Bridgitte CarrollKNH 413Gretchen Matuszak 24 April 2014

2 g Sodium Diet

1. Purposea. To help decrease high blood pressureb. High sodium intakes will cause fluid retention and vasoconstriction, increasing BP

2. Populationa. Assign diet to hypertensive patients, BP > 140/80b. 5% of population is affected by a high sodium intake that will increase their BP

3. General Guidelinesa. 2 g Sodium per dayb. Should be paired with a weight loss plan to increase success of blood pressure reductionc. Can also use DASH diet, which incorporates fresh fruits and vegetables, whole grains and has a

2,300 mg sodium intaked. Aim to decrease blood pressure

Meal 24-hour recall Substitutions/SuggestionsBreakfast 2 Scrambled Eggs with Veggies

Hot Sauce Eliminate or use Cayenne Pepper in eggs

2 Slices of BaconOrange Juice

Lunch Tomato Soup Low-sodium varietyGrilled Cheese –1 whole wheat English muffin

2 slices of lower sodium whole wheat bread

Kraft American Cheese Natural CheeseMilk

Snack Pretzels Unsalted nuts or crackers

Dinner Corn TortillasChicken prepared with season salt

Prepare with Mrs. Dash

Salsa & Hot Sauce Use Mrs. Dash to flavor, use fresh tomatoes more than salsa

Corn, canned No salt added varietyBlack beans, canned No salt added variety, wash

thoroughly4. Education Material

a. Educate on lower sodium options and substitutionsb. Mrs. Dash and spices to liven up food instead of saltc. Teach patient how to read labels to determine amount of sodium and if it is high/low sodium

option

Tips for Reducing Sodium in Your Diet

o Buy fresh, plain frozen, or canned "with no salt added" vegetables.

o Use fresh poultry, fish, and lean meat, rather than canned or processed types.o Use herbs, spices, and salt-free seasoning blends in cooking and at the table.o Cook rice, pasta, and hot cereals without salt. Cut back on instant or flavored rice, pasta, and cereal mixes,

which usually have added salt.o Choose "convenience" foods that are lower in sodium. Cut back on frozen dinners, pizza, packaged mixes,

canned soups or broths, and salad dressings — these often have a lot of sodium.o Rinse canned foods, such as tuna, to remove some sodium.o When available, buy low- or reduced-sodium, or no-salt-added versions of foods.o Choose ready-to-eat breakfast cereals that are lower in sodium.

Top 10 Sources of Sodium in the American Diet

1. Bread and rolls2. Cold cuts/cured meats3. Pizza4. Fresh and processed poultry5. Soups6. Sandwiches like cheeseburgers7. Cheese8. Pasta dishes like spaghetti with meat sauce9. Meat dishes like meatloaf with tomato sauce

10. Snacks, including chips, pretzels, popcorn and puffs

5. Samples Menua. Foods Recommended – Low- or reduced-sodium, or no-salt-added versions of foods such as

soup and vegetables, spices, lower sodium ready to eat breakfast cereals and frozen dinners, natural cheeses, lower sodium breads

b. Foods Avoided – Condiments, processed cheeses, high sodium breads and rolls, cold cuts/cured meats, high sodium snacks like pretzels and chips

c. Sample Menu

Breakfast

1 cup fresh mixed fruits, such as melons, banana, apple and berries, topped with 1 cup fat-free, low-calorie vanilla-flavored yogurt and 1/3 cup walnuts1 bran muffin1 teaspoon trans-free margarine1 cup fat-free milkHerbal tea

Lunch

Curried chicken wrap made with: 1 medium whole-wheat tortilla 2/3 cup cooked, chopped chicken, about 3 ounces 1/2 cup chopped apple 2 tablespoons fat-free mayonnaise* 1/2 teaspoon curry powder

1/2 cup, or about 8, raw baby carrots1 cup fat-free milk

Dinner 1 cup cooked whole-wheat spaghetti with 1 cup marinara sauce, no added salt2 cups mixed salad greens

1 tablespoon low-fat Caesar dressing1 whole-wheat roll1 teaspoon trans-free margarine1 nectarineSparkling water

Snack (anytime)

Trail mix made with: 1/4 cup raisins 1 ounce, or about 22, unsalted mini twist pretzels 2 tablespoons sunflower seeds

i. (N.A., 2011)6. Websites

a. American Heart Association – www.heart.org/conditions/highbloodpressureb. Mayo Clinic – Hypertensionc. National Heart, Lung and Blood Institute -

http://www.nhlbi.nih.gov/health/health-topics/topics/hbp/d. Academy of Nutrition and Dietetics - http://www.eatright.org/Public/content.aspx?

id=6442469653&terms=hypertension

References

Mayo Clinic Staff. (2012) Hypertension. Mayo Clinic. Retrieved from: http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/definition/con-20019580

Nelms, M., Sucher, K. P., Lacey, K., & Long Roth, S. (2011). Nutrition therapy & pathophysiology. (2nd ed. ed.). Belmont, CA: Wadsworth, Cengage Learning.

Carolyn KlempayKNH 413

Diet Instruction

1 gram Sodium DietPatient History:

Darla is a 42-yr old wife and mother of three. She loves to cook and enjoys trying new foods and recipes in the kitchen as she cooks meals for her entire family. Darla works full-time, volunteers with her local church, and attends many games and recitals for her children who play soccer and instruments in the school band. With such a full household and hectic schedule, Darla spends all of her time caring for others and has sacrificed her own well-being in the process. With little time to exercise or focus on her own health, she is 5’2” and weighs 160 lbs (72.7kg). Recently Darla went to her doctor’s office and was told she was pre-hypertensive. The doctor said she should meet with a dietitian and ask specifically how to decrease her salt intake.

BMI = wt (kg) / ht2 (m2)BMI = 72.7 kg / (1.57m)2

BMI = 72.7/2.46BMI = 29.5 kg/m2

24-hour Dietary Recall:

Breakfast 2 eggs over-medium with salt and pepper, 2 slices bacon, one medium plain bagel with butter

Lunch Deli sliced ham sandwich on white bread, Provolone cheese, lettuce, and mustard. 1 medium pickle slice

Dinner Spaghetti with pork sausage, Parmesan cheese, Italian bread, creamed corn, salad with Italian dressing

Snack Pretzels with 2 Tbsp peanut butter

24-hour Dietary Recall Analysis:Food Item Sodium Content

(mg)2 eggs 1401/16 tsp table salt 1452 slices bacon 3001 medium plain bagel 4001 Tbsp salted butter 802 slices white bread 3401 oz deli ham 7501 oz low-fat provolone cheese 250Lettuce 01 tsp mustard 551 medium pickle slice 3703 oz Spaghetti pasta with ¼ cup sauce

300

2 oz pork sausage 4001 Tbsp Parmesan cheese 751 slice Italian bread 120½ cup creamed corn 365Salad with 1 Tbsp Italian dressing 2421 oz pretzels 4002 Tbsp peanut butter 150

Total 4,882 mg sodium

Diet Instruction:1g (1,000 mg) Sodium Diet

Basic Information on Pre-Hypertension:-Blood pressure is the force of blood against the walls of arteries-When BP is elevated for an extended period of time, this is hypertension-Hypertension makes the heart work too hard and contributes to atherosclerosis (hardening of the arteries)-Hypertension increases risk of heart attack, stroke, heart failure, kidney disease, and blindness-Blood pressure between 120/80 and 139/89is pre-hypertension (don’t have high BP now, but likely in the future)-Above 140/90 is hypertension-Systolic/Diastolic (BP when heart beats/BP when heart is at rest)(National Institute of Health)

Basic Information on Sodium:-Salt is commonly referred to as “Sodium”-We need salt in our diets for proper functioning of nerves and muscles and correct balances of fluids in our bodies-Kidneys are responsible for helping regulate our sodium levels-When we take in too much sodium, our kidneys can’t get rid of it all and it builds up in the blood

This results in high blood pressure, or hypertension-Typically, it is recommended to consume less than 2,400 mg sodium (2.4 g) per day (MedlinePlus)

24-hour Dietary Recall Modifications Analysis:Food Item Sodium Content

(mg)Food Modifications Sodium Content

(mg)2 eggs 140 2 eggs 1401/16 tsp table salt 145 ½ cup honeydew 302 slices bacon 300 8 oz yogurt 1001 medium plain bagel 400 1 cup oatmeal 101 Tbsp salted butter 80 unsalted pecans &

raisins0

2 slices white bread 340 2 slices wheat bread 2602 oz deli ham 750 3 oz turkey 601 oz low-fat provolone cheese

250 1 oz Swiss cheese 55

Lettuce 0 Lettuce 01 tsp mustard 55 1 tsp mustard 551 medium pickle slice 370 1 cup canned peaches 103 oz Spaghetti pasta with ¼ cup sauce

300 1 cup brown rice, cooked tomatoes & avocado

10

2 oz pork sausage 400 3 oz ground beef meatballs

60

1 Tbsp Parmesan cheese 75 ½ cup cauliflower 101 slice Italian bread 120 sweet potato baked in

skin40

½ cup creamed corn 365 ½ cup cooked broccoli 30Salad with 1 Tbsp Italian dressing

242 spinach with oil & spices

65

1 oz pretzels 400 3 cups air popped popcorn

0

2 Tbsp peanut butter 150 1 oz unsalted almonds 0

Total 4,882 mg sodium Total 935 mg sodium

Foods to Avoid:-Salt-Processed foods

-Canned, frozen foods-Snack foods-Packaged starchy foods (stuffing mix)-Instant cooking foods (potatoes)-Mixes (biscuits, cake)

-Certain meats and cheeses-Deli/ lunch meats (ham, bologna)-Cured/ smoked meats (sausage, bacon)-Canned meats (Spam, Vienna sausage)-Cheeses - avoid over 140mg sodium per

serving (American cheese, Velveeta)-Condiments and Sauces

- Ketchup and salad dressings-Worcestershire, pizza, barbeque, steak,

soy-Pickles and Olives

Low Sodium Foods: Fruit -unsalted fresh, frozen, or canned

-fruit juicesVegetables -unsalted fresh, frozen, or canned

-vegetable juices, without salt added-tomatoes

Protein -plain meats-fish-poultry-eggs

Starch -shredded wheat-plain pasta or rice-homemade yeast breads, made without salt

Dairy -milk-yogurt-low sodium cheese-hard cheeses (cheddar, Swiss)

Other -ice cream-unsalted nuts-unsalted butter or margarine

Tips to lower Sodium in foods:-Make foods homemade, you can control the amount of salt that is added-Choose fresh, frozen, or canned items without added salt-Snack on fresh fruits, vegetables, or unsalted nuts which are low in sodium-Read the nutrition facts label!-Use fresh or salt-free spices to add flavor to foods-When eating out, ask for gravies and sauces on the side for better portion control

SUMMARY:Goals:-Begin 1 gram (1,000 mg) sodium dietary regimen-Become educated on foods high and low in sodium-Decrease BP to below 120/80, rid pre-hypertension

Closing Questions:-Can you name 2 foods high in sodium?-Can you name 2 foods low in sodium?-Can you explain 2 changes you are going to implement this week to help reduce your sodium intake?

**Here is my card and I think it would be good to have a follow-up appointment in 2 weeks to see how things are coming along!!

Resources:Academy of Nutrition and Dietetics. (2013, January). The Basics of the Nutrition

Facts Panel. A Guide on How to Read a Nutrition Facts Panel from the Academy. Retrieved February 19, 2014, from http://www.eatright.org/Public/content.aspx?id=10935

American Heart Association. (2013). Eat Less Salt. - book review by the Academy of Nutrition and Dietetics. Retrieved February 19, 2014, from http://www.eatright.org/Media/content.aspx?id=6442475958#.UwTliIWurK

ClevelandClinic. (2013). Eat Right. Cleveland Clinic. Retrieved February 19, 2014, from http://my.clevelandclinic.org/healthy_living/nutrition/hic_low-sodium_diet_guidelines.aspx

Columbia Edu. (2012). Sample Menus for the DASH Eating Plan. Mayo Clinic Source. Retrieved February 19, 2014, from http://www.cumc.columbia.edu/student/health/pdf/Sample%20menus%20for%20the%20D

Department of Health and Human Services. (2014, February 18). Low Sodium Foods: Shopping list. Low Sodium Foods: Shopping list. Retrieved February 19, 2014, from http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/heart-health/low-sodium-foods-shopping-list

Dugdale, D. C. (2012, September 6). Low-salt diet : MedlinePlus Medical Encyclopedia. U.S National Library of Medicine. Retrieved February 19, 2014, from http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000109.htm

FDA. (2013, April 18). Food. Sodium in Your Diet: Using the Nutrition Facts Label to Reduce Your Intake. Retrieved February 19, 2014, from http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm315393.htm

MayoClinic Staff. (2013). Low-sodium recipes. - Healthy Recipes. Retrieved February 19, 2014, from http://www.mayoclinic.org/healthy-living/recipes/low-sodium-recipes/rcs-20077197

Nutrition Care Manual. (2014). NCM Nutrition Care Manual eat right. Public Home Page. Retrieved February 19, 2014, from.http://www.nutritioncaremanual.org/category.cfm?ncm_category_id=1&ncm_heading=Meal%20Plans&client_ed=1

Zernel, M. B. (1997). McKinley Health Center - DASH Diet/1500, 1800, and 2000 calories per day - University of Illinois. McKinley Health Center - DASH

Diet/1500, 1800, and 2000 calories per day - University of Illinois. Retrieved February 19, 2014, from http://www.mckinley.illinois.edu/handouts

Jessica AndersonKNH 4133/21/14

Diet Instruction: 50g Fat Restricted Diet

Patient Description and Diagnosis: Alex Reschke is an 18-year-old Caucasian female, 5’8”, and 218 pounds. She is currently a senior at Mentor High school and a member of the varsity track-and-field team, in which she participates in shot put and discus. The other night, Alex could not sleep. She experienced severe right upper quadrant pain and back pain between the shoulder blades that lasted for hours. Immediately, her parents rushed her to the hospital. After Alex described her symptoms and personal/family health history, the doctor performed an abdominal ultrasound and computerized tomography (CT) scan to analyze and look for signs of gallstones. The scan came back positive for cholelithiasis. Due to the presence of gallstones, the doctor performed a test to check the bile ducts for gallstones. Using a HIDA scan, a dye was used to highlight the bile ducts, determining that a gallstone was blocking the bile duct pathway. Thus, Alex’s severe pain was a result of bilary obstruction, in which the gallstone passed from the gallbladder through the cystic duct and lodged itself into the common bile duct. Alex did not show signs of inflammation. Due to her recent diagnosis of symptomatic cholelilthiasis, specifically choleldocholithiasis (common bile duct stones), as well as her family history of gallbladder cancer, she decided to undergo a cholecystectomy (removal of the gallbladder laproscopically). In about 6-12 weeks, Alex will have undergone surgery. In the meantime, Alex has been asked by her physician to see a Registered Dietitian for instruction on a 50g fat restrictive diet to help relieve her symptoms prior to surgery.

Etiology: Gallstones and bilary tract infections are known to affect 20 million American’s each year. Gallstone related diseases are responsible for about 10,000 deaths per year in the United States. Interestingly, only 1 in 3% of the population complains of symptoms during the course of a year, and fewer than half of these people have symptoms that return. Women are at higher risk of developing gallstones than men, occurring in nearly 25% of women in the US by the age of 60 and as many as 50% by the age of 75. Women are at an increased risk due to estrogen, which stimulates the liver to remove more cholesterol from blood and transfer it into bile. Other risk factors associated with cholelithiasis include being overweight or obese, eating a high fat diet, having a family history of gallstones, having diabetes, and much more. Gallstones may cause no signs or symptoms and may last a few minutes to hours. Symptoms which may appear include sudden and rapidly intensifying pain in upper right or center portion of abdomen, back pain between shoulder blades, pain in the upper right shoulder, as well as high fever with chills and possible yellowing of the skin and whites of eyes (Jaundice). When the gallbladder is removed, the liver continues to make enough bile to digest food; however, the bile drips continuously from the liver into the intestine. The causes of

the formation of gallstones is still unclear, but it is suggested that such formation may occur due to bile containing too much cholesterol, bile too high in bilirubin or the gallbladder does not empty correctly. In such abnormal conditions, cholesterol precipitates as gallstones rather than remaining in the solution of bile salts and lecithin in the form of micelles.

Diagnostic Measures: The challenge is diagnosing gallstones is verifying that the abdominal pain is caused by the stones and not other conditions. Ultrasounds and imaging techniques are commonly used in the detection of gallstones. Because gallstones most often do not cause any symptoms, simply finding stones does not necessarily explain a patient’s pain. In diagnosing gallstones, disorders should be ruled out, such as if the patient’s pain lasts less than 15 minutes, frequently coming and going, or not severe enough to limit activities. Disorders with similar symptoms include IBS and Pancreatitis. In patient’s with known gallstones, the doctor can often diagnosis acute cholecystitis based on classic symptoms of constant and severe pain in the upper right quadrant of the abdomen and imaging techniques to confirm the diagnosis. Blood tests can be used to identify abnormalities that may indicate gallstones or complications: bilirubin and enzyme alkaline phosphatase levels elevated, especially in choledocholithiasis; elevated levels of aspartate aminotransferase and alanine when common bile duct stones are present. Additionally, a high white blood cell count is common in many patients with cholecystitis. Imaging and diagnostic techniques for gallstones may include Ultrasonography, Endoscopic Ultrasound, Computed Tomography, Magnetic Resonance Cholangiography, X-rays, HIDA scan (Gallbladder Radionuclide Scan), Virtual Endoscopy, and Endoscopic Retrograde Cholangiopancreatography (ERCP).

Ultrasounds can help in the diagnosis of various conditions: accurately detect stones as small as 2mm in diameter; indicate gangrene when air is present in the gallbladder. In contrast, ultrasounds may not be helpful in the diagnosis of cholecystitis when gallstones are not present in those with symptoms, and may not be helpful in identifying common bile duct stones or imaging the cystic duct. Additionally, X-rays of the abdomen may detect calcified gallstones and gas. An HIDA scan is a nuclear imaging technique that is more sensitive than ultrasound for diagnosing acute cholecystitis and is noninvasive. During this procedure, a tiny amount of radioactive dye is injected intravenously and excreted into the bile. If the dye does not enter the gallbladder, the cystic duct is obstructed, indicating acute cholecystitis. False results are commonly found in alcoholics with liver disease or patients who are fasting or receiving all their nutrition intravenously.

Treatment: Acute pain from gallstones and gallbladder disease is usually treated in the hospital, where diagnostic procedures are performed in ruling out other possible conditions and complications. There are three approaches to gallstone treatment: expectant management (“wait and see”), nonsurgical removal of stones, and surgical removal of gallbladder. For expectant management, a person has no symptoms, the risks of both surgical and nonsurgical treatments for gallstones outweigh the benefits. Those who show no signs of severe pain or complications

may be discharged from the hospital with oral antibiotics and pain relievers. Exceptions to this policy are those who show risk for complications for gallstones, including those at risk of gallbladder cancer, Pima Native Americans, and patients with stones larger than 3cm. Because the presence of gallstones at an early age increases ones risk for gallbladder cancer, young adults who do not have symptoms may be recommended to have their gallbladder removed. When gallstones are present without inflammation, patients have the following options: intravenous painkillers for severe pain, elective gallbladder removal, lithotripsy, and drug therapy. In regards to the presence of common bile duct stones, a laparoscopic cholecysectomy has taken a role in the detection and removal of common bile duct stones. Because the gallbladder is not an essential organ, its removal is one of the most common surgical procedures performed on women. The advantage of surgical treatment over the other methods is its ability to eliminate gallstones and prevent gallbladder cancer. Cholecystectomy may be performed within days to weeks after hospitalization for an acute attack, depending on the severity of the condition. During a laparoscopic cholecystectomy, the surgeon separates the gallbladder from the liver and other areas, and removes it through one of the 3 small incisions made in the abdomen. Often times, patients will need to stay in the hospital overnight.

Although she does not show signs of inflammation, a laparoscopic cholecystectomy was chosen for Alex. This is due to her family history of gallbladder cancer, her age, the severity of her pain, as well as her ethnicity – Caucasian.

Medical Nutrition Therapy: For the next 6-12 weeks, prior to surgery, Alex will follow a 50g fat restrictive diet. Doing so will assist in relieving her symptoms associated with choledocholithiasis.

BMI: kg/m2

Ht. 5’8” 5’ x 12in/ft + 8in = 68in x 2.54cm/in = 172.72cm 172.72cm x 1m/100cm = 1.7272m

~1.73m

Wt. 218lbs 218lbs x 1kg/2.2lb = 99.09kg

BMI = (99.09kg)/(1.73m2) = 33.1kg/m2d

Alex is classified as obese, according to BMI for children (>95th percentile). Such status of health risk for a classification as obese is associated with further increased risk of disease.

Although Alex is considered obese, weight loss at this time is not of primary focus. The relieving of symptoms due to her recent diagnosis of choledocholithiasis, in preparation for her laparoscopic cholecystectomy, is of greatest concern. Weight maintenance and achievement of proper macronutrient ratios as well as a consuming a well-balanced diet high in fiber, various vegetables and fruits as well as

nuts, with a decreased intake in sugar, alcoholic beverages and caffeine are recommended to Alex at this time. In regards to fat, it is recommended for Alex to consume foods containing monounsaturated fats – found in olive and canola oils, as well as omega-3 fatty acids – found in canola, flaxseed and fish oil. Fish oil may be beneficial in regards to Alex’s triglyceride levels, because it improves the emptying action of the gallbladder.

The Total Energy Expenditure (TEE) was used in determining Alex’s estimated energy needs at rest. With the re-addition of added physical activity, post surgery, an estimation of Alex’s energy needs and estimated energy expenditure will need to be reassessed and revised to best fit her overall health and wellness and nutrition goals.

Total Energy Expenditure for Overweight and Obese Females Aged 3 through 18 Years:

TEE = 389 – 41.2 x age + PA x (15.0 x wt. + 701.6 x ht.)

PA Factor: 1.24 for active Wt. = 99.09kg

Ht. = 172.72cmAge = 18yrs

Prior to Operation, with caution, unless told doctor advises not to participate in sport:

TEE = 389 – 41.2 x 18 + 1.24 x (15.0 x 99.09kg + 701.6 x 1.7272m)= 389 – 741.6 + 1.24 x (1486.35 + 1211.80352)

= 389 – 741.6 + 1.24 x (2698.15)= 389 – 741.6 + 3345.706

= 2993.106 Kcal/d~ 3000 – 3100Kcal/d with PA (active PA = 1.24)

Post Operation/No Activity:

No PA Factor (when PA = 1.0)= 389 – 741.6 + 2698.15

= 2354.55 Kcal/d ~ 2350 – 2450 Kcal/d without PA (sedentary PA = 1.0)

Using the TEE for overweight and obese females aged 3 to 18 years, prior to operation, Alex requires about 3000Kcal/d with physical activity. If the doctor advises Alex not to participate in track and field for the next couple of weeks, she should consume about 2350 to 2450Kcal/d. This requirement should be followed post operation, when recovering. Prior and when recovering from surgery, it is best for Alex to avoid fatty foods at first and slowly add them back into her diet. It is

important for her to consume the right fats – monounsaturated and omega-3’s, while avoiding high consumption and foods high in saturated and trans fats as well as foods that are high in cholesterol. Such foods can cause bilary irritation; thus, resulting in symptoms of discomfort, cramping, and diarrhea.

Below are the calculations for Alex’s macronutrient ratio. In order to prevent excessive diarrhea and symptoms related to choledocholithiasis, she should follow this ratio daily.

Without physical activity:

Total Kcal: ~2400Kcal/d

Fat: 20% daily Kcal

2400kcal/d x 1g fat/9kcal = 266.7g fat x .20 = 53.34g fat/d

Protein: 25% daily Kcal

2400kcal/d x 1g protein/4kcal = 600g pro x .25 = 150g pro/d

Carbohydrate: 55% daily Kcal

2400Kcal/d x 1g carbohydrate/4kcal = 600 kcal CHO x .55 = 330g CHO/d

As the information above displays, it is advised for Alex to restrict her fat intake to roughly 53g per day. That is, she should consume 20% of her calories from fat sources. Because Alex is an athlete and her body is under stress, her protein needs are increased. Increasing Alex’s protein content may assist in controlling symptoms until surgery. Alex’s protein needs were calculated to be 150g/d, which makes up about 25% of her daily calories. Lastly, Alex requires 330g of carbohydrate per day, which is 55% of her total daily energy needs.

It is recommended for Alex to consume small and frequent meals, about 5-6 a day. Due to poor absorption of fat, water-soluble form of vitamins A, D, E, and K may be necessary. Such foods include dark leafy green vegetables, carrots, dairy products fortified with vitamin D, sunflower seeds, almonds, as well as olive oil and soybean oil. Post-surgery diarrhea may be managed through increased fiber intake to increase fecal bulk, and patient avoidance of food that may cause diarrhea.

In helping to aid with digestion, it is advised for Alex to eat foods high in fiber. Although this is important, it should be noted to up her total fiber intake slowly. Increasing fiber intake too drastically may result in additional cramping and discomfort. It is also important for Alex to drink plenty of fluids, especially water. Because diarrhea frequently occurs for a few days post-operation, it is important for Alex to stay well hydrated. In addition, fluid helps encourage the passage of waste

through the digestive system and helps to soften stools. Because Alex will be eating foods with higher fiber content, constipation may occur. By drinking enough fluids daily, she will be able to avoid such conditions. It is advised for Alex to drink at least 8 8oz glasses of fluid each day, at least 4 servings of fruits and vegetables, and at least 4 servings of breads or cereals (2 of those servings being whole grain).

During counseling with Alex, it is important to review the macronutrient ratio designed for her specific needs as well as obtaining adequate intake through a well-balanced diet. The patient will be informed on the importance of obtaining her fat intake from monounsaturated and omega-3 sources, increasing fluid intake to at least 8 8oz glasses of water per day, as well as eating a diet rich in fiber. The patient’s 24-hour recall will be reviewed. Additionally, Alex will receive suggestions for improvement in her overall diet, based on the nutritional recommendations determined. She will be educated and given handouts on specific foods to avoid – causing the onset of symptoms, and those to consume as well as foods high in fat-soluble vitamins – A, D, E, and K. Alex will be given a list of food exchanges that she can use to assist her in educating herself on energy contents of specific foods while using it to easily swap out foods for one another throughout the week.

24-Hour Recall With Suggestions: for a 2400Kcal diet

If needed, patient may make meals into smaller, more frequent, meals. Total: 53g fatFat per meal: ~ 12.3g fatFat per snack: ~ 8g

Foods Consumed Suggestions for ImprovementBreakfast:2 slices of white toast (160kcal; 2g fat)1T butter (135kcal; 15g fat)3 eggs (225Kcal; 15g fat)1tsp hot sauce8 oz glass 2% milk (120Kcal; 5g fat)

Total: 640Kcal and 37g fat

2 whole wheat slices of toast (160 Kcal; 1g fat)

1T peanut butter (100Kcal; 8g fat)

Scrambled - 2 egg whites and 1 egg (125Kcal; 5g fat)2T mild salsa (10Kcal; 0g fat)8 oz skim milk (90Kcal; 1.5g fat)

485Kcal and 15.5g fatSnack:½ cup Almonds (200Kcal; 16g fat)Banana (60Kcal; 0g fat)1 cup Greek Vanilla Yogurt, low-fat (120Kcal; 4g fat)1/3 cup granola (80Kcal; 1g fat)

Smoothie:1 ½ cup nonfat vanilla Greek Yogurt (180Kcal; 0g fat)¼ cup Almonds (100Kcal; 8g fat)Banana (60Kcal; 0g fat)½ cup special K cereal (80Kcal; 1g fat)½ cup Strawberries (60Kcal; 0g fat)

460Kcal and 21g fat 420Kcal and 9g fatLunch:

2 slices white bread (160Kcal; 2g fat)1T mayonnaise (135Kcal; 15g fat)2 slices provolone cheese (200Kcal; 16g fat)2oz luncheon meat – ham (200Kcal; 16g fat)2 leafs of lettuce – romaine (0Kcal; 0gfat)

½ cup diced pineapple (60Kcal; 0g fat)

755Kcal and 33g fat

2 slices whole wheat bread (160Kcal; 2g fat)1 slice skim American cheese (55Kcal; 3g fat)2oz grilled chicken breast (110Kcal; 6g fat)2 leafs of lettuce (0Kcal; 0g fat)

½ cup diced pineapple (60Kcal; 0g fat)½ cup steamed broccoli (25Kcal; 0g fat)8 oz glass skim milk (90Kcal; 1.5g fat)

500Kcal and 12.5g fatDinner:

1 ½ cup bow-tie pasta (240Kcal; 3gfat)2 1oz beef meatballs (200Kcal; 16g fat)¾ cup marinara (95Kcal; 0g fat)1 oz parmesan cheese – regular (100Kcal; 8g fat)2 breadsticks (160Kcal; 2g fat)

8 oz glass 2% milk (120Kcal; 5g fat)

915 Kcal and 34g fat

1 cup whole wheat pasta (160kcal; 2g fat)2oz grilled chicken breast (110Kcal; 6g fat)½ cup asparagus – steamed (25Kcal; 0g fat)1 oz red. Fat Kraft parmesan cheese (55kcal; 3g fat)1 breadstick (80Kcal; 1g fat)

8 oz glass skim milk (90Kcal; 1.5g fat)

520Kcal and 13.5g fatSnack:

1 oz plain cream cheese (100Kcal; 8g fat)1 plain bagel (160Kcal; 2g fat)

260Kcal and 10g fat

Snack:1oz low fat cream cheese (55Kcal; 3g fat)1 whole wheat bagel – 2halves (160Kcal; 1g fat)2Tbsp Jelly (60Kcal; 0g fat)

Snack:½ cup blueberries (60Kcal; 0g fat)½ cup raspberries (60Kcal; 0g fat)1/2 cup special K cereal (80Kcal; 1g fat)

Total: 475Kcal and 5g fat

Total Kcal: 3030KcalTotal g fat: 135g

Total Kcal: 2400KcalTotal g fat: 55.5g

Prognosis:

Assessment:

A: presence of gallstones; choledocholithiasis; cholecystectomy in 6-12 weeksB. No biochemical measuresC. BMI 33kg/m2 (categorizing as obese); height 5’8”; weight 218lbs; age 18yrsD. 50g fat restrictive diet; high fiber and increased fluid intake; increase consumption of fat-soluble vitamins and protein; obtain fat sources from mainly monounsaturated and omega-3’s (avoid saturated and trans fats)

Less than optimal intake of types of fats (NI-5.6.3) R/T food and nutrition knowledge deficit concerning type of fat and choledocholithiasis AEB patient 24-hour recall, frequent consumption of fats that are undesirable for condition, BMI > 30kg/m2 (BMI of 33kg/m2), obesity, and family history of gallstones.

Inadequate fiber intake (NI-5.8.5) R/T food- and nutrition related knowledge deficit concerning desirable quantities of fiber AEB patient 24-hour recall, diarrhea, and choledocholithiasis.

Increased nutrient needs of protein, fat-soluble vitamins and fiber (NI-5.1) R/T altered absorption of fat from cholecystectomy and comprise of organs related to GI function AEB diarrhea, choledocholithiasis and patient 24-hour recall.

Intervention:

Provide patient with a 50g fat restrictive diet (20% Kcal/d). Change diet, increasing fluid intake, fiber intake, protein intake, and fat-soluble vitamins. If unable to meet fat-soluble vitamin recommendations, may provide patient with supplement. Instruct patient on importance of increasing fiber intake gradually to avoid digestive discomfort. Instruct patient on methods of obtaining a well-balanced diet, achieving 4 servings of grains/cereals (most whole grains), 4 servings of non-starchy fruits and vegetables and at least 8 8oz glasses of water/fluid per day. Advise patient to keep a daily food-log.

Monitoring and Evaluation:

Provide patient with knowledge of maintaining a food-log. Have patient state foods that they should avoid and consume to see if they have obtained knowledge of the diet.

Works Cited

Academy of Nutrition and Dietetics. (2013). Standardized Language for the Nutrition Care Process:

Pocket Guide for International Dietetics & Nutritional Terminology (IDNT) Reference Manual

(Fourth ed.). Chicago, IL: Academy of Nutrition and Dietetics.

Adams, M. (2013, September). Fat-Restricted Diet. Retrieved March 19, 2014, from NYU Lagone Medical

Center website: http://www.med.nyu.edu/content?ChunkIID=196199

Fat-Soluble Vitamins: A, D, E, and K [PDF]. (n.d.). Retrieved from http://www.ext.colostate.edu/pubs/

foodnut/09315.pdf

Gallbladder Diseases. (n.d.). Retrieved March 19, 2014, from Medline Plus website: http://www.nlm.nih.gov/medlineplus/gallbladderdiseases.html

Gallstones and gallbladder disease. (2013, June 27). Retrieved March 19, 2014, from University of

Maryland Medical Center website: http://umm.edu/health/medical/reports/articles/

gallstones-and-gallbladder-disease

Good foods to help your digestion. (2012, June 21). Retrieved March 19, 2014, from NHS Choices

website: http://www.nhs.uk/Livewell/digestive- health/Pages/stomach- friendly-foods.aspx

Health Information: Health Facts for You [Cholecystectomy Home Care] [Fact sheet]. (2013, October

15). Retrieved March 19, 2014, from UW Health website: http://www.uwhealth.org/healthfacts/

surgery/4432.html

Low Fat Diet [Fact sheet]. (n.d.). Retrieved from Hartford Healthcare Medical Group website:

http://www.hartfordhealthcaremedicalgroup.org/ed_guide_lowfat.php

Mayo Clinic Staff. (2013, July 25). Gallstones. Retrieved March 19, 2014, from Mayo Clinic website:

http://www.mayoclinic.org/diseases-conditions/gallstones/basics/symptoms/con-20020461

My Daily Food Plan [PDF]. (n.d.). Retrieved from http://myplate.gov/food-groups/downloads/results/

MyDailyFoodPlan_2400_18plusyr.pdf

Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy for Ischemic Heart Disease. In Nutrition Therapy & Pathophysiology (2nd ed., p. 319). Belmont, CAL/USA: Wadsworth Cengage Learning.

Annelise ChmelikApril 24, 2014

KNH 413

Diet Instruction: Bland Diet

1. Description of Patient and Diagnosisa. Patient:

Client name: Anthony CiceroDOB: 2/15Age: 37Sex: MaleEducation: College Degree, Law DegreeOccupation: LawyerHours of work: 70 hours/weekHousehold members: Lives with his wife Rosanna age 34, son Michael age 7, and daughter Francesca age 3.Ethnic background: ItalianReligious affiliation: CatholicReferring physician: P. A. Rocco, MD

Chief complaint:“For about 6 weeks now I have had horrible abdominal pain and a pretty consistent burning sensation. My symptoms worsen every time I eat food, and are even worse at night. My wife said that I am not eating as much as I used to, and I tell her it is because I do not have much of an appetite.“

Patient history:Mr. Cicero is a 37-yo male lawyer, who recently was assigned a very important case. He has been working at the office at least 70 hours a week, and has been significantly stressed. A majority of his meals have been fast food because he does not have time to sit and eat a home cooked meal. Therefore, he has been picking up McDonalds or Chipotle on a regular basis since those restaurants are down the block from the firm he works at. Mrs. Cicero said that whenever he gets a chance to relax,

he indulges in a Scotch, sometimes two or three a night. Mrs. Cicero also noted that her husband has lost about 7 pounds in the last month. Onset of disease: 6 weeksMeds: Aspirin for occasional backachesSmoker: Yes. ½ pack per day

Anthropometric Data:Height: 5’10”Weight: 205 lbsVitals: Temp 97.6˚F, BP 135/90 mm Hg

Nutrition Hx:General: Appetite has been poor.

Usual dietary intake:Breakfast: Black coffee – 2 cups

McDonalds Breakfast BurritoLunch: Chipotle Burrito Bowl with white rice, steak, tomato salsa, corn salsa,

extra hot salsa, sour cream, cheese, and lettuceTortilla chips and guacamole 12 oz. Coca-Cola

PM snack: Black coffee – 2 cupsDinner: Spaghetti and Meatballs with a vodka cream sauce

Side salad with vinagrette dressingScotch on the rocks with lemon

HS snack: Slice of chocolate cake

24-hr recall:Breakfast: Black coffee – 2 cups

McDonalds Egg McMuffinMcDonalds Hasbrown

Lunch: No appetite/time for lunch, just a 12 oz. Coca-ColaPM Snack: Black coffeeDinner: 1 piece of Spicy Italian Sausage

Garlic breadHS Snack: 2 glasses of Scotch on the rocks with lemon

Food allergies/intolerances/aversions (specify): NonePrevious MNT? NoFood purchase/preparation: Self and wifeVit/min intake: NoneDiet order: Bland diet

Tx plan:Antibiotic to kill H. pylori

Proton Pump Inhibitor (PPI): suppresses acid production by halting the mechanism that pumps acid into the stomachNutrition consultation for education on Bland Diet, which will assist in the reduction or elimination of symptoms

b. Diagnosis:

After Dr. Rocco listened to his symptoms, stress, and intake of caffeine, alcohol, cigarettes, and high-fat foods, the physician decided to perform an endoscopy to determine if an ulcer was present. The endoscopy revealed a peptic ulcer. The physician also conducted a urea breath test to confirm the presence of H. pylori. Peptic ulcer disease involves ulcerations of the mucosa of the gastrointestinal tract and can occur in the esophagus, stomach, duodenum, and jejunum. This break in the mucosa results in a crater surrounded by an acute and chronic inflammatory cell infiltrate.

2. Discussion of Disease:a. Etiology:

An ulceration can develop in the following conditions: The stomach produces excess amounts of pepsin and acid The lining of the stomach or duodenum is impaired and is more

susceptible to damage from gastric acid and pepsinFactors that may affect the mucosal integrity include the following:

Helicobacter pylori infection: Helicobacter pylori bacteria commonly live in the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems, but it can cause inflammation of the stomach’s inner layer, producing an ulcer

Aspirin: aspirin or certain over-the-counter and prescription pain medications can irritate or inflame the lining of your stomach and small intestine.

Nonsteroidal, anti-inflammatory drugs Alcohol: alcohol can irritate and erode the mucous lining of your

stomach, and it increases the amount of stomach acid that is produced. Steroids

Factors that decrease the blood supply to the gastric or duodenal mucosa include the following:

Smoking Stress Injury

Factors that increase acid secretion include the following: Foods:

o Peppero Alcoholo Caffeine

Rapid gastric emptying

Stress Other conditions such as Zollinger-Ellison syndrome

b. Diagnostic Measures Tests for H. pylori:

o Blood: a blood sample is taken from the patient’s vein and tested for H. pylori antibodies

o Urea Breath Test: the patient swallows a capsule, liquid, or pudding that contains urea “labeled” with a special carbon atom. After a few minutes, the patient breathes into a container, exhaling carbon dioxide. If the carbon atom is found in the exhaled breath, H. pylori is present, as this bacterium contains large amounts of urease, a chemical that breaks urea down into carbon dioxide

o Stool: the patient provides a stool sample, which is tested for H. pylori antigens

Endoscopy of the gastrointestinal tracto During an endoscopy, the physician passes a hollow tube

equipped with a lens down the throat and into the esophagus, stomach, and small intestine. Using the endoscope, the physician will look for ulcers. If the doctor detects an ulcer, small tissue samples may be removed for examination in a lab. A biopsy can also identify the presence of H. pylori in the stomach lining

o A doctor is more likely to recommend endoscopy if the patient is older, having signs of bleeding, or have experienced recent weight loss or difficulty eating and swallowing.

X-ray of upper digestive systemo This procedure is sometimes called a barium swallow or upper

gastrointestinal series. This series of X-rays creates images of your esophagus, stomach, and small intestine. During the X-ray, the patient swallows a white liquid, containing barium, which coats the digestive tract and makes an ulcer more visible.

Tests to determine contributions from other conditions that may contribute to hypersecretion (Zollinger-Ellison Syndrome) include the following:

o Serum gastrino Secretin stimulation test

c. Treatment:i. Medical, surgical, and/or psychological treatment

The treatment for peptic ulcers depends on the cause. Treatments can include:

Antibiotic medications to eliminate H. pylori: if H. pylori is found within the digestive tract, the physician may recommend a combination of antibiotics to kill the bacterium

Medications that block acid production and promote healing: proton pump inhibitors reduce stomach acid by blocking the action of the

parts of cells that produce acid. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium), and pantoprazole (Protonix).

Medications to reduce acid production: Acid blockers – also called histamine (H-2) blockers – reduce the amount of stomach acid released into your digestive tract, which relieves ulcer pain and encourages healing. Available by prescription or over-the-counter, acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet), and nizatidine (Axid).

Antacids that neutralize stomach acid: antacids neutralize existing stomach acid and can provide rapid pain relief, but generally are not used to heal the ulcer.

Medications that protect the lining of your stomach and small intestine: in some cases, the physician may prescribe medications called cytoprotective agents that help protect the tissues that line your stomach and small intestine. Options include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol)

ii. Medical Nutrition Therapy treatment for clientNutrition therapy for peptic ulcer disease calls for the following:

Optimize nutritional intake to correct any deficiencies and to meet nutrition needs

Avoid foods that potentially increase gastric acid secretion or can damage the gastric mucosa

oAlcoholoPepperoCaffeineoTeaoCoffee (including non-caffeinated)oChocolate

Identify foods that directly irritate the gastric mucosa or are not individually tolerated

Avoid eating at least 2 hours before bedtimeBland Diet:

A bland diet is made up of foods that are soft, not very spicy, and low in fiber

Alcoholic and caffeinated beverages should be avoided Smoking should be ceased

iii. PrognosisTreatment for peptic ulcers is often successful, leading to ulcer healing. Along with the medication to kill the H. Pylori, the Bland diet will eliminate any stimulating, irritating, and seasoned products from the diet. It is crucial

to take the prescribed medications according to the directions, cease regular tobacco use, and discontinue use of pain relievers that increase the risk of ulcers to ensure that the ulcer heals properly.

3. Client Instruction Materials

The purpose of a bland diet is to alleviate the gastric distress the patient is having. Therefore, the foods included are limited to non-stimulating, non-irritating and mildly seasoned products. This diet should be well balanced and individualized according to the patient’s appetite and food tolerance. With time and recovery, the patient may be able to expand this diet to their individual tolerances.

The following recommendations may help provide some relief: Avoid alcohol, cigarette smoking, aspirin, and other non-steroidal anti-

inflammatory agents Avoid frequent meals and or bedtime snacks to prevent increased acid

secretion, unless you note you gain relief from certain foods. Foods and seasonings that stimulate gastric acid secretion such as caffeine,

black pepper, garlic, cloves, and chili powder should be limited Do not eat within two hours of bedtime, Omit any particular foods that cause discomfort. Eat a well-balanced diet that includes a variety of foods Cook by baking, boiling, broiling, roasting, stewing, microwaving or

creaming. Avoid frying

Usual dietary intake:Breakfast: Black coffee – 2 cups

McDonalds Breakfast BurritoLunch: Chipotle Burrito Bowl with white rice, steak, tomato salsa, corn salsa,

extra hot salsa, sour cream, cheese, and lettuceTortilla chips and guacamole 12 oz. Coca-Cola

PM snack: Black coffee – 2 cupsDinner: Spaghetti and Meatballs with a vodka cream sauce

Side salad with vinaigrette dressingScotch on the rocks with lemon

HS snack: Slice of chocolate cake

24-hr recall:Breakfast: Black coffee – 2 cups

McDonalds Egg McMuffinMcDonalds Hashbrown

Lunch: No appetite/time for lunch, just a 12 oz. Coca-ColaPM Snack: Black coffeeDinner: 1 piece of Spicy Italian Sausage

Garlic breadHS Snack: 2 glasses of Scotch on the rocks with lemon

Sample Meal Plan:

Meal Food ChoicesBreakfast ¾ cup of oatmeal

½ cup of canned peaches8 oz skim milk

Lunch Chipotle Burrito Bowl with white rice, chicken, cheese, and lettuce12 oz. Orange Juice

PM Snack Creamy peanut butter and crackers made with refined white flour

Dinner ½ cup Spaghetti with red sauce, grilled chicken

½ cup of cooked green beans½ cup of applesauce8 oz. skim milk8 oz. water

HS Snack ------

Client Instructions

Breakfast:

Exchange McDonalds Breakfast Burrito for oatmealExchange black coffee for skim milkInclude canned peaches

Lunch:

Eliminate tomato, corn, and hot salsaEliminate sour cream because of high fat contentEliminate the guacamole Eliminate Coca Cola for orange juice

PM Snack:

Eliminate coffee for waterInclude creamy peanut butter and crackers

Dinner:

Exchange spicy/processed meats, e.g. sausage for grilled chickenExchange vodka sauce for red sauceExchange side salad for cooked green beansInclude apple sauceEliminate garlic breadExchange scotch for skim milk

HS Snack:

Eliminate chocolate cakeEliminate scotch on the rocks

**Client should not consume any food stuff 2 hours prior to bed time

References:

Arizona Diet Manual. (1998). Bland Diet. Retrieved from http://web.squ.edu.om/med-lib/med_cd/e_cds/Griffith's%20Instructions%20Patients/pdf/Pg537.pdf

Dempsey DT & Harbison Sp. (2005). Peptic Ulcer Disease. 42(6): 346-454. http://www.ncbi.nlm.nih.gov/pubmed/15988415?dopt=Abstract

FDA Diet Manual. (2014). Bland Diet. Retrieved from http://www.medfusion.net/templates/groups/2328/3078/Bland%20Diet.pdf

Mayo Clinic. (2014). Peptic Ulcer. Retrieved from http://www.mayoclinic.org/diseases-conditions/peptic-ulcer/basics/prevention/con-20028643

MedlinePlus. (2014). Bland Diet. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000068.htm

Myrtue Medical Center. (2008). Bland Diet Peptic Ulcer. Retrieved from http://myrtuemedical.org/assets/pdf/dietary/bland-diet-for-peptic-ulcer.pdf

Nutrition Care Manual. (2014). Peptic Ulcer. Retrieved from http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145083&ncm_toc_id=20009&ncm_heading=Nutrition%20Care

UC Davis. (2014). Nutritional Management of Gastrointestinal Diseases. Retrieved from http://nutrition.vetmed.ucdavis.edu/client_info_sheets/gastrointestinal_disease.cfm

U.S. Department of Health and Human Services. (2014). H. pylori and Peptic Ulcers. Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/hpylori/index.aspx

University of Maryland Medical Center. (2014). Gastritis. Retrieved from http://umm.edu/health/medical/altmed/condition/gastritis

Kelsey Conrad

KNH 413 Spring 2014

Professor Matuszak

February 2, 2014

Diet Instruction: Celiac Disease

Patient and Diagnosis

The patient is a 22-year-old female collegiate tennis player at The Ohio State

University. At the age of 20, she sought medical treatment after experiencing several

bouts of gastrointestinal distress and was diagnosed with irritable bowel syndrome. Last

month, she began experiencing significant fatigue, joint pain, and muscle cramping.

These symptoms were initially attributed to the strenuous conditioning regimen that she

was participating in for her sport. When these symptoms did not subside and a skin rash

appeared she again sought medical treatment. She reported to the physician her diagnosis

of irritable bowel syndrome and, upon evaluation, the physician noted signs of

malnutrition. Due to all of these symptoms, he ordered a series of blood tests to identify

antibodies to gluten including anti-tissue transglutaminase (anti-tTG), endomysial IgA

(EMA), and anti-gliadin (AGA). The results of her tests were indicative of celiac disease

and the physician explained to her that the only current treatment for CD is nutrition

therapy consisting of a gluten-free diet. She was then referred to a registered dietitian to

educate her about a gluten-free diet and help aid her in adopting this new, challenging

diet.

Etiology

Celiac disease (CD) is an incredibly complex disease. Genetic, environmental,

and autoimmune factors triggered by the atypical reaction of the body to gluten

contribute to the etiology, but the exact cause of this condition is unknown (Nelms et al.,

2011). When an individual with this condition is exposed to the gliadin component of

gluten, the body produces an inflammatory response that results in damage to the

intestinal mucosa (Dugdale, 2012). The villi of the intestinal mucosa become shorter and

appear flat, resulting in reduced absorptive ability and malnutrition. Various

gastrointestinal symptoms are associated with CD, but other symptoms such as fatigue,

joint pain, depression, seizures, and skin rash also present themselves in CD patients

(Nelms et al., 2011). Because the symptoms of celiac disease vary person to person and

the GI symptoms of CD are common in various other conditions, the patient may initially

be misdiagnosed (Celiac Disease, 2011). Specific diagnostic criteria are being developed

and used to increase the rate of diagnosis. There is a genetic component associated with

the development of celiac disease. Additionally, women are more affected by this

condition than men (Celiac Disease, 2011).

Diagnostic Measures

The gold standard for diagnosing an individual with celiac disease is a biopsy of

the small intestine mucosa. This paired with subsequent indication of villous atrophy,

crypt hyperplasmia, andlymphocytic and plasma cell infiltration in the lamina propria

provides more evidence of the condition. Finally, the absence of symptoms upon the

removal of gluten from the diet results in diagnosis of CD. A more common diagnostic

measure is to perform blood tests to identify antibodies to gluten in the body. These

include anti-tissue transglutaminase (anti-tTG), endomysial IgA (EMA), and anti-gliadin

(AGA) with anti-tTG being the most commonly used to diagnose this disease (Nelms et

al., 2011). Genetic testing is also performed to identify individuals at a greater risk for its

development (Celiac Disease, 2012).

Treatment

There is currently no cure for celiac disease. There are no medical treatments or

surgical procedures that will cure this disease (Gluten Induced Conditions, 2011). The

only current treatment is medical nutrition therapy and the adoption of a gluten-free diet

(Understanding Celiac Disease, 2012). When gluten is removed from the diet, the

symptoms of the disease will subside and the villi of the intestinal mucosa will return to a

normal height and regular functionality (Celiac Disease Health Center, 2014). The

adoption of a gluten-free diet requires the individual to avoid all foods, beverages, and

medications that contain wheat, barley, rye, and possibly oats (Recommended Diet,

2012).

Individuals diagnosed with celiac disease should undergo nutrition assessment to

determine the extent of anthropometric changes and nutrient imbalances present. The

level of nutrition therapy administered to the patient depends on the condition of the

intestinal mucosa and the degree of malabsorption (Nelms et al., 2011). Typically, the

patient would be prescribed a gluten-free and lactose-free diet due to a lactase deficiency

commonly seen when the villi are damaged. As the villi regain their anatomical and

functional properties, lactose can slowly be added back into the diet (Nelms et al., 2011).

A gluten-free diet, however, is a life-long regimen. Individuals must be educated about

the food products and beverages containing gluten, as well as the medications, additives,

and ingredients that may contain gluten. Patients should be provided with a list of

allowed foods, foods to avoid, and foods to question. Educating the patient and

supporting the patient in this significant lifestyle change is crucial for the success and

health of the patient.

Being diagnosed with celiac disease as an athlete can be incredibly stressful.

Adopting a gluten-free diet while trying to compete at a high level can become very

complicated and challenging. Because of this, it is suggested that these athletes meet

with a registered dietitian as well as a sports psychologist (Mancini et al., 2011). Because

of the high demand for carbohydrate during athletic training, eliminating all sources of

wheat, rye, barley, and oats requires athletes to find alternative healthy sources of

carbohydrate to meet their energy needs. Some examples of these healthy sources of

carbohydrates include beans, rice, corn meal, corn flour, nuts, potatoes, tapioca, quinoa,

fruits, and vegetables. The athletes, coaches, and athletic training staff should all be

educated about the condition and what all it entails in order to best support the

individuals dealing with this condition. Another concern with individuals with celiac

disease is iron-deficiency anemia, and all athletes should be tested for this condition.

They should be advised to include iron-rich foods as a part of their gluten-free diet to

prevent complications associated with an iron deficiency. Additionally, vitamin D and

calcium deficiencies are commonly seen in individuals diagnosed with celiac disease.

Athletes, especially female athletes, should undergo assessment of bone mineral density

to identify these deficiencies and take measures to prevent injury during training.

Because celiac disease patients often experience lactose intolerance, athletes showing

signs of these deficiencies should add nondairy sources of calcium to the diet.

Multivitamin supplements, including vitamin D and calcium supplements are strongly

recommended for these athletes to resolve and prevent malnutrition and to ensure that

they are getting the nutrients they need to train and perform at their high level of

competition.

Prognosis

With the adoption of a gluten-free diet, the anatomy of the intestinal mucosa

returns to normal, malabsorption and maldigestion resolve, and the signs and symptoms

subside (Nelms et al., 2011). Unfortunately, some patients continue to experience

damage to the intestines despite the adoption of a gluten-free diet. This has been found to

be related to gluten contamination and cross-contamination, as well as the presence of

other diseases (Nelms et al., 2011). Most individuals, however, show significant

improvements with the restriction of gluten from the diet and can live essentially

symptom-free for a lifetime with the adoption of this lifestyle (Celiac Disease, 2013).

For athletes specifically, the adoption of a gluten-free diet may prevent some

additional challenges, but these athletes have the ability to perform at the highest level

despite the diet restrictions associated with this condition (Mancini et al., 2011). This

lifestyle change eliminates symptoms such as indigestion, abdominal pain, diarrhea, and

fatigue, improves energy levels during exercise, and helps to prevent complications such

as anemia, vitamin and mineral deficiencies, and bone mineral disturbances (Gluten

Sensitivity in Athletes, 2009). The elimination of these symptoms and the prevention of

these complications make athletic success possible for these individuals.

