Nutrition Manual

MANUALOFCLINICALNUTRITIONMANAGEMENT
TABLEOFCONTENTS
I. NORMALNUTRITIONANDMODIFIEDDIETS
A. NormalNutrition StatementonNutritionalAdequacy................................................................................................................A1 EstimatedEnergyRequirement(EER)forMaleandFemalesUnder30YearsofAge...............A2 EstimatedEnergyRequirement(EER)forMenandWomen30YearsofAge...............................A2 EstimatedCalorieRequirements(InKilocalories)forEachGenderandAgeGroupat ThreelevelsofPhysicalActivity.....................................................................................................................A3 DietaryReferenceIntake(DRIs):RecommendedintakesforIndividuals,Macronutrients....A4 DietaryReferenceIntakes(DRIs):RecommendedIntakesforIndividuals,Vitamins...............A5 . DietaryReferenceIntakes(DRIs):RecommendedIntakesforIndividuals,Elements...............A6 DietaryReferenceIntakes(DRIs):EstimatedAverageRequirements............................................A7 DietaryReferenceIntakes(DRIs):TolerableUpperIntakeLevels(UL),Vitamins.....................A8 DietaryReferenceIntakes(DRIs):TolerableUpperIntakeLevels(UL),Elements.....................A9 FoodFortificationandDietarySupplementsPositionoftheAmericanDieteticAssoc(ADA)A10 RegularDietAdult...............................................................................................................................................A11 HighProtein,HighCalorieDiet........................................................................................................................A13 ImmunocompromisedDiet(NeutropenicDiet).........................................................................................A14 NutritionManagementDuringPregnancyandLactation......................................................................A15 NutritionandtheOlderAdult............................................................................................................................A22 MechanicalSoft(DentalSoft)Diet...................................................................................................................A27 PureedDiet................................................................................................................................................................A29 NutritionManagementofFluidIntakeandHydration............................................................................A31 VegetarianDiets......................................................................................................................................................A35 KosherGuidelines...................................................................................................................................................A39 B. TransitionalDiets ClearLiquidDiet.....................................................................................................................................................B1 . FullLiquidDiet........................................................................................................................................................B3 FullLiquidBlenderizedDiet...............................................................................................................................B4 NutritionManagementofDysphagia..............................................................................................................B6 DumpingSyndromeDiet.....................................................................................................................................B15 . NutritionManagementofBariatricSurgery................................................................................................B16 SpecializedNutritionSupport...........................................................................................................................B32 EnteralNutritionSupportforAdults..............................................................................................................B34 ParenteralNutritionSupportforAdults.......................................................................................................B48

C. ModificationofCarbohydrateandFat MedicalNutritionTherapyforDiabetesMellitus......................................................................................C1 MedicalNutritionTherapyforGestationalDiabetes.........................................................................C15 DietaryManagementwiththeExchangeSystem................................................................................C20 . SugarinModerationDiet.....................................................................................................................................C34 CalorieControlledDietforWeightManagement......................................................................................C35 MedicalNutritionTherapyforDisordersofLipidMetabolism...........................................................C39 FatControlledDiet.................................................................................................................................................C55 MediumChainTriglycerides(MCT)................................................................................................................C57
Manual of Clinical Nutrition Management
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D. ModificationofFiber FiberRestrictedDiets(LowFiber).................................................................................................................D1 HighFiberDiet........................................................................................................................................................D4 DietaryFiberContentofFoods...................................................................................................................D11 GastrointestionalSoftDiet..................................................................................................................................D13
E. PediatricDiets NutritionManagementoftheFullTermInfant.........................................................................................E1 InfantFormulaComparisonChart.............................................................................................................E4 NutritionManagementoftheToddlerandPreschoolChild.................................................................E7 NutritionManagementoftheSchoolAgedChild......................................................................................E9 NutritionManagementoftheAdolescent.....................................................................................................E12 KetogenicDiet..........................................................................................................................................................E14 F. ModificationOfMinerals SodiumControlledDiet.......................................................................................................................................F1 . FoodGuideforNoAddedSaltDiet(4000mgSodium)..........................................................................F4 . FoodGuidefor3,000mgSodiumDiet.....................................................................................................F5 2,000mgand1,500mgSodiumRestrictedDietPattern.................................................................F6 FoodGuidefor1,000mgSodiumDiet.....................................................................................................F8 NutritionManagementofPotassiumIntake................................................................................................F10 PotassiumContentofCommonFoods...................................................................................................F11 NutritionManagementofPhosphorusIntake............................................................................................F12 PhosphorusContentofCommonFoods................................................................................................F13 NutritionManagementofCalciumIntake....................................................................................................F14 . CalciumContentofCommonFoods........................................................................................................F15 G. ModificationOfProtein ProteinControlledDietforAcuteandRefractoryHepaticEncephalopathy.................................G1 ProteinBasedExchanges...............................................................................................................................G4 MedicalNutritionTherapyforChronicKidneyDisease.........................................................................G6 DeterminationofGlucoseAbsorptioninPeritonealDialysis.........................................................G16 DietaryManagementUsingtheHealthyFoodGuideforPeoplewithChronicKidneyDisease ..................................................................................................................................................................................G17 SimplifiedRenalDiet.............................................................................................................................................G28 H. DietsforSensitivity/MiscellaneousIntolerance GlutenFreeDiet......................................................................................................................................................H1 FoodGuideforGlutenFreeDiet..............................................................................................................H6 SuppliersofGlutenFreeandLowProteinProducts......................................................................H8 TyramineRestrictedDiet....................................................................................................................................H10 LactoseControlledDiet.......................................................................................................................................H12 . NutritionManagementofFoodHypersensitivities..................................................................................H16 I. Facility/TestDiets
II.
NUTRITIONASSESSMENT/INTERVENTION
BodyWeightEvaluationandNutritionalIndicatorsofNutritionRelatedProblems.........................II1 StatureDetermination..................................................................................................................................................II4 BodyMassIndex.............................................................................................................................................................II5 StandardBodyWeight(SBW)DeterminationBasedonNHANESII.........................................................II6 DeterminingIdealBodyWeight(IBW)BasedonHeighttoWeight:TheHAMWIMethod..............II7 DeterminationofFrameSize.....................................................................................................................................II8 EstimationofIdealBodyWeightandBodyMassIndexforAmputees....................................................II9
ii
EstimationofEnergyExpenditures........................................................................................................................II11 EstimationofProteinRequirements......................................................................................................................II15 LaboratoryIndicesofNutritionalStatus..............................................................................................................II16 ClassificationofSomeAnemias................................................................................................................................II18 DiagnosticCriteriaofDiabetesMellitus................................................................................................................II19 MajorNutrients:FunctionsandSources..............................................................................................................II21 . PhysicalSignsofNutritionalDeficiencies............................................................................................................II24 FoodandMedicationInteractions...........................................................................................................................II25 HerbandMedicationInteractions...........................................................................................................................II31
III. CLINICALNUTRITIONMANAGEMENT
Introduction......................................................................................................................................................................III1 AnticoagulantTherapy.................................................................................................................................................III4 Burns....................................................................................................................................................................................III7 Cancer..................................................................................................................................................................................III11 ChronicObstructivePulmonaryDisease.............................................................................................................III16 CorticosteroidTherapy...............................................................................................................................................III20 MonitoringinDiabetesMellitus...............................................................................................................................III21 DiabetesMellitus:ConsiderationsforExercise..........................................................................................III23 DiabetesMellitus:ConsiderationsforAcuteIllness.................................................................................III24 DiabetesMellitus:GastrointestinalComplications...................................................................................III26 DiabetesMellitus:OralGlucoseLoweringMedicationsandInsulin.................................................III28 DiabetesMellitus:FatReplacersandNutritive/NonnutritiveSweeteners....................................III31 Dysphagia...........................................................................................................................................................................III34 RelationshipofDysphagiatotheNormalSwallow...................................................................................III36 EnteralNutrition:ManagementofComplications............................................................................................III37 GastroesophagealRefluxDisease(GERD)............................................................................................................III39 HeartFailure.....................................................................................................................................................................III41 HIVInfectionandAIDS................................................................................................................................................III45 Hypertension....................................................................................................................................................................III60 Hypertriglyceridemia....................................................................................................................................................III67 Hypoglycemia...................................................................................................................................................................III69 InbornErrorsofMetabolism.....................................................................................................................................III71 IronDeficiencyAnemia................................................................................................................................................III73 NephroticSyndrome.....................................................................................................................................................III75 ObesityandWeightManagement............................................................................................................................III77 Pancreatitis.......................................................................................................................................................................III85 ParenteralNutrition(PN):MetabolicComplicationsofCentralParenteralNutrition(CPN).........III90 CalculatingTotalParenteralNutrition..................................................................................................................III94 PepticUlcer.......................................................................................................................................................................III98 Pneumonia.........................................................................................................................................................................III99 PressureUlcers................................................................................................................................................................III101 ManagementofAdultRenalinjuryandChronicRenalDisease..................................................................III105 NutritionApproachesinRenalReplacementTherapyBasedonPatientAssessment Parameters................................................................................................................................................................III110 WilsonsDisease..............................................................................................................................................................III113
IV. APPENDIX
CaffeineandTheobromineContentofSelectedFoodsandBeverages....................................................IV1 . Metric/EnglishConversionsofWeightsandMeasures..................................................................................IV2 Milligram/MilliequivalentConversions................................................................................................................IV2 SalicylateContentofSelectedFoods......................................................................................................................IV3
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STATEMENTONNUTRITIONALADEQUACY
The Dietary Reference Intakes (DRIs) of the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences, are used as the standard for determining the nutritional adequacy of the regular and modifieddietsoutlinedinthismanual.DRIsreferencevaluesthatarequantityestimatesofnutrientintakesto beusedforplanningandassessingdietsforhealthypeople.TheDRIsconsistoffourreferenceintakes: RecommendedDailyAllowances(RDA),areferencetobeusedasagoalfortheindividual. TolerableUpperIntakeLevel(UL),theintakelevelgiventoassistinadvisingindividualsofwhatintake levelsmayresultinadverseeffectsifhabituallyexceeded. Estimated Average Requirement (EAR), the intake level which data indicates that the needs for 50% of individualsconsumingthisintakewillnotbemet. AdequateIntake(AI),arecommendedintakevalueforagrouporgroupsofhealthypeoplebasedonfewer dataandsubstantiallymorejudgmentthanusedinestablishinganEARandsubsequentlytheRDA. An AI is given when the RDA cannot be set. Both of these reference intakes are to be used as goals in planningandassessingdietsforhealthyindividuals(1,2).TheDRIsdonotcoverspecialneedsfornutrientsdue tovariousdiseaseconditions.DRIsarereferencevaluesappropriateforbothassessingpopulationintakesand planningdietsforhealthypeople(1,2). Whenreferringtoenergy,useEstimatedEnergyIntake(EER).EERistheaveragedietaryenergyintakethat ispredictedtomaintainenergybalanceinahealthyadultofadefinedage,gender,weight,heightandlevelof physicalactivity,consistentwithgoodhealth.Forchildren,pregnantandlactatingwomen,theEERincludes theneedsassociatedwithdepositionoftissuesorthesecretionofmilkatratesconsistentwithgoodhealth(7). ThesamplemenusthroughoutthismanualhavebeenplannedtoprovidetherecommendedDRIsformen, 31 to 50 years of age, unless indicated otherwise, and have been analyzed by a nutrient analysis software program.Forspecificvalues,refertothefollowingtablesofrecommendedDRIsfromtheFoodandNutrition Board of the National Academy of Sciences,. However, it is acknowledged that nutrient requirements vary widely.Thedietitiancanestablishanadequateintakeonanindividualbasis. TheDRIsareprovidedinaseriesofreports(37).Fulltextsofreportsareavailableatwww.nap.edu.
References 1. YatesAA,SchlickerSA,SuitorCW.DietaryReferenceIntakes:Thenewbasisforrecommendationsforcalciumandrelatednutrients, Bvitamins,andcholine.JAmDietAssoc.1998;98:699706. 2. TrumboP,YatesA,SchlickerS,PoosM.DietaryReferenceIntakes:VitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine, Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc.JAmDietAssoc.2001;101(3):294301. 3. InstituteofMedicine.DietaryReferenceIntakesforCalcium,Phosphorus,Magnesium,VitaminD,andFluoride.FoodandNutrition Board,Washington,DC:NationalAcademyPress;1997. 4. InstituteofMedicine.DietaryReferenceIntakesforThiamin,Riboflavin,Niacin,VitaminB6,Folate,VitaminB12,PantothenicAcid, Biotin,andCholine.FoodandNutritionBoard,Washington,DC:NationalAcademyPress;1998. 5. InstituteofMedicine.DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCartotenoids.FoodandNutritionBoard, Washington,DC:NationalAcademyPress;2000. 6. InstituteofMedicine.DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine,Iron,Molybdenum, Nickel,Silicon,VandiumandZinc.FoodandNutritionBoard.Washington,DC:NationalAcademyPress;2001. 7. Institute of Medicines Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. (Macronutrients). Washington, DC: National Academy of Sciences, 2005: 107180. ManualofClinicalNutritionManagement A1 Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.
ESTIMATEDENERGYREQUIREMENT(EER)FORMALEANDFEMALES UNDER30YEARSOFAGE
Age 26mo 712mo 13y 48y 913y 1418y 1930y Sex M F M F M F M F M F M F M F BodyMass MedianReference Reference Index(kg/m2)a Heightbcm(in) Weightakg(lb) Kcal/day 62(24) 6(13) 570 62(24) 6(13) 520 71(28) 9(20) 743 71(28) 9(20) 676 86(34) 12(27) 1046 86(34) 12(27) 992 115(45) 20(44) 1,742 115(45) 20(44) 1,642 17.2 144(57) 36(79) 2,279 17.4 144(57) 37(81) 2,071 20.5 174(68) 61(134) 3,152 20.4 163(64) 54(119) 2,368 22.5 177(70) 70(154) 3,607c 21.5 163(64) 57(126) 2,403c
aTakenfromnewdataonmaleandfemalemedianbodymassindexandheightforagedatafromtheCentersforDiseaseControland PreventionNationalCenterforHealthStatisticsGrowthCharts(Kuczmarski,etal.,2000). bCalculatedfromCDC/NCHSGrowthCharts(Kuczmarskietal.,2000);medianbodymassindexandmedianheightforages4through 19years. cSubtract10kcal/dayformalesand7kcal/dayforfemalesforeachyearofageabove19years. Adaptedfrom:DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol,Protein,andAminoAcids (Macronutrients).Washington,DC:NationalAcademiesPress,2002.
ESTIMATEDENERGYREQUIREMENT (EER)FORMENANDWOMEN30YEARSOFAGEa
Height (m[in]) PALb WeightforBMI of18.5kg/m2 (kg[lb]) WeightforBMI of24.99kg/m2 (kg[lb]) EER,Men(kcal/day) EER,Women(kcal/day) BMIof BMIof BMIof BMIof 18.5kg/m2 24.99kg/m2 18.5kg/m2 24.99kg/m2
1.50 Sedentary (59) Lowactive Active VeryActive 1.65 Sedentary (65) Lowactive Active VeryActive 1.80 Sedentary (71) Lowactive Active VeryActive
a
41.6(92)
56.2(124)
1,848 2,009 2,215 2,554 2,068 2,254 2,490 2,880 2,301 2,513 2,782 3,225
2,080 2,267 2,506 2,898 2,349 2,566 2,842 3,296 2,635 2,884 3,200 3,720
50.4(111)
68.0(150)
59.9(132)
81.0(178)
1,625 1,803 2,025 2,291 1,816 2,016 2,267 2,567 2,015 2,239 2,519 2,855
1,762 1,956 2,198 2,489 1,982 2,202 2,477 2,807 2,221 2.459 2,769 3,141
Foreachyearbelow30,add7kcal/dayforwomenand10kcal/dayformen.Foreachyearabove30,subtract7kcal/dayforwomenand 10kcal/dayformen. bPhysicalactivitylevel. cDerivefromthefollowingregressionequationsbasedondoublylabeledwaterdata: Adultman:EER=661.89.53xAge(y)xPAx(15.91xWt[kg]+539.6xHt[m] AdultwomanEER=354.16.91xAge(y)xPAx(9.36xWt[kg]+726xHt[m]) WherePAreferstocoefficientforPhysicalActivityLevels(PAL) PAL=totalenergyexpenditure+basalenergyexpenditure. PA=1.0ifPAL>1.0<1.4(sedentary). PA=1.12ifPAL>1.4<1.6(lowactive). PA=1.27ifPAL>1.6<1.9(active). PA=1.45ifPAL>1.9<2.5(veryactive). Source:DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol,Protein,andAminoAcids(2002).This reportmaybeaccessedviawww.nap.edu. Copyright2002bytheNationalAcademyofSciences.Allrightsreserved. ManualofClinicalNutritionManagement
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ESTIMATEDCALORIEREQUIREMENTS(INKILOCALORIES)FOREACHGENDER ANDAGEGROUPATTHREELEVELSOFPHYSICALACTIVITY(1)a
Estimatedamountsofcaloriesneededtomaintainenergybalanceforvariousgenderandagegroupsatthreedifferentlevelsof physicalactivity.Theestimatesareroundedtothenearest200caloriesandweredeterminedusingtheInstituteofMedicine equation. ActivityLevelb b Gender Age(years) Sedentary ModeratelyActive Active Child 23 1,0001,200c 1,0001,400c 1,0001,400c 1,4001,800 1,4001,600 1,2001,400 Femaled 48 1,8002,200 1,6002,000 1,4001,600 913 2,400 2,000 1,800 1418 2,400 2,0002,200 1,8002,000 1930 2,200 2,000 1,800 3150 2,0002,200 1,800 1,600 51+ 1,6002,000 1,4001,600 1,2001,400 Male 48 2,0002,600 1,8002,200 1,6002,000 913 2,8003,200 2,4002,800 2,0002,400 1418 3,000 2,6002,800 2,4002,600 1930 2,8003,000 2,4002,600 2,2002,400 3150 2,4002,800 2,2002,400 2,0002,200 51+
a.BasedonEstimatedEnergyRequirements(EER)equations,usingreferenceheights(average)andreferenceweights(healthy)foreach age/gendergroup.Forchildrenandadolescents,referenceheightandweightvary.Foradults,thereferencemanis5feet10inchestalland weighs154pounds.Thereferencewomanis5feet4inchestallandweighs126pounds.EERequationsarefromtheInstituteofMedicine. DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol,Protein,andAminoAcids.Washington(DC):The NationalAcademiesPress;2002. b.Sedentarymeansalifestylethatincludesonlythelightphysicalactivityassociatedwithtypicaldaytodaylife.Moderatelyactivemeans alifestylethatincludesphysicalactivityequivalenttowalkingabout1.5to3milesperdayat3to4milesperhour,inadditiontothelight physicalactivityassociatedwithtypicaldaytodaylife.Activemeansalifestylethatincludesphysicalactivityequivalenttowalkingmore than3milesperdayat3to4milesperhour,inadditiontothelightphysicalactivityassociatedwithtypicaldaytodaylife. c.Thecalorierangesshownaretoaccommodateneedsofdifferentageswithinthegroup.Forchildrenandadolescents,morecaloriesare neededatolderages.Foradults,fewercaloriesareneededatolderages. d.Estimatesforfemalesdonotincludewomenwhoarepregnantorbreastfeeding. Reference DietaryGuidelinesforAmericans2010.Availableat: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.AccessedJan31,2011.
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DIETARYREFERENCEINTAKES(DRIs):RECOMMENDEDINTAKESFOR INDIVIDUALS,MACRONUTRIENTS
LifeStageGroup FoodandNutritionBoard,InstituteofMedicine,NationalAcademies Total Total Linoleic Linolenic Water Carbohydrate Fiber Fat Proteinb Acid Acid
a
Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150y
(L/d)
(g/d)
(g/d) (g/d) (g/d)
(g/d)
(g/d)
0.7* 0.8*
60* 95*
ND ND
31* 30*
4.4* 4.6*
0.5* 0.5*
9.1* 11.0c
1.3* 1.7*
130 130
19* 25*
ND ND
7* 10*
0.7* 0.9*
13 19
2.4* 3.3* 3.7* 3.7* 3.7* 3.7*
130 130 130 130 130 130
31* 38* 38* 38* 30* 30*
ND ND ND ND ND ND
12* 16* 17* 17* 14* 14*
1.2* 1.6* 1.6* 1.6* 1.6* 1.6*
34 52 56 56 56 56
2.1* 2.3* 2.7* 2.7* 2.7* 2.7*
130 130 130 130 130 130
26* 26* 25* 25* 21* 21*
ND ND ND ND ND ND
10* 11* 12* 12* 11* 11*
1.0* 1.1* 1.1* 1.1* 1.1* 1.1*
34 46 46 46 46 46
3.0* 3.0* 3.0*
175 175 175
28* 28* 28*
ND ND ND
13* 13* 13*
1.4* 1.4* 1.4*
71 71 71
3.8* 3.8* 3.8*
210 210 210
29* 29* 29*
ND ND ND
13* 13* 13*
1.3* 1.3* 1.3*
71 71 71
NOTE:ThistablepresentsRecommendedDietaryAllowances(RDAs)inboldtypeandAdequateIntakes(AIs)inordinarytypefollowedby anasterisk(*).RDAsandAIsmaybothbeusedasgoalsforindividualintake.RDAsaresettomeettheneedsofalmostall(97to98percent) individualsinagroup.Forhealthyinfantsfedhumanmilk,theAIisthemeanintake.TheAIforotherlifestageandgendergroupsisbelieved tocovertheneedsofallindividualsinthegroup,butlackofdataoruncertaintyinthedatapreventbeingabletospecifywithconfidencethe percentageofindividualscoveredbythisintake. aTotalwaterincludesallwatercontainedinfood,beverages,anddrinkingwater. bBasedon0.8g/kgbodyweightforthereferencebodyweight. cChangefrom13.5inprepublicationcopyduetocalculationerror.
DietaryReferenceIntakes(DRIs):AdditionalMacronutrientRecommendations FoodandNutritionBoard,InstituteofMedicine,NationalAcademies Macronutrient Recommendation Dietarycholesterol Aslowaspossiblewhileconsuminganutritionallyadequatediet Transfattyacids Aslowaspossiblewhileconsuminganutritionallyadequatediet Saturatedfattyacids Aslowaspossiblewhileconsuminganutritionallyadequatediet Addedsugars Limittonomorethan25%oftotalenergy
SOURCE:DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol,Protein,andAminoAcids(2002).
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DietaryReferenceIntakes(DRIs):RecommendedDietaryAllowancesandAdequateIntakes,Vitamins
FoodandNutritionBoard,InstituteofMedicine,NationalAcademies
LifeStage Group Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y VitA (g/d)a VitC (mg/d) VitD (g/d)b,c VitE (mg/d)d VitK (g/d) Thiamin (mg/d) Riboflavin (mg/d) Niacin (mg/d)e VitB6 (mg/d) Folate (g/d)f VitB12 (g/d) Pantothenic Acid(mg/d) Biotin (g/d) Cholineg (mg/d)
400* 500*
40* 50*
15* 15*
4* 5*
2.0* 2.5*
0.2* 0.3*
0.3* 0.4*
2* 4*
0.1* 0.3*
65* 80*
0.4* 0.5*
1.7* 1.8*
5* 6*
125* 150*
300 400
15 25
15* 15*
6 7
30* 55*
0.5 0.6
0.5 0.6
6 8
0.5 0.6
150 200
0.9 1.2
2* 3*
8* 12*
200* 250*
600 900 900 900 900 900
45 75 90 90 90 90
15* 15* 15* 15* 15* 20*
11 15 15 15 15 15
60* 75* 120* 120* 120* 120*
0.9 1.2 1.2 1.2 1.2 1.2
0.9 1.3 1.3 1.3 1.3 1.3
12 16 16 16 16 16
1.0 1.3 1.3 1.3 1.7 1.7
300 400 400 400 400 400
1.8 2.4 2.4 2.4 2.4i 2.4i
4* 5* 5* 5* 5* 5*
20* 25* 30* 30* 30* 30*
375* 550* 550* 550* 550* 550*
600 700 700 700 700 700
45 65 75 75 75 75
15* 15* 15* 15* 15* 20*
11 15 15 15 15 15
60* 75* 90* 90* 90* 90*
0.9 1.0 1.1 1.1 1.1 1.1
0.9 1.0 1.1 1.1 1.1 1.1
12 14 14 14 14 14
1.0 1.2 1.3 1.3 1.5 1.5
300 400i 400i 400i 400 400
1.8 2.4 2.4 2.4 2.4h 2.4h
4* 5* 5* 5* 5* 5*
20* 25* 30* 30* 30* 30*
375* 400* 425* 425* 425* 425*
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Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150
750 770 770
80 85 85
15* 15* 15*
15 15 15
75* 90* 90*
1.4 1.4 1.4
1.4 1.4 1.4
18 18 18
1.9 1.9 1.9
600j 600j 600j
2.6 2.6 2.6
6* 6* 6*
30* 30* 30*
450* 450* 450*
1,200 1,300 1,300
115 120 120
15* 15* 15*
19 19 19
75* 90* 90*
1.4 1.4 1.4
1.6 1.6 1.6
17 17 17
2.0 2.0 2.0
500 500 500
2.8 2.8 2.8
7* 7* 7*
35* 35* 35*
550* 550* 550*
Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.
NOTE:Thistable(takenfromtheDRIreports,seewww.nap.edu)presentsRecommendedDietaryAllowances(RDAs)inboldtypeandAdequateIntakes(AIs)inordinarytypefollowedbyanasterisk(*).AnRDAistheaveragedaily dietaryintakelevel;sufficienttomeetthenutrientrequirementsofnearlyall(97to98percent)healthyindividualsinagroup.ItiscalculatedfromanEstimatedAverageRequirement(EAR).Ifsufficientscientificevidenceisnotavailable toestablishanEAR,andthuscalculateanRDA,anAIisdeveloped.Forhealthybreastfedinfants,theAIisthemeanintake.TheAIforotherlifestageandgendergroupsisbelievedtocoverneedsofallhealthyindividualsinthegroup,but lackofdataoruncertaintyinthedatapreventbeingabletospecifywithconfidencethepercentageofindividualscoveredbythisintake. aAsretinolactivityequivalents(RAEs).1RAE=1mgretinol,12mgbcarotene,24mgacarotene,or24mgbcryptoxanthin.TheRAEfordietaryprovitaminAcarotenoidsistwofoldgreaterthanretinolequivalents(RE),whereasthe RAEforpreformedvitaminAisthesameasRE. bAscholecalciferol.1gcholecalciferol=40IUvitaminD. cIntheabsenceofadequateexposuretosunlight. dAsatocopherol.aTocopherolincludesRRRatocopherol,theonlyformofatocopherolthatoccursnaturallyinfoods,andthe2Rstereoisomericformsofatocopherol(RRR,RSR,RRS,andRSSatocopherol)thatoccurinfortified foodsandsupplements.Itdoesnotincludethe2Sstereoisomericformsofatocopherol(SRR,SSR,SRS,andSSSatocopherol),alsofoundinfortifiedfoodsandsupplements. eAsniacinequivalents(NE).1mgofniacin=60mgoftryptophan;06months=preformedniacin(notNE). fAsdietaryfolateequivalents(DFE).1DFE=1gfoodfolate=0.6goffolicacidfromfortifiedfoodorasasupplementconsumedwithfood=0.5gofasupplementtakenonanemptystomach. gAlthoughAIshavebeensetforcholine,therearefewdatatoassesswhetheradietarysupplyofcholineisneededatallstagesofthelifecycle,anditmaybethatthecholinerequirementcanbemetbyendogenoussynthesisatsomeof thesestages. hBecause10to30percentofolderpeoplemaymalabsorbfoodboundB12,itisadvisableforthoseolderthan50yearstomeettheirRDAmainlybyconsumingfoodsfortifiedwithB12orasupplementcontainingB12. iInviewofevidencelinkingfolateintakewithneuraltubedefectsinthefetus,itisrecommendedthatallwomencapableofbecomingpregnantconsume400gfromsupplementsorfortifiedfoodsinadditiontointakeoffoodfolatefrom avarieddiet. jItisassumedthatwomenwillcontinueconsuming400gfromsupplementsorfortifiedfooduntiltheirpregnancyisconfirmedandtheyenterprenatalcare,whichordinarilyoccursaftertheendofthepericonceptionalperiodthe criticaltimeforformationoftheneuraltube.
SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper, Iodine,Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);DietaryReferenceIntakesforWater,Potassium,Sodium,Chloride,andSulfate(2005);andDietaryReferenceIntakesforCalcium andVitaminD(2011).Thesereportsmaybeaccessedviawww.nap.edu.
DietaryReferenceIntakes(DRIs):RecommendedDietaryAllowancesandAdequateIntakes,Elements
LifeStage Group Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150y Calcium (mg/d) Chromium (g/d) Copper (g/d) Fluoride (mg/d) Iodine (g/d) Iron (mg/d) Magnesium (mg/d) Manganese (mg/d) Molybdenum (g/d) Phosphorus (mg/d) Selenium (g/d) Zinc (mg/d) Potassium (g/d) Sodium (g/d) Chloride (g/d) ManualofClinicalNutritionManagement
200* 260*
0.2* 5.5*
200* 220*
0.01* 0.5*
110* 130*
0.27* 11
30* 75*
0.003* 0.6*
2* 3*
100* 275*
15* 20*
2* 3
0.4* 0.7*
0.12* 0.37*
0.18* 0.57*
700* 1,000*
11* 15*
340 440
0.7* 1*
90 90
7 10
80 130
1.2* 1.5*
17 22
460 500
20 30
3 5
3.0* 3.8*
1.0* 1.2*
1.5* 1.9*
1,300* 1,300* 1,000* 1,000* 1,000* 1,200*
25* 35* 35* 35* 30* 30*
700 890 900 900 900 900
2* 3* 4* 4* 4* 4*
120 150 150 150 150 150
8 11 8 8 8 8
240 410 400 420 420 420
1.9* 2.2* 2.3* 2.3* 2.3* 2.3*
34 43 45 45 45 45
1,250 1,250 700 700 700 700
40 55 55 55 55 55
8 11 11 11 11 11
4.5* 4.7* 4.7* 4.7* 4.7* 4.7*
1.5* 1.5* 1.5* 1.5* 1.3* 1.2*
2.3* 2.3* 2.3* 2.3* 2.0* 1.8*
1,300* 1,300* 1,000* 1,000* 1,200* 1,200*
21* 24* 25* 25* 20* 20*
700 890 900 900 900 900
2* 3* 3* 3* 3* 3*
120 150 150 150 150 150
8 15 18 18 8 8
240 360 310 320 320 320
1.6* 1.6* 1.8* 1.8* 1.8* 1.8*
34 43 45 45 45 45
1,250 1,250 700 700 700 700
40 55 55 55 55 55
8 9 8 8 8 8
4.5* 4.7* 4.7* 4.7* 4.7* 4.7*
1.5* 1.5* 1.5* 1.5* 1.3* 1.2*
2.3* 2.3* 2.3* 2.3* 2.0* 1.8*
A6
1,300* 1,000* 1,000*
29* 30* 30*
1,000 1,000 1,000
3* 3* 3*
220 220 220
27 27 27
400 350 360
2.0* 2.0* 2.0*
50 50 50
1,250 700 700
60 60 60
12 11 11
4.7* 4.7* 4.7*
1.5* 1.5* 1.5*
2.3* 2.3* 2.3*
1,300* 1,000* 1,000*
44* 45* 45*
1,300 1,300 1,300
3* 3* 3*
290 290 290
10 9 9
360 310 320
2.6* 2.6* 2.6*
50 50 50
1,250 700 700
70 70 70
13 12 12
5.1* 5.1* 5.1*
1.5* 1.5* 1.5*
2.3* 2.3* 2.3*
NOTE:Thistable(takenfromtheDRIreports,seewww.nap.edu)presentsRecommendedDietaryAllowances(RDAs)inboldtypeandAdequateIntakes(AIs)inordinarytypefollowedbyanasterisk(*).AnRDAistheaveragedaily dietaryintakelevel;sufficienttomeetthenutrientrequirementsofnearlyall(97to98percent)healthyindividualsinagroup.ItiscalculatedfromanEstimatedAverageRequirement(EAR).Ifsufficientscientificevidenceisnotavailable toestablishanEAR,andthuscalculateanRDA,anAIisdeveloped.Forhealthybreastfedinfants,theAIisthemeanintake.TheAIforotherlifestageandgendergroupsisbelievedtocoverneedsofallhealthyindividualsinthegroup,but lackofdataoruncertaintyinthedatapreventbeingabletospecifywithconfidencethepercentageofindividualscoveredbythisintake.
SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine, Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);DietaryReferenceIntakesforWater,Potassium,Sodium,Chloride,andSulfate(2005);andDietaryReferenceIntakesforCalciumand VitaminD(2011).Thesereportsmaybeaccessedviawww.nap.edu.
DietaryReferenceIntakes(DRIs):EstimatedAverageRequirements
LifeStage Group Infants 0to6mo 612mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150y Cal cium
(mg/d)
CHO
(g/kg/d)
Protein (g/kg/d) 1.0 0.87 0.76 0.76 0.73 0.66 0.66 0.66 0.66 0.76 0.71 0.66 0.66 0.66 0.66 0.88 0.88 0.88 1.05 1.05 1.05
VitA
(mg/d)a
VitC (mg/d)
VitD
(g/d)
VitE
(mg/d)
b
Thia min
(mg/d)
Ribo flavin (mg/d)
Niacin
(mg/d)c
VitB6
(mg/d)
Folate
(mg/d)d
Vit B12
(mg/d)
(mg/d)
Cop per
Iodine (mg/d)
Iron
(mg/d)
Magnes ium (mg/d)
Molyb denum (mg/d)
Phos phorus (mg/d)
Sele nium
(mg/d)
Zinc
(mg/d)
500 800 1,100 1,100 800 800 800 1,000 1,100 1,100 800 800 1,000 1,000 1,000 800 800 1,000 800 800
100 100 100 100 100 100 100 100 100 100 100 100 100 100 135 135 135 160 160 160
210 275 445 630 625 625 625 625 420 485 500 500 500 500 530 550 550 885 900 900
6.9 13 22 39 63 75 75 75 75 39 56 60 60 60 60 66 70 70 96 100 100 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 5 6 9 12 12 12 12 12 9 12 12 12 12 12 12 12 12 16 16 16 0.4 0.5 0.7 1.0 1.0 1.0 1.0 1.0 0.7 0.9 0.9 0.9 0.9 0.9 1.2 1.2 1.2 1.2 1.2 1.2 0.4 0.5 0.8 1.1 1.1 1.1 1.1 1.1 0.8 0.9 0.9 0.9 0.9 0.9 1.2 1.2 1.2 1.3 1.3 1.3 5 6 9 12 12 12 12 12 9 11 11 11 11 11 14 14 14 13 13 13 0.4 0.5 0.8 1.1 1.1 1.1 1.4 1.4 0.8 1.0 1.1 1.1 1.3 1.3 1.6 1.6 1.6 1.7 1.7 1.7 120 160 250 330 320 320 320 320 250 330 320 320 320 320 520 520 520 450 450 450 0.7 1.0 1.5 2.0 2.0 2.0 2.0 2.0 1.5 2.0 2.0 2.0 2.0 2.0 2.2 2.2 2.2 2.4 2.4 2.4 260 340 540 685 700 700 700 700 540 685 700 700 700 700 785 800 800 985 1,00 0 1,00 0 65 65 73 95 95 95 95 95 73 95 95 95 95 95 160 160 160 209 209 209 3.0 4.1 5.9 7.7 6 6 6 6 5.7 7.9 8.1 8.1 5 5 23 22 22 7 6.5 6.5 65 110 200 340 330 350 350 350 200 300 255 265 265 265 335 290 300 300 255 265 13 17 26 33 34 34 34 34 26 33 34 34 34 34 40 40 40 35 36 36 380 405 1,055 1,055 580 580 580 580 1,055 1,055 580 580 580 580 1,055 580 580 1,055 580 580 17 23 35 45 45 45 45 45 35 45 45 45 45 45 49 49 49 59 59 59
2.5 2.5 4.0 7.0 8.5 9.4 9.4 9.4 9.4 7.0 7.3 6.8 6.8 6.8 6.8 10.5 9.5 9.5 10.9 10.4 10.4
A7
NOTE:AnEstimatedAverageRequirements(EAR),istheaveragedailynutrientintakelevelestimatedtomeettherequirementsofhalfofthehealthyindividualsinagroup.EARshavenotbeenestablishedfor vitaminK,pantothenicacid,biotin,choline,chromium,fluoride,manganese,orothernutrientsnotyetevaluatedviatheDRIprocess. aAsretinolactivityequivalents(RAEs).1RAE=1gretinol,12gbcarotene,24gacarotene,or24gcryptoxanthin.TheRAEfordietaryprovitaminAcarotenoidsistwofoldgreaterthanretinol equivalents(RE),whereastheRAEforpreformedvitaminAisthesameasRE. bAstocopherol.TocopherolincludesRRRtocopherol,theonlyformoftocopherolthatoccursnaturallyinfoods,andthe2Rstereoisomericformsoftocopherol(RRR,RSR,RRS,andRSStocopherol) thatoccurinfortifiedfoodsandsupplements.Itdoesnotincludethe2Sstereoisomericformsoftocopherol(SRR,SSR,SRS,andSSStocopherol),alsofoundinfortifiedfoodsandsupplements. cAsniacinequivalents(NE).1mgofniacin=60mgoftryptophan. dAsdietaryfolateequivalents(DFE).1DFE=1gfoodfolate=0.6goffolicacidfromfortifiedfoodorasasupplementconsumedwithfood=0.5gofasupplementtakenonanemptystomach. SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine, Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol,Protein,andAminoAcids(2002/2005);andDietary ReferenceIntakesforCalciumandVitaminD(2011).Thesereportsmaybeaccessedviawww.nap.edu.
DietaryReferenceIntakes(DRIs):TolerableUpperIntakeLevels,Vitamins
LifeStage ManualofClinicalNutritionManagement Group Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150y VitaminA (g/d)a VitaminC (mg/d) VitaminD (mg/d) VitaminE (mg/d)b,c VitaminK Thiamin Ribo flavin

ND ND

ND ND
Niacin (mg/d)c
VitaminB6 (mg/d)
Folate (mg/d)
c
VitaminB12
Pantothenic Acid
Biotin
Choline (g/d)
Carote noidsd

ND ND

ND ND
600 600
NDe ND
25 37.5
ND ND
ND ND ND ND
ND ND
ND ND
ND ND ND ND
ND ND
600 900
400 650
62.5 75
200 300
ND ND
ND ND
ND ND
10 15
30 40
300 400
ND ND
ND ND
ND ND
1.0 1.0
ND ND
1,700 2,800 3,000 3,000 3,000 3,000
1,200 1,800 2,000 2,000 2,000 2,000
100 100 100 100 100 100
600 800 1,000 1,000 1,000 1,000
ND ND ND ND ND ND
ND ND ND ND ND ND
ND ND ND ND ND ND
20 30 35 35 35 35
60 80 100 100 100 100
600 800 1,000 1,000 1,000 1,000
ND ND ND ND ND ND
ND ND ND ND ND ND
ND ND ND ND ND ND
2.0 3.0 3.5 3.5 3.5 3.5
ND ND ND ND ND ND
1,700 2,800 3,000 3,000 3,000 3,000
1,200 1,800 2,000 2,000 2,000 2,000
100 100 100 100 100 100
600 800 1,000 1,000 1,000 1,000
ND ND ND ND ND ND
ND ND ND ND ND ND
ND ND ND ND ND ND
20 30 35 35 35 35
60 80 100 100 100 100
600 800 1,000 1,000 1,000 1,000
ND ND ND ND ND ND
ND ND ND ND ND ND
ND ND ND ND ND ND
2.0 3.0 3.5 3.5 3.5 3.5
ND ND ND ND ND ND
A8
2,800 3,000 3,000
1,800 2,000 2,000
100 100 100
800 1,000 1,000
ND ND ND
ND ND ND
ND ND ND
30 35 35
80 100 100
800 1,000 1,000
ND ND ND
ND ND ND
ND ND ND
3.0 3.5 3.5
ND ND ND
2,800 3,000 3,000
1,800 2,000 2,000
100 100 100
800 1,000 1,000
ND ND ND
ND ND ND
ND ND ND
30 35 35
80 100 100
800 1,000 1,000
ND ND ND
ND ND ND
ND ND ND
3.0 3.5 3.5
ND ND ND
NOTE:ATolerableUpperIntakeLevel(UL)isthehighestlevelofdailynutrientintakethatislikelytoposenoriskofadverseeffects toalmostallindividualsinthegeneralpopulation.Unlessotherwisespecified,theULrepresents totalintakefromfood,water,andsupplements.Duetolackofsuitabledata,ULscouldnotbeestablishedforvitaminK,thiamin,riboflavin,vitaminB12,pantothenicacid,biotin,carotenoids.IntheabsenceofULs,extracautionmaybe warrantedinconsuminglevelsaboverecommendedintakes.MembersofthegeneralpopulationshouldbeadvisednottoroutinelyexceedtheUL.TheULisnotmeanttoapplytoindividualswhoaretreatedwiththenutrientunder medicalsupervisionortoindividualswithpredisposingconditionsthatmodifytheirsensitivitytothenutrient.
AspreformedvitaminAonly. Astocopherol;appliestoanyformofsupplementaltocopherol. dTheULsforvitaminE,niacin,andfolateapplytosyntheticformsobtainedfromsupplements,fortifiedfoods,oracombinationofthetwo. dbCarotenesupplementsareadvisedonlytoserveasaprovitaminAsourceforindividualsatriskofvitaminAdeficiency. eND=Notdeterminableduetolackofdataofadverseeffectsinthisagegroupandconcernwithregardtolackofabilitytohandleexcessamounts.Sourceofintakeshouldbefromfoodonlytoprevent highlevelsofintake.

a b
SOURCES:DietaryReferenceIntakesforCalcium,Phosphorous,Magnesium,VitaminD,andFluoride(1997);DietaryReferenceIntakesforThiamin,Riboflavin,Niacin,VitaminB6,Folate,VitaminB12, PantothenicAcid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);andDietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron, Chromium,Copper,Iodine,Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);andDietaryReferenceIntakesforCalciumandVitaminD(2011).Thesereportsmaybeaccessedvia www.nap.edu.
DietaryReferenceIntakes(DRIs):TolerableUpperIntakeLevels,Elements
LifeStage Group Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation
Arse Nica
Boron (mg/d)
Calci um (mg/d)
Chrom ium
Copper (g/d)
Fluor ide (mg/d)
Iodine (g/d)
Iron (mg/d)
Magnes ium (mg/d)b
Manga nese (mg/d)
Molyb denum (g/d)
Nickel (mg/d)
Phos phorus (g/d)
Selen ium (g/d)
Sili con c
Vana dium (mg/d)d
Zinc (mg/d)
Sodi um (g/d)
Chlor ide (g/d)

NDe ND
ND ND
1,000 1,500

ND ND
ND ND
0.7 0.9
ND ND
40 40
ND ND
ND ND
ND ND
ND ND
ND ND
45 60

ND ND
ND ND
4 5
ND ND
ND ND
ND ND
3 6
2,500 2,500
ND ND
1,000 3,000
1.3 2.2
200 300
40 40
65 110
2 3
300 600
0.2 0.3
3 3
90 150
ND ND
ND ND
7 12
1.5 1.9
2.3 2.9
ND ND ND ND ND ND
11 17 20 20 20 20
3,000 3,000 2,500 2,500 2,000 2,000
ND ND ND ND ND ND
5,000 8,000 10,000 10,000 10,000 10,000
10 10 10 10 10 10
600 900 1,100 1,100 1,100 1,100
40 45 45 45 45 45
350 350 350 350 350 350
6 9 11 11 11 11
1,100 1,700 2,000 2,000 2,000 2,000
0.6 1.0 1.0 1.0 1.0 1.0
4 4 4 4 4 3
280 400 400 400 400 400
ND ND ND ND ND ND
ND ND 1.8 1.8 1.8 1.8
23 34 40 40 40 40
2.2 2.3 2.3 2.3 2.3 2.3
3.4 3.6 3.6 3.6 3.6 3.6
ND ND ND ND ND ND
11 17 20 20 20 20
3,000 3,000 2,500 2,500 2,000 2,000
ND ND ND ND ND ND
5,000 8,000 10,000 10,000 10,000 10,000
10 10 10 10 10 10
600 900 1,100 1,100 1,100 1,100
40 45 45 45 45 45
350 350 350 350 350 350
6 9 11 11 11 11
1,100 1,700 2,000 2,000 2,000 2,000
0.6 1.0 1.0 1.0 1.0 1.0
4 4 4 4 4 3
280 400 400 400 400 400
ND ND ND ND ND ND
ND ND 1.8 1.8 1.8 1.8
23 34 40 40 40 40
2.2 2.3 2.3 2.3 2.3 2.3
3.4 3.6 3.6 3.6 3.6 3.6
A9
ND ND ND
17 20 20
3,000 2,500 2.500
ND ND ND
8,000 10,000 10,000
10 10 10
900 1,100 1,100
45 45 45
350 350 350
9 11 11
1,700 2,000 2,000
1.0 1.0 1.0
3.5 3.5 3.5
400 400 400
ND ND ND
ND ND ND
34 40 40
2.3 2.3 2.3
3.6 3.6 3.6
1418y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 1.0 4 400 ND ND 34 2.3 3.6 1930y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND ND 40 2.3 3.6 3150y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND ND 40 2.3 3.6 NOTE:ATolerableUpperIntakeLevel(UL)isthehighestlevelofdailynutrientintakethatislikelytoposenoriskofadverseeffectstoalmostallindividualsinthegeneralpopulation.Unlessotherwisespecified,theULrepresents total intakefromfood,water,andsupplements.Duetolackofsuitabledata,ULscouldnotbeestablishedforvitaminK,thiamin,riboflavin,vitaminB12,pantothenicacid,biotin,carotenoids.IntheabsenceofULs,extracautionmaybe warrantedinconsuminglevelsaboverecommendedintakes.MembersofthegeneralpopulationshouldbeadvisednottoroutinelyexceedtheUL.TheULisnotmeanttoapplytoindividualswhoaretreatedwiththenutrientunder medicalsupervisionortoindividualswithpredisposingconditionsthatmodifytheirsensitivitytothenutrient.
AlthoughtheULwasnotdeterminedforarsenic,thereisnojustificationforaddingarsenictofoodorsupplements. TheULsformagnesiumrepresentintakefromapharmacologicalagentonlyanddonotincludeintakefromfoodandwater. cAlthoughsiliconhasnotbeenshowntocauseadverseeffectsinhumans,thereisnojustificationforaddingsilicontosupplements. dAlthoughvanadiuminfoodhasnotbeenshowntocauseadverseeffectsinhumans,thereisnojustificationforaddingvanadiumtofoodandvanadiumsupplementsshouldbeusedwithcaution.TheULis basedonadverseeffectsinlaboratoryanimalsandthisdatacouldbeusedtosetaULforadultsbutnotchildrenandadolescents. eND=Notdeterminableduetolackofdataofadverseeffectsinthisagegroupandconcernwithregardtolackofabilitytohandleexcessamounts.Sourceofintakeshouldbefromfoodonlytopreventhigh levelsofintakes.

a b
SOURCES:DietaryReferenceIntakesforCalcium,Phosphorous,Magnesium,VitaminD,andFluoride(1997);DietaryReferenceIntakesforThiamin,Riboflavin,Niacin,VitaminB6,Folate,VitaminB12, PantothenicAcid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron, Chromium,Copper,Iodine,Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);DietaryReferenceIntakesforWater,Potassium,Sodium,Chloride,andSulfate(2005);andDietaryReference IntakesforCalciumandVitaminD(2011).Thesereportsmaybeaccessedviahttp://www.nap.edu.
FOODFORTIFICATIONANDDIETARYSUPPLEMENTS POSITIONOFTHEAMERICANDIETETICASSOCIATION(ADA)
ItisthepositionoftheAmericanDieteticAssociation(ADA)thatthebestnutritionalstrategyforpromoting optimalhealthandreducingtheriskofchronicdiseaseistowiselychooseawidevarietyoffoods.Additional vitaminsandmineralsfromfortifiedfoodsand/orsupplementscanhelpsomepeoplemeettheirnutritional needsasspecifiedbysciencebasednutritionstandardssuchastheDietaryReferenceIntakes(DRIs)(1,2). Recommendations regarding supplementation and the therapeutic use of vitamins and minerals for treating specific conditions may be found in the corresponding sections of this manual. The latest recommendations from the Food and Nutrition Board for the first time include recommendations that supplements or fortified foods be used to obtain desirable amounts of some nutrients, eg, folic acid and calcium,incertainpopulationgroups. Under the Dietary Supplement Health and Education Act of 1994, manufacturers must adhere to restrictions regarding the types of claims that are allowed on product labels. Statements regarding the efficacyofspecificproductsinthetreatmentorpreventionofparticularconditionsareprohibited.Aclaim statementisallowedifthestatementclaimsabenefitrelatedtoaclassicalnutrientdeficiencydiseaseand discloses the prevalence of such disease in the United States, describes the role of a nutrient or dietary ingredientintendedtoaffectthestructureorfunctioninhumans,characterizesthedocumentedmechanism by which a nutrient or dietary ingredient acts to maintain such structure or function, or describes general wellbeingfromconsumptionofanutrientordietaryingredient(1). The manufacturer mustspecify that theclaims are truthful and notmisleading. The followingstatement must also accompany any claims, This statement has not been evaluated by the Food and Drug Administration.Thisproductisnotintendedtodiagnose,treat,cure,orpreventanydisease(1).Inaddition, all supplements must have the identity and strength of contents listed on the label, and meet appropriate specificationsforquality,purityandcomposition(3).
References 1. PositionoftheAmericanDieteticAssociation:NutrientSupplementation.JAmDietAssoc.2009;109:20732085125. 2. PositionoftheAmericanDieteticAssociation:Functionalfoods.JAmDietAssoc.2009;109:735746. 3. DietarySupplementHealthandEducationActof1994.PublicLaw(S.784)(1994)(codifiedat42USC287C11). . ManualofClinicalNutritionManagement
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REGULARDIETADULT
Description The diet includes a wide variety of foods to meet nutritional requirements and individual preferences of healthyadults.Itisusedtopromotehealthandreducetherisksofdevelopingmajor,chronic,ornutrition relateddisease.
Indications Thedietisservedwhenspecificdietarymodificationsarenotrequired.
NutritionalAdequacy ThedietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedinStatementonNutritional Adequacy in Section IA. The diet uses the 2,000 kilocalorie level asthe standardreference level foradults. Specificcalorielevelsmayneedtobeadjustedbasedonage,genderandphysicalactivity.
HowtoOrdertheDiet OrderasRegularDiet,indicatinganyspecialinstructions.
PlanningtheDiet The Dietary Guidelines for Americans and portion sizes use the USDA Food Guide and the DASH (Dietary Approaches to Stopping Hypertension) Eating Plan as the basis for planning the menu (1). The Dietary Guidelines are intended for all Americans, healthy and those at increased risk of chronic disease. However, modifications may be required while treating patients who are ill, as the main goal is to encourage food intake,whichfrequentlyrequirescomfortfoods,suchassoup,sandwiches,andotherfoodsthepatientis accustomed to. With that consideration, the number of servings of foods from each food group may differ fromtherecommendations.However,themealwillstillbeplannedtomeettheDRIswheneverpossible. DietaryGuidelinesforAmericansencompassestwooverarchingconcepts(1): Maintaincaloriebalanceovertimetoachieveandsustainahealthyweight Focusonconsumingnutrientdensefoodsandbeverageswithinbasicfoodgroupswhilecontrolling calorieandsodiumintake Recommendedhealthyeatingpattern: dailysodiumintaketolessthan2,300mgandfurtherreduceintaketo1,500mgamongpersonswhoare 51 and older and any age who are African American or have hypertension diabetes, or chronic kidney disease.Atthesametime,consumefoodswithmorepotassium,dietaryfiber,calciumandvitaminD. increasedailyintakeoffruitsandvegetables,wholegrains,andfatfreeorlowfatmilkandmilkproducts consumelessthan10percentofcaloriesfromsaturatedfattyacidsbyreplacingwithmonounsaturated andpolyunsaturatedfattyacids.Oilsshouldreplacesolidfatswhenpossible. keeptransfataslowaspossible. reducetheintakeofcaloriesfromsolidfatsandaddedsugars. limit consumption offoods that containrefined grains, especially refinedgrainfoods thatcontain solid fats,addedsugars,adsodium. ifyoudrinkalcoholicbeverages,dosoinmoderation,foronlyadultsoflegalage keepfoodsafetoeat
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RegularDietAdult
FOODGUIDEFORAMERICANS(18002000caloriepattern)(1) FoodGroup Fruits Vegetables Grains Meat,Poultry, DryBeans, Eggs,andNuts Milk,Yogurt,and Cheese Oils RecommendedDaily 34servings Consumecitrusfruits,melons,berries, andotherfruitsregularly 5servings Darkgreenleafyvegetables:3 Redandorangevegetables:5 cups/week Legumes:1cups/week Starchyvegetables:5cups/week Othervegetable:4cups/week ServingSize Mediumsizeorange,apple,orbanana cupofchopped,cooked,orcannedfruit(nosugaradded) cupof100%fruitjuice 1cupofrawleafyvegetables:spinach,lettuce cupofothervegetables,cookedorchoppedraw cupofvegetablejuice
6servings 1sliceofbread Wholegrainproducts:3daily Othergrains:3daily 2largeor4smallcrackers cupcookedcereal,rice,orpasta 1cupreadytoeatcereal 1smallrollormuffin English muffin,bagel,hamburgerbun,orlargeroll 55ouncesday Choosefish,drybeans,peas,poultry 1ounceofcookedfish,poultry,orleanmeat withoutskin,andleanmeat cupcookeddrybeansortofu 1egg 1Tbsppeanutbutter ouncenutsorseeds 3servings Chooseskimmilkandfatfree yogurt 1cupofmilkoryogurt Choosepartskimandlowfatcheeses 1ouncesofnaturalcheese (Mozzarella,Swiss,Cheddar) 2ouncesofprocessedcheese(American) 35tspdaily Oilsandsoftmargarinesinclude vegetablesoilsandsoftvegetableoil tablespreadsthatarelowinsaturated fatandaretransfree SAMPLEMENU Breakfast Noon Evening OrangeJuice RotisserieBakedChicken BraisedBeefandNoodles Oatmeal RicePilaf SeasonedGreenBeans ScrambledEgg SteamedBroccoliwithCarrots SlicedTomatoSalad Biscuit WholewheatRoll FrenchDressing Margarine Margarine Peachhalves Jelly FruitCup DinnerRoll LowfatMilk LowfatMilk Margarine Coffee IcedTea LowfatMilk
References 1. DietaryGuidelinesforAmericans2010.Availableat: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.AccessedJan31,2011.
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HIGHPROTEIN,HIGHCALORIEDIET
Description Additional foods and supplements are added to meals or between meals to increase protein and energy intake. Indications A highprotein, highcalorie diet is served when protein and energy requirements are increased by stress, proteinloss(proteinlosingenteropathy,nephroticsyndrome),andcatabolism.Thisdietmaybeindicatedin patientswith: proteinenergymalnutrition failuretothrive cancer burns cysticfibrosis humanimmunodeficiencyvirus(HIV)/acquiredimmunodeficiencysyndrome(AIDS) chronicgastrointestinaldiseases Thisdietmayalsobeindicatedinpreparationforsurgery.Anincreaseinenergyisrequiredtopromotethe efficientutilizationofproteinsforanabolism. NutritionalAdequacy ThedietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedinStatementonNutritional AdequacyinSectionIA. HowtoOrdertheDiet OrderasHighProtein,HighCalorieDiet.Thedietitiandeterminesatargetlevelofproteinandenergyto meetindividualneedsbasedonguidelinesasstatedinEstimationofProteinRequirementsinSectionII. PlanningtheDiet ThedietisplannedasaRegularDietwithadditionofbetweenmealsupplementsthatincreaseenergyintake byatleast500kcalandproteinintakeby25gforadults.Examplesofhighprotein,highenergysupplements aremilkshakes,eggnogs,puddings,custards,andcommercialsupplements. Forchildren,thedietgenerallyshouldprovide120%to150%oftheDietaryReferenceIntakes(DRIs)for energy and protein. The actual amounts of energy and protein provided will depend on the childs or adolescentsage,height,weight,medicalstatus,andnutritiongoals.
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IMMUNOCOMPROMISEDDIET(NeutropenicDiet)
Description The Immunocompromised Diet eliminates certain foods in order to serve a diet requiring a lower level of bacteriathanispresentinatypicalhospitaldiet.FoodsfromtheRegularDietareservedwiththeexceptionof unwashed raw fruits and vegetables; meat cooked less than welldone, cured meats, yogurt, aged cheese and preparedsalads. Indications Personswithdecreasedimmunefunctionduetochemotherapyorradiationareatahigherriskofdevelopinga foodrelatedinfection.Therearenotcontrolledstudiesthatdocumenttheefficacyofthisdiet.Thepremiseof the diet is to avoid specific foods that could potentially introduce infection causing organisms into the gastrointestinaltract.Whenthedietisbeingconsidered,thelengthoftimethepatienthasbeenneutropenic (absoluteneutrophilcountof<2,000/mm3),thepatientscurrentnutritionalstatus,andanticipatednutrition relatedsideeffectsthatwilloccurfromthetreatmentshouldbeconsidered(1).. NutritionalAdequacy TheImmunocompromisedDietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedin theStatementonNutritionalAdequacyinSectionIA. HowtoOrdertheDiet OrderasImmunocompromisedDietorNeutropenicDiet. PlanningtheDiet The diet does not differ significantly from the Regular Diet except it eliminates foods that are higher in pathogenicorganisms.Althoughrawfruitsandvegetablesareeliminated,theFredHutchinsonCancerResearch Center (2) allows raw fruits and vegetables (including peel) if they have been washed under running water, exceptrawvegetablesprouts. There is little evidence in the literature to support the Immunocompromised Diet. The diet outlined belowistheconsensusofstaffmembersofindividualhospitals,notaconsensusfromtheliterature. FoodstoExclude(14) Vegetables allrawvegetables;preparedsalads Fruits allrawfruits;preparedsalads Meats,Poultry,Fish,andEggs raworundercookedproducts;cured,smokedorpickledmeats,suchasbacon, sausage,luncheonmeats,andlox;shellfish Milk,Yogurt,andCheese rawmilk/milkproducts, unpasteurized yogurt,agedcheese,suchasBrie, Camembert,blue,sharpcheddar,andfeta FatsandOils refrigeratedcheesebasedsaladdressing,suchasbluecheese,thatisnotshelfstable Beverages coldbrewedteamadewithwarmorcoldwater
References 1. Neutropenia.In:AmericanDieteticAssociationNutritionCareManual.Chicago,Ill:AmericanDieteticAssoication;2004.Availableat: nutritioncaremanual.org.AccessedNovember14,2005. 2. DietGuidelinesforImmunosuppressedPatients.FredHutchinsonResearchCenter,2005.Availableat:www.fhcrc.org.Accessed November14,2005. 3. LFanning.Writtencommunication.Charlottesville,Va:UniversityofVirginiaHealthScienceCenter;December1999. 4. MKockley.Writtencommunication.StLouis,Mo:St.LouisChildrenHospital;December1999.
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NUTRITIONMANAGEMENTDURINGPREGNANCYANDLACTATION
Description DietsforpregnantorlactatingwomenincludeadditionalservingsoffoodfromtheRegularDiettomeetthe increasedrequirementfornutrientsduringpregnancyandlactation.
NutritionalAdequacy ThefoodpatternswillmeettheDietaryReferenceIntakes(DRIs)forpregnancyandlactation,asoutlinedin theStatementonNutritionalAdequacyinSectionIA,exceptfortheironrequirementsinthesecondandthird trimestersofpregnancy.Factorsthatmayincreasenutritionalrequirementsabovetheestimateddemandsof pregnancy include: poor nutritional status; young maternal age; multiple pregnancy; closely spaced births; breastfeedingduringpregnancy;continuedhighlevelofphysicalactivity;certaindiseasestates;andtheuse ofcigarettes,alcohol,andlegalorillegaldrugs.Dietaryintakeofiron,folate,zinc,protein,andcalciumshould be carefully assessed for adequacy (1). Supplementation is justified when evidence suggests that the inadequate intake of specific nutrients can increase the risk of an adverse effect on the mother, fetus, or pregnancyoutcome.Vegetarianswhoexcludeallanimalproductsneed2mgofvitaminB12daily (1).Alsosee VegetarianDietinSectionIA.
HowtoOrdertheDiet Order as Regular Diet Pregnancy or Regular Diet Lactation. Any special instructions should be indicatedinthedietorder.
PlanningtheDiet DailyFoodGroupGuidelines(2) FoodGroup Grains,Breads,andCereals Fruits Vegetables LowfatMeat,Poultry,Fish,andEggs LowfatMilk,Yogurt,Cheese Fats,Oils,andSweets
No.ofServings PregnantWomen LactatingWomen nine sixtoeleven three twotofour four threetofive two ormore(6oz) twoormore(78oz) threeorfour fourorfive Asneededtoprovideenergy
SpecificNutrientRequirementsDuringPregnancy Weightgain:TheNationalAcademyofSciencesFoodandNutritionBoardhasstatedthattheoptimalweightgain duringpregnancydependsonthemothersweightatthebeginningofpregnancy(1).Thetargetrangeforweight gain is associated with a fullterm, healthy baby, weighing an average of 3.1 to 3.6 kg (6.8 to 7.9 lb) (3). The optimumweightgainforawomanofnormalprepregnancyweightforherheight(bodymassindex(BMI),19.8to 26 kg/m2) who is carrying a single fetus is 25 to 35 lbs; however, there are individual differences based on maternalanthropometryandethnicdecent (3).Thepatternofweightgainismoresignificantthantheabsolute weight gain. The desired pattern of weight gain is approximately 3 to 8 lb in the first trimester and about 1 lb/weekduringthelasttwotrimesters.
The BMI, defined as weight divided by the height squared (kg/m2) (2), is a better indicator of maternal nutritional status than is weight alone. Recommendations for weight gain during pregnancy should be individualized according tothe prepregnancyBMI (3). (See Body Mass Index in Section II.) To identifythe BMIcategoriesandappropriateweightgain,useTableA1(1).
TableA1:GuidelinesforWeightGainAftertheFirstTrimesterofPregnancy(1,3,4) RecommendedWeightGain InterventionSuggested BMI(kg/m2) <19.8 1lb/wk <2lb/mo (underweight) 19.826 1lb/wk <2lb/mo,>6.5lb/mo (normalweight) >2629 0.66lb/wk >3.5 lb/wk,<1lb/wk (overweight) >29 Individualized <llb/wk,>2.5lb/wk (obese) Twinpregnancy 1.5lb/wk Individualized Individualized Individualized Tripletpregnancy
OverallWeightGain 2840lb 2535lb 1525lb 15lb 3445lb 50lb
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NutritionManagementDuringPregnancyandLactation
AccordingtotheInstituteofMedicine,youngmothersandAfricanAmericanmothersshouldstriveforaweight gainattheupperendoftherecommendedranges(1,3).Womenwithaheightlessthan62inchesshouldstrivefora weightgainatthelowerendoftherange (1).Womenwhoarepregnantwithtwinsshouldgain35to45lb(ora rateof0.7kg/weekafterthefirsttrimester)(1).Forwomenpregnantwithtriplets,aweightgainofmorethan50lb has been suggested (4). In a multiple pregnancy, such as a twin pregnancy or triplet pregnancy, the recommendations for optimal material weight gain (up to 36 to 38 weeks) vary according to pregravid weight status:underweight,targetweightgainof50to62lbs;normalweight,40to54lbs;overweight,38to47lbs;and obese,29to38lbs(3).
On average, each successive birth contributes an additional 2 lb above the amount of weight that is normallygainedwithage.However,womenwithhighgestationalweightgainsmaysurpassthisaverage (1). Preliminary evidence suggests that prenatal weight gain may influence birth weight and the risk of overweight in offspring (1). One prospective study reported that the children of women whose prenatal weightgainswereadequateorexcessive(accordingtothe1990InstituteofMedicineguidelines)weremore likelytobeoverweightat3yearsofage,ascomparedtothechildrenofmotherswhodidnotgainenough weight (5). Women with an excessive weight gain have a greater risk of adverse infant outcomes, including hypoglycemia,largeforgestationalage,alowApgarscore,seizures,andpolycythemia(1).
Energy:Thetotalenergyneedsduringpregnancyrangebetween2,200and2,900kcal/dayformostwomen (3,5). However, the mothers age, prepregnancy BMI, rate of weight gain, and physiologic appetite must be considered when determining individual needs (3). Based on a review of evidence, an average additional intakeofapproximately340to452kcal/dayissuggestedinthesecondandthirdtrimesters (6).Fornormal weightandoverweightwomenindevelopedcountries,theadditionalenergyneedmayactuallybelessthan 300kcal/day,especiallyinsedentarywomen (3).Appropriateweightgainandappetitearebetterindicators ofenergysufficiencythantheamountofenergyconsumed (3).Ithasbeensuggestedthatanadditional500 kcal/dayforatwinpregnancyisaddedtothecalculatedneeds.Thereisnoabsoluterecommendationinthe literaturefortheamountofadditionalenergyneededforamultiplepregnancy.Theindicationistoadd500 kcal/day in the first trimester as soon as the multiple pregnancy is diagnosed, because these pregnancies usually do not go to term and the goal is to maximize the early weight gain (4). Pregnant women should consume a variety of foods according to the Dietary Guidelines to meet nutrient needs and gain the recommended amounts of weight (3). MyPyramid guidelines include MyPyramid for Moms, which contains foodplansforpregnantwomen(3).
Protein: The 2002 DRIs list the recommended daily allowances for protein for all age groups during pregnancyandlactationtobe1.1g/kgperdayoranadditional25g/dayinadditiontothe0.8g/kgperday foranonpregnantstate (6).Onaverage,thisrecommendationequatestoapproximately71g,butforwomen withgreaterenergyneeds,theproteinneedsmayneedtobeadjusted.Foratwinpregnancy,anadditional50 g/day of protein above the recommended daily allowance of 0.8 g/kg per day for a nonpregnant state is suggested during the second and third trimesters (6). Protein utilization depends on energy intake. Therefore,adequateenergyintakeisimportantsothatproteinmaybespared.
Vitaminsandminerals:Amultivitaminandmineralsupplementisrecommendedinseveralcircumstances (1,3). Pregnant women who smoke or abuse alcohol or drugs should take a multivitamin and mineral supplement (3).Forwomeninfectedwiththehumanimmunodeficiencyvirus,especiallywomenwhoreceive antiretroviral treatment, a supplement containing Bcomplex, vitamin E, and vitamin C may slow the progression of disease and reduce complications (3). A multivitamin and mineral supplement is also recommendedforwomenwithirondeficiencyanemiaorpoorqualitydietsandwomenwhoconsumeanimal productsrarelyornotatall (3).B12supplementationisrecommendedforpersonswhofollowavegetarian dietpattern,includingthelactoovovegetariandietpattern(3).Womencarryingtwoormorefetusesarealso advised to consume a multivitamin and mineral supplement (3). Additional nutrients that may need to be supplemented include folic acid, iron, zinc, copper, calcium, and vitamin D. The Food and Nutrition Board recommendstheuseofsupplementsorfortifiedfoodstoobtaindesirableamountsofsomenutrients,suchas iron.TheFoodandNutritionBoardalsorecommends400g/dayofsyntheticfolicacidfromfortifiedfoods, supplements, or both for women who are trying to become pregnant and 600 g/day for women who are pregnant(7).
Iron: To meet the DRI of 27 mg/day of ferrous iron during pregnancy, a lowdose supplement is recommendedatthefirstprenatalvisit (1,3,6).Anironsupplementcontaining150mgofferroussulfate,300 mgofferrousgluconate,or100mgofferrousfumaratecanfulfillthisadditionalneed.Irondeficiencyanemia
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isthemostcommonanemiaduringpregnancy.Ifthematernalironstoresarelow,60to120mgofironmay berecommended (4),inadditiontoamultivitaminsupplementcontaining15mgofzincand2mgofcopper, since iron may interfere with the absorption of zinc and copper (3). If the laboratory values indicate macrocyticanemia,vitaminB12andfolatelevelsshouldbeassessed(1).
Zincandcopper:Ironcaninterferewiththeabsorptionofotherminerals.Therefore,womenwhotakedaily supplementswithmorethan30mgofironshouldadd15mgofzincand2mgofcopper(3).Theseamountsof zincandcopperareroutinelyfoundinprenatalvitamins.
Folate:TheDRIforfolateforwomen19to50yearsofageis600g/day (7,8).Thisleveloffolateshouldbe consumedthroughsyntheticfolicacidfromfortifiedfoodsorsupplementsorboth,inadditiontotheintakeof folatefromavarieddiet (3,6).Comparedtonaturallyoccurringfolatefoundinfoods,thefolicacidcontained in fortified foods and supplements is almost twice as well absorbed, so that 1 g from these sources is equivalentto1.7gofdietaryfolate(3).Womenwhotakefolicacidatthetimeofconceptionarelesslikelyto givebirthtoachildwithneuraltubedefects (912).Toensurethatbloodvitaminlevelsareadequateatthe time of neural tube closure, supplementation should begin at least 1 month before conception (3). Women whotakemultivitaminscontainingfolicacid1to2monthsbeforeconceptionhaveareducedriskofhavinga child with orofacial clefts (13). Research also indicates that abnormal folate metabolism may play a role in Downsyndromeandotherbirthdefects (3).Womenwhohavedeliveredaninfantwithneuraltubedefects may need to consume more than the recommended amount of dietary folate equivalents (3). Until more evidence is available, it is recommended that women older than 19 years of age not exceed the tolerable upper limit of 1,000 g/day of folate from foods, fortified foods, and supplements (3). Although extensive publiceducationabouttheimportanceoffolicacidhasoccurredinthepastdecade,thepercentageofwomen whotakefolicacidremainslowatapproximately33% (3).Dietitiansshouldprovidenutritioneducationand counselingastotheimportanceoffolicacidconsumption,especiallyforwomenwhoarenonwhite,Hispanic, lowincome,oryoungorwholackahighschooleducation(3).
Calcium:Duetotheincreasedefficiencyofcalciumabsorptionduringpregnancy,calciumrequirementsfor pregnantwomenaresimilartotherequirementsforwomenwhoarenotpregnant.Adailyintakeof1,000 mgisrecommendedforpregnantandlactatingwomen(13)olderthan19years(<19yearsold,1,300mg/day) (13).Womenwhoavoiddairyproductsandrelyoncalciumfortifiedorangejuiceorotherfortifiedfoodsmay have lower intakes of vitamin D and magnesium than milk consumers, therefore their diets should be evaluatedfortheadequacyofthesenutrients(3). Sodium:Sodiumisrequiredduringpregnancyfortheexpandingmaternaltissueandfluidcompartmentsand toprovidefetalneeds.Routinesodiumrestrictionisnotrecommended(6).
VitaminA:HighdosesofvitaminAduringpregnancyhavecausedbirthdefectsofthehead,heart,brain,and spinalcord.TheFoodandDrugAdministration(FDA)andtheInstituteofMedicinerecommendthatvitamin AintakebelimitedtotheDRIof5,000IUduringpregnancy(14,15).Inaddition,pregnantwomenshouldlimit their intake of liver and fortified cereals. The FDA recommends that women of childbearing age choose fortifiedfoodsthatcontainvitaminAintheformofbetacaroteneratherthanpreformedvitaminA.Ahigh intakeoffruitsandvegetablesrichinbetacaroteneandothercarotenoidsisnotaconcern(15).
Fluids: Adequate fluid intake is extremely important. The recommended daily fluid intake for pregnant womenis8to10cupsor35to40mL/kgofpregravidweight(3).
Fiber: Ingestion of fiber is important to speed digestion and prevent constipation and hemorrhoids. The 2002DRIforadequateintakeoftotalfiberis28g/dayforallagegroupsduringpregnancy(3,6).
OtherSubstances Alcohol:Theconsumptionofalcoholduringpregnancymayresultinfetalalcoholsyndrome.Evenlightto moderatedrinkingmaycauseneurologicabnormalitiesnotdetectableatbirth.Sinceasafelevelofalcohol consumptionhasnotbeendetermined,pregnantwomenshouldabstainfromalcohol(3).
Caffeine:Caffeineisrapidlyabsorbedandcrossestheplacentafreely.Afteringestionof200ofmgcaffeine, intervillous bloodflow inthe placenta is reduced by 25% (16). High levels ofcaffeine intakeare associated withdelayedconception,spontaneousmiscarriage,andlowbirthweight,butnotwithbirthdefects(3,16).The positionoftheAmericanDieteticAssociationisthatpregnantwomenshouldavoidcaffeineintakesgreater than 300 mg/day (3). Some studies have found no adverse effects as a result of moderate caffeine consumption, while other studies have found an increase in stillbirths, spontaneous abortions, and fetal
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malformations in pregnant women who consumed high levels of caffeine (>300 to 500 mg/day) (16,17). A more recentprospective study foundthat fetalgrowth restrictionoccurredatcaffeine intakesgreaterthan 100 mg/day (18). Until further evidence provides guidelines for setting a specific limit on caffeine intake, womenshouldbeeducatedontherisksassociatedwithcaffeineconsumptionandthepotentialneedtolimit caffeinebasedonpredisposingriskfactors(3,19).
Olestra: Studies of the fat substitute olestra conclude that pregnant or breastfeeding women should not consumeproductscontainingolestra.Olestracausesgastrointestinaldistressanddiarrhea,whichmaylead tothelossofthefatsolublevitaminsA,D,E,andK(20).
Sugar substitutes: The FDA has approved five nonnutritive sweeteners for general use: saccharin, aspartame, acesulfameK, neotame, and sucralose. Regulatory bodies and expert communities have concludedthatthesesweetenersaresafe,basedonstudiesoftheeffectsofthesesweetenersonthefetusand thereproductiveabilitiesoffemalesandmales(21).Thus,consumptionofacesulfameK,aspartame,saccharin, sucralose,andneotamewithintheacceptabledailyintakesissafeduringpregnancy (21).Researchcontinues toindicatethataspartameissafeduringpregnancy,althoughwomenwithphenylketonuriashouldexercise cautionwiththissweetenerbecausetheyneedtocloselymonitortheirintakeofphenylalanine(3,21).Thereis limitedevidencethatsaccharincanpassthroughtheplacentaandthatitremainsinfetaltissues;therefore, women should moderate their intake of this sweetener (3). AcesulfameK crosses the placenta, but it has shownnoadverseeffectonthefetusandisconsideredsafe(21).
Herbalandalternativetherapies:Veryfewrandomizedclinicaltrialshaveexaminedthesafetyandefficacy ofalternativetherapiesduringpregnancy (3).Severalherbalandbotanicalsupplementsareharmfulifused during pregnancy (3). The American Academy of Pediatrics recommends that pregnant women limit their consumptionof herbalteas. Women who optto consume herbal teasshould limit their intaketotwo 8oz servingsperdayandchooseherbalteasinfilteredteabags(3).
Fish:Duetothehighlevelsofmercuryincertaintypesoffishandmercurysadverseeffectsonthefetus,the USDepartmentofHealthandHumanServicesandtheUSEnvironmentalProtectionAgencysuggestlimiting thetypeandamountoffishconsumedduringpregnancy(3).Pregnantwomenshouldavoidconsumingshark, swordfish,kingmackerel,ortilefish.Twelveouncesorlessperweekoffishandshellfishlowerinmercury, suchasshrimp,cannedlighttuna,salmon,pollock,andcatfish,issafe (3).Consumptionofalbacore(white) tunashouldbelimitedto6oz/week,becausethistypeoftunacontainsmoremercurythancannedlighttuna (3). If no information regarding fish caught from local water sources is available, pregnant women should limittheirconsumptionofthesefishto6oz/weekandnotconsumeanyotherfishduringthatweek(3).
FoodborneIllnessDuringPregnancy Pregnantwomenandtheirfetusesareathigherriskofdevelopingfoodborneillness (3).Pathogenssuchas Listeria monocytogenes, Salmonella, and Toxoplasma gondii cause foodborne illness (3). Proper food storage and preparation techniques should be reviewed to ensure safety (3). Unpasteurized foods and raw or undercookedmeat,poultry,orfishshouldbeavoidedtoreducetheriskofexposuretopathogens (3).Careful sanitationmethodsshouldbeused,andpetsshouldnotbehandledbeforeorduringfoodpreparation(3). RiskFactorsDuringPregnancy(1,3) Womenshouldbeevaluatedforfactorsthatmayputthematriskforadversematernaland/orfetaloutcomes while they are pregnant. If any of the following risks are identified, appropriate medical and nutritional monitoringshouldbeprovidedthroughoutthepregnancy. Riskfactorsattheonsetofpregnancy: Adolescence:youngerthan15yearsoldattimeof conceptionorlessthan3yearssincetheonsetof menses Olderthan35yearsofage Threeormorepregnancieswithin2years Historyofpoorobstetricorfetalperformance Lowincome
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Unusualdietarypractices Smoking Excessivealcoholintake Recreationaldrugusea Chronicsystemicdisease Obesity PrepregnancyBMI<19.8kg/m2or>29 kg/m2 Multiplegestation
Recreationaldrugsoroverthecountermedicationsordietarysupplementsthathaveadverseeffects(eg,laxatives,antacids,orherbal remediescontainingteratogens) . ManualofClinicalNutritionManagement
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Riskfactorsduringpregnancy(1,3): Hemoglobinlevel<11g/dL(firstandthirdtrimesters),<10.5g/dL(secondtrimester); orhematocrit<33%(firstandthirdtrimesters),<32%(secondtrimester) Inadequateweightgain: <1lb/monthforveryoverweightwomen <2lb/monthfornormalorslightlyoverweightwomen <4to8lb/monthforwomenwithmultiplegestationandunderweight women Excessiveweightgain(>6.6lb/monthafterfirsttrimester),possiblyassociatedwithfluidretention Ferritinlevel<20g/dL(22) Serumfolatelevel<3mg/dL Serumalbuminlevel<2.5g/dL Totalserumproteinlevel<5.5g/dL VitaminB12level<80pg/mL NauseaandVomitingofPregnancy Nauseaandvomitingarethemostcommonsymptomsexperiencedinearlypregnancy,withnauseaaffecting 70% to 80% of women (2325). Dry, salty foods are traditionally recommended for resolving nausea or vomiting;however,thesefoodsdonotalwaysrelievesymptoms(24).Foodswiththefollowingcharacteristics arewelltolerated:cold,warm,sour,creamy,crunchy,soft,wet,salty,andchocolaty (25).Increasedolfactory senses often are a leading cause of nausea during early pregnancy; thus, strong odors and sensitive unpleasant odors should be avoided (24,25). Individualization in meal planning is necessary. Other managementtechniquesincludethefollowingrecommendations(25): Eatsmall,frequentmealsandsnacks. Eatlowfatproteinfoodsandeasilydigestedcarbohydratefoods. Eatdrycrackersbeforerisinginthemorning. Avoidspicyfoodsandgasformingfruitsandvegetables. Drinkfluidsbetweenmeals(milkisoftennotwelltolerated). Avoiddrinksthatcontaincaffeineoralcohol.
Hyperemesis gravidarum: Hyperemesis gravidarum is a condition characterized by severe, persistent nausea and vomiting that causes dehydration, fluid and electrolyte abnormalities, acidbase disturbances, ketonuria,andweightloss(ie,a5%decreasefrompregravidweight)(26).Hyperemesisgravidarumoccursin approximately 2% to 5% of pregnant women (25). Nausea and vomiting of pregnancy and hyperemesis gravidarumbegininthefirsttrimester,usuallybetweenweeks6and12,andsymptomsoftenpeakbetween weeks 15 and 17. Symptoms often begin to decrease by week 20 (25). The pathogenesis of hyperemesis gravidarum is not well understood. Nausea and vomiting of pregnancy and hyperemesis gravidarum are thoughttoberelatedtoincreasedsecretionofhumanchorionicgonadotrophinandincreasedestrogenlevels (25). Other potential causes that have been implicated but not proven include thyroid changes, such as hyperthyroidism, and bacterial infections, such as an underlying Helicobacter pylori infection (25,26). Complications of hyperemesis gravidarum includedehydration, hyponatremia, inadequate weightgain,and MalloryWeisstears (26).Anothercomplication,Wernickesencephalopathy,isaresultofinsufficientthiamin levelsthatarerelatedtovomitingortheresultofglucoseadministrationwithouttheadditionofthiamin(25).
Treatment of hyperemesis gravidarum depends on the risk level of the patient and the severity of symptoms, such as dehydration and the inability to meet nutrition needs orally. Intensive nutrition counseling and individualized meal planning is the first line of treatment (24,25). If nutrition and behavior modification does not alleviate symptoms, medications, such as metoclopramide (Reglan) and ranitidine (Zantac), or antiemetic drugs, such as prochlorperazine (Compazine) and ondansetron (Zofran), are often prescribed (26). Patients with severe symptoms may require hydration with intravenous fluids, electrolyte replacement,orvitaminreplacementwithvitaminB6 (pyridoxine)andvitaminB1(thiamin) (25,26).Ifpatients do not achieve the DRIs for thiamin (1.4 mg/day) and pyridoxine (1.9 mg/day) during pregnancy, dietary supplementationshouldbeprovided (25).Asmallpercentageofpatientswithhyperemesisgravidarummay require nasogastric, gastrostomy, or jejunostomy feedings or total parenteral nutrition to ensure adequate nutritionsupport.Only2%to5%ofwomenwithhyperemesisgravidarumrequiretotalparenteralnutrition (25).Nearlyalloftheliteratureregardingnutritionsupportduringpregnancyisanecdotal,consistingofcase studies. Treatment and intervention strategies are based on experience and patient needs. If nutrition support is indicated, treatment should be consistent with standards outlined for nonpregnant adults or in
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managing coexisting medical conditions or risks (eg, refeeding syndrome). Refer to Section IB: Specialized NutritionSupportandSpecificNutrientRequirementsDuringPregnancyearlierinthissection. Obesity Obesity in pregnancy not only increases risks for pregnant women during gestation, but also increases risksforthefuturehealthofthechild (27).Obesityduringpregnancyhasbeenassociatedwithgestational diabetes, gestational hypertension, preeclampsia, birth defects, Cesarean delivery, fetal macrosomia, perinataldeaths,postpartumanemia,andchildhoodobesity (27,28).Morewomenarebeginningpregnancy with high BMIs, and more are gaining weight in excess of the 1990 Institute of Medicine (IOM) recommendations for gestational weight gain (27). Overweight and obese women are more likely to maintainexcessweightwitheachsuccessivepregnancy.Thosewhogainmorearemorelikelytoretainit and continue at a higher weight throughout their lifetime, as compared to women who gain less weight duringpregnancy (27,28).Weightgainduringpregnancyhasalsobeenshowntohaveimplicationsforthe childsfutureriskofbeingoverweight (27, 28).ItisthepositionofTheAmericanDieteticAssociationand the American Society for Nutrition that all overweight and obese women of reproductive age should receivecounselingpriortopregnancy,duringpregnancy,andintheinterconceptionalperiodontheroles of diet and physical activity in reproductive health (27). During pregnancy overweight and obese clients should target IOM gestational weight gain targets, be advised not to lose weight during pregnancy, and counseledabouthealthfuleatinghabits (27).Inadditionencouragementshouldbegiventobreastfeedand bemadeawareofthebenefitsforboththemomsandherchildshealth(27). GestationalHypertension(3) Gestational hypertension is defined as systolic blood pressure of 140 mm Hg or greater or diastolic blood pressure of 90 mm Hg or greater with onset after 20 weeks gestation (29). About 25% of women with gestationalhypertensionwilldeveloppreeclampsia,whichischaracterizedbyproteinuria(>300mgina24 hour urine sample). Preeclampsia occurs more often in primigravid women and in women older than 35 yearswithchronichypertensionorrenaldisease. Gestational hypertension is associated with marked changes in renal function that may lead to excessive extracellularfluidretention.Preeclampsiaaccompaniedbygrandmalseizuresisaconditioncalledeclampsia (3,29). Preeclampsia usually occurs after the 20th week of conception. Preeclampsia is more common in women with chronic hypertension and renal disease, adolescents, underweight women with inadequate weightgain,womenwhoareolderthan35years,obesewomen,womenwithahistoryofpreeclampsia,and womenwhoarecarryingmultiplefetuses(3). Nospecificnutritiontherapyhasbeenproventobeeffectiveinpreventingordelayingpreeclampsiaand improvingpregnancyoutcomes(3,29).Adequatecalcium,protein,energy,andpotassiummaybenecessary.A metaanalysisof17randomizedcontrolledtrialsconcludedthatcalciumsupplements(1to2g/day)reduced blood pressure and the risk of preeclampsia but had no significant effect on reducing maternal and infant morbidityandmortality (30).Studiesofothernutrients,suchasvitaminsCandE,haveyieldedinconclusive results. The efficacy of dietary modifications, including sodium restriction, magnesium supplements, zinc supplements,andconsumptionoffattyfishoils,hasnotbeenproven(3,31).Diureticsshouldbeavoidedunless strictmedicalsupervisionisprovided. SpecificNutrientRequirementsDuringLactation Energy:Theaverageenergycostsoflactationare500kcal/day(6)inthefirst6monthsand400kcal/dayinthe second6months(6).Excessiverestrictionofenergy(<1,800kcal/day)maycausedecreasedmilkproduction. Fluids:Dailyintakeof2to3qtoffluidtocompensateforthevolumeofmilkproducedisencouraged. Alcohol:Alactatingwomanshouldavoidalcoholconsumption,unlessitispermittedbyherphysician. Caffeine:Lactatingwomenshouldlimittheirdailyconsumptionofcaffeinetotwo5ozcupsofcoffee(<200 mg)(16). Fiber:The2002DRIforadequateintakeoftotalfiberis29g/dayforallagegroupsduringlactation(6).
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NutritionManagementDuringPregnancyandLactation References 1. Subcommittee on Nutritional Status and Weight Gain During Pregnancy, Committee of Nutritional Status During Pregnancy and Lactation,FoodandNutritionBoard,InstituteofMedicine,NationalAcademyofSciences.NutritionDuringPregnancy.Washington, DC:NationalAcademyPress;1992. 2. FoodGuidePyramid:AGuidetoDailyFoodChoices.Washington,DC:USDeptofAgriculture,HumanNutritionInformationService. HomeandGardenBulletinNo.252. 3. Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome. J Am Diet Assoc. 2008;108:553561. 4. BrownJE,CarlsonM.Nutritionandmultifetalpregnancy.JAmDietAssoc.2000;100:343348. 5. OkenE,TaverasEM,KleinmanKP,RichEdwardsJW,GillmanMW.Gestationalweightgainandchildadiposityatage3years.AmJ ObstetGynecol.2007;196:322.e1322.e8. 6. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. National Academy of Sciences; 2002:265334. Preprint available at: http://www.nap.edu.books/0309085373/html/index.html.AccessedSeptember16,2002. 7. YatesAA,SchlickerSA,SuitorCW.DietaryReferenceIntakes:thenewbasisforrecommendationsforcalciumandrelatednutrients, Bvitamins,andcholine.JAmDietAssoc.1998;98:699706. 8. InstituteofMedicine,FoodandNutritionBoard.DietaryReferenceIntakesforThiamin,Riboflavin,Niacin,VitaminB6,Folate,Vitamin B12,PantothenicAcid,Biotin,andCholine.Washington,DC:NationalAcademyPress;1998. 9. MRC Research Group. Prevention of neural tube defects: results of the Medical Research Council vitamin study. Lancet. 1991;338:131137. 10. DepartmentofHealthandHumanServices,PublicHealthService.Recommendationsfortheuseoffolicacidtoreducethenumber ofcasesofspinabifidaandotherneuraltubedefects.MMWRMorbMortalWklyRep.1992;41(RR14):17. 11. AmericanCollegeofObstetriciansandGynecologists.Folicacidforthepreventionofrecurrentneuraltubedefects.Washington,DC: AmericanCollegeofObstetriciansandGynecologists;1993(LevelIII).ACOGCommitteeOpinion120. 12. AmericanCollegeofObstetriciansandGynecologists.NutritionandWomen.Washington,DC:AmericanCollegeofObstetriciansand Gynecologists;1996.TechnicalBulletinNo.229. 13. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride.Washington,DC:NationalAcademyPress;1997. 14. FoodandDrugAdministration.VitaminAandbirthdefects[pressrelease].October6,1995. 15. InstituteofMedicine.NutritionDuringPregnancy.Washington,DC:NationalAcademyPress;1990:19. 16. HigdonJV,FreiB.Coffeeandhealth:areviewofrecenthumanresearch.CritRevFoodSciNutr.2006;46:101123. 17. KlebanoffMA,LevineRJ,DerSimonianR,ClemensJD,WilkinsDG.Maternalserumparaxanthine,acaffeinemetabolite,andtherisk ofspontaneousabortion.NEnglJMed.1999;341:16391644. 18. CARE Study Group. Maternal caffeine intake during pregnancy and risk of fetal growth restriction: a large prospective observationalstudy.BMJ.2008;337:a2332. 19. SuitorCW.Nutritionforwomanintheirchildbearingyears:areviewoftheliteratureandsummaryofexpertrecommendations. NutrClinCare.1999;2:1145. 20. MiddletonSJ,DwyerJ,PetersJC.Anindirectmeansofassessingpotentialnutritionaleffectsofdietaryolestrainhealthysubgroups ofthegeneralpopulation.JNutr.1997;127(suppl8):1710517185. 21. PositionoftheAmericanDieteticAssociation:useofnutritiveandnonnutritivesweeteners.JAmDietAssoc.2004;104:255275. 22. Institute of Medicine. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among US ChildrenandWomenofChildbearingAge.Washington,DC:NationalAcademyPress;1993. 23. JewellD,YoungD.Interventionsfornauseaandvomitinginearlypregnancy.CochraneDatabaseSystRev.2003;4:CD000145. 24. American College of Obstetricians and Gynecologists. Nausea and Vomiting of Pregnancy. Washington, DC: American College of ObstetriciansandGynecologists;2004.PracticeBulletinNo.52. 25. Hyperemesis gravidarum. In: Nutrition Care Manual. American Dietetic Association; 2004. Available at: www.nutritioncaremanual.org.AccessedJanuary25,2009. 26. IsmailSK,KennyL.Reviewonhyperemesisgravidarum.BestPractResClinGastroenterol.2007;21:755769. 27. PositionoftheAmericanDieteticAssociationandAmericanSocietyforNutrition:Obesity,Reproduction,andPregnancyOutcomes. JAmDietAssoc.2009;109:918927. 28. ViswanathanM,SiegaRizAM,MoosMK,DeierleinA,MumfordS,KnaackJ,ThiedaP,LuxLJ,LohrKN.OutcomesofMaternalWeight Gain,EvidenceReport/TechnologyAssessmentNo.168(PreparedbyRTIInternationalUniversityofNorthCarolinaEvidencebased PracticeCenterundercontractNo.290020016.)Rockville,MD:AgencyforHealthcareResearchandQuality;2008.AHRQPubNo. 08E09. 29. AmericanCollegeofObstetriciansandGynecologists.ACOGPracticeBulletinNo.33.Diagnosisandmanagementofpreeclampsia andeclampsia.ObstetGynecol.2002;99:159167. 30. Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems.CochraneDatabaseSystRev.2006;3:CD001059. 31. MakridesM,DuleyL,OlsenSF.Marineoil,andotherprostaglandinprecursor,supplementationforpregnancyuncomplicatedby preeclampsiaorintrauterinegrowthrestriction.CochraneDatabaseSystRev.2006;3:CD003402.
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NUTRITIONANDTHEOLDERADULT
Aging is a process that occurs throughout life. Its impact, however, is often ignored until adulthood. Progressivechangesinbodycomposition,sensoryperception,functionalstatus,andphysiologicfunctioning occuratallages.Therateofchangeisstronglyinfluencedbythegeneticbackgroundandlifeexperiencesof theindividual(13).
Older adults display wide individual variations in aging processes and thus in nutritional needs and concerns. Maximizing and maintaining functional status and quality of life becomes the major healthcare objective. The nutritional care goal is to provide education and support to achieve this objective, as decreasedmetabolicneedsandactivitylevels,illnessandinfirmity,economichardship,lossofsocialsupport systems,andothervariablesmandateadjustmentsinfoodintake.
Eacholderadultshouldbeviewedasauniqueindividual.Chronologicalageandfunctionalcapacityare not directly correlated. Diversity in nutritional needs and in functional capacity increases with age (4). Provisionofqualitynutritionalcarerequirestheregular,systematic,longitudinalassessmentofeacholder individual as well as a nutritional care plan based on the specific needs that are identified. The least restrictiveregimenpossibleshouldbeimplemented.
DietaryConsiderationsfortheOlderAdult When planning the diet for older adults, the Dietary Reference Intakes (DRIs) and Dietary Guidelines for Americans (58)providepopulationspecificguidelines.TheDRIsdividetheadultpopulationolderthan50 years into two lifestage groups: 51 through 70 years and older than 70 years (57). Overall nutrient requirementsaresimilarbetweentheseagegroupswiththeexceptionofthevitaminDrequirement,which increaseswithage.ToensureadequateconsumptionofvitaminB12andvitaminD,theDietaryGuidelinesfor AmericansrecommendsconsumingvitaminB12initscrystallineform,eg,fortifiedfoodsorsupplements,and consumingextravitaminDfromvitaminDfortifiedfoodsand/orsupplements(8).
Inaddition,tasteandsmelldysfunction,whichcaneffectnutritionalintake, tendstobeginataround60 yearsofageandbecomesmoresevereafter70yearsofage (5,9).Therefore,moresweetflavoringsorsalty foods may be required to satisfy the appetite of elderly individuals and improve their nutritional intake. Two thirds of persons older than 75 years are edentulous. When planning nutrient restrictions to accompany medical care in this population, moderate to mild restrictions of nutrients such as sodium are recommendedtoensureoveralladequatenutritionintake(10).
EnergyandNutrientConsiderations Inhealthyadults,thebasalmetabolicratedecreases2%witheachdecadeoflife.Leanbodymassdecreases 6% with each decade of life and is usually replaced with fat. Energy needs decrease with advancing age becauseofdecreasesinthebasalmetabolicrateandphysicalactivitylevel.TheDRIssuggestthatthedaily energy intake should be reduced by 10 kcal for men and 7 kcal for women for each year of age above 19 years.Fora51yearoldman,thiswouldequatetoa320kcalreductionfromthebaselineDRI(11).(Referto Section IAfor Dietary Reference Intake Values for Energy by Active Individuals.) Meeting thenutritional needs of the older adult is challenging because although energy needs decrease, the requirements for protein,vitamins,andmineralsremainthesameorincrease.Theaveragedailyenergyintakeforpersons olderthan51yearsofageis2,400kcalformenand2,000kcalforwomen (11).Decreasedenergyintakeis accompanied by a decrease in the intake of micronutrients, especially calcium, zinc, iron, and vitamins (5). Healthproblemsarisewhentheenergyintakeislessthan1,500kcal/day(12).
TheAmericanDieteticAssociationrecentlyreviewedstudiestodeterminetheenergyneedsofadultsolder than65years.Theenergyneedsofhealthyadultsolderthan65years,asmeasuredbyindirectcalorimetry, werereportedtobe18to22kcal/kgperdayforwomenand20to24kcal/kgperdayformen (GradeII)(13). Thedailyenergyneedsofolderadultswhoareacutelyorchronicallyillorunderweight(bodymassindex (BMI)<20kg/m2)werereportedtobe18to22kcal/kgforwomenand20to23kcal/kgformen(GradeII)(13). Therestingmetabolicrateincreaseswiththedegreeofmalnutritionandunderweightstatusandmaybeas highas27to28kcal/kgperdayinolderadultswithaBMIlessthan20kg/m2(GradeII)(I3).Emergingresearch supportsarelationshipbetweenanincreasednumberofmedicationsanddecreasedenergyneeds,however further research is needed in this area (13). Also, further research is required to determine differences in energyneedsbasedonraceandethnicity(13). EmergingdatafromtheAmericanDieteticAssociationevidencelibrarysuggestthataregistereddietitian
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shouldprescribeadailyenergyintakeof25to35kcal/kgforhealthyolderwomenand30to40kcal/kgfor healthy older men for weight maintenance. Research indicates that physical activity levels ranging from 1.25to1.75canbeappliedtotherestingmetabolicrate(determinedviaindirectcalorimetry)toyieldthe meantotaldailyenergyestimatesforhealthyolderadults(GradeII)(13). Whenestimatingenergyneedsforunderweightolderadults,theregistereddietitianshouldprescribeadaily energy intake of 25 to 30 kcal/kg for weight maintenance or a greater energy intake for weight gain. Research indicates that physical activity levels ranging from 1.25 to 1.5 can be applied to the resting metabolicrate(determinedviaindirectcalorimetry)todeterminethemeantotaldailyenergyestimatesin olderadultswhoarechronicallyoracutelyillorunderweight(GradeIII)(13). The2002DRIsrecommendthattheRDAforproteinshouldbeaminimumof0.8g/kgperdayforadultsof allages(10).However,otherstudiesrecommendthatproteinintakefortheelderlybeincreasedto1.0to1.25 g/kgperdayor12%to14%oftotalenergyintake(1115). MetabolicandphysicalchangesthataffectthestatusofvitaminB6,B12,andfolicacidmayalterbehavior andgeneralhealth,whereasadequateintakeofthesenutrientspreventssomedeclineincognitivefunction associatedwithaging (5,16,17).Deficienciesofthesenutrients,alongwithinadequateintakeofvitaminCand riboflavin, may result in poor memory (5,16). Immune function affected by nutritional status may be improvedbyanincreasedintakeorsupplementationofprotein,vitaminsB6andE,andzinc (5,16).Persons older than 50 years should consume foods fortified with vitamin B12 or take a supplement containing the crystalline form of vitamin B12, as 10% to 30% of older adults have proteinbound vitamin B12 malabsorption (5,8,1618). In addition, inadequate intake of folate and vitamins B6 and B12 may result in hyperhomocysteinemia,asignificantriskfactorforatheroscleroticvasculardisease(5,18).
VitaminDlevelsmaybereducedintheelderlyevenwithadequateexposuretosunlight.Thisdeficiency may be exacerbated by homebound status, use ofsun block, poor dietary intake,decreased capabilities to synthesize cholecalciferol in the skin, and a decreased number of gastrointestinal receptors (13,1921). For adultsaged51to70years,theDRIforvitaminDis600IU(15g)andincreasesto800IU(20g)forolder individuals.Therecommendedintakeofcalciumforadultsolderthan50yearsis1,200mg/day(22).Because ofinadequacyofintakeandabsorptionissues,olderadultsandthosewithdarkskinareinneedofoversight for adequacy of these nutrients in order to maintain bone integrity and maintain serum 25 hydroxy vitaminD[25(OH)D]levelsat80nmol/L (21). Othernutrients,includingvitaminsAandK,magnesium,and phytoestrogens,arealsoinvolvedinmaintainingbonehealthandshouldbeevaluatedforadequateintake (5). NutritionAssessmentConsiderationsforOlderAdults Weight is a vital sign that should be routinely evaluated in the older adult population. Evidencebased nutritionpracticeguidelinesrecommendabaselineweightmeasurement,regardlessofsetting,uponinitial visit, admission, or readmission, followed by weekly weight measurements for older adults (13). There is strongevidenceinsupportofanassociationbetweenunintendedweightlossandincreasedmortality (Grade II) (13). The registered dietitian should use clinical judgment in interpreting nutrition assessment data to diagnose unintended weight loss and underweight in the older adult (13). Studies support an association betweenincreasedmortalityandunderweight(BMI<20kg/m2orcurrentweightcomparedwithusualor desired body weight) or unintended weight 5% or more in 30 days (Grade II) (13). Studies also show an associationbetweenreducedappetiteandpoorproteinandenergyintake,resultinginweightlossandpoor nutritional status (Grade I) (13). Medical nutrition therapy that includes a thorough nutrition assessment of biochemicaldata,medicaltestsandprocedures,clienthistory(seeTableA2)andfoodandnutritionrelated historyisneededtoeffectivelydeterminethenutritiondiagnosisandplanfornutritioninterventions(13).
Dehydrationisamajorproblemfortheelderly.Fluidintakeneedsarethesamefortheyoungandtheold, buttheelderlyarepronetoinadequatefluidintake.Frequently,diseaseswillreducetheabilitytorecognize thirst, create an inability to express thirst, or decrease access to fluids (5,23). Even healthy elderly persons havereducedthirstinresponsetofluiddeprivation.Fearofincontinenceanddifficultymakingtripstothe toilet,duetoarthriticpainorotherimmobility,mayalsointerferewithadequatefluidconsumption (5).An important part of the nutrition assessment in older adults is an assessment of hydration status based on physicalsignsandsymptomsincludingdrytongue,longitudinaltonguefurrows,drymucousmembranesof the nose and mouth, eyes that appear recessed in their sockets, upper body muscle weakness, speech
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difficulty,andconfusion(GradeIII)(23).Theelderlyshouldbeencouragedtoingestabout2litersoffluidperday or30mL/kgofbodyweight. Theuseofquantitativemethodstoassesstheintakeoffood,fluids,nutrients,andenergyoverseveraldays isrecommendedandsupportedbyresearch (GradeII)(13).Amultidayintakeanalysisbasedonthepercentage offoodeatenandindividualplatewastestudiesissuggestedoversingleinterviews(GradeII)(13).
ContributorstoPoorNutritionalStatusinOlderAdults Studies indicate that elderly individuals are at increased risk of malnutrition, declining nutritional status, and adverse health effects. (13). These unfavorable nutrition outcomes are associated with the female gender, cognitive decline, loss of appetite, swallowing problems, low activity level, eating dependency, recent hospitalization, and admission to healthcare communities (Grade I) (13). A variety of factors may contribute to poor nutritional status as individuals age (13,2428). The factors listed in Table A2 should be considered when evaluating nutritional status and developing a care plan to prevent, delay, or correct nutritional problems. Althoughacureisnotpossibleforsomeconditions,ameliorativeorpalliativenutritionalinterventionsareoften indicatedandcanimprovetheolderindividualsqualityoflife(27,28). TableA2:ContributorstoUnintendedWeightLoss(13)andMalnutritioninOlderAdults(13,2428) Nutritional Psychological Alcoholandaddictivesubstances Bereavement Decreasedappetite(GradeI)(13) Changeinbodyhabits Drugnutrientinteractions(prescription/overthecounter Confusion drugs) Depression(GradeII)(13) Inappropriatefoodintake Fear Withdrawal Increasednutrientrequirements Overlyrestrictivedietaryprescriptions(10)
Physical Social Acuteorchronicdisease Fixedincomeorpoverty Prevalenceofinfection(GradeI)(13) Ignorance Changesinbodycomposition Isolation Changesinorgansystemstructure/function Limitedfoodprocurement,preparation,or Changesinsensoryperception storagecapabilities Dependenceordisability Relianceoneconomicassistanceprograms Cognitiveimpairment(eg,dementiadisorders)(GradeI)(13) Decreasesinactivitiesofdailyliving(GradeI)(13) Infirmityorimmobility Poordentitionorpoorlyfittingdentures Swallowingproblems NutritionInterventionstoImproveOutcomesinOlderAdults(5) Minimize dietary restrictions to encourage greater food intake. Liberalized diets are associated with increasedfoodandbeverageintake (GradeI)(13).Maintainingthedesiretoeatandtheenjoymentoffood minimizestherisksofweightlossandundernutrition,especiallyineldersinlongtermcare (10,13).For thesepeople,amoreliberalizednutritionintervention,ratherthanatherapeuticdiet,maybewarranted to maintain quality of life (5, 10). Research has not demonstrated benefits of restricting sodium, cholesterol, fat, and carbohydrate in older adults (Grade I) (13). Refer to Section IC: Medical Nutrition TherapyforDiabetesMellitusforspecificrecommendationsforolderadultswithdiabetesmellitus. Involve older adults in planning menus and establishing meal patterns. The involvement of longterm care residents in menu planning and flexibility of the meal pattern and composition may result in improvedintakeoffoodandfluid(GradeI)(13). Encouragediningwithothersandcreativediningprograms.Researchindicatesthatolderadultswhoeat inasociallystimulatingcommondiningareahaveimprovedfoodintakeandnutritionalstatus(13). Olderadultsaremorepronetochewingandswallowingproblems.Manyolderadultsexperiencebone lossaround their teeth, resulting intooth loss and reduced bonemass. Someolderadults have poorly fittingdenturesthatcausechewingproblemsormouthpain.Drymouthcancauseproblems,especiallyif thefoodishardtochewordry.Asweage,theamountofsalivaweproducediminishes,affectingour abilitytosoftenfoodandswallowitappropriately.Modificationoffoodandfluidconsistencycanhelp
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withchewingandswallowingproblems (29). Collaborationwithaspeechlanguagepathologistandother healthcare professionals can ensure that older adults with dysphagia receive appropriate and individualized modifiedtexture diets. Older adults consuming modifiedtexture diets report an increasedneedforassistancewitheating,dissatisfactionwithfoods,anddecreasedenjoymentofeating, resultinginreducedfoodintakeandweightloss(GradeI)(13). Providemedicalfoodsupplementsforolderadultswhoareundernourishedoratriskformalnutrition. Studies support medical food supplementation as a method to provide energy and nutrient intake, promoteweightgain,andmaintainorimprovenutritionalstatusorpreventundernutrition(GradeI)(13). Consider enteral nutrition for older adults who are undernourished or at risk of undernutrition, especially in patients with dysphagia (13). Studies support enteral nutrition as a method to provide energyandnutrientintake,promoteweightgain,andmaintainorimprovenutritionalstatusorprevent undernutrition(13). Encourageadequateintakeofhighfiberfoods.The2002DRIforadequateintakeoftotalfiberforadults older than 50 years is 14 g of fiber per 1,000 kcal or 30 g/day for men and 21 g/day for women (30). Includefoodsthatcanbeeasilychewedandnotcausegastrointestinaldiscomfort. Ensure that all older adults who need assistance to eat receive it by collaborating with other healthcare professionals. A review of research by the American Dietetic Association has found a positive association between eating dependency and poor nutritional status, especially in older adults with dysphagia who receive modified-texture diets (13). Also, the evidence indicates an association between poor nutritional status, frailty, underweight, and/or weight loss with cognitive impairment and a decrease in the activities of daily living, including the decreased ability to eat independently (13).
References 1. Dwyer J. Screening Older Americans Nutritional Health: Current Practices and Future Possibilities. Washington, DC: Nutrition ScreeningInitiative;1991. 2. WhiteJV.Riskfactorsforpoornutritionalstatus.PrimaryCare.1994;21:1932. 3. GopalanC.Dieteticsandnutrition:impactofscientificadvancesanddevelopment.JAmDietAssoc.1997;97:737741. 4. NationalResearchCouncil.RecommendedDietaryAllowances.10thed.Washington,DC:NationalAcademyPress;1989. 5. PositionoftheAmericanDieteticAssociation:nutritionacrossthespectrumofaging.JAmDietAssoc.2005;105:616633. 6. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride.Washington,DC:NationalAcademyPress;1997. 7. InstituteofMedicine,FoodandNutritionBoard.DietaryReferenceIntakesforThiamin,Riboflavin,Niacin,VitaminB6,Folate,Vitamin B12,PantothenicAcid,Biotin,andCholine.Washington,DC:NationalAcademyPress;1998. 8. DietaryGuidelinesforAmericans2010.Availableat: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.AccessedJan31,2011. 9. SchiffmanSS.Changesintasteandsmell:druginteractionsandfoodpreferences.NutrRev.1994;52:S11. 10. PositionoftheAmericanDieteticAssociation:liberalizationofthedietprescriptionimprovesqualityoflifeforolderadultsinlong termcare.JAmDietAssoc.2005;105:19551965. 11. InstituteofMedicine,FoodandNutritionBoard.DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids, Cholesterol,Protein,andAminoAcids.NationalAcademyofSciences,2002:265334;preprintat: www.nap.edu.books/0309085373/html/index.html.AccessedSeptember16,2002. 12. Campbell WW, Crim MC, Dallal GE, Young VR, Evans WJ. Increased protein requirements in elderly people: new data and retrospectivereassessments.AmJClinNutr.1994;60:501509. 13. Unintended Weight Loss in Older Adults EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence AnalysisLibrary.AmericanDieteticAssociation;2009.Availableat:www.adaevidencelibrary.com.AccessedJuly31,2010. 14. HarrisNG.Nutritioninaging.In:MahanLK,EscottStumpS. KrausesFood,Nutrition,andDietTherapy.10thed.Philadelphia,Pa: WBSaundersCo;2000:294. 15. EvansWJ,CyrCampbellD.Nutrition,exercise,andhealthyaging.JAmDietAssoc.1997;97:632638. 16. TrippF.Theuseofdietarysupplementsintheelderly:currentissuesandrecommendations.JAmDietAssoc.1997;97:S181S183. 17. RosenbergIH,MillerJW.Nutritionalfactorsinphysicalandcognitivefunctionsofelderlypeople.AmJClinNutr.1995;55:1237S 1243S. 18. HoC,KauwellGPA,BaileyLB.PractitionersguidetomeetingthevitaminB12RecommendedDietaryAllowanceforpeopleaged51 yearsandolder.JAmDietAssoc.1999;99:725727. 19. BogdenJD,BendichA,KempFW,BrueningKS,ShurnickJH,DennyT,BakerH,LouriaDB.Dailymicronutrientsupplementsenhance delayedhypersensitivityskintestresponsesinolderpeople.AmJClinNutr.1994;60:437447. 20. HeaneyRP,WeaverCM.CalciumandvitaminD.EndocrinolMetabClinNorthAm.2003;32:181194 21. TrumboP,SchlickerS,YatesAA,PoosM;FoodandNutritionBoardoftheInstituteofMedicine,TheNationalAcademiesDietary referenceintakesforenergy,carbohydrate,fiber,fat,fattyacids,cholesterol,proteinandaminoacids.JAmDiet Assoc.2003;102:16211630. 22. DietaryReferenceIntakesforCalciumandVitaminD.InstituteofMedicineofthenationalAcademies.Availableat: www.iom.edu/vitamind.AccessedJanuary14,2011. 23. HydrationEvidenceAnalysisProject.AmericanDieteticAssociationEvidenceAnalysisLibrary.AmericanDieteticAssociation;2007. Availableat:www.adaevidencelibrary.com.AccessedJanuary23,2009. 24. WeinburgAD,MenakerKL.Dehydration:evaluationandmanagementinolderadults.CouncilonScientificAffairs,American MedicalAssociation.JAMA.1995;274:15521556. 25. WhiteJV.Riskfactorsassociatedwithpoornutritionalstatus.NiedertK,ed.NutritionCareoftheOlderAdult.Chicago,Ill:American DieteticAssociation;1998. 26. WhiteJ.RiskfactorsassociatedwithpoornutritionalstatusinolderAmericans.In:NutritionScreening1:TowardaCommonView. Manual of Clinical Nutrition Management
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Nutrition and the Older Adult Washington,DC:NutritionScreeningInitiative;1991. 27. WhiteJ,HamR,LipschitzD,DwyerJ,WellmanN.ConsensusoftheNutritionScreeningInitiative:riskfactorsandindicatorsofpoor nutritionalstatusinolderAmericans.JAmDietAssoc.1991;91:783787. 28. GoodwinJ.Social,psychologicalandphysicalfactorsaffectingthenutritionalstatusofelderlysubjects:separatingcauseandeffect. AmJClinNutr.1989;50:12011209. 29. PositionoftheAmericanDieteticAssociation:oralhealthandnutrition.JAmDietAssoc.2003;103:615625. 30. PositionoftheAmericanDieteticAssociation:healthimplicationsofdietaryfiber.JAmDietAssoc.2008;108:17161731. Bibliography: PositionoftheAmericanDieteticAssociation:individualizednutritionapproachesforolderadultsinhealthcarecommunities.JAmDiet Assoc.2010;110:15541563.
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MECHANICALSOFT(DENTALSOFT)DIET
Description The diet is a modification of the Regular Diet for the edentulous resident who has difficulty chewing or swallowing,orfortheresidentwhohasundergonetemporomandibularjoint(TMJ)surgery.Forthegreatest varietyoffoods,allfoodsthatareeasilymasticatedareincludedinthediet. Indications TheMechanicalSoftDietisindicatedfortheresidentwhohasdifficultychewingorswallowing. NutritionalAdequacy The diet can be planned to meet the Dietary Reference Intakes as outlined in the Statement on Nutritional AdequacyinSectionIA. HowtoOrdertheDiet OrderasMechanicalSoftDietorDentalSoftDiet. NonchewingDietorTMJDietneedstobeindicatedtoidentifythisvariationoftheMechanicalSoftDiet. PlanningtheDiet The menu selection and the individual residents tolerances should be considered when planning a MechanicalSoftDiet. SAMPLEMENU Breakfast OrangeJuice CreamofWheat ScrambledEgg Biscuit Margarine Jelly Milk Coffee Sugar Creamer Noon HoneyGlazedChicken,Chopped ButteredPotatoes SoftCookedBroccoli OrangeMousse DinnerRoll Margarine FrostedBananaCake Milk Tea Sugar Evening BraisedBeef(chopped)andNoodles SeasonedGreenBeans PeachSlices DinnerRoll Margarine SoftCookie IcedTea Sugar
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Mechanical Soft (Dental Soft) Diet
FOODGUIDEMECHANICALSOFT(DENTALSOFT)DIET
FOODGROUP Beverages BreadsandCrackers CerealsandGrains RECOMMENDED All Softbreads,rolls Plaincrackerssoftenedinsouporbeverage Pancakes,plainmuffins Biscuits Cookedcereals Drycereals Pasta,noodles,rice Moistbreaddressing Tendersoftcookedvegetables AVOID None Breadswithnuts,thickcrusts Drybread,toast,ortoughbread Breadswithraisinsifnottolerated Hardcrackers Cerealswithraisinsornuts Granolatypecereals Coarseordrycereals,suchas shreddedwheatorAllBran Raworcookedvegetableswith toughskinsorseeds;friedorraw vegetables;cookedcorn Fruitwithtoughskinifnottolerated (e.g.,rawapple,driedfruit) Freshorrawstrawberries
Vegetablejuices Fruitjuices Ripebanana,melon,peeledpeaches,pears Cookedorfrozenfruit;applesauce Stewedprunes;othertendersteweddried fruit Cannedpeaches,pears,apricots,pineapple, fruitcocktail,citrussections Meat,MeatSubstitutes, Tendermeat,fish,orpoultry Entrees Softcheese Choppedorgroundmeats,poultry Softcasseroles Meat,fish,oreggsalads Hardcookedorscrambledeggs Smoothpeanutbutter;liverwurst Yogurtwithoutnutsorcoconut Fats Allexceptthosetoavoid Soups Desserts SugarandSweets
Vegetablesand Potatoes FruitsandJuices
Toughfibrousmeats(e.g.,sausage casings) Friedeggs Yogurtwithnutsorcoconut
Fatswithcoarse,difficulttochew, orchunkyadditives Soupswithtoughmeatsor vegetables Dessertscontainingnuts,coarse driedfruit,ortoughfruit Desertsbakedtoahardconsistency
Mostsoups Cake,tendercookies Icecream,sherbet,gelatin,custard,pudding, frozenyogurt Pie:cream,custard,pumpkin,softfruit Flavoredyogurt Softcandy Jelly,smoothjams
Candycontainingtoughfruitsor nuts,hardcandy
Dietfollowingtemporomandibularjointsurgery:Foodssuchasbreads,crackers,andcookiesshouldbe brokenintosmallpiecesbeforeeatingtoavoidbitingdownorwidelyopeningthemouth.Foodsthatmaynot betoleratedinclude:toast,ungroundmeat,snackchips,foodscontainingcoconut,andcorn.

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PUREEDDIET
Description The diet is soft in texture and mechanically nonirritating. Foods prepared on the Pureed Diet follow the standardsof the MorrisonHealthcareClassicPuree program/Morrison Senior LivingSimply Puree program. Selectfoodsareallowedintheirnaturalstateprovidedtheydonotrequireadditionalmastication(i.e.cottage cheese,scrambledeggs,etc). Indications The Pureed Diet is used for patients who have problems chewing and swallowing and patients who have esophagealinflammationorvarices. NutritionalAdequacy The diet can be planned to meet the Dietary Reference Intakes as outlined in the Statement on Nutritional AdequacyinSectionIA.
HowtoOrdertheDiet OrderasPureedDiet.
PlanningtheDiet
FOODGUIDEPUREEDDIET
FOODGROUP BeveragesandMilk CerealsandGrains FOODSALLOWED Allsmooth,asdesired Allfarinatypecookedcereals; oatmeal Pregelledorslurriedthroughthe entirethickness:doughnuts, pancakes,waffles,Frenchtoast, andbread Pasta,rice,anddressingthatare pureedtosmoothconsistency Regularsoftbreadifresidents swallowingabilitypermits Pureedorstrainedvegetables withoutchunksorseeds; mashedwhitepotatoes Allsmoothcreamsoupsorbroth typesoupswithpureedor strainedingredients FOODSEXCLUDED Beverageswithseeds,lumps,or pulp Coarsecookedcereal;drycereals; cerealswithseedsornuts Allotherbreads Crackers
VegetablesandPotatoes/Soups
FruitsandJuices
Applesauce,pureedfruits,well mashedbananas,fruitjuices Meats,MeatSubstitutes,Entrees Pureedorstrainedmeats,poultry, orfish Soufflsthataresmoothand homogenous Cottagecheese Scrambledegg Cheesesauce
Regularcookedorrawvegetables Potatoskinsandchips Friedorfrenchfriedpotatoesor vegetables Regularsoupswithrice,corn, peas,orlargechunksofmeat andvegetables Regularcanned,fresh,orfrozen fruits;fruitjuicewithpulp Regularorchoppedmeatsor casseroles Cheeseslicesorcubes Hardcookedegg Peanutbutter Sandwiches Pizza
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PureedDiet
FOODGROUP Desserts
Fats
Miscellaneous
FOODSALLOWED Custard,pudding,icecream, sherbet,gelatin,fruitwhips Cakes,cobblers,andpiespureed toasmoothandmoist consistency Softcookiesandplaincakes,such asvanillawafersorsugar cookies,preparedinaslurry Smoothcustardandpudding; plainorcustardstyleyogurt Butter,margarine,smoothgravy, creamsauces,mayonnaise, saladdressings,creamcheese, sourcream,whippedtoppings Sugar,jelly,honey,syrup Ketchup,mustard,smoothsauces
FOODSEXCLUDED Regularcake,pie,cookies Breadandricepudding Fruitedyogurt
Fatswithcoarseorchunky additives
Jamsandpreserves Coarselygroundpepperand spices
SAMPLEMENU Breakfast OrangeJuice CreamofWheat ScrambledEgg BiscuitwithSlurry Milk Coffee Sugar Creamer Noon ClassicPuree Chicken MashedPotatoeswithGravy ClassicPureeCarrots ClassicPureeRosyPears Pudding Tea Sugar Evening ClassicPureeBeefand Noodles ClassicPureeGreenBeans TomatoJuice ClassicPureePeaches Milk
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NUTRITIONMANAGEMENTOFFLUIDINTAKEANDHYDRATION
Description Adequate fluid intake is necessary to maintain optimum hydration or to correct a state of dehydration or overhydration. The amount of fluid required to maintain the optimum hydration level varies with the medicalconditionofthepatient.Thevastmajorityofhealthypeopleadequatelymeettheirdailyhydration needs (1). When assessing total water intake, all food and beverage sources providing water should be included in estimating daily fluid intake (1). The Dietary Reference Intake for water and daily fluid requirementsofolderadultsisbasedonwaterconsumedinthedietfromavarietyofsourcesincludingfoods and beverages such as milk, tea, coffee, juice and water (1). Recommendations for daily water intake for womenisapproximately2.7liters(91ouncesdaily)and3.7liters(125ouncesdaily)formen(1). Indications In the healthy individual, normal sensations of thirst promote the consumption of adequate fluid and the maintenanceofoptimumhydration (1).However,somepatientsmaynotrecognizethirst,maynotbeableto communicate thirst, or may not freely consume liquids. Risk factors for dehydration include any of the following:
unconscious;semiconsciousandconfusedstate severedepression tranquilizerorsedativeuse enteralfeeding mustbefedorrequireassistancewithfeeding diarrhea poorappetite immobility diureticuse frequentlaxativeuse perspiration(inhotweatherwhereair conditioningisunavailable) dysphagia/swallowingdifficulties
increasedrespiratoryrate salivationdecreasedbymedicationsorradiation therapy fever fistulousdrainage highoutputileostomy vomiting severeburns polyuria(eg,glycosuria,ketonuria) highrenalsoluteload(eg,HighProteinDiet) denudedbodysurface hyperpnea
Whileconsumptionofbeveragescontainingcaffeineandalcoholhavebeenshowninsomestudiestohave diureticeffects,availableinformationindicatesthatthismaybetransientinnature,andthatsuchbeverages cancontributetototalwaterintakeandthuscanbeusedinmeetingrecommendationsfordietaryintakeof totalfluid(1).Evidenceindicatesthatconsuminguptosixmgofcaffeineperkilogramofbodyweightperday does not impact the hydration status of healthy adults, above that of a placebo or noncaffeinecontaining beverage(Grade1)(2).
NutritionalAdequacy Seestatementpertainingtodietorder.
HowtoOrdertheDiet Thepatientsusualdietcanbeamendedasfollows:_______________diet,________ml/day,or_______________________ diet,restrictfluidsto_________ml/day.OrdershouldincludeamountoffluidtobegivenbyFoodandNutrition Serviceswithmealsandsnacksandamountoffluidtobegivenbynursing(i.e.,withmedicationsorbetween meals).
PlanningtheDiet Whenthedietitiancalculatestheintakeoffluids,foodsthatareliquidatroomtemperatureshouldbecounted bymillileters.Suchfoodsincludewater,carbonatedbeverages,coffeeandtea,gelatin,milk,watericesand popsicles,soups,supplements,eggnog,icecreamandsherbet,andmilkshakes.
Fluidisusuallyorderedintheformofcubiccentimeters(ml)(1mL=1cc).Thiscanbeconvertedtocups orouncesasfollows: 30ml=1floz 120ml=4flozorcup 180ml=6flozorcup 240ml=8flozor1cup 960ml=32flozor1qt

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NutritionManagementofFluidIntakeandHydration
FLUIDCONTENTOFTHEREGULARDIETSample (ContainerSizeandMenusMayVary) Breakfast Juice(4oz) 120ml 240ml Milk(8oz) Coffee(6oz) 180ml 240ml Water(8oz) Noon 180ml Soup(6oz) Tea(8oz) 240ml Water(8oz) 240ml Evening 240ml Milk(8oz) 240ml Tea(8oz) Water(8oz) 240ml TOTAL 2160ml TreatmentandPreventionofFluidDeficit Anappropriateassessmentismadebythephysiciantodetermineifwaterdepletionalone(dehydration)or the more common sodium/water (volume) depletion is present. Treatment is accomplished by increasing oralintakeoffluidandelectrolytesasneeded.Patientswithmoreseverecasesandthosewhoareunableto takefluidsbymoutharetreatedbyappropriateintravenousfluidreplacement.(Note:Internalsequestering, alsoknownasthirdspacing,maycreateadeficitofwaterinsomecompartments,althoughtotalbodywateris unaltered. Replacement water requirements may be greatly increased in peritonitis, pancreatitis, enteritis, ileus,orportalveinthrombosis.)
Anevaluationoffluidrequirementsshouldbemadeonanindividualbasis.Urinaryspecificgravity(Usg) andurinaryosmolality(Uosm)aregoodindicatorsofhydrationordehydrationinyoung,healthyandactive adult males and females (Grade II) (2). Urine color (Ucol) correlates well with urinary specific gravity and urinaryosmolalityandcanbeusedasanindicatorofhydrationstatus (GradeII)(2).Inaddition,bodymassloss ofover3%isanothergoodindicatorofdehydration (Grade II) (2).Insomecases,apreciseintakeandoutput recordmaybenecessarytodetermineandmeetfluidrequirements.Thereareseveralmethodstodetermine fluid requirements (2). Currently, no evidence exists comparing which methods are best to use when estimatingfluidneedsinadults(GradeV)(2).Variousmethodsinclude: Generalguidelinesforcalculatingfluidneedsbasedonageare: 1. Pediatrics(16) Weight(kg)a FluidRequirement(ml/kg/day) First10kg 100 1120kg 1000+50ml foreachkgabove10kg >20kg 1500+20ml foreach kg>20kg aThis method referred to as HollidaySegar
Method, original citation: Holliday MA, Seger WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19:823832.
2.
Adults(79) Weight(kg) First10kgofbodyweight Second10kgofbodyweight Eachadditionalkilogram
FluidRequirement(ml/kg/day) 100 50 20mL/kg(<50yearsofage) 15mL/kg(>50yearsofage)
*Inobesepatients,actualweightforheightisused OtherSuggestedMethods(6,7,8) Childrenover20kg:1500ml/day+20ml/kgabove20kg Activeyoungadultswithlargemusclemass:40ml/kgperday(6)
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3. 4. 5. 6.
7.
Adultsbetween1855years:35ml/kgperday(8) Forpersons5565yearsoldwithnomajorcardiacorrenaldiseases:30ml/kgactualweightperday(7) Forpersons>65yearsold:25ml/kg Forresidentsoflongtermcarefacilities,minimum1500ml2000mldaily(9,10) Patientswithpressureulcers:3035ml/kgofbodyweight Patientswithheartfailure:2025ml/kgofbodyweight RDA:1ml/kcal(1,7) Calculatingfluiddeficit(5) CalculatedWaterDeficit=(%TBW)(BW)[1(NaPredicted/NaMeasured)]whereTBW=totalbody water %TBW,normaladultmale=60 %TBW,leanadultmale=70 %TBW,obeseadultmale=50 %TBW,normaladultfemale=50 %TBW,leanadultfemale=60 %TBW,obeseadultfemale=42 BW=actualbodyweightinkilograms NaPredicted=constantaverageserumsodiumof140mEq/L NaMeasured=patientsactualmeasuredserumsodium Onebedchangeduetoperspirationrepresentsapproximately1Loffluidlost(12). Patientsreceivingmechanicalventilationorothersourceofhumidifiedoxygencanabsorbuptoan additional1000mloffluiddaily,whereasunhumidifiedoxygentherapycanresultinanetlossoffluid(12). Patientstreatedonairfluidizedbedssetathighertemperaturesareatgreaterriskofdehydrationdueto anincreaseininsensiblewaterlossassociatedwiththewarmerbedtemperatures.Patientswhorequire airfluidizedbedssetatahighertemperaturewillneedadditionalfluids,estimatedtobeapproximately 10to15mL/kg(13,14).Forbedssetattemperatures(86F),fluidlossissimilartothatonaconventional bed(480ml/m2/24h).However,whenthebedtemperatureishigh(94F),fluidlossmayincreaseupto 80%(938ml/m2/24h)ina70kgperson(13).(Bedtemperaturesareadjustableandusuallysetbetween 88and93F.) Minimalfluidrequirements: 2000to3000ml/dayintakeisnecessarytoyieldapproximately1000to1500ml/dayinurineoutput.
AssessmentofFluidStatus Theclinicalassessmentoftotalbodywater(TBW)isgenerallyinaccurate(GradeII)(2).Abodymasslossofover 3% is a good indicator of dehydration (Grade II) (2). More than 10% of TBW may be lost before evidence of hypovolemiaappears.ThethirstmechanismisactivatedwhenthedecreaseinTBWreachesapproximately 2%. Serial assessment of body weight is probably the most reliable parameter, especially because water makes up such a large proportion of total body weight (2,12). Along with serial assessment, the following physicalalterationscanbeassessedtohelpdeterminehydrationstatus(15,16). Volumedeficit Decreasedmoistureintheoralcavity Decreasedskinandtongueturgor(elasticity);skinmayremainslightlyelevatedafterbeingpinched Flattenedneckandperipheralveinsinsupineposition Decreasedurinaryoutput(<30ml/hwithoutrenalfailure) Acuteweightloss(>1lb/day) Volumeexcess Clinicalapparentedemaisusuallynotpresentuntil1215Loffluidhasaccumulated 1Lfluid=1kgweight Pittingedema,especiallyindependentpartsofthebody(eg,feet,ankles,andsacrum) Distendedperipheralandneckveins Symptomsofheartfailureorpulmonaryedema Centralvenouspressure>11cmH20 Laboratory values used to evaluate fluid status include urine specific gravity, urine osmolality, serum electrolytes; serum osmolality; hematocrit; blood, urea nitrogen (BUN); and urine specific gravity. Serum sodiumisthebestindicatorofintracellularfluiddisorders.Thehematocritreflectstheproportionofblood plasma to red blood cells. Fluid loss causes hemoconcentration and serum osmolality; fluid gain causes
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hemodilutionanddecreasesserumosmolality.AriseinBUNlevelfrequentlyreflectsafluiddeficitstateand afluiddeficitcausesurinetobeconcentrated(specificgravity>1.030);afluidexcessdilutesurine(specific gravity<1.010)(12). Agingincreasestheriskfordehydrationbasedonthephysicalandpsychologicalchanges.Theelderlyoften lacktheabilitytorecognizethirst,haveagedkidneysthatmayhaveadecreasedabilitytoconcentrateurine, fear urinary incontinence and thus do not drink sufficient fluids, have acute or chronic illnesses that alter fluidandelectrolytebalance(17),andhaveadecreaseintotalbodywaterfrom60%to45%. Refertothefollowingsectionforfurtherinformation: SeeEnteralNutrition,inSectionIBfordiscussionof calculationoffreewaterintubefeeding. FluidRestriction Inheartfailure,ascites,endstagerenaldisease,andotherdisorders,patientsretainfluid.Afluidrestriction isoftenusefulinthemanagementoftheseconditions. SeeSectionIII:ClinicalNutritionManagement
HEARTFAILURE MANAGEMENTOFACUTEKIDNEYINJURYANDCHRONICKIDNEY DISEASE(STAGEV) References 1. Institute of Medicine. Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate. Washington, D. C: National AcademyPress;2004. 2. Hydration EvidenceAnalysis Project. American Dietetic Association Evidence Analysis Library. American Dietetic Association; 2007.Availableat:http://www.adaevidencelibrary.com.AccessedNovember9,2007. 3. KleinerSM,Wateranessentialbutoverlookednutrient.JAmDietAssoc.1999;99:200205. 4. HendricksKM,WalkerWA.ManualofPediatricNutrition.2nded.Philadelphia:Pa:BCBeckerInc;1990. 5. Blackburn G, Bell SJ, Mullen JL. Appendix B: Macronutrient requirements. In: Blackburn GL, Bell SJ, Mullen JL, eds. Nutritional Medicine:ACaseManagementApproach.Philadelphia,Pa:W.B.SaundersCo;1989. 6. PediatricManualofClinicalDietetics.2nded.Chicago:Il:TheAmericanDieteticAssociation;2003. 7. FoodandNutritionBoard,NationalAcademyofSciences.RecommendedDietary Allowances.10thed.Washington,DC:National AcademyPress;1989. 8. ChidesterJC,SpanglerAA.Fluidintakeintheinstitutionalizedelderly.JAmDietAssoc.1997;97:2328. 9. Dietitiansinnutritionsupport:fluidrequirements.SupportLine.1991;13:18. 10. ChernoffR.Meetingthenutritionalneedsoftheelderlyintheinstitutionalizedsetting.NutrRev.1994;52:132136. 11. HolbenDH,HassellJT,WilliamsJL,HelleB.Fluidintakecomparedwithestablishedstandardsandsymptomsofdehydrationamong elderlyresidentsofalongtermcarefacility.JAmDietAssoc.1999;99:14471449. 12. DolanJT. FluidandElectrolytePhysiologyandpathophysiology.In:DolanJT,ed.CriticalCareNursing.Philadelphia,Pa:FADavis Co.;1991:434. 13. AyelloEA,ThomasDr,LitchfordMA.Nutritionaspectsofwoundhealing.HomeHealthcNurse.1999;17:719729. 14. BreslowRA.Nutritionandairfluidizedbeds:aliteraturereview.AdvWoundCare.1994;3:5760. 15. Methany NM. Fundamental concepts and definitions. In: Methany NM, ed. Fluid and Electrolyte Balance: Nursing Considerations. Philadelphia,Pa:JBLippincott;1989:2934. 16. LysenL.QuickReferencetoClinicalDietetics.Gaithersburg,Md:AspenPublishers;1997. 17. Position of The American Dietetic Association: nutrition across the spectrum of aging. J Am Diet Assoc. 2005;105: 616633.
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VEGETARIANDIETS
Description Avegetarianisapersonwhodoesnoteatmeat,includingfowlorseafood,orproductscontainingthesefoods(1). Awidespectrumofdietarypracticesisconsideredvegetarian (1).Avegetarianwhosedietconsistsoffoodsof plantoriginonlyisatotalvegetarianorvegan.However,manyvegetariansalsoconsumeeggs(ovovegetarian), dairyproducts(lactovegetarian),orbotheggsanddairyproducts(lactoovovegetarian).Thetwomostcommon definitionsforvegetariandietsintheresearcharevegandiets,whicharedevoidofallfleshfoods,andvegetarian diets,whicharedevoidofallfleshfoodsbutdoincludeeggs,dairyproducts,orboth(GradeII)(1).Accordingtothe American Dietetic Associations Evidence Analysis Library, these broad categories mask important variations within vegetarian diets. Thus, the absolute categorization of vegetarian dietary practices is difficult and may resultinunclearrelationshipsbetweenvegetariandietsandotherhealthfactors(GradeII)(1).
Indications Vegetariandietsareadoptedforavarietyofhealth,ecological,economical,philosophical,andethicalreasons (1). Vegetarian diets offer a number of health advantages, including lower blood cholesterol levels, lower blood pressurelevels,andlowerrisksofhypertension,heartdisease,andtype2diabetes (1).Vegetarianstendtohave alowerbodymassindexandloweroverallcancerrates(1).Vegetariandietstendtobelowerinsaturatedfatand cholesterolandhavehigherlevelsofdietaryfiber,magnesium,potassium,folate,antioxidants(eg,vitaminsCand E),carotenoids,flavonoids,andotherphytochemicals(1).Thesenutritionaldifferencesmayexplainsomeofthe health advantages of a varied, balanced vegetarian diet (1). Many epidemiologic studies suggest a positive relationship between vegetarian lifestyles and reduced risks of several chronic degenerative diseases, such as ischemicheartdisease (Grade I) (1),coronaryarterydisease,hypertension,type2diabetes,obesity,renaldisease, andsomecancers(1). NutritionalAdequacy Vegan, lactovegetarian, ovovegetarian and lactoovovegetarian diets are healthful and nutritionally adequate whenappropriatelyplannedforallstagesofthelifecycle,includingpregnancyandlactation (1).Appropriately planned vegan, lactovegetarian, ovovegetarian and lactoovovegetarian diets will meet the nutrient needs of infants,children,andadolescentstosupportandpromotenormalgrowthanddevelopment(13). AvegetariandietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedintheStatementon NutritionalAdequacyinSectionIA.VegansandsomeothervegetariansmayhavelowerintakesofvitaminsB12 andD,calcium,zinc,longchainn3fattyacids,andoccasionallyiron (1).Thegreaterproductionandaccessto fortifiedandenrichedfoodsismakingiteasierforvegetarianstoimprovetheirintakeofthesekeynutrients.All vegetarians should have a reliable source of vitamin B12 and vitamin D. If sun exposure is limited, vitamin D supplementsorfortifiedfoodsshouldbeemphasized(16). Results of evidencebased analysis suggest that vegetarian diets can be nutritionally adequate in pregnancy andcanleadtoapositivebirthoutcome (7).Thenutrientandenergyneedsofpregnantandlactatingvegetarian women do not differ from those needs of nonvegetarian women with the exception of higher iron recommendationsforvegetarians (1).Inadditiontoiron,keynutrientstoassessinpregnancyincludevitamin B12,vitaminD,andfolate,whereaskeynutrientsinlactationincludevitaminB12,vitaminD,calcium,andzinc (1). Breastfed infants whose mothers do not have an adequate intake of vitamin B12 should receive a vitamin B12 supplement (1,4).Inaddition,thezincintakeofbreastfedinfantsshouldbecarefullyassessed;zincsupplements or zincfortified foods should be used when complementary foods are introduced if the diet is low in zinc or mainly consists of foods with low zinc bioavailability (1). Because of the variability of dietarypracticesamong vegetarians,theindividualassessmentofdietaryintakesisnecessary(1).
HowtoOrdertheDiet OrderasRegularDietVegetarian.Thepatientsparticulardietaryconstraintswillbeconsidered.
PlanningtheDiet A vegetarian diet can be made nutritionally adequate by careful planning and giving consideration to the followingguidelines(1): Chooseavarietyoffoods,includingfruits,vegetables,wholegrains,legumes,nuts,seeds,tofuorothersoy products,and,ifdesired,dairyproductsandeggs. Choosewholeorunrefinedgrainproductswheneverpossible,insteadofrefinedproducts. ManualofClinicalNutritionManagement A35 Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.
VegetarianDiet
Minimizeintakeoffoodsthatarehighlysweetened,highinsodium,orhighinfat,especiallysaturatedfatand transfattyacids. Ifanimalfoodssuchasdairyproductsandeggsareused,chooselowerfatdairyproductsandusebotheggs anddairyproductsinmoderation. UsearegularsourceofvitaminB12,and,ifsunlightexposureislimited,provideasourceofvitaminD.
Inadditiontotheseguidelines,theDRIsareavaluableresourceformealplanning(1). Protein:Thebodysneedforessentialaminoacidscanbemetbyconsumptionofanimalorplantsourcesof protein.Althoughplantfoodscontainlessoftheessentialaminoacidsthandoequivalentquantitiesofanimal foods,aplantbaseddietcanprovideadequateamountsofaminoacidswhenenergyneedsaremetandavaried dietisconsumedonadailybasis (1).Researchindicatesthatanassortmentofplantfoodseatenoverthecourse ofadaycanprovideallessentialaminoacidsandensureadequatenitrogenretentionanduseinhealthyadults; thus,complementaryproteinsdonotneedtobeconsumedatthesamemeal(1,8).Amixtureofdifferentproteins from unrefined grains, legumes, seeds, nuts, and vegetables will complement each other in their amino acid profiles to meet nutritional needs. Estimates of protein requirements may vary based on dietary choices selected, particularly for vegans. Isolated soy protein can meet protein needs as effectively as animal protein, whereas wheat protein eaten alone may be 50% less usable than animal protein (1). Therefore, protein needs mightbesomewhathigherthantheRecommendedDailyAllowanceinthosevegetarianswhosedietaryprotein sourcesaremainlythosethatarelesswelldigested,suchassomecerealsandlegumes(1,9).Theconsumptionof lysine,anessentialaminoacid,shouldbeevaluatedinpersonswhoconsumeavegandietorwhoacquirealarge percentageofproteinfromcerealsources.Cerealstendtobelowinlysine.Dietaryadjustments,suchastheuse ofmorebeansandsoyproductsinplaceofotherproteinsourcesthatarelowerinlysineoranincreaseinprotein fromallsources,canensureanadequateintakeoflysine(1,10). Vitamin B12: Unfortified plant foods do not contain significant amounts of active vitamin B12. Although the requirementforvitaminB12 isrelativelysmall,vegetariansmustincludeareliablesourceofvitaminB12 intheir dietstoreducetheirriskofdevelopingadeficiency.LactoovovegetarianscanobtainadequatevitaminB12from theregularconsumptionofdairyfoods,eggs,fortifiedfoods,orsupplements(1).Vegansshouldsupplementtheir dietswithvitaminB12 byselectingfortifiedfoods,suchasfortifiedsoyorricebeverages,breakfastcereals,meat analogs,orRedStarVegetarianSupportFormulanutritionalyeast;otherwise,adailyvitaminB12supplementis neededtoensureanadequateintakeoftheactiveformofthenutrient(1).Olderadultswhoarevegetarianshould consumefortifiedfoodsorsupplementstoincreasetheirvitaminB12intake,becausetheabsorptionofvitamin B12oftenbecomeslessefficientinolderadultsduetoatrophicgastritis (1).Also,breastfedveganinfantsshould receive a source of vitamin B12 if the mothers diet is not supplemented (1,4,10). If vitamin B12 foods are not consumedregularly(atleastthreeservingsperday),patientsareadvisedtotakeadailyvitaminB12supplement of5to10mcgoraweeklyB12supplementof2,000mcg(11).VitaminB12statusisbestdeterminedbymeasuring serumlevelsofhomocysteine,methylmalonicacid,orholotranscobalaminII (1,12).Folacinrichvegetariandiets maymaskthehematologicalsymptomsofvitaminB12deficiency;therefore,adeficiencymaygoundetecteduntil themanifestationofneurologicalsignsandsymptoms(1,13).
Calcium:Calciumispresentinmanyplantfoodsandfortifiedfoods.Thecalciumintakeoflactovegetariansis comparable to or higher than that of nonvegetarians (1). However, the calcium intake of vegans is generally lower than that of lactovegetarians and nonvegetarians and is often below the recommended level (1). In one study,theriskofbonefracturewassimilarforlactoovovegetariansandmeateaters,whereasveganshada30% higherriskoffracturepossiblyduetotheirconsiderablylowermeancalciumintake (1,14).Adietthatprovides foodswithrelativelyhighratiosofsulfurcontainingaminoacidproteins,suchaseggs,meat,fish,poultry,dairy products,nuts,andmanygrains,mayincreasecalciumlossfromthebones(1).Excessivesodiumintakemayalso promote calcium loss from the bones (1). Studies show that the ratio of dietary calcium to protein is more predictiveofbonehealththancalciumintakealone (1).Typically,thisratioishighinlactoovovegetariandiets and favors bone health. However, vegan diets have calciumtoprotein ratios that are similar to or lower than thoseofnonvegetariandiets (1,15). Loweroxalategreens,suchasbokchoy,broccoli,Chinesecabbage,collards, and kale, and fruit juices fortified with calcium citrate malate are good sources of highly bioavailable calcium (50%to60%and40%to50%,respectively),whilecalciumsettofu,andcowsmilkhavegoodbioavailabilityof calcium(30%to35%),andsesameseeds,almonds,anddriedbeanshavealowerbioavailability(23%to27%) (1,15).Oxalatesinsomefoods,suchasspinachandSwisschard,greatlyreducecalciumabsorption,makingthese vegetablesapoorersourceofusablecalcium(1).Foodsrichinphytatemayalsoinhibitcalciumabsorption(1).If vegansdonotmeetcalciumrequirementsfromfood,fortifiedfoodsanddietarysupplementsarerecommended (1).
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VegetarianDiet
Vitamin D: Vitamin D status depends on sunlight exposure and intake of vitamin Dfortified foods or supplements(1).Ifsunexposureandintakeoffortifiedfoodsareinsufficienttomeetnutritionalneeds,vitaminD supplements are recommended (1). Vitamin D3 (cholecalciferol) is of animal origin and may not be used by vegans. Vitamin D2 (ergocalciferol) is produced from ergosterol from yeast and is a form that may be more frequentlyusedbyvegans.ThereisdisparityintheresearchastowhetherthebioavailabilityofvitaminD2is lessthanthatofvitaminD3 (1,16). TheneedforadditionalrequirementswhenvitaminD2sourcesareprimarily usedisnotcurrentlysuggestedbytheevidence (1,16).BothvitaminD2andvitaminD3areusedinsupplements and to fortify foods (1). Because cutaneous vitamin D production decreases with aging process, dietary or supplementalsourcesofvitaminDareimportantwhenassessingthedietsofolderadults(1,17).
Energy: Because vegan diets tend to be high in bulk, it can be challenging for vegans, especially infants, children,andadolescents,tomeettheirenergyneeds.Frequentmealsandsnacksandtheuseofsomerefined foods(suchasfortifiedbreakfastcereals,breads,andpasta)andfoodshigherinunsaturatedfatscanhelpvegan childrenmeettheirenergyandnutrientneeds(1).
Iron: The nonheme iron found in plant foods is more sensitive than heme iron to both inhibitors and enhancersofironabsorption (1).Theinhibitorsofironabsorptionincludephytate,calcium,andpolyphenolsin teas(includingsomeherbteas),coffee,andcocoa(1).Fiberonlyslightlyinhibitsironabsorption(1,18).Somefood preparationtechniques,suchassoakingandsproutingbeans,grains,andseedsandtheleaveningofbread,can diminish phytate levels and thereby enhance iron absorption (1). Western vegetarians have a relatively high intake of iron from plant foods, such as darkgreen leafy vegetables, ironfortified cereals, and whole grains. Althoughvegetariandietsarehigherintotalironthannonvegetariandiets,ironstoresarelowerbecauseiron fromplantfoodsisnotabsorbedaswellasironfromanimalsources(1).Becauseofthelowerbioavailabilityof ironfromavegetariandiet,therecommendedironintakesforvegetariansare1.8timesthoseofnonvegetarians (1,19). However, the frequency of anemia is not higher in the vegetarian population than in the nonvegetarian population (1). There is evidence of longterm adaptation to low iron intakes that involves both increased absorptionanddecreasedlosses (1,20,21).Inaddition,vitaminCandotherorganicacidsinfruitsandvegetables consumedbyvegetarianscansubstantiallyenhanceironabsorptionandreducetheinhibitoryeffectsofphytates, leadingtoimprovedironstatus(1). Zinc: Because phytate binds zinc, and animal protein is believed to enhance zinc absorption, total zinc bioavailabilityappearstobelowerinvegetariandiets(1,22).Vegetarians,especiallythosewhoconsumephytate richunrefinedgrainsandlegumes,shouldstrivetomeetorexceedtheDRIsforzincduetothelowbioavailability ofzincfromplantsourcesandthehighphytatecontentofavegetariandiet (1,19).Inaddition,breastfedinfants should have their diets evaluated for zinc intake. Zincfortified foods or supplements should be used when complementary foods are introduced, if the diet is low in zinc or mainly consists of foods with low zinc availability(1).Duetodifficultyinevaluatingzincdeficiency,itisnotpossibletodeterminethepossibleeffectof lowerzincabsorptionfromvegetariandiets (22).Zincsourcesincludesoyproducts,legumes,grains,cheese,and nuts.Foodpreparationtechniques,suchasthesoakingandsproutingofbeans,grains,andseeds,aswellasthe leaveningofbread,canreducethebindingofzincbyphyticacidandincreasezincbioavailability (1,23).Organic acids,suchascitricacid,canalsoenhancezincabsorptiontosomeextent(1,23). Omega3 fatty acids: Diets that do not include fish, eggs, or generous amounts of algae are generally low in docosahexaenoicacid(DHA)andeicosapentaenoicacid(EPA),whicharelongchainn3fattyacidsimportantfor cardiovascular health as well as eye and brain development (1). Vegetarians, particularly vegans, have lower blood levels of DHA and EPA than nonvegetarians (1,24). Diets that do not include fish, eggs, or sea vegetables generallylackdirectsourcesofDHAandEPA (1).Thebioconversionofalphalinolenicacid(ALA),aplantbased n3fattyacid,toEPAisgenerallylessthan10%inhumans,andtheconversionofALAtoDHAissubstantially less (1,25). The DRIs for ALA may not be sufficient for vegetarians who consume little if any DHA and EPA (1). VegetariansmayneedmoreALAfortheconversiontoDHAandEPA.Therefore,vegetariandietsshouldinclude highquality sources of ALA, such as walnuts, flaxseed, flaxseed oil, canola oil, and soy. Vegetarians with increased n3 fatty acid requirements (eg, pregnant and lactating women) may benefit from direct sources of longchainn3fattyacids(eg,codliveroil,mackerel,salmon,crab,shrimp,andoyster),DHAfortifiedfoods,eggs fromhensfedDHArichmicroalgae,oraDHArichmicroalgaesupplement (1,26).DHAsupplementsderivedfrom microalgae are well absorbed and positively affect blood levels of DHA andof EPA through reconversion (1,27). Soy milk and breakfast bars fortified with DHA are now available in the marketplace (1).
References
1. 2. PositionoftheAmericanDieteticAssociationandDietitiansofCanada:vegetariandiets.JAmDietAssoc.2009;109:12661282. MessinaV,MangelsR,MessinaM.TheDietitiansGuidetoVegetarianDiets:IssuesandApplications.2ndedition.Sudbury,Mass:Jones andBartlettPublishers;2004.
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VegetarianDiet 3. MessinaV,MangelaAR.Considerationsinplanningvegandiets:children.JAmDietAssoc.2001;101:661669. 4. MangelaAR,MessinaV.Considerationsinplanningvegandiets:infants.JAmDietAssoc.2001;101:670677. 5. Subcommittee on Nutritional Status and Weight Gain During Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation,FoodandNutritionBoard,InstituteofMedicine,NationalAcademyofSciences.NutritionDuringPregnancy.Washington,DC: NationalAcademyPress;1992. 6. Subcommittee on Nutrition During Lactation, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board,InstituteofMedicine,NationalAcademyofSciences.NutritionDuringLactation.Washington,DC:NationalAcademyPress;1991. 7. Vegetarian Nutrition in Pregnancy. Vegetarian Nutrition EvidenceAnalysis Project. American Dietetic Association Evidence Analysis Library.AmericanDieteticAssociation.Availableat:www.adaevidencelibrary.com/topic.cfm?cat=3125.AccessedSeptember10,2010. 8. YoungVR,PellettPL.Plantproteinsinrelationtohumanproteinandaminoacidnutrition.AmJClinNutr.1994;59(suppl):1203S 1212S. 9. YoungVR,FajardoL,MurrayE,RandWM,ScrimshawNS.Proteinrequirementsofman:comparativenitrogenbalanceresponsewithin thesubmaintenancetomaintenancerangeofintakesofwheatandbeefproteins.JNutr.1975;105:534542. 10. InstituteofMedicine,FoodandNutritionBoard.DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol, Protein,andAminoAcids.Washington,DC:NationalAcademyPress;2002. 11. MessinaV,MelinaV,MangelsAR.AnewfoodguideforNorthAmericanvegetarians.JAmDietAssoc.2003;103:771775. 12. HerrmannW,SchorrH,PurschwitzK,RassoulF,RichterV.Totalhomocysteine,vitaminB12,andtotalantioxidantstatusinvegetarians. ClinChem.2001;47:10941101. 13. HerrmannW,GeiselJ.VegetarianlifestyleandmonitoringofvitaminB12status.ClinChimActa.2002;326:4759. 14. Appleby P, Roddam A, Allen N, Key T. Comparative fracture risk in vegetarians and nonvegetarians in EPICOxford. Eur J Clin Nutr. 2007;61:14001406. 15. WeaverC,ProulxW,HeaneyR.Choicesforachievingadequatedietarycalciumwithavegetariandiet.AmJClinNutr.1999;70(suppl): 543S548S. 16. Holick MF, Biancuzzo RM, Chen TC, Klein EK, Young A, Bibuld D, Reitz R, Salameh W, Ameri A, Tannenbaum AD. Vitamin D2 is as effectiveasvitaminD3inmaintainingcirculatingconcentrationsof25hydroxyvitaminD.JClinEndrocrinolMetab.2008;93:677681. 17. HolickMR.VitaminDdeficiency.NEnglJMed.2007;357:266281. 18. CoudrayC,BellangerJ,CastigliaDelavaudC,RemesyC, Vermorel M,Rayssignuier Y.Effectofsolubleorpartlysolubledietary fibres supplementationonabsorptionandbalanceofcalcium,magnesium,iron,andzincinhealthyyoungmen.EurJClinNutr.1997;51:375 380. 19. InstituteofMedicine,FoodandNutritionBoard.DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper, Iodine,Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc.Washington,DC:NationalAcademiesPress;2001. 20. Hunt JR, Roughead ZK. Adaptation of iron absorption in men consuming diets with high or low iron bioavailability. Am J Clin Nutr. 2000;71:94102. 21. Hunt JR, Roughead ZK. Nonhemeiron absorption, fecal ferritin excretion, and blood indexes of iron status in women consuming controlledlactoovovegetariandietsfor8wk.AmJClinNutr.1999;69:944952. 22. HuntJR.Bioavailabilityofiron,zinc,andothertracemineralsfromvegetariandiets.AmJClinNutr.2003;78(suppl):633S639S. 23. LonnerdalB.Dietaryfactorsinfluencingzincabsorption.JNutr.2000;130(suppl):1378S1383S. 24. RossellMS,LloydWrightZechariah,ApplebyON,SandersTA,AllenNE,KeyTJ.Longchainn3polyunsaturatedfattyacidsinplasmain Britishmeateating,vegetarian,andveganmen.AmJClinNutr.2005;82:327334. 25. WilliamsCM,BurdgeG.Longchainn3PUFA:plantv.marinesources.ProcNutrSoc.2006;65:4250. 26. Conquer JA, Holub BJ. Supplementation with an algae source of docosahexaenoic acid increases (n3) fatty acid status and alters selectedriskfactorsforheartdiseaseinvegetariansubjects.JNutr.1996;126:30323039. 27. Geppert J, Kraft V, Demmelmair H, Koletzko B. Docosahexaenoic acid supplementation in vegetarians effectively increases omega3 index:arandomizedtrial.Lipids.2005;40:807814.
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KOSHERGUIDELINES
Description KosherisaHebrewwordthatmeansfitorwholesome.Kosherdietarylawsdefinefoodsandcombinationsof foodsthatareallowedorforbidden.ThecollectivetermfortheJewishlawsandcustomsrelatingtothetypesof foods permitted for consumption and their preparation is kashruth. The observance of kosher dietary laws variesaccordingtothetraditionsoftheindividualandinterpretationsofthedietarylaws. In a nonkosher food service facility, observance of dietary laws usually involves service of commercially preparedkosherdinnersondisposableplasticwareforthepatientfollowingastrictkosherdiet.Forpatients notfollowingastrictkosherdietorifthepatientsowishes,thefoodsusuallypreparedbytheFoodandNutrition Services Department can be served, as long as milk and milk products are separated from meat and meat productsandcertainforbiddenfoodsareexcluded(seethefollowinglist). Thestrictobservanceofthekashruthbythekosherfoodservicerequiresseparatesetsofequipment,dishes, andsilverware,aswellaskosherfoodsuppliersformanyitems.Dairyfoodsarestoredandpreparedseparately frommeatandmeatproducts. Indications KosherdietsmaybeorderedforindividualsoftheJewishfaithiftheysodesire. NutritionalAdequacy ThedietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedintheStatementonNutritional AdequacyinSectionIA. HowtoOrdertheDiet OrderasKosherDiet.Anyadditionaldietarymodificationsthatmaybewarrantedshouldbestatedinthediet prescription(eg,KosherDiet,SugarinModeration). GuidelinesforFoodSelection: 1. Kosher meats and poultry may come only from animals that have cloven hooves, chew their cud, and are slaughtered according to the humane and specific guidelines prescribed by the Jewish dietary laws. In addition,koshermeatsundergoaprocesscalledkoshering,inwhichbloodisextractedbysoakinginsaltor broilingonaregulargrill.(Pangrillingisnotacceptable.) 2. Foodsareclassifiedasdairy,meat,orpareve.Mealsareclassifiedeitherasdairyormeat.Meatandmeat products are not to be combined with any dairy products in recipe, food preparation, or service. Pareve foodsmaybeservedatdairyormeatmeals. 3. ThestrictobservanceoftheKashruthrequiresseparatesetsofequipment,dishes,andsilverwarefordairy or meat meals. In a kosher kitchen, dairy foods are stored and prepared separately from meat and meat products. 4. In a nonkosher food service facility, observance of dietary laws usually involves service of commercially prepared kosher dinners on disposable plastic ware for the patient following a strict kosher diet. For patientsnotfollowingastrictkosherdietorifthepatientsowishes,theusualfoodspreparedbytheFood& NutritionServicesDepartmentcanbeserved,aslongasmilkandmilkproductsareseparatedfrommeatand meatproductsandcertainforbiddenfoodsareexcluded(seethefollowinglist). 5. Processedfoods:Noproductshouldbeconsideredkosherunlesssocertifiedbyareliablerabbinicauthority whosenameofinsigniaappearsonthesealedpackage.Theinsignia,Uwhichisthecopyrightedsymbolof the Union of Orthodox Jewish Congregations of America, indicates that the product is certified as to its koshernature.Packagesmarkedwithothersymbolsmaybesuitableforcertainbutnotallkosherdiets.Itis importantthatakosherfoodpackageremainssealedwhenpresentedtotheuser.Thepackageshouldbe openedonlyunderthesecircumstances:bytheuser,intheuserspresence,orbysomeoneauthorizedbythe religiousauthoritiestoopenthefoodpackage. 6. Nonkosher foods may be used if considered essential in the treatment of an ill person. However, a rabbi shouldbeconsultedbeforewaivingdietaryrestrictions.
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KosherGuidelines
FOODGUIDE KOSHERDIET
Dairy FOODGROUP MilkProducts FOODSALLOWED Allfoodscontainingmilkorwhitesauces Note:Foodscontainingmilkderivativessuch assodiumcaseinateandlactoseare considereddairy
FOODSEXCLUDED
Meat
Meat
Onlymeatfromananimalthatchewsitscud andhassplithooves Beef:chuck,brisket,plate,shank,ribuptoand including12thrib Broiledliver Veal/lamb:shoulder,rack,shank,breast
Porkandporkproducts Beef:loin,rump,flank,shank, hindquarter Veal:loin,leg,flank,shank, Lamb:loin,leg,hindquarter
Fowl
Mostdomesticatedfowlarebytradition consideredtobekosher:chicken,turkey, domesticduck
Wildfowlthatishunted
Pareve
Breads, Cereals,and Grains Eggs Fishand Seafood
AllexceptlistedinFoodsExcludedcolumn
Breadmadewithlardoranimal shortening. Note:Breadsandcerealscontainingany dairyproductsareclassifiedasdairy
Eggsfromdomesticfowl
Eggscontainingbloodspots Catfish,eel,marlin,sailfish,shark, sturgeon,swordfish,lumpfish, scallops,andshellfishsuchas lobster,shrimp,crabandoysters
Fishhavingboth finsandscales: halibut,flounder,cod,tuna,haddock, pollack,turbot,salmon,trout,whitefish, herring,etc.
Vegetablesand All,preparedwithparevecertificationand Fruit allowedingredients;freshdonotrequire Kashruthcertification. Bakedbeans,catsup,chickpeas,chowmein noodles,dehydratedorcannedsoupand bases,preparedsauces,tomatojuice, tomatoproducts,frozenfruitsand vegetablesinsauce,grapejuice,blended fruitjuicedrinksandpunches,musthave Kashruthcertification
Fats
Purevegetableoil Margarinemadewithvegetableshortening andwithoutmilk
Lardoranimalshortening Margarinewithaddedmilk Butter
Sweets
Imitationsourcreamorwhippedtoppingwith parevecertification Sugar,jam,jelly(grapejellyonlyifhas Kashruthcertification),syrup Candywithoutmilk
Beverages
Coffee,tea,carbonatedbeverages Alcoholicbeverages Nondairycreamerwithparevecertification Thosemadewithmilkormilkproductsare consideredtobeapartofthedairygroup
Other
Desserts
Dessertsmadewithoutmilkoranimal productsareconsideredtobepareve certified
Dessertsmadewithlardoranimal shortening Monoglyceridesanddiglyceridesand emulsifiersthatmaybefromanimal fats
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CLEARLIQUIDDIET
Description The Clear Liquid Diet is designed to provide fluids mainly in the form of sugar and water to prevent over stimulatingextensivedigestiveprocesses,minimizecolonicresidue,relievethirst,andprovideoralfeedingsthat promote the return to the normal ingestion of food (1). The diet as served will yield 700 to 1,000 kcal when energycontainingclearliquidsareservedbetweenmeals. Indications TheClearLiquidDietisindicatedforthefollowing: shorttermusewhenanacuteillnessorsurgerycausesanintoleranceforfoods(eg,abdominaldistention, nausea,vomiting,anddiarrhea) to temporarily restrict undigested material in the gastrointestinal tract or reintroduce foods following a periodwithnooralintakewhenpoortolerancetofood,aspiration,orananastomoticleakisanticipated topreparethebowelforsurgeryoragastrointestinalprocedure NutritionalAdequacyandNutritionIntervention TheClearLiquidDietisinadequateinallfoodnutrientsandprovidesonlyfluids,energy,andsomevitaminC. LongtermuseoftheClearLiquidDietmaycontributetohospitalmalnutrition(1).Currentpreparationmethods forbowelsurgeryorbowelprocedureshavedecreasedthetimerequiredforbowelpreparationto1to2days (1). Knowledge regarding the time required for gastric emptying has increased; thus, usually only one preoperativemealasclearliquidisrequiredbeforesurgery(1).TheAmericanSocietyofAnesthesiologistsTask ForceonPreoperativeFastingrecommendsabstainingfromclearliquidsfor2ormorehoursbeforeprocedures requiringgeneralanesthesiaandabstainingfromtheintakeoflightmealsornonhumanmilkatleast6hours before elective surgery requiring general anesthesia (2). The resumption of bowel sounds is no longer a prerequisite to resume a regular diet after surgery (1). Improved anesthesia and evidence have led to the postoperative transition to a regular diet based on individual tolerance (1). Lowresidue food supplements providingenergyandproteinaredesirableifthedietisprolongedformorethan3to4days(1).TheClearLiquid Dietprovidesapproximately200g/dayofcarbohydrateinequallydividedamounts.Liquidsarenotsugarfree, even for persons with diabetes mellitus, because all patients require carbohydrates and energy to meet nutritionalneeds(3,4).Diabetesmedicationsmayneedtobeadjustedtoachieveandmaintainmetaboliccontrol (3,4). HowtoOrdertheDiet Order as Clear Liquid Diet. Variations of this standard diet should be specifically ordered; specify the exclusionofcertainfoodsorspecifyadietlimitedtocertainfoods. Adietorderspecifyingthenumberofmealsordaysofliquidsorthedietprogressions,astolerated,will ensurethatthisnutritionallyinadequatedietisadvancedorevaluated.
FOODGUIDECLEARLIQUIDDIET
FOODSALLOWED Carbonatedbeverages,regularanddecaffeinated; coffeeandtea;fruitflavoredsoftdrinks Clearflavoredgelatin,fruitices,Popsicles Cranberry,apple,andgrapejuices Lightlyseasonedclearbrothorconsomm(fatfree) Sugar,honey,syrup FOODSEXCLUDED Allotherfoodsorfluidsexceptwater
B1
ClearLiquidDiet
SAMPLEMENU (600kcal)
Breakfast CranberryJuice FlavoredGelatin CoffeeorTea Sugar
Noon BeefBroth GrapeJuice FlavoredGelatin CoffeeorTea Sugar
Evening ChickenBroth AppleJuice WaterorIceChips CoffeeorTea Sugar
CLEARLIQUIDSBETWEENMEALSASDESIRED
References 1. Clear liquid diet. In: The American Dietetic Association Nutrition Care Manual. Available at: www.nutritioncaremanual.org. Accessed December1,2008. 2. American Society of Anesthesiologist Task Force on Preoperative Fasting. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology.1999;90:896905. 3. AmericanDiabetesAssociation.Diabetesnutritionrecommendationsforhealthcareinstitutions.DiabetesCare.2004;27:55S57S. 4. Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsch IB. Management of diabetes and hyperglycemia in hospitals.DiabetesCare.2004;27:553591.
B-2
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FULLLIQUIDDIET
Description TheFullLiquidDietconsistsoffoodsthatareliquidatbodytemperature,includinggelsandfrozenliquids.The dietprovidesnourishmentthatiseasytoconsumeanddigestwithverylittlestimulationtothegastrointestinal tract.
Indications TheFullLiquidDietmaybeindicatedfollowingoralsurgeryorplasticsurgeryofthefaceorneckareainthe presenceofchewingorswallowingdysfunctionforacutelyillpatients.
TheFullLiquidDiethasbeentraditionallyusedasapostoperativetransitionaldiet.Thedietisintendedfor shortterm use only; therefore, attempts are not usually made to increase the variety of foods offered to provideforthetotaladequacyofnutrients.
Contraindications Due to the liberal use of milk and foods made with milk, the diet is high in lactose. A temporary lactose intolerancemayoccurinsomepatientsfollowingsurgery.Symptomsoflactoseintoleranceuponingestionof aFullLiquidDietmayresult,andthedietshouldbemodifiedforthepatient.SeeLactoseControlledDiet,in SectionIH.
NutritionalAdequacy The diet as served meets the Dietary Reference Intakes (DRIs) for ascorbic acid, vitamin D, vitamin B12, calcium,phosphorus,andriboflavin.Itmaynotmeettheproteinandcaloricrequirementsoftheindividual. The diet as served will provide approximately 1200 kcal and 40 g of protein. When betweenmeal nourishmentisadded,theintakeisincreasedto1500to1800kcaland65gofprotein.Proteinandcaloric intakecanbeincreasedthroughtheuseofadditionalfullliquidfoodsatmealsandbetweenmeals.Thediet canbenutritionallyadequatewhensupplementsareofferedandconsumedinsufficientamounts.
HowtoOrdertheDiet OrderasFullLiquidDiet.Variationsinthisstandarddietshouldbespecificallyordered(eg,theexclusionof certain foods or a diet limited to certain foods). A diet order specifying the duration of the diet or the diet progression,astolerated,willensurethatthisnutritionallyinadequatedietisadvancedorevaluated.
FOODGUIDEFULLLIQUIDDIET
FOODSALLOWED Carbonatedbeverages,regularanddecaffeinatedcoffeeandtea,softdrinks,cocoa Cookedrefinedcereal,farina,creamofrice,orstrainedcereal Custard,plaingelatin,icecream,sherbet,pudding,yogurt,allwithoutnuts; fruitorpreserves Eggnog*,milkshake,andothermilkdrinks Butter,margarine,cream Fruitandvegetablejuices(includingoneservingofcitrusfruitjuicedaily) Broth,bouillon,consomm,strainedcreamsoup Honey,sugar,syrup
*
FOODSEXCLUDED Allsolidfoods
Madefrompasteurizedeggsonlyorcommercialproduct.
Breakfast OrangeJuice CreamofWheat Milk CoffeeorTea Sugar
SAMPLEMENU Noon StrainedCreamofChickenSoup GrapeJuice VanillaIceCream Milk CoffeeorTea Sugar
Evening StrainedCreamofCelerySoup AppleJuice Custard Milk CoffeeorTea Sugar
FULLLIQUIDSBETWEENMEALSASDESIRED
B3
FULLLIQUIDBLENDERIZEDDIET
Description The Full Liquid Blenderized diet consists of a variety of liquids, as well as semisolid foods that have been thinnedtoaconsistencythatcanbeconsumedthroughastraw,fedbysyringe,orsippedfromacup.Thediet also includes foods that, if eaten by spoon, will turn to a liquid consistency in the mouth. The method of feedingwilldeterminethedesiredviscosityoftheliquid. Indications Theobjectiveofthedietistoprovideoralnourishmentinaformthatrequiresnomastication.Thisdietis indicatedforthefollowing: patientsfollowingoralsurgeryorplasticsurgeryofthefaceorneckareainthepresenceofchewingor swallowingdysfunction(eg,awiredjaworintermaxillaryfixationsurgery) acutelyillpatientswithoralesophagealdisorders,neuromusculardisabilities,advancedcarcinomaofthe oralcavity,facialornecktrauma patientswhohavereceivedradiationtherapyandfindeatingdifficult NutritionalAdequacy TheFullLiquidBlenderizedDietcanmeettheDietaryReferenceIntakes(DRIs)asoutlinedintheStatement onNutritionalAdequacyinSectionIA,iftheproperamountandvarietyoffoodisconsumedbythepatient. Because some patients experience palatability problems or may have difficulty consuming an adequate volumeofliquids,liquidsupplementsmaybenecessarytomeettheirnutrientandfluidneeds. HowtoOrdertheDiet OrderasFullLiquidBlenderizedDietorWiredJaw.ThesetermswilldistinguishthisdietfromtheFull LiquidDiet,whichislowerinenergyandnutrients.Thedietitiandeterminestheamountandtypeoffoodor supplementstobeserved,basedonpatientacceptance,nutrientneeds,andchangeincondition.
B-4
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Full Liquid Blenderized Diet
FOODGUIDEFULLLIQUIDBLENDERIZEDDIET
NOTE:Thefoodslistedbelowvarygreatlyincaloricandnutrientdensity.Itmaybenecessarytoencourage certainfoods,dependingonthenutritionalgoalsfortheindividual. FOODGROUP FOODSALLOWED FOODSEXCLUDED Beveragesand Milk,eggnog,milkshake,milkdrinks Allother Milk Allbeverages:coffee,tea,etc. Yogurtwithoutseedsorfruit(mayneedtobethinnedfor straworsyringefeeding) BreadandCereals Cerealgruelsoffarina,creamofrice,grits Allother (Cerealgruelsareequalpartswholemilkwithcereal) Strainedoatmealorcreamofwheat Note:ironfortifiedcerealsarerecommended Vegetables Mashedwhitepotato,thinnedwithsouporbroth Allother Vegetablejuices Vegetablepureesthinnedwithsoups Fruits Fruitjuices Allother Pureedfruitsthinnedwithfruitjuice Juicesmayneedtobestrainedtoremoveexcesspulpfor straworsyringefeeding Note:Citrusjuicesmaynotbewelltoleratedbyallsurgical patients Meats,Poultry, Pureedmeatsandpoultry(babystrained),thinnedwith Allother Fish,Cheese, broth andEggs Fats Margarine,butter Nondairycreamers,halfandhalf Soups Broth,strainedcreamsoups Allother Desserts Icecream,sherbet,plaingelatin,custards,puddings,fruit Allother ices Popsicle(mayneedtobeliquefiedormeltedforstrawor syringefeeding). SugarandSweets Sugar,syrup Allother Hardcandyiftolerated Salt,pepper,herbs Allother Miscellaneous Lemonjuice,othercondimentsandseasoningsastolerated
B5
NUTRITIONMANAGEMENTOFDYSPHAGIA
Description Dysphagiaisnotadisease,butadisruptioninswallowingfunction.Althoughdysphagiacanoccuratanyage, itisparticularlyprevalentinolderadults(1).Dysphagiamayresultfromneurologicaldisorders,degenerative diseases,cancers,orpostintubationtrauma (1).Thenutritionmanagementofdysphagiaincludesmodifying theconsistencyandtextureoffoodsandliquidsaccordingtothepatientstolerance,whichisdeterminedbya comprehensivemedical,swallowing,andnutritionevaluationbythehealthcareteamincludingthephysician, speechlanguage pathologist, and registered dietitian. Therapeutic goals for nutrition are customized and oftenincludedietmodificationsandswallowingretraining.Anindividualizedmealplanwillgenerallyinclude modificationsinthetextureandconsistencyoffoods(eg,pureedortexturedmodifiedfoodsandthickened liquids)thatoptimizethequalityofnutritionalintakewhilereducingtheriskofaspirationorchoking.
Indications Dysphagia is an impairment in one or all stages of swallowing, resulting in the reduced ability to obtain adequate nutrition by mouth and a possible reduction of safety during oral feeding (1,2). Patients with dysphagiahavedifficultymovingfoodfromthefronttothebackofthemouth,channelingthefoodintothe esophagus, or both processes. Dysphagia may be caused by weak or uncoordinated muscles of the mouth and/orthroat,motorandsensorydefectsimpedingchewingorswallowing,orbothconditions.Ifdysphagia is suspected, a swallowing evaluation should be performed by a qualified healthcare provider (1). This evaluation may include a bedside evaluation, indirect or fiberoptic laryngoscopy, fiberoptic endoscopic evaluationofswallowing,andavideofluoroscopicswallowstudy(VFSS),whichisalsoknownasamodified barium swallow study. The VFSS is a definitive test in diagnosing the type of dysphagia (1). Fiberoptic endoscopic evaluation of swallowing was recently shown to be as reliable as VFSS when using the PenetrationAspiration Scale (1). However, the VFSS remains the preferred diagnostic tool for dysphagia because it determines any structural and functional problems that may occur with varied food and liquid consistenciesandrulesoutinappropriatedietconsistencies.
Thenutritioncareplanforpatientswithdysphagiaisdevelopedbasedon(3): resultsofVFSS recommendationsfromthespeechlanguagepathologist nutrientrequirementsofthepatient foodpreferencesofthepatient othermedical,psychological,orsocialfactorsaffectingthepatient'seating
NutritionalAdequacy Dysphagia diets can be planned to meet the Dietary Reference Intakes as outlined in the Statement on Nutritional Adequacy in Section IA. Enteral feedings may be necessary to supplement oral intake until a sufficientquantityoffoodcanbeconsumed.Ifenteralnutritionforneurologicaldysphagiaisanticipatedto lastforlongerthan4weeks,apercutaneousendoscopicgastrostomy(PEG)tubeispreferabletoanasogastric tube(4).PEGtubesareassociatedwithfewertreatmentfailuresandimprovednutritionalstatusascompared tonasogastrictubes,andtheyallowthepatienttoreceiveadequatenutritionwhileoralintakeisstabilized(4). Inonestudy,morethanhalfofthepatientswhoreceivedaPEGtubeduetopoortoleranceofthickenedfood were eventually able to resume oral feedings (1,5). If a patient can tolerate oral liquids, the medical food supplementsshouldbeincompliancewiththeconsistencyprescribedforthepatient. Arecordoffoodintake,includingfluidintakeandenteralfeedings,isnecessaryatallstagesofdysphagia therapy. When oral intake approaches the patients energy and protein requirements, the patient should begintobeweanedfromtheenteralfeedings.Areviewofsevenstudiesofmodifiedtexturedietsinolder adults with dysphagia found that people who consume these diets report an increased need for assistance witheating,dissatisfactionwithfoods,anddecreasedenjoymentineating,resultingindecreasedfoodintake and weight loss (Grade I) (4). Recognition of the social and psychological burden of dysphagia, creation of an individualized treatment approach, and provision of eating assistance may contribute to increased food intakeandweightmaintenanceorweightgaininolderadults(GradeI)(4).
HowtoOrdertheDiet Thedietitianandthespeechlanguagepathologistshouldworkcollaborativelyandusetheresultsfromboth themedicalevaluationandaswallowingstudytochooseappropriatefoodsandbeveragesfortheindividual patient(1).TheNationalDysphagiaTaskForcefoundthattheDysphagiaOutcomeandSeverityScaleprovided the best scale to determine the level at which the National Dysphagia Diet (NDD) should be recommended (1,6). ManualofClinicalNutritionManagement B6 Copyright2011MorrisonManagementSpecialists,Inc.
Allrightsreserved.
Nutrition Management of Dysphagia
Priortotheinitialoralfeeding,adietorderspecifyingthatthepatientcaneatmustbeobtainedfromthe physician. The dietitian and the speechlanguage pathologist must coordinate efforts to determine the appropriateconsistencyoffoodsandliquidsforthepatientbothbeforefeedingsbeginandwithsubsequent feedings.Theconsistencyoffoodsandliquidsshouldbealteredasthepatientprogresses. Theseverityofdysphagiadeterminesthelevelofthedietrequired.Thefoodplanisdividedintomultiple levels of solid food and liquid consistency to maximize the dysphagic patients nutritional intake (2). Diet ordersshouldincludetheNationalDysphagiaDietlevelsandthedesiredliquidconsistency(eg,thin,nectar like,honeylike,orspoonthick)(6).Witheachprogressionofthediet,boththelevelofthedietandtheliquid consistencyneedtobespecifiedinthenutritionprescription(6).ThethreeNDDlevelsare(6): NDD Level 1: Dysphagia Pureed: Foods are thick and smooth and have a moist puddinglike consistencywithoutpulporsmallfoodparticles.Theyclingtogether,areeasytoswallow,andrequirea minimumamountofmanipulationinthemouth.Stickyfoodsorfoodsthatrequireabolusformationor controlled manipulation of the mouth (eg, melted cheese and peanut butter) are omitted. The diet provides no coarse textures (eg, fibrous foods) to prevent irritation. Food and fluid intake should be monitored. NDD Level 2: Dysphagia Mechanically Altered: Foods are moist, soft, and simple to chew, and they easily form a cohesive bolus. The diet provides a transition from pureed foods to easytochew foods. Moistenedgroundmeats(piecesshouldnotexceedinchcube),vegetablescookedtoasoftmashable texture,softcookedorcannedfruits,andbananasareincluded.Somemixedtexturesareexpectedtobe tolerated.Morefrequentfeedingsmaybebeneficial.Foodandfluidintakeshouldbemonitored. NDD Level 3: Dysphagia Advanced: Foods are moist, soft, in bitesize pieces, and nearly regular in texture.Hard,sticky,andcrunchyfoodsareexcluded.
PlanningtheDiet Generalconsiderations:Dietaryconsiderationsvarywitheachpatient.Theimportanceofindividualfood consistenciescannotbeoveremphasized.Forexample,dysphagicpatientswithanobstructionmaybeableto safely consume liquids, while other dysphagic patients may aspirate liquids and require thickened liquids with a puree consistency. A recent study showed that carbonated liquids are a dietary option for patients who experience penetration/aspiration into their airways (7); thickened liquids are also safe for these patients(1).Ifapatientcannottoleratethinliquids,foodsthatbecomethinliquidatroomtemperature(70oF) orbodytemperature(98oF),suchasgelatin,icecream,andsherbet,shouldalsobeavoided.
Thefollowingguidelinesshouldbeconsideredwhenplanningthedietforadysphagicpatient:Oneofthe most important considerationsof foodtexture iscohesiveness,or the ability to staytogether. Patientscan often chew through foods but are unable to press the food into a bolus unless it is naturally or artificially cohesive. For patients who cannot swallow a smooth pureed food,a highertexture food (more viscous) is desiredtorehabilitatemuscles.Thelargersurfaceareaprovidesstimulationtothenerveandmusclegroups thatassisttheswallowingprocess. Do not combine textures, such as dry cereal with milk or chunky vegetable soup in broth, in the same bolus.Donotusefluidstowashdownthebolus.Itmaybeappropriatetoalternateliquidandsolids. Presentfoodsandfluidsseparately,checkingforcompleteswallowsaftereachmouthful. Usesmoothgraviesonallgroundmeat. Riceandcottagecheesearedifficultforsomedysphagicpatientstoswallow.Usericeincasseroleswitha soup base, and include only pureed smallcurd cottage cheese in the diet. Milk does not cause mucous formation. However, milk can aggravate thickening of mucus in some people, which can reduce their ability to manage secretions. Blended yogurt or lactosefree supplements may be used if milk is not tolerated.
Liquids: Patients who have dysphagia frequently have difficulty drinking thin liquids, which are not easily channeled to the back of the mouth. Fluid intake is often limited in patients with dysphagia, leading to an increasedriskofdehydration(1).Adequatehydrationcanbeensuredbytheintroductionofthickenedliquids followedbytheprogressiontothinnerliquidsasswallowingproficiencyisgained.While there is some fluid content in many foods, especially pureed foods, the use of thickened liquids may be necessary to assure adequate hydration. Theeffectsofthickeningpowdersinachievingtargetedlevelsofthicknessaregenerallyinconsistentdueto variations in the temperature, pH, and protein content of foods and beverages (2). There are currently no nationally recognized standards for thickened liquids (2). The majority of commercially prepared powder
B7
thickenersrequire1tbspofthickeningproductper4floztoachieveanectarlikethickness,1tbspper4fl ozforahoneylikethickness,and2tbspper4flozforspoonthickthickness.Registereddietitiansneedtobe aware that there is wide variation in the viscosity of commercially prepared thickened beverages and that manyproductlabelsdonotincludeviscosity (2).Theuseofdrystarchthickenersaddedtothinliquidsalso resultsinwidevariationsinviscosity(2).
ViscosityBordersandRangesforThickenedLiquids The NDD Task Force has suggested the following viscosity borders and ranges (All measurements were performedat25oCwithashearrateof50s1.)(2,6): thinliquid:150cP* nectarlikeliquid:51350cP honeylikeliquid:3511750cP spoonthickliquid:>1750cP
*cP=centipoise,ameasurementofliquidthickness
Thin liquids include all unthickened beverages and supplements such as clear juices (fruit or vegetable), water,coffee,tea,soda,milk,eggnog,juicefromcannedfruit,fruitwiththinliquidproperties(watermelon, grapefruit, and orange sections), broth, ice cream, sherbet, malts, most nutritional supplements (at room temperature), frozen yogurt, gelatin, and other foods that will liquefy in the mouth within a few seconds. Nectarlikeliquidsincludenectars,vegetablejuices,chocolatemilk,buttermilk,thinmilkshakes,creamsoups, and other beverages properly thickened (1,6). Medical food supplements providing 1.5 to 2.0 kcal/mL are usually considered nectarlike when chilled. Honeylike liquids are thickened to a honey consistency (1,6). Spoonthickliquids,whichincludepudding,custard,andhotcereal,arethickenedtopuddingconsistencyand needtobeeatenwithaspoon(1,6). Factorsthataffectthickenedliquidviscosityinclude(1,8): temperature continuoushydrationofthethickeningagentinprethickenedbeverages abilityofinstantfoodthickenertomaintainthickness inconsistencyacrossproductlineswithinmanufacturersorbetweencompetitors
References 1. Dysphagia.In:NutritionCareManual.AmericanDieteticAssociation;2004.Availableat:nutritioncaremanual.org.AccessedSeptember 20,2010. 2. Niedert KC, ed.Nutrition Care of the Older Adult: A Handbook for Dietetics Professionals Working Throughout the Continuum of Care.2nded.Chicago,Ill:AmericanDieteticAssociation;2004:211. 3. WalkerG,ed.PocketResourceforNutritionAssessment.Chicago,Ill:AmericanDieteticAssociation;2005:173181. 4. Unintended Weight Loss in Older Adults EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence AnalysisLibrary.AmericanDieteticAssociation;2006.Availableat:www.adaevidencelibrary.com.AccessedJuly31,2010. 5. WilkinsonTJ,ThomasK,MacGregorS,TillardG,WylesC,SainsburyR.Toleranceofearlydiettexturesasindictorsofrecoveryfrom dysphagiaafterstroke.Dysphagia.2002;17:227232. 6. National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. Chicago, Ill: American Dietetic Association;2002. 7. Mahan K, EscottStump S.Medical nutrition therapy for neurologic disorders. In:Krause's Food & Nutrition Therapy.12th ed. St. Louis,Mo:Saunders;2008:10741077. 8. AdeleyeB,RachalC.Comparisonoftherheologicalpropertiesofreadytoserveandpowderedinstantfoodthickenedbeveragesat differenttemperaturesfordysphagicpatients.JAmDietAssoc.2007;107:11761182.
B-8
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FOODGUIDE DYSPHAGIADIETS
NDDLevel1:DysphagiaPureed
FOODGROUP BeveragesandMilk FOODSALLOWED FOODSEXCLUDED Smoothbeverageswithoutlumps, Milk,coffee,tea,sodas,nutritional chunks,orpulp.Beveragesmay supplements(maybegivenif needtobethickenedtothe thinliquidsareallowed) appropriateconsistency. Farinatypecookedcereals; Coarsecookedordrycereals cookedcerealshouldhavea Cerealswithseedsornuts puddingliketexture Allotherbreads Pregelledorslurriedthroughthe Crackers entirethickness:doughnuts, Regularrice pancakes,waffles,Frenchtoast, Oatmeal bread Muffins Pasta,rice,anddressingthatare pureedtoasmoothconsistency
CerealsandGrains Cerealsshouldhaveapuddinglike consistencyandmayhaveenough milktomoisten.
Vegetables,Potatoes,andSoups FruitsandJuices
Pureedorstrainedvegetables withoutchunksorseeds; mashedwhitepotatoes Smoothcreamsoupsorbrothtype soupswithpureedandstrained ingredients Applesauce,pureedfruits,well mashedbananas Fruitjuiceswithoutpulporseeds (maybegivenifthinliquidsare allowed) Pureedorstrainedmeats,poultry, orfish Pureedscrambledeggs Soufflsthataresmoothand homogenous
Regularcookedorrawvegetables Potatoskinsandchips Friedorfrenchfriedpotatoesor vegetables Regularsoupswithrice,corn, peas,orlargechunksofmeat andvegetables
Meats,MeatSubstitutes,and Entrees
Regularcanned,fresh,orfrozen fruits Fruitjuicewithpulporseeds(may begivenifthinliquidsare allowed) Regular,chopped,orground meatsorcasseroles Cottagecheese Cheeseslicesorcubes Scrambledorhardcookedeggs Peanutbutter Sandwiches Pizza
Desserts
Smoothcustardandpudding Plainorcustardstyleyogurt Dessertspureedtoasmoothand moistconsistency
Fats
Miscellaneous
Butter,margarine,smoothgravy, creamsauces,mayonnaise, saladdressings,creamcheese, sourcream,whippedtoppings Sugar,jelly,honey,syrup Ketchup,mustard,smoothsauces B9
Icecream,sherbet,frozenyogurt, otherices(maybegivenifthin liquidsareallowed) Regularcake,pie,cookies Breadandricepudding Fruitedyogurt Allfatswithcoarseorchunky additives
Jamsandpreserves Coarselygroundpepperand spices
NutritionManagementofDysphagia
SAMPLEMENU Breakfast OrangeJuice CreamofWheat PureedScrambledEgg BiscuitwithSlurry Margarine Jelly Milk Coffee Sugar,Creamer Noon ClassicPuree Chicken MashedPotatoeswithGravy ClassicPureeCarrots ClassicPureeRosyPears Margarine Pudding Tea Sugar Evening ClassicPureeBeef ClassicPureePasta ClassicPureeGreenBeans TomatoJuice Margarine ClassicPureePeaches Milk
Beveragesthickenedtoappropriateviscosity,perdietorder
B-10
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NDDLevel2:DysphagiaMechanicallyAltered
FOODGROUP BeveragesandMilk FOODSALLOWED Beverages withminimalamounts oftextureorpulp(anytexture shouldbesuspendedinthe liquidandshouldnot precipitateout) CerealsandGrains Softpancakes,wellmoistened Cerealsmayhavecupmilkor withsyrup justenoughmilktomoistenifthin Cookedcerealwithlittletexture, liquidsarerestricted.Themoisture includingoatmeal;slightly shouldbewellblended. moistenedcoldcerealswith littlestructure,suchascorn flakes,RiceKrispies,Wheaties Unprocessedwheatbranstirred intocerealsforbulk Pregelledorslurriedbreadsthat aregelledthroughtheentire thickness Wellcookedpastainsauce Vegetables,Potatoes,andSoups Softcookedormashedvegetables, includingcookedvegetables Vegetablesshouldbe<inchand withouthullorstringyfibers easilymashedwithafork. Wellcooked,moistened,boiled, baked,ormashedpotatoes Wellcookedshreddedhash brownpotatoesthatarenot crisp Soupswitheasytocheworeasy toswallowmeatsorvegetables FruitsandJuices Softdrainedcannedorcooked fruitswithoutseedsorskin; freshsoft/ripebanana,jelled cranberrysauce Fruitjuiceswithsmallamountsof pulp(Ifthinliquidsare restricted,fruitjuicesshouldbe thickenedtoappropriate viscosity.)
FOODSEXCLUDED Milk,coffee,tea,sodas,nutritional supplements(maybegivenif thinliquidsareallowed)
Coarsecookedorwholegraindry cereals;cerealswithseeds, nuts,ordryfruits Allotherbreads Crackers Rice
Cookedpeasorcorn;raw vegetables Potatoskinsandchips Friedorfrenchfriedpotatoesor vegetables Broccoli,cabbage,brussels sprouts,asparagus,orother fibrous,nontender,orrubbery cookedvegetables Soupswithrice,corn,peas,or largechunksofmeatand vegetables Fruitcocktail,grapes,cherries,or apricotswithskin;fresh, canned,orcookedpineapple; freshfruitsexceptripebanana; driedfruits;frozenfruits Watermelonwithoutseeds(may begivenifthinliquidsare allowed) Dryortoughmeats(suchas bacon,sausage,hotdogs, bratwurst) Drycasserolesorcasseroleswith riceorlargechunks Cheeseslicesorcubes Hardcookedegg Peanutbutter Sandwiches Pizza
Allrightsreserved.
Meats,MeatSubstitutes,and Entrees Meatpiecesshouldnotexceed inchcubeandshouldbetender.
Moistgroundmeat;casseroles (withoutrice);meltedcheesein casseroles Proteinsalads,suchastunaoregg, withoutlargechunks,celery,or onion Cottagecheese;smoothquiche withoutlargechunks Scrambledeggs,souffls Wellcooked,slightlymashed, moistlegumessuchasbaked beans B11
NDDLevel2:DysphagiaMechanicallyAltered(Cont.) FOODSALLOWED FOODSEXCLUDED FOODGROUP Desserts Custard,pudding Icecream,sherbet,frozenyogurt, Softfruitpieswithbottomcrust otherices(maybegivenifthin only liquidsareallowed) Crispsandcobblerswithoutseeds, Drycookiesorcake coconut,ornutsandwithsoft Breadandricepudding breadingorcrumbmixture Anythingwithnuts,seeds, Soft,moistcakeswithicingor pineapple,ordriedfruit slurriedcakes Chocolateswithnutsandfruits Pregelledcookiesorsoft,moist cookiesthathavebeendunked inmilk,coffee,orotherliquid Soft,smoothchocolatebarsthat areeasilychewed Fats Butter,margarine,gravy,cream Allfatswithcoarseorchunky sauces,mayonnaise,salad additives dressings,creamcheese,sour cream,whippedtoppings Miscellaneous Jamsandpreserveswithoutseeds; Seeds,coconut,nuts jelly Stickyorhardfoods Saucesandsalsaswithsmall tenderchunks(<inch) SAMPLEMENU Breakfast Noon Evening OrangeJuice HoneyGlazedChicken,Ground BraisedBeefwithGravy,Ground CreamofWheat ButteredPotatoes SoftCookedNoodleswithGravy ScrambledEgg SoftCookedCarrots SoftCookedGreenBeans BiscuitwithSlurry Margarine PeachSlices,Drained Margarine FrostedBananaCake Margarine Jelly Milk Pudding Milk Tea IcedTea Coffee Sugar Sugar Sugar Creamer Beveragesthickenedtoappropriateviscosity,perdietorder
B-12
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NDDLevel3:DysphagiaAdvanced
FOODGROUP BeveragesandMilk CerealsandGrains Allitemsmustbewellmoistened. Moistencerealswithcupmilkor enoughmilktomoistenifthin liquidsarerestricted. FOODSALLOWED Allbeverages Cookedcereals Wellmoisteneddrycereals Pasta,noodles,rice Moistbreaddressing Wellmoistenedsoftbreads,rolls, pancakes,plainmuffins, biscuits(Usemargarine,butter, jelly,orsyruptomoisten.) Tendersoftcookedvegetables Vegetablejuices Mostsoups Shreddedlettuce Fried,mashed,orbakedpotatoes withoutskin FOODSEXCLUDED None Cerealsorbreadswithraisinsor nuts Granolatype,coarse,ordry cerealssuchasshreddedwheat orAllBran Thickcrustbreads(suchas Frenchbreadorbaguettes) Crackers
Vegetables,Potatoes,andSoups
FruitsandJuices
Meats,MeatSubstitutes,and Entrees Allmeatsmustbewellmoistened. Addextragravyorsaucesas needed.
Fats Desserts
Ripebanana,melon,peeled peaches,pears Cookedorfrozenfruit Cannedpeaches,pears,apricots Fruitjuices Softberrieswithsmallseedssuch asstrawberries Tendermeat,fish,orpoultry Softcheese Choppedorgroundmeats,poultry Softcasseroles Meat,fish,oreggsalads Eggs(preparedanyway) Smoothpeanutbutter;liverwurst Yogurtwithoutnutsorcoconut Allexceptthosetoavoid
Raworcookedvegetableswith toughskinsorseeds;friedor rawvegetables;cookedcorn Tough,crispfriedpotatoes Soupswithtoughmeatsor vegetables;clamorcorn chowder Fruitcocktail,grapes,cherries,or apricotswithskin;freshfruit exceptripebananaandthose listedasallowed;driedfruits Watermelonwithoutseeds(may begivenifthinliquidsare allowed)
Dryortoughmeats(suchas bacon,sausage,hotdogs, bratwurst) Chunkypeanutbutter
Fatswithcoarse,difficulttochew, orchunkyadditives Dessertscontainingnuts,coarse driedfruit,ortoughfruit Dessertsbakedtoahard consistency
Miscellaneous
Cake,tendercookies Custard,pudding Icecream,sherbet,frozenyogurt, otherices(maybegivenifthin liquidsareallowed) Pies:cream,custard,pumpkin,soft fruitwithbottomcrustonly Softcandy Jelly,smoothjams Allsauces B13
Candycontainingtoughfruits, coconut,ornuts;hardcandy Chewycaramelortaffytype candies
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Breakfast OrangeJuice CreamofWheat ScrambledEgg Biscuit Margarine Jelly Milk Coffee Sugar Creamer SAMPLEMENU Noon HoneyGlazedChicken,Ground ButteredPotatoes SoftCookedCarrots DinnerRoll Margarine FrostedBananaCake Milk Tea Sugar Evening BraisedBeefwithGravy,Ground NoodleswithGravy SoftCookedGreenBeans PeachSlices DinnerRoll Margarine SoftCookie IcedTea Sugar
Beveragesthickenedtoappropriateviscosity,perdietorder
B-14
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DUMPINGSYNDROMEDIET
Description The diet is modified to prevent the rapid introduction of a hyperosmolar solution into the proximal jejunum (dumping). Several nutritionstrategies maybe employed, includingalteredmacronutrientcomposition,size andtimingofmealsandavoidanceofcertainfoodconstituents.Thedietlimitsbeveragesandliquidsatmeals, limitstheintakeofsimplecarbohydrates,andishighinproteinandmoderateinfat.
Indications Thedumpingsyndromeisacomplicationthatmayresultfrom:
thereducedstoragecapacityofthestomachfollowinggastrectomy any procedure that interferes with the pyloric sphincter or compromises the reservoir function of the stomach
The dumping syndrome occurs in response to the presence of undigested food in the jejunum. When this occurs,plasmafluidsshiftintotheintestineareatoequalizeosmoticpressure,causingadropinbloodvolume. Symptoms vary among individuals and may consist of the following: abdominal bloating, nausea, cramps, diarrhea,weakness,diaphoresisandtachycardia.Inmostcases,symptomsappearwithin10to20minutesafter ameal (1).Somepostgastrectomypatientsexperiencelatepostprandialdumpingsyndromecharacterizedby hypoglycemia1to3hoursafterameal.
Contraindications Ifpatienthasmalabsorptionoffat,donotincreasefatintakewiththedumpingsyndromediet.
NutritionalAdequacy ThedietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedintheStatementonNutritional AdequacyinSectionIA.Theadequacyofthedietdependsontheextentofthesurgeryandtheindividualsfood tolerance. After gastric surgery some patients experience malabsorption, which may be specific for macro or micronutrients.Vitaminandmineralsupplementationmaybenecessary,dependingontheextentofsurgeryand whetherthedumpingsyndromesymptomspersist(1).
HowtoOrdertheDiet Order as Dumping Syndrome Diet or Postgastrectomy Diet. One or more features of the diet may be individuallyordered,eg,SugarinModerationDiet,120ccfluidto1hourbeforeoraftermeals,5to6small meals,LactoseControlledDiet,LowFiberDiet,orotherstrategieslistedunderPlanningtheDiet.
PlanningtheDiet 1. Simple carbohydrate (lactose, sucrose, and dextrose) consumption is kept to a minimum to prevent the formation of a hypertonic solution and the subsequent osmotic symptoms, as well as to prevent late hypoglycemia.(SeeSugarinModerationDietinSectionIC.)Complexcarbohydratesmaybeincluded. 2. Takingliquidswithmealsisthoughttohastengastrointestinaltransit.Consumeadequateamountsofliquid throughoutthedayinsmallamountsatatime (2).Carbonatedbeveragesandmilkarenotrecommendedin theinitialstagesofthediet. 3. Smaller, more frequent feedings (5 to 6 per day) are recommended to accommodate the reduced storage capacityofthestomachandtoprovideadequatenourishment. 4. Lactose, especially in milk or ice cream, may be poorly tolerated due to rapid transit time, so should be avoided.Cheeseandyogurtarebettertolerated.ALactoseControlledDietmaybebeneficial.(SeeLactose ControlledDietinSectionIH.) 5. Proteins and fats are increased as necessary to meet energy requirements. An increased fat intake also delaysgastricemptying. 6. Liedownandavoidingactivityforanhouraftermealsmaylessensymptoms(2). 7. Ifadequatecaloric intakecannot beprovidedduetosteatorrhea,use mediumchaintriglycerideproducts. (SeeMediumChainTriglyceridesinSectionIC.) 8. Pectinmaybeutilizedinthedietregimentoslowgastricemptyingtime(2).
References 1. Gastrointestinal Disease. In: Nutrition Care Manual. The American Dietetic Association. Updated annually. Available at: www.nutritioncaremanual.org.AccessedJanuary12,2011. 2. Escott-Stump S. Gastrectomy and/or Vagotomy. Nutrition and Diagnosis-Related Care. Baltimore, Md: Lippincott, Williams, & Wilkins; 2007.
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NUTRITIONMANAGEMENTINBARIATRICSURGERY
Discussion Severe obesity (also referred to as morbid obesity) is a chronic condition that is difficult to treat with traditionalweightlossmethods(14).Surgerytopromoteweightlossbyrestrictingfoodintakeorinterrupting the normal digestive process is recognized by the medical community as an effective medical option for severelyobesepeoplewhenotherweightmanagementapproacheshaveprovedunsuccessful (14).Bariatric surgery promotes weight loss by introducing anatomical alterations that reduce the size of the gastric reservoirorcausemalabsorption (13).Theroleofnutritionisparamountinbariatricsurgery.Patientswho undergo bariatric surgery require intensive nutrition intervention, routine nutrition evaluation, and close nutrition monitoring to produce optimal nutrition care and weight loss outcomes (1,4). Another critical element is the patients themselves who must be committed to make permanent and sustainable lifestyle changeswhileundergoingmedicalmonitoringforlife. The American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery evaluated presurgical and postsurgical management strategies for obesity treatmentandoutlinedconsensusandevidencebasedpracticeguidelines (1).Bariatricsurgeryremainsan emerging field. The longterm health implications and nutritional consequences associated with rapid and substantialweightlosscontinuetorequirestudytodeterminethebesttreatmentandmanagementoptions (1,4). IndicationsforBariatricSurgery Thefollowinggroupsofpatientsmeetthecriteriaforsurgicalinterventionforweightlossifthey(andtheir parents, in the case of pediatric or adolescent patients) are motivated and able to comply with a lifelong program(13): adultswithabodymassindex(BMI)greaterthanorequalto40kg/m2withnocomorbidconditionsor healthrisksandacceptableoperativerisk adults with a BMI of 35 kg/m2 or greater with comorbid conditions or health risks such as cardiopulmonaryproblems,type2diabetesmellitus,orphysicallimitations adults whose weight is 100 lb greater than their ideal body weight and who have made multiple unsuccessfulattemptstoloseweightwithnonsurgicalmethods children and adolescents who are above the 95th percentile of weight for age and have a severe comorbidity(1)(Thesebariatricproceduresshouldbeperformedinspecializedcenters.) The most common types of bariatric surgery are laparoscopic adjustable gastric banding and RouxenY gastric bypass (1). Although risks and benefits are associated with both approaches, laparoscopic bariatric proceduresarepreferredtoopenproceduresifsufficientsurgicalexpertiseexists(1).Thebestchoiceforany bariatricprocedureshouldbebasedontheexpertiseofthesurgeonorinstitution,patientpreferences,and patient risk stratification (1). Only the laparoscopic adjustable gastric band and RouxenY gastric bypass shouldbeofferedtochildrenandadolescents(1).Restrictiveprocedures,suchasthelaparoscopicadjustable gastric band, may be combined with modified gastric bypass procedures, such as the RouxenY gastric bypass,tofurtherlimittheabsorptionofenergyornutrients.Aninvestigationalprocedureknownasafirst stagesleevegastrectomymaybeperformedinhighriskpatientstoinduceinitialweightloss(25to45kg), withthepossibilityofthenperformingasecondstageRouxenYgastricbypassoramoreadvancedgastric bypass surgery (1). Although anatomicalchangesaremade duringbothtypes ofsurgeries, the patient who does not strictly adhere to the volume restrictions and types of food allowed can negatively affect the outcomesoftheprocedure(1).Consumingtoomuchfoodcanstretchthesurgicalpouch(pouchdilation),and eating highenergy, lownutrient quality foods can compromise the amount and rate of weight loss, thus defeatingtheprimarygoalofthesurgery.Asinothertreatmentsofobesity,successfulresultsdependmainly onlongtermmotivation,adherence,andbehaviormodificationstrategiesemployedbythepatient(13). TypesofBariatricSurgery A variety of procedures are included under the umbrella term of bariatric surgery. These operations are categorizedaseitherrestrictiveormalabsorptive (13).Thefollowingdiscussionaddressesbothcategoriesof operations and the associated nutrition implications and problems. Nutrition interventions, including progressionofmealplanning,shouldbecustomizedbasedonthetypeofprocedure(13).Adetailedoverview ofthebariatricdiet,nutritioninterventions,andmealplanningapproachesisprovidedlaterinthissection.
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NutritionManagementinBariatricSurgery
Restrictiveoperations:Restrictiveoperationslimittheamountoffoodthatthestomachcanholdbyclosing off or removing parts of the stomach. These operations also delay the emptying of the stomach (gastric pouch). Regurgitation is a common side effect of these procedures. The types of restrictive surgical proceduresinclude(1): Laparoscopic adjustable gastric banding: A band made of special material is placed around the stomachnearitsupperend,creatingasmallpouchandanarrowpassageintothelargerremainderofthe stomach. Necessary adjustments to the band are made during followup procedures (1). Laparoscopic adjustablegastricbandinghasyieldedgreatersuccessinachievingweightlossoutcomesthanvertical bandedgastroplastyoradjustablesilasticgastricbanding(4). Verticalbandedgastroplasty:Bothabandandstaplesareusedtocreateasmallstomachpouchsimilar tothepouchformedinlaparoscopicadjustablegastricbanding. Adjustable silastic gastric banding: Approved in 2001 for use in the United States, this operation is functionally similar to verticalbanded gastroplasty. This procedure makes a small pouch out of the upperstomach.Thepouchisstapledofffromtherestofthestomachexceptforasmallopening,whichis thenreinforcedwitharingmadeofSilastic,asoftandrubberybutstrongmaterial. Sleevegastrectomyorverticalsleevegastrectomy:Thisisanewerprocedureinwhichthestomach capacityisrestrictedbystaplinganddividingitverticallyandremovingmorethan85%ofthestomach. Thispartoftheprocedureisnotreversible.Thestomachthatremainsisshapedlikeaveryslimbanana andhasacapacityof1to5oz(30to150cc). Inadditiontotheseprocedures,anotherprocedureperformedlessoftenisthesilasticringgastroplasty (1). Laparoscopic adjustable gastric banding has largely replaced vertical banded gastroplasty (1). Restrictive operationsarethesurgeriesmostcommonlyprescribedbybariatricsurgeons(1). Restrictive operations do not interfere with the normal digestive process (1). Rather, these procedures restrict food intake through the creation of a small pouch at the top of the stomach where the food enters fromtheesophagus.Thepouchinitiallyholdsabout1to2ozoffood,butitexpandstoa4to8ozcapacity over a 6 to 9month period. The pouchs lower outlet has a diameter of approximately inch. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness. Although restrictive operationsleadtoweightlossinalmostallpatients,somepatientsdoregainweight(1).Sixto8weeksaftera restrictiveoperation,thepatientusuallycaneatto1cupoffoodwithoutdiscomfortornausea.Foodhasto bewellchewedandconsumedslowly.Mostpatientsareunabletoeatalargeamountoffoodatonetime,but some individuals return to eating modest amounts of food without feeling hungry. A common risk of restrictive operations is vomiting (1,4). This occurs when insufficiently chewed food particles overly stretch thesmallstomach.Documentedrisksofverticalbandedgastroplastyincludeerosionoftheband,breakdown ofthestapleline,and,inasmallnumberofcases,leakageofstomachcontentsintotheabdomen.Thisleakage requiresanemergencyoperation.Inlessthan1%ofcases,infectionordeathduetocomplicationsmayoccur (3).Becauseofthelowenergycontentandsmallvolumeoffoodconsumedfollowingarestrictiveprocedure, longtermmultivitaminandmineralsupplementationisrequiredtomeetthedietaryreferenceintakes(DRIs) formostnutrients(1). Malabsorptiveoperations:Malabsorptiveoperationsarealsoreferredtoasgastricbypassoperations.In these procedures, a surgeon makes a direct connection from the stomach to a lower segment of the small intestine,bypassingthegastricfundus,body,antrum,duodenum,andavariablelengthofproximaljejunum. Because gastric bypass operations cause both malabsorption and restricted food intake, these operations produce more weight loss than restrictive operations. Patients who have bypass operations generally lose twothirdsoftheirexcessweightwithin2years (2,3).Therisksofpouchstretching,banderosion,breakdown ofstaplelines,andleakageofstomachcontentsintotheabdomenareaboutthesameastherisksinvertical bandedgastroplasty(3).Typesofmalabsorptiveorgastricbypassoperationsinclude(1): RouxenY gastric bypass: This operation is the most common gastric bypass procedure (1). First, to restrictfood intake, a small stomach pouch iscreatedby stapling or vertical banding. Next,a Yshaped section of the small intestine is attached to the pouch to allow food to bypass the duodenum (the first segment of the small intestine) and the first portion of the jejunum (the second segment of the small intestine).Thisstepoftheprocedurecausesreducedabsorptionofenergyandcriticalnutrients(1). Biliopancreatic diversion and biliopancreatic diversion with duodenal switch: In the biliopancreaticdiversionoperation,portionsofthestomachareremoved.Thesmallpouchthatremains is connected directly to the final segment of the small intestine, thus completely bypassing both the
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duodenum and jejunum. In the biliopancreatic diversion with duodenal switch, the distal stomach, duodenum, and entire jejunum are bypassed, leaving only a 50cm distal ileum common channel for nutrientstomixwithpancreaticandbiliarysecretions.Thisprocedurehasasubstantialincreaseinthe risk of nutritional and metabolic complications (1,3). Although this procedure successfully promotes weightloss,itisnotcommonlyusedbecauseofthehighriskofnutritionaldeficiencies,especiallywith thebiliopancreaticdiversionwithduodenalswitch(1).
Becausegastricbypassoperationscausefoodtobypasstheduodenum,wheremostironandcalciumare absorbed, the risks of nutritional deficiencies are higher in these procedures (1,3,5,6). Iron deficiency is common secondary to the lack of contact of food iron with gastric acid and the consequently reduced conversionofironfromtherelativelyinsolubleferrousformtothemoreabsorbableferricform (1).Vitamin B12deficiencymayresultfromthelackofcontactbetweenfoodandthegastricintrinsicfactors,decreasesin acidandpepsindigestionofproteinboundcobalaminsfromfoods,andtheincompletereleaseofvitaminB12 fromRbinders(1).VitaminDandcalciumabsorptionmayalsobereducedsincetheduodenumandproximal jejunum,whicharethepreferentialsitesofabsorption,arebypassedbythisprocedure(1).Anemiamayresult from malabsorption of vitamin B12 and iron in menstruating women, and decreased absorption of calcium may lead to the development of osteoporosis and metabolic bone disease (1,3,5,6). Shikora (7) studied the nutritional consequences of gastric bypass surgery and found deficiencies in vitamin B12 (26% to 70% of patients),folate(33%ofpatients),vitaminA(10%ofpatients),potassium(56%ofpatients),andmagnesium (34% of patients). Patients are required to take nutritional supplements that usually prevent these deficiencies.Lifelongsupplementsofmultivitamins,vitaminB12,iron,andcalciumaremandatoryfollowing thisprocedure(1,5).
Gastric bypass operations often cause dumping syndrome (1). Dumping syndrome occurs when stomach contents move too rapidly through to the remaining small intestine (1). Symptoms include tachycardia, weakness, sweating, and abdominal pain that usually occur immediately after eating. Diarrhea may also occur, especially if the patient eats concentrated sweets. Patients with dumping syndrome will need to lie down until the symptomspass. Refer to the Dumping Syndrome Diet in Section IB forappropriate medical nutritiontherapyinterventionandtreatment.
Rationale TheBariatricDietmealplanisforseverelyobesepatientsspecificallybeingtreatedforweightmanagement. Theprimaryoutcomeofthedietapproachistocomplimentthesurgicalprocedurebypromotingsubstantial weightlossthroughreductionsinfoodvolumeandenergyintake.Thisdietisnotintendedforusewithother typesofgastricsurgery,suchasgastrectomy,thatareusedastheprimarytreatmentforotherconditionsor diseases such as cancer of the gastrointestinal tract, peptic ulcer disease, or trauma. Refer to Section IB: DumpingSyndromeDietorothertransitionaldietsasneeded.
NutritionalAdequacy During the first 6 weeks after surgery, energy, protein, vitamin, and mineral needs are difficult to meet. However,thecombinationofdietandmultivitaminandmineralsupplementationcanbeplannedtomeetthe DRIsasoutlinedintheStatementonNutritionalAdequacyinSectionIA.Theadequacyofthedietwilldepend on the type and extent of surgery and on the postoperative progression of food based on the individuals tolerance.Upto3monthsaftersurgery,deficienciesinproteins,vitamins,andmineralsmayoccur(1).Dueto the small volume of food in the Bariatric Diet, vitamin and mineral supplementation is necessary to meet specificvitaminandmineralneeds(1).Twoto3daysaftersurgery,patientsshouldbeginamultivitaminand mineralsupplementregimentomeet100%oftheDRIs,includingiron,Bcomplexvitamins(B12, folate),and 1,200 to 2,000 mg of calcium (1). Additional supplementation is often required for patients who have had RouxenY gastric bypass or biliopancreatic diversion with duodenal switch (1). The vitamin and mineral regimen should be consumed daily andconsidered necessaryfor lifelong maintenanceof nutritional health (1,5).Chewableformsofsupplementsmaybebettertoleratedintheinitialstagesaftersurgery (15).Referto the discussion of vitamins and minerals in Medical Nutrition Therapy and Nutrition Intervention After BariatricSurgeryandStrategiesforVitaminandMineralSupplementationFollowingBariatricSurgery(later inthissection).
HowtoOrdertheDiet Order as Bariatric Diet. One or more features of the diet may be individually ordered based on the postoperativestage,forexample,BariatricClearLiquids,BariatricFullLiquids,BariatricPureed,orBariatric Soft. Other modificationsmay be needed to promoteindividual tolerance and weight loss, such as Lactose Controlled Diet, Sugar in Moderation Diet, LowFiber Diet, LowFat Diet, or other strategies discussed in PlanningtheDiet.
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PlanningtheDiet Limitedscientificevidenceisavailabletosupportspecificguidelinesandstrategiesfornutritionintervention followingbariatricsurgery.Theexistingguidelinesarebasedonemergingevidencefrombariatriccenters andinstitutionsthatspecificallyprovidebariatricsurgicalproceduresandlongtermobesitymanagement(1). The guidelines are based on scientific evidence and identified nutrition intervention strategies that are effectiveinmanagingpostsurgicalbariatricsurgerypatients.BariatricDietisageneraltermfortheoverall dietapproachappliedtoallpatientsfollowingabariatricsurgery.Mealplanningshouldbecustomizedbased onthetypeofprocedureandtheindividualpatientsneeds.portthisrationale.Inaddition,thecliniciancan refer to the summary by Mechanick et al for specific meal progression plans for laparoscopic adjustable gastricbanding,RouxenYgastricbypass,andbiliopancreaticdiversiongastricbypass (1).TheBariatricDiet mealplanincorporatesthefollowingnutritionalguidelines(1).
Energyrequirements:Totalenergyrequirementsarebasedonthepostoperativestage,progressionofmeal plan,andvolumeoffoodtolerated.Ensuringnutrientquality istheprimarygoalwhendesigningthemeal plan. Proteinshouldprovideatleast25%ofthetotalenergyintake(or60to120g/dayofproteinor1.5g/kg of ideal body weight) to minimize lean muscle loss during rapid weight loss (1). Modular protein supplementsmayberequiredduringthefirst6postoperativemonthsuntilsolidfoodintakeissufficient tomeettheproteinrequirements(1). Fats should provide 25% to 30% of total energy. Small amounts of dietary fat, along with prescribed medication,canhelpmaintaingallbladderemptyingandreducetheriskofgallstoneformation(5). Carbohydratesshouldprovideapproximately50%ofthedailyenergyintake.Theintakeofconcentrated sugars should be limited for gastric surgery patients. Concentrated sweets or sugary foods should be avoided after RouxenY gastric bypass to minimize the symptoms of dumping syndrome or after any bariatricproceduretoreducetheenergyintake (1).Foodsthatprovidelowqualitynutrientswithhigh amountsofenergyandfatmaycompromisetheprimarygoalofpromotingweightloss. After a diet of full liquids or semisolid food begins (usually 2 to 3 days postoperatively), initiate a chewablemultivitaminandmineralsupplementregimen(oneortwosupplementsperday)thatprovides 100% of the DRIs for age and sex. Additional specialized supplementation may be required for iron, calcium (1,200 to 2,000 mg/day), vitamin B12, folate, or other vitamins and minerals as indicated by laboratory assessment and the ability to consume food sources (1). Patients who have extensive malabsorptionwillhaveevenhighersupplementationrequirementsforvitaminD,calcium,andvitamin B12andpossiblythiamin,copper,andvitaminA(1,5). Initially, the meal plan should provide multiple small meals each day, with the focus of chewing food thoroughlywithoutdrinkingbeveragesatthesametime;beveragesshouldbeconsumedmorethan30 minutesbeforeoraftersolidfoods(1,5).
Volumeandconsistency:Thevolumeandconsistencyoffoodsprovideddependonthepostoperativestage andindividualtolerance.Initially,thestomachcanholdonly1to2oz(2to4tbsp).Overtime,thestomach pouchwillstretchuntilitcanhold4to8oz(to1cup).
Fiber: Highfiber foods may not be initially tolerated. Fiber should be gradually introduced based on the patientsprogresstowardtheconsumptionofsolidfoodsandaregulardiet(usuallymorethan6to8weeks aftersurgery).Patientsshouldadheretoabalancedmealplanthatincludesmorethanfivedailyservingsof fruits and vegetables for optimal fiber consumption, colonic function, and phytochemical consumption (1). Anecdotalevidencesuggeststhatbulkyfoods,suchasbran,popcorn,rawvegetables,anddriedbeans,should beavoidedorlimitedbasedonindividualtoleranceoruntilthedietprogressesandtoleranceofthesefoodsis verified.
Fluid:Adequateconsumptionoffluidsisessentialtopreventdehydration.Aminimumof1.5Lor6cups(48 oz)shouldbeconsumedeachday(1).Whenthepatientisabletoconsumepureedorsolidfoods,fluidsshould be consumed at least 30 minutes before or after meals to prevent nausea and vomiting (1). Fluids should consistofwaterorcontrolledenergy(lowsugar,lowfat,ordiet)beverages.Caffeinecontainingbeverages andcarbonatedbeveragesmayneedtobelimitedbasedonindividualtolerance. OutcomesofBariatricSurgery Weightlossusuallyreachesamaximumbetween18and24monthsafterbariatricsurgery(1).Morethan90% ofpatientsexperiencesubstantial(21%to25%)weightloss,andbetween50%and80%ofpatientsmaintain the weight loss for more than 5 years. In contrast, the 5year efficacy of other weight loss approaches is approximately5% (2).Meanpercentexcessweightlossat5yearsrangesfrom48%to74%afterRouxenY gastric bypass, from 50% to 60% after verticalbanded gastroplasty, and 50% following laparoscopic
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adjustable gastric banding (1). Bariatric surgery improves several comorbid conditions, such as glucose intolerance,diabetesmellitus,sleepapnea,hypertension,andserumlipidabnormalities(1).A10yearfollow upstudydemonstratedthattheexcessweightlossofbariatricsurgerypatientsremainedwithin14%to25% ofthebaselineweightloss(8).Adamsetaldemonstratedthatafter7.1years,theadjustedlongtermmortality decreasedby40%inpatientsmanagedwithbariatricsurgery(9). Theimmediateoperativemortalityratesforthelaparoscopicadjustablegastricbandingprocedureandthe RouxenYgastricbypassarerelativelylow(810).MorbidityintheearlypostoperativeperiodfollowingRoux enY gastric bypass (eg, wound infections, dehiscence, leaks from staple breakdown, stomal stenosis, marginal ulcers, pulmonary problems, and deep thrombophlebitis) may be as high as 10% or more (1). However, theaggregate risk ofthe most seriouscomplicationsofgastrointestinalleakageanddeep venous thrombosisislessthan1%(1,810). MedicalNutritionTherapyApproachesinBariatricSurgery Therisksofcomplicationsandnutritionaldeficienciesincreaseastheextensivenessofthebypassoperation increases (1). Patients with extensive bypasses of the normal digestive process require not only close monitoringbutalsothelifelonguseofspecialfoodsandvitaminandmineralsupplementation (1,5).Before any type of bariatric surgery, patients should have a comprehensive multidisciplinary screening, nutrition assessment, and nutrition education to address the longterm plans for postoperative nutrition care and weight loss strategies (1). Each individual should clearly understand the proposed operation. Bariatric surgeryisaseriousundertaking.Patients,physicians,psychologists,anddietitiansshouldtogethercarefully considerthebenefitsandrisksduringthenutritionassessmentandevaluationperiod(1,2,4).
Benefits: Immediatelyaftersurgery,mostpatientsloseweightrapidly,andtheycontinuetoloseweightfor18to 24months(1).Althoughmostpatientsthenstarttoregainsomeoftheirlostweight,fewpatientsregainit all(13). Surgeryimprovesmostobesityrelatedconditions.Bloodglucoselevelsreturntonormalaftersurgeryin 65%ofobesepatientsaged45to71yearsoldwithtype2diabetesmellitus (6).TheAmericanDiabetes Associationrecognizesbariatricsurgeryasaviableoptionforpatientswithtype2diabetesmellitusand aBMIofatleast35kg/m2whohavepoorcontrolofsymptoms.Patientsalsousuallyexperiencelower bloodpressureandlowerserumcholesterollevelspostoperatively(1).
Risks: Of patients who have weightloss operations, 10% to 20% require followup operations to correct complications (2,3).Abdominalherniasarethemostcommoncomplicationsthatrequirefollowupsurgery. Lesscommoncomplicationsincludebreakdownofthestaplelineandstretchedstomachoutlets(3). Gallstonesdevelopinmorethanonethirdofobesepatientswhohavegastricsurgery(2,11,12).Gallstonesare clumpsofcholesterolandothermatterthatforminthegallbladder.Duringrapidorsubstantialweightloss, theriskofdevelopinggallstonesisincreased.Gallstonescanbepreventedbytakingsupplementalbilesalts suchasursodiolforthefirst6monthsaftersurgery (1,2). Inaddition,consumingdietaryfat(approximately 30%oftotalenergyor10goffatpermeal)canhelpmaintaingallbladderemptyinganddecreasetheriskof gallstoneformation(1,5). Nearly 30% of patients who have bariatric surgery develop nutritional deficiencies such as anemia, osteoporosis,andmetabolic bone disease (1,3,6,7). These deficienciescan be avoided if adequate vitamin andmineralintakesaremaintainedthroughlifelongsupplementation. Womenofchildbearingageshouldavoidpregnancyforatleast12monthsperioperativelyanduntiltheir weightstabilizes,becauserapidweightlossandnutritionaldeficienciescanharmadevelopingfetus (1). Womenwhobecomepregnantafterthesesurgicalproceduresneedspecificattentionfromthesurgical care team. There are several reports in the literature of pregnancy outcomes following gastric bypass withoutevidenceoffetalimpairment(1,13).
MedicalNutritionTherapyandNutritionInterventionAfterBariatricSurgery Guidelines are based on scientific evidence and emerging evidence from bariatric centers and institutions that specifically provide management and treatment for gastric bypass patients (1). The meal plan must be individualized based on the type of surgery performed, postoperative stage, and individual tolerance to volumeandconsistencyoffood.Thedietitianshouldcloselymonitorpatientsfornutritionrelatedsignsand symptomsthatmayindicatevitamin,mineral,orproteindeficiencies;mealplanningproblems;andproblems meeting weight loss goals (1,5). Nutrition diagnoses are common in patients following any gastric bypass surgeryduetothemalabsorptiveprocessusedtoachieveweightloss. B-20 ManualofClinicalNutritionManagement Copyright2011MorrisonManagementSpecialists,Inc.
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Energy requirements: An objective estimation of the required total energy is difficult due to the rapid weightlossandrapidchangesintheratiooffatfreemasstofatmass.Onestudyevaluatedchangesinthe measured resting energy expenditure after RouxenY gastric bypass for severe obesity. The measured resting energy expenditure was significantly less than the HarrisBenedictpredicted resting energy expenditure before the operation, but it increased to the predicted value by 6 weeks postoperatively and remainedsoduringthe24monthevaluationperiod(14).Themeasuredrestingenergyexpenditureofpatients whowerehypometabolicbeforesurgery(definedasameasuredrestingenergyexpenditurelessthan15% the HarrisBenedictpredicted resting energy expenditure) increased significantly despite reductions in energyintake(14).Dailyenergyintakewasapproximately2,603kcalbeforesurgeryforallsubjectsandfellto anaverageof815kcalat3months,969kcalat6months,1,095kcalat12months,1,259kcalat18months, and1,373kcalat24monthspostoperatively(14).TotalenergyrequirementsoftheBariatricDietwillnotmeet predicted ormeasured energy requirements in mostcases and will dependonthe postoperative stage and volumeoffoodsconsumedbythepatient.Thegoalofthedietisenergydeficittopromotesubstantialweight loss.Asenergyintakeincreases,therateofweightlossgenerallydecreasesorplateaus(1).
Proteinrequirements:Mostprogramsrecommendthatatleast25%ofthetotalenergyintakeshouldbe from protein to minimize lean muscle loss during rapid weight loss, build new tissue after surgery, and maintain lean muscle tissue long term (1). During energy restriction, patients should consume 60 to 120 g/day of highquality protein (1,15) or 1.5 g/kg of ideal body weight (5). Protein malnutrition is common in biliopancreatic diversion surgeries and increases to 17.8% if the pouch volume is less than 200 mL (5). Patientswithbiliopancreaticdiversionorbiliopancreaticdiversionwithduodenalswitchproceduresrequire the higher endof theprotein range with a minimumconsumption of 80g/day (1). Patients who ingest too littleprotein(<40g/day)orproteinthatismostlylowbiologicalqualityareatriskofdevelopingventricular arrhythmias (16). Consuming adequate sources of highbiological value protein at each meal and snack is suggested.Oneto2weeksaftersurgery,highproteinliquidsthatprovideatleast15gofproteinper8oz serving with less than 20 g of total carbohydrate and less than 5 g of fat are suggested (5). Foods such as regular(notreducedsugar)CarnationInstantBreakfastTM,EnsureTM,SlimFastTM,andBoostTMmaynotmeet thesecriteriaandshouldbeavoided(5).Oncesolidfoodsaretolerated(generally4to6weeksaftersurgery), foodsthatarelowinfatandhighinprotein,suchasleanredmeatorpork,chicken,orturkeywithoutthe skin,fish,eggs,andcottagecheese,aregoodproteinsources.Modularproteinsupplementsmayberequired during the first 6 postoperative months until solid food intake is sufficient to meet the requirements, especially since meat and dairy products are some of the most frequently reported food intolerances after surgery (17).Theproteindigestibilitycorrectedaminoacidscorefortheevaluationofproteinqualityshould be assessed for patients who are dependent on supplements for a large percentage of their protein intake. This score reflects the overall quality of a protein, because it represents the relative adequacy of the most limitingaminoacid (18).Thepractitionermustreviewtheaminoacidcompositionofthepatientsselected commercial proteinproducts to ensure that they include adequate amounts of all limiting amino acids (18). Patientsshouldbecarefullymonitoredandevaluatedforsymptomsofproteindeficiencyandproteinenergy malnutrition.Hairlossisanindicatorofinadequateproteinintakeandcanbeasideeffectofgastricbypass procedures (1). (Refer to the discussionof Medical Complicationsand NutritionEvaluation and Monitoring FollowingBariatricSurgeryforadditionalinformation.)
Fat:Fatshouldprovideapproximately25%to30%oftotalenergy.Fatmaybedifficulttodigestortolerate aftergastricbypasssurgery,especiallyfriedfoodsandsnackfoods.Steatorrheaisoftenacomplicationofthe biliopancreaticdiversionandbiliopancreaticdiversionwithduodenalswitchprocedures.Toomuchfatcan delay gastric emptying and cause reflux leading to heartburn. After bariatric surgery, all patients are at increasedriskforgallstoneformationduetotherapidweightloss(1).Smallamountsofdietaryfatconsumed at each meal (approximately 10 g per meal) can be helpful in maintaining gallbladder emptying and preventing gallstone formation (5,11,12). Gallstones can also be prevented with supplemental bile salts (eg, ursodiolorallyadministered300mgtwiceperday)takenforthefirst6monthsaftersurgery (1).Longterm, aprudentlowfatdietfollowingtheNationalCholesterolEducationProgramAdultTreatmentIIIguidelines shouldbeadvocatedtosustainweightlossandreduceriskfactorsforothercomorbidconditions(1).
Carbohydrate: Carbohydrates should provide approximately 45% to 50% of total energy. Carbohydrates helptopreventthelossofleantissue(15).Whilecarbohydrateintakedoesnothavetobehigh,itissuggested that energyrestricted diets contain more than 100 g/day of carbohydrate to minimize ketosis (15). Hyperuricemiacanalsoresultfromweightloss,particularlywiththeuseofalowcarbohydratediet.Ketone bodies,productsoffatoxidationintheenergyrestrictedpatient,competewithuratefortubularreabsorption inthekidney,resultinginincreaseduricacidlevelsandanincreasedriskofgout.Increasingthecarbohydrate content of the diet will reduce the risk of increasing uric acid levels (19). Sugar intake should be limited; sugars are generally not tolerated and can cause symptoms associated with the dumping syndrome (1). ManualofClinicalNutritionManagement B21 Copyright2011MorrisonManagementSpecialists,Inc.
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Inaddition,sugaryfoodsoftenprovidelowqualitynutrientsandhighamountsofenergyandfat.Foodsto avoidorlimitincludecandy,cookies,icecream,milkshakes,slushes,sodapop,sweetenedjuicesorgelatin, andmostdesserts. Fiber:Anecdotalevidencesuggeststhathighfiberfoodsaregenerallynottoleratedandshouldbeavoided untilprogressiontoregularfoodshasoccurred(usually>6to8weekspostoperatively).Bulkyfoods,suchas bran,popcorn,rawvegetables,anddriedbeans,mayneedtobeavoideduntilindividualpatienttoleranceis verified.Itisthoughtthatthenewlycreatedsurgicalpouchdoesnothavethecapacitytoholdmanyofthese foods. In addition, gastric acid is reduced and may not be asreadily available to help digest fibrous foods. However,morerecentguidelinesrecommendthatpatientsshouldbeadvisedtoadheretoabalancedmeal plan that contains more than five servings of fruits and vegetables daily for optimal fiber consumption, colonicfunction,andphytochemicalconsumption(1).
Vitaminsandminerals:BecausetheBariatricDietallowsonlyasmallamountoffoodsandlimitsthetypes and variety of foods, vitamin and mineral supplementation is necessary. Immediately after a full liquid or semisolidfooddietbegins(usually2or3daysaftersurgery),apatientshouldbeginsupplementationwitha chewablemultivitaminandmineralsupplementthatprovides100%oftheappropriateDRIsforthepatients age and sex (1). For gastric bypass procedures that cause malabsorption (eg, RouxenY, biliopancreatic diversion,andbiliopancreaticdiversionwithduodenalswitch),additionalsupplementationmayberequired for key nutrients whose absorption is impacted, predominately iron, folate, vitamin B12, and calcium (1), or other vitamins and minerals as indicated by routine laboratory assessment. The RouxenY and biliopancreaticdiversionprocedureshaveagreaterimpactonnutrientabsorptionbecauseoftheanatomical alterations and the impact on gastric acidity (1,17,20). Because these procedures can lead to metabolic bone disease,routinediagnostictestingisrecommendedsothattheappropriateinterventioncanbedelivered (1). ForpatientswhohaveRouxenYorbiliopancreaticdiversionprocedures,vitaminandmineralsupplement regimensthatcontainhigherdosesofiron,calcium,vitaminB12,andfolateareoftenindicated (17,20).Intakes of40to65mgofelementaliron(1,17)and800to1,000goffolateperdayhavebeenrecommended(17,21).An average daily doseof 350 g of sublingual vitamin B12 maintainsadequate stores (1). Although this dose is 175timestheDRI,asmallpercentageofpatientswillstillbecomevitaminB12deficientandrequiremonthly intramuscularinjections (1,17,20,21).Calciumsupplementsof1,200to2,000mg/dayplus400to800IU/dayof vitaminDshouldbeprovidedtoallpatientsfollowingbariatricsurgery (1,17).CalciumcitratewithvitaminD isthepreferredpreparationbecauseitismoresolublethancalciumcarbonateintheabsenceofgastricacid production(1,21,22).Calciumshouldbedividedintodosesofnomorethan500mgthroughouttheday(17).For patients with the biliopancreatic diversion procedure who have clinical steatorrhea, a highdose calcium supplementationregimen(2,000mg/day)andamonthlyintramuscularvitaminDinjectionisrecommended toreducetheriskofmetabolicbonedisease (17).Patientswhohavethebiliopancreaticdiversionprocedure mustalsotakesupplementsoffatsolublevitaminsA,D,E,andK,ifclinicallyindicated (5).(RefertoTableB 1:RoutineNutrientSupplementationAfterBariatricSurgery(1).)Inaddition,thesummarybyMechanicketal outlines recommended medical testing and routine evaluation and monitoring for nutritional deficiencies that may occur specific to malabsorptive bariatric surgical procedures such as RouxenY gastric bypass, biliopancreatic diversion, or biliopancreatic diversion with duodenal switch (1). Signs and symptoms of nutritional deficiencies should be routinely evaluated and monitored postoperatively to determine if additionalvitaminormineralsupplementationisnecessary(1).
TableB1:RoutineNutrientSupplementationAfterBariatricSurgerya Supplement Dosage Multivitamin One to two daily CalciumcitratewithvitaminD 1,2002,000mg/day ofcalcium plus400800IU/dayofvitaminD Folicacid 400mcg inmultivitamin 4065mg/day ElementalironwithvitaminDb VitaminB12 >350mcg/dayorally or1,000mcg/monthintramuscularly or3,000mcgevery6monthsintramuscularly or500mcg/weekintranasally
a b
Patientswithpreoperativeorpostoperativebiochemicaldeficienciesrequireadditionalsupplementation(1). Formenstruatingwomen
Adapted from: Mechanick JI, Kushner RF, Sugerman HJ, GonzalezCampoy JM, CollazoClavell ML, Guven S, Spitz AF, Apovian CM, LivingstonEH,BrolinR,SarwerDB,AndersonWA,DixonJ.ExecutivesummaryoftherecommendationsoftheAmericanAssociationof Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract. 2008;14:331. ManualofClinicalNutritionManagement
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Studies have found a significant correlation between eating habits (quality of food consumed) and laboratoryvalues (1,15,20).InastudyofpatientswhoreceivedaRouxenYgastricbypass,themeanlevelsof serumironsaturation,vitaminB12,andfolicacidweresignificantlyhigherinpatientswhoatemeatthanin patientswhodidnoteatmeat (15).Ironstatuscontinuedtodecline6to8yearsaftersurgery,dependingon eatingbehavior (15).Oralvitaminandmineralsupplementationsignificantlyimprovedthenutritionalstatus of the study patients (15). Patients who have biliopancreatic diversion or biliopancreatic diversion with duodenalswitchproceduresshouldbeevaluatedfrequentlytoassessbenefitsorimprovementsinnutritional outcomesfollowingbariatricsurgery(1).
Fluids: Adequate consumption of fluids is essential to prevent dehydration. A minimum of 6 cups (48 oz) shouldbeconsumedperday,withagoalofconsuming64oz/day (1,5,20).Patientsshouldinitiallyconsume2 to3ozatatimeandgraduallyincreasetheirfluidintaketo3to4ozatatime8weeksaftersurgery (1,5,20). Oncepureedorsolidfoodsareintroducedintothediet,fluidsshouldbeconsumedatleast30minutesbefore mealsandshouldconsistof wateror energycontrolled (lowsugar,lowfat, or diet) beverages. The patient shoulddelaydrinkingbeverageswithfood;rather,thepatientshouldwaitatleast30minutesaftermealsto prevent increasing the transit time of food through the pouch, which may lead to nausea and vomiting (1). After 6 to 9 months, most patients can tolerate drinking fluids with meals. Intake of caffeinecontaining beveragesandcarbonatedbeveragesshouldbeindividualizedaccordingtothepatientstolerance.
Volume,consistency,andtiming:Thevolumeandconsistencyoffoodsdependonthepostoperativestage andindividualtolerance.Initiallyaftergastricbypasssurgery,thestomachcanholdonly1to2oz(2to4 tbsp). Over time, the stomach pouch will stretch until it can hold 4 to 8 oz (or about to 1 cup). The Bariatric Diet progresses in stages from clear liquids (1 to 2 days) to full liquids and pureed foods (4 to 6 weeks)andthentosoftandregularfoods(6to8weeks).Thetimingofprogressionvariesamongpatients,so itisappropriateforindividualstoadjusttheirownprogressdependingonhowtheyfeel.Fourtosixsmall mealsperdaymaybebettertoleratedlongterm;however,coordinatingthemealswithfluidintakemaybe challenging and should be individualized (5). After the pouch matures (6 months), most food consistencies canbetolerated.(RefertoTableB2:GuidetoChoosingRegularFoodsAfterBariatricSurgery.)
Foodintolerances:Patientreportshaveindicatedcommonpostoperativeintolerancestospecificfoods (23 25).Redmeat,milk,andhighfiberfoodsareamongthefoodsmostcommonlyreportedasnotwelltolerated. Onestudyfoundmeatintolerancein51%ofpatientsduringpostoperativemonths0to12;60.3%ofpatients at13to24months;59.5%ofpatientsat25to72months;and55.1%ofpatientsat73to96months(15).Soft breads are often not tolerated. However, crispy breads and crackers (eg, welltoasted breads, Melba toast, andlowfatcrackers)aregenerallybettertolerated.Milkintolerancemaybecausedbyanintolerancetofat orasecondarylactosedeficiencyrelatedtothesurgicalprocedure(1,5,2325).Fatfreemilkinsmallamountsis suggestedtoimprovetolerance.Individualmealplanningshouldbeaccommodatedtomeetnutrientspecific needsifcertainfoodsarenottolerated.
PostoperativeBariatricDietMealPlanning Thefollowingmealplanningandbehaviormodificationrecommendationsshouldbegiventothepatientafter surgery (1).Themealplanmustbeindividualizedbasedonthetypeofprocedureperformed,postoperative stage,andindividualtolerancetofoodvolumeandconsistency (1,5,). Thefollowingstagesandmealpatterns arebasedonareviewofbariatricsurgeryprogramsandpublishedpracticeguidelines(1,5,2325).
Stage1(postoperativedays1and2) Days1to2:BariatricClearLiquids Providesixtoeightsmallfeedingsofclearliquidfoods.Beginwithsipsofwater,thenaddbouillon or clear broth, unsweetened juices, diet gelatin, and flat (no fizz) diet soda. In general, avoid carbonatedbeverages. Portion:Sip2to3oz(1to2tbsp)atatime. Water:Sip2to3ozatatimethroughouttheday. Thecombinedvolumeofsixtoeightsmallfeedingsandthewaterintakeshouldbeatleast48to64 oz/day(6to8cups)tomeethydrationneeds. If the patient tolerates Bariatric Clear Liquids well, progress to Bariatric Full Liquids and then BariatricPureed/SoftDiet(seebelow).
Stage2(postoperativeday3anddischargediet) Days3to4:BariatricFullLiquids Provide six to eight small feedings per day. Begin with highprotein liquids such as diet instant breakfast(usingfatfreemilk),GlucernaTM,orspecializedhighprotein(lowfat,sugarfree,or<15g
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ofsugarperserving)drinks.Graduallyincreaseintaketo60to80g/dayofprotein (1,15).Mayalso usenonfatmilkwithwheyorsoyproteinpowder(limitto20gofproteinperserving),Lactaidmilk orsoymilkwithsoyproteinpowder,lightyogurt(blended),orplainnonfatyogurt(1). Portion:Sip2to3oz(1to2tbsp)atatime.Mayincreaseto4oz(6to8tbsp)byweek2. Water:Sip2to3ozatatimethroughouttheday. Thecombinedvolumeofthesixtoeightsmallfeedingspluswaterintakeshouldbeatleast48to64 oz/day(68cups)tomeethydrationneeds. Beginachewablemultivitaminandmineralsupplement(usuallytwodosesperday)tomeet100%of theDRIsforageandsex.AlsobeginchewableorliquidcalciumcitratewithvitaminD (1).(SeeTable B1.) Afullliquidmenuplanusuallylasts1to2weekspostoperatively.
Stage3(weeks2to6) Weeks2to5:BariatricPureed/SoftDiet Providefourtosixsmallfeedingsofpureedorsoftsemisolidfoods.Usehighqualityproteinfoods such as scrambled eggs, Egg Beaters, lowfat cheese or cottage cheese, or blenderized lean meats suchastunafish,chicken,orpork.Strainedbabyfoodsareaconvenientoption.Integrateahigh quality protein food with each meal or snack (1,5,2325). (Refer to Table B2: Foods to Choose on a Pureed/SoftDietFollowingBariatricSurgery.) Portion:2to4oz(4to8tbsp)atatimeofsolidfoods. Avoidrice,bread,andpastauntilthepatientiscomfortablyconsuming60gofproteinperdayplus fruitsandvegetables(1). Consume protein food first, vegetables and fruit second, and starch foods last to help ensure adequateproteinconsumption(5). Alternatefluidintakewithfoodintake.Avoidconsumingfluidswithmeals.Waitatleast30minutes after consumption of solid foods or meals to drink fluids (1). The combination of water with controlledenergybeveragesandmilkshouldequalatleast6cups/day(48oz/day). Avoidalcohol,asitmayleadtodehydrationanddoesnotprovidenecessarynutrients(5). Avoidchewinggum.Ifswallowed,gumcanblockthestomachopening(5). Avoiddrinkingfromstrawsbecausetheairswallowedcancausebloatingandstretchthepouch(5). Behaviortechniquesneedtobeappliedandreinforced(eg,eatingsmallamounts,eatingslowly,and chewingfoodcompletelybeforeswallowing). Atabout4to6weeks,beginagradualintroductionofsofttoregularconsistency,lowfat,controlled energyfoods.Thepatientshouldkeepafoodrecordtodocumenttolerancetofoodstodiscusswith thedietitianduringfollowupvisitsandtoassessadherencetovitaminandmineralsupplementation regimen.
Stage4(weeks6to8) Weeks6to8:BariatricDiet Providefourtosixsmallfeedingsofregularconsistencyfood.Usehighqualityproteinfoodssuchas scrambledeggs,EggBeaters,lowfatcheeseorcottagecheese,orleanmeatssuchastunafish,chicken, orpork.(RefertoTableB3:GuidetoChoosingRegularFoodsAfterBariatricSurgery(1,5).) Portion:4to6oz(8to12tbsp)atatimeofsolidfoods. Alternatefluidintakewithfoodintake.Consumefluidsatleast30minutesbeforeoraftersolidfoods. The combined volume of water, lowenergy beverages, and milk should equal at least 6 cups/day, andatleasthalfofthebeveragesshouldbeagoodsourceofprotein(1). Avoidrice,bread,andpastauntilthepatientiscomfortablyconsuming60g/dayofproteinplusfruits andvegetables(1). Consume protein food first, vegetables and fruit second, and starch foods last to help ensure adequateproteinconsumption(5). Patientsshouldavoidalcohol,asitmayleadtodehydrationanddoesnotprovidenecessarynutrients (5). Avoidchewinggum;ifgumisswallowed,itcanblockthestomachopening(5). Behavior techniques need to be applied and reinforced (eg, eating small amounts, eating slowly, chewingfoodcompletelybeforeswallowing,andeatingfromsmallplates). Avoiddrinkingfromstrawsbecausetheairswallowedcancausebloatingandstretchthepouch(5). Thepatientshouldkeepafoodrecordtodocumentfoodintakeandeatingbehavior,includingfoods toleratedornottolerated,todiscusswiththedietitianduringfollowupvisitsandtoassess adherencetothemultivitaminandmineralregimen. B-24 ManualofClinicalNutritionManagement Copyright2011MorrisonManagementSpecialists,Inc.
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TableB2: FoodstoChooseonaPureed/SoftDietFollowingBariatricSurgery(5) Food Choose Avoid Fruitdrinks,icedteawithsugar, Beverages CrystalLight,decaffeinatedcoffeeortea, alcohol,sodaandothercarbonated carbonationfreebeverages,andhigh beverageswithahighsugarcontent qualitynutritiondrinkssuchas GlucernaTMornosugaraddeddietinstant (>15gofsugarperserving)(1) breakfastpreparedwithfatfreemilk Soup Eggdropsoup,reducedfatcreamsoups, Allothers broth,bouillon,lowfatsoupswithadded proteinpowderorstrainedmeat Breads,cereals,rice, Cooked,refined/strainedcereals (withno Allothers andpasta addedsugar) Softdiet:Addpasta,rice,toastedbreads, Melbatoast,andcrackers. Chooseitemswith<2gfiberperserving. Vegetables Pureedvegetables,vegetablejuice Allothers Softdiet:Addsoftcookedvegetablesand Soft diet: vegetables with tough hulls mashedpotatoeswithoutskin. orskinssuchaspeasandcorn Fruits Unsweetenedapplesauce,pureedbanana Allothers orotherfruitwithoutseedsorhulls, unsweetenedfruitjuice Softdiet:Addsoftunsweetenedcanned fruitsorfreshsoftfruitswithoutskinor seeds. Meat,protein,and Pureedfish,tuna,poultry,veal,pork,or Crunchypeanutbutter,allothers proteinsubstitutes beef;lowfatcottagecheese;lowfator nonfatcheese;babyfoodmeats(all types);mashedorpureedtofu;pureedegg oreggsubstitute Softdiet:Addgroundleanmeat;fishor poultry;creamyorsmoothpeanutbutter; casserolesmadewithgroundmeatand softcookedvegetables;andchoppedtofu. Milkandmilkproducts Fatfreeor1%milk;sugarfreeorlowfat Chocolatemilk,sweetenedcondensed yogurtwithlivecultures(withoutfruit), milk,2%orwholemilk,icecream soymilk(withnoaddedsugar)or powderedmilk;selectlactosefreeorsoy milkiflactoseintolerant. Softdiet:Addsugarfreeorfatfreeyogurt withfruitandlowfat,sugarfreefrozen yogurtoricecream. Others SugarfreegelatinorPopsicles;lowfat Allothers frozenyogurt,pudding,orcustard

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SampleMenu: Stage2:BariatricFullLiquids(postoperativedays3and4) Time SuggestedMeal/Food 8AM tocupunsweetenedfruitjuice 99:30AM tocupfatfreemilkwithone packageofdietinstantbreakfast tocupunsweetenedfruitjuice 11AM tocupstrainedlowfatcreamsoup 12PM tocupfatfreemilkwithonepackageofdietinstantbreakfast 11:30PM to1cupwater 2PM to cup of fatfree, sugarfree yogurt (may try two or three saltine 33:30PM crackersorMelbatoast) to1cupwater 5PM tocupstrainedlowfatcreamsoup 66:30PM tocupfatfreemilkwithonepackageofdietinstantbreakfast 7PM to cup sugarfree, lowfat pudding (may try two or three saltine 8PM crackersorMelbatoast) cupdietgelatin 9PM SampleMenu: Stage3:BariatricPureed/SoftDiet(postoperativeweeks2to4) Time SuggestedMeal/Food 8AM 4to6tbspcookedrefinedcereal;add2tbspfatfreemilktothincereal. 99:30AM to1cupfatfreemilk 3tbsplowfatcottagecheese,1tbspunsweetenedapplesauce 11AM to1cupunsweetenedfruitjuice 12PM 2to3tbsppureedham,2tbspmashedpotatoes, 2tbsppureedbroccoli 11:30PM 1cupwater 2PM to1 cupoffatfreemilkwithonepackageofdietinstantbreakfast 33:30PM 4to6tbspfatfree,sugarfreeyogurt 5PM 2 to 3 tbsp pureed chicken, 2 tbsp pureed carrots, 2 tbsp mashed potato 66:30PM with1tbspfatfreegravy to1cupfatfreemilk 7PM Two slices of fatfree or lowfat cheese, 3 to 4 tbsp pureed or finely 8PM choppedcannedpears(innaturaljuice) 1cuplowfatcreamsouporlentil soup 9PM SampleMenu: Stage3:BariatricSoftDiet(postoperativeweeks4to6) Time SuggestedMeal 7:30AM cuporangejuice 8:15AM Scrambledegg,onetotwo slicesoftoast,2tsplowfatmargarine 1cupfatfreemilkwithonepackageofdietinstantbreakfast 9:30AM Onesliceofcheesemeltedover2tbspcookedpasta,onesmallsoftcooked 11AM broccoliflowerette tocupwater 11:45AM 3tbspflakedfish,2 tbspchoppedcookedspinach,onepearhalf 12:30PM 1:30PM cuporangejuice tocupfatfree,sugarfreeyogurt 2:30PM tocupwater 3PM cupsugarfree,lowfatpudding 4PM 1cupfatfreemilk 5:30PM 4tbspdicedchickenandricecasserole,2 tbspsoftcookedgreenbeans,one 6:30PM peachhalf(cannedinnaturaljuice) tocupwater 8PM 2ozoftuna,1tsplowfatorfatfreemayonnaise,foursaltinecrackers 8:30PM tocupwater 9:30PM
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SampleMenu:Stage4:BariatricDiet(postoperativeweeks6to8)a(1,5) Breakfast Lunch Dinner Bananaaquarter(medium) BroiledChickenBreast2oz Haddock,BakedorBroiled2oz ScrambledEggone Carrots,Boiledcup GreenBeanscup Toast,Whiteonehalfslice Margarine1tsp DinnerRollonehalf Margarine1tsp PastaSaladcup Margarine1tsp ChewableMultipleVitamin ChewableCalciumTablet ChewableMultipleVitamin (ifprescribed) MorningSnack AfternoonSnack EveningSnack GrahamCrackerstwosquares FruitCocktail (waterpacked) Cheese,American1oz Pudding,Sugarfree(madewith cup SaltineCrackerstwosquares fatfreemilk)cup Mustard1tsp ChewableCalciumTablet (ifprescribed)
aConsumefatfreemilkbetween mealsthroughouttheday.Drink approximatelyto3/4cupatatime,foradailytotalof2 cups. Add protein powders to beverages to increase protein content as needed. Some patients may need protein supplementation to achieve a minimum of 80 g/day, especially those patients with a pouch volume less than 200 mL after biliopancreaticdiversionorbiliopancreaticdiversionwithduodenalswitch (1).
SampleMenu:Stage4:RegularDietNutrientContentBreakdown 1056kcal Fat Energy Protein 71g Calcium Carbohydrates 97g Iron TableB3: GuidetoChoosingRegularFoodsAfterBariatricSurgery(1,5) FoodsAllowed FoodsThatMayBe FoodCategory DifficulttoTolerate Beverages Water,tea,clubsoda, Milkmaynotbetolerated dietsoftdrinks,coffee, exceptforfatfreemilkin fatfreemilk smallamounts.Uselow fatorfatfree,sugarfree yogurtandcheesesfor othersourcesofcalcium. Breads Dry,coarse,orwell Softbreadsthatbecome toastedbread;crispy gummy;breadswithnuts, crackersorbaked seeds,ordriedfruit tortillachips Cereals Allcookedanddried Cerealscontainingdried cerealswithoutadded fruitornuts sugar Potatoes,rice,pasta Boiled,mashed,or Potatoskins,sweet bakedpotatoes(white potatoes,rice,noodles orsweetpotatoes); wellcookedpastaand rice Fruits Fresh,canned,frozen, Driedfruits;fruitswith orcookedfruit;be core,seeds,orskin;whole cautiouswithapples, citrusfruits(eg, grapes,orotherfruits grapefruit,oranges);citrus withpeelorskin. fruitsshouldbejuiced. Vegetables Fresh,canned,frozen, Vegetableswithtough orcookedvegetables skinsorseeds
42g 1065mg 6mg
FoodstoLimitforBest WeightLoss Highenergydrinks:whole milk,milkshakes,alcoholic beverages,sweetenedfruit juicesanddrinks;avoid drinkswithmorethan15g ofsugarperserving. Sweetbreads,bagels,Danish pastries,anddonuts
Cerealswithaddedsugaror providingmorethan1015g ofsugarperserving None
Cannedfruitinsyrup
None
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FoodCategory Meats
FoodsAllowed Allifdicedtoinch (sizeofapencil eraser)andwell chewed Frozenyogurt;lowfat gelatin,sherbet,fruit pies;lowfat,low sugarpudding; sugarfreegelatinor Popsicles All,insmallamounts
FoodsThatMayBe FoodstoLimitforBest DifficulttoTolerate WeightLoss Tough meatsorthosewith Bacon,sausage,lunchmeats gristle;somepatientsdo nottolerateredmeat. Anydessertwithnuts, driedfruit,seeds,or coconut;candycontaining sugar,nuts,driedfruit, jams,ormarmalade Friedfoodswithahard crustycoating Soupswithlargepiecesof meat;popcorn;nuts;chili andotherhighlyspiced foods;avoidchewinggum. All,exceptfreshfruit
Desserts
Fats
All
Miscellaneous
Fried,saltysnackfoods; creamedsoupsunlessmade withnonfatmilk
StrategiesforVitaminandMineralSupplementationFollowingBariatricSurgery Vitaminandmineralsupplementationisnecessaryformaintenanceofnutritionalstoresandshouldbeapart ofthepatientslifelongdietarystrategiesfollowingbariatricsurgery.Amultiplevitaminandmineraltablet usually given twice a day (one at breakfast and one at dinner) is recommended to meet the DRIs for most patients (5).Chewableforms(orliquidforms)ofsupplementsarerecommendedforatleast2to3months, after which the patient may switch to a form that they can swallow (5). Prenatal vitamins are good for individualswhoneedextrairon (5).Allowatleast2hoursbetweenironandcalciumsupplementstoavoid interferenceandabsorption (5).Oneoptionistogivethecalciumsupplementatlunchwhile providingthe iron supplements at breakfast and dinner (5). If iron is needed, it is recommended to be consumed with vitaminCfoodsources (5).Signsandsymptomsofnutritionaldeficienciesshouldberoutinelyevaluatedand monitoredpostoperativelytodetermineifadditionalvitaminormineralsupplementationisnecessary(1).
StrategiesforBehaviorModificationFollowingBariatricSurgery Behaviormodificationisacriticalelementforshorttermandlongtermsuccessfollowingbariatricsurgery, asitdirectlyaffectsfortheBariatricDiet.Behaviormodificationhelpstoimprovetoleranceduringtheinitial postoperativestages.Thecontinuedapplicationofthebehaviormodificationtechniquesdescribedbelowwill alsoleadtoimprovedlongtermweightlossoutcomes(1,8,2325). 1. Thepatientshouldeatslowly,chewingfoodscompletelybeforeswallowing.Thesuggestedaveragetime tocompleteamealis20to30minutes(8,2325). 2. Thepatientshoulddrinklowfat,lowsugarbeveragesincludingwaterbetweenmeals.Thepatientshould avoidconsumingfluidwithmealsandwaitatleast30minutesaftermealstoresumefluidintake(1). 3. Thepatientshouldconsumeproteinfoodsfirst,vegetablesandfruitsecond,andstarchfoodslasttohelp ensurethatadequateproteinisconsumed(5). 4. Portioncontroliscritical.Foodsshouldbecut,diced,andportionedtopreventovereating.Theuseof smallservingplatesmayalsobehelpfulwithportioncontrol(1). 5. Thepatientshouldbecomeawareofsatietysensationsandsignsofpouchfullness.Afeelingofpressure or nausea after consuming a food or beverage is a sign that the pouch may be full. The patient should avoidovereatingoreatinguntilfullness.Thereisadelayinresponsefromwhenthepouchisfulland when the brain signals fullness, so sticking with planned portions is important. Patients should be assuredthathungeriscommonandnormalpostoperatively(1).Thepatientisencouragedtoeatthreeto sixservingsofproteinfoodsthroughthedaytohelpsatietysincehungeriscommon(especiallywithin1 week postoperatively)(1). Chronic overeating may cause pouch dilation, ineffective weight loss, and prematureweightgain(1,23,24). 6. Ifvomitingoccursaftereating,thepatientshouldeatmoreslowlyatthenextmeal.Thepatientshould properlychewfood,waitatleast30minutesaftereatingbeforedrinkingfluids,andavoidovereating (1). Lyingdownaftereatingmaybehelpful (2325).Prolongedorprotractedvomitingorintolerancetofood consumptionshouldbeimmediatelyreportedtothephysiciantopreventcomplicationsofmalnutrition, dehydration,andthiamindeficiency(1).
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7.
Food intolerances are common. The patient should keep detailed food records to determine how to achieveahighqualitymealplanthatintegratesavarietyofnutrientdensefoods.
MedicalComplicationsandNutritionEvaluationandMonitoringFollowingBariatricSurgery Closemedicalmonitoringiscriticalduringtheacutepostoperativestagesofweightloss(1to16weeks)to determinetheadequacyofnutritionalintakeandthephysiologicimpactofrapidandsubstantialweightloss. Vitalsigns,suchasbloodpressureandheartrate,shouldberoutinelymonitored,andthepatientselectrolyte levels, hydration status, and cardiac status should be monitored with laboratory assessments. Risks associated with rapid weight loss include the loss of potassium and body protein, which could lead to ventriculararrhythmias (16).However,lossesofbodyproteinarelessinseverelyobesepatients,whichmay provideprotectionfromarrhythmiasduringrapidweightloss(15).Duetolowenergyintakeduringtheinitial stagesoftheBariatricDiet,urinaryketonelevelsaregenerallyincreased.Urinaryketonesinterferewiththe renalclearanceofuricacid,resultinginincreasedserumuricacidlevels,whichmayleadtogout (19).Daily consumptionofmorethan100gofcarbohydratesmayhelpminimizeketosisanduricacidlevels(15).Higher serum cholesterol levels resulting from mobilization of adipose tissue may increase the risk of gallstone formation(1).
Patientswhodonotappropriatelymodifytheirbehaviorandpatientswhohaveanatomicalcomplications mayexperienceconstantpostprandialvomiting.Becauseofacompletelackofnutrition,thesepatientscan develop complications such as proteinenergy malnutrition and thiamin deficiency, which can lead to WernickeKorsakoffsyndrome (1,17,22,26).A3%to5%incidenceofhospitalizationfortreatmentofprotein energy malnutrition after biliopancreatic diversion procedures has been reported (17,26). If prolonged vomiting or projectile vomiting occurs, the patient should be clinically assessed for medical complications, suchasthiamindeficiency,andtreatedfordehydrationorthiamindeficiency,ifindicated(1).Patientsshould be evaluated for enteral or parenteral nutrition support whenever necessary to prevent complications associatedwithmalnutritionornutritionaldeficiencies(1).Enteralfeedingscanbeprovidedbyusingasmall caliber nasogastric tube placed into the distal stomach or remaining small bowel. An isotonic elemental formula given slowly with a pump over a 24hour period may promote greater tolerance (26). With any feedingregimen,theclinicianshouldbealertforrefeedingsyndrome (17,19,26)bycarefullymonitoringserum levelsofphosphorus,potassium,andmagnesium (19).Ifparenteralnutritionisindicated,theinitial24hour infusionshouldcontainonly50%oftheestimatedenergyneedsand50%oftheestimatedfluidvolume.A hypocaloricfeedingwithadequateprotein,suchas14to18kcal/kgofidealbodyweightand1.5to2.0gof protein per kg of ideal body weight, is often recommended in the literature (10,19). (Refer to Specialized NutritionSupportinSectionBforadditionalinformationonrefeedingsyndrome.)Patientswhoexperience prolonged vomiting may develop acute neurological deficits 1 to 3 months after restrictive gastric surgery (1,26). Symptoms of these neurological deficits include double vision, ataxia, nystagmus, bilateral facial weakness, acute polyneuropathy with paralysis, reduced deep tendon reflex, and mental confusion. WernickeKorsakoff syndrome related to thiamin deficiency has also been observed in this population. Patientswhomanifestneurologicalsymptomsshouldbetreatedwith100mgofthiaminthatisintravenously orintramuscularlyadministeredfor7to14days,followedbyoraladministrationof100mg/dayofthiamin untilthepatientfullyrecoversorneurologicsymptomsresolve(1).
Skeletal and mineral homeostasis, including nephrolithiasis, is common after RouxenY gastric bypass, biliopancreaticdiversion,andbiliopancreaticdiversionwithduodenalswitch(1).Laboratoryteststoevaluate calciumandvitaminDmetabolismandmetabolicbonediseasearerecommendedforallpatientswhohave theseprocedures.Treatmentwithorallyadministeredcalcium,ergocalciferol(vitaminD2),orcholecalciferol (vitamin D3) is indicated in these patients to prevent or minimize secondary hyperparathyroidism without inducing hypercalcuria (1). The bone density of these patients should be evaluated to assess for the development of osteoporosis (1). Orally administered bisphosphonates for bariatric surgery patients with osteoporosisinclude:alendronate(70mg/week),risedronate(35mg/weekortwotabletsof75mg/month), and ibandronate (150 mg/month) (1). Oral phosphate supplementation may be provided for mild to moderate hypophosphatemia (1.5 to 2.5 mg/dL), which is usually due to vitamin D deficiency (1). The managementofoxalosisandcalciumoxalatestonesincludesavoidanceofdehydrationandadoptionofalow oxalate meal plan and oral calcium and potassium citrate therapy (1). Probiotics that contain Oxalobacter formigenesimproverenaloxalateexcretionandareatreatmentoption(1).
References 1. Mechanick JI, Kushner RF, Sugerman HJ, GonzalezCampoy JM, CollazoClavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, BrolinR,SarwerDB,AndersonWA,DixonJ.ExecutivesummaryoftherecommendationsoftheAmericanAssociationofClinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract. 2008;14:318336. ManualofClinicalNutritionManagement
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NutritionManagementinBariatricSurgery NationalHeart,Lung,andBloodInstituteObesityEducationInitiativeExpertPanel.ClinicalGuidelinesontheIdentification, Evaluation,andTreatmentofOverweightandObesityinAdults:TheEvidenceReport.Bethesda,Md:NationalInstitutesofHealth; 1998.NIHPublicationNo.984083.Availableat:http://nhlbi.nih.gov/nhlbi/htm.AccessedFebruary19,2009. 3. GastrointestinalSurgeryforSevereObesity.ConsensusStatement.NIHConsensusDevelopmentConference,March2527,1991. Bethesda,Md:USPublicHealthService,NationalInstitutesofHealth,OfficeofMedicalApplicationsofResearch. 4. PositionoftheAmericanDieteticAssociation:weightmanagement.JAmDietAssoc.2009;109:330346. 5. Bariatricsurgery.In:NutritionCareManual.AmericanDieteticAssociation;2004.Availableat:www.nutritioncaremanual.org. AccessedJanuary15,2009. 6. FujiokaK.Followupofnutritionalandmetabolicproblemsafterbariatricsurgery.DiabetesCare.2005;28:481484. 7. ShikoraA.Thenutritionalconsequencesofgastricrestrictivesurgery.Presentedat:ASPEN22ndClinicalCongress;January20, 1998;LakeBuenaVista,Fla. 8. SjostromL,NarboK,SjostromCD,KarasonK,LarssonB,WedelH,LystigT,SullivanM,BouchardC,CarlssonB,BengtssonC, DahlgrenS,GummessonA,JacobsonP,KarlssonJ,LindrossAK,LonrothH,NaslundI,OlbersT,StenolfK,TorgersonJ,AgrenG. EffectsofbariatricsurgeryonmortalityinSwedishobesesubjects.NEngJMed.2007;357:741752. 9. AdamsTD,GressRD,SmithSC,HalversonRC,SimperSC,RosamondWD,LaMonteMJ,StroupAM,HuntSC.Longtermmortality aftergastricbypasssurgery.NEngJMed.2007;357:753761. 10. ShahMV.Nutritionsupportinthecomplicatedbariatricpatient.SupportLine.2007;29(6):711. 11. WeinsierRL,UllmannDO.Gallstoneformationandweightloss.ObesRes.1993;1:5156. 12. GebhardRL,PriggeWF,AnselHJ,SchlasnerL,KetoverSR,SandeD,HoltmeierK,PetersonFJ.Theroleofgallbladderemptyingin gallstoneformationduringdietinducedrapidweightloss.Hepatology.1996;24:544548. 13. WittgroveAC,JesterL,WittgroveP,ClarkGW.Pregnancyfollowinggastricbypassformorbidobesity.ObesSurg.1998;8:461464. 14. FlancbaumL,ChobanPS,BradleyLR,BurgeJC.ChangesinmeasuredrestingenergyexpenditureafterRouxenYgastricbypassfor clinicallysevereobesity.Surgery.1997;122:943949. 15. NonasCA.Amodelforchroniccareofobesitythroughdietarytreatment.JAmDietAssoc.1998;98(suppl2):16S22S. 16. VanItallieTB,YangMU.Currentconceptsinnutrition:dietsandweightloss.NEngJMed.1977;297:11581161. 17. KushnerR.Managingtheobesepatientafterbariatricsurgery:acasereportofseveremalnutritionandreviewoftheliterature.J ParenterEnteralNutr.2000;24:126132. 18. AillsLA,BlankenshipJ,BuffingtonC.Bariatricnutrition:suggestionsforthesurgicalweightlosspatient.SurgObesRelatDis. 2008;4:S73S108. 19. PiSunyerFX.Shorttermmedicalbenefitsandadverseeffectsofweightloss.AnnInternMed.1993;119:722726. 20. ElliotK.Nutritionalconsiderationsafterbariatricsurgery.CritCareNursQ.2003;26:133138. 21. RhodeBM,ArseneauP,CooperBA,KatzM,GilfixBM,MacLeanLD.VitaminB12deficiencyaftergastricsurgeryforobesity.AmJClin Nutr.1996;63:103109. 22. O'DonnellK.Smallbutmighty:selectedmicronutrientissuesingastricbypasspatients.PractGastroenterol.2008;XXXII(5):3748. 23. NutritionalGuidelinesFollowingAdjustableGastricBanding(AGB)andLaparoscopicorRouxenYGastricBypass.JohnsHopkins CenterforBariatricSurgeryBayviewMedicalCenter.Availableat:www.hopkinsbayview.org/bariatrics/docs/nutrition_band.pdf. AccessedJanuary20,2009. 24. PilcherJandSurgicalConsultantsofSanAntonio,Tex.NewDimensionsWeightLossCenter.GastricBypassDiet.Availableat: http://www.sabariatric.com/_life_and_/diet_plan.htm.AccessedJanuary22,2009. 25. SchirmerB.UniversityofVirginiaGastricBypassProgramGuidelines.Charlottesville,Va:UniversityofVirginiaHealthSystem;2002. 26. MasonEE.Starvationinjuryaftergastricreductionforobesity.WorldJSug.1998;22:10021007. Bibliography AillsL,BlankenshipJ,BuffingtonC,FurtadoM,ParrottJ,AlliedHealthSciencesSectionAdHocNutritionCommittee.Suggestionsforthe surgicalweightlosspatient[correctedproof,21May2008].SurgObesRelatDis.Availableat:www.soard.org.AccessedJuly30,2008. BrolinRE.Bariatricsurgeryandlongtermcontrolofmorbidobesity.JAMA.2002;288:27932796. 2.
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SPECIALIZEDNUTRITIONSUPPORTTHERAPY
Specialized nutrition support therapy is the provision of nutrients orally, enterally, or parenterally with therapeutic intent (1). The preferred route for patients who cannot meet their nutritional needs thorough voluntaryoralintakeisenteralnutrition,thenonvolitionaldeliveryofnutrientsbytubeintothegastrointestinal tract through a feeding tube, catheter, or stoma (14). Parenteral nutrition is the administration of nutrients intravenously(1).Themodalityofnutritiontherapyselectedshouldpermitthedeliveryofrequirednutrientsby thesafest,mostcosteffectiverouteforthepatient.
Thegoalsofnutritionsupporttherapyinbothwellnourishedandmalnourishedcriticallyillpatientsareto preventthedepletionofleanbodymass,promoteacutephaseandwholebodyproteinsynthesis,andprevent physiologicdeterioration(2).Traditionally,nutritionsupportincriticallyillpatientswasregardedasadjunctive caredesignedtoprovideenergytosupportthepatientduringthestressresponse(4).Recently,thesegoalshave becomemorefocusedonnutritiontherapy,specificallyattemptingtoattenuatethemetabolicresponsetostress, preventoxidativecellularinjury,andfavorablymodulatetheimmuneresponse(4).
The following section is a brief outline of nutritional management with these two modalities of nutrition support therapy. More detailed information related to specialized nutrition support therapy for critically ill patientscanbefoundinthecitedliteratureandevidencebasedguidelines(24). Indications(14) Evidencebased guidelines for managing critical ill patients support early nutrition intervention. Enteral nutrition is recommended over parenteral nutrition in critically ill patients who are hemodynamically stable andhaveafunctioninggastrointestinaltract.Enteralnutritionalongwithadequatefluidresuscitationshouldbe initiated 24 to 48 hours after injury or admission to the intensive care unit (Grade I)* (24). In the critically ill patient, early enteral nutrition is associated with a reduction in infectious complications (Grade I) (2) and may reducethelengthofhospitalization (2).Patientswhoreceiveenteralnutritionexperiencelowerratesofseptic morbidityandfewerinfectiouscomplicationsthanpatientswhoreceiveparenteralnutrition (Grade I) (25).Ina largesampleofpatientswithtraumaticbraininjury,earlynutritioninterventionwasassociatedwithimproved medical outcomes and reduced mortality (6). It is advised that patients with traumatic brain injury should receive some form of nutrition support within 24 to 48 hours after injury to support their increased energy needs (5).Insurgicalpatientsandcriticallyillpatients,enteralfeedingsshouldbeprovidedwithoutwaitingfor theresumptionofflatusorbowelmovements(5). AccordingtoguidelinesfromtheAmericanSocietyforParenteralandEnteralNutritionandtheSocietyof CriticalCareMedicine,ifenteralnutritionisnotfeasibleoravailableforthefirst7daysfollowingtheintensive care unit admission of a critically ill patient who was previously healthy with no evidence of proteincalorie malnutrition,nonutritionsupporttherapyshouldbeprovided (4).RefertoSectionIIforguidelinestoidentify patients who are malnourished or may become malnourished. The use of parenteral nutrition should be reservedandinitiatedonlyafterthefirst7daysofhospitalization (4).However,ifthereisevidenceofprotein calorie malnutrition on admission and enteral nutrition is not feasible, it is appropriate to initiate parenteral nutrition as soon as possible following adequate resuscitation (4). If a patient is expected to undergo major upper gastrointestinal surgery and enteral nutrition is not feasible, parenteral nutrition should be provided underthespecificconditionsdescribedbelow(4): If the patient is malnourished, parenteral nutrition should be initiated 5 to 7 days preoperatively and be continuedintothepostoperativeperiod(4). Shouldenteralnutritionnotbefeasibleaftersurgery,theinitiationofparenteralnutritionshouldbedelayed for5to7days(4). Parenteralnutritionshouldbeinitiatedonlyifthedurationoftherapyisanticipatedtobeatleast7days. Parenteralnutritiontherapyprovidedforadurationoflessthan5to7dayswouldbeexpectedtohaveno beneficialeffectandmayresultinanincreasedrisktothepatient(4). Contraindications Specialized nutrition therapy is usually not indicated for: malnourished patients who are eating adequate amountstomeettheirestimatednutrientrequirements;wellnourishedpatientswhoareanticipatedtoresume adequateoralintakewithin7days;andpatientswhoseprognosisdoesnotwarrantaggressivenutritionalcare
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(1,4,5,7).Thedecisiontoprovidenutritiontherapyshouldbebasedoneffectivecommunicationwiththepatient andfamily,realisticgoals,andrespectforpatientautonomy(4).
References 1. ASPENBoardofDirectorsandStandardsCommittee.AmericanSocietyforParenteralandEnteralNutrition.Definitionofterms, style,andconventionsusedinA.S.P.E.N.guidelinesandstandards.NutrClinPract.2005;20:281285. 2. CriticalIllnessEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociationEvidenceAnalysisLibrary.American DieteticAssociation;2006.Availableat:www.adaevidencelibrary.com.AccessedSeptember29,2010. 3. BankheadR,BoullataJ,BrantleyS,CorkinsM,GuenterP,KrenitskyJ,LymanB,MethenyNA,MuellerC,RobbinsS,WesselJ;ASPEN BoardofDirectors.Enteralnutritionpracticerecommendations.JParenterEnteralNutr.2009;33:122167.Alsoavailableat: www.eatright.org(EvidenceBasedPracticelink).AccessedSeptember20,2010. 4. McClaveSA,MartindaleRG,VanekVW,McCarthyM,RobertsP,TaylorB,OchoaJB,NapolitanoL,CresciG;ASPENBoardof Directors;AmericanCollegeofCriticalCareMedicine.Guidelinesfortheprovisionandassessmentofnutritionsupporttherapyin theadultcriticallyillpatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition (A.S.P.E.N.).JParenterEnteralNutr.2009;33:277316. 5. BraunschweigCL,LevyP,SheeanPM,WangX.Enteralcomparedwithparenteralnutrition:ametaanalysis.AmJClinNutr. 2001;74:534542. 6. HartlR,GerberLM,NiQ,GhajarJ.Effectofearlynutritionondeathsduetoseveretraumaticbraininjury.JNeurosurg. 2008;109:5056. 7. PositionoftheAmericanDieteticAssociation:ethicalandlegalissuesinnutrition,hydration,andfeeding.JAmDietAssoc. 2008;108:873882.
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ENTERALNUTRITIONSUPPORTTHERAPYFORADULTS
Definition Enteralnutritionsupporttherapyistheprovisionofnutrientstothegastrointestinaltractviaafeedingtube, catheter, or stoma to maintain or replete the patients nutritional reserves (1). Enteral nutrition is the preferredroutefortheprovisionofnutritionforpatientswhocannotmeettheirneedsthroughvoluntaryoral intake(1).Thissectionpertainstonutritionsupportviaenteraltubefeeding. NutritionAssessment Indications(15) Enteral nutrition support via tube feeding should be considered as a proactive therapeutic strategy for patientswhoareunabletoingestadequateamountsofnutrientsorallyandhaveanadequatelyfunctioning gastrointestinaltract.Theadvantagesofenteralnutritionoverparenteralnutritioninclude: amuchlowercost(GradeII)*(3)andshorterlengthofhospitalstay(58) the avoidance of complications associated with parenteral feedings (eg, infectious complications (Grade I) (3), pneumothorax,catheterembolism,andcholecystitis) (3,4,9,10) thesupportofthemetabolicresponsetostress andafavorablemodulationoftheimmuneresponseincriticallyillpatients(5) themaintenanceofgastrointestinalmucosalintegrityandpreventionofbacterialtranslocation(4,10) Nutritionalmanagementofthestressresponseinvolvesearlyenteralnutrition,appropriatemacronutrientand micronutrientdelivery,andglycemiccontrol(5).Earlyenteralnutritioniswelltoleratedbyintensivecareunit (ICU)patients (3).Evidencebasedguidelinesforcriticallyillpatientsrecommendinitiatingenteralnutrition 24to48hoursafterinjuryoradmissiontotheICUifthepatientishemodynamicallystable,hasafunctioning gastrointestinaltract,andisadequatelyfluidresuscitated (Grade I) (3).Earlyenteraltubefeedingmayprevent bacterialtranslocation,whichisthepassageofbacteriaacrosstheintestinalwallduetoatrophyofintestinal villi (10). Maintaining gastrointestinal integrity by enteral feedings is theorized to prevent translocation, whichleadstofewerinfectiouscomplications(5,1012). Guidelines from the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM) state that traditional nutrition assessment tools (albumin, prealbumin, and anthropometry)arenotvalidatedincriticalcarepatients (5).Beforetheinitiationoffeedings,assessments shouldincludetheevaluationofweightlossandpreviousnutrientintakepriortoadmission,levelofdisease severity,comorbidconditions,andfunctionofthegastrointestinaltract. Contraindications(1,35) Enteral nutrition support should be avoided in patients who do not have an adequately functioning gastrointestinaltract.Specificcontraindicationsinclude: intractablevomiting severediarrhea highoutputenterocutaneousfistula(greaterthan500mL/day) conditionswarrantingtotalbowelrest,suchassevereacutepancreatitis(unlessjejunalenteralfeeding canbeprovidedbeyondtheligamentofTreitz)(1,3) severeinflammatoryboweldisease uppergastrointestinalhemorrhage(causedbyesophagealvarices,portalhypertension,orcirrhosis)(4) shortbowelsyndrome(lessthan100cmofsmallbowelremaining) intestinalobstruction(dependingonlocation) aprognosisthatdoesnotwarrantaggressivenutritionsupport Theinitiationofenteralfeedingsisnotcontraindicatedbyalackofbowelsounds,flatus,orstoolpassage (4,5,10,11,13).Paralyticileusisthetemporarylossofcontractilemovementsoftheintestinalwallthatresultsin an absence of bowel sounds or flatus. Ileus was once considered a contraindication to enteral feedings; however, it is now known that ileus has different effects on different areas of the intestine. For example, postoperative ileus appears to affect colonic and stomach function to a greater extent than small bowel function (5,13). The period of time that a patients oral intake is prohibited due to diagnostic tests or procedures should be minimized. A delay in the resumption of feeding or oral intake may exacerbate the ManualofClinicalNutritionManagement B33 Copyright2011MorrisonManagementSpecialists,Inc.
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potentialforileus (5).Theclinicalconditionofthepatientisanimportantconsiderationinthedecisionto initiate enteral nutrition. A soft, nontender abdomen, adequate perfusion, and hemodynamic stability are indicators of the potential for the safe administration of enteral nutrition (3,4). For most patients, lower gastrointestinalbleedingdoesnotaffecttheadministrationofenteralsupport(4,14). NutritionIntervention Enteral feedings can be nutritionally adequate if an appropriate formula is selected with consideration of each patients individual estimated requirements. Energy requirements may be calculated by predictive equationsormeasuredbyindirectcalorimetry (5).Predictiveequationsshouldbeusedwithcaution,asthey providealessaccuratemeasureofenergyrequirementsthanindirectcalorimetry (5).Intheobesepatient, thepredictiveequationsareevenlessaccurate (5).(RefertoSectionII:EstimationofEnergyRequirements.) Tubefeedingsmaybeusedasthesolesourceofnutrientsorasasupplementtoinadequateoralnutrition. Enteralnutritionshouldbeinitiatedwithin48hoursofinjuryoradmissiontotheICU,andtheaverageintake deliveredwithinthefirstweekshouldbeatleast60%to70%ofthetotaltheestimatedenergyrequirements, asdeterminedbythenutritionassessment (Grade II) (3).Provisionofenteralnutritionwithinthistimeframe andatthisintakelevelisassociatedwithashorterhospitalstay,fewerdaysonmechanicalventilation,and fewer infectious complications (Grade II) (3). Guidelines for critically ill patients from ASPEN and the SCCM includesimilarrecommendations (5).Theseguidelinesrecommendtheprovisionofmorethan50%to65%of theestimatedenergyrequirementsduringthefirstweekofhospitalizationtoachievetheclinicalbenefitsof enteralnutrition(5). The delivery of 14 to 18 kcal/kg per day, or 60% to 70% of the enteral feeding goal, is associated with improvedoutcomes(GradeII)(3).InitialevidencesuggeststhatICUpatientsandobesesurgicalpatientswhoare providedgreaterthan70%oftheirenteralfeedinggoalmayhaveoutcomesthataremoredetrimentalwhen compared to patients who received 60% to 70% of their enteral feeding goal (Grade III) (3). Guidelines from ASPENandtheSCCMrecommendpermissiveunderfeedingorhypocaloricfeedingwithenteralnutritioninthe criticallyillobesepatient (5).Forpatientswithabodymassindex(BMI)greaterthan30kg/m2,thegoalofthe enteral nutrition regimen should not exceed 60% to 70% of target energy requirements or 11 to 14 kcal/kg actualbodyweightperday(or22to25kcal/kgidealbodyweightperday)(5). Inadditiontothedeliveryofenergy,theadequacyofproteinprovisionshouldbeassessedonanongoingbasis (5).Theuseofadditionalmodularproteinsupplementsisacommonpractice,asstandardenteralformulations tendtohaveahighratioofnonproteinenergytonitrogen (5).Theproteinrequirementsofcriticallyillpatients withaBMIlessthan30kg/m2are1.2to2.0g/kgactualbodyweightperday;theserequirementsmaybehigher in burn patients or multipletrauma patients (5). Critically ill patients who are obese have higher protein requirementstomaintainanadequatenitrogenbalanceandaccommodatetheneedsforwoundhealing.The proteinrequirementforclassIandIIpatients(BMI,30to40kg/m2)isgreaterthan2.0g/kgidealbodyweight perday,andtheproteinrequirementforclassIIIpatients(BMI>40kg/m2)isgreaterthan2.5g/kgidealbody weightperday(5). Antioxidantvitamins (including vitamin Eand ascorbic acid) andtraceminerals (including selenium, zinc, and copper) may improve patient outcome, especially in burns, trauma, and critical illness requiring mechanicalventilation (5).Acombinationofantioxidantvitaminsandtraceminerals(specificallyselenium) shouldbeprovidedtoallcriticallyillpatientsreceivingspecializednutritiontherapy(5). HowtoOrdertheDiet The physician in collaboration with the dietitian determines the appropriate prescription for the enteral nutrition regimen, including the route and type of formula. A dietitian should facilitate the selection of the formula type and goal rate for tube feeding. Once the goal rate is reached, a nutrient intake study may be beneficialtoverifythatthetotalnutrientintake(oralplusenteral)isadequate.
Theorderspecifies: product,eitherbynameorasStandardTubeFeeding,accordingtohospitalprotocol volume,rate,andtiming,includingtheinitialvolumeandrate,aswellastheprogressionandgoalvolumeand rate(Atastandarddilutionof1.0kcal/mL,thevolumewillberoughlyequaltothenumberofkilocalories specified.) administration and monitoring, following either the facilitys standard procedures or individualized orders,includingtheadministrationofextrawatertoflushthetubeormeetfluidrequirements
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SeeSectionIII:ClinicalNutritionManagement
ENTERALNUTRITION:MANAGEMENTOFCOMPLICATIONS
RoutesofAccessforEnteralTubeFeeding(4) The type and route of feeding tube should depend on the patients needs and the route that optimizes nutrientdelivery(stomachorsmallbowel)fordiseasemanagement.Thesmallesttubepossibleshouldbe usedforpatientcomfort (4),andcorrectplacementofthefeedingtubeshouldbeconfirmedbyXraypriorto use (4).Whentheanticipatedneedforenteralnutritionexceeds4weeks,amorepermanententeralaccess deviceisindicated(4).
Thereareseveraltypesoffeedingtubeplacements: Orogastric:Thefeedingtubeisinsertedthroughthemouth,withthetiprestinginthestomach. Nasogastric:Thefeedingtubeisinsertedthroughthenose,withthetiprestinginthestomach. Nasoduodenal:Thefeedingtubeisinsertedthroughthenose,withthetiprestingintheduodenum. Nasojejunal:Thefeedingtubeisinsertedthroughthenose,withthetiprestinginthejejunum. Esophagostomy:Thefeedingtubeisinsertedthroughasurgicalopeningintheneckandpassedthrough theesophagus,withthetiprestinginthestomach. Gastrostomy: The feeding tube is inserted through the abdominal wall into the stomach via percutaneousendoscopicguidanceorsurgicalplacement(surgicalopengastrostomy). Jejunostomy:Thefeedingtubeisinsertedthroughtheabdominalwallintothejejunumviapercutaneous endoscopicguidanceorsurgicalplacement(surgicalopenjejunostomy). EnteralFormula:CategoriesandSelection Choosing the most appropriate tubefeeding formula is critical for achieving nutritional goals. Formulas shouldbeselectedbasedondigestibility/availabilityofnutrients,nutritionaladequacy,viscosity,osmolality, ease of use, and cost (4). In addition, the nutritional status of the patient, including electrolyte balance, digestiveandabsorptivecapacity,diseasestate,renalfunction,medicalordrugtherapy,andpossibleroutes ofenteralinfusionshouldbeconsidered (4).EnteralformulationsareconsideredmedicalfoodsbytheFood andDrugAdministration(FDA);therefore,theirlabelscanmakestructureandfunctionclaimswithoutthe approvaloftheFDA(4).Limitedevidenceisavailableregardingtheefficacyandoutcomesassociatedwiththe useofspecializedenteralformulations(4).
Enteral formulas can be classified as standard (or polymeric), elemental, or semielemental. Standard formulasincludesyntheticformulasandblenderizedformulas.Specializedenteralformulasincludedisease specific formulas and nutrientmodified formulas. Additionally, individual modular components that can supplementtheformulaareavailable (15).Mostenteralformulationsprovideadequateamountsofvitamins andmineralstomeettheReferenceDailyIntakeswhenprovidedinvolumesof1,000mLto1,500mLdaily (16).Enteralformulascontainalargeamountofwater;theirwatercontentgenerallyrangesfrom70%to85% (15).Itisimportanttobeawareofpatientswithpotentialfoodallergieswhenprescribinganenteralformula. Enteral formulations may contain milk, soy, corn, or egg products, all of which are common allergens (15). Mostenteralformulationsarelactosefreeandglutenfree(15).
Standard or polymeric formulas: Standard or polymeric formulas must be digested into dipeptides and tripeptides, free amino acids, and simple sugars in the small bowel. Polymeric formulas require adequate digestiveandabsorptivecapabilityandareindicatedinpatientswithnormalornearnormalgastrointestinal function. There are two basic types of polymeric formulas, synthetic formulas and blenderized formulas. Syntheticformulasarethemostcommonlyusedformulasduetotheirsafetyandfeasibilityinaninstitutional setting(4). Synthetic formulas are used for standard tube feedings. Their energy content ranges from 1.0 to 2.0 kcal/mL.Theproteincontentprovides12%to20%oftotalenergyandconsistsofintactprotein,generally casein or soy protein isolate (15). Lactalbumin, whey, and egg albumin are also sources of intact proteins. Formulas that contain intact proteins require normal levels of pancreatic enzymes for digestion and absorption (15). Carbohydrate sources include corn syrup solids, hydrolyzed cornstarch, maltodextrin, sucrose,fructose,andsugaralcohols.Carbohydratesprovide40%to90%oftotalenergy(15).Thefatcontent rangesfromlessthan10%tomorethan50%oftotalenergy.Commonfatsourcesarecornoilandsoybean oil;however,safflower,canola,andfishoilsarealsousedinenteralformulas(15).Theosmolalityofsynthetic formulas ranges from 270 to 700 mOsm/kg. Because a high incidence of lactase deficiency in illness is presumed,lactoseisnotpresentinmostsyntheticenteralformulas(15).
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Elementalorsemielementalformulas:Theseformulasconsistofhydrolyzedmacronutrients.Proteinis present either as free amino acids (monomeric) or as bound amino acids in dipeptides or tripeptides (oligomeric).Carbohydratesourcesconsistofoligosaccharides,sucrose,orboth.Mostmonomericformulas arelowinfatorcontainalargepercentageofmediumchaintriglycerides(MCT)oil.Theseformulasarelow residue, hyperosmolar, and usually lactose free. They are indicated for patients with compromised gastrointestinal function, such as patients who have acute pancreatitis (15) or persistent diarrhea (5). Formulaswithpredigestednutrientsshouldnotbeusedforpatientswithnormaldigestionandabsorption, because they are unnecessary for these patients and cost more than standard intact (polymeric) nutrient formulas.
Modular components: These products are individually packaged components that may be combined in varying amounts to meet the patients individual nutritional needs. Examples include protein powders, carbohydrate powders, MCT oil, fiber, and specific amino acids (eg, glutamine and arginine). Protein powders,whichprovide7to15gofproteinperserving,arethemostcommonlyusedmodularadditives,as standard enteral formulations tend to have a high ratio of nonprotein energy to nitrogen (5,15). Modular componentsmayalsobeaddedtopremixedformulastoenhancetheintakeofoneormoremacronutrients.If modular components are added to premixed formulas, the preparation should follow the organizations HazardAnalysisandCriticalControlPointEnteralNutritionPlan(7).
NutrientModifiedandDiseaseSpecificFormulas Nutrientmodifiedanddiseasespecificformulashavebeenalteredinoneormorenutrientsinanattemptto optimizenutritionsupportwithoutexacerbatingthemetabolicdisturbancesassociatedwithvariousdiseases. Limited evidence is available regarding the efficacy and outcomes associated with the use of most disease specificenteralformulations (4).Standardenteralformulasareappropriateformostcriticallyillpatients (3). Diseasespecificformulasaremoreexpensivethanstandardenteralformula,andadietitianshouldcarefully evaluate their potential benefit for an individual patient before recommending them. If such formulas are used,thepatientshouldbemonitoredandadvancedtoastandardformulaassoonaspossible(3).
Nutrientmodifiedformulasinclude:
Formulascontainingfiber:Fiberisaddedtoenteralformulasforavarietyofpotentialhealthbenefits (17).Solublefibers,suchasguargum,oatfiber,andpectin,arefermentedtoshortchainfattyacids,which are easily absorbed by the gastrointestinal mucosa. Shortchain fatty acids, the preferred fuel for colonocytes, help to increase mucosal growth and promote sodium and water absorption (17). It is importanttoconsiderthetypeoffibersupplementedintheenteralformula.Soypolysaccharideisthe mostcommontypeoffiberusedinformulasandcontains94%solublefiber.Solublefiberreducesthe incidenceofdiarrhea,butstudiesofformulationssupplementedwithinsolublefiberhavenotyieldedthe same results (5,15,1820). ASPEN guidelines recommend avoiding the use of insoluble fiber formulas in criticallyillpatients(5).Ithasalsobeensuggestedthatbothsolubleandinsolublefibershouldbeavoided inpatientsathighriskforbowelischemiaorseveredysmotility (5,15).Casesofbowelobstructionfrom the use of these formulations have been reported (21,22). Enteral formulas containing fiber generally provide 5 to 14 g/L, which is less than the recommended 20 to 35 g of fiber per day. When a fiber formula is used, adequate freewater needs should be maintained and tolerance closely monitored, especiallyforpatientsreceivinglargervolumesoffibercontainingformulas(eg,greaterthan2Lper24 hourperiod).Solublefibercontainingformulasareindicatedincriticallyillpatientswhenthereareno contraindications for their use and the goal is to maintain a normally functioning gastrointestinal tract anddefecationpattern(5,23).
Formulascontainingomega3fattyacids:Thetypeandamountoffatinenteralformulasmayaffect immune function (2427). Fish oils, a rich source of omega3 fatty acids, provide eicosapentaenoic acid. Unlikeomega6fattyacids,whicharefoundinmorecommonfatsources(eg,cornoilandsoybeanoil) and have a greater immunosuppressive effect, eicosapentaenoic acid metabolizes into less immunosuppressiveprostaglandinsandleukotrienes.Astudyhasshownthebeneficialeffectsofomega 3 fatty acids on the length of hospital stay and the infection rate following burn injury (26). In another study, fewer gastrointestinal and infectious complications occurred in patients who received a formula rich in fish oils when compared to patients who received a standard polymeric formula (27). Enteral supplementation with omega3 fatty acids has beneficial effects in the treatment of acute respiratory distresssyndrome(ARDS).Inastudyof146patientswithARDS,patientswhoreceivedenteralformula supplementedwithomega3fattyacids(eicosapentaenoicacid)andgammalinolenicacid(anomega6 fatty acid) had significant improvements in oxygenation, lower ventilation variables, fewer days of ventilator support, and shorter stays in the ICU when compared to controls (28). According to ASPEN B-36 Copyright2011MorrisonManagementSpecialists,Inc. ManualofClinicalNutritionManagement
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guidelines, critically ill ARDS patients and those with severe acute lung injury should be placed on an enteralformulationcharacterizedbyanantiinflammatorylipidprofile(eg,omega3fishoils,borageoil) andantioxidantsbasedonacomprehensivereviewofstudies(5).
Formulascontainingarginine:Arginineisaconditionallyessentialaminoacidduringstressduetothe greaterutilizationoftheureacycle.Arginineisimportantinimmunefunctionandwoundhealingandis commonly found in immuneenhancing and woundhealing enteral formulas. The immuneenhancing properties of arginine include effects on the production and maturation of T lymphocytes and natural killer cells (29,30). Arginine may be useful in treating inflammatory diseases and acquired immunodeficiency syndrome, and it enhances collagen formation in wound healing (31,32). Although studieshavedemonstratedpositiveoutcomesofargininesupplementation,otherstudieshaveassociated argininecontaining formulations with an increased risk of mortality as compared to standard enteral formulas in severely septic ICU patients (5). The mechanism proposed for this adverse effect was hemodynamic instability caused by the conversion of arginine to nitric oxide in patients with severe sepsis (6). More research is needed to determine the optimal dose, timing, and specific patient criteria prior to the use of arginine supplemented formulas (3,5). (See the discussion of immuneenhancing enteralformulationsforsuggestedpatientcriteria.) Formulas containing glutamine: Classified as a nonessential amino acid, glutamine is the primary oxidativefuelforrapidlydividingcells,suchasenterocytesandleukocytes.Duringstressorinjury,the metabolic demand for glutamine can exceed the capacity of skeletal muscle to release it (33). A fall in glutamineconcentrationisassociatedwithatrophyoftheintestinalmucosa,impairedimmunefunction, anddecreasedproteinsynthesis (29).Substantialresearchhasbeencompletedinthepastdecadeonthe effectsofglutamineinenhancingsmallintestinegrowthandrepairfrominjury.Glutamineisnotpresent in standard parenteral formulas, and it is present in only small amounts in enteral formulas (16). Formulas that contain intact proteins contain some bound glutamine. Although most research has involved parenteral glutamine, one study demonstrated that patients who received glutaminerich enteral formula had significantly reduced hospital costs due to the prevention of secondary infections, whencomparedtopatientswhoreceivedisoenergeticcontrolformula (34).However,otherstudieshave foundnoeffectwithglutaminesupplementation (35,36).Theoptimalamountandformoforalglutamine requiredtoachievebeneficialresultsisstillunknown(3).Dosageandsafetystudieshavefoundthat20to 40g/dayofglutaminesupplementationissafeandwelltoleratedbyadults (37).Theadditionofenteral glutamine to an enteral nutrition regimen (not already containing supplemental glutamine) should be considered in burn, trauma, and ICU patients with multiple medical conditions or comorbidities (5A reviewofstudiesfoundthatadditionalglutamineisusuallyprovidedintwoorthreedivideddosesthat yield0.3to0.5g/kgbodyweightperday. (5).Glutaminesupplementationiscontraindicatedinpatients with hyperammonemia, hepatic failure, or renal failure due to excess ammonia production (4). Enteral glutamineshouldnotbeaddedtoanimmunemodulatingformulationalreadycontainingsupplemental glutamine(5). Formulascontainingbranchedchainaminoacids(BCAA):FormulassupplementedwithBCAAhave primarily been used for patients with hepatic failure in an attempt to improve the ratio of BCAA to aromaticaminoacidsandpreventorimprovehepaticencephalopathy.TheuseofBCAAsupplemented enteral formulas has not been validated because studies have provided mixed results. A randomized studyfoundthatBCAAsupplementationreducedhospitaladmissionsandimprovednutritionalstatusin patientswithadvancedliverdiseasewhencomparedtoastandardformulation;however,therewasno difference in encephalopathy scores between the two groups (38). The routine use of BCAAenriched formulasisnotrecommended (15).Consideringthelimitedevidencetosupporttheseformulations,the ASPEN guidelines for nutrition therapy in liver disease restrict the use of BCAAenriched formulas to patientswithrefractory(chronic)encephalopathythatisunresponsivetopharmacotherapy(1,2,39).
Diseasespecificformulasinclude:
Formulasforrenaldisease:Renalformulasareenergydenseformulasthatcontainwholeproteinsand have a modified electrolyte content (eg, sodium, potassium, phosphorus, and magnesium). These formulasmaybeindicatedinrenalpatientswhoseserumelectrolytelevelsaredifficulttomanageorfor whomrenaldialysisisdelayed (15).ASPENrecommendationssuggestthatICUpatientswithacuterenal failure receive standard enteral formulations and that standard ICU recommendations for protein and energy provision should be followed (5). If significant electrolyte abnormalities exist or develop, then a specialty formulation designed for renal failure (with an appropriate electrolyte profile) may be considered(5).
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Mostspecialtyrenalformulasareenergydense,sothatvolumecanberestrictedifneeded.Theprotein content ranges from less than 40 g to more than 70 g in 2,000 kcal. These formulas meet the Dietary ReferenceIntakesformostnutrientswiththeexceptionofselectvitamins,minerals,andelectrolytesthat are normally restricted in renal insufficiency (eg, potassium, sodium, phosphorus, and magnesium). If dialysisisdelayed,anenergydense,reducedproteinformulaisappropriate(40).However,longtermuse of these formulas requires close monitoring of the patients nutritional status (15). Patients receiving hemodialysis or continuous renal replacement therapy should receive increased protein, up to a maximumof2.5g/kgperday(5).Proteinshouldnotberestrictedinpatientswithrenalinsufficiencyasa means to avoid or delay the initiation of dialysis therapy (5,15,41). The nutrition goals of patients with renalfailureshouldincludeadequateproteinandenergyintake,withmodificationsinfluidvolumeand electrolytecontentthatareindividualizedbasedonthepatientsclinicalcondition.Thereisinsufficient datatodetermineifrenalformulasproducedifferentoutcomesthanstandardizedformulas(5,42).
Formulas for hepatic disease: Standard formulations should be used in ICU patients with acute and chronic liverdisease (1,4,5,15). Nutrition regimens should avoid restrictingprotein in patients with liver failure (5).Specialenteralformulashavebeendesignedforpatientswithhepaticfailure.Theseformulas aremodifiedinfluid,protein,andmineralcontentandmaynotmeettheDietaryReferenceIntakesfor various nutrients. These formulas contain increased levels of BCAA along with decreased levels of aromaticaminoacidsinanattempttotreatorpreventhepaticencephalopathy.Thetotalproteincontent varies among formulas and is often low. Studies of these formulas are inconclusive (5,39). The BCAA enhanced formulations should be reserved for the rare encephalopathic patient who is refractory to standardtreatmentwithluminalactingantibioticsandlactulose(5,39). FormulasforpulmonarydiseaseandARDS:Pulmonarydiseaseformulasarelowincarbohydrateand high in fat to decrease carbon dioxide (CO2) production in patients with compromised pulmonary function.Formulasthatcontainomega3fattyacidsmaybebeneficialinpatientswithearlyARDS(1).The ASPENguidelines,whicharebasedonacomprehensivereviewofstudies,suggestthatcriticallyillARDS patientsreceiveenteralformulationsthathaveanantiinflammatorylipidprofile(eg,omega3fishoils, borage oil) and contain antioxidants (5). The evidence regarding the impact of higher fat and lower carbohydrateenteralformulacompositiononCO2productionisstilllimited.Althoughafewstudieshave shown decreased CO2 levels in hypercapnic patients who received these formulas (28,43), more data are needed. Talpers et al found that an excess of total energy was as deleterious to CO2 production as carbohydrateintake (43).Thus,anexcessoftotalenergyshouldbeavoided,andenergyintakeshouldbe equaltoorlessthantheenergyneedsofpatientswithpulmonarydiseaseandCO2retention (1,15).The high lipid content of these formulas may cause delayed gastric emptying (44). These formulas tend to containintactnutrientsandareusuallylowinfluidandnutritionallycomplete.Fluidrestricted,energy denseformulations(1.5to2.0kcal/mL)shouldbeconsideredforpatientswithacuterespiratoryfailure to prevent fluid accumulation and pulmonary edema (5). If pulmonary formulas are used, the patients ventilatorystatusandCO2productionshouldbemonitored,andoverfeedingshouldbeavoided(2,15).
Formulasfordiabetesmellitus:Patientswithdiabetesmellituswhofollowadietwithincreasedintake ofmonounsaturatedfattyacidsalongwithlowercarbohydrateintakemayhaveimprovedbloodglucose control (15).Therefore,enteralformulaswithmodifiedamountsandtypesofcarbohydrateandfathave been developed. These formulas contain less carbohydrate (34% to 40%), more modified fat (40% to 49%),and10to15g/Loffiber (15).Outcomesdataregardingtheseformulasarelimitedintheircontext and their applicability to persons with diabetes mellitus (15). A prospective study that compared a diabeticformulatoastandardfibercontainingformulainlongtermcarepatientsdidnotdemonstrate anyclinicallysignificantbenefitfromthediabeticformula,withtheexceptionofimprovedhighdensity lipoprotein cholesterol levels (45). A study of hospitalized diabetes patients concluded that diabetic formulations had no effect on glycemic control (46). According to the American Dietetic Associations EvidenceAnalysisProjectforDiabetes,thereisinsufficientevidencetodeterminewhetherthenutrient composition of enteral formulations has an impact on medical costs, mortality rates, infectious complications,andlengthofhospitalstayinpatientswithdiabetes (GradeV) (46,47).Diabeticformulasmay be appropriately used in patients with blood glucose levels that are difficulttocontrol withtraditional methods (15).TheAmericanDiabetesAssociationsuggeststhateitherastandard(50%carbohydrate)or a lower carbohydrate content (33% to 40%) formula be used for tubefed patients (48). It is generally recommendedthatdiabeticpatientsreceiveastandardformulawithclosemonitoringofbloodglucose levelsandthatinsulinbeusedasneededforglycemiccontrol(15,49).
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Formulas for immune enhancement: Formulas have been designed with increased amounts of immuneenhancingnutrients(eg,arginine,glutamine,nucleicacid,omega3fattyacids)andantioxidant vitamins and minerals. It is theorized that these formulas will enhance the immune response and prevent infection. Immuneenhancing enteral nutrition (an enteral formula that contains pharmacological doses of nutrients intended to impact the immune system) is not recommended for routineuseintraumapatientsandcriticallyillpatientsintheICU (GradeII)(3).Immuneenhancingenteral nutrition is not associated with reductions in infectious complications, length of hospital stay, cost of medicalcare,daysonmechanicalventilation,ormortalityinmoderatelytolessseverelyillICUpatients (Grade II) (3). These formulas may be associated with increased mortality in severely ill ICU patients, althoughadequatelypoweredtrialsevaluatingthisfindinghavenotbeenconducted(3).ASPENguidelines statethatimmunemodulatingenteralformulationsbeusedonlyfortheappropriatepatientpopulation, which includes patients who undergo major elective gastrointestinal surgery, patients who have abdominal trauma, patients who have burns on more than 30% of their bodies, head and neck cancer patients, and critically ill patients on mechanical ventilation who are not severely septic; immune modulating enteral formulations should be used with caution in patients who have severe sepsis (5). PatientsintheICUwhodonotmeetthesecriteriashouldreceivestandardenteralformulations(5).These guidelines also suggest the provision of at least 50% to 65% of goal energy requirements from the immunemodulatingformulationstoreceiveoptimaltherapeuticbenefits(5).
Water/FluidRequirements The National Research Council recommends 1 mL of fluid per 1 kcal of energy expenditure for adults with average energy expenditure who live under average environmental conditions (50). Medical conditions that mayreducefluidrequirementsincludeheartfailure,acuterespiratoryfailure,renalfailure,ascites,syndrome of inappropriate antidiuretic hormone, and malignant hypertension. Fluid requirements may be increased forpregnantpatients;patientswithfever,burns,diarrhea,vomiting,orhighoutputfistulasorostomies;and patientsreceivingventilatorysupport (51).Patientswithpressureulcersandpatientsmedicallymanagedon airfluidized beds also have additional fluid needs. (Refer to Section IA: Nutrition Management of Fluid Requirements.)
There are several methods to determine fluid requirements (50). There is no evidence that compares the effectivenessofthesemethodsforestimatingthefluidneedsofadults(GradeV)(51).Themethodsinclude(51):
Method1:HollidaySegarMethoda BodyWeight(actual) 10kg between10kgand20kg >20kg
WaterRequirement 100mL/kg 1,000mL+50mL/kgforeachkg>10kg 1,500mL+20mL/kgforeachkg>20kg
Method2:RecommendedDailyAllowancesMethodb 1mLperkilocalorieofenergyexpenditure
Method3c Urineoutput+500mL/day
HollidayMA,SegarWE.Themaintenanceneedforwaterinparenteralfluidtherapy.Pediatrics.1957;19:823832. InstituteofMedicine.DietaryReferenceIntakes:Water,Potassium,Sodium,Chloride,andSulfate.Washington,DC:NationalAcademy Press;2004. cNutritionassessment.In:ManualofClinicalDietetics.6thed.Chicago,Ill:AmericanDieteticAssociation;2000:33.
a b
ApproximateFreeWateraContentofNutritionalFormulas Formula mLH2O/mLFormula 1.0kcal/mL 0.84 1.0kcal/mLwithfiber 0.83 1.5kcal/mL 0.78 2.0kcal/mL 0.71
mLH20/kcal 0.84 0.83 0.52 0.36
aFreewaterdeliveredintubefeeding=millilitersofformuladeliveredmillilitersofH2Opermilliliterofformula
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CriteriaforFormulaSelection(15) Thereareavarietyofenteralnutritionproductsonthemarket,manyofwhichhaveonlysubtledifferencesin composition.Thefollowingcriteriashouldbeconsideredwhenselectingaformula: Energydensity:Anenergydensityof1kcal/mLisconsideredstandard.Additionalfreewaterisusually necessary to meet fluid requirements. Higher energy concentrations (1.5 to 2.0 kcal/mL) may be indicatedwhenfluidmustberestrictedorwhenfeedingvolumessufficienttomeetenergyrequirements cannotbetolerated.Fluidrestricted,energydenseformulationsshouldbeconsideredforpatientswith acuterespiratoryfailuretopreventfluidaccumulationandpulmonaryedema(5). Osmolality: Products are available at isotonic osmolalities (300 mOsm/kg), moderate osmolalities (400 mOsm/kg), and high osmolalities (700 mOsm/kg). The main contributors to osmolality are sugars, free amino acids, and electrolytes. Highcarbohydrate, amino acidbased, or peptidebased formulas have moderate to high osmolality. Formula osmolality has not been conclusively found to be a direct cause of diarrhea(15). Protein:Proteinsourcesareintactproteins,peptides,oraminoacids.Generally,proteincontributes9% to24%oftotalenergy.Highnitrogenformulasmaynotbewelltoleratedinpatientswithcertainrenal or hepatic disorders. Highnitrogen concentrations can result in a higher renal solute load and can predispose elderly patients to dehydration. One gram of nitrogen requires 40 to 60 mL of water for excretion. Fat:Fatsourcesarelongchaintriglycerides(LCT)andMCT.Thefatcontentusuallyrangesfrom3%to 35% of energy for amino acidbased or peptidebased formulas and from 25% to 55% of energy for standardformulas.Fatsdonotcontributetoosmolality.InclusionofMCTmaybebeneficialforpatients who experience fat malabsorption or maldigestion, since MCT do not require pancreatic lipase for absorption,andintraluminalhydrolysisismorerapidandcompletethanwithLCT (15). TheMCTdonot supplyessentialfattyacids,andtheymaycausecomplicationsforcirrhoticpatientswhohavealimited ability to oxidize MCT. The administration of MCT along with LCT increases the total intestinal absorptionofbothtypesoffats,ascomparedwiththeabsorptionofeitherfatadministeredalone. Carbohydrate: Carbohydrate is the most easily digested and absorbed nutrient. Enzyme digestion is veryefficient,assurfacedigestionisnotratelimiting(exceptwithlactose).Thetransportprocessisthe slowestpartofcarbohydratemetabolism.Carbohydratesourcesaremonosaccharides,oligosaccharides, and lactose. The carbohydrate content of formulas ranges from 35% to 90% of energy. Longer carbohydratemoleculesexertlessosmoticpressure,tastelesssweet,andrequiremoredigestionthando shorterones.Glucosepolymersarebetterabsorbedthanfreeglucoseandenhanceabsorptionofcalcium, zinc, and magnesium in the jejunum. Some specialty formulas include fiber, fructose, and/or fructo oligosaccharides. Fructooligosaccharides occur naturally in a variety of fruits and vegetables and provide sweetening at a lower cost than sucrose. Fructooligosaccharides are poorly absorbed by the smallintestineandfermentedinthecolon,wheretheypromotethegrowthofhealthyspeciesofbacteria (15). Lactose: Lactose is present in milkbased formulas and some blenderized formulas. Most commercial formulasarelactosefree.Duetothepresumedhighincidenceofsecondarylactasedeficiencyinillness, lactoseisnotpresentinmostenteralformulas(15). Residue: Milkbased formulas and other formulas with intact nutrients are generally low residue. Blenderizedandfibersupplementedformulasleaveamoderatetohighresidue. Fiber:Seethepreviousdiscussionofformulascontainingfiberinthenutrientmodifiedformulaslist. Sodiumandpotassium:Selectformulaaccordingtothepatientsnutritionprescriptionandlaboratory profile. Renal solute load: The main contributors to renal solute load are protein, sodium, potassium, and chloride.Ahighrenalsoluteloadinsensitivepatientscanresultinclinicaldehydration. Safety:Areadytouseclosedbagorsystemisrecommended,asitismoresterileandprovideslessrisk forcontaminationthancanned or powdered products (52). Formulas that are made in a blender in the facility are discouraged because they carry a greater risk of infection, require careful handling, tend to clog tubes, and need a high volume to meet nutrient needs. If formulas are mixed, follow the organizationsHazardAnalysisandCriticalControlPointEnteralNutritionGuidelinestoensuresafety(52). Viscosity:Blenderized,highfiber,andhighdensityformulasshouldnotbeadministeredthroughtubes withadiametersmallerthan10Frenchunlessapumpisused.Formulasmayflowthroughan8French diametertubewhenapumpisused(15). VitaminK:Patientswhoarereceivingenteralnutritionsupportwhileonanticoagulanttherapyshould bemonitoredclosely.SignificantvitaminKintakefromenteralformulascanantagonizetheeffectofthe anticoagulant drug warfarin and result in treatment failure (53). Most enteral formulations contain modest amounts of vitamin K and provide daily vitamin K intake similar to the average dietary intake
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fromfoods(53).Consistentintakeofanenteralformulationcontaininglessthan100mcgofvitaminKper 1,000kcalisnotexpectedtocausewarfarinresistance(53).RefertoSectionIII:AnticoagulantTherapyfor specificguidelinesforenteralnutritionregimensinthisgroupofpatients. Cost:Aminoacidbasedformulasandpeptidebasedformulasareusuallymoreexpensivethansynthetic formulascontainingintactnutrients.
EnteralFeedingAdministration(52,54) Continuous feeding/delivery: Continuous feedings require that the enteral formula be administered at a controlledratewithapumpovera24hourperiod.Thepumpshoulddeliverthecontrolledratewithin10% accuracyandbecalibratedperiodicallytoensureaccuracy(52).Continuousfeedingsareindicatedforunstable critically ill patients, patients unable to tolerate highvolume feedings, patients with malabsorption, and patientsatincreasedriskforaspiration (5).Feedingsmaybeinitiatedatfullstrengthinthestomachoratan isotonicstrengthinthesmallbowelatarateof10to50mL/hour.Then,theratemaybegraduallyincreased astoleratedinincrementsof10to25mL/hourtothegoalrate.Strengthandvolumeshouldnotbeincreased simultaneously.
Intermittentorcyclicfeeding/delivery:Intermittentorcyclicfeedingsareadministeredoveran8to20 hourperiodbyusingapumptocontroltherateofdelivery.Thismethodoftubefeedingismostbeneficialfor patients who are progressing from complete tube feeding support to oral feedings as discontinuation of feedingsduringthedaymayhelptostimulatetheappetite.Intermittentorcyclicfeedingisalsobeneficialfor ambulatoryhomecarepatientswhoareunabletotoleratebolusfeedingsbecauseitallowsfreedomfromthe pump and equipment. Since this method of delivery usually requires a higher infusion rate, monitoring for formulaanddeliverytoleranceisnecessary.Formulaanddeliveryintolerancecanbeavoidedbyagradual transitioningofthepatientfromcontinuousfeedingtoanintermittentfeedingschedule.
Formuladeliverynotrequiringapump:Thesyringebolusfeedingmethodinvolvesthedeliveryof240to 480 mL of formula via a feeding tube over a 20 to 30minute period, three to four times a day, to meet estimated nutritional requirements. This method is usually restricted to gastric feedings and may be contraindicated in patients who have a high risk of aspiration, disorders of glucose metabolism, or fluid managementissues.
EnteralFeedingFormulaandEquipmentMaintenanceGuidelines(52) Formula: Bring formula to room temperature before feeding, but do not allow the formula to remain unrefrigeratedformorethan4hours(52). The hang time for formula in an open system should be less than 8 hours or as specified by the manufacturer.Formulafromaclosedsystemisprovidedinreadytohang,prefilledcontainersandmay hangforupto24hoursatroomtemperature (52).Discardanyformularemaininginthecontainerafter thehangtimehasexpired. Opened,unusedformulashouldbekeptrefrigeratedfornolongerthanthemanufacturersspecifications (usually24hours)(52). Refer to the ASPEN Enteral Nutrition Practice Recommendations or organizationspecific interdisciplinaryenteralnutritionmonitoringprotocolandpolicyasneeded(52).
Formuladeliveryguidelines: Irrigatethetubeevery4hourswith20to30mLofwarmsterilewaterorsalinetoensurepatencyfor continuousfeeding (52).Also,irrigatethetubebeforeandaftereachintermittentfeedingormedication administration(2,52). To reduce bacterial contamination, flush water through the bag and tube every 8 hours before adding newformulawhenanopensystemisinplace. Avoidputtingfoodandbeveragesintothetube(eg,juice,milk,andsoda). Flush tube with purified sterile water or saline before and immediately after the administration of medicinestoavoidcloggingthetube(52). Toreducetheriskofcontaminationandinfection,thefeedingbagshouldbeproperlylabeled,andtubing shouldbechangedevery24hoursorasspecifiedbythemanufacturer(52). Refer to organizationspecific interdisciplinary enteral nutrition monitoring protocol and policy as needed.
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PatientMonitoringGuidelines Refer to the American Dietetic Associations Critical Illness EvidenceBased Nutrition Practice Guideline, the ASPENEnteralNutritionPracticeRecommendations,theASPENGuidelinesforNutritionSupportTherapyinthe Adult Critically Ill Patient, and the Enteral Nutrition Acute Care Nutrition Protocol (3,5,52,55,56). Also refer to organizationspecificinterdisciplinaryenteralnutritionmonitoringprotocolsasneeded.Guidelinesforpatient monitoring and avoidance of complications associated with the delivery of enteral nutrition are described below.
Patientswithnasoenterictubes: Providemouthandnosecareevery8hourstopreventparotitisandskinbreakdownaroundthenose. Verifytheplacementofanasoenterictubepriortofeedinginitiationandevery4to8hoursthereafter,or asspecifiedbytheorganizationsprotocol(52).
Avoidanceofintestinalhypoxiaandbowelnecrosis(4,15,56): Assessbowelsoundsevery8hours. Feedintothesmallbowel(postpyloricposition). Administerfeedinginpatientswhoareadequatelyfluidresuscitatedandhaveasustainedmeanarterial pressureofatleast70mmHg. Useisoosmolarformulationsandadvancethefeedingswhentoleranceisdemonstrated. Assesstheneedtoholdfeedingsifthepatientexperiencesasuddenperiodofhypotension,ifthedosages of pressor agents (eg, dobutamine, norepinephrine, and epinephrine) are increased, or if the need for ventilatorysupportisincreased(56). Assess the need to hold feedings if the patient develops increased nasogastric output, abdominal distention,orabdominalpain.
Avoidanceofgastrointestinalintoleranceandaspiration(3,5,52,57): RecommendationsfromtheNorthAmericanSummitonAspirationintheCriticallyIllstatethatfeeding ideallyshouldbeintothesmallbowelwiththetubetipatorbelowtheligamentofTreitzwhentwoor moreriskfactorsforaspirationarepresent(4,5,57).Theseriskfactorsinclude:prioraspiration,decreased level of consciousness, neuromuscular disease, structural abnormalities of the aerodigestive tract, endotrachealintubation,vomiting,persistentlyhighgastricresidualvolumes(GRVs),andtheneedfora supine position (57). ASPEN guidelines also suggest that patients at high risk for aspiration receive a continuousinfusiontodecreaseintolerancetogastricfeeding(5). Usea50mLor60mLsyringetocheckGRVsinnasogastricfedorgastrostomyfedpatientsbeforeeach intermittent or bolus feeding (52). Feeding tubes with a diameter smaller than 10 French may be unreliable in determining residuals (58,59). The GRV should be checked before bolus feedings, intermittently during continuous pump feedings, or when there are signs of feeding intolerance (eg, abdominaldistentionorvomiting).GuidelinesforGRVcutoffvaluesvaryamongorganizations(3,5).The AmericanDieteticAssociationsuggeststhatenteralnutritionbeheldwhenaGRVgreaterthanorequalto 250mLisdocumentedontwoormoreconsecutiveassessments (3). Holdingenteralnutritionwhenthe GRVislessthan250mLcanresultinnutritionalrequirementsnotbeingmet (GradeIV)(3,52).TheASPEN guidelinesaremoreliberalandsuggestthatGRVsintherangeof200to500mLshouldraiseconcernand lead to the implementation of measures to reduce the risk of aspiration; however, feedings should not automaticallybestoppediftheGRVislessthan500mLandtherearenoothersignsofintolerance (5). These ASPEN guidelines are based on studies that demonstrated no greater risk for regurgitation, aspiration,orpneumoniawhena250mLto500mLcutoffvalueforGRVwasused (5).Inanycase,the clinicianshouldconsidertheindividualpatientcircumstanceandadheretoorganizationspecificpolicies whendeterminingcutoffvaluesforGRV.IfapatienthasreoccurringelevatedGRVsthatexceedtarget cutoff goals, the underlying causes should be evaluated, and preventive interventions should be provided.Forexample,considerasmallboweltubeplacementinpatientswhohavemorethan250mL GRVorformularefluxintwoconsecutivemeasures (GradeII)(3).Smallboweltubeplacement(postpyloric position) is associated with reduced GRV (Grade I) (3). Adequately powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia (3). Patients with high GRVs may benefitfrommedicationsthatstimulategastricmotility(eg,metoclopramide,erythromycin,ornarcotic antagonistssuchasnaloxoneandalvimopan) (GradeII)(3,5).PatientswithconsistentlyhighGRVsmustbe evaluated to exclude underlying medical problems (eg, ileus, bowel impaction, gastroparesis, or pancreatitis)thatmaycausefeedingintolerance. Blue dye should not be added to enteral formulas to detect aspiration. The risk of using blue dye outweighs any perceived benefit. The presence of blue dye in tracheal secretions is not a sensitive indicatorforaspirations(GradeIII)(3,5,60).
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Ifnotcontraindicated,maintaintheheadofthepatientsbedata45angleduringfeedingstoreducethe riskofaspirationpneumonia (Grade II)andtherefluxofgastriccontentsintotheesophagusandpharynx (GradeI)(3,4,).Ifbolusfeeding,keeptheheadofthebedinthispositionfor30to60minutesafterfeeding. IfthepatienthasahistoryofgastroparesisorrepeatedhighGRVs,thenconsidertheuseofapromotility agent, if there are no contraindications (Grade II) (3). Promotility agents (eg, metoclopramide or others listedabove(5))havebeenassociatedwithincreasedgastrointestinaltransit,improvedfeedingtolerance, improvedenteralnutritiondelivery,andpossiblyareducedriskofaspiration(GradeII)(3). Use of chlorhexidine mouthwash twice a day should be considered to reduce the risk of ventilator associated pneumonia (5). Two studies have demonstrated that the use of chlorhexidine mouthwashes twice daily reduced the incidence of respiratory infection and nosocomial pneumonia in patients undergoingheartsurgery(5). Diarrhea in the ICU patient receiving enteral nutrition should prompt an investigation to distinguish between infectious diarrhea, osmotic diarrhea, or malabsorption. Check for excessive intake of hyperosmolar medications and substances, such as sorbitol; the use of broadspectrum antibiotics that can cause pseudomembranous colitis due to an overpopulation of Clostridium difficile; and other infectious etiologies. Most episodes of nosocomial diarrhea are mild and resolve independently (5). Solublefibermaybebeneficialforfullyresuscitated,hemodynamicallystable,criticallyillpatientswho receiveenteralnutritionanddevelopdiarrhea(5).
Metabolic/laboratory data monitoring guidelines: Serum protein levels are no longer considered to be reliableorvalidasanindicatorofacriticalcarepatientsnutritionalstatusorresponsetonutritiontherapies (61).Evidencehasshownthatserumproteinlevelsaremarkersofthestressresponseanddiseaseseverity, ratherthanindicatorsofnutritionalstatusorproteinrequirements.Formonitoringtheadequacyofprotein intake,themostuseful(althoughstilllimited)laboratoryindicatormaybenitrogenbalance,whichreflects theadequacyofproteinintakeinmatchingcatabolicdemand (61).(RefertoSectionII: Estimation of Protein Requirements or Section III: Burns.) Recent evidence has identified the importance of blood glucose control and hyperglycemia prevention in critically ill patients (3). In a singlecenter trial, strict blood glucose control was associated with decreased mortality, shorter hospital stays, and fewer infectious complications in critically ill patients (Grade I) (3,5). However, ongoing studies suggest that moderate control (keeping glucose levels between 140 and 180 mg/dL)mightreducethemortalityassociatedwithhypoglycemiaascomparedtostrictercontrol(80to110 mg/dL)(5).Therefore,theASPENguidelinesrecommendamoremoderatetargetrangeof100to150mg/dL whenprovidingnutritionsupporttherapytocriticallyillpatients(5).Specificguidelinesforglucosecontrolin criticalcarepatientsarecurrentlybeingevaluatedandrevisedbytheAmericanDieteticAssociation (3).In addition, specific recommendations are also provided for critically ill patients with diabetes. Dietitians shouldbeinvolvedinpromotingtheattainmentofbloodglucosecontrolwhenprovidingnutritionsupport therapies and should refer to emerging evidence, practice guidelines, and facilityspecific protocols for recommendations (3,5). Refer to Section C: Medical Nutrition Therapy for Diabetes Mellitus for specific glycemicgoalsinmanaginghospitalizedpatientswithdiabetesmellitus. Suggestedlaboratorymonitoringguidelinesinclude: daily measurements of sodium, potassium, chloride, CO2, blood urea nitrogen, creatinine, and glucose levelsuntilstable,thenbiweeklytoweeklymeasurements baselinemeasurementsofprealbuminoralbuminforpatients,suchaschronickidneydiseasepatients, fortodeterminethemorbidity,mortality,orseverityofdiseaseorinflammatorystatus(notreliablein criticallyillpatients) baselinemeasurementsofliverfunctiontests dailymeasurementsofcalcium,magnesium,andphosphorusuntilstable,thenweeklymeasurements baselinecompletebloodcellcount,thenmeasuredasneeded a24hoururineanalysisforurineureanitrogen(ortotalureanitrogen)oncethegoalrateoftubefeeding isattained,thenweeklymeasurementsuntilstable
Otherpatientmonitoringguidelines: Weighthepatientatleastonceperweek. Maintaindailyrecordsofintake,output,andbowelmovements. Monitorvitalsignstodeterminewhetherasystemicinflammatoryresponseispresent(62).Thesystemic inflammatoryresponsesyndromeisnonspecificandcommonincriticalcarepatients.Itspresenceonthe second day after ICU admission prognosticates morbidity (organ failure) and mortality and therefore
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mightbeonecriterioninidentifyingthepatientathigherriskforcomplicationsandwhomightbenefit from early initiation of enteral feeding (61). Signs of systemic inflammatory response syndrome include thefollowing(61): bodytemperatureof>38.0Cor<36.0C heartrateof>90beats/minute breathingrateof>20breaths/minute(oftenobscuredbymechanicalventilation) leukocytecountof>12,000mm3or<4,000mm3,oraleftshift(>10%bands)
Medications via enteral feeding tubes: Feeding tubes should be irrigated with at least 15 mL of warm purifiedorsterilewater(orsaline)beforeandimmediatelyaftertheadministrationofmedications(52).Since crushedmedicationscanclogtubes,liquidmedicationsshouldbeusedwhenpossible.Manyoralmedicines formulated for slow release may be surrounded by an enteric coating and should not be crushed and administeredthroughthefeedingtube.Multipletypesofmedicationshouldbeadministeredseparately (52). Temporary cessation of enteral feeding may be indicated for 1 hour before and 1 hour after the administration of phenytoin sodium (Dilantin), a commonly used anticonvulsant medication, because componentsoftheenteralformula,suchascalcium,decreasethebioavailabilityofthisdrug(15,6365). Transitional feedings, enteral to oral or supplemental parenteral nutrition: Depending on the swallowingfunctionofthepatient,oralintakeshouldbeginwithliquidsandadvancetoappropriatefoodsas tolerated.Whenoralintakereaches500kcalormore,thedosageoftubefeedingsmaybeproportionately tapered. Switching the patient from a continuous tube feeding to night tube feeding only or discontinuing tubefeeding1to2hoursbeforemealswilloftenstimulatetheappetiteandspeedtransitiontoadequateoral intake.Whenoralintakeconsistentlymeetsorexceeds60%ofthepatientsenergyrequirementsand100% ofthefluidrequirements,discontinuationoftubefeedingsshouldbeconsidered (3,5).Ifacriticallyillpatient is unable to meet energy requirements (100% of the target energy goal) after 7 to 10 days by the enteral route alone, supplemental parenteral nutrition should be considered (5). The provision of supplemental parenteral nutrition prior to this 7 to 10day period does not improve the patients nutritional status and maybedetrimental(5). SeeSectionIII:ClinicalNutritionManagement
ENTERALNUTRITION:MANAGEMENTOFCOMPLICATIONS References 1. ASPENBoardofDirectorsandStandardsCommittee.AmericanSocietyforParenteralandEnteralNutrition.Definitionofterms, style,andconventionsusedinA.S.P.E.N.guidelinesandstandards.NutrClinPract.2005;20:281285. 2. Joint Standards Task Force of ASPEN and the American Dietetic Association Dietitians in Nutrition Support Practice Group. Russell M, Stieber M, Brantley S, Freeman AM, Lefton J, Malone AM, Roberts S, Skates J, Young LS. American Society for Parenteral and Enteral NutritionandAmericanDieteticAssociation:standardsofpracticeandstandardsofprofessionalperformanceforregistereddietitians (generalist,specialty,andadvanced)innutritionsupport.JAmDietAssoc.2007;107:18151822. 3. CriticalIllnessEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociationEvidenceAnalysisLibrary.American DieteticAssociation;2006.Availableat:www.adaevidencelibrary.com.AccessedOctober1,2010. 4. MarianM,McGinnisC.Overviewofenteralnutrition.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:A CaseBasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:187207. 5. McClaveSA,MartindaleRG,VanekVW,McCarthyM,RobertsP,TaylorB,OchoaJB,NapolitanoL,CresciG;ASPENBoardof Directors;AmericanCollegeofCriticalCareMedicine.Guidelinesfortheprovisionandassessmentofnutritionsupporttherapyin theadultcriticallyillpatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition (A.S.P.E.N.).JParenterEnteralNutr.2009;33:277316. 6. NeumayerLA,SmoutRJ,HornHG,HornSD.Earlysufficientfeedingreduceslengthofstayandchargesinsurgicalpatients.JSurg Res.2001;95:7377. 7. FarberMS,MosesJ,KornM.Reducingcostsandpatientmorbidityintheenterallyfedintensivecareunitpatients.JParenter EnteralNutr.2005;29:S562S569. 8. KudskDA,MinardG,CroceMA,BrownRO,LowreyTS,PritchardFF,DickersonRN,FabianTC.Arandomizedtrialofisonitrogenous enteraldietsafterseveretrauma:animmuneenhancingdietreducessepticcomplications.AnnSurg.1996;224:531543. 9. MagnottiLJ,DeitchEA.Burns,bacterialtranslocation,gutbarrierfunction,andfailure.JBurnCareRehabil.2005;26:383391. 10. ChoiJ,OConnellTX.Safeandeffectiveearlypostoperativefeedingandhospitaldischargeafteropencolonresection.AmSurg. 1996;62:853856. 11. UgarteF.Re:Safeandeffectiveearlypostoperativefeedingandhospitaldischargeafteropencolonresection.AmSurg. 1997;63:565566. 12. LordL,HarringtonM.Enteralnutritionimplementationandmanagement.In:MerrittR,ed.TheA.S.P.E.N.NutritionSupport PracticeManual.2nded.SilverSpring,Md:AmericanSocietyforParenteralandEnteralNutrition;2005:7689. 13. McClaveSA,ChangeWK.Whentofeedthepatientwithgastrointestinalbleeding.NutrClinPract.2005;20:544550. 14. LeftonJ,HalasaEsperD,KochevarM.Enteralformulations.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCore Curriculum:ACaseBasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition; 2007:209231. 15. CharneyP,RussellMK.Enteralformulations:standard.In:RolandelliRH,ed.ClinicalNutrition:EnteralandTubeFeeding.4thed. Philadelphia,Pa:ElsevierSaunders;2005:216223. 16. MaloneA.Enteralformulaselections:areviewofselectedproductcategories.PractGastroenterol.2005;24:4474. ManualofClinicalNutritionManagement
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Enteral Nutrition Support for Adults 17. SpapenH,DiltoerM,MalderenCV,OpdenackerG,SuysE,HuyghensL.Solublefiberreducestheincidenceofdiarrheainseptic patientsreceivingtotalenteralnutrition:aprospective,doubleblind,randomized,andcontrolledtrial.ClinNutr.2001;20:301305. 18. RushdiTA,PichardC,KhaterYH.ControlofdiarrheabyfiberenricheddietinICUpatientsonenteralnutrition:aprospective randomizedcontrolledtrial.ClinNutr.2004;23:13441352. 19. FrankenfieldDC,BeyerPL.Soypolysaccharidefiber:effectondiarrheaintubefed,headinjuredpatients.AmJClinNutr. 1989;50:533538. 20. McIvorAC,MeguidMM,CurtasS,WarrenJ,KaplanDS.Intestinalobstructionfromcecalbezoar;acomplicationoffibercontaining tubefeedings.Nutrition.1990;6:115117. 21. McClaveSA,ChangWK.Feedingthehypotensivepatient:doesenteralfeedingprecipitateorprotectagainstischemicbowel?Nutr ClinPract.2003;18:279284. 22. ZimmaroBlissD,JungHJG.Fiber.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACaseBased ApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:98. 23. GottschlichMM.Selectionofoptimallipidsourcesinenteralandparenteralnutrition.NutrClinPract.1992;7:152165. 24. KinsellaJE,LokeshB.Dietarylipids,eicosanoids,andtheimmunesystem.CritCareMed.1990;18:S94S113. 25. GottschlichMM,JenkinsM,WardenGD,BaumerT,HavensP,SnookJT,AlexanderJW.Differentialeffectsofthreeenteraldietary regimensonselectedoutcomevariablesinburnpatients.JParenterEnteralNutr.1990;14:225236. 26. KenlerAS,SwailsWS,DriscollDE,DeMicheleSJ,DaleyB,BabineauTJ,PetersonMB,BistrianBR.Earlyenteralfeedingin postsurgicalcancerpatients:fishoilstructuredlipidbasedpolymericformulaversusastandardpolymericformula.AnnSurg. 1996;223:316333. 27. GadekJE,DeMicheleSJ,KarlstadMD,PachtER,DonahoeM,AlbertsonTE,VanHoozenC,WennbergAK,NelsonJL,NoursalehiM. EnteralNutritioninARDSStudyGroup.Effectofenteralfeedingwitheicosapentaenoicacid,gammalinolenicacid,andantioxidants inpatientswithacuterespiratorydistresssyndrome.CritCareMed.1999;27:14091420. 28. YoungLS,KearnsLR,SchoepfelSL.Protein.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACaseBased ApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:8385. 29. SenkalM,KemenM,HomannHH,EickhoffU,BaierJ,ZumtobelV.Modulationofpostoperativeimmuneresponsebyenteralnutrition with a diet enriched with arginine, RNA, and omega3 fatty acids in patients with upper gastrointestinal cancer. Eur J Surg. 1995;161:115122. 30. Jacobs DG, Jacobs DO, Kudsk KA, Moore FA, Oswanski MF, Pooole GV, Sacks G, Scherer LR 3rd, Sinclair KE. Practice management guidelinesfornutritionsupportofthetraumapatient.JTrauma.2004;57:660679. 31. StehleP.Nutritionsupportincriticalillness:aminoacids.In:CynoberL,MooreFA,eds.NutritioninCriticalCare.NestleNutrition WorkshopSeriesClinicalandPerformanceProgram,Basel,Nestec,Ltd;Vevey/S.KargerAG.2003;8:5773. 32. SavyGK.Enteralglutaminesupplementation:clinicalreviewandpracticalguidelines.NutrClinPract.1997;12:259262. 33. JonesC,PalmerTE,GriffithsRD.Randomizedclinicaloutcomestudyofcriticallyillpatientsgivenglutaminesupplementedenteral nutrition.Nutrition.1999;15:108115. 34. JensenGL,MillerRH,TalabiskaDG,FishJ,GianferanteL.Adoubleblind,prospective,randomizedstudyofglutamineenriched comparedwithstandardpeptidebasedfeedingincriticallyillpatients.AmJClinNutr.1996;64:615621. 35. CoghlinTM,WongRM,NegrinRS,ShizuruJA,JohnstonLJ,BlumeKG,StockerlGoldsteinKF.Effectoforalglutamine supplementationduringbonemarrowtransplantation.JParenterEnteralNutr.2000;24:6166. 36. ZieglerTR,BenfellK,SmithRJ,YoungLS,BrownE,FerrariBalivieroE,LoweDK,WilmoreDW.SafetyandmetaboliceffectsofL glutamineadministrationinhumans.JParenterEnteralNutr.1990;14:137S146S. 37. MarchesiniG,GiampaoloB,ManuelaM,BianchiG,MerliM,AmodioP,PanellaC,LoguercioC,RossiFanelliF,AbbiatiR,ItalianBCAA StudyGroup.Nutritionalsupplementationwithbranchedchainaminoacidsinadvancedcirrhosis:adoubleblind,randomized trial.Gastroenterology.2003;124:17921801. 38. BleiAT,CordobaJ,andthePracticeParameterCommitteeoftheAmericanCollegeofGastroenterology.Hepaticencephalopathy. AmJGastroenterol.2001;96:19681975. 39. MaloneAM.Theclinicalbenefitsandefficacyofusingspecializedenteralfeedingformulas.SupportLine.2002;24:311. 40. RussellMK,CharneyP.Istherearoleforspecializedenteralnutritionintheintensivecareunit?AmJKidneyDis.2005;46:387 405. 41. StrattonRJ,BircherG,FongueD,StenvinkelP,deMutsertR,EngferM,EliaM.Multinutrientoralsupplementsandtubefeedingin maintenancedialysis:asystematicreviewandmetaanalysis.AmJKidneyDis.2005;46:387405. 42. TalpersSS,RombergerDJ,BunceSB,PingletonSK.Nutritionallyassociatedincreasedcarbondioxideproduction:excesstotal caloriesvshighproportionofcarbohydratecalories.Chest.1992;102:551555. 43. AkrabawiSS,MobarhanS,StoltzRR,FergusonPW.Gastricemptying,pulmonaryfunction,gasexchange,andrespiratoryquotient afterfeedingamoderateversushighfatenteralformulamealinchronicobstructivepulmonarydiseasepatients.Nutrition. 1996;12:260265. 44. Craig LD, Nicholson S, Silverstone FA, Kennedy RD. Use of a reducedcarbohydrate, modifiedfat enteral formula for improving metaboliccontrolandclinicaloutcomesinlongtermcareresidentswithtype2diabetes:resultsofapilottrial.Nutrition.1998;14:529 534. 45. LeonSanz M, GarciaLuna PP, SanzParis A, et al for the SPAI97004 Study Cooperative Group. Glycemic and lipid control in hospitalizedtype2diabeticpatients:evaluationof2enteralnutritionformulas(lowcarbohydratehighmonounsaturatedfatvs.high carbohydrate).JParenterEnteralNutr.2005;29:2129. 46. Diabetes Mellitus (DM) Type 1 and Type 2 Evidence-Based Nutrition Practice Guideline for Adults. American Dietetic Association Evidence Analysis Library. American Dietetic Association; 2008. Available at: www.adaevidencelibrary.com. Accessed December 2, 2009. 47. AmericanDiabetesAssociation.Nutritionrecommendationsandinterventionsfordiabetes.DiabetesCare.2008;31(suppl1):61S78S.. 48. CharneyP,HertzlerSR.Managementofbloodglucoseanddiabetesinthecriticallyillpatientreceivingenteralfeeding.NutrClinPract. 2004;19:129136. 49. Food and Nutrition Board, National Academy of Sciences. Recommended Dietary Allowances. 10th ed. Washington, DC: National AcademyPress;1989. 50. KleinerSM.Water:anessentialbutoverlookednutrient.JAmDietAssoc.1999;99:200206. 51. Hydration EvidenceAnalysis Project. American Dietetic Association Evidence Analysis Library. American Dietetic Association; 2007. Availableat:www.adaevidencelibrary.com.AccessedSeptember27,2010. 52. BankheadR,BoullataJ,BrantleyS,CorkinsM,GuenterP,KrenitskyJ,LymanB,MethenyNA,MuellerC,RobbinsS,WesselJ;ASPEN BoardofDirectors.Enteralnutritionpracticerecommendations.JParenterEnteralNutr.2009;33:122167. 53. Rollins CJ. Drugnutrient interactions. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A CaseBased ApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:340359. ManualofClinicalNutritionManagement
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EnteralNutritionSupportforAdults 54. BankheadRR,FangJC.Enteralaccessdevices.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACaseBased ApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:233245. 55. Enteralnutritionacutecareprotocol.In:InmanFeltonA,SmithKG.NutritionCareProtocolsfortheAcuteCareSetting.Atlanta,Ga: MorrisonManagementSpecialistsInc;2009.Availableat: www.morrisontoday.com/Documents/Forms/AllItems.aspx?RootFolder=%2fDocuments%2fNutrition%2fMHFS%20NUTRITION% 2fNutrition%20Care%20Process&FolderCTID=0x01200076035A4CEC8A4B4B827A74CE5B3B1A44&View=%7b1F2F11DB%2d20 30%2d4BBC%2dB712%2dEFE12EF45909%7d. 56. Kattelmann K, Hise M, Russell M, Charney P, Stokes M, Compher C. Preliminary evidence for a medical nutrition therapy protocol: enteralfeedingsforcriticallyillpatients.JAmDietAssoc.2006;106:12261241. 57. McClaveSA,DeMeoMT,DeleggeMH,DiSarioJA,HeylandDK,MaloneyJP,MethenyNA,MooreFA,ScolapioJS,SpainDA,ZalogaGD. NorthAmericanSummitonAspirationintheCriticallyIll:consensusstatement.JParenterEnteralNutr.2002;26:S80S85. 58. American Gastroenterological Association. American Gastroenterological Association technical review on tube feeding for enteral nutrition.Gastroenterology.1995;108:12821301. 59. RussellM,CromerM,GrantJ.Complicationsofenteralnutritiontherapy.In:GottschlichMM,ed.TheScienceandPracticeofNutrition Support:ACaseBasedCoreCurriculum.Dubuque,Iowa:Kendall/HuntPublishingCo;2001. 60. MaloneyJP,RyanTA,BraselKJ,BinionDG,JohnsonDR,HalbowerAC,FrankelEH,NyffelerM,MossM.Fooddyeuseinenteralfeedings: areviewandacallforamoratorium.NutrClinPract.2002;17:169181. 61. Critical care. Nutrition care. In: The American Dietetic Association Nutrition Care Manual. Updated annually. Available at: nutritioncaremanual.org.AccessedSeptember27,2010. 62. RobertsonCM,CoopersmithCM.Thesystemicinflammatoryresponsesyndrome.MicrobesInfect.2006;8:13821389. 63. DoakKK,HaasCE,DunniganKJ,ReissRA,ReiserJR,HuntressJ,AltavelaJL.Bioavailabilityofphenytoinacidandphenytoinsodiumwith enteralfeedings.Pharmacotherapy.1998;18:636645. 64. FarajiB,YuPP.Serumphenytoinlevelsofpatientsongastrostomytubefeeding.JNeurosciNurs.1998;30:5559. 65. GilbertS,HattonJ,MagnusonB.Howtominimizeinteractionbetweenphenytoinandenteralfeedings:twoapproaches.NutrClinPract. 1996;11:2831. Bibliography Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A CaseBased ApproachThe Adult Patient. Silver Spring, Md: AmericanSocietyofEnteralandParenteralNutrition;2007. Critical Illness EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American Dietetic Association;2006.Availableat:www.adaevidencelibrary.com.AccessedOctober1,2010. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2008;108:873882. Joint Standards Task Force of ASPEN and the American Dietetic Association Dietitians in Nutrition Support Practice Group. Russell M, Stieber M, Brantley S, Freeman AM, Lefton J, Malone AM, Roberts S, Skates J, Young LS. American Society for Parenteral and Enteral NutritionandAmericanDieteticAssociation:standardsofpracticeandstandardsofprofessionalperformanceforregistereddietitians (generalist,specialty,andadvanced)innutritionsupport.JAmDietAssoc.2007;107:18151822. BankheadR,BoullataJ,BrantleyS,CorkinsM,GuenterP,KrenitskyJ,LymanB,MethenyNA,MuellerC,RobbinsS,WesselJ;ASPEN BoardofDirectors.Enteralnutritionpracticerecommendations.JParenterEnteralNutr.2009;33:122167.Alsoavailableat: www.eatright.org(EvidenceBasedPracticelink).AccessedSeptember20,2010.
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PARENTERALNUTRITIONSUPPORTFORADULTS
Overview Parenteralnutritionistheprovisionofnutrientsintravenously.Sincethe1960s,majoradvanceshavebeen seeninthetechnique,delivery,andformulationofparenteralnutrition (1).Theuseofguidelinesforpractice has improved nutritional markers and reduced the rates of complications of patients receiving parenteral nutrition (1,2). The two primary types of parenteral nutrition are central parenteral nutrition (CPN) and peripheralparenteralnutrition(PPN). In CPN (or total parenteral nutrition), nutrients are provided through a largediameter vein, usually the superiorvenacava,byaccessofthesubclavianorinternaljugularvein.TheCPNformulasarehyperosmolar (1,300to1,800mOsm/L)andconsistofglucose(15%to25%),aminoacids,andelectrolytestofullymeetthe patientsnutritionalneeds.ThenutrientandfluidcompositionofCPNcanbeadjustedtomeettheindividual needs of patients who require fluid restriction (3). When venous access for the delivery of nutrients is requiredforlongerthan2weeks,CPNisindicatedbecauseitcanbemaintainedforprolongedperiods(1). InPPN,aperipheralveinprovidesvenousaccess.ThisformofparenteralnutritionissimilartoCPNexcept thatlowerformulaconcentrationsmustbeusedbecausetheperipheralveincanonlytoleratesolutionsthat are less than 900 mOsm/L. Compared with CPN formulas, PPN formulas have lower concentrations of dextrose (5% to 10%) and amino acids (3%). Because higher concentrations cannot be infused into the peripheral vein, PPN requires larger fluid volumes to provide energy and protein doses comparable to the dosesprovidedbyCPN.Thelargerfluidvolumeposesachallengeforpatientswhorequirefluidrestriction. ThemaximumvolumeofPPNthatisusuallytoleratedis3L/day(125mL/hour).Repletionofnutrientstores is not a goal of PPN, and it should not be used in severely malnourished patients (1). The use of PPN is indicated only for mildly to moderately malnourished patients who are unable to ingest adequate energy orallyorenterally,orforpatientsinwhomCPNisnotfeasible.Typically,PPNisusedforshortperiods(5 daysto2weeks)becauseoflimitedtoleranceandthevulnerabilityofperipheralveins(eg,riskofperipheral venousthrombophlebitis)(1). NutritionAssessment Ametaanalysisofparenteralnutritionsuggeststhatthisrouteofnutritionsupportincreasesinfectionrates without measurable beneficial outcomes when compared to controls (4). Parenteral nutrition is costly and mayresultinseriouscomplicationsandrisksifthepatientisnotmonitoredclosely(5,6).Stepsmustbetaken to maximize the benefit and efficacy of parenteral nutrition while reducing the inherent risks of hyperglycemia, immune suppression, increased oxidative stress, and potential infectious morbidity (6). Patientswhoarecandidatesforparenteralnutritionmustbecarefullyselected,andstepsmustbetakento providethemosteffectivedose,content,monitoringprocess,andsupplementaladditives(6). Indications(13) GuidelinesfortheimplementationofparenteralnutritionhavebeendevelopedbytheAmericanSocietyfor ParenteralandEnteralNutrition(ASPEN) (1,6).Parenteralnutritionisindicatedforpatientswhoareunable to receive adequate nutrients via the enteral route (eg, patients who have a nonfunctional or severely compromised gastrointestinal tract). The indications for parenteral nutrition include (1,3,6,7): malnutrition whenenteralnutritionisnotfeasible(6) major surgical procedures where the preoperative assessment indicates that enteral nutrition is not feasiblethroughtheperioperativeperiod,andthepatientismalnourished(6) perioperativesupportofmoderatelytoseverelymalnourishedpatientswithgastrointestinalcancer after 7 days of hospitalization when enteral nutrition has not been feasible or has been insufficient to consistentlymeetthetargetenergygoal(6) severemalabsorptioncausedbymassivebowelresection(70%resected)orseverediarrhea intractablevomiting severeacute,necrotizingpancreatitisinpatientswhohaveahistoryofpoortolerancetoenteralnutrition orforwhomenteralfeedingisnotpossibleatorbeyondtheligamentofTreitz(6,8,9)(Parenteralnutrition shouldnotbeinitiateduntilafterthefirst5daysofhospitalization.)(6) paralyticileusrequiringprolongedbowelrest completeintestinalobstruction
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ParenteralNutritionSupportforAdults
Contraindications(1,3,6,7) Parenteralnutritionisnotindicatedforpatients: whohaveafullyfunctionalandaccessiblegastrointestinaltract forwhomvenousaccesscannotbeobtained whoseprognosisdoesnotwarrantaggressivenutritionsupport whoseneedforparenteralnutritionisexpectedtobelessthan7days(6) for whom the risks of parenteral nutrition exceed the potential benefits, such as in cases of severe hyperglycemia(>300mg/dL),azotemia,encephalopathy,hyperosmolality(>350mOsm/kg),andsevere fluidandelectrolytedisturbances(3) NutritionIntervention ParenteralFeedingFormulations Theosmolarityofaparenteralformuladependsontheenergysubstratemixture,primarilythedextrose(5 mOsm/g),aminoacid(10mOsm/g),andelectrolyte(1mOsm/mEq)content(3).Forexample,theestimated osmolarityofaparenteralfeedingformulathatprovides150g/Lofdextrose,50g/Lofaminoacids,and150 mEq/Lofelectrolyteadditivesis1,400mOsm/L (3).Themaximumosmolaritytoleratedbyaperipheralvein is900mOsm/L (10,11).Formulasforperipheralveinadministrationusuallyrequiremorefluidandahigher contentoffatasanenergysourcethanformulasforcentralaccess,aslipidsareisotonic(3).Midlinecatheters canbeusedtoimproveperipheralveintolerancetothenutritioninfusionbecausethesecatheterscanaccess larger veins where the blood flow may dilute the parenteral feeding formulations to a more tolerable concentration (3).Fluidrestricted,energydenseformulationsshouldbeconsideredforpatientswithacute respiratoryfailure(6). NutrientSourcesandIndications Energyrequirements:Mildlypermissiveunderfeedingshouldbeconsidered,atleastinitially,foralladult criticallyillintensivecareunit(ICU)patientsreceivingparenteralnutrition (6).Theultimategoalordoseof parenteralfeedingshouldbe80%ofthepatientsenergyrequirements (6).Thisstrategyavoidsthepotential for insulin resistance, greater infectious morbidity, prolonged duration of mechanical ventilation, and increased length of hospitalization that is associated with excessive energy intake (6). As the patient stabilizes,parenteralnutritionmaybeincreasedtomeetenergyrequirements (6).Forobesepatients(body massindex(BMI)>30kg/m2),thedoseofparenteralnutritionwithregardtoproteinandenergyprovision should follow the same recommendations given for enteral nutrition (6). Guidelines for critically ill adult patients from ASPEN and the Society of Critical Care Medicine recommend permissive underfeeding or hypocaloricfeedingwithenteralnutritionforobesepatients (6).Thegoaloftheenteralnutritionregimenfor obesepatientsshouldnotexceed60%to70%oftargetenergyrequirementsor11to14kcal/kgactualbody weightperday(or22to25kcal/kgidealbodyweightperday)(6). Carbohydrate sources: The most commonly used source of carbohydrate is dextrose. Dextrose in its monohydrate form provides 3.4 kcal/g. Commercial dextrose solutions are available in concentrations rangingfrom2.5%to70% (11).Thesesolutionsareacidic,withapHrangingfrom3.5to6.5 (11).Formulas withfinaldextroseconcentrationsgreaterthan10%arereservedforcentralvenousaccess(11).Sugaralcohol glycerol is a less frequently used carbohydrate source, and it provides 4.3 kcal/g. Parenteral formulas containingsugaralcoholglycerolareproteinsparingandinduceasmallerinsulinresponseascomparedto dextrosebased solutions (1214). More research is needed to determine the efficacy of the routine use of parenteralformulasthatcontainsugaralcoholglycerol. Carbohydrate requirements: The minimum requirements for dextrose are 1 mg/kg per minute (approximately 100 g/day for a 70kg person). The maximum amount of carbohydrate tolerated is approximately 5 to 7 mg/kg per minute (1,15). Hyperglycemia, which is caused by various factors including stress, is the most common complication of parenteral nutrition (11). When carbohydrate is provided in excess,hyperglycemia,hepaticsteatosis,andincreasedCO2productioncanoccur.Maintainingglucoseinthe rangeof80to110mg/dLhasbeenassociatedwithdecreasedmorbidityandmortalityinsurgicalintensive care patients (1618). However, recent studies have suggested that moderate glucose control (140 to 180
enterocutaneous fistula with an output greater than 500 mL/day (A trial of enteral nutrition can be consideredwhentheoutputislessthan200mL/dayorwhenenteralaccessmaybeplacedposteriorto thefistula.)(1) acuteexacerbationsofinflammatoryboweldisease(eg,Crohndisease)complicatedbyfistulas radiationtherapyorallogeneicbonemarrowtransplantation
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mg/dL) reduces the risk of hypoglycemia and hypoglycemiaassociated mortality as compared to stricter glucosecontrol(80to110 mg/dL) (6).Consideringthisevidence,ASPENguidelinesrecommendtargetinga moremoderaterangeof100to150mg/dLwhenprovidingnutritionsupporttherapytocriticallyillpatients (6). The Standards of Medical Care in Diabetes, updated annually by the American Diabetes Association, recommendsatargetglucoselevelof140to180mg/dLincriticallyillpatientswithexistingdiabetesmellitus (19). Specific guidelines for glucose control in critical care are currently being evaluated and revised by the AmericanDieteticAssociation.Dietitiansshouldcollaboratewiththemedicalteamtoidentifyprotocolsfor optimalglucosecontrolbasedonclinicalmanagementguidelines(6). For patients with hyperglycemia, the parenteralnutrition dextrose should be started conservatively and graduallyincreasedtothepatientsindividualizedgoalrate.Itisrecommendedthatthegoalrateshouldnot exceed4to5mg/kgperminuteor20to25kcal/kgperday(20).Capillarybloodglucoseshouldbemeasured atleastevery6hours(19).Regularinsulincanbeprovidedsubcutaneouslyoraddeddirectlytotheparenteral solution (18,20). An insulin drip provides more consistent and safe glucose control (19). Blood glucose concentrationscanbecontrolledbyaninitialinsulinregimenof0.05to0.1U/gofdextroseintheparenteral solution or by 0.15 to 0.2 U/g of dextrose in hyperglycemic patients (20). When added to the solution, it is recommendedthattwothirdsofthetotalamountofslidingscaleinsulinrequiredover24hoursbeaddedto thenextdaysparenteralformula(20).Aproportionalincreaseinfatmaybenecessarytoincreasetheenergy providedtopatientswhosebloodglucoselevelsaredifficulttocontrol (20).Rarely,hyperglycemiaiscaused by a chromium deficiency. If insulin is ineffective or a chromium deficiency is confirmed, increasing the chromium contained in the parenteral formula may be appropriate (21). Refer to Section III: Metabolic Complications of Parenteral Nutrition and Section C: Medical Nutrition Therapy for Diabetes Mellitus for specificglycemicgoalsinmanaginghospitalizedpatientswithdiabetesmellitus. Patientsatriskofdevelopingrefeedingsyndromeshouldbemonitoredclosely.Refeedingsyndromerefers tometabolicandphysiologicshiftsofelectrolytesandminerals(eg,phosphorus,magnesium,andpotassium) caused by aggressive nutrition support (1,22). Carbohydrate delivery stimulates insulin secretion, which causes an intracellular shift of these electrolytes and minerals with the potential for severe hypophosphatemia, hypomagnesemia, and hypokalemia (19,22). Symptoms of refeeding syndrome include fatigue, lethargy, muscle weakness, edema, cardiac arrhythmia, and hemolysis (19,22). Patients who have marginal nutrient stores secondary to a disease or medical therapy are at the greatest risk for refeeding syndrome;thesepatientsshouldinitiallyreceive15to20kcal/kgofformulaperday,andthentheamountof parenteral formula should be slowly increased (20,22). (Refer to Section III: Metabolic Complications of ParenteralNutrition.) Proteinsources:Crystallineaminoacids,whichprovide4kcal/g,arethemostcommonsourceofproteinin parenteral formulas. Standard or balanced aminoacid products are mixtures of essentialand nonessential aminoacidsranginginconcentrationsfrom3%to20%,although8.5%and10%aremostfrequentlyusedfor parenteral nutrition compounding (11). Most commercially available amino acid formulations also contain electrolytes, buffers, or both. Modified or special amino acid products have been formulated for certain diseasestatesandconditionsinwhichconventionalaminoacidsolutionsmaynotbewelltolerated(eg,renal failure and hepatic failure) (11). The contribution of these formulas to an improvement in overall clinical outcome is debatable. These formulas usually cost much more than conventional amino acid solutions. Therefore,theclinicianshouldevaluatethecostinlightofthepotentialbenefittothepatient. ASPENguidelinesfornutritionsupportarethebasisforthefollowingdiscussionofspecializedaminoacid formulas(1,6): Formulations for liver disease: Standardformulations should beused in ICU patients with acuteand chronicliverdisease (6).Proteinrestrictionshouldbeavoidedinpatientswithliverfailure (6).Formulas thatcontainhighlevelsofbranchedchainaminoacids(BCAA)andlowlevelsofaromaticaminoacidsare designedtocorrectabnormalaminoacidprofilesassociatedwithhepaticencephalopathy,asBCAAare metabolizedindependentlyofliverfunction.ASPENguidelinesrecommendthatBCAAformulasonlybe used in the rare case of a patient who has hepatic encephalopathy that is refractory to standard treatmentwithluminalactingantibioticsandlactulose(1,6). Formulationsforrenaldisease:Essentialaminoacidsaretheprimaryproteinsourceinformulations designed for patients with renal disease. This formula design is based on the theory that nonessential aminoacidscanbephysiologicallyrecycledfromurea,whiletheessentialaminoacidsmustbeprovided bythediet (11).Theseformulashavenostatisticallysignificantadvantageswhencomparedtostandard B49
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amino acid formulas (1,23). The ASPEN guidelines suggest that ICU patients with acute renal failure receive standard enteral or parenteral formulations and that the standard ICU recommendations for protein and energy provision should befollowed (6).A specialty formulationdesignedfor renal failure (withtheappropriateelectrolyteprofile)maybeconsideredforpatientswhohavesignificantelectrolyte abnormalities (6). Patients receiving hemodialysis or continuous renal replacement therapy should receive increased amounts of protein, up to a maximum of 2.5 g/kg per day (6). Protein should not be restricted in patients with renal insufficiency as a means to avoid or delay the initiation of dialysis therapy(6). Concentrated amino acid formulations: Highly concentrated (15% to 20%) amino acid formulations areavailableforusewhenfluidrestrictionisrequired.Theseformulationsaresimilarincompositionto standardaminoacidformulas,exceptthattheymaycontainlargeramountsofchlorideandacetate(11). Pediatric formulations: Pediatric formulas have been designed to meet the unique amino acid requirementsofneonates,infants,andchildreninordertopromoteweightgain,nitrogenbalance,and growth and to avoid an excess of certain amino acids (eg, phenylalanine and methionine) (1). These products generally contain taurine, tyrosine, histidine, arginine, and Lcysteine (semiessential to neonates)(1). Glutamine:Glutamineisaconditionallyessentialaminoacidduringtimesofmetabolicstress.Therehas beenconsiderableinterestinthepotentialbeneficialeffectsofglutamine,includingsystemicantioxidant effects,maintenanceofgutintegrity,inductionofheatshockproteins,anduseasafuelsourceforrapidly replicating cells (6). The addition of parenteral glutamine at a doseof 0.5 g/kg per day to a parenteral regimenreducesinfectiouscomplications,ICUlengthofstay,andmortalityincriticallyillICUpatients,as comparedtothesameparenteralnutritionregimenwithoutglutamine (6).Currently,crystallineamino acid formulations in the United States and Canada do not contain glutamine (6). Due to stability and compatibility issues, there is no intravenous form of glutamine that is commercially available for admixture in parenteral solutions (6,11). Studies of glutaminesupplemented parenteral formulas have used preparations of powdered Lglutamine sterilized by filtration (6,24,25). The ASPEN guidelines recommendthatsupplementationwithparenteralglutaminebeconsideredwhenparenteralnutritionis usedinthecriticalcaresetting(6).
Proteinrequirements:Proteinrequirementsshouldbebasedonthepatientsindividualneedsanddisease process. Critical illness and hypermetabolism are associated with increased protein turnover, protein catabolism, and negative nitrogen balance (6,26). During a critical illness, protein requirements can double increasingtoapproximately15%to20%oftotalenergy.Proteinrequirementsforthecriticallyillpatientare atleast1.5g/kgperday,andadequateenergyshouldbeprovidedtomeettheestimatedneedsasdetermined byindirectcalorimetryorpredictiveequations (26).Theproteinrequirementsofcriticallyillpatientswhoare notobese(BMI<30kg/m2)are1.2to2.0g/kgactualbodyweightperday,althoughburnpatientsormultiple traumapatientsmayrequiregreateramountsofprotein (6).Proteinsparingdoesnottypicallyimprovewith proteinintakesgreaterthan1.5g/kgperday,exceptinseverelyburnedpatients (26).TheASPENguidelines forcriticalcareICUadultpatientsrecommendadailyproteinintakeofmorethan2.0g/kgidealbodyweight forclassIandIIobesepatients(BMI,30to40kg/m2)andmorethan2.5g/kgidealbodyweightforclassIII obesepatients(BMI>40kg/m2)(6). Lipidsources:Isotoniclipidemulsionsprovideenergyandessentialfattyacids.Lipidsourcesarederived from soybean oil or a 50:50 mixture of soybean and safflower oils (11). In North American, the choice of parenteral lipid emulsion is severely limitedtoasoybased, 18carbon omega6 fattyacid preparationthat hasproinflammatorycharacteristicsintheICUpopulation(6).Duringthefirst7daysintheICUsetting,asoy based,lipidfreeparenteralnutritionregimenhasbeenshowntobeassociatedwithasignificantreductionin infectiousmorbidity(pneumoniaandcatheterrelatedsepsis),adecreasedlengthofhospitalizationandICU stay,andashorterdurationofmechanicalventilationascomparedtotheuseoflipidcontainingparenteral nutrition (6). ASPEN guidelines for critically ill ICU patients recommend that during the first week of hospitalization when enteral nutrition is not feasible, a parenteral formulation without soybased lipids shouldbeconsidered (6).Lipidsourcesareemulsifiedwitheggyolkphospholipid;therefore,theirusemay be contraindicated in patients with egg allergies. Each gram of lipid provides 9 kcal. Lipid emulsions are availablein10%(1.1kcal/mL),20%(2kcal/mL),and30%(3kcal/mL)concentrations (11).The30%lipid formulation is approved only for compounding of the total nutrient admixture, not for direct intravenous administration(11).
Investigational intravenous fat emulsion (IVFE) products include physical mixtures of mediumchain triglyceridesandlongchaintriglycerides.Theseformulationsmaybeusefulforpatientswhoareintolerant tothelongchaintriglycerideproductsduringcriticalillnessandmetabolicstressandalsoforpatientswith
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carnitinedeficiency(11).Structuredlipidformulascontaininglinoleicacid,mediumchainfattyacids,andvery longchain omega3 fatty acid are being investigated to determine if they produce less inflammatory and nonthrombogenic prostaglandins than standard lipid emulsions (11). These formulas have been studied in patientswithsepsis,atopicdermatitis,orsevereulcerativecolitisandpatientsundergoingelectivesurgery (27,28).TheseformulasareunderinvestigationalstudyandarenotavailableforintravenoususeintheUnited States(11). BecauseoftheenhancedmicrobialgrowthpotentialwiththeinfusionofIVFEseparatelyfromdextroseand aminoacidformulations,theCentersforDiseaseControlandPreventionrecommendsa12hourhangtime limit for IVFE (29). The United States Pharmacopeial has also endorsed the use of IVFE products within 12 hours of opening the original manufacturers container if the IVFE products are infused as separate preparations from dextrose and amino acids (30). However, because of the lower pH (5.6 to 6.0) of a total nutrientadmixturethatcontainsIVFE,dextrose,andaminoacidsinthesamecontainer,thefatemulsionmay beadministeredover24hourswheninfusedinatotalnutrientadmixture(11).Whetherinfusedseparatelyor asatotalnutrientadmixture,theinfusionrateofIVFEsshouldnotexceed0.11g/kgperhourtoreduceside effects,suchashypertriglyceridemia,andinfectiouscomplications(11,31). Lipidrequirements:Whenapatientismedicallystable,lipidsprovideanimportantsourceofessentialfatty acids.Atotalof2%to4%ofdailyenergyneedsshouldbesuppliedaslinoleicacid(1%to2%oflinoleicacid and0.5%ofalphalinolenicacid)(1)or25to100mg/kgofessentialfattyacids(1,32,33).Aminimumof500mL of10%lipidstocksolutionor250mLof20%stocksolutionadministeredover8to10hours,twotothree timesperweek,issufficienttopreventadeficiencyofessentialfattyacids.Alternately,500mLofa20%fat emulsioncanbegivenonceaweek (34).Excessiveamountsofintravenouslipidsorrapidinfusionratescan cause hyperlipidemia (20). Levels of serum triglycerides should be evaluated before the infusion of intravenous lipids. Four hours after lipid infusion, acceptable serum triglycerides levels are less than 250 mg/dL for piggybacked lipids and less than 400 mg/dL for continuous lipid infusion (1). The infusion of intravenous lipids has been associated with impaired immune responses and vascular integrity (19,32,35). Infusion rates of greater than 110 mg/kg per hour may result in reduced lipid clearance and impaired reticuloendothelialfunctionandpulmonaryexchange (32).Itisrecommendedthatfatintakeberestrictedto less than 25% to 30% of total energy, or 1 g/kg per day, and provided slowly over 8 to 10 hours if administeredasanintravenoussupplement(32,34).Nomorethan2.5g/kgper24hoursshouldbeprovidedto adultpatients (1).Therapidinfusionoffatemulsions,regardlessofthetotalamount,shouldbeavoidedin patientswhohaveseverepulmonaryfailure(6). The recommendations for lipids given to critically ill patients requiring parenteral nutrition are more conservative;thedatasupporttheadministrationoflessthan1.0g/kgperday (1,34).ASPENguidelinesfor critically ill ICU patients suggests during the first week of hospitalization (when enteral nutrition is not feasible), the use of a parenteral formulation without soybased lipids should be considered in order to reduce the risks associated with the proinflammatory effects previously discussed (6). These guidelines acknowledge that parenteral nutrition without lipids might exacerbate stressinduced hyperglycemia; therefore, the recommendation should be cautiously applied with consideration to the individual patients nutritional needs and acute medical situation (6). Carnitine deficiency can leadtofatdepositionin the liver andmuscle,impairedketogenesis,andneurologicsymptoms.Parenteralnutritionsolutionsdonotcontain carnitine, and the supplemental use of carnitine in adults has not been studied. However, carnitine supplementation has been suggested for neonates who receive parenteral nutrition for more than 2 weeks (36). ParenteralIntravenousVitaminsandRequirements In 2000, the Food and Drug Administration (FDA) modified the requirements for adult intravenous multivitamin products. The required amounts of ascorbic acid, thiamin, pyridoxine, and folic acid were increased,andarequirementforvitaminKwasadded (37) (seeTableB4).WiththeadditionofvitaminKto these formulations, the prothrombin time and international normalized ratio of patients who receive anticoagulant therapy should be closely monitored, and anticoagulant medication should be adjusted as needed (20). Two formulas without vitamin K are available for patients whose prothrombin time or internationalnormalizedratiolevelsaredifficulttomanage (38).Thevitaminandmineralrequirementsfor parenteral nutrition should be based on the Dietary Reference Intakes for the patients age and sex (38). Clinicians should consider the deleterious impact of exceeding the FDArecommended levels of parenteral vitamins,andthepotentialharmthatexcessivevitaminintakehasonothermicronutrients,traceelements, andimmunestatus(38).
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TableB4:FDARequirementsforParenteralMultivitaminProducts(37) Vitamin Amount Thiamin(B1) 3 mg Riboflavin(B2) 3.6 mg 6 mg Pyridoxine(B3) 5 mcg Cyanocobalamin(B12) Niacin 40 mg Folicacid 600 mcg Pantothenicacid 15 mg Biotin 60 mcg Ascorbicacid 200 mg VitaminA(retinol) 1 mg VitaminD 5 mcg VitaminE 10 mg 150 mcg VitaminK
ParenteralIntravenousTraceMineralsandRequirements TheASPENrecommendationsfordailyparenteralintakeofthetraceelementszinc,copper,chromium,and manganese were updated in 2004 (Table B5) and remains the most current (16). These updated recommendationsincludetheadditionofseleniumsupplementation(20to60mcg/day) (16).Traceminerals are available as singleentity and combination products in various concentrations for adults, children, and neonates; products with a combination of trace minerals and electrolytes are also available (11,38). Other elementsthatmaybesupplementedonanindividualizedbasisincludemolybdenum,iodine,andiron.Iron supplementationisgenerallynotrequiredforshorttermparenteralnutrition,unlessthepatientisanemic. Oralironsupplementationisthepreferredroute.However,iforalsupplementationisinfeasible,irondextran canbeintravenouslyadministered(38).Theadditionofirontototalnutrientadmixturesisnotrecommended becauseofcompatibilityproblems (39).Patientswithintestinalfluidlosses(eg,patientswithostomies)may require additional supplementation of zinc and chromium (see Table B5). Patients with intestinal losses requireanadditional12mgofzincperliterofoutputfromthesmallbowelandanadditional17mgofzinc perliterofstoolorileostomyoutput (16,40).Chromiumrequirementsmayalsoincreaseto20mcg/daywith gastrointestinallossesinadults(16). TableB5:ParenteralTraceElementSupplementationforAdults(DoseperDay) 2004ASPEN Gastrointestinal TraceElement Recommendation Losses Zinca 2.55.0mga Addb Copper 0.30.5mg 500mcg Chromium 1015mcg 20mcg Manganese 60100mcg Selenium 2060mcg
a b
Add2mg/dayforhypermetabolicpatients. Add12mg/Lofoutputfromthesmallbowel,andadd17mg/Lofstoolorileostomyoutput.
AdaptedfromthefollowingtwosourceswithpermissionfromASPEN.ASPENdoesnotendorsetheuseofthismaterialinanyformother thanitsentirety: ClarkSF.Vitaminsandtraceelements.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACaseBasedApproach TheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:148(Table85). ASPEN Board of Directors. Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition Support in Adults. Silver Spring,Md:AmericanSocietyforParenteralandEnteralNutrition;1998:5.
ParenteralElectrolytesandRequirements Therapeutic amounts of electrolytes are added to parenteral formulations depending on the patients requirements (11). The serum phosphate levels of critically ill patients should be monitored closely, and phosphate should be provided when needed due to its essential role in optimal pulmonary function (6). Electrolytes are available in salt forms, including sodium and potassium as chloride acetate or phosphate; calciumaschloride,gluconate,orgluceptate;andmagnesiumassulfateorchloride.Calciumgluconateand magnesium sulfate are the preferred forms of these cations because they produce fewer physiochemical incompatibilities (11). The standard daily electrolyte ranges for adults (Table B6) should be adjusted as indicatedbytheclinicalsituation(11).Acetateandchloridedonothavespecificrangesforintake;rather,they areadjustedasneededtomaintaintheacidbasebalance(10,11).
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TableB6:ElectrolyteRequirements(11) Electrolyte Requirement Sodiumandpotassium 12mEq/kg+replacementlosses Calcium 1015mEq Magnesium 820mEq Phosphate 2040mmol
TotalNutrientAdmixtureParenteralSolutions Total nutrient admixture parenteral solutions, also known as threeinone or allinone solutions, are composedofaminoacids,dextrose,lipids,vitamins,traceelements,andelectrolytesinonecontainer.This method of nutrient delivery differs from the conventional method (twoinone) of providing CPN, in which lipidsareinaseparatecontainerandpiggybackedinwiththeaminoaciddextrosesolution.Bothtypesof parenteralformulationsystemsareinusetoday (11). Bydefinition,thetotalnutrientadmixtureincludesthe lipid emulsion on a daily basis, providing an additional energy source (11). Total nutrient admixtures have decreased the cost of CPN due to the decreased administrative and equipment costs associated with CPN preparationandthedecreasednursingtime (39).Totalnutrientadmixturesmayalsohelppreventexcessive dextrose administration in critically ill patients (39,41). Also, lipids are administered over a 24hour period, whichmaypromotebetterpatienttolerance(41).
Onedisadvantageoftotalnutrientadmixturesisthattheyprovideabetterbacterialgrowthmediumthan theconventionalsystem.Also,mostparticulatematterintheadmixturecannotbevisuallyinspected(39,41,42). Conventionalsolutionsusea0.22minlinefilter;however,totalnutrientadmixturesrequirealargerinline filter (1.2 m) because they contain lipids. This larger filter is sufficient for trapping solution particulates, precipitates, and Candida albicans, but it does not protect against contaminates such as Staphylococcus epidermidis, Escherichia coli, and bacterial endotoxins (11,39,41,42). Refer to the previous discussion on lipid sourcesforhangtimeandinfusionguidelines. StabilityandCompatibility Theconcentrationsofcalciumandphosphateionsaredirectlyrelatedtotheriskofprecipitation,whichcan result in serious injury and death (43). As the concentration of either micronutrient rises, the likelihood of precipitation increases (11). Productspecific solubility curves that depict solubility limits for calcium and phosphatesaltshavebeenpublished (43).Theverificationoflargecalciumdoses(morethantwotimesthe DietaryReferenceIntake)canhelpminimizetheriskofprecipitation(11).
TableB7:MonitoringHospitalizedPatientsReceivingCPN(4445) MetabolicorClinicalParameter MonitoringFrequency Bloodglucose Every6hoursuntilstable;100to150mg/dLin criticallyillpatients(6,16,20,45,46)and140to180 mg/dLincriticallyilldiabeticpatients(46) Baseline,dailyuntilstable,thentwoorthreetimesper Electrolytes(Na,K,Cl),CO2,bloodureanitrogen, week creatinine,Mga,Cab,phosphorus Totalbilirubin,liverfunctiontests(alanine Baseline,dailyuntilstable,thenweekly aminotransferase,aspartateaminotransferase, andalkalinephosphatase) Completebloodcellcountwithdifferential Baseline,thenweekly a Magnesium(Mg)andalbuminlevelsarelinearlyrelatedathighandlowalbuminconcentrations,with25%ofthetotalserummagnesium
bound to albumin and 8% bound to globulins (41). Hypomagnesia can be corrected for hypoalbuminemia by the following formula: CorrectedMg++=Mg+++0.005(40mg/dLAlbumin). b Half of total calcium (Ca) is protein bound; therefore, during hypoalbuminemia, the true calcium status may not be represented by measuringserumcalciumlevels.Thereisa0.8mg/dLdecreaseinthetotalconcentrationofserumcalciumforeach1.0mg/dLdecrease inthealbuminconcentrationbelow4.0g/dL.Correctserumcalciumcanbeestimatedbythefollowingformula:Ca++(mg/dL)=Measured Ca++ (mg/dL) + 0.8 [4.0 Albumin (g/dL)] (13). However, this formula provides only an estimate. When an accurate evaluation is needed,theionizedcalciumlevelshouldbeobtained.

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TableB7:MonitoringHospitalizedPatientsReceivingCPN(4445)(Cont.) MetabolicorClinicalParameter MonitoringFrequency Prothrombintime/partialthromboplastintime Baseline,thenweekly Albuminc Baseline,thenasneeded(>21days) Prealbuminc Baseline,thenweekly Transferrinc Baseline,thenweekly Nitrogenbalance Asneeded Weight Dailyuntilstable,thentwoorthreetimesperweek Vitalsigns(temperature,pulse,bloodpressure, Every8hoursasneeded respiratoryrate)
c The levels of acute phase hepatic proteins (albumin, prealbumin, and transferrin) can decrease by as much as 25% as a result of
acuteorchronicinflammatoryconditionsandarenolongerreliableindicatorsincriticallyillpatients.Thisdecreaseimpactstheir usabilityindeterminingnutritionrepletion.Ifinflammatorymarkers(eg,Creactiveprotein)indicateaninflammatorymetabolism, these proteins may not be reliable indicators of nutritional status. Acute phase hepatic proteins may only be reliable when malnutritionisnotcomplicatedbyinflammatorymetabolismcausedbyacuteorchronicdisease.
SeeSectionIII:ClinicalNutritionManagement PARENTERALNUTRITION(PN):METABOLICCOMPLICATIONSOFPN CALCULATINGTOTALPARENTERALNUTRITION TransitionalFeeding(6) CyclicCPN:TheinfusionofCPNoveralimitedamountoftime(usually12to18hours)iscalledcyclicCPN. CyclicCPNisindicatedforpatientswhoaremetabolicallystableandforpatientswhorequirelongtermCPN, such as patients who receive CPN at home. One advantage of cyclic CPN is that feedings more closely resemble physiologic (discontinuous) feedings, which may reduce the hepatic toxicity associated with continuous feedings. Another advantage is improved quality of life, because the patient is free from CPN equipmentduringtheday. Parenteraltoenteral:Whenthepatientistransitionedfromparenteralsupporttoenteralsupport,thetube feedingcanbeinitiatedatfullstrength(10to50mL/hour).Astherateoftubefeedingisincreased,therateof parenteralnutritionisproportionatelydecreased.Taperingofparenteralformulacanbeginwhenenteraltube feedingsareproviding33%to50%ofnutrientrequirements.Onceenteraltubefeedingsarewelltoleratedand providemorethan60%ofenergyrequirementsand100%offluidrequirements,parenteralnutritioncanbe discontinued(6). Parenteral to oral: When patients are transitioned from parenteral support to an oral diet, oral intake is startedasclearliquidsandthenprogressedinastepwisefashiontoanappropriatedietastolerated.Nutrient intakestudiesshoulddocumenttheadequacyoforalintake.Thetotalparenteralnutritionshouldbetaperedto halfoftheoriginalratewhenthepatientiseating50%ofthetotalestimatedenergyneeds.TheCPNshouldbe discontinuedwhenoralintakeconsistentlymeets60%ofestimatednutrientneedsand100%offluidneeds (6). Iforalintakedoesnotprogresstoadequateamounts,enteralnutritionshouldbeconsideredinlieuofPPNor CPN(6).

References 1. ASPENBoardofDirectorsandtheClinicalGuidelinesTaskForce.Guidelinesfortheuseofparenteralandenteralnutritioninadult andpediatricpatients.JParenterEnteralNutr.2002;26(suppl)(1):1SA138SA. 2. Trujillo EB, Young LS, Chertow GM, Randall S, Clemons T, Jacobs DO, Robinson MK. Metabolic and monetary costs of avoidable parenteralnutritionuse.JParenterEnteralNutr.1999;23:109111. 3. MirtalloJM.Overviewof parenteralnutrition.In: Gottschlich MM, ed.The A.S.P.E.N. NutritionSupportCoreCurriculum:ACase BasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:264276. 4. KoretzRL,LipmanTO,KleinS.AGAtechnicalreview:parenteralnutrition.Gastroenterology.2001;121:9701001. 5. TwomeyPL,PatchingSC.Costeffectivenessofnutritionalsupport.JParenterEnteralNutr.1985;9:310. 6. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; ASPEN Board of Directors;AmericanCollegeofCriticalCareMedicine.Guidelinesfortheprovisionandassessmentofnutritionsupporttherapyin theadultcriticallyillpatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition (A.S.P.E.N.).JParenterEnteralNutr.2009;33:277316. 7. Klein S, Kinney, Jeejeebhoy K, Alpers D, Hellerstein M, Murray M, Twomey P. Nutrition support in clinical practice: review of publisheddataandrecommendationsforfutureresearchdirections:summaryofaconferencesponsoredbytheNationalInstitutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition. J Parenter Enteral Nutr.1997;21:133156.
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12. 13. 14. 15. 16. 17. 18. 19. 20.
21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45.
Parenteral Nutrition Support for Adults TiuAmy,McClaveSA.Pancreatitis.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACaseBased ApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:558574. McClaveSA,ChangWK,Dhaliwal R,HeylandDK. Nutrition supportinacutepancreatitis:a systematicreviewoftheliterature.J ParenterEnteralNutr.2006;30:143156. National Advisory Group on Standards of Practice Guidelines for Parenteral Nutrition. Safe practices for parenteral nutrition formulations.JParenterEnteralNutr.1998;22:4966. Barber JR, Rollins CJ, Sacks GS. Parenteral nutrition formulations. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum:ACaseBasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition; 2007:277299. SingerP,BurszteinS,KirvelaO,MansourB,YoshimuraN,BlausteinJ,AskanaziJ.Hypercaloricglycerolininjuredpatients.Surgery. 1992;112:509514. LevRan A, Johnson M, Hwang DK, Askanazi J, Weissman C, Gersovitz M. Doubleblind study of glycerol vs. glucose in parenteral nutritionofpostsurgicalinsulintreateddiabeticpatients.JParenterEnteralNutr.1987;11:271274. McEvoyGK,ed.AHFSDrugInformation1999.Bethesda,Md:AmericanSocietyofHealthSystemPharmacists;1999. WolfeRR,ODonnellTFJr,StoneMD,RichmandDA,BurkeJF.Investigationoffactorsdeterminingtheoptimalglucoseinfusionrate intotalparenteralnutrition.Metabolism.1980;29:892900. Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition. J Parenter Enteral Nutr.2004;28(6suppl):S39S70. Van de Berg G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensiveinsulintherapyincriticallyillpatients.NEngJMed.2001;345:13591367. LewisKS,KaneGillSL,BobekMB,DastaJF.Intensiveinsulintherapyforcriticallyillpatients.AnnPharmacother.2004;38:1243 1251. AmericanDiabetesAssociation.Standardsofmedicalcareindiabetes2010.DiabetesCare.2010;33(suppl1):11S61S. Kumpf VJ, Gervasio J. Complications of parenteral nutrition. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum:ACaseBasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition; 2007:323339. JeejeebhoyKN,ChuRC,MarlissEB,GreenbergGR,BruceRobertsonA.Chromiumdeficiency,glucoseintolerance,andneuropathy reversedbychromiumsupplementation,inpatientreceivinglongtermtotalparenteralnutrition.AmJClinNutr.1977;30:531538. SolomonSM,KirbyDF.Therefeedingsyndrome:areview.JParenterEnteralNutr.1990;14:9097. MelnickG.Valueofspecialtyintravenousaminoacidsolutions.AmJHealthSystPharm.1996;53:671674. Schloerb PR, Skikne BS. Oral and parenteral glutamine in bone marrow transplantation: a randomized, doubleblind study. J ParenterEnteralNutr.1999;23:117122. ZieglerTR,BenfellK,SmithRJ,YoungLS,BrownE,FerrariBalivieraE,LoweDK,WilmoreDW.SafetyandmetaboliceffectsofL glutamineadministrationinhumans.JParenterEnterNutr.1990;14:137S146S. YoungLS,KearnsLR,SchoepfelSL.Protein.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACaseBased ApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:83. MayserP,MayerK,MahloudjianM,BenzingS,KramerHJ,SchillWB,SeegerW,GrimmingerF.Adoubleblind,randomized,placebo controlledtrialofn3versusn6fattyacidbasedlipidinfusioninatopicdermatitis.JParenterEnteralNutr.2002;26:151158. WeissG,MeyerF,MatthiesB,ProssM,KoenigW,LippertH.Immunomodulationbyperioperativeadministrationofn3fattyacids. BrJNutr.2002;87:S89S94. CentersforDiseaseControlandPrevention.Guidelinesforthepreventionofintravascularcatheterrelatedinfections[published erratumappearsinMMWRRecommRep.2002;51:711].MMWRRecommRep.2002;51:(RR10):129. Chapter <797>. Pharmaceutical compoundingsterile preparations. Physical tests. United States Pharmacopeia 28/National Formulary23.Rockville,Md:UnitedStatesPharmacopeialConvention;2005:24612477. KleinS,MilesJM.Metaboliceffectsoflongchainandmediumchaintriglyceridesinhumans.JParenterEnteralNutr.1994;18:396 397. SeidnerDL,MascioliEA,IstfanNW,PorterKA,SelleckK,BlackburnGL,BristrianBR.Effectsoflongchaintriglycerideemulsionson reticuloendothelialsystemfunctioninhumans.JParenterEnteralNutr.1989;13:614619. Holman RT. The ratio of trienoic:tetraenoic acids in tissue lipids as a measure of essential fatty acid requirement. J Nutr. 1960;70:410415. HisseM,BrownJC.Lipids.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACaseBasedApproachThe AdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:5457. KollefMN,McCormackMT,CarasWE,ReddyVV,BaconD.Thefatoverloadsyndrome:successfultreatmentwithplasmaexchange. AnnInternMed.1990;112:545546. TibboelD,DelemarreFM,PrzyrembelH,BosAP,AffourtitMJ,MolenaarJC.Carnitinedeficiencyinsurgicalneonatesreceivingtotal parenteralnutrition.JPediatrSurg.1990;25:418425. Parenteralmultivitaminproducts; drugsforhuman use;drugefficacystudyimplementation;amendment(21CFR5.70).Federal Register.April20,2000;65:2120021201. Clark S. Vitamins and trace elements. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A CaseBased ApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:5457. DriscollD.Totalnutrientadmixtures:theoryandpractice.NutrClinPract.1995;10:114119. WolmanSL,AndersonGH,MarlissEB,JeejeebhoyKN.Zincinoraltotalparenteralnutrition:requirementsandmetaboliceffects. Gastroenterology.1979;76:458467. DAngio RG, Reichers KC, Gilsdorf RB, Costantino JM. Effect of the mode of lipid administration on parenteral nutritionrelated infections.AnnPharmacother.1992;26:1417. ErdmanSH,McElweeCL,KramerJM,ZuppanCW,WhiteJJ,GrillBB.Centrallineocclusionwiththreeinonenutritionadmixture administeredathome.JParenterEnteralNutr.1994;18:177181. Trissel LA, ed. Trissels Calcium and Phosphate Compatibility in Parenteral Nutrition. Houston, Tex: TriPharma Communications; 2001. ASPEN Board of Directors. ASPENs Adult Parenteral Nutrition (PN) Support Pathway. Silver Spring, Md: American Society for ParenteralandEnteralNutrition;1998. Critical Illness EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2006.Availableat:www.adaevidencelibrary.com.AccessedOctober20,2007.
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ParenteralNutritionSupportforAdults Bibliography Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A CaseBased ApproachThe Adult Patient. Silver Spring, Md: AmericanSocietyofEnteralandParenteralNutrition;2007. CriticalIllnessEvidenceBasedNutritionPracticeGuideline. AmericanDieteticAssociationEvidenceAnalysisLibrary.AmericanDietetic Association;2006.Availableat:www.adaevidencelibrary.com.AccessedOctober20,2007. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2008;108:873882. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; ASPEN Board of Directors; American College of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult criticallyillpatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition(A.S.P.E.N.).J ParenterEnteralNutr.2009;33:277316. JointStandardsTaskForceofASPENandtheAmericanDieteticAssociationNutritionSupportPracticeGroup.RussellM,StieberM,Brantley S,FreemanAM,LeftonJ,MaloneAM,RobertsS,SkatesJ,YoungLS.AmericanSocietyforParenteralandEnteralNutritionandAmerican DieteticAssociation:standardsofpracticeandstandardsofprofessionalperformanceforregistereddietitians(generalist,specialty,and advanced)innutritionsupport.JAmDietAssoc.2007;107:18151822.
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MEDICALNUTRITIONTHERAPYFORDIABETESMELLITUS
Description The goals of medical nutrition therapy for diabetes mellitus are to improve overall metabolic outcomes (glucoseandlipidlevels),provideappropriateenergytomaintaindesirablebodyweight,andimproveoverall health through optimal nutrition (1). The consistentcarbohydrate meal planning approach incorporates consistent carbohydrate intake, fat intake modifications, and consistent timing of meals and snacks (if needed). The American Diabetes Association recommends the consistentcarbohydrate meal planning approachoverthestandardizedenergylevelmealpatternsbasedontheexchangelists(13).
IndicationsandNutritionDiagnosis Diabetesisdiagnosedandclassifiedbasedontheresultsofappropriatemedicalandlaboratorytests.After extensivereviewoftheliteratureandimprovedstandardizationoftheassayin2009,theExpertCommittee on Diagnosis and Classification of Diabetes Mellitus has approved the use of the A1C test for diagnosing diabetes mellitus (1). An A1C test of > 6.5% is the threshold used to diagnose diabetes mellitus (1). See Diagnosis Criteria for Diabetes Mellitus in Section II. The classification of diabetes mellitus includes four clinicalclasses(1): type1diabetes(causedbybetacelldestructionthatusuallyleadstoabsoluteinsulindeficiency) type2diabetes(causedbyprogressiveinsulinsecretorydefectonthebackgroundofinsulinresistance) other specific types (due to other causes, eg, genetic defects in betacell function, genetic defects in insulinaction,diseasesoftheexocrinepancreas,ordrugorchemicalinduced) gestationaldiabetesmellitus(diabetesmellitusdiagnosedduringpregnancy)
Thetypeofdiabetesandtheindividualpatientsneeds,aspresentedbythenutritionsignsandsymptoms, willdeterminethenutritiondiagnosis,medicalnutritiontherapy,andapproachtoselfmanagementtraining.
Theoverallgoalofnutritioninterventionistoassistandfacilitateindividuallifestyleandbehaviorchanges thatwillleadtoimprovedmetaboliccontrol (2).Thefollowinggoalsofmedicalnutritiontherapyapplytoall personswithdiabetes(2): Attainandmaintainoptimalmetabolicoutcomesincluding(2): a)abloodglucoselevelinthenormalrange,orasclosetothenormalrangeassafelypossible,toreduce theriskofdiabeticcomplications, b)alipidandlipoproteinprofilethatreducestheriskofmacrovasculardisease,and c)bloodpressurelevelsthatreducetheriskofvasculardisease. Prevent,treat,ordelaythedevelopmentofobesity,dyslipidemia,cardiovasculardisease,hypertension, nephropathy,retinopathy,andneurologiccomplicationsassociatedwithdiabetesmellitus. Improvehealththroughhealthyfoodchoicesandphysicalactivity. Address individual nutrition needs, taking into consideration the patients personal and cultural preferencesandwillingnesstochange. Maintainthepleasureofeatingbyonlylimitingfoodchoiceswhenindicatedbyscientificevidence. Contribute to normal outcomes of pregnancies for women with preexisting diabetes and gestational diabetes. Provideadequateenergyandnutrientsforincreasedneedsduringpregnancyandlactation. Provideadequateenergytomaintainnormalgrowthanddevelopmentratesinchildrenandadolescents withdiabetes.
GlycemicControlforPeopleWithDiabetesa BiochemicalIndex(WholeBloodValues) Preprandialplasmaglucose,mg/dL(mmol/l) Peakpostprandialplasmaglucose,mg/dL(mmol/l) HemoglobinA1c
Normal <100(5.6) <110(6.1) <6%
Goal 90130(5.07.2) <180(10.0) <7%
a These values are generalized to the entire population of individuals with diabetes. Patients with comorbid diseases, very young
children,olderadults,andpatientswithunusualconditionsorcircumstancesmaywarrantdifferenttreatmentgoals.Thesevaluesare for nonpregnant adults. Additional actions that are suggested depend on the individual patients circumstances. Such actions may includeenhanceddiabetesselfmanagementeducation,comanagementwithadiabetesteam,referraltoanendocrinologist,changein pharmacologic therapy, initiation of or increase in selfmonitoring blood glucose records, or more frequent contact with the patient. HemoglobinA1cvaluesforanondiabeticpersonrangefrom4.0%to6.0%(mean,5.0%;SD,0.5%). Source:AmericanDiabetesAssociation.Standardsofmedicalcareindiabetes.DiabetesCare.2009;32(suppl1):13S61S. ManualofClinicalNutritionManagement
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MedicalNutritionTherapyforDiabetesMellitus
NutritionalAdequacy ThenutritionprescriptioncanbeplannedtomeettheDietaryReferenceIntakesasoutlinedintheStatement onNutritionalAdequacyinSectionIA.
HowtoOrdertheDiet Thephysicianmayspecifyoneofthefollowing: Consistentcarbohydratemealplan:Themealplanincorporatesconsistentcarbohydrateintake(15g ofcarbohydratepermealorsnack),fatintakemodifications,andconsistenttimingofmealsandsnacks, notspecificenergylevels.Theplanprovidesfourcarbohydrateselections(60grams)atbreakfast and five carbohydrate selections (75 grams) at lunch and dinner with the remaining selections fromvegetables,leanmeats,andappropriatefats.Thisdietisthestandardhospitalmealplanfor peoplewithdiabetesanddoesnotincludeinbetweenoreveningsnacks.Themealplanprovides 1,500 to 1,800 kcal/day, with approximately 50% ofthe energy from carbohydrate, 20% fromprotein, and30%fromfat(<7%saturatedandtransfatcombined)(24). Ifthepatientrequestsadditionalfood,selectchoicesfromthevegetableandleanmeatgroups.Between mealsnacksaregivenbasedontheindividualpatientsnutritionneedsandpreferenceortocomplement medicaltreatment(eg,medications)tooptimizebloodglucoselevels;thus,snacksarenotautomatically providedtopatients.Foodintakefrequency(forexample,threemealsvssmallermealsandsnacks)is not associated with longterm differences in glucose levels, lipid levels, or insulin responses in type 2 diabetesmellitus (2).Therefore,divisionoffoodintakeshouldbebasedontheindividualspreferences. Conditions for which an evening snack may be warranted include pregnancy, lactation, diabetes in a person with higher energy and protein needs, or prescription of medications that increase the risk of hypoglycemia. Nutrition prescription per a registered dietitians recommendations: The dietitian plans an individualized diet, taking into account the patients energy and protein needs, fat restrictions, food preferences,andeatinghabits.Snacksareplannedforpatientstakinginsulinorareservedaccordingto facility protocols. Meal plans based on exchange lists or carbohydrate counting may be used with this order.Individualizationofthemealpatternisemphasized,ratherthanaspecificstandardmacronutrient distribution.Fatcontentofthedietismanipulatedaccordingtothebloodglucose,lipid,andbodyweight goals.Protein,carbohydrate,andmineralcontentofthedietmaybemanipulatedtoachieveindividual metabolicandclinicalgoals. Regular diet: This may be considered as an option for patients with increased needs for energy and proteinbecauseofothermedicalconditions,suchaspressureulcers,cancer,burns,sepsis,orsurgery.
Note: Noconcentratedsweetsisnotrecommended,sinceitconveystheimpressionthatsimplyavoiding sweetswillinitselfpromotegoodcontrolofbloodglucose(2,3).
DIABETESMELLITUS:CONSIDERATIONSFORACUTEILLNESS DIABETESMELLITUS:GASTROINTESTINALCOMPLICATIONS DIABETESMELLITUS:ORALGLUCOSELOWERINGMEDICATIONSANDINSULIN DIABETESMELLITUS:CONSIDERATIONSFOREXERCISE DIABETESMELLITUS:FATREPLACERSANDNUTRITIVE/NONNUTRITIVESWEETENERS
NutritionInterventionandPlanningforMedicalNutritionTherapy
CarbohydratesandDiabetes Thefollowingtermsarepreferredwhendescribingcarbohydrates:sugars,starch(eg,amylase,amylopectin, modified starches), and fiber (eg, cellulose, hemicellulose, pectins, hydrocolloids) (1). Regulation of blood glucoselevelstoachievenearnormallevelsistheprimarygoalinthemanagementofdiabetes (1).Dietary techniquesthatlimithyperglycemiafollowingamealareimportantinlimitingthecomplicationsofdiabetes (1).Boththeamount(grams)andtypeofcarbohydrateinafoodinfluencebloodglucoselevels (GradeI)*(1,4,5). Thetotalamountofcarbohydrateconsumedatmealsandsnacksinfluencesthepostmealglucoseresponseto agreaterextentthanothermacronutrients (GradeI)(4,5).Thereisadirectrelationshipbetweentheamountof carbohydrate in a meal, postmeal blood glucose response, and premeal rapidacting or shortacting insulin requirements to maintain desirable blood glucose goals (Grade I) (4,5). Therefore, the total amount of carbohydrate consumed is a strong predictor of glycemic response, and monitoring the total grams of
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carbohydrate(whether by use of exchanges orcarbohydrate counting) remains a key strategyin achieving glycemiccontrol(GradeI)(1,4,5).
*TheAmericanDieteticAssociationhasassignedgrades,rangingfromGradeI(good/strong)toGradeV(insufficientevidence),toevidence andconclusionstatements.ThegradingsystemisdescribedinSectionIII:ClinicalNutritionManagement:AReferenceGuide,pageIII1.
Studieshavedemonstratedthatwhenpersonswithtype1ortype2diabetesmellitusconsumeavarietyof sugars or starches, there is no substantial difference in the glycemic response when the total amount of carbohydrate remains constant (2,5). Sucrose intakes of 10% to 35% of total energy intake do not have a negativeeffectonglycemicorlipidresponsesinpersonswitheithertype1totype2diabeteswhensucroseis substitutedforisoenergeticamountsofstarch (4)(GradeI).Basedonthesefindings,sugar(eg,sucrose)intake does not have to be avoided. Instead, sugar intake should be based on the total amount of carbohydrate neededtoachieveoptimalmetaboliccontrolandthenutritionalcontributiontothediet.Foodscontaining carbohydratefromwholegrains,fruits,vegetables,andlowfatmilkareimportantcomponentsandshouldbe includedinahealthydietforpersonswithdiabetesmellitus(GradeI)(2,4).
Recently,theuseoflowglycemicindexfoodsorlowglycemicdietshasreceivedrenewedinterest.Factors that influence the glycemic response to food include: the type and amount of carbohydrate, type of sugar, nature of starch, cooking and food processing, as well as other food components (eg, fat and natural substancesthatslowdigestionlectins,phytates,tannins,andstarchproteinandstarchlipidcombinations) (2,69). Fasting and preprandial glucose concentrations, the severity of glucose intolerance, and the second mealorlenteeffectareotherfactorsthataffecttheglycemicresponsetofood (2,1013).Becauseofthevariety offactorsthatcaninfluenceafoodsglycemicresponseandthelimitednumberoflongtermstudies,thereis stillinsufficientscientificevidencetosupporttheuseornonuseoflowglycemicdietsinimprovingmetabolic outcomes (Grade II) (1,2,4,14). Ametaanalysisoflowglycemicindexdiettrialsindiabeticsubjectsshowedthat suchdietsproduceda0.4%decrementinhemoglobinA1C(A1C)whencomparedwithhighglycemicindex diets (15). Some studies have shownshortterm improvements inglycemiccontrol by incorporating high fiber,lowglycemicindexfoodsinmealsorsnacks (GradeI)(4).Theglycemicindexand/orglycemicloadused in conjunction with a consideration of total carbohydrate intake may provide greater benefits than consideration of only the total carbohydrate intake (1,2). Therefore, the consideration of the glycemic index maybehelpfulasanadjunctforselectindividuals.Individualscandeterminetheglycemicindexsusefulness in maintaining their glycemic goals only by measuring their premeal and postmeal blood glucose levels (1,14,15).
Theamountoftotalcarbohydrateintakeshouldbeindividualizedbasedontheindividualsenergygoalsto achieveormaintainadesirablebodyweight,eatinghabits,andglucoseandlipidgoals(13).Intype2diabetes mellitus, an individuals metabolic profile and the need for weight loss should be considered when determiningthecarbohydrateandmonounsaturatedfatcontentofthediet(1,2).Forweightloss,eitheralow carbohydrateorlowfat,energyrestricteddietmayprovideshorttermeffectiveness(forupto1year) (1,2). Forpatientsonlowcarbohydratediets,itisimportanttomonitorlipidprofiles,renalfunction,andprotein intake (in patients with nephropathy)and adjust hypoglycemiatherapyas needed (2). See Energy Balance, Overweight,andObesityinDiabetesinthissection. SectionIII:ClinicalNutritionManagement
DIABETESMELLITUS:FATREPLACERSANDNUTRITIVE/NONNUTRITIVESWEETENERS
Fiber According to The American Diabetes Association and evidencebased nutrition practice guidelines fiber consumptionrecommendationsforpeoplewithdiabetesarethesameasforthegeneralpopulation (2,4).The Dietary Reference Intake (DRI) recommends consumption of 14 g dietary fiber per 1,000 kcal, or 25 g for adultwomenand38gforadultmen (2,16).However,emergingevidencesuggestspersonswithdiabetesmay benefitfromhigherdietaryfiberintake.Basedonacurrentreviewofevidence,dietsproviding30to50g fiberperdayfromwholefoodsourcesconsistentlyproducedlowerserumglucoselevelscomparedtolow fiber diets (Grade III) (16). The addition of viscous dietary fibers slow gastric emptying rates, digestion, and absorptionofglucosetobenefitimmediatepostprandialglucosemetabolismandlongtermglucosecontrolin individualswithtype2diabetesmellitus (16, 17). Fiber supplementsprovidingdosesof10to29g/daymay alsohavesomebenefitintermsofglycemiccontrol (Grade III) (16).Thereisconclusiveevidencethatdietary fiber intake from whole foods or supplements may lower blood pressure, improve serum lipid levels, and reduceindicatorsofinflammation (GradeII)(16).Benefitsmayoccurwithintakeof12to33gfiberperdayfrom
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wholefoodsorupto42.5gfiberdayfromsupplements(GradeII)(16).Forpatientswithdiabetescomplicatedby disorders of lipid metabolism, particularly hypercholesterolemia, lower cholesterol levels are an important benefit of consuming a highfiber diet (16). Potential gastrointestinal side effects of excessive dietary fiber shouldbeconsideredwhenintegratingfiberintomealplanning.Agradualincreaseinfiberfromwholefoods andsupplementsissuggestedwithinrecommendedrangestopreventnegativesideeffects (16).Fiberisnot digestedandabsorbedlikesugarsorstarches.Forpurposesofcarbohydratecounting,whentherearemore than5goffiberperserving,halfthenumberofgramsoffibershouldbesubtractedfromthetotalgramsof carbohydratetodeterminetheamountofavailablecarbohydrate(5).
ResistantStarch Resistant starch (nondigestible oligosaccharides and the starch amylase) is not digested and therefore not absorbedasglucoseinthesmallintestine.Legumesarethemajorfoodsourceofresistantstarchinthediet; 100gofcookedlegumescontain2to3gofresistantstarch,and100g(dryweight)ofcornstarchcontains about6gofresistantstarch(18).Ithasbeensuggestedthatresistantstarchproducesasmallerincreaseinthe postprandial glucose level than digestible starch and corresponds to lower insulin levels (2). Studies of persons with diabetes have focused on uncooked cornstarch and its potential to prevent nocturnal hypoglycemia. Some studies have demonstrated less hypoglycemia when cornstarch snacks are used; however,theevidenceislimited.Thereiscurrentlynoestablishedbenefitofresistantstarchforpeoplewith diabetes(2).
TimingofCarbohydrateandFoodIntake:Type1Diabetes Forindividualsrequiringinsulin,thetotalcarbohydratecontentofmealsandsnacksisthefirstpriorityand determines the premeal insulin dosage and postprandial glucose response (14,19). Individuals receiving intensiveinsulintherapycanadjustthepremealinsulindosebasedontheamountofcarbohydrateatmeals to maintain their blood glucose goals (Grade I) (4). Individual needs should dictate the time when meals and snacksareeaten,howmuchtimeelapsesbetweeninsulininjectionandfoodintake,andthenumberofmeals andsnacks (1).Selfmonitoringofbloodglucoselevelsisnecessarytoachieveoptimalbloodglucosecontrol andtopreventordelaytheonsetofdiabeticcomplications (4).Checkingbloodglucoselevelsthreetoeight timesperdayhasbeenassociatedwithbetterglycemiccontrolregardlessofdiabetestypeortherapy (GradeI) (4). The American Diabetes Association recommends that people with type 1 diabetes or pregnant women who take insulin check their blood glucose levels three or more times daily, so that they can adjust food intake,physicalactivitylevel,and/orinsulindosagetomeetbloodglucosegoals (1).Daytodayconsistency offoodconsumptioniscrucialforindividualswhoinjectafixeddailydosageofinsulin(1,2).
For individuals who are on fixed insulin regimens and do not adjust premeal insulin dosages, consistent carbohydrateintakeisthefirstpriority (1,2,20).Individualsreceivinginsulintherapyshouldeatatconsistent timesthataresynchronizedwiththeactiontimeoftheirinsulinpreparationandwithbloodglucoseresults, andinsulindosesshouldbeadjustedfortheamountoffoodusuallyeatenorrequired (13).Thedecisionto adjustinsulindosesshouldbebasedonareviewofbloodglucoserecordsanddiscussionwiththepatients physicianandcoordinatinghealthcareteam.
Intensifiedinsulintherapy(multipledailyinjectionsorinsulinpumptherapy):Thegoalofintensified insulin therapy is to bring the blood glucose levels as close to the normal range as is feasible for the individual.Insulininfusionpumpsmimicthenormalphysiologicinsulindeliveryandallowflexibilityinmeal sizeandtiming.Individualsthatuserapidactinginsulinbyinjectionoraninsulinpumpshouldadjusttheir mealandsnackinsulindosesbasedonthecarbohydratecontentofthemealsandsnacks (2).Carbohydrate counting,atanadvancedlevel,cangreatlyincreaseflexibilityinmealplanning (21).TheDiabetesControland Complications Trial found that individuals who adjusted their premeal insulin dosages based on the carbohydratecontentofmealshadstatisticallysignificantly(0.5%)lowerA1Clevelsthanindividualswhodid not adjust preprandial insulin dosages (22). Potential problems associated with intensified insulin therapy include hypoglycemia and weight gain (2,2325). Given the potential for weight gain to adversely affect glycemia, dyslipidemia, blood pressure, and general health, the prevention of weight gain is desirable (2,26). Reductions in blood glucose levels and A1C may cause hypoglycemia, which occurs more frequently in individuals with type 1 diabetes (2). Hypoglycemia should be treated appropriately (2). (See Treatment of Hypoglycemiainthissection.) Adjustmentsforexercise:Becausetheamountofphysicalactivitymayvaryconsiderablyfromdaytoday, individualswithtype1diabetesmayneedtomakeadjustmentsinenergyintakeandinsulindosagetoavoid
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hypoglycemia.Severalstrategiesmaybeusedtoaverthypoglycemiaduringorafterexercise.Whenexercise is planned, the insulin dose should be adjusted to prevent hypoglycemia (2,27). If exercise is unplanned, additional carbohydrate may need to be consumed (2,27). Carbohydrate supplementation is based on the blood glucose level before exercise, previous experience with the particular form of exercise, and the individualsinsulinregimen(1,2,27).Moderateintensityexerciseincreasesglucoseuptakeby2to3mg/kgper minute above the usual requirements. More carbohydrate may be needed for higher intensity activities (1,2,,27).(SeeSectionIII:DiabetesMellitus:ConsiderationsforExercise.)
TimingofCarbohydrateandFoodIntake:Type2Diabetes Food intake frequencythree meals or smaller meals and snacksis not associated with longterm differencesinglucoselevels,lipidlevels,orinsulinresponses(28,29).Therefore,divisionoffoodintakeshould be based on individual preferences, the lipid profile, and the type of diabetes medications used (Grade I) (2,4). Preprandialandpostprandialbloodglucosemonitoringdatalevelscanbeusedtodetermineifadjustmentsin foodormealplanningwill behelpfulor ifmedicationsneedtobecombinedwithnutritiontherapy (1,2).If individualswithtype2diabetesrequireinsulin,theconsistencyandtimingofmealsandtheircarbohydrate contentbecomeimportant,aswithtype1diabetes (1,2).Flexibleinsulindosingregimensallowforvariations in food intake and a more flexible lifestyle. Treatment with sulfonylureas and other insulin secretagogues also requires consistency in meal timing and the carbohydrate content of meals (1). People with type 2 diabetesaremoreresistanttohypoglycemiathanpeoplewithtype1diabetes;however,whenapersonwith type2diabeteswhoistreatedwithinsulinorinsulinsecretagoguesisunabletoeat,dosagesmayneedtobe modified(1,2).(SeeTreatmentofHypoglycemiainthissection.)
Adjustments for exercise: Supplemental food before and during exercise is not needed to prevent hypoglycemia and is not recommended except under conditions of strenuous, prolonged exercise, such as endurance sports. Individuals taking sulfonylurea agents have a slightly increased risk of hypoglycemia during exercise, and supplemental energy intake may be required in some cases (1,27). The need for supplementalenergyintakemaybedeterminedbyglucoseselfmonitoring.Individualswithtype2diabetes who use insulin should also monitor their blood glucose levels closely during and after exercise. Several strategiesmaybeusedtoaverthypoglycemiaduringandaftervigorous,prolonged,ornonhabitualexercise. Thesestrategiesinvolvetheconsumptionofsupplementalcarbohydratecontainingfoodsbefore,during,and after exercise as well as adjustments in insulin dosage and timing (27). (See Section III: Diabetes Mellitus: ConsiderationsforExercise.) SectionIII:ClinicalNutritionManagement
DIABETESMELLITUS:ORALGLUCOSELOWERINGMEDICATIONSANDINSULIN DIABETESMELLITUS:CONSIDERATIONSFOREXERCISE
Protein Therecommendedproteinintakeforindividualswithdiabeteswhohavenormalrenalfunctionisthesameas for the general population (1). This recommendation translates into approximately 15% to 20% of daily energyintakefromprotein,whichcanbederivedfrombothanimalandvegetablesources (1,2,17).Individuals with type 2 diabetes and suboptimal glycemic control may have greater protein requirements due to increasedproteinturnover.However,theincreasedrequirementsdonotexceed20%oftotalenergyintake (2).Intakesofproteinthatexceed20%ofdailyenergymaybeariskfactorforthedevelopmentofdiabetic nephropathy (1).Basedonstudiesofpatientswithnephropathy,itseemsprudenttolimitproteinintaketo theRecommendedDietaryAllowancesof0.8g/kgofbodyweight,whichcorrespondstoapproximately10% of total energy (1,4,30). During a catabolic state induced by injury, inflammation, or severe illness, protein needsare1.0to1.5g/kgofbodyweight,withthehigherendoftherangeformorestressedpatients.Referto SectionII:EstimationofProteinRequirements.
In individuals with type 1 or type 2 diabetes, microalbuminuria predicts the later development of overt nephropathy(2).Microalbuminuriagreaterthan30mg/dayor20g/minisanindicatorfornephropathyand increased cardiovascular morbidity and mortality (Grade II) (1,4). In patients with diabetic nephropathy, reductionofdietaryproteinto0.8g/kgofbodyweightperday(theRecommendedDietaryAllowances)may slowtheprogressionofnephropathy (GradeII)(2,4).Alongwithtestingformicroalbuminuria,theanalysisofa spoturinesampletodeterminethealbumintocreatinineratioisstronglyencouraged(1).
Smallshorttermstudiessuggestthatdietswithaproteincontent>20%oftotalenergyreduceglucoseand insulinconcentrations,reduceappetite,andincreasesatietyinpatientswithdiabetes (31,32).Theamountof

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proteinconsumedatmealshasminimalinfluenceontheglycemicresponse,lipidlevels,andhormonesand metabolites,andithasnolongtermeffectoninsulin (4) (Grade II).Asthepercentageofproteinincreasesand thepercentageofenergyfromcarbohydratedecreasesitisdifficulttodeterminewhetherthehigherprotein intakes or the lower carbohydrate intakes are responsible for significant effects on metabolic outcomes in studies (4)(GradeII).Theeffectsofhighproteindietsonthelongtermregulationofenergyintake,satiety,and weightaswellastheabilityofindividualstofollowsuchdietslongtermhavenotbeenadequatelystudied; therefore,highproteindietsarenotrecommendedasastrategytoimproveglycemicoutcomesorpromote weight loss (1,2,4) (Grade I). See the discussion of EnergyBalance, Overweight, and Obesity in Diabetes in this section.
FatIntakeandDisordersofLipidMetabolism The distribution of energy from fat should be individualized based on the patients nutrition assessment, cardiacriskassessment,disordersoflipidmetabolism,andtreatmentgoals(14,17,33,34).
Type2diabetesisassociatedwithatwofoldtofourfoldexcessriskofcoronaryheartdisease(CHD) (GradeI) (4,33). The most common disorders of lipid metabolism in patients with type 2 diabetes are elevated triglycerideslevelsanddecreasedhighdensitylipoproteincholesterollevels (33).Theconcentrationoflow density lipoprotein (LDL) cholesterol in patients with type 2 diabetes is similar to that in nondiabetic individuals (33).TheNationalCholesterolEducationProgram(NCEP)AdultTreatmentPanelIIIcategorizes persons with diabetes mellitus in the highrisk category with therapeutic goals to reduce LDL cholesterol levels to less than 100 mg/dL through therapeutic lifestyle changes (diet and physical activity) and cholesterollowering drug therapy (34). A subcategory of high risk, very high risk, consists of persons with existing cardiovascular disease and diabetes as well as persons with cardiovascular disease and severe or poorly controlled multipleriskfactors (34). The veryhighriskcategory hasatherapeutic option to reduce LDL cholesterol levels to less than 70 mg/dL (34). These lower LDL cholesterol goals, in combination with initiatingcholesterolloweringdrugtherapyatlowerthresholds,arebasedonevidencefromfiverandomized controlledtrialsthatdemonstratedasignificantlyreducedriskforcardiaceventsattheselowerthresholds (34).PharmacologictherapyisintegralinachievingtheselowerLDLthresholdsandisrecommendedbythe NCEPtoachievea30%to40%reductioninbaselineLDLcholesterollevelsinallhighriskpatients(34).
Therecommendedpercentageofenergyfromfatdependsonthepatientslipidlevelsandtreatmentgoals for glucose, disorders of lipid metabolism, and weight. Because persons with diabetes mellitus are at high risk of CHD and cardiovascular mortality (33,34), they should target the lowest LDL cholesterol goal (<100 mg/dL,or<70mg/dLifcategorizedasveryhighrisk)(2,3335).Basedonriskfactorassessment,apersonwith diabetesmellitusshouldfollowtherecommendationsoftheNCEPAdultTreatmentPanelIII, theAmerican HeartAssociationDietaryGuidelines2000,andtheAmericanDiabetesAssociationStandardsofMedicalCare 2008 (1,35,36). The NCEP recommends that individuals with increased risk and/or disorders of lipid metabolism limit their fat intake to less than 35% of total energy, with saturated and trans fat combined targetinglessthan7%oftotalenergy (4),polyunsaturatedfatrestrictedtolessthan10%oftotalenergy,and monounsaturatedfattargeting10%to15%oftotalenergy(GradeI)(4,33).
Severalstudieshaveinvestigatedtheoptimalmixofmacronutrientstobestsupportmetabolicoutcomesin personswithdiabetesandcardiovasculardisease.Dietsthatarehighinmonounsaturatedfathavenotbeen showntoimprovefastingplasmaglucoselevelsorA1Cvalues (2).Lowsaturatedfat(<10%ofenergy),high carbohydrate diets increase postprandial levels of plasma glucose and insulin and increase plasma triglycerides levels (37); in some studies, these diets decrease plasma highdensity lipoprotein cholesterol levelswhencomparedwithisoenergetichighmonounsaturatedfatdiets (2,37,38).Whensaturatedfatenergy isreplacedwitheitherenergyfromcarbohydrateormonounsaturatedfat,thereisareductioninplasmaLDL cholesterol levels (2). In other studies, when energy intake was reduced, the adverse effects of high carbohydrate diets were not observed (2). Individual variability in response to higher carbohydrate diets (~55% of total energy) suggests that the plasma triglyceride response to dietary modifications should be monitoredcarefully,particularlyintheabsenceofweightloss (2).Anindividualsmetabolicprofileandthe need for weight loss should determine the medical nutrition therapy recommendations and nutrition prescription. Consumption of omega3 fatty acids from fish or from supplements reduces adverse cardiovascular disease outcomes (2,39). In addition, fish consumption displaces foods that are high in saturatedfatfromthediet (2).Twoormoreservingsoffishperweek(withtheexceptionoffriedfishfillets) arerecommendedforpersonswithdiabetes(2,40,41).
Metaanalyses of prospective studies indicate that elevated triglycerides levels are also an independent riskfactorforCHD.TheNCEPAdultTreatmentPanelIIIestablishedaclassificationsystemandguidelinesfor
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intervention andtreatment of hypertriglyceridemia (35). Refer to Section IC: Medical NutritionTherapy for Disorders of Lipid Metabolism for the latest recommendations. The following table outlines strategies to treatdisordersoflipidmetabolisminpatientswithdiabetes: DisordersofLipidMetabolism GoalsandTreatmentStrategies ElevatedLDLcholesterol levela(>70mg/dLwithvery Goal:decreaseserumLDLcholesterol highCHDrisk,>100mg/dLwithhighCHDrisk, TherapeuticLifestyleChangesDiet: >130mg/dLwithmoderatelyhighCHDrisk)(34) 25%to35%energyfromfat <7%energyfromsaturatedandtransfatb <200mgcholesterolperday Weightreductionandphysicalactivity Hightriglycerideslevel(200500mg/dLmeasured Goals:decreaseLDLcholesterol,decrease whenbloodglucoseisinfairorgoodcontrol)(35) triglycerides TherapeuticLifestyleChangesDiet: 25%to35%energyfromfat <7%energyfromsaturatedandtransfatb >10%energyfrommonounsaturatedfat Approximately50%energyfrom carbohydrate Weightreductionandphysicalactivity Drugtherapy Goals:decrease triglyceridestopreventacute Veryhightriglycerideslevel(>500mg/dLmeasured pancreatitisandchylomicronemiasyndrome, whenbloodglucoseisinfairorgoodcontrol)(34) decreaseLDLcholesterol Dietapproach: <15%energyfromallfat if triglycerides are >1,000 mg/dL, omega3 fatty acidsmaybeusedc(2,39). Weightreductionandphysicalactivity Drugtherapy
a Pharmacologic therapy should be initiated as an adjunct to behavioral interventions to achieve a 30% to 40% decrease in LDL cholesterolfrombaselinevaluesformoderatelyhighrisk,andveryhighriskpatients(34). b Trans fatty acids increase LDL cholesterol (4). The American Heart Association (2006) recommends <1% of energy from trans fatty acids. cSeediscussionofomega3fattyacidsinSectionC:MedicalNutritionTherapyforDisordersofLipidMetabolism.
Sodium Recommendations regarding dietary sodium are the same for people with diabetes and the general population. Both normotensive and hypertensive individuals should limit sodium consumption to 2,400 mg/day.Forpeoplewithmildtomoderatehypertension,lessthan2,400mg/dayofsodiumisrecommended, as are the principles of the Dietary Approaches to Stop Hypertension Diet and weight reduction to lower bloodpressureasanadjuncttopharmacotherapy (2,42).Forpeoplewithhypertensionandnephropathy,less than 2,000 mg/day of sodium is recommended (1,2). People with diabetes should maintain blood pressure levelslessthan130/80mmHg(1).(SeeSectionF:SodiumControlledDiets.)
Alcohol The precautions regarding alcohol consumption that apply to the general population also apply to people with diabetes. The US Dietary Guidelines for Americans recommends no more than two drinks per day for menandnomorethanonedrinkperdayforwomen (1,2).Abstentionfromalcoholisadvisedforpeoplewith ahistoryofalcoholabuseordependence,pregnantwomen,andpeoplewithmedicalproblemssuchasliver disease,pancreatitis,advancedneuropathy,orseverehypertriglyceridemia(2).
Theeffectofalcoholonbloodglucoselevelsdependsnotonlyontheamountofalcoholingestedbutalsoon the relationship to food intake. Alcohol used in moderation and ingested with food does not affect blood glucoselevelswhendiabetesiswellcontrolled (2).Alcoholicbeveragesshouldbeconsideredanadditionto theregularfood/mealplanforpatientswithdiabetes.Foodshouldnotbeomittedbecauseofthepossibility of alcoholinduced hypoglycemia. When energy from alcohol needs to be calculated as a part of the total energyintake,alcoholshouldbesubstitutedforfatexchangesorfatenergy.
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MicronutrientsandDiabetes Thereisnoclearevidencethatvitaminormineralsupplementationbenefitspeoplewithdiabeteswhodonot have underlying deficiencies (2). Chromium supplements have been reported to have beneficial effects on glycemia (1,17). However, due to study limitations and other studies that have not found these benefits in people with diabetes, the benefit of chromium supplementation has not been conclusively demonstrated (1,2,17,43).Increasedconsumptionoffolatebywomenofchildbearingagetopreventbirthdefectsaswellas calcium consumption for the prevention of bone disease are recommended for people with or without diabetes.
TreatmentofHypoglycemia Hypoglycemiaisprimarilyanissuefordiabeticswhotakeinsulinandinsulinsecretagogues.Changesinfood intake, physical activity level, andmedicationscan contribute tohypoglycemia.Accordingtothe American Diabetes Associations evidencebased guidelines, a glucose level of less than 70 mg/dL should be treated immediately (eg, carbohydrate ingestion, exercise delay, change in insulin dose) (1,2,44). The primary treatmentsforhypoglycemiaarecarbohydrateingestionandmedicationadjustment.Glucoseingestionisthe preferredtreatmentforhypoglycemia,althoughanyformofcarbohydratethatcontainsglucosemaybeused (1,2).Theglycemicresponsehasagreatercorrelationwithtotalglucosecontentthanwithtotalcarbohydrate contentoffood(41).Forexample,treatmentofinsulininducedhypoglycemiawith20gofglucoseresultsina greaterriseintheplasmaglucoselevelthantreatmentwith20gofcarbohydratefromorangejuiceormilk (45).Theformofthecarbohydrateliquidorsoliddoesnotimpacttheoutcomeoftheglycemicresponse. The addition of protein to the carbohydrate does not assist in the treatment of hypoglycemia or prevent subsequenthypoglycemiaepisodes (1,2).Theamountofproteinconsumedatmealshasaminimalinfluence ontheglucoseresponse;however,theinsulinresponsetoproteinissimilartocarbohydrate (GradeII)(4).The addition of fat may retard the acute glycemic response (2,45). Ingestion of 15 to 20 g of glucose or total carbohydrateisaneffectivetreatmentofhypoglycemia;but,thebloodglucoselevelmaybeonlytemporarily corrected (1,2).Tengramsoforalglucoseraisesplasmaglucoselevelsby~40mg/dLover30minutes,while 20 g of oral glucose raises plasma glucose levels by ~ 60 mg/dL over 45 minutes. The initial response to treatmentshouldbeseeninapproximately10to20minutes,andbloodglucoselevelsshouldbeevaluated again in 10 to 15minute increments and again at 60 minutes when glucose levels often begin to fall to determineifadditionaltreatmentisnecessary(1).Sulfonylureainducedhypoglycemiainpatientswithtype2 diabetes differs from insulininduced hypoglycemia. Sulfonylureainduced hypoglycemia can be prolonged and can recur, and therefore requires more persistent treatment (2). For mild to moderate hypoglycemic reactions, the following items, which contain about 15 g of carbohydrate, may be given (46,47). These food itemsareusedbecausetheyarereadilyavailableand/oreasytocarrywhenawayfromhome,notbecause theyarefastacting(46,47): 4to6ozfruitjuice 4to6ozregularsoda threeorfourglucosetablets(4gofglucoseeach) 2tbspraisins fiveorsixLifesaverscandies 1tbsphoneyorcornsyrup 4tsporfourpacketsofgranulatedsugar
Retestthepatientsbloodglucoselevel15to20minutesafteringestionofthefood.Ifthepatientsblood glucose level is still low, give an additional 15 g of carbohydrate and retest in 15minute increments until stabilized(1).Glucagonshouldbeprescribedforallpatientsatsignificantriskofseverehypoglycemia(1). Individuals who have hypoglycemia unawareness or who experience one or more episodes of severe hypoglycemiashouldbeadvisedtoincreasetheirglycemictargetstostrictlyavoidfurtherhypoglycemiafor atleastseveralweeks(1). CarbohydrateReplacementforAcuteIllness,MissedMeals,orDelayedMeals Acuteillnessormissedmeals:Acuteillnessinpersonswithtype1diabetescanincreasetheriskofdiabetic ketoacidosis (1,2). During acute illness, the need for insulin continues and actually may increase due to an increased level of counterregulatory hormones associated with stress (2). Measuring blood glucose levels, measuring blood or urine ketones levels, drinking adequate amounts of fluids, and ingesting carbohydrate, especiallyifthebloodglucoselevelislessthan100mg/dL,areallimportantduringacuteillness (2).When illness or diagnostic tests prevent a diabetic individual from consuming the usual diet, systematic
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replacementofcarbohydrateisappropriate.Inadults,thedailyingestionof150to200gofcarbohydrate(or 45to50gevery3to4hours),alongwithmedicationadjustments,shouldbesufficienttokeeptheglucose levelinthegoalrangeandpreventstarvationketosis (2).Thecarbohydratevalueofthefoodsinthemissed mealcanbereplacedwitheasilyconsumedliquidsorsoftfoodsastolerated.Usuallyamissedmealmaybe satisfactorily replaced by at least 50 g of carbohydrate (or three to four carbohydrate choices) taken by mouth.Theconsumptionofatleast50gofcarbohydrateevery3to4hourshasbeenrecommended (1,2).If thepatientisincapableoftakingfoodbymouth,alternativenutritionsupportshouldbeevaluated.
Delayed meals: When the meal is delayed and the blood glucose level is normal, carbohydrate should be given.Usually15gofcarbohydrate(onefruitorbreadexchange)every30to45minutesuntilthemealis served,or15to30gofcarbohydratefora1or2hourdelay,protectsthepatientfromhypoglycemia.
Enteral nutrition: For tube feedings, either a standard enteral formula (50% carbohydrate) or a lower carbohydrate content formula (33% to 40% carbohydrate) may be used (2). Care should be taken not to overfeedpatientsbecauseoftheriskofexacerbatinghyperglycemia(1,2).
CarbohydrateContentofFoods Foodsselectedfromthefollowinglistcanbeusedassubstitutesforfoodsofsimilarcarbohydratecontentin themissedmealorduringillness. 15gofCarbohydrate Applejuice cup Jellybeans nine Applesauce,sweetened cup Jelly,jam 1tbsp fiveorsix Applesauce,unsweetened cup Lifesaverscandy Cookedcereal cup Orangejuice cup Cranberryjuice 1/3cup Pineapplejuice cup Creamsoup,madewithwater 1cup Popsiclebar(3oz) one Custard cup Regularsoda cup Gelatin cup Sherbet cup Grapejuice 1/3cup Sugar,granulated 4tsp Icecream cup Syrup 1tbsp 12gofCarbohydrate Milk(whole,reducedfat,nonfat) 1cup Eggnog cup Plainyogurt 1cup
Note: Patients who experience hypoglycemia and are being treated with acarbose (Precose) or miglitol (Glyset)shouldbetreatedwithglucose.
GlycemicGoalsinaHospitalSetting A rapidly growing body of evidence supports targeting glucose control in the hospital setting with the potential for reduced mortality and morbidity and improved health care outcomes (1). Studies of surgical patients, neurological patients, and patients acutely managed for myocardial infarction have demonstrated significant improvement in outcomes when glycemic goals are tightly managed (1). Hyperglycemia in the hospitalcanresultfromfactorsincludingstressanddecompensationoftype1diabetes,type2diabetes,or other formsof diabetes; hyperglycemiamay also be iatrogenicdue to the administration or withholding of pharmacologicagents,includingglucocorticoidsandvasopressors (1).Insulintherapyshouldbeinitiatedfor treatmentofpersistenthyperglycemiastartingatathresholdofnotgreaterthan180mg/dL(1).Onceinsulin therapyisstarted,thebloodglucoselevelsofamajorityofcriticallyillpatientsshouldtargetarangeof140to 180mg/dL(1).Theserevisedrangesarecurrentlysuggestedastheprotocolfortreatmenttopromotesafety inachievingthedesiredglucoserangewithoutincreasingriskforseverehypoglycemia (1).Fornoncritically illpatientsthereisnoclearevidenceforspecificbloodglucosegoals (1).Iftreatedwithinsulin,thepremeal blood glucose levels should generally be < 140 mg/dL with random blood glucose < 180 provided these targetscanbesafelyachieved(1).Morestringenttargetsmaybeappropriateinstablepatientswithprevious tightcontrol.Lessstringenttargetsmaybeappropriateinthosewithseverecomorbidities(1).Insulinshould be initiated when necessary to achieve target values (1). Scheduled prandial insulin doses should be giveninrelationtomealsandshouldbeadjustedaccordingtopointofcareglucoselevels.Thetraditional slidingscaleinsulinregimensareineffectiveandarenotrecommended (1).Inaddition,glucosemonitoring shouldbeinitiatedinanypatientnotknowntobediabeticwhoreceivestherapyassociatedwithhighriskfor
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hyperglycemia, including high dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, octreotide or immunosuppressive medications. If hyperglycemia is documented and persistent, treatment shouldbeprovidedusingthesameglycemicgoalsaspatientswithoutknowndiabetes(1). SeeSectionIII:ClinicalNutritionManagement
DIABETESMELLITUS:CONSIDERATIONSFORACUTEILLNESS
DiabetesNutritionManagement:MealPlanningApproaches(21) Familiaritywiththevarietyofmealplanningapproachesavailablecanhelpdietitiansmoreeffectivelyteach patients how to reach their nutrition goals. The type of approach selected should depend on the goals for metabolic outcomes and the patients nutrition needs, literacy, motivation, and lifestyle. The American Diabetes Association patient education publications are based on current diabetes treatment guidelines. Approachesthatcanbeusedforteachingmealplanninginclude:
Basicnutritionguidelines
These guidelines provide the patient with an understanding of the basic principles of nutrition and guidance in selecting an adequately balanced diet for optimal health, eg, Dietary Guidelines for Americans, Food Guide Pyramid,andGuidetoGoodEating.
These guidelines provide the patient with an understanding of the connection between food intake and metabolic outcomes. They give the patient direction in making appropriate food choices for managing diabetes, eg, the American Diabetes Association/American Dietetic Associations The First Step in Diabetes Meal Planning for the Newly Diagnosed,DiabetesFoodGuidePyramid,andHealthyFoodChoices. Menuapproachestomeal These approaches provide simple examples to assist patients with meal planning planning, eg, The New Family Cookbook for People with Diabetes and the American Diabetes Associations Month of Meals cookbook series and individualizedmenus. Exchangelistsformealplanning This approach is designed to provide patient structure and guidance in mealplanning.Exchangesareorganizedbycalorielevelswhichishelpful in designing caloriecontrolled meal plans. Food groups are organized basedonfoodsthatprovidesimilaramountsofcarbohydrate,proteinand fatcontent.Thishelpstoassistthepatientinmealplanningandmeeting target nutrient and carbohydrate intake goals. The most common exchange list is the American Diabetes Association/American Dietetic Associations Eating Healthy with Diabetes: An Easy Read Guide; Choose Your Foods: Exchange List for Diabetes; and Exchange List for Weight Management. Countingapproaches These approaches provide structure with specific rules that are clearly identified. They allow optimal flexibility with food choices and meal planning, eg, American Diabetes Association/American Dietetic Associations Basic Carbohydrate Counting, Advanced Carbohydrate Counting,andTheDiabetesCarbohydrate&FatGramGuide. EnergyBalance,Overweight,andObesityinDiabetes Overweight and obesity affect insulin resistance and metabolic outcomes; therefore, weight loss is recommended for persons with diabetes who are overweight or obese as well as persons at risk for developingdiabeteswhoareoverweightorobese (1,2,4).Shorttermstudieshavedemonstratedthatweight lossinsubjectswithtype2diabetesisassociatedwithdecreasedinsulinresistance,improvedmeasuresof glycemiaanddyslipidemia,andreducedbloodpressure (Grade II)(4).Theevidencebasednutritionguidelines encouragesettinggoalsforareasonablebodyweight,definedasaweightthatthepatientandthehealthcare teamacknowledgeasbeingachievableandmaintainable(1,2,4).Aweightlossof5%to10%frombaselinehas positiveeffectsonmetabolicoutcomes.Thebodymassindexmaybeusedtoidentifyhealthyweightranges and estimate the desirable body weight. National guidelines for weight management can be applied to personswithdiabeteswhoareoverweightorobeseandforwhomweightlossisaprimaryhealthoutcome
Basicdiabetesguidelines
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(1,48).Forpatientswithtype2diabeteswhohaveaBMI>35kg/m2,bariatricsurgeryshouldbeconsidered
especiallyifthediabetesisdifficulttocontrolwithlifestyleandpharmacologictherapy(1).RefertoSectionB: NutritionManagementofBariatricSurgery.
A standard weightloss diet that adjusts total energy intake to achieve an energy deficit of 500 to 1,000 kcal/daywillinitiallyachieve1to2lbofweightlossperweek(48).Althoughmanypeoplecanloseweight(as muchas10%ofinitialweightin6months)withthesestandarddiets,withoutcontinuedsupportandfollow up, people usually regain the weight that was lost (2,48). Lowfat, lowenergy diets have traditionally been promoted for weight loss; however, three randomized controlled trials found that subjects on low carbohydrate diets lost more weight at 6 months than subjects on lowfat diets (4951). A metaanalysis showedthatat6months,lowcarbohydratedietswereassociatedwithgreaterimprovementsintriglycerides levels and highdensity lipoprotein cholesterol concentrations than lowfat diets; however, the LDL cholesterollevelwassignificantlyhigheronthelowcarbohydratediets (52).Amorerecentmetaanalysisof restrictedcarbohydratedietsinpatientswithtype2diabetesrevealedsimilarfindings,withtheexceptionof elevated LDL levels (53). The analysis showed that a decrease in carbohydrate intake from 65% to 35% of totalenergyyieldsanexpecteddecreaseofapproximately23%inthetriglycerideslevel (53).Acomparison ofthestudiesdemonstratedvariablecarbohydrateintakes(4%to45%oftotalenergy),andinmoststudies the carbohydrate intake fell below the Recommended Daily Allowance of 130 g/day (53). The authors concludedthatalowercarbohydratedietcanbebeneficialintreatingtype2diabetesduetobeneficialeffects on the levels of glucose, A1C, and triglycerides; however, the impact of these diets on cardiovascular outcomesremainstobedetermined(53).
Inamajorityofstudies,alowcarbohydratedietbeginswithaninductionphaseof<30gofcarbohydrate perdaywithincrementalincreasestoachieve~30%to40%ofenergyfromcarbohydrate(54).TheAmerican DiabetesAssociationrecommendseitheralowcarbohydrateorlowfat,energyrestricteddietasaneffective optionforshortterm(upto1year)weightlossinoverweightandobesepersonswithtype2diabetes (1,2). However,theAmericanDiabetesAssociationdoesnotrecommendalowcarbohydratedietinwhichthetotal carbohydrateintakeisrestrictedtolessthan130g/day (2,53).Lowcarbohydratedietsarebroadlydefinedin theliterature;themacronutrientcompositionfromcarbohydraterangesfrom4%to45%inthesediets (53). AreviewofpopulardietsbytheU.S.DepartmentofAgriculturedefinedalowcarbohydratedietascontaining <30% of energy from carbohydrate, a mediumcarbohydrate diet as 30% to 55% of energy from carbohydrate,andahighcarbohydratedietas>55%ofenergyfromcarbohydrate(54).Becauseconsiderable variationsexistforlowcarbohydratediets,itisimportantforthedietitiantoworkcollaborativelywiththe physicianandpatientindesigninganoptimalmealpatternthatbestsupportsdesiredmetabolicoutcomes. When prescribing a lowcarbohydrate diet to diabetic patients, it is prudent to provide a carbohydrate amountthatmeetstheRecommendedDailyAllowanceof130g/daybecauselowerintakeseliminatemany foodsthatareimportantsourcesofenergy;fiber;watersolublevitaminsfolate,thiamin,andpyridoxine;fat soluble vitamins A and E; and minerals including calcium, potassium, and magnesium (53). The safety concernsthatsurroundlowcarbohydratedietsincludeincreaseduricacidlevelsingoutpatientsaswellas otherrelatedsideeffectsincludingconstipation,diarrhea,dizziness,halitosis,headaches,andinsomnia(55,56). Lowcarbohydrate diets may not be suitable for children, reproductiveage women, and hypertensive individuals (55). In addition, the American Diabetes Association does not advocate the use of highprotein dietsduetoincreasedrisksofglomerularhyperfiltrationandacceleratedrenalcomplicationsassociatedwith diabetes (2,53). Therefore, the ratio of protein generally should not exceed 20% of total energy when determiningthemacronutrientdistributionforalowcarbohydratemealplan.Patientswhoareprescribeda lowcarbohydratemealplanshouldbecloselymonitoredandhavefrequentassessmentsoftheirlipidprofile, renalfunction,proteinintake,urinelevelsofketonesandglucose,aswellasuricacidlevelsinpatientsatrisk forgout.Inaddition,thehypoglycemicriskmustbeassessedtopreventepisodesofhypoglycemia(1,2).
Inselectedpatients,drugtherapyasanadjuncttolifestyle changemaybeappropriatetoachieveweight loss (1).However,itiscommonforpatientstoregainweightafterthediscontinuationofmedications (1,57).In patients with severe obesity, surgical options, such as gastric bypass and gastroplasty, may be appropriate andallowsignificantimprovementinglycemiccontrolwithreductionordiscontinuationofmedications(1,58).
See CalorieControlled Diet for Weight Management in Section IC and Nutrition Management of Bariatric SurgeryinSectionIB,BodyMassIndex(BMI)inSectionII,EstimationofEnergyExpendituresinSectionII, andObesityandWeightManagementinSectionIII. Formedicalnutritiontherapyoutcomesmonitoringandsuggesteddeliveryofcareintheacutecaresetting, refertoDiabetesmellitusuncontrolled/complicationsacutecarenutritionprotocol(59).
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SpecialPopulations
Childrenandadolescentswithdiabetes:Nutrientrequirementsforchildrenandadolescentswithtype1or type2diabetesaresimilartotherequirementsforchildrenandadolescentswhodonothavediabetes.The primarygoalforchildrenandadolescentswithtype1diabetesisachievingbloodglucosegoalsthatmaintain normal growth and development without excessive hypoglycemia. Individualized food/meal plans and intensiveinsulinregimenscanprovideflexibilitytoaccommodateirregularmealtimesandschedulesaswell as varying appetite and activity levels (1,2). Withholding food or having a child eat consistently without an appetite,inanefforttocontrolbloodglucoselevels,should bediscouraged (1,2).Nutritionforchildrenand adolescents with type 2 diabetes should focus on healthy lifestyle changes that normalize glycemia (1,2). Cessation of weight gain with normal linear growth is a primary outcome that will help achieve glycemic goalsinoverweightandobesechildrenwithdiabetes(1,2).
Pregnancyandlactationwithpreexistingdiabetes:Nutrientrequirementsduringpregnancyandlactation aresimilarforwomenwithandwithoutdiabetes(1,2).Thedistributionofenergyintakeandcarbohydratesin themealplanofapregnantwomanwithpreexistingtype1ortype2diabetesshouldbebasedonhereating habits, blood glucose levels, and stage of pregnancy. Regular meals and snacks are important to avoid hypoglycemiaduetothecontinuousfetaldrawofglucosefromthemother (1,2).Aneveningsnackisusually necessary to decrease the potential for overnight hypoglycemia and fasting ketosis (1,2). (See the end of SectionICforinformationongestationaldiabetes.)
Older adults with diabetes: The American Geriatrics Society emphasizes the importance of medical nutrition therapy for older adults with diabetes (1,2). Obese older adults with diabetes may benefit from modestenergyrestrictionandanincreaseinphysicalactivitytopromotemodestweightlossof5%to10%of bodyweight (1,2,5963).Lifestylemodifications,andweightlossgoalsestablishedforyoungeradultsarealso suggested for older adults. However, an involuntary weight loss of >10 lb or 10% of body weight in <6 months should be addressed in the nutrition assessment and medical nutrition therapy evaluation (2,64). Oldernursinghomeresidentswhohavediabetestendtobeunderweightratherthanoverweight (2,3).Low bodyweighthasbeenassociatedwithgreatermorbidityandmortalityinthispopulation (3).Therefore,the imposition of dietary restrictions on elderly patients with diabetes in longterm care facilities is not warranted (2).Residentswithdiabetesshouldbeservedaregularmenuwithconsistencyintheamountand timingofcarbohydrateintake(2).Thereisnoevidencetosupportprescribingdietssuchasnoconcentrated sweetsornosugaradded(2).Intheinstitutionalizedelderly,undernutritionislikelyandcautionshouldbe exercisedwhenprescribingweightlossdiets (2).Thetreatmentteamshouldconsidertheresidentsage,life expectancy, comorbidities, and preferences when outlining a plan for care (2). Adjusting the residents medications to control glucose levels, lipid levels, and blood pressure rather than implementing food restrictionscanreducetheriskofiatrogenicmalnutrition(2,65).
References 1. AmericanDiabetesAssociation.Standardsofmedicalcareindiabetes2010.DiabetesCare.2010;33(suppl1):11S61S. 2. AmericanDiabetesAssociation.Nutritionrecommendationsandinterventionsfordiabetes.DiabetesCare.2008;31(suppl1):61S 78S. 3. AmericanDiabetesAssociation.Diabetesnutritionrecommendationsforhealthcareinstitutions:positionstatement.DiabetesCare. 2004;27(suppl1):55S57S. 4. American Dietetic Association Type 1 and Type 2 Diabetes Evidence-Based Nutrition Practice Guideline for Adults. The American Dietetic Association, 2008. In: The American Dietetic Association Evidence Analysis Library at http://www.adaevidencelibrary.com (accessed 12/2/09). 5. SheardNF,ClarkNG,BrandMillerJC,FranzMJ,PiSunyerFX,MayerDavisE,KulkarniK,GeilP.Dietarycarbohydrate(amountand type) in the prevention and management of diabetes. A statement by the American Diabetes Association. Diabetes Care. 2004;27:22662269. 6. Gannon MC, Nuttall FQ, Westphal SA, Fang D, ErcanFang N. Acute metabolic response to highcarbohydrate, highstarch meals comparedwithmoderatecarbohydrate,lowstarchmealsinsubjectswithtype2diabetes.DiabetesCare.1998;21:16191626. 7. WoleverTMS,NguyenPM,ChiassonJL,HuntJA,JosseRG,PalmasonC,RodgerNW,RossSA,RyanEA,TanMH.Determinantsof dietglycemicindexcalculatedretrospectivelyfromdietrecordsof342individualswithnoninsulindependentdiabetesmellitus. AmJClinNutr.1994;59:12651269. 8. ODeaK,SnowP,NestelP.Rateofstarchhydrolysisinvitroasapredictorofmetabolicresponsestocomplexcarbohydrateinvivo. AmJClinNutr.1981;34:19911993. 9. JarviA,KarlstromB,GranfeldtY,BjorckI,VessbyB.Theinfluenceoffoodstructureonpostprandialmetabolisminpatientswith NIDDM.AmJClinNutr.1995;61:837842. 10. NielsenOH,NielsenGL.Preprandialbloodglucosevalues:influenceonglycemicresponsestudies.AmJClinNutr.1989;53:1243 1246. 11. Rasmussen I, Hermansen K. Preprandial blood glucose values and glycemic responses in insulindependent diabetes mellitus at constantinsulinemia.AmJClinNutr.1991;53:520523. 12. Fraser RJ, Horowitz M, Maddox AF, Harding PE, Chatterton BE, Dent J. Hyperglycemia slows gastric emptying in type 1 (insulin dependent)diabetesmellitus.Diabetologia.1990;33:675680. ManualofClinicalNutritionManagement
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MedicalNutritionTherapyforDiabetesMellitus 13. SchvarczE,PalmerM,AmanJ,LindkvistB,BeckmanKW.Hypoglycaemiaincreasesthegastricemptyingrateinpatientswithtype 1diabetesmellitus.DiabetMed.1993;10:660663. 14. FranzMJ.Theglycemicindex:notthemosteffectivenutritiontherapyintervention.DiabetesCare.2003;26:24662468. 15. BrandMillerJ,HayneS,PetoczP,ColagiuriS.Lowglycemicdietsinthemanagementofdiabetes:ametaanalysisofrandomized controlledtrials.DiabetesCare.2002;26:22612267. 16. PositionoftheAmericanDieteticAssociation:healthimplicationsofdietaryfiber.JAmDietAssoc.2008;108:17161731. 17. ChandaliaM,GargA,LutjohannD,vonBergmannK,GrundySM,BrinkleyLJ.Beneficialeffectsofhighdietaryfiberintakeinpatients withtype2diabetesmellitus.NEngJMed.2000;23:14611466, 18. EnglystHN,VeenstraJ,HudsonGJ.Measurementofrapidlyavailableglucose(RAG)inplantfood:apotentialinvitropredictorof theglycemicresponse.BrJNutr.1996;75:327337. 19. Wolever TMS, Hamad S, Chiasson JL, Josse RG, Leiter LA, Rodger NW, Ross SA, Ryan EA. Daytoday consistency in amount and sourceofcarbohydrateintakeassociatedwithimprovedglucosecontrolintype1diabetes.JAmCollNutr.1999;18:242247. 20. RabasaLhoret R, Garon J, Langelier H, Poisson D, Chiasson JL. Effects of meal carbohydrate content on insulin requirements in type1diabeticpatientstreatedintensivelywiththebasalbolus(ultralenteregular)insulinregimen.DiabetesCare.1999;22:667 673. 21. HollerHJ,PastorsJG,eds.DiabetesMedicalNutritionTherapy.Chicago,Ill:AmericanDieteticAssociation;1997. 22. DelahantyLM,HalfordBH.Theroleofdietbehaviorsinachievingimprovedglycemiccontrolinintensivelytreatedpatientsinthe DiabetesControlandComplicationsTrial.DiabetesCare.1993;16:905912. 23. DCCTResearchGroup.Weightgainassociatedwithintensivetherapyinthediabetescontrolandcomplicationstrial.DiabetesCare. 1988;11:567573. 24. Wing RR, Klein R, Moss SE. Weight gain associated with improved glycemic controlin populationbased sample of subjects with type1diabetes.DiabetesCare.1990;13:11061109. 25. CarlsonMG,CampbellPJ.IntensiveinsulintherapyandweightgaininIDDM.Diabetes.1993;42:17001707. 26. PurnellJQ,HokansonJE,MarconvinaSM,SteffesMW,ClearyPA,BrunzellJD.Effectofexcessiveweightgainwithintensivetherapy oftype1diabetesonlipidlevelsandbloodpressure.JAMA.1998;280:140146. 27. AmericanDiabetesAssociation.Physicalactivity/exerciseanddiabetesmellitus:positionstatement.DiabetesCare.2004;27(suppl 1);58S62S. 28. ArnoldL,MannJ,BallM.Metaboliceffectsofalterationsinmealfrequencyintype2diabetes.DiabetesCare.1997;20:16511654. 29. BeebeCA,VanCauterE,ShapiroT,TillelH,LyonsR,RubensteinA,PolonskyK.Effectoftemporaldistributionofcaloriesondiurnal patternsofglucoselevelsandinsulinsecretioninNIDDM.DiabetesCare.1990;13:748755. 30. Hansen HP, TauberLassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy.KidneyInt.2002;62:220228. 31. Gannon MC, Nuttal FQ. Effect of a highprotein, lowcarbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes.2004;53:23752382. 32. GannonMC,NuttallFZ,SaeedA,JordanK,HooverH.Anincreaseindietaryproteinimprovesthebloodglucoseresponseinpersons withtype2diabetes.AmJClinNutr.2003;78:734741. 33. American Diabetes Association. Dyslipidemia management in adults with diabetes: position statement. Diabetes Care. 2004;27(suppl1):68S71S. 34. GrundySM,CleemanJI,MerzCN,BrewerHBJr,ClarkLT,HunninghakeDB,PasternakRC,SmithSCJr,StoneNJfortheCoordinating Committee of the National Cholesterol Education Program. Implications of recent trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines [published erratum appears in Circulation. 2004;110:763]. Circulation. 2004; 110:227239. 35. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation,andTreatmentofHighBloodCholesterolinAdults(AdultTreatmentPanelIII).JAMA.2001;285:24862497. 36. AHA Dietary Guidelines: revision 2000: a statement for healthcare professionals from the Nutrition Committee of the American HeartAssociation.Circulation.2000;102:22842299. 37. GargA,BantleJP,HenryRR,CoulstonAM,GriverKA,RaatzSK,BrinkleyL,ChenYD,GrundySM,HuetBA,ReavenGM.Effectsof varyingcarbohydratecontentofdietinpatientswithnoninsulindependentdiabetesmellitus.JAMA.1994;271:14211428. 38. GargA.Highmonounsaturatedfatdietsforpatientswithdiabetesmellitus:ametaanalysis.AmJClinNutr.1998;67:577S582S. 39. MontoriVM,FarmerA,WollanPC,DinneenSF.Fishoilandglycemiccontrolindiabetes:aquantitativesystematicreview.Diabetes Care.2000;23:14071415. 40. Mozaffarian D, Bryson CL, Lemaitre RN, Burke GL, Siscovick DS. Fish intake and risk of incident heart failure. J Am Coll Cardiol. 2005;45:20152021. 41. ErkkilaAT,LichtensteinAH,MozaffarianD,HerringtonDM.Fishintakeisassociatedwithareducedprogressionofcoronaryartery atherosclerosisinpostmenopausalwomenwithcoronaryarterydisease.AmJClinNutr.2004;80:626630. 42. SacksFM,SvetkeyLP,VollmerWM,AppelLJ,BrayGA,HarshaD,ObarzanekE,ConlinPR,MillerER,SimonsMortonDG,KaranjaN, LinPHfortheDASHSodiumCollaborativeResearchGroup.EffectsonbloodpressureofreduceddietarysodiumandtheDietary ApproachestoStopHypertension(DASH)diet.NEnglJMed.2001;344:310. 43. AlthuisMD,JordanNE,LudingtonEA,WittesJT.Glucoseandinsulinresponsestodietarychromiumsupplements:ametaanalysis. AmJClinNutr.2002;76:148155. 44. Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of type 1 and type 2 diabetes. Diabetologia. 2002;45:937948. 45. BrodowsRG,WilliamsC,AmatrudaJM.Treatmentofinsulinreactionsindiabetes.JAMA.1984;252:33783381. 46. MedicalManagementofNonInsulinDependent(TypeII)Diabetes.3rded.Alexandria,Va:AmericanDiabetesAssociation;1994. 47. SlamaG,TraynardPY,DesplanqueN,PudarH,DhunputhI,LetanouxM,BornetFRJ,TchobroutskyG.Thesearchforanoptimized treatmentofhypoglycemia.ArchInternMed.1990;150:589593. 48. National Heart, Lung, and Blood Institute Obesity Education Initiative Expert Panel. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, Md: National Institutes of Health; 1998.NIHpublicationNo.984083.Availableat:http://www.nhlbi.nih.gov/nhlbi/htm.AccessedSeptember24,2002. 49. FosterGD,WyattHR,HillJO,McGuckinBG,BrillC,MohammedBS,SzaparyPO,RaderDJ,EdmanJS,KleinS.Arandomizedtrialofa lowcarbohydratedietforobesity.NEnglJMed.2003;348:20822090.
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MedicalNutritionTherapyforDiabetesMellitus 50. SternL,IqbalN,SeshadriP,ChicanoKL,DailyDA,McGroryJ,WilliamsM,GracelyEJ,SamahaFF.Theeffectsoflowcarbohydrate versus conventional weight loss diets in severely obese adults: oneyear followup of a randomized trial. Ann Intern Med. 2004;140:778785. 51. GardnerC,KiazandA,AlhassanS,SoowonK,StaffordR,BaliseR,KraemerH,KingA.ComparisonoftheAtkins,Zone,Ornish,and LEARNdietsforchangeinweightandrelatedfactorsamongoverweightpremenopausalwomen.JAMA.2007;297:969977. 52. NordmannAJ,NordmannA,BrielM,KellerU,YancyWSJr,BrehmBJ,BucherHC.Effectsoflowcarbohydratevslowfatdietson weightlossandcardiovascularriskfactors:ametaanalysisofrandomizedcontrolledtrials.ArchInternMed.2006;166:285293. 53. KirkJK,GravesDE,CravenTE,LipkinEW,AustinM,MargolisKL.Restrictedcarbohydratedietsinpatientswithtype2diabetes:a metaanalysis.JAmDietAssoc.2008;108:91100. 54. Kennedy ET, Bowman SA, Spence JT, Freedman M, King J. Popular diets: correlation to health, nutrition, and obesity. J Am Diet Assoc.2001;101:411420. 55. CroweTC.Safetyoflowcarbohydratediets.ObesRev.2005;6:235245. 56. LastAR,WilsonSA.Lowcarbohydratediets.AmFamPhysician.2006;73:19421948. 57. LeungWY,NeilTG,ChanJC,TomlinsonB.Weightmanagementandcurrentoptionsinpharmacotherapy:orlistatandsibutramine. ClinTher.2003;25:5880. 58. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and metaanalysis.JAMA.2004;292:17241737. 59. Diabetesmellitusuncontrolled/complicationsacutecarenutritionprotocol.In:InmanFeltonA,SmithK.NutritionCareProtocols intheAcuteCareSetting.Atlanta,Ga:MorrisonManagementSpecialists;2009.Availableat: https://www.morrisontoday.com/Documents/Forms/AllItems.aspx?RootFolder=%2fDocuments%2fNutrition%2fMHFS%20NUTR ITION%2fNutrition%20Care%20Process&FolderCTID=0x01200076035A4CEC8A4B4B827A74CE5B3B1A44&View=%7b1F2F11D B%2d2030%2d4BBC%2dB712%2dEFE12EF45909%7d. 60. BrownAF,MangioneCM,SalibaD,SarkisianCA.Guidelinesforimprovingthecareoftheolderpersonwithdiabetesmellitus.JAm GeriatrSoc.2003;51:265S280S. 61. MillerCK,EdwardsL,KisslingG,SanvilleL.Nutritioneducationimprovesmetabolicoutcomesamongolderadultswithdiabetes mellitus:resultsfromarandomizedcontrolledtrial.PrevMed.2002;34:252259. 62. HoraniMH,MooradianAD.Managementofobesityintheelderly:specialconsiderations.TreatEndocrinol.2002;1:387398. 63. HeiatA,VaccarinoV,KrumholzHM.Anevidencebasedassessmentoffederalguidelinesforoverweightandobesityastheyapply toelderlypersons.ArchInternMed.2001;161:11941203. 64. Roberts SB, Hajduk CL, Howarth NC, Russell R, McCrory MA. Dietary variety predicts low body mass index and inadequate macronutrientandmicronutrientintakesincommunitydwellingolderadults.JGerontolABiolSciMedSci.2005;60:613621. 65. ReedRL,MooradianAD.Managementofdiabetesmellitusinthenursinghome.AnnLongTermCare.1998;6:100107.
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MEDICALNUTRITIONTHERAPYFORGESTATIONALDIABETES MELLITUSANDPREGNANCYWITHPREEXISTINGDIABETESMELLITUS
Overview Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognitionduringpregnancy (1).Thedefinitionappliesregardlessofwhetherinsulinisusedfortreatment ortheconditionpersistsafterpregnancy.Itdoesnotexcludethepossibilitythattheglucoseintolerancemay haveantedatedthepregnancy(2).Approximately7%ofallpregnanciesarecomplicatedbyGDM(1). NutritionAssessmentandDiagnosis A risk assessment for GDM should be performed during the first prenatal visit (1,2). Women with clinical characteristics consistentwith a high riskof GDM (markedobesity, personal historyof GDM,glycosuria, or strong family history of diabetes) should undergo glucose testing as soon as feasible (1,2). If this initial screening does not detect GDM, the test should be repeated between 24 and 28 weeks of gestation (1). All pregnantwomenofaverageriskshouldbescreenedbetweenthe24thand28thweekofpregnancy.Women whohavealowriskstatusdonotrequireglucosetesting;but,lowriskstatusislimitedtowomenwhomeet allofthefollowingcharacteristics(1,2): youngerthan25yearsold normalweightbeforepregnancy memberofanethnicgroupwithalowprevalenceofdiabetes noknowndiabetesinfirstdegreerelatives nohistoryofabnormalglucosetolerance nohistoryofpoorobstetricoutcome Allpregnantwomenofaverageriskstatusshouldhaveascreeningglucoseloadbetweenthe24thand28th weekofpregnancy.Forthistest,50goforalglucoseisgivenwithoutregardtothetimeofthelastmealor the time of day. A value of 1hr blood glucose level greater than 130 or 140 mg/dL is the recommended thresholdtoindicatetheneedforafulldiagnosticglucosetolerancetest(1).ThediagnosisofGDMisbasedon theresultsofthe100goralglucosetolerancetest;theseresultsareinterpretedaccordingtothediagnostic criteriaofOSullivanandMahan,asmodifiedbyCarpenterandCoustanforcurrentglucoseassaytechniques (1,2).Adefinitivediagnosisrequiresthattwoormoreofthevenousplasmaglucoseconcentrationsmeetor exceed the following values: fasting, 95 mg/dL; 1 hour, 180 mg/dL; 2 hours, 155 mg/dl; and 3 hours, 140 mg/dL(1,2).SeeDiagnosticCriteriaforDiabetesMellitusinSectionII. The results of the Hyperglycemia and Adverse Pregnancy Outcomes study were recently reported at the AmericanDiabetesAssociations67thScientificSession.Thislargescale,multinational,epidemiologicstudy demonstrated that the risk of adverse maternal, fetal, and neonatal outcomes continuously increased as a functionofmaternalglycemiaat24to28weeksofgestation,evenwithinrangespreviouslyconsideredtobe normalforpregnancy.Formostcomplications,therewasnothresholdforrisk.Theseresultsmaycallfora carefulreconsiderationofthediagnosticcriteriaforGDM(3). ClinicalMonitoring Maternal metabolic monitoring should be directed at detecting hyperglycemia severe enough to increase risks to the fetus (4). Fasting hyperglycemia (>105 mg/dL) may be associated with an increased risk of intrauterine fetal death during 4 to 8 weeks of gestation (1). For both GDM and preexisting diabetes, self monitoring of blood glucose levels is essential for the management of diabetes during pregnancy. Urine shouldalsobetestedforketonesonaroutinebasis,andthesetestresultscanbeusedtodetectinsufficient energyorcarbohydrateintakeinwomentreatedwithenergyrestriction (14).Monitoringtheurineglucose levels is not appropriate in GDM (1). The patients blood pressure and urine protein levels should be monitoredtodetecthypertensivedisorders (1).Monitoringschedulesforpatientswithpreexistingdiabetes havebeendevelopedbytheAmericanDiabetesAssociation(1,3,4). NutritionInterventionforGestationalDiabetesMellitus AllwomenwithGDMshouldreceivenutritioncounselingbyaregistereddietitian,whichisconsistentwith the recommendations of the American Diabetes Association (1,3,4). Medical nutrition therapy for GDM primarily involves a carbohydratecontrolled meal plan that promotes optimal nutrition for maternal and fetalhealthwithadequateenergyforappropriategestationalweightgain,achievementandmaintenanceof
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MedicalNutritionTherapyforGestationalDiabetesMellitus
normoglycemia,andtheabsenceofketosis(4).Specifictherapeuticgoalsarebasedonanindividualnutrition assessmentandselfmonitoringofbloodglucoselevels.Optimumneonataloutcomesoccurmorefrequently in women who gain the recommended amount of weight based on prepregnancy body mass index (BMI) levelsestablishedbytheInstituteofMedicine(5)(GradeI). OverweightandobesewomenwithGDMbenefitfromnutritioncounselingbyadietitiantodecreasetherate of weight gain, decrease the levels of fasting and postpartum serum glucose, and normalize infant birth weight (5) (Grade I). Weight loss is not recommended during pregnancy; however, modest energy and carbohydraterestrictionmaybeappropriateforoverweightandobesewomenwithGDM(4).RefertoTable C1 for the current weight gain guidelines and Section IA: Nutrition Management During Pregnancy and Lactation(68).
TableC1:RecommendedWeightGainforPregnantWomenBasedonPrepregnancyBMI RecommendedTotalGain(kg[lb]) PrepregnancyWeightClassification BMI(kg/m2) LowBMI <19.8 12.518(2840) NormalBMI 19.825.9 11.516(2535) HighBMI 2629 711.5(1525) Obese >29 Atleast7(atleast15) Forwomencarryingmultiplefetuses,thefollowingweightgainisappropriate(8) 15.920.5kg(3545lb) Twinpregnancy Tripletpregnancy 20.511.3kg(4555lb)
Sources:SubcommitteeonNutritionalStatusandWeightGainDuringPregnancy,CommitteeofNutritionalStatusDuringPregnancyand Lactation, FoodandNutrition Board,InstituteofMedicine,National AcademyofSciences.NutritionDuringPregnancy. Washington, DC:NationalAcademyPress;1992. BrownJE,CarlsonM.Nutritionandmultifetalpregnancy.JAmDietAssoc.2000;100:343348.
EnergyRequirements The MNT should include adequate energy and nutrients to meet the needs of pregnancy and should be consistentwiththematernalbloodglucosegoals.Cohortstudiesshowthatenergyrequirementsarehighly variable and can be met by increasing food intake, decreasing physical activity, or decreasing fat storage. Therefore, recommendations for energy levels are best determined by monitoring weight gain, physical activity, appetite, daily food intake, and glucose and ketone records (5) (Grade I). Refer to Table C2 for the suggesteddailyenergyintakeforpregnantdiabeticwomen(1,9). TableC2:RecommendedDailyEnergyIntakeforPregnantDiabeticWomen PrepregnancyWeightStatus Energy(kcal/kgperday) Energy(kcal/lbperday) Desirablebodyweight 30 13.6 >120%ofdesirablebodyweight,BMI>30kg/m2 25 10.9 <90%ofdesirablebodyweight 3640 16.318.2
Sources:AmericanDiabetesAssociation.Gestationaldiabetesmellitus:positionstatement.DiabetesCare.2004;27(suppl1):88S90S. MedicalManagementofPregnancyComplicatedbyDiabetes.2nded.Alexandria,Va:AmericanDiabetesAssociation;1995.
ManagingKetosis The prevention of ketosis is a primary outcome of medical nutrition therapy in GDM (1). Casecontrol and cohort studies have found an association between ketonemia and ketonuria during GDM and a lower intelligencequotientinoffspring(5)(GradeII).Ketonetestingisanimportantpartofselfmonitoringandaidsin adjustingtheenergyintakelevel,carbohydratedistribution,andphysicalactivitylevel (5)(GradeII).Toprevent ketosis, adequate energy intake and the appropriate distribution of meals and snacks is important. An eveningsnackmaybeneededtopreventacceleratedketosisovernight(4).Lowenergydietsinobesewomen with GDM can result in ketonemia and ketonuria (4). Randomized controlled trials have shown that restrictingenergyintaketo1,200kcal/dayinobesewomen(BMI>30kg/m2)withGDMresultsinketonemia orketonuria,whereasrestrictingthedailyenergyintaketoamoreliberalamountof~1,800kcal(25kcal/kg ofactualweight)doesnotresultinketonemiaorketonuria(5)(GradeI).Moderateenergyrestriction,definedas a30%reductioninestimatedenergyneeds,inobesewomenwithGDMmayimproveglycemiccontroland reduceexcessivematernalweightgainwithoutthedevelopmentofketonemia;however,insufficientdataare availabletodeterminetheeffectofsuchdietsonperinataloutcomes (4).Dailyfoodrecords,weeklyweight checks,andketonetestingremainparamountinassessingtheadequacyofapatientsenergyintake(4).
CarbohydrateIntake The amount and kind of carbohydrate in meals and snacks are key to maintaining optimal blood glucose levelsandreducingtheneedforinsulinwhilecontrollingmaternalweightgainandinfantbirthweight (4,5,10)
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The amount and distribution of carbohydrate intake should be based on the clinical outcome measures of hunger, plasma glucose levels, weight gain, and ketone levels (4). A minimum of 175 g of carbohydrateshouldbeprovidedonadailybasis(GradeII)(4,5).Adietcomprisedof42%to45%carbohydrate distributedamongsixtoeightmealsandsnacksthroughoutthedaywithsmalleramountsofcarbohydrate (15to45g)atbreakfastandsnackspromotesnormalbloodglucoselevels (5) (Grade II).Lowercarbohydrate intake is suggested at breakfast, because carbohydrate is generally less well tolerated at breakfast than at other meals during pregnancy (4). It has been suggested that nonnutritive sweeteners may be used in moderationasameanstocontroltotalenergyintakeandpromotebloodglucosecontrolinGDM (1).While there are recognizable benefits of the use of nonnutritive sweeteners with maintenance of blood glucose control,thereislimitedevidencetosupporttheuseornonuseofnonnutritivesweetenersinpregnancyand even less evidence addressing this issue specifically in GDM (5) (Grade IV). Refer to Section IA: Nutrition ManagementDuringPregnancyandLactationforadditionalinformationaboutthenutrientrequirementsand useofnonnutritivesweetenersduringpregnancy.
(Grade II).
SelfMonitoringofBloodGlucoseGoals Selfmonitoring of blood glucose levels is an essential component of maintaining desirable blood glucose levelsinwomenwithGDM.Studieshaveshownthatthebestoutcomesareachievedwhenbothfastingand 1or2hourpostprandialbloodglucoselevelsaremonitoredthreetoeighttimesperdayandusedtomodify food intake or meal patterns and physical activity levels (5) (Grade I). The American Diabetes Association recommends that people with type 1 diabetes and pregnant women who take insulin check their blood glucose levels three or more times daily so that they can adjust their food intake, physical activity level, and/orinsulindosagetomeetbloodglucosegoals(3).Thefollowingtableprovidesthegoalsforbloodglucose management(1).Evidencehasshownthatmeanserumglucoselevelsof86mg/dLincreasetheriskforsmall for gestational age infants and that mean glucose levels of 105 mg/dL increase the risk for macrosomia (5) (GradeI).
BloodGlucoseGoalsinDiabeticPregnancy TimeofMeasurement WholeBloodGlucose(mg/dL) Fasting <95 1hpostprandial <140 2hto6hpostprandial <120
PlasmaGlucose(mg/dL) <105 <155 <130
Source: American Diabetes Association. Gestational diabetes mellitus: position statement. Diabetes Care. 2004;27(suppl1):88S90S.
The newer modelsof glucose meters are oftenplasma calibrated. Plasmacalibrated meters usually read 10%to15%higherthanwholebloodglucosemeters.Therefore,healthcareprovidersandpatientsshouldbe awareofwhichtestisbeingusedtomeasureglucoselevels (1,4).Plasmametersalsoallowthepatienttotest glucoselevelsatothersites,suchasthethigh,arm,orcalf.Toaccountfordifferencesinbloodglucoselevels fromdifferentsites,plasmaglucoseismeasuredinsteadofwholebloodglucosebecausethevaluesaremore consistentfromsitetosite.
MedicationManagement Research indicates that pharmacological therapy, such as the use of insulin, insulin analogs and glyburide, improves glycemic control and reduces the incidence of poor maternal and neonatal outcomes (Grade II) (5). Insulin therapy is recommended if medical nutrition therapy fails to maintain the following selfmonitored glucose levels: a fasting plasma glucose level of 105 mg/dL, a 1hour postprandial blood glucose level of <155mg/dL,and/ora2hourpostprandialplasmaglucoselevelof130mg/dL (1,5) (Grade I).Humaninsulin should be used when insulin is prescribed, and selfmonitoring blood glucose records should guide the dosageandtimingofinsulintherapy.Ifinsulintherapyisaddedtonutritiontherapy,aprimarygoalmustbe to maintain consistent carbohydrate intake at meals and snacks to facilitate insulin adjustments (4). The prevention of ketosis may require multiple daily insulin injections and the distribution of dietary carbohydrate into small frequent meals (three meals and three or four snacks). Insulin requirements normally increase as the pregnancy proceeds, and the insulin regimen must be continually adjusted throughoutthepregnancy.Bloodglucosemonitoringbythepatientisanessentialpartofthisprocess (1,4,10). Theheightenedinsulinrequirementwillplummetwithinhoursofdelivery.Metaboliccontrolduringlabor, delivery,andthepostpartumperiodshouldbemanagedbyfrequentdeterminationsofbloodglucoselevels andadjustmentstotheinsulindose. A number of drugs commonly used in the treatment of patients with diabetes may be relatively or absolutelycontraindicatedduringpregnancy(3).Statinsandangiotensinconvertingenzymeinhibitors,which are used to manage disorders in lipid metabolism or hypertension, should be discontinued prior to
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conception (3).Amongtheoralantidiabeticdrugs,metforminandacarboseareclassifiedascategoryBdrugs (noevidenceofriskinhumans),whileallotheroralantidiabeticdrugsincludingsulfonylureas(eg,glyburide) are classified as category C drugs (risk cannot be ruled out) (1,3,4). The potential risks and benefits of oral antidiabetic agents in the preconception period must be carefully evaluated, recognizing that data are insufficienttoestablishthesafetyoftheseagentsinpregnancy (3).Particularlyforpatientswithpreexisting diabetes,medicationevaluationshouldbecarefullyassessedaspartofpreconceptioncare(3).
PhysicalActivity Regularphysicalactivityreducesinsulinresistance,lowersfastingandpostprandialglucoseconcentrations, andmaybeusedasanadjuncttonutritiontherapytoimprovematernalglycemia (4,5) (Grade II).Theoptimal frequencyandintensityofexerciseforloweringmaternalglucoseconcentrationshavenotbeendetermined; but,itappearsthataminimumofthreeweeklyexercisesessions,eachlongerthan15minutes,isrequiredto modify maternal glucose levels. In addition, 2 to 4 weeks of regular exercise may be required before a reduction of glycemia occurs (4). Regular physical activity hasalsobeen shown to reduce excessive weight gainduringpregnancy (5) (Grade II).Personsshouldfrequentlymonitortheirbloodglucoselevelsbeforeand afterphysicalactivity.Personswhodoexerciseshouldbeawarethatprolongedexercise(>60minutes)is morelikelytocausehypoglycemiainpregnancy(5)(GradeII).
FollowupEvaluationandMonitoring The recurrence rate of GDM in subsequent pregnancies is 30% to 65% (5) (Grade I). The American Diabetes Association recommends a followup evaluation of each woman diagnosed with gestational diabetes (1,4), because these women may be prone to the development of type 2 diabetes later in life (4) (Grade I). Reclassification of maternal glycemic status should be performed 6 to 12 weeks after delivery (3). If postpartumglucoselevelsarenormal,thenglycemiashouldbereassessedataminimumof3yearintervals (3).Womenwithimpairedfastingglucoseorimpairedglucosetoleranceinthepostpartumperiodshouldbe annually tested for diabetes (1). See Diagnostic Criteria for Diabetes Mellitus in Section II. It is prudent to provide nutrition counseling and guidance to these women after the birth of their children. Lifestyle modifications aimed at reducing weight or preventing weight gain and increasing physical activity after pregnancyarerecommendedtoreducetheriskofdevelopingtype2diabetesmellitus(3).
DietaryRecommendationsforPregnantWomenWithPreexistingDiabetes Preconception care is a key factor in successful pregnancy outcomes for persons with preexisting diabetes (type1ortype2).Allwomenwithdiabetesshouldbeeducatedregardingtheneedforgoodbloodglucose control before pregnancy and should participate in family planning (3). A womans A1C level should be as close to normal as possible (<7%) before conception is attempted (3). Medication use should be evaluated before conception because drugs commonly used to treat diabetes and its complications may be contraindicatedornotrecommendedinpregnancy(3).Nutrientrequirementsduringpregnancyandlactation are similar for women with and without diabetes (4). For pregnancy complicated by diabetes, nutrition therapy should attempt to achieve and sustain optimal maternal blood glucose control. A favorable pregnancy outcome is defined as a gestational duration of 39 to 41 weeks and the birth of a live infant weighing6.8to7.9lb(3.1to7.9kg) (7).Duringpregnancywithprioronsetoftype1ortype2diabetes,the distribution of energy intake and carbohydrates in the meal plan should be based on the womans eating habits, blood glucose records, and stage of pregnancy. Regular meals and snacks are important to avoid hypoglycemiaduetothecontinuousfetaldrawofglucosefromthemother (4).Aneveningsnackisusually necessary to decrease the potential for overnight hypoglycemia and fasting ketosis (4). Energy intake to achieveappropriateweightgainmaybeestimatedbasedonthepercentofdesirablebodyweightbeforethe pregnancy(1,4).PregravidBMImaybeusedtoestimateagoalforweightgainduringpregnancy(68).
Lactation Breastfeeding is recommended for infants of women with preexisting diabetes or GDM. Research indicates that even short duration of breastfeeding results in long-term improvements in glucose metabolism and may also reduce the risk of type 2 diabetes in children (Grade III) (5). Successfullactationrequiresplanningandcoordination ofcare(11).Inmostsituations,breastfeedingmothersrequirelessinsulinbecauseoftheenergyexpendedby nursing.Lactatingwomenhavereportedfluctuationsinbloodglucoselevelsrelatedtonursingsessions,and theyoftenrequireacarbohydratecontainingsnackbeforeorduringnursingsessions(11).
References 1. AmericanDiabetesAssociation.Gestationaldiabetesmellitus:positionstatement.DiabetesCare.2004;27(suppl1):88S90S. 2. AmericanDiabetesAssociation.Diagnosisandclassificationofdiabetesmellitus:positionstatement.DiabetesCare.2010;33(suppl 1):62S69S. 3. AmericanDiabetesAssociation.Standardsofmedicalcareindiabetes2010.DiabetesCare.2010;33(suppl1):11S61S.
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MedicalNutritionTherapyforGestationalDiabetesMellitus American Diabetes Association. Nutrition recommendations and interventions for diabetes: position statement. Diabetes Care. 2008;31(suppl1):61S78S. 5. Gestational Diabetes EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. AmericanDieteticAssociation;2008.Availableat:http://www.adaevidencelibrary.com.AccessedJanuary5,2009. 6. Food and Nutrition Board. Nutrition During Pregnancy. Part I: Weight Gain. Part 2: Nutrient Supplements. Washington, DC: InstituteofMedicine,NationalAcademyofSciences;1990. 7. ButteNF,KingJC.Energyrequirementsduringpregnancyandlactation.PublicHealthNutr.2005;8:10101027. 8. BrownJE,CarlsonM.Nutritionandmultifetalpregnancy.JAmDietAssoc.2000;100:343348. 9. MedicalManagementofPregnancyComplicatedbyDiabetes.2nded.Alexandria,Va:AmericanDiabetesAssociation;1995. 10. MajorCA,HenryMJ,DeVecianaM,MorganMA.Theeffectsofcarbohydraterestrictioninpatientswithdietcontrolledgestational diabetes.ObstetGynecol.1998;91:600604. 11. ReaderD,FranzMJ.Lactation,diabetes,andnutritionrecommendations.CurrDiabRep.2004;4:370376. Bibliography PositionoftheAmericanDieteticAssociation:Nutritionandlifestyleforahealthypregnancyoutcome.JAmDietAssoc.2008;108:553 561. ACOG Practice Bulletin. Clinical management guidelines for obstetriciangynecologists. No. 30, September 2001 (replaces Technical BulletinNo.200,December1994).Gestationaldiabetes.ObstetGynecol.2001;98:525538. SuitorCW.Nutritionforwomenintheirchildbearingyears:areviewoftheliteratureandasummaryofexpertrecommendations.Nutr ClinCare.1999;2:1145. 4.
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DIETARYMANAGEMENTWITHTHEEXCHANGESYSTEM
This system is used in the calculation of energycontrolled and diabetic diets. Various exchange groups within the systemcanalsobeusedinthecalculationoffatcontrolleddiets. Each list shows the kinds and amounts of foods to use for one exchange. Exchanges are based upon roughly equivalent carbohydrate, protein, andfat content. Exchanges havebeen defined in householdmeasures. For food serviceportioning,theymaybefurtherdefinedbyservingutensilsormultiples(orfractions)ofthestandardportion. Theselistsareareferenceforinitialplanningofdiets,menuwriting,andcarbohydratecounting.Additionalfoods andrecipescanbetranslatedintoexchangesand/orgramsofcarbohydratesthroughtheevaluationofmacronutrient content.Thefollowingchartshowstheamountofnutrientsinoneservingfromeachlist.
FoodList
Carbohydrate (g)
Protein (g)
Fat (g)
Energy (kcal)
Carbohydrates Starch:breads, 15 03 01 80 cerealsandgrains; starchyvegetables; crackersandsnacks; andbeans,peas, andlentils Fruits 15 60 Milk Fatfree,lowfat,1% 12 8 03 100 Reducedfat,2% 12 8 5 120 Whole 12 8 8 160 varies Sweets,desserts,and 15 varies varies othercarbohydrates Nonstarchyvegetables 5 2 25 MeatsandMeatSubstitutes Lean 7 03 45 Mediumfat 7 47 75 Highfat 7 8+ 100 Plantbasedproteins varies 7 varies varies Fats 5 45 Alcohol 5 2 100 ChooseYourFoods:ExchangeListsforDiabetes.2008AmericanDietetic Association.Reprintedwith permission.
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DietaryManagementwiththeExchangeSystem
STARCH Onestarchexchangeequals15gofcarbohydrate,03gofprotein,01goffatand80kcal. Breads Amount StarchyVegetables Amount Bagel,large(about4oz) cup 1/4(1oz) Refriedbeansb,c,canned Biscuita,2inchesacross Cassava 1/3cup 1 Bread Corn cup reducedcalorie oncob,large 1/2(5oz) 2slices(1oz) white,wholegrain,pumpernickel, 1slice(1oz) Hominyb,canned cup Mixedvegetableswithcorn, rye,unfrostedraisin 1cup peas,andpastab Chapatti,small,6inchesacross 1 Parsnipsb Cornbreada,1inchcube cup 1(1oz) Englishmuffin Peas,greenb cup 1/2 Plantain,ripe Hotdogbunorhamburgerbun 1/3cup 1/2(1oz) Potato Naan,8inchesby2inches 1/4 bakedwithskin Pancake,4inchesacross,inchthick 1 1/4large(3oz) boiled,allkinds Pita,6inchesacross cupor1/2medium(3oz) 1/2 mashed,withmilkandfata Roll,small,plain cup 1(1oz) Frenchfried(ovenbaked) Stuffing,breada 1cup(2oz) 1/3cup Tacoshella,5inchesacross Pumpkinb,canned,nosugar 1cup 2 Tortilla,corn,6inchesacross added 1 Tortilla,flour,6inchesacross Spaghetti/pastasauce cup 1 Tortilla,flour,10inchesacross Squash,winterb(acorn, 1cup 1/3tortilla butternut) Wafflea,4inchsquareor4inches cup 1 across Succotashb cup Yam,sweetpotato,plain CerealandGrains Amount CrackersandSnacks Amount Barley,cooked 8 1/3cup Animalcrackers Bran,dry Crackers oatb 6 cup roundbuttertypea wheatb saltinetype 6 cup Bulgur(cooked) sandwichstylea,cheeseor 3 cup peanutbutterfilling Cereals wholewheata,regular branb 25(oz) cup cooked(oats,oatmeal) wholewheata,lowerfator 25(oz) cup crispbreads puffed 1cups Grahamcrackers,2inch shreddedwheat,plain 3 cup square sugarcoated oz cup Matzoh unsweetened,readytoeat 4 cup Melbatoast,2by4inchpiece 20 Couscous,cooked 1/3cup Oystercrackers Granola 3cups Popcorn lowfat 3cups cup withbuttera,b regulara 3cups cup Grits,cooked nofataddedb 3cups cup Kasha lowerfatb oz cup Pretzels Millet,cooked 2 1/3cup Ricecakes,4inchesacross Muesli cup Snackchips Pasta,cooked 1/3cup fatfreeorbaked(tortilla, Polenta,cooked 1520(oz) 1/3cup potato),bakedpitachips Quinoa,cooked 1/3cup regulara(tortilla,potato) Rice,whiteorbrown,cooked 913(oz) 1/3cup Tabbouleh(tabouli),prepared cup Wheatgerm,dry 3tbsp Wildrice,cooked cup Beans,Peas,andLentils Amount aExtrafat,orpreparedwithaddedfat(Countas1starch+1fat) Bakedbeansb 1/3cup bMorethan3gofdietaryfiberperserving Beansb,cooked(black,garbanzo, cup c480mgormoreofsodiumperserving kidney,lima,navy,pinto,white) Lentilsb,cooked(brown,green,yellow) cup Peasb,cooked(blackeyed,split) cup
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FRUITS Onefruitexchangeequals15gofcarbohydrateand60kcal. Fruits Amount Fruits(Cont.) Apple,unpeeled,small 1(4oz) Pears Apples,dried 4rings canned Applesauce, cup fresh,large unsweetened Pineapple Apricots canned canned cup fresh dried 8halves Plums fresha 4whole(5oz) canned Banana,extrasmall 1(4oz) dried(prunes) Blackberriesa cup small Blueberries cup Raspberriesa Cantaloupe,small 1/3melonor1cupcubed(11oz) Strawberriesa Tangerines,smalla Cherries Watermelon sweet,canned cup sweet,fresh 12(3oz) Dates 3 FruitJuices Driedfruits 2tbsp Applejuice/cider (blueberries,cherries, Fruitjuiceblends,100% juice cranberries,mixed Grapejuice fruit,raisins) Grapefruitjuice Figs Orangejuice dried 1 Pineapplejuice fresha 1largeor2medium(3oz) Fruitcocktail Prunejuice cup Grapefruit large (11oz) sections,canned cup Grapes,small 17(3oz) Honeydewmelon 1sliceor1cupcubed(10oz) Kiwia 1(3oz) Mandarinoranges, canned cup Mango,small fruit(5oz)orcup Nectarine,small 1(5oz) Orange,smalla 1(6oz) Papaya 1/2fruitor1cupcubed(8oz) Peach canned cup fresh,medium (6oz)
aMorethan3gofdietaryfiberperserving
Amount cup 1/2(4oz) cup cup cup 3 2(5oz) 1cup 1cupwholeberries 2(8oz) 1sliceor1cupscubes(13oz) Amount cup 1/3cup 1/3cup cup cup cup 1/3cup
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MILK Onemilkexchangeequals12gofcarbohydrateand8gofprotein. Food ServingSize Fatfreeorlowfat(1%) Milk,buttermilk,acidophilusmilk,Lactaid 1cup Evaporatedmilk cup Yogurt,plainorflavoredwithanartificialsweetener 2/3cup(6oz) Reducedfat(2%) Milk,acidophilusmilk,kefir,Lactaid 1cup Yogurt,plain 2/3cup(6oz) Whole Milk,buttermilk,goatsmilk 1cup Evaporatedmilk cup Yogurt,plain 8oz
Countas 1fatfreemilk 1fatfreemilk 1fatfreemilk 1reducedfatmilk 1reducedfatmilk 1wholemilk 1wholemilk 1wholemilk

DAIRYLIKEFOODS Onemilkexchangeequals12gofcarbohydrateand8gofprotein. Food ServingSize Chocolatemilk fatfree 1cup whole 1cup Eggnog,wholemilk cup Ricedrink flavored,lowfat 1cup plain,fatfree 1cup Smoothies,flavored,regular 10oz Soymilk light 1cup regular,plain 1cup Yogurt andjuiceblends 1cup lowcarbohydrate(lessthan6gofcarbohydrate 2/3cup(6oz) perchoice) withfruit,lowfat 2/3cup(6oz)
Countas 1fatfreemilk+1carbohydrate 1wholemilk+1carbohydrate 1carbohydrate+2fats 2carbohydrates 1carbohydrate 1fatfreemilk+2carbohydrates 1carbohydrate+fat 1carbohydrate+1fat 1fatfreemilk+1carbohydrate fatfreemilk 1fatfreemilk+1carbohydrate
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SWEETS,DESSERTS,ANDOTHERCARBOHYDRATES Onecarbohydrateexchangeequals15gofcarbohydrateandvariable amountsofprotein,fat,andenergy. Food ServingSize Countas Beverages,Soda,andEnergy/SportsDrinks Cranberryjuicecocktail 1carbohydrate cup Energydrink 2carbohydrates 1can(8.3oz) Fruitdrinkorlemonade 2carbohydrates 1cup(8oz) Hotchocolate regular 1envelopeaddedto8ozwater 1carbohydrate+1fat sugarfreeorlight 1envelopeaddedto8ozwater 1carbohydrate Softdrink(soda),regular 2carbohydrates 1can(12oz) Sportsdrink 1carbohydrate 1cup(8oz) Brownies,Cake,Cookies,Gelatin,Pie,andPudding Brownie,small,unfrosted 1inchsquare,7/8inchhigh 1carbohydrate+1fat (about1oz) Cake angelfood,unfrosted 2carbohydrates 1/12ofacake(about2oz) frosted 2carbohydrates+1fat 2inchsquare(about2oz) unfrosted 1carbohydrate+1fat 2inchsquare(about1oz) Cookies chocolatechip 1carbohydrate+2fats 2(2inchesacross) gingersnap 1carbohydrate 3 sandwichwithcrmefilling 1carbohydrate+1fat 2small(about2/3oz) sugarfree 1carbohydrate+12fat 3smallor1large(3/41oz) vanillawafer 1carbohydrate+1fat 5 Cupcake,frosted 2carbohydrates+11 1small(about1oz) fats Fruitcobbler 3carbohydrates+1fat cup(3oz) Gelatin,regular 1carbohydrate cup Pie 1/6of8inchpie commerciallypreparedfruit,2crusts 3carbohydrates+2fats 1/8of8inchpie pumpkinorcustard 1carbohydrates+1 fats Pudding cup regular(madewithreducedfatmilk) 2carbohydrates sugarfreeorsugarandfatfree(madewithfatfree cup 1carbohydrate milk) Candy,Spread,Sweets,Sweeteners,Syrups,and Toppings 2funsizebars(1oz) Candybar,chocolate/peanut 1carbohydrates+1 fats 3pieces Candy,hard 1carbohydrate 5 Chocolatekisses 1carbohydrate+1fat Coffeecreamer 4tsp dry,flavored carbohydrate+fat 2tbsp liquid,flavored 1carbohydrate 1roll(3/4oz) Fruitsnacks,chewy(pureedfruitconcentrate) 1carbohydrate 1tbsp Fruitspreads,100%fruit 1carbohydrate 1tbsp Honey 1carbohydrate 1tbsp Jamorjelly,regular 1carbohydrate 1tbsp Sugar 1carbohydrate Syrup 2tbsp chocolate 2carbohydrates 2tbsp light(pancaketype) 1carbohydrate 1tbsp regular(pancaketype) 1carbohydrate
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SWEETS,DESSERTS,ANDOTHERCARBOHYDRATESLIST(Cont.) Onecarbohydrateexchangeequals15gofcarbohydrate andvariableamounts ofprotein,fat,andenergy. Food ServingSize Countas CondimentsandSauces Barbequesauce 3tbsp 1carbohydrate 1carbohydrates Cranberrysauce,jellied cup carbohydrate+fat Gravya,cannedorbottled cup Saladdressing,fatfree,lowfat,creambased 1carbohydrate 3tbsp Sweetandsoursauce 1carbohydrate 3tbsp Doughnuts,Muffins,Pastries,andSweetBreads Banananutbread 2carbohydrates+1fat 1inchslice(1oz) Doughnut cake,plain 1carbohydrates+2fats 1medium(1oz) yeasttype,glazed 2carbohydrates+2fats 3inchesacross(2oz) Muffin(4oz) 1carbohydrate+fat 1/4muffin(1oz) SweetrollorDanishpastry 2carbohydrates+2fats 1(2oz) FrozenBars,FrozenDesserts,FrozenYogurt, andIceCream Frozenpops carbohydrate 1 Fruitjuicebars,frozen,100%juice 1carbohydrate 1(3oz) Icecream fatfree 1carbohydrate cup light 1carbohydrate+1fat cup nosugaradded 1carbohydrate+1fat cup regular 1carbohydrate+2fats cup Sherbet,sorbet 2carbohydrates cup Yogurt,frozen fatfree 1carbohydrate 1/3cup regular 1carbohydrate+01fats cup GranolaBars,MealReplacementBars/Shakes, andTrailMix Granolaorsnackbar,regularorlowfat 1carbohydrates 1(1oz) Mealreplacementbar 1carbohydrates+01fat 1(11/3oz) Mealreplacementbar 2carbohydrates+1fat 1(2oz) Mealreplacementshake,reducedenergy 1carbohydrates+01fat 1(1011oz) Trailmix candy/nutbased 1carbohydrate+2fats 1oz driedfruitbased 1carbohydrate+1fat 1oz a480mgormoreofsodiumperserving

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NONSTARCHYVEGETABLES One vegetable exchange equals 5g ofcarbohydrate, 2 g ofprotein, 0 gof fat,and 25 kcal. Each exchange is a cup portionofcookedvegetablesora1cupportionofrawvegetables. AmaranthorChinesespinach Kohlrabi Artichoke Leeks Artichokehearts Mixedvegetables(withoutcorn,peas,orpasta) Asparagus Mungbeansprouts Babycorn Mushrooms,allkinds,fresh Bambooshoots Okra Beans(green,wax,Italian) Onions Beansprouts Orientalradishordaikon Beets Peapods Borschta Peppersb(allvarieties) Broccoli Radishes Brusselssproutsb Rutabaga Cabbage(green,bokchoy,Chinese) Sauerkrauta b Soybeansprouts Carrots Cauliflower Spinach Celery Squash(summer,crookneck,zucchini) Chayoteb Sugarsnappeas Coleslaw,packagednodressing Swisschardb Tomato Cucumber Tomatoes,canned Eggplant Tomatosaucea Gourds(bitter,bottle,luffa,bittermelon) Tomato/vegetablejuicea Greenonionsorscallions Turnips Greens(collard,kale,mustard,turnip) Waterchestnuts Heartsofpalm Yardlongbeans Jicama Note:Saladgreens(likechicory,endive,escarole,lettuce,arugula,radicchio,andwatercress)areontheFreeFoodslist.
a480mgormoreofsodiumperserving bMorethan3gofdietaryfiberperserving
MEATS ANDMEATSUBSTITUTES Oneexchangeequals7gofprotein. LeanMeatsandMeatSubstitutes Amount LeanMeats andMeatSubstitutes(Cont.) Amount (03goffat,45kcalperexchange) 1oz Organmeats:heart,kidney,liver Note:Maybehighincholesterol Beef:selectorchoicegradestrimmedoffat: 1oz 6medium Oysters,freshorfrozen groundround,roast(chuck,rib,rump),round, Pork,lean sirloin,steak(cubed,flank,porterhouse,Tbone), 1oz Canadianbacona riborloinchop/roast,ham,tenderloin tenderloin 1oz Poultry without skin: Cornish hen, chicken, 1oz Beefjerkya oz Cheeseswith3goffatorlessperounce domestic duck or goose (welldrained of 1oz Cottagecheese fat),turkey cup Eggsubstitutes,plain Processedsandwichmeatswith3gof cup 1oz Eggwhites fatorlessperounce:chippedbeef, 2 Fish,freshorfrozen,plain:catfish,cod,flounder, deli thinsliced meats, turkey ham, turkey 1oz haddock,halibut,orangeroughy,salmon,tilapia, kielbasa,turkeypastrami trout,tuna Salmon,canned 1oz Fish,smokeda:herringorsalmon(lox) Sardines,canned 1oz 2small Game:buffalo,ostrich,rabbit,venison Sausageawith3goffatorlessperounce 1oz 1oz Shellfish:clams,crab,imitationshellfish, Hotdogawith3goffatorlessperounce 1 1oz (Eighthotdogsper14ozpackage) lobster,scallops,shrimp Note:maybehighincarbohydrate Tuna,cannedinwateroroil,drained 1oz Lamb:chop,leg,orroast Veal,loinchop,roast 1oz 1oz
a480mgormoreofsodiumperserving(basedonthesodiumcontentofatypical3ozservingofmeat,unless1or2ozisthenormalservingsize)
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MediumFatMeatsandMeatSubstitutes (47goffat,75kcalperexchange) Beef:cornedbeef,groundbeef,meatloaf, primegradestrimmedoffat(primerib), shortribs,tongue Cheeseswith47goffatperounce:feta, mozzarella,pasteurizedprocessedcheese spread,reducedfatcheeses,string Egg Note:Highincholesterol,solimittothreeper week Fish:anyfriedproduct Lamb:ground,ribroast Pork:cutlet,shoulderroast Poultry:chickenwithskin,dove,pheasant, wildduckorgoose,friedchicken,ground turkey Ricottacheese Sausageawith47goffatperounce Veal,cutlet(nobreading)
Amount
HighFatMeats andMeatSubstitutes (8+goffat,100kcal perexchange) Bacon porka(16slicesperlb,eachsliceis1oz beforecooking) turkeya(ozeachbeforecooking) Cheese,regular:American,bleu,brie, cheddar,hardgoat,Montereyjack, queso,andSwiss Hotdoga,b:beef,pork,orcombination (10per1lbpackage) Hotdoga:turkeyorchicken (10per1lbpackage) Pork:ground,sausage,spareribs Processedsandwichmeatswith8gof fatormoreperounce:bologna, pastrami,hardsalami Sausageawith8goffatormoreper ounce:bratwurst,chorizo,Italian, knockwurst,Polish,smoked,summer
Amount
1oz 1oz 1 1oz 1oz 1oz 1oz 2ozorcup 1oz 1oz
2slices 3slices 1oz 1 1 1oz 1oz 1oz
a480mgormoreofsodiumperserving(basedonthesodiumcontentofatypical3ozservingofmeat,unless1or2ozisthenormalservingsize) bExtrafat,orpreparedwithaddedfat.(Addanadditionalfatchoicetothisfood.)
PLANTBASEDPROTEINS Oneexchangeequals7gofprotein. Food ServingSize Baconstrips,soybased 3 Bakedbeansa 1/3cup Beansa,cooked:black,garbanzo,kidney,lima,navy, cup pinto,white Beeforsausagecrumbles,soybaseda 2oz Chickennuggets,soybased 2(1oz) Edamamea cup Falafel(spicedchickpeaandwheatpatties) 3(about2inchesacross) Hotdog,soybased 1(1oz) Hummusa 1/3cup Lentils,brown,green,oryellowa cup Meatlessburger,soybaseda 3oz Meatlessburger,vegetableandstarchbaseda 1(about2oz) Nutspreads:almondbutter,cashewbutter,peanut 1tbsp butter,soynutbutter Peasa,cooked:blackeyedandsplitpeas cup Refriedbeansa,b,canned cup Sausagepatties,soybased 1(1oz) Soynuts,unsalted oz Tempeh cup Tofu 4oz(cup) Tofu,light 4oz(cup)
aMorethan3gofdietaryfiberperserving
b
Countas 1mediumfatmeat 1starch+1leanmeat 1starch+1leanmeat carbohydrate+1leanmeat carbohydrate+1mediumfatmeat carbohydrate+1leanmeat 1carbohydrate+1highfatmeat carbohydrate+1leanmeat 1carbohydrate+1highfatmeat 1carbohydrate+1leanmeat carbohydrate+2leanmeats 1carbohydrate+2leanmeats 1highfatmeat 1starch+1leanmeat 1starch+1leanmeat 1mediumfatmeat carbohydrate+1mediumfatmeat 1mediumfatmeat 1mediumfatmeat 1leanmeat
480mgormoreofsodiumperserving
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FATS Onefatexchangeequals5goffatand45kcal. Unsaturated/MonounsaturatedFats Amount PolyunsaturatedFats (Cont.) Saladdressing Avocado,medium 2tbsp(1oz) reducedfata Note:Maybehighincarbohydrate Nutbutters(transfatfree):almondbutter, 1tsp regulara cashewbutter,peanutbutter(smoothor Seeds crunchy) flaxseed,whole Nuts pumpkin,sunflower almonds 6 sesameseeds Brazil 2 Tahiniorsesamepaste cashews 6 filberts(hazelnuts) 5 SaturatedFats macadamia 3 Bacon,cooked,regularorturkey mixed(50%peanuts) Butter 6 peanuts reducedfat 10 pecans stick 4halves pistachios whipped 16 Oil:canola,olive,peanut Butterblendsmadewithoil 1tsp Olives reducedfatorlight black(ripe) regular 8large green,stuffed Chitterlings,boiled 10large PolyunsaturatedFats Amount Coconut,sweetened,shredded Margarine:lowerfatspread(30%50% 1tbsp Coconutmilk vegetableoil,transfatfree) light Margarine:stick,tub(transfatfree),or 1tsp regular squeeze(transfatfree) Cream Mayonnaise halfandhalf reducedfat 1tbsp heavy regular 1tsp light Mayonnaisestylesaladdressing whipped reducedfat 1tbsp whipped,pasteurized regular 2tsp Creamcheese Nuts reducedfat pignolia(pinenuts) 1tbsp regular walnuts,English 4halves Lard Oil:corn,cottonseed,flaxseed,grapeseed, 1tsp Oil:coconut,palm,palmkernel safflower,soybean,sunflower Saltpork Oil:madefromsoybeanandcanolaoil 1tsp Shortening,solid (eg,Enova) Sourcream Plantstanolesters reducedfatorlight light 1tbsp regular regular 2tsp
a480mgormoreofsodiumperserving
Amount 2tbsp
1tbsp 1tbsp 1tbsp 1tbsp 2tsp Amount 1slice 1tbsp 1tsp 2tsp 1tbsp 1tsp 2tbsp(oz) 2tbsp 1/3cup 1tbsp 2tbsp 1tbsp 1tbsp 2tbsp cup 1tbsp(oz) 1tbsp(oz) 1tsp 1tsp oz 1tsp 3tbsp 2tsp
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FREEFOODS Afreefoodisanyfoodordrinkthatcontainslessthan20kcal ornomorethan 5gofcarbohydrateperserving. Foodswithservingsizesshouldbelimitedtothreeservingsperday.Besuretospreadthemoutthroughoutthe day. If you eat all three servings at one time, it could raise your blood glucose level. Foods listed without a servingsizecanbeeatenwheneveryoulike. ServingSize Condiments ServingSize LowCarbohydrateFoods Cabbage,raw cup Barbecuesauce 2tsp Candy,hard(regularorsugarfree) 1piece Catsup(ketchup) 1tbsp Carrots,cauliflower,orgreenbeans,cooked cup Honeymustard 1tbsp Cranberries,sweetenedwithsugar cup Horseradish substitute Lemonjuice Cucumber,sliced cup Miso 1 tsp Gelatin Mustard dessert,sugarfree Parmesancheese,freshlygrated 1tbsp unflavored Picklerelish 1tbsp Gum Pickles 1medium Jamorjelly,lightornosugaradded 2tsp dilla Rhubarb,sweetenedwithsugarsubstitute cup sweet,breadandbutter 2slices Saladgreens sweet,gherkin oz Sugarsubstitutes(artificialsweeteners) Salsa cup 2tbsp Soysaucea,lightorregular 1tbsp Syrup,sugarfree
ModifiedFatFoodswithCarbohydrate Creamcheese,fatfree Creamers nondairy,liquid nondairy,powdered Margarinespread fatfree reducedfat Mayonnaise fatfree reducedfat Mayonnaisestylesaladdressing fatfree reducedfat Saladdressing fatfreeorlowfat fatfree,Italian Sourcream,fatfreeorreducedfat Whippedtopping lightorfatfree regular
ServingSize Sweetchilisauce 1tbsp Tacosauce Vinegar 1tbsp Yogurt,anytype 2tsp 1tbsp 1tsp 1tbsp 1tsp 1tbsp 1tsp 1tbsp 2tbsp 1tbsp 2tbsp 1tbsp
2tsp 1tbsp 2tbsp
FreeSnacks Thesefoodsintheseservingsizesareperfect freefoodsnacks. 5babycarrotsandcelerysticks cupblueberries ozslicedcheese,fatfree 10goldfishstylecrackers 2saltinetypecrackers 1frozencreampop,sugarfree ozleanmeat 1cuplightpopcorn 1vanillawafer Drinks/Mixes Foodonthislistwithoutaservingsizecanbe consumedinmoderateamounts. Bouillon,broth,consomma Bouillonorbroth,lowsodium Carbonatedormineralwater Clubsoda Cocoapowder,unsweetened(1tbsp) Coffee,unsweetenedorwithsugarsubstitute Dietsoftdrinks,sugarfree Drinkmixes,sugarfree Tea,unsweetenedorwithsugarsubstitute Tonicwater,diet Water Water,flavored,carbohydratefree
Seasonings Foodsonthislistcanbeconsumedinmoderate amounts. Flavoringextracts(forexample,vanilla,almond, peppermint) Garlic Herbs,freshordried Nonstickcookingspray Pimento Spices Hotpeppersauce Wine,usedincooking Worcestershiresauce a480mgormoreofsodiumperserving
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COMBINATIONFOODS Entres ServingSize Casseroletypea(tunanoodle,lasagna,spaghetti 1cup(8oz) withmeatballs,chiliwithbeans,macaroni andcheese) Stewsa(beef/othermeatsandvegetables) 1cup(8oz) Tunasaladorchickensalad cup(3oz) FrozenMeals/Entres ServingSize Burritoa,b(beefandbean) 1 (5oz) generally1417oz Dinnertypemeala a Entreormealwithlessthan340kcal about811oz Pizza cheese/vegetarian,thincrust 1/4ofa12inch(45oz) meattopping,thincrust 1/4ofa12inch(5oz) Pocketsandwich 1 (4oz) 1 (7oz) Potpiea Salads(DeliStyle) ServingSize Coleslaw cup Macaroni/pastasalad cup a Potatosalad cup Soups ServingSize Bean,lentil,orsplitpeaa 1cup Chowdera(madewithmilk) 1cup(8oz) 1cup(8oz) Creama(madewithwater) Instanta 6ozprepared withbeansorlentilsa 8ozprepared Misosoupa 1cup Orientalnoodlea 1cup Rice(congee) 1cup Tomatoa(madewithwater) 1cup(8oz) Vegetable beef, chicken noodle, orotherbroth 1cup(8oz) typea
a600mgormoreofsodiumperserving(forcombinationfoodmaindishes/meals) bMorethan3gofdietaryfiberperserving
Countas 2carbohydrates+2mediumfat meats 1carbohydrate+1mediumfat meat+03fats carbohydrate+2leanmeats+1 fat Countas 3carbohydrates+1leanmeat+2 fats 3carbohydrates+3mediumfat meats+3fats 23carbohydrates+12leanmeats 2carbohydrates+2mediumfat meats 2carbohydrates+1mediumfat meat+3fats 2carbohydrates+2mediumfat meats+1fats 3carbohydrates+1leanmeat+1 2fats Countas 1carbohydrate+1fats 2carbohydrates+3fats 1carbohydrates+12fats Countas 1carbohydrate+1leanmeat 1carbohydrate+1leanmeat+1 fats 1carbohydrate+1fat 1carbohydrate 2carbohydrate+1leanmeat carbohydrate+1fat 2carbohydrates+2fats 1carbohydrate 1carbohydrate 1carbohydrate

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BreakfastSandwiches Egg,cheese,meat,Englishmuffina Sausagebiscuitsandwicha MainDishes/Entres Burritoa,b(beefandbeans) Chickenbreast,breadedandfrieda Chickendrumstick,breadedandfried Chickennuggetsa Chickenthigh,breadedandfrieda Chickenwings,hota OrientalFoods Beef,chicken,orshrimpwithvegetablesin saucea Eggroll,meata Friedrice,meatless Meatandsweetsaucea(orangechicken) Noodlesandvegetablesinsaucea,b(chowmein, lomein) Pizza Pizza cheese,pepperoni,regularcrusta cheese/vegetarian,thincrusta Sandwiches Chicken,sandwich,grilleda Chicken,sandwich,crispya Fishsandwichwithtartarsauce Hamburger largewithcheesea regular Hotdogwithbuna Submarinesandwich lessthan6goffata regular Taco,hardorsoftshell(meatandcheese)
bMorethan3gofdietaryfiberperserving
FASTFOODS ServingSize 1 1 ServingSize 1 (8oz) 1 (5oz) 1 (2oz) 6 (3oz) 1 (4oz) 6 (5oz) ServingSize 1cup(about5oz) 1 (about3oz) cup 1cup 1cup ServingSize 1/8ofa14inch (about4oz) 1/4 ofa12inch (about6oz) ServingSize 1 1 1 1 1 1 6inchsandwich 6inchsandwich 1 small
Countas 2carbohydrates+2mediumfatmeats 2carbohydrates+2highfatmeats+ 3fats Countas 3carbohydrates+3mediumfatmeats +3fats 1carbohydrate+4mediumfatmeats 2mediumfatmeats 1carbohydrate+2mediumfatmeats+ 1fat carbohydrate+3mediumfatmeats +1fats 5mediumfatmeats+1fats Countas 1carbohydrate+1leanmeat+1fat 1carbohydrate+1leanmeat+1fat 1carbohydrates+1fats 3carbohydrates+3mediumfatmeats +2fats 2carbohydrates+1fat Countas 2carbohydrates+1mediumfat meat+1fats 2carbohydrates+2mediumfat meats+1fats Countas 3carbohydrates+4leanmeats 3carbohydrates+3mediumfat meats+1fat 2carbohydrates+2mediumfat meats+2fats 2carbohydrates+4mediumfat meats+1fat 2carbohydrates+1mediumfatmeat + 1fat 1carbohydrate+1highfatmeat+1fat 3carbohydrates+2leanmeats 3carbohydrates+2mediumfat meats+1fats 1carbohydrate+1mediumfatmeat+ 1fats
a600mgormoreofsodiumperserving(forfastfoodmaindishes/meals)
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Salads Salad,maindisha,b(grilledchickentype,no dressingorcroutons) Salad,side,nodressingorcheese Sides/Appetizers Frenchfries,restaurantstylec Nachos,withcheesea Onionringsa Desserts Milkshake,anyflavor Softserveicecream,cone
bMorethan3gofdietaryfiberperserving cExtrafat,orpreparedwithaddedfat
FASTFOODS(Cont.) ServingSize salad small(about5oz) ServingSize small medium large small(about4oz) 1serving(about3oz) ServingSize 12oz onesmall
Countas 1carbohydrate+4leanmeats 1vegetable Countas 3carbohydrate+3fats 4carbohydrates+4fats 5carbohydrates+6fats 2carbohydrates+4fats 2carbohydrates+3fats Countas 6carbohydrates+2fats 2carbohydrates+1fat
a600mgormoreofsodiumperserving(forfastfoodmaindishes/meals)
ALCOHOL AlcoholicBeverages Beer light(4.2%) regular(4.9%) Distilledspirits:vodka,rum,gin,whiskey(80or86 proof) Liqueur,coffee(53proof) Sake Wine dessert(sherry) dry,red,orwhite(10%) ServingSize 12floz 12floz 1floz 1floz 1floz 3floz 5floz Countas 1alcoholequivalent+carbohydrate 1alcoholequivalent+1carbohydrate 1alcoholequivalent alcoholequivalent+1 carbohydrate alcoholequivalent 1alcoholequivalent+1carbohydrate 1alcoholequivalent
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SAMPLEEXCHANGEPATTERNSFORCALCULATEDDIETSUSING EXCHANGESYSTEM
1,200kcal
Breakfast Snack Lunch Snack Supper Snack Totals:
CHO 3 3 3 9
= Starch 1 2 1 4
Fruit 1 1 1 3
Milk 1 1 2
Meat 1 3 2 6
Vegetable 1 1 2
Fat 1 1 1 3
1,500kcal

CHO 4 4 3 11
= Starch 2 3 2 7
Fruit 1 1 2
Milk 1 1 2
Meat 1 3 3 7
Vegetable 1 1 2
Fat 1 1 2 4
1,800kcal
CHO 4 5 5 14
= Starch 2 4 3 8
Fruit 1 1 1 1 4
Milk 1 1 2
Meat 1 3 3 7
Vegetable 1 1 2
Fat 2 2 2 6
2,000kcal

CHO 4 5 5 2 16
= Starch 2 3 3 1 9
Fruit 1 1 1 1 4
Milk 1 1 1 3
Meat 1 3 3 1 8
Vegetable 1 1 2
Fat 1 2 2 1 6
2,200kcal
CHO 5 5 1 5 2 18
= Starch 3 3 1 3 1 11
Fruit 1 1 1 1 4
Milk 1 1 1 3
Meat 1 3 3 1 8
Vegetable 2 1 3
Fat 1 2 2 1 6
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SUGARINMODERATIONDIET
Description Thedietrestrictsfoodshighinaddedsugarandfat.Addedsugarisdefinedasthataddedtosweetenfoodat thetableoraddedbythemanufacturer,andischieflysucroseorcornsyrup. Indications Thisisalessrestricteddietforpeopletryingtoloseweight.ItisalsousedinconjunctionwiththeDumping SyndromeDiet.(SeeDumpingSyndromeDietinSectionIB.)Thisdietisnotmeantforpeoplewithtype1 diabetesortype2diabetes. NutritionalAdequacy The diet can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in the Statement on NutritionalAdequacyinSectionIA. HowtoOrdertheDiet OrderasSugarinModerationDiet. PlanningtheDiet Excludethefollowingfoods. FOODGROUP FOODSEXCLUDED BeveragesandMilk Regularcarbonatedbeverages;fruitades;sugarsweetenedsoftdrinks;sugar sweetenedicedtea;chocolatemilk;milkshake;eggnog;sweetenedyogurt; cocoa(sweetened) BreadsandCrackers Sweetrollsorbreads;doughnuts CerealsandGrains Sugarcoatedcereals;granolatypecereals;presweetenedcookedcereals Meat,Fish,Poultry,Cheese, Glazedmeats Eggs,Legumes VegetablesandPotatoes Candiedorglazedvegetables;sweetpickledvegetables FruitsandJuices Sweetenedfruitsorjuices;candiedorglazedfruits Desserts Cakes,pies,cookies,pastries,sherbets,puddings,gelatindesserts(regularly sweetened),icecream SugarandSweets Candy,chewinggum,sugar,honey,jam,jelly,marmalade,syrup,molasses Miscellaneous Sweetrelishes

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CalorieControlledDietforWeightManagement
CALORIECONTROLLEDDIETFORWEIGHTMANAGEMENT
Description For the CalorieControlled Diet for Weight Management, the Regular Diet is modified by reducing energy intake below what is necessary for maintenance of body weight. Intake of essential protein, vitamins, and mineralsismaintainedbylimitingtheamountoffatandsugarinthedietandsubstitutinglowenergyfoods forfoodsofsimilarnutrientcontentthatarehigherinenergy.Weightlossandweightmaintenancetherapy should be based on a comprehensive weight management program including diet, physical activity, and behaviortherapy.Thecombinationtherapyismoresuccessfulthananyoneinterventionalone(GradeI)*(1).
*TheAmericanDieteticAssociationhasassignedgrades,rangingfromGradeI(good/strong)toGradeV(insufficientevidence),toevidence andconclusionstatements.ThegradingsystemisdescribedinSectionIII:ClinicalNutritionManagementAReferenceGuide,pageIII1.
Indications Weight reduction is desirable because obesity is related to increased mortality and because weight loss reduces the risk factors for several chronic diseases. Thus, weight loss may help to both control diseases worsenedbyobesityanddecreasethelikelihoodofdevelopingthesediseases.Strongandconsistentclinical evidence supports weight loss in overweight or obese persons who have hypertension, hyperlipidemia, or type 2 diabetes, as well as in overweight or obese persons who are at risk for developing these conditions (GradeI) (16).Obesityisasignificantriskfactorfornonalcoholicfattyliverdisease,anemergingconditionthat is the most common cause of abnormal liver function tests in obese children and adults (7). Nonalcoholic fatty liver disease can lead to significant liver damage including cryptogenic cirrhosis, steatohepatitis, and hepatocellularcarcinoma(7).Inoverweightandobesepersons,weightlossisrecommendedto(17): lowerbloodpressureinpatientswithhypertension(5) lower total cholesterol, lowdensity lipoprotein cholesterol, and triglycerides levels in patients with hyperlipidemia(4) lowerbloodglucoselevelsinpatientswithtype2diabetes(3,4,6) preventliverdisease(7) Fat is lost when the body is in a state of negative energy balance, which is achieved by reduced energy intake,increasedenergyoutput(throughmusclework),orboth.Thereductionoftotalenergyintakevsthe macronutrient composition of the diet is the most important component for achieving negative energy balanceandsubsequentweightloss(8). Bodymassindex(BMI),definedasweight(kg)dividedbyheight2(m2),andwaistcircumferenceshouldbe usedtoclassifyoverweightandobesity,estimateriskfordisease,andidentifytreatmentoptions (GradeII)(13). TheBMIishighlycorrelatedtoobesity,fatmass,andriskofotherdiseases(GradeII)(13).Foroptimalhealth,a BMIof18.5to24.9kg/m2 isrecommendedforadults,basedonevidencethatthisrangeisassociatedwith minimal riskofdisease. Table C3 outlines the health risk classes associated with differentBMI levels and waistcircumferencesinadultsaged18yearsandolder. TableC3:WeightClassificationbyBMI,WaistCircumference,andAssociatedHealthRisks HealthRiskRelativetoWaistCircumference Men102cm(40inches) Men>102cm(>40inches) BMI Weight RiskClass Women>88cm(>35 Women88cm(35 (kg/m2) inches) inches) Underweight <18.5 Normal 18.524.9 0 Increased Overweight 25.029.9 0 Increased High 30.034.9 I High Veryhigh Obesity 35.039.9 II Veryhigh Veryhigh III Extremelyhigh Extremelyhigh Extreme >40.0 obesity
Source:NationalHeart,Lung,andBloodInstituteObesityEducationInitiativeExpertPanel.Clinicalguidelinesontheidentification, evaluation,andtreatmentofoverweightandobesityinadults.Availableat:http://www.nhlbi.nih.gov/nhbli/htm.AccessedJanuary21, 2004.

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Children and adolescents: Complications of obesity in children and adolescents include hypertension, dyslipidemia, orthopedic disorders, sleep disorders, gall bladder disease, and insulin resistance (9). The NationalHeart,Lung,andBloodInstituteObesityEducationInitiativeExpertPanelrecommendsevaluations and possible treatment for: (1) children and adolescents who have a BMI greater than or equal to the 85th percentileandcomplicationsofobesity;and(2)childrenandadolescentswhohaveoraBMIgreaterthanthe 95thpercentilewithorwithoutcomplicationsofobesity (9).Theuseofweightmaintenancevsweightlossto achieve weight goals depends on the patients age, baseline BMI percentile, and the presence of medical complications(9). The committee recommends treatment that begins early, involves family, and institutes permanentchangesinastepwisemanner(9).(RefertoObesityandWeightManagementinSectionIII.) Contraindications Weightreductionisnotrecommendedforthefollowinggroups: pregnant women (Energy restriction during pregnancy that is sufficient to produce weight loss can be dangerousforthedevelopmentofthefetus.)(10) patientswithunstablementalormedicalconditions,unlessmedicallysupervised(2) patientswithanorexianervosaorahistoryofthisdisorder,unlessmedicallysupervised(2) terminallyillpatients(2) SeeSectionIII:ClinicalNutritionManagement
HEARTFAILURE GASTROESOPHAGEALREFLUXDISEASE(GERD) HYPERTENSION HYPERTRIGLYCERIDEMIA HYPOGLYCEMIA OBESITYANDWEIGHTMANAGEMENT
NutritionalAdequacy Thepreciselevelatwhichenergyintakeisinsufficientforanadequatedietisdifficulttodefinewithouttaking intoconsiderationtheageandsexoftheindividualandthecorrespondingDietaryReferenceIntakes.Diets that provide 1,200 kcal or less of energy are generally inadequate to meet Dietary Reference Intakes. Therefore, a daily multivitamin is recommended when energy levels of this range are prescribed (2,3). Determiningtheenergylevelthatpromotesweightlossisdifficultinoverweightandobeseindividuals,and estimatedenergyneedsshouldbebasedonrestingmetabolicrate(RMR)(GradeI)(1).Wheneverpossible,RMR shouldbemeasured(eg,indirectcalorimetry).IfRMRcannotbemeasured,theMifflinSt.Jeorequationusing actualweightisthemostaccuratemethodforestimatingRMRforoverweightandobeseindividuals(GradeI)(1). (RefertoSectionII:EstimatingEnergyExpenditures.)Metaanalysisoftheliteraturehasidentifiedthat1,200 kcal/day for women and 1,400 to 1,500 kcal/day for men (2,3,8,11) are acceptable energy intake levels that promotegradualandsafeweightlossof0.5to1lb/week (2,3,8).Anindividualizedreducedenergydietalong with energy expended through physical activity should reduce body weight at an optimal rate of 1 to 2 lbs/week for the first 6 months and achieve an initial weight loss goal of up to 10% from baseline. These goalsarerealistic,achievable,andsustainable(GradeI)(1). Recent studies have evaluated the impact of total energy and macronutrient composition on weight loss. TheUSDepartmentofAgriculturehasfoundthatdietshighincarbohydrate(>55%)andlowtomoderatein fat (15% to 30%) tend to be lower in total energy and higher in diet quality when compared to low carbohydrate diets (<30%). In these studies, the BMI was significantly lower for men and women on the highcarbohydratediet;the highest BMIs were notedfor individuals on a lowcarbohydratediet. Based on these findings, weight loss is independent of macronutrient composition, and energy restriction is the key variableassociatedwithshorttermweightreduction(8,11).Arandomizedcontrolledtrialinvestigatedweight loss outcomes using a lowcarbohydrate diet compared to a lowfat, lowenergy, highcarbohydrate (conventional) diet. Initial weight loss was significantly greater in the lowcarbohydrate group; however, after1yearthedifferencebetweenthegroupswasnotstatisticallysignificant (GradeII)(1,12).Thedifferencein weightlossbetweenthetwogroupsinthefirst6monthswasattributedtooverallgreaterenergydeficitin the lowcarbohydrate group (Grade II) (1,12). The lowcarbohydrate diet was associated with a greater improvementinsomeriskfactorsforcoronaryheartdisease.Adherencewaspoorandattritionwashighin bothgroups (12).Resultsofthisstudyshouldbeinterpretedwithcaution,giventherelativelysmallsample size and short duration (12). Longer and larger studies are required to determine the longterm safety and efficacyoflowcarbohydrate,highprotein,highfatdiets (12).Alowglycemicindexdietisnotrecommended forweightlossorweightmaintenancebecauseithasnotbeenshowntobeeffectiveintheseareas(GradeI)(1). C36 Copyright2011MorrisonManagementSpecialists,Inc. ManualofClinicalNutritionManagement Allrightsreserved.
HowtoOrdertheDiet Thephysicianmayspecifyanyofthefollowing: WeightReductionDiet:Thedietitiandeterminesanappropriateweightlossgoalandenergylevel. ____kcalDiet:Thedietitianplansanindividualizedmealplanwithintheenergyprescription. Restrictionofsodium,fat,cholesteroloranotherdietarycomponent:Ifarestrictionisrequired,itshould beprescribedalongwiththedietorder. Initiation of a weight reduction diet is not usually recommended in a hospital setting. Weight loss and weight maintenance therapy should be based on a comprehensive weight management program including diet,physicalactivity,andbehaviortherapy(GradeI)(1).Medicalnutritiontherapyforweightlossshouldlastat least6monthsoruntilweightlossgoalsareachieved,withimplementationofaweightmaintenanceprogram afterthattime (Grade I) (1).Agreaterfrequencyofcontactsbetweenthepatientandpractitionermayleadto moresuccessfulweightlossandweightlossmaintenance(GradeI)(1). Moderate energy restriction for weight loss is recommended (2,3). Individualized meal plans of 1,200 to 1,500 kcal/day for women and 1,400 to 2,000 kcal/day for men can promote retention of lean body mass while facilitating weight reduction when combined with physical activity and behavioral modification (2,3). Reducingdietaryfatand/orcarbohydrateisapracticalwaytocreateanenergydeficitof500to1,000kcal belowestimatedenergyneedsandshouldresultinaweightlossgoalof1to2lbs/week (Grade I) (1).Portion control should be included as part of a comprehensive weight management program. Portion control at mealsandsnacksresultsinreducedenergyintakeandweightloss (GradeII)(1).Inaddition,totalenergyintake distributedthroughouttheday,achievedbytheconsumptionoffourorfivemeals/snacksperday(including breakfast), may be preferable and result in greater weight loss than eating in the evening (Grade II) (1). For peoplewhohavedifficultywithselfselectionorportioncontrol,mealreplacements(eg,liquidmeals,meal bars, energycontrolled packaged meals) may be used as part of a comprehensive weight management program (Grade I) (1). Substituting one or two daily meals or snacks with meal replacements is a successful weightlossandweightmaintenancestrategy(GradeI)(1).Whensettinggoalswithpatients,thedietitianshould establisharealisticandpracticaltarget,suchasa5%to10%decreaseinthebaselineweightoradecreaseof 2BMIunits(GradeI)(13). Successfulweightreductionrequiresacommitmenttobehavioralchange,familysupport,andattentionto physical activity patterns (Grade I) (13). Behavioral therapy should use multiple strategies including self monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support (Grade I) (1). Moderate physical activity promotes the maintenance of lean bodymass,contributestotheenergydeficitneededforweight loss,andmayhelpwiththemaintenanceof weightloss (GradeI)(1).Physicalactivityshouldbeassessedwithindividualizedlongtermgoalsestablishedto accumulateatleast30minutesofmoderateintensityphysicalactivityonmost,andpreferablyall,daysofthe week,unlessmedicallycontraindicated(GradeI)(1). WeightlossmedicationsapprovedbytheFoodandDrugAdministrationmaybepartofacomprehensive weightmanagementprogram (1).Cliniciansshouldcollaboratewithothermembersofthehealthcareteam regardingtheuseoftheseweightlossmedicationsforpeoplewhomeetthecriteria.ABMIof30kg/m2 or greaterwithnocomorbidconditionsoraBMIexceeding27kg/m2 withcomorbidconditionsshouldbeone criterionfortheuseofmedicationstotreatobesity (3).Othercriteriainclude:failuretomanageweightwith more conservative behavioral methods; number and severity of associated comorbidities; absence of contraindications,suchasdepressionorischemicheartdisease;andtheneedforshorttermweightlossto reduceoperativerisk (2).Dependingonthetypeofmedication,alossof10%to15%ofthebaselineweight hasbeenobservedwiththeadjunctoflifestylemodification(lowenergydietandincreasedphysicalactivity) (Grade I) (1,13). Weight regain occurs after drug withdrawal; thus, longterm use is required to maintain the weightloss(13).Dataontheuseofweightlossmedicationforlongerthan2yearsarelimited,andtheefficacy and safety of longterm treatment with pharmacologic agents remains unclear (1,13). Pharmacologic agents are a useful adjunct to, but not a substitute for, necessary changes in diet and physical activity. The effectiveness of pharmacologic intervention depends on its use with appropriate dietary nutrition intervention,increasedphysicalactivity,andlifestylechange (1,2).RefertoSectionIB:NutritionManagement ofBariatricSurgeryandSectionIII:ObesityandWeightManagementformoreinformation. PlanningtheDiet The dietitian should plan an energycontrolled diet to meet the individual needs and lifestyle of the client. Suggestionstoreducedailyenergyintakeinclude(15,13):
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Reduceintakeoffoodswithhighenergydensity(eg,alcoholandfat).FollowtheUSDietaryGuidelinesof lessthan30%energyfromfat,10%to20%fromprotein,and50%to60%fromcarbohydrates. Reduce the total amount of food consumed by decreasing portion size and frequency of consumption. Employbehaviormodificationtechniquestoimprovecontroloverthefoodselectionprocessandtheact ofeating. Establish selfmanagement training techniques that will enhance the satiety of meals but reduce the energyintake.Forexample,encouragethepatienttoeatslowlysothatthebraincanregisterthatthe stomachisfull,orrecommendeatingampleamountsoflowenergydensityvegetables(eg,saladswith smallamountsofsaladdressingorfatfreedressing)toprovidechewingsatisfactionandfillthestomach.
References 1. Adult Weight Management EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. AmericanDieteticAssociation;2006.Availableat:http://www.adaevidencelibrary.com.AccessedAugust1,2006. 2. PositionoftheAmericanDieteticAssociation:weightmanagement.JAmDietAssoc.2009;109:330346. 3. National Heart, Lung, and Blood Institute Obesity Education Initiative Expert Panel. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, Md: National Institutes of Health; 1998.NIHpublicationNo.984083.Availableat:http://www.nhlbi.nih.gov/nhlbi/htm. 4. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation,andTreatmentofHighBloodCholesterolinAdults(AdultTreatmentPanelIII).JAMA.2001;285:24862497.Available at:http://nhlbi.nih.gov/guidelines/cholesterol/index.htm. 5. ChobanianAV,BakrisGL,BlackHR,CushmanWC,GreenLA,IzzoJLJr,JonesDW,MatersonBJ,OparilS,WrightJTJr,RoccellaEJ,and theNationalHighBloodPressureEducationProgramCoordinatingCommittee.SeventhReportoftheJointNationalCommitteeon Prevention,Detection,Evaluation,andTreatmentofHighBloodPressure.Hypertension.2003;42:12061252. 6. American Dietetic Association Diabetes Type 1 and 2 Evidence Based Nutrition Practice Guideline for Adults. American Dietetic Association Evidence Analysis Library. American Dietetic Association; 2008. Available at: http://www.adaevidencelibrary.com. AccessedDecember10,2008. 7. Festi D, Colecchia A, Sacco T, Bondi M, Roda E, Marchesini G. Hepatic steatosis in obese patients: clinical aspects and prognostic significance.ObesRev.2004;5:2742. 8. Kennedy ET, Bowman SA, Spence JT, Freedman M, King J. Popular diets: correlation to health, nutrition, and obesity. J Am Diet Assoc.2001;101:411420. 9. BarlowSE,DietzWH.Obesityevaluationandtreatment:ExpertCommitteerecommendations.Pediatrics.1998;102:111. 10. Subcommittee on Nutrition Status and Weight Gain During Pregnancy, Committee of Nutritional Status During Pregnancy and Lactation,FoodandNutritionBoard,InstituteofMedicine.NutritionDuringPregnancy.Washington,DC:NationalAcademyPress; 1990. 11. KennedyET,BowmanSA.Assessmentoftheeffectoffatmodifiedfoodsondietqualityinadults,19to50years,usingdatafrom theContinuingSurveyofFoodIntakeofIndividuals.JAmDietAssoc.2001;101:455460. 12. FosterGD,WyattHR,HillJO,McGuckinBG,BrillC,MohammedBS,SzaparyPO,RaderDJ,EdmanJS,KleinS.Arandomizedtrialofa lowcarbohydratedietforobesity.NEnglJMed.2003;348:20822090. 13. FabricatoreAN,WaddenTA.Treatmentofobesity:anoverview.ClinDiabetes.2003;21:6772.
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MEDICALNUTRITIONTHERAPYFORDISORDERSOFLIPIDMETABOLISM
Description The dietary approach for the treatment of disorders of lipid metabolism, which include both hypercholesterolemiaandhypertriglyceridemia,isaprogressivereductionintotalfat,saturatedfat,transfat, and cholesterol, coordinated in a plan to obtain or maintain reasonable body weight. The diet follows the recommendationsoftheNationalCholesterolEducationProgram(NCEP)AdultTreatmentPanel(ATP)IIIof theNationalInstitutesofHealthandtheAmericanHeartAssociation(AHA)(14).
Indications Medical nutrition therapy (MNT) is recommended as the primary treatment and management tool for disorders of lipid metabolism. MNT is recommended before administration of cholesterollowering medication in lower risk cases or in combination with drug therapy in higher risk cases. Recommended therapeuticlifestylechangesandtargetgoalsforlowdensitylipoprotein(LDL)cholesterollevelsarebased onriskfactorassessment.Majorindependentriskfactors(exclusiveofLDLcholesterol)thatpredictthe10 yearriskforcoronaryheartdisease(CHD)arebasedonFraminghamriskevaluationscores (1).Theserisk factorsinclude(1): cigarettesmoking hypertension(bloodpressuregreaterthan140/90mmHgand/orreceivingantihypertensivemedication) lowlevelofhighdensitylipoprotein(HDL)cholesterol(lessthan40mg/dL) familyhistoryofprematureCHD(CHDinmalefirstdegreerelativeyoungerthan55years;CHDinfemale firstdegreerelativeyoungerthan65years) age(men,45yearsorolder;women,55yearsorolder)
ThehighriskcategoryconsistsofpersonswhohaveexistingCHD,personswhohaveCHDriskequivalents thatconfera10yearriskofCHDgreaterthan20%,andpersonswithdiabetes.ThetargetLDLcholesterol levelfortheseindividualsislessthan100mg/dL.Asubcategoryofhighrisk,veryhighrisk,containspersons with existing cardiovascular disease and diabetes and persons with cardiovascular disease and severe or poorlycontrolledmultipleriskfactors (4).Theveryhighriskcategoryhasatherapeuticoptiontotargetthe LDLcholesteroltolessthan70mg/dL (4).Personswithmorethanoneriskfactoranda10yearriskofCHD of 20% or less have an LDL cholesterol target goal of less than 130 mg/dL. Persons with one or no risk factorsanda10yearriskofCHDlessthan10%haveanLDLtargetgoaloflessthan160mg/dL.Primary intervention using therapeutic lifestyle changes and drug therapy should begin after evaluation of the patients fasting lipid profile, consisting of levels of LDL cholesterol, total cholesterol, HDL cholesterol, and triglyceridesandconsiderationoftheriskfactorassessment (1,4).LDLcholesterolistheprimarytargetfor risk reduction intervention (1,4). Targeting lower LDL goals, in combination with initiating cholesterol lowering drug therapy at lower thresholds, is based on evidence from five randomized controlled trials demonstrating significant risk reduction for cardiac events at the recommended lower thresholds (4). The NCEPrecommendspharmacologictherapythatissufficienttoachievea30%to40%reductioninbaseline LDLcholesterollevelsinallhighriskandmoderatelyhighriskpatients(4).
TableC4:LDLCholesterolGoals(4) RiskCategorya Highriskandveryhighrisk: CHDorCHDriskequivalent, 10yearrisk>20% Moderatelyhighrisk: Twoormoreriskfactors, 10yearrisk10%20% Moderaterisk: Twoormoreriskfactors, 10yearrisk<10% Lowerrisk: Zerooroneriskfactor LDLCholesterolGoal(mg/dL) <100 <70optional <130 LDLCholesterolLevel(mg/dL)to ConsiderDrugTherapyb >100 <100forveryhighrisk >130 100129optionalc >160
<130
<160
>190 160189optional
aRiskfactorsthatmodifyLDLgoalsaregiveninthebulletedlistabove,underIndications.
bItisadvisedthatintensityofdrugtherapybesufficienttoachievea30%to40%reductioninLDLcholesterollevels(4). cFormoderatelyhighriskpersons,whenLDLcholesterolis100129mg/dLatbaselineoronlifestyletherapy,initiationofanLDL
loweringdrugtoachieveanLDLcholesterollevel<100mg/dLisatherapeuticoption(4). ManualofClinicalNutritionManagement
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MedicalNutritionTherapyforDisordersofLipidMetabolism
Forpatientshospitalizedduetoacardiacevent,LDLcholesterollevelsbegintodeclineinthefirstfewhours afteraneventandaresignificantlydecreasedwithinthefirst24to48hours.Theselevelsmayremainlow forupto3months.Thus,theinitialLDLcholesterollevelobtainedinthehospitalmaybesubstantiallylower thanisusualforthepatient (1).TheNCEPATPIIIemphasizestheneedtobegindrugtherapyforhighrisk patients(RefertoTableC4:LDLCholesterolGoals)inadditiontotheTherapeuticLifestyleChangesDietto reachthegoalforLDLcholesterol.Whendrugsareprescribed,theTherapeuticLifestyleChangesDietshould alwaysbemaintainedandreinforced(1). ClinicaltrialsdemonstratethatloweringLDLcholesterolreducestotalmortality,coronarymortality,major coronaryevents,coronaryarteryprocedures,andstrokesinpersonswithestablishedCHD (1,4).TheATPIII specifiesLDLcholesterollessthan100mg/dLasthegoaloftherapyinsecondaryprevention.TheATPIII recognizesthattheriskofCHDisinfluencedbyotherfactorsnotincludedamongthemajor,independentrisk factorslistedpreviously.Lifehabitriskfactorsincludeobesity,physicalinactivity,andatherogenicdiet (1). Emergingriskfactors,forwhichscientificevidencedemonstratesvaryingdegreesofcontributiontoCHDrisk in select persons, include lipoprotein, homocysteine, prothrombotic and proinflammatory factors, and impairedfastingbloodglucoselevels(morethan110mg/dL) (1).Atthistime,theevidencedoesnotsupport specificmodificationstotargetLDLcholesterolbasedontheserisks. MetabolicSyndrome Metabolicsyndromeisaclusteringofthreeormoreriskfactorsthatincludeabdominalobesity,atherogenic dyslipidemia (elevated triglycerides level and low HDL cholesterol), hypertension, and insulin resistance (with or without glucose intolerance) (1). The NCEP ATP III recognizes the need to address metabolic syndrome as a secondary target of riskreduction therapy, after the primary target of LDL cholesterol lowering (1). Management of metabolic syndrome primarily focuses on reducing underlying causes (eg, obesityandphysicalinactivity)andtotreatassociatednonlipidandlipidriskfactors.Physicalactivityatany level(light,moderate,orvigorous)aswellasfoodpatternsemphasizingadiethighinfruits,vegetables,and whole grains is associated with reduced incidence of metabolic syndrome (Grade II)* (5). In the metabolic syndromepatient,acardioprotectivedietarypattern(lowinsaturatedfat,transfat,andcholesterol;limited in simple sugar intake; and increased in consumption of fruits, vegetables, and whole grains) provides the background for modifying the energy balance to achieve weight loss (Grade IV) (5). Extremes in intakes of carbohydrates or fats should be avoided (Grade IV) (5). Restricted energy intake combined with at least 30 minutes of physical activity on most days of the week should be used recommended for individuals with metabolicsyndrome (GradeII)(5).Weightlossof7%to10%ofbodyweightshouldbeencouragedifindicated (GradeII)(5).
*TheAmericanDieteticAssociationhasassignedgrades,rangingfromGradeI(good/strong)toGradeV(insufficientevidence),toevidence andconclusionstatements.ThegradingsystemisdescribedinSectionIII:ClinicalNutritionManagement,AReferenceGuide,pageIII1.
TableC5:ClinicalIdentificationoftheMetabolicSyndrome RiskFactor DefiningLevel Abdominalobesitya Waistcircumference Men >102cm(>40inches)b Women >88cm(>35inches) Triglycerides >150mg/dL HDLcholesterol Men <40mg/dL Women <50mg/dL Bloodpressure >130/>85mmHg Fastingbloodglucose >100mg/dLc
aOverweightandobesityareassociatedwithinsulinresistanceandthemetabolicsyndrome.However,abdominalobesityismorehighly
correlatedwiththemetabolicriskfactorsthanisanelevatedbodymassindex.Therefore,thesimplemeasureofwaistcircumferenceis recommendedtoidentifythebodyweightcomponentofthemetabolicsyndrome. b Somemalepatientscandevelopmultiplemetabolicriskfactorswhenthewaistcircumferenceisonlymarginallyincreased,suchas94 to102cm(37to39inches).Thesepatientsmay haveastronggeneticcontributiontoinsulinresistance.They shouldbenefitfrom changesinlifehabits,similartomenwithcategoricalincreasesinwaistcircumference. cTheATPIIIcriteriaforthemetabolicsyndromearenowthesameastheAmericanDiabetesAssociationsreviseddefinitionofimpaired fastingglucose.Thus,thethresholdforelevatedfastingglucosewasreducedfrom110mg/dLto100mg/dL.
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NutritionalAdequacy TheTherapeuticLifestyleChangesDietisplannedtomeettheDietaryReferenceIntakesasoutlinedinthe StatementonNutritionalAdequacyinSectionIA.
The National Institutes of Health maintain that the Therapeutic Lifestyle Changes Diet is consistent with good nutrition, and the aim of this diet is to achieve healthy eating patterns consistent with the Dietary GuidelinesforAmericansandAmericanHeartAssociationDietandLifestyleRecommendations2006 (1,3).A dietlowinsaturatedfat,transfats,cholesterol,andtotalfatisrecommendedforallhealthypersons2years ofageandolder(1,3).
HowtoOrdertheDiet Specifyallthatapply: IndicateTherapeuticLifestyleChangesDiet(preferred)orLowFat,LowCholesterolDiet.Theregistered dietitian will determine the specific approaches used to implement the Therapeutic Lifestyle Changes Dietandmedicalnutritiongoalsbasedonindividualizedassessmentandtargettreatmentobjectivesto reduceCHDrisk. Further reduction in total fat intake may be implemented. This additional reduction depends on the dietitiansassessmentandthepatientscompliance. Ifrequired,sodiumcontrolorotherdietarymodificationshouldbespecificallyordered. Ifweightreductionisdesired,thedietitianshouldsettheweightlossgoalwiththepatientanddetermine theappropriateweightlossregimen.
PlanningtheCardioprotectiveDiet TheTherapeuticLifestyleChangesDietstressesreductionsinintakeofsaturatedandtransfat(lessthan7%) and cholesterol (less than 200 mg/dL) as the primary dietary modifications to lower LDL cholesterol in patientsrequiringprimaryandsecondaryprevention (1).Basedontheresponsetoalowsaturatedfat,low cholesteroldiet,additionaltherapeuticoptions,suchasplantstanols/sterols(2g/day)andincreasedviscous (soluble)fiber(10to25g/day),canbeimplementedaspartofMNTselfmanagementtraining (1).Referto DisordersinLipidMetabolismEvidenceBasedNutritionPracticeGuideline(5).Whenmetabolicsyndromeorits associated lipid risk factors (elevated triglycerides level or low HDL cholesterol level) are present, therapeuticlifestylechangesalsoshouldincludeweightreductionandincreasedphysicalactivity(1,5).
TableC6:NutrientCompositionofTherapeuticLifestyleChangesDiet(1,3,5) Nutrient RecommendedIntake Saturatedandtransfata <7%oftotalenergycombined(5) (transfat<1%oftotalenergy)(3) Polyunsaturatedfat Upto10%oftotalenergy Monounsaturatedfat Upto20%oftotalenergy Totalfat 25%to35%oftotalenergy Carbohydrateb 50%to60%oftotalenergy Fiber 25to30g/day Protein Approximately15%oftotalenergy Plantstanol/sterols 2g/day(optional) Cholesterol <200mg/day Totalenergyc Balanceenergyintakeandenergyexpendituretomaintaindesirablebodyweight andtopreventweightgain
aTransfattyacidsareanLDLraisingfat;AHArecommends<1%ofenergyfromtransfats(3). bCarbohydrateshouldbederivedpredominatelyfromfoodsrichincomplexcarbohydrates,includinggrains(especiallywholegrains), fruits,andvegetables.
cDailyenergyexpenditureshouldincludeatleastmoderatephysicalactivity(contributingapproximately200kcal/day).
Source: Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation,andTreatmentofHighBloodCholesterolinAdults(AdultTreatmentPanelIII).JAMA.2001;285:24862497. Updates based on: Disorders in Lipid Metabolism EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence AnalysisLibrary.AmericanDieteticAssociation;2005.Availableat:http://www.adaevidencelibrary.com.AccessedJune1,2006.
CardioprotectiveDietaryApproachesinManagingDisordersinLipidMetabolism Total fat and saturated fatty acids: Elevated LDL cholesterol is an independent risk factor for CHD (1). Saturated fat is the principal dietary determinant of LDL cholesterol levels (6). The reduction of dietary saturatedfatdirectlydecreasesclearanceofLDLandverylowdensitylipoprotein(VLDL)remnants (1).The recommendations for saturated fat are based on existing cardiovascular disease, risk factors, and LDL cholesterol value. A diet consisting of 25% to 35% total fat, <7% saturated and trans fat, and <200 mg
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cholesterollowersserumtotalcholesterolandLDLcholesterolby9%to16%anddecreasestheriskofCHD
(Grade I) (5). Sources of saturated fatty acids include: butter, lard, vegetable shortening, baked and pastry
products, fat in meat, poultry, whole dairy products, palm oil, palm kernel oil, and cocoa butter. Moderate reductionoftotalfat(25%to30%oftotalenergy)facilitatesadecreaseinsaturatedfattyacidsandmayalso helpinweightreductioninoverweightpatients (1,7).Therecommendationsfortotalfatintakearebasedon thepercentageofthepatientstotaldailyenergyintake,metabolicprofile,andneedforweightloss.TheAHA does not recommend verylowfat diets (less than 15% of total energy) (3). Verylowfat diets may lead to inadequateintakeofessentialfattyacids.Inaddition,verylowfatdietsareoftenassociatedwiththeuseof processedlowfatfoodsthatareenergydense,compoundingthemetabolicabnormalitiesfoundinpersons withhightriglycerideslevels,lowHDLcholesterollevels,orinsulinresistance(8,9). Polyunsaturated fatty acids (PUFA): The two major categories of PUFA are omega6 and omega3 fatty acids. Linoleic acid is the primary omega6 fatty acid and predominates in the American diet. The AHA recommendsthatlessthan10%oftotalfatenergycomefromPUFA.ThelatestWorldHealthOrganizations guidelines set a range of 4% to 10% for PUFA intake (10). Isocalorically replacing saturated fatty acids with monounsaturated fatty acids (MUFA) and PUFA is associated with reductions in LDL cholesterol (Grade I) (5). Studies have demonstrated that intakes of greater than 10% PUFA are associated with decreasing HDL cholesterol level, an independent predictor for CHD (10). Sources of omega6 fatty acids include corn oil, saffloweroil,sunfloweroil,soybeanoil,nuts,andseeds. Omega3 fatty acids: Studies have demonstrated beneficial effects of increased intake of omega3 fatty acidsinpatientswithcoronaryarterydisease(1114).Mostofthesestudiesusedsupplementscontaininglong chain omega3 fatty acids (eg, eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA] or fish oil) at daily dosages ranging from 850 mg to 2.9 g. Studies that demonstrate a reduction in plasma triglycerides levelprovidehigherdosages(3to4g/day)(15).TheGISSItrialdemonstratedthathighdosesofomega3fatty acids provide benefits in preventing recurrent myocardial infarction events (1,14). Epidemiological studies indicatethatregularconsumptionofanaverageoftwoservingsoffattyfishperweek(about3.5oz)highin longchainomega3fattyacidsisassociatedwitha30%to40%reducedriskofdeathfromcardiaceventsin subjectswithpriordisease (Grade II) (5).Oneservingoffattyfishcanprovideapproximately1,000mgofEPA andDHA(3).ThisamountfromasupplementorfishreducesCHDmortalityratesinpatientswithCHD(GradeII) (5). Because of the benefits of omega3 fatty acids, the AHA Dietary Guidelines 2006 recommends consumption of more than two fish meals per week for the general population. Epidemiological studies indicate that inclusion of vegetable oils and food sources high in alphalinolenic acid, resulting in a total intake of more than 1.5 g/day, is associated witha 40% to 65%reduced riskof death fromcardiac events (Grade III) (5). This amount is equivalent to consuming to 1 tablespoon ground flaxseed meal, 1 teaspoon flaxseedoil,or1tablespoonofcanolaorwalnutoil.The2006AHArecommendationsadvisepatientswith documentedCHDtoconsume approximately 1g/dayofEPAplus DHA, preferably fromoily fish. EPA plus DHA supplements could be considered in consultation with a physician (3). For individuals with hypertriglyceridemia(>200mg/dL),2to4g/dayofEPAplusDHA,providedascapsulesunderaphysicians care,arerecommendedasatherapeuticoption(GradeII)(3,5).Sourcesofomega3fattyacidsincludecoldwater fish (salmon, mackerel, Atlantic herring, lake trout, albacore tuna, sardines, swordfish) tofu, soybean and canolaoils,flaxseed,andEnglishwalnuts. MUFA:OleicacidistheprimaryMUFA.Evidenceindicatesthatoleicacidmaycauseasgreatadecreasein LDLcholesterollevelsasdoeslinoleicacidwhensubstitutedforsaturatedfattyacidsinthediet.Substitution ofMUFAforsaturatedfatlowersLDLcholesterollevelswithoutdecreasingHDLcholesterollevels(GradeI)(5,16). EvidencesupportsthatadiethighinMUFA(upto30%oftotalenergy)canimprovespecificdyslipidemias compared with diets of equal energy value that replace fat with carbohydrate. A diet relatively high in unsaturatedfatcanpreventadecreaseinHDLcholesterollevelsandanincreaseintriglycerideslevelsthat canoccurinsomeindividualsconsumingahighcarbohydrate(morethan60%totalenergy),lowfatdiet(17). SourcesofMUFAincludecanolaoil,oliveoil,peanutoil,andavocados. Transfattyacids:Transfattyacidsarecreatedthroughhydrogenation,aprocessinwhichvegetableoils are heated in the presence of metal catalysts to produce vegetable shortening and margarine. Trans fatty acids increase LDL cholesterol levels and decrease HDL cholesterol levels. Because saturated fats increase LDL cholesterol levels but do not decrease HDL cholesterol levels, trans fatty acids can produce a greater increaseintheratioofLDLcholesteroltoHDLcholesterol (Grade I) (5).Populationandcohortstudiesshow thatahightransfattyacidintakeincreasesriskofCHDevents(GradeII)(5).Itisestimatedthat5%to6%ofthe fatintheAmericandietiscomposedoftransfattyacids (16).Sourcesoftransfattyacidsincludehardened C42 Copyright2011MorrisonManagementSpecialists,Inc. ManualofClinicalNutritionManagement Allrightsreserved.
MedicalNutritionTherapyforDisordersofLipidMetabolism vegetablefat,stickmargarine,shortening,andbakedproductsmadewiththesefats.Publicconcernhasbeen raisedabouttheuseofmargarineandwhetherotheroptions,includingbutter,mightbeabetterchoice.The AHANutritionCommitteerecommendsmargarineasapreferablesubstituteforbutter.Softmargarinewith no more than 2 g of saturated and trans fat per tablespoon and with liquid oil as the first ingredient is recommendedinplaceofstickmargarine.Accordingtothe2005ADAguidelines,adietconsistingof<7% saturatedandtransfatcombinedshouldbethetherapeuticgoalforsaturatedandtransfatintake (GradeI)(5). Accordingtothe2006guidelinesfromtheAHA,adietshouldconsistof<7%saturatedfatand<1%transfat (3). Cholesterol:Dietary cholesterol isfound only in animal products, especially those foodsthat are high in saturatedfattyacids(eg,meatsandwholedairyproducts).Thereissomeevidencethatdietarycholesterol enhances the serum cholesterolraising action of saturated fatty acids, although to a lesser extent than saturatedfat (1,3).Mostfoodshighinsaturatedfatarealsosourcesofdietarycholesterol.Reducedintakeof foods high in saturated fat provides the additional benefit of limiting cholesterol intake. Cholesterolrich foods that are relatively low in saturated fatty acids, notably eggs and, to a lesser extent, shellfish, have smallereffectsonLDLcholesterol(3).Therefore,periodicconsumptionofeggsandshellfishcanbeintegrated intotheTherapeuticLifestyleChangesDietmealplan. Carbohydrates:Complexcarbohydratesshouldmakeupthemajorityofdigestiblecarbohydrates.When fat intake is reduced and nutrient replacement is required to maintain energy balance, the replacement shouldbecomplexcarbohydrates.Recommendedsourcesincludewholegrains,legumes,fruits,vegetables, nuts,andlowfatdairyproducts.Dataontheidealisocaloricsubstitutionofcarbohydrateforfattomaximize LDLcholesterolloweringarepresentlynotavailable(GradeV)(5). Total protein and soy protein: Approximately 15% of total energy should be provided as protein. Currently there is no scientific evidence to support the concepts that highprotein diets result in sustained weightloss,significantchangesinmetabolism,orimprovedhealth(7,18).Recentrandomized,controlledtrials have demonstrated that consumption of 20 to 50 g of soy protein daily may reduce LDL cholesterol levels (5,1922). Studies vary greatly in their estimation of the effect of diets low in saturated fat and cholesterol containing26to50gofsoyprotein,eitherasfoodorasasoysupplementwith0to165mgofisoflavones (GradeII),andeffectsmayvarybasedoninitialcholesterollevel(GradeIII)(5).Ifconsistentwithpatientpreference and not contraindicated by risks or harms, then soy (eg, isolated soy protein, textured soy, tofu) may be included as part of a cardioprotective diet. Consuming 26 to 50 g/day of soy protein in place of animal proteincanreducetotalcholesterolby0%to20%andLDLcholesterolby4%to25% (GradeII)(5).Evidenceis insufficienttoestablishabeneficialroleforisoflavonesasanindependentcomponent(GradeIII)(5).Soyprotein concentrates that remove isoflavones during processing may not be as effective (21). In October 1999, the FoodandDrugAdministrationapprovedahealthclaimthatallowsfoodlabelclaimsforreducedriskofheart diseaseonfoodsthatcontainmorethan6.25gofsoyproteinperserving(3).Theclaimstatesthat25gofsoy proteinperday,aspartofadietlowinsaturatedfatandcholesterol,mayreducetheriskofheartdisease. Sources of soy protein include soy milk, soybeans, tofu, soybased meat and cheese substitutes, and alfalfa sprouts. Soy protein may not be recommended in some individuals with breast cancer. Individuals with breastcancerorathighriskforbreastcancershouldspeakwiththeirphysician (5).Consumptionofgreater than 50 g of soy protein with isoflavones may cause gastrointestinal distress in some individuals (5). Additionally,careshouldbetakenwhenintroducingsoyintoapatientsdiet,becausesomeindividualshave anundiagnosedallergytosoyprotein(5). Total energy: Maintaining a balance between energy intake and expenditure is a goal of MNT. Some patientswithhighLDLcholesterollevelsaresensitivetoenergyintake.Weightreductionandattainmentofa reasonable body weight will completely correct their elevated LDL cholesterol concentrations. In many people,weightreductionwillalsoreduceplasmatriglycerideslevelsandraiseHDLcholesterollevels(3). Fiber: A high intake oftotal dietaryfiber (eg, 25forwomen and 38 g/day for men) is recommendedfor adults and is associated with decreased risk for CHD and cardiovascular disease (Grade II) (3,5,23). Increased intake of foods rich in soluble fiber correlates with decreased serum cholesterol levels (Grade I) (3,5,23). Consuming diet from whole food or supplements in total fiber (17 to 42 g/day) and soluble fiber (7 to 13 g/day)aspartofadietlowinsaturatedfatandcholesterolcanfurtherreducetotalcholesterollevelsby2% to 3% and LDL cholesterol levels by up to 7% (Grade I) (5). Choosing soluble fibers (notably beta glucan and pectin) found in oats, barley, and pectincontaining fruits and vegetable, beans and legumes provides adjunctive lipidlowering benefits beyond those achieved through the reduction of total and saturated fat ManualofClinicalNutritionManagement
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alone(3,23).TheAHArecommendstheintakeofmorethan25g/dayofsolublefiberfromavarietyofsources, includinggrains,vegetables,fruits,legumes,andnuts(3). OtherDietaryFactorsInfluencingBloodLipidLevelsandRiskFactors Antioxidants:Oxidativeprocessesareinvolvedinthedevelopmentandclinicalexpressionofcardiovascular disease,anddietaryantioxidantsmaycontributetodiseaseresistance (3).Epidemiologicaldatasuggestthat intake of foods rich in vitamin E, C, and beta carotene as part of a cardioprotective dietary pattern is associated with decreased risk for coronary artery disease (Grade III) (5,2429). Most studies have involved the consumptionofantioxidantrichfoods,suchasfruits,vegetables,andwholegrains,fromwhichantioxidants werederived (29).Becausesomanynutrientsarecontainedinthesefoods,itisdifficulttodirectlylinkthe antioxidant nutrients to the reduction in CHD risk. Antioxidants such as vitamin E, vitamin C, and beta carotene (or carotenoids) should be specifically planned into a cardioprotective dietary pattern (Grade III) (5). TheAHArecommendsincreasedconsumptionofantioxidantrichfruits,vegetables,andwholegrains,which is associated with reduced disease risk (Grade III) (5,29). There is limited evidence to support the use of antioxidant supplements for disease prevention, even though this topic has been an issue of considerable debate (29).VitaminE,vitaminC,andbetacarotenesupplementsshouldnotberecommendedtoreducethe risk of cardiovascular disease because they have shown no protection for cardiovascular disease events or mortality (GradeII)(5).TheobservationthatadequateconsumptionofvitaminEmaybedifficulttoachieveby dietary means leadsthe debate regarding vitamin E supplementation (26,27). Recent trials provide stronger evidence that vitamin E supplementation does not reduce cardiovascular disease or allcause mortality; in some cases, vitamin E supplementation may lead to negative health outcomes including increased risk of deathfromhemorrhagicstroke (3034).TheCambridgeHeartAntioxidantStudy(32)demonstratedabenefitof vitaminEinsecondaryprevention;however,theGISSItrial (14)andHeartOutcomesPreventionEvaluation Study (33) showed no beneficial effects of vitamin E at doses of 300 mg and 400 mg, respectively. Supplemental vitamin E, vitamin C, beta carotene, and selenium should not be taken with the simvastatin/niacin drug combination because of possible blunting of HDL2 (the HDL subfraction that is thoughttobemostprotective)andanincreasedpercentageofstenosisdemonstratedinonestudy(GradeIII)(5). Supplementalbetacarotenecannotberecommendedforindividualswhosmokebecauseofanincreasedrisk forlungcancerintheseindividuals(GradeIII)(5,28,29,34). Folic acid and vitamins B6 and B12: Homocysteine, an amino acid in the blood, appears to oxidize LDL cholesterol (16).Ahighlevelofserumhomocysteine,independentofothercardiacriskfactors,isassociated with increased risk for coronary artery disease. Conversely, low homocysteine levels are associated with reduced risk. (Grade II) (5,16). An increase in blood total homocysteine levels of 5 mol/L elevates the risk of coronaryarterydiseaseasmuchasdoesa20mg/dLincreaseintotalcholesterol (16).Factorsthatinfluence blood homocysteine levels include: deficiencies of folate, B6, and B12; age; sex; menopausal status; renal function;andcertainmedications.Folateisrequiredfortheconversionofhomocysteinetomethionine,an aminoacid.Serumfolatelevelshaveaninverserelationshipwithtotalhomocysteinelevels (3537).Although supplemental folate (0.5 to 2.5 mg) taken alone or in combination with B6 (10 to 25 mg) and B12 (0.4 mg) reducedhomocysteinelevelsby17%to34%,itdidnotreducetheriskforcoronaryeventsafteraperiodof6 months to 2 years in stable coronary artery disease patients, poststroke patients, or postangioplasty patients that had normal baseline homocysteine levels and total cholesterol levels (Grade II) (5,38,39). Folate, vitamin B6, and vitamin B12 should be included in the cardioprotective dietary pattern to meet the Dietary Reference Intakes. If an individual has high serum homocysteine levels (usually greater than 13 mol/L), theseBvitaminsmaylowerserumhomocysteinelevelsby17%to34%(GradeII)(5) Alcohol: Alcohol does not affect LDL cholesterol concentrations, but it does increase serum triglycerides concentrations and HDL cholesterol levels in many individuals. The mechanism for the rise in HDL cholesterolisnotknown.ItisalsonotknownwhetherthehigherlevelofHDLaffordsanyprotectionagainst CHD.Populationandcohortstudies,primarilyofmen,suggestthatoneortwodrinksofalcoholcontaining beveragesperdayareassociatedwithreducedriskofcardiovasculardisease,whileexcessiveconsumptionof alcoholisassociatedwithincreasedCHD (Grade II) (5,4042 ).TheNCEPreportandtheAHAdonotspecifically recommend alcohol consumption for CHD prevention (1,5). Most data do not support an association the betweentypeofalcoholicbeverage(wine,beer,orliquor)andprotectionagainstcardiovasculardisease(Grade II) (5,4042). The cardiovascular disease benefits of alcohol may be realized when alcohol is consumed with meals (Grade III) (5,4042). Observational studies have found a relationship between high alcohol intake (more thanthreedrinksperday)andelevatedbloodpressure(3,5).TheAHAGuidelines2000areconsistentwiththe USDietaryGuidelinesinrecommendingthatdailyalcoholconsumptionbelimitedtotwodrinksformenand onedrinkforwomen. C44 Copyright2011MorrisonManagementSpecialists,Inc. ManualofClinicalNutritionManagement Allrightsreserved.
MedicalNutritionTherapyforDisordersofLipidMetabolism Phytochemicals: Phytochemicals are nutritive substances found in plants. Nuts, whole grains, fruits, and vegetablescontainavarietyofphytochemicals.Epidemiologicstudiesshowarelationshipbetweentheintake ofphytochemicals,primarilyplantsterols,flavonoids,andplantsulfurcompounds,andCHD.Plantsterolsfound in rice bran decrease cholesterol levels (43). Flavonoids found in tea, onions, soy, and wine have antioxidant properties.Plantsulfursubstancesfoundingarlic,onions,andleeksdecreaseserumcholesterol (44).Studies aredifficulttointerpretbecausefoodsourcescontainingphytochemicalshavemultiplecompounds,andresults distinguishingaspecificcauseandeffecttotheatheroscleroticprocesshavebeenlimited.Studiesarecurrently assessingtherelationshipofphytochemicalstoCHD.
Nuts:Nutsmayenhancethecardioprotectivedietarypatternbecauseoftheirbeneficialfattyacidprofile aswellasotherfavorablenutritionalcomponents(5,43).Thedailyconsumptionof50to113g(to1cups)of nuts with a diet low in saturated fat and cholesterol decreased total cholesterol by 4% to 21% and LDL cholesterol by 6% to 29% when weight was not gained (Grade II) (5,45,46). Nuts (walnuts, almonds, peanuts, macadamia, pistachios, and pecans) may be isocalorically incorporated into a cardioprotective dietary patternlowinsaturatedfatandcholesterol (5).Consuming5oz/weekofnutsisassociatedwithareduced riskofCHD(5,45,46). Stanolandsterolestercontainingfoods:Plantsterolsoccurnaturallyandareisolatedfromsoybeanoils (3). Plant sterols are generally esterified, forming sterol esters, to increase solubility; in some cases, plant sterols are saturated to form stanol esters (3). Esterified forms of plant sterols and stanols are potent hypercholesterolemicagents,andthedailyconsumptionof2to3g(intheformofmargarine,lowfatyogurt, orangejuice,breads,andcereals)lowerstotalcholesterolconcentrationsinadosedependentmannerby4% to11%andLDLcholesterolconcentrationsby7%to15% (GradeI)(5,47,48).Theefficacyofthetwoforms,plant stanolestersandplantsterolesters,iscomparable(GradeII)(5,47,48).Inaddition,nonesterifiedformsofsterols andstanolsareequallyeffective (Grade III) (5,49).ThetotalcholesterolandLDLcholesterolloweringeffectsof stanolsandsterolsareevidentevenwhensterolsandstanolsareconsumedaspartofacholesterollowering diet (Grade I) (5,47,48). For patients receiving statin therapy, plant stanols further reduce LDL cholesterol and totalcholesterol (GradeIII)(5).AlimitedeffectofplantstanolsandsterolsonHDLcholesterolandtriglycerides has been reported. If consistent with patient preference and not contraindicated by risks or harms, then plantsterolesterandstanolesterenrichedfoodsmaybeconsumedtwoorthreetimesperday,foratotalof 2 or 3 g/day, in addition to a cardioprotective diet to further lower total cholesterol and LDL cholesterol levels (Grade I) (5).Formaximaleffectiveness,foodscontainingplantsterolsandstanols(spreads,juices,and yogurts) should be eaten with other foods (5). To prevent weight gain, isocalorically substitute stanol and sterolenriched foods for other foods (5). Plant stanols and sterols are effective in people who take statin drugs.Plantsterolandstanolproductsshouldnotbeusedinindividualswithsitosterolemia(5). OtherDietApproaches Verylowfat, highcarbohydrate (VLFHC) diets: Verylowfat (up to 15% of total energy), high carbohydrate(greaterthanorequalto60%oftotalenergy)dietshavebeenimplementedwithpatientswho are not responsive to diets with more moderate fat intake (eg, 25% to 30%). Progression of coronary atherosclerosis was delayed among patients who consumed a VLFHC diet and engaged in regular exercise (50,51).Replacingbothsaturatedfatandunsaturatedfatwithcarbohydratescanlowertotalcholesteroland LDL cholesterol levels. In addition, carbohydrate increases VLDL concentrations by addingtriglycerides to VLDL particles, a characteristic unfavorable to individuals who have preestablished characteristics of metabolic syndrome. A VLFHC diet also decreases HDL cholesterol levels (1). However, the VLFHC diet induced lowering of HDL cholesterol concentrations has not been associated with the increased risk of atherosclerosisseenwithlowHDLcholesterollevelsthatareassociatedwithahighfatdiet(52).Decreasesin total cholesterol and HDL cholesterol levels with VLFCH diet plans may result in a more favorable total cholesteroltoHDL ratio. This finding was observed in participants in the Lifestyle Heart Trial who demonstratedangiographicregressionoftheirCHDwhilealsodemonstratingdietinducedloweringofHDL cholesterollevels(51). TheVLFCHdietplansincludethePritikinprogramandtheOrnishmealplans(50,51).Thesemealplanslimit totalfatintaketolessthan10%oftotalenergyandencouragetheconsumptionofwholegrains,fruits,and vegetables in addition to increased physical activity and reduced stress. In certain individuals under a physicians supervision, verylowfat diets may lead to weight loss and improved lipid profiles. However, these diets are not recommended by the AHA, as previously mentioned, especially for personswho exhibit characteristicsofmetabolicsyndromeorwhohavehypertriglyceridemia (3).SeeTotalfatandsaturatedfatty acidsinthissection. ManualofClinicalNutritionManagement C45 Copyright2011MorrisonManagementSpecialists,Inc.
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Mediterraneandiet:ThetraditionalMediterraneandiethasbeeninvestigatedbasedonfavorableeffects on the lipid profile and decreased CHD risk in persons who live in Mediterranean countries. The Mediterranean diet is a plantbased diet that emphasizes fruits, vegetables, breads and other cereal grains, potatoes,beans,nuts,andseeds (53).Oliveoilistheprincipalfatsource.Cheeseandyogurtarethekeydairy products consumed daily. Fish, poultry,and eggs are consumed in moderate amounts. Desserts consist of fresh fruit, and concentrated sugars are eaten only a few times per week. Little red meat is eaten, and moderate amounts of red wine can be consumed with meals (53). Total fat content of the diet ranges from 25% to 35% of total energy, and saturated fat contributes less than 8% of total energy. Few studies have examined the Mediterranean diet plan. In one study, recurrent myocardial infarction, all cardiovascular events,andcardiacandotherdeathswerereducedby70%inthegroupconsumingaMediterraneandiet(54). Further research is needed to investigate the impact of this diet plan on cholesterol lowering and to determine if it is the specific dietary components (eg, omega3 fatty acid), increases in specific fatty acid consumption (eg, oleic acid or linolenic acid), or increased antioxidant consumption (eg, vitamins C and E) thatcausethecholesterolloweringeffect(54). Cardiovascular risk (1,3,4): Increased blood cholesterol levels or, more specifically, increased levels of LDL cholesterol are related to increased risk of CHD. Coronary risk rises progressively with an increase in cholesterollevels,particularlywhencholesterollevelsaregreaterthan200mg/dL.Patientswithestablished CHDareathighriskofsubsequentmyocardialinfarctionorCHDdeath,ariskfivetoseventimeshigherthan withoutestablishedCHD. SubstantialevidenceindicatesthatloweringtotalcholesterolandLDLcholesterollevels(oftencombinedwith druginterventions)willdecreasetheincidenceofCHDinbothprimaryandsecondarypreventionsettings(eg, patientswithandwithoutevidenceofCHD,respectively)(3,4). Shorttermclinicaltrialssupporttheprojectionthatforindividualswithserumcholesterollevelsinitiallyin the250to300mg/dLrange,each1%reductioninserumcholesterollevelyieldsapproximatelya2%reduction in CHD rates. Epidemiologic studies suggest that the reduction in CHD rates achievable by a longterm cholesterollowering regimen amounts to as much as 3% for each 1% reduction in serum cholesterol level. Thus,itisreasonabletoestimatethatthe10%to15%reductioninserumcholesterollevelresultingfromMNT shouldreduceCHDriskby20%to30%. PatientCenteredvsPopulationApproaches(1,3) The patientcentered and population approaches are complimentary and together represent a coordinated strategyaimedatreducingcholesterollevelsandcoronaryrisk. Patientcentered approach: A clinical or patientbased approach seeks to identify individuals at high risk who will benefit from intensive intervention efforts. Criteria define the candidates for medical intervention. Guidelines describe how to detect hypercholesterolemia, how to set goals for patients, and how to treat and monitorthesepatients. Populationapproach:Thepopulationorpublichealthapproachattemptstolowerbloodcholesterollevels inthewholepopulationbypromotinghealthfulchangesindietaryhabitsandphysicalactivitylevels.TheAHA and the NCEP III take the position that a generalized reduction in cholesterol levels in Americans should decrease the prevalence of CHD. It is widely assumed that the eating habits of Americans are primarily responsible for high cholesterol levels. For this reason, the AHA and the NCEP III recommend that the populationat large adoptaneatingpatterndesignedtomaintainplasmacholesterollevelsnearthedesirable range. SpecialGroups Older adults: According to the AHA, advanced age does not preclude the need to follow the Therapeutic LifestyleChangesDietorhearthealthyguidelines(3,4).Postmenopausalwomenandoldermenwithelevated LDLcholesterolareatincreasedriskofdevelopingcardiovasculardiseaseandthereforeshouldbemanaged basedonriskassessment (1,3,4).Whenolderindividualsfollowareducedsaturatedfatandcholesteroldiet, LDLcholesterol levels decrease (1,3,55). In addition, drugtherapy (eg, statins) can be a beneficial adjunct in highriskpatientsandisthepreferredtherapyinplaceofhormonereplacementtherapyinpostmenopausal women (1,4). Because older adults have decreasing total energy needs, they have the added challenge of requiring education on the need for nutrientdense foods within various food groups to meet nutritional needs(56). C46 Copyright2011MorrisonManagementSpecialists,Inc. ManualofClinicalNutritionManagement Allrightsreserved.
MedicalNutritionTherapyforDisordersofLipidMetabolism Pregnantwomenwithpreexistinglipiddisorders:Elevationsinbloodcholesterolandtriglycerideslevels may occur during pregnancy, with maximal levels in the third trimester and a return to normal levels after delivery. Generally, the MNT previously prescribed for the preexisting lipid disorder should be continued duringpregnancy.IfMNTisveryrestrictive,carefulconsiderationshouldbegiventoensureadequatenutrient intake.Drugtherapyshouldbediscontinuedduringpregnancy,sincetheeffectoflipidloweringdrugsonthe fetushasnotbeencarefullystudied(1,3). Childrenandadolescents:TheAHAGuidelines2000areindicatedforallhealthyindividualsolderthan2 years (3).However,accordingtotheAHA,itshouldnotbeassumedthatadietforadultsisalsoappropriate for children. Individual growth and nutritional requirements need to be considered at each stage of development. Studies havedemonstrated thatdiets low in saturated fat can support adequate growthand development in children and adolescents (57,58). The prevalence of obesity and type 2 diabetes mellitus is increasinginthepediatricpopulation(3).Nutritionstrategiesforthispopulationshouldfocusonappropriate nutritionalintake,balancingenergyintake,andincreasingphysicalactivity(3). Racial and ethnic populations: African Americans have the highest overall CHD mortality rate and the highestoutofhospitalcoronarydeathratesofanyethnicgroupintheUnitesStates,particularlyatyounger ages (1). The increased incidence is partly attributed to increased prevalence of coronary risk factors, including hypertension, ventricular hypertrophy, diabetes mellitus, cigarette smoking, obesity, and physical inactivity. Other highrisk ethnic groups and minority populations in the United States include Hispanics, NativeAmericans,AsianandPacificIslanders,andSouthAsians.TheNCEPATPIIIrecommendsintervention forcholesterolmanagementconsistentwithrecommendationsoutlinedforallotherpopulations(1). ATPIIIGuidelines CriteriathatdefinecandidatesforMNTinterventionandtheTherapeuticLifestyleChangesDietandlifestyle modificationshavebeenestablishedbytheNCEPATPIII,whichbuildsonthepreviousrecommendationsof ATPIIandATPI (1).TheseguidelinesemphasizetheimportanceofMNTprovidedbyaregistereddietitianin facilitating the behavior changes needed to follow the recommended diet and lifestyle changes before initiatingtherapywithcholesterolloweringmedicationsorinadjunctwiththistherapy.Theguidelinesare expectedtosubstantiallyincreasethenumberofAmericansbeingtreatedforhighcholesterol.Thenumberof peoplereceivingdietarytreatmentisexpectedtoincreasefrom52millionto65million,andthenumberof peoplereceivingprescribedcholesterolloweringdrugsisexpectedtoincreasefrom13millionto36million (1). TableC7:FeaturesofATPIIIGuidelines FocusonMultipleRiskFactors IdentifiespersonswithdiabetesbutwithoutCHD,mostofwhomhavemultipleriskfactors,asCHD riskequivalent UsesFraminghamprojectionsof10yearabsoluteCHDrisk(i.e.,thepercentprobabilityofhavinga CHDeventin10years)toidentifycertainpatientswithtwoormoreriskfactorsformoreintensive treatment Identifies persons with multiple metabolic risk factors (metabolic syndrome) as candidates for intensifiedtherapeuticlifestylechanges LipidandLipoproteinClassification IdentifiesLDLcholesterollevels<100mg/dLasoptimal CategorizeslowHDLcholesterollevelsas<40mg/dL Specifieslowercutofflevelsfortriglyceridestoincreasetheattentiongiventomoderateelevations SupportforImplementation Recommendsacompletelipoproteinprofile(totalcholesterol,LDLcholesterol,HDLcholesterol,and triglycerides)asthepreferredinitialtest,ratherthanscreeningforonlytotalcholesterolandHDL Encouragesuseofplantstanolsandsterolsandviscous(soluble)fiberastherapeuticdietaryoptions toenhanceloweringofLDLcholesterol Presentsstrategiesforpromotingadherencetotherapeuticlifestylechangesanddrugtherapies RecommendstreatmentbeyondLDLloweringforpersonswithtriglycerideslevels>200mg/dL

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TableC8:LDLCholesterol(LDLC)GoalsandRecommendationsforTherapeuticLifestyleChanges andDrugTherapyinDifferentRiskCategories(4) LDLCLevel(mg/dL)to LDLCLevel(mg/dL) LDLCGoal RiskCategory InitiateTherapeutic toConsiderDrug (mg/dL) LifestyleChanges Therapya CHDorCHDriskequivalent, <100 >100 >100 <100optional 10yearrisk>20% <70optional Twoormoreriskfactors, >130 <130 >130 100129optional 10yearrisk10%to20% Twoormoreriskfactors, <130 >130 >160 10yearrisk<10% >190 Zerooroneriskfactorb <160 >160 160189optional
aItisadvisedthattheintensityoftherapybesufficienttoachieveatleasta30%to40%reductioninLDLClevels.Ifapersonhashigh
triglycerideslevelsandlowHDLlevels,considercombiningnicotinicacidorfibratewiththeLDLloweringdrug.
bAlmostallpeoplewith0or1riskfactorhavea10yearrisk<10%;thus,10yearriskassessmentintheseindividualsisunnecessary.
The degree of reduction of LDL cholesterol levels achieved by MNT depends on dietary habits before startingtherapy,degreeofcompliance,andinherentbiologicalresponsiveness.Ingeneral,patientswithhigh cholesterol levels experience greater absolute reductions in LDL cholesterol levels than do those with low cholesterollevels(1).Loweringtotalcholesterolandsaturatedfatintake(lessthan7%to8%oftotalenergy) reducestotalcholesterolandLDLcholesterolby13%and16%,respectively (59).Forevery1%decreasein energyconsumedfromsaturatedfat,totalcholesterollevelsandLDLcholesterollevelsmayeachdecreaseby approximately2mg/dL (59).StudiesofMNTprovidedbyaregistereddietitianindicatethatwithtwotosix plannedvisitspatientsreporteda15%to22%reductionintotaldietaryfat(from32%to33%ofenergyto 25%to28%ofenergy)anda22%to36%reductioninsaturatedfat(from11%to12%ofenergyto7%to 9% of energy). These dietary changes were accompanied by a 6% to 13% reduction in total plasma cholesterollevelsanda7%to14%reductioninLDLcholesterollevels(GradeI)(5). ManagementofSpecificDyslipidemiasandSpecialConsiderations BecausetheLDLcholesterolleveloffersmorepreciseriskassessmentandistheprimarytargetofmedical interventions,treatmentdecisionsareprimarilybasedonLDLcholesterollevels.However,theNCEPATPIII recommendstheevaluationofacomprehensivelipoproteinpanelthatincludesfastingbloodLDLcholesterol, HDL cholesterol, triglycerides, and total cholesterol. A comprehensive panel provides a more accurate picture so that the Therapeutic Lifestyle Changes Diet and drug therapy can be individualized based on a patientsmetaboliccharacteristics. Low HDL cholesterol (<40 mg/dL): Low HDL cholesterol levels are a significant risk factor for CHD, independentofLDLcholesterollevelsandotherriskfactors(1).AreducedserumlevelofHDLcholesterolis definedasaconcentrationlessthan40mg/dL.Forevery1mg/dLdecreaseinHDLcholesterollevel,therisk ofCHDisincreasedby2%to3% (60).Likewise,higherHDLcholesterollevelsappeartoaffordadegreeof protectionagainstCHD.ThisprotectionwarrantsconsideringahighHDLcholesterollevel(60mg/dL)asa negativeriskfactor.HDLcholesterolismeasuredaspartofthelipoproteinanalysesforprimaryprevention in adults without CHD. For secondary prevention in adults with evidence of CHD, lipoprotein analysis is requiredinallpatients,andclassificationisbasedononlyLDLcholesterol.Appropriateadviceintreatment includes smoking cessation, weight reduction, and increased physical activity. Avoidance of certain drugs thatreduceHDLcholesterol,suchasbetaadrenergicblockingagents(betablockers),anabolicsteroids,and progestationalagents,shouldalsobeconsidered(1). Very high LDL cholesterol (>190 mg/dL): Persons with very high LDL cholesterol levels usually have geneticformsofhypercholesterolemia(eg,familialhypercholesterolemia,familialdefectiveapolipoproteinB, and polygenic hypercholesterolemia). Early detection should be completed in young adults to prevent prematureCHD.Thesedisordersoftenrequirecombineddrugtherapy(statinandbileacidsequestrant)to achievethegoalsofLDLloweringtherapy(1). Elevated serum triglycerides levels (>200 mg/dL): According to the NCEP ATP III, metaanalyses of prospectivestudiesindicatethatelevatedtriglycerideslevelsareanindependentriskfactorforCHD.Factors
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MedicalNutritionTherapyforDisordersofLipidMetabolism thatcontributetoelevatedtriglycerideslevelsinclude obesityandoverweight,physicalinactivity,cigarette smoking,excessalcoholintake,highcarbohydratediets(morethan60%ofenergyintake),certaindiseases (eg, type 2 diabetes mellitus, chronic renal failure, and nephrotic syndrome), certain drugs (eg, corticosteroids, estrogens, retinoids, and higher doses of betaadrenergic blocking agents), and genetic disorders (1). Generally, elevated serum triglycerides levels are most often observed in persons with metabolicsyndrome(1).TheNCEPATPIIIadoptsthefollowingclassificationofserumtriglycerideslevels: Normaltriglycerides <150mg/dL Borderlinehightriglycerides 150to199mg/dL Hightriglycerides 200to499mg/dL Veryhightriglycerides >500mg/dL
The VLDL level is the most readily available measure of atherogenic remnant lipoproteins. The ATP III identifiesthesumofLDLandVLDLcholesterol(termednonHDLcholesterol,whichcanalsobecalculatedby taking total cholesterol minus HDL cholesterol) as a secondary target of therapy in persons with high triglycerideslevels(morethan200mg/dL)(1).ThegoalfornonHDLcholesterolinpersonswithhighserum triglycerideslevelscanbesetat30mg/dLhigherthanthatforLDLcholesterol(eg,ifLDLgoalislessthan 100mg/dL,nonHDLgoalwouldbelessthan130mg/dL)(1). Thetreatmentforelevatedtriglyceridesleveldependsonthecausesandseverity (1).Theprimaryaimof therapy is to achieve the target goal of LDL cholesterol. Fibrates and nicotinic acid can be used in combination with LDLlowering drugs to lower triglycerides and achieve lipid goals (1,4). The ideal macronutrientcompositionforloweringtriglyceridesinpatientswithhypertriglyceridemia>150mg/dLis unclear(GradeIII)(5).Acaloriecontrolled,cardioprotectivedietarypatternthatavoidsextremesincarbohydrate andfatintake,limitsalcohol,limitsrefinedsugarwhileincreasingcomplexcarbohydratefoodandincludes physical activity is suggested (Grade III) (5). Weight loss of 7 to 10% of body weight should be encouraged if indicated (5).Theselifestylechangeshavebeenshowntolowertriglyceridelevels (Grade III) (5).Ifapatientis identifiedtohaveveryhightriglycerides(>500mg/dL),thedietitianshouldrefertotheATPIIIguidelines described below and recommend a very lowfat diet (< 15% of energy intake) (Grade II) (5). High doses of supplementalEPA/DHAhavebeenshowntolowertriglyceridesinpatientswithelevatedtriglycerides(GradeII) (5).Ifapatienthashightriglycerides(>200mg/dL)supplementalEPA/DHAcapsulesof2to4gramsperday maybeprescribedbythephysicianorbeconsideredatherapeuticintervention(GradeII)(5).
Triglycerides(TG)Level Borderlinehigh(150199 mg/dL) High(200499mg/dL)
Veryhigh(>500mg/dL)
ATPIIIRecommendedApproaches(1) weightreduction increasedphysicalactivity weightreduction increasedphysicalactivity drugtherapy(LDLloweringdrugsand/ornicotinicacidorfibratetolower TG) verylowfatdiet(<15%ofenergyintake)topreventacutepancreatitis weightreduction increasedphysicalactivity drugtherapy(LDLloweringdrugsand/ornicotinicacidorfibratetolower TG)
WhenlowHDLcholesterol(lessthan40mg/dL)isassociatedwithahightriglycerideslevel(200to499 mg/dL), the secondary priority is achieving the nonHDL cholesterol goal (as previously described). The HDLraisingdrugs,whichincludefibratesandnicotinicacid,canbeconsideredinpersonswithCHDandCHD riskequivalents.FibratesandnicotinicacidcanbeusedincombinationwithLDLloweringdrugstoachieve lipidgoals(1,4).AlsoseeSectionIII:Hypertriglyceridemia. PhysicalActivityandWeightManagement Excessbodyfat,orobesity,isamajorriskfactorforCHDandalsocontributestothedevelopmentofother risk factors, such as diabetes and hypertension. Weight management plays a vital role in achieving and maintaining good health while enhancing the quality of life. Proper nutrition and physical activity are key factorsthatinfluenceweightcontrol.TheNationalHeart,Lung,andBloodInstitutehasestablishedclinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. These guidelinesidentifyaneedforMNTweightmanagement(61).
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Animportantadjuncttolongtermchangeineatinghabitsandlifestyleisanincreaseinphysicalactivity.There isevidencethatregularexercisealonereducesCHDmortalitybyincreasingHDLcholesterollevelsand,insome patients,loweringLDLcholesterollevels.Theexerciseshouldemphasizeaerobicactivity,suchasbriskwalking, jogging, swimming, bicycling, and tennis. Improvements in cardiovascular fitness result from exercising at moderateintensityfor30to45minutesonmost,ifnotall,days(GradeII)(1,5).Vigorous,highintensityexercisemust beperformedwithcautioninhighriskpersonsandonlywiththeadviceofaphysicianandunderthesupervision oftrainedpersonnel(1). SelfManagementTrainingforthePatientwithDisorderofLipidMetabolism Once the patients risk assessment, clinical status, motivation, comprehension, and environmental support areassessed,thedietitianshouldsetgoalswiththepatientand/orcaregiverandprovideselfmanagement trainingtomeetthepatientsindividualizedneeds.Refertothefollowingevidencebasednutritionpractice guidelines (5, 62) or a combination of treatment guidelines as needed for treatment and frequency of MNT intervention: Coronaryarterybypassgraft(CABG)orAngioplastyAcuteCareNutritionProtocol(63) DisordersofLipidMetabolismEvidenceBasedNutritionPracticeGuideline(5)
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TribbleDA.AHAScienceAdvisory:antioxidantconsumptionandriskofcoronaryheartdisease:emphasisonvitaminC,vitaminE, andbetacarotene:astatementforhealthcareprofessionalsfromtheAmericanHeartAssociation.Circulation.1999;99:591595. 30. MillerER3rd,PastorBarriusoR,DalalD,RiemersmaRA,AppelLJ,GuallarE.Metaanalysis:highdosagevitaminEsupplementation mayincreaseallcausemortality.AnnInternMed.2005;142:3746. 31. LonnE,BoschJ,YusufS,SheridanP,PogueJ,ArnoldJM,RossC,ArnoldA,SleightP,ProbstfieldJ,DagenaisGR,HOPEandHOPETOO TrialInvestigators.EffectsoflongtermvitaminEsupplementationoncardiovasculareventsandcancer:arandomizedcontrolled trial.JAMA.2005;293:13381347. 32. StephensNG,ParsonsA,ScholfieldPM,KellyF,CheesemanK,MitchinsonMJ.RandomisedcontrolledtrialofvitaminEinpatients withcoronarydisease:CambridgeHeartAntioxidantStudy(CHAOS).Lancet.1996;347:781786. 33. LonnE,YusufS,HoogwerfB,PogueJ,YiQ,ZinmanB,BoschJ,DagenaisG,MannJF,GersteinHC;HOPEStudy;MICROHOPEStudy. EffectsofvitaminEoncardiovascularandmicrovascularoutcomesinhighriskpatientswithdiabetes:ResultsoftheHOPEstudy andtheMICROHOPEsubstudy.DiabetesCare.2002;25:19191927. 34. VivekananthanDP,Penn MS,SappSK,HsuA,TopolEJ.Useofantioxidantvitaminsforthepreventionofcardiovasculardisease: metaanalysisofrandomizedtrials.Lancet.2003;361:20172023. 35. Gallagher PM, Meleady R, Shield D, Tan KS, McMaster D, Rozen R, Evans A, Graham I, Whitehead A. Homocysteine and risk of prematurecoronaryheartdisease.Circulation.1996:21542158. 36. MorrisonH,SchaubelD,DesmeulesM,WigleD.Serumfolateandriskoffatalcoronaryheartdisease.JAMA.1996;275:18931896. 37. Bautista LE, Arenas IA, Penuela A, Martinez LX. Total plasma homocysteine level and risk of cardiovascular disease: a meta analysisofprospectivecohortstudies.JClinEpidemiol.2002;55:882887. 38. SchnyderG,RoffiM,FlammerY,PinR,HessOM.Effectofhomocysteineloweringtherapywithfolicacid,vitaminB12,andvitamin B6onclinicaloutcomeafterpercutaneouscoronaryintervention:theSwissHeartstudy:arandomizedcontroltrial.JAMA.2002; 288:973979. 39. TooleJF,MalinowMR,ChamblessLE,SpenceJD,PettigrewLC,HowardVJ,SidesEG,WangCH,StampferM.Loweringhomocysteine in patients with stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention(VISP)RandomizedControlledTrial.JAMA.2004;291:565575. 40. Di Casteinuovo A, Rotondo S, Iacoviello L, Donati MB, deGaetano G. Metaanalysis of wine and beer consumption in relation to vascularrisk.Circulation.2002;105:28362844. 41. Goldberg IJ, Mosca L, Paino MR, Fisher EA. AHA Science Advisory: wine and your heart: a science advisory for healthcare professionalsfortheNutritionCommittee,CouncilonEpidemiologyandPrevention,andCouncilonCardiovascularNursingofthe AmericanHeartAssociation.Circulation.2001;103:472475. 42. MukamalKJ,ConigraveKM,MittlemanMA,CamargoCA,StampferMJ,WillettWC,RimmEB.Rolesofdrinkingpatternandtypeof alcoholconsumedincoronaryheartdiseaseinmen.NEnglJMed.2003;348:109118. 43. Craig,W.Phytochemicals:Guardiansofourhealth.JAmDietAssoc.1997:97:S199S204. 44. Science Advisory and Coordinating Committee of the American Heart Association. Phytochemicals and cardiovascular disease. Circulation.1997;95:25912593. 45. KrisEthertonPM,ZhaoG,PelkmanCL,FishellVK,CovalSM.Beneficialeffectsofadiethighinmonounsaturatedfattyacidsonrisk factorsforcardiovasculardisease.NutrClinCare.2000;3:153162. 46. Sabate J, Haddad E, Tanzman J, Rajaram S. Serum lipid response to the graduated enrichment of a Step I diet with almonds: a randomizedfeedingtrial.AmJClinNutr.2003;77:13791384. 47. Hallikainen MA, Sarkkinen ES, Uusitupa MI. Plant stanol esters affect serum cholesterol concentrations of hypercholesterolemic menandwomeninadosedependentmanner.JNutrition.2000;130:767776. 48. Homma Y, Ikeda I, Ishikawa T, Tateno M, Sugano M, Nakamura H. Decrease in plasma lowdensity lipoprotein cholesterol, apolipoproteinB,cholesterylestertransferprotein,andoxidizedlowdensitylipoproteinbyplantstanolestercontainingspread:a randomized,placebocontrolledtrial.Nutrition.2003;19:369374. 49. VanstoneCA,RaeiniSarjazM,ParsonsWE,JonesPJH.UnesterifiedplantsterolsandstanolslowerLDLcholesterolconcentrations equivalentlyinhypercholesterolemicpersons.AmJClinNutr.2002;76:12721278. 50. OrnishD,ScherwitzLA,BillingsJH,BrownSE,GouldKL, MerrittTA,SparlerS,ArmstrongWT,PortsTA,etal. Intensivelifestyle changesforreversalofcoronaryheartdisease.JAMA.1998;280:20012007. 51. GouldKL,OrnishD,ScherwitzL,BrownS,EdensRP,HessMJ,MullaniN,BolomeyL,DobbsF,etal.Changesinmyocardialperfusion abnormalitiesbypositronemissiontomographyafterlongterm,intenseriskfactormodification.JAMA.1995;274:894901. 52. ConnorWE,ConnorSL.Shouldalowfat,highcarbohydratedietberecommendedforeveryone?NEnglJMed.1997;337:562566. 53. WillettWC,SacksF,TrichopoulouA,DrescherG,FerroLuzziA,HelsingE,TrichopoulosD.Mediterraneandietpyramid:acultural modelforhealthyeating.AmJClinNutr.1995;61(suppl):1402S1406S. 54. Renaud S, deLoregeril M, Delaye J, Gaidollet J, Jacquerd T, Marmelle N, Martin JL, Monjaud L, Salen P, Toubel P. Cretan Mediterraneandietforpreventionofcoronaryheartdisease.AmJClinNutr.1995;61(suppl1):1360S1376S. 55. Ginsberg HN, KrisEtherton P, Dennis B, Elmer PJ, Ershow A, Levevre M, Pearson T, Roheim P, et al. Effects of reducing dietary saturatedfattyacidsonplasmalipidsandlipoproteinsinhealthysubjects:theDELTAstudy,protocol1.ArteriosclerThrombVasc Biol.1998;18:441449. 56. Russell RM, Rasmussen H, Lichtenstein AH. Modified Food Guide Pyramid for people over seventy years of age. J Nutr. 1999; 129:751753. 57. ObarzanekE,HunsbergerSA,VanHornL,HartmullerVV,BartonBA,StevensVJ,KwiterovichPO,FranklinFA,KimmSY,LasserNL, SimonsMorton DG, Laaer RM. Safety of a fatreduced diet: the Dietary Intervention Study in Children (DISC). Pediatrics. 1997;100:5159. 58. Daniels SR, Greer FR, and the Committee on Nutrition. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122:198208. ManualofClinicalNutritionManagement
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MedicalNutritionTherapyforDisordersofLipidMetabolism 59. YuPothS,ZhaoG,EthertonT,NaglakM,JonnalagaddaS,KrisEthertonPM.EffectsoftheNationalCholesterolEducationPrograms Step I and Step II Dietary intervention programs on cardiovascular disease risk factors: a meta analysis. Am J Clin Nutr. 1999;69:632646. 60. Oster G, Thompson D. Estimated effects of reducing dietary saturated fat intake on the incidence and costs of coronary heart diseaseintheUnitedStates.JAmDietAssoc.1996;96:127132. 61. National Heart, Lung, and Blood Institute Obesity Education Initiative Expert Panel. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report. Bethesda, Md: National Institutes of Health; 1998.NIHpublicationNo.984083.Availableat:http://nhlbi.nih.gov/nhlbi/htm. 62. PositionofTheAmericanDieteticAssociationandDietitiansCanada:Dietaryfattyacids.JAmDietAssoc.2007;107:15991611. 63. CoronaryArteryBypassGraft(CABG)orAngioplastyNutritionAcuteCareProtocol.In:NutritionCareProtocolsfortheAcuteCare Setting.Atlanta,Ga:MorrisonManagementSpecialistsInc;2009.Availableat: https://www.morrisontoday.com/Documents/Forms/AllItems.aspx?RootFolder=%2fDocuments%2fNutrition%2fMHFS%20NUTR ITION%2fNutrition%20Care%20Process&FolderCTID=0x01200076035A4CEC8A4B4B827A74CE5B3B1A44&View=%7b1F2F11D B%2d2030%2d4BBC%2dB712%2dEFE12EF45909%7d.
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FOODGUIDELOWSATURATEDFAT,LOWCHOLESTEROLORTLCDIETS
FOODGROUP Beverages Breads,Cereals andGrain Products FOODSALLOWED Carbonatedbeverages,softdrinks,coffee, tea,cocoamixes Mostbreads,cereals,pasta,rice,dried peas,beans,andpotatoes.Lowfat crackers:RyeCrisp,Saltines*,bread sticks,fatfreecrackers*,melbatoast, Englishmuffins,bagels,pitabread Allfresh,canned,ordriedfruitsand vegetables Chicken&turkey:removetheskinandany visiblefat Fish&shellfish Veal&wildgame Beef,pork&lamb:useleancutsonly. Beef:extraleangroundbeef,sirlointip, groundsteak,andrumproast. Pork:centercutham*,loinchopsand tenderloin Luncheonmeatsatleast95%fatfree Eggwhites,cholesterolfreeeggsubstitute Reducedcholesteroleggsoregg substitutes Fatfreeor1%fatmilkandbuttermilk, lowfatornonfatyogurt,fruitedor frozen(1%orlessmilkfat) Lowfatcheese:anycheeselabeled2to6 goffatperoz,partskimmozzarella cheese,cottagecheese(1%or2%)or, partskimricottacheese(1/4cup) FOODSEXCLUDED Commercialbakedgoods:croissants,cheese breads,doughnuts,muffins,biscuits, buttertyperolls,quickbreads,granola typecereals,snackcrackerslikecheese crackers,potatochips,eggnoodles, creamedpotatoes/pasta Vegetablespreparedinbutter,cream,or othersauces Poultry:goose,domesticduck Fattycutsofmeat Friedfish Beef:cornedbeefbrisket*,regularground beef,shortribs Pork:spareribs,groundpork Processedmeats:bacon*,bologna*,salami*, sausage*,hotdogs* Organmeats:liver,gizzard,brains,heart& kidney(limittoonceamonth) Eggwhitesunlimited,eggyolks(2to4per weekbasedonlipidprofileandresponseto lowfatdiet) Wholemilk(4%),regular,evaporated, condensed;cream,half&half,reducedfat milk,imitationmilkproducts,nondairy creamers,whippedtoppings,eggnog,whole milkyogurt,milkshakes Allnaturalcheeses(eg,bleu,brie,feta, muenster,Roquefort,camembert,cheddar, Swiss,American)
Vegetablesand Fruits Meat,Fishand Poultry (limitto5to6 oz/day)
Eggs MilkandDairy Products (2to3serving/day)
*Highinsalt.Individualslimitingtheirsaltintakeshouldavoidthesefoods.
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Medical Nutrition Therapy for Disorders of Lipid Metabolism
FoodGuideLOWSATURATEDFAT,LOWCHOLESTEROLORTLCDIETS(Cont.) FOODGROUP FOODSALLOWED FOODSEXCLUDED Fats&Oils Unsaturatedtransfatfreevegetableoils: Saturatedfats&oils:butter,coconutoil, Limitto6to8 canola,safflower,sunflower,corn,peanut, cocoabutter,palmkerneloil,lard,orbacon tsporportions olive,soybean.Margarineinwhichthefirst fat.Margarineorshorteningsinwhichthe aday,including ingredientisliquidoil. firstingredientisapartiallyhydrogenatedoil fatusedin Dietmargarine.Nonfatbuttersubstitutes. oranimalfat.Margarinescontainingtrans cooked Nonstickspray.Nonfatorfatfreesalad fat.Dressingsmadewitheggyolk,bleu products. dressingormayonnaise. cheese,orsourcream.Coconut,chocolate, Fatfreecreamcheeseandsourcream commercialdips. Lowfatorlightcreamcheeseorsour cream Foodswithhiddenfat: Olives*(5large) Biscuit*(2)1tspoffat Nuts(1oz=3tspfat) Cornbread*(2cube)1tspoffat Avocado(1/8med) Muffin*(small)1tspoffat Mayonnaisetypedressing(2tsp) Pancakes*(2)1tspoffat Saladdressing(1Tbsp) Stuffing/dressing*(cup)1tspoffat Peanutbutter(2Tbsp=3tspofallowed fat) Cake*(3square)1tspoffat Fruitpie*(1wedge)1tspoffat Cookies*(2to2)1tspoffat Thesefoodsareacceptableifprepared homemadewithoilorliquidmargarine. Countthehiddenfatinthesefoodstoward thedailyfatallowances. Soups Brothtypemadewithallowedingredients. Creamsoups.Condensedcreamsoups.* Desserts& Fatfreefrozendesserts,cakes,andcookies; Commercialbakedgoods:pies,cakes, Sweets angelfoodcake;sherbet,sorbet,gelatin; cookies,doughnuts,pastries;icecream, occasionallyicemilk,lowfatyogurt brownies,fudgetopping,milkchocolate Syrups:chocolate(madewithcocoa), candy strawberry,etc. Cookies:grahamcrackers,gingersnaps, animalcrackers,figbars,vanillawafers Puddingmadewithfatfreemilk Hardcandy
*Highinsalt.Individualslimitingtheirsaltintakeshouldavoidthesefoods.
Forpatientsonsodiumrestrictions,usethefollowingsampledailymealplans. FoodGroup NumberofServings NumberofServings 2,000mgsodium 1,500mgsodium Bread,Cereals,andGrainProducts 6regularbreadorcereal items 5regularbreadorcereal items (150mg/serving) Vegetables/Fruits 5 5 (10mg/cserving) Meat,Fish,PoultryandEggs 6 6 (60mg/1oz) MilkandDairy(150mg/serving) 2 2 Fats(100mg/serving) 1 0 45tspunsalted 78tspunsalted Soup(unsaltedonly) Calculateintodiet Calculate DessertsandSweets Readlabelandcalculateintodiet Readlabelandcalculateintodiet Miscellaneous Calculateintodiet Calculateintodiet;noaddedsaltin cookingorattable TotalSodium 1710mg 1460mg
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FATCONTROLLEDDIET (50Grams)
Description Omittingand/orlimitingfatcontainingfoodsrestrictsthetotalamountoffatinthediet.Thetypeoffatisnot considered. Indications Afatcontrolleddietisindicatedforindividualswhoareunabletoproperlydigest,metabolize,andabsorbfat. Common diseases of the hepatobiliary tract, pancreas, intestinal mucosa, and lymphatic system impair fat digestion,metabolism,andabsorption (15).Alowfatdietmayalsobeusefulinthetreatmentofpatientswith gastroesophagealreflux(4,6). Contraindications In pancreatic insufficiency, enzyme preparations remain the primary treatment for steatorrhea. As normal a diet as possible is encouraged to increase the likelihood that a nutritionally adequate diet will be consumed (5,7,8).Thedietshouldrestrictfatonlytotheindividualstolerancelevel. Thetreatmentofchoiceforgallstonesatthepresenttime,whereindicated,issurgery.Thereisnoreasonin thepostoperativeperiodtorestrictormodifyfatintakeinanyway. NutritionalAdequacy TheFatControlledDietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)forallnutrientsasoutlined inthe StatementonNutritionalAdequacy inSectionIA.VitaminEintakewillbe lowerthan inaregulardiet. However,therequirementforvitaminEisproportionaltotheintakeofpolyunsaturatedfattyacids,whichwill alsobereducedinaFatControlledDiet. OrderingtheDiet Order as LowFat Diet or 50GramFat Diet can be ordered (this is sufficiently restricted for many indications). Otherlevelsoffatrestrictioncanbespecified,eg,25to35gfatdiet. If a cholesterol restriction is desired, the diet ordered should be Therapeutic Lifestyle Changes Diet in MedicalNutritionTherapyforDisordersofLipidMetabolisminSectionIC.
FOODGROUP BeveragesandMilk FOODGUIDE FATCONTROLLEDDIET FOODSALLOWED Coffee,tea,carbonateddrinks,fatfreemilk orbuttermilk,evaporatedskim,nonfatdry milk,skimorlowfatyogurt FOODSEXCLUDED Whole,reducedfat, evaporated,condensed,or chocolatemilk,yogurtmade fromwholemilk,cocoa mixes Quickbreadssuchasmuffins, biscuits,richorsweetrolls, doughnuts,pancakes, waffles,partycrackers, potatochips,granolaunless calculatedintodiet Friedorfattymeats,suchas luncheonmeats,curedand processedmeats,other cheeses
Breads,CerealsandGrains
Wholegrainorenrichedbreads,dinner rolls,cerealsandgrains,pasta,plain crackers
Meat,Fish,Poultry,Cheese, Eggs(average3to5gfat/oz) (limitintaketo5oz/day)
Leanmeat(trimmedofvisiblefat),fish,and fowl(withoutskin).Thefollowingare equalto1ozmeat:1egg,cuptuna, salmon(waterpacked),orcottagecheese. Thefollowinglowfatcheesesareallowed (oneservingperday):1ozlowfatorfat freemilkcheeses(sapsago,mozzarella, farmers)orcup1%cottageorricotta cheese C55
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FatControlledDiet
FOODGROUP Vegetables
FOODGUIDE FATCONTROLLEDDIET(Cont.) FOODSALLOWED FOODSEXCLUDED Anypreparedwithoutfat. Vegetablesincreamsaucesor gravies,friedvegetables includingpotatoes All Butter,margarine,vegetableoil,crisp bacon(1strip=1tspfat) Anysoupsmadewithfatfreemilkorfat freebroth Fruit,sherbet,sorbet,fatfreefrozen desserts,gelatin,angelfood/sponge cake,lowfatcookies(gingersnaps, vanillawafers),fatfreecakes, puddingsmadewithfatfreemilk, meringues Sugar,jelly,honey,syrupswithnofats, molasses,plainmarshmallows,hard candy None Cream,avocado,nuts,coconut, olives,peanutbutter Commerciallycannedsoups, creamsoups,soupscontaining fatorwholemilk Icemilk,icecream,pie,cake, cookies,pastries,anydesserts madewithshortening,chocolate, cream,nuts,orfat Anycontainingchocolate,nuts, cream,coconut,butterflavored orfudgesyrup
FruitsandJuices Fats(limitintaketo5tsp/day;use nomorethan2servings/meal) (Average:1tspfat=5gfat) Soup
Desserts
Sweets
Miscellaneous
Vinegar,lowcalorieorfatfreedressings, Chocolate,coconut,gravy cocoaorcarobpowder,herbsand spices,salt,pepper,ButterBuds
SAMPLEMENU Breakfast Orangejuice Creamofwheat Scrambledegg Wheattoast Margarine Jelly Fatfreemilk Coffee Sugar Noon Honeyglazedchicken(skinless) Bakedpotato/margarine Steamedbroccoli Fruitedgelatin Dinnerroll Margarine Sherbet IcedTea Sugar Evening Leanbeeftipsandnoodles Seasonedgreenbeans Slicedtomatosalad FatfreeFrenchdressing Peachhalves Dinnerroll Margarine Fatfreemilk Icedtea Sugar
References 1. Gastrointestinal Disease/Gallbladder. In: American Dietetic Association Nutrition Care Manual. Chicago: Ill: American Dietetic Association;2007.Availableat:nutritioncaremanual.org.AccessedJanuary6,2007. 2. BurchJM.Acutepancreatitis.In:RakelRE,ed.ConnsCurrentTherapy.Philadelphia:WBSaundersCo;1993:502506. 3. ChakA,BanwellJG.Malabsorptionsyndromes.In:RakelRE,ed.ConnsCurrentTherapy.Philadelphia:WBSaundersCo;1993:496502. 4. DwyerJT,RoyJ.Diettherapy.In:IsselbacherKJ,BraunwaldE,etal,eds.HarrisonsPrinciplesofInternalMedicine.12thed.NewYork, NY:McGrawHill,Inc;1991:420427. 5. MarottaRB,FlochMH.Dietarytherapyofsteatorrhea.GastroenterolClinNAm.1989;18:485512. 6. GoyalRK.Diseasesoftheesophagus.In:IsselbacherKJ,BraunwaldE,etal,eds.HarrisonsPrinciplesofInternalMedicine.13thed. NewYork,NY:McGrawHill,Inc;1992:15031515. 7. BradyMS,RickardK,YuPL,EigenH.Effectivenessofentericcoatedpancreaticenzymesgivenbeforemealsinreducingsteatorrhea inchildrenwithcysticfibrosis.JAmDietAssoc.1992;92:813817. 8. Bone R. Cystic fibrosis. In: Wyngaarden JB, Smith LH, Bennett JC, eds. Cecil Textbook of Medicine. 19th ed. Philadelphia: WB SaundersCo;1992;418421.
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MEDIUMCHAINTRIGLYCERIDES(MCT)
Description Commercialmediumchaintriglycerides(MCT)arecomposedof8to10carbonfattyacidssynthesizedfrom palmkernelandcoconutoils(1).MCTprovide8.3kcalpergand116kcalpertablespoon(2). Indications MCT are indicated in conditions where longchain triglycerides (LCT) are not well tolerated. MCT are commonly used in fatcontrolled diets to provide increased calories and improve the palatability of a reducedfatdietSeeFatControlledDietinSectionIC.ThefollowingpropertiesofMCTmaymakeitusefulin disorderswhereLCTareproblematic: Absorptioncanoccurdespitepancreaticlipasedeficiency(2). Bilesaltsormicellesarenotrequiredfordispersioninwaterandsubsequentabsorption(2). TransportacrosstheintestinalmucosaoccursmorereadilythanwithLCT(2). MCTarenotdependentuponchylomicronsfortransitandconsequentlydonotrequirelipoproteinlipase foroxidation(2). Transportdoesnotoccurthroughthelymphaticsystem.MCTtraveldirectlytotheliverviatheportal vein,asfreefattyacidsboundtoalbumin(2). MCThydrolyzestofattyacidsmorequickly(2)andoxidizesmorerapidlyandefficientlythanLCT(1). MCTmaybeadjunctivetoafatcontrolleddietinthefollowingconditions: pancreaticinsufficiency(1) cysticfibrosis(1) intestinalresection(1) hepatobiliarydisease(1) lymphangiectasia(2) chyluria(2) chylousascites(2) chylothorax(2) secondarycarnitinedeficiencysyndromes(3) whipplesdisease(4) hyperchylomicronemia(4) MCTmaybetherapeuticallyincorporatedintotheketogenicdiet,whichisusedtocontrolepilepticseizures (seeKetogenicDiet)andmayalsobeusedinadjunctwithantineoplastictreatmentforpediatrics(5). Contraindications Undernormalphysiologicconditions,MCTareketogenic.Therefore,MCTarecontraindicatedinpersonswho arepronetodiabeticketoacidosis(2). Incirrhosis,MCTaccumulateintheblood,resultinginaconditionthatpresentswithsymptomssimilarto hepatic encephalopathy, including hyperlactacidemia, hyperammonemia, hyperventilation, and altered EKG findings(2). NutritionalAdequacy MCT are used in conjunction with specific diets, such as fatcontrolled or ketogenic diets. Nutritional adequacywilldependontheprescribeddiet. HowtoOrdertheDiet MCTaregenerallyorderedinconjunctionwithafatcontrolleddiet.Theordershouldspecifythenumberof mLorgMCTtobeaddedtothediet.Forexample:____gFatControlledDietplus____mL(g)MCT.
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MediumChainTriglycerides(MCT)
PlanningtheDiet MCTareavailableasMCToilorinformulascontainingMCT. MCT should be introduced slowly to avoid the abdominal distention and pain, nausea, vomiting, and diarrheaassociatedwithrapidinfusionorhighdose(2). MCTindivideddosesofnomorethan15to20mL(3to4tsp)atatimearegenerallywelltolerated (2). Patientsshouldinitiallyreceivenomorethan20to30mLperday,increasingby5to10mLperdayas tolerateduntiltheMCTgoalismet. ToincorporateMCTintothediet,thefollowingaresuggested(2): Add1tspMCToilto4ozfatfreemilk,carbonatedbeverages,juices,orflavoreddrinks.Ifpatientis prescribedaketogenicdiet,usesugarfreebeveragesandfollowfluidrestrictions. SubstituteanequalamountofMCToilforotherfatswhencookingandbaking. PreparesaladdressingswithMCToil.
References 1. Babineau TJ, Pomposelli J, Forse RA, Blackburn GL. Specific nutrients: carbohydrates, lipids, nucleic acids. In: Zaloga GP, ed. NutritioninCriticalCare.St.Louis,Mo:Mosby;1994:196197. 2. Nelson JK, Moxness KE, Jensen MD, Gastineau CF, eds. Gastrointestinal diseases and disorders. In: Mayo Clinic Diet Manual: A HandbookofNutritionPractices.7thed.St.Louis,Mo:Mosby;1994:230232. 3. PonsR,DeVivoDC.Primaryandsecondarycarnitinedeficiencysyndromes.JChildNeuro.1995;10:S8S24. 4. Longchain trigylceride restricted mediumchain triglyceride diet. In: Manual of Clinical Dietetics. 6th ed. Chicago, Ill: American DieteticAssociation;2000:725. 5. NebelingLC,LernerE.Implementingaketogenicdietbasedonmediumchaintriglycerideoilinpediatricpatientswithcancer.JAm Diet. ManualofClinicalNutritionManagement
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FIBERRESTRICTEDDIETS (LowFiber*)
Description The LowFiber Diet restricts dietary fiber and provides less than 10 grams a day. Foods that have been defined in qualitative terms as having tough fibers are also eliminated. Animal products, refined grain products,andselectedfruitsandvegetablesareincluded. Indications Topreventtheformationofanobstructingboluswhentheintestinallumenisnarrowed. Todelayintestinaltransittimeinconditionsofdiarrhea. Toreduce(noteliminate)thefiberinthecolonpreandpostoperatively. To allow the bowel to rest during acute exacerbation of inflammatory bowel disease, acute phases of diverticulitis,orregionalenteritis(Crohnsdisease). Thedietisintendedforshorttermuse.Thegoalofnutritiontherapyistoestablishatolerancetoawider varietyoffoodsandtomakeatransitiontoaregulardiet. Contraindications Afiberrestricteddietiscontraindicatedwhenasoftstoolisdesired,asinindividualswithdiverticulosis.A lowfiberintakemayaggravatethesymptomsofirritablebowelorconstipation.Inthesecases,ahighfiber intakeisrecommended.(SeeSectionD:HighFiberDiet.) Whereadietsoftintextureisdesired,asinthecaseofapatientwithesophagealnarrowing,amechanical softdietmaybeordered. NutritionalAdequacy TheLowFibercanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedintheStatementon NutritionalAdequacyinSectionIA.Atleastoneservingofcitrusfruitjuiceisrecommendedfordailyvitamin C. HowtoOrdertheDiet Order as LowFiber Diet. Milk and other lactosecontaining foods will not be restricted unless ordered. Milk is fiberfree and a mediumresidue food; therefore, it is not necessary to eliminate it. However, for individuals with inflammatory bowel disease and lactose intolerance, a lowfiber, lowlactose dietary restrictionmaybeappropriate. PlanningtheDiet(1): 1. Selectcereals,grainsandbreadproducts,andvegetablesthatlowinfiber(<2gfiber/serving) 2. Forpatientswithalactoseintolerance,dairyproductsmayneedtobeavoidedorlimited 3. Clean,prepareandstorefoodsusingpropersanitationtechniques *Previously this diet had also been titled the low residue diet. Due to no scientific acceptable definition of residue and the lack of widespread availability of resources to provide this information, the term is not included in this manual. Since fiber content of the diet can be estimated from food composition tables, the low fiber diet is the preferred title of this diet and used throughout this manual.
Reference
1.
LowFiberNutritionTherapy.GastrointestinalDiseases.In:TheAmericanDieteticAssociationNutritionCareManual.Updatedannually. Availableat:http://www.nutritioncaremanual.org.AccessedFebruary7,2011.
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FiberRestrictedDiet
FOODGUIDELOWFIBERDIET
FOODGROUP Beverages (0gmfiber/serving) Nolimitofallowed foods MilkProducts (0gmfiber/serving) Nolimitofallowed foods FOODSALLOWED Norestriction FOODSEXCLUDED
Choose yogurt with live, active cultures, Milkisavoidedonlywhenlactose evaporated skim, and lowfat milk, soy intoleranceispresent(1).Yogurtwith berries,orangeorlemonrind,ornuts. milk, powdered milk, cheese, lowfat ice Wholemilk,halfandhalf,cream,sour cream,sherbet cream,regularicecream BreadsandStarches, All breads and crackers made from white Wholewheat,rye,pumpernickelor flour or choose grain foods with less branbreads,crackers,muffins Pasta,Rice than2gramsdietaryfiberperserving (0.5gmfiber/serving Buckwheatpancakes perallowedfoods) Grahamcrackers Ryewafers Nolimitofallowed Cornandflourtortillas Breadsandcrackerscontainingfruit, foods Cornbread nuts,orseeds Pasta,noodles,whiterice Brownrice;barley Wheatena, rolled wheat, and other whole BreakfastCereals Farina,creamofrice,grits,oatmeal graincookedcereals (0.5gmfiber/serving) Readytoeatcerealsfromcorn,rice,or Nolimitofallowed whiteflourorothersproviding<2g Readytoeat wholegrain, oat and bran cereals including bran flakes, granola, foods fiberperserving(1) GrapeNuts, oat bran, 100% bran, puffed wheat, shredded wheat, wheat bran, wheatflakes,wheatgerm Fruitjuicewithoutpulp(exceptforprune Prunejuice. FruitJuices juice) Juicewithpulp (0gmfiber/serving perallowedfoods) Nolimitofallowed foods Fruits Banana,applesauce Allfreshfruitsexceptbanana (2.0gmfiber/serving Cannedandwellcookedfruits perallowedfoods) Countin36servings ofallowedfiber containingfoods/day Vegetablesand Mushrooms(cooked) Raworfriedvegetables VegetablesJuices Tomato/vegetablejuice Broccoli (2.0gmfiber/serving Tomatosauce Corn perallowedfoods) Cannedandwellcookedvegetables Mixedvegetables Countin36servings exceptthoseontheFoodsExcluded Skinofpotato ofallowedfiber list BrusselSprouts containingfoods/day Cabbage Cauliflower Succotash(alsoseelegumes) Collard,mustard,andturnipgreens
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FOODGROUP Meat,Fish,Poultry, Cheese,Eggs (0gmfiber/serving) Nolimitofallowed foods Legumes Noneallowed FOODSALLOWED FOODSEXCLUDED Tender, wellcooked meats, poultry, fish, Avoid fried meat including sausage and eggs,andsoypreparedwithoutadded bacon.Luncheonmeats,suchasbolognaor fat.Smoothnutbutter salami, hot dogs, tough or chewy cuts of meat,friedeggs,alldriedbeans,peas,and nuts.Chunkynutbutters. None All legumes: chickpeas, lima beans, black eyedpeas,kidneybeans,pintobeans,etc Peanutbutter Bakedbeans Meat,rice,noodlesoups Minestronesoup Soupsmadefromallowedvegetables Bean,pea,andlentilsoups Oils,butter,cream,margarine, mayonnaise Cranberrysauce,seedless,sherbet Nuts,seeds
Soup (2.0gmfiber/serving perallowedfoods) Countin36servings ofallowedfiber containingfoods/day Fats (0gmfiber/serving) Nolimitofallowed foods SugarandSweets (0gmfiber/serving) Nolimitofallowed foods Miscellaneous (0gmfiber/serving) Nolimitofallowed foods
Candycontainingfruits,nuts,orcoconut Jam, marmalade, relishes containing seeds, orskins Pickles
Catsup,spices,herbs,seasonings
Breakfast Orangejuice Grits SoftCookedegg Whitetoast Margarine Grapejelly Milk Coffee Sugar
SAMPLEMENU(lessthan10gfiber) Noon Chickenricesoup Roastbeefsandwichonwhitebread Mayonnaise Tomatojuice Orangesherbet Coffeeandtea Sugar
Evening Bakedchickenwithgravy Whippedpotatoes Greenbeans Dinnerroll Margarine Cannedpeaches Milk Tea Sugar
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Description Dietaryfiberisbeneficialforhealthmaintenanceanddiseasepreventionandisakeynutritionintervention strategyforseveralchronicdiseasesincludingcardiovasculardisease,diabetesmellitus,andalsoeffectivein weightmanagement,andbowelrelateddiseases(1).Ahighfiberdietemphasizestheconsumptionofdietary fiberfromfoodsofplantorigin,particularlyminimallyprocessedfruits,vegetables,legumes,andwholegrain andhighfibergrainproducts.Aplantbaseddietmayalsoprovideothernonnutritivecomponentssuchas antioxidantsandphytoestrogensthathaveimplicationshealthbenefits (1).DietaryfiberintakeintheUnited States continues to be at less than the recommended levels, with an average daily intake of only 15 g (1,2). MajorsourcesofdietaryfiberintheUSfoodsupplyincludegrainsandvegetables(1,3).Whiteflourandwhite potatoes provide the most fiber in the US diet, about 16% and 9%, respectively, not because they are concentratedfibersources,butbecausetheyarethemostwidelyconsumed(1,3).Legumesonlyprovideabout 6%offiberandfruitsprovideonly10%offiberintheoverallUSdietbecauseoflowfoodconsumption (1,3). TheAmericanDieteticAssociationrecommendsthathealthyadultsconsumetheDietaryReferenceIntakes (DRIs)of14gdietaryfiberper1,000kcal,or25g/dayforwomenand38g/dayformen (1).TheAmerican AcademyofPediatricsrecommendsthatchildren2yearsandolderconsumeadailyamountoffiberequalto orgreaterthantheirageplus5g(1).InSeptember2002,theInstituteofMedicinesFoodandNutritionBoard releasedthefirstDRIsfortotalfiberthatarebasedonlifestage(seeTableD1) (2).InadditiontotheDRIs, theamountandsourcesoffiberinthedietshouldbedeterminedbythenutritionobjectivesforthespecific diseasestate,asoutlinedbelow. TableD1: DRIsaforTotalFiberbyLifeStage(2) Age Male Female 012months NDb ND 13years 19g 19g 48years 25g 25g 913years 31g 26g 1418years 38g 26g 1950years 38g 25g >50years 30g 21g Pregnancy(1450years) 28g Lactation(1450years) 29g
a b
DRIsbasedon14gtotalfiberper1,000kcal ND,notdetermined
DefinitionsofDietaryFiber There are a variety of definitions of dietary fiber (1,2). Some definitions are based primarily on analytical methodsusedtoisolateandquantifydietaryfiber,whereasothersarephysiologicallybased (1).Crudefiber istheamountofplantmaterialthatremainsaftertreatmentwithacidoralkalisolvents.Itispredominantly ameasureofthecellulosecontentofafoodand,assuch,significantlyunderestimatesthetotaldietaryfiber foundinplantfood.Manyolderfoodcompositiontablesreportonlycrudefiber(4).Forlabelingpurposesin the United States, dietary fiber is defined as the material isolated by analytical methods approved by the Association of Official Analytical Chemists. Although the Institute of Medicine recommends that the terms solubleandinsolublefibernotbeused(2),foodlabelsstillmayincludesolubleandinsolublefiberdata(1). ThePanelontheDefinitionofDietaryFiberundertheFoodandNutritionBoardoftheNationalAcademy of Sciences has developed definitions for dietary fiber, functional fiber, and total fiber. Dietary fiber is the nondigestible component of carbohydrates and lignin naturally found in plant foods (2,5). Functional fiber refers to fiber sources that have similar health benefits as dietary fiber, but are isolated or extracted from naturalsourcesorsyntheticsources (2,5).Totalfiberisthesumofdietaryfiberandfunctionalfiber (2,5).The intentofthesedefinitionsistorecognizethephysiologicactionsoffiberanditsdemonstrablehealtheffects andtoreducetheemphasisondietaryfiberasaconstituentoffoodrequiringquantification (2,5).Therehas been a trend to assign specific physiologic effects either to soluble or insoluble fibers (5). This approach makesitdifficulttoevaluatetheeffectsoffiberprovidedbymixeddiets (5).Dietaryfiberprovidedbymixed dietsistwothirdstothreefourthsinsoluble;however,theexactdistributionbetweensolubleandinsoluble
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fiberdependsonthemethodofanalysis (5).Inaddition,solubleandinsolublefiberfoodsoftenhavesimilar benefits vs independent benefits that affect health outcomes. For example, both psyllium seed husk, an insolublefibersource,andoatbran,asolublefibersource,increasestoolweight,improvelaxation,andlower blood cholesterol levels (1). Onlytheviscoussolublefibers(notallsolublefibers)arehypocholesterolemic agents (1).Basedonthereviewofevidence,theNationalAcademyofSciencespanelrecommendsthatthe terms soluble fibers and insoluble fibers gradually be eliminated and replaced by the specific beneficial physiologiceffectsoffiber(2,5). IndicationsandNutritionInterventionGuidelines Constipation and normal laxation: Consumption of dietary fiber is a frequently prescribed nutrition interventionforthepreventionortreatmentofconstipation.Fibersupplementsmayproducebenefitsinthe laxationofhealthyindividuals (GradeIII)(1).However,moreresearchisneededtoclarifythedoseandtypeof fiber needed for gastrointestinal health and management (Grade III) (1). Many fiber sources, including cereal brans, psyllium seed husk, and methylcellulose, and a mixed highfiber diet increase stool weight, thereby promotingnormallaxation(1,6).Theincreaseinstoolweightiscausedbythepresenceoffiber,thewaterthat thefiberholds,andthepartialfermentationofthefiber,whichincreasestheamountofbacteriainstool (7). The large intestine responds to the larger and softer mass of residue produced by a highfiber diet by contracting,whichmovesthecontentstowardexcretion (1).Fiberinmixeddiets,legumes,andwholegrain andhighfibergrainproductsareparticularlyeffectivepromotersofnormallaxation (1).Afibersupplement maybeneededwhenfoodintakeislow,asinthecaseofinactiveolderadults(1).Commonfibersupplements are psyllium seed husk and methylcellulose (1). Many foods are natural laxatives because they contain indigestible carbohydrates and other compounds with natural laxative properties; these foods include cabbage, brown bread, oatmeal porridge, fruits with rough seeds, vegetable acids, aloe, rhubarb, cascara, senna,castoroil,honey(fructose),tamarinds,figs,prunes,raspberries,strawberries,andstewedapples (1). Fluidintake,exercise,stress,andrelaxationalsoinfluencefecaleliminationandshouldbeconsideredwhena dietitianisplanningtreatment.
Diverticulosis: Diverticular disease of the colon is thought to occur secondary to increased intracolonic pressurecausedbyhard,dryfecalmaterialandtheincreasedeffortnecessarytoeliminatethistypeofstool. Wellcontrolled, experimental studies confirming the benefits of a highfiber diet in the prevention and management of diverticular disease are relatively few, with less than conclusive results. One study found that90%ofpatientswithdiverticulardiseaseremainedsymptomfreeafter5yearsonahighfiberdiet (1,8). Thisresultmaybeexplainedbythefactthatahighfiberdietpromotestheformationofsoft,largestoolsthat aredefecatedmoreeasily,resultinginlowercolonicpressureandlessstrainingduringelimination(1).Also,a highfiber diet may reduce the chance that an existing diverticulum will burst or become inflamed (1). The NationalInstituteofDiabetesandDigestiveandKidneyDiseasesrecommends20to35goffibereachdayfor themanagementofdiverticulardisease (1,9).Mildpainmedicationsmayhelptorelievesymptoms,however many pain medications affect the emptying of the colon, an undesirable side effect for people with diverticulosis(9). To increase stool bulk, studies suggest increasing the consumption of wholegrain breads, cereals, and brans.Incasesofdiverticulosis,acommonpracticehasbeentoprovideahighfiberintakethatexcludesthe hulls of nuts, corn, and seeds because they maygettrappedinthediverticula (1).However,arecentstudy found that the consumption of nuts, corn, and popcorn was not associated with an increased risk of complicated diverticular disease. Instead, the researchers observed inverserelationshipsbetweennutand popcornconsumptionandtheriskofdiverticulitis (10).AccordingtotheNationalInstituteofDiabetesand Digestive and Kidney Diseases, foods such as nuts, popcorn hulls, and sunflower, pumpkin, caraway, and sesameseedshavebeenrecommendedtobeavoidedbyphysiciansoutoffearthatfoodparticlescouldenter, block, or irritate diverticula, however this is not validated by the research (9). Poppy seeds and seeds in tomatoes,zucchini,cucumbers,strawberries,andraspberriesaregenerallyconsideredharmless(9).Because of the limited evidence, the dietitian should customize the patients meal plan taking into account the patients individual tolerances (1,911). The recommendation to avoid nuts, seeds, corn, and popcorn in diverticulardiseaseshouldbereconsidered(11). Irritablebowelsyndrome:Diagnosticcriteriaforirritablebowelsyndrome(IBS)isintestinaldysfunction of at least 3 months duration, during which time diarrhea, diarrhea alternating with constipation, and chronic constipation may be experienced in the absence of any underlying disease states (12). IBS is
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characterized by abdominal discomfort associated with altered bowel function; structural and biochemical abnormalities are generally absent (12). Patients who present with rectal bleeding, weight loss, iron deficiency anemia, nocturnal symptoms, and a family history of selected organic diseases (colon cancer, inflammatoryboweldisease,orceliacdisease)shouldundergomedicaltestingtoexcludeunderlyingcauses (12). Microscopic colitis can masquerade as IBS (12). IBS is a prevalent and expensive condition that is associated with a significantly impaired healthrelated quality of life and reduced work productivity (12). Basedonstrictcriteria,7%to10%ofpeopleworldwidehaveIBS (12).Approximately60%ofIBSpatients believe that certain foods exacerbate their symptoms, and research suggests that allergies to certain foods could trigger IBS symptoms (12). However, based on an extensive review of the literature, there is no correlation between foods that patients identify as a cause of their IBS symptoms and the results of food allergytesting(12).Psylliumhydrophilicmucilloid(ispaghulahusk)ismoderatelyