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NSI--Nutrition Screening Initiative

-Identifies nutritional problems early for the elderly. Uses DETERMINE checklist
-LEVEL I / LEVEL II

NNMRRP--National Nutrition Monitoring and Related Research Program


-Run by DHHS & USDA


-Data collection and analysis activities of the federal government r/t measuring the health and nutritional status, food consumption, attitudes about diet and health.

PedNSS--Pediatric Nutrition Surveillance System



-Operated by HHS (Health & Human Services)


-birth to 17 y/o--low income/high risk children


-monitors growth and nutritional status

PNSS--Pregnancy Nutrition Surveillance System



-Run by HHS


-low income/high risk pregnant women


-counts # of women who breast-feed


-Purpose is to identify and reduce pregnancy-related health risks

NHANES--National Health and Nutrition Examination Survey



-Ongoing survey to obtain information on the health of the American people.


-Uses clinical, chemical, anthropometric, nutritional data (24 hr recall/food frequency)

NHANES III

Large sample of adults >65 years with NO upper age limit


-useful data to study aging and nutrition

BRFSS--Behavioral Risk Factor Surveillance System



-Run by HHS


-Adults 18 years and older residing in households with telephones


-Telephone interviews collecting info on ht, wt, smoking, etoh use, food frequency for fat, fruits, veggies, preventable health issues--DM

YRBS--Youth Risk Behavior Survey



-Run by HHS


-Grades 9-12


-Priority health risk behaviors--smoking, etoh use, wt control, exercise, eating habits

Which ethnic groups depend heavily on federal assistance programs?

Native Americans & Alaskan natives

TANF--Temporary Assistance for Needy Families



-States determine the eligibility of needy families & the benefits/services the families will receive.

CSFP--Commodity Supplemental Food Program



-USDA program--administered by state health agencies


-low income women, infants, and children up to 6, some elderly at nutritional risk


-Monthly commodity of canned/packaged food

NSLP--National School Lunch Program



-run by USDA Food and Nutrition Services


-Entitlement program to improve nutrition of children (esp. low income)


-Utilize surplus production of food


-Implement the Dietary Guidelines into the Lunch and Breakfast programs


-Lunch must provide on avg. each school wk: 1/3 recommended intake for protein, vitamin A, C, iron, and calcium.

SBP--School Breakfast Program



-run by the USDA


-Entitlement program that must meet the Dietary Guidelines


-Must provide on avg. over each school week: 1/4 daily recommended levels for protein, vitamin A, C, iron, calcium

ASP--After School Snack Programs



-run by the USDA


-Schools receive cash subsidies for each snack served

Special Milk Program

-Run by the USDA


-Encourage milk consumption among children



SFSP--Summer Food Service Program



-USDA


-Maintain foodservice programs to children when school is not in session

CACFP--Child and Adult Care Food Program



-USDA


-Provides healthy meals and snacks to children and adult day care facilities


-Meals must be dietary guidelines like (NSLP)

WIC---Women Infants and Children



-USDA


-provides food for low income mothers at nutritional risk (medically and dietary based) that are breast-feeding, pregnant, or postpartum


-provides food for infants/children at risk through age 5


-food and nutrition education are provided


-health exam is required


-must meet income standards


-not an entitlement program


-Congress sets a cap on dollars WIC receives each year

EFNEP--Expanded Food and Nutrition Education Program

-USDA


-trains nutrition aides to educate the public


-improve food practices of low income homemakers with young children


-works with small groups and teaches skills on how to shop and cook



Maternal and Child Health Block Grants

-run by DHHS


-federal program concerned with the health of mothers, infants and children

Healthy Start Program

-run by DHHS


-funds programs in communities with high infant mortality rates.

OAA--Older Americans Act Nutrition Program

-HHS


-One hot meal each day, 5x/wk, provides 1/3 recommended intake


-Eligibility: all aged 60 and older plus spouse--regardless of income



Congregate Meals

-ambulatory patients

Home delivered meals

-for homebound patients


(meals on wheels)

SNAP--Supplemental Nutrition Assistance Program

-USDA


-assistance program for low income individuals and family providing monthly benefits.


-largest food assistance program (entitlement)


-net income must be at or below certain % of poverty level

Medicare

-Run by HHS


Health insurance for people 65 y/o or older


or any age with ESRD


Part A: covers hospital care


Part B: covers supplemental services

CMS

Centers for Medicare & Medicaid Services

Medicaid

-run by HHS


-joint state and federal program


-provides assistance for all eligible needy--all ages, blind, disabled, dependent children

CHIP--Children's Health Insurance Program

-under Social Security Act


-joint federal and state program


-expands health coverage to uninsured children whose families earn too much income to qualify for Medicaid but too little for private coverage

Headstart

HHS


-helps low income children (3-5 y/o)


-introduces new food and teaches good food habits


-children participation is important

NET--Nutrition Education Training Program

-USDA


-trains teachers and school food service personnel



Quasi-governmental agencies

-Receive both federal and private funding


-American Red Cross


-National Research Council

National Research Council

Food and Nutrition Board (develop RDAs)

Non-governmental agencies

-voluntary health agencies: American Heart Association (AHA)


-professional: Academy of Nutrition and Dietetics (AND)


-business foundations: Rockefeller foundation

FAO--Food and Agricultural Organization

-interested in raising world-wide levels of nutrition by increasing efficiency of production and distribution of foods


-international agency

WHO--World Health Organization

-developed RDAs for developing countries

Grant

An award of financial or direct assistance


-anyone can apply

Entitlement

requires payment of benefits to all eligible people as established by law


-usually for a finite time (1 year)


-SNAP (food stamps), Medicare, NSLP, SFSP, SBP

Block grants

from the federal government


-given to states or local communities for broad purposes authorized by legislation


-Ex: CDC STEPS: health initiatives r/t obesity

True or False: WIC is an entitlement program

False.


-WIC is NOT an entitlement program

FTC--Federal Trade Commission

internet, TV, radio; bogus weight loss claims

NCAHF--National Council Against Health Fraud

voluntary health agency that focuses upon health misinformation, fraud, and quackery as public health problems

Use the CARS checklist when evaluating information...

Credible


Accurate


Reasonable


Supported by science

HIPPA--Health Insurance Portability & Accountability Act

passed by Congress in 1996. Requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.

