APPNUT FINALS 2018

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- Defined by National Kidney Foundation (NFK) Kidney Disease
Topics: Outcome Quality Initiatives (K/DOQI)
 Diet Therapy In Kidney Diseases - Based on kidney function indicated by GFR and evidence of
kidney damage
 Diet Therapy In Selected Metabolic Diseases
- Stages:
 Dietary Management In Surgical Conditions 1. Kidney Damage (protein in urine) with normal GFR (90
 Critically Ill Patients ml/min) or above
 Nutrition Implications of Aging 2. Kidney damage with mild decrease in GFR 60-89 ml/min
3. Moderate decrease in GFR 30-59 ml/min
4. Severe reduction in GFR 15-29 ml/min
5. Kidney Failure less than 15 ml/min
- Definition of Chronic Kidney Disease Criteria
NUTRITION THERAPY IN KIDNEY DISEASES
o Kidney damage ≥ to 3 months, as defined by
Urinary System structural or functional abnormalities of the kidney,
- Kidney  bladder  ureter  urethra with or without decreased GFR, manifest by either:
- Remove waste from body pathological abnormalities; or markers if kidney
- Maintain acid base balance of the blood damage, including abnormalities in the
- Convert Vitamin D into its active form and produces composition of the blood or urine, or abnormalities
erythropoietin  RBC synthesis in imaging tests
- Fasting  produce glucose from amino acids 2
o GFR < 60 ml/min/1.73 m for ≥ to 3 months with or
Acute Renal Failure without kidney damage
- Rapid, severe decrease in GFR with reduced urine output Diet Prescription in CKD stages 1-4
- ECF expansion  edema, hypertension, CHF - Protein
- Etiology: ischemia, nephrotoxic injury due to drugs or o Stage 1-3: 0.75 g/kg/day (close to recommendation
endogenous pigments, sepsis, severe renovascular disease, for non-CKD which is 0.8 g/kg/day)
pregnancy o At least 50% should be of high biological value
- Reversible: Prerenal & Postrenal (HBV)
- Protein recommendations: o Stage 4-5: 0.6 g/kg/day
o Not on dialysis: no less than 0.8 g/kg/day with an - Energy
upper limit of 1.2 g/kg/day o Stage 4-5: <30-35 kcal/kg
o On dialysis: 1.2-1.5 g/kg/day - Minerals and Water
o Intakes greater than 1.5 g/kg/day shows no benefit o Na intake: 1-4 g/day depending on blood pressure,
- Goal: provide adequate calories to minimize protein fluid balance, presence of CHF
catabolism without overfeeding o Fluid intake is closely linked with urine output and
- Used to estimate energy needs: 25-35 kcal/kg/day is not restricted unless oliguria is present
- Good guideline: Urine output plus 500 ml for insensible o Stage 1-4: Potassium restriction is not necessary
losses (skin, sweat, stool) unless urine output decreases to less than 1000
Chronic Kidney Disease (CKD) ml/day or serum level is high
- Diabetes is the leading cause of ESRD o Stage 1-3: Phosphorus restriction is effective in
- Patients who begin renal replacement therapy (either dialysis controlling serum levels
or transplantation) with compromised nutritional status have o Phosphate-binding medications are needed along
a higher morbidity and mortality than those adequately with diet therapy to maintain recommended serum
nourished levels
- Primary nutritional goals for management of early stages of o In earlier stages, calcium levels should be
CKD include: maintained within normal lab value not exceeding
o Prevent protein-energy malnutrition 2000 mg/day due to risk of vascular calcification
o Minimize the buildup of uremic toxins and and bone disease
associated symptoms Hemodialysis
o Delay the progression of the disease - Requires direct access to the circulation either via native AV
o Prevent secondary hyperparathyroidism and fistula, usually the wrist; AV graft, or stiff large-bore IV
control acidosis catheter
o Treat any complications resulting from lifestyle - Blood is pumped through hollow fibers of an artificial kidney
issues (dialyzer) and bathed in a solution of favourable chemical
Stages of Chronic Kidney Diseases composition (isotonic, free of urea and other nitrogenous
compounds, low in potassium)
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Medical Nutrition Therapy for Hemodialysis Medical Nutrition Therapy in Peritoneal Dialysis
- Change in nutrients when patients reaches ESRD and begins 1. Energy and Protein
regular hemodialysis treatment - Absorb up to third of their total energy requirement from
- Significant concern: Malnutrition diasylate
- Affects oral intake and contribute to declining nutritional - 5-15 g are lost daily, mostly albumin
status: 2. Potassium and Sodium
o Diabetes - Potassium balance: 3-4g daily
o Chronic inflammation - Patients with excess sodium: need to use hiogher dextrose
o Cardiovascular disease diasylate to remove excess fluid retained as a result of
- Hemodialysis patient: chronic inflammation with elevated increased sodium intake
CRP levels - Frequent use of high dextrose can damage peritoneal
- Serum albumin: marker of chronic inflammation, protein membrane, aggravate diabetes, hypertriglyceridemia and
intake and nutritional status in dialysis patient along with hypercholesterolemia, overweight and obesity
body weight - Sodium intake: 2-4 g daily
o < 3.5 g/dl: mortality rate 1.38x higher 3. Cholesterol and Triglycerides
o Goal: 4.0 g/dl - Weight gain and absorption of dextrose from diasylate
1. Potassium, Sodium, Fluid Other Kidney related diseases
- Anuric/Oliguric: urine output <1000 ml/day  hyperkalemic Kidney Stones (Renal calculi)
without potassium restriction
- Accumulation of mineral salts lodging anywhere along
- Reduced daily intake of 2500 mg potassium: sufficient to
urinary tract
prevent hyperkalemia
- Calcium stones, Uric acid stones, Struvite, Cysteine stones
- As kidney function declines, gut compensates and becomes
- Symptoms: upper back pain, frequent urination, pus and
efficient at removing potassium through stool  potassium
blood in the urine
balance
- Pain relief: juice of half fresh lemon (or apple) in 8 oz of
- 40 mg/kg of ideal body weight is recommended
water every half-hour until pain subsides
2. Phosphorus, Calcium, PTH, Vitamin D
- Drink plenty of water at least 3 quarts daily
- Maintaining balance is crucial in prevention of secondary
- Increase Vitamin A consumption: alfalfa, apricots,
hyperparathyroidism
cantaloupe, carrots, pumpkin, sweet potatoes, squash
- Excess phosphorus  hyperphosphatemia, elevated calcium
- Minimize consumption of animal protein, potassium and
phosphate product, high PTH  renal osteodystrophy, soft
phosphates
tissue, vascular calcification
- Calcium supplements with meals if with family history
- High phosphorus foods:
- Avoid oxalic acid precursors like asparagus, beet greens,
o Dairy products
beets, blueberries, celery, eggs, fish, grapes, parsley,
o Dried beans
rhubarb, sorrel, spinach, swiss chard, cabbage
o Beer
Urinary Tract Infection
o Nuts
o Chocolate - Escherichia coli adhere to uroepithelial cells that line the
o Cola bladder, kidney, urethra
- Calcium intake: should not exceed 2000 mg/day - Adherence required p-fimbriae on cell walls
3. Vitamins and Other Minerals - Cranberry juice may lead to reduction in number of bacteria
- Vitamins A & E accumulate in kidney failure: not - Proanthocyanidins prevent bacterial adhesions
supplemented o Cranberry, blueberry
- B6, B12, B9: supplemented
- Vitamin C: not supplemented DIET THERAPY IN SELECTED METABOLIC DISEASES
o Excess levels: oxalate kidney stones
Diabetes Mellitus
- Low zinc levels: decreased taste acuity: supplemented
- Hyperglycemia from defects in insulin secretion, action or
- Iron loss from use of synthetic erythropoietin and chronic
both
blood loss: supplemented through IV iron
- Chronic hyperglycemia: long-term damage, dysfunction and
o IV iron > oral iron
organ failure
Peritoneal Dialysis
- Classification:
- Does not require access to circulation o Type 1: beta-cell destruction  ABSOLUTE insulin
- Obligates placement of peritoneal (tenckoff) catheter that deficiency
allows infusion of diasylate solution into abdominal cavity o Type 2: insulin RESISTANCE with relative insulin
which allows transfer of solute across peritoneal membrane deficiency
which served as artificial kidney
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o Due to other causes: genetic defects in beta cell - Glycemic Index: rate and extent of rise in blood glucose after
production, defects in insulin action, exocrine meal
pancreas diseases (cystic fibrosis), drug or chemical o Incremental area under 2h blood glucose response
induced curve (IAUC) after test food
o Gestational: during pregnancy NOT overt o Foods with higher glycemic index, produce high
Type 1 Diabetes peak in postprandial blood glucose and greater
- Immune Mediated blood glucose after 2h
o 5-10% - Insulinemic Index
o Previous terms: insulin dependent, juvenile-onset o Insulin maintains blood glucose homeostasis
diabetes o High Insulinemic index  high degree of
o Results from: cellular mediated autoimmune postprandial insulin concentration  high insulin
destruction of beta-cells of pancreas demand in the long term
 Rapid: infants & children - Glycemic Load
 Slow: Adults o Represent overall glycemic effects of available
- Idiopathic carbohydrate in a serving
o No known etiology o Higher glycemic load  greater the expected
o Permanent insulinopenia elevation in blood glucose level & insulinogenic
o Prone to ketoacidosis effect of the food
o No evidence of autoimmunity o Long term consumption: risk for T2DM & coronary
o African or Asian ancestry heart disease

Type 2 Diabetes Medical Nutrition Therapy in Diabetes

- Complex heterogenous group - Prevention of diabetes, managing existent diabetes,

- Increased levels of blood glucose due to impaired insulin preventing or slowing rate of development of complications
action and/or secretion Energy balance, overweight and obesity
o Physiologically: beta cells synthesize insulin - Overweight & Obese: modest weight loss
regardless of blood glucose levels - Low carbohydrate, low fat-calorie restricted or
o Insulin is stored in vacuoles and released once Mediterranean diet in short term (up to 2 years)
blood glucose is elevated - Monitor lipid profiles, renal function and protein intake (if
o Insulin is the key hormone regulating glucose with nephropathy), adjust hypoglycemic therapy if needed
uptake from blood into most cells - Physical activity & behaviour modification
o Insulin is the major signal for conversion of glucose Recommendation for primary prevention of Diabetes
to glycogen for internal storage in liver and skeletal - Moderate weight loss: 7% of body weight
muscle - Regular physical activity (150 min/week)
o Drop in blood glucose level  decrease in insulin - Reduced calories
release from beta cell  increase of glucagon - Reduced intake of dietary fat
release from alpha cells  glycogen to glucose - Dietary fiber: 14g/1000 kcal
o Fasting: Glycogenolysis & Gluconeogenesis = - Foods containing whole grain (one half of grain intake)
Glucose - Presence of fiber  glucose to be absorbed slowly through:
- Three key defects in the onset: o Reduces gastric emptying
o Increased hepatic production o Slow diffusion of nutrients to gut wall
o Diminished insulin secretion o Presence of intact remnants of plant cells inhibit
o Impaired insulin action access digestive enzymes to starch
- Insulin resistance: suppressed or delayed response to insulin,
Recommendations on macronutrients in diabetes
post-receptor phenomenon due to defects in cell that
- Saturated fat intake: <7% of total calories
respond to insulin
- Reduction in trans fat
- Pivotal physiologic defect: insulin resistance in muscle and
- Alcohol
liver with beta-cell failure
o Women: ≤ 1 per day
- Other factors for glucose intolerance:
o Men: ≤ 2 per day
o Accelerated lipolysis in fat cells
- Antioxidants, Vitamins E & C and carotene are NOT advised
o Incretin deficiency/resistance in GIT
- Physical activity
o Hyperglucagonemia in alpha cell
o 150 min/week of moderate intensity aerobic
o Increase glucose reabsorption in kidney
physical activity (50-70% maximum heart rate)
o Insulin resistance in brain
o T2DM: resistance training 3x/week
Glycemic Index, Insulinemic index, Glycemic Load
Hyperthyroidism
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- Hypermetabolic state resulting from excess thyroid hormone Hypothyroidism & Myxedema
- 2% in women; 0.2% in men - Hypothyroidism: Deficient activity & lessened secretion of
- Toxic multinodular goiter thyroxine or triiodothyronine or both
o Women > 55 year old - Common, 1% of general population
o More common than Grave’s disease in elderly - 5% over age 60 years old
- Disorder of carbohydrate metabolism (with abnormal blood - Most common cause: Iodine deficiency
sugar curves & increased glucose metabolism) - In areas of iodine sufficiency, causes are autoimmune
- Increase protein metabolism (hashimoto’s) or iatrogenic
- Calcium imbalance - Myxedema: fluid retention caused by interstitial
- Disorders of creatinine metabolism accumulation of hydrophilic mucopolysaccharides which
- Depressed serum cholesterol leads to lymphedema
- Changes in liver and destruction of muscle cell - Hyponatremia: impaired renal tubular sodium reabsorption
- Also referred: exophthalmic goiter, thyrotoxicosis, Basedow’s due to reductions in Na-K ATPase
disease, Grave’s disease - 7 point reduction in intelligence of children 7-9 years old
SYMPTOMS SIGNS whose mother had SCH at pregnancy
- Hyperactivity - Tachycardia SYMPTOMS SIGNS
- Irritability - Atrial fibrillation in - Tiredness - Dry coarse skin
- Dysphoria elderly - Weakness - Cool peripheral
- Heat intolerance and - Tremor - Dry skin extremities
sweating - Goiter - Feeling cold - Puffy face, hands, feet
- Palpitations - Warm, moist skin - Hair loss (myxedema)
- Fatigue and weakness - Muscle weakness - Difficulty concentrating - Diffuse alopecia
- Weight loss with - Proximal myopathy - Poor memory - Bradycardia
increased appetite - Lid retraction or lag - Constipation - Peripheral edema
- Diarrhea - gynecomastia - Weight gain with poor - Delayed tendon reflex
- Polyuria appetite relaxation
- Oligomenorrhea - Dyspnea - Carpal tunnel syndrome
- Loss of libido - Hoarse voice - Serous cavity effusion
Nutritional management of Hyperthyroidism - Menorrhagia (later
- high calorie diet oligomenorrhea or
- Calories amenorrhea)
o Increase - Paresthesia
- Impaired hearing
o Mild cases: 15-25% above normal limit
Treatment
o Severe: 50-75%
- Treatment of choice; Levothryoxine (Thyroxine, T4)
o 4500-5000 kcal or more
o partially converted to T3 (active hormone)
- Protein
- Thyroxine replacement: lower T3 than normal
o Negative nitrogen balance & decrease in muscle
mass Dietary Management of Hypothyroidism and Myxedema
o 100 gm - Low calorie diet
- Fat - Fiber
o Increase o Help prevent weight gain and promote weight loss
- Minerals and vitamins o Helps control insulin levels in bloodstream
o Vitamin B o Digestion and elimination (solves constipation)
- Iodine o Controls appetite
o Essential component of thyroxine (active principle - Selenium
of thyroid gland) o Essential in converting T4 to T3
o Administration of large doses (potassium iodide) o Chicken, salmon, onions, garlic
will increase storage of thyroid hormone - Tyrosine
o Normally used in conjunction with antithyroid o Component of thyroxine
drugs and before surgery or therapy o Animal protein, dairy product, almond, banana
- Foods to avoid: dairy products, sea salt, iodized salt, seafood, - Iodine
eggs, tea, coffee, alcohol, nicotine, soft drinks because they o Seaweed, iodized salt, seafood
increase metabolic rate - Foods to avoid:
- Food that help: brussel sprouts, cauliflower, peaches, pears, o Goitrogenic foods: Soy products, cruciferous
cabbage, turnips, spinach, soybeans vegetables such as broccoli, turnips, cabbage;
mustard, peaches, peanuts, radish, strawberry,
walnut
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o Gluten: can trigger autoimmune response - Exclude foods such as liver, kidney, sweetbreads, meat
 Wheat, rye, barley, oats, soy sauce, extracts, smoked meat, anchovies, sardines, leguminous
mustard vegetables
o Fluoride and Chlorine: tap water because they may - Severe advanced cases:
block iodine receptors in the thyroid. o Purine restriction
- Drink bottled water o Protein intake: 50-75 g/day
Gout  Protein intake is limited because
- Disorder of purine metabolism endogenous uric acid biosynthesis may
- Excess of uric acid appears in the blood and sodium urates be accelerated in both normal and gouty
are deposited as tophi in small joints and surrounding tissues patients
- Most common site: Helix of ear - Cheese, eggs, milk
- Crystals in joints: Arthritis (recurring attacks of joint - Fluid: 2000 ml
inflammation) Alcohol
- Abnormality in uric acid  painful arthritis  kidney stones - Mild to moderate use may not necessarily induce attack
 blockage of kidney-filtering tubules with uric acid crystals - Lactate (ethanol metabolism)  renal retention of urate
 kidney failure Obesity
- Precursor of gout: Asymptomatic hyperuricemia - Weight loss should not be drastic but it should be gradually
- Risk factors: to avoid ketonemia which is a result of drastic weight loss
o Inherited abnormality - Ketonemia: precipitating factor for acute gout
o Obesity
Low purine diet
o Excessive weight gain
- Normal diet: 600-1000 mg/daily
o Moderate to heavy alcohol intake
- If with gout, diet should be: 100-150 mg
o High blood pressure
- Fat: 40% of caloric intake
o Abnormal kidney function
o Drugs: thiazide diuretics, low-dose aspirin, niacin, Food Groups According to Purine Content
cyclosporine, pyrazinamide, ethambutol - Group 1: High Purine Diet
o Diseases: leukemias, lymphomas, hemoglobi o 100-1000 mg of purine nitrogen per 100 gm
disorders o These should be omitted from diet of patients with
o Diabetes, Hyperlipidemia, Arteriosclerosis gout
o Family history of gout o Anchovies, Bouillon, brains, Gravy, mackerel, meat
o Very low calorie diet extracts, mincemint, mussels, sardines, heart,
o African race herring, kidney, liver, scallops, sweetbreads, yeasts
o 40-50 years old (baker’s and brewer’s)
Diet management of gout - Group 2: Moderate Purine Diet
o 9-100 mg of purine per 100 gms
- Purine-free
o Meat and Fish: Fish, poultry, meat, shellfish (avoid
- Restriction of foods containing nucleoproteins
group 1 fish and meats)
- Avoid excessive fats because it prevents normal excretion of
urates o Vegetables: Asparagus, Beans (shell), Lentils,
Mushrooms, Peas, Spinach
Acute Stage
o One serving (2-3 oz) of meat, fish or fowl
- Rigid restriction of foods containing purines o 1 sering (1/2 cup) vegetable each day or five days a
- Diet is composed of high carbohydrates, moderate protein, week during remissions
low fat - Group 3: Negligible Purine Content
- Fluids such as water or fruit juice (3L/day): assist excretion o Bread (enriched white and crackers), butter or
- Sodium bicarbonate or Trisodium citrate: alkalinize urine & fortified margarine, cake and cookies, carbonated
increase solubility of urate beverages, cereal beverages, cereal, herbs, ice
- If sodium restricted: potassium salt of carbonate and citrate cream, milk, macaroni products, noodles, nuts, oil,
Interval Stage olives, pickles, cheese, chocolate, coffee,
- Uricosuric acid (Probenecid): achieve negative acid balance & condiments, cornbread, cream, custard, egg, fats,
control urate deposits and serum uric acid level fruit, gelatin desserts, popcorn, puddings, relishes,
- Moderate protein: 60-70 grams rice, salt, sugar, sweets, tea, vegetables (except
- Increase carbohydrate those in group 2), vinegar, white sauce
- Low fat o Foods in this group can be used daily
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DIETARY MANAGEMENT IN SURGICAL CONDITIONS o Preexisting conditions may also increase risk: HPN
Advantages of bringing a patient to an adequate nutritional status and DM
before surgery: o No quick way for an obese person to safely lose
- Shortens period of disability weight prior to surgery
- Improves healing process o If time permits, low-calorie diet, high in essential
- Lessens complications nutrients
- Reduces mortality o Starvation or fad diets are NOT recommended
preoperatively
Metabolic Changes in Surgery
o Reduction diet post-op is also not of best interest
- Cessation of peristalsis
- Dietary considerations: rich in carbohydrates, protein,
- Rapid protection catabolism  loss of nitrogen  weight
minerals, vitamins and fluids
loss
o This will assist in a rapid recovery as it promotes
- Increased blood glucose (traumatic diabetes)
wound healing and decreases risk of infection
- Increased utilization of adipose tissues
- Pre-existing conditions should be stabilized before surgery
- Dehydration: blood loss, water loss, potassium loss
- Preoperative diet:
- Calcium loss
o High calorie: withstand stress of surgery
- Increased ascorbic acid utilization in response to stress
o High protein
- Anemia: Iron and B12 deficiency
 Fast wound healing
 Make up for nitrogen loss
- Stress hormones: catecholamines & glucocorticoid increase  Increase resistance to infection
during trauma or major illnesses  Haemoglobin regeneration
- Marked increase in urinary nitrogen excretion to 15-25  Hasten muscle strength
grams/day due to breakdown of skeletal muscle protein  o High carbohydrates
rapid muscle wasting  Extra energy for increased metabolism
- Each gram of urinary nitrogen loss:  Spare body proteins
o 6.25 g of muscle protein catabolized  Promote glycogen stores in liver
o Loss of 30 g of lean body mass  Prevent ketosis
o Loss of 70 ml of blood plasma o Adequate fat: contribute to total caloric
o Loss of 25-50 ml of whole blood requirement
Factors that determine preoperative diet: o Increase vitamins: ascorbic acid, Vitamin K, Vitamin
- Type of surgery: minor/major B-complex
- Emergency / elective  Wound healing
- Metabolic circumstances before surgery  Prevent hemorrahge
 Carbohydrate and protein metabolism
Preoperative Diet
o Increased minerals, phosphorus and potassium,
- Major problems are: over nutrition and undernutrition
sodium, chloride
- Undernourished:
 Electrolyte balance
o Lack of major nutrients necessary for recovery
 Make up for losses via urine and sweat;
o Higher risk in surgery than patient of normal
iron due to anemia
weight
o Increase fluids
o Most common: Protein Deficiency
 Restore salt and water balance if there is
o Low protein  shock
vomiting, diarrhea, diuresis
o Less detoxification of anesthetic agent by the liver
Postoperative Diet
o Increased edema at the incision site
o Decreased antibody formation Calories and Proteins
o Increase risk of infection - Elective surgical patient: increase by 10% if no complications
o Intravenous feeding to replenish nutrients o If preceded by multiple fractures or trauma:
o Aggressive oral nutrition may accomplish same increase by 10-25%
goals - Moderate or severe tissue damage by injury or surgery:
- Obese: increased excretion of nitrogen
o Higher health risk in surgery - Sepsis, fever, infection, trauma: accelerate nitrogen loss
o Complicate surgery further
o Puts strain in heart o Body shifts from carbohydrate to protein as energy
o Increase risk of infection and respiratory problems source  increased urinary nitrogen loss
o Delays healing - Exudates, discharges, peritonitis, open wounds: much
o Risk of dehiscence and evisceration nitrogen lost daily
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- Caloric requirement: 35-45 calorie per kg desirable body - Diet transition:
weight per day NPO / IV feeding
- Protein intake: 1-1.5 g per kg DBW/day
Vitamins IV feeding / ice chips / sips of water
- 1000 mg or more ascorbic acid may be required in extreme
conditions IV feeding / clear fluid diet
- Vitamin A: wound healing, normal epithelialization, prevent
gastric stress ulceration IV feeding / full liquid diet
- Vitamin K deficiency: hypoprothrombinemia with clotting
defect IV feeding / soft diet
- Thiamine, Riboflavin, Niacin: provides essential coenzyme
factors to metabolize carbohydrates and protein Full diet
o Thiamine requirement is doubled in - 5% dextrose in Lactate-Ringer’s solution for IV feeding
hypermetabolic states such as fever, trauma or - Amino acid solution are usually added to IV feeding during
hyperthyroidism first three days or so
- Patients fasting > 4days post or pre operatively requires - Maintenance fluid: 100 ml per 100 cal. of energy
therapeutic doses of vitamins requirement per day
- Advanced age or those with extensive abdominal surgery:
Minerals
prolonged recovery with difficulty of eating and tolerating
- Administration of zinc helps wound healing
oral nutrition needs special attention
- Zinc seems necessary for amino acid metabolism and
Dietary Management for Recovery
synthesis of collagen precursors
- In general, diet prescription:
Fluids
o 40-50 kcal/kg body weight/day
- Maintain normal water and electrolyte balance
o 12-15% of total calories as protein
- Supplied intravenously
o Well-balanced intakes of established RDAs/DRIs
- Fluids may be given by mouth as soon as patient has
o Carefully monitored intakes of Vitamins A,K,C,B12;
recovered from anesthesia
folic acid, minerals, iron, zinc
Foods
Tonsillectomy
- Depends on condition of patient’s GIT
- Very cold and very mild flavoured foods
- As soon as bowel sounds return: clear liquid diet for a few st
- 1 24 hours post-op:
meals
o Cold milk
- Then full liquid diet can be given for a day or so followed by
th th
o Milk beverage like malted milk and eggnogs
soft diet and full diet by 5 or 6 day post op.
o Chocolate and vanilla ice cream
Feeding the Patient Immediately After the Operation o Fruit juice
- Solid food is withheld from a few hours to 2-3 days post op - Warm fluids & food may be started by second day &
- Early feeding may nauseate and cause vomiting and possible cautiously replaced by hot foods as healing progress
aspiration  further fluid and electrolyte loss, discomfort, Gastric Surgery
potential pneumonia
- Metabolic changes:
- Outline of dietary support used for post-op:
o Absence of Hcl and pepsin
o NPO
o Defective mixing of food with digestive juices 
o Intravenous feeding: BT, fluids and electrolytes, 5%
impairment of fat utilization
dextrose, vitamin and mineral supplements,
o Impairment of protein digestion
protein-sparing solutions (with or without
o Increased intestinal motility
intralipid), or combination of above
o Less absorption of iron  hypochromic anemia
o Oral feeding: routine hospital progressive liquid
o Absence of gastric factor & intrinsic factor of Castle
diets with or without supplement, liquid-protein
(binds Vitamin B12)  macrocytic anemia
supplement with or without non-protein calories or
Dumping Syndrome
combination of above
o Combination of oral and intravenous feeding - Physiological response to presence of undigested food in
jejunum
- After food is swallowed, it is dumped into jejunum for 10-15
minutes
- Abdominal fullness, nausea, crampy abdominal pain followed
by diarrhea within 15 minutes after eating
- Warm, dizzy, weak and faint
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- Fast pulses, cold sweat - Principal mediators of hypermetabolism: catecholamines
- Leads to hypertonic intestinal content  rapidly diluted by (return to baseline when skin coverage is complete)
fluid drawn from plasma  sharp drop in circulating blood - Burns >50% of BSA: hourly fluid loss 10x greater than normal
volume  decrease in CO  dilatation of jejunum  - Initial: fluid & electrolytes replacement
sympathetic vasomotor response  sweating, tachycardia, o 7-10 L/day
ECG changes, weakness o To maintain circulatory volume and prevent renal
- Hyperosmolarity of jejunal chyma  Release of serotonin, failure
histamine and prostaglandins  cramping, hypermotility, - Second: prevent infection
diarrhea Nutritional Care
- Symptoms of hypoglycaemia: weakness, perspiration, - High Calorie: meet demands of hypermetabolism & tissue
hunger, nausea, anxiety, tremors, 1 to 2 hours after a meal repair
o d/t rapid digestion and absorption of food o Females: 22 kcal/kg/day
especially carbohydrates has been dumped into o Males: 25 kcal/kg/day
duodenum o + 40 kcal per % of burned TBSA
o glucose rapidly enters bloodstream  postprandial - High protein: correct negative nitrogen loss, wound healing,
elevation in blood glucose  overproduction of infection
insulin  hypoglycaemia o Normal: 0.8 g/kg/d
Dietary Management o Increase to: 2.5 g/kg/d
- Postgastrectomy patients: underweight, malnourished, - High Carbohydrate:
frustrated o Hypermetabolic phase: 0-14 days
o Goal: restore nutritional status and pleasant - Fat is moderately increased
leaving for patient - Increased Vitamins
- Proteins and fats are better tolerated because they are - Increase F & E
slowly hydrolyzed into osmotically active particle - Must also be given supplemental arginine, nucleotides,
- Simple carbohydrates (dextrose, sucrose, lactose) are rapidly omega 3 polyunsaturated fat: stimulate and maintain
hydrolyzed and should be limited but starch must be immunocompetence
included
- Liquids should only be taken between meals without food
NUTRITION IN CRITICALLY ILL PATIENTS
- Fat: 30-40%
Definition of Terms
- Low simple carbohydrates: 20%
- High in protein - Critically Ill Patient
- Purpose: achieving or maintaining optimal weight and o Any disease process causing physiological
nutritional status of patient instability leading to disability or death within
- Milk in small amounts minutes or hours
o Dry skim milk or casein hydrosylates may be used o Admitted to ICU d/t a serious illness (high baseline
mortality rate)
Rectal Surgery
o Mechanically ventilated patients
- Hemorrhoidectomy
o Trauma patients, closed head injury, burns, severe
- Nutritional care should allow wound repair, prevent frequent
inflammations, hypoxic injury, necrosis of tissues
stool, prevent infection
o DOES NOT include elective surgery patients with
- Minimal residue diet & use of constipating drugs are
low baseline mortality rate
indicated
- Metabolic stress:
- Start from clear liquid diet  full liquid diet (omitting milk)
o Hypermetabolic, catabolic response to acute injury
 low residue diet until wound is healed and patient can
3 Phases of Stress Response
tolerate full diet
- Bulky stools: Milk, potatoes, egg, cheese, butter, lard 1. Ebb phase
o Immediate period after injury (2-48 hours)
Burns
o Shock  hypovolemia and decreased O2 to tissues
- Impact on metabolism: prolonged, intense neuroendocrine
o Decreased blood volume
stimulation
o Decreased CO & UO
- Extensive burns: 2x-3x the REE & urinary nitrogen losses
o Deficit plasma volume and insulin levels
producing a loss of 1500 g/day of lean tissue
o Initial signs of shock
- Median survival: 7-10 days without nutritional support
o Hypothermia
- Infection: nitrogen losses are greater
o Low oxygen consumption
- Exudation: protein loss, fluid & electrolytes, potassium,
o Decrease overall metabolic rate
sodium, chloride losses
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o Goal of therapy: restore blood flow to organs, Major Metabolic Abnormalities in Stress Response:
maintain oxygenation to all tissues and stop - Increased catabolic hormones (cortisol, glucagon,
haemorrhage catecholamines)
2. Flow Phase - Decreased anabolic hormones (GH & testosterone)
o Classis s/sx of metabolic stress: hypermetabolism, - Marked increase in metabolic rate
catabolism, altered immune and hormonal - Increase in body temperature
response - Increase in glucose demands and liver gluconeogenesis
o Increased conc. Of catabolic hormones - Rapid skeletal muscle breakdown with amino acid used as
o Increase in HR, body temperature, calorie energy source
consumption, proteolysis, neoglycogenesis - Lack of ketosis (Fat is not a major source)
o Aims at wound healing - Unresponsiveness of catabolism to nutrient intake
3. Final Adaptation Phase or Recovery Phase Malnutrition in Critically Ill Patients
o Resolution of stress with return to anabolism and
- Malnutrition is an independent risk factor impacting on
normal metabolic rate
mortality, length of hospital stay and costs
Metabolic Alterations in Critical Illness - Excessive caloric and protein intakes cannot overcome
- Energy expenditure proportional to the amount of stress catabolic response
- “diabetes of stress” with hyperglycemia and insulin Causes of Malnutrition in critically ill patients
resistance
- Impaired intake
- Most striking metabolic feature of critical illness: protein
- Impaired digestion and absorption
catabolism and net negative nitrogen balance
- Altered nutritional requirements
- Major mediators: catabolic hormones (glucagon,
- Excess nutrient losses
epinephrine, cortisol and reduced anabolic influence of
- Up to 40% of patients in ICU are malnourishes
growth hormone, insulin & testosterone)
Sequela of malnutrition
Hyperglycemia and Insulin Resistance
- Impaired wound healing
- Increase hepatic gluconeogenesis
- Impaired immune response
- Increase liver gluconeogenesis from 2.0-2.5 mg/kg body
- Impaired coagulation capacity
weight/min to 4.4-5.1 mg/kg body weight/min
- Impaired GUT function
- Decreased suppressive action of exogenous glucose and
- Muscle wasting
insulin on hepatic gluconeogenesis
- Reduced respiratory muscle function
- Decreased peripheral glucose utilization in insulin dependent
Specialized Nutrition Support
tissues
Protein Catabolism - Nutrition support can slow catabolism in ICU patients
- Improve patient outcome and reduce subsequent duration of
- Sustained hypercatabolism:
recover  reduced length of hospital stay and reduce overall
o Substantial loss of lean body mass (LBM)
hospital costs
o Muscle weakness
Why feed the critically ill patient?