Celiac Disease Instruction Materials

The only treatment for celiac disease is the adoption of a gluten-free diet. The adoption

of this diet will alleviate symptoms associated with the condition and will allow the

intestines to regain their absorption and digestion ability. The principles of a gluten-free

diet include:

Avoid all foods made from or containing wheat, rye, and barley.

Avoid oats or only consume oats in small quantities.

Refer to food labels of processed foods because many of these products contain

gluten.

Beware of tablets, capsules, and vitamin products because many fillers in these

products contain gluten.

Avoid beer because it is made from barley.

If lactose intolerance is present, avoid milk and other dairy products that contain

lactose. Once the intestinal mucosa regains functionality, lactose intolerance may

no longer be a problem and lactose can be slowly added back to the diet.

Consume a daily multivitamin due to the vitamin and mineral deficiencies that

commonly result from the damage to the intestinal mucosa.

Supplement with iron, folic acid, vitamin B12, vitamin K, calcium, or vitamin D

if deficiencies are present.

Take measures to avoid gluten cross-contamination.

Understand the inconsistency in the amount of gluten allowed to be in foods

labeled “gluten free”.

(Gluten Free Diet, 2008)

Client 24-Hour Recall

Breakfast Lunch Dinner

2 Slices Whole Wheat

Toast

1 Medium Banana

1 Cup Skim Milk

1 Whole Wheat Bun

4 oz Luncheon Turkey

Lettuce

Tomato

1 Slice American Cheese

2 Tablespoons Mayo

1 Medium Apple

1 Cup Pretzels

¼ Cup Brown Rice

4 oz Marinated Chicken

Breast

1 Cup Fresh Broccoli

1 Medium Sweet Potato

Snacks/Miscellaneous

½ Cup Dry Roasted Peanuts

2 Beers

Reported Symptoms

Indigestion, abdominal pain, diarrhea, fatigue, joint pain, muscle cramping, skin

rash

Client Instructions

Breakfast:

Exchange whole-wheat toast for puffed rice cereal or grits

Exchange skim milk for lactose-free milk

Lunch:

Exchange whole-wheat bun for corn tortilla

Exchange luncheon meat for fresh meat

Exchange American cheese for cheddar or Swiss cheese

Ensure that the mayonnaise is pure

Exchange pretzels for popcorn

Dinner:

Use pure spices and herbs instead of marinade

Snacks/Miscellaneous:

Exchange dry-roasted nuts for raw nuts

Exchange beer for wine

Resources

Celiac Disease. (2011). In National Foundation for Celiac Awareness. Retrieved from

http://www.celiaccentral.org/Celiac-Disease/Diagnosis-Treatment/33/

Celiac Disease. (2012). In National Digestive Diseases Information Clearinghouse.

Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/index.aspx

Celiac Disease. (2013). In Celiac Disease Foundation. Retrieved from http://celiac.org/

Celiac Disease Educational Materials and Resources. (2013). In Celiac Disease

Awareness Campaign of the National Institutes of Health. Retrieved from

http://www.celiac.nih.gov/

Celiac Disease Health Center. (2014). In WebMD. Retrieved from

http://www.webmd.com/digestive-disorders/celiac-disease/celiac-disease

Dugdale, D.C. (2010). In MedlinePlus. Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/article/000233.htm

Gluten Free Diet. (2008). In Massachusetts General Hospital. Retrieved from

http://www.massgeneral.org/digestive/assets/pdf/gluten_free_diet.pdf

Gluten Induced Conditions. (2011). In Celiac Support Association. Retrieved from

http://www.csaceliacs.info/gluten_induced_conditions.jsp

Gluten Sensitivity in Athletes. (2009). In Sports, Cardiovascular, and Wellness Nutrition

(SCAN). Retrieved from http://www.scandpg.org/local/resources/files/2009/SD-

USA_Fact_Sheet_Gluten_Sensitivity_In_Athletes_Oct%2009.pdf

Mancini, L.A., Trojian, T., & Mancini, A.C. (2011). Celiac disease and the athlete.

Current Sports Medicine Reports (American College of Sports Medicine), 10(2),

105-108.

Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L. (2011). Nutrition therapy &

pathophysiology: Second edition. Belmont, CA: Wadsworth, Cengage Learning.

Recommended Diet. (2012). In American Celiac Society Dietary Support Coalition.

Retrieved from http://www.americanceliacsociety.org/index.html

Understanding Celiac Disease. (2012). In Academy of Nutrition and Dietetics. Retrieved

from http://www.eatright.org/Public/content.aspx?id=5542

Maria ChambersFebruary 27, 2014

Diet Instruction: Clear LiquidsPatient History

Josie is a 32-year-old female living in Chicago, Illinois. She’s 5’5” (165.1 cm) and weighs 250 lbs (113.64) with a BMI of 41.6 classifying her as obese. She has been overweight her whole life and has spent a good portion of it following fad diets and weight loss plans only to put the weight back on and even more than before her dieting. About one year ago after her last attempt to lose weight and putting on an additional 15 pounds, Josie made the decision to consult her doctor about bariatric surgery. She is currently on step nine of the ten-step program. The first step involves seeing if the patient qualifies for bariatric surgery. This includes having a BMI greater than 40, over 18 years of age, and overweight for more than 5 years. The patient should also make sure their insurance policy covers such surgery. The second step is to attend an information session. During the information session, the patient can meet the medical team and hear of a patient’s success story. The third step is to schedule and attend the first appointment. During this appointment patients can view an informational video about the procedure, meet the medical team, and have the medical history reviewed. A dietitian will speak with the patient about the patient’s current diet as well as how to improve the diet prior to the surgery. A set of goals will be given that must be met before the surgery. A psychologist will also meet with the patient to make sure there aren’t any mental health concerns that need to be treated prior to the surgery. The fourth step is to start an exercise program and lose some weight before surgery. The fifth step is to come to the preoperative appointments and complete preoperative testing. The sixth step is to meet with your surgeon. This is done once the appropriate changes in the patient’s eating and exercise behaviors are seen. This is when the appointment for the surgery will be assigned. The surgery will typically happen 2 months after the initial visit. The seventh step is to attend the pre-surgery skills groups and an optional support group. These classes help establish lifestyle changes. Step eight is to final pre-surgical appointments. During this appointment, the patient will meet with the dietitian speaking about how to prepare for the surgery, what will happen during the surgery and hospital stay, and postoperative recommendations (Lahey Hospital and Medical Center, 2014). This is the current meeting that we are in with Josie. During this meeting the dietitian will discuss a clear liquid diet for Josie after her operation.

Discussion of the diseaseObesity is seen to be the result of an imbalance of energy between the calories consumed and the calories expended. From a global perspective, there has been an increased intake of energy-dense foods that are high in fat. There has also been an increased amount of physical inactivity due to a multitude of reasons such as the sedentary nature of work, various modes of transportation, and increasing urbanization (WHO, 2013). Obesity contributes as a major risk factor for many diseases including cardiovascular diseases, diabetes, musculoskeletal disorders, and some cancers.

This disease can be prevented by having supportive environments and communities that can positively shape people’s lifestyle choices. This includes healthier foods and regular physical activity. Moreover, individuals can limit his or her intake of fats and sugars, increase consumption of fruits and vegetables, whole grains, and nuts, and participate in 150 minutes of physical activity per week (WHO, 2013).

Etiology Obesity is developed when more energy is consumed than is expended. Factors contributing to obesity include medical and psychiatric disorders, genetics, and an obesigenic environment. Medical disorders that can result in obesity include Cushing’s syndrome, hypothroidism, or Prader-Willi syndrome. Some pharmacological treatments can cause weight gain as well. Eating patterns that can contribute to obesity include night eating and binge eating. Genetics plays a role in obesity because it affects body weight and body composition by increasing appetite, taste preferences, energy intake, resting energy expenditure, the thermic effect of food, and the efficiency the body has in storing energy (Nelms, 2011). It remains to be difficult to differentiate the difference between genetics and the impact a person’s environment has on body weight. An obesigenic environment is described as that of low-cost energy dense foods and the availability of large portion sizes in North America (Nelms, 2011). A clear liquid diet is prescribed for patients right before a medical test or procedure, specific types of surgery, or if certain digestive problems have occurred (Medline Plus, 2012). It can also be recommended if certain digestive issues are present such as nausea, vomiting, or diarrhea (Mayo Clinic Staff, 2011). In this case, a clear liquid diet was prescribed for a post-bariatric surgery. A clear liquid diet is necessary to maintain vital body fluids, salts, and minerals. It can provide some of the necessary energy when normal and solid foods cannot be consumed. The reason this is recommended the day before surgery is because the body can easily absorb clear liquids. Clear liquids don’t stimulate the digestive system that normal foods would and therefore do not leave any residue in the intestinal tract (UCLA). They require very little digestion. A clear liquid diet does not provide adequate energy and nutrients and therefore should not be maintained for a long time unless high-protein gelatin and other low-residue supplements are consumed along with the clear liquids (Stanford). It should be limited to 24 to 48 hours unless supplements are added (Nelms, 2011).

Diagnostic Measures Obesity is classified as having a body mass index (BMI) of 30 kg/m2 or higher. This is calculated by dividing the body weight of the individual (kg) by the height (m2). Obesity is a risk factor for a multitude of health conditions including diabetes, cardiovascular diseases, and cancer (WHO, 2013).

Treatment Treatment for obesity includes assessment and management. The assessment portion includes calculating the person’s BMI, measuring the waist circumference of the individual, evaluating the person’s dietary and exercise habits, and also

determining the person’s readiness to lose weight. The management portion of treatment includes using therapies to lose and maintain weight loss and using the therapies to control disease risk factors. For some patients, pharmacologic treatment and bariatric surgery are appropriate (Nelms, 2011). Bariatric surgeries are recommended for those who have a BMI over 40 kg/m2 and have not lost weight by other less invasive ways. There are four different types of bariatric surgeries including adjustable gastric banding, vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch (Nelms, 2011).

Medical, surgical and/or psychological treatment Josie is getting the Roux-en-Y gastric bypass surgery (RYGB). This surgical treatment creates a small pouch located at the top of the stomach. This pouch restricts food intake, and induces satiety quickly. The food bypasses the remainder of the stomach, the duodenum, and the beginning part of the jejunum. With the bypassing of these parts, this reduces the amount of food digestion and nutrient absorption. The procedure will be performed laproscopically (Nelms, 2011).

Medical Nutrition Therapy After the bariatric surgery, Josie should be on a clear liquid diet for one to two days. From there she will have liquids or pureed foods for at least three to six weeks after the surgery. Soft food and then regular food will then be added slowly back into the diet at least one month after the surgery (Johns Hopkins Medicine Health Library). Today I will be instructing Josie on a clear liquid diet that she should consume for 24 to 48 hours after her surgery. Recommended clear liquids include: water, tea, or coffee (plan without milk or cream), strained fruit juices without pulp (lemonade and apple juice), soft drinks and sports drinks (ginger ale, Sprite, Gatorade), chicken/beef bouillon/broth – low sodium and fat free, gelatin (Jell-o – no fruit or toppings, stick with lemon, lime, or orange), popsicles (no fruit bars or sherbets), and hard candies (Stanford). The goal and suggested amount of fluid is around 2-4 ounces of fluid per hour totaling to 64 ounces per day (Saint Clares).

Avoid: anything with red or purple coloring –this can leave a residue that resembles blood in the bowel, no solid food, and no milk or milk products (Stanford Medicine, 2014).

Prognosis Josie’s clear liquid diet is intended to provide her with fluid and some energy without causing a lot of stimulation of the gastrointestinal tract. A full liquid diet is then prescribed which is a good transition between clear liquid and solid food. A full liquid diet includes all clear liquids, cream soups, milk, ice cream, pudding, and yogurt (Nelms, 2011). From this diet, Josie can progress on to soft foods and then normal foods. There is considered to be three phases after bariatric surgery in regard to nutrition therapy. The first phase is a clear liquid diet for the first 48 hours. The second phase is a full liquid diet. The patient should consume 3 to 4

ounces at one time over a 20 to 30 minute period and consume 3 meals each day. The third phase should take place about one month after the procedure and continue throughout the person’s life. This phase includes a solid food diet consisting of 3 to 4 ounces of low fat and low sugar choices (Saint Clares).

Instruction Materials

Foods Allowed Foods to avoidPlain water Avoid liquids or gelatin with red or

purple coloringFruit juices without pulp Dairy productsStrained lemonade or fruit punch **Anything not on the list should be

avoidedClear, fat-free brothClear sodasPlain gelatinHoneyIce pops (no bits of fruit or fruit pulp)Tea or coffee (no milk or cream)

ReferencesClear liquid diet guidelines (2014). Stanford Medicine. Retrieved from http://cancer.stanford.edu/surgery/colorectal/clearLiquidDiet.html

A clear liquid diet (N.D.). UCLA. Retrieved from http://pancreas.ucla.edu/workfiles/For_Patients/Clear_Liquid_Diet.pdf

Clear liquid diet (2014). Saint Vincent Health. Retrieved from http://www.saintvincenthealth.com/Services/Colon-and-Rectal-Surgery/Patient-Education/Clear-Liquid-Diet/Default.aspx

Diet-clear liquid (2012). Medline Plus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000205.htm

Gastric Banding Progression Diet (N.D.). Saint Clares. Retrieved from http://www.saintclares.org/assets/Uploads/Bariatrics_Images/Gastric-Banding-Progression-Diet-Booklet.pdf

Mayo Clinic Staff (2011). Clear liquid diet. Retrieved from http://www.mayoclinic.org/clear-liquid-diet/art-20048505?pg=1

Nelms, Sucher, Lacey, Long Roth. (2011). Nutrition Therapy & Pathophysiology. Belmont, CA: Brook/Cole Cengage Learning.

Roux-en-Y Gastric Bypass Weight-Loss Surgery | Johns Hopkins Medicine Health Library. (n.d.). Retrieved from http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/roux-en-y_gastric_bypass_weight-loss_surgery_135,65/

Step-by-step guide to surgical weight loss (2014). Lahey Hospital and Medical Center. Retrieved from http://www.lahey.org/Departments_and_Locations/Departments/Medical_and_Surgical_Weight_Loss_Center/Step-By-Step_Guide_to_Surgical_Weight_Loss.aspx

WHO: Obesity and overweight. (2013). Retrieved from http://www.who.int/mediacentre/factsheets/fs311/en/

Medical Nutrition Therapy Diet

1. Purposea. Nutrition indicators

Assessment by a registered dietitian is required to establish appropriate nutrient

and energy intake and to determine meal plans

b. Criteria to assign the DietTwo consecutive measurements of an A1C level of >7 or a fasting blood glucose of >126 is diagnosed as type 2 diabetes and meets the criteria for a diabetic diet involving regulation of carbohydrate consumption.

c. Rationale for DietMNT is recommended for individuals with Type 2 diabetes to instruct them in managing carbohydrate intake to maintain glycemic control. Individuals should also be presented with information on best types of carbohydrates, adequate intake of fiber, better fat choices and adding exercise. This information will help them control their blood sugar and alleviate potential diabetic complications such as neuropathy, retinopathy and cardiovascular disease.

2. Populationa. Overview

Type 2 diabetes accounts for 90-95% of all diagnosed diabetes cases. It is progressive disease. Symptoms develop gradually and may not be severe enough for the individual to recognize them as such. Individuals with Type 2 diabetes typically do not develop ketoacidosis, but are at risk for macrovascular and microvascular complications

Type 2 diabetes has a genetic predisposition and the risks increase with age, obesity and lack of physical activity. Typically, persons diagnosed are over 40, but it is currently being seen in young adults, adolescents and children

Type 2 diabetes has two major pathophysiological abnormalities: insulin resistance (associated with increased hepatic glucose production and reduced glucose clearance) and insulin deficiency (impaired beta cell secretion). Insulin resistance can be present many years before the development of diabetes, but as long as the beta cells of the pancreas can secrete adequate insulin, blood glucose will remain normal. Once the beta cells cannot produce adequate

insulin, insulin deficiency develops and hyperglycemia results. Therapy to lower blood glucose is required as soon as possible to prevent the negative effects of hyperglycemia on the body.

b. Disease Process

Type 2 diabetes results from a combination of insulin resistance and beta cell failure. Insulin levels may be depressed, normal or elevated, but are inadequate to overcome the decreased tissue responsiveness to insulin. This results in hyperglycemia. Hyperglycemia is first noted by an elevation of postprandial blood glucose and then by elevated fasting blood glucose levels. Insulin resistance is first seen in muscle and liver tissues and in fat cells. Initially, insulin levels increase to compensate for this resistance, but eventually, insulin production declines as the disease progresses. As insulin decreases and the cells are receiving less glucose, hepatic production of glucose increases which leads to hyperglycemia or glucotoxicity.

Insulin resistance is seen at the adipocyte level which can lead to lipolysis and elevated levels of free fatty acids in circulation. Increased free fatty acids can result in decreased insulin sensitivity, impaired pancreatic insulin secretion and increased hepatic glucose production. This results in a condition called lipotoxicity which arises from insulin resistance of the adipose cells.

Viscera, or abdominal fat, in particular, releases excessive free fatty acid. The increase in free fatty acid reduces glucose utilization by skeletal muscle, insulin secretion by the pancreas and increases glucose production in the liver.

c. Biochemical and Nutrient Needs

A client with Type 2 diabetes can consume a ‘normal’ diet, but must monitor carbohydrate intake to insure that it is even distributed throughout the day. The client should also consume less than 5% of their calories in saturated fats, choosing mono and poly unsaturated fats instead. The client may follow the standard 50-55% carbohydrate, 15-20% protein and 20-30% fat guidelines stated for a non diabetic population.

3. General Guidelinesa. Nutrition Rx

Determine individual energy needs, manage and schedule carbohydrate intake to maintain stable blood glucose levels, maintain or reduce weight and reduce risk of diabetic complications (especially hypertension and hyperlipidemia) while meeting nutritional DRI.

b. Adequacy of nutrition RxA diabetic diet is nutritionally sound, incorporating adequate energy, carbohydrates, fats, fiber and protein.

c. GoalsThe goals of the diabetic diet are :1) maintain blood glucose levels as close to normal as possible 2) maintain cardiovascular health 3) maintain or reduce weight 4) prevent diabetic complications 5) increase physical activity to improve health and assist with blood glucose management

d. Does it Meet DRIA carefully planned diabetic diet meets DRI.

4. Educational Material

Diabetes and Diet, http://www.eatright.org/Public/content.aspx?id=6813Eating Right with Diabetes, http://www.eatright.org/Public/content.aspx?id=10748What Can I eat? http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/

Tips for complianceUse a scale and measuring tools to insure that you are consuming the correct portion sizes!

5. Sample Menua. Foods Recommended

Although all foods can be part of a diabetic diet, whole grains, fresh fruits and vegetables, dairy and lean proteins are especially recommended to maintain healthy levels of blood glucose.

b. Foods to avoid

As with any diet, foods with high caloric content and little nutritional value should be avoided. Some examples of these would be regular soda, cakes and/or cookies and high fat, processed meats. These can be consumed occasionally if they are included in the carbohydrate count for the day.

c. Example of a meal planCarbohydrates should make up 50-55% of total calories. A diet of 1500 calories would consist of between 187g and 206g of carbohydrates. A carb unit is the equivalent of 15g of carbohydrates, so this is equivalent to between 12.5 and 13.75 carb units per day.

This is a sample menu based on 12.5 unitsMeal Amount Grams of

CarbohydrateCarb unit

High fiber breakfast cereal

1C 30 2

Skim milk 1C 12 1Banana ½ 15 1

LunchTurkey and Swiss sandwich

2 slices whole wheat bread2 oz turkey1oz low fat Swiss1T low fat mayo1t mustard

30

0000

2

0000

Carrot sticks, grape tomatoes, celeryLow fat ranch dressing

½ c each

2T

5

0

Free *

Large apple 1 30 2Skim milk 1C 12 1

DinnerButternut squash 1C 15 1Whole wheat dinner roll with margarine

1 small2t

15 1

Broccoli, steamed ½ C 5 Free*Tossed saladLow fat Italian dressing

1C1T

5 Free*

Baked Tilapia with lemon

3 oz 0 0

SnackFruit flavored fat free sugar free yogurt

6 oz 12 1

Total 186 13* 3 ‘free’ carb units is the equivalent of one carb unit.

6. Websitesa. Organizations with Websites

American Diabetes Association, http://www.diabetes.org/Academy of Nutrition and Dietetics, www.eatright.org

b. Government WebsitesNational Institutes of Health, Medline Plus; http://www.nlm.nih.gov/medlineplus/diabetes.htmlUS Department of Health and Human Services;http://diabetes.niddk.nih.gov/dm/pubs/overview/

7. Referencesa. Journal Articles References

Martins, M.R,; Ambrosio A.C.T,; Nery M.;Aquino, R dC,; Queiroz, M.S., 2014, Assessment guidance of carbohydrate counting method in patients with type 2 diagetes mellitus; Primary Care Diabetes, Volume 8, issue 1, p. 39-42

Kulkarni, K; 2005, Carbohydrate counting; a practical meal planning option for people with diabetes, Clinical Diabetes, Volume 23, issue 3 p. 120-124

Type 2 Diabetes, 2014, retrieved from Nutrition Care Manual, http://www.nutritioncaremanual.org

Zach Pfirrman

KNH 413

3/16/14

Diet Instruction: Burn Victim, High Protein Diet

Patient Description & Diagnosis:

Client's Name: Julian Dickens

DOB: February 4th, 1984 (30 y/o)

Sex: Male

Weight: 210 lb.

Height: 6' 1''

Occupation: Construction Worker

Julian was admitted to the UC Hospital Burn Center after suffering from severe

burns in a fire that started at the construction site he works at. Julian suffered

superficial partial-thickness and some deep partial-thickness burns to his legs,

calculated at 20% of his skin area. He has underwent procedures to clean, debride,

and dress his wounds. He also needed to have skin grafting done on a few areas

where he was severely burned. He is getting silver nitrate cream applied between

dressings to prevent infection. His doctor has placed Julian on a High Energy, High

Protein Diet. Julian has already had a discussion with a RD about the prescribed diet.

Diet Recall

Julian's latest calorie count is lower than it should be. He had taken in 125g of

protein, which is low for what he was prescribed to take in. Also his nitrogen

balance measurements show that his nitrogen losses have decreased since Julian's

admission, but nitrogen losses are indicating that Julian is not taking in enough

protein for proper wound healing.

Etiology:

Burns can result from many different sources, the most common being thermal

exposure, such as direct contact with a heat source like fire or steam. Other types of

burns include chemical, electrical, and radiation exposure. Chemical burns are

suffered when the skin comes in direct contact with and acidic or alkaline

substances. Electrical Burns occur when an electrical current passes through the

body, damaging the skin, muscles, and even bone. Sun burns would be considered a

radiation burn.

Diagnostic Measures:

Burn injuries are diagnosed by determining the extent of the burn injury. The extent

of the burn is measured with two factors: the depth of the burn and the Body

Surface Area (BSA) affected. The depth of the burn is characterized in four main

classifications: Superficial burns, Superficial Partial-thickness burns, Deep Partial-

thickness burns, and Full-thickness burns. Superficial burns are caused by very

short exposure to high heats that burn the top layer of the epidermis or can be

caused by long exposure to ultra-violet light, causing a sun burn. These types of

burns are painful, but heal within one week. Superficial Partial-thickness burns can

be caused by short exposures to extremely hot sources like fire of boiling water.

They are very painful and may produce blistering, weeping wounds. These tend to

heal within a 1-3 weeks. When Deep Partial-thickness burns occur, the epidermis

and some, if not most, of the dermis layer of skin is destroyed. This is usually not as

painful because of the destruction to nerve endings. Grafting may be required for

this type of burn and it takes usually 21+ days to recover from these burns. Full-

thickness burns destroy all layers of the skin and may do some damage to muscle,

organs, or bone. Skin grafting is almost always necessary and there is a severe risk

of contracture, which is when the burn scars thicken and tighten, preventing

movement.

The method of measuring the BSA affected is called the Rule of Nines. The

body is divided into sections that have a percentage value of nine or a derivative of

nine. The head and neck have a value of 9, measured by the front of the head at 4.5

and the back at 4.5. Each arm is valued at 9 with the front and back of each arm

having a value of 4.5. The chest and abdomen are scored separate, each having a

value of 9. Just the same, the upper and lower back have separate values of 9. The

genital area holds a value of 1. Each leg is scored with the front and back being 9, so

the legs total value is 36.

Protein catabolism declines with wound coverage and healing. Adequacy of

protein intake can be evaluated by following:

Wound healing of burn and donor sites

Adherence of skin grafts

Nitrogen balance

Treatment:

For severe burns, patients will go through procedures that keep the wound sites

clean to prevent the possibility of infection. Sometimes the top layers of skin are

destroyed in a burn, but the dead skin tissue remains attached the body. In these

cases, a procedure known as Debridement is done. Debridement is the medical and

manually removal of all the layers of dead skin from a burn area. When burns are

deep enough, such as in full-thickness burns, skin grafting becomes necessary. Skin

grafting is done by a piece of skin is surgically sewn over the burn after dead tissue

is removed. After such procedures, the application of topical agents such as silver

sulfadiazine cream and silver nitrate to prevent infection, followed by dressing the

wound with sterile dressings.

Medical Nutrition Therapy

First thing to do is to calculate Mr. Dickens' energy needs and from that we can find

out how much Protein he should be receiving. I decided to use the Curreri formula

which is specifically used to find the energy needs of burn victims.

The Curreri formula:

(25 kcal x kg of body weight) + (40 kcal x %TBSA)

25 x 95.5 + 40 x 20 = 3187.5 rounded to 3200 kcal/day

Burn victims should be receiving more protein than is usually prescribed to the

average patient because their wounds quickly sap any protein in the body. It has

been estimated that as much a 20% of body protein can be lost within the first two

weeks of a burn injury. It is recommended that a burn patient with severe burns

should receive 20-25% of total kilocalories in protein alone.

Protein:

3200kcal x 20-25% = 640-800kcal of PRO / 4kcal/g = 160-200g PRO/day

Julian's diet recall shows that he only took in 125g of protein. That is 35g under the

minimum amount he should be taking in. So my plan is to have a discussion with

him about how to ensure that he receives enough protein. I will have him receive his

normal 3 meals, but include two Ensure High Protein shakes, one between breakfast

and lunch, and one between lunch and dinner. This will boost his protein intake by

50g. I will also discuss with him what foods are the best sources of protein and how

to hide extra protein into his meals.

Prognosis

If we can get Julian to regularly take in 160-200g of protein a day, the nitrogen

losses would decrease which will optimize wound healing. By keeping up with this

diet he will better maintain weight and strength and should have a normal recovery.

Foods Recommended

Eat 3 meals and at least 3 snacks every day.

Include at least one of the following at each meal:

◦ Meat

◦ Eggs

◦ Peanut butter

◦ Tofu

◦ Dried beans

◦ Lentils

◦ Milk

◦ Yogurt

◦ Cheese

Eat a variety of fruits and vegetables.

Eat a variety of breads, cereals, pasta, potatoes, and rice.

Sample of a meal plan

Breakfast 2 well-cooked eggs (prepared any way)2 oz sausage1/2 cup yogurt12 cup banana

1 slice whole-wheat toast1 cup milk

Snack ½ cup nuts

Lunch

Tuna salad sandwich2 slices whole-wheat bread1/2 cup carrots1 peach1 cup milk

Snack 1/2 cup yogurt

Evening Meal

4 oz chicken breast1 medium potato1/2 cup mixed vegetables1 apple1 slice whole-wheat bread1/2 cup ice cream1 cup milk

Snack High Protein ShakeReferences

Burns. (2013, February 14). University of Maryland Medical Center. Retrieved March

19, 2014, from http://umm.edu/health/medical/altmed/condition/burns

Burns Part 2 (Early Excision of the Burn Wound) . (2011, November 4). Short Notes

in Plastic Surgery. Retrieved March 16, 2014, from

http://shortnotesinplasticsurgery.wordpress.com/2011/11/04/18-burns-

part-2-early-excision-of-the-burn-wound/

Burns: Nutrition Prescription. (n.d.). NCM Nutrition Care Manual eat right. Retrieved

March 17, 2014, from http://www.nutritioncaremanual.org/content.cfm?

ncm_content_id=92068&highlight=burns

Burns: Nutritional Considerations. (n.d.). NutritionMD.org ::. Retrieved March 16,

2014, from

http://www.nutritionmd.org/health_care_providers/integumentary/burns_

nutrition.html

Medical Student LC. (n.d.). Classification of Burn Depths. Retrieved March 16, 2014,

from http://www.medstudentlc.com/page.php?id=84

Nelms, M. N. (2011). Metabolic Stress and the Critically Ill. Nutrition therapy and

pathophysiology (2nd ed., pp. 692-696). Belmont, CA: Wadsworth, Cengage

Learning.

University of Rochester Medical Center. (n.d.). University of Rochester Medical

Center. Retrieved March 14, 2014, from

http://www.urmc.rochester.edu/Encyclopedia/Content.aspx?

ContentTypeID=90&ContentID=P01754

Ellen SwaryDiet Instruction: High-Iron DietMarch 13, 2014

Description of Patient and DiagnosisAllie is a 21 year-old female who is 5 feet 5 inches (165 cm) and weighs 124

pounds (56 kg). Allie is a college student who is active in her studies and loves to

run and has recently been diagnosed with iron deficient anemia due to her Celiac’s

Disease. Because she is always on the go, Allie tends to consume lots of pre-

packaged, fast-food meals and lacks fruits and vegetables in her diet.

Allie has recently been feeling very fatigued and occasionally is short of

breath, dizzy or has headaches. After doing a physical exam as well as running some

blood tests, her doctor found her hemoglobin level to be at 8.0 g/dL, indicating

moderate anemia, and a hematocrit level below 36%, which is an indicator of

anemia. Her doctor has referred her to a Registered Dietitian in order to help her

improve her eating habits and anemia status.

Discussion of the DiseaseA. Etiology- Causation or origination of disease

Anemia is a disease, which occurs when an individual’s blood does not have

enough healthy red blood cells. Anemia can be temporary, or long term, and can

range from mild to severe cases. This can occur in a few circumstances, including

when the body does not make enough red blood cells, bleeding causes loss of red

blood cells more quickly than the body can replace them, or when the body destroys

red blood cells.

Red blood cells are contained within hemoglobin, which is the red, iron-rich

protein that gives blood its red color. Hemoglobin allows red blood cells to carry

oxygen to the lungs and carry carbon dioxide from other parts of the body to the

lungs to be expelled from the body. In order for the body to make enough blood

cells, certain vitamins, minerals and nutrients are needed for proper function. Three

important vitamins and minerals to consider are iron, vitamin B12, and folic acid.

Essentially, without these three components, the body can’t effectively carry oxygen

throughout the body, making it difficult for individuals to live their daily life.

Individuals with Celiac’s Disease are prone to inflammation and damage to

the lining of the intestine, which can prevent the absorption of iron, vitamin B12 and

folic acid. Additionally, poor diet (where there is a lack of vegetables and fruits rich

in vitamins, minerals and iron) and blood loss (heavy menstrual periods) can also

contribute to symptoms of anemia.

B. Diagnostic Measures Suspicion of anemia may result due to general findings in a physical

examination and medical history, which may include tiring easily, pale skin and lips,

or a fast heartbeat. Additionally, it can be detected through medical examination and

blood tests that measure the concentration of hemoglobin and the number of red

blood cells. A complete blood count (CBC) should be conducted in order to measure

the red blood cells, white blood cells and platelets, this will include measurements of

hemoglobin, hematocrit and mean corpuscular volume, which can help indicate

whether a patient is anemic or not. Other blood tests can indicate the status of iron

levels, including the serum ferritin, serum iron, and total iron binding capacity,

which are also indicators for anemia. Below are the lab values summarized, which

would indicate an individual to be anemic:

Severity of anemia can be measured through hemoglobin levels:

Severity Hemoglobin Concentration

Mild Anemia 9.5-13.0 g/dL

Moderate Anemia 8.0-9.5 g/dL

Severe Anemia <8.0 g/dL

A diagnosis of anemia can be clarified if hematocrit levels fall below: 39% for adult men

36% for adult non-pregnant women

33% for adult pregnant women

The following chart summarizes iron levels that would be normal, but if lower or

higher may indicate anemia (depending on the specific type)

Test Level (for women)Serum Ferritin 12-150 ng/mL

High- hemolytic anemiaLow- iron deficient anemia

Serum Iron 60-170 mcg/dLHigh- hemolytic anemia or Vitamin B12Low- iron deficient anemia or anemia of

chronic diseaseTotal Iron Binding Capacity High- iron deficient anemia

Low- anemia of chronic disease

C. Treatment i. Medical, surgical and/or psychological treatment

The status of Allie’s anemia is not harmful enough for surgical treatment, but

medical treatment may be necessary. Oral iron supplements are often

recommended for anemic patients. Depending on the severity, age, and weight, the

doctor can prescribe a oral supplement in doses ranging from 60-200mg. Oral iron

supplementation is the best way to restore iron levels for people who are iron

deficient, but this should only be used when dietary measures have failed. In

extreme cases, procedures including blood transfusions and blood and marrow stem

cell transplants may be needed. Evaluating Allie’s diet and making adjustments

where necessary would be beneficial for beginning her treatment plan.

ii. Medical Nutrition Therapy Using a nutrient calculator while reviewing Allie’s 24-hour recall, it is evident

that she is lacking in her iron intake as well as her total caloric needs. With someone

who always on the go and busy in school, it is important that she consumes the right

balance of foods in order to receive the proper amount of calories on a daily basis.

The following calculations show Allie’s energy needs based on her height, weight,

age and activity level:

Harris Benedict:

Women: 655+ (9.56 x kg) + (1.85 x cm) – (4.68 x age)

655+ (9.56 x 56) + (1.85 x 165) – (4.68 x 21)

= 1400 kcalories

Physical Activity Level: 1.4

1400 x 1.4 = 2,000 kcalories

Additionally, it is recommended that someone Allie’s age should consume at

least 18 mg of iron daily in their diet. It is also important to consider that due to her

Celiac condition, consuming more than 18 mg of iron would be beneficial to Allie’s

health, due to complications with absorption of iron in relation to this disease.

Setting an initial goal of receiving 18 mg of iron through her diet would be helpful.

It is necessary for Allie to increase her consumption of fruits and vegetables

as well as consider combining certain food choices to optimize the iron absorption

for her body. While the RDA for someone’s Allie’s age is 18mg, consuming more iron

would be beneficial in her case. Iron overload would likely only be of concern if

supplementation were to be implemented into her daily intake. It is vital that Allie

learn some key factors that will influence the absorption of her iron, as well.

Meat proteins and vitamin C will improve the absorption of nonheme iron,

which is found in plant sources. Allie should get about 75mg or more of vitamin C

per day. To put that into perspective, 1 medium sized orange has about 70 mg of

vitamin C. Additionally, tannins, calcium, polyphenols and phytates (found in

legumes and whole grains) can decrease the absorption of nonheme iron. Heme iron

comes from animal sources, is more readily absorbed than nonheme, and is not

significantly affected by other foods in the diet.

24-Hour Recall2 scrambled eggs

Chobani Greek Yogurt

Mcdonald’s Chicken Nuggets

Mcdonald’s Medium French Fries

Gluten free penne pasta

Tomato Basil pasta sauce

Kashi Peanut Butter Granola Bar

Naked Strawberry Banana Fruit

Smoothie

Total Calories: 1,780 Kcalories

Total Iron: 3 grams

Assessment

Age: 21

Height: 165 centimeters

Weight: 56 kilograms

Previously diagnosed with Crohn’s Disease

Hemoglobin level to be at 8.0 g/dL - indicating moderate anemia

Hematocrit level below 36% (anemic)

Diagnosis

Inadequate iron intake related to food choices as evidence by 24-hour recall.

Inadequate energy intake related to food choices as evidence by a 24-hour

recall.

Intervention

Goal: Increase iron intake to a minimum of 18 grams (RDA) by incorporating

iron rich foods into the client’s diet. Educate them on good food

combinations and food choices to allow for proper iron intake and

absorption.

Goal: Increase caloric intake to around 2000 kcalories per day and balance of

nutrients to allow for adequate energy needs. Educate the client on proper

caloric needs and provide menu ideas.

Monitor & Evaluate

Monitor client compliance with new food suggestions and evaluate changes

in energy level. Continue regular check-ups in order to assess whether

adjustments in the diet or oral supplements are necessary.

iii. Prognosis

Although the outcome of anemia depends on the cause, if treated and cared

for appropriately through diet and supplementation, if necessary, then the outcomes

are likely to be good. In Allie’s case, however, other complications may result due to

her status of Celiac’s Disease.

References

Anemia and Iron-rich Foods. (2010, May). Retrieved from http://my.clevelandclinic.org/disorders/anemia/hic-anemia-and-iron-rich-

foods.aspx

Anemia : Diagnostic Procedures | Florida Hospital. (2013). Retrieved from https://www.floridahospital.com/anemia/diagnostic-procedures

Anemia: MedlinePlus Medical Encyclopedia. (2011). Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000560.htm

Anemia | University of Maryland Medical Center. (2013, September 18). Retrieved from http://umm.edu/health/medical/reports/articles/anemia

Celiac disease - sprue: MedlinePlus Medical Encyclopedia. (2012, February 19). Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/article/000233.htm

Dietary Supplement Fact Sheet: Iron — Health Professional Fact Sheet. (2007, August 24). Retrieved from http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/

Iron deficiency anemia: MedlinePlus Medical Encyclopedia. (2013, March 3). Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/article/000584.htm

Nahikian-Nelms, M. (2011). Nutrition therapy and pathophysiology. Belmont, CA: Wadsworth, Cengage Learning.

Vitamin C — Health Professional Fact Sheet. (2013, June). Retrieved from http://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/#h2

What Are the Signs and Symptoms of Anemia? - NHLBI, NIH. (2012, May 18). Retrieved from

http://www.nhlbi.nih.gov/health/health-topics/topics/anemia/signs.html

Good Sources of Iron

Good Heme Sources: animal sources that are better absorbed in the body Beef (chuck roast, lean ground beef) Turkey Tuna Eggs Shrimp Lamb

Good Nonheme Sources (from plants): Cereals (check labels for enrichment) Beans (kidney, lima, Navy) Tofu Lentils Spinach Quinoa Peanut butter Brown rice Dried Fruit Beans: White, Lima, Soy

Combining nonheme iron sources with a source of vitamin C will help with

absorption, for example, it would be good to consume an orange at breakfast with

iron fortified breakfast cereal.

Good Sources of Vitamin C

Citrus fruit: oranges, grapefruit, Clementine’s

Kiwi Canataloupe Orange Juice Green & Red Peppers Strawberries Broccoli Tomato juice Spinach (cooked)

Additional education on reading a nutrition facts panel may also be helpful

for Allie to monitor the amount of calories she is consuming and knowing the iron

content of some of her foods. An example nutrition facts panel (below) could be

used for demonstration:

Rachael HuntKNH 413Diet Instruction

Weight Reduction

Patient:Patient: G.MAge: 36Sex: femaleWeight: 183Ht: 5’3’Occupation: receptionist

Medical Concerns: Obesity, SOB, sleep apnea, HTN, BMI 36

Diagnosis: Obesity Stage 2 as evidence by B=36

24-hour recall:Breakfast- 3 pieces of French toast with butter 2 tablespoons maple syrup3 sausage patties½ cup hash browns1 cup coffee with ½ cup 2% milk 1 cup orange juice

Lunch- 2 grilled cheese sandwiches made with 4 slices of white bread and ½ cup shredded cheddar 12-ounce coca-cola½ cup chocolate ice cream

Snack- 2 peanut butter sandwiches1-cup water

Dinner- Fried chicken (2 thighs an 1 leg)½ cup Mac and cheese1 baked potato with 1-tablespoon butter2 sweet rolls with butter1-cup water

Snack- 1/3-cup popcorn and 5 Oreo cookies1 cup 2% milk

Calories: 3,000kcalsFat: 120gProtein: 115g

Etiology:

Although there are genetic and hormonal influences on body weight, obesity occurs when you take in more calories than you burn through exercise and normal daily activities. Your body stores these excess calories as fat. Obesity usually results from a combination of causes and contributing factors, including:

Inactivity. If you're not very active, you don't burn as many calories. With a sedentary lifestyle, you can easily take in more calories every day than you use through exercise and normal daily activities.

Unhealthy diet and eating habits. Having a diet that's high in calories, eating fast food, skipping breakfast, eating most of your calories at night, drinking high-calorie beverages and eating oversized portions all contribute to weight gain.

Pregnancy. During pregnancy, a woman's weight necessarily increases. Some women find this weight difficult to lose after the baby is born. This weight gain may contribute to the development of obesity in women.

Lack of sleep. Getting less than seven hours of sleep a night can cause changes in hormones that increase your appetite. You may also crave foods high in calories and carbohydrates, which can contribute to weight gain.

Certain medications. Some medications can lead to weight gain if you don't compensate through diet or activity. These medications include some antidepressants, anti-seizure medications, diabetes medications, antipsychotic medications, steroids and beta-blockers.

Medical problems. Obesity can sometimes be traced to a medical cause, such as Prader-Willi syndrome, Cushing's syndrome, polycystic ovary

syndrome, and other diseases and conditions. Some medical problems, such as arthritis, can lead to decreased activity, which may result in weight gain. A low metabolism is unlikely to cause obesity, as is having low thyroid function.

Risk Factors:Obesity occurs when you eat and drink more calories than you burn through exercise and normal daily activities. Your body stores these extra calories as fat. Obesity usually results from a combination of causes and contributing factors, including:

Genetics. Your genes may affect the amount of body fat you store and where that fat is distributed. Genetics may also play a role in how efficiently your body converts food into energy and how your body burns calories during exercise. Even when someone has a genetic predisposition, environmental factors ultimately make you gain more weight.

Inactivity. If you're not very active, you don't burn as many calories. With a sedentary lifestyle, you can easily take in more calories every day than you burn off through exercise and normal daily activities.

Unhealthy diet and eating habits. Having a diet that's high in calories, eating fast food, skipping breakfast, consuming high-calorie drinks and eating oversized portions all contribute to weight gain.

Family lifestyle. Obesity tends to run in families. That's not just because of genetics. Family members tend to have similar eating, lifestyle and activity habits. If one or both of your parents are obese, your risk of being obese is increased.

Quitting smoking. Quitting smoking is often associated with weight gain. And for some, it can lead to a weight gain of as much as several pounds a week for several months, which can result in obesity. In the long run, however, quitting smoking is still a greater benefit to your health than continuing to smoke.

Pregnancy. During pregnancy a woman's weight necessarily increases. Some women find this weight difficult to lose after the baby is born. This weight gain may contribute to the development of obesity in women.

Lack of sleep. Not getting enough sleep at night can cause changes in hormones that increase your appetite. You may also crave foods high in calories and carbohydrates, which can contribute to weight gain.

Certain medications. Some medications can lead to weight gain if you don't compensate through diet or activity. These medications include some antidepressants, anti-seizure medications, diabetes medications, antipsychotic medications, steroids and beta-blockers.

Age. Obesity can occur at any age, even in young children. But as you age, hormonal changes and a less active lifestyle increase your risk of obesity. In addition, the amount of muscle in your body tends to decrease with age. This lower muscle mass leads to a decrease in metabolism. These changes also reduce calorie needs and can make it harder to keep off excess weight. If you don't control what you eat as you age, you'll likely gain weight.

Social and economic issues. Certain social and economic issues may be linked to obesity. You may not have safe areas to exercise, you may not have been taught healthy ways of cooking, or you may not have money to buy healthier foods. In addition, the people you spend time with may influence your weight — you're more likely to become obese if you have obese friends or relatives.

Medical problems. Obesity can rarely be traced to a medical cause, such as Prader-Willi syndrome, Cushing's syndrome, polycystic ovary syndrome, and other diseases and conditions. Some medical problems, such as arthritis, can lead to decreased activity, which may result in weight gain. A low metabolism is unlikely to cause obesity, as is having low thyroid function.

Even if you have one or more of these risk factors, it doesn't mean that you're destined to become obese. You can counteract most risk factors through diet, physical activity and exercise, and behavior changes.

Complications:

With obesity, you're more likely to develop a number of potentially serious health problems, including:

High cholesterol and triglycerides Type 2 diabetes High blood pressure Metabolic syndrome — a combination of high blood sugar, high blood

pressure, high triglycerides and high cholesterol Heart disease Stroke Cancer, including cancer of the uterus, cervix, ovaries, breast, colon, rectum

and prostate Sleep apnea, a potentially serious sleep disorder in which breathing

repeatedly stops and starts Depression Gallbladder disease Gynecologic problems, such as infertility and irregular periods Erectile dysfunction and sexual health issues, due to deposits of fat blocking

or narrowing the arteries to the genitals Nonalcoholic fatty liver disease, a condition in which fat builds up in the liver

and can cause inflammation or scarring Osteoarthritis Skin problems, such as poor wound healing Depression Disability Physical discomfort Sexual problems Shame

Social isolation

Diagnostic Measures:

These exams and tests generally include: Taking your health history. Your doctor may review your weight history,

weight-loss efforts, exercise habits, eating patterns, what other conditions you've had, medications, stress levels and other issues about your health. Your doctor may also review your family's health history to see if you may be predisposed to certain conditions.

Checking for other health problems. If you have known health problems, your doctor will evaluate them. Your doctor will also check for other possible health problems in the examination and laboratory tests, such as high blood pressure and diabetes.

Calculating your BMI. Your doctor will check your body mass index (BMI) to determine your level of obesity. Your BMI also helps determine your overall health risk and what treatment may be appropriate.

Measuring your waist circumference. Fat stored around your waist, sometimes called visceral fat or abdominal fat, may further increase your risk of diseases such as diabetes and heart disease. Women with a waist measurement (circumference) of more than 35 inches and men with a waist measurement of more than 40 inches may have more health risks than do people with smaller waist measurements.

A general physical exam. This includes measuring your height, checking vital signs, such as heart rate, blood pressure and temperature, listening to your heart and lungs, and examining your abdomen.

Blood tests. What tests you have depend on your health and risk factors. They may include a cholesterol test, liver function tests, fasting glucose, a thyroid test and others, depending on your health situation. Your doctor may also recommend certain heart tests, such as an electrocardiogram.

Gathering all this information helps you and your doctor determine how much weight you need to lose and what health conditions or risks you have. And this will shape what treatment options are right for you.

Treatments:

You can start feeling better and seeing improvements in your health by just introducing better eating and activity habits. The initial goal is a modest weight loss — 5 to 10 percent of your total weight. That means that if you weigh 200 pounds (91 kg) and are obese by BMI standards, you would need to lose only about 10 to 20 pounds (4.5 to 9.1 kg) to start seeing benefits. All weight-loss programs require changes in your eating habits and increased physical activity. The treatment methods those are right for you depend on your level of obesity, your overall health and your willingness to participate in your weight-loss plan. Other treatment tools include:

Dietary changes

Exercise and activity Behavior change Prescription weight-loss medications Weight-loss surgery

Dietary changesReducing calories and eating healthier are vital to overcoming obesity. Although you may lose weight quickly at first, slow and steady weight loss of 1 or 2 pounds (1/2 to 1 kilogram) a week over the long term is considered the safest way to lose weight and the best way to keep it off permanently. Avoid drastic and unrealistic diet changes, such as crash diets, because they're unlikely to help you keep excess weight off for the long term. Dietary ways to overcome obesity include:

A low-calorie diet. The key to weight loss is reducing how many calories you take in. You and your health care providers can review your typical eating and drinking habits to see how many calories you normally consume and where you can cut back. You and your doctor can decide how many calories you need to take in each day to lose weight, but a typical amount is 1,000 to 1,600 calories.

Feeling full on less. The concept of energy density can help you satisfy your hunger with fewer calories. All foods have a certain number of calories within a given amount (volume). Some foods, such as desserts, candies, fats and processed foods, are high in energy density. This means that a small volume of that food has a large number of calories. In contrast, other foods, such as fruits and vegetables, have low energy density. These foods provide a larger portion size with a fewer number of calories. By eating larger portions of foods less packed with calories, you reduce hunger pangs, take in fewer calories and feel better about your meal, which contributes to how satisfied you feel overall.

Adopting a healthy-eating plan. To make your overall diet healthier, eat more plant-based foods, such as fruits, vegetables and whole-grain carbohydrates. Also emphasize lean sources of protein, such as beans, lentils and soy, and lean meats. Try to include fish twice a week. Limit salt and added sugar. Stick with low-fat dairy products. Eat small amounts of fats, and make sure they come from heart-healthy sources, such as nuts and olive, canola and nut oils.

Meal replacements. These plans suggest that you replace one or two meals with their products — such as low-calorie shakes or meal bars — and eat healthy snacks and a healthy, balanced third meal that's low in fat and calories. In the short term, this type of diet can help you lose weight. Keep in mind that these diets likely won't teach you how to change your overall lifestyle, though, so you may have to keep this up if you want to keep your weight off.

Be wary of quick fixes. You may be tempted by fad diets that promise fast and easy weight loss. The reality, however, is that there are no magic foods or quick fixes. Fad diets may help in the short term, but the long-term results don't appear to be any better than other diets. Similarly, you may lose weight

on a crash diet, but you're likely to regain it when you stop the diet. To lose weight — and keep it off — you have to adopt healthy-eating habits that you can maintain over time.

Exercise and activity:Increased physical activity or exercise also is an essential part of obesity treatment. Most people who are able to maintain their weight loss for more than a year get regular exercise, even simply walking. To boost your activity level:

Exercise. The American College of Sports Medicine recommends that people who are overweight or obese get at least 150 minutes a week of moderate-intensity physical activity to prevent further weight gain or to lose a modest amount of weight. But to achieve significant weight loss, you may need to get as much as 250 to 300 minutes of exercise a week. You probably will need to gradually increase the amount you exercise as your endurance and fitness improve. To make your own exercise goal more doable, break it up into several sessions throughout the day, doing just five or six minutes at a time.

Increase your daily activity. Even though regular aerobic exercise is the most efficient way to burn calories and shed excess weight, any extra movement helps burn calories. Making simple changes throughout your day can add up to big benefits. Park farther from store entrances, rev up your household chores, garden, get up and move around periodically, and wear a pedometer to track how many steps you actually take over the course of a day.

Behavior changes:A behavior modification program can help you make lifestyle changes, lose weight and keep it off. Steps to take include examining your current habits to find out what factors, stresses or situations may have contributed to your obesity. Behavior modification, sometimes called behavior therapy, can include:

Counseling. Therapy or interventions with trained mental health or other professionals can help you address emotional and behavioral issues related to eating. Therapy can help you understand why you overeat and learn healthy ways to cope with anxiety. You can also learn how to monitor your diet and activity, understand eating triggers, and cope with food cravings. Counseling may be available by telephone, email or Internet-based programs if travel is difficult. Therapy can take place on both an individual and group basis.

Support groups. You can find camaraderie and understanding in support groups where others share similar challenges with obesity. Check with your doctor, local hospitals or commercial weight-loss programs for support groups in your area, such as Weight Watchers.

Prescription weight-loss medication:Losing weight requires a healthy diet and regular exercise. But in certain situations, prescription weight-loss medication may help. Keep in mind, though, that weight-loss medication is meant to be used along with diet, exercise and behavior changes, not instead of them. If you don't make these other changes in your life, medication is unlikely to work.

Your doctor may recommend weight-loss medication if other methods of weight loss haven't worked for you and you meet one of the following criteria:

Other methods of weight loss haven't worked for you Your body mass index (BMI) is 30 or greater Your body mass index (BMI) is greater than 27 and you also have medical

complications of obesity, such as diabetes, high blood pressure or sleep apnea

Examples of Prescription weight-loss medications your doctor may prescribe include:

Orlistat (Xenical). Orlistat is a weight-loss medication that has been approved by the Food and Drug Administration (FDA) for long-term use in adults and children 12 and older. This medication blocks the digestion and absorption of fat in your stomach and intestines. Unabsorbed fat is eliminated in the stool. Average weight loss with orlistat is about 5 to 7 pounds (2.3 to 3.2 kilograms) more than you can get from diet and exercise after one or two years of taking the medication. Side effects associated with orlistat include oily and frequent bowel movements, bowel urgency, and gas. These side effects can be minimized as you reduce fat in your diet. Because orlistat blocks absorption of some nutrients, take a multivitamin while taking orlistat to prevent nutritional deficiencies. The FDA has also approved a reduced-strength version of orlistat (Alli) that's sold over-the-counter, without a prescription. Alli is not approved for children. This medication works the same as prescription-strength orlistat and is meant only to supplement — not replace — a healthy diet and regular exercise.

Lorcaserin (Belviq). Lorcaserin is a long-term weight-loss drug approved by the FDA for adults in 2012. It works by affecting chemicals in your brain that help decrease your appetite and make you feel full, so you eat less. Your doctor will carefully monitor your weight loss while taking lorcaserin. If you don't lose about 5 percent of your total body weight within 12 weeks of taking lorcaserin, it's unlikely the drug will work for you and the medication should be stopped. Side effects of lorcaserin include headaches, dizziness, fatigue, nausea, dry mouth and constipation. Rare but serious side effects include a chemical imbalance (serotonin syndrome), suicidal thoughts, psychiatric problems, and problems with memory or comprehension. Pregnant women shouldn't take lorcaserin.