Ulcer

Eroded mucosal lesion. Usually caused by Helicobacter pylori bacteria. Treatment involves antacids, H2 blockers, abx, rest, and diet therapy. Diet is as tolerated (whatever doesn't aggravate pt). Avoid late night snacks. Omit gastric irritants--cayenne, black pepper, large amt of chili powder, excess caffeine and alcohol.

Hiatal hernia

Main symptom=heartburn

Small bland feedings/avoid late night snacks

Dumping syndrome

Occurs following a gastrectomy (Billroth I/II). Holding capacity of stomach decreases, so food is literally dumped into the intestines. s/s=cramps, full feeling, rapid pulse, weakness, sweating, dizziness. Rapidly hydrolyzed CHO enters the jejunum, H2O is drawn from the blood into the intestines to achieve osmotic balance. This causes a rapid decrease in the vascular fluid compartment so blood pressure drops and signs of cardiac insufficiency appear. 2 hrs later, CHO is digested/absorbed rapidly. BG rises and insulin is overproduced, causing a drop in BG below fasting. Reactive/alimentary hypoglycemia.

Billroth I--gastroduodenostomy

attaches the remaining stomach to the duodenum

Billroth II--gastrojejunostomy

attaches the remaining stomach to the jejunum. This is a more serious surgical procedure. When food bypasses the duodenum, the secretion of secretin/pancreozymin are reduced (these hormones stimulate the pancreas). Now, there is little pancreatic secretion which causes steatorrhea. May develop deficiency of iron, B12, folate. Restrict simple sugars, limit fluids during meals, protein w/ each meal.

B12 deficiency

lack of intrinsic factor and bacterial overgrowth in loop of intestine being bypassed interfere with B12 absorption. Schilling test diagnoses pernicious anemia.

Folate deficiency

folate needs B12 for transport inside the cell. Also from poor folate intake and low iron (cofactor in folate metabolism).

Gastroparesis

Delayed gastric emptying--surgery, DM, viral infections, obstructions. Mod-sev hyperglycemia may slow gastric emptying and affect gastric nerves. Treat with prokinetic agents (erythromycin, metoclopramide) to increase stomach contractility and shorten gastric emptying time. Small frequent meals, pureed foods, avoid high fiber, fat in liquid form is better tolerated.

Tropical sprue

(bacterial, viral, or parasitic infection)


-chronic GI disease, may cause intestinal lesions


-s/s diarrhea, malnutrition, B12/folate def due to decreased HCL and intrinsic factor


-treatment: abx, high kcal/pro, intramuscular inj B12 and oral folate suppl.

Non-tropical sprue

Celiac disease


Rxn to gliadin found in certain grains. Affects the jejunum & ileum and causes malabsorption, and macrocytic anemia. To eliminate symptoms, gliadin-free (gluten-restricted diet). Corn & rice are permitted.

Constipation

treated with high fluid/fiber, exercise

Diverticulosis

presence of diverticula (small mucosal sacs that protrude through the intestinal wall due to structural weakness). R/t constipation and intra-colonic pressures. Diet is high in fiber

Diverticulitis

when diverticula becomes inflamed as a result of food/residue accumulation. Clear liquid diet...gradually returning to high fiber plan

Fiber

indigestible bulk that promotes intestinal function. Oat bran and soluble fibers decrease cholesterol by binding bile acids, converting more cholesterol into bile.



Ex of soluble fibers

pectins, gums, fruits, veggies, legumes, oats, barley, carrots, apples, citrus fruits, strawberries, bananas. Delay gastric emptying, absorb water, form soft gel in small intestine causing a delay in absorption of glucose & cholesterol.


-38 g M/25 g F recommended

Inflammatory Bowel Disease (IBD)

-Crohn's disease--damage to ileum

-Ulcerative colitis (UC)--damage to colon


-When IBD is in remission, high fiber diet recommended to stimulate peristalsis.



Crohn's disease

inflammatory condition primarily affecting the terminal ileum. There is diarrhea and wt loss. B12 def may develop (may lead to megaloblastic anemia) due to targeting the ileum.


Treatment includes maintaining fluid/electrolyte balance, antidiarrheal agent. For acute flare-ups, bowel rest, parenteral nutr, or minimal residue.

Ulcerative colitis

disease of the colon. Colon's main function is to reabsorb water and electrolytes. Chronic bloody diarrhea and loss of electrolytes (Na, K) are major symptoms. Flare-ups--elemental diet may be needed to minimize fecal volume

Irritable bowel syndrome

chronic abd discomfort, altered intestinal motility, bloating. Goals: adequate nutr intake, avoid large meals, excess caffeine, alcohol, sugars.

Lactose intolerance

due to lactase deficiency. Lactase splits lactose into glucose and galactose (which are easily absorbed into the bloodstream). If lactase is missing, lactose molecule remains intact and exerts hyperosmolar pressure causing water to be drawn into intestines to dilute the load. This causes distention, cramping, and diarrhea. Bacteria ferment undigested lactose--releasing CO2 gas.

What tests are used to identify lactose intolerance? Describe them

-Hydrogen breath test: hydrogen is produced by colonic bacteria on lactose, absorbed into the bloodstream, and exhaled in 60-90 minutes.


-Lactose tolerance test: oral dose of lactose after a fast (~50 g). Blood glucose will rise <25 mg/dl above fasting=intolerant. >25 mg/dl above=tolerant.



What does a lactose intolerant diet look like?

lactose-free, no animal or milk products, no whey, calcium and B2 suppl are recommended, yogurt and small amounts of aged cheese may be tolerated.

Diarrhea in infants and children

Acute diarrhea: requires aggressive and immediate rehydration--replacing fluids and electrolytes lost in the stool.


Chronic nonspecific: not associated w/ significant malabsorption. Look at the ratio between the nutrients provided: volume of ingested fluid. Adjust fat intake and balance w/ limited fluids. Restrict or dilute fruit juices with a high osmolar load--apple or grape.


*Children up to age 6 should be limited to 4 oz. of juice/day

Adult diarrhea

Other than bowel rest, replace fluids and electrolytes lost in the stool. Prebiotics and probiotics may help. When diarrhea stops, begin w/ low fiber foods, followed by protein foods, fat need not be limited.

Steatorrhea

consequence of fat malabsorption.


Fecal fat>7 g


High protein, high complex CHO, fat as tolerated, MCT oil.

Short bowel syndrome (SBS)

Results from significant resections of the small intestine. Severity reflects length/location of resection, age of pt, and health of remaining tract. Major concerns: loss of distal ileum, ileocecal valve, colon.


-Initial care requires parenteral support, enteral feeding should be started early and increase as tolerated.

Where does most digestion take place?

Duodenum and upper jejunum

Jejunal resection

ileum can adapt and take over jejunal functions.


Requires a normal balance of CHO, protein, fat. Avoid lactose, oxalates, large amounts of concentrated sweets, need vit/min suppl.

Ileal resection

pt experiences significant challenges.


-Distal ileum: bile salts, intrinsic factors, and B12 is absorbed. Also absorbs major portion of fluids. Pt requires at least 1 more liter of water than output. Without the ileum=bile salts aren't recycled.


-If ileum cannot recycle bile salts, the liver is not able to produce enough to adequately emulsify lipids. Fats and fat-soluble vitamins are malabsorbed.


-Limit fat, use MCT (doesn't require bile salts), suppl fat-soluble vitamins, need Ca, Mg, Zn, parenteral B12 followed by monthly inj. may be needed.

What are the functions of the liver?

-stores and releases blood


-filters toxic elements


-metabolizes and stores nutrients


-regulates fluid/electrolyte balance

Elevated liver enzyme levels indicate...

liver tissue damage or disease

Hepatitis

Characterized by inflammation and partial necrosis of the liver (death of tissue due to lack of oxygen). Anorexia is a major symptom.


-Provide high fluid intake to guard against dehydration. Nutrition care varies based on symtpoms and physical status


-50-55% CHO to replenish liver glycogen and spare protein


-1-1.2 g/kg of protein for cell regeneration, provides lipotropic agents to convert fat into lipoproteins to move them out of the liver. Helps prevent a fatty liver.


-mod-liberal fat. Small frequent feedings due to anorexia.


-Coffee consumption is encouraged (antioxidant)

Cirrhosis

damaged liver tissue is replaced by bands of connective tissue (not functional) which divides liver into clumps and reroutes many of the veins/capillaries. Blood flow through liver is disrupted, which can lead to ascites (blood can't leave liver) and esophageal varices (blood can't enter liver). Poor food intake levels lead to deficiencies.


-Protein deficiencies lead to ascites, fatty liver, and impaired blood clotting.

Healthy liver

Blood from the esophageal, abdominal, and collateral veins, enters the portal vein. The portal vein takes blood to the liver to be cleansed. Blood is then redistributed back through the body via vena cava.




blood--abd veins+esophageal veins+collateral veins-->portal vein-->liver-->vena cava

When does ascites occur?

When blood cannot leave the liver. Connective tissue overgrowth is the problem because it blocks blood flow out of the liver into the vena cava. Then, the blood backs up inside the liver, liver can only store about 1 liter of excess blood. Once 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 to dilute the load, leading to sodium and water retention.

Esophageal varices

Occurs when the blood cannot enter the liver.


Connective tissue overgrowth causes resistance to blood entering from the portal vein. The increased pressure forces blood back into collateral veins (due to less resistance). As a result, esophageal, abdominal, and collateral veins enlarge and causing portal hypertension. This increased blood pressure forces the blood back upward in the system , increasing the blood pressure in the abdominal and esophageal veins. This results in an outpouching of the vessels wall--known as a varices. They can burst or tear open by a diet high in roughage.

What's the diet look like for Cirrhosis?

-high protein: 0.8-1 g/kg (1.5g/kg-stress)


-high calorie: 25-35 kcal/kg


-mod-low fat: Omega 3s, MCT if needed. Fat is the preferred fuel in cirrhosis. Decrease LCTs if steatorrhea


-low fiber if varices are present


-low sodium if edema or ascites


-B vitamins, C, K, Zn, Mg, may need A and D



Alcoholic Liver Disease

Has 3 stages--hepatic steatosis (fat buildup), alcoholic hepatitis, cirrhosis


-Injury is due to the constant presence of alcohol


-Alcohol is converted into acetaldehyde, releasing large quantities of hydrogen.


-The hydrogen steps into the TCA cycle instead of fat, fat therefore accumulates in the liver (fatty liver) and blood (raises TG).


-Malnutrition occurs, protein deficiency-------malabsorption


-Alcohol causes GI tract inflammation and interferes with the absorption of thiamin, folic acid, b12, vitamin C. Magnesium is excreted after alcohol consumption.


-Long term thiamin deficiency-->Wernicke-Korsakoff syndrome

Hepatic Failure (ESLD)

Defined as 25% or less of normal liver function.


Liver cannot convert (NH3) ammonia to urea. Ammonia levels buildup in the blood--leading to confusion, drowsiness, coma.


If pt is not comatose, mod to high protein increasing as tolerated 1-1.5 g/kg. 30-35 kcal/kg, to prevent muscle catabolism provide extra energy in the form of CHO and fats.


-Standard treatment: lactulose (removes nitrogen); neomycin (abx that destroys bacterial flora that produce ammonia).

What is the altered neurotransmitter theory?

In encephalopathy, the normal ratio between neurotransmitters is altered. The level of the BCAAs is decreased/level of aromatic AA is increased.


-Therapeutic approach: give pt more BCAAs and few aromatic AAs--also a way of providing additional nitrogen to pt (seldom alleviate s/s).

Cholecystitis

inflammation of the gallbladder. Usually results from low grade infection that causes excess water to be absorbed causing cholesterol to precipitate out leading to gallstones--cholelithiasis.


-Treatment: low fat diet


cholecystectomy--surgical removal of the gallbladder--bile will now be secreted from liver directly into intestines.

Pancreatitis

Inflammation of the pancreas characterized by edema, cellular exudate, fat necrosis. May be the result of a blockage or reflux of the ductal system. Premature activation of enzymes within the pancreas leading to autodigestion. Therefore, the pancreatic enzymes digest the pancreas.

Acute Pancreatitis

Withhold all oral feedings and maintain hydration. Progress slowly with foods easy to digest and low in fat.


