steps in program planning (5)

Answer 166

Budget development: controls and coordinates activities, indicates how and at what
rate dollars are to be expended
1. 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
2. phases of budget cycle: prepare requests, evaluate revenue potential,
formulate document, send to legislative body, legislative review and authorization, execute the budget (run the program), evaluation and review
3. performance budget - summarizes program activities performed in terms of the
cost of specified accomplishments. Ex: what it costs to supervise a food bank, or what it costs to screen 200 children for anemia
4. funding: public health departments derive a portion of their income from
general revenue (taxes), and federal, local or foundation grants.
a. Grant: an award of financial or direct assistance: usually lasts over a few years.
b. Block grants from federal government are given to states or local communities
for broad purposes as authorized by legislation. Recipients have great flexibility
in distributing funds. Five federal block grant areas: maternal and child health,
community services, social services, preventive health services, primary care
c. CDC STEPS 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.

Question 167

Implementation of program plan requires

Answer 167

administrative support, realistic budget, staff commitment,
support of target population
1. educate - increase awareness, knowledge, options (cognitive learning)
a. scientifically sound information explained to client so they understand
the reasons for the changes you are recommending
b. to reach large numbers: use media, hotlines, point-of choice or point of
purchase (POP) intervention
c. in health fairs, evaluate nutritional risk using BMI
2. enable - reduce 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
3. skill development - competencies necessary to make and sustain new eating
habits (psychomotor learning)
a. one on one counseling, small group sessions
b. teaches how to: select appropriate foods, budget for healthful foods, how
to obtain Food Stamps if needed, how to develop new eating behaviors