Domain 2: Clinical

DETERMINE checklist

-10 questions to help raise public awareness of nutrition risk -Each question contains a point value. If answered yes, the points are added to the total. Score is tallied to determine low risk, moderate risk, or high risk D = disease E = eating poorly T = tooth loss or mouth pain E = economic hardship R = reduced social contact M = multiple medicines I = involuntary weight loss or gain N = needs assistance in self care E = elder years above age 80 I have an illness or condition that made me change the kind and/or amount of food I eat: 2 points I eat fewer than 2 meals per day: 3 points I eat few fruits or vegetables or milk products: 2 points I have three or more drinks of alcohol almost everyday: 2 points I have tooth or mouth problems that make it hard for me to eat: 2 points I dont always have enough money to buy the food I need: 4 points I eat alone most of the time: 1 point I take 3 or more different medications each day: 1 point Without wanting to, I have lost or gained ten points in the last 6 months: 2 points I am not always physically able to shop, cook, and/or feed myself: 2 points 0-2 = good nutritional health 3-5 = moderate nutritional risk 6+ = high nutritional risk

Food Intake Collection Methods

-24-hour recall -Food frequency questionnaire (examines long-term food intake) -Food record -Observation (usually in hospital setting)

Galactosemia

-A disorder that affects how the body processes the simple sugar galactose -Galactose is part of the disaccharide lactose and is present in all dairy products and some baby formulas -Type 1: classic galactosemia- most common/severe -Type 2: galactokinase deficiency -Type 3: galactose epimerase deficiency, most rare Symptoms: -develop few days after birth -irritability -lethargy -poor feeding -poor weight gain -jaundice -vomiting -convulsions Pathophysiology: -mutation in a particular gene and affects different enzymes involved in breaking down galactose -inherited disorder that often results from a profound loss of galactose-1-phosphate uridylytransferase (GALT) activity -galactose levels build up and may lead to potentially lethal symptoms if untreated Diagnosis: -tested as part of the newborn screening protocol -high levels of galactose in the blood -low levels of the enzyme activity of GALT: <24.5 mmol/mg of hemoglobin -low levels of galactokinase (GALK, type 2) or UDP-galactose-4-epimerase (GALE, type 3) -urine test -genetic testing MNT: -low galactose diet -limiting dairy foods -breastfeeding may not be possible since breastmilk contains galactose -lactose-free formula

Atherosclerosis

-buildup of plaque in the interior walls of the arteries that leads to narrowing and hardening of the arteries -plaque is made up of of fatty deposits, cholesterol, and/or calcium -blood flow restricted to heart and organs -major contributing risk factor in the development of hypertension, heart attack, heart failure, and stroke -can be treated with lifestyle modifications and medications, such as: cholesterol-lowering medications (statins), ACE inhibitors, diuretics, beta blockers, anticoagulants Symptoms: -may be asymptomatic until the arteries become clogged enough to limit blood flow, can take years to accumulate -chest pain -pain in arms/legs -SOB -dizziness -confusion -heart attack, stroke Pathophysiology: -damage to arteries is first step -lesions along interior artery walls occur due to inflammation, smoking, hypertension, or other diseses -plaque in the blood begins to accumulate where the arteries are damaged -inner lining of artery becomes thickened with plaque buildup and blood flow may decrease -Risk factors include: -HTN -High cholesterol (>200 mg/dL) -High LDL or low HDL cholesterol -Obesity -Smoking -Family hx -decreased physical activity -diabetes Diagnosis: -diagnosed with a combination of physical exam, blood tests, and imaging -Labs indicative of atherosclerosis risk: -Total cholesterol > 200 mg/dL -HDL cholesterol < 40 mg/dL -LDL cholesterol > 100 mg/dL -Ultrasound, angiograms (chest x-ray), and electrocardiograms (EKG) are used to detect blocked arteries and impaired blood flow MNT: -Encourage physical activity to promote weight loss and improve heart health -Diet low in fat and cholesterol -Avoid fried foods, processed foods, red meats, and hydrogenated oils -Increase intakes of polyunsaturated fats from fish, fish oils, and plant oils -Decrease sugar intake -Avoid sweetened beverages and limit sweets -Increase fiber intake to eliminate cholesterol from the body -Supplement with vitamin K2 to help deposit circulating calcium in the skeletal system instead of the arteries

Rickets

-childhood bone disease involving impaired mineralization of growing bones -structural abnormalities of the weight-bearing bones, resulting in bowed legs, breaded ribs, pigeon breast, and front bossing of the skull -result of deprivation of vitamin D and deficiencies of calcium and phosphorus -children most at risk have dark skin and are breastfed for long periods without exposure to sunlight or vitamin D supplementation -can be treated with vitamin D supplementation

Components of energy expenditure

Basal metabolism: -BMR: energy expended for life-sustaining activities when the body is at complete rest -RMR: similar to BMR but slightly higher and is the amount of energy expended at rest in a comfortable setting Physical Activity: -Most variable component -Sedentary to lightly active: BMR X 1.2 -Lightly active: BMR X 1.4 -Moderately active: BMR X 1.6 -Very active: BMR X 1.7 -Extremely active: BMR X 1.9 Thermic Effect of Food: -Estimated 10% -CHO: 5-10% -Fats: 0-5% -Protein: 20-30% -Alcohol: 15-20% Total Energy Expenditure (TEE) TEE = BMR + activity thermogenesis + thermic effect of food

Cancer

Benign tumor: -noncancerous masses that do not spread -generally non life-threatening, unless they occur in the brain -if removed surgically, they do not grow back Malignant tumor: -cancerous tissues that require treatment and are life-threatening -if removed surgically, they can sometimes grow back Metastatic cancer: -cancer that has spread from one area of the body to another Side effects of cancer and cancer treatments: -nausea -vomiting -diarrhea -weight loss -constipation -loss of appetite -muscle wasting -malnutrition Pathophysiology: -caused by genetic changes that control the way cells grow, function, and divide -can occur almost anywhere within the body Prevention: -no one way to prevent cancer -regular cancer screening tests -HPV vaccine -diet rich in fruits and vegetables -maintaining a healthy lifestyle Risk Factors: -poor diet -increased age -alcohol/tobacco use -obesity -immunosuppression -chronic inflammation -infections agents Diagnosis and Treatment: -diagnosed based on where the cancer cells originate and what type of cell they originated from -Carcinoma: most common type, formed by epithelial cells -Sarcoma: bones/soft tissues, fat, muscles, and vessels -Leukemia: blood-forming tissues of bone marrow -Lymphoma: T-cell or B-cell lymphocytes involved in the immune system -Multiple myeloma: plasma cells involved in the immune system -Melanoma: melanocytes -brain and spinal cord tumors: brain/spinal cord cells -germ cell tumors: cells that produce sperm or eggs and can occur anywhere in the body -neuroendocrine tumors: cells that release hormones into the bloodstream as instructed by the brain -carcinoid tumors: slow-growing neuroendocrine tumor usually found in the GI system Common side effects of various treatments: -chemotherapy & hormone therapy: loss of appetite, nausea, dry mouth, vomiting, mouth/throat sores, changes in taste, difficulty chewing, diarrhea, constipation, fullness -radiation therapy: loss of appetite, nausea, vomiting, sore mouth and gums, pain with swallowing, inability to open mouth fully, colitis, bowel obstruction, diarrhea, choking, breathing problems -immunotherapy: tiredness, fever, diarrhea, nausea, vomiting -stem cell transplant: diarrhea, throat and mouth sores, and graft versus host disease (GVHD), which can impact the liver and GI tract and inhibit nutrient absorption -surgery: loss of appetite, difficulty chewing and swallowing, feeling full quickly after eating MNT: -optimize nutrition and promote weight gain/preventing weight loss and muscle wasting -nutrition assessment -NFPE -nutrition counseling -glutamine supplementation may help in the treatment of mucositis and diarrhea caused by radiation and chemotherapy Dietary recommendations: -High protein foods -Fruits/vegetables -avoid processed meats and pickled foods -healthy physical activity -food safety For poor appetite: -milkshakes, smoothies, and blended foods -high-calorie nutrition shakes -larger meals when patient is feeling good -regular teeth brushing to minimize aftertaste and oral symptoms that can reduce appetite -separate liquid from food intake to prevent early fullness For nausea: -bland foods -crackers in the morning before standing up -hard candies -5-6 small meals -sit up after eating -loose and comfortable clothing -anti-nausea medications For dry mouth: -easy to swallow foods -water throughout the day -smoothies/shakes -moisten foods For mouth sores: -drink with straw -suck on ice cube to numb the mouth -avoid crunchy, spicy, and acidic foods For taste changes: -try tart foods -use gum, mints, or lemon drops -chew food longer -use plastic utensils

Assessment of fluid status

Edema: -dry and scaly skin -localized edema commonly occurs in ankles and sacrum -generalized edema found throughout the body, commonly in patients w/ renal and heart failure -Mild edema (+1): 2mm depression with an immediate rebound -Moderate edema (+2): 2-4mm pit that takes a few seconds to rebound -Moderately severe edema (+3): 4-6mm pit with a 10-12 second rebound, if at all Ascites: -fluid accumulation in peritoneal cavity -often associated with liver failure or metastatic cancer of the abdomen -present with a positive fluid wave test, distended abdomen, and decreased serum sodium (confirmed with an ultrasound) Dehydration: -dry appearance, dry lips, cracked skin, dry mucous membranes -sunken eyes and sunken tongue -serum sodium, BUN, and creatinine are biochemical markers of dehydration -decreased urine output with dark color and odor -constipation

Amputations

Each body part consists of a percentage of BW Upper body: Hand: 0.7% Forearm: 1.6% Upper arm: 2.7% Below elbow amputation (BEA): 2.3% Above elbow amputation (AEA): 5% Lower body: Foot: 1.5% Lower leg: 4.4% Upper leg: 10.1% BKA: 5.9% AKA: 16%

Nutrition Screening

a process used to identify individuals at nutritional risk or with nutritional problems All newly-admitted patients should be screened for nutrition problems within 24 hours of admission. Not every patient screened will enter the NCP.

Food Drug Interactions: NSAIDS

-Designed to relieve pain, fever, and inflammation -Aspirin and ibuprofen -Interaction w/ alcohol --> can cause stomach bleeding and risk is elevated with alcohol consumption of 3+ drinks/day

Federal Nutrition Programs- Children

-All federally-funded nutrition programs are funded through the Farm Bill and Child Nutrition Reauthorization Act -These programs are administered by the US Department of Agriculture Food and Nutrition Service but are managed through different agencies at the state level Child and Adult Care Food Program (CACFP) -provides reimbursement for nutritious meals and snacks to eligible children/adults National School Lunch Program (NSLP) -Established under the National School Lunch Act in 1946 -Available in all 50 states -Provides low-cost or free lunches meeting federal nutrition requirements to children in public, nonprofit private schools, and residential childcare institutions -Meals must contain <30% total fat, <10% saturated fat, and provide at least 33% of the --RDA for protein, vitamins A and C, iron, calcium, and calories -Income eligibility: 130-185% of federal poverty level for reduced price meals; < 130% of federal poverty level for free meals -Categorically eligible: Participation in other programs such as SNAP -Status of homelessness, migrant, runaway, or foster child School Breakfast Program -Same eligibility requirements for the NSLP Special Milk Program -Provides milk to children who do not participate in other federal meal service programs -Provides pasteurized low-fat or fat-free milk Summer Food Service Program (SFSP) -When school is not in session for 15 or more days -Free healthy meals to children and teens in low-income areas who are eligible for free or reduced price meals WIC -Purpose is to safeguard the health of low-income pregnant, postpartum, and breastfeeding women and infants and children up to age 5 who are at nutritional risk -Provides nutritious foods, information about breastfeeding, and referrals to care -Categorical eligibility requirements: pregnant: during and up to 6 weeks after postpartum: up to 6 months after birth breastfeeding: up to 12 months infant: up to 12 months child: up to child's 5th birthday -Income eligibility requirements: income must be at or below an income level set by the state or eligibility based on participation in other federal programs -Nutrition risk eligibility: must have conditions including anemia, underweight, hx of poor pregnancy or poor diet

Assessment of micronutrient deficiencies- Hair

-Alternating bands of light/dark colors: iron -Thin, brittle hair: protein, essential FAs, biotin -Hair loss: iron, zinc, biotin, protein -Soft, white, downy hair that grows all over the body: prolonged calorie deficiency -Corkscrew hairs: vitamin C, copper -Lighter than usual hair without sun exposure: selenium -Seborrheic dermatitis (cradle cap): zinc, B6, biotin -Follicular hyperkeratosis: Vitamins A or C, essential fatty acids

Celiac Disease

-Autoimmune disorder triggered by gluten Gluten: -found in wheat, rye, and barley -commonly found in gravies, sauces, soups, imitation seafood, and processed meat Symptoms: -may appear in many parts of the body -babies/children more likely to exhibit digestive symptoms such as diarrhea, constipation, vomiting, bloating, gas, nausea, fatty stools -pediatric symptoms also include fatigue, delayed growth, behavioral issues, and iron deficiency anemia -adults may experience the GI symptoms as well but also more likely to exhibit body-wise symptoms such as fatigue, iron deficiency anemia, join pain, bone loss, depression, infertility, seizures, skin rashes, and dermatitis herpetiformis Pathophysiology: -symptoms caused by the production of antibodies in response to gluten -antibodies trigger the immune system that causes inflammation in the S.I. -villi of the SI become damaged -large gaps between villi, allowing undigested molecules from the SI to the bloodstream -nutrient malabsorption and malnutrition can occur as a result of a compromised small intestine -deficiency in Fe, Ca, Mg, Zn, B vitamins, and vitamins A, D, E, and K -Genetic factors and some autoimmune conditions that may increase the likelihood of developing celiac: -autoimmune liver disease -lupus -rheumatoid arthritis -T1 diabetes -down syndrome, turner syndrome, williams syndrome Diagnosis: -Blood tests detect the antibodies that are produced in response to gluten -Quantitative immunoglobin (IgA) -IgA anti-tissue transglutaminase antibodies (tTG-IgA) -Antibody tests are 95% accurate in detecting celiac disease -A positive test should be followed with a small intestine endoscopy and biopsy to confirm the diagnosis and determine the extent of damage to the villi -Clinicians may also choose to perform other blood tests to determine the extent of deficiencies in nutrients such as: -iron, vitamins A, D, and K, folate, B vitamins, and minerals such as calcium, magnesium, and zinc MNT: -Only treatment is a lifelong adherence to a gluten-free diet -Damage to the SI can heal after months or years of following a GF diet -Vitamin and mineral supplementation may be needed to help reserve nutrient deficiencies -Educate patients on gluten containing foods and how to read food labels -"wheat-free" may not be GF foods -awareness of hidden sources of gluten such as malt and malt vinegar, seitan, wheat starch, dextrin, and brewer's yeast

Eating Disorders

-Behaviors may include restrained eating, fasting, binge eating, and purging -Prevalence is higher in women and more common in athletes and teens -People suffer from eating disorders because of sociocultural, psychological, and/or neurochemical factors Anorexia Nervosa: -Self-starvation resulting in emaciation -Body image distortion, causing them to feel fat regardless of how little body fat they may have Criteria for diagnosing anorexia: -refusal to maintain weight at or above a minimal normal weight for age and height -intense fear of gaining weight -disturbances in weight or shape or denial of a current low body weight -Amenorrhea: absence of at least 3 consecutive menstrual cycles MNT for anorexia: -Initial therapy: 30-40 cals/kg/d -Aiming for: 70-100 cals/kg/d -Assess risk for refeeding syndrome -Increase calories in small, gradual amount to promote a controlled weight gain -Protein: 15-20% of calories -CHO: 50-55% of calories with sources of insoluble fiber for treatment of constipation -Fats: 30% of calories including EFAs -Multivitamin providing 100% of the RDA, except for iron -Avoid iron supplementation during initial phase of weight restoration Bulimia Nervosa: -Recurrent episodes of binge eating followed by inappropriate compensatory behaviors to prevent weight gain -Inappropriate behaviors may include self-induced vomiting, laxative misuse, diuretic misuse, compulsive exercising, or fasting -Bulimic patients are typically within normal body ranges but are frustrated by their inability to attain underweight state Criteria for diagnosing bulimia: -eating larger amount of food than most people would eat in a similar amount of time -lack of control during eating -recurrent compensatory behaviors -occurs at least 2x/week for 3 months -Russell's signs: scarring on the top of hands to induce vomiting -erosion in the dental enamel from stomach acid MNT for bulimia: -if evidence of hyper metabolic rate, provide 1,500-1,600 cals/d -if metabolic rate is normal, provide the DRI for energy -avoid weight reduction diets until eating patterns and body weight are stable -Protein: 15-20% of calories -CHO: 50-55% of calories with sources of insoluble fiber for treatment of constipation -Fats: 30% of calories including EFAs -Multivitamin providing 100% of the RDA -Iron supplementation may aggravate constipation Binge Eating Disorder: -Similar to bulimia nervosa, but with no inappropriate compensatory behaviors to correct the action of binge eating -episodes must occur 2x/week for 6 months -most patients are overweight Criteria for diagnosing BED: -eating large amounts of food more rapidly than normal -eating until feeling uncomfortably full -eating when not feeling physically hungry -eating alone because of the embarrassment of how much they are eating -feeling of disgust, depression, or guilt after overeating

Food Drug Interactions: Diuretics

-Designed to eliminate water, sodium, and chloride from the body in hopes to reduce swelling and excess fluid retention caused by heart or liver disease -Used to treat high blood pressure -Bumetanide, furosemide, triamterene -Take w food if causes upset stomach -Some can cause a loss of potassium, calcium, and magnesium. Thiazide diuretics can reduce calcium excretion by the kidneys, resulting in higher levels -Interaction w/ foods high in potassium

Traumatic Brain Injury (TBI)

-Blow to the head or a penetrating head injury that disrupts the normal function of the brain -The body's response to stress from a TBI results in the production of cytokines, such as: -Interleukin-1 -Interleukin-6 -Interleukin-8 -Tumor necrosis factor Pathophysiology -Brain injury categorized as a concussion, contusion, and diffuse axonal injury -Concussion: brief loss of consciousness, lasting less than 6 hours, no damage found on CT or MRI scans -Contusion: damaged capillaries and swelling, followed by resolution of the damage, detected by CT and MRI scans -Diffuse axonal injury: results from the shearing of axons by rotational acceleration of the brain inside the skull MNT: -Primary goal is to oppose the hypercatabolism and hypermetabolism associated with inflammation -hypercatabolism caused by protein degradation, as evidenced by increased urinary urea nitrogen excretion -Nitrogen catabolism in healthy person: 2-3 g of N per day -Nitrogen catabolism in TBI patient: 14-25 g of N per day -hypermetabolism increases energy expenditure -energy needs of 100-140% of with 15-20% nitrogen calories to reduce nitrogen loss -feeding administered by either EN or PN -nutrition support to begin within 72 hours after injury -supplement with zinc and essential omega-3 fatty acids DHA and EPA --> antioxidant, anti-inflammatory, and anti-apoptosis effect, leading to neuron protection in the damaged brain

Gestational Diabetes

-Body does not make enough insulin during pregnancy Symptoms: -Usually develops in mid-pregnancy and does not have any symptoms -Gestational diabetes test is a routine test for pregnant women between 24-28 weeks of pregnancy Pathophysiology: -Likely influenced by changing hormones and weight gain that occur during pregnancy -Hormones cause changes in the ability of the cells to use insulin as effectively as normal -Results in insulin resistance, which increases the body's need for insulin Diagnosis: -Tested between 24 and 48 weeks, or earlier if more risk factors are present -Glucose screening test: -Normal: 140 mg/dL or lower -If above 140, glucose tolerance test is indicated MNT: -Regular blood sugar monitoring -Following a healthy eating plan that may include carbohydrate counting -Regular physical activity -Monitoring the development of the baby -Potentially prevent GD by being physically active and achieving healthy weight before pregnancy -Weight loss should not be pursued if the woman is already pregnant -Pregnant women with GD should be advised to gain same amount of weight as a non-diabetic women -Blood sugar levels should be tested 6-12 weeks following delivery of the baby and then every 1-3 years after to make sure levels are normal

Type 1 Diabetes

-Body does not produce adequate amounts of insulin Symptoms: -increased urgency/frequency of urination -increased thirst -unintentional weight loss -blurred vision -numbness or tingling in the hands/feet -excessive tiredness -very dry skin -slower than normal wound healing -increased susceptibility to infections -nausea, vomiting, stomach pains Pathophysiology: -Thought to be caused by an autoimmune reaction in which the body attacks itself -The reaction destroys the beta cells in the pancreas which make insulin -The reaction can go on for months to years before enough beta cells are destroyed that symptoms appear -Family hx can be a risk factor -May have environmental trigger -Not caused by diet/exercise habits Diagnosis: -Identified via one or more blood tests -HbA1c: measures avg blood sugar levels over past 2-3 months -normal: below 5.7% -pre-diabetes: 5.7-6.4% -diabetes: 6.5% or higher -Fasting blood sugar: measures blood sugar levels after an overnight fast or not eating for at least 8 hours -normal: 99 mg/dL or lower -pre-diabetes: 100-125 mg/dL -diabetes: 126 mg/dL or higher -Glucose tolerance test (GTT): follows an overnight fast and measures blood sugar levels before and then 1, 2, and possibly 3 hours after drinking a glucose-containing liquid -normal: 140 mg/dL or lower -pre-diabetes: 140-199 mg/dL -diabetes: 200 mg/dL or higher Random blood test: performed at any time with no preparation and does not require fasting -diabetes: 200 mg/dL or higher -If type 1 diabetes is suspected, a test for autoantibodies or a urine test for ketones may be done -Presence of autoantibodies or ketones indicates Type 1, not Type 2 MNT: -requires taking insulin injections or wearing an insulin pump for regular blood sugar monitoring -can help to follow an eating plan that involves carbohydrate counting -check blood sugar levels about 30 mins prior to beginning exercise -if under 100 mg/dL, consume 10-15 g of carbohydrates before moderate-intensity, and 20-30 g of cho before high-intensity -check blood sugar levels about 60 minutes after exercise and adjust CHO intake as necessary

Type 2 Diabetes

-Cells do not respond well to insulin Symptoms: -increased urgency/frequency of urination -increased thirst -unintentional weight loss -blurred vision -numbness or tingling in the hands/feet -excessive tiredness -very dry skin -slower than normal wound healing -increased susceptibility to infections Pathophysiology: -cells stop responding normally to insulin, which leads to insulin resistance and the pancreas producing more insulin trying to get the cells to respond -Once the pancreas can no longer keep up with insulin needs, blood sugar levels rise -Risk factors include: -overweight/obese -family hx -high blood pressure & triglyceride levels -high-fat diet -high alcohol intake -sedentary lifestyle -hx of gestational diabetes -being african american, native american, hispanic american, or asian american -over 45 years old Diagnosis: -Identified via one or more blood tests -HbA1c: measures avg blood sugar levels over past 2-3 months -normal: below 5.7% -pre-diabetes: 5.7-6.4% -diabetes: 6.5% or higher -Fasting blood sugar: measures blood sugar levels after an overnight fast or not eating for at least 8 hours -normal: 99 mg/dL or lower -pre-diabetes: 100-125 mg/dL -diabetes: 126 mg/dL or higher -Glucose tolerance test (GTT): follows an overnight fast and measures blood sugar levels before and then 1, 2, and possibly 3 hours after drinking a glucose-containing liquid -normal: 140 mg/dL or lower -pre-diabetes: 140-199 mg/dL -diabetes: 200 mg/dL or higher Random blood test: performed at any time with no preparation and does not require fasting -diabetes: 200 mg/dL or higher MNT: -requires regular monitoring of blood sugar levels -may require insulin shots or oral diabetes medications to manage blood sugar levels medically if not managed by diet/exercise -can help to follow an eating plan that involves carbohydrate counting

Multiple Sclerosis (MS)

-Chronic disease that affects the central nervous system -Characterized by the destruction of the myelin sheath, which is responsible for transmitting electrical nerve impulses -Myelin is replaced with sclera (scar tissue) in the brain, optic nerves, and spinal cord -Symptoms are usually mild, but severe symptoms can render a person unable to speak, write, or walk -As the disease progresses, neurological deficits and dysphagia may occur because of damage to cranial nerves -Patients may have a more difficult time preparing meals with decreased vision and poor ambulatory -Neurogenic bladder: urinary incontinence, increased urgency, increased frequency -Neurogenic bowel: constipation, diarrhea, fecal impaction -Exact cause is unknown, but research is finding a correlation between MS and vitamin D deficiency MNT: -Close assessment of vitamin D status -Supplemental vitamin D -Mechanically-altered diet if dysphagia is present -Reliance on comfort foods and convenience foods -Fluids distributed evenly throughout the day and limited near bedtime -Adequate fluids to decrease risk of UTIs -Adequate fiber and fluids to help with constipation

Food Drug Interactions: Lovastatin

-Designed to lower cholesterol levels by decreasing the production of LDL cholesterol -Some also lower triglycerides, help raise HDL, and lower risk of heart attack -Interaction w/ alcohol and grapefruit juice

Ulcerative Colitis

-Chronic inflammation and ulcers in the digestive tract, primarily in the colon and rectum Symptoms: -small ulcers throughout entire colon, with significant areas of narrowing -severe bleeding -severe dehydration -malnutrition -perforated colon -toxic megacolon -colon cancer -blood clots -osteoporosis -inflammation of skin, eyes, and joints Pathophysiology: -cause is unknown, but symptoms can be worsened by diet and stress -Risk factors: -family history, caucasian or Eastern European Jewish descent Diagnosis: -Primarily by colonoscopy as well as stool samples, blood tests, and imaging studies MNT: -Low fiber and caffeine-free diet for flare-ups can help -Omega 3 fatty acid supplementation -Smaller, more frequent meals -liquid nutritional supplements in periods of poor appetite -MCT supplements to provide extra calories and assist with fat soluble nutrient transport

Hypertension

-Chronic, consistently elevated blood pressure -Blood pressure: -force of blood on artery walls -measured in millimeters of mercury (mm Hg) -measures the pressure on artery walls during contraction of the heart (systolic) and when the heart is relaxed (diastolic) -Classified in 3 stages based on the risk of developing coronary heart disease -Elevated blood pressure ages and stiffens arteries, increasing risk for heart attack and stroke -Blood pressure can be managed with lifestyle modifications and medication. Some meds include diuretics, beta blockers, angiotensin-converting enzymes (ACE) inhibitors, and vasodilators Symptoms: -often asymptomatic, but chronic -headaches -SOB -flushed appearance -dizziness Pathophysiology: -Occurs when blood vessels are consistently constricted -Several physiological processes are involved in regulated blood pressure, including renal and adrenal function -family hx and genetics play a role -risk factors include: -overweight/obese -physical inactivity -smoking -excessive alcohol consumption -increased age -high stress levels -high salt intakes -low potassium intakes -diabetes -atherosclerosis Diagnosis: -average of several blood pressure readings -must be consistently elevated to diagnose -normal: 120/80 mm Hg -elevated: 120-129 / < 80 mm Hg 3 stages of hypertension Stage 1: 130-139 / 80-89 mm Hg Stage 2: 140+ / 90+ mm Hg Stage 3 (hypertensive crisis): >180 / >120 mm Hg MNT: -Patients should be encouraged to lose weight through diet and exercise -Reduce sodium intakes -Increase intakes of potassium through fruit and vegetable consumption -DASH: healthy eating plan that encourages increased consumption of fruits, vegetables, low-fat dairy, whole grains, and lean protein, and a decrease of red meats, sweets, fats, and oils -Mediterranean diet: potential for protecting against cardiovascular disease and cancer, healthy eating plan that encourages increased consumption of fruits, vegetables, grains, healthy fat sources, and foods with good sources of omega-3 fatty acids and decreased intake in foods with saturated fats -reduced intakes of saturated fats, trans fatty acids, and cholesterol to support overall cardiovascular health -limit alcohol to 1 drink/day for women and 2 drinks/day for men

Diabetes- Intro

-Condition of high blood sugar levels -Either a problem with the organ that produces insulin (pancreas) or a problem at the level of the cells to accept glucose, both cases result in elevated blood sugar levels Terms: Postprandial hypoglycemia: blood glucose levels that fall below normal within 2-5 hours after a meal Reactive hypoglycemia: normal insulin secretion, but increased insulin sensitivity and a reduced response to glucagon Insulin: hormone secreted by the pancreas, moves glucose from the bloodstream to the inside of the cell Ketones: substances produced by the liver when more fat is being used for energy instead of glucose as a result of an inadequate amount of insulin Diabetic ketoacidosis: serious complication of diabetes that occurs when the body produces very high levels of ketones Somogyi effects: hypoglycemia followed by rebound hyperglycemia. This may occur when a patient takes insulin before bed. If the insulin lowers the blood sugar too much, it can trigger a release of hormones that release glucose to the blood. These hormones can cause insulin resistance for several hours. Dawn phenomenon: an abnormal early morning increase in blood sugar levels, usually between 2-8am Honeymoon phase: the phenomenon some patients might experience shortly after being diagnosed with diabetes. May experience normal BS levels without needing insulin. Hyperosmolar hyperglycemic state: metabolic complication of type 2 diabetes characterized by severe hyperglycemia, dehydration, hyperosmolar plasma, altered consciousness, and absence of significant ketosis. Usually develops after a period of symptomatic hyperglycemia when fluid intake is inadequate Insulin shock: state where there is too much insulin in the bloodstream and blood sugar levels fall very low. Body becomes "starved" for glucose and begins to shut down 3 P's of diabetes: -Polyuria: condition of frequent urination. Develops bc kidneys are attempting to get rid of excess glucose in the blood -Polydipsia: condition of excessive thirst bc kidneys are excreting extra fluid from the blood -Polyphagia: condition of excess hunger. May be d/t glucose in the blood not being utilized for energy bc of the lack of insulin Diabetic nephropathy: kidney damaged caused by diabetes Diabetic neuropathy: nerve damaged caused by diabetes Glycemic index (GI): -used to rank carbs by their ability to raise blood glucose levels -white bread or glucose are used as the reference foods -GI does not measure how rapidly blood glucose levels rise. However, foods with a high GI tend to result in a quick rise, followed by a quick drop -Low GI foods produce a moderate rise/fall -Presence of fat & fiber lower the GI of food -GI and blood sugar response is only valid when a single food is consumed Glycemic Load (GL): -The glycemic index of a food divided by 100 and multiplied by its amount of available carbohydrate content (CHO - fiber) in grams -The GL can help determine how high blood sugar levels can rise since it includes the available CHO content -For example, watermelon has a high GI of 72, but a serving of watermelon contains so few carbohydrates that it has a GL of about 4 15/15 Rule: -easy way for a person to treat a hypoglycemic event -when blood sugar levels are below 70 mg/dL, consume 15 g of easily-digestible CHO -after consuming, blood sugar levels check again 15 minutes later -if levels are still below 70 mg/d, the cycle repeats -Infants only need 6 grams, toddlers need 8 grams, and small children need 10 grams -Insulin is counterproductive and should not be used in times of hypoglycemic reaction -If the person is unconscious, they should receive a shot of glucagon Classifications: Pre-diabetes: -Blood sugar high enough to be concerning, but not enough to be T2D -More than 1/3 Americans have pre-diabetes -Increases the risk for heart disease, stroke, and T2D -Risk factors for pre-diabetes: overweight, 45+ years old, family hx, physically active <3x/week, hx of gestational diabetes or birthing a baby over 9 lbs, PCOS Type 1 diabetes (IDDM): -Body either does not produce insulin or makes very little of it as a result of damage to the beta cells of the pancreas -More commonly first diagnosed in children, teens, and young adults -Insulin-dependent diabetes mellitus -Accounts for 5-10% of all diabetes cases -No known way to prevent onset Type 2 diabetes (NIDDM): -Cells do not respond normally to insulin (insulin resistance) -Causes the pancreas to over produce insulin and results in high blood sugar levels -Non-insulin dependent diabetes mellitus -90-95% of all diabetes cases -If uncontrolled, can lead to heart disease, kidney damage, and loss of vision Gestational Diabetes: -body cannot make enough insulin during pregnancy, resulting in higher-than-normal blood sugar levels -affects 2-10% of pregnancies every year in US -Increases the risk for high blood pressure during pregnancy and having a large baby that has to be delivered via C-section -Puts a baby at a higher risk of: >9 pounds at birth, born prematurely, low blood sugar, developing T2D later in life -Nearly half of women with gestational diabetes develop T2D after pregnancy

Cirrhosis

-Condition where healthy liver tissue is replaced by scar tissue -Scar tissue blocks the flow of blood through the liver and results in loss of liver function -Common causes are hepatitis B, C, or alcoholism -Medical treatment of ascites usually includes: -use of diuretics -paracentesis: removal of fluid w/ catheter -Transjugular intrahepatic portosystemic shunt procedure (TIPS): reroutes blood flow to the liver to reduce vein pressure -Hepatic encephalopathy from cirrhosis causes impaired mental status and neuromuscular function d/t inability to metabolize toxins to the brain, including ammonia Symptoms: -fatigue, weakness, nausea, poor appetite, malaise, jaundice, dark urine, light stools, steatorrhea, itching, abdominal pain, bloating -bruising and bleeding may be present due to decreased vitamin K absorption and synthesis of protein-clotting factors -major complications include hypertension, encephalopathy, ascites, esophageal varices, and hepatorenal syndrome -Malnutrition and vitamin/mineral deficiencies Diagnosis: -CT scan, abdominal ultrasound, MRI, biopsy -Elevated liver enzymes including bilirubin, ALT, AST, and alkaline phosphatase -Decreased levels of blood proteins and CBC -tests for viral infections MNT: -Ascites: <2000 mg/d of sodium, fluid restriction of 1-1.5 L/d should be considered when sodium levels are less than 130 mEq/L. -Esophageal varices: difficulties swallowing and require soft textured foods -Encephalopathy: temporarily reduce protein intake to 0.6-0.8 g/kg/d -Prioritize intake of vegetarian sources of protein and dairy proteins over animal proteins -Use of BCAAs and leucine-enriched amino acid supplements may be helpful in patients with decompensated cirrhosis -Physical activity -Optimal daily energy should not be lower than 35 cals/kg in non-obese patients (corrected for ascites) -Daily protein intake should not be lower than 1.2-1.5 g/kg/d

Gastroparesis

-Delayed gastric emptying -Common causes: viral infection, diabetes, and surgery -Symptoms: reflux, nausea, bloating, vomiting, decreased appetite, postprandial hypoglycemia, bacterial overgrowth Diagnosis: -Scintigraphy: patient consumes a radionucleotide-labeled meal, and images are taken over 4 hours to assess the rate of gastric emptying -SmartPill: capsule containing a small electronic device is swallowed and sends information to a device as it moves through GI tract Medical Management: -Reglan: med that causes stomach muscles to contract -erythromycin: antibiotic that also helps with stomach contractions -antiemetics: med to help with nausea MNT: -Small, frequent meals -Diet consisting of liquid or puree may be beneficial -Avoid high-fiber foods -Fats may be limited but not restricted -Patients tend to tolerate liquid fats better than solid fats

Food Drug Interactions: Antihistamines

-Designed to alleviate allergy and cold symptoms -Blocks histamines which the body releases when an allergen causes the symptoms present -Interaction w/ alcohol: can add to the drowsiness caused by this medication

Dysphagia

-Difficulty swallowing food/beverages safely -Often leads to malnutrition Symptoms: -drooling -choking or coughing during meals -inability to suck from a straw -holding pockets of food in the cheeks -absent gag reflex -chronic upper respiratory infections Common in patients with: -late-stage parkinson's disease -multiple sclerosis -amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease -Dementia -Stroke MNT: -weight loss and malnutrition are concerns -patient should be observed during meals -may require texture modified diet -goal is to keep diet palatable and nutritionally adequate -cool temperatures facilitate swallowing and may be better tolerated -sauces and gravies lubricate foods for ease in swallowing -avoid foods that crumble easily in the mouth -EN may be required for patients at high risk for aspiration Reducing risk of aspiration: -Providing a 30 min rest period prior to feeding -Position patient with head and shoulders above their chest, about a 90 degree angle -alternate between solid and liquid intakes -determine appropriate texture with speech therapist -check residuals of tube fed patients before and after feedings and every 4 hours

Protein-Energy malnutrition (PEM)

-Energy deficit due to deficiency of all macronutrients and commonly includes deficiencies of many micronutrients -Can be sudden or gradual -Common in children in developing countries -Graded as mild, moderate, or severe -Grade determined by calculating weight as a percent of expected weight for length or height -After adipose tissue has been depleted as an energy source, the body may use protein for energy, resulting in a negative nitrogen balance -Developed from primary or secondary causes: -primary: caused by inadequate intake of nutrients -secondary: results from disorders of medications that interfere with nutrient use Primary PEM: Marasmus: -most common form in children in developing countries -causes weight loss and depletion of fat and muscle -dry form of PEM Kwashiorkor: -wet, swollen, or edematous form of PEM -Results from premature abandonment of breastfeeding or from an acute illness, such as gastroenteritis -Diet very low in protein and very high in CHO -Cell membranes leak, causing leakage of intravascular fluid and protein, resulting in peripheral edema Starvation: -lack of nutrients -occurs from fasting or anorexia nervosa or unavailability of food Stunting: -low height-for-age -results from chronic or recurrent undernutrition -associated with poor economic status, poor maternal health and nutrition, frequent illness, and improper feeding of young children early in life -holds children back from reaching their physical and cognitive potential Wasting: -low weight-for-height -loss of muscle and fat mass -indicates recent and severe weight loss that may be caused by unavailability of food or infectious diseases -severe wasting has an increased risk of death Secondary PEM: -GI disorders interfering with digestion, absorption, or lymphatic transport of nutrients -Wasting disorders resulting in undernutrition via anorexia or cachexia -Conditions that increase metabolic demands, such as infections, hyperthyroidism, burns, trauma, etc Symptoms: -Weakness -Impairment of cognition and consciousness -Diarrhea, possibly due to lactase deficiency -Fat and muscle wasting -Dry, pale, cold, inelastic skin -Hair is dry and easily falls out -Poor wound healing -Hip fractures and pressure injury risk -Low body temperature -Hunger, weight loss, growth retardation, and wasting in infants with marasmus -Edema and decreased serum albumin in children with kwashiorkor MNT: -IV solutions to correct fluid and electrolyte deficits, gradually replenishing nutrients -Possibly avoidance of lactose if diarrhea persists -Delayed feeding for 24-48 hours if diarrhea persists

Cushing Syndrome

-Excessive cortisol remains in the bloodstream over a long period of time -Cortisol is a steroid hormone produced by adrenal glands which helps respond to stress, maintain blood pressure, assist with immune function, and metabolize macronutrients into energy -Exogenous cushing's syndrome: more common, may occur when steroid or other similar medications are used, but then ceases once the medication is stopped -Endogenous cushing's syndrome: rare, may occur as a result of a tumor on the adrenal or pituitary gland Symptoms: -weight gain -brushing easily -depression -muscle loss -weakness -hyperglycemia -hypertension Diagnosis: -sample of saliva to test cortisol levels taken between 11pm-midnight when cortisol levels are generally low -24-hour urine test may also be used MNT: -management of normal, healthy weight -diet low in simple carbohydrates to prevent hyperglycemia

Renal Failure

-Gradual loss of kidney function -critical processes in the body may be impaired, leading to toxic waste buildup and electrolyte abnormalities -Nutrition is key with focus on decreasing or closely monitoring intakes of sodium, potassium, phosphorus, protein, and fluid -People most at risk for renal disease include those with diabetes, HTN, vascular disease, infections, autoimmune diseases, genetics, obesity, heart disease, and metabolic syndrome Acute renal failure: -rapid decline of kidney function -often occurs as a result of an acute illness or injury to the kidney -can increase risk for chronic kidney disease -those with chronic renal failure are also at increased risk for acute renal failure Chronic renal failure: -gradual loss of kidney function -if left untreated, chronic renal failure can progress to end-stage kidney failure, requiring dialysis or a kidney transplant -dialysis is the process of removing excess water, solutes, and toxins from the blood. The dialysis machine performs the function of the kidneys Types of Dialysis: Hemodialysis: -administered typically 3 days/week at a dialysis center over a 3-5 hour session -access may be through an arteriovenous fistula, an artificial loop graft, or a subclavian catheter -waste products and electrolytes move by diffusion, ultrafiltration, and osmosis from the blood into the dialysate and are removed -patients are generally prescribed a renal diet with various restrictions. This is based on how effectively the dialysis is normalizing blood levels Peritoneal dialysis: -administered via a catheter placed in the peritoneum (abdominal lining) -administered in several exchanges throughout the day and is a more continuous process -dietary restrictions are often not as restrictive Renal Solute Load: -amount of nitrogenous waste and minerals that must be excreted by the kidney -protein is a major contributor -also takes sodium, potassium, and chloride into account -in healthy individuals, increasing fluid consumptions can lower the renal solute load. However, renal disease patients may have fluid restrictions, so they need to balance the renal solute load and fluid intake closely -Renal solute load = (g pro X 5.8) + (mEq sodium + mEq potassium + mEq chloride) -*this formulas is intended for adults, if calculating for children, 5.8 becomes 4.0 Symptoms: -Decreased appetite -fatigue -reduced mental acuity -CKD may not become apparent until kidney function is significantly impaired -decreased urine output -seizures -restless leg syndrome -hypertension -fluid retention and edema -heart failure Pathophysiology: - 5 main stages of renal disease -The decline of kidney function occurs as a result of one or several of the following factors: -Ischemia: decreased renal blood flow -Hypoxia: decreased oxygen flow in kidneys -Drugs or medications that can be toxic to the kidneys -hyperglycemia -genetic factors -autoimmune disease -In advanced renal failure, urine output is decreased and electrolytes and waste products can rise to toxic levels Diagnosis: -Blood tests: -levels of specific waste products to determine how well kidneys are filtering out waste -GFR, BUN, and creatinine levels -Urine tests: -creatinine clearance test: compares the creatinine in a 24 hour sample of urine to the creatinine level in the blood to show how much waste products the kidneys are filtering out -urine protein test: an excess amount of protein in the urine is called proteinuria, and this is an indicator of renal dysfunction -Imaging tests: -renal ultrasound: identifies abnormalities in the size or position of the kidneys or for obstructions, such as stones or tumors -CT scan: identify structural abnormalities or obstructions -Renal biopsy: -determines cause of renal failure Pertinent Labs: Glomerular filtration rate (GFR): -The rate at which the kidneys filter the blood -GFR # = filtering at that capacity -Lower GFR = more advanced stage -Normal: 90-120 ml/min -Mild kidney damage: 60-89 ml/min -Moderate kidney damage: 30-59 ml/min -Severe kidney damage: 15-29 ml/min -Kidney failure: < 15 ml/min Blood urea nitrogen (BUN): -Urea nitrogen comes from the breakdown of protein consumed in food -In renal failure, this is often elevated as the kidneys are unable to adequately clear urea nitrogen out of the blood -Normal range: 6-20 mg/dL -Renal disease: >20 mg/dL Creatinine: -creatinine is a waste product that is present in the blood from normal wear and tear of the muscle -as renal function declines, creatinine levels further increase above normal levels -normal range (men): 0.9-1.3 mg/dL -normal range (women): 0.6-1.1 mg/dL -renal disease: >1.2 mg/dL Electrolytes: -potassium: builds up in the blood as the kidneys are unable to adequately filter and excrete in the urine. Renal disease >5.0 mEq/L -phosphorus: builds up in the blood often in later stages of kidney disease as parathyroid hormone levels increase. RD >4.5 mg/dL -calcium: decreases as parathyroid hormone increases. phosphorus levels consequently increase in the blood. Calcium binds to phosphorus, thereby reducing calcium. RD <8.4 mg/dL Common medications: -Phosphate binders: -used when phosphorus levels are too high and not enough is removed during dialysis -when using phosphate binders, additional calcium and vitamin D supplements should be avoided to prevent hypercalcemia -commonly used: calcium carbonate (tums), calcium acetate, calcium chloride MNT: Sodium: -excess sodium can increase BP, fluid retention, and put strain on the kidneys and cardiovascular system -sodium restrictions vary from 2000-4000 mg/d Potassium: -mineral that controls nerve and muscle function to maintain proper fluid and electrolyte balance in the body -restriction ranges from 1500-4000 mg/d -leaching is a practice to lower potassium in some foods, such as potatoes Phosphorus: -involved in the acid-base balance in the body and regulates calcium levels for bone health -restrictions vary from 1000-3000 mg/d -limit high phosphorus foods such as convenience foods with added phosphorus, processed cheeses, red meats, dairy and colas Protein: -malnutrition is common at any stage -ensure patient meets daily protein needs without consuming excess -excess protein can increase the waste products in the body, making the kidneys work harder -Protein recommendations: -non-dialysis: 0.6-0.8 g/kg -peritoneal dialysis: 1.2-1.5 g/kg -hemodialysis: 1.2 g/kg -kidney transplant (4-6 weeks post): 1.3-2.0 -kidney transplant (>6 weeks post): 1.0 g/kg Fluid: -fluid retention can worsen in renal disease and result in fluid accumulation in the lungs and heart -can increase blood pressure and put strain on the kidneys to remove buildup of fluid -fluid restriction may be necessary even for patients on dialysis -fluid restrictions range from 800-2000 ml/day

Chronic Obstructive Pulmonary Disease (COPD)

-Group of lung diseases that causes obstructed airflow, making it difficult to breath -2 main respiratory diseases: emphysema and chronic bronchitis -Emphysema: affects air sacs in lungs and the walls between them which become damaged and less elastic -Chronic bronchitis: irritates the lining of the airways causing inflammation and mucus production -Most people with COPD have both -Medications include bronchodilators, inhaled corticosteroids, and oral steroids -Associated with vascular disease, osteoporosis, muscle wasting, and cancer Symptoms: -SOB -Chronic coughing -Wheezing -Chest tightness -frequent respiratory infections -lack of energy -unintended weight loss -swelling in ankles, feet, or legs Pathophysiology: -Cigarette smoking is leading cause -second leading cause is long-term exposure to other lung irritants or pollution, chemical fumes, or dust -characterized by airway obstruction caused by inflammation -emphysema causes destruction of the walls and elastic fibers of the alveoli -chronic bronchitis is characterized by inflammation of the bronchial, lungs produce more mucus, and chronic cough develops -degree of inflammation is associated with faster decline in lung function and increased incidence of cardiac disease, diabetes, hypertension, and osteoporosis Diagnosis: -Pulmonary function tests: most common is spirometry, which measures how well the lungs can move oxygen into the blood and remove CO2 -Spirometry: detects COPD before symptoms develop and can be used to test severity -Chest x-ray: shows emphysema and also rules out other lung problems -CT scan of the lungs: detects emphysema and determine if patient may benefit from surgery -Arterial blood gas test: measures how well the lungs are bringing oxygen into the blood and removing carbon dioxide -The RD should assess serum vitamin D levels and consider supplementation is low MNT: -goal is to prevent weight loss and improve lung function, mortality, and quality of life -weight loss is related to difficulty swallowing or chewing due to SOB, chronic mucus production, coughing, fatigue, confusion, anorexia, depression, side effects of meds -Energy requirements: -maintenance: 30 kcal/kg -weight gain: 45 cals/kg -Protein requirements: -15-20% of daily calories -general: 1-1.2 g/kg -older patients who are malnourished or those with chronic disease: 1.2-1.5 g/kg -CHO requirements: -40-55% of daily calories -CHO intake lower bc CHO metabolism generates greater amount of CO2, which would make the lungs work harder expelling gases -small, frequent, nutrient-dense meals -liquid nutritional supplements -daily multivitamin -vitamin D supplementation

Food Drug Interactions: ACE inhibitors

-Helps lower blood pressure or treat heart failure -Relaxes blood vessels to blood can flow more smoothly and heart can pump blood more efficiently -Captopril and lisinopril -Interaction w/ foods high in potassium --> bananas, oranges, leafy vegetables, salt -ACE inhibitors can increase amount of potassium in the body

Insulin

-Hormone produced by the beta cells of the pancreas -Helps transport glucose from the bloodstream into cells where it can be used for energy -Without insulin, glucose builds up in the bloodstream and results in high blood sugar levels Exogenous Insulin: -Onset: length of time before insulin reaches the bloodstream and beings working -Peak time: time when insulin is most effective in lowering blood sugar levels -Duration: how long the insulin continues to lower blood sugar levels Types of Insulin: Rapid acting insulin: -Onset: 15 mins -Peak: 1-2 hours -Duration: 2-4 hours -When to take: before a meal -Common names: humalog, novolog, apidra Short Acting Insulin (Regular): -Onset: 30 mins -Peak: 2-3 hours -Duration: 3-6 hours -When to take: 30-60 mins before a meal -Common names: Novolin R, Humulin R Intermediate Acting Insulin: -Onset: 2-4 hours -Peak: 4-12 hours -Duration: 12-18 hours -When to take: before bed -Common names: Novolin N, Humulin N Long Acting Insulin: -Onset: 1-2 hours -Peak: minimal peak, but could be up to 6-8 hours -Duration: up to 24 hours -When to take: same time each day -Common names: Lantus, Tresiba Ultra Long Acting Insulin: -Onset: 6 hours -Peak: does not peak -Duration: 36 hours or longer -When to take: every 36 hours -Common names: Toujeo Inhaled Insulin: -Introduced in 2015 in the US -Rapid acting insulin that is inhaled -For patients using this insulin, it must be in combination with long acting injectable insulin -Onset: 15-30 mins -Peak: 30 mins -Duration: 3 hours -When to take: before a meal -Common names: Afrezza Mixtures: -Mixtures of insulins may be combined in the same syringe -The mixture will begin working as quickly as the fastest-acting insulin in the mix, will peak when each type peaks, and will last as long as the longest-acting insulin

Lactose Intolerancd

-Inability to digest and utilize the simple sugar lactose -Due a lactase enzyme deficiency or insufficiency -Secondary lactose intolerance can develop with infections of the SI, inflammatory disorders, or malnutrition -Symptoms: abdominal pain, bloating, gas, diarrhea Pathophysiology: -Lactose may act osmotically, which increases fecal water, and provide a substrate for rapid fermentation by intestinal bacteria -Lactose that is not hydrolyzed into glucose and galactose passes into the colon, where bacteria ferment it to SCFA, CO2, and hydrogen gas Diagnosis: -Hydrogen breath test: -hydrogen produced during the fermentation process of lactose in the colon is absorbed into the bloodstream and exhaled from the lungs -Lactose Intolerance test: -if blood sugar levels rise after ingesting lactose, this indicates proper digestion of lactose into galactose and glucose -if blood sugar levels do not rise, this indicates that lactose is not being hydrolyzed MNT: -Reduce consumption of lactose foods -may need calcium and vit D supplementation -hard aged cheeses and yogurt may be better tolerated -possible to gradually build up tolerance -lactase enzymes

Short Bowel Syndrome

-Inadequate absorptive capacity resulting from reduced length or decreased functional bowel after resection -Inability to maintain nutrition and hydration needs with normal fluid and food intake -Loss of 70-75% of small bowel remaining -Complications: -malabsorption, frequent diarrhea, steatorrhea, dehydration, electrolyte imbalances, weight loss, growth failure in children, gastric hypersecretion, oxalate renal stones, gallstones Pathophysiology: -Most common reasons for major resections of the intestine in adults include Crohn's disease, radiation enteritis, mesenteric infarction, and malignant disease -Duodenal resection: -rare, complications for absorbing iron, zinc, copper, and folate -Jejunal resection: -reduced surface area and faster transit -Absorption of excess sugar and lipids is reduced -ileum adapts to perform function of jejunum -Ileal resection: -distal ileum is the only site for absorption of bile salts and the vitamin B12-intrinsic factor complex -ileocecal valve responsible for controlling the rate of passage of contents to the colon and to prevent reflux of colonic bacteria -lack of bile salts being recycled, may lead to malabsorption of vitamins A, D, E, and K -lack of fatty acids in combination with calcium, zinc, and magnesium, these nutrients may be deficient -increased risk of renal oxalate stone formation because of dehydration, concentrated urine, and increased absorption of oxalates MNT: -May require PN initially -When advancing to normal diet, small/frequent meals are likely to be better tolerated (6-10 mini meals/day) -Nocturnal enteral feedings may be considered -transition to normal foods may take weeks or months, and some patients may never tolerate normal concentration or volume of food -avoid lactose, large amounts of concentrated sweets, and caffeine to reduce the risk of bloating, abdominal pain, and diarrhea -supplemental glutamine may help with absorption -supplemental nucleotides may help enhance mucosal adaptation -MCTs help to add calories and to serve as a vehicle for lipid-soluble nutrients

Comprehensive Metabolic Panel (CMP)

-Includes each lab in the BMP plus the ones listed below Albumin -Protein made by the liver and can be used as a liver function test -Adult reference range: 3.4-5.4 g/dL -Elevated: may indicate dehydration, but electrolyte levels are a better indicator -Decreased: liver disease, kidney disease, inflammation, shock, malnutrition, infection, chronic disease, hypothyroidism, heart failure Total Protein -Used along with albumin to measure amount of protein in the blood to help evaluate overall health status -Adult reference range: 6-8.3 g/dL -Elevated: infection, chronic inflammation, bone marrow disorders -Decreased: liver disorder, kidney disorder, malnutrition, malabsorption caused by IBD or celiac Alkaline Phosphatase (ALP) -Enzyme found in several tissues in the body -Used along with other liver enzyme tests mainly to help detect liver disease and sometimes bone disorders -Reference range: 44-147 IU/L -Elevated: liver damage or disease, bile duct obstruction, gallbladder disease, bone disorder -Decreased: post-blood transfusions, heart bypass surgery, malnutrition Alanine Aminotransferase (ALT) -Enzyme found mainly in liver and kidney -Levels are normally low, but when the liver is damaged, ALT is released into the blood -ALT and AST are the 2 most important tests to detect liver injury -Adult male: 10-40 IU/L -Adult female: 7-35 IU/L -Elevated: hepatitis, obstruction of bile ducts, alcohol abuse -Decreased: considered normal Aspartate Aminotransferase (AST) -Enzyme found throughout the body, primarily in heart and liver -When liver and muscle cells are damaged, they release AST into the blood -Used with ALT to detect liver damage -Reference range: 10-34 IU/L -Elevated: hepatitis, liver cancer -Decreased: considered normal Bilirubin -Waste product produced by the breakdown of heme -Assess liver function or help diagnose anemias caused by RBC damage -Adult reference range: 0.1-1.2 mg/dL -Elevated: hemolytic or pernicious anemia, liver disease, viral hepatitis, gallstones, tumors -Decreased: considered normal

Irritable Bowel Syndrome (IBS)

-Inflammation of the large intestine, cramping, abdominal pain, bloating, gas, mucus in the stool, diarrhea or constipation or both -Does not cause damage to bowel tissue or increase risk for colon cancer Symptoms: -Can be triggered by increased levels of stress, hormones, and dietary factors (wheat, beans, dairy, citrus, cabbage, and carbonated beverages) -Complications can include depression and mood disorders Pathophysiology: -Causes may include intestinal muscle contractions, neurological overreactions, bacterial overgrowth or intestinal infection, or changes in gut bacteria -Risk factors include: -Under age of 50, female, estrogen therapy, family history, anxiety, depression Diagnosis: -Primarily by ruling out other conditions and may include: -colonoscopy, flexible sigmoidoscopy, Xray of abdomen, hydrogen breath tests, stool tests, upper endoscopy MNT: -Individualized -low-fodmap diet, eliminating gluten and high-gas foods -increasing fiber and fluid intakes -other therapies to alleviate symptoms: -exercise, mindfulness training, relaxation exercises, counseling

Maple Syrup Urine Disease (MSUD)

-Inherited disorder in which the body is unable to process certain amino acids properly, specifically leucine, isoleucine, and valine -affects 1 in 185,000 infants Symptoms: -develops within 48 hours after birth -sweet odor in urine -poor feeding -lethargy -vomiting -abnormal movements -delayed development -if untreated, seizures, coma, death Pathophysiology: -mutations in the BCKDHA, BCKDHB, and DBT genes -body is unable to process 3 amino acids properly (BCAAs), and they build up in body -high levels are toxic to the brain and organs -when accumulated and left untreated, this can lead to serious health issues Diagnosis: -Part of routine newborn screenings -Urine analysis: high level of keto acids may indicate diagnosis -Blood tests: detects high level of BCAAs -Enzyme analysis of WBC or skin cells MNT: -goal is to reduce toxic build up of the BCAAs -limiting/avoiding leucine is of most concern -high protein foods that contain BCAAs are restricted -specialized formulas and supplements are often recommended that provide required nutrients with minimal BCAAs

Pressure Injuries

-Injury to the body as a result of continuous pressure that slows or stops capillary blood flow to the skin and underlying tissues -common in older adults with neurological disorders, heavily-sedated patients, dementia patients, overweight/obese patients, and other patients with the inability to shift positions to alleviate pressure -Additional factors: malnutrition, undernutrition, incontinence, paralysis, sensory losses, and rigidity -Injuries have 4 stages based on depth and level of tissue involvement Stages: Suspected deep tissue injury: -purple/maroon discolored intact skin -painful, firm, mushy, warmer/cooler -may be difficult to detect in patients with darker skin -energy needs: 30 cals/kg -protein needs: 0.8 g/kg for adults, 1.0 g/kg for elderly Stage I: -skin intact -nonblanchable redness of area -usually over bony prominence -painful, soft, warmer/cooler -difficult to detect in dark-skin -energy needs: 30-35 cals/kg -protein needs: 1.25-1.5 g/kg -fluid needs: 30-33 ml/kg (less in patients with renal disease or CHF) Stage II: -shallow open sore w/ red/pink wound -may also present as a serum-filled blister -may appear shiny or dry -energy needs: 30-35 cals/kg -protein needS: 1.25-1.5 g/kg -fluid needs: 30-33 ml/kg (less in patients with renal disease or CHF) Stage III: -Full-thickness loss of skin area -subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed -may include undermining or tunneling -energy needs: 35-40 g/kg -protein needs: 1.5-1.75 g/kg -fluid needs: 30-33 ml/kg -supplementation: 15 mg zinc may help Stage IV: -full-thickness loss of skin area -bone, tendon, and/or muscle may be exposed -undermining or tunneling present -energy needs: 35-40 g/kg -protein needs: 1.75-2.0 g/kg -fluid needs: 30-33 ml/kg -supplementation: 15 mg zinc may help Unstageable: -full thickness loss of skin area -base of injury covered in slough with a yellow, tan, gray, green, or brown color -once slough is removed to expose the base of the wound, stage often identified -often treated as a stage IV MNT: -optimize protein intake with a goal of 1.25-2.0 g/kg/d -meet calorie requirements of 30-40 cals/kg/d -assess the effect of medications on wound healing and provide supplements as necessary -replace micronutrients if depleted

Amyotrophic Lateral Sclerosis (ALS)

-Lou Gehrig's disease; a chronic, degenerative neuromuscular disease -Progressive denervation, atrophy, and weakness of muscles -More prevalent among men with an average onset in the mid-50s -Cause is unclear, may be linked to chromosome mutations -In early phase, patients have normal resting energy expenditure and are generally in a positive nitrogen balance -In late phase, patients reach a hypermetabolic status with increased resting energy expenditure and are in negative nitrogen balance -Muscle and fat wasting are common in late stages of the disease -As the disease progresses, a progressive loss of function in the respiratory muscles contributes to oral and pharyngeal dysphagia Pathophysiology: -Death of motor neurons in the ventral gray matter of the spinal cord, brainstem, and in the motor cortex -Results in generalized skeletal muscular weakness, atrophy, and hyperreflexia -As motor nerves deteriorate, almost all of the voluntary skeletal muscles are at risk for atrophy and complete loss of function -sensation remains intact and mental acuity is maintained -Loss of function in cortical motor neurons lead to spasticity of jaw muscles, slurred speech and dysphagia -usually progresses to death in 2-6 years MNT: -Early phase: maintain calories and protein to match EE -Late phase: energy protein, and fluid needs increased to combat malnutrition and dehydration -Nutrition support via PEG tube may be required with the development of dysphagia

Food Drug Interactions: Corticosteroids

-Lowers inflammation in the body -Treats arthritis, asthma, lupus, allergies -May be localized or delivered orally or intravenous -May cause a decrease in sodium excretion, leading to sodium and water retention -Calcium and potassium are excreted at higher rates -Patients may be required to follow a low-sodium, high-potassium, high-protein diet -Many possible side effects

Food Drug Interactions: Acetaminophen

-Medications that relieves mild to moderate pain and lower fever -prolonged use can cause liver damage -Interaction w/ alcohol --> risk of severe liver damage increases when taken and alcohol consumption is 3+ servings/day

Alzheimer's Disease

-Most common form of dementia -Few genes have been discovered that cause early-onset familial Alzheimer's disease -Age and family hx are the most known risk factors -Begins gradually, advances, and eventually leads to confusion, personality and behavior changes, impaired judgement, and deterioration of motor skills -Ability to recognize hunger, thirst, and satiety decline -Weight loss is common, but weight gain from over eating may occur -Pressure injuries are of concern with weight loss -During the terminal stage, bowel and bladder controls are lost, limb weakness occurs, and intellectual activity ceases MNT: Preventative- -NSAIDS/aspirin in combination with dietary vitamin E, other antioxidants, and omega-3 fatty acids have been shown effective in delaying progression -Diet rich in unsaturated fatty acids, vitamins, antioxidants, wine, curcumin, and some spices help prevent oxidative damage -Limit saturated fat and alcohol as these have been shown to promote onset of the disease Management- -keep mealtimes simple with minimal distractions -foods may need to be served one at a time, or not too many choices -close supervision during meals -use of colored bowls and plates which differ in color to the food -may have difficulty with utensils -finger foods may be offered, only if patient has no difficulty chewing/swallowing and is not prone to swallowing large boluses of food -If weight loss is a concern, frequent snacks, nutrient-dense foods, and nutrition supplements should be offered

Stroke

-Occurs when blood flow to an area of the brain is impaired - affected ares of the brain tissue begin to die -Ischemic stroke: most common, caused by a blood clot or plaque buildup that blocks blood flow to brain -Hemorrhagic stroke: caused by a ruptured blood vessel that leaks blood into brain tissue -Transient ischemic attack (TIA): mini strokes, caused by temporary clots that do not cause lasting brain damage, clots dissolve on their own Symptoms: -sudden onset and affect motor and sensory functions relating to the area of the brain where the stroke occurs -Remember the acronym 'FASTER' Face: drooping/numbness to one side Arms: one arm is weaker/numb Stability: dizziness, loss of coordination Talking: slurring words, unable to speak Eyes: double vision or difficulty seeing React: call 911 immediately Pathophysiology: -Caused by either a blockage (ischemic) or rupture (hemorrhagic) in blood vessels that impairs blood flow to the brain -Embolic stroke: caused by blockages that formed in another part of the body and traveled through the arteries to the brain -Thrombotic stroke: caused by blockages that form in an artery that delivers blood to the brain -Hypertension is a common cause of weakened blood vessels that lead to ruptures/brain bleeds -Loss of blood flow = brain cells die and areas of the brain stop working -Risk factors include: -increased age -smoking -HTN -Atherosclerosis -Atrial fibrillation -Diabetes -Obesity Diagnosis: -X-ray of the brain taken with contrast dye injected into the blood vessels determines if and where a blockage or bleed is present MNT: -assess for dysphagia immediately after -may require modified textured diet -EN may be required -Recommend heart healthy diet such as DASH or Mediterranean -Reduce/avoid alcoholic beverages

Care Plans

-Outlines the roadmap of interventions to be implemented -Documented in medical chart -Involves the 4 components of the NCP -Basic 4 step process: 1. Counseling and Training Patients -May involve the patient, their family, or caregiver, therapeutic diet education, tube feeding teaching, etc 2. Writing Care Plans -Follow the NCP model: -Assessment -Diagnosis -Intervention -Monitoring/evaluation 3. Communicating and Documenting -communicate plan to IDT -both written and verbal 4. Patient Discharge Planning -prepare for any changes they will need to make upon discharge -therapeutic diet, diet texture, oral supplements, tube feeding or PN, referrals for follow-up services

Small Intestine Bacterial Overgrowth (SIBO)

-Over-proliferation of bacteria in the small bowel -Bacterial protective features in the GI tract: -Gastric acid, bile, and pancreatic enzymes have bacterial growth inhibiting characteristics -Normal propulsion of bowel motility moves bacteria along into the distal bowel -Ileocecal valve prevents bacteria from migrating in large numbers from the colon to the small intestine -Complications: -chronic diarrhea from fat maldigestion -carbohydrate malabsorption bc injury to brush border -Vitamin B12 deficiency with elevated folic acid -Bloating and abdominal distention Pathophysiology: -Usually more than one of the protective measures above must be impaired before over-proliferation occurs and symptoms develop -May be caused by: -meds that suppress gastric acid -liver disease or chronic pancreatitis -dysmotility disorders, such as gastroparesis -surgical resection of the distal ileum and ileocecal valve Medical Treatment: -Controlling bacterial growth with antibiotics, prebiotics, probiotics, and in some cases, surgical modification of the blind loop MNT: -diet limited in refined starches, sugars, and sugar alcohols since carbohydrates reach the site of the bacterial growth and serve as fuel -incorporate whole grains and vegetables -low FODMAP diet -MCT may be beneficial -Possible supplementation of vitamin B12

Assessment of micronutrient deficiencies- Skin

-Pale appearance: iron, folate, B12 -Dry and scaly: vitamin A, essential FAs, biotin -Dermatitis: zinc, niacin, riboflavin, tryptophan, essential FA -Perifollicular hemorrhage: Vitamins C, K -Naso-labial dermatitis: zinc, B6, A, as well as vitamin A toxicity -Hyperpigmented rash (pellagra): niacin, tryptophan -Poor turgor: dehydration -Blistering, peeling skin: niacin -Follicular hyperkeratosis: Vitamins A, C, essential fatty acids -Seborrheic dermatitis (cradle cap): zinc, biotin, vitamin B6

Growth Charts

-To evaluate physical development of infants and children -Generally, above 80th percentile and below 10th percentile may be cause for concern Standard charts for measurement: -Height for age -Weight for age -Weight for height -Head circumference for age (2 yrs or below) -BMI for age

Food Drug Interactions: Brochodilators

-Treat/prevent breathing difficulties from asthma, bronchitis, emphysema, and COPD -Relaxes and opens airways to the lungs -Albuterol and theophylline -Interactions w/ caffeine and alcohol --> can increase risk of side effects

Osteoporosis

-Porous bone -bone mineral density becomes so low that the skeleton is unable to sustain ordinary strains, resulting in bones that break more easily Primary: occurs at 70+ years, affects women more than men, results from inadequate calcium and vitamin D intakes throughout life Secondary: identifiable drug or disease process that causes loss of bone tissue Estrogen-androgen deficient: occurs in women within a few years of menopause Risk factors: -age 60+ -women -family hx -inadequate calcium or vitamin D intake -Sedentary lifestyle -Being underweight -Amenorrhea for excessive exercise -Estrogen depletion from menopause -White or asian ethnicity -Excessive intakes of alcohol, caffeine, or fiber (each interfere w/ calcium absorption) -Medications that increase calcium loss MNT: -Supplemental calcium (1000 mg/d) -Supplemental vitamin D (800-1000 IU/d) -reduce alcohol and caffeine -weight gain in those who are underweight -weight-bearing exercises 3-5x/week

Macrocytic Anemia

-Presence of erythrocytes that are large, irregular, immature, with a decreased capacity for iron transfer Pathophysiology: -Typically caused by a decreased intake or absorption of folate or vitamin B12 -Decreased absorption of vitamin B12 could be due to the lost ability of parietal cells in the stomach that produce intrinsic factor, which is required for B12 absorption (atrophic gastritis) -Vitamin B12 deficiency can also be caused by gastrectomy, bariatric surgery, advanced age, inadequate oral intake, and chronic illness -Long-term B12 deficiency can lead to irreversible nerve damage -Folate deficiency can be caused by celiac disease, alcoholism, rapid growth, hemolysis, renal dialysis, and pregnancy/lactation -Vitamin B12 acts as a cofactor in enzymes responsible for the conversion of succinyl-CoA into succinate and coenzyme A during the production of RBCs -Succinyl-CoA is needed for the production of heme in late erythropoiesis -Active folate is a cofactor for enzymatic reactions essential for productions of proteins, nucleic acids, neurotransmitters, phospholipids, and histones -Lack of folate leads to DNA damage through a build-up of uracil in RBCs and cause them to become irregular in appearance Labs: -CBC: RBC: low hg: low hct: low MCV: high MCH: high MCHC: may be normal -Transcobalamin: low -Serum folate: high MNT: -vitamin B12 or folate supplementation: -increase consumption of foods containing vitamin B12 or folate -consider inhibitors of B12 and folic acid: proton pump inhibitors, histamine H2 receptor antagonists, cancer medications, contraceptives, antituberculosis medications, and anticonvulsants

Microcytic Anemia

-Presence of small and often hypochromic (pale) RBCs -Most commonly caused by iron deficiency, but may also be seen in a vitamin B6 deficiency Pathophysiology: -Heme synthesis is impaired as a result of an inability to either absorb, transport, store, or utilize iron and/or impaired by deficiencies or toxicities of other nutrients -Microcytic anemia is the most common nutritional anemia with a variety of causes, which include: -blood loss: GI diseases such as IBD & celiac, traumatic conditions such as surgical operations, wounds, etc, long-term dysmenorrhea w/ abnormal bleeding -periods of rapid growth: children, pregnancy -result of chronic disease: cancer, HIV, alcoholic liver disease, renal disease, and other diseases that directly affect iron -exposure to contaminants: lead poisoning leads to reduced synthesis of heme to carry iron -other: anemia may be seen in female athletes due to a combination of inadequate oral intake, increased needs for oxygen due to physical activity, menstrual losses, and RBC losses from high-impact Labs: -Iron panel test: -serum iron: low -serum ferritin: low -total iron binding capacity (TIBC): high in iron deficiency anemia and may be low in non-iron deficiency anemias -transferrin saturation: low -CBC: -RBC: may be normal -Hemoglobin (hg): low -Hematocrit (hct): low -MCV: low -MCH: low -MCHC: low MNT: -Iron supplementation: -Ferrous sulfate and ferrous gluconate are supplemental iron form that are better absorbed and tolerated compared to other iron chelates, such as ferrous fumarate -May cause GI upset, constipation, nausea -Increase iron-containing foods: -heme-containing foods found in animal products -also found in fortified grains, leafy greens, nuts, seeds, legumes, dried fruit -Optimizing iron absorption: -enhanced by vitamin C -cooking with cast iron cookware -avoid high-dose supplementation of calcium, zinc, copper, manganese (decrease iron absorption bc shared transport proteins) -Consider inhibitors of non-heme iron absorption, such as: -polyphenols including tannins and chlorogenic acid found in tea and coffee -Oxalic acid, found in spinach, chard, berries, chocolate, and tea -Phytates, found in beans, nuts, seeds, and grains

MyPlate

-Project of the USDA Center for Nutrition Policy and Promotion -Based on Dietary Guidelines for Americans 2020-2025 -Simplified, easy to understand symbol of a plate with the various food groups portioned off -Dropped the fats/oils and sweets/desserts that were found on the pyramid to simplify the message. Fats are typically a component of other food groups, such as protein and dairy Fruits: children- 1 cup for 2-3 years; 1-1.5 cups for 4-8 years girls: 1.5 cups for 9-18 boys: 1.5 cups for 9-13 years, 2 cups for 14-18 years women: 2 cups for 19-30 years, 1.5 cups for 31+ years men: 2 cups for 19+ years -Sample one cup equivalents: 1/2 large apple 1 large banana 32 grapes 1 large orange 8 large strawberries 1 wedge watermelon Vegetables: children- 1 cup for 2-3 years; 1.5 cups for 4-8 years girls: 2 cups for 9-13; 2.5 cups for 14-18 years boys: 2.5 cups for 9-13 years, 3 cups for 14-18 years women: 2.5 cups for 19-50 years, 2 cups for 50+ years men: 3 cups for 19-50 years, 2.5 cups for 51+ years -Sample one cup equivalents: 3 spears broccoli 2 cups raw spinach 2 medium carrots 1 large bell pepper 1 large tomato 1 large baked sweet potato 1 medium potato 1 avocado Grains: children: 3oz for 2-3 years; 5oz for 4-8 years girls: 5 oz for 9-13 years; 6oz for 14-18 years boys: 6oz for 9-13 years; 8oz for 14-18 years women: 6oz for 19-50 years; 5oz for 51+ years men: 8oz for 19-30 years; 7oz for 31-50 years; 6oz for 51+ years -Sample ounce equivalents: 1 large bagel = 4oz 1 slice bread = 1oz 1 english muffin = 2oz 1/2 cup oatmeal = 1oz 1 /2 cup rice = 1oz 1/2 cup pasta = 1oz Protein: children: 2oz for 2-3 years; 4oz for 4-8 years girls: 5 oz for 9-18 years boys: 5oz for 9-13 years; 6.5oz for 14-18 years women: 5.5oz for 19-50 years; 5oz for 51+ years men: 6.5oz for 19-30 years; 6oz for 31-50 years; 5.5oz for 51+ years -Sample one ounce equivalents: 1 ounce cooked meat/poultry/fish 1 egg 1/2 ounce nuts/seeds 1 tbsp peanut butter or almond butter 1/4 cup cooked beans 2 tbsp hummus Dairy: children: 2 cups for 2-3 years; 2.5 cups for 4-8 years girls: 3 cups for 9-18 years boys: 3 cups for 9-18 years women: 3 cups for 19+ years men: 3 cups for 19+ years -Sample one cup equivalents -1 cup milk -1 cup yogurt -1.5 ounces of hard cheese -1/3 cup shredded cheese -2 cups cottage cheese -1.5 cups ice cream -1 cup frozen yogurt

Food Drug Interactions: Beta blockers

-Treats high blood pressure, prevent angina, treat heart attacks -Relaxes blood vessels -Carvedilol and metoprolol -Should be taken with food or right after meal --> lowers chance of blood pressure dropping too much

Food Drug Interactions: antidepressants

-Treats mood disorders by increasing amount of serotonin in the brain -Interaction w/ alcohol --> can increase potential drowsy effect from medication

Food Drug Interactions: Antipsychotics

-Treats psychotic disorders -Thorazine is common -Should be taken with milk or food -Patients at higher risk of a riboflavin deficiency, especially with a poor overall diet -Vitamin B12 absorption may also be reduced

