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126 Cards in this Set

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Define Anorexia and give some common characteristics of the disease.
i) Anorexia nervosa: refusal to maintain body weight at or above minimally normal weight for age and height
(1) Body weight less than 85% of expected
(2) Intense fear of gaining weight or becoming fat
(3) Disturbed perception of body shape or weight
(4) Amenorrhea—no period
(5) Restrictive: no binge eating or purging—70%
(6) Binge/purge type: 30%
Define Bulimia and give some common characteristics of the disease.
ii) Bulimia nervosa: recurrent episodes of binge eating, characterized by
(1) eating in a discrete period of time an amount of food definitely larger than others would
(2) sense of lack of control over eating
(3) recurrent inappropriate compensatory behavior to prevent weight gain (self induced vomiting, misuse of laxatives, diuretics, enemas, fasting, excessive exercise)
(4) inappropriate eating and compensation occurs on average of 2x/week for 3 months
(5) purging: regular engagement in self induced vomiting or misuse of laxatives, diuretics or enemas
(6) nonpurging: use of inappropriate compensatory behavior such as fasting or excessive exercise only
What is binge eating disorder/compulsive eating?
(1) Recurrent episodes of binge eating, characterized by eating in a discrete period of time amounts of food definitely larger than most others would
(2) The binge episodes are associated with 3 or more of the following
(a) Eating very rapidly, eating until feeling uncomfortable, eating large amounts when not hungry, eating alone, feeling disgusted/angry/guilty about intake
(3) Marked distress occurs about the binge eating
(4) Binge eating occurs, on average at least 2x/week for 6 months
(5) Binge eating is not associated with regular inappropriate compensatory behaviors, such as purging or fasting
(6) Often starts with a successful yet extreme diet
What individuals are most likely to struggle with eating disorders?
i) “Appearance sports” athletes: gymnasts, figure skaters, body builders, wrestlers, ballerinas, distance runners, divers
ii) 11% of Type 1 diabetics
iii) Vegetarians
iv) Overachievers/perfectionists
What's the incidence of eating disorders?
ii) 90% of females—male #s are increasing
iii) Anorexia nervosa: .28% or about 1%--preadolescence/adolescence
iv) Bulimia: 1-3%--adolescent and college age, as many as 1 in 5 female collegians
v) Binge: 4% of adults, 5-8% of obese; 2:3 ratio of male to female, varied ages
vi) Overall total estimates of sufferers
(1) 5-10 million females, 1 million males
What is meant by EDNOS and what are health implications?
i) EDNOS: often involves fear of eating in public places
(1) Frequent dieting, obsessive desire for weight loss, distorted body image can still adversely affect health
ii) The earlier disordered eating patterns are identified and dealt with, the greater the likelihood of a positive outcome
iii) It’s estimated that 50% of cases go unrecognized
What is the SCOFF questionnaire?
i) Do you make yourself Sick because you feel uncomfortably full?
ii) Do you worry that you have lost Control over how much you eat?
iii) Have you recently lost more than “One stone” (14 pounds) in a 3 month period?
iv) Do you believe yourself to be Fat when others say you are thin?
v) Would you say that Food dominates your life?
(1) Developed by 3 English psychiatrists
(2) Questions designed to raise suspicion that an eating disorder might exist prior to rigorous clinical assessment
What are common triggers initiating an eating disorder?
i) Intentional, possibly even necessary, dieting (most common)
ii) Dieting shifts from reliance on physiological hunger to cognitive e control over food behaviors
What are signs/symptoms that can be seen in the early stages of an eating disorder?
i) Fine lanugo-type hair on sides of the face, under nose and on arms
ii) Brittle nails
iii) Thinning hair
iv) Cold sensitivity
v) Lightheadedness
vi) Abdominal pain or distention
What are suggestions to help those that you know have disordered eating?
i) Building trust with them
ii) Be ready to provide a solution for every excuse
iii) Be consistent, trustworthy in following up with the solutions you suggest
iv) Tell the person you are concerned about him/her—use “I” statements
v) DO NOT discuss weight, kcals, or eating habits—discuss feelings
vi) DO NOT say “You look terribly thin”
vii) Avoid giving simple solutions
viii) DO NOT compliment weight gain
ix) Encourage the person to talk to a parent, friend, teacher, school nurse, counselor
What is the importance of early identification of disordered eating to enact positive treatment outcome?
i) The key to success it to catch and treat the disordered eating early (within 6 months)—the earlier dysfunctional eating patterns are treated, the greater the success rate
What are 6 reasons why people eat?
ii) Availability, emotions
iii) Religious
iv) Entertainment, enjoyment
v) Status, peer pressure, norms
vi) Tradition, culture
What are cultural food traits?
i) Both conscious and unconsciously known to the individual
What are characteristics of Southern Blacks food traits?
(1) Dried peas/beans
(2) Yams, greens, corn
(3) Fish, pork
(4) Cornbread, biscuits, white bread
(5) Heavy seasonings (smoked, BBQ, pickled, salt pork)
(6) Limited milk
(7) Commonly fry in lard
(8) Long cooking times for veggies
(9) Overall—excessive intake of starch, sodium, fat and limited calcium
What are charactristics of Jewish food traits?
(1) Only meat from the forequarter of cloven hoofed quad-rupeds that chew cud=cattle, sheep, goat, deer
(2) Only fish with scales of fins (no shellfish)
(3) Animals killed using rigid rules to decreased pain, drain blood=soak in water ½ hour, add course salt, drain, re rinse (or else meat is quickly seared)
(4) Meat and dairy aren’t allowed in the same meal
(5) Separate utensils may be used to cook and serve meat and milk
(6) Neutral foods=fruits, uncooked veggies, grains, tea, coffee
What is the Jewish level of observance?
(a) Orthodox=strict
(b) Conservative=nominal observance
(c) Reform=minimal observance
What advice should you use when counseling someone with cultural food habits different than your own?
i) Admit what you do not know
ii) Educate yourself ahead of time
iii) Involve the family in the consulting session
iv) Avoid being judgemental
v) Ask open ended questions to gain more info
What is the difference b/n alkaline and acid ash diets?
i) Alkaline
(1) Milk and milk products
(2) All other veggies
(3) All other fruits
(4) All increase urine pH
ii) Acid ash
(1) Meats, poultry, fish, eggs
(2) Cheese
(3) Grains
(4) Corn and lentils
(5) Cranberries
(6) Prunes and plums
(7) All decrease urine pH
What is the importance of fluid in decreasing stone formation?
i) Fluid will inhibit uric acid calculi (kidney stones) and cystic (gallbladder) stones
ii) Alkaline ash diet may be recommended
iii) Increased fluid intake (3-4 liters/day) also highly recommended
What is cranberry juice used for?
i) A phytochemical in cranberry juice inhibits the growth of bacteria in the ureter
ii) Drinking cranberry juice may be used in conjunction with antibacterial drugs
Where are purines found?
What would be the effect of reduction of purines in the diet?
ii) If reduction of purines in diet, possibility of gout (increased levels of uric acid in blood)
Describe the clear liquid diet.
(1) Aka the “jello” diet
(2) No milk products
(3) Includes: jello, soda, some juices (apple, grape, cranberry and possibly OJ without pulp), reg and decaf coffe and tea, popsicles, hard candy, sherbet, broth/bouillon
(4) Very short term use pre & post operation
Describe the full liquid diet.
(1) A milk based diet
(2) Includes: all clear liquid foods plus milk and milk shakes, cream soups, farina, eggnog, custard, pudding, ice cream
(3) For short term use: especially inadequate in iron, fiber and possibly kcals
Describe the soft diet.
(1) Many types/variations
(2) Soft: well cooked foods simply prepared; generally no frying and veggies are cooked
(3) Other soft diets may be mechanical soft, edentulous (jaw surgeries), or pureed
Describe the general, normal, house, regular, or standard diet.
(1) Used when no modifications are necessary
(2) Typically all house diets are also “heart healthy”
What are diet histories?
(1) The portions of the medical and social history related to diet (occupation, activity, sleep patterns, cultural background, dentition, chronic disease, use of meds, etc.)
What is a 24 hour diet recall?
(1) Intake of the past 24 hours
What is a food frequency questionnaire?
(1) Number of times in a day/week/month certain foods are consumed
What is a food diary?
(1) Written records of actual intake (3days=more reliable indicator of typical intake and 7 days is even better)
What is meant by iatrogenic malnutrition?
i) Malnutrition that is health care induced
What is the importance of height and weight measurements in even minimal screening protocols?
i) a common reason for not catching malnutrition is failure to record height and weight
What is meant by NPO?
i) NPO=nil per os
ii) Nothing by mouth—no foods, beverages, meds given orally
iii) Uses: pre/post testing or surgery
iv) High risk for promoting malnutrition—use only when absolutely necessary!
What is the function of hormone insulin?
i) Secretion from the beta cells of the pancreas=allows skeletal muscle and adipose cells to utilize glucose for energy
ii) Stimulate hepatic gluconeogenesis
iii) Enhances amino acid deposition in muscle—protein synthesis
iv) Promotes lipgenesis
What is the difference b/n type 1 and type 3 diabetes?
i) Type 1
(1) About 5-10% of all diabetics
(2) Typically the young, lean client
(3) Autoimmune disease, resulting in beta cell destruction
(4) Diet and insulin controlled
(5) Symptoms: polyuria (pee a lot), polydipsia (always thirsty), polyphagia (always hungry)
ii) Type 2
(1) About 90-95% of all diabetics
(2) Typically the older, heavy client, especially upper body obesity but due to huge increases in childhood obesity kids can also get type 2
(3) Impaired beta cell function—decreased insulin production/insulin sensitivity
(4) Diet controlled, pills, possibly insulin
What are diagnostic criteria used to identify diabetes?