Phentermine-topiramate (Qsymia). This weight-loss medication is a combination drug approved by the FDA for long-term use in adults. Qsymia combines phentermine, a weight-loss drug prescribed for short-term use, with topiramate, a medication that's used to control seizures. Your doctor will monitor your weight loss while taking the drug. If you don't lose at least 3 percent of your body weight within 12 weeks of starting treatment, your doctor may suggest either stopping use of Qsymia or increasing your dose, depending on your condition.

Side effects include increased heart rate, tingling of hands and feet, insomnia, dizziness, dry mouth and constipation. Serious but rare side effects include suicidal thoughts, problems with memory or comprehension, sleep disorders and changes to your vision. Pregnant women shouldn't take Qsymia. Qsymia increases the risk of birth defects.

Phentermine (Adipex-P, Suprenza). Phentermine is a weight-loss medication for short-term use (three months) in adults. Using weight-loss medications short-term doesn't usually lead to long-term weight loss. While some health care providers prescribe phentermine for long-term use, few studies have evaluated its safety and weight-loss results long term.

Weight-loss surgeryIn some cases, weight-loss surgery, also called bariatric surgery, is an option. Weight-loss surgery offers the best chance of losing the most weight, but it can pose serious risks. Weight-loss surgery limits the amount of food you're able to comfortably eat or decreases the absorption of food and calories, or both. Weight-loss surgery for obesity may be considered if:

You have extreme obesity, with a body mass index (BMI) of 40 or higher Your BMI is 35 to 39.9, and you also have a serious weight-related health

problem, such as diabetes or high blood pressure You're committed to making the lifestyle changes that are necessary for

surgery to work Weight-loss surgery can often help you lose as much as 50 percent or more of your excess body weight. But weight-loss surgery isn't a miracle obesity cure. It doesn't guarantee that you'll lose all of your excess weight or that you'll keep it off long term. Weight-loss success after surgery depends on your commitment to making lifelong changes in your eating and exercise habits. Common weight-loss surgeries include:

Gastric bypass surgery. This is the favored weight-loss surgery in the United States because it has shown relatively good long-term results. In gastric bypass (Roux-en-Y gastric bypass), the surgeon creates a small pouch at the top of your stomach. The small intestine is then cut a short distance below the main stomach and connected to the new pouch. Food and liquid flow directly from the pouch into this part of the intestine, bypassing most of your stomach.

Laparoscopic adjustable gastric banding (LAGB). In this procedure, your stomach is separated into two pouches with an inflatable band. Pulling the band tight, like a belt, the surgeon creates a tiny channel between the two pouches. The band keeps the opening from expanding and is generally designed to stay in place permanently. LAGB is popular because it is less invasive, generally causes slow, steady weight loss and the band can be adjusted if needed. However, as with other procedures, this won't work without changes in your behavior. Results are usually not as good as with other procedures. The LAP-BAND gastric banding device has also been approved for use in people who have a BMI of 30 to 34 and have an additional health condition related to their obesity.

Gastric sleeve. In this procedure, part of the stomach is removed, creating a smaller reservoir for food. There are ongoing studies evaluating this procedure.

Biliopancreatic diversion with duodenal switch. In this procedure, most of your stomach is surgically removed. This weight-loss surgery offers sustained weight loss, but it poses a greater risk of malnutrition and vitamin deficiencies, and you require close monitoring for health problems. It's generally used for people who have a body mass index of 50 or more.

Medical Nutrition Therapy:Pt ideal weight: 115lbsPt. TER: 1,400-1,500kcals/dayStart pt. at 2,000kcals/day once pt. is adjusted to new diet begin finals goal of 1,500kcal/day diet.50-60g Protein a dayRecommend 30 min a day of low impact activity like walking. Pt. nutrition education resources provided

Menu Adjustments:

2,000- meal plan provided1,500-meal plan provided

Patient Resources:

United States Department of Agriculturehttp://www.usda.gov/wps/portal/usda/usdahome

Center For Disease Controlhttp://www.cdc.gov/obesity/

Obesity Action Coalitionhttp://www.obesityaction.org

Ohio Obesity and/or Health and Nutrition ProgramsOhio Department of HealthBureau of Healthy Ohio246 North High Street, 8th FloorColumbus, OH 43215Phone: 614-466-2144Fax: 614-564-2409healthyohioprogram.org/

Ohio Vocational Rehabilitation ProgramThe Ohio Rehabilitation Services Commission400 E. Campus View BlvdColumbus, OH 43235-4604Phone: 1-800-282-4536www.rsc.ohio.gov

Lauren Arnett2-20-14

Diet Instruction

Discussion of the Disease:Dysphagia is the difficulty of swallowing. This is a problem with the throat or esophagus and the muscular tube moving food and liquids from the back of the mouth to the stomach. This is most likely to occur in older adults and babies who have brain or nervous system problems. Dysphagia is characterized by regular difficulty swallowing and not just once or twice. There may be pain associated as well as food getting stuck in through or chest, drooling, hoarseness, regurgitation, frequent heartburn, weight loss, and coughing or gagging. For the regular difficulty swallowing a person should go and see their doctor, and if there is an obstruction interfering with breathing than emergency help is needed. Swallowing is made up of 50 pairs of muscles and nerves that accomplish this act and there are many issues that can cause this not to function properly. Reasons for this muscular tube not working properly include a stroke, brain or spinal cord injury, muscular dystrophy, immune system problem causing swelling or weakness, esophageal spasm, or scleroderma. Another reason for swallowing difficulty is that something is blocking this area. This includes GERD, esophagitis, diverticula, esophageal tumors and lymph nodes pressing on he esophagus.

Tests that will be conducted at the doctors include a barium x-ray to give a better visual of muscular activity. A dynamic swallowing study may occur where a person will swallow food at different consistencies coated with barium to see how certain foods are traveling. An endoscopy which is an instrument that passes down the throat to view the esophagus as well as an esophageal muscle test which is inserted into the esophagus to measure muscle contractions during swallowing.

Treatment:Treatment depends on the type or cause of difficult swallowing. Options include a swallowing therapist to provide certain exercises that will stimulate the nerves, and learning new ways to make swallowing easier by place food in certain positions. Other treatments include esophageal dilation, surgery and medications. Severe dysphagia leads to special liquid diets and tube feeding. Support groups are very important to help the client from feeling lonely. Talking about how they feel throughout there daily activities and expressing concerns as well as solving problems together. Making the eating experience enjoyable is very important. A general therapist may be a good idea to allow the client to open up about this problem.

Medical Nutrition Therapy:Lily will be put on a diet following the level 2 recommendations for food intake. This is a diet that allows for mechanically altered food through blending, chopping, grinding or mashing to consume food more easily. She is consuming a lot of hard to eat items such as thin liquids, chunky additives and dry food products. Moistening foods and making substitutions to her current meal choices will help her as well as her continuation of Swallowing therapy. Training the muscles to allow for initial swallowing function to occur as well as using tips such as eating slowly, small bites, in an environment that is not distracting, sitting with good posture, and thickening foods will contribute to a successful road ahead. Specifically, this type of dysphagia is difficulty of moving food from the mouth to the throat and esophagus.

Prognosis:If dysphagia is not treated complications such as malnutrition and dehydration as well as respiratory problems can occur. By following the therapy plan and diet instruction Lily has a good outlook. Many stroke patients phase out of swallowing difficulty and will hopefully not need to move to thicker liquids and stricter diet requirements. Surgery is rarely a solution for Oropharyngeal dysphagia.

Client: 52-year old Lily James (5’2” and 120#) went into the doctor because she has been having trouble swallowing her food and has noticed that she is choking while eating quite often. She has been eating less throughout the day due to her nervousness of eating. This has caused her some weight loss. She had a stroke recently and has been cautious about eating healthier as well as being active, but doesn’t know what could be wrong. She likes to go on walks with her husband, but doesn’t want to do too much. She likes to go out to eat with friends, but has been embarrassed because she will cough a lot when trying to eat. She has been making most of her meals at home. After seeing her doctor and running some tests it was concluded that she has Oropharyngeal dysphagia and needs to go to a swallowing therapist as well as make changes in her diet.

24 hour recall:Breakfast: 1 cup of coffee with cream 1 cup oatmeal with raisins1 slice of whole grain toast1 over easy eggMedium Banana

Snack: 1 cup fruit salad½ cup yogurt with nuts

Lunch:1 cup milk1 cup tomato Soup with handful of crackersGrilled cheese sandwich

Snack:½ cup chocolate pudding1 small muffin

Dinner:1 medium baked potato with bacon 3 oz. roasted chicken ½ cup cooked vegetables1/3 cup applesauce1 cup milk

References

(2014). Communication facts: special populations: dysphagia. American Speech-Language-Hearing Association. Retrieved February 16, 2014 from http://www.asha.org/research/reports/dysphagia/

(2013). Dysphagia mechanically advanced diet. Wexner Medical Center. Retrieved February 16, 2014 from

https://patienteducation.osumc.edu/documents/dys-3.pdf

(2014). Dysphagia. MayoClinic. Retrieved February 16, 2014 from

http://www.mayoclinic.org/diseases-conditions/dysphagia/basics/definition/CON- 20033444

(2014). Dysphagia. National Stroke Association. Retrieved February 16, 2014 from http://www.stroke.org/site/PageServer?pagename=dysphagia

(2014). Dysphagia. WebMD. Retrieved February 16, 2014 from http://www.webmd.com/digestive-disorders/tc/difficulty-swallowing-

dysphagia- overview

Lembo, A.J. (2014). Oropharyngeal dysphagia: clinical features, diagnosis, and management. UpToDate. Retrieved February 16, 2014 fromhttp://nutritioncaremanual.org/vault/editor/Docs/Level%202%20NT

%20fo r%20Dysphagia_MechAltered.pdf

(2014). Level 2 nutrition therapy for dysphagia: mechanically altered foods. American Dietetic Association. Retrieved February 16, 2014 from

http://nutritioncaremanual.org/vault/editor/Docs/Level%202%20NT%20for%20Dysphagia_MechAltered.pdf

McCullough, G., Pelletier, C., & Steele, C. (2014). National dysphagia diet: what to swallow?. The ASA Leader. Retrieved February 16, 2014 from http://www.asha.org/Publications/leader/2003/031104/f031104c/

(2014). Swallowing disorders. MedlinePlus. Retrieved February 16, 2014 from http://www.nlm.nih.gov/medlineplus/swallowingdisorders.html

(2014). Swallowing support groups. National Foundation of Swallowing Disorders. Retrieved February 16, 2014 from http://www.swallowingdisorderfoundation.com/swallowing-support-

groups/

Oropharyngeal Dysphagia: Difficulty moving food from mouth to throat and esophagus. We want to make it easier for you so that you are not in pain and are able to enjoy food, and eat again.

Caffeine is not recommendedDrink thickenersDon’t have sticky foodsAdding starch and flour

At a restaurant: sauces and softened noodles, moist rice, bring thickener packet for a drink, nectar packets

Care plan: swallowing therapist, Mechanically altered food (nectar thick foods)- due to weight loss and pain

What to have instead:

Breakfast:BOOST drink: pack in proteinOatmeal moistened with milk without raisinsMake sure the banana is ripe

Commercially softened bread dipped in eggPancakes with syrupPineapple juice

Snack:Soft drained canned fruits, pudding,

Lunch:Thickening tomato soup with dry milk powderRoll dipped in soupSoft mac n cheese

Dinner:Moistened mashed potatoes- add milk, butter or gravyMoistened chicken with sauces and cut up into small piecesRice with butter

Meatloaf with ketchup

Desserts:Cookies moistened in milkGelatinIce cream

Diet Instruction: Enteral Tube Feeding

Etiology:

Enteral nutrition is used when a patient is severely underweight and/or

malnourished. It can only be prescribed if the patient has a fully or partially functioning

gastrointestinal tract. If not, the patient must be placed on parenteral nutrition. There are

three different types of feeding tubes for enteral nutrition. These include the nasogastric,

gastrostomy, and jejunostomy tubes. The type of tube that a patient receives depends on

if the tube will be temporary or permanent. It also depends on which part of the

gastrointestinal tract is functioning. Enteral tube feedings can be safely and effectively

performed at home if the patient is given instruction by a health professional

(www.nestle-nutrition.com).

Some health conditions that can require enteral nutrition are gastrointestinal

disorders, cardiopulmonary disorders, hyper-metabolism, and neuromuscular disorders

(www.nutritioncare.org). My patient has Dysphagia and she is placed on enteral tube

feedings to ensure that she is getting her necessary daily caloric and nutrient intakes.

Dysphagia is more prevalent in the elderly population (www.nidcd.nih.gov). It is

usually seen as a symptom caused by a variety of disorders instead of as a disease state

(Nelms 354-355). Dysphagia is defined as “any condition that weakens or damages the

muscles and nerves used for swallowing (www.nidcd.nih.gov). Diseases of the nervous

system such as cerebral palsy, multiple sclerosis, and Parkinson’s disease can cause

dysphagia (www.nlm.nih.gov). Stroke or head injury can affect the ability of the

necessary muscles for swallowing or they can reduce sensations in the individual’s mouth

or throat. Some forms of cancer and even some treatments of cancer can cause dysphagia

as well (www.nidcd.nih.gov).

Diagnostic Measures:

Dysphagia is first diagnosed with a clinical bedside evaluation and a bedside

swallowing assessment. A healthcare team usually performs the diagnosis. The team

typically consists of physicians, nurses, a speech language pathologist, a physical

therapist, and an occupational therapist. The diagnosis is confirmed by performing either

a videofluoroscopy swallowing study or a fiber optic endoscopic swallowing evaluation.

For either diagnostic procedure, barium is added to a range of foods and beverages with

differing textures. Barium can be viewed by fluoroscopy or x-ray. This makes it possible

to monitor the movement of the food or beverage with barium. Barium is used to pinpoint

the specific location of dysphagia. Knowing the location makes it possible for the

healthcare team to establish an appropriate treatment plan (Nelms 355-356).

In Rose’s case, she has been diagnosed with inadequate oral food and beverage

intake related to her dysphagia. She has also been diagnosed with difficulty swallowing

and malnutrition.

Treatment:

Medical, surgical and/or psychological treatment:

The patient had a gastrostomy to insert a permanent gastric tube. The gastric tube

is being used for enteral tube feedings. The patient could receive treatment from a variety

of health professionals. The patient can be referred to a psychiatrist since she is going

through depression due to her inability to swallow and chew food. She can see a speech

pathologist or an occupational therapist in order to improve her chewing and swallowing

abilities. This can sometimes be attained by practicing muscle exercises to strengthen

facial muscles or to improve muscle coordination (www.nidcd.nih.gov).

Medical Nutrition Therapy:

The medical nutrition treatment therapy for the patient with dysphagia depends on

the cause and the severity. In Rose’s case, her dysphagia is preventing her from receiving

adequate oral intake. In order to bypass the passage of foods or beverages through the

esophagus, Rose is placed on enteral tube feeding. She is placed on enteral nutrition

because she had severe weight loss in the past 6 months. Enteral nutrition is chosen

instead of parenteral nutrition because Rose has a functioning gastrointestinal tract. A

gastrostomy was performed because Rose will need to be on long-term enteral nutrition.

Gastric tube feeding will also allow for bolus feedings, which mimic a regular eating

schedule (Nelms 85).

Before determining Rose’s enteral prescription, her fluid and electrolyte balance

must be restored. Her poor skin turgor and dry skin are evidences of dehydration. Her

electrolyte values are all elevated and this is common in individuals with dehydration.

Her hydration status has to return to normal in order for the electrolyte level readings to

be accurate.

Enteral formulas are typically the primary source of water for patients so it is

important to maintain an adequate fluid intake (Nelms 87). It is also recommended that

the patient consumes 2 cups of water per day to make sure that she is getting enough

fluid. Her enteral formula has 85% free water. Rose will use Nutren 1.0 and she will give

herself 5 bolus feedings a day. She will use 6 ½ cans of formula each day; this is

approximately 1 can and 1/3 cup of formula per feeding. She will be instructed on the

syringe method for bolus feeding at home. In order to make sure that there are no

complications with enteral feeding at home, she will monitor her weight once a week, her

hydration status at least 3 times a week, and her vital signs at least 3 times a week. She

will have her blood glucose levels measured every 2 weeks (Nelms 91). She will be

monitored closely for aspiration because her unstable mental state puts her at a higher

risk of developing it.

Description of patient and diagnosis:

Patient name: Rose Bush

DOB: 07/10/1942

Age: 72 y/o

Height: 5’ 4”

Weight: 120 lbs.

Sex: Female

Education: Bachelor’s Degree

Occupation: Retired business owner

Household members: daughter age 40, son-in-law age 41, granddaughter age 10

Ethnic background: Caucasian/ white

Chief Complaints

Patient: “I am embarrassed to eat in front of my friends and family members because I

take a long time to chew my food and my food does not always make it into my mouth.

Sometimes I drool and I think it is impolite to do that.”

Patient’s mother: “Lately she pushes her food around on her plate more than she eats it.

She is getting very thin and she seems depressed. She is very quiet during meals.”

Patient History

Onset of disease: Rose is a 72 year old female who had a stroke 7 months ago. She has

recovered from the stroke, but she had severe weight loss. In 6 months, she dropped from

145 pounds to 120 pounds (17.2% weight loss). She was admitted to the hospital for tests.

Rose complained of pain while swallowing and difficulty chewing. She was diagnosed

with Dysphagia and the doctor recommended a gastrostomy to insert a permanent feeding

tube. Rose is recovering from the gastrostomy and she has been administered enteral tube

feedings. Rose will be released from the hospital tomorrow. She will continue enteral

tube feedings at home. She needs instruction from a R.D. on how to perform the tube

feedings at home.

Physical Exam Upon Admission

General appearance: tired-looking woman, c/o fatigue and difficulty swallowing

Vitals:

HEENT

Heart: tachycardia

Eyes: sunken, membranes dry

Ears: membranes dry

Nose: dry mucous membranes

Throat: dry, inflamed

Neurologic: irritable, confused

Skin: poor turgor, dry skin

Chest/lungs: deep, rapid respiration

Biochemical Lab Values

1 day post-op

Electrolyte Current Serum Level Normal Serum Level

Sodium 151 mEq/L 136-146 mEq/L

Potassium 5.5 mEq/L 3.5-5.0 mEq/L

Chloride 110 mEq/L 98-106 mEq/L

Glucose 160 mg/dL 70-120 mg/dL

5 days post-op

Electrolyte Current Serum Level Normal Serum Level

Sodium 140 mEq/L 136-146 mEq/L

Potassium 4.0 mEq/L 3.5-5.0 mEq/L

Chloride 108 mEq/L 98-106 mEq/L

Glucose 122 mg/dL 70-120 mg/dL

Patient 24- hour recall

breakfast: ½ mashed banana, 8 oz. whole milk, 1/3 c. instant oatmeal

snack: 1 c. applesauce

lunch: ¾ c. mashed potatoes with gravy, 16 oz. water, ½ c. creamed corn

snack: skipped because her throat was very sore

dinner: 3 oz. meatloaf with gravy, 8 oz. Coca-Cola, ¼ rolled biscuit

snack: ½ c. pudding, 8 oz. water

Enteral Nutrition Prescription

Adjusted Body Weight Calculation:

AdBW=.25 (120 lbs.-145 lbs.) + 145 lbs.

AdBW=139 lbs.

139 lbs./2.2=63.2 kg

“dosing wt.”=63.2 kg

Mifflin-St. Jeor calculation for women:

wt=63.2 kg

ht= 162.6 cm

age=72 yrs.

10 (63.2 kg) + 6.25 (162.6 cm) – 5 (72 yrs.) – 161

1,127 kcal/day

PAL=1.4 (some seated work)

1,127 kcal*1.4= 1,578 kcal/day

Protein Goal:

RDA for older adults is 1.0 g/kg so Rose needs 63 kg protein/ day

63 kg pro *4=252 kcal

252 kcal/1,580 kcal*100=16 % pro

Electrolyte Needs:

There are no abnormal electrolyte losses so electrolyte needs should follow the RDA for

adults over 70 years old.

Sodium: 1,200 mg

Potassium: 4,700 mg

Chloride: 1,800 mg

Vitamin and Mineral Needs:

DRIs for adults 70 years and older

Vit. A: 700 mcg/day

Vit. C: 75 mg/day

Vit D: 15 mg/day

Calcium: 1,200 mg/day

Iron: 8 mg/day

Fluid Needs:

Patient’s hydration status has been restored

1,580 kcal* 1 mL=1,580 mL

osmolality should be about 300 mOsm/kg water

Enteral Formula Prescription:

The patient will receive 1,580 mL or Nutren 1.0 daily

Nutren 1.0:

1.0 kcal/mL

16% pro

51% CHO

33% fat

osmolality=370 mOsm/kg water

meets 100% for 20 key micronutrients

Continuous Feeding:

1,580 kcal/24 hrs.=66 mL/hr.

Bolus feedings 5 times/day:

1,580 mL/4=316 mL

250 mL/can of Nutren 1.0

316 mL/250 mL=1.3 cans

1 can and 75 mL per bolus feeding (1.3 cans)

household measurements: approx. 1 can and 1/3 cup

Prognosis:

  If the patient’s swallowing ability improves and her throat pain decreases, she will

be able to switch to a diet with partial oral intake (Nelms 358). The oral intake would

follow the NDD (National Dysphagia Diet) Level 1, which includes only pureed foods or

smooth foods with no lumps (www.anfponline.org). The food should have a “pudding-

like consistency (Nelms 357).” The patient will be educated by a R.D. on her modified

enteral tube feedings and appropriate foods for NDD Level 1. If the patient has trouble

tolerating the NDD Level 1, she will return to a full enteral tube feeding diet.

(Educational Materials)

At-Home Gastric Tube Feeding Overview*Patient will decide times for feedings; feedings should be at least 2-3 hours apart

Your Formula: Nutren 1.0Cans per day: 6 ½

Amount per feeding: 1 can and 1/3 c.

Your feeding schedule: 5 bolus feedings daily (at least 15 min. per feeding)

Times Amount of formulaAM 1 can and 1/3 cupAM 1 can and 1/3 cup

AM/PM 1 can and 1/3 cupPM 1 can and 1/3 cup

PM 1 can and 1/3 cup

Wash your hands thoroughly with soap and water then gather supplies:

formula syringes lukewarm water (1 cup) feeding bag (if using) feeding pump (if using)

Things to remember:

You must flush the tube before and after administration of formula or medications.

if the tube becomes clogged, take immediate action to unclog it.

Store unopened cans of formula at room temperature.

When a can is opened, use immediately. Date and refrigerate the unused portion, but it must be thrown away if it is not used within 24 hours.

Syringes need to be cleaned with warm, soapy water and left to air dry between each use.

Bolus Feeding: Syringe Method

1. Draw up 60 ml of warm water in the syringe. Gently flush the waterthrough the tube to make sure the feeding tube is clean and open. Disconnect the syringe. Recap the end of the feeding tube.

2. Remove the plunger from the syringe.

3. Uncap the feeding tube.

4. Attach the syringe directly to your feeding tube. Pour 1 can and 1/3 cup of feeding into the syringe, allowing it to flow freely until all of the feeding is given.

5. Take the syringe and draw up 60 ml warm water. Gently flush the water through the tube again to make sure the tube is clean and open. This water also helps keep

you hydrated.

6. Disconnect the syringe from the feeding tube.

7. Recap the feeding tube.

6. Repeat the procedure 4 more times. If you do not tolerate the prescribed amount of formula, notify your dietitian.

Helpful Resources:

American Society for Parenteral and Enteral Nutrition (ASPEN)

Nestle Health Science: Medicare Coverage of Enteral Nutrition Therapy

References

Academy of Nutrition and Dietetics. (2014). Nutrition Care Manual. Retrieved from http://www.nutritioncaremanual.org

American Gastroenterological Association. (1995). American gastroenterological position statement: guidelines for the use of enteral nutrition. Retrieved fromhttp://www3.us.elsevierhealth.com/gastro/policy/v108n4p1280.html

American Society for Parenteral and Enteral Nutrition. (2013). What is enteral nutrition? Retrieved from http://www.nutritioncare.org/Information_for_Patients

Cleveland Clinic. (n.d.). Tube-feeding instructions for home. Retrieved from www.my.clevelandclinic.org./home-enteral-nutrition-booklet.pdf

Dietary Manager. (2004).Understanding and implementing dysphagia diets. Association of Nutrition & Foodservice Professionals. Retrieved fromhttp://www.anfponline.org/Publications/articles/2004_03_008Dysphagia

Fletcher, J. (2011). Nutrition: safe practice in adult enteral tube feeding. British Journal Of Nursing, 20(19), 1234-1239. Retrieved fromhttp://eds.b.ebscohost.com.proxy.lib.muohio.edu

Lloyd, D. & Powell-Tuck, J. (2004). Artificial nutrition: Principles and practices of enteral feeding. Clinics in Colon and Rectal Surgery, 17(2), 107–118. doi: 10.1055/s-2004-828657

National Institutes of Health. (2010). Dysphagia. National Institute on Deafness and Other Communication Disorders. Retrieved fromhttp://www.nidcd.nih.gov/health/voice/Pages/dysph.aspx

Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy & pathophysiology 2/e. Belmont, CA: Wadsworth, Cengage Learning.

Nestle Health Science. (2013). Best practices in enteral feeding safety. Retrieved from http://www.nestle-nutrition.com/Products

Katie ArlinghausKNH 413; Matuszak

MNT DietApril 24, 2014

Medical Nutrition Therapy Diet: High Calorie, High Protein

1. Purposea. Nutrition IndicatorsA high calorie, high protein diet is appropriate for those who need more energy. This often occurs during healing or in times of increased metabolic stress such as with cancer patients, HIV patients, burn victims, trauma cases, etc. Weight loss is a major indicator that the patient is not receiving enough calories.b. Criteria to Assign the DietThe patient should present with increased calorie and protein needs to be assigned the diet. This need is commonly presented in cases of trauma, burn victims, and cancer patients. The diet may be appropriate for an athlete as well. c. Rationale for DietThe rational for the diet is to give the patient the proper amount of energy and protein needed to heal and function properly.

2. Populationa. OverviewThis diet is given to anyone who is not receiving the proper amounts of energy and protein. This includes cancer patients, burn victims, and trauma clients.b. Disease ProcessAs mentioned previously, there are a variety of diseases that may require the use of a high calorie, high protein diet. A case in which the diet is severely needed is with cachexia. Cachexia is one of the most common causes of death among patients with cancer and is present in almost 80% of cancer patients that die. Cachexia has a much higher rate of incidence with lung and gastrointestinal cancers than with breast and hematopoietic cancers. The pathophysiology of cachexia is not understood fully, but is attributable to a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism. It is believed that changes in carbohydrate metabolism in cancer patients probably arise as a consequence of meeting the metabolic demands of the tumor and may contribute to the cachectic state. Amino acids are not spared in cancer cachexia and lean body mass is depleted. This may occur due to hypercatabolism, decreased protein synthesis, or both. Cachexia has been found to occur even when anorexia is not present. The presence of malignancy often increases lipid metabolism, decreases lipogenesis, and decreases the activity of lipoprotein lipase.c. Biochemical and Nutrient NeedsAn increase in macronutrients is a key component to the diet. Protein needs, as the name of the diet suggests, are increased. Fat is also often increased as an easy way to increase total calories because fat has 9 kcal/g versus 4kcal/g found in protein and carbohydrates. Carbohydrates, however should also be increased as part of the effort to increase the overall calorie consumption. Protein status can be monitored through albumin levels. A nitrogen balance may also be determined.

3. General Guidelinesa. Nutrition RxIncrease protein and calorie intake. This can be done with diet or often through enteral nutrition supplements or parental nutrition.b. Adequacy of Nutrition RxThe adequacy of the nutrition can be seen by monitoring weight, protein status (albumin levels), nitrogen balance, c. GoalsThe goal of the diet is to increase caloric and protein intake to meet the higher caloric and protein demands of a patient in metabolic stress with the ultimate goal to promote healing and recovery. A measurable goal is to increase or maintain weight d. Does it Meet DRIThe diet meets, if not exceeds, DRI/RDA/AMDR recommendations for the general population.

4. Education Materiala. Nutrition TherapyFirstly the dietician should provide the client education on what are high calorie and high protein foods. The dietician should also prescribe appropriate enternal or parental nutrition supplements.b. Ideas for ComplianceNoncompliance could occur for many reasons. Often symptoms of the client’s disease or disease treatment cause the patient to not want to eat. Managing these symptoms, and providing the client with alternatives specific to his/her symptoms is key to encouraging the client to eat. For example, if the smell of food makes the client nauseous, the client should stay away from the cooking area, and opt for colder foods instead of hot foods (foods that are cooked) and liquids. Noncompliance may also stem from a mental or emotional issue. If this is the case, a psychologist may be helpful. Often, it is just difficult to consume that many calories or that much protein for just diet alone

5. Sample Menua. Foods RecommendedEnternal supplements, pre made or homemade shakes/smoothiesAdd extra fat, for example: cook with butter, make oatmeal with milk instead of water, drink whole milk instead of lowfat milk, etchigh protein foods: meats, cheese, milk, eggs, tofu, yogurt, nuts, legumes, seeds, nut buttersFavorite foodsb. Foods to Avoidfoods that discourage the patient from eatinghated foodslow calorie foodshigh fiber foodslow calorie fluids like water c. Example of a meal planBreakfast (700-800 calories)2 whole wheat tortillas each with 1⁄4 cup or 1 slice 2% cheese, 1 scrambled egg and 2-3 oz lean Canadian bacon1 fruit 8 oz 2% milkSnack (350 calories)1 whole wheat mini bagel with 2 Tbsp peanut butter and 2 Tbsp all-natural

jellyLunch (700-800 calories)1 whole wheat pita w/ 6 oz chicken breast, 1⁄2 cup 2% grated cheese, lettuce, tomato, and sauce 15 whole wheat crackers or baked chips 1 banana16 oz low-fat chocolate milk or 100% juiceSnack (250-350 calories)200-250 calorie energy/protein bar or shake

Dinner (700-800 calories)6-8 oz meat, palm size (chicken, fish, beef, pork) 2 cups vegetables 2 cups carbohydrate item (pasta, rice, potato, sweet potato, peas, crackers, beans, corn, fruit) Side salad with dressing, if desired 16 oz 2% milkSnack (200-250 calories)Banana chocolate shake with protein powder and 2% milk

6. Websitesa. Organizations with WebsitesAmerican Cancer SocietyVarious medical centers and hospitals

ex: UCSF Medical CenterAcademy of Nutrition and DieteticsAbbot Nutritionb. Government WebsitesNational Cancer Institute: http://www.cancer.gov/Cancer Research UK: http://www.cancerresearchuk.org/

7. Referencesa. Journal Articles

Fearon, Kenneth C., Anne C. Voss, and Deborah S. Hustead. "Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis." The American journal of clinical nutrition 83.6 (2006): 1345-1350.

Kern, K. A., and J. A. Norton. "Cancer cachexia." Journal of Parenteral and Enteral Nutrition 12.3 (1988): 286-298.

Julia KaesbergCounseling Session

KNH 413February 27th, 2014

Patient Description and Diagnosis: Sarah Jones is a 50-year-old female, 5’4”, 131

pounds and her usual body weight is 125 pounds. Her %UBW is 104% (131/125 x

100). Sarah has been diagnosed with Stage 5 Kidney Disease and is beginning

hemodialysis. Sarah’s decline in kidney function is a result of her uncontrolled

hypertension. Currently, Sarah is presenting with edema in her legs and feet. She

has been asked by her physician to see a Registered Dietitian for instruction on a

hemodialysis diet, including fluid restriction. Sarah’s current urine output averages

about 0.7 L per day and brought a 24- hour recall with her to this session.

Etiology: The two leading causes of kidney failure in the United States are Type 2

Diabetes and high blood pressure. Effective treatment of these conditions can

prevent or slow down kidney disease. End stage kidney disease occurs when 90%

of kidney function has been lost and the patient may have symptoms such as nausea,

vomiting, weakness, fatigue, confusion, difficulty concentration and loss of appetite

(“Kidney disease: Causes,”).

Diagnostic Measures: There are three simple diagnostic measures that are

typically used to diagnosis kidney disease. The first is blood pressure. A blood

pressure of 140/90 or higher is considered high blood pressure and with kidney

disease 130/80 or less is recommended. The second diagnostic measure is

urinalysis. Protein and blood in the urine may indicate kidney disease, especially in

patients with diabetes. One test used to test for the presence of urine is the protein

to creatinine ratio and a value of 200 mg/gm is considered high. Another urine test

is the albumin to creatinine ratio and a value of 30 mg/gm per day or higher can be

a sign of early kidney disease. The third diagnostic test is the Glomerular filtration

rate (GFR), which is estimated from the results of a serum creatinine test. This

value indicates how well the kidneys are removing waste from the blood and a value

of 60 or lower may indicate kidney disease (“Three simple tests,”).

In addition to these simple diagnostic measures, physicians can also use renal

ultrasounds to determine the size and shape of the kidney to see any abnormalities.

A kidney biopsy can also be done to determine if cancerous or abnormal cells are

present. Finally, a CAT scan can be used (“End stage renal,”).

Medical Treatment: The first choice for medical treatment of End Stage Renal

Disease (ESRD) is hemodialysis. Hemodialysis cleans and filters the blood through a

machine that removes waste, extra salt and extra water. This helps to control blood

pressure and keep the proper balance of chemicals such as potassium, sodium,

calcium and bicarbonate in the body. Another choice is peritoneal dialysis, which

also removes waste, chemicals and water from your body using the linin of your

abdomen or belly. A third choice with ESRD is kidney transplantation where the

donated kidney does the work that the patient’s two failed kidneys used to do

(“Kidney failure: Choosing,”). For Sarah, hemodialysis was chosen as the best choice

of treatment for the current time. She will be receiving hemodialysis three times

per week.

Medical Nutrition Therapy:

Sarah’s protein needs are increased because of the hemodialysis and therefore

requires 1.2 g pro/kg (“Chronic kidney disease,”). Sarah needs about 71 grams of

protein per day. Using the Harris Benedict equation, Sarah requires about 1,800

calories per day. Based on the Nutrition Care Manual from the Academy of Nutrition

and Dietetics, Sarah must consume less than 2.4 g of sodium and potassium per day,

between 800-1000 mg of phosphorus per day and less than 2 g from protein per

day. Because the kidneys are not functioning properly, they cannot remove excess

water from the body, so Sarah must restrict her fluid intake to her urine output plus

1,000 cc of fluid per day. Her current urine output is an average of 400 cc per day,

so she can consume 1,400 cc of fluid in her diet daily (“Chronic kidney disease,”).

Calculations:

1.2 g pro/kg (59.5 kg) = 71 g protein/day

71 g pro x 4 kcal/g= 284 calories from protein

71 g pro/7 grams per ounce= 10 ounces of meat

Energy Requirements using Harris- Benedict equation:

655 + (9.56 x wt (kg)) + (1.85 x ht (cm)) – (4.68 x age)

655 + (9.56 x 59.5) + (1.85 x 163 cm) – (4.68 x 50)

655 + (569) + (302) – 234

1,292 x (1.4 PAL) = 1,808

1,750-1,850 calories per day

1,800 calories- 284 calories from protein= 1,516 calories from carbohydrate and fat.

1,800 x 0.55 = 990 calories from carbohydrate/4 kcal/g= 247 g carbohydrate

1,800 total calories -990 (kcal from CHO) -284 (kcal from PRO) = 526 calories from

fat/ 9 kcal/g= 58 g fat per day

During the counseling session, the patient will be informed on the importance of

restricting fluid, sodium, potassium, phosphorus and calcium. The patient’s 24-

hour recall will be reviewed and Sarah will be given tips on making food choices low

in these minerals and higher in protein. The patient will also be given lists of foods

that are low in potassium, sodium and phosphorous. In addition, Sarah will be

educated on sodium and foods that have added salt, with the recommendation of

choosing foods with 300 mg or less per serving.

Website:

The National Kidney Foundation www. Kidney.org

Educational Material:

http://www.nutritioncaremanual.org/client_ed.cfm?

ncm_client_ed_id=157&actionxm=ViewAll

References: Chronic kidney disease (ckd) stage 5 dialysis . (n.d.). Retrieved from

http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5537&lv2=255347&ncm_toc_id=255666&ncm_heading=Nutrition Care

End stage renal disease. (n.d.). Retrieved from http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/end_stage_renal_disease_esrd_85,P01474/

Kidney disease: Causes. (n.d.). Retrieved from http://www.kidney.org/atoz/content/kidneydiscauses.cfm

Kidney failure: Choosing a treatment that's right for you. (n.d.). Retrieved from http://kidney.niddk.nih.gov/kudiseases/pubs/choosingtreatment/

Three simple tests to check for kidney disease. (n.d.). Retrieved from http://www.kidney.org/kidneydisease/threesimpletests.cfm

Medical Nutrition Therapy Diet- NPO/Peripheral ParenteralMelissa Girgis4/21/14

1. Purposea. Nutrition IndicatorsAn NPO (nothing by mouth)/ peripheral parenteral diet is required in clinical situations in which patients are unable to meet their needs orally or with the help of enteral nutrition products. Often, these patients do not have a functioning gastrointestinal tract, so it is necessary to utilize a feeding route that bypasses the digestive tract. Nutrition indications for PPN diet include

abdominal trauma, injury, or infection, impaired GI motility, GI tract obstruction, excessive vomiting, or inability to digest/absorb nutrients as a result of bowel resection, or short bowel syndrome.

b. Criteria to Assign the DietWhile total parenteral nutrition (administered through a large vein in the center of the body, such as the jugular, subclavian, or femoral veins) is often used for long periods of time, peripheral parenteral nutrition is not sustainable for more than a few days. This feeding method delivers large volumes of dilute nutrient solutions through veins of the back of the hand or arm. Because large volumes are required to meet the nutritional needs of the patient, patients with limited fluid intake would not use this feeding method.

c. Rationale for DietPPN is not used frequently. This diet is for patients whose gastrointestinal tract requires a few days of rest to heal properly before transitioning to an oral diet. This diet allows for healing while providing readily available nutrients.

2. Populationa. OverviewPatients with Crohn’s disease, ulcerative colitis, or other conditions that may require surgical interventions such as ileostomy or colostomy, would use a PPN diet for a few days post-surgery to allow bowel rest and healing before transitioning back to an oral diet. Surgical complications, other existing medical conditions, or damage to the gastrointestinal tract due to accidents or trauma may also require temporary disuse of the digestive tract.

b. Disease ProcessDiseases of the gastrointestinal tract such as Crohn’s disease and ulcerative colitis can have a severe effect on normal digestion and absorption of nutrients. Patients typically do not meet their calorie, protein, and fluid/electrolyte needs. Due to malabsorption these patients are at high risk for deficiency of iron, magnesium, zinc, calcium, vitamin D, B12, folate, fat-soluble vitamins and water-soluble vitamins. If the disease continues to be unresponsive to medication and diet therapy, surgical resection of the gastrointestinal tract is indicated. Disease complications such as abscess, obstruction, or perforation may also necessitate surgery. Post-surgery the patient will use PPN to allow for intestinal adaptation and healing of the GI tract, as well as delivery and supplementation of nutrients.

c. Biochemical and Nutrient NeedsFor patients with malabsorption, trauma, infection, or other serious cases, a very high amount of calories, protein, and nutrients will needs to be delivered, often much higher than the general population. Most pharmacies

use multiple vitamin infusions rather adding vitamins individually. The levels provided are often higher than those required by the general population because it is assumed that the PPN patient is dealing with some type of stress. Medications may also be delivered through parenteral nutrition. The following vitamins and minerals and their dosing is provided in the table below. Since vitamins are administered intravenously, absorption is not a problem. If toxicity is a concern, supplements may be administered every other day.

Vitamin/Mineral RequirementThiamin 6 mgRiboflavin 3.6 mgNiacin 40 mgFolic acid 600mcgPantothenic acid 15 mgPyridoxine (B6) 6 mgCyanocobalamin (B12) 5 mcgBiotin 60 mcgAscorbic acid 200 mgVitamin A 3300 IUsVitamin D 200 IUsVitamin E 10 IUsVitamin K 150 mcgChromium 10-15 mcgCopper 0.3-0.3 mgIron Not usually includedManganese 60-100 mcgSelenium 20-60 mcgZinc 2.5-5 mg

3. General Guidelinesa. Nutrition RxA parenteral nutrition order form will be filled out for the patient based on the recommendations of the dietitian, doctor, and pharmacist. Steps involved in writing the nutrition prescription are (1) Consider dosing weight and energy needs (2) establish protein goal (3) divide remaining kilocalories between lipid and carbohydrate (4) consider electrolyte needs (5) evaluate vitamin and mineral requirements (6) evaluate fluid needs (7) calculate final parenteral prescription. An example order form is shown below.

http://jacquelinefarrallportfolio.files.wordpress.com/2012/12/parenteral-nutrition-3.jpg

b. Adequacy of Nutrition RxTo check for tolerance and adequacy, patients will be monitored regularly. Weight, and fluid input and output will be monitored daily, glucose will be

checked three times per day until consistently below 200mg/dL, blood work will be done three times per week, triglycerides, CBC, PT, PTT will be checked weekly, and nitrogen balance will be checked as needed.

c. Goals1. Promote healing of illness, infection, injury, or disease state,2. Deliver necessary fluids, vitamins, minerals, protein, calories, and fat3. Avoid complications associated with inadequate intake such as weight loss, muscle wasting, and malnutrition

d. Does it Meet DRIPPN exceeds the DRI due to the assumption of increased needs in critically ill or stressed patients.

4. Education Materiala. Nutrition TherapyThe patient will likely receive PPN for 1-5 days then progress to a clear liquid diet. With toleration, patient can progress to all liquids, then to a low-residue diet. Four to six smaller meals throughout the day are recommended. Patients should eat slowly, drink plenty of fluids, chew food completely, and avoid any foods that may not be completely digested such as fruit skins, seeds, spinach, corn, peas, popcorn, and tough meats. The goal is for the patient to be eating their usual diet by the eighth week post-operatively. Enteral products may be used as necessary.

b. Ideas for ComplianceIf a patient is determined to be in a healthy and stable condition they may be given the option to continue PPN in the comfort of their own home. Home care has proven to improve patient outlook and decrease health care costs. Before approving this option it must be determined that the patient’s living environment is appropriate, the patient possesses ability for self-care, caregivers/friends/family are available, and insurance coverage is available.

5. Sample Menua. Foods Recommended/ b. Foods to AvoidNPO means nothing by mouth. Patients on this diet who are receiving peripheral parenteral nutrition will not eat or drink any food at all.

c. Example of a meal planThe parenteral nutrition will be infused at a constant rate that is controlled with a pump. Cyclic PN where the patient is fed at night and fasts during the day is only used for patients receiving long-term PN to allow them freedom from the pump during their waking hours.

6. Websites/ 7. References

Abbott Nutrition. (2014). http://abbottnutrition.com/

Academy of Nutrition and Dietetics-Nutrition Care Manual. (2014) Inflammatory Bowel Disease Nutrition Therapy. Nutrition Therapy for Ileostomy. http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=181

ACI. Parenteral Nutrition Pocketbook for Adults. http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/159805/aci_parenteral_nutrition_pb.pdf

ASPEN. (2014). What is Parenteral Nutrition? https://www.nutritioncare.org/wcontent.aspx?id=270

California State University. Parenteral Nutrition Tutorial. http://www.csun.edu/~cjh78264/parenteral/cpn_vs_ppn/

Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition therapy & pathophysiology. Belmont, CA: Wadsworth.

Parrish, Susan Rees, R.D., M.S.. (2006) The Hitchhiker’s Guide to Parenteral Nutrition Management for Adult Patients. http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/MadsenArticle.pdf

RX Kinetics (2014) TPN Tutorial. http://www.rxkinetics.com/tpntutorial/3_1.html

University Health Systems (2009) Parenteral and Peripheral Nutrition Support. http://www.universityhealthsystem.com/files/01-Guidelines%20for%20Creating%20TPN%20Orders.pdf

Lynne RollerKNH 413

Medical Nutrition Therapy Diet- Pancreatitis Chronic

1. Purposea. Nutrition IndicatorsA special should be used with pancreatitis patients. Since the pancreas is

inflamed, it cannot heal or produce enzymes such as insulin or glucagon. This inflammation also causes the inability to digest food, especially fat.

b. Criteria to Assign the dietA patient should be placed on a high carbohydrate, low fat diet if they are

experiencing any of the symptoms of pancreatitis, such as abdominal pain or digestive problems. They should also show signs of high levels of triglycerides in the blood.

c. Rationale for the diet

Since patients with pancreatitis cannot produce proper amounts of enzymes, a high carbohydrate and low fat diet will help the body to digest foods and obtain proper nutrients. Alcohol intake should also be minimal, since it has a high tendency to increase symptoms.

2. Populationa. OverviewChronic pancreatitis is an inflammation of the pancreas that does not heal or

get worse over time. This can lead to permanent damage. Inflammation can prevent the pancreas from producing the enzymes insulin and glucagon. Inflammation causes inability to digest food, especially fats.

b. Disease ProcessThe first sign of chronic pancreatitis usually occurs in 8-9 years into an

alcoholic’s drinking life. The first sign is usually maldigestion and can lead to fibrosis, calcification of the pancreas, destruction of the glandular structure, and chronic digestive issues.

c. Biochemical and Nutrient NeedsIt is common to see deficiency in vitamins A, D, E, and K as symptoms

continue. There are also deficiencies in calcium, magnesium, thiamin, and folic acids. 3. General Guidelines

a. Nutrition RxDiet: high carbohydrate intake, low fat intake. Small meals throughout the

day, Creon 10 oral, 1 capsule per meal, avoid alcohol, multivitamin supplement, smoking cessation.

b. Adequacy of Nutrition RxDepending on the severity of the patient’s symptoms, further diet instruction

may be needed. For example, if the patient is experiencing major pain eating and digesting, a soft or NPO diet maybe needed.

c. GoalsSince chronic pancreatitis is not reversible, our main goal is to reduce the

patient’s symptoms by following the above nutrition guidelines.

d. Does It meet DRIThis diet will meet DRI for the most part. However, fat intake may be slightly

lower than guidelines, simply to reduce symptoms quickly. 4. Education Material

a. Nutrition therapyRecommendations: High carbohydrate diet, low fat intake, small meals, high

fiber, maintain a healthy body weight, medium-chain triglyceride oils, vitamin B12 supplement, drink adequate amount of fluids. Concerns include : nausea, vomiting, diarrhea, loss of appetite, steatorrhea, poor digestion of proteins, fats, and carbohydrates, glucose intolerance

b. Ideas for ComplianceCreating meals that are well liked by the patient but also follow guidelines.

Working to educate family members to encourage patient. 5. Sample Menu

a. Foods recommendedRecommended Foods

Food Group FoodsProtein Lean meats and poultry, fish, or eggs.Dairy Low fat milk, cheese, yogurt, or ice

creamGrains Whole grains (pasta, cereal, bagels,

bread)Fruits Fresh, frozen, or cannedVegetable Fresh, frozen, or cookedBeverages Water, juice, tea

b. Foods to Avoidc.

Food Group FoodsProtein Fried, high fat meats and poultry, fried

eggs, processed meatsDairy Whole fat dairy products, milkshakes,

half and half, cream, fried cheesesGrains White breads, croissants, biscuits, fried

potatoes, granolaFruits AvocadoVegetables Fried vegetablesBeverages Creamed drinks or soda

d. Example of a meal planBreakfast: 1 slice of whole wheat bread, fruit smoothie made with skim milk. Snack: appleLunch: pasta salad and skim milkSnack: crackers Dinner: Baked potato and broccoli and skim milkSnack: low fat ice cream

6. Websitesa. Organizations with WebsitesMayoClinic: http://www.mayoclinic.org/diseases-conditions/pancreatitis/basics/definition/con-20028421University of Chicago Medicine:

http://www.uchospitals.edu/specialties/pancreas/pancreatitis/chronic.htmlb. Government Websites http://www.nlm.nih.gov/medlineplus/

7. Referencesa. Journal articles references

Chronic Pancreatitis. Pancreatic Disease Center: University of Cincinnati. http://www.ucpancreas.org/chronicpancreatitis.htm

Chronic Pancreatitis. The University of Chicago Medicine. http://www.uchospitals.edu/specialties/pancreas/pancreatitis/chronic.html.

Chronic Pancreatitis. MedlinePlus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000221.htm

Chronic Pancreatitis - Symptoms, Diagnosis, Treatment of Chronic Pancreatitis - NY Times Health Information. (n.d.). Health News - The New York Times. Retrieved from http://health.nytimes.com/health/guides/disease/chronic-pancreatitis/overview.html

Huffman, MD, J. L. (2012, March 8). Chronic Pancreatitis. Medscape. Retrieved from http://emedicine.medscape.com/article/181554-overview

Longstreth, MD, G. F. (2010, January 20). Chronic pancreatitis - PubMed Health. National Center for Biotechnology Information. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001268/

Nelms, M., Sucher, K., Lacey, K., Roth, S. Nutrition Therapy and Pathophysiology. 2/e.

Pancreatitis. (2013, September 7). Mayoclinic. http://www.mayoclinic.org/diseases-conditions/pancreatitis/basics/definition/con-20028421.

Stevens, Tyler; Lee, Peter. Chronic pancreatitis. Cleveland Clinic.http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/chronic-pancreatitis/.

What is chronic pancreatitis. University of Southern California. http://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web%20pages/PANCREATITIS/what%20is%20chronic%20pancreatit.html.

Emily RohanKNH413 – Diet Instruction

Hepatic Failure, Coma1. Description of patient and diagnosis. 26-year old female, Cynthia Applebottom is admitted to McCullough Hyde Hospital with increasing symptoms of liver disease 2 years after being diagnosed

with hepatitis C virus (chronic liver disease). A liver biopsy and CT scan diagnose Cynthia with chronic liver failure, or Cirrhosis. A day after admittance, Cynthia falls in to a coma and a liver transplant is immediately ordered. The transplant was successful and Cynthia has been recovering for 4 days. She can intake food orally but her chief complaint is that she doesn’t have a big appetite. She has lost another 3 pounds since the surgery. She had lost 6 pounds unintentionally prior to the surgery.

Temp: 96.5 Pulse: 80Blood Pressure: 122/76Height: 5’8”Current Weight: 121 lbsUsual Body Weight: 130 lbs (pre-surgery)BMI: 18.5 (lower end of normal, almost underweight)

2. Discussion of the DiseaseThere are many types of liver disease and some are more serious/life threatening than others. Jaundice, Portal Hypertension/Ascites, Hepatic Encephalopathy, Hepatitis (A,B,C,D,E) , Cirrhosis are all diseases of the liver and all can lead to liver failure and/or a coma if left untreated. The liver has many functions including the removal of by-products from the digestion of food, the absorption of food and proteins necessary for normal blood consistency and clotting as well as other molecules involved in metabolism. Initial damage to the liver can elevate certain enzymes in the blood due to leakage from the liver. Measuring blood glucose, cholesterol, bilirubin, albumin, aminotransferases, alkaline phosphatase, and prothrombin time will help evaluate liver function. When the liver fails some or all of these substances can decrease. A bile acid test may also be used to further test liver failure.

a. EtiologyThe pathophysiology of hepatic encephalopathy (HE) is very similar

to the pathophysiology of liver failure because HE is a syndrome of impaired mental status and abnormal neuromuscular function that occurs from major liver failure. Ammonia is thought to be a direst toxin to the brain that is generated from the catabolism of proteins, amino acids, purines, and pyrimidines. Liver disease interferes with the detoxification process and shifts ammonia metabolism to skeletal muscle and then used to convert glutamate to glutamine instead of being synthesized, absorbed, and transported in the intestinal venous blood to the lever and then metabolized to urea. Mercaptans, ammonia, tyramine, octopamine, beta-phenylethanolamines, manganese, and gamma-aminobutyric acid also accumulate in liver failure as well as in HE. The symptoms of hepatic coma are often corrected by decreasing endogenous ammonia production. Aromatic amino acids, such as tryptophan, tyrosine, and phenylalanine, are elevated in the brains of patients with liver failure and HE.

Liver failure means that the liver is losing or has lost all of its function. It is life threatening and demands urgent medical care. The first symptoms usually seen in liver failure patients are nausea, loss of appetite, fatigue, and diarrhea. As liver failure progresses, these symptoms become more serious and severe to the point where the patient may become disoriented or confused and the risk for coma or death increases. If the liver is not responding to any treatment the only option is a liver transplant. When liver failure occurs as a result of cirrhosis, this essentially means the liver has been failing gradually for a portion of time and is then termed Chronic Liver Failure (CLF). CLF can also be caused by malnutrition. Cirrhosis represents the end of the pathophysiology spectrum for a wide variety of chronic liver diseases in which health tissue is replaced by scar tissue, blocking the blood flow through the organ and resulting in the loss of liver function.

In comparison, acute liver failure is failure of the liver that occurs suddenly, as little as 48 hours and is usually due to poisoning or a medication overdose.

b. Diagnostic MeasuresDiagnosing Hepatitis C Virus: There are several blood laboratory tests that are used to diagnose HCV infections, with the most common once being measurement of antibodies to hepatitis C virus (anti-HCV), negative tests for antibodies to HAV and HBV help confirm the diagnosis as well.Diagnosing Cirrhosis:No serologic or radiographic test can accurately diagnose cirrhosis but a significant correlation has been demonstrated between persistently elevating liver function tests and biopsy-proven underlying hepatic disease. Symptoms of cirrhosis include fatigue, weakness, nausea, poor appetite, jaundice, dark urine, light stools. Steatorrhea, itching, abdominal pain, bloating, and malnutrition. Vitamin and mineral deficiencies can cause or contribute to depressed hematocrit and hemoglobin values. Decreased vitamin K values are due to malabsorption and the inability of the liver to synthesize protein clotting factors which can result in bleeding and bruising.

c. Treatmenti. Medical, surgical and/or psychological treatment

The primary medical treatments for cirrhosis are abstention from alcohol, treatment of HCV, or other complications depending on patient, and nutrition therapy.

The most common liver disorders that require a liver transplant include chronic active hepatitis, cirrhosis, and biliary-related disorders. After transplant, all patients require immunosuppressive drugs to prevent rejection of the new liver.

ii. Medical Nutrition TherapyNutrition Concerns for patients with liver disease/liver failure:

-decreased abdominal room due to ascites, if present-delayed gastric emptying-decreased appetite-poor nutrient absorption

-decreased bile production = low fat absorption-diarrhea

-altered mental status/encephalopathyThe main goal for patients before transplant is to lessen the effects of malnutrition and complications of liver disease.

Nutrition concerns post-operative liver transplant:The risks for preoperative malnutrition, surgical stress, post-interventional complications, post-operative protein catabolism, fasting periods, and side effects of immunosuppressant medications suggest the need for early nutrition support after the transplant. After recovery, patients are more susceptible to food-borne infections as a result of the immune-suppressing medications.

Nutrition concerns for post-liver transplant:-increased energy expenditure-inadequate energy intake-inadequate oral food/beverage intake-inadequate protein-energy intake-malnutrition-inadequate vitamin/mineral intake (thiamin)-altered GI function-impaired nutrient utilization-underweight-altered nutrition-related laboratory values-food-medication interactions-food and nutrition related knowledge deficit-involuntary weight loss

RecommendationsAfter transplant, most nutritional deficiencies and metabolic disturbances common in patients improve. The main goal is to meet the needs for healing and preferred nutrition support should either oral or enteral. Fluid Intake:-avoid overhydration 6-8 cups a day is adequate -avoid dehydration since it can lead to renal problems

Calorie Recommendations:15-30% above basal needsCynthia’s Calorie Intake (Mifflin St. Jeor)

REE= 10 (55kg) + 6.25 (172.3cm) – 5 (26yrs) – 161REE= 1336REE x Activity Factor (1.2 for confined to bed) x Injury Factor (1.2 for surgery)Total Energy Requirements: 1336 x 1.2 x 1.2= 1924kcal1924 x 15%= 288kcal extra 1924 x 30%= 577kcal extraRANGE: 2210kcals to 2500kcals

Protein Recommendations:1.5-2.0 g/kgCynthia’s needs:55kg x 1.5g PRO= 82.5 grams 55kg x 2.0g PRO= 110 gramsRANGE: 82.5 – 110 grams of protein per day

Carbohydrate Recommendations:To prevent/manage hyperglycemia it is recommended that the patient decreases simple sugars and have carbohydrates provide 50-60% of total kcal. It is also recommended to restrict sodium intake by 2-4grams.Cynthia’s needs:Cynthia is recovering well so I will use the lower value of kcal to calculate CHO needs:2210kcal x .50= 1105kcal from CHO / 4 grams per kcal= 276 grams CHO2210kcal x .60= 1326kcal from CHO / 4 grams per kcal= 330 grams CHORANGE: 276-330 grams of Carbs per day

Fat Recommendations:Some people with liver disease have problems digesting and absorbing fat. The fat that is not digested is eliminated through bowel movements. Fat present in the feces is a nutritional concern and the patient should be put on a low-fat diet.

Other Nutrient Recommendations:Calcium supplements along with a multivitamin may be recommended post surgery to help maintain bone health and ensure overall nutritional needs are being met. Patient should be educated on food safety because of their increased susceptibility to food-borne illnesses.

iii. Prognosis- (supported by professional source)Patients with cirrhosis, or any end-stage liver disease, average 1-

and 5- year survival rates are 80% - 50% respectively. The clinical tools used to determine prognosis with patients with cirrhosis are the Child-Turcotte-Pugh (CTP) classification and the prognostic model for end-stage liver disease (MELD). MELD score is based on three blood tests: international normalized ration (INR) which tests the clotting tendency of the blood, bilirubin which tests the amount of bile

pigment in the blood, and finally creatinine which tests kidney function. Essentially, the prognosis depends on the cause of the hepatic failure and two main factors involved in determining prognosis are etiology and coma grade upon admission.

After liver transplant, overall patient survival rates that were at one and five years immediately increase to 86.4% and 72.9% respectively.

PATIENT CHARTPatient: Cynthia Apple Bottom

Anthropometrics:Temp: 96.5 Pulse: 80Blood Pressure: 122/76Height: 5’8”Current Weight: 121 lbsUsual Body Weight: 130 lbs (pre-surgery)BMI: 18.5 (lower end of normal, almost underweight)

Chief complaints post-op:The transplant was successful and Cynthia has been recovering for 4 days. She can intake soft foods orally but her chief complaint is that she doesn’t have a big appetite. She has lost another 3 pounds since the surgery. She had lost 6 pounds unintentionally prior to the surgery.

Nutrition:General: Poor appetite for the past 3 weeks. She drinks almond milk for

calcium supplement for breakfast everyday. Lunch is either a small salad or soup with crackers and iced tea. Dinner is usually at home and consists of a piece of plain chicken or fish with a vegetable and rice.

Current diet intake: ice chips or sips of orange juice. Breakfast: Soft scrambled eggs with ½ slice of wheat toast. Mid day: Soft noodles with butter. Dinner: None- no appetite.

Current diet order: mostly soft, 4 grams sodium restriction, high calorie, frequent meals (4-6 x day)

Food purchase/prep: herself

Vitamin/Mineral Intake: 600 mg Calcium with 400 IU vitamin D, multivitamin/mineral daily

Instruction Materials

Why is the liver important?The liver is the second largest organ in your body and is located under your rib cage on the right side. It weighs about three pounds and is shaped like a football that is flat on one side.The liver performs many jobs in your body. It processes what you eat and drink into energy and nutrients your body can use. The liver also removes harmful substances from your blood.

Why is nutrition important after liver transplantation?Nutrition plays a key role in your recovery after liver transplantation. As with any surgery, adequate calories, protein, vitamins, and minerals are needed for wound healing. Also, your nutrient and diet needs may change if you have complications and/or side effects from your medications after your transplant.

Once you have successfully recovered from the early stage after transplant (ex. your appetite is back to normal, your weight is stable, and your wounds are healing well) then you should change to a diet that is low in saturated fat and high in fiber, fruits, and vegetables. This type of diet will help reduce risks for other chronic diseases including heart disease and diabetes. Always discuss your individual dietary needs and concerns with your dietitian or doctor.

It is important to maintain a healthy weight. Obesity, gaining an unhealthy amount of excess fat, increases your risk of chronic diseases and can damage your new liver.

Eating a healthy diet helps the liver to do its functions well and to do them for a long time.

Eating an unhealthy diet can lead to liver disease. For example, a person who eats a lot of fatty foods is at higher risk of being overweight and having non-alcoholic fatty liver disease.

For people who have liver disease, eating a healthy diet makes it easier for the liver to do its jobs and can help repair some liver damage. An unhealthy diet can make the liver work very hard and can cause more damage to it.

Where should my calories come from?You should eat enough calories to prevent muscle wasting and allow for gradual regaining of lean body weight that is often lost with severe illness before transplant and during hospitalization (bed-rest) after transplant. Choose nutrient dense foods (dairy, whole grains, plant foods) instead of foods considered “empty calories” (ex. sodas, candy). If appetite is poor, broaden your scope of food choices to allow for food preferences. Fruits and vegetables need to be part of your diet to provide enough vitamins and minerals.

Where should my protein be coming from?Protein is important to promote healing and muscle gain.Suggestions of animal based high protein sources:-fish-poultry-egg whites-eggs with yolk no more than 4 times per week-dairy products-milk, cheese, yogurt-red meats- pork, beef, vealSuggestions of plant based high protein sources:-unsalted nuts-peanut butter

-soy products-dried beans, lentilsChoose lean protein foods more often and prepare them using lean cooking methonds like drilling or baking rather than pan frying. Avoid using iron pans.

How can I avoid hyperglycemia?Hyperglycemia is a side effect of the medications given after transplantation. To prevent or manage this condition, foods high in simple sugars should be limited. These include:-sugar-molasses-doughnuts, pastries, sweet rolls-pies, cakes, cookies-honey-syrups-jam, jelly, marmalade-soft drinks (diet sodas are acceptable)-candy, chocolate-ice cream, frozen yogurt-jell-o-other sweetened beverages (juices, teas)Blood sugar levels should be monitored and if you develop high blood sugar you diet may need to be modified to the following guidelines:-carbohydrates should be high in fiber- consume more whole grain products, legumes, vegetables instead of refined white breads and cereals. -Limit fruits to one serving per meal. One serving = ½ cup chopped or canned or one medium whole -eat often, avoid skipping meals. Each meal and/or snack should include some high quality protein

How much sodium am I allowed?Some medications such as prednisone can cause your body to retain sodium and water. This can then cause increased blood pressure. To help avoid this, it is best to restrict salt intake. The “No Added Salt” diet, which is usually recommended, suggests eating less than 3000 mg of sodium each day. To follow these recommendations, you should:

1. limit salt when cooking, Use herbs and spices for flavor instead.2. Do not add salt after food is prepared3. Avoid or limit the following foods

a. High salt/canned soups, processed meats, fast food items, salted snacks (i.e. pretzels, crackers, potato chips, etc.

4. Condiments

What else can help benefit my health after transplant?EXERCISE.Long periods of inactivity and/or bed rest causes loss of muscle mass and strength (including strength of the heart) and limits your ability to perform exercise. A successful transplant does not automatically return you to normal physical activity. For muscles to regain their function and strength, they must be used regularly. Many people after transplant have high blood pressure, high cholesterol, and gain fat weight. All of these increase your risk of heart attacks or stroke.

There is enough scientific evidence to say that regular physical activity: •Decreases risk of death from heart disease. •Prevents or delays the development of high blood pressure. •Reduces blood pressure in people who already have high blood pressure. •Keeps muscles and joints strong and functioning.•Helps bones develop during childhood and helps adults prevent osteoporosis (thinning of the bones).

FOOD SAFETY AND SANITATIONPost liver transplant surgery you are more susceptible to food borne illnesses so continuing food safety practices is essential. DRUG/NUTRIENT INTERACTIONS:You are taking immunosuppressant medication. There are many potential food-drug interactions that can occur. The following table will guide you:Immunosuppressant Drug Generic Name Possible food-drug interaction

Cyclosporine, tacrolimus No Potassium supplement or salt substitute, caution with grapefruitAnorexia, diarrhea, increase glucose, esophagitis, steatorrhea

Azathioprine Diarrhea, steatorrhea, negative nitrogen balance

Rapamune Increased cholesterol, hypertriglyceridemiaMycophenolate mofetil Take on empty stomach, anorexia, stomatitis,

dyspepsia, abdominal pain, colitis, diarrhea, constipation

Should I be worried about potassium toxicity?If you are taking Cyclosporine or Tacrolimus, these can increase your blood potassium levels.Abnormal blood potassium levels can cause problems with muscle and heart function. Below is a list of food items that are high in potassium. If you are taking these medications you will be asked to limit the intake of these items.-Apricots, avocados, bananas, dried fruit, melons, oranges, nectarines, peaches-leafy greens, pumpkins, potatoes, split peas, dried beans, lentils, tomatoes-orange juice, prune juice, tomato juice, v-8 juices-milk and dairy, peanut butter, nuts, chocolate

SAMPLE 1 DAY MENU

Breakfast AM Snack Lunch PM Snack Dinner*3 scrambled egg whites

½ cup Oatmeal

2 oz. turkey breast lunchmeat (low sodium)

½ cup cottage cheese

Whitefish with Tomato Mousse and Fresh Herbs

2 pieces soft wheat bread

1 cup almond milk

1 slice Swiss Cheese

Fresh fruit/berries

Kale Blueberry and Pomegranate Salad

1 cup vanilla greek yogurt

½ cup apple sauce

2 TBSP hummus

8 crackers no salt

1 cup orange juice

Lettuce, Tomato

Peanut butter

2 slices whole grain bread

Side Salad with low fat dressing

*recipes attachedRECIPES ADOPTED FROM “HEALTHY RECIPES” OF THE AMERICAN LIVER FOUNDATION

Whitefish with Tomato Mousse and Herbs

Serves 4

1-pound White fish fillet (halibut, cod, etc.)

10 large, ripe tomatoes

1 clove of garlic

1⁄2 cup fresh or dried herbs (chervil, tarragon, basil, etc.) fine chopped

Salt and pepper to taste

DIRECTIONS:

-Cut the fish into four equal portions of 4 ounces each, season with salt and pepper,

keep refrigerated. -Cut tomatoes in half and remove seeds but save the juice. Using a

blender, puree the tomatoes and garlic. Place the tomato puree in a saucepan, and

simmer over medium heat for about 20 minutes.

-After cooking gently remove the red tomato mousse that is forming at the top and

reserve draining in a strainer lined with a coffee filter adding the additional liquid to

the rest and stain it though a coffee filter as well. What happens when the puree is

cooking it separates and forms a red thick puree on the top and a clear broth on the

bottom.

-Broil the fish under the oven broiler to desired doneness.

-Place the fish into a shallow bowl and pour tomato broth on top. Garnish with

tomato mousse, and fresh herbs.

KALE, BLUEBERRY AND POMEGRANATE SALAD

Kale is usually thought of as a green for cooking, but in this recipe, it’s used as a

salad green, one with a lot more texture than lettuce. Its hardiness means that the

leaves won’t wilt after the salad is dressed. Kale’s pleasant bitterness is nicely

balanced by the sweetness of the blueberries and the tartness of the pomegranate

seeds. This salad is rich in brain-boosting foods: Kale is an excellent source of

flavonoids and vitamin C, blueberries and pomegranates are high in antioxidants.

Serves 4

3 bunches Kale, stemmed and chopped

1 cup fresh blueberries

2 medium carrots, peeled and shredded

1⁄2 cup pomegranate seeds

1/3 cup pumpkin seeds, toasted

1/3 cup sliced almonds, toasted

1 tablespoon chopped fresh mint leaves

1⁄2 cup Soy-Seasame Vinaigrette

Salt and freshly ground black pepper

DIRECTIONS:

Combine the kale, blueberries, carrots, pomegranate seeds, pumpkin seeds,

almonds, and mint in a medium bowl and toss well.

Drizzle with the vinaigrette and toss again.

Season to taste with salt and pepper and serve right away.

WORKS CITED Healthy Recipes. American Liver Foundation. July 2013. Retrieved from: http://www.liverfoundation.org/downloads/alf_download_1068.pdf

Liver Transplant Patient Handbook. UCSF Medical Center. 2011. Retrieved from: http://www.ucsfhealth.org/pdf/liver_transplant_manual.pdf

Liver Disease Diet. 2014. Retrieved from: http://www.drugs.com/cg/liver-disease-diet.html

Liver and Wellness. American Liver Foundation. 2009. Retrieved from: http://www.liverfoundation.org/downloads/alf_download_729.pdf

Nutrition Therapy and Pathophysiology, Nelms, pages 447-460.

The Progression of Liver Disease. American Liver Foundation. October 2011. Retrieved from: http://www.liverfoundation.org/abouttheliver/info/progression/

Renal Diet for Dialysis

Description of Patient and Diagnosis:Client Name: Beth Anderson DOB: 7/21/1946 (68 years old)Sex: FemaleEducation: Bachelors Degree Occupation: Secretary at a Real Estate OfficeHours of Work: 8:00 AM- 5:00 PM (sometimes 6:00PM) Ethnic Background: Caucasian Household Members: Husband- 69 years old

Patient History:Beth is 68-year-old female who is 5’5’’ and weighs 134 pounds. She has

previously been diagnosed with kidney disease as a result of untreated high blood pressure throughout most of her life. Even when she was diagnosed with kidney disease she didn’t take into account the nutrition and medical therapy. Now that she has reached stage five, kidney failure, she has realized how serious this is. She said she is very busy throughout the day between work and taking care of her husband. She has started hemodialysis at the hospital and will eventually go to a clinic that specializes in dialysis once she gets used to the routine. Beth is educated about kidney failure but she wants to start to meet with a dietitian to get educated on

healthier eating while dealing with dialysis. She is taking time off work and said she will eventually work part time or retire at this point. Nutrition History:

She considered herself to have a balance diet. Is not that picky about foods. Loves to cook and is willing to try new recipes. She knows that she has to consume more calories because she heard that meeting caloric needs is important while on dialysis. Main reason for coming in:

She knows that she has waited way to long to realize the severity of her disease. She knows how serious kidney failure is and is embarrassed that she let her kidney disease get to this point. She wants to start to meet with a dietitian to get her eating on track as she is adjusting to dialysis. She likes to cook and is open to knew ideas and recipes she can try

Discussion of the Disease:Etiology: There are many different factors associated with kidney failure, however the

most leading causes of this disease are Diabetes, hypertension, and glomerulonephritis. Other factors that result in developing Kidney disease is ones, ethnicity, family history, direct blow to the kidneys, and prolonged consumption of over-the counter pain killers that combine aspirin and ibuprofen.

Diagnostic Measures: Chronic kidney disease (CKD) progresses slowly over time and even times

when the kidney functions remain stable. Kidney function is assessed based on glomerular filtration rate (GFR), which is reflected in clearance tests that measures the rate at which substances are cleared from the plasma by the glomeruli. The National Kidney Disease Education Program has defined CKD of less than 60 mL/min/1.73m2 for three months or longer and having an albuminuria of more than 30 mg of unrinary albumin per gram of urinary creatinine. Stage 5 CKD is defined as kidney function that is inadequate to sustain life and requires initiation of renal replacement therapy.

Stage Description1 Kidney damage with normal GFC2 Kidney damage with mild decrease in

GFR3 Moderate decrease in GFR4 Severe decrease in GFR5 Kidney Failure

Treatment: Hemodialysis: This is the most common method of medical treatment.

It requires access to the circulatory system; therefore patients need to have a procedure done that allows continual access to the bloodstream. Patients

who decide to go with this method of treatment will have dialysis done three times a week for about four hours in the hospital or a dialysis center. This treatment can also be done at home, which allows the patient to be more flexible with how long each cycle is and how often they do it.

Peritoneal Dialysis: This type of treatment is done by surgically placing a catheter into the peritoneal cavity. Dialysate is the liquid that enters the body through the catheter that is placed in the peritoneal cavity that cleans out the blood in the system. There are two types of PD: continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD). CAPD is a method that requires no machine and can be done in any clean and well lit location. It takes about four to six hours followed by another 40 minutes to for draining of used dialysate and replacement of fresh solution. Patients will usually sleep with the solution in the stomach CCPD does require a machine called a cycler, which empties their stomach three to five times during the night.

Renal Transplant: There are about 18,000 that are performed annually and about 70,000 people are waiting for a transplant. For the transplant to be successful the donor must match the recipients medical and immunological characteristics. Medical Nutrition Therapy:Protein:If a patient is receiving dialysis a protein level of 1.2 grams/kg is important

to maintain proper protein levels within the body. If the protein levels are too low the patient will end up with a negative nitrogen balance indicating that aren’t receiving adequate essential amino acids. It is recommended to eat high- quality proteins, which are proteins that produce less waste than others. Some examples are meat, fish, poultry and eggs.

Fluid: Controlling fluid intake is important in dialysis pateints. Too much fluid

consumption can cause high blood pressure, interdialytic weight gain, presenece of edema, and congestive heart failure. Most patients start with an allowance of 1 L per day within the first 12 months. As output and input become more regular the 1 L can be pushed up to 2 L depending on the individual situation.

Sodium: ~1,500-2,000 mgIt is important to monitor sodium intake so you can control the levels of fluid

within your system. Consuming foods high in sodium can cause you to drink more fluids. The more fluids in your blood system the hard your heart pumps, which can cause hypertension.

Potassium: ~2,000 mgPotassium is an important mineral that is found in many foods such as fruits

and vegetables; however, it can affect heart rate. Healthy kidneys regulate the amount of potassium within your system to keep a steady regular heart beat. High levels of potassium in between dialysis can be dangerous. Avoiding foods such as oranges, bananas, tomatoes, potatoes, and dried fruits.

Phosphorus: ~800- 1,000 mgPhosphorus is a mineral that tends to pull calcium from the bones in our

body. This causes our bones to be brittle and weak allowing them to be perceptible to fractures and breaks. People will take phosphate binders in between dialysis sessions to absorb the phosphate within the system.

Supplements:

Monitor/ Evaluating Prognosis-

Since Beth is just starting hemodialysis she has a little bit of time to get adjusted to the treatment and adapting to the new eating habits. If she takes control of her medical condition from this point on and follows the new eating plan she will be able to live a somewhat normal life. Once she adapts to these changes going to dialysis a few times a week will become part of her weekly activities. I have faith that Beth is serious about these changes and is willing to do what it takes to allow herself to be healthier. **FIX**

Medical Nutrition Therapy- treatment for client

HB= 655 + (9.56 X wt(kg)) + (1.85 X ht (cm))- (4.68 x age) =655 + (9.56 X 61.24kg) + (1.85 X 165.1cm))- (4.68 x 68) =655 + (585..45) + (305.44)- (318.24) = 1,227 kcals/day Stress Factor of 1.2-1.4 = 1.2 x 1,227 to 1.4 1,227 = 1,472 – 1,717 kcals/day = ~1,550kcals/day

Protein: =1.2 grams of protein/kg of body weight

=1.2 grams of protein X 61.24 kg = 73 grams of protein/day

Carbohydrates: = 1,550 kcals X .55 = 852 kcals/day

Fat: = 1,500 kcals X .30 = 465 kcals/day

Helpful Resources: American Association of Kidney Patients Nutrition Counter National Kidney Foundation: Recipes Healthy Eating for People on Hemodialysis- American Kidney Fund

24 Hour Recall: Amount Na +

(mg)K+ (mg) Phos

(mg)Protein

(g)kcal

Breakfast

Orange Juice ½ cup 1 248 21 .85 56Scrambled Egg 1 egg 71 69 99 6.3 72Cheese 1 ounce 461 78 146 5.1 95Whole Wheat Toast

1 slice 132 69 57 3.7 69

Banana 1 medium 1 422 26 1.3 105

Coffee 1 Cup 7 54 5 .2 42% Milk ¼ cup in

coffee29 86 56 2 61

Sugar About 1 packet

Lunch

Whole Wheat Bread

2 slices 264 138 114 7.4 138

Deli Meat- 2-3 slices 545 160 112 11 86

HamCheese 1 slice 461 78 146 5.1 95

Lettuce ¼ cup ~2 ~29 ~4 0 ~2

Tomato 2 medium slices

4 63 9 ~1 7

Mayonnaise 1 tablespoon 105 1 4 .1 57

Orange 1 medium 1 232 32 1.3 69

Dinner

Steak 3 oz 41 233 23.3 180

Brussels Sprouts and Asparagus

½ cup 11/1 85.5/77 15/22 ~1/~1 ~10/~10

Mashed Potatoes

½ cup 349 245 59 2 119

Snack

Popcorn 1-2 cups 1 ~61 ~62 ~2.5 79

2,486 1,0149 989 69 1.304

Instruction Materials Instructions and Focus

Learn how to eat properly while going through dialysis. How to limit amounts of sodium, potassium, and phosphorus but still eat adequate foods throughout the day that will meet caloric needs. Goal for appointment:

Start guiding Beth in the right direction for proper nutrition while she adjusts to dialysis. Introduce foods that will help meet her caloric needs but low in sodium, potassium, and phosphorus. Nutrition Points to Cover

- Discuss calories, protein, fat, and carbohydrate - Review sodium, potassium, and phosphorus - Go over 24-hour recall - Discuss goals that Beth would like to achieve throughout her experience

meeting with a dietitian

Weekly Tips:Tips to Control…

Thirst:o Consume foods that say low Sodium o Drink out of smaller cups and glasseso Freeze your drinks and eat them like popsicles

Potassium:o Cut the food in half and only eat half one day and the other half the

next day o Food such as potatoes dice or shred and boil in water to removed

the potassium

References"Acute Kidney Failure ." MedlinePlus. N.p., 1 Feb. 2013. Web. 13 Apr. 2014. <http://www.nlm.nih.gov/medlineplus/ency/article/000501.htm>."Dialysis ." National Kidney Foundation . National Kidney Foundation, Inc., 20 Jan. 2013. Web. 13 Apr. 2014. <https://www.kidney.org/atoz/content/dialysisinfo.cfm>."Education ." American Association of Kidney Patients. N.p., 1 Jan. 2013. Web. 13 Apr. 2014. <https://www.aakp.org/education.html>.Kidney Failure . (n.d.). American Kidney Fund. Retrieved April 13, 2014, from http://www.kidneyfund.org/kidney-health/kidney-failure/"Kidney Failure: Eat Right to Feel Right on Hemodialysi." National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). N.p., 20 Nov. 2013. Web. 13 Apr. 2014. <http://kidney.niddk.nih.gov/KUDiseases/pubs/eatright/>."Kidney Failure ." MedlinePlus. N.p., 1 Feb. 2013. Web. 13 Apr. 2014. <http://www.nlm.nih.gov/medlineplus/kidneyfailure.html>."Kidney (Renal) Failure ." Urology Care Foundation . N.p., 1 Mar. 2013. Web. 13 Apr. 2014. <http://www.urologyhealth.org/urology/index.cfm?article=20>.Recipes . (n.d.). National Kidney Foundation . Retrieved April 13, 2014, from http://www.kidney.org/patients/kidneykitchen/recipes.cfm"The Renal Diet ." American Association of Kidney Patients. VCU Health System MCV Hospitals and Physicians , 1 Jan. 2013. Web. 13 Apr. 2014. <http://www.vcuhealth.org/transplant/docs/renal_diet.pdf>.Resenius Medical Care . (n.d.). Meal Planning . Retrieved April 13, 2014, from http://www.ultracare-dialysis.com/HealthyLifestyles/EatHealthy/MealPlanning.aspx

Bryn WilkinKNH 413

Medical Nutrition Therapy Diet – Soft Diet

1. Purposea. Nutrition Indicators

A soft diet is used for patients who cannot tolerate a regular diet, and can be used as a transition diet from full liquids to solid foods. Soft foods may be recommended for patients who are unable to swallow normal food items due to a stroke, oral surgery, metabolic stress, etc. A speech-language pathologist would accurately diagnose this diet. However, a dietitian may recommend a soft diet prescription if they notice difficulty chewing, swallowing, dental problems, weakness, stomach discomfort, head or neck trauma, or a patient is taking chemotherapy.

b. Criteria to Assign the DietThere are several criterions that are used to assign a soft diet. The patient must show GI tolerance of a full liquid diet before transitioning to a soft diet. In addition, a speech pathologist should test the patient in order to ensure that they are capable of chewing and swallowing the foods in a soft diet. A dietitian should feel confident that the patient will be compliant with a soft diet before prescribing it. Finally, the patient’s GI tract should be tolerating a full liquid diet with no negative side effects such as the presence of steatorrhea, diarrhea, or vomiting.

c. Rationale for DietThis diet is most often used as a transition diet. The soft diet should be used to increase a patient’s tolerance to solid foods. As a patient’s GI tract improves, a soft diet can be used to slowly introduce solid food and the required digestion to the body. This diet allows for some bowel rest as the patient begins to return to a regular diet.

2. Populationa. Overview

A soft diet is most often used as a transition diet for people who are recovering from surgery. Many times a soft diet will be used after an individual undergoes gastrointestinal surgery or resection. The soft diet is part of a progression that comes after a full liquid diet. Although there are many surgeries where a soft diet may be prescribed, the following example covers how a soft diet would incorporated into a patient’s recovery from a bowel resection, as the result of damage from Crohn’s disease or ulcerative colitis.

b. Disease ProcessInflammatory bowel disease (IBD) is defined as an autoimmune, chronic inflammatory condition of the gastrointestinal tract. It can be used as a general term to describe one of two diseases: ulcerative colitis, and/or Crohn’s disease. The complete etiologies for both inflammatory bowel diseases are not known. However, it is clear that environmental factors play a part in causing an abnormal inflammatory response. These factors include smoking, infectious agents, intestinal flora, and physiological changes in the small intestine. There is also a strong

connection between IBD and family history. These genetic associations have been connected within both the innate and acquired immune response. (Nelms, pg. 415-417)

c. Biochemical and Nutrient NeedsDepending on what part of the bowel is removed, the patient will have different biochemical and nutrient needs. If the jejunum is resected, it is very likely that the ileum will be able to adapt to absorb nutrients typically absorbed in the jejunum. The distal ileum is the only site for absorption of bile salts, vitamin B12 and also absorbs a large volume of fluid. The ileocecal valve is crucial in maximizing nutrient absorption. It controls the rate of passage of ileal contents into the colon. The colon is also essential for reabsorbing electrolyte-rich fluid each day and helps to maintain a person’s hydration status. Proper healing will require adequate protein and energy needs. Therefore, it may be necessary to supplement a soft diet with continued enteral feedings.

3. General Guidelinesa. Nutrition Rx

Diet Order: “Soft Diet” Purpose: To decrease peristalsis and limit stimulation of the GI tract. Often used as a transitional diet after surgery.General Description & Priniciples: Includes easily digestible foods that are low fiber, mildly seasoned, and tender. Omit caffeine and alcohol.

b. Adequacy of Nutrition RxA soft diet nutrition prescription would be written to cover 100% of the patient’s energy needs via soft foods. However, depending on GI tolerance of the new diet, it is possible that a soft diet alone will not supply the patient with adequate nutrition. Therefore, it may be necessary to continue enteral feeding supplementation to ensure that the patient is receiving enough calories, protein, and micronutrients.

c. GoalsOnce the patient begins a soft diet, it would be important to monitor the patient’s weight maintenance/gain to UBW, the redevelopment of bacterial flora in the GI tract, and nutrient absorption in the remaining small intestine. The patient’s blood panels should be evaluated, including levels of macro and micronutrients. In addition, it would be important to see signs of diet tolerance from the patient. The patient should not be experiencing excessive diarrhea or vomiting. In addition, the patient should not feel GI discomfort in the stomach or intestines. It would be important to monitor for signs and symptoms of steatorrhea or dumping syndrome. The goal would be for the patient to experience a smooth transition to the soft diet, with adequate energy and few negative clinical symptoms.

d. Does it Meet DRIYes, a soft diet will meet the recommended energy allowances as specified by the DRIs. However, if patient compliance is low, or a new GI tract does not tolerate the diet, enteral supplementation may be required for adequate nutrition.

4. Education Materiala. Nutrition Therapy

When an oral soft diet is first initiated, the patient should be given a low-residue, lactose-free with small, frequent meals—as tolerated. As the patient tolerates the mild diet, small amounts of fiber could be introduced. Foods that are considered to be “gas-producing,” such as spicy/fried foods or caffeinated beverages should be avoided. A multivitamin should be give throughout this time in order to ensure delivery of complete nutrition to the patient. In addition, probiotics should be incorporated into the diet in order to ensure that the patient’s new GI tract builds a new bacterial flora. The patient should be asked to maintain a food and exercise journal during their transition to the soft diet. In addition, the patient should note any episodes of vomiting, diarrhea, or steatorrhea. Compliance and tolerance of the diet should be evaluated during follow-up appointments.

b. Ideas for ComplianceIncorporating some of the patient’s favorite foods into the diet can increase patient compliance. During an initial counseling session, the dietitian should try to modify the patient’s pre-surgery usual food intake to fall within the restrictions of a soft diet. In addition, the dietitian should involve a patient’s family in the counseling sessions. Involving family members and receiving their support for the new diet can greatly improve patient compliance – especially if the patient is an elderly client. Finally, the dietitian should inform the patient of the prognosis for their recovery. Inflammatory bowel disease can be managed by diet and exercise. A soft diet prescription is not a lifetime prescription. The client will be able to return to a regular diet if he or she is compliant with the current soft diet prescription.

5. Sample Menua. Foods Recommended

Food Group Recommended FoodsGrains Breads, biscuits, muffins, pancakes,

waffles that have been well moistened with syrup, jelly, margarine, or butter. Well-moistened cooked or dry cereals. All pasta and noodles, rice, wild rice, and moist bread dressing.

Vegetables Tender-fried potatoes. All cooked tender vegetables. Shredded lettuce.

Fruits All canned and cooked fruits. Soft, peeled fresh fruits such as peaches, nectarines, kiwi, mangoes, cantaloupe, honeydew, watermelon (without seeds). Soft berries with small seeds such as strawberries.

Milk Milk, cream, half and half, pudding, custard, ice cream, sherbet, malts, frozen yogurt, and cottage cheese

Meat and Other Protein Products Well-moistened, thin-sliced, tender, or ground meat, poultry, or fish with gravy

or sauce. Eggs prepared in any way. Yogurt without nuts or coconut. Casseroles with small chunks of meat, ground or tender meats.

b. Foods to AvoidFood Group Foods Not RecommendedGrains Dry bread, toast, and crackers that have

not been moistened. Tough, crusty breads such as French bread or baguettes. Coarse or dry cereals such as shredded wheat or All Bran. Dry bread dressing. Dry cakes or cookies that are chewy or very dry.

Vegetables All raw vegetables expect shredded lettuce. Cooked corn. Tough crisp-fried potatoes, potato skins, or other fibrous, tough, or stringy cooked vegetables.

Fruits Difficult to chew fresh fruits such as apples or pears. Stringy, high-pulp fruits such as papaya, pineapple, or mango. Fresh fruits with difficult to chew peels such as grapes. Uncooked dried fruits such as prunes and apricots. Fruit leather, fruit roll-ups, fruit snacks, dried fruits.

Milk None unless liquids are restricted.Meat and Other Protein Foods Anything with nuts, seeds, dry fruits,

coconut, pineapple. Tough, dry meats and poultry. Dry fish or fish with bones. Chunky peanut butter. Yogurt with nuts or coconut.

Fats and Oils All fats with coarse, difficult to chew, or chunky additives such as cream cheese spread with nuts or pineapple.

c. Example of a meal planMeal MenuBreakfast ½ cup (4 ounces) orange juice – no pulp

½ cup well-moistened dry cereal with ¼ cup of milk1 scrambled egg with cheese on a moist biscuit1 cup (8 ounces) milk

Lunch 1 cup moist beef stew in small chunks

with a variety of well-cooked vegetables1 slice moistened bread with butter or margarine½ cup canned fruit salad½ cup pudding with a moist cookie1 cup (8 ounces) milk

Dinner ½ cup potato soup made with milk1 slice moistened bread with butter or margarine3 ounces moist chicken on ½ cup soft-cooked rice½ cup soft-cooked green beans1 slice apple pie with a moist crust, cheese wedge, and ice cream1 cup (8 ounces) milk

6. Websitesa. Organizations with Websites

Digestive Healthcare of Georgia. (2013). Retrieved from: http://www.digestivehealthcare.net/diets/soft_diet.html

Drugs.com: Know more. Be sure. (2013). Retrieved from: http://www.drugs.com/cg/soft- diet.html Fine, B. (2012). Nutrition Assessment. Retrieved from:

www.uic.edu/depts/mcam/nutrition/ppt/nutrition_assessment.pptNutrition Care Manual. (2014). Soft Diet. Retrieved from: http://www.nutritioncaremanual.org/University of Minnesota Medical Center: Fairview. (2014). Retrieved from:

http://www.uofmmedicalcenter.org/healthlibrary/Article/86513b. Government Websites

http://www.cdc.gov/nchs/data/nhanes/nhanes_07_08/DBQ_e_eng.pdfhttp://www.nlm.nih.gov/medlineplus/

7. Referencesa. Journal articles references

NCBI Database. (2002). Short bowel syndrome: a nutritional and medical approach. Retrieved

from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/

NCBI Database. (2009). Surgical therapy of recurrent Crohn’s disease. Retrieved from:

http://www.ncbi.nlm.nih.gov/books/NBK6915/

Patient Description

Janice is a 50 year old female who has been diagnosed with Type II Diabetes within the past six months. She is 61 inches (1.55m) tall and weighs 185lbs (84.1kg) giving her a BMI of 35. Janice’s BMI classifies her as stage two obese. Her mother was diagnosed with type II diabetes when she was 45 and her father died of a heart attack when he was 67. Janice works in a high school as a classroom aid, a job that requires some physical activity but does not meet the requirement of 30 minutes of moderate activity 5 days a week. Her job requires her to spend hours every evening coming up with new lesson plans for the following day. Her busy schedule does not allow her enough time to make regular visits to the gym. When Janice was diagnosed with type II diabetes, her fasting serum glucose was 223 mg/dL and her total cholesterol was 335 mg/dL. Janis’s LDL-cholesterol levels were 140mg/dL, her HDL-cholesterol levels were 35 mg/dL, and her triglyceride levels were 160 mg/dL. Her doctor proscribed her Januvia and Lipitor to manage her blood glucose and cholesterol, respectively. Janice was screened again 2 weeks prior to this visit and was told that these numbers had little to no change at all. Her doctor recommended she schedule a nutrition management session with a dietician to improve her glucose control and manage her dyslipidemia.

Family History

Mother: diagnosed with type II diabetes at age 45Father: died of a myocardial infarction at age 67

Medications

Januvia: class- DPP-inhibitorLipitor: class- statin

24-hour Recall

Breakfast: 1 bacon, egg, and cheese sandwich on 1 bagel with 2 slices of bacon and 1 slice of American cheese with 8oz of 2% milk.

Snack: 1 glazed donut from the conference room with 1 cup of decaffeinated coffee and 1 Tbsp of French vanilla flavoring

Lunch: from the cafeteria- 3 chicken tenders with ½ cup of fries, an 8oz fruit cup, and water

Dinner: 4oz breaded pork chop pan fried in olive oil, ½ cup of mashed potatoes with a tsp of butter, and a frosted cupcake for dessert

Snack: 1 cup of rich vanilla ice cream

Caloric breakdown provided by Fitday.com

Grams Calories % CaloriesCalories 2584Fat 117.14 1046.3 40.5 Saturated Fat 45.98 411.2 39.3 Polyunsaturated Fat 15.3 136.2 13 Monounsaturated Fat 48.1 429.5 41Carbohydrates 298.8 1163.4 45 Dietary Fiber 13.8Protein 92.8 373.7 14.5

Cholesterol: 744mg

Type II diabetes is a disease where the body’s cells become resistant to insulin and therefore cannot utilize the glucose in the blood resulting in abnormally high blood glucose levels. The risk factors for diabetes are obesity, inactivity, fat distribution, age, race, family history, pre-diabetes, and gestational diabetes.

Type II diabetes is diagnosed by three laboratory testing procedures: hemoglobin A1c test, Fasting plasma glucose test, and the oral glucose tolerance test. The hemoglobin A1c test analyses an individual’s average blood glucose levels over a period of three months. A1c is represented as a percentage of the total blood and any percentage greater than 6.5 is considered abnormally high. The Fasting plasma glucose test is administered after eight hours of fasting and is most accurate in the morning. Readings of 100 mg/dL-125mg/dL indicates the individual is glucose intolerant and multiple reading of 200 mg/dL or higher means the individual has diabetes. The oral glucose tolerance test measures an individual’s blood after a fast period of eight hours and two hours after an individual has been given a solution containing 75 grams of glucose dissolved in water. If after the two hours the individual’s blood glucose levels are higher than 200 mg/dL the individual can be diagnosed with diabetes.

Dyslipidemia is defined as having abnormal levels of lipids present in the blood. Lipids found in the blood are LDL-cholesterol, HDL-cholesterol, and triglycerides. These three components make up the total blood cholesterol of an individual. Cholesterol is a waxy substance found in animal source foods. LDL-cholesterol functions as a dietary cholesterol transport in the blood. High concentrations of LDL-cholesterol is associated with high levels of cholesterol and is often referred to as “bad cholesterol”. Abnormally increased levels of LDL-C are greater than 130 mg/dL. HDL-cholesterol acts as a scavenger in the blood and searches for cholesterol to bring back to the liver to be processed. HDL-C is called the “good” or “happy” cholesterol and should be found in concentrations greater than 40 mg/dL in the blood. Triglycerides are fats found in your blood that can be stored and later used for energy. A normal level of triglycerides is less than 150 mg/dL in the blood.

Type II diabetes and dyslipidemia can be medically managed with the use of medications. However, the MNT for Janice will be to initiate use of the TLC diet. The TLC, or Therapeutic Lifestyle Changes diet, was designed by the National Cholesterol Education Program (NCEP) and aims to lower cholesterol through an

increase in physical activity and weight reduction. The guidelines for the TLC diet are as follows:

Less than 7% total calories from saturated fats25-30% total calories from fatless than 200mg of dietary cholesterol per day20-30g of fiber per day.

Foods to stay away from include high amounts of animal source foods such as beef, pork, milk, and cheeses. Foods that increase HDL-C and decrease LDL-C while also working to lower blood glucose levels are fruits, vegetables, beans, and whole grains.

Resources

http://tlcdiet.org/

http://care.diabetesjournals.org/content/30/suppl_1/S48.full

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748661/

http://www.webmd.com/drugs/drug-3330-Lipitor+oral.aspx?drugid=3330&drugname=Lipitor+oral&source=0

http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/oral-medications/what-are-my-options.html

http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/#3

Medical Nutrition Therapy Diet Haley Robertson

KNH 413- Spring 2014

1. Purposea. Nutrition Indicators-

There are several tests used to determine Wilson’s disease including: examination for Kayser-Fleisher rings, serum ceruloplasmin test, 24-hour urine copper test, liver biopsy, and genetic testing.

Liver, nerurological, musculoskeletal and psychiatric areas of health can also have indicators of Wilson’s disease helping to diagnose the disease.

o These can include chronic active hepatitis, cirrhosis, jaundice, hematemesis, difficulty speaking, excessive salivation, ataxia, personality changes, dystonia, grand mal seizures, emptional liability, compulsiveness, self-injurous behavior, schizophrenic-like behavior, skeletal abnormalities, and cardiac manifestations.

Testso Serum ceruloplasmin levels < 20 mg/dLo Urinary copper excretion rate > 100mcg/dayo Hepatic copper concentration (liver biopsy) > 250 mcg/g of

dry weightb. Criteria to Assign the Diet:

If the patient has any of the above testing levels or multiple it is recommended they follow a Wilson’s Disease diet.

c. Rationale for Diet:The diet is recommended to decrease the levels of copper in the blood by decreasing the amount of copper in the diet.

2. Populationa. Overview-

An autosomal recessive disease Occurs equally in men and women Both parents must carry the gene in order to inherit Wilson’s disease At least 1 in 20,000 people of all known rates and nationalities has the

disease The carrier frequency of the gene is 1 in around 100 people in the U.S.

o This gene is located on the 13th chromosome and is called ATP7B

b. Disease Process-o The genetic mutation located on chromosome 13 of the body is

responsible for Wilson’s disease.o This gene contains the necessary information for making a

copper transport protein that is responsible for removing copper from the liver, but mutations in the gene inhibit proper removal of excess copper from the liver and allows copper to accumulate in other organs and the liver.

o This excess build up of copper can lead to the symptoms described above.

c. Biochemical and Nutrient Needs- It is important to limit foods high in copper because the body is

not able to excrete the excess amounts from the organs, especially during the beginning stages of the disease. The copper content of drinking water must also be tested because it is possible for water to contain copper as well so bottled water is recommended. It is recommended also to be cautious of vitamins and supplements containing copper.

A zinc supplement, such as Zinc acetate prevents the absorption of dietary copper in your body so a low copper diet can be tolerated.

3. General Guidelinesa. Nutrition Rx –

Patients must avoid copper-rich foods and beverages and restrict copper intake to < 1 mg/day. A Zinc supplement can be added into the diet to help with copper excretion in addition.

b. Adequacy of Nutrition Rx This Nutrition Rx is an adequate Rx because it is focused on the

issue of the patients’ in ability to excrete copper. By decreasing the intake of copper and increasing a supplement that will help

with the excretion of copper, the amount of excess copper in the body should be able to be maintained.

c. Goals The goal of this diet is to ultimately decrease excess levels of

copper within the body and be able to maintain a balanced level of copper intake with excretion through diet and supplementation.

d. Does it Meet DRI The RDA for copper in an adult is 900 mcg or 0.9 mg. If a

patient follows the Wilson’s disease diet of low copper intake they will meet the RDA for copper.

4. Education Materiala. Nutrition Therapy

It is important for the client to fully understand the implications of their disease from a nutrition and diet stand point. Using nutrition handouts and nutrition education tools, the client can gain a better understanding of high copper foods they should avoid and low copper foods they are allowed to include in their diet. By going through their typical day and understanding their likes and dislikes it would be helpful in order to advise them on slight changes they can make in their eating plans in order to follow the diet successfully. Also, keeping a food log and tracking the amount of copper in their diet will also be a helpful tool in making sure they are following the recommended diet.

b. Ideas for Compliance In order to increase compliance the patient should be fully

aware of the consequences of not accommodating to the low copper diet and the health risks that are likely if non-compliant.

Building a positive relationship with the client and using a reward system can also be beneficial in compliance to the diet so the patient knows the dietitian is invested in their health and they should be as well.

5. Sample Menua. Foods Recommended

Beef Eggs White meat turkey and chicken Cold cuts and frankfurters that do not contain pork, dark

turkey, dark chicken, or organ meats Most vegetables including fresh tomatoes

Breads and pasta from refined flour Rice Regular oatmeal Cereals with <0.1 mg of copper per serving (check label) Butter Cream Margarine Mayonnaise Non-dairy creamer Sour cream Oils Salad dressings (made from allowed ingredients) Most milk products Milk flavored with carob Cheeses Cottage cheese Jams, jellies, and candies made with allowed ingredients Carob Flavoring extracts Coffee Tea Fruit juices Fruit-flavored beverages Lemonade Soups made with allowed ingredients

b. Foods to Avoid Lamb Pork Pheasant Quail Duck Goose Squid Salmon Organ meats including liver, heart, kidney, and brain Shellfish including oysters, scallops, shrimp, lobster, clams,

and crab Soy protein meat substitutes Tofu Nuts and seeds Vegetable juice cocktail Mushrooms Nectarines Commercially dried fruits including raisins, dates, prunes

Avocado Dried beans including soy beans, lima beans, baked beans,

garbanzo beans, pinto beans Dried peas Lentils Millet Barley Wheat germ Bran breads Cereals with >0.2 mg of copper per serving (check label) Soy flour Soy grits Fresh sweet potatoes Chocolate milk Soy milk Cocoa Instant breakfast beverages Mineral water Soy-based beverages Copper-fortified formulas Brewer’s yeast Multi-vitamins with copper or minerals

c. Example of a meal plan

Sample MenuBreakfast

1 C Oatmeal ½ C 2% Milk 1 Scrambled Egg (with cheese) 8 oz. Orange Juice

Snack Greek yogurt with Strawberries

Lunch Turkey Sandwich

o 2 oz. Turkeyo Refined white breado Mustardo Lettuceo Cheese

1/2 C carrots chopped 1 small apple 1 bottled water

Snack ½ PBJ Sandwich

o 1T PBo 1 T Jellyo 1 slice refined white breado 1 bottled water

Dinner Chicken 2 oz (baked) ½ C Green Beans ½ C Cooked Corn Salt/Pepper 2 T Margarine ½ C 2% Milk 2 Sugar cookies

Snack 3 C Air-Popped Popcorn Smoothie 8 oz.

o Yogurto Fruit juiceo Strawberrieso Banana

6. Websitesa. Organizations with Websites

Arizona Digestive Healtho http://www.arizonadigestivehealth.com/low-copper-diet-

for-wilsons-disease/ Wilson’s Disease Association

o http://www.wilsonsdisease.org/wilson-disease/ Oregon State University (Linus Pauling Institute)

o http://lpi.oregonstate.edu/infocenter/minerals/copper/

b. Government Websites Center for Disease Control (CDC)

o http://www.cdc.gov/niosh/npg/npgd0151.html Genetics Home Reference

o http://ghr.nlm.nih.gov/condition/wilson-disease Better Health Channel

o http://www.betterhealth.vic.gov.au/bhcv2/ bhcarticles.nsf/pages/Wilson's_disease#

7. Referencesa. Journal articles references

http://www.wilsonsdisease.org/wilson-disease/wilsondisease-diet.php

a. Websiteso About Wilson Disease. (2009, January 1). Wilson Disease Association.

Retrieved , from http://www.wilsonsdisease.org/about-wilsondisease.php

o Diseases and conditions: Wilson's Disease. (2011, September 23). Mayo Clinic. Retrieved , from http://www.mayoclinic.org/diseases-conditions/wilsons-disease/basics/treatment/con-20043499

o Gilroy, R. (2013, October 1). Wilson Disease. Medscape. Retrieved , from http://emedicine.medscape.com/article/183456-overview

o Higdon, J., Delage, B., & Prohaska, J. (2014, January 1). Micronutrient information center: Copper. Oregon State University Linus Pauling Institute. Retrieved , from http://lpi.oregonstate.edu/infocenter/minerals/copper/

o Low copper diet for Wilson's Disease. (2014, January 1). Arizona Digestive Health. Retrieved , from http://www.arizonadigestivehealth.com/low-copper-diet-for-wilsons-disease/

Emily HawleyKNH 413: TPN DietApril 24, 2014

PurposeThe purpose of total parenteral nutrition (TPN) is to sustain life and promote

growth and healing to patients whose gastrointestinal tract has been altered to the point where it is no longer able to metabolize and/or absorb nutrients for a significant period of time. This may be due to a massive bowel resection or short bowel syndrome, abdominal trauma or infection, or certain disease states. A patient’s complete inability to consume their energy and nutrients orally is another reason why TPN may be required. A patient may exert various signs that point to needing TPN such as rapid weight loss, fatigue, hypoglycemia, or nutrient

deficiencies. A TPN solution is tailored to the patient’s individual energy, fluid, protein, carbohydrate, lipid, and micronutrient needs and will drip through a needle or catheter placed in the vein. TPN bypasses the normal way the body digests food in the stomach. It supplies the fuels the body needs directly into the blood stream through a central IV line. The body needs three kinds of fuel carbohydrates, protein and fat. TPN also contains other nutrients, such as vitamins and minerals, electrolytes and water.PopulationPeople of all ages have received parenteral nutrition. It may be given to infants and children, as well as to adults. People can live very well on parenteral nutrition for as long as it is needed. Many times, parenteral nutrition is used for a short time; then it is removed when the person can begin to eat normally again. People would need TPN if You have had surgery on your intestines or digestive tract, you have a medical condition that prevents your intestines from working, such as a blockage, Crohn disease, or short-bowel syndrome, you have other medical conditions, such as cancer, AIDS (acquired immunodeficiency syndrome), pancreatitis, or hyperemesis gravidarum, or you have severe burns or other trauma.General GuidelinesTPN requires water (30 to 40 mL/kg/day), energy (30 to 45 kcal/kg/day, depending on energy expenditure), amino acids (1.0 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins, and minerals. Children who need TPN may have different fluid requirements and need more energy (up to 120 kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day). Basic TPN solutions are prepared using sterile techniques, usually in liter batches according to standard formulas. Normally, 2 L/day of the standard solution is needed. Solutions may be modified based on laboratory results, underlying disorders, hypermetabolism, or other factors. Most calories are supplied as carbohydrate. Typically, about 4 to 5 mg/kg/min of dextrose is given. Standard solutions contain up to about 25% dextrose, but the amount and concentration depend on other factors, such as metabolic needs and the proportion of caloric needs that are supplied by lipids. Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides; 20 to 30% of total calories are usually supplied as lipids.Progress should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, CBC, electrolytes, and BUN should be monitored often. Plasma glucose should be monitored every 6 h until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often.Liver function tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or retinol-binding protein), prothrombin time, plasma and urine osmolality, and Ca, Mg, and phosphate should be measured twice a week. Changes in transthyretin and retinol-binding protein reflect overall clinical status rather than nutritional status alone. A full nutritional assessment should be done every 2 weeks.Education Material

a. Nutrition Therapy: The specialized Registered Dietitian calculates the exact nutritional needs for the patient. The needs are supposed to meet the patients needs of energy, fat, carbohydrates, and protein by 100%. Vitamins, minerals, and electrolytes are also taken into consideration.

b. Compliance: If the patients continue TPN on 12 hours cycles at home they are required to be given education materials in order to properly administer the formula as well as how to do so in a sanitary fashion to prevent infection at the tube injection site or any other kind of TPN complication; this may require a training session with a nurse or registered dietitian as well as several check-ups once the patient is home. Educating a patient on recognizing the specific signs of infection and complication is also critical.

Sample MenuPatients on TPN do not have a set menu because they do not receive any food orally due to bowel rest or another kind of malabsorption problem.WebsitesASPEN: http://www.nutritioncare.org/Information_for_Patients/What_is_Parenteral_Nutrition/Canadian Cancer Society: http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/tube-feeding-and-total-parenteral-nutrition/?region=on Referenceshttp://www.nutritioncare.org/Information_for_Patients/What_is_Parenteral_Nutrition/http://www.drugs.com/cg/total-parenteral-nutrition.htmlhttp://www.merckmanuals.com/professional/nutritional_disorders/nutritional_support/total_parenteral_nutrition_tpn.html