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Slide 1: DIET THERAPY OF DIFFERENT DISEASE Presented by: Dave Jay S. Manriquez RN.
Slide 2: DIET THERAPY IN NURSING
Slide 3: Nutrition Index
Slide 4: Mr. Tucker’s (actual) weight is 3% less than his admission wt.
Slide 6: Types Of Diets LIQUID DIETS INDICATIONS FOR CLEAR LIQUID DIET oProvide oral fluids; before/after surgery; prepare bowel for diagnostic tests (colono­scopic examination, barium enema, and other procedures); minimize stimulation of GI tract; promote recovery from partial paralytic ileus (early refeeding); minimize residue in the GI tract; transition feeding from < IV feeding to solid foods; acute GI disturbances; diarrhea . CONTRA INDICATIONS FOR CLEAR LIQUID DIET o Should not be used more than 24 hours; inadequate GI function; nutrient needs requiring parenteral nutrition INDICATIONS FOR FULL LIQUID DIET o Provide oral fluids; after surgery; transition between clear liquids and solid food; oral or plastic surgery to the face and neck; mandibular fractures; patients who have chewing or swallowing difficulties; esophageal or GI strictures; diarrhea CONTRA INDICATIONS FOR FULL LIQUID DIET: Dysphagia
Slide 7: PUREED, MECHANICAL, OR SOFT DIETS INDICATIONS FOR PUREED DIET o Neurologic changes; inflammation or ulcerations of the oral cavity and/or esophagus; edentulous patients; fractured jaw; head and neck abnormalities; cerebrovascular accident . CONTRA INDICATIONS FOR PUREED DIET oSituations where ground or chopped foods are appropriate INDICATIONS FOR MECHANICAL SOFT DIET I oPoorly fitting dentures; edentulous patients; limited chewing or swallowing ability; dysphagia; strictures of intestinal tract; radiation treatment to oral cavity; progression from enteral tube feedings or parenteral nutrition to solid foods CONTRA INDICATIONS FOR MECHANICAL SOFT DIET o Situations where regular foods are appropriate INDICATIONS FOR SOFT DIET Debilitated patients unable to consume a­regular diet; mild GI problems CONTRAlNDICATIONS FOR SOFT DIET oSituations where regular­foods are appropriate
Slide 11: Indicators of Potential Nutritional Problems  Clear or full liquid diets for more than three days without nutrient supplementation or with inappropriate or insufficient nutrient supplementation.  Intravenous feeding (dextrose or saline) or NPO for more than 3 days without supplementation.  Low intakes of prescribed diet or tube feedings  Inconsistent growth or weight for height, above or below norms in children.  Pregnancy weight gain deviating from normal patterns Diagnoses that increase nutritional needs or decrease nutrient intake (or both):cancer,malabsoprption, diarrhea, hyperthyroidism, excessive inflammation, postoperative
Slide 12: Chronic use of drugs, especially alcohol, that affects nutritional status Alterations in chewing, swallowing, appetite, taste, and smell Temperature consistently above 37o C (98.6 Fo) for more than 2­days Hematocrit: <43% in men, <37% in women Hemoglobin: <14 g/dl in men, <12 g/dl in women; accompanied by mean cell volume <82 cu or >100 cu Absolute decrease in lymphocyte count (<1500 cells/mm3) Elevated (>250mg/dl) or decreased (<130 mg/dl) total plasma cholesterol Serum albumin, <30 g/dl in patients without renal disease, liver disease, generalized dermatitis,overhydration.
Slide 14: Dysphagia  Position the patient in a comfortable with the head in an upright position, slightly tilted forward Textured foods that require chewing stimulate a better swallow, e.g. toast instead of bread or boiled potato instead of mashed potatoes. Offer juices diluted with water at first, and use flexible straws if the patient has suckling capabilities Mildly sweetened and salted foods are generally favored. Foods should be close to room temperature. Avoid acid or bitter flavors and sticky foods (e.g. soft bread, bananas, or peanut butter). Make consistency adjustments according to the patient’s tolerance. Liquids can be used to moisten foods for individuals with decreased saliva production Adapt the diet to the patients’ need and gradually upgrade it as feeding skills improve.     
Slide 15: Gastroesophageal Reflux        Achieve and maintain ideal body weight to improve mechanical and postural status (except pregnant women, who should not try to lose weight). Increase protein and reduce fat intake to increase sphincter pressure. Avoid foods like chocolate, alcohol, peppermint, coffee, and carbonated drinks. Avoid foods that may irritate and cause spasms; citrus juices, tomatoes, and tomato sauce. Stop smoking, if that is a habit. Eat small meals four times a day. Eat large meal at noon with a lighter meal in the evening. Finish the evening meal at least two to four hours before bedtime. Avoid late evening snacks.