-Elemental (pre-digested) enteral feedings into the jejunum may be tolerated.

Chronic Pancreatitis

Provide oral pancreatic enzymes WITH meals and snacks to minimize fat malabsorption due to a lack of pancreatic lipase.


-MCTs do NOT require lipase and can be added to mixed dishes, jams, jellies.


-Parenteral b12 and antacids may be needed.


-Provide fat-soluble vitamins in the water soluble form.


-Avoid large meals with a lot of fat and alcohol.

Cystic Fibrosis

Disease of the exocrine glands. Secretion of thick mucus that obstructs glands and ducts--chronic pulmonary disease, pancreatic enzyme deficiency, and malabsorption result.


-Treatment: PERT w/ meals and snacks, high protein, high kcal, unrestricted fat/liberal salt. Age-appropriate doses of water-soluble vitamins and minerals. and fat-soluble in water soluble form esp (A and E)

Hypertension

Systolic reading > 140 mmHg


Diastolic reading >90, or both




-May be primary or secondary (due to another disease). Optimal range <120/80 mmHg


-Thiazide diuretics may be prescribed.


-4 modifiable risk factors: overweight, high salt intake, alcohol consumption, physical inactivity


-<2400 mg Na, DASH diet, Mediterranean diet

Systolic pressure

measures the heart in contraction...greatest pressure

Diastolic pressure

measures the heart during relaxation...least pressure

Thiazide diuretics

Prescribed to reduce fluid retention, induce hypokalemia.

Mediterranean Diet

Rich in linolenic acid (omega 3s), high in monounsaturated fats


-Includes olive oil, fruits, root veggies, nuts, seeds, red wine, leafy greens.

Resveratrol

found in the skin of red grapes may lower blood pressure

Atherosclerosis

Progressive narrowing of arteries. Fat deposits accumulate in the heart, brain, and legs.


Risks: HTN, smoking, obesity, elevated LDLs, family hx

CAD--Coronary Artery Disease

Occurs when the arteries supplying blood to the heart muscle become hard and narrow due to plague buildup.

Ischemia

Local and temporary deficiency of blood caused by an obstruction--thrombosis.

Arteriosclerosis

loss of elasticity of blood vessel walls

myocardial infarction

reduction of coronary blood flow to myocardium due to blood clot blocking a narrowed coronary artery.

Dyslipidemia

high triglycerides and low HDL

Fat is transported in the blood bound to...

proteins (lipoproteins)

Chylomicron

Made in the small intestine from dietary fat.


-carries dietary TG from gut to adipose cells

VLDL

carries endogenous TG from liver to adipose cell

LDL

carries cholesterol from diet and from liver to all cells

HDL

"reverse cholesterol transport"


carries cholesterol from the cells to liver for excretion

IDL

LDL precursor

Metabolic syndrome

3 or more of the following risk factors are linked to insulin resistance (increases risk for coronary events)


-BP >130 systolic, and/or >85 diastolic


-TG >150 mg/dl


-Fasting glucose >100 mg/dl


-waist measurement >40" men; >35" women


-Low HDL <40 mg/dl (men); <50 mg/dl (women)

National Cholesterol Education Program (NCEP)

offers general guidelines for high blood lipid levels

High homocysteine levels (Hcy)

are independent risk factors for CHD

Therapeutic Lifestyle Change (TLC) Diet

Endorsed by AHA


-35% kcal from total fat, <7% SFA, 5-10% PUFA, up to 20% MUFA, <200 mg total cholesterol


-25-30 g fiber (1/2 soluble)


-stanols or sterols inhibit cholesterol absorption (2-3 g/d)


-PA 30 mins of moderate intensity most days--expend at least 200 kcals

Heart Failure

-Weakened heart fails to maintain an adequate output of blood. Resulting in diminished flow of blood to the tissues. Fluid is held in the tissues (edema) rather than be returned to the circulation.


-Reduced blood flow to the kidneys causes them to think something is wrong. So hormones are secreted to retain sodium and fluid leading to weight gain.

Heart Failure treatment options

-Digitalis increases the strength of heart contractions.


-Diuretics: nutrient loss, glucose intolerance, increased uric acid


-Diet: 2-3 g Na, Dash diet, may need fluid restriction, 1.2 g/kg protein.


*Evaluate thiamin status if pt on loop diuretics.


Without thiamin, pyruvate cannot be converted into acetyl CoA for energy.

Nephron

functional unit of the renal system.


all blood passes through nephrons to be cleansed/filtered. Includes the glomerulus.

glomerulus

tuft of capillaries held closely together by Bowman's capsule, produces ultrafiltrate, which then passes through tubules. The capsule blocks passage of RBCs and large molecules like protein.

proximal convoluted tubule

site of major nutrient reabsorption

Loop of Henle

water and sodium balance

distal tubule

acid-base balance

Renal functions

As blood passes through the glomerulus, RBCs and protein remain in the blood and are returned to general circulation. All else is filtered through the tubules. Absorbs 100% glucose, AA; 85% water, sodium, and potassium.


Excretes wastes, urea, excess ketones. Secretes hormones that control blood pressure, blood components; secretes ions that maintain acid-base balance.

Renal artery

blood comes to the kidneys from abdominal aorta and inferior vena cava, oxygenated blood is carried via renal artery for the kidney to clean.


Renal vein

filtered blood leaves the kidneys through the renal vein to the inferior vena cava, then back to the heart.

Vasopressin/antidiuretic hormone (ADH)

Made in the hypothalamus and stored/released from the pituitary gland. 2 primary functions are to retain water in the body and to constrict blood vessels--elevating blood pressure.

SIADH-


syndrome of inappropriate antidiuretic hormone

Hyponatremia caused by hemodilution--treated with fluid restriction.

Renin

Formed within the kidneys and released by the glomerulus when blood volume decreases. Stimulates aldosterone to increase sodium absorption and increase blood pressure to normal.

Erythropoietin (EPO)

produced by the kidneys. Stimulates bone marrow to produce red blood cells.

Renal disease decreases...

Decreases glomerular filtrate rate (GFR) & creatinine clearance (urine tests)




Increases BUN & serum creatinine (blood tests)

What does a BUN: creatinine ratio of >20:1 mean?

