Dieth Therapy Final

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Dieth Therapy Final for all diseases.

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Dieth Therapy Final

  1. 1. DIET THERAPY OF DIFFERENT DISEASE Presented by: Dave Jay S. Manriquez RN.
  2. 2. DIET THERAPY IN NURSING
  3. 3. Nutrition Index
  4. 4. Mr. Tucker’s (actual) weight is 3% less than his admission wt.
  5. 6. <ul><li>LIQUID DIETS </li></ul><ul><li>INDICATIONS FOR CLEAR LIQUID DIET </li></ul><ul><li>Provide oral fluids; before/after surgery; prepare bowel for diagnostic tests (colono­scopic examination, barium enema, and other procedures); minimize stimulation of GI tract; promote recovery from partial paralytic ileus (early refeeding); minimize residue in the GI tract; transition feeding from < IV feeding to solid foods; acute GI disturbances; diarrhea . </li></ul><ul><li>CONTRA INDICATIONS FOR CLEAR LIQUID DIET </li></ul><ul><li>  Should not be used more than 24 hours; inadequate GI function; nutrient needs requiring parenteral nutrition </li></ul><ul><li>INDICATIONS FOR FULL LIQUID DIET </li></ul><ul><li>  Provide oral fluids; after surgery; transition between clear liquids and solid food; oral or plastic surgery to the face and neck; mandibular fractures; patients who have chewing or swallowing difficulties; esophageal or GI strictures; diarrhea </li></ul><ul><li>  CONTRA INDICATIONS FOR FULL LIQUID DIET: Dysphagia </li></ul>Types Of Diets
  6. 7. <ul><li>PUREED, MECHANICAL, OR SOFT DIETS </li></ul><ul><li>INDICATIONS FOR PUREED DIET </li></ul><ul><li>  Neurologic changes; inflammation or ulcerations of the oral cavity and/or esophagus; edentulous patients; fractured jaw; head and neck abnormalities; cerebrovascular accident . </li></ul><ul><li>CONTRA INDICATIONS FOR PUREED DIET </li></ul><ul><li>Situations where ground or chopped foods are appropriate </li></ul><ul><li>INDICATIONS FOR MECHANICAL SOFT DIET I </li></ul><ul><li>Poorly fitting dentures; edentulous patients; limited chewing or swallowing ability; dysphagia; strictures of intestinal tract; radiation treatment to oral cavity; progression from enteral tube feedings or parenteral nutrition to solid foods </li></ul><ul><li>CONTRA INDICATIONS FOR MECHANICAL SOFT DIET </li></ul><ul><li>Situations where regular foods are appropriate </li></ul><ul><li>  INDICATIONS FOR SOFT DIET </li></ul><ul><li>Debilitated patients unable to consume a-regular diet; mild GI problems </li></ul><ul><li>CONTRAlNDICATIONS FOR SOFT DIET </li></ul><ul><li>Situations where regular-foods are appropriate </li></ul>
  7. 11. Indicators of Potential Nutritional Problems <ul><li>Clear or full liquid diets for more than three days without nutrient supplementation or with inappropriate or insufficient nutrient supplementation. </li></ul><ul><li>Intravenous feeding (dextrose or saline) or NPO for more than 3 days without supplementation. </li></ul><ul><li>Low intakes of prescribed diet or tube feedings </li></ul><ul><li>Inconsistent growth or weight for height, above or below norms in children. </li></ul><ul><li>Pregnancy weight gain deviating from normal patterns </li></ul><ul><li>Diagnoses that increase nutritional needs or decrease nutrient intake (or both):cancer,malabsoprption, diarrhea, hyperthyroidism, excessive inflammation, postoperative status, hemorrhage, wounds (large, draining, or infected wounds), burns, infection, sepsis, major trauma (or multi system injury) </li></ul>
  8. 12. <ul><li>Chronic use of drugs, especially alcohol, that affects nutritional status </li></ul><ul><li>Alterations in chewing, swallowing, appetite, taste, and smell </li></ul><ul><li>Temperature consistently above 37 o C (98.6 F o ) for more than 2-days </li></ul><ul><li>Hematocrit: <43% in men, <37% in women </li></ul><ul><li>Hemoglobin: <14 g/dl in men, <12 g/dl in women; accompanied by mean cell volume <82 cu or >100 cu </li></ul><ul><li>Absolute decrease in lymphocyte count (<1500 cells/mm 3 ) </li></ul><ul><li>Elevated (>250mg/dl) or decreased (<130 mg/dl) total plasma cholesterol </li></ul><ul><li>Serum albumin, <30 g/dl in patients without renal disease, liver disease, generalized dermatitis,overhydration. </li></ul>
  9. 14. <ul><li>Position the patient in a comfortable with the head in an upright position, slightly tilted forward </li></ul><ul><li>Textured foods that require chewing stimulate a better swallow, e.g. toast instead of bread or boiled potato instead of mashed potatoes. </li></ul><ul><li>Offer juices diluted with water at first, and use flexible straws if the patient has suckling capabilities     </li></ul><ul><li>Mildly sweetened and salted foods are generally favored. Foods should be close to room temperature. Avoid acid or bitter flavors and sticky foods (e.g. soft bread, bananas, or peanut butter). </li></ul><ul><li>Make consistency adjustments according to the patient’s tolerance. Liquids can be used to moisten foods for individuals with decreased saliva production </li></ul><ul><li>Adapt the diet to the patients’ need and gradually upgrade it as feeding skills improve. </li></ul>Dysphagia
