NURSING 001 Chapter 19 Nutritional Concepts and Related Therapies

NURSING 001 Chapter 19 Nutritional Concepts and Related Therapies Ch 19 Nutritional Concepts and Related Therapies Wednesday pg 485-508 ch 6 box 6-4 pg 101-105/ Thursday test 508-532 Nutrition: sum of all processes involved in taking in nutrients and using them to maintain body tissue and provide energy (one of the foundation of life); Good nutrition is essential for optimal health throughout all stages of life Role of the nurse in promoting nutrition ● Pt look at nurse for more information ● Lvn responsible for assisting a pt to eat, record intake, observe signs of poor nutrition and communicating about dietary concerns to hcp ● Nurse needs knowledge of nutrition to help pt Basic nutrition: Diet planning guides ● Guidelines started as farmers bulletin more than 100 yrs ago and then evolved into basic 7, basic four, the food guide pyramid,Mypyramid, and currently MyPlate MyPlate: Developed by USDA in 2011 ● Image of round plates divided into 4 different color selection ● Vegetables, fruit, grain, protein and a seperate group dairy ● USDA suggest ppl balance calories by reducing portions;increase intake of fruit and vegetables ● Reduce amount of sodium and sugary foods in the diet Dietary guidelines for americans: the latest of these guidelines and include recommendation for the general population ● Help choose overall healthy diet ● This guide balances calories: consuming more fruits, vegetables, whole grains, increasing fat-free or low-fat dairy and seafood; consuming low sodium, saturated fat, trans fat, cholesterol, added sugars, and refined grains ● Dietary guidelines for americans affects: food stamps, WIC, school breakfast and lunch programs ○ The government developed these guidelines to address adequate nutrition, avoid overnutrition and chronic disease Dietary Reference intakes (DRI): refers to a set of nutrients based values that serve for both assessing and planning diet ● DRI replace and expand on recommended dietary allowance (RDA) have been around for more than 50 years ● Purpose of the DRI is to help provide individuals optimize their health, prevent disease, and avoid consuming too much of a nutrient Essential nutrients: Basic functions A nutrient: a chemical compound or element in food that is necessary for good health Essential nutrient: nutrients that the body cannot make in the amounts essential for good health; therefore, it is necessary to obtain these nutrients through a diet ○ 6 classes of essential nutrients: carbohydrates, fats, proteins, vitamins, minerals, and water ○ Each necessary for life ○ 3 major functions of nutrients: 1) providing energy 2) building and repairing tissue 3) regulating body processes Providing energy ● Kilocalorie(kcal): is a measurement of energy, much as a pound is measured in weight ○ The more kcal a food has the more energy it will provide ● Of the 6 essential nutrients only 3 provide energy: carbohydrate, fats, and proteins ○ Carbs and proteins provide approximately 4 kcal/g ○ Fats provide 9 kcal/g ○ Alcohol supplies 7 kcal/g ● Caloric distribution ○ Obtain 45-65% of daily kcal from carbs ○ 20-35% from fats ○ 10-35% from protein Building and repairing tissue ● Protein is the nutrient that places the most important role in building and repairing ○ It contains amino acids ● Calcium and phosphorus are minerals that are necessary nutrients in bone structure, iron, another mineral makes up a large part of hemoglobin in RBC Regulating body processes ● Metabolism: combination of all chemicals processes that take place in living organisms ○ Processes of building up and breaking down tissue ○ Nutrients play a role in metabolism and help regulate certain body processes ■ The presence of carbs is required for fat to be used correctly ■ Vitamin B are necessary for the body to derive energy from food ■ Water is an integral part of almost all chemical reactions in the body ● By studying how the body uses nutrients scientist have found 2 important facts ○ Individual nutrients have many functions in the body ○ No nutrient works alone Carbohydrate: organic compounds containing carbon, hydrogen, and oxygen ● Main function to provide energy ● Also needed in adequate amounts to keep protein from being used as energy ● Made up of saccharides (sugar units) ● Classified as simple or complex carbohydrates ○ Simple carbohydrates: include monosaccharides and disaccharides ■ Monosaccharides have one unit of sugar require no digestion ■ Fructose (monosaccharide) found in fruits ■ glucose (blood sugar) ○ Disaccharides are made up of two sugar units bonded together ■ Once they go into the body hydrolysis breaks them down into monosaccharides ■ Ex. table sugar (sucrose) and milk (lactose) ● DRIs relating to carbohydrates indicates that 45%-65% of adult calories should be a form of carbohydrates ○ Added sugar should be no more than 8% (40g) ○ Simple sugars are found in milk and fruits ● Complex carbohydrates: polysaccharides made of long chains of glucose units ○ All break down into simple sugars when digested ○ 3 types of complex carbohydrate are ■ Starch- found in plant foods such as grains, legumes, and vegetables (breaks down more slowly b/c its larger ■ Glycogen: (animal starch) made of simple sugars, stored in liver used when body glucose level is low ■ Dietary fiber: foods that humans cannot break down (digest), fiber consumed is secreted in the feces has no nutritional value ● It can lower cholesterol and blood glucose level and assist in weight loss ● Insoluble fiber: found in wheat bran, vegetables, whole grains and some fibrous fruit ● Water-soluble fiber: fruits, oats, barley, and legumes Daily requirements of Carbohydrates ● Fiber intake 21 and 38g/day ● MyPlate recommends inc fruits and vegetables and consuming at least half of grains as whole grains NOT refined ● Increase in fiber can cause gas, bloating and constipation, too much can lead to osteoporosis and anemia ● 8 glasses of water per day Digestion and metabolism of carbohydrates ● Digestion of carbohydrates begins at mouth with mechanical digestion ● In the stomach mechanical digestion breaks down food into smaller pieces and combined with gastric secretion ● All carbohydrates are broken down in digestive tract into monosaccharides before absorbed and converted to glucose except fibers ● Extra carbohydrates are stored as glycogen Fats (lipids): organic substances of a fatty nature that are insoluble in water and necessary for good health ○ Both fats and cholesterol are lipids ● They provide the most concentrated source of energy of all nutrients 9 kcal/g ● Dietary fats provide Satiety (a feeling of fullness and satisfaction from food ○ Adds food and aroma to foods and provides the body with essential fatty linoleic acids and linolenic acid ○ Dietary fats also carry fat soluble vitamins: A,D,E, and K ● Composed of carbon, hydrogen and oxygen just like carbohydrates ● Lipids also contain fatty acid and glycerol ○ b/c of this they may be called glycerides or triglyceride ● Fatty acids are the building blocks of fat ● Classified as either saturated or unsaturated ○ Saturated fatty acid: chemical bonds are completely filled or saturated with hydrogen ■ Are generally of animal origin and solid at room temp. ■ Have a long shelf life because the fat is strong so it takes long to spoil ■ Tend to increase blood cholesterol, increasing the risk of atherosclerosis ■ 7% of total daily calories ○ Unsaturated fatty acid: one or more places where hydrogen is missing on its chemical chain (called points of unsaturation) ■ A fatty acid with only one point of unsaturation is called monounsaturated fatty acid ■ Fatty acids with 2 or more points of unsaturated fats are polyunsaturated Food sources of fatty acids 19-2 Fatty acid class Food contributing significant amounts to the diet Saturated Coconut, palm, and palm kernel oils Fat in and on