i) Random (casual) blood sugar reading
ii) FBS (Fasting Blood Sugar)—8 hours or more fast
iii) Oral glucose tolerance test (OGTT)
What is a 1C lab test?
i) Measures glucose molecules attached to hemoglobin
ii) A good measure of control over time (2-3 months)
iii) Normal (non-diabetic) A 1c=4-6%
iv) Try to keep diabetics under at least 7%
What was learned from the results of the diabetics complications and control trial?
i) Found that tight blood glucose control dramatically decreased the risk of complications
ii) Use glucometers frequently to realize tighter control
iii) Use A1C tests
iv) Use multiple injections/day to facilitate tighter blood glucose control
v) Found the Type 1 clients who continued intensive therapy showed persistent decreases in risk of retinopathy and nephropathy
Is it advisable for diabetics to excercise?
i) Exercise decreases insulin requirements and improves glucose tolerance in well controlled Type 1 clients
ii) For Type 2 clients, exercise improves glucose sensitivity—helps control weight
iii) Need about 10-15 g/hour moderate exercise
iv) Need frequent blood sugar monitoring to see the effect of exercise—use the glucometers!
Describe the food intake and sick day management of a diabetic
i) Modified pyramid plan—follow pyramid guides to help normalize food selections
ii) Exchange diet plan—groups foods according to CHOs, protein, and fat content
iii) CHO counting plan—meals, snacks based on grams of CHOs supplied
iv) FIBER is a very important component for diabetes management—especially successful foods include an apple, a salad, baked beans or milk
v) Sick day management
(1) Illness, fever and stress may throw off diabetic control—often leading to hyperglycemia
(2) Importance of supplying CHOs and continuing insulin when ill: regular sodas, popsicles, juices, toast, milk, cereals, hard candy
(3) Monitor blood glucose and urinary ketones
(4) Maintain fluid balance
What types of medications are used for diabetics?
i) Oral hypoglycemic agents
(1) 2nd generation Sulfonylureas: Glipizide (Glucotrol), Glyburide (DiaBeta)
(2) Biguanides: Glycophage (Metformin)
(3) Alpha-gluconsidase inhibitors: Acarbose (Precose) and Miglitol (Glyset)
(4) Thiazolidinediones (Roseiglitzone (Avandia) and Pioglitazone (Actos)
ii) Short or rapid acting
(1) Regular, semilente
(2) Ultra short—onset within 15 minutes
(3) Rapid—peak within 2-3 hours and duration is 3-6 hours
iii) Intermediate
(1) Lente, NPH
(a) Peak 4-12 hours and duration is 10-18 hours
iv) Long acting
(1) Ultra Lente, PZI
(a) Peak is minimal and duration is 18-24 hours
What are signs/symptoms of diabetes?
i) Polyuria=pee a lot
ii) Polydipsia=always thirsty
iii) Polyphagia=always hungry
iv) Hyperglycemia=too much food, not enough meds, stressors
(1) Drowsiness, extreme thirst, very frequent urination, flushed skin, heavy breathing, eventual stupor or even unconciousness
v) Glucosuria: glucose in urine
vi) Nonketoic hyperosmolar coma/ketoacidosis: with high blood sugars be sure to always monitor ketones because this can be a life threatening situation
What are complications of diabetes?
i) Hypoglycemia: insulin reaction, insulin shock
(1) Caused by too little food, too much meds, excessive exercise
(2) Staggering, poor coordination, anger, pale color, confusion, sudden hunger, excessive sweating, trembling, eventual stupor or unconciousness
(3) Treatment: consume concentrated sugar
ii) Hyperglycemia
iii) Ketoacidosis
(1) Greatest risk during times of injury or illness—STRESS
(2) Liver partially breaks down fat for fuel
(3) Elevated ketones causing blood aciditiy
(4) Dehydration because kidneys try to eliminate sugar in urine
(5) Treatment: insulin and IV fluids
iv) Macroangiopathies
(1) Diabetics have 3-4X the risk for Coronary Vascular Disease
(a) Know the ABC’s
v) Microangiopathies
(1) Retinopathy diabetes—leading cause of blindness among working age Americans
(2) Neuropathy including gastroparesis: avoid high fat, high fiber—numbing, tingling, even painful parasthesias of extremities
What are causes, symptoms, and treatments of hyperglycemia?
(1) Causes: too much food, not enough meds, stressors
(2) Symptoms: more gradual onset
(3) Treatment: fluids and meds
What are causes, symptoms, and treatments of hypoglycemia?