BUN reabsorption is increased due to acute kidney damage. May be reversible and no dialysis.

What does a BUN: creatinine ratio of <10:1?

Suggests reduced BUN reabsorption due to renal damage (may need dialysis).

Renal solute load

measures solutes excreted in 1 L urine. Mainly measuring 60% nitrogen and sodium

What are some manifestations of renal disease?

-Anemia (reduced production of EPO)


-Upset in blood pressure


-Decreased activation of vitamin D (kidneys produce active form which promotes efficient absorption of calcium by the gut).

What are renal calculi?

Kidney stones...most common is calcium oxalate stone. Minerals are not oxidized in metabolism. Form a residue and excreted in urine as "ash." Can change the composition of diet to change the pH of ash in the urine.


Treatment: 1.5-2L fluid to dilute urine

Calcium oxalate stones

Treatment: adequate calcium intake to bind oxalate and low oxalate diet (chocolate, leafy greens, nuts, beets, tea)

To prevent acidic renal stones:

Increase cations (Ca, Na, K, Mg) by creating an alkaline ash.


Add fruits and veggies

To prevent alkaline stones:

Increase anions (Cl, Ph, Su) by creating an acidic ash. Add meat, fish, eggs, cheese.

Acute Kidney Injury

Sudden shutdown of kidney function usually due to trauma (burns, severe dehydration, obstruction). Decreased GFR, s/s=oliguria (urine output of <500 ml) and azotemia (increase of urea in the blood).

AKI treatment

-begin w/ protein restriction to delay dialysis, and advance as renal function improves.


-adequate kcal to spare protein

Nephrosis/nephrotic syndrome

Caused by a defect in capillary basement membrane of glomerulus which permits the escape of large amounts of protein in the filtrate moving through the tubules.


-s/s=albuminuria, edema, malnutrition, hyperlipidemia


-0.8-1 g/kg protein (50% BV), fat intake is restricted <30%


-abnormalities in iron, copper, zinc, calcium r/t protein loss.

Chronic Kidney Disease (CKD) 1-4

Anemia may result from a lack of EPO. Provide adequate kcal, restrict Na as needed, and protein is restricted as GFR falls. Fluid is generally unrestricted.

Protein requirements for CKD stages

Stage 1: GFR >90-------0.8-1.4 g/kg protein


Stage 2: GFR 60-89----0.8-1.4 g/kg protein


Stage 3: GFR 30-59----0.6-0.8 g/kg protein


Stage 4: GFR 15-29----0.6-0.8 g/kg protein




Stage 1/2=0.8-1.4 g/kg


Stage 3/4=0.6-0.8 g/kg

Phosphorus requirements for CKD stages

Stage 1/2=maintain normal phos. levels


Stage 3/4= 800-100 mg/day or 10-12 mg/g protein

Potassium requirements for CKD stages

Generally not recommended to restrict unless serum level is elevated and urine output <1L/d

ESRD-End stage renal disease

Few functioning nephrons remain. Nitrogen is retained, requiring a very low protein intake (mostly HBV), increase kcals and control edema.

Hemodialysis

1.2 g/kg SBW protein or adjusted BW(50% HBV)


<60 y/o=35 kcal/kg


≥60 y/o or obese pt=30-35 kcal/kg

Peritoneal dialysis

1.2-1.3 g/kg SBW protein or adjusted BW (≥50% HBV)


<60 y/o=35 kcal/kg (including dialysate)


≥60 y/o or obese pt=30-35 kcal/kg


May need extra thiamin due to losses

Endocrine vs exocrine glands

-Endocrine gland (ductless glands) is one that secretes its hormones directly into the bloodstream from where it is transported to the target cells, tissues or organs to bring about its effects. Ex: thyroid, pituitary.


-Exocrine gland is one that secretes its hormones into a system of ducts that lead to the external environment. As a result, exocrine glands are commonly known as duct glands. Ex: sweat, salivary glands.

Type 1 DM

insulin deficient. Pt's depend on exogenous insulin.

Type 2 DM

insulin resistant with a relative insulin deficiency (pt may require insulin).

Normal blood glucose

70-100 mg/dl


<140 mg/dl (2hr post-prandial)

Diabetes glucose levels

FPG (fasting plasma glucose) ≥ 126 or


GTT (glucose tolerance test) ≥ 200 or


s/s of diabetes + casual plasma glucose ≥ 200


HgA1c ≥ 6.5%

glycosylated hemoglobin (HbA1c)

Measures the % hemoglobin carrying glucose.


This tests tells you the pt's glucose control over the past 2-3 months.


DM goal: <7%


non DM goal: <5.7%

Therapeutic goals for all DM patients

-Maintain normal blood glucose:


| pre-prandial: 70-130| post-prandial: <180


-Optimal serum lipid levels:


| LDL <100 |TG <150 | HDL>40M, >50F


-Blood pressure goals:


-systolic <130 | diastolic <80


-Prevent and treat chronic complications

Strategies for T1DM

-Monitor blood glucose and adjust insulin doses for the amount of food eaten


-With fixed daily doses of insulin, CHO consistency is key


-For planned exercise, reduction in insulin dosage may be the best choice

Strategies for T2DM

-Encourage healthy eating and physical activity


-Achieve glucose, lipid, and blood pressure goals


-Wt loss if necessary

Gestational diabetes

Risk factors: BMI>30, hx of GDM


Tested at 24-28 weeks of gestation, with 50g oral glucose load, ≥140 requires further testing


**GDM increases the risk of fetal macrosomia (LGA) & fetal hypoglycemia at birth.

glycemic index

compares blood glucose response of a food with a standard glucose load.


-affected by cooking methods, starch processing, as particle size decreases, index increases.