meats and poultry Egg yolk, butter, cream, milk fat, cocoa butter, olive oil,olives Monounsaturated Canola oil, peanuts and peanut oil Most other nuts avocados Polyunsaturated Safflower oil, sunflower oil,cottonseed oil, soybean, corn oil fish oil Trans Partially hydrogenated plant and fish oil, stick margins, shortening, commercial fats used for frying, baking Hydrogenated fats: Hydrogenation is a process in which hydrogen is added to a fat of vegetable origin (unsaturated) in order to make it more saturated or solid ● Most oils such as corn oil have been hydrogenated to some extent Trans fatty acid: are unsaturated fatty acids that have been completely hydrogenated ● Synthetic trans fatty acids are produced during hydrogenation and can be found in some deep-fried restaurant foods, packaged cookies, crackers, and other ● Trans fatty acids are like saturated fats and tend to increase cholesterol levels Cholesterol: is a lipid belonging to a class of chemical substances called sterols ● Is a building block for cell membrane and for hormones such as estrogen and testosterone ● Found in animal origin foods: meats, egg yolk, seafood, poultry, and dairy products ● Plant sterols sometimes decrease cholesterol levels in the blood ● Recommended intake is 30mg/day Digestion and metabolism of fats: ● In order for fats to be digested they have to be broken down into smaller globules ● Bile is necessary to emulsify fat (bile is stored in gallbladder and dispensed to duodenum when fat is present) ● When fat is emulsified the body is able to break down and absorb it ● Lipids are packaged as lipoproteins(molecules made of lipids surrounded by protein) ○ Body makes 4 types of lipoproteins ○ 1)chylomicrons 2)high-density lipoproteins HDLs 3) low-density lipoproteins LDLs 4)very low-density lipoproteins VLDLs ■ Higher the protein content of lipoproteins the greater the density ○ LDLs (bad cholesterol) and HDLs (good cholesterol) are important in cardiovascular disease ■ Both carry cholesterol to bloodstream ○ Recommended that serum cholesterol levels stay below 200 mg/dL Classification of LDL, total ,and HDL cholesterol 19-3 LDL cholesterol <100 mg/dL Optimal 100-129 mg/dL Near or above optimal 130-159 mg/dL Borderline high 160-189 mg/dL ≥190 mg/dL High Very high Total cholesterol <200 mg/dL 200-239 mg/dL ≥240 mg/dL Desirable Borderline high High HDL Cholesterol <40 mg/dL for men <50 mg/dL for women Low Protein: another nutrient vital to the human body, provide building blocks for blood and bone and are part of every cell ● Contains 1000s of different proteins all essential for tissue growth, repair, and wound healing ● Collagen a vital connective tissue is made of protein ● Some hormones such as thyroxine and insulin are proteins ● Enzymes are proteins produced by living cells ● Albumin is a plasma protein attracts water and has the capacity to pull fluids from one body compartment to another ● Hemoglobin a protein in the RBC carry o2 throughout body ● Immunoglobulins (antibodies) are also proteins which emphasizes the role of protein in immune function ● If necessary body can use protein as energy ● Supplies 4 kcal/g ● Carbohydrates, fats, and proteins all contain carbon hydrogen and oxygen but protein also contains nitrogen ○ They all combine in a specific way to form amino acids( building blocks of protein) ○ 20 amino acids have been identified as important but only 9 are essential amino acids(necessary to obtain from diet) ● Recommendation is 10-35% of total daily calories come from proteins Complete proteins: food proteins are classified according to the number and kind of amino acids they contain ● Complete protein are generally of animal origin and found in foods such as meat, poultry, fish, milk,cheese, eggs, soy products Incomplete proteins: lack in 1 or more essential amino acid ● Plant origins: grains,legumes, nuts, and seeds Vegetarian diets: Made up of mainly plant foods ● Some include dairy and eggs ● Legumes play an important role they have nitrogen fixing bacteria in their roots (increasing protein 3 times more than other veggies) ● Vegan: strictest vegetarian diet excludes all animal products, ○ Vegans eat soy beans, soy milk and other soy products to enhance protein intake ○ Have to include B12 b/c this vitamin is found in animal products ○ are lower risk for chronic diseases such as coronary artery disease, colon cancer, obesity, and type 2 diabetes Digestion and metabolism of protein ● Protein containing foods are the bodys only external source of nitrogen ● Once protein containing food is eaten the nitrogen is removed from amino acids and some excreted as urea nitrogen in urine ● Nitrogen balance: (nitrogen equilibrium) is achieved when the amount of nitrogen(protein) taken in is equal to the amount of excreted in urine ● Positive nitrogen balance: is when more nitrogen is taken in than excreted ○ The body is building more tissue (anabolism) than is is breaking down ● Negative nitrogen balance: less nitrogen is consumed than is being excreted ○ This condition occurs when insufficient protein is being taken in and the body is breaking down more tissue (catabolism) ○ Nitrogen balance is negative in states of undernutrition, illness and trauma ○ Missing protein for a day won’t cause this, prolonged negative nitrogen balance can cause atrophy of muscles as well as poor functioning of all body systems ○ When too much protein is taken amino acids are chemically changed and converted to fat and stored as adipose tissue Protein energy malnutrition:(PEM) ● When there is lack of energy or protein intake, protein malnutrition (PEM) may result ● PEM is common in both children and adults in developing countries ○ Associated with more than half the death of children younger than 5 worldwide ● 2 types of PEM: ○ Marasmus: protein and energy-providing foods deficiency that affect people of all ages ■ Is a chronic condition characterized by wasting of body tissue ■ Leaving victim with skin and bones ○ Kwashiorkor : severe protein restriction in the presence of the other calories ■ Occurs in developing countries ■ Characterized as edema in the feet, legs, and often face and hands ■ May also have swelling of the abdomen due to ascites related to hypoalbuminemia results in low oncotic pressure as well as enlarged liver ■ PEM results in multiple nutrient deficiencies and lead to stunted growth & impaired cognitive Method of preserving the nutrient content of foods 19-3 ● Expose food to as little water as possible ● Expose food to as little air ● Avoid very high temperatures ● Keep and use the cooking water ● Store fruits and vegetables cold ● Keep milk in opaque containers ● Use foods in whole form whenever possible Vitamins: organic compounds that are essential in small quantities for normal metabolism and for growth and maintenance of the body Refer to table 19-4 PG 495 FOR VITAMINS ● Organic compounds are derived from living matter and contain carbon ● They are not a source of energy ● Work with other nutrients in the body to regulate many processes, including energy production ● Amount of vitamins needed are so small and referred to as micronutrients ● Vitamins can be destroyed by heat, light, and exposure to air (some vitamins lost when food is prepared) ● One vitamin can not perform the function of another ● Vitamins classified by being soluble in water or soluble in fat ○ Vitamins A, D,E and ,K are fat soluble ■ Fat soluble vit. Are absorbed by intestine in the same way as fats ○ Water soluble: dissolved in water and include vitamin B and C ■ Body is unable to store these vitamins and is usually excreted in the urine Antioxidant vitamins ● Vitamin E,C, and A have been found to delay or prevent the destruction or breakdown of cell membrane in the presence of oxygen (antioxidant) and thereby reduce the risk of certain cancers Vitamin C: refer to TABLE 19-5 for content of selected foods ● Ascorbic