Slide 16: Peptic Ulcer  Trend in nutritional therapy of peptic ulcerindividualized approach, i.e. based on the individual patient’s tolerance for specific foods. To reduce or neutralize gastric acid secretion: Eat three meals daily; avoid skipping meals. Avoid stomach distention with large quantities of food at a meal. Avoid drinking milk frequently. Limit caffeine intake by reducing consumption of coffee, tea, cola, chocolate and other foods and beverages that contain caffeine. Limit alcohol intake and avoid drinking on any empty stomach.
Slide 17: . Limit intake of spicy, fatty or otherwise bothersome foods and beverages. Some fibers, especially the soluble forms, are beneficial. Citric acid juices may induce gastric reflux and discomfort in some patients. Avoid bedtime snacks to prevent acid secretion if symptoms often occur in the middle of the night. Avoid cigarette smoking, which may increase gastric acid secretion and delay the healing process and is also associated with an increased frequency of duodenal ulcers.
Slide 19: GASTRITIS The aim is to rest the stomach and reduce further irritation of the mucosa.   Acute type: NPO for 24 to 48 hours: give glucose parenterally, followed by liquids, then soft to full diet as tolerated.    Chronic type: Bland, low fiber diet. Correct faulty food habits.
Slide 20: Intestinal Malabsorption Decreased Absorption Increased Absorption Diet specific to etiology
Slide 21: Diarrhea Clinical Implications Fluids must be replaced to avoid dehydration, solids should be gradually added as tolerated. A low-residue diet may be in order to decrease the intake of fibrous materials. Evaluate the use of foods that may contribute to diarrhea, especially those high in fiber, caffeine, and alcohol. Encourage juices high in potassium Remove milk products from the diet if there is a possibility of lactose intolerance. Bananas, grated raw apples, or cooked apple-sauce contain pectin, which helps bind the fluid and retard its transit time. Extremely hot or cold foods increase peristalsis and may aggravate diarrhea.      
Slide 22: Constipation Clinical Implications Ask patients about their use of cathartics or laxatives.  Gradually increase the amount of fiber or bulk in the diet (raw vegetables and fruits, whole-grain breads, and cereals).  Force fluid intake; drink at least the equivalent of six to eight glasses of water a day.  Dried fruits, especially prunes, contain natural laxatives.  Any hot beverage upon arising, such as coffee, tea, or lemon water, may stimulate peristalsis because duodenalileal or gastric colic is strongest in the morning. Breakfast is also important and should contain some fiber.  Encourage activity and relaxation as much as possible allow sufficient time for bowel habits
Slide 23:      Flatus Clinical Implications Discourage drinking with straws. Avoid foods that produce gas (This is highly individual matter, one which the patient must be observant). In many persons, dried beans, peas, and foods from the cabbage family (broccoli and Brussels sprouts) cause problems. Decrease the amount of fat in the diet. Encourage the patient to chew food slowly, closing the mouth. Malabsorption syndrome, peptic ulcers, and cholelithiasis are disorders that cause excessive flatulence; these treatable disorders must be excluded by conventional means (Van Ness & Cattau, 1985)
Slide 24: Crohn’s Disease (Regional Enteritis) Clinical Implications  During bouts with diarrhea, sources of potassium intake should be increased. Multivitamin and mineral supplements are frequently recommended. 
Slide 25: Ulcerative Colitis    Clinical Implications Patients with severe diarrhea or steatorrhea should be monitored for magnesium, which is usually deficient in chronic inflammatory bowel disease (Philips & Garnys, 1981). Low serum zinc levels are prevalent among children with chronic inflammatory bowel disease. Response to zinc intake is abnormal and growth is retarded (Nishl et al, 1980). The use of azulfidine requires a daily intake of eight to ten cups of fluid.
Slide 26: Irritable Bowel Syndrom (IBS) Clinical Implications  Patients with irritable bowel syndrome must be tested for lactose intolerance or malabsorption before further treatment (Goldsmith & Patterson, 1985). Hydrophilic mucilloids necessitate large amounts of fluid intake. 