Dumping Syndrome

-Rapid emptying of undigested food into the jejunum -Usually occurs following gastric surgery that allows excessive amounts of liquid or solid food to enter the small intestine in a concentrated form -Symptoms: fullness and nausea within 10-30 minutes of eating, bloating, cramps, increased flatulence, and explosive diarrhea within 60 minutes of eating, reactive hypoglycemia -Symptoms likely related to malabsorption of carbohydrates and other foods and the subsequent fermentation of substrates entering the colon -May experience weight loss and malnutrition caused by inadequate intake, malabsorption, or both -Fats and proteins are better tolerated than carbohydrates since they are hydrolyzed more slowly -simple carbs are hydrolyzed rapidly -liquids enter the jejunum quickly MNT: -Small, frequent meals -Limiting fluid during meals and consume between meals in small, frequent quantities -Reduced intakes of simple sugars -Focus on intakes of complex carbohydrates, soluble fiber, and fat -If steatorrhea occurs (presence of 7 g fat or more in the stool in a 24 hour period), reduced fat diet or pancreatic enzymes may be needed -Lactose may need to be limited or restricted -Vitamin D and calcium supplements may be needed if the patient is omitting dairy foods -Lying down after meals may help decrease severity of symptoms

Addison's Disease

-Rare condition of primary adrenal insufficiency caused by damage to the adrenal glands or an autoimmune disease -Insufficient production of steroid hormones, including cortisol and aldosterone Symptoms: -poor blood glucose regulation -loss of appetite, weight loss -fatigue -low blood pressure -hypoglycemia -nausea and vomiting -muscle/joint pain -salt cravings -darkening of skin on the face/neck MNT: -supplementing with sodium, especially in those who live in warmer climates and have increased sweat losses (not those w/ hypertension) -supplementing with calcium and vitamin D in patients taking corticosteroids and at risk for osteoporosis -Avoid/limit coffee, tea, alcohol, bananas, oranges, and salt substitutes

Phenylketonuria (PKU)

-Rare genetic disorder that causes the amino acid phenylalanine to build up in the body -Phenylalanine is an essential amino acid needed for the synthesis of proteins, catecholamines, and melanin -Babies are screened for PKU soon after birth -Two types of PKU: 1. Classic PKU: more severe form, enzyme needed to convert phenylalanine to tyrosine is missing or severely reduced 2. Less severe forms of PKU: enzyme retains some function, phenylalanine levels are not as high, smaller risk of complications -If disorder is not treated, it can lead to serious health problems Symptoms: -no initial symptoms in newborns -Musty odor in breath, skin, or urine -Seizures -Skin rash (eczema) -Abnormally small head (microcephaly) -Intellectual disability -Delayed development -Behavioral and psychological problems Pathophysiology: -caused by a defect in the gene that creates the enzyme needed to break down phenylalanine -Without the enzyme necessary to process phenylalanine, a dangerous build up can develop when a person with PKU eats foods that contain protein or eats aspartame. Therefore, a special diet is required. Diagnosis: -Blood test performed from baby's heel when they're at least 24 hours old and after some protein has been ingested in the diet -If there is a positive result, additional testing may be necessary to confirm diagnosis, such as more blood or urine tests -Regular monitoring of phenylalanine levels are required. Goal is to keep between 1-6 mg/dL MNT: -During infancy, baby may consume breastmilk or a special baby formula, Lofenalac -Once solids are started, the diet involves limiting high protein, phenylalanine-containing foods, such as: -dairy, eggs, nuts, beans, chicken, pork, fish -Certain low-protein, PKU-friendly foods found at specialty health food stores can be consumed

Anemia

-Reduced number of circulating erythrocytes (RBCs) -Condition in which the number of RBCs and their oxygen-carrying capacity is insufficient to meet physiological needs -Hemoglobin: protein in RBCs that carries oxygen throughout the body, contains an iron atom bound to a heme group Pathophysiology: -develops due to an imbalance in erythrocyte loss vs erythrocyte production -Can be related to ineffective or deficient erythropoiesis from nutritional deficiencies, inflammation, genetic hemoglobin disorders, or excessive blood loss -Can occur from either nutrition-related or non-nutrition causes -Most common structural hemoglobinopathy is sickle cell anemia: homozygous abnormal hemoglobin causes a sickle shape to erythrocytes that reduces the body's ability to move blood to different parts of the body -Sickle cell anemia may be linked to a zinc deficiency -Nutritional anemias include microcytic anemia and megaloblastic or macrocytic anemia Diagnosis: -Medical hx, physical exam, blood testing results -Nutrition focused physical exam -Skin: pallor, angular cheilitis or angular stomatitis, jaundice -Eyes: pale conjunctiva -Mouth: pale gums, glossitis, pale or beefy red tongue -Nails: spoon shaped, central ridges -Hair: dull, thin, and sparse -Other symptoms: fatigue, depression, nerve damage, digestive problems, functional deterioration Labs: -Iron panel test: serum iron, total iron binding capacity, transferring saturation -CBC: RBC, hg, hct, MCV, MCH, MCHC -Reticulocyte count: blood test commonly performed as a follow-up to a CBC when anemia is the diagnosis. Measures # of reticulocytes (newly produced, immature RBCs) MNT: -Common medical interventions for anemia include transfusions of blood products, erythropoietin-stimulating agents, iron dextran infusion -Treatment of underlying conditions -For nutrition-related anemia, interventions include vitamin supplementation, dietary changes, and lifestyle changes

Gastric Surgery

-Roux-en-Y: creates a stomach pouch out of a small portion of the stomach that is attached directly to the jejunum, bypassing a large part of the stomach and duodenum. Dumping is common, and fat absorption is greatly reduced -Gastric bypass -Gastric banding -Vertical banding gastroplasty -Jejunoileal bypass Post-Op Medical Nutrition Therapy: -If GI tract is functional, oral intakes may be initiated -Immediately post-op, small/frequent feedings of ice and water are provided -Clear liquids are provided for the first day or up to one week after surgery -After tolerating clear liquids, the patient is moved to strained and pureed or soft foods -After tolerating pureed foods for a few weeks, the patient is advanced to soft foods -At about 8 weeks post-op, the patient transitions to a regular diet with new foods introduced one at a time -Diet should remain lower to moderate in fat, low in simple sugars, and high in protein -Patient may require enteral nutrition via jejunostomy if requiring additional healing time -Lactase deficiency is possible if the patient was lactose intolerant prior to surgery -Monitor iron, calcium, vitamin B12, and other micronutrients for potential deficiencies

Dietary Guidelines for Americans

-Runs in 5 year cycles -Current cycle 2020-2025 -First edition to provide recommendations by life stage, from birth through older adulthood Guidelines: 1. Follow a healthy dietary pattern at every life stage: -First 6 months of life: exclusively human-fed through first year of life, iron-fortified formula if human milk is not available, supplemental vitamin D soon after birth -6 to 23 months: introduce foods including potentially allergenic foods, include foods rich in iron and zinc, avoid foods/beverages high in sodium -2 years to adulthood: follow healthy dietary pattern across the lifespan to meet nutrient needs, help achieve a healthy bodyweight, and reduce risk for chronic disease 2. Customize and enjoy nutrient-dense food and beverage choices to reflect personal preference, cultural traditions, and budgetary considerations 3. Focus on meeting food group needs with nutrient-dense foods and beverages, and stay within calorie limits. Nutrient-dense foods provide vitamins, minerals, and other health-promoting components and have little or no added sugars, saturated fat, and sodium 4. Limit foods and beverages higher in added sugars, saturated fat, and sodium, limit alcoholic beverages -added sugars <10% -saturated fat <10% -sodium <2300 mg/d

Crohn's Disease

-Severe cases can involve inflammation of eyes, skin, joints, liver and bile ducts, as well as delayed growth and sexual maturation in children -complications can include bowel obstruction, open sores along the digestive tract, malnutrition, fistulas, anal fissure, and colon cancer Symptoms: -Inflammation affects all layers of the mucosa but may not be present along the entire digestive tract -abdominal pain/cramping -severe diarrhea, may be bloody -fever -fatigue -mouth sores -reduced appetite -weight loss Pathophysiology -Risk factors: -family history, caucasian or Eastern European Jewish descent, cigarettes, urban industrialized areas -The use of NSAIDS can worsen Crohn's disease symptoms Diagnosis: -no specific diagnostic test -primarily by endoscopy as well as stool samples, blood tests, and imaging studies MNT: -No specific diet has proven effective -Low fiber diet during flare-ups can help -trigger foods often include dairy, high fiber grains, alcohol and hot spices -Can lead to B12 deficiency, so B12 shots are often prescribed -Vitamin C, folic acid, zinc, and selenium deficiencies may result from long-term steroid use -Patient should pay attention to calcium, vitamin d, magnesium, and vitamin k as steroid use can also cause osteoporosis

Diverticulosis

-Small pouches that bulge through the colon (called diverticula) -Most often occurs on the left side of the S-shaped sigmoid colon -Diverticulitis is the inflammation of the diverticula, which can cause severe pain and other symptoms -Together, diverticulosis and diverticulitis are known are diverticular disease Symptoms: -Mostly asymptomatic but can cause mild cramps, diarrhea, or bloating -If pouches become inflamed, this becomes diverticulitis which causes pain on the left side of the abdomen, fever, nausea, chills, and constipation -Can lead to burst diverticula sacs, tears, bleeding, and blockages in the intestinal tract Pathophysiology: -More common among people over 60 -Common in Western cultures -Risk factors include: -low-fiber diet, overweight, smoking Diagnosis: -Diagnosed via barium enema, colonoscopy, or CT scan -Often found when performing a test for something else MNT: -high fiber diet -low fiber during diverticulitis attacks -plenty of fluids -avoiding nuts, seeds, and popcorn is unnecessary from recent research

Nutrition Intervention

-Strategies should be directed at the etiology of the nutrition diagnosis Intended to positively change: -food and/or nutrient delivery and intake -nutrition-related knowledge or behavior -environmental conditions -access to supportive care and services Changes through: -alterations to the diet -nutrition education -nutrition counseling -coordination of nutrition care

Alcoholic Liver Disease

-The body can handle moderate intakes of alcohol, where it is efficiently metabolized and converted to fat -Chronic alcohol abuse displaces nutrients from the diet and interferes with the body's metabolism of nutrients Alcohol Metabolism: -Stomach: no digestion, quickly absorbed across the walls of an empty stomach, broken down by alcohol dehydrogenase -Small Intestine: absorbed rapidly into the small intestine, taking priority over most other nutrients -Liver: alcohol dehydrogenase oxidizes alcohol to acetaldehyde, which is then converted to acetate, which is then converted to either carbon dioxide or acetyl CoA "fatty liver": alcohol metabolism takes precedence over fat metabolism, and fat begins to accumulate and the liver deteriorates Malnutrition Concerns: -Folate and thiamin deficiencies -liver loses ability to retain folate, and kidneys increase excretion of it -alcohol interferes with action of folate converting homocysteine to methionine, resulting in excess homocysteine, a risk factor for heart disease -Wernicke-Korsakoff syndrome: alcohol-related thiamin deficiency characterized by paralysis of eye muscles, poor muscle coordination, and damaged nerves -Vitamin B6 deficiency -acetaldehyde dislodges vitamin B6 from its binding protein, resulting in deficiency and lower production of red blood cells -stomach cells over secrete gastric acid and histamine, an immune system agent that produces inflammation -intestinal cells fail to absorb thiamin, folate, and vitamin B12 -liver cells lose efficiency in activating vitamin D Spectrum of 3 Disorders: -Hepatic steatosis (fatty liver): condition of intrahepatic triglycerides making up at least 5% of liver weight. Occurs in 90% of chronic alcohol abusers -Alcohol hepatitis: toxic liver injury associated with chronic alcohol consumption -Alcohol cirrhosis Symptoms: -Alcohol fatty liver: mostly asymptomatic, lab abnormalities return to normal once patient is under treatment -Alcohol hepatitis: fever, jaundice, hepatomegaly, ascites, encephalopathy, portal hypertensive bleeding, increased susceptibility to infections such as pneumonia Diagnosis: -significant history of alcohol use -High AST/ALT ratio > 2 -Hepatomegaly -Liver biopsy or radiographic evidence showing steatosis or cirrhosis Pertinent Labs: Blood tests: -ammonia > 60 mcg/dL -cholesterol ester > 75% of cholesterol Urine tests: -bilirubin > 0 -urobilinogen > 4 mg/24 hours Pigment tests: -serum bilirubin > 0.9 mg: reflects livers ability to excrete bilirubin. Increased levels cause jaundice Enzymes: -Alkaline phosphatase > 95 U/L -GGT > 30 U/L -Aspartate transaminase (AST) > 40 U/L: detects hepatocellular injury secondary to cellular necrosis -Alanine aminotransferase (ALT)> 40 U/L: most sensitive test to detect hepatocellular injury secondary to exacerbation of infectious hepatitis MNT: -Healthy diet w/ fruits & vegetables and foods with anti-inflammatory nutrients -Avoidance of alcohol -Small, frequent meals -Multivitamin or B-complex vitamin -Educate patient on fat-restricted diet -2000 cals/d and 1.2-1.5 g/kg/d protein

Assessment of micronutrient deficiencies- Nails

-Thin, spoon-shaped: iron -dull, lacking luster: protein -half and half nails: renal failure -mottle, pale, blanching: vitamin A & C -splinter hemorrhage: vitamin C -pale nail beds: anemia from deficiency of iron, folate, B6, B12 -white spots: zinc -white banding: protein, zinc deficiency or hypercalcemia

Hypothyroidism

-Underactive thyroid gland which does not produce an adequate supply of hormones -Hashimoto's thyroiditis: autoimmune disorder which attacks and destroys thyroid gland tissue -May also be caused by thyroid surgery, radiation therapy, and certain medications, such as lithium -Commonly treated medically with thyroid hormone replacement medications Pathophysiology: -Adrenal stress and oxidative stress: decreased ability of the adrenal glands to respond adequately to stress -Increased age: thyroid activity decreases -Pregnancy: related to pregnancy-related conditions -Autoimmune disease, such as celiac or T1DM Symptoms: -fatigue -depression -heavy menses -dry hair and/or skin -mood swings -weight gain -hoarse voice -constipation MNT: -Iodine: -helps produce biochemically active thyroid hormones -adequate intakes recommended -Iodine supplementation should be avoided in patients with Hashimotos -Selenium: -Necessary component of enzymes integral to thyroid function -Also monitor intakes of Vitamin D, iron, and zinc

Ventilated Patients

-Ventilator patients often have preexisting conditions such as malnutrition -Critically ill patients are at risk of malnutrition, muscle wasting, delayed wound healing, slower recovery, and increased risk of morbidity and mortality -Early enteral nutrition support for ventilator patients provides necessary nutrients to promote wound healing, preserve lean body mass, and reduce complications Symptoms: -Conditions that may require ventilation include: -coma -brain/spinal cord injuries -stroke -COPD or pneumonia -drug overdose -lung infection Pathophysiology: -Unable to exchange air and expire CO2, while results in high CO2 and low pH -Ventilators are routinely used for general anesthesia for surgery Labs (RD should assess): -fluid status -renal function -adequacy of glucose control Need for supplementation or restriction of electrolytes by monitoring: -BUN -Creatinine -Fasting glucose -Sodium -Potassium -Calcium -Magnesium -chloride -venous bicarbonate -phosphorus MNT: -goal is to improve outcomes, such as infection rate, days spent on the ventilator/in the ICU -EN is the preferred nutritional support method due to its reduced septic risk, lower cost, and role in maintaining GI function -Critical illness increases energy expenditure and increases risk of malnutrition -Energy requirements: 25-30 cals/kg -Protein requirements: 1.2-2.0 g/kg

Food Drug Interactions: Warfarin

-Vitamin K agonist or anticoagulant, designed to be a blood thinner -Decreases chances of blood clots -Foods high in Vitamin K (broccoli, cabbage, spinach, kale, brussel sprouts) can make it less effective -Alcohol can affect the dose -Cranberry juice can change the effect -Garlic, ginger, glucosamin, ginseng, and ginkgo can increase the chances of bleeding

Assessment of micronutrient deficiencies

-Vitamins D, E, and K are stored for 2-6 weeks -Vitamin A can be stored for up to 1-2 years -Thiamin and biotin are stored for up to 4-10 days -Patients who consume excessive amounts of alcohol are at greater risk of developing micronutrient deficiencies -Alcohol interferes with absorption of several micronutrients such as biotin, folate, niacin, riboflavin, thiamin, B6, B12, and zinc

Insulin to Carbohydrate Ratio

-Way for a diabetic patient to determine the number of units of insulin to take based on the meal to be consumed -Used for patients taking a rapid acting or a short acting insulin -Ratio is expressed as 1 to X, where "X" refers to the number of grams of carbohydrates one unit of insulin can effectively cover -In general, one unit of a short/rapid acting insulin will cover 12-15 g of carbohydrates -

Heart Failure

-Weakened or damaged heart muscle that pumps inefficiently, resulting in reduced blood flow to organs and cells -Most cases of heart failure are due to impaired left ventricle function -Treatment for advanced heart failure may require surgery for a stent or pacemaker or heart transplant Symptoms: -usually do not occur until advanced stages of congestive heart failure -Fluid retention -SOB -fatigue -congestion -irregular pulse -heart palpitations -coughing Pathophysiology: -characterized by structural changes to the heart, resulting in an enlarged or thickened heart and increased pumping to compensate for decreased cardiac output -Other heart conditions that are main causes of heart failure include: -HTN -CHD -Heart valve disease -previous heart attack -heart arrhythmias Diagnosis: -chest x-rays, EKG, echocardiogram, MRIs, catheterization, holter monitoring, exercise stress test -Stage A: high risk for heart failure with no structural changes or symptoms present -Stage B: structural changes present but patient is asymptomatic -Stage C: structural changes with symptoms -Stage D: advanced structural changes and severe symptoms at rest MNT: -Sodium and fluid restrictions are usually required to manage fluid retention. Exact amounts depend on the stage of heart failure and amount of edema -Eliminate the use of table salt and avoid high sodium foods, such as processed meats, canned vegetables, canned soups, salted snacks, prepared sauces and condiments, and cheeses -Diet low in fat and cholesterol -Reduced intakes or avoidance of alcoholic beverages -Small, frequent meals throughout the day tend to be better tolerated by heart failure patients -Monitor potassium, magnesium, and thiamin levels since the use of diuretics can increase excretion of these nutrients

GERD

-episodes of reflux overwhelm esophageal protective mechanisms -results in symptoms of heartburn Pathophysiology: -reduced LES pressure, inadequate esophageal tissue defense, direct mucosal irritants, decreased gastric motility, and increased intra-abdominal pressure -higher risk in COPD patients and during pregnancy -may also be caused by muscle relaxants and NSAIDs -esophagitis: inflammation of the esophagus Treatment: -proton pump inhibitors: decrease acid production by the gastric parietal cells -fundoplication: procedure where the fundus of the stomach is wrapped around the lower esophagus to limit reflux -antacids MNT: Avoid- -large high fat meals -acidic and highly spiced foods -carbonated beverages -smoking, alcohol, and caffeine -eating 3-4 hours before lying down -tight-fitting clothes Weight loss if overweight staying upright and avoiding vigorous activity after a meal