acid has many functions ○ Healing wounds, burns, and fractures ○ Serves as antioxidant ○ Necessary for adrenal gland function ● Enhances the absorption of iron and is needed to convert folic acid, a B vitamin to its active form ○ Adult DRI for vitamin C is 90 mg/day for men ○ 75mg/day for women ○ Intake above this level pose risk of diarrhea and GI disturbance and causes body to store too much iron which results in tissue damage ○ Deficiency in Vitamin C can result in bleeding in the bones and joints easy fracture and poor wound healing B-complex vitamins ● All are water soluble ● All necessary for proper metabolism Niacin: AKA vitamin B3 ● Production of energy from glucose and involved in the repair of DNA ● The body can produce niacin if tryptophan is present ● Measured in niacin equivalents ● DRI: 16 mg niacin equivalents/day for men and 14 mg niacin equivalents/day for women ● Obtained through- meat, poultry, fish, peanuts, or enriched whole grain breads and cereals ● Deficiency is rare ● Toxicity has no risk except with excess vitamin supplementation Folate: AKA folic acid (synthetic form) ● Water soluble B vitamin ● Obtained through- spinach, lentils, and garbanzo beans ● Necessary for the formation of DNA and proper cell division ● Deficiency can lead to megaloblastic anemia ● Recommended for women prior/ during pregnancy- proven to reduce risks of neural tube defects in the infant ● Recommended dose for these women is 400 mcg/day in addition to the absorption from their diet VItamin B12: AKA Cyanocobalamin ● Essential part in the production of hemoglobin and myelin ● Absorption only happens if intrinsic factor (protein) is secreted by the lower portion of the stomach ● When intrinsic factor is missing like after stomach excision or resection B12 cannot be absorbed and pernicious anemia occurs ● Pernicious anemia: progressive macrocytic megaloblastic anemia, treatment consists if lifetime B12 injections (oral B12 would not absorb due to lack of intrinsic factor) ● Found in foods of animal origin-lean meat, liver, seafood, eggs, and dairy products ● Vegetarians don’t receive this vitamin unless they take a B12 supplement ● People >50 y/o have difficulty absorbing because of low stomach acid secretion; they need to take oral supplement; recommended that they get the majority from fortified foods ● DRI in adults is 2.4 mcg/ day Vitamin A: Antioxidant and fat-soluble vitamin ● 2 forms available: ○ Retinol (preformed-complete state when it is eaten and it can be used immediately by the body) ○ Carotene (provitamin-needs to be converted in the body to a form that can be used) ○ Both are important for maintaining vision and skin and bone growth ● DRI is 700 mcg for women and 900 mcg for men ● Most people consume in form of beta-carotene, found in bright yellow and orange fruits, carrots, pumpkins, and dark leafy veggies ● Liver contains about 90% of the body’s stored Vit A Vitamin D: Promotes the absorption of calcium and phosphorus which promotes bone and tooth health ● Found in most fortified dairy product, yeast, and fish liver oils ● The body also synthesizes Vit D when the skin is exposed to sunlight ● b/c it is fat-soluble and can be stored in the body, excess intake can cause GI upset, muscular weakness, and in extreme cases calcium deposits in the kidneys, lungs, brain, or heart ● Deficiency can lead to brittle bones (osteoporosis), may be of concerns for older pts in long term care facilities (doesn’t receive sunlight or drink any milk products) ● DRI is adults up to 70 y/o 15 mcg/day and over 70 y/o 20 mcg/day Vitamin K: Blood Clotting ● Important to maintain 4 of 11 clotting factors found in the blood ● 2 forms of Vit K: green leafy veggies and made by intestinal bacteria ● b/c of effect of clotting, pts on antiplatelet drugs or anticoagulants should consume consistent amounts of Vit K ● Fluctuations in Vit K can alter the effects of the anticoagulant drug ● DRI is 120 mcg/day for adult males and 90 mcg for adult females Minerals (look at TABLE 19-6 pg 498) ● Differ from vitamins b/c minerals are organic and they are single elements rather than compounds ● Similar in that they help regulate bodily functions w/o providing energy and are essential to good health ● Classified as: ○ Major Minerals- those needed in amounts greater than 100 mg/ day; include calcium, phosphorus, magnesium, sulfur, sodium, potassium, and chloride ○ Trace Minerals- needed in much smaller amounts <100 mg/ day; include iron, zinc, iodine, selenium, copper, manganese, fluoride, chromium, and molybdenum ○ Other possibly essential minerals, not much is known, arsenic, boron, nickel, and silicon Calcium: Several functions in the body ● Important for formation of bones and teeth; plays a role in blood clotting;place a role in transmission of nerve impulses and muscle action; metabolic reactions throughout the body ● Necessary to protect against Osteoporosis: ○ An abnormal reduction in bone density that leads to bone pain, fractures, loss of stature, and deformities such as kyphosis (hunchback) ○ Affects 1.5 mil in the US; women are affected more ○ 12%-20% of people with hip fractures die from complication w/in 1 year ● Peak bone mass is determined by calcium, genetic influences, gender, hormone levels, physical activity, and dietary intake of Vit D, fluoride, and other trace minerals ● Peak bone mass is achieved between 19 and 30 years of age ● >peak bone mass while younger lowers the risk of bone fractures later in life ● Menopause accelerates the bone loss ● Calcium intake in childhood, adolescence, and young adulthood is important ● DRI: Older children and adolescents is 1300 mg/ day ○ Adults <50 y/o is 1000 mg/ day and Adults >50 y/o is 1200 mg/ day ○ Pts with Osteoporosis is 1500 mg/ day ○ Not necessary for pregnant women, has no effect ● Calcium supplements should never be used to replace calcium rich foods in the diet ● Calcium absorption may be affected by physiological circumstances and dietary factors ● Factors affecting calcium absorption and excretion ○ Improve calcium absorption from GI tract ■ Increased physiological need ■ Acidic conditions in the stomach ■ Small doses (< 500 mg) are better absorbed than larger doses ○ Decrease calcium absorption from GI tract ■ Decreases w/ age ■ Poorly absorbed from foods rich in oxalic or phytic acids (spinach, sweet potatoes, rhubarb, beans,seeds, nuts, grains) ○ Dietary factors that increase excretion (loss) of calcium in urine ■ High sodium diets ■ Low potassium diets ■ Caffeine CALCIUM CONTENT OF SELECTED FOODS TABLE 19-7 FOOD SERVING SIZE CALCIUM CONTENT (mg) Sardines 3 oz 371 American cheese 1 oz 348 Cheddar cheese 1 oz 306 Milk 1 cup 291-315 Yogurt 1 cup 274-415 Tofu (processed w/ calcium) 3 oz 225 Ice cream 1 cup 176 Salmon w/ bones (canned) 1 oz 167 Processed cheese 1 oz 159-199 Collard greens (cooked) 1 cup 148-357 Broccoli (cooked) 1 cup 94-177 Cottage cheese ½ cup 77 Sodium: Functions as an electrolyte (compound that is able to conduct an electrical current) ● Needed in very small amounts for good health and is found naturally in almost all foods ● Sodium deficiency is virtually unheard of in the US ● Sodium excess is of more concern ● Salt (sodium chloride) is the largest contributor of sodium in the diet ● Eaten in large amounts can cause hypertension and edema ● ~65 million (31%) ppl suffer from hypertension ● DRI 1500 mg/day <50 y/o, 1300 mg/day >50-70y/o, 1200 mg/day >70y/o ● Upper limit intake is set at 2300 mg/day ● Most adults in US consume 3400 mg/day ● Monitoring sodium levels is important b/c it is lost in sweating, diarrhea, vomiting, renal disease, and cystic fibrosis Potassium: An electrolyte needed for conduction of nerve impulses and the contraction of muscles including the heart ● Helps maintain acid-base balance and is required for conversion of glucose to glycogen ● Plays a role in energy production and insulin release from the pancreas ● Severe deficiency can lead to hypokalemia (potassium levels < 3.5 mmol/L) (life threatening) ● Individuals taking potassium-wasting diuretics and chronic laxatives users may also be at risk for hypokalemia ● Excessive intake leads to hyperkalemia (potassium levels >5.0 mmol/L) results in renal failure and cardiac arrest ● DRI 4700 mg/day for all adults ● Most people consume less than this ● Moderate deficiency may lead to increased BP, increased risk of kidney stones, and increased bone loss ● Found in fruits, veggies, and milk ● Plant forms are water-soluble; may may be lost when food processing ● Supplementation not recommended unless instructed by provider b/c of toxicity risk that lead to cardiac arrest Iron: Essential part of hemoglobin(part of RBC carries O2 to the cells), myoglobin( found in muscle tissue and stores O2 in the muscle tissue), and some enzymes ● Deficiency can cause iron-deficiency anemia ○ Most prevalent nutritional problem in the world; from low iron in diet, excessive blood loss, absorption problems, and hemoglobin production problems ● Deficiency limits O2 delivery to cells resulting in fatigue, weakness, headaches, pallor, decreased immune function ● Deficiency in children has been linked to short attention span, irritability, and reduced ability to learn ● At risk: children 6 months-4y/o, adolescents, menstruating women, and pregnant women ● Dietary requirements are higher for women than men b/c of menstruation ● DRI 15 mg/day for adolescent girls and 18 mg/day for premenopausal adult women, 8 mg/day for postmenopausal women, men and children, 27 mg/day for pregnant women (through food and supplement b/c it is so high) ● Food sources: meat (esp. organs), poultry, fish, whole grains, and soy foods, fortified and enriched grain products ● Dietary iron is found in 2 forms: heme and nonheme ○ Heme:found in animal tissue and is absorbed well ○ Nonheme:sound in plant products and iron supplements; not absorbed well from GI tract ● Iron absorption from the GI tract may be enhanced/inhibited by certain dietary factors; ex-taking Vit C w/ iron supplements may enhance absorption; taking it w/ fiber or coffee can inhibit absorption ● Iron overdose can be fatal; seen each year in children from overdose of supplements ● Factors affecting Iron absorption ○ Enhance ■ Meat, fish, poultry (MFP) have a factor that enhances iron absorption ■ Vit C when eaten in the same meal w/ iron containing foods ○ Inhibit ■ Bran and some fibers that contain phytates bind iron in the GI tract so it is not absorbed ■ Polyphenols, components food in coffee, tea, and red wine ■ Some meds such as antacids ■ Calcium in milk and supplement form ■ Vegetable proteins, especially soy protein Chromium: Necessary for glucose metabolism and seems to work w/ insulin in regulating blood glucose levels ● Adequate intake may help pts suffering from Type II DM (it is inconclusive and controversial) ● DRI 25 mcg/day for 19-50 y/o women and 35 mcg/day for men ● Found: whole grains, cheese, liver, eggs, peas, apples, and nuts Vitamin and mineral supplementation: help reduce stress, prevent colds, increase sexuality and energy, improve physical performance, and reduce the risk for certain diseases ● Vitamins and minerals are best obtained from a balanced diet; some people may need supplements ● It is best to avoid large doses of nutrients and avoid taking numerous types of supplement, except for therapeutic purposes ● All medications, including vitamins and minerals should be taken under the supervision of a healthcare provider Water: Nutrient most vital to life ● Humans can survive longer w/o food than they can w/o water ● Brings about detrimental changes in the body more rapidly than lack of any other nutrient ● Makes up ~60% of adult body weight and 80% of infant weight ● Performs many functions in the body ● Provides form and structure to body tissues, act as a solvent, and necessary for most of the body’s chemical processes ● Transports nutrients and other substances through the blood, body secretions, tissue fluids ● Lubricates and protects moving parts of the body (joints) ● Aids in digestion and in regulating body temperature ● Dehydration occurs from inadequate intake or abnormal losses (vomiting, hemorrhage, etc) ● Severe dehydration (>10% of body weight loss) life threatening ● Signs of dehydration: poor skin turgor;flush dry skin;dry mouth; cracked, dry lips;decreased urine output;irritability; disorientation ● In infants: sunken fontanels, decreased # of wet diapers, and no tears when they cry ● 80% of water intake comes from drinking water and other beverages; 20% comes from food ● Need for water varies on factors like body size, age, activity level, metabolic needs, temperature ● There is no specific amount given for intake but recommended daily intake is 9 cups for women and 13 cups for men; pregnant/lactating women 3 L/day ● Infants are at greater risk for dehydration b/c they have higher percentage of body water ● Young infants obtain their intake from breastmilk and formula ● Older adults drink less water and are also at greater risk for dehydration ● Important to monitor both infants and older adults b/c they are at greater risk for dehydration; make sure they meet fluid needs Life Cycle Nutrition Pregnancy and Lactation ● Nutrient needs are greater during pregnancy and infancy than any other life cycle ● Optimal nutrition during pregnancy reduces risks of complications, premature deliveries, and low birth weight ● Mother’s nutrition before pregnancy is also important ● Women of childbearing age should consume healthy diets and care in alcohol and caffeine ● Always provide information before conception to women so they are aware of diet importance ● Early weeks of pregnancy-folic acid is important to reduce risk of neural tube defects (spina bifida)in the infant ● Pregnant women are recommended to increase their caloric intake by 300 kcal/day during the 1st trim, 340 kcal/day during the 2nd trim, 450-500 kcal/day during the 3rd trim ● Should be obtained from nutrient-dense foods (foods containing large amount of nutrients than kcal) Concerns in pregnancy Weight gain: Important in pregnancy ● Varies depending on prepregnancy weight ● Optimal weight gain is 25 to 35 lbs ● Underweight women should gain 28-40 lbs ● Overweight women should gain 15-25 lbs ● Intentional weight loss should not be attempted during pregnancy ● Mothers who do not gain weight are at risk for giving birth to low birth weight infant (weighing <5.5 lbs) Discomforts and complications: ● Common are nausea and vomiting “morning sickness” ○ Can be alleviated w/ certain diet modifications ○ To reduce nausea, eat soda crackers or other dry grains before getting out of bead ○ Consume 5 or 6 small meals that include protein each day ○ Avoid letting the stomach become empty ○ Drink plenty of fluids during the day; drink liquids before and after meals to avoid being too fll ○ Avoid high fat it fried food in excess ○ Limit consumption of smelly foods during times of nausea; avoid odors that bother the patient ○ Allow time after eating before lying down or going to bed to prevent epigastric distress ● Constipation: Drink plenty of fluids, especially water ○ Include fiber-rich foods at each meal ○ Include moderate daily exercise ● Some pregnancy brings about medical conditions that pose potential dangers for both mother and fetus ○ Hypertensive disorders: Chronic HTN, preeclampsia, eclampsia, gestational HTN ■ 2nd leading cause of maternal death ■ Contribute to stillbirths and neonatal complications ○ Proper nutrition is vital before and throughout pregnancy and may help maintain blood pressure ○ Diet rich in fruits, veggies, and milk products, adequate proteins, and moderate sodium intake should be encouraged ○ Controlling blood glucose levels during pregnancy is very difficult ○ Hypoglycemia: common in 1st