Slide 27: Disease of th e Li ver, Pancre as and Gall Blad der
Slide 29: Hepatitis During acute phase: 5-10% dextrose Intravenously and/or protein parenterally: To minimize protein losses, prevent ketosis, to replace fluids and electrolytes.  High calories: To counteract weight loss and for maximum protein utilization.  High CHO: To spare protein: Insure glycogen reserve and maintenance of hepatic function. High protein: To repair hepatic cells; from cholic and other bile acids; to prevent hypothermia; supply lipotropic factors which mobilize liver fat. 
Slide 31: Cirrhosis       Moderate fat, MCT preferred over LCT (Restrict fat if there is billiary obstruction): To meet high energy needs, at the same time preventing fatty liver. High vitamins: To maintain liver function. Frequent small feeding in cases of anorexia: For better tolerance. Consistency: liquid to soft in acute attacks; more liberal in convalescence: Adjusted to patient’s tolerance. Low sodium: In cases of ascites. Alcohol prohibited: Detoxification function of the liver is impaired by alcohol.
Slide 32: Hepatic Encephalopathy (Hepatic Coma) Protein Intake  Initially: non-protein diet (Borst Diet) Progress to: 20-30 gm/day (Giordano-Giovanetti Diet) if condition improves until the normal protein allowance is tolerated: To eliminate completely a source of nitrogen for ammonia synthesis.  Calories: 1500 to 2000 a day to come mostly from CHO and fat: Minimize tissue protein breakdown which is a source of ammonia.  Liberal vitamins and minerals: For adequate nutrition.  Low sodium: Prevent ascites.  Tube feeding: when oral feeding is not possible.
Slide 33: Cholecystitis      IV fluids and electrolytes; progress to clear liquid: To rest inflamed gallbladder, prevent and correct dehydration, volume depletion and electrolyte abnormalities. Low fat: Reduce discomfort by preventing stimulation of sphincter of Oddi, and contraction of GB. Bland low fiber: Decrease mechanical and chemical stimulation. Low calorie for obese patients: For weight loss, obesity is predisposing factor. Small frequent feedings: To prevent dyspepsia.
Slide 34: Pancreatitis         Acute attack: NPO: To rest the organ. Low fat: To control steatorrhea and prevent stimulation for bile production. Moderate CHO and protein: Prevention of hypoglycemia and creatorrhea. Plus enzyme supplements: Utilization of nutrients. Six small feedings, bland: Avoid undue distention and stimulation. Avoidance of alcohol: Alcohol may precipitate attack. Supplements of fat-soluble vitamins and calcium: To prevent deficiencies. MCT oil: Better absorbed than LCT.
Slide 35: DIETARY MANAGEMENT OF SURGICAL CONDITIONS
Slide 36: Dietary Management in General   Pre-operative Post-operative
Slide 37: Pre-Operative  To improve the nutriture of the patient. To prepare the patient for nutrient losses during surgery. To hasten post-operative recovery. To build up glycogen reserves. To strengthen bodily resistance to infections.    
Slide 38: Pre-Operative Dietary Management in: Emergency Operation  If patient is in good nutritional status – NPO 8 hours prior to surgery  To avoid vomiting during anesthesia or recovery from anesthesia, and decrease the risk of post-operative gastric retention since peristalsis is stropped For adequate stores of serum protein to prevent hypoproteinemia and shock.  If patient is in poor nutritional status (protein deficient) parenteral administration of whole blood or plasma.  In addition, 5% glucose in water, saline solution, vitamins and potassium. For adequate nutrition
Slide 39: Pre-Operative Dietary Management in: Elective Surgery High calorie underweight for To build up any weight deficit Low to adequate calories for others if patient is overweight, weight reduction is indicated to reduce surgical risks.
Slide 40: High carbohydrates For glycogen stores and to spare protein for tissue synthesis. Stores of glycogen exert a protective action on the liver and help to prevent post-operative ketosis and vomiting. High protein To build reserves for anticipated blood losses during surgery and increased tissue catabolism, to reduce the possibility of edema at the site of the wound which is a hindrance to wound healing.
Slide 41: Increased vitamins, especially ascorbic acid, vitamin K; Bcomplex increased minerals, especially phosphorus and potassium; Na and chloride Iron Increased fluids For wound healing and prevention of hemorrhage To replace electrolyte losses due to the breakdown of body tissue; and due to vomiting, diarrhea, perspiration and diuresis. To correct anemia To replace losses due to vomiting and diuresis
Slide 42: Immediate Pre-operative Period – usually nothing is given by mouth for at least 8 hours before general surgery so that the stomach will have no retained food at the time of the operation
Slide 43: Post-operative Dietary Management in: Minor Surgery Liquids Tolerated within a few hours; for maintenance or restoration of fluid and electrolyte balance. Normal Diet As soon as activity of GIT is restored
Slide 44: Post­operative Dietary Management in: Major Surgery NPO 24 ­ 48 Hours GI tract not yet functioning normally. To allow for recovery from anesthesia; prevent aspiration. Nutrition support: type and duration depends on recovery of GIT function  Conventional intravenous administration of amino acid solution As soon as activity of GIT is restored Patient is expected to tolerate an enteral diet within a few days. Total parenteral nutrition (TPN) To meet nutritional needs for extended periods when enteral feeding is not possible
Slide 45:  Tube feeding. If there is GIT function, but patient cannot tolerate an oral diet. To meet nutritional needs until patient can tolerate food by mouth. Oral Diet – liquid to full, as tolerated To give patient a feeling of being “normal” and hasten recovery; also, less expensive.
Slide 46: Specific Surgical Conditions       Surgery of the Mouth, Throat and Esophagus. Gastrectomy Dumping Syndrome Intestinal Surgery Diet following other abdominal Operations Rectal Surgery
Slide 47: Surgery of the Mouth, Throat and Esophagus  The aim is to provide food that require little chewing, comfortable and prevent bleeding. For tooth extraction: fluid diet progressing to soft until full diet is tolerated. Surgery of the mouth: full fluid or pureed foods; or tube feeding. Tonsillectomy: very cold or mild flavored foods the first few days. Avoid fibrous foods; then warm fluids and foods on the 2nd day, progress to a normal diet after a week.   
Slide 48: Gastrectomy       NPO first 24­48 hours; intravenous feedings Day 2 to 4: iced water with intravenous feedings Day 5: 1 to 2 oz. Water every even hours, and 1 to 2 oz milk every odd hour between. Day 6: Soft low fiber foods are used – eggs, custards, thickened soups, cereals, crackers, milk and fruit purees are suitable. Day 7: Tender meats, cottage cheese, and pureed vegetables are the next foods added to all the foods allowed in the previous days. Meats are divided into 5 or 6 small feedings daily with emphasis on foods high in protein and fat. CHO is kept relatively low. If not liquids are taken with meals, and the diet continues to be low in CHO, especially the simple sugars, many patients progress satisfactorily.
Slide 49: Dumping Syndrome: Major Surgery Small frequent feedings (5 or6) fed in supine position. High protein To prevent dumping of food into the intestines. Better tolerate because proteins are hydrolyzed into osmotically active substances more slowly; needed to rebuild tissues and gain strength. To meet energy needs For strength Simple CHO increases osmolarity of jejunum contents * “dumping syndrome.” High fat High calories Simple CHO (sugar, sweets or desserts, restricted)
Slide 50: Dry solid diet Better than liquids as they enter the jejunum less rapidly. Low fiber, low residue diet Avoid alcohol or sweet carbonated beverages To prevent rapid dumping of food into the intestines.
Slide 51: Intestinal Surgery: Major Surgery Clear fluid Low residue, bland Initial oral intake after surgery To promote healing of the stoma and to prevent irritation For weight recovery HI calorie, HI PRO VIT B12 supplemented To prevent possible macrocytic anemia in later years
Slide 52: Intestinal Surgery: Colostomy Same for Ileostomy Jejunoileostomy Low fat, low CHO, low fiber To prevent from diarrhea To restore electrolyte balance and to provide for losses of K, Ca and Mg. HI PRO
Slide 53: Diet following Other Abdominal Operations Cholecystectomy Low fat – for several weeks or months To avoid pain since large amounts of fats cause contraction of the tissues irritated and inflamed by surgery For faster convalescense HI PRO
Slide 54: Diet following Other Abdominal Operations Peritonitis and intestinal obstruction NPO – 1ST 24 to 48 hours, intravenous therapy Gastrointestinal function has not yet returned and drainage of the stomach and upper intestine is essential until there is reduction of distention and passage of gas. Better tolerated; transition to full diet Clear liquids to low residue
Slide 55: Rectal Surgery Hemorrhoidectomy NPO – 1ST 24 to 48 hours Clear liquid Low fiber-low residue: Fruits and vegetables are omitted except for strained fruit juices Due to anaesthesia Initial Feeding To discourage early bowel movements
Slide 56: Allergy  Avoidance diet: An adequate diet which excludes the food(s) causing allergic reactions (e.g. milk-free, egg-free diet, wheat-free diet, etc.) Desensitization: The allergenic food is given in gradually increasing amounts over a long period of time. 
Slide 57: Most Common Food Allergens       Chicken Cow’s milk Wheat Peanuts/nuts Soy products Fish, shellfish
Slide 58: Diabetes Mellitus (DM) Dietary Modification   Current concepts There is no one “diabetic diet” that will suit the individual and special needs of a person with diabetes. The diet for an individual with diabetes can only be defined as a “dietary prescription” based on nutrition assessment and treatment goals. 
Slide 59:       Goals of Nutrition Therapy of DM Maintenance of as near-normal blood glucose levels as possible Achievement of optimal serum lipid levels Provision of adequate energy to maintain/achieve reasonable body weight Prevention and treatment of the acute complications and of long-term complications Improvement of overall health through optimal nutrition
Slide 60: Recommended Dietary Modification Total calories – sufficient to maintain/achieve reasonable weight in adults, or meet increased needs of children, adolescents, pregnant and lactating women and individuals recovering from catabolic illness.   Caloric distribution: Carbohydrates : Protein : Fat : 50 – 70% 10 – 20% 20 – 30%   Cholesterol – limit to 300 mg/day or less Carbohydrates sweeteners are permissible
Slide 61: Low-Glycemic Index Foods: Less Than 50 * Eat foods printed in red sparingly; these are high in empty calories. 1 2 3 4 5 6 7 Artichoke <15 Asparagus <15 Broccoli <15 Cauliflower <15 Celery <15 Cucumber <15 Eggplant <15 Intermediate-Glycemic Index Foods: 50 to 70 * Eat foods printed in red sparingly; these are high in empty calories. 1 2 3 4 5 6 7 Brown Rice 55 Canned fruit cocktail 55 Linguine 55 Oatmeal cookies 55 Popcorn 55 Sweet corn 55 Muesli 56 High-Glycemic Index Foods: More Than 70 * Don't avoid or even limit highglycemic index foods printed in green; these are low-calorie and very nutritious foods. 1 2 3 4 5 6 7 Golden Grahams 71 Bagel 72 Corn chips 72 * Watermelon 72 Honey 73 Kaiser roll 73 Mashed potatoes 73
Slide 62: 8 Green beans <15 9 Lettuce, all varieties <15 1 Low­fat yogurt, artificially 0 sweetened <15 1 Peanuts <15 1 1 Peppers, all varieties 2 <15 1 Snow peas <15 3 1 Spinach <15 4 1 Young summer squash 5 <15 1 Zucchini <15 6 1 Tomatoes 15 7 8 White rice 56 9 Orange juice from frozen concentrate 57 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 Bread stuffing mix 74 * Cheerios 74 Cream of Wheat, instant 74 Graham crackers 74 Puffed wheat 74 Doughnuts 75 French fries 76 Frozen waffles 76 * Total cereal 76 Vanilla wafers 77 1 Pita bread 57 0 1 Canned peaches, heavy 1 syrup 58 1 Mini shredded wheats 58 2 1 Bran Chex 58 3 1 Blueberry muffin 59 4 1 Bran muffin 60 5 1 Cheese pizza 60 6 1 Hamburger bun 61 7
Slide 63: 1 Cherries 22 8 1 Peas, dried 22 9 2 Plum 24 0 2 Grapefruit 25 1 2 Pearled barley 25 2 2 Peach 28 3 2 Canned peaches, natural 4 juice 30 2 Dried apricots 31 5 2 Soy milk 30 6 2 Baby lima beans, frozen 7 32 1 * Ice cream 61 8 1 Kudos Whole Grain Bars 9 (chocolate chip) 61 2 Beets 64 0 2 Canned apricots, light 1 syrup 64 2 Canned black bean soup 2 64 2 Macaroni and cheese 64 3 2 Raisins 64 4 2 Couscous 65 5 2 Quick­cooking oatmeal 65 6 2 Rye crispbread 65 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 Grape­Nuts Flakes 80 Jelly beans 80 Pretzels 81 * Rice cakes 82 Rice Krispies 82 Corn Chex 83 Mashed potatoes, instant 83 Cornflakes 84 * Baked potato 85 Rice Chex 89
Slide 64: 2 Fat­free milk 32 8 2 * Table sugar (sucrose) 8 65 2 8 Rice, instant 91 2 Fettuccine 32 9 2 Canned green pea soup 66 9 2 9 French bread 95 3 * M&M's Chocolate 0 Candies, Peanut 32 3 Instant oatmeal 66 0 3 0 * Parsnips 97 3 Low­fat yogurt, sugar 1 sweetened 33 3 Pineapple 66 1 3 1 Dates 103 3 Apple 36 2 3 Angel food cake 67 2 3 2 Tofu frozen dessert 115
Slide 65: 33 Pear 36 33 Grape­Nuts 67 34 Whole wheat spaghetti 37 34 Stoned Wheat Thins 67 35 Tomato soup 38 35 American rye bread 68 36 Carrots, cooked 39 36 Taco shells 68 37 * Mars Snickers Bar 40 37 Whole wheat bread 69 38 Apple juice 41 38 Life Savers 70 39 Spaghetti 41 39 Melba toast 70 40 All­Bran 42 40 White bread 70
Slide 66:    Sodium –limit to about 3000 mg/day; less for people with hypertension or renal complications. Alcohol – moderate amounts may be allowed, contingent on good metabolic control. Vitamins and mineral supplement – not usually necessary, but may be given to individuals, on reduced calorie diets (1400 kcal/day or less).