  10. 15. <ul><li>Achieve and maintain ideal body weight to improve mechanical and postural status (except pregnant women, who should not try to lose weight). </li></ul><ul><li>Increase protein and reduce fat intake to increase sphincter pressure. </li></ul><ul><li>Avoid foods like chocolate, alcohol, peppermint, coffee, and carbonated drinks. </li></ul><ul><li>Avoid foods that may irritate and cause spasms; citrus juices, tomatoes, and tomato sauce. </li></ul><ul><li>Stop smoking, if that is a habit. </li></ul><ul><li>Eat small meals four times a day . </li></ul><ul><li>Eat large meal at noon with a lighter meal in the evening. Finish the evening meal at least two to four hours before bedtime. Avoid late evening snacks. </li></ul>Gastroesophageal Reflux
  11. 16. Peptic Ulcer <ul><li>Trend in nutritional therapy of peptic ulcer- </li></ul><ul><li>individualized approach, i.e. based on the individual </li></ul><ul><li>patient’s tolerance for specific foods. </li></ul><ul><li>To reduce or neutralize gastric acid secretion: </li></ul><ul><li>Eat three meals daily; avoid skipping meals. </li></ul><ul><li>Avoid stomach distention with large quantities of </li></ul><ul><li>food at a meal. </li></ul><ul><li>Avoid drinking milk frequently. </li></ul><ul><li>Limit caffeine intake by reducing consumption of </li></ul><ul><li>coffee, tea, cola, chocolate and other foods and </li></ul><ul><li>beverages that contain caffeine. </li></ul><ul><li>Limit alcohol intake and avoid drinking on any </li></ul><ul><li>empty stomach. </li></ul>
  12. 17. <ul><li>. Limit intake of spicy, fatty or otherwise bothersome foods and beverages. </li></ul><ul><li>Some fibers, especially the soluble forms, are beneficial. </li></ul><ul><li>Citric acid juices may induce gastric reflux and discomfort in some patients. </li></ul><ul><li>Avoid bedtime snacks to prevent acid secretion if symptoms often occur in the middle of the night. </li></ul><ul><li>Avoid cigarette smoking, which may increase gastric acid </li></ul><ul><li>secretion and delay the healing process and is also </li></ul><ul><li>associated with an increased frequency of duodenal ulcers. </li></ul>
  13. 19. <ul><li>The aim is to rest the stomach and reduce further irritation of the mucosa. </li></ul><ul><li>Acute type: </li></ul><ul><li>NPO for 24 to 48 hours: give glucose parenterally , followed by liquids, then soft to full diet as tolerated. </li></ul><ul><li>Chronic type: </li></ul><ul><li>Bland, low fiber diet. </li></ul><ul><li>Correct faulty food habits. </li></ul>GASTRITIS
  14. 20. <ul><li>Decreased Absorption </li></ul><ul><li>Increased Absorption </li></ul><ul><li>Diet specific to etiology </li></ul>Intestinal Malabsorption
  15. 21. <ul><li>Clinical Implications </li></ul><ul><li>Fluids must be replaced to avoid dehydration, solids should be gradually added as tolerated. A low-residue diet may be in order to decrease the intake of fibrous materials. </li></ul><ul><li>Evaluate the use of foods that may contribute to diarrhea, especially those high in fiber, caffeine, and alcohol. </li></ul><ul><li>Encourage juices high in potassium </li></ul><ul><li>Remove milk products from the diet if there is a possibility of lactose intolerance. </li></ul><ul><li>Bananas, grated raw apples, or cooked apple-sauce contain pectin, which helps bind the fluid and retard its transit time. </li></ul><ul><li>Extremely hot or cold foods increase peristalsis and may aggravate diarrhea. </li></ul>Diarrhea
  16. 22. <ul><li>Clinical Implications </li></ul><ul><li>Ask patients about their use of cathartics or laxatives. </li></ul><ul><li>Gradually increase the amount of fiber or bulk in the diet (raw vegetables and fruits, whole-grain breads, and cereals). </li></ul><ul><li>Force fluid intake; drink at least the equivalent of six to eight glasses of water a day. </li></ul><ul><li>Dried fruits, especially prunes, contain natural laxatives. </li></ul><ul><li>Any hot beverage upon arising, such as coffee, tea, or lemon water, may stimulate peristalsis because duodenal-ileal or gastric colic is strongest in the morning. Breakfast is also important and should contain some fiber. </li></ul><ul><li>Encourage activity and relaxation as much as possible allow sufficient time for bowel habits </li></ul>Constipation
  17. 23. <ul><li>Clinical Implications </li></ul><ul><li>Discourage drinking with straws. </li></ul><ul><li>Avoid foods that produce gas (This is highly individual matter, one which the patient must be observant). In many persons, dried beans, peas, and foods from the cabbage family (broccoli and Brussels sprouts) cause problems. </li></ul><ul><li>Decrease the amount of fat in the diet. </li></ul><ul><li>Encourage the patient to chew food slowly, closing the mouth. </li></ul><ul><li>Malabsorption syndrome, peptic ulcers, and cholelithiasis are disorders that cause excessive flatulence; these treatable disorders must be excluded by conventional means (Van Ness & Cattau, 1985) </li></ul>Flatus
  18. 24. <ul><li>Clinical Implications </li></ul><ul><li>During bouts with diarrhea, sources of potassium intake should be increased. </li></ul><ul><li>Multivitamin and mineral supplements are frequently recommended. </li></ul>Crohn’s Disease (Regional Enteritis)
  19. 25. <ul><li>Clinical Implications </li></ul><ul><li>Patients with severe diarrhea or steatorrhea should be monitored for magnesium, which is usually deficient in chronic inflammatory bowel disease (Philips & Garnys, 1981). </li></ul><ul><li>Low serum zinc levels are prevalent among children with chronic inflammatory bowel disease. Response to zinc intake is abnormal and growth is retarded (Nishl et al, 1980). </li></ul><ul><li>The use of azulfidine requires a daily intake of eight to ten cups of fluid. </li></ul>Ulcerative Colitis