trimester b/c of increased insulin production and nausea and vomiting ○ Hyperglycemia: common in the last trimester (2nd and 3rd) b/c of insulin resistance ○ It is important that women undergo screening for gestational diabetes ○ Controlled through nutrition therapy and moderate exercise; insulin may be necessary for some ○ Anemia: another common nutritional problem (iron deficiency anemia and folic acid deficiency anemia) ■ Should consume an adequate diet that includes meats, poultry, fish, veggies, and fruits w/ prenatal vitamins containing iron and folic-acid Practices to avoid : ● Alcohol: Contributes to increased risk for mental and physical disabilities ○ Fetal alcohol syndrome can develop-physical deformities, learning disabilities, and behavioral problems ○ Total abstinence is best - also if planning on getting pregnant ● High caffeine: Associated w/ delayed conception, increased risk of spontaneous abortion, and low birth weight ○ Should not consume more than 200 mg per day to avoid decreased blood flow to fetus ● Nicotine: Decreases blood supply to the fetus, which can cause babies to be born premature, and have low birth weight ○ Birth defects like cleft palate or cleft lip also common ● Drugs (meds) of any kind should be avoided unless under the supervision of the provider this includes OTC meds and herbal supplements ● High mercury intake: Can cause fetal brain damage as well as hearing and vision problem ○ Advised to avoid shark, swordfish, and king mackerel b/c of the high mercury content Lactation: during lactation, woman should follow diet similar to that followed during pregnancy ● Kilocalorie needs and many nutrient needs are actually higher during pregnancy. ● adequate fluid and nutrient intake is important to maintain the quantity and quality of breast milk. ○ Lactating women should increase their calorie intake by 500 kcal/day. ○ Should come from foods that supply protein, calcium, phosphorus, iron, vitamins, and minerals. ○ Fluids should be increased during lactation: water, juice, milk, and other nutrient beverages. ■ Moderate consumption on coffee, tea, and alcohol: caffeine and alcohol can affect the infant. Infancy: Rapid growth and development from time of birth to 1 year of age. ● Infants Body weight doubles by 6 months, triples by 1 year. ● Breast milk or iron-fortified formula is recommended for entire 1st year of life. ○ Breast milk contains antibodies and easily digested fats. ○ Tends to lead to a lower risk of infections and fewer episodes of GI upset. ○ Cows milk before 1 year could lead to iron-deficiency anemia and risk for developing milk allergies later in life. Can also cause damage to the kidneys. ○ Whole milk is acceptable after 1 year. Skim or nonfat are insufficient in fat content. ● At 4-6 months it is possible to introduce solid foods into the diet. ○ Solid feedings are usually initiated with iron-fortified rice cereal; less allergenic than most foods. ○ Single ingredient foods should be introduced one at a time a weekly intervals. ■ Allows sufficient time to detect any food allergies. ■ Withhold wheat, and egg whites until 1 year. ○ SHould never be given honey, especially wild honey, because of the potential for botulism. ● Commercially prepared baby food are nutritious, safe, and high quality. ○ Read labels carefully and make sure there is no added salt, sugar, or honey. ● Juice before solid foods may cause the infant to prefer juice over breast milk or formula. ○ Important to note that once infant develops teeth, nighttime feedings should be limited to water; breastfeeding mothers should not allow nursing throughout the night. ○ Prolonged exposure of teeth to breast la is a major contributing factor in dental caries Childhood: At 1 year of age, appetite general tapers off and growth rate slows ● Nutrient needs relative to weight a generally less than in infancy. ● As child grows, the serving size should increase. ○ By toddler years, digestive tract should be able to handle all nutrients found in normal diet ○ by school age taste preferences begin to emerge. ● Childhood is also a crucial time for instilling good dietary habits. ○ Food is source of contention (disagreement) at mealtime: parents coax child to eat or gain compliance. ○ The more pressure, the more negative the experience. ● Ways to encourage food dietary habits in children: ○ Encourage children to eat meals/ snacks at regular times and at a table: children earn they cannot eat continuously throughout day. ○ Try to make meals relaxed and enjoyable. Children need time to eat (not feel rushed) and should be a positive experience. ○ Offer a variety of food from all food groups and allow children a choice, within reason. ○ Physical growth and appetite come in spurts. Do not force children more. ○ Give small servings/ teach children to serve themselves small servings. Allow for seconds if still hungry. ○ Offer new foods, do not force children to eat foods they dislike. Offer another time. ○ Encourage children to help with food selection and preparation. ○ Keep nutritious snacks available: fruits, cheese, crackers, raw vegetables, and bread. ○ Limit sweets. Do not use sweets and foods as rewards or bribes. ○ Encourage children to be physically active. ○ As adults, set a good example. Adolescence: At puberty, growth very rapid and nutrition more important for development. ● May be more likely to practice good nutrition if they consider: helps skin and facial appearance, strength (for any athlete), and ability to concentrate in school. ○ Diets are often filled with kilocalorie-rich and nutrient-poor snack foods. ○ Common dietary inadequacies are iron, calcium, vitamins A and C, and folic acid. ■ Iron needs increase with onset of menstruation in girls: anemia is common. ● Another factor to consider is that many teenagers experiment with drugs and alcohol. ● Though obesity in younger people is common problem in U.S., restrictive diets not recommended. ○ Can cause harm by suppressing development and eating disorders. ● Encourage to develop healthy eating habits and use moderation when consuming sodas and sugar-and-laden-fat snacks. ● Emphasize adequate physical activity and minimal TV and computer usage Adulthood: nutrient needs change little in comparison with those of adolescent ● Basal metabolic rate gradually slows and caloric needs decrease: activity levels tend to decrease. ○ Combined effect often result in weight gain. ● Older adults suffer from conditions: heart disease, arthritis, osteoporosis, diabetes. Kidney disease, and other disorders with increased frequency. ○ Special conditions may warrant differing nutrient needs that may vary greatly from individual to individual. ○ Important to consider lifespan considerations and educate pt about their particular dietary needs and its importance. Lifespan considerations: Older Adults ● Aging affects eating process: Changes in detention, decreased saliva production, and alterations in swallowing have potential to affect nutrient intake ○ Sometimes necessary to adjust food consistency to facilitate food intake. ○ Chopped, ground, pureed, an liquid diets tend to be less appealing. ● Aroma and taste of food sometimes affected by aging. Some older adults may be on diets that restrict the use of salts, sugars, and fats. The use of flavoring, seasoning, and spices helps. ● Older adults experience changes in digestive secretions, GI mucosa, and enzyme production. This affects how food is digested, absorbed, and excreted. Water, dietary fiber and adequate physical activity are crucial. ● Aging often leads to loss of muscle mass, reducing basal metabolic rate. Kilocalorie needs may decrease approx. 