Pancreatitis

-inflammation of the pancreas -normally, enzymes secreted by the pancreas do not become active until they reach the small intestine -with pancreatitis, enzymes inside it can attack and damage the tissues that produce them Risk factors: -excessive alcohol consumption (4+ drinks/day) -cigarette smoking -family hx Symptoms: -sudden onset of upper abdominal pain that often radiates towards the back -nausea, vomiting, diarrhea -loss of appetite -rapid pulse -abdominal tenderness -uncontrolled pain -fever -patients w/ chronic pancreatitis may also experience steatorrhea, weight loss, and uncontrolled blood glucose Pathophysiology: -inflammation of the pancreas caused by release of enzymes into the tissues of pancreas -enzymes cause irritation, edema, and blockage of blood vessels Acute pancreatitis: -isolated event characterized by abdominal pain and elevated amylase/lipase levels Chronic pancreatitis: -disease where the inflammation may be resolved, but the damage may result in fibrosis, calcification, and in severe cases, necrosis and hemorrhage of the tissue -can lead to decreased endocrine and exocrine function, protein-calorie malnutrition, and diabetes Diagnosis: -2/3 of the following symptoms are required for a diagnosis: -abdominal pain consistent w/ acute pancreatitis -increased lipase or amylase atleast 3x UL -acute pancreatitis found on an ultrasound -when lipase/amylase are not elevated, but diagnosis is in question, CT scan may be ordered -chronic pancreatitis best diagnosed with tests that can evaluate the structure of the pancreas via x-ray Pertinent Labs: -Amylase and lipase (lipase being more specific than amylase) -CBC (WBC indicate infection) -CMP -Glucose tolerance test (assesses endocrine function) -C-reactive protein (measures inflammation) -Fecal elastase (enzyme reduced w/ pancreatitis) -Markers of malnutrition (prealbumin, hemoglobin, retinol binding protein, vitamin d, vitamin e, magnesium, zinc) MNT (acute pancreatitis): -NPO prescribed upon hospital admission -low-fat, soft oral diet used if tolerated -EN or PN may be required MNT (chronic pancreatitis): -malnutrition is common -high-protein, high-calorie, limited fiber -EN or PN may be required

Glycogen Storage Disease (GSDI)

-inherited disorder caused by buildup of glycogen -affects 1 in 100,000 people -Two types of GSDI: 1. Glycogen storage disease type 1a (GSDIa) 2. Glycogen storage disease type 1b (GSDIb) -complications include hypoglycemia, lactic acidosis, elevated uric acid levels, and hyperlipidemia -treatment often aims to keep blood glucose levels as normal as possible Symptoms: -typically appear around 3-4 months old, or when babies start to sleep through the night and do not eat as frequently as newborns -hypoglycemia -seizures -lactic acidosis -hyperuricemia: build up of the waste product uric acid -hyperlipidemia Pathophysiology: -glycogen accumulates in the liver, kidneys, and small intestines, and impairs their ability to function normally -caused by mutations in two genes: G6PC & SLC37A4 -the proteins produced from these genes work together to break down a type of sugar molecule called glucose 6-phosphate -G6P is not broken down to glucose but instead converts to glycogen -results in hypoglycemia and excess storage of glycogen in the cells and organs Diagnosis: -genetic testing to look for mutations, specifically G6PC and SLC37A4 -an abnormal ultrasound to see if liver is enlarged -delayed growth -abnormal blood tests: -hypoglycemia: serum glucose <45 mg/dL -triglycerides: >250 mg/dL -hyperuricemia: uric acid levels > 5.0 mg/dL -total cholesterol: >200 mg/dL MNT: -aimed at keeping right amount of glucose in the blood -small, frequent meals that are lower in sugar can prevent excess glycogen storage in liver -sometimes, uncooked cornstarch is given as a complex carbohydrate source. It is difficult to digest and therefore maintains normal blood sugar levels longer than most other CHO would

Acute Respiratory Distress Syndrome (ARDS)

-life-threatening illness in which the lungs are severely inflamed due to injury, trauma, or infection -fluid leaks into the lungs and prohibits oxygen from getting into the bloodstream which deprives organs of oxygen -often requires ventilation between 7-14 days Symptoms: -SOB -rapid breathing -low blood pressure -altered mental status -extreme fatigue -dry, hacking cough -fever -headache -rapid pulse Pathophysiology: -Caused by fluid leaked from the smallest blood vessels in the lungs into the tiny air sacs where blood is oxygenated -Most common cause of ARDS is sepsis -Other causes include inhalation of harmful substances, inhalation of vomit, near-drowning episodes Diagnosis: -physical exam, chest x-ray, CT scan, oxygen levels -chest X-ray checks for fluid in lungs -CT scan shows problems within the lungs and is used to rule in/out pneumonia, tumors, etc -electrolyte, renal profiles, blood glucose, and acid-base balance lab values are necessary to assess fluid status, renal function, adequacy of glucose control, and the need for supplementation or restriction of electrolytes MNT: -goal is to prevent malnutrition, loss of lean body mass, and deterioration of respiratory muscle strength -goal for EN is to minimize risk of overfeeding -trophic (10-20 cals/hr or 500 cals/d) results in lower incidence of GI intolerance -EN supplemented with fish oils and antioxidants

Assessment of micronutrient deficiencies- Face, mouth, and neck

-moon face: protein-calorie deficiency or chronic steroid use -enlarged thyroid (goiter): iodine -bleeding gums: vitamin C -tongue that is sore, burning, or purple-colored: riboflavin -beefy, red tongue with diminished taste: niacin, folate, riboflavin, iron, B6, B12 -pale tongue: iron, folate, B12

Assessment of micronutrient deficiencies- Eyes

-night blindness, dull dry appearance, keratomalacia, bitot's spots: vitamin A -redness and fissures: riboflavin, niacin, zinc, B6 -excessive tearing: riboflavin, B6 -pale conjunctiva: copper or anemia from deficiency of iron, folate, B6, B12

Complementary and Alternative medicine (CAM)

-practices which are not a customary part of conventional medicine naturopathy: natural medicine, the healing force of nature that emphasizes the prevention of disease and maintenance of health chiropractic care: bodies ability to heal itself, manual manipulation of the body homeopathy: help the body heal itself by treating like with like (law of similars) traditional oriental medicine acupuncture: thin needles inserted into points on the 12 meridians of the body to stimulate the body's energy

Osteomalacia

-softening of the bones from a vitamin D deficiency -commonly affects older adults, mostly women -noted by a bend in the spine and bowing of the legs -increased risk of bone fractures -may occur if dietary intake of vitamin D is too low, with inadequate exposure to sunlight, or if there is a malabsorption of vitamin D in the intestines -can be treated with vitamin D supplementation

Inflammatory Bowel Disease

-umbrella term for 2 main GI disorders: Crohn's disease and ulcerative colitis -main difference is the location of the inflammation and the layer of the mucosa each impacts -First onset is most often in patients from 15-30 years of age -People with IBD are more likely to have other chronic conditions -Treated with certain medications such as aminosalicylates, corticosteroids, immunomodulators, and IBD biologics -Severe IBD cases may require surgery Symptoms: -diarrhea -food intolerances -fever -weight loss -anemia -malnutrition -growth failure -extraintestinal manifestations Pathophysiology: -immune response that results in an inflammatory response and damage to GI tissues -some degree to a genetic component -food sensitivities, allergies, or intolerances may play a role Diagnosis: -symptom assessment -GI tests such as colonoscopy, endoscopy, barium enemy, CT scan, and MRI -No diagnostic lab tests, but routine blood tests to evaluate IBD include: -CBC, C-reactive protein, ESR, liver function test, electrolyte panel, vitamin B12 MNT: -Prevent malnutrition or maintain nutrition status -may include supplements, multivitamins, enteral, or parenteral nutrition -Depends on condition and symptoms -Adjustments in fiber and fluid intake during flare-ups and avoiding trigger foods unique to the individual -Some alternative and complementary medicines, such as pre/probiotics, glutamine, and omega-3s are often used in conjunction with traditional IBD treatments

Nutrition Care Process (NCP)

A systematic approach to medical nutrition therapy Consists of 4 steps: -Assessment -Diagnosis -Intervention -Monitoring and Evaluating Assessment: -collection and analysis of health-related information for the purpose of identifying specific nutrition problems and underlying causes -medical records, nutrition-focused physical exam, lab data, medical procedures, interview, consultations w/ other health professionals Diagnosis: -Identifying existing and potential nutrition problems -Each problem receives a separate diagnosis -Problem, Etiology, and Signs/Symptoms (PES statement) Intervention: -Target the cause of problem identified in diagnosis -Goals are stated in measurable outcomes -Goals may also include anticipated positive changes in dietary behaviors and lifestyles Monitoring and Evaluation: -Periodic evaluation of the nutrition care's effectiveness

Braden Scale

A tool for predicting pressure ulcer risk The lower the score = the higher the risk 19-23 = no risk 15-18 = mild risk 13-14 = moderate risk 12 and below = high risk Risk factor categories: 1. Sensory Perception: ability to respond meaningfully to pressure-related discomfort (1-4 scale from completely limited to no impairment) 2. Moisture: degree to which the skin is exposed to moisture (1-4 scale from constantly moist to rarely moist) 3. Activity: degree of physical activity (1-4 scale from bedfast to walks frequently) 4. Mobility: ability to change and control body position (1-4 scale from completely immobile to no limitations) 5. Nutrition: usual food intake pattern (1-4 scale from very poor to excellent) 6. Friction and shear (1-3 scale from problem to no apparent problem)

Assessment of fat stores

Assessment of 4 areas: orbital, buccal, triceps, and ribs Orbital: -area of the sockets in the skull which hold the eyes -moderate loss: slightly darkened circles and somewhat hollow appearance under the eyes -severe loss: dark circles under and around the eyes with an obvious hollowed appearance Buccal: -commonly referred to as the cheeks -moderate loss: some flattening around the cheeks and may have resistance when pressed -severe loss: hollow, narrow facial appearance Triceps: -moderate loss: some tissue btwn the fingers with fat that easily pulls away from the muscle -severe loss: fingers will nearly touch when pinching the tissue Ribs and mid-axillary line: -area running from clavicle to the mid-abdomen -moderate loss: ribs will be apparent, but no distinguishable depressions between the rib bones -severe loss: ribs very apparent, noticeable depression between rib bones

Assessment of muscle stores

Assessment of 7 areas: temple, clavicle, shoulder, scapula, interosseous, thigh/patella, and calf -Top half of body more likely to display wasting before lower half -wasting is defined as presence of atleast 2 areas Temple: -moderate loss: slightly hollowed appearance and decreased bounce back -severe loss: hollowing scooping, dark circles, loose skin Clavicle: -moderate loss: visible bone in men, some protrusion of the bone in women -severe loss: protruding, prominent bone, able to feel the underside of bone Shoulder: -moderate loss: less roundness, visible acromion w/ less tone in the muscle -severe loss: squared-off appearance and prominent acromion Scapula: -moderate loss: bone may show slightly, noticable loss of muscle tone and firmness -severe loss: prominent, visible bones along with depressions between the ribs and scapula and the shoulders and spine Interosseous: -muscles of the hands that are attached to the metacarpal bones -moderate loss: flattened area may have a slight depression -severe loss: clear depression btwn thumb and index finger Thigh/patella: -moderate loss: slight depression along inner thigh and more noticeable keecap -severe loss: significant depression of the thigh and a squared-off and prominent kneecap Calf: -moderate loss: bulb will be present but may lack firmness when squeezed -severe loss: thin calf with minimal to no definition. Diameter of calf may be the same size or small than the knee

Fad Diets

Atkins diet -restrict carbs to correct metabolic imbalances -lose weight without restricting calories Keto diet -very low carbohydrate diet -lowers insulin levels and shifts primary fuel source from sugar to ketones, the byproduct of fat metabolism Paleo diet -based on that of hunters and gatherers -higher intakes of protein, fruit, and vegetables

Herbal Supplements

Black cohosh: used as relief to women experiencing hot flashes and other menopausal symptoms Cranberry: treatment of UTIs Echinacea: prevent and treat upper respiratory infections Garlic: reducing high cholesterol, blood pressure, blood clotting, alleviating common cold, prevention of cancer. Can interfere w/ effectiveness of some medications, such as saquinavir (HIV med) Ginger: treatment of nausea, rheumatoid arthritis, osteoarthritis Ginkgo: treatment of dementia St. John's Wort: treatment of depression, menopausal symptoms, ADHD, OCD. Can weaken the effects of antidepressants, BC, some HIV and cancer medications, and warfarin.

Carb counting and Exchange List

Carbohydrate counting: -For diabetic meal planning, 1 carbohydrate source = 15 grams of carbohydrates -On average, people with diabetes should aim to get half of their daily calories from carbs Diabetic exchange list: Starches: -encompasses foods such as dried beans/peas/lentils, starchy vegetables, cereals/grains/pasta, bread, crackers/snacks, and starchy foods prepared with fat -general rule: 1/2 cup cereal, grain or pasta and 1 ounce of bread product = 1 serving -Nutrition per serving: -CHO: 15 g -Fiber: 2 g in whole grain products -Protein: 3 g -Fat: trace amount -Calories: 80 kcals Fruits: -general rule: a serving yields 1/2 cup of fresh fruit or fruit juice, 1/4 cup of dried fruit, or 1 cup of fresh high-water fruits, like melons -Nutrition per serving: -CHO: 15 g -Fiber: 2 g -Protein: 0 -Fat: 0 -Calories: 60 kcals Milk and milk products: -Carbs and protein are fairly consistent between the different categories -Fat and calories will vary by category -Nutrition per serving: -Carbohydrates: 12 g -Protein: 8 g -Fat: -Skim/very low-fat: 0-3 g -Low-fat: 5 g -Whole milk: 8 g -Calories: -Skim/very low-fat: 90 g -Low-fat: 120 g -Whole milk: 150 g Other carbohydrates: -foods in this list can be substituted for foods from the starch, fruit, or milk lists -some from this group will also count as 1 or more fat exchange -cakes, brownies, doughnuts, cookies, ice cream, chips, frozen yogurt, sherbert, granola bars, etc Vegetables: -A serving yields 1/2 cup of cooked vegetables, or 1 cup raw vegetables -Nutrition per serving: -Carbohydrates: 5 g -Fiber: 2-3 g -Protein: 2 g -Fat: 0 g -Calories: 25 kcals Meat and Meat Substitutions: -Categories: very lean meat and substitutes, lean mean and substitutes, medium-fat meats, and high-fat meats -The amount of fat and calories varies per category -General rule: a serving yields 1 ounce of meat, poultry, fish, or cheese, or 1/2 cup dried beans -Special note: peanut butter is classified as a high-fat meat +1 fat exchange (5 g), and the serving size is 2 tbsp -Nutrition per serving: -Carbohydrates: 0 g -Protein: 7 g -Fat -Very lean meat and substitutes: 0-1 g -Lean meat and substitutes: 3 g -Medium-fat meats: 5 g -High-fat meats: 8 g -Calories -Very lean meat and substitutes: 35 -Lean meat and substitutes: 55 -Medium-fat meats: 75 -High-fat meats: 100 Fats: -The Fats list is divided up into monounsaturated fats, polyunsaturated fats, and saturated fats -Nutrition per serving: -Carbohydrates: 0 -Protein: 0 -Fat: 5 g -Calories: 45 Free Foods: -A variety of foods/drinks that contain less than 20 calories or less than 5 g/CHO per serving -Grouped into: fat-free or reduced-fat foods, sugar-free or low-sugar foods -Some items in the list have a serving size, and patients are encouraged to limit these to 3 servings per day -Other items do not list a serving size, and patients may use these without limitation Combination foods: -Foods that are combinations of exchange categories -Possibilities are endless for this list -Examples may include: -Casserole: 1 cup serving. Count as 2 carbohydrates and 2 medium-fats -Cheese pizza: 1/4 of a 10 inch pie. Count as 2 carbohydrates, 2 medium-fats, and 1 fat

Nutritionally-Modified Diets

Carbohydrate-controlled: -"no concentrated sweets" -for patients with a need to manage blood sugar -same amount of CHO each day -focus on fiber-containing foods -snacks/desserts often limited to low-sugar or sugar-free options Fat-controlled: -reduce symptoms of fat malabsorption associated with diseases of the liver, gall bladder, pancreas, and intestines -limited to about 25-50 g/day -foods generally provide < 1 g/fat per serving Sodium-controlled: -prevent or correct fluid retention, or to treat HTN, CHF, kidney or liver disease -2,000-3,000 mg sodium restriction generally Fiber-restricted: -intestinal disorders where fiber may exacerbate discomfort -may be used before surgery to minimize fecal volume -may be used after surgery during a transition to a regular diet -not recommended for long-term use Low-residue: -a fiber-restricted diet with further exclusions -avoid foods that contribute to colonic residue bc some of their nutrients are poorly digested or poorly absorbed -foods on fiber-restricted, plus -most fruits/vegetables -foods high in resistant starch (dietary fibers which support healthy digestive system) -high-lactose-containing milk products -foods containing fructose or sugar alcohols High-calorie, high-protein: -Prescribed to increase calorie and protein intakes in patients who have unusually high requirements -high-fat foods may exceed 35% of total calories -may be encouraged to eat small, frequent meals and include nutritional liquid supplements Clear liquid Full liquid Soft or bland Nothing by mouth (NPO)

Epilepsy

Chronic condition characterized by unprovoked, recurring seizures that disrupt the nervous system -Seizure: intermittent derangements in brain function caused by abnormal electrical activity of brain cells -Tonic-clonic seizure (grand mal): dramatic seizure event lasting about 1-2 minutes that leaves the person feeling groggy and disoriented -Absence seizure (petit mal): mild seizure where the person appears to be daydreaming but recovers within a few seconds with no fatigue or disorientatoin -Often begins early in life but may happen at any age -Usually caused by developmental defects, birth injuries, or metabolic disease MNT: -Ketogenic diet: -may be used for treatment of all types of seizures in children -ketones inhibit neurotransmitters, producing an anticonvulsant effect -individual fasts in the hospital for 24-72 hours until ketonemia is produced, once ketosis is established, caloric intake resumes in a ratio of 3:1 or 4:1; fats:protein&carbs -with a 4:1 ratio, fat calories make up about 90% of total calories. Calculated as: -4 g fat x 9 cals = 36 fat calories -1 g of carb-protein combo x 4 cals = 4 carb-protein calories -36 fat cals / 40 total cals = 90% -Protein calculated to provide adequate growth, about 1 g/kg/d -carbohydrates added to make up the remaining small portion of calories -diet may discontinue after 2-3 years, after child has been seizure free for 1 year -risks: low blood sugar, upset stomach, constipation -elevated serum cholesterol is possible, but temporary, and usually disappears shortly after discontinuing the diet

Nutrition Screening Tools

Common nutrition screen tools for malnutrition: Malnutrition Universal Screening Tool (MUST) -current weight & height w/ known BMI -unintentional weight loss -acute disease effect on nutrition status for >5 days -0 = low risk -1 = medium risk -2+ = high risk Mini Nutritional Assessment (MNA) -65 years and older -questions related to food intake, weight loss, mobility, stress, neuropsychological condition, and BMI -12 to 14 = normal nutrition status -8 to 11 = at risk of malnutrition -0 to 7 = malnourished Geriatric Nutritional Risk Index (GNRI): -Relies on serum albumin and differences between current and previous body weights -IBW is used in lieu of usual weight since usual weight is difficult to assess in older population Subjective Global Assessment (SGA) -Based on historical, symptomatic, and physical parameters -Historical data: weight changes over past 2 weeks and 6 months, dietary intake changes, GI symptoms persisting over 2 weeks, functional capacity -Physical data: -Normal = 0; Mild = +1, Moderate = +2, Severe = +3 -Assesses: -loss of subcutaneous fat in the triceps and chest -muscle wasting in the quads and deltoids -edema in the ankles and sacral regions -ascites -Rating: well-nourished, moderately malnourished, severely malnourished

Input/Output

Commonly referred to as I/O or I and O -Input: any fluids taken in by a person by way of beverage, fluid from food, enteral feeding, parenteral feeding, and intravenous administration -Output: any fluids excreted by the body -Insensible fluid loss: amount of body fluid that is not easily measured, such as from the respiratory system, skin, and stool (~40-800 ml/d) -Fluid equilibrium: when input matches very closely to output -Positive fluid balance: input > output, could indicate kidney dysfunction or edema -Negative fluid balance: output > input, could indicate dehydration I/O = total input - total output

Spinal Cord Injury

Complete spinal cord injury = paralyzed below the injury Incomplete injury = patient may have some movement and sensation below the injury MNT: -daily needs roughly 10% lower than predicted needs to prevent risk of obesity, diabetes, and cardiovascular disease -monitor weight closely -1,500 ml/d of fluid to prevent constipation -Calcium and vitamin D are of of concern because of a decrease in absorption of calcium caused by immobilization -fiber important to assist with GI function -Fish oil supplements for their anti-oxidative, anti-inflammatory and anti-apoptosis effects -cranberry juice to prevent UTIs -If pressure injuries are present, 30-40 cals/kg and 1.2-1.5 g/kg protein for stage 2 pressure injuries or 1.5-2.0 g/kg for stages 3 & 4 pressure injuries

Cystic Fibrosis

Complex multi-system disorder inherited by an autosomal-recessive gene -almost all exocrine glands are affected and secrete abnormally thick mucus that obstructs glands and ducts in various organs -involves the respiratory tract, sweat and salivary glands, intestine, pancreas, liver, and reproductive tract Factors interfering with adequate nutrition intake/retention of nutrients: -Dyspnea: difficulty breathing -Coughing -GI discomfort -Anorexia -Impaired taste or smell -Glucosuria: glucose in the urine Complications: -Pulmonary complications: -acute/chronic bronchitis -bronchiectasis: bronchial tubes permanently damaged, widened, or thickened -pneumonia -atelectasis: collapse of lung -scarring of lung tissue -Pancreatic insufficiency: -found in ~85-90% of patients -plugs of thick mucus reduce the quantity of digestive enzymes released from the pancreas into the small intestine -food is maldigested, fats malabsorbed -risk of steatorrhea, malnutrition, and deficiencies of fat-soluble vitamins -may require pancreatic enzyme replacement therapy -Distal intestinal obstruction syndrome (DIOS): -Recurrent intestinal impaction -treated medically with stool softeners, laxatives, and hyperosmolar enemas Diagnosis: -routine neonatal screening -genotyping -sweat test: measures amount of chloride in sweat MNT: -goal is to control maldigestion and malabsorption, provide adequate nutrients, promote optimal growth, support pulmonary function, and prevent nutritional deficiencies -high-calorie, moderate-fat diet -pancreatic enzyme replacement therapy -larger food portions and additional snacks -protein at least 15-20% of total energy -fat intake of 35-40% of total energy -Include essential FAs from fish, canola oil, flaxseed oil, soybean oil, or corn oil -multivitamin/mineral supplementation -water-soluble vitamins are usually adequately absorbed and not as concerning -sodium needs increased because of increased sweat losses -plasma zinc may be low in cases of malnutrition

Polycystic Ovary Syndrome (PCOS)

Condition causing an imbalance of a woman's hormones May result in: -Amenorrhea -Anovulation -Enlarged ovaries with multiple cysts -Infertility -Acne -Excessive/abnormal hair growth -Male-patterned baldness -Obesity -Sleep apnea Medical management: -Oral contraceptives to help regulate the menstrual cycle -Thyroid hormone replacement therapy if evidence of hypothyroidism -Metformin to improve insulin resistance MNT: -Encouraged to consume a well-balanced diet -Refined and simple carbohydrates should be avoided -High-fiber foods to help with glucose tolerance -Anti-inflammatory foods -Small, frequent meals -800-1200 IU/d of vitamin D and 200-1000 mcg/d of chromium picolinate may improve glucose tolerance, insulin secretion, and insulin sensitivity -Increased physical activity & weight loss

Dietary Supplements

Dietary Supplement Health and Education Act (DSHEA) protects dietary supplements from being required to demonstrate proof of efficacy or safety Health claim: describes a relationship between two components (a substance and disease). Requires pre-notification of the FDA Qualified health claim: claim based on emerging scientific evidence. FDA does not review supporting evidence. Structured-function claim: physiological effects can be noted, but no claims may be made. No FDA pre-notification.

Flatulence, Constipation, Dirrhea

Flatulence: -Gas from the stomach that is expelled orally though belching or rectally -Gas may be produced by swallowing air or by bacterial fermentation -Most gases are absorbed into circulation and exhaled form the lungs -Excess gas in the stomach and intestines may cause bloating, abdominal distention cramping, and sometimes diarrhea -Factors: -Inactivity -Decreased GI motility -Aerophagia -Diet including soluble fibers, resistant starches, lactose, fructose, sugar alcohols, or known gaseous foods -GI disorders MNT: avoid consumption of foods containing raffinose, a complex sugar resistant to digestion found in beans, cabbage, brussel sprouts, broccoli, asparagus, and some whole grains Constipation: -Factors: Opiod medication for pain: binds to motility receptors in the gut Physical inactivity Inadequate hydration Inadequate fiber intakes Laxative abuse: may damage structure and innervation of the colon Condition causing dysmotility Pregnancy Elderly MNT: Consume adequate amounts of soluble and insoluble fiber -25 g for women -38 g for men -19-25 g for children -Consume adequate amounts of fluids -Avoid or limit the use of laxatives to treat constipation Diarrhea: -Occurs with: accelerated transit of intestinal contents decreased digestion of food decreased absorption of fluids and nutrients increased secretion of fluids into the GI tract -Factors: fungal, viral, or bacterial infection inflammatory disease, such as Chron's or UC malabsorptive disorders such as IBS medications including antiobiotic therapy overconsumption of sugars or osmotic foods insufficient or damaged mucosal absorptive surfaces MNT: -Primary concern: fluid/electrolyte replacement -Supplementation with probiotics if on antibiotic therapy -Avoid or limit sugar alcohols, lactose, fructose, and large amounts of sucrose -Regular diet as tolerated and inclusive of moderate amounts of soluble fiber -Use of the BRAT diet is no longer recommended since this diet is nutrient-poor

Nutrition Focused Physical Exam (NFPE)

Four basic techniques: 1. Inspection: general observations of sight, smell, and hearing from head to toe 2. Palpation: tactile examination to feel pulsations and vibrations, including texture, temperature, size, tenderness, and mobility 3. Percussion 4. Auscultation

HIV/AIDS

HIV: virus which invades the genetic core of cells that protect against infection AIDS: caused by HIV -HIV progression through 4 stages -Lean body mass and total fat mass tends to be lower in patients -Food-drug interactions are of concern -Some medications have known side effects such as vomiting, diarrhea, nausea, GERD, dyslipidemia, insulin resistance, and fatigue MNT: -optimize nutritional status & immunity -maintain healthy weight -prevent deficiencies -education of food safety Nutritional Needs: -small, frequent, nutrient-dense meals -energy: 30-40 cals/kg -protein: 1.2-2.0 g/kg -special concerns for vitamins A, D, E, and B12, selenium, zinc, and iron bc of malabsorption tissues or inadequate intakes Neutropenic diet: -designed for people with weak immune systems -helps protect from bacterial/harmful organisms in some foods & drinks Guidelines: -avoid raw or rare-cooked meats -avoid all fresh fruits/vegetables -avoid lunch meat sliced at deli counter -avoid raw nuts -all dairy should be pasteurized -avoid soft cheeses and cheeses w/ mold -avoid all yogurt -bottled water should be labeled as "reverse osmosis, distilled, or filtered through an absolute 1 micron or smaller filter" -avoid cold-brewed tea and sun tea

Gastritis and Peptic Ulcer

Gastritis: -inflammation of the lining of the stomach -most often caused by H. pylori infection -Atrophic gastritis: chronic inflammation with deterioration of the mucous membrane and glands -may also be caused by chronic use of NSAIDS, steroids, alcohol, erosive substances, and tobacco -Prolonged gastritis may result in: -atrophy and loss of stomach parietal cells -achlorhydria: the loss of secretion of hydrochloric acid -loss of secretion of intrinsic factor -pernicious anemia -diagnosed with an endoscopy -medical treatment includes antibiotic therapy Peptic Ulcer: -painful, open sores that develop on the inside of the lining of the stomach and upper portion of the small intestine -most often caused by H. pylori infection and also by long term use of NSAIDS, corticosteroids, severe illness, and alcohol/tobacco use -stress and spicy foods do not cause ulcers but. may worsen the symptoms -medical treatment includes: -antibiotic therapy to treat bacterial infections -antacids to treat pain -antiulcer agents to suppress or inhibit gastric acid secretion MNT: -well balanced diet rich in vitamins A and C to assist healing -bland diet is no longer recommended since foods limited in the diet are essential for healing and helping with symptoms -avoid alcohol, acidic foods, spicy foods, coffee, and caffeine -probiotics and omega 3 and omega 6 fatty acids may have a protective effect -in atrophic gastritis, vitamin b12 levels should be evaluated bc of the lack of intrinsic factor

Basic Metabolic Panel (BMP)

Glucose -Used to screen for diabetes -Elevated levels can also indicate chronic kidney disease, hyperthyroidism, pancreatic cancer, pancreatitis, and acute stress -Normal fasting glucose: 70-99 mg/dL -Pre-diabetes: 100-125 mg/dL -Diabetes: 126 mg/dL and above on more than one testing occasion Calcium -Can diagnose conditions related to the bones, heart, nerves, kidneys, teeth, and also kidney stones and neurologic disorders -Adult reference range: 8.5-10.2 mg/dL -Elevated: hyperparathyroidism, hyperthyroidism, excessive calcium/vit D intake, prolonged immobilization, kidney transplant -Decreased: low protein levels (particularly low albumin), hypoparathyroidism, inadequate calcium intake, decreased vit D levels, pancreatitis, renal failure, tetany -When calcium is low because of hypoalbuminemia, calculate corrected calcium: corrected Ca = serum Ca + 0.8 X (4 - serum albumin) Sodium -Adult reference range: 135-145 mEq/L -Elevated: dehydration, diabetes insipidus, high salt intake, use of laxatives -Decreased: fluid losses, kidney disease, heart failure, cirrhosis, addison's disease, ketonuria Potassium: -Used to evaluate electrolyte imbalances, pH imbalances, high blood pressure, and kidney disease -Adult reference range: 3.7-5.2 mEq/L -Elevated: kidney disease, addison disease, diabetes, dehydration, infection -Decreased: diarrhea, vomiting, acetaminophen overdose, unmanaged diabetes Chloride: -Usually mirrors sodium -Used to diagnose cause of prolonged vomiting, diarrhea, weakness, and respiratory distress -Adult reference range: 96-106 mEq/L -Elevated: dehydration, metabolic acidosis, respiratory alkalosis, cushing syndrome, kidney disease -Decreased: congestive heart failure, diabetic ketoacidosis, aldosterone deficiency, prolonged vomiting, addison disease, chronic lung diseases, metabolic alkalosis, respiratory acidosis Carbon Dioxide/Bicarbonate: -Electrolyte to help maintain the body's pH balance -Measures amount of carbon dioxide in the blood. CO2 is a byproduct of many metabolic processes -Used to identify/monitor an electrolyte or pH imbalance -Used to monitor various disease states such as kidney, liver, lung disease and HTN -Adult reference range: 23-29 mEq/L -Over 60 yrs: 23-31 mEq/L -Over 90 yrs: 20-29 mEq/L Blood Urea Nitrogen (BUN): -Urea is a waste product formed in the liver when protein is broken down in AAs. This produces ammonia which is converted to urea -Used along with the creatinine test to evaluate and monitor kidney function -Adult reference range: 6-20 mg/dL -Over 60: 8-23 mg/dL -Elevated: CHF, excessive protein intake, GI bleeding, dehydration, heart attack, kidney disease, shock, urinary tract obstruction, decreased blood flow to kidneys -Decreased: liver failure, low protein diet, malnutrition, over-hydration Creatinine: -waste product produced by the muscles from breakdown of creatine -cleared from the body by the kidneys -creatinine blood levels are an indicator of how well the kidneys are working -Interpreted along with BUN test to assess kidney function -Adult male: 0.9-1.3 mg/dL -Adult female: 0.6-1.1 mg/dL -Elevated: kidney dysfunction that may be attributed to various conditions, such as kidney infections, kidney stones, dehydration, heart failure, diabetes, or shock -Decreased: decreased muscle mass, malnutrition

Behavioral Change Models

Health Belief Model -focuses on a disease/condition and the factors that may influence behavior related to the disease -clients have a desire to avoid illness or become well if already ill -Perceived susceptibility: risk of acquiring illness -Perceived severity: how serious a condition is -Perceived benefits: positive effects of advised action in reducing risk -Perceived barriers: obstacles to performing a recommended health action -Self-efficacy: person's capability of performing the recommended health action -Cues to action: strategies involved to activate one's readiness to change a behavior Social Cognitive Theory -represents the reciprocal interaction among personal, behavioral, and environmental factors -Personal: expected outcomes, self-efficacy, reinforcements, goals and interventions, relapse prevention -Behavioral: knowledge and skills, self-regulation and control, and setting goals -Environmental: imposed, selected, and created environments Transtheoretical Model -describes behavior change as a process in which people progress through a series of stages of change -Pre-contemplation: person is not ready or has not thought about making a change -Contemplation: person is getting ready or has thought about making a change -Preparation: ready to change or has taken some steps -Action: made change and continued for < 6 months -Maintenance: continued for > 6 months -Termination: change has become a habit and person no longer thinks about the change Theory of Planned Behavior: -Based on the concept that intentions predict behavior -Behavioral achievement depends on both the motivation (or intention) and the ability for behavioral control -Subjective norms -Attitudes -Perceived control -Behavioral intention

Weight Anthropometrics

IBW -men: 106 lbs for first 5 ft + 6 lbs per inch over 5 ft -women: 100 lbs for first 5 ft + 5 lbs per inch over 5 ft -If under 5 ft, subtract 6 lbs per inch for men, and 5 per inch for women -Generally use +/- 10% % IBW - current weight / ideal weight x100 % UBW -current weight / usual weight x100 % weight change -(usual weight - current weight) / usual weight x100 BMI kg/m^2 lbs /in^2 x 703 Underweight = < 18.5 Normal weight = 18.5-24.9 Overweight = 25-29.9 Obesity 1 = 30-34.9 Obesity 2 = 35-39.9 Extreme obesity class 3: >40 Frame size -height in cm / wrist circumference in cm Men frame size: -small frame: > 10.4 -medium frame: 9.6-10.4 -large frame: < 9.6 Women frame size: -small frame: > 11 -medium frame: 10.1-11 -large frame: < 10.1

Texture Modified Diets

IDDSI Level 7: Regular Foods Level 7: Easy to Chew Foods: -safe for level 0 thin liquids -requires ability to bite soft foods, chew, and orally process food to form a bolus for swallowing Level 6: Soft and Bite-Sized Foods: -soft and moist but no separate thin liquid -chewing is required before swallowing -biting is not required Level 5: Minced and Moist -minimal chewing required Level 4: Pureed foods and Extremely Thick Liquids -liquid must not separate from solid -moves slowly under gravity -no biting or chewing required -holds its shape Level 3: Liquidized foods and Moderately Thick Liquids -moderate effort required to suck through a straw -will drip through fork prongs -needs some tongue propulsion effort Level 2: Mildly thick liquids -mild effort required to drink through straw Level 1: Slightly thick liquids -thicker than water -requires a little more effort to drink than thin liquids -flows through a straw, syringe, or nipple -used when thin drinks flow too fast to be safely controlled Level 0: -flows fast, like water -functional ability to safely manage liquids of all types

Food Allergies

IgE-Mediated Reactions: -requires presence of sensitization and the development of specific signs/symptoms on exposure to the food -Immunoglobulin E (IgE) is a antibody produced by the immune system in response to a foreign material -Reactions occur within minutes to a few hours of exposure -Any food is capable of causing this reaction, but the big 9 allergens are most common -Food-induced anaphylaxis: acute, often severe, and sometimes fatal immune response that usually occurs within a limited period following exposure, may require injectable epinephrine Non-IgE-Mediated Reactions: -Immune response to a food that does not involve IgE antibodies -Possibly a response from food-related inflammatory diseases, such as colitis, enteritis with bleeding, malabsorption disorders, and ulcerations -Food Protein-Induced Enterocolitis Syndrome (FPIES): -inflammation of small intestine and colon with symptoms of vomiting, diarrhea, and dehydration -commonly seen in formula-fed infants and typically provoked by cow's milk or soy protein formulas -formula-fed infants should be switched to an extensively hydrolyzed casein formula at first but may require a specialized elemental formula -usually resolved after a few weeks to months once the problematic protein is removed from the diet Cell-Mediated Reactions: -Non-IgE-mediated reaction that acts in response to viruses, fungi, tumor cells, and other foreign cells through its production of T lymphocytes (T cell) -When an antigen stimulates a T-cell response, the T cells produce cytokines Testing for Food Allergies: Skin-prick test: -skin is pricked, and a food allergen placed under the skin in contact with allergen-specific IgE CAP-FEIA: -Blood test for detecting IgE antibodies -Reliable only for milk, eggs, wheat, cow's milk, peanuts, and soy Food challenge: -suspect food is given to the patient orally in clinical setting -may be double-blinded, single-blinded, or unblinded Food elimination diet: -suspected foods are eliminated from the diet for a specified period, usually 4-12 weeks -patient enters symptoms into a journal -foods systematically reintroduced into the diet, one at a time MNT: -Avoid foods that cause allergic reaction -ensure diet is nutritionally adequate -micronutrient supplementation may be needed -monitor weight-for-height in children/infants -educate patients on reading food labels -educate patients on cross contamination of foods