-foods w/ low index produce greater satiety


-low index: legumes, milk, nuts, pasta, ice cream, yogurt

glycemic load

weighted average of the glycemic indexes of all foods eaten

CHO (Exchange list)

CHO|Pro|Fat|Kcal


-starch/bread: 15 | 3 | 1 | 80


-fruit: 15 | 0 | 0 | 60


-Fat-free, low fat milk (1%): 12 | 8 | 0-3 | 100


-Reduced fat milk (2%): 12 | 8 | 5 | 120


-Whole milk: 12 | 8 | 8 | 160


-Sweets, desserts: 15 | varies | varies | varies


-non-starchy veggies: 5 | 2 | 0 | 25

Proteins (Exchange list)

CHO|Pro|Fat|Kcal


-Lean: 0 | 7 | 2 | 45


-Med. fat: 0 | 7 | 5 | 75


-High fat: 0 | 7 | 8 | 100


-Plant proteins: varies | 7 | varies | varies

Fats (Exchange list)

CHO|Pro|Fat|Kcal


0 | 0 | 5 | 45

Alcohol (Exchange list)

1 equivalent=


CHO |Pro|Fat|Kcal


varies|--- | ---- | 100

Rapid-acting insulin

-Aspart (Novolog) | Lispro (Humalog)


-Take 5-15 minutes before eating


-Duration 4 hours






*Insulin used to cover the meal

Short-acting (Regular) insulin

-Take 30-45 min before meal


-One unit covers 10-15 g CHO


-Lasts for 3-6 hours




*Insulin used to cover the meal

Intermediate-acting (NPH) insulin

(Humulin, Novolin)


-Onset 2-4 hours


-Duration 10-16 hours


*requires a bed time snack with CHO/pro

Long-acting insulin

Glargine (Lantus) | Determir (Levemir)


-Onset 2-4 hours


-Duration 20-24 hours




*Basal insulin. Covers in between meals

Insulin secretagogues

-Includes sulfonylureas, meglitinides (Glucotrol)


**promotes insulin secretion

Biguanides

-Metformin (Glucophage)


**enhances insulin action, while suppressing hepatic glucose production.

Thiazolidinediones

**improves peripheral insulin sensitivity

alpha glucosidase inhibitors

**inhibit enzymes that digest CHO, which delays absorption

glucagon-like peptide 1 (GLP-1) agonist

(Byetta)


**enhances insulin secretion, suppresses postprandial glucagon

amylin agonist

**decreases glucagon production

Dawn phenomenon

natural increase in early morning glucose and insulin requirements due to increased hepatic glucose production after overnight fasting.




*increased need for insulin at dawn

acute ketoacidosis

hyperglycemia due to insulin deficiency or excess CHO intake. Pt shows s/s of dehydration due to polyuria, increased pulse.


Treatment: insulin and rehydration

acute hypoglycemia

Can be caused by too much insulin or lack of eating. s/s=slow pulse, hungry, clammy


Treatment: 15 g CHO via glucose tabs, fruit juice,


wait 15 minutes, if BG <70, give pt another 15 g. Repeat until BG is WNL

long term consequences of uncontrolled DM

-neuropathy: peripheral and autonomic (gastroparesis)


-retinopathy: leads to blindness


-nephropathy: leads to decreased kidney function

Addison's disease

due to a deficiency of adrenal hormones.


s/s= hypoglycemia, sodium loss, tissue wasting.


therapy is hormone replacement.


diet: high protein, high CHO, frequent feedings, liberalized salt.

hyperthyroidism

-Excess secretion of thyroid hormone.


-Elevated T3 and T4


-Causes an increased BMR, leading to weight loss


-diet: increase kcals

hypothyroidism

-thyroid hormone deficiency


-T4 is low | T3 is low or WNL


-Leads to a decrease in BMR and leads to
weight gain


-diet: wt reduction

Goiter

the thyroid gland becomes enlarged due to insufficient thyroid hormone


diet: iodized salt, free of goitrogens--cabbage family (brussel sprouts)

Endemic goiter

due to inadequate iodine intake

Gout

due to an abnormal metabolism of purines.


Results in an increase in uric acid, which is then deposited in the joints causing pain and swelling.


-diet: low in purines may not be helpful since the body makes purines.

galactosemia

inborn error of metabolism due to a missing enzyme that would have converted galactose to glucose.


-diet: galactose and lactose free.


-NO: organ meats, dates, bell peppers, milk products. Soy, lactate is okay

urea cycle defects

ammonia does not convert to urea, instead it builds up in the blood.


-diet: protein restriction based on tolerance to lower the amount of ammonia.

phenylketonuria--PKU

-missing enzyme is phenylalanine hydroxlase- which would convert phenylalanine into tyrosine. Instead, phenylalanine accumulates leading to poor intellectual function.


-diet: low phenylalanine diet, supplement tyrosine, avoid aspartame, need for phenylalanine decrease with age and in infection.


**low protein, high CHO may lead to increased dental caries.

glycogen storage disease

caused by deficiency of glucose-6-phosphatase in liver.


-Impairs gluconeogenesis and glycogenolysis.


-liver can't convert glycogen into glucose, which leads to hypoglycemia.


-high CHO, low fat diet

homocystinurias

treatable inherited disorder of AA metabolism.


Characterized by severe elevations of methionine and homocysteine in plasma and excessive secretion of homocystine in urine.


-Associated with low levels of folate, B6, B12.


-Treatment: large doses of folate, B6, B12

Maple syrup urine disease (MSUD)

Inborn error of metabolism of the BCAAs--leucine, isoleucine, and valine. Pt may have poor sucking reflex, FTT.


-Treatment: restrict BCAAs, provide adequate CHO and fat to spare AA. Avoid meat, nuts, eggs, and dairy.

Arthritis

inflammation of the peripheral joints. Regular, well balanced diet. Some patients may develop normocytic anemia (not diet related, inflammatory process prevents reuse of iron)

Systemic lupus erythematosus

affect nutr metabolism, needs, and excretion. no specific dietary guidelines exist. some may have anemia due to inflammation. some may show signs of celiac disease.

Osteoclasts

resorb and remove bone

Osteoblasts

reform or build bone

Osteoporosis

loss of bone density is so acute, skeleton is unable to sustain ordinary stress. Caused by protein malnutrition, lack of exercise, and estrogen decline.


Treatment: HRT, wt bearing exercises, vitamin D+Ca suppl., adequate protein.


*most @ risk is elderly, frail, white females

Osteomalacia

adult Rickets. Caused by a vitamin D deficiency. Treated w/ vitamin D and Ca suppl

Epilepsy

seizure disorder. Treated with anticonvulsants Phenytoin (Dilantin). Take drug separate from meals and suppl. Hold enteral feedings ≥ 2 hrs.