  20. 26. <ul><li>Clinical Implications </li></ul><ul><li>Patients with irritable bowel syndrome must be tested for lactose intolerance or malabsorption before further treatment (Goldsmith & Patterson, 1985). </li></ul><ul><li>Hydrophilic mucilloids necessitate large amounts of fluid intake. </li></ul>Irritable Bowel Syndrom (IBS)
  21. 27. Disease of the Liver, Pancreas and Gall Bladder
  22. 29. <ul><li>During acute phase: 5-10% dextrose Intravenously and/or protein parenterally: To minimize protein losses, prevent ketosis, to replace fluids and electrolytes. </li></ul><ul><li>High calories: To counteract weight loss and for maximum protein utilization. </li></ul><ul><li>High CHO: To spare protein: Insure glycogen reserve and maintenance of hepatic function. </li></ul><ul><li>High protein: To repair hepatic cells; from cholic and other bile acids; to prevent hypothermia; supply lipotropic factors which mobilize liver fat. </li></ul>Hepatitis
  23. 31. <ul><li>Moderate fat, MCT preferred over LCT (Restrict fat if there is billiary obstruction): To meet high energy needs, at the same time preventing fatty liver. </li></ul><ul><li>High vitamins: To maintain liver function. </li></ul><ul><li>Frequent small feeding in cases of anorexia: For better tolerance. </li></ul><ul><li>Consistency: liquid to soft in acute attacks; more liberal in convalescence: Adjusted to patient’s tolerance. </li></ul><ul><li>Low sodium: In cases of ascites. </li></ul><ul><li>Alcohol prohibited: Detoxification function of the liver is impaired by alcohol . </li></ul>Cirrhosis
  24. 32. <ul><li>Protein Intake </li></ul><ul><li>Initially: non-protein diet (Borst Diet) </li></ul><ul><li>Progress to: 20-30 gm/day (Giordano-Giovanetti Diet) if condition improves until the normal protein allowance is tolerated: To eliminate completely a source of nitrogen for ammonia synthesis. </li></ul><ul><li>Calories: 1500 to 2000 a day to come mostly from CHO and fat: Minimize tissue protein breakdown which is a source of ammonia. </li></ul><ul><li>Liberal vitamins and minerals: For adequate nutrition. </li></ul><ul><li>Low sodium: Prevent ascites. </li></ul><ul><li>Tube feeding: when oral feeding is not possible . </li></ul>Hepatic Encephalopathy (Hepatic Coma)
  25. 33. <ul><li>IV fluids and electrolytes; progress to clear liquid: To rest inflamed gallbladder, prevent and correct dehydration, volume depletion and electrolyte abnormalities. </li></ul><ul><li>Low fat: Reduce discomfort by preventing stimulation of sphincter of Oddi, and contraction of GB. </li></ul><ul><li>Bland low fiber: Decrease mechanical and chemical stimulation. </li></ul><ul><li>Low calorie for obese patients: For weight loss, obesity is predisposing factor. </li></ul><ul><li>Small frequent feedings: To prevent dyspepsia . </li></ul>Cholecystitis
  26. 34. <ul><li>Acute attack: NPO: To rest the organ. </li></ul><ul><li>Low fat: To control steatorrhea and prevent stimulation for bile production. </li></ul><ul><li>Moderate CHO and protein: Prevention of hypoglycemia and creatorrhea. </li></ul><ul><li>Plus enzyme supplements: Utilization of nutrients. </li></ul><ul><li>Six small feedings, bland: Avoid undue distention and stimulation. </li></ul><ul><li>Avoidance of alcohol: Alcohol may precipitate attack. </li></ul><ul><li>Supplements of fat-soluble vitamins and calcium: To prevent deficiencies. </li></ul><ul><li>MCT oil: Better absorbed than LCT. </li></ul>Pancreatitis
  27. 35. DIETARY MANAGEMENT OF SURGICAL CONDITIONS
  28. 36. <ul><li>Pre-operative </li></ul><ul><li>Post-operative </li></ul>Dietary Management in General
  29. 37. <ul><li>To improve the nutriture of the patient. </li></ul><ul><li>To prepare the patient for nutrient losses during surgery. </li></ul><ul><li>To hasten post-operative recovery. </li></ul><ul><li>To build up glycogen reserves. </li></ul><ul><li>To strengthen bodily resistance to infections. </li></ul>Pre-Operative
  30. 38. <ul><li>If patient is in good nutritional status – NPO 8 hours prior to surgery </li></ul>Pre-Operative Dietary Management in: Emergency Operation <ul><li>To avoid vomiting during anesthesia or recovery from anesthesia, and decrease the risk of post-operative gastric retention since peristalsis is stropped </li></ul><ul><li>If patient is in poor nutritional status (protein deficient) parenteral administration of whole blood or plasma. </li></ul>For adequate stores of serum protein to prevent hypoproteinemia and shock. <ul><li>In addition, 5% glucose in water, saline solution, vitamins and potassium. </li></ul>For adequate nutrition
  31. 39. <ul><li>High calorie for underweight </li></ul>Pre-Operative Dietary Management in: Elective Surgery To build up any weight deficit Low to adequate calories for others if patient is overweight, weight reduction is indicated to reduce surgical risks .
  32. 40. <ul><li>High carbohydrates </li></ul>For glycogen stores and to spare protein for tissue synthesis. Stores of glycogen exert a protective action on the liver and help to prevent post-operative ketosis and vomiting . High protein To build reserves for anticipated blood losses during surgery and increased tissue catabolism, to reduce the possibility of edema at the site of the wound which is a hindrance to wound healing.
  33. 41. <ul><li>Increased vitamins, especially ascorbic acid, vitamin K; B- complex </li></ul>For wound healing and prevention of hemorrhage increased minerals, especially phosphorus and potassium; Na and chloride To replace electrolyte losses due to the break-down of body tissue; and due to vomiting, diarrhea, perspiration and diuresis. Iron To correct anemia Increased fluids To replace losses due to vomiting and diuresis
  34. 42. <ul><li>Immediate Pre-operative Period – usually nothing is given by mouth for at least 8 hours before general surgery so that the stomach will have no retained food at the time of the operation </li></ul>
  35. 43. <ul><li>Liquids </li></ul>Post-operative Dietary Management in: Minor Surgery Tolerated within a few hours; for maintenance or restoration of fluid and electrolyte balance. Normal Diet As soon as activity of GIT is restored
  36. 44. <ul><li>NPO 24 - 48 Hours </li></ul>Post-operative Dietary Management in: Major Surgery GI tract not yet functioning normally. To allow for recovery from anesthesia; prevent aspiration. Nutrition support: type and duration depends on recovery of GIT function As soon as activity of GIT is restored <ul><li>Conventional intravenous administration of amino acid solution </li></ul>Patient is expected to tolerate an enteral diet within a few days. Total parenteral nutrition (TPN) To meet nutritional needs for extended periods when enteral feeding is not possible
  37. 45. <ul><li>Tube feeding. If there is GIT function, but patient cannot tolerate an oral diet. </li></ul>To meet nutritional needs until patient can tolerate food by mouth. To give patient a feeling of being “normal” and hasten recovery; also, less expensive. Oral Diet – liquid to full, as tolerated
  38. 46. <ul><li>Surgery of the Mouth, Throat and Esophagus. </li></ul><ul><li>Gastrectomy </li></ul><ul><li>Dumping Syndrome </li></ul><ul><li>Intestinal Surgery </li></ul><ul><li>Diet following other abdominal Operations </li></ul><ul><li>Rectal Surgery </li></ul>Specific Surgical Conditions
  39. 47. <ul><li>The aim is to provide food that require little chewing, comfortable and prevent bleeding. </li></ul><ul><li>For tooth extraction: fluid diet progressing to soft until full diet is tolerated. </li></ul><ul><li>Surgery of the mouth: full fluid or pureed foods; or tube feeding. </li></ul><ul><li>Tonsillectomy: very cold or mild flavored foods the first few days. Avoid fibrous foods; then warm fluids and foods on the 2 nd day, progress to a normal diet after a week. </li></ul>Surgery of the Mouth, Throat and Esophagus
  40. 48. <ul><li>NPO first 24-48 hours; intravenous feedings </li></ul><ul><li>Day 2 to 4: iced water with intravenous feedings </li></ul><ul><li>Day 5: 1 to 2 oz. Water every even hours, and 1 to 2 oz milk every odd hour between. </li></ul><ul><li>Day 6: Soft low fiber foods are used – eggs, custards, thickened soups, cereals, crackers, milk and fruit purees are suitable. </li></ul><ul><li>Day 7: Tender meats, cottage cheese, and pureed vegetables are the next foods added to all the foods allowed in the previous days. </li></ul><ul><li>Meats are divided into 5 or 6 small feedings daily with emphasis on foods high in protein and fat. CHO is kept relatively low. If not liquids are taken with meals, and the diet continues to be low in CHO, especially the simple sugars, many patients progress satisfactorily. </li></ul>Gastrectomy
  41. 49. <ul><li>Small frequent feedings (5 or6) fed in supine position. </li></ul>Dumping Syndrome: Major Surgery To prevent dumping of food into the intestines. High protein Better tolerate because proteins are hydrolyzed into osmotically active substances more slowly; needed to rebuild tissues and gain strength. High fat To meet energy needs High calories For strength Simple CHO (sugar, sweets or desserts, restricted) Simple CHO increases osmolarity of jejunum contents * “dumping syndrome.”
  42. 50. <ul><li>Dry solid diet </li></ul>B etter than liquids as they enter the jejunum less rapidly. Low fiber, low residue diet To prevent rapid dumping of food into the intestines. Avoid alcohol or sweet carbonated beverages
  43. 51. Intestinal Surgery: Major Surgery Clear fluid Initial oral intake after surgery Low residue, bland To promote healing of the stoma and to prevent irritation HI calorie, HI PRO For weight recovery VIT B 12 supplemented To prevent possible macrocytic anemia in later years
  44. 52. Intestinal Surgery: Colostomy Same for Ileostomy Jejunoileostomy L ow fat, low CHO, low fiber To prevent from diarrhea HI PRO To restore electrolyte balance and to provide for losses of K, Ca and Mg.
  45. 53. <ul><li>Cholecystectomy </li></ul>Diet following Other Abdominal Operations Low fat – for several weeks or months To avoid pain since large amounts of fats cause contraction of the tissues irritated and inflamed by surgery HI PRO For faster convalescense
  46. 54. <ul><li>Peritonitis and intestinal obstruction </li></ul>Diet following Other Abdominal Operations NPO – 1 ST 24 to 48 hours, intravenous therapy Gastrointestinal function has not yet returned and drainage of the stomach and upper intestine is essential until there is reduction of distention and passage of gas. Clear liquids to low residue Better tolerated; transition to full diet
  47. 55. <ul><li>Hemorrhoidectomy </li></ul>Rectal Surgery NPO – 1 ST 24 to 48 hours Due to anaesthesia Clear liquid Initial Feeding Low fiber-low residue: Fruits and vegetables are omitted except for strained fruit juices To discourage early bowel movements
  48. 56. <ul><li>Avoidance diet: An adequate diet which excludes the food(s) causing allergic reactions (e.g. milk-free, egg-free diet, wheat-free diet, etc.) </li></ul><ul><li>Desensitization: The allergenic food is given in gradually increasing amounts over a long period of time. </li></ul>Allergy
  49. 57. <ul><li>Chicken </li></ul><ul><li>Cow’s milk </li></ul><ul><li>Wheat </li></ul><ul><li>Peanuts/nuts </li></ul><ul><li>Soy products </li></ul><ul><li>Fish, shellfish </li></ul>Most Common Food Allergens
  50. 58. <ul><li>Dietary Modification </li></ul><ul><li>Current concepts </li></ul><ul><li>There is no one “diabetic diet” that will suit the individual and special needs of a person with diabetes. </li></ul><ul><li>The diet for an individual with diabetes can only be defined as a “dietary prescription” based on nutrition assessment and treatment goals. </li></ul>Diabetes Mellitus (DM)
  51. 59. <ul><li>Goals of Nutrition Therapy of DM </li></ul><ul><li>Maintenance of as near-normal blood glucose levels as possible </li></ul><ul><li>Achievement of optimal serum lipid levels </li></ul><ul><li>Provision of adequate energy to maintain/achieve reasonable body weight </li></ul><ul><li>Prevention and treatment of the acute complications and of long-term complications </li></ul><ul><li>Improvement of overall health through optimal nutrition </li></ul>
  52. 60. <ul><li>Recommended Dietary Modification </li></ul><ul><li>Total calories – sufficient to maintain/achieve reasonable weight in adults, or meet increased needs of children, adolescents, pregnant and lactating women and individuals recovering from catabolic illness. </li></ul><ul><li>Caloric distribution: </li></ul><ul><li>Carbohydrates : 50 – 70% </li></ul><ul><li>Protein : 10 – 20% </li></ul><ul><li>Fat : 20 – 30% </li></ul><ul><li>Cholesterol – limit to 300 mg/day or less </li></ul><ul><li>Carbohydrates sweeteners are permissible </li></ul>
  53. 61. Low-Glycemic Index Foods: Less Than 50 Intermediate-Glycemic Index Foods: 50 to 70 High-Glycemic Index Foods: More Than 70 * Eat foods printed in red sparingly; these are high in empty calories. * Eat foods printed in red sparingly; these are high in empty calories. * Don't avoid or even limit high-glycemic index foods printed in green; these are low-calorie and very nutritious foods. 1 Artichoke <15 1 Brown Rice 55 1 Golden Grahams 71 2 Asparagus <15 2 Canned fruit cocktail 55 2 Bagel 72 3 Broccoli <15 3 Linguine 55 3 Corn chips 72 4 Cauliflower <15 4 Oatmeal cookies 55 4 * Watermelon 72 5 Celery <15 5 Popcorn 55 5 Honey 73 6 Cucumber <15 6 Sweet corn 55 6 Kaiser roll 73 7 Eggplant <15 7 Muesli 56 7 Mashed potatoes 73
  54. 62. 8 Green beans <15 8 White rice 56 8 Bread stuffing mix 74 9 Lettuce, all varieties <15 9 Orange juice from frozen concentrate 57 9 * Cheerios 74 10 Low-fat yogurt, artificially sweetened <15 10 Pita bread 57 10 Cream of Wheat, instant 74 11 Peanuts <15 11 Canned peaches, heavy syrup 58 11 Graham crackers 74 12 Peppers, all varieties <15 12 Mini shredded wheats 58 12 Puffed wheat 74 13 Snow peas <15 13 Bran Chex 58 13 Doughnuts 75 14 Spinach <15 14 Blueberry muffin 59 14 French fries 76 15 Young summer squash <15 15 Bran muffin 60 15 Frozen waffles 76 16 Zucchini <15 16 Cheese pizza 60 16 * Total cereal 76 17 Tomatoes 15 17 Hamburger bun 61 17 Vanilla wafers 77
  55. 63. 18 Cherries 22 18 * Ice cream 61 18 Grape-Nuts Flakes 80 19 Peas, dried 22 19 Kudos Whole Grain Bars (chocolate chip) 61 19 Jelly beans 80 20 Plum 24 20 Beets 64 20 Pretzels 81 21 Grapefruit 25 21 Canned apricots, light syrup 64 21 * Rice cakes 82 22 Pearled barley 25 22 Canned black bean soup 64 22 Rice Krispies 82 23 Peach 28 23 Macaroni and cheese 64 23 Corn Chex 83 24 Canned peaches, natural juice 30 24 Raisins 64 24 Mashed potatoes, instant 83 25 Dried apricots 31 25 Couscous 65 25 Cornflakes 84 26 Soy milk 30 26 Quick-cooking oatmeal 65 26 * Baked potato 85 27 Baby lima beans, frozen 32 27 Rye crispbread 65 27 Rice Chex 89
  56. 64. 28 Fat-free milk 32 28 * Table sugar (sucrose) 65 28 Rice, instant 91 29 Fettuccine 32 29 Canned green pea soup 66 29 French bread 95 30 * M&M's Chocolate Candies, Peanut 32 30 Instant oatmeal 66 30 * Parsnips 97 31 Low-fat yogurt, sugar sweetened 33 31 Pineapple 66 31 Dates 103 32 Apple 36 32 Angel food cake 67 32 Tofu frozen dessert 115
  57. 65. 33 Pear 36 33 Grape-Nuts 67 34 Whole wheat spaghetti 37 34 Stoned Wheat Thins 67 35 Tomato soup 38 35 American rye bread 68 36 Carrots, cooked 39 36 Taco shells 68 37 * Mars Snickers Bar 40 37 Whole wheat bread 69 38 Apple juice 41 38 Life Savers 70 39 Spaghetti 41 39 Melba toast 70 40 All-Bran 42 40 White bread 70
  58. 66. <ul><li>Sodium –limit to about 3000 mg/day; less for people with hypertension or renal complications. </li></ul><ul><li>Alcohol – moderate amounts may be allowed, contingent on good metabolic control. </li></ul><ul><li>Vitamins and mineral supplement – not usually necessary, but may be given to individuals, on reduced calorie diets (1400 kcal/day or less). </li></ul>
  59. 67. <ul><li> Type I DM Type II DM </li></ul><ul><li>Strategy Obese Non-Obese </li></ul><ul><li>Calorie restriction * *** * </li></ul><ul><li>Timing of meals *** ** ** </li></ul><ul><li>Meal spacing ** *** ** </li></ul><ul><li>Fat modification *** *** *** </li></ul><ul><li>Sucrose limitation ** ** ** </li></ul><ul><li>Exercise ** *** *** </li></ul><ul><li>Exercise snack *** * * </li></ul><ul><li>Other nutrition variables ** ** ** </li></ul><ul><li>Blood glucose monitoring *** *** *** </li></ul><ul><li>_________________________________________ </li></ul><ul><li>* Low ** Moderate *** High </li></ul>Strategies for Diabetes Medical Nutrition Therapy
  60. 68. <ul><li>Overweight/Obese </li></ul><ul><li>Low calorie: To enable the body to deplete adipose tissue stores. </li></ul><ul><li>High protein: For high safety value; exerts higher specific dynamic action; to minimize tissue nitrogen loss </li></ul><ul><li>Moderate fat: For safety value; emphasis on PUFA. </li></ul><ul><li>Normal to low CHO: Close relation of glucose to fat formation. </li></ul><ul><li>Bulky, low calorie foods: To provide safety without increasing calorie intake. </li></ul><ul><li>Supplement of PUFA: Accelerates oxidation of body fat. </li></ul>
  61. 69. <ul><li>Underweight </li></ul><ul><li>High calorie diet: For storage of fat in the adipose tissue, to restore DBW </li></ul><ul><li>Gradual increases: To avoid gastric upsets and spells of discouragement. </li></ul><ul><li>High protein: For replacement and repair of body tissue </li></ul><ul><li>High CHO: For added calories; protein-sparer. </li></ul><ul><li>Bulky, low calorie foods: To provide satiety without increasing calorie intake. </li></ul><ul><li>Supplement of PUFA: Accelerates oxidation of body fat. </li></ul>
  62. 70. <ul><li>High calories: to compensate for increased BMR </li></ul><ul><li>Adequate vitamins – thiamin, riboflavin, B12, ascorbic acid, pyridoxine and vitamin A, D, E. </li></ul><ul><li>- increased requirements for enhanced cellular metabolism </li></ul><ul><li>- Degradation of vitamin is accelerated. </li></ul><ul><li>Increased iodine: Iodine is needed for thyroxine formation. </li></ul><ul><li>Adequate calcium: Correct Ca resorption from bone and prevent hypercalciuria. </li></ul>Hyperthyroidism
  63. 71. <ul><li>Iodine supplementation </li></ul><ul><li>Low calorie: To minimize weight gain due to lowered BMR </li></ul>Hypothyroidism
  64. 72. <ul><li>Functional Type </li></ul><ul><li>Low CHO (75-110 g/day): emphasis on complex CHO: CHO serves as stimulus to insulin secretion. </li></ul><ul><li>High protein, high fat. If obese emphasize MUFA: To supply glucose in as slow even but continuous flow and to prevent marked rise of sugar at any one time. </li></ul><ul><li>Maintenance of DBW: To prevent oversecretion of insulin. </li></ul><ul><li>Restriction on coffee, tea and cola beverages: Caffeine stimulates the adrenals to cause glycogenolysis and gluconeogenesis * increased blood glucose * stimulation of pancreas * increased insulin. </li></ul><ul><li>Avoidance of alcohol: Alcohol has hypoglycemic </li></ul>Hyperinsulinism
  65. 73. Hyperinsulinism Fasting High CHO: To provide constant sucrose of available glucose .
  66. 74. <ul><li>Calorie level, depends on weight status or weight goal: Weight loss of 5-6% in over-weight/obese can lower BP. </li></ul><ul><li>Sodium – restricted: Excess sodium may increase: </li></ul><ul><li>- cardiac output due to over-filling of vasculature </li></ul><ul><li>- peripheral resistance to blood flow </li></ul><ul><li>Fluids and roughage – adequate: Prevent constipation which hinders absorption of anti-hypertensive drugs. </li></ul>Hypertension
  67. 75. <ul><li>● Modifiable ● Nonmodifiable </li></ul><ul><li>● Dyslipidemia - Age </li></ul><ul><li>- Sex </li></ul><ul><li>- Family history of CHD </li></ul><ul><li> ● Smoking </li></ul><ul><ul><li>● Hypertension </li></ul></ul><ul><ul><li>● Diabetes mellitus </li></ul></ul><ul><ul><li>● Obesity </li></ul></ul><ul><ul><li>● Dietary factors </li></ul></ul><ul><ul><li>● Thrombogenic factors </li></ul></ul><ul><ul><li>● Sedentary lifestyle </li></ul></ul>Risk Factors for CHD
  68. 76. <ul><li>Low HDL cholesterol is a strong independent predictor of CHD 1 </li></ul><ul><li>The lower the HDL cholesterol level the higher the risk for atherosclerosis and CHD 2 </li></ul><ul><li>Low HDL is defined categorically as a level < 40 mg/dl (a change from < 35 mg/dl in ATP II) 1 </li></ul><ul><li>HDL cholesterol tends to be low when triglycerides are high 2 </li></ul>HDL Cholesterol
  69. 77. <ul><li>Recent data suggest that elevated triglycerides are an independent risk factor for CHD </li></ul><ul><li>Normal triglyceride levels: < 150 mg/dl </li></ul><ul><li>Borderline-high triglycerides: 150 to 199 mg/dl </li></ul><ul><li>High triglycerides: 200 to 499 mg/dl </li></ul><ul><li>Very high triglycerides: ( > 500 mg/dl) increase pancreatitis risk </li></ul><ul><li>Initial aim of therapy is prevention of acute pancreatitis. </li></ul>Triglycerides
  70. 78. <ul><li>Total fat – not more than 30% of TER: </li></ul><ul><li>- avoid post-prandial hyperlipedemia and its possible </li></ul><ul><li>adverse effect of coagulation. </li></ul><ul><li>- reduce plasma LDL cholesterol </li></ul><ul><li>SFA – approx 10% of TER period of time. </li></ul><ul><li>PUFA – approx. 10% of TER consisting of omega-6 PUFA (e.g linoleic acid), promotes prostaglandin synthesis, which in turn promotes arterial dilation and heart muscle contractility </li></ul><ul><li>Long chain PUFA or omega 3 fatty acids </li></ul>CHD
  71. 79. <ul><li>MUFA – approx. 10% of TER. </li></ul><ul><li>as effective as PUFA in lowering serum total cholesterol, but has the advantages of not lowering HDL cholesterol, less susceptible to oxidation, less thrombogenic potential, does not raise serum triglycerides; also has less tumorigenic potential. </li></ul><ul><li>Cholesterol – not more than 300 mg/day </li></ul><ul><li>reduce plasma LDL cholesterol </li></ul><ul><li>Sodium – moderate intake: -control blood pressure </li></ul><ul><li>Carbohydrates – type and amount depends on lipid abnormality </li></ul><ul><li>Alcohol – avoid high intake: control blood pressure </li></ul><ul><li>- reduce fibrinogen </li></ul><ul><li>- exessive intake can produce hypertriglyceridemia, elevated LDL cholesterol, arrythmia, cardiac enlargement and heart failure </li></ul>
  72. 80. <ul><li>Calories – sufficient to maintain/achieve desirable body weight. </li></ul><ul><li>- reduce insulin resistance </li></ul><ul><li>- reduce synthesis of cholesterol, esp. LDL, VLDL, triglycerides </li></ul><ul><li>- reduce risk of cholesterol gallstone formation </li></ul>
  73. 81. <ul><li>Acute phase: 500 – 800 cal liquid diet for 2-3 days </li></ul><ul><li>* to avoid gagging and aspiration of solid foods. </li></ul><ul><li>No extremes in temperature </li></ul><ul><li>- To prevent possible precipitation of arrythmias. </li></ul><ul><li>No coffee or tea </li></ul><ul><li>- maybe stimulating and increases heart rate. </li></ul><ul><li>Parenteral feeding </li></ul><ul><li>- For those unwilling to consume liquid diet </li></ul><ul><li>Restriction of Na </li></ul><ul><li>- to prevent/correct edema </li></ul>Acute MI or Coronary Occlusion or Thrombosis
  74. 82. <ul><li>Subacute phase </li></ul><ul><li>* 1000 – 1200 cal: 20% Pro. 45% CHO 35% fat </li></ul><ul><li>- To meet resting metabolism requirements. </li></ul><ul><li>Cholesterol, 300 mg </li></ul><ul><li>* To control blood cholesterol possible precipitation level </li></ul><ul><li>Soft, low fiber, free of gastric irritants </li></ul><ul><li>* To avoid indigestion and flatus </li></ul><ul><li>Sodium restriction </li></ul><ul><li>* To prevent /correct edema </li></ul><ul><li>Small frequent feeding </li></ul><ul><li>* to reduce possibility of post prandial dyspnea or pain. </li></ul>
  75. 83. <ul><li>Low calories </li></ul><ul><li>- reduce weight; decrease work of heart </li></ul><ul><li>Moderate protein </li></ul><ul><li>- maintenance of N balance </li></ul><ul><li>Sodium restriction – 500 mg initially, 1000 mg later </li></ul><ul><li>- to control edema. </li></ul><ul><li>Small frequent feedings </li></ul><ul><li>- decreased circulatory load </li></ul><ul><li>Fluid as desired </li></ul>Congestive Heart Failure
  76. 84. <ul><li>Iron Deficiency Anemia </li></ul><ul><li>Iron supplementation </li></ul><ul><li>Adequate diet with emphasis on vitamin C to enhance iron absorption and utilization. </li></ul><ul><li>Megaloblastic anemia </li></ul><ul><li>Vitamin B 12 must be given by injection because of the lack of intrinsic factor necessary for its absorption. </li></ul>Nutritional Anemias
  77. 85. Nutrition in Renal Diseases
  78. 86. <ul><li>Renal clearance or urea guanidines, other products of N metabolism, Na, K, Ca, Mg, trace elements and many medicines. </li></ul><ul><li>Impaired ability to conserve nutrients such as Na and sometimes protein. </li></ul><ul><li>Reduce intestinal absorption of Ca and Iron </li></ul><ul><li>Impaired ability to synthesize or metabolize </li></ul><ul><li>Loss of excretory function </li></ul><ul><ul><li>Impaired metabolic action, resulting in altered nutrient, metabolic and hormone levels. </li></ul></ul><ul><ul><li>Synthesis of certain hormones (erythropoietin and 1, 25 dihydroxycholecalciferol) </li></ul></ul><ul><li>Altered synthesis or degradation of nutrients by other tissues </li></ul><ul><li>Intestinal formation of dimethylamine and trimethylamine </li></ul><ul><ul><li>Metabolic clearance of pyridoxine. </li></ul></ul>Metabolic Abnormalities
  79. 87. <ul><li>Loss of excretory function </li></ul><ul><li>Impaired metabolic action, resulting in altered nutrient, metabolic and hormone levels </li></ul><ul><li>Adaptive changes in metabolic feedback loops involving hormones, enzymes and reaction products. </li></ul><ul><li>Reduced food intake </li></ul>Possible mechanism underlying these metabolic alterations
  80. 88. <ul><li>Blood levels – amines, phenols and indoles and other nitrogenous substances </li></ul><ul><li>Enzymes of amino acid metabolism, tricarboxylic acid enzyme and gluconeogenic enzyme. </li></ul><ul><li>Serum nitrogen-containing hormones (insulin, glucagon, PTH, growth hormones, gastrin, rolactin, leutinizing hormones, gastrin, prolactin, leutinizing hormones </li></ul><ul><li>Serum somatostatin </li></ul><ul><li>Serum erythropoietin and 1, 25 dihydroxycholecalciferol </li></ul>Effects of these abnormalities
  81. 89. <ul><li>Serum Renin – normal, increased or reduced </li></ul><ul><li>Deficiencies of vit. D and folic acid and vit. B 6 due to medicine. </li></ul><ul><li>Wasting syndrome: </li></ul><ul><ul><li>Relative body weight, muscle mass and body fat </li></ul></ul><ul><ul><li>Slow growth rate in children </li></ul></ul><ul><ul><li>Decreased serum concentration of total protein, albumin, transferin, C 3 and other complement proteins </li></ul></ul><ul><ul><li>Abnormal plasma amino acid concentration </li></ul></ul>
  82. 90. <ul><li>Objectives of nutritional therapy in chronic failure </li></ul><ul><li>To maintain nutritional status </li></ul><ul><li>To minimize uremic toxicity </li></ul><ul><li>To prevent net protein catabolism </li></ul><ul><li>To stimulate patient’s well-being </li></ul><ul><li>To retard progression of renal failure </li></ul><ul><li>To postpone initiation of dialysis </li></ul>DIETARY PRINCIPLES
  83. 91. <ul><li>Nutritional treatment of CRF </li></ul><ul><li>Judicious regulation of protein intake </li></ul><ul><li>Regulation of fluid intake to balance fluid output and insensible water loss </li></ul><ul><li>Regulation of sodium to balance fluid output </li></ul><ul><li>Restriction of potassium and phosphate </li></ul><ul><li>Insistence on an adequate calorie intake </li></ul><ul><li>Supplementation with appropriate vitamins </li></ul>DIETARY PRINCIPLES
  84. 92. <ul><li>Acute or chronic glomerulonephritis </li></ul><ul><li>Controlled fluid intake = fluid output </li></ul><ul><li>Kcal </li></ul><ul><li>Controlled protein -according to laboratory data & renal function </li></ul><ul><li>Sodium </li></ul><ul><li>Potassium </li></ul><ul><li>Nephritis </li></ul><ul><li>Treat symptomatically when there is significant uremia, hyperkalemia or edema. Replace all lost fluids </li></ul>Renal Disorders-1
  85. 93. <ul><li>Uremia </li></ul><ul><li>Adequate calories and controlled protein, fluid and electrolytes according to laboratory data and renal function </li></ul><ul><li>Nephrotic Syndrome </li></ul><ul><li>Protein - 1.5 g/kg/day + 1 g Protein for each </li></ul><ul><li>gram protein lost in urine </li></ul><ul><li>Kcal - increased kcal to spare protein </li></ul><ul><li>Sodium - low sodium (2 grams) to reduce edema </li></ul>Renal Disorders-2
  86. 94. <ul><li>Acute Renal Failure </li></ul><ul><li>Protein - not restricted below 1.0 – 2.0 g/kg DBW </li></ul><ul><li>Kcal - increased kcal to spare protein for a </li></ul><ul><li>malnourished child, 1 ½ - 2 times normal </li></ul><ul><li>requirements </li></ul><ul><li>Sodium - varies according to fluid retention and </li></ul><ul><li>hydration states </li></ul><ul><li>Potassium - decreased due to hypercalcemia as a </li></ul><ul><li>result of catabolic process </li></ul>Renal Disorders-3
  87. 95. <ul><li>Chronic Renal Failure </li></ul><ul><li>Regulation of protein intake </li></ul><ul><li>Balance of fluid intake and output </li></ul><ul><li>Adequate calorie intake </li></ul><ul><li>Regulation of sodium, potassium and phosphorus </li></ul><ul><li>intake </li></ul><ul><li>Supplementation of appropriate vitamins and minerals </li></ul><ul><li>*Restriction is not fixed dependent on patient’s clinical and biochemical status </li></ul>Renal Disorders-4
  88. 96. <ul><li>Acne Low fat </li></ul><ul><li>Acute gastroenterities (diarrhea) Clear liquid </li></ul><ul><li>Acute glomerulonephritis Low Na, Low protein </li></ul><ul><li>Addisons’ disease Hi Na, Low K </li></ul><ul><li>Angina pectoris Low cholesterol </li></ul><ul><li>Arthritis, gout Purine restricted </li></ul><ul><li>ADHD Finger foods </li></ul><ul><li>Bipolar disorder Finger foods </li></ul><ul><li>Burn High calorie, hi pro </li></ul>THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS
  89. 97. <ul><li>Celiac’s disease Gluten free </li></ul><ul><li>Cholecystitis Hi pro, hi CHO, low fat </li></ul><ul><li>Congestive heart failure Low Na, low cholesterol </li></ul><ul><li>Cretinism Hi pro, hi Ca </li></ul><ul><li>Crohn’s dse. Hi pro, hi CHO, low fat </li></ul><ul><li>Cushings’ dse. Hi K,low Na </li></ul><ul><li>Cystic fibrosis Hi calorie, high Na </li></ul><ul><li>Cystitis Acid Ash (for alkaline stones) </li></ul><ul><li>Calculi Alkaline Ash (for acid stones) </li></ul><ul><li>Decubitus ulcer (bedsore) High protein, High vit. C. </li></ul>THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS
  90. 98. <ul><li>Diabetes mellitus Well balanced </li></ul><ul><li>Diarrhea Hi K, high Na </li></ul><ul><li>Diverticulitis Low residue </li></ul><ul><li>Diverticulosis Hi residue with no seeds </li></ul><ul><li>Dumping syndrome Hi fat, high protein, dry </li></ul><ul><li>Hepatic encephalopathy Low protein </li></ul><ul><li>Hepatitis Hi protein, high calorie </li></ul><ul><li>Hirschprungs’ dse. Hi calorie, low residue, hi pro </li></ul><ul><li>Hyperparathyroidism Low calcium </li></ul><ul><li>Hypothyroidism Low cal, low cholesterol, </li></ul><ul><li>low sat fat </li></ul>THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS
  91. 99. <ul><li>Kawasaki’s dse. Clear liquid </li></ul><ul><li>Liver cirrhosis Average protein </li></ul><ul><li>Meniere’s dse. Low sodium </li></ul><ul><li>Myocardial infarction Low fat, low Chol, low Na </li></ul><ul><li>Nephrotic syndrome Low Na, hi pro, hi cal </li></ul><ul><li>Osteoporosis Hi cal, Hi vit. D </li></ul><ul><li>Pancreatitis Low fat </li></ul><ul><li>Peptic ulcer Hi fat, hi Cho, low pro </li></ul><ul><li>Phenylketonuria Low pro/phenylalanine </li></ul><ul><li>PIH Hi pro </li></ul>THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS
  92. 100. <ul><li>Renal colic Low Na, low pro </li></ul><ul><li>ARF: Low pro, hi Cho, Low Na (Oliguric phase), Hi pro, hi Cal, & restricted fluid (diuretic phase) </li></ul><ul><li>CRF Low pro, low Na, low K </li></ul><ul><li>Tonsillitis Clear liquid; cold diet </li></ul>THERAPEUTIC DIET FOR SPECIFIC DISEASE CONDITIONS

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