Ileostomies and colostomies

Ileostomy: Opening at the ileum at the abdominal wall. Entire colon, rectum, and anus were removed. Stool output is more liquid. Colostomy: Opening of the colon at the abdominal wall. Rectum and anus are removed. Stool output is more mushy (firmer when on the left side). MNT: -post-op may require clear liquids that are low in sugars -ostomy patients should follow a regular diet of small, frequent meals with the avoidance of any known foods that cause problems -limit/avoid odorous foods -Buttermilk, cranberry juice, parsley and yogurt may help with odor -Additional water and salts to compensate for excessive losses in stool -Vitamin B12 supplements or injections may be needed -Vitamin C and folate supplements may be needed in patients with ileostomy who also have low fruit/vegetable intakes -avoid very fibrous vegetables and foods with skins or seeds, and patients should be instructed to chew food well to prevent food becoming trapped in the stoma

Historical Data

Includes -medical history -medication/supplement history -personal/social history -food and nutrition history

Hepatitis

Inflammation of the liver caused by a virus, bacteria, toxins, obstruction, or parasites -Hepatitis A: transmitted through oral-fecal route, sources include water, food, sewage -symptoms last >2-6 months -rarely result in acute liver failure -Hepatits B: transmitted through blood transfusions -30% are asymptomatic -15-25% w/ chronic HBV develop cirrhosis or liver cancer -Hepatits C: Occurs with exposure to blood or body fluids -most acute infections turn into chronic -60-70% w/ chronic infections will develop liver disease, and 5-30% develop cirrhosis -Hepatitis D & E: Uncommon in the US Symptoms: -Fatigue, nausea, vomiting, abdominal pain, clay-colored stools, dark urine, loss of appetite, low-grade fever, joint pain Diagnosis: -detected through presence of virus in serology lab tests -liver function test -CAT scan, liver biopsy, sonogram Pertinent Labs: Blood tests: -ammonia > 60 mcg/dL -cholesterol ester > 75% of cholesterol Urine tests: -bilirubin > 0 -urobilinogen > 4 mg/24 hours Pigment tests: -serum bilirubin total > 0.9 mg -direct bilirubin > 0.3 mg -indirect bilirubin > 0.5 mg Enzymes: -Alkaline phosphatase > 95 U/L -GGT -Aspartate transaminase (AST) -Alanine aminotransferase (ALT) -Lactate dehydrogenase (LDH) MNT: -prevent or resolve malnutrition due to hyper metabolism, replenish micronutrient deficiencies, and prevent and/or reduce exacerbation of symptoms -avoid alcohol and other substances that may damage the liver -encourage small, frequent meals -encourage fluid intake and rest

Portion Size Visual Aids

Measurements: -fist/cupped hand = 1 cup -baseball = 1 cup -lightbulb = 1/2 cup -golfball = 2 tbsp or 1 ounce -poker chip = 1 tablespoon -tip of the thumb = 1 tsp

Metabolic Acidosis and Alkalosis

Metabolic acidosis: -High levels of acid in the blood May occur in patients with: -untreated diabetes and in ketoacidosis (ketones are acidic) -excessive diarrhea from loss of sodium bicarbonate -buildup of lactic acid from excessive alcohol use, excessive sweating, or liver failure -kidney disease where excessive bicarbonate is excreted Correction: -Lungs increase respirations, which makes the body eliminate more CO2 and creates respiratory alkalosis Metabolic alkalosis: -low levels of acid in the blood, or high levels of an alkaline compound bicarbonate Often caused by: -excessive vomiting, which causes an increased loss of electrolytes -overuse of diuretics -large doses of potassium or sodium in a short amount of time -Use of antacids or laxatives -Accidental ingestion of bicarbonate, such as baking soda -Severe hypokalemia -decrease in blood flow to the kidneys, which stimulates reabsorption of sodium and water, thereby increasing bicarbonate reabsorption Correction: -Lungs decrease respirations in order to retain carbon dioxide, an acidic compound, which creates respiratory acidosis

Screening and Surveillance Systems

National Health and Nutrition Examination Survey (NHANES) -program of NCHS -assess the health & nutrition status of adults and children in the US -combines interviews & physical exams Youth Risk Behavior Surveillance System (YRBSS) -national school-based survey conducted by the CDC and state -monitors 6 categories of health-related behaviors that contribute to the leading causes of death and disability among youth and adults -Behaviors that contribute to unintentional injuries/violence -sexual behaviors related to unintended pregnancy and STDs -alcohol and drug use -tobacco use -unhealthy dietary behavors -inadequate physical activity Food safety survey, health and diet survey, food safety and nutrition survey --> conducted by the FDA

Kidney Stones

Nephrolithiasis: the presence of kidney stones -complex process consisting of saturation, supersaturation, nucleation, crystal growth, and crystal retention -calcium stones are most common -incidence increases with obesity, diabetes, metabolic syndrome, and family history Hypercalcuria: -calcium in excess in the urine of 300 mg/d for men and 250 mg/d for women -may be triggered by excessive dietary calcium intake, increased intestinal absorption of calcium, or decreased renal tubular reabsorption of calcium Hyperoxaluria: -greater than 40 mg of oxalate in the urine per day -patients with IBD or gastric bypass may develop because of fat malabsorption -unabsorbed fatty acids bind with calcium to form soaps Uric acid stones: -Uric acid is the end product of purine metabolism from food -Meat, fish, and poultry are high in purines and should be consumed in moderation for those susceptible -Gout: painful joints caused by excess uric acid MNT: -Goal is to prevent new stones from forming and existing stones from growing -Fluid and urine volume: -low urine volume increases risk of stone formation -2000-2500 ml/d of urine production is ideal to prevent stone recurrence -250 ml fluid intake at each meal, between meals, at bedtime, and upon awakening -cranberry juice acidifies urine and may help -tea, coffee, beer, and wine have been associated with reduced risk of stones -milk reduces oxalate absorption and is good to be served with tea/coffee -avoid soft drinks bc of phosphoric acid content -Diet should be low in animal proteins as high intakes increase risk of stone formation -Potassium is inversely related to stone formation -<2300 mg/d of sodium in patients w/ hypercalciuria -Encourage vegetable intake over fruits for lower fructose content -Avoid excessive intakes of vitamin C >500 mg/d Oxalates: -absorption affected by amount of dietary calcium -calcium intake of 1200 mg/d to lower oxalate absorption -restrict oxalate intake to 60 mg/d -High-oxalate foods: -wheat, cereals, dried apricots, figs, kiwi, spinach, eggplant, beets, nuts, sesame seeds, chocolate, tea, soy milk

Federal Nutrition Programs- Elderly

Older Americans Act Nutrition Program -Include Congregate Nutrition Services and Home-Delivered Nutrition Services -Purpose is to reduce hunger, food insecurity, and malnutrition in older adults, promote socialization, and improve the health and well-being of older people -Eligibility requirements: atleast 60 years old particular attention given to older adults who are low-income, minorities, in rural communities, at risk of institutional care, or limited english proficiency

Hyperthyroidism

Overactive thyroid producing excessive amounts of thyroid hormones -Grave's disease: autoimmune disease where the thyroid is enlarged (goiter) and overactive Symptoms: -weight loss -changes in appetite -profuse sweating -frequent bowel movements -fatigue and muscle weakness -red, dry, swollen, puffy eyes -menstrual disturbances -impaired fertility -sleep disturbances -enlarged thyroid (goiter) Pathophysiology: -family hx -acute stress-induced immunosuppression followed by immune system hyperactivity -other factors: infection, excessive iodine intake, female gender, and toxins MNT: -Low-iodine diet: -high iodine foods: seafood, dairy, egg yolks, iodized salt -adequate intake of iron -adequate intake of selenium -healthy fats to reduce inflammation -other nutrients of concern: zinc, calcium, vitamin D

Obesity

Overweight: weight exceeds a standard based on height Obesity: condition of excessive fatness -related to lifestyle, environment, and genetics -Android obesity: excess subcutaneous truncal-abdominal fat (apple-shaped) -Gynoid obesity: excess gluteofemoral fat in the thighs and buttocks (pear-shaped) Associated medical conditions: -heart disease -type 2 diabetes -hypertension -stroke -cancer -NAFLD -Metabolic syndrome: combination of HTN, hyperlipidemia, and elevated blood glucose levels -cellulitis: bacterial infection that develops in deep layers of the skin -Acanthosis nigricans: areas of dark, velvety discoloration found in the folds and creases of the body -Infertility -Sleep apnea -Osteoarthritis Diagnosis: BMI classifications: -Underweight: <18.5 -Normal weight: 18.5-24.9 -Overweight: 25-29.9 -Obesity class 1: 30-34.9 -Obesity class 2: 35-39.9 -Extreme obesity class 3: >40 Waist circumference measurements: -Men: >40 inches at risk -Women: >35 inches at risk Waist-to-hip ratio for men: -Low risk: <0.95 -Moderate risk: 0.95-1.0 -High risk: >1.0 Waist-to-hip ratio for women: -Low risk: <0.80 -Moderate risk: 0.80-0.85 -High risk: > 0.86 MNT: -Food choice changes, physical activity, behavior modification, nutrition education, and psychological support -Balance of energy intake and energy expenditure -For first 6 months, aim for weight loss of 0.5-2 lbs/week, then move into maintenance phase -Diet should be nutritionally adequate, except for calories -Deficit of 500-1000 calories/day -Carbs: 50-55% of total calories from fruits, vegetables, beans, and whole grains -Protein: 15-25% of total calories -Fat: < 30% of total calories -Artificial sweeteners and fat substitutes improve acceptability of limited food intakes -Morbidly obese patients (BMI >40) may require surgery -Extreme calorie restriction (diets providing 200-800 calories per day) are not recommended and have little evidence to support

Visceral Protein Labs

Prealbumin -One of the major blood proteins and produced primarily by liver -Half-life: 2-3 days -Used as an indicator of protein status -Adult reference ranges: 19-38 mg/dL -Decreased: malnutrition, inflammation, malignancy, protein-wasting disease Retinol-Binding Protein (RBP) -Binding and transporting retinol (Vit A) -Half-life: 12 hours -Adult reference range: 3-6 mg/dL -Decreased: malnutrition, acute and chronic hepatic disease, advanced chronic renal insufficiency, cystic fibrosis, inflammation Transferrin -Main protein in the blood which binds to iron and transports it throughout the body -Half-life: 7-10 days -Adult reference range: 204-360 mg/dL -Elevated: Iron deficiency anemia -Decreased: liver disease, hemolytic anemia, inflammation C-Reactive Protein (CRP) -Protein made by the liver -Levels increase when there is a condition causing inflammation in the body -Test detects inflammation or to monitor the severity of disease -A low prealbumin level is a good indication of poor nutrition status. However, when prealbumin are CRP are both assessed, malnutrition may be ruled out if CRP is elevated -Reference range: < 0.8 mg/L

Health promotion and disease prevention

Primary: aims to prevent disease before it ever occurs Secondary: aims to reduce the impact of a disease after it has already occurred Tertiary: aims to soften impact of an ongoing illness or injury that has lasting effects

PES Statements

Problem: 3 domains -Intake: inadequate or excessive intakes of nutrients, energy, fluid, alcohol, supplements, or other ingredients -Clinical: medical or physical conditions that disrupt nutrition status -Behavioral: problems related to the patient's knowledge, attitudes, or beliefs, or the physical environment such as access to food Etiology: -what is the cause of the problem? -based off findings from the nutrition assessment and information gained from the patient Signs/symptoms: -why is the problem occurring? -evidence supporting the nutrition diagnosis (The problem) related to (the etiology) as evidenced by (signs/symptoms)

Complete Blood Count (CBC)

Red Blood Cells -also called erythrocytes -carry oxygen throughout the body -RBC count totals the number of RBC that are present in a blood sample -Adult male: 4.5-5.9 x 106/microliter -Adult female: 4.1-5.1 x 106/microliter -Elevated: dehydrations, lung disease, kidney disease -Decreased: anemia, nutritional deficiency, bone loss, bone marrow disorders, chronic inflammatory disease Hemoglobin -Iron containing protein found in all RBCs and is responsible for giving the red color -Allows the RBCs to bind to oxygen in the lungs and carry it to tissues and organs -Often used to check for anemia -Adult male: 13.8-17.2 g/dL -Adult female: 12.1-15.1 g/dL -Elevated (along with elevated RBC & hematocrit): polycythemia (blood cancer), lung disease, congenital heart disease, dehydration -Decreased (along with decreased RBC & hematocrit): anemia secondary to excessive loss of blood, nutritional deficiencies, or bone marrow disorders Hematocrit -Test measures the proportion of blood that is made up of red blood cells -Way of assessing RBC and for diagnosing conditions like anemia -Adult male: 40.7-50.3% -Adult female: 36.1%-44.3% -Elevated (along with elevated RBC & hemoglobin): polycythemia, lung disease, congenital heart disease, dehydration -Decreased (along with decreased RBC & hemoglobin): anemia Mean Corpuscular Volume (MCV) -Measures average size of RBCs -Adult reference range: 80-95 femtoliters (FL) -Elevated (large RBCs): vitamin B12 deficiency, folic acid deficiency, liver disease, hypothyroidism -Decreased (small RBCs): anemia Mean Corpuscular Hemoglobin (MCH) -Average amount of hemoglobin inside the red blood cells -Adult reference range: 27-33 picograms per cell -Elevated: no concern -Decreased: anemia White blood cells (WBCs) -Also called leukocytes -Important part of body's immune system -Bone marrow produces more WBCs in presence of infection or inflammation -Adult reference range: 4,500-11,000 WBC/microliter -Elevated: infection, inflammation, leukemia, physical trauma, allergic response -Decreased: bone marrow damage, lymphoma, autoimmune disorder, dietary deficiencies

Respiratory Acidosis and Alkalosis

Respiratory acidosis: -high levels of acid in the blood -reduced rate of respirations = increased levels of carbon dioxide in the body -less CO2 expelled, high CO2 in the body -excess CO2 causes pH of blood to decrease Decreased rate of respiration can be caused by: -diseases of airways: asthma, COPD -diseases of lung tissue: pulmonary fibrosis -diseases that affect the chest: scoliosis -diseases affecting nerves and muscles which signal the lungs to inflate and deflate -medications that suppress breathing Correction: -Kidneys work to compensate by increasing bicarbonate reabsorption, an alkaline compound, which creates metabolic alkalosis Respiratory alkalosis: -low levels of acid in the blood, or high levels of an alkaline compound -increased respirations = reduced levels of carbon dioxide in the body -More CO2 expelled, low CO2 in the body -Low levels of CO2 cause pH of blood to increase, making it more alkaline Increased respirations can be caused by: -conditions leading to hyperventilation, such as anxiety or a panic attack Correction: Kidneys compensate by excreting more bicarbonate, which creates metabolic acidosis

Federal Nutrition Programs- Adults

SNAP -formerly known as food stamp program -administered by the Food and Nutrition Service of the USDA -gross income not exceeding 130% of federal poverty level, and net monthly income not exceeding 100% of poverty -must meet work requirements -students enrolled in college are not eligible -non-citizens must have lived in US for at least 5 years -Foods purchased to be eaten at home, no hot food, alcohol, vitamins, pet foods The Emergency Food Assistance Program (TEFAP) -Supplement diets of low-income americans by providing no-cost, nutritious emergency food assistance with USDA foods

Body composition anthropometrics

Skin fold: -assesses body fat -pinches skin & subcutaneous fat -back of tricep, below scapula, above iliac crest, and upper thigh -assumes 50% of body fat is subcutaneous -accuracy decreases w increasing obesity Waist circumference: -measures distance around smallest area below the rib cage and above the umbilicus -not useful if less than 5 ft tall or a BMI of 35+ -Men: > 40in at risk -Women: >35in at risk Midarm circumference: -can indirectly determine arm muscle & fat when combined with skin fold Waist to hip ratio: -waist measurement / hip measurement -Classifications for men: low risk = < 0.95 moderate risk = 0.95-1 high risk = > 1 -Classifications for women: low risk: < 0.80 moderate risk: 0.80-0.85 high risk: >0.86

Cholesterol Panel

Total Cholesterol -Total cholesterol = LDL + HLD + (triglycerides x 0.2) -Elevated levels increase the risk of heart disease -Desirable: < 200 mg/dL -Borderline high: 200-239 mg/dL -High: 240 mg/dL and above LDL Cholesterol -"bad" cholesterol -Elevated levels increase risk of heart disease by sticking to the blood vessel walls, narrowing blood flow -Optimal: < 100 mg/dL -Near optimal: 100-129 mg/dL -Borderline high: 130-159 mg/dL -High: 160-189 mg/dL -Very high: 190 mg/dL and above HDL Cholesterol -"good" cholesterol -helps remove LDL cholesterol from the arteries -Decreased levels are a risk for heart disease -Optimal: 60 mg/dL and above -Suitable: 40-59 mg/dL for men; 50-59 mg/dL for women -Poor: < 40 mg/dL for men; < 50 mg/dL for women Triglycerides -form of fat in the blood that can raise the risk for heart disease and diabetes -desirable: <150 mg/dL -borderline high: 150-199 mg/dL -high: 200-499 mg/dL -very high: 500 mg/dL and above

Risk Factors

Underweight -unable to preserve lean tissue with wasting diseases -women with menstrual irregularities -infants health at risk when mother is underweight -osteoporosis and bone fractures Overweight and obesity -T2 diabetes -gestational diabetes -hypertension -cardiovascular disease -sleep apnea -osteoarthritis -metabolic syndrome: cluster of at least 3 of the following risk factors: high blood pressure, high blood glucose, high blood triglycerides, low HDL cholesterol, high waist circumference -some cancers Diet high in saturated fat, trans fat, and cholesterol -cardiovascular disease -atherosclerosis -hyperlipidemia Prolonged diet inadequate in calcium and vitamin D -osteoporosis -bone fractures Excessive alcohol consumption -micronutrient deficiencies -high blood pressure -cardiovascular disease -cancer of the breast, mouth, throat, esophagus, liver, and colon -osteoporosis -weakened immune system

Whipple Procedure

also known as a pancreaticoduodenectomy -operation to treat pancreatic cancer -removal of head of the pancreas, duodenum, section of the bile duct, gallbladder, and part of the stomach MNT: -small amounts of easily digestible food -pancreatic enzymes to assist with digestion -nutrients of most concern for deficiency as result of malabsorption are calcium, iron, zinc, vitamin b12, and fat soluble vitamins