Nutritional Disorders Flashcards
where does the body get its energy source from?
- Carbohydrate
- Indigestible carbohydrate (fiber)
- Nitrogen
- Water
RDA (Recommended Dietary Allowances) is the most recognizable what?
Most recognizable way nutritional requirements have been expressed in past
-Initially designed to meet the nutritional needs of healthy individuals
RDAs (Recommended Dietary Allowances) initially designed to meet what?
the nutritional needs of healthy individuals
what has replaced RDAs (Recommended Dietary Allowances)?
DRI’s (Dietary Reference Intakes)
what do the DRI’s do?
Broader approach to defining nutritional adequacy
Attempt to include nutritional information as it relates to long term health and reduction of chronic disease
what does energy support?
normal functions and activity, growth and repair of damaged tissues
how is energy provided to the body?
by the oxidation of dietary protein, fat, carbohydrate and alcohol
what are the 3 factors of energy expenditure?
- Basal energy expenditure (BEE)
- Thermic effect of food (TEF)
- Physical activity
what is Basal energy expenditure (BEE)?
amount of energy required to maintain basic physiologic functions
how is the Basal energy expenditure (BEE) measured?
in a warm room, not having eaten for 12 hours
what equation can you use to estimate Basal energy expenditure (BEE)?
Harris-Benedict equation
what is thermic effect of food (TEF)?
amount of energy expended during and following the ingestion of food
-averages approx. 10% of the BEE
what is protein required for?
growth and maintenance of body structure and function
what is the RDA (Recommended Dietary Allowances) for protein? (in men and women)
56g/day for men
45g/day for women
how many carbs does an American diet contain?
approx 45% carbs
what are dietary carbs?
- Simple sugars
- Complex carbohydrates (starches)
- Indigestible carbohydrates (dietary fiber)
what is the most concentrated course of food energy?
fat
Average American diet contains how much fat and recommendations to limit it to what?
Average American diet contains 35-40% of calories as fat
Current recommendations are to limit this to 20-35%
what is fat primarily composed of?
fatty acids and dietary cholesterol
cholesterol is the major constitute of what?
cell membranes
cholesterol is synthesized by what?
the body - not essential nutrient
the assessment of nutritional status is important to what patient populations?
patient populations who are at risk for nutritional deficiencies
- Elderly
- Adolescent
- Pregnant or lactating women
- Low socioeconomic status
what historical information must be obtained when trying to identify high risk patients who are at risk for nutritional deficiencies?
- Regularity and availability of meals
- Grocery shopping and food preparation
- Changes in appetite
- Weight loss or gain
- Food allergies
- Use of drugs, alcohol, medications
- Presence of co-morbidities affecting nutritional needs
physical examination when assessing nutritional status?
- Body weight
- Muscle wasting
- Fat stores
- Volume status
- Signs of nutritional deficiency
what is BMI?
body weight in relation to height
what is more of a reliable predictor of nutritional status over BMI?
a recent unintentional change in body weight reported by a patient
what does protein-energy malnutrition result from?
from relative or absolute deficiency of energy or protein
what are the 2 syndromes of protein-energy malnutrition?
Kwashiorkor
Marasmus
what is Kwashiorkor?
Syndrome of protein-energy malnutrition
-deficiency of protein in presence of adequate energy (sufficient caloric intake, insufficient protein deficiency)
Kwashiorkor is sufficient in what and insufficient in what?
sufficient caloric intake, insufficient protein consumption
what is Marasmus?
Syndrome of protein-energy malnutrition
combined protein and energy deficiency (severe malnutrition, emaciated appearance)
Marasmus is severe what?
severe malnutrition (combined protein and energy deficiency)
what type of appearance do Marasmus pts have?
emaciated appearance
where does primary protein-energy malnutrition pose a health problem?
in developing nations
in developing nations, in what areas does Kwashiorkor occur?
in areas where foods containing protein are insufficient
- occurs in areas of famine or poor food supply
- occurs in developing countries in children after women stop breast feeding
in who does Kwashiorkor occur in, in developing countries?
children after women stop breast feeding
in developing nations, where is Marasmus seen?
where adequate quantities of food are not available
protein-energy malnutrition is often what in industrialized societies?
secondary to other disease
in industrialized societies, Kwashiorkor-like deficiency syndrome occurs in?
associated with illnesses where the body is in a hypermetabolic state (ex: trauma, sepsis, burns)
in industrialized societies, Marasmus-like deficiency syndromes result from what?
chronic disease like heart failure, cancer, COPD, AIDS
what organ system doe protein-energy malnutrition affect?
every organ system
how much loss of body weight d/t protein-energy malnutrition results in death?
losses of 35-40% of body weight usually results in death
how much loss of protein can be tolerated without compromise?
5-10%
protein losses begin with what and progress to what?
begin with skeletal muscle and progress to internal organs (liver, GIT, kidneys, heart)
when does organ dysfunction develop in protein-energy malnutrition?
with progressive muscle loss
what liver dysfunction occurs from protein malnutrition?
hepatic synthesis slows, circulating proteins decrease
what heart dysfunction occurs from protein malnutrition?
decreased cardiac output and contractility
what respiratory dysfunction occurs from protein malnutrition?
functionality is affected by weakness and muscle atrophy reducing lung volumes
what GIT dysfunction occurs from protein malnutrition?
malabsorption occurs with loss of mucosal definition and loss of vili
what immune dysfunction occurs from protein malnutrition?
T lymphocytes decrease and B cell function is depressed resulting in infections and impaired wound healing
what are the clinical findings of protein-energy malnutrition?
progressive muscle wasting in setting of early weight loss to severe cachexia
-TEMPORAL MUSCLE WASTING
progressive muscle wasting in protein-energy malnutrition is typically in what patients?
patients with marasmus-like secondary protein-energy malnutrition
who should you call ASAP if pt has protein malnutrition?
nutrition colleagues - call ASAP for protein malnutrition
protein malnutrition should be followed by what?
daily by nutrition consultant
CHECK THIS CARD-nutrition consultants do what for protein malnutrition?
- Help manage dietary requirements
- Correct electrolyte abnormalities
- Replace vitamins and minerals
- Supplements with enteral or parenteral nutrition
obesity definition
excess adipose tissue
obesity a direct result of what and in what setting?
excess caloric ingestion in setting of sedentary lifestyle
for obese pts, what hx should you obtain when evaluating them?
- Recent weight changes
- Occupation
- Eating behaviors
- Exercise
- Smoking and alcohol consumption
- Medications: OTC, herbal, prescribed, supplemental
do many obese pts have an identifiable secondary cause? if concerned, refer to who?
NO!!!
Very small population of patients will have an identifiable secondary cause such as hypothyroidism or Cushing’s syndrome
-if concerned, refer to endocrinologist
what is essential to tx of obesity?
close follow-up
where do you refer obese motivated pts to?
active tx programs
tx programs for obesity emphasize what?
maintenance of weight loss
through what do tx programs for obesity emphasize maintenance of weight loss?
- Dietary instruction and education
- Behavior modification
- Exercise
- Medications
- Bariatric surgery
anorexia nervosa definition
disturbance in body image and intense fear of weight gain
anorexia nervosa is most common in who?
females
some anorexia nervosa pts may exhibit features of disease without having what?
severe weight loss
important clinical findings of anorexia nervosa
- Weight loss leading to body weight 15% below expected
- In female patients, amenorrhea is almost always present
in female anorexic pts, what is almost always present?
amenorrhea
other clinical s/sx’s of anorexia nervosa
- Constipation
- Cold intolerance
- Bradycardia
- Hypotension
- Loss of body fat
- Dry and scaly skin
dx of anorexia nervosa
Behavioral features such as distorted body image, fear of weight gain and refusal to maintain normal body weight in setting of weight loss to a body weight 15% below expected
in female, absence of at least 3 menstrual cycles
what is the goal of tx for anorexia nervosa?
restoration of normal body weight and elimination of psychological features
inpatient tx programs for anorexia nervosa may be necessary in what cases of anorexia?
in severe cases for management of volume status and electrolytes
does psychotherapy and meds show evidence of improvement for anorexia nervosa?
NO!!!
what is essential in tx of anorexia nervosa?
referral to psychiatrist is essential
what is bulimia nervosa?
Episodic, uncontrolled ingestion of large quantities of food followed by recurrent inappropriate compensatory behavior to avoid weight gain
how do bulimia pts avoid weight gain?
- Self-induced vomiting
- Diuretics
- Cathartics
- Strict dieting
- Vigorous exercise
bulimia is common in who?
young, white females in middle and upper class
is bulimia obvious to the clinician?
NO! less obvious than anorexia
are bulimia pts usually within in normal body weight?
Body weight fluctuations but generally within 20% of normal body weight
what issues do bulimia pts commonly describe?
family and psychological issues
what type of behavior may be present in bulimia pts?
Impulsive or antisocial behavior
what is preserved in bulimia that isn’t preserved in anorexia?
menstruation
what bulimia complications can occur after binges?
Gastric dilatation, pancreatitis
what bulimia complications can occur secondary to vomiting?
poor dentition, esophagitis
what bulimia complications can occur secondary to diuretics and cathartics?
Electrolyte abnormalities, dehydration secondary
bulimia nervosa tx’s
Supportive care to include psychotherapy
Antidepressants may be helpful
All patients should be referred to psychiatrist
what is worse in bulimia than with anorexia?
long-term psychiatric prognosis
are pts usually deficient in one or multiple vitamins?
multiple vitamines
do vitamin deficiencies usually exhibit noticeable exam findings?
not until later in the course of the syndrome
what is the most common cause of anemia worldwide?
iron deficiency
what is a reliable indicator of iron deficiency?
Serum ferritin value < 12 ng/mL without anemia or < 30 ng/mL with anemia
iron deficiency developing stages
- Depletion or iron stores without anemia
- Anemia with a normal red blood size (MCV)
- Anemia with low MCV, low reticulocyte count
iron deficiency signs and sx’s
Fatigue, Tachycardia, Palpitations, Dyspnea on exertion
ALL ARE ANEMIA SX’S
severe iron deficiency signs and sx’s
- Smooth tongue
- Brittle nails
- Spooning of nails
- Cheilosis
what do many iron deficient pts develop?
pica
tx for iron deficiency?
First identify cause b/c often d/t blood loss
Treat with PO iron (Ferrous sulfate and continue for 3-6 months after restoration of normal labs)
-use parenteral iron if indicated
when is parenteral iron tx indicated for iron deficiency?
- Refractory to PO iron
- GI disease
- Hemodialysis
what is thiamine deficiency due to?
chronic alcoholism
early sx’s of thiamine deficiency
- Anorexia
- Muscle cramps
- Paresthesias
- Irritability
late sx’s of thiamine deficiency
- Cardiovascular dysfunction – wet beriberi
- Neurological dysfunction – dry beriberi
what is wet beriberi?
cardiovascular dysfunction in thiamine deficiency (late sx)
- Marked peripheral vasodilation caused high output heart failure
- Dyspnea, tachycardia, cardiomegaly, edema
what is dry beriberi?
neurological dysfunction in thiamine deficiency (late sx)
Peripheral nerve involvement causing motor and sensory neuropathy, paresthesias and loss of reflexes
what is Wernicke – Korsakoff Syndrome?
develops from severe acute thiamine deficiency
dry beriberi
CNS involvement causing encephalopathy, amnesia, and confabulation
tx of thiamine deficiency?
replace thiamine, initially IV followed by PO
what must you have to absorb vitamin B12?
intrinsic factor
what is pernicious anemia?
autoimmune disease where there are autoantibodies against gastric parietal cells that produce intrinsic factor
-no intrinsic factor, no B12 absorption -> B12 deficiency
what surgery can cause vitamin B12 deficiency? what does it eliminate?
gastrectomy (abd surgery)
-eliminates site of intrinsic factor production
-surgical resection of ileum eliminates site of B12-intrinsic factor complex
B12 deficiency causes what kind of anemia?
moderate-severe anemia of slow onset
has elevated MCV (MCV >100)
pts can have what manifestations of B12 deficiency despite having what?
patients can have non-hematologic manifestations of this deficiency despite having a normal CBC
sx’s of B12 deficiency
Complex neurologic syndrome
- Paresthesias
- Balance difficulty
- Cerebral dysfunction: dementia
what is a normal B12 level?
> 210 pg/mL
Vitamin B12 deficiency anemia and folic acid anemia peripheral smear
megaloblastic and hypersegmented neutrophils
tx for B12 deficiency
with parenteral therapy
- IM or subcutaneous injections of 100mcg
- Daily for first week
- Weekly for first month
- Monthly for life
folic acid deficiency due to?
lack of dietary intake
when do requirements for folic acid increase?
during pregnancy
signs and sx’s of folic acid deficiency
- GI symptoms
- Swollen, painful tongue
- Neurologic symptoms such as cognitive impairment, dementia, depression
what type of anemia is seen in folic acid deficiency?
Megaloblastic anemia is again seen
-identical in appearance to vitamin B12 deficiency
tx of folic acid deficiency
folic acid 1mg PO daily
what should you always measure during folic acid deficiency evaluation?
vitamin B12
supplementation with large doses of folic acid can improve what but allow what to progress?
Critical to recognize that supplementation with large doses of folic acid can improve anemia seen with vitamin B12 deficiency but allow the neurologic damage to progress
where is vitamin D synthesized?
in skin during exposure to UV-B light
vitamin D gets converted into what hormone?
1,25 dihydroxyvitamin D
what does 1,25 dihydroxyvitamin D do?
increases absorption of dietary calcium in addition to stimulating osteoclasts which release calcium from bone
vitamin D deficiency causes what?
decreased bone density from defective mineralization
vitamin D deficiency is the most common cause of what?
osteomalacia
vitamin D deficiency arises from what?
insufficient sun exposure, malnutrition, or malabsorption
what levels may you check with vitamin D deficiency and when do you check it?
calcium levels and check if pt is malnourished
vitamin D deficiency tx?
Ergocalciferol (D2) 50,000 units 1x weekly x8 weeks
Cholecalciferol (D3) 2,000 units daily