o Decreased immune function
- Increase protein breakdown 2-4x the usual (esp. in burn) - Provide nutritional substrates to meet protein and energy
- Protein loss of 60-70g (240 to 280 g of muscle tissue) per day requirements
- Severe trauma or sepsis: protein loss of 150-200 g (600 to - Help protect vital organs and reduce breakdown of skeletal
1000 g muscle tissue) per day muscle
- Provide nutrients needed for repair and healing of wounds
1. Negative nitrogen balance and injuries
o Consistent sign during metabolic stress by nitrogen - Maintain GUT barrier function
loss and skeletal muscle catabolism: - Modulate stress response and improve outcome
 Immunosuppression - Decrease complications
 Increased infection rates Nutritional therapy aims:
 Delayed or impaired wound healing - Favourable conditions for therapeutic plan
 Increased mortality - Offer energy, fluids and nutrients in adequate quantities to
Fat Metabolism maintain vital functions and homeostasis
- Increased catecholamines and cortisol  lipolysis in - Recover activity immune system
peripheral adipose tissues - Reduce risk of overfeeding
- Futile recycling of free fatty acids and triglycerides from - Offer protein and energy necessary to minimize protein
enhanced lipolysis with fat oxidation catabolism and nitrogen loss
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Specialized Nutrition Support (SNS) g. Coma
- For patients unable to maintain their nutritional status using h. Mechanical ventilators
oral diets, supplements or appetite stimulants 4. Contraindications (Serious medical conditions)
- Administration of nutrients with therapeutic intent a. Diffuse peritonitis
Benefits of nutrition support in critically-ill patients b. Intestinal obstruction (preventing passing intestinal
contents)
- Improve wound healing
c. Intractable vomiting not responding to medical tx
- Improve GIT structure and function
d. Paralytic ileus
- Improve clinical outcome
e. Intractable diarrhea that cannot be controlled
o Reduction in complication rates
f. GI ischemia (insufficient blood flow)
o Reduce length of hospital stay
5. Types of Enteral feed
- Decrease catabolic response to injury
o Mixture of fat, CHO, protein, vitamins, minerals,
Enteral Nutrition
water, electrolytes and fiber in proportions that
- Greek word: “enteron” or “intestine" mimic a balanced diet
- Delivers nutrients distal to (or beyond) the oral cavity o Pulmocare (enteral feeds): provides greater
- Used interchangeably with “enteral feeding” and “tube percentage of calories as fat
feeding”  Less CHO – less CO2
- Start within 24-48 hours in hemodynamically stable patients o Combination of nutrients in enteral feeds:
following admission to ICU
Elderly/Frail Normal Sepsis
- Preferred route over parenteral route
Protein 8-10 g 10-16 g 16-20 g
1. Routes:
Carbohydrate 700 cal 1000 cal 1200 cal
a. Nasogastric: nose to stomach
Fat 700 cal 1000 cal 1200 cal
i. Most commonly used
ii. Easiest to achieve Total calories 1400 2000 2400
(non-nitrogen)
iii. Easiest to maintain
Total volume 2.5 L 2.5 L 3.0 L
iv. Least expensive
b. Orogastric: mouth to stomach
c. Nasointestinal: nose to duodenum or jejunum 6. Components of enteral feeding:
i. More difficult to achieve and maintain a. Protein
ii. Used to bypass stomach:  Soy or casein
1. Gastroparesis  Usual amount: 10-15% of kcal
2. Gastric outlet obstruction  High protein formulas containing 25% of
3. Previous gastric surgery kcal
precludes feeding into stomach  Supplemented with arginine or glutamine
d. Skin: surgical gastrostomy or surgical jejunostomy;  2 g protein/kg/d or 15-20% of total
percutaneous gastric feeding or percutaneous caloric intake in 24 hours
jejunal feeding – long term enteral feeding b. Carbohydrate
2. Advantages  Monosaccharides, oligosaccharides,
a. Cost-effectiveness dextrins, maltodextrins, lactose-free
b. Reduced rate of infectious and metabolic formula
complications  Sucrose: rarely used
c. Relative ease & safety of administration  Fiber: improve bowel function
d. Improved wound healing c. Lipid
e. Reduced surgical interventions  Corn and soy-oil (long and medium chain
f. Maintenance of GIT function or preservation of fatty acids)
GUT mucosal integrity  Omega-3 FA: fish & plant sources
3. Indications: for functioning GIT but cannot feed themselves: d. Vitamins & minerals: stress and wound healing
a. Mentally incapacitated d/t confusion, dementia or e. Immunonutrients: modulate immunosystem
neurological difficulties  Glutamine
b. Swallowing dysfunction  Most abundant AA in body
c. Disorders of upper GIT that can be bypassed  60% of intracellular AA pool
d. Impaired digestive function and unable to ingest  Energy source after stress
hydrolyzed formulas orally response from gluconeogenesis
e. Undergone intestinal resection and beginning  Primary fuel source for rapidly
enteral dividing cells like epithelial cells
f. Little or no appetite especially malnourished during healing