Phenytoin interferes w/ calcium absorption, so vitamin D suppl is necessary

Ketogenic diet

Used to treat epilepsy. High fat, very low CHO


4 g fat: 1 g non fat


-Need supplements: Ca, D, B6, B12, Folate

Cerebral palsy

from brain damage, results in inadequate control over the voluntary muscles.


(1) spastic form: limited activity-->obesity


(2)athetoid form: constant wormlike motions of the limbs leading to weight loss, requires the use of finger foods (that can be eaten w/o utensils)

Paralysis

Stroke due to brain embolism. Pt may be undernourished or overweight. Due to the pt's immobilization, decreases Ca absorption and increases urinary nitrogen loss.

Decubitus ulcers

often have low albumin and calcium levels. High protein, high kcals, normal Ca, and adequate fluids. Supplemental vitamin C and zinc may be recommended.

Hyperactivity-ADHD

Feingold diet: no salicylates, artificial colors/preservatives. Efficacy not proven. May be due to placebo effect.




*Sugar does not cause hyperactivity

Alzheimer's disease

avoid distractions during meals, encourage self-feeding, offer one course at a time.

Anemia

Caused by a decrease in total red cell mass due to fewer amount of RBCs or smaller RBCs (less hemoglobin).

Microcytic, hypochromic anemia

small, pale cells, due to iron deficiency.


All labs values are low except RBC (may be normal). Low MCV (small size) and low MCH (pale color)

Macrocytic, megaloblastic anemia

FEW large cells, filled with hemoglobin, due to a deficiency in folate or B12 (schilling test for pernicious anemia).


Lab values: decreased RBC, high MCV (large cells) and high MCH (dark red color)

MCV--mean corpuscular volume

average RBC size.


80-95 fL=normal

MCH--mean corpuscular hemoglobin

amount of hemoglobin available per cell


27-32 pg=normal

Ag-Ab reaction

when antigen enters body, antibody reacts. This is a response to foreign substances (dust, flowers)

Immunoglobumin E (IgE)

mediated reaction to normally harmless food protein.


most common: peanuts, eggs, milk, soy, wheat, shellfish.


**cow milk=most common for infants


**rice=least likely to cause an allergy

Fever or infection

excessive fluid loss may lead to dehydration. BMR increases 7% for each degree rise in temp above 98.6 F

Burns

immediate shock period=catabolism


BMR rises 50-100%


1st step is to replace fluids/electrolytes lost, then increase kcal and protein.

Ebb and flow response to injury

hypermetabolic process. Catabolic response following trauma (accelerated catabolism of lean body mass leading to negative nitrogen balance as protein is catabolized to release glucose for energy. Results of trauma: hyperglycemia, hyperinsulinemia, increased glucagon. Provide adequate kcal and 1.5-2 g/kg protein.

Ebb phase

Occurs immediately following an injury. hypovolemia, shock, tissue hypoxia

Flow phase

occurs following fluid resuscitation and the return of oxygen transport

Radiation

affects the function of the GI tract, xerostomia (dry mouth), mucositis

Chemotherapy

affects the function of the GI tract, N/V, anorexia, stomatitis (cracks in corner of mouth-B2 def)

Marasmus

-protein and calorie starvation.


-anthropometrics are used to make a diagnosis.--albumin levels= normal, no edema


-starved appearance, severe fat/muscle wasting

Iatrogenic malnutrition

protein-calorie malnutrition


Caused as a result from hospital, medications, treatment

Kwashiorkor

pitting edema common in hands and legs, skin lesions/dermatitis

Anorexia nervosa

-distorted body image, dramatic wt loss.


-immediate concern: correct electrolyte imbalance--potassium


-plan w/ pt regular mealtimes, varied and moderate intake, gradually reintroduce feared foods


-focus on the reason to eat "survival"


-re-feeding increases cardiac load--go slow

Bulimia

gorging and vomiting syndrome. typically close to a normal wt. damage to teeth, throat, rectal bleeding due to laxative abuse.


-low potassium and chloride blood levels

Obesity

begins at a BMI of 30. Class III ≥ 40


-3500 kcals/lb body fat. Reduce kcals by 500/d to lose 1 lb. fat per week.


-Early rapid wt loss is due to water, as liver glycogen is utilized and H2O is released.


-when diet reaches plateau, BMR drops to reflect loss


**healthy obese=elevated LDL/normal or low HDL

Bariatric surgery

Can be an option for BMI ≥ 40 or
BMI ≥ 35+co-morbidities

gastric bypass & gastroplasty

purpose is to reduce the amount of food that can be eaten at one time and produce early satiety.

Roux-en-y gastric bypass

-creates a small gastric pouch and connects directly to the jejunum. The intestines resemble the letter Y.


-dumping syndrome may develop and anemia


-Supplement: B12, folate, potassium, magnesium

gastroplasty

uses staples to create a small gastric pouch, leaving only a small opening to the distal stomach.


liquids--pureed--soft--regular small meals/snacks

gastric banding

band creating the reduced stomach pouch can be adjusted, so the opening to the rest of the stomach can be enlarged or reduced. this procedure is fully reversible.


no suppl of b12, folate, or iron

Prader Willi Syndrom

congenital disorder resulting in obesity, hypogonadism, short stature, and FTT. pt's have decreased energy requirements, but do NOT sense satiety. best treatment is to control food intake

dental caries

caused by acids that demineralize the tooth.


when pH in mouth drops below 5.5, there is enough acid to damage the enamel.


-low cariogenic foods: minimal concentration of fermentable CHO, foods w/ pH>6. sorbitol does not promote tooth decay. fluoride can help control cavities. suppl starting 6 months if water supply inadequate.

stomatitis

inflammation of the mouth due to a b2-riboflavin deficiency

esophagitis

treat by decreasing gastric acid reflux


-small, low fat, bland, low fiber diet

achalasia

disorder of lower esophageal sphincter. does not relax and opens upon swallowing.


-causes dysphagia


pureed moist thick foods, progress to thick liquids

GERD-gastro-esophageal reflux disease

avoid eating before bed, soda, caffeine, acidic foods


small, low fat meals, liquids empty more rapidly

pre-eclampsia

mother develops high blood pressure and protein in the urine around 20 weeks gestation. can progress to eclampsia (convulsions/seizures)


*sodium restriction is NOT recommended. sodium is needed during pregnancy.

AIDS--acquired immune deficiency syndrome

virus debilitates immune system by attacking lymphocytes. s/s=diarrhea, wt loss


-neutropenic diet (low bacteria, avoid raw foods)


-Pediatric HIV=high kcal, high protein, supplementation

COPD--chronic obstructive pulmonary disease

chronic obstruction of airflow through lungs.


(1) emphysema: alveoli (air sacs) lose elasticity, diff exhaling.


(2) bronchitis: excess mucus production and chronic cough.


s/s=wt loss, emaciation, anorexia


-goal is to maintain stable wt and do not overfeed



ARDS--acute respiratory distress syndrome

respiratory failure may follow advanced COPD.

lungs are no longer able to exchange gases, increase energy needs, severely underwt.


-goal maintain stable wt and preserve LBM

Enteral nutrition formulas

(1) standard polymeric--normal GI func. Lecithin may be added as an emulsifier.


-modular: mix individual nutrients, adds flexibility


-blenderized: whole foods, large bore tube, high residue


(2) elemental: used for pt's w/ malabsorption. pre-digested formula. low to no residue, don't need pancreatic enzymes (Peptamen)


(3) specialized: Nepro, Glucerna. more specialized formula=greater cost

nasogastric tube

for pt's w/ normal GI function, requiring short term 3-4 weeks. bolus, continuous drip, or intermittent drip are options




**pt's unable to tolerate gastric feedings, nasoduodenal or nasojejunal tube

transpyloric feeding

passed by the pyloric valve in stomach. used for comatose pts or w/ no gag reflex

gastrostomy or jejunostomy feedings

used for longer than 3-4 weeks.


Ex: PEG--inserts tube into stomach through abdominal wall. x-ray confirms location

gastric residuals

check gastric residual volume every 4 hours for the 1st 24 hrs. Then every 6-8 (unless critically ill)


-GRV >250 after the 2nd check, consider promotility agent


-GRV > 500 ml=hold TF

EN example calculation

Patient needs 2000 kcals/d, 1500 ml fluid restriction, formula selected 1.5 kcal/ml, 55 g/L protein, 77% H2O.


2000 kcal/1.5 kcal/ml=1333 ml/24 hr= 56 ml/hr


55 g/L pro *1.33 L=73 g protein


1333 ml*.77=1026 ml free H20


1500ml-1026 ml=474 ml for H2O flushes

PPN-peripheral parenteral nutrition

indicated for small surface veins. short term use. minimum effect on nutr status.


-to figure calories=


(ml formula provides)(% dextrose)(3.4 kcal/g)


*10% highest dextrose concentration for PPN


-protein: 3-15% AA


-IVFE--intravenous fat emulsion


-10%=1.1 kcal/ml


-20%=2.0 kcal/ml

Parenteral nutrition

used to achieve an anabolic state when pt's are unable to eat by mouth and enteral feeding is not possible.


-PICC (short term) or CVC (longer term)


-dextrose infusion should not exceed
4-5 mg/kg/min to prevent hyperglycemia


**main concern: translocation of bacteria.


when the gut is not used, the gut wall breaks down, bacteria leaves the GI tract and travels through the blood steam causing sepsis.

Transitioning off PN

introduce full strength EN @ low rate 30-40 ml/hr to establish GI tolerance.


d/c PN, when pt can tolerate 75% EN

re-feeding syndrome

aggressive administration on nutrition to malnourished pt, unfed 7-10 days, chronic alcoholism.


**starved cells take up nutrients. potassium and phosphorus shift into intracellular compartments. results in hypokalemia, hypophosphatemia, and hypomagnesemia



DRI--Dietary Reference Intakes

umbrella of nutrient guidelines

RDA--Recommended Dietary Allowances

goals for healthy individuals to prevent nutr deficiencies--gender, age, life phases

EAR--Estimated Average Requirement

for 50% population, assesses group nutritional adequacy

AI--Adequate Intake

used when insufficient evidence available for EAR, RDA

UL--Tolerable Upper Level

not associated with adverse side effects in most individuals of a healthy population

Healthy Eating Index

USDA's overall measure of diet quality. Measures how well Americans follow the Dietary Guidelines. 5 food groups, 4 nutrients (fat, sat fat, cholesterol, sodium)

third party reimbursement

payment by a 3rd party for service rendered by a health care provider to a pt.


--Blue Cross, Medicare

TEFRA--Tax Equity & Fiscal Responsibility Act

established the Prospective Payment System

Prospective Payment System

includes Medicare and Medicaid pts.


-pt's are classified by their diagnosis, age, sex, and complicating conditions.


-hospitals are paid a specific amount/per pt based on diagnosis, regardless of the types of services rendered.


-LOS is not considered when determining payment

Transtheoretical Stages of Change

behavior change involves a series of stages.


(1)pre-contemplation: not even thinking about change


(2)contemplation: thinking about making a change


(3)preparation: decides to make a change and plans to do so.


(4)action: tries to make the change.


(5) maintenance: sustains change for ≥6 months


**tailor intervention to stage of change

Health Belief Model

developed to explain why people (esp. high risk), fail to participate in programs designed to detect or prevent disease. person must perceive severity and their susceptibility of the treat, for it to be a behavior-motivating factor.

diffusion of innovation

innovation, idea, or behavior spreads throughout the community.

program intervention

primary prevention: early screening


secondary prevention: setting up an employee gym


tertiary intervention: as disease progresses, intervention to reduce severity

Steps in program planning (know in order)

(1) develop mission statement: which describes the philosophy of the program. needs/problem statement describes the current situation, who says it is a problem, and what will happen if nothing is done.


(2) set goals: statements of broad direction and general purpose. determine which health problems have nutr. implications (current high risk groups and most critical needs).


(3) Measurable objectives: more defined and specific. specific target dates for completed projects. SMART objectives-specific, measurable, achievable, relevant, time frame.

Budget

controls and coordinates activities. how and at what rate money will be expended. consider: expenditures or preceding period, present budget, expenditures of current period, budget requests for next period

What are the phases of a budget cycle?

prepare requests, evaluate revenue potential, formulate document, send to legislative body, legislative review/authorization, execute budget, evaluate/review.