Slide 67: Strategies for Diabetes Medical Nutrition Therapy Strategy Calorie restriction Type I DM * *** ** *** ** ** *** ** *** Type II DM Obese Non-Obese *** * ** *** *** ** *** * ** *** ** ** *** ** *** * ** Timing of meals Meal spacing Fat modification Sucrose limitation Exercise Exercise snack Other nutrition variables Blood glucose monitoring _________________________________________ * Low ** Moderate *** High ***
Slide 68: Overweight/Obese  Low calorie: To enable the body to deplete adipose tissue stores.  High protein: For high safety value; exerts higher specific dynamic action; to minimize tissue nitrogen loss  Moderate fat: For safety value; emphasis on PUFA.  Normal to low CHO: Close relation of glucose to fat formation.  Bulky, low calorie foods: To provide safety without increasing calorie intake.  Supplement of PUFA: Accelerates oxidation of body fat.
Slide 69: Underweight  High calorie diet: For storage of fat in the adipose tissue, to restore DBW Gradual increases: To avoid gastric upsets and spells of discouragement. High protein: For replacement and repair of body tissue High CHO: For added calories; protein-sparer. Bulky, low calorie foods: To provide satiety without increasing calorie intake. Supplement of PUFA: Accelerates oxidation of body fat.     
Slide 70: Hyperthyroidism     High calories: to compensate for increased BMR Adequate vitamins – thiamin, riboflavin, B12, ascorbic acid, pyridoxine and vitamin A, D, E. - increased requirements for enhanced cellular metabolism - Degradation of vitamin is accelerated. Increased iodine: Iodine is needed for thyroxine formation. Adequate calcium: Correct Ca resorption from bone and prevent hypercalciuria.
Slide 71: Hypothyroidism   Iodine supplementation Low calorie: To minimize weight gain due to lowered BMR
Slide 72: Hyperinsulinism Functional Type Low CHO (75­110 g/day): emphasis on complex CHO: CHO serves as stimulus to insulin secretion.  High protein, high fat. If obese emphasize MUFA: To supply glucose in as slow even but continuous flow and to prevent marked rise of sugar at any one time.  Maintenance of DBW: To prevent oversecretion of insulin.  Restriction on coffee, tea and cola beverages: Caffeine stimulates the adrenals to cause glycogenolysis and gluconeogenesis * increased blood glucose * stimulation of pancreas * increased insulin.  Avoidance of alcohol: Alcohol has hypoglycemic
Slide 73: Hyperinsulinism Fasting High CHO: To provide constant sucrose of available glucose.
Slide 74: Hypertension  Calorie level, depends on weight status or weight goal: Weight loss of 5­6% in over­weight/obese can lower BP. Sodium – restricted: Excess sodium may increase: ­ cardiac output due to over­filling of vasculature ­ peripheral resistance to blood flow   Fluids and roughage – adequate: Prevent constipation which hinders absorption of anti­hypertensive drugs.
Slide 75: Risk Factors for CHD ● Modifiable ● Dyslipidemia ● Nonmodifiable ● ● ● ● ● ● ● Smoking Hypertension Diabetes mellitus Obesity Dietary factors Thrombogenic factors Sedentary lifestyle ­ Age ­ Sex ­ Family history of CHD
Slide 76: HDL Cholesterol Low HDL cholesterol is a strong independent predictor of CHD1  The lower the HDL cholesterol level the higher the risk for atherosclerosis and CHD2  Low HDL is defined categorically as a level < 40 mg/dl (a change from < 35 mg/dl in ATP II)1  HDL cholesterol tends to be low when triglycerides are high2
Slide 77: Triglycerides  Recent data suggest that elevated triglycerides are an independent risk factor for CHD Normal triglyceride levels: < 150 mg/dl Borderline-high triglycerides: 150 to 199 mg/dl High triglycerides: 200 to 499 mg/dl Very high triglycerides: (> 500 mg/dl) increase pancreatitis risk Initial aim of therapy is prevention of acute pancreatitis.     