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 Component of glutathione i. Administration of large-volume, dilute
(antioxidant) into vein in the arm or back of the hand
 Substrate for metabolism by ii. Irritating to small veins and peripheral
leukocytes and enterocytes access
 Augment lymphocyte & iii. Difficult to maintain
macrophage iv. Insufficient calories
 Anticatabolic and anabolic 3. Components
 Rate limiting for new protein - Balanced mixture of protein, CHO, lipid with water, vitamins,
synthesis minerals & electrolytes
 Arginine a. Protein: 40% essential, 60% non-essential
 Decreases after major trauma i. Normal adults: 0.8 g/kg
& wounds ii. Burn/trauma: 1.5 – 1.8 g/kg
 Enhances immune function – iii. Protein restriction are needed for those
improves T cell function with renal failure who are not receiving
 Role in wound healing – dialysis
increase tissue collagen content b. Carbohydrate: serve as energy source
 Stimulates insulin, prolactin, GH i. Dextrose monohydrate: 3.4 kcal/g
 Needed for NO production to ii. Minimum CHO: 130 g/d
regulate blood flow iii. 100 g CHO is required to allow for protein
 NOT recommended in critically sparing
ill patients with severe sepsis iv. Excess: hyperglycemia
7. Complications of enteral feeding v. Excess CO2: difficulty weaning
a. Mechanical (tube misplacement, clogged, twisted c. Lipid in PN: emulsion of soybean or safflower oil
or knicked tubes) i. Provides essential FA & conc. Energy
b. GI (diarrhea, abdominal discomfort, N/V) ii. Minimum of 10% kcal
c. Metabolic (hyperglycemia, fluid and electrolyte iii. Reduced need for dextrose
imbalance) iv. Lowers risk of hyperglycemia
d. Aspiration (sedated patient) d. Fluids and electrolytes
o
i. To avoid this, elevate head 45 during i. Young adult: 30 to 40 ml/kg BW
feeding ii. Older adult: 30 ml/kg BW
e. Tube feeding syndrome (hyperosolar-nonketotic iii. Daily average of 1500-2500 ml for most
dehydration; insufficient fluid intake) people
i. Give fluid 1ml/kcal e. Vitamins & Minerals
Parenteral Nutrition i. All water soluble vitamins are required as
- Sometimes called central venous nutrition (CVN) or well as Vit. A,D,E
intravenous hyperalimentation (IVH) ii. Vit. K is omitted and must be added
- Used only when enteral is not possible or cannot provide separately
sufficient nutrient input iii. Iron is excluded as it alters stability
1. Indications: unable to meet needs by oral diet or thru EN 4. Complications
a. Inability to digest & absorb nutrients such as a. Technical: related to insertion or sepsis secondary
malabsorption to contamination of central venous catheter
b. Massive bowel resection or SBS b. Metabolic: glucose abnormalities
c. Intractable vomiting c. GIT
d. GIT obstruction Clinical Practice Evidence-based guidelines for nutrition support in
e. Impaired GI motility Adult Critically-Ill patients
f. Abdominal trauma, injury, infection - Use of PN vs. EN
g. Severe pancreatitis o EN is strongly recommended
h. Post-surgery: if disturbed bowel function o EN is associated with reduction in infectious
2. Types of PN complications, lower incidence of hyperglycemia
a. Total Parenteral Nutrition and cost savings
i. Administration of concentrated - Early vs. delayed nutrient intake
macronutrients, vitamins, minerals, o EN within 24-48 hrs after ICU admission
electrolytes into large central vein o Early EN improves nutritional intake, reduces
b. Peripheral PN (PPN) and Peripheral Venous mortality, infectious complication
nutrition (PVN) - Immune enhancing diets
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o EN with Glutamine
 Glutamine not recommended in critically-
ill
 Effects:
 Reduces mortality
 Reduces hosp. stay
 Reduces infec. Complic.
 Dose: 0.2 – 0.57 gm/kg/d
o EN with Arginine: not recommended for critically ill
o EN with Fish Oils (OXEPA – fish oil, borage oil,
antioxidants)
 For patients with Acute Lung Injury and
ARDS
 Effects:
 Reduces mortality
 Decrease incidence of newly
acquired pneumonia
 Reduces ICU stay
 Reduces ventilated days
 Reduces new organ failures
- Protein/peptides in EN
o Use of whole protein formulas (polymeric) instead
of peptide-based formulas
- Fiber in EN
- Motility agents
o Metoclopramide
o Improve EN tolerance
o For those who have feed intolerance (high gastric
residuals, emesis)
- Enteral feeding via small bowel compared with gastric
feeding
o Small bowel feeding reduces infection (pneumonia)
compared to gastric feeding
o For patients at high risk of regurgitation &
aspiration (nursed in supine position)
o Those who are tolerating EN
o Improves calorie and protein intake
- Body position
o
o Head elevation to 45 (semi recumbent)
o Decrease in ventilation assoc. pneumonia
- PN in combination with EN
o Increase mortality
- Blood Sugar Control
o Intensive insulin therapy for blood sugar: 4.4-6.1
mmol/L

NUTRITION IMPLICATIONS OF AGING

(not in manual)