5% for each decade between 55 and 75 y/o, 7% for each decade after 75 y/o depending on activity level. ● Older adults are in greater need of: protein, riboflavin, vitamin B6 folic acid, vitamin B12, vitamin D, and calcium. A multivitamin and mineral supplement is often beneficial for individuals with low kilocalorie intake. May not need as much vitamin A than a younger adult. Advise not to take large doses of any nutrient without the supervision of a healthcare provider. ● Many medications tend to affect nutritional status. Be aware of drug-nutrient interactions and side effects that may influence dietary intake. ● Because of illness, restricted mobility, or financial limitations, or a combination of of these, some older adults have difficulty in obtaining and preparing nutritious food. ● Age related social and mental changes are likely to affect eating habits: forgetfulness, loneliness, and apathy. ● Chronic medical conditions often need the use of therapeutic diets. Most common include diabetes mellitus, cardiovascular disease, renal insufficiency, osteoporosis, diverticulitis, anemia, and lactose intolerance. ● Always determine individual needs and situations before deciding the most appropriate nutrition therapy. Nutritional Concerns of Adults in Long-Term Care Facilities pg 507 ● Malnutrition common in long-term facilities. Poor nutritional status in residents related to a number of factors: ○ Residents of ltcf may experience cognitive or physical impairment, disease processes,a and emotional disturbances, all of which have an effect on nutritional intake and status. ○ Many residents need encouragement with eating and drinking. ○ Restricted diets may be prescribed. Common modification include sodium and fat restrictions. Diabetic features may be used for some residents. Restrictions can impact the palatability of food. ○ Inadequate fluid intake and dehydration are sometimes secondary to decreased thirst sensation. Decreased independence, dysphagia, and incontinence. ○ Pressure sores occur in non ambulatory residents, increasing kilocalorie, protein and nutrient needs. ● Concerns need to be identified quickly and treatment plan ensure that nutritional compromise does not occur. ● Offering familiar foods and incorporating cultural needs within prescribed diet is important. ○ Promotes a sense of control and independence. ● Liquid nutritional supplements may help increase kilocalorie, protein and nutrient intake if resident’s intake is inadequate. ○ These supplements should not be used as a substitute for regular food. ○ Fluids should be offered at all meals and between meals to ensure adequate intake. ■ Look for signs of dehydration. Nutrient-drug-interactions ● Medications have the potential to increase or decrease appetite and ability to eat. ○ Also affects absorption, metabolism and extraction of some nutrients. ○ Food intake may also affect absorption, distribution, metabolism and action of some medications. ● Caffeine: has potential to cause nervousness, irritability, anxiety, insomnia, and heart dysrhythmia. Advise older adults to use in moderation, can cause symptoms of anxiety attack STOP FOR QUIZ 1 Medical Nutrition Therapy and Therapeutic Diets Medical nutrition therapy: use of specific nutritional variations to build good health. ● Involves modifying nutritionally adequate diet so that it becomes adequate, or changing texture or calorie content. ● It is up to the nurse to ensure that the patient understands and follows the diet, as well as record how the patient reacts. ● Consistency, Texture, and Frequency Modifications Therapeutic Diet: often brings to mind nutrient-modified diets; low-fat or low-sodium ● Modifications in textures, consistencies, and meal frequency are also therapeutic; diets may include liquid, soft, and regular diets. ● Common medications that effect on nutrition ● Antacids, antibiotics, anticoagulants, aspirin, antihypertensives, diuretics, laxatives. Liquid Diets: Clear and full liquids: ● Clear: non irritating and consists of liquids that are easily digested and absorbed and leave little residue (waste) in the GI tract. Typically used before GI diagnostic tests and before surgery, postoperatively, and episodes of vomiting and diarrhea. ○ Water, juice, apple juice, white grape juice, fat-free broth or bouillon, plain gelatin, tea, or black coffee. ○ To be used only temporarily as it is low in protein, kilocalories, and most nutrients: 2-3 days. ● Full: used as a transition diet after clear liquid diet. More nutritionally complete, but still lacking in some nutrients: zinc, iron, and fiber. ○ Ice cream, creamy soups, gelatin, pudding, milk, and juices Soft and Low-Residue Diets: Often serve as an intermediate step when a pt is progressing from liquid to regular diet. ● Generally low in fiber and is similar to regular diet: meat, fish, poultry, eggs, milk, grains fruits, and vegetables. ● Low residue is similar to soft diet but also includes restrictions on milk and milk products as they leave residue in the colon. ○ Pt will need adequate calcium from other sources. High-Fiber Diets: Often used in treatment of constipation. With adequate fluids, fiber has the capacity to reduce constipation in young pts and older adults; helps eliminates the need for laxatives. ● Also recommended for pts with DV . ● Fiber should be introduced slowly to prevent excess gas formation Kilocalorie modifications ● Energy comes from the intake of foods and fluids. ● Basal metabolic rate (BMR): the use of energy to maintain necessary, involuntary body functions to digest nutrients, or diet-induced thermogenesis,and physical activity. ○ During zero energy balance, weight remains constant-equilibrium. ○ Positive energy balance results in weight gain. ○ Negative= weight loss. High-Kilocalorie and High-Protein Diets ● Medical trauma can cause increase in BMR, therefore energy needs needs to increase as well. ○ Trauma and cancer pts may develop anorexia (lack of appetite) so a high-kilocalorie/high-protein diets provide kilocalorie and protein in a small volume and are used to help compromised pt maintain adequate nutritional intake. ○ Important to maintain a positive attitude and provide encouragement when serving meals. ○ Box 19-8: Suggestions for increasing Kilocalories and protein Obesity: an excess of adipose tissue or body fat above level considered healthy. ● In the U.S., 35% of adults and +16% of children and adolescents are obese. ○ More at risk of hypertension, coronary heart disease, stroke, type 2 diabetes, dyslipidemia, osteoarthritis, gallbladder, and some cancers and sleep apnea. ● Body Mass Index (BMI): number calculated from person’s weight and height, provides an indicator of body fat and is used to screen for health problems; accounts for total body weight, not just fat. ○ Divide weight in kg and height in meters squared. ○ If BMI<18.5, pt is underweight; if BMI falls between 25-29.9, pt is considered overweight; if BMI is over 30, pt is considered obese. ○ Location and amount of body fat combined with BMI is more accurate in determining health risks. ○ Upper body: at risk of cardiovascular diseases and diabetes. Etiology of Obesity: ● Caused by energy imbalance that results when more energy is consumed than expended. ○ Genetic, environmental, and behavioral factors contribute to obesity. ○ Genetic, hormonal, and metabolic factors combine to control and regulate appetite and energy metabolism. ○ Sedentary lifestyles are common in the U.S. Both adults and children spend an increasing amount of time in electronic entertainment. ○ Because food is abundant in the U.S., it is easy to overeat as it is usually readily available and can eat almost everywhere. Treatment of Obesity: ● Should be treated as a complex, chronic, relapsing disease. ○ Effective treatments require lifelong commitment to healthy lifestyle. ○ The goal is to maintain weight, not just weight loss. ○ Should set realistic, achievable goals that they can maintain. ○ Even a weight loss of 5%-15% body fat can help reduce health risks significantly. ● Weight management programs should focus on not only reducing energy intake but also on changing the pts dietary and exercise habits. ○ Physical activity is an integral part of weight loss effort and weight maintenance. ○ Itis possible to perform physical activities in shorter increments rather than one long session; recreational activities such as sports and gardening count toward physical activity. ○ Aerobic (oxygen-using) exercises (brisk walking, jogging, cycling, cross-country skiing, and across-training are helpful in reducing body fat. ○ Resistance training (weight lifting, calisthenics) also beneficial in maintaining lean body mass and bone density. ● Effective psychological interventions in treating obesity foster more healthful attitude about eating and body image. ○ Counseling about self-esteem, body in=mike, body acceptance, and coping with societal pressures. ○ A support system consisting of family, friends, and/or a support group is also beneficial. ● Bariatric surgery treats obesity and has become more common, candidates are morbidly obese (BMI>40) or have a BMI>35 with other medical conditions; cardiovascular disease/type 2 diabetes. ○ Pts with weight-related disorders such as preexisting diabetes, hyperlipidemia, hypertension, or sleep apnea may also benefit. ○ Like with any major surgery, risks so exist: nutrition-related complications such a s nutrient deficiencies, dumping syndrome, and diarrhea. ○ Common nutritional deficiencies include iron, folic acid, and vitamin B12. Encourage pts to eat small portion sizes, eat slowly, and to shew foods completely. Consume foods and beverages separately. ● Pharmacological therapy involves the use of prescription drugs or otc medications to treat obesity. ○ Important to make these drugs part of the comprehensive program with diet and physical activity. ○ OTC medications sometimes help suppress the appetite; usually temporarily. Eating Disorders: An illness that disrupts the normal eating pattern. ● Three most common are anorexia nervosa, bulimia nervosa, and binge eating. ● Related to a number of factors including family relationships, cultural values, and genetic predisposition. ● Frequently appear during teen years and young adulthood. ● Society with its focus on thinness has contributed to the rise in their occurrence. Anorexia Nervosa: characterized by self-imposed starvation. ● Common characteristics: intense drive for thinness, intense fear of gaining weight/ becoming fat, and disoriented body image. ● Some pts express obsessive-compulsive behaviors toward food; maintaining strict control over intake by meticulously counting calories, practicing unusual food behaviors and rituals, making excuses to avoid eating, and hiding food that they claim they have eaten. ● Periods of starvation, compulsive exercising, and purging episodes after meals are common behaviors. ● Weight loss and maintenance of weight at or below 85% of goal weight, cessation of menstruation in women, loss of sexual drive, cold intolerance, growth of fine hair in body and face (lanugo), hypotension, and heart irregularities are apparent physical symptoms. ● Bone density is compromised which can lead to compression of vertebrae and stress fractures. ● GI tract is affected: delayed gastric emptying, slowed peristalsis, severe constipation, deterioration of digestive tract lining (causes malabsorption, flatulence, and diarrhea. ● brain affected leading to altered thinking patterns, disturbed sleep, and bad dreams, as well as brain tissue loss, which can be irreversible. ● Multidisciplinary treatment: nutrition therapy, individual psychological counseling, and family counseling. ● Nutritional goals: increasing and improving dietary intake to reverse nutrient deficiencies, chives a healthy weight for height, and re establishing normal eating patterns. Bulimia Nervosa: characterized by periods of binge eating followed by purging/ inappropriate compensatory behavior to prevent weight gain ● Binge eating followed by purging (self-induced vomiting and misuse of diuretics, laxatives, emetics, and enemas) or by other compensatory behaviors such as severe caloric restrictions, excessive exercising, or use of diet pills ● usually within normal weight range and aware of abnormal eating patterns; but lack of control over eating ○ Fear of not being able to stop eating and experience depression, guilt, and remorse after binge ● Occur in combination w/ other psychiatric disorders (depression, substance abuse, self- injurious behavior, obsessive-compulsive disorder) ● Clinical symptoms: possible tooth erosion, calloused knuckles, swollen parotid (salivary) glands, broken blood vessels in eyes/face, stomach lacerations, esophageal and sinus infections resulting from vomiting ● Electrolyte imbalance: muscle weakness and cramps, abnormal heart rhythms, cardiac complications, and occasionally sudden death ● Treatments: multidisciplinary; psychological counseling and therapy are necessary ○ Nutritional goals: improve dietary intake to correct deficiencies and electrolyte imbalances; cessation of binge-purge behavior w/ reestablishment of normal eating pattern Binge-Eating Disorder: compulsive overeating; characterized by frequent, recurrent episodes of binge eating; that is, eating a larger amount of food than normal during short period of time ● Most common eating disorder affecting millions of Americans ● Report feeling of lack of control over eating during binge episodes but not associated with purging ● Many obese; but should consider tx focusing on binge-eating behavior before attempting to lose weight ● Treatments: combo of cognitive-behavioral therapy, interpersonal psychotherapy, antidepressants, and self-help groups Comparison of Eating Disorder Diagnoses Characteristics Anorexia Nervosa Bulimia Nervosa Binge-Eating Disorder Body weight/ other physical indicators Body weight at/below 85% of normal for age, sex, and height; amenorrhea in women Possibly underweight, normal weight or overweight Usually obese Eating behaviors 1. Restricting type: self 1.Recurrent episodes of 1.Recurrent episode of imposed starvation 2. Binge eating/ purging type: regular episodes of binge eating binge eating: compulsive eating of excessive amount 2. Binge eating/purging occurs at leas 2x week for period of 3 months or more binge eating 2. Episodes occur at least 2x week for period of 6 months and associated with at least 3 of following: A. Eating until uncomfortably full B. Eating when not hungry C. Eating rapidly D. Eating alone due to embarrassment E. Feeling guilt, disgust, or depression after overeating Compensatory behaviors (purging) 1. Restricting type: may use excessive exercise 2. Binge-eating/purging type: regular episodes of self-induced 1. Purging type: regular episodes of self induced 2. Non-purging type: use of fasting/excessive exercise None Psychological indicators -Distorted body image: perceives self as fat -Fear of being fat -Denial of problem and its seriousness -feelings of self-worth disproportionately based on body weight, shape, and size -usually awareness that there is problem -poor self esteem; possible depression -awareness that there is a problem Carbohydrate-Modified Diets Diabetes Mellitus: disease which body doesn’t produce or properly use insulin (hormone needed to convert sugar, starches, and other food into energy for daily life) ● Cause unknown; although both genetics and environmental factors (obesity/ lack of exercise) play a role Two major types: ● type 1 most often diagnosed in children and young adults (approx 5% of diabetes cases) ○ Disease in which body does not produce any insulin; required to take insulin therapy for life ● Type 2: metabolic disorder resulting from body’s inability to make enough/properly use insulin ○ most common form and accounts for 95% of cases Nutrition therapy: overall goal is to control and prevent complications with normal nutrition and dietary modifications to control blood glucose and lipid levels ● Educate pt on proper diet to make changes in food and exercise habits to improve metabolic control ● Achieving goals necessitates coordinated effort by provider, nurse, diabetes educator, registered dietitian, patient and patient’s family ● Individualize each therapy to pt; avoid standardized preprinted diet sheets ● All pts should develop realistic and achievable eating plans to adhere by ● Factors to consider when developing eating plan: lifestyle, current eating and exercise patterns, caloric and nutrient needs, presence of other diseases, and use of insulin/ oral antidiabetic meds ● The need to more closely monitor and control carbohydrate intake ● Consistent meal timing, approx every 4-5 hrs, and consistent carb content important to stress during pt teaching ● Total amount of carb in meals and snacks is more important than the source/type of carb ● Encouraged to consume variety of fiber-containing food but no reason to recommend greater amount ● Should also limit amount of fat in diet to control blood lipid levels: ○ Saturated fats limited to < 7% of calories and dietary cholesterol to <200mg/day ○ Trans fatty acids should be kept to minimum ● Type 1 Diabetes Mellitus: most pts still in childhood/ adolescence so it is necessary for eating plan to provide adequate kilocalories for growth and to be as flexible as possible ○ Balance carb intake w/ insulin administration and exercise ○ Able to monitor blood glucose levels and learn to make adjustments in insulin dosages ● Type 2 Diabetes Mellitus: primary goal is to achieve and maintain desirable weight, normal blood cholesterol concentration, and normal blood glucose levels ○ Many are overweight and insulin resistant so it’s helpful to encourage lifestyle changes that result in reduced energy intake and increased physical activity ○ Mild to moderate weight loss (5%-7% of starting weight) shown to improve metabolic control ○ Increased physical activity aids in weight reduction, improved blood glucose levels, decrease insulin resistance, and reduce cardiovascular risk factors Meal Planning Approaches: Even though diabetic pts must monitor carb and fat content of diets, they do not need to buy special foods since many meal planning tools are available for use with normal foods. ● Exchange lists: have been used for many years and sometimes still used in diabetic meal planning ○ Very complex and overwhelming for some pts ○ Foods are divided into groups on basis of carbs, protein, and fat content ○ Pt receives instructions to include certain number of servings from each food group at each meal/snack ○ Pts able to better control intake through day by identifying correct serving sizes and nutrient components ○ Example on Table 19-13 p 517 ● Carbohydrate counting: meal planning approach focusing on total amount of carbs eaten at meals/ snacks ○ approach simpler than exchange lists since it only focuses on one nutrient and pt can see direct correlation between carb intake and blood glucose level ○ difficult because of weighing and measuring of food and need to calculate grams of carbs consumed ○ Protein and fat are not counted with this type but pt encouraged to eat same amount of protein Other nutritional considers: If person taking insulin fails to consume adequate carbs, the blood glucose level may drop causing hypoglycemia (low blood glucose level). ● Symptoms of hypoglycemia: headache, disorientation, weakness, perspiration, shallow breathing, nervousness, visual disturbances, vertigo, and sometimes unconsciousness ● Necessary to treat hypoglycemia w/ immediate administration of glucose or any carb containing glucose ● Good strategy for pts to practice is the 15-15 rule ○ Take 15 g of carb, wait 15 minutes and test blood glucose to see whether response to carb is adequate ● Acute illness increases risk of diabetic ketoacidosis in pts w/ type 1 diabetes and hyperosmolar hyperglycemic nonketotic syndrome in pts w/ type 2 diabetes ○ Important pt continue taking insulin and carefully monitor blood glucose levels ○ Encourage pt to drink adequate amounts of fluid to ingest carbs ○ Juices and punch, popsicles, gelatin, crackers, pudding, and ice cream all contain carbs and tend to be more palatable to sick people ● Guidelines for alcohol use are same as general population ○ If pt chooses to drink, teach them to limit intake: one drink/ day for women and two drinks/day for men ○ Because alcohol increase risk of hypoglycemia, consuming w/ food is best Dumping Syndrome: possible after surgery which portion or all of stomach is removed or after bariatric surgery for weight reduction ● Occurs when contents of stomach empty too quickly into small intestine ○ Partially digested food draws excess fluid into small intestine, which leads to nausea, cramping, diarrhea, sweating, lightheadedness, and palpitations ○ Symptoms occur shortly after meals/ consumption of too much simple or refined sugar ● Diet therapy: aimed to slow gastric emptying and distributing amount of gastric contents in bowel over time ○ Gives small, frequent meals higher in protein and fat and lower in carbs ○ Encouraged to avoid concentrated sweets and drink fluids 30-60 min before and after meals ○ Pt lie down for 30-60 min after meal to slow stomach emptying ○ Needed temporarily until body adjusts to changes caused by surgery Lactose Intolerance: occurs when lack of digestive enzyme lactase which leads to the GI tract unable to break down lactose, the milk sugar ● Hereditary; increased risk among African Americans, Hispanics, Asian Americans, and Native Americans ● It is not the same condition as an allergy to cow’s milk ● Symptoms occur 30 min-2 hrs after ingestion of milk products such as: nausea, cramps, bloated feeling, flatulence, and diarrhea ● Diet: excludes milk and milk products (ice cream, puddings, cheese, powdered milk) ○ Should avoid foods with milk added (biscuit/muffin mixes, some soups, other prepared foods), processed foods (waffles, pancakes, processed meats) ○ Include counseling with alternative sources of calcium and recommend supplements ● When there is deficiency rather than total absence of lactase, pts often able to tolerate small amounts of milk products especially yogurt and cheese ● Lactase enzyme-containing preparations available to take before consuming dairy products or lactose free Fat-Modified Diets Research shows modifying amount of fat in diet may reduce risk of heart and vascular disease by about 14% and the risk for some cancers can be reduced as well. Low-Fat Diets: limited amounts of total fat, saturated fat and trans fatty acids diet ● This diet is needed for prevention and treatment of atherosclerosis (diet characterized by buildup of cholesterol and lipids on artery walls), heart disease, and hyperlipidemia (elevated levels of blood lipids) ● AHA recommended dietary guidelines for general population to decrease amount of fat in diet ● National Cholesterol Education Program also developed Therapeutic Lifestyle Changes (TLC) diet to help decrease amount of fat and cholesterol ingested Table 19-14 p 519 ● Pts struggle complying with diet because they think required foods lack flavor and are not satisfying ● pts need to reduce saturated and trans fatty acids, but pts still able to pick low-fat foods from all food groups ○ Encourage to choose low-fat dairy products, lean meats, skinless poultry, and fish ○ Advise limiting eggs to four or fewer/ week, limit organ meats (liver) to one serving or less/week ○ Limit added fats: butter, stick margarine, mayo, cream, and sour cream ● Inclusion of monounsaturated fats and omega-3 fatty acids helps lower blood cholesterol and triglyceride levels ○ Encourage pts to substitute unsaturated fatty acids instead of saturated and trans fatty acids ○ Identify sources such as: fish, olive oil, canola oil, peanut oil, flaxseed oil, soy products, and nuts ● Many tend to rebel low-fat diet because they believe it is necess