Slide 78: CHD  Total fat – not more than 30% of TER: - avoid post-prandial hyperlipedemia and its possible adverse effect of coagulation. - reduce plasma LDL cholesterol   SFA – approx 10% of TER period of time. PUFA – approx. 10% of TER consisting of omega-6 PUFA (e.g linoleic acid), promotes prostaglandin synthesis, which in turn promotes arterial dilation and heart muscle contractility Long chain PUFA or omega 3 fatty acids 
Slide 79:      MUFA – approx. 10% of TER. as effective as PUFA in lowering serum total cholesterol, but has the advantages of not lowering HDL cholesterol, less susceptible to oxidation, less thrombogenic potential, does not raise serum triglycerides; also has less tumorigenic potential. Cholesterol – not more than 300 mg/day reduce plasma LDL cholesterol Sodium – moderate intake: -control blood pressure Carbohydrates – type and amount depends on lipid abnormality Alcohol – avoid high intake: control blood pressure - reduce fibrinogen - exessive intake can produce hypertriglyceridemia, elevated LDL cholesterol, arrythmia, cardiac enlargement and heart failure
Slide 80: Calories – sufficient to maintain/achieve desirable body weight. - reduce insulin resistance - reduce synthesis of cholesterol, esp. LDL, VLDL, triglycerides - reduce risk of cholesterol gallstone formation
Slide 81: Acute MI or Coronary Occlusion or Thrombosis       Acute phase: 500 – 800 cal liquid diet for 2-3 days * to avoid gagging and aspiration of solid foods. No extremes in temperature - To prevent possible precipitation of arrythmias. No coffee or tea - maybe stimulating and increases heart rate. Parenteral feeding - For those unwilling to consume liquid diet Restriction of Na - to prevent/correct edema
Slide 82:  Subacute phase * 1000 – 1200 cal: 20% Pro. 45% CHO 35% fat - To meet resting metabolism requirements. Cholesterol, 300 mg * To control blood cholesterol possible precipitation level Soft, low fiber, free of gastric irritants * To avoid indigestion and flatus Sodium restriction * To prevent /correct edema Small frequent feeding * to reduce possibility of post prandial dyspnea or pain.    
Slide 83: Congestive Heart Failure  Low calories - reduce weight; decrease work of heart Moderate protein - maintenance of N balance Sodium restriction – 500 mg initially, 1000 mg later - to control edema. Small frequent feedings - decreased circulatory load Fluid as desired    
Slide 84: Nutritional Anemias Iron Deficiency Anemia Iron supplementation Adequate diet with emphasis on vitamin C to enhance iron absorption and utilization. Megaloblastic anemia Vitamin B12 must be given by injection because of the lack of intrinsic factor necessary for its absorption. 
Slide 85: Nutrition in Renal Diseases
Slide 86: Metabolic Abnormalities Renal clearance or urea guanidines, other products of N metabolism, Na, K, Ca, Mg, trace elements and many medicines.  Impaired ability to conserve nutrients such as Na and sometimes protein.  Reduce intestinal absorption of Ca and Iron  Impaired ability to synthesize or metabolize Loss of excretory function • Impaired metabolic action, resulting in altered nutrient, metabolic and hormone levels. • Synthesis of certain hormones (erythropoietin and 1, 25 dihydroxycholecalciferol)  Altered synthesis or degradation of nutrients by other tissues Intestinal formation of dimethylamine and trimethylamine Metabolic clearance of pyridoxine.
Slide 87: Possible mechanism underlying these metabolic alterations     Loss of excretory function Impaired metabolic action, resulting in altered nutrient, metabolic and hormone levels Adaptive changes in metabolic feedback loops involving hormones, enzymes and reaction products. Reduced food intake
Slide 88: Effects of these abnormalities     Blood levels – amines, phenols and indoles and other nitrogenous substances Enzymes of amino acid metabolism, tricarboxylic acid enzyme and gluconeogenic enzyme. Serum nitrogen-containing hormones (insulin, glucagon, PTH, growth hormones, gastrin, rolactin, leutinizing hormones, gastrin, prolactin, leutinizing hormones Serum somatostatin Serum erythropoietin and 1, 25 dihydroxycholecalciferol
Slide 89:   Serum Renin – normal, increased or reduced Deficiencies of vit. D and folic acid and vit. B6 due to medicine. Wasting syndrome: • Relative body weight, muscle mass and body fat • •  Slow growth rate in children Decreased serum concentration of total protein, albumin, transferin, C3 and other complement proteins Abnormal plasma amino acid concentration •
Slide 90: DIETARY PRINCIPLES Objectives of nutritional therapy in chronic failure  To maintain nutritional status      To minimize uremic toxicity To prevent net protein catabolism To stimulate patient’s well-being To retard progression of renal failure To postpone initiation of dialysis
Slide 91: DIETARY PRINCIPLES Nutritional treatment of CRF   Judicious regulation of protein intake Regulation of fluid intake to balance fluid output and insensible water loss Regulation of sodium to balance fluid output Restriction of potassium and phosphate Insistence on an adequate calorie intake Supplementation with appropriate vitamins    
Slide 92: Renal Disorders-1 Acute or chronic glomerulonephritis Controlled fluid intake = fluid output Kcal Controlled protein -according to laboratory data & renal function Sodium Potassium Nephritis Treat symptomatically when there is significant uremia, hyperkalemia or edema. Replace all lost fluids
Slide 93: Renal Disorders-2 Uremia  Adequate calories and controlled protein, fluid and electrolytes according to laboratory data and renal function Nephrotic Syndrome Protein Kcal 1.5 g/kg/day + 1 g Protein for each gram protein lost in urine increased kcal to spare protein low sodium (2 grams) to reduce edema Sodium -
Slide 94: Renal Disorders-3 Acute Renal Failure Protein - not restricted below 1.0 – 2.0 g/kg DBW Kcal - increased kcal to spare protein for a malnourished child, 1 ½ - 2 times normal requirements Sodium - varies according to fluid retention and hydration states Potassium - decreased due to hypercalcemia as a result of catabolic process
Slide 95: Renal Disorders-4 Chronic Renal Failure  Regulation of protein intake    Balance of fluid intake and output Adequate calorie intake Regulation of sodium, potassium and phosphorus intake Supplementation of appropriate vitamins and minerals *Restriction is not fixed dependent on patient’s clinical and biochemical status 
Slide 96: THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS          Acne Low fat Acute gastroenterities (diarrhea) Clear liquid Acute glomerulonephritis Low Na, Low protein Addisons’ disease Hi Na, Low K Angina pectoris Low cholesterol Arthritis, gout Purine restricted ADHD Finger foods Bipolar disorder Finger foods Burn High calorie, hi pro
Slide 97: THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS           Celiac’s disease Cholecystitis Congestive heart failure Cretinism Crohn’s dse. Cushings’ dse. Cystic fibrosis Cystitis Calculi Decubitus ulcer (bedsore) Gluten free Hi pro, hi CHO, low fat Low Na, low cholesterol Hi pro, hi Ca Hi pro, hi CHO, low fat Hi K,low Na Hi calorie, high Na Acid Ash (for alkaline stones) Alkaline Ash (for acid stones) High protein, High vit. C.
Slide 98: THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS  Diabetes mellitus Well balanced          Diarrhea Hi K, high Na Diverticulitis Low residue Diverticulosis Hi residue with no seeds Dumping syndrome Hi fat, high protein, dry Hepatic encephalopathy Low protein Hepatitis Hi protein, high calorie Hirschprungs’ dse. Hi calorie, low residue, hi pro Hyperparathyroidism Low calcium Hypothyroidism Low cal, low cholesterol, low sat fat
Slide 99: THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS           Kawasaki’s dse. Liver cirrhosis Meniere’s dse. Myocardial infarction Nephrotic syndrome Osteoporosis Pancreatitis Peptic ulcer Phenylketonuria PIH Clear liquid Average protein Low sodium Low fat, low Chol, low Na Low Na, hi pro, hi cal Hi cal, Hi vit. D Low fat Hi fat, hi Cho, low pro Low pro/phenylalanine Hi pro
Slide 100: THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS     Renal colic Low Na, low pro ARF: Low pro, hi Cho, Low Na (Oliguric phase), Hi pro, hi Cal, & restricted fluid (diuretic phase) CRF Low pro, low Na, low K Tonsillitis Clear liquid; cold diet