(1) Causes: too little food, too much meds, excessive exercise
(2) Symptoms: sudden onset
(3) Treatment: consume concentrated sugar
What are the problems of eating disorders with diabetics?
i) Estimate 7-45% of Type 1
ii) Estimate around 5% Type 1 decrease insulin dose or skip it to lose weight
iii) Watch for signs of unexplained weight loss, poor control in diabetics
Enteral vs. Parenteral
i) Enteral
(1) Enteral=intestines
(2) Enteral feedings use the GI tract
(3) They include oral supplements and tube feedings
(4) TEN=refers to feedings that are totally supplied by tube
ii) Parenteral
(1) Parenteral nutrition=along side (outside) the intestines
(2) Feedings are provided intravenously (in the blood stream)
(3) Can be either supplied Peripherally (PPN) or with a central line (TPN or total parenteral nutrition)
What are the advantages and disadvantages of parenteral and enteral?
i) Always use the oral route whenever possible –if the gut works, use it! (enteral)
ii) If client not receiving sufficient kcals, first try to use enteral supplements such as ensure or boost
iii) Next feeding choice would be adding enteral nutrition in a tube feeding form
iv) Finally, use parenteral nutrition when the GI tract is compromised (non functioning)
v) ADVANTAGE OF ENTERAL=keeps the gut functional—use it or lose it! Prevents bacterial translocation, readily supplies glutamine which fuels the gut and is cost effective
vi) ADVANTAGE OF PARENTERAL=it allows the GI tract to rest while the client is still being well nourished
(1) Same osmolality as blood—lipids
(1) Lower osmolality than blood
(1) Higher osmolality than blood—CHOs are the most hyperosmolar of the macronutrients
(1) Measurement of osmotically active particles per kg of solvent
(2) Normal body fluid osmololity=285 mOsm
intact vs. hydrolyzed
(1) Intact: polymeric—intact nutrients (CHOs, proteins, fats)
(a) Requires a functioning GI tract
(2) Hydrolyzed: monomeric, elemental
(a) Nutrients are somewhat predigested or broken down
(b) For those only with impaired GI ability
(a) Pure CHOs, pure lipids, pure proteins
(a) Immune system boosters: for cancer clients
(b) Glucerna: for diabetics
(c) Nepro: for kidney dialysis clients
(d) BCAA: branch chain amino acids: for trauma and liver disease clients
(a) Method of enteral feeding meaning “all at one time”
(i) Fed directly to the stomach usually by syringe and in a short period of time
intermittent bolus
(a) Very common method of enteral feeding-delivering a 4-6 hour volume in about 20-30 minutes about 5-6 times a day
(a) Aka cyclic feedings: a continuous feeding infused for 8-12 hours, usually done at night for extra nutrient intake
(a) Round the clock feedings—almost always fed to the small intestine for those with poor tolerance
(a) Nil per os=nothing by mouth
open or closed systems
(a) Closed
(i) Hang time=48 hours
(ii) More aseptic meaning a decreased rate of infection
(iii) Less labor intensive
(iv) Directly hung
(b) Open
(i) Hang time is 24 hours
(ii) Labor intensive
role as a fuel for the bowel during catabolic stress
What is dumping syndrome?
(a) Aka Jejunal hyperosmolic syndrome
(b) Often dumping syndrome is also seen with GI diseases when part of the GI tract is surgically removed
What are BCAAs?
(a) Leucine, isoleucine, valine—for stressed (trauma) and liver disease clients
(b) Somewhat controversial if costs justifies its use
(14) Kcals per ml (cc) of standard dilution enteral formulas
(a) 1 kcal/ml
(15) Tube feeding orders—what is included?
(a) The product name, the strength and the rate
(b) Also included is the rate of advancement and the H20 flushes
(17) Be ready to calculate grams of glucose (dextrose) and kcal supplied in an IV solution (like shown on the handout)
(a) % of dextrose=g in water so 5%=5 grams
(b) Remember 3.4 kcals/g
i) Pyrosis
(1) A burning sensation in the upper abdomen also called heartburn
ii) Flatulence
(1) Caused by aerophagia=swallowing air
(a) Eating too fast
(b) Bacterial fermentation
(c) Food intolerances/allergies
(d) Malabsorption of CHOs
(2) Treatment: reverse the causes
(a) Beano
(b) Liquid alpha galactosidase
iii) Syncope
(1) Partial or complete loss of consciousness
(2) Fainting
iv) Steatorrhea
(1) Formation of bulky feces
(2) Due to excess gas and malabsorption
vi) Diverticula//osis/it is
(1) Diverticula: pouch like herniations protruding from the muscular layer of the GI tract
(a) Most frequently occur in the colon (large intestine)
(2) Symptoms of diverticulosis
(a) Depends on location
(b) Esophageal: dysphagia, coughing, bad breath
(c) Small intestine/colon: more delayed after eating; abdominal distention, vomiting, diarrhea, constipation
(d) May be asymptomatic
(e) A relationship between diverticulosis and our “westernized diet” (high fat, low fiber)
(3) Treatment:
(a) Surgical removal of large diverticulum
(b) Diet: high fiber, high fluid diet as tolerated
(c) Weight loss if necessary
vii) Ulcers
(1) An eroded lesion (loss of tissue)
(2) Types
(a) Esophageal
(b) Duodenal (most common)
(c) Gastric (most often in lower 1/3)
(d) Peptic (general term)
(e) Stress (occurs in conjunction with medical emergencies like burns)
(3) Causes
(a) Imbalance between gastric acid and pepsin and tissue resistance
(b) Bacterial component (H. or C. pylori)
(i) Irregular and fast paced meals, excessive smoking, excessive NSAIDS or aspirin, ingestion, heredity, stress (Type A personality?), excessive coffee or colas
viii) Gastritis
(1) Inflammation of the stomach and intestines
(2) Very common
(3) Both acute and chronic types
(4) Symptoms
(a) Nausea and vomiting
(b) Anorexia
(c) Belching
(d) Feeling of fullness
(e) Epigastric pain
(5) Causes and treatment (acute)
(a) Often violent, sudden onset
(b) Eliminate irritations
(c) Rest stomach, provide fluids
(d) Progress to clear/full liquid, soft, general diet as tolerated
(6) Causes and treatment (chronic)
(a) More long term causes
(b) Treatment is same as for acute but also monitor B12 status
ix) Irritable bowel syndrome
(1) Irritation of the intestinal mucous membrane causing irregular bowel contractions
(2) Frequent complaints of abdominal distention/pressure/pain
(3) Can go from constipation to diarrhea and then back again
(4) Causes
(a) Emotional upset, abnormal innervation fo the GI tract
(b) Irregular, fast paced meals
(c) Irregular bowel habits, may be lactose intolerant
(5) Treatment
(a) Eliminate causes if possible
(b) Use food/stress diaries to identify patterns and triggers of attacks
(c) Increase fiber and fluid when diarrhea is absent
(6) Dumping of jejunal hyperosmolic syndrome
(a) If dumping syndrome occurs after GI resection, remember that CHOs are poorly tolerated
(b) Offer high protein, higher fat with fluid between meals
(7) Short bowel syndrome
(a) Associated with malabsorption (dumping syndrome)
(b) Seen following the resection of a large portion of the small intestine
(c) Severity depends on how much was removed
(d) Clients do best if less than 50% of the small intestine is removed
(8) Ileostomy
(a) Opening to the ileum following the removal of the colon, rectum and anus
(b) Excretory contents more liquid—messier to manage
(9) Colostomy
(a) Opening in colon following the removal of the rectum and anus
(b) Excretory content relatively formed, but may carry odors
(10) Possible causes of constipation or diarrhea
(a) Constipation
(i) Lack of exercise, poor bowel habits, poor diet (low fiber and fluid), obstruction
(b) Diarrhea
(i) Associated with bacteria, viruses
(ii) Associated with lactose intolerance
(iii) Associated with fat malabsorption
(11) Predisposing factors (H or C pylori) of ulcer disease
(a) Irregular fast paced meals, excessive smoking, excessive NSAIDS or aspirin, ingestion, heredity, stress (type a), excessive coffee or colas
(a) Espophageal reflux disease
(i) Result of the irritating effect of acidic gastric reflux on the esophageal mucosa
(ii) Symptoms
1. similar to achalasia plus pyrosis (heartburn)
2. may lead to esophageal or gastric ulcers
3. may mistake for a heart attack
4. see with pregnancy due to hormone changes
(b) Ulcers
(i) Symptoms: depends on location, often feel better when eating and the client gains weight
(ii) May be anemic if ulcer is bleeding
(iii) May be asymptomatic
(c) Crohns
(i) Crohns: a type of inflammatory bowel disease
1. inflammation can occur anywhere in the GI tract but usually effects the terminal ileum and possibly the proximal colon
2. classic cobblestone appearance scattered with normal tissue
3. can cause scarring, thickening, abscesses, obstruction as the disease progresses
4. symptoms: abdominal pain, cramping, anorexia, diarrhea, weight loss, growth impairment
5. treatment: diet must be highly individualized to meet client needs and tolerances
a. many crohn’s clients have trouble with milk products, fiber and possibly gluten
b. use multivitamin/mineral supplement of around 100-150% DRI
(ii) Ulcerative colitis
(ii) Ulcerative colitis: a type of inflammatory bowel disease
1. when the inflammatory process involves the colon (and sometimes the rectum) only
2. no cobblestones, segmented appearance
3. often seen in young adults
4. bleeding common
5. symptoms: similar to Crohn’s
6. treatment: same as Crohn’s diet
(d) Celiac Diseas
avoid Abrow (barley, rye, oats, wheat) foods
(e) Diverticulosis
(i) Esophageal: dysphagia, coughing, bad breath
(ii) Small intestine/colon: more delayed after eating, abdominal distention, vomiting, diarrhea, constipation
(iii) Treatment: diet high in fiber, high fluid, avoid small seeds, corn husks and nuts
(f) Diarrhea
(i) Frequent loose stools due to rapid passage of feed through the GI tract
(ii) Key treatment: oral rehydration therapy
1. proceed to clear/full liquid, general as tolerated
2. may need to be lactose free for a few days
(g) Constipation
(i) Treatment: reverse causes, avoid laxative habit, avoid mineral oil (it interferes with fat soluble vitamin absorption
(h) Irritable bowel
(i) Frequent complaints of abdominal distention/pressure/pain
(ii) Clients can switch from constipation to diarrhea and then back
(iii) Treatment: eliminate causes if possible, use food/stress diaries to identify patterns, increase fiber and fluid intake when diarrhea is absent, peppermint oil, tea, psychocognitive therapy (change negative self talk)
(13) What is the difference between low fiber and low residue?
(a) Low fiber
(i) No indigestible CHOs (in fruits, veggies, legumes, grains)
(b) Low residue
(i) Low fiber plus 2 glasses milk maximum, may restrict some fat, no coconut
(14) Probiotics—what are they? Specific examples and areas for possible use
(a) Definition: cultures of micro-organisms that promote health and help maintain healthy intestinal function
(b) Some probiotics come directly from foods, such as the bacteria in certain brands of yogurt, kefir, and buttermilk
(c) Primary proven benefit of probiotics is prevention of antibiotic-induced diarrhea
(d) Lactobacillus, acidophilus, lactobacillus, GG—may help prevent traveler’s diarrhea
(e) Saccharomyces boiuldardil—may help reduce risk of Clostridium Dificile Diarrhea
(f) Bifidobacteria Infantis
(1) Types of liver diseases
hepatitis, cirrhosis, hepatic encephalopathy
(a) Hepatitis
(i) HAV=oral fecal route (contaminated water and food)
(ii) HBV=”the silent epidemic”-sex/blood routes (transmitted by infected blood, contaminated needles, contaminated saliva, contaminated semen, much more contagious than the HIV virus)
(iii) HCV=most common blood-borne illness in the US
(iv) Symptoms: anorexia, fatigue, low grade fever, Jaundice, tenderness in the liver region, liver enlargement, pale stools, dark urine, abnormal liver enzymes
(v) Treatment: bedrest and optimal nutrition (also medication such as analgesics, antiemetics, newer steroids)
(vi) Good nutrition is vital---HIGH PROTEIN
(vii) As the severity of the disease increases, the protein allowance may need to decrease (as NH3 levels rise)—goal=to maintain as high a protein level as possible
(b) Cirrhosis
(i) CHRONIC liver disease
(ii) Inactive fibrous connective tissue replaces healthy liver cells following long standing fatty liver infiltration and/or inflammation
(iii) Scarred, necrotic liver and an it increases the risk for liver cancer
(iv) Alcoholism=the most common cause of cirrhosis; 90% of cirrhosis cases are secondary to alcohol related liver damage
(v) Symptoms: hepatitis symptoms (anorexia, jaundice, abnormal liver enzymes), MALNUTRITION (protein energy malnutrition) a huge problem, edema (especially abdominal distention—ASCITES), portal hypertension, esophageal varices, intestinal bleeding, anemias
(vi) Treatment: alcoholism rehab if appropriate, meds (see hepatitis), nutritional support (similar to hepatitis-small frequent feedings, vitamin/mineral supplements)-moderately high protein, moderately high kcals, sodium and fluid restrictions with edema, texture modified as needed for varices, may use tube feedings
(c) Hepatic encephalopathy
(i) COMA (uncontrolled cirrhosis)
(ii) When diseased liver is unable to remove ammonia by converting it to urea for excretion—get ammonia intoxification
(iii) Nutrient metabolism severely compromised
(iv) Symptoms: disorders of consciousness (apathy, confusion, slurred speech, changes in personality or mood), alterations in motor function (asterixis=flapping hand tremor), fetor hepaticas (fecal or musty odor to the breath), coma
(v) Treatment: ultimate goal=to remove excess ammonia
1. may use lactulose (traps NH3 in stools), nutritional support—protein is given at the highest level that does not induce or worsen encephalopathy
(2) Importance of keeping protein intake as high as possible without abnormally elevating ammonia levels
(a) Increase protein gradually while watching for signs of NH3 toxicity
(b) May need sodium, fluid texture restrictions
(c) Protein given at the highest level without worsening encephalopathy—start at 40-60g/day
(d) May need to severely reduce protein if symptoms do not improve or worsen
(3) Functions of the liver
(a) CHO Metabolism
(i) Form and store glycogen (glycogenesis)
(ii) Convert glycogen to glucose (glycogenolysis)
(iii) Convert galactose and fructose to glucose (glucogenesis)
(iv) Convert amino acid residues to glucose (gluconeogenesis)
(b) Protein Metabolism
(i) Deaminate amino acids
(ii) Form plasma proteins
(iii) Form urea for ammonia removal
(iv) Synthesize nonessential amino acids
(v) Store vitamins (A,D, B12, K) and iron
(vi) Form blood coagulation factors (with disease—use soft tooth brush to avoid bleeding)
(vii) The liver is a very busy gatekeeper organ (1 ½ quarts of blood/minute flow)
1. the regenerative capacity of the liver is TREMENDOUS
(5) 5 F’s of gallbladder disease
(a) Fair, Female, Fat, Forty, Flatulence
(6) Importance of weight loss and decreased fat intake with gallbladder disease
(a) Long term low fat and weight loss emphasis—after the removal o f the gallbladder, bile enters the small intestines continually rather than in response to food fat
(7) Use of BCAA’s with liver disease
(a) Pros
(i) Reduce malnutrition by helping to maintain N balance without exacerbating hepatic encephalopathy
(ii) Reduce length and # of hospitalizations
(iii) Less rapid disease progression
(iv) Overall increased quality of life
(b) Cons
(i) Cost
(ii) Poor palatability of BCAA’s
(8) Alcohol-metabolism overview and the effect of alcohol abuse on malnutrition
(a) Alcohol is directly toxic to the liver, as it is metabolized by the microsomal ethanol oxidizing system, resulting in energy wastage
(b) It inhibits fat oxidation (fat sparing)—most apparent in clients who are overweight or consume high fat diets
(c) Alcoholics also often have hyppoalbuminemia and have bouts of hypoglycemia
(d) Wernicke-Korsakoff Syndrome seen in alcoholics (nystagmus, poor coordination, mental confusion, amnesia)
(e) The bottom line is: there’s probably a good chcance an alcoholic can benefit from very basic nutrition counseling and increasing physical activity can be beneficial as well
(9) Endocrine/exocrine functions of the pancreas
(a) Endocrine
(i) Hormone such as insulin and glucagons
(b) Exocrine
(i) Enzyme such as pancreatic lipase
Potential need for insulin therapy with chronic pancreatitis
(a) Fibrous, necrotic disease with decreased enzyme processes—frequent beta cell destruction which leads to decreased insulin production
(b) May need insulin therapy (besides meds already mentioned with acute)
(1) American Cancer Society’s dietary guidelines to prevent cancer
(a) Yes to: plant foods (great antioxidants)
(b) No to: animal based foods
(c) Priority—choose a diet rich in a variety of plant based oofds
(i) Especially eat plenty of fruits and veggies
(ii) Maintain a healthy weight and be physically active
(iii) Drink alcohol only in moderation, if at all
(iv) Select foods low in fat and salt
(v) Prepare and store food safely
(vi) Do NOT use tobacco in any form
(2) Potential dietary carcinogens (nitrosamines, aflotoxins, acrylamide) and potential dietary protective factors (fiber, selenium and other antioxidants, phytochemicals
(a) Potential carcinogens
(i) Nitrosamines: formed when nitrites are heated to a high temp—in hot dogs, bacon
(ii) Aflatoxins: in molds of grains, seeds, nuts, acceptable limits set in the food supply (don’t eat moldy peanuts)
(iii) Acrylamide: used to produce plastics and dyes and to purify water—known to cause cancer in animals but not yet proven to be a carcinogen in humans
(b) Potential dietary protective factors
(i) Phytochemicals: sulforaphanes isthiocyantes (block tumor formation), diallysulfides (in garlic, onions, chives), limonene in citrus fruits, polyphenols in green tea, lycopene in tomates, flavonoids in soy, resveratrol in grape skin and red wine
(3) Review the dietary suggestions to help cancer patients increase their food intake
(a) Ultimate goal=high protein, high kcal diet to avoid cancer cachexia (severe wasting)
(b) 2X normal protein—1.5-2 g/kg
(c) Follow a schedule of eating NOT dependent on appetite alone
(d) Exercise prior to meal time
(e) Eat the largest meal at the time one feels best
(f) Do NOT offer favorite foods at times when one feels lousy
(g) Cold, warm temps usually are preferred to hot
(h) Use antinausea meds and pain meds
(i) Use zinc supplements if deficient to increase the sense of taste
(j) Avoid red meats and avoid use of metal utensils
(k) Clean mouth to enhance taste
(l) Modify texture as needed
(n) Lactose free with diarrhea
(o) Fortify foods (high kcal shakes, instant breakfast, jellies/jams, dry milk powder, enteral products)
(p) Oral first, enteral 2nd, parenteral 3rd
(4) Characteristics of a cancer cell
(a) Incapable of normal cell life
(b) Shape is abnormal—larger, mutant and malformed
(c) Anaplasia—lack of cell differentiation (do not look like cell of origin)
(d) More rapid growth—do not respond to normal contact inhibition
(e) Irregular, large nucleus
(5) High protein, high kcal diet=?
ultimate goal of cancer patients
(6) Foods to avoid on a low microbial diet
(a) No or limited fresh fruits or veggies, no aged cheese, no yogurt with live bacterial cultures, no ground pepper
(7) What is Cancer Cachexia?
(a) Severe wasting due to lack of appetite and nutrition during cancer
(b) Cachexia=”severe wasting”
(8) Nutritional problems commonly seen with HIV/AIDs patients
(a) AIDs wasting syndrome (energy needs are higher than standard estimates)
(b) Lactose intolerance
(c) Gluten intolerance
(d) Medication related side effects
(e) Easily affected by food borne illness
(f) Diarrhea/malabsorption
(g) Anorexia
(h) Mouth sores
(9) Importance of safe food handling with transplant and HIV/AIDs patients
(a) Food MUST be safely handled and prepared—FOOD BORNE ILLNESS should be avoided at all costs!
(1) Latest update of the National Cholesterol Education Program/Am. Heart Association’s Guidelines for total cholesterol and HDL levels
(a) HDLs: equal to or greater than 50 mg/dl is desirable
(2) Step Two diets for adults and children over age 2 years
(a) More restrictive than the first step
(b) Energy to achieve, maintain IBW
(c) Total fat less than 30% of total kcals; saturated fat less than 7%; polys up to 10%; monos 10-15%
(d) Cholesterol less than 200 mg
(e) CHOs 50-60% of total kcals
(f) Protein 10-20% of total kcals
(3) American Heart Association’s 2006 edition of dietary guidelines
(a) Use up as many kcals as you take in
(b) Strive for 30 minutes daily exercise
(c) Eat a variety of nutritious foods (veggies, fruits, whole grains, 2 weekly servings (3oz each) of fatty fish like tuna/salmon), eat less nutrient poor foods (select low fat, fat free)
(4) Risk factors of CHD
(a) Hypercholesterolemia
(b) Hypertension (HTN)
(c) Smoking
(d) Obesity—a MAJOR risk factor
(e) Diabetes—a MAJOR modifiable risk factor
(f) Elevated blood homocysteine levels
(5) Protective dietary factors against cardiovascular disease
(a) Omega 6 polyunsaturated fatty acids: corn, soybeans, safflower, sunflower, linseed oils
(b) Omega 3 polyunsaturated fatty acids: fatty darker fish, mackerel, salmon, tuna, eel, herring, walnuts, flaxseed, flaxseed oil
(c) Monounsaturated fatty acids: canola oil such as Puritan, olive oil, peanut oil, and almonds
(d) Plant sterol esters
(e) Dietary fiber (especially soluble)
(f) Antioxidant nutrients: vitamin E, Vitamin C, Carotenoids, Selenium
(6) Polyunsaturated, monounsaturated, saturated fat and cholesterol food sources
(7) Homocysteine-what is its significance in heart disease risk and which B vitamins play a role in maintaining healthy homocysteine levels?
(a) Definition: an amino acid by-product formed when the body breaks down methionine
(b) Unregulated homocysteine is associated with increased blood clotting
(c) Elevations of homocysteine is also associated with poor FOLATE, B6 and B16 status
(d) Increasing folic acid, B6 and B12 will help lower homocysteine levels
(8) Low sodium diets (no added salt, 2 gram, etc)—what are the main differences in foods allowed?
(a) No added salt diet
(i) For moderate heart failure, possibly HTN
(ii) AVOID highly salted foods=salty snacks/crackers/chips, condiments, pickles, luncheon meats, smoked or salted meats, canned foods
(iii) Limit salt used in cooking or at the table (1/4-1/2 tsp. per day max)
(b) 1,000 mg (43 meq)
(i) For HTN, edema, renal diseases, chronic, liver disease, moderate to severe cardiac disease
(ii) ALSO AVOID: buttermilk, reg. cheese, commercially prepared desserts, reg. salad dressings, most dry cereals, carbonated beverages, most commercially softened water
(iii) May limit the amount of regular bread, regular milk and ounces of meat
(iv) No salt used in cooking
(c) 500 mg (22 meq)
(i) For severe Congestive Heart failure, extreme edema, pulmonary congestion
(ii) Also use all salt free products=low sodium bread, low sodium cheese, unsalted margarine
(iii) If go lower, may even use low sodium milk
(9) Diet and HTN included the Dash diet
(a) DASH=dietary approaches to stop hypertension diet
(b) Main emphasis: heavy fruit, veggie intake (8-10 minimum servings)
(c) Also higher in low fat dairy products
(d) Purpose: to determine if BP could be further lowered by combining the Dash Diet and a lower sodium intake
(e) Results: for all, the Dash diet plus lowest sodium intake level lowered BP the most
(f) Other related advice
(i) Reduce salt intake
(ii) Reduce alcohol
(iii) Exercise more
(iv) Possibly increase poly, mono and unsaturated fatty acid intake
Characteristics of congestive heart failure and diet therapy used
(a) Progressively weakened heart doesn’t fully contract; unable to maintain adequate circulation of 2 rich blood to the body
(b) Diet therapy:
(i) Moderate kcals, small, frequent meals
(ii) No extremes in temperature
(iii) No caffeine—no gassy foods (ups workload)
(iv) Restrict fluids—sodium as needed
(11) What are salt substitutes made of?
(a) Some reduce sodium, some are sodium free
(b) Some may add potassium in place of sodium
(c) Morton Lite Salt: 1,160 mg Na/tsp (sodium cut to ½)
(d) No salt: o mg Na/tsp
(e) Mrs. Dash’s: o mg of either Na or K/tsp
(12) What is cardiac cachexia?
(a) Body wasting due to chronic heart failure
(12) What is cardiac cachexia?
(a) Body wasting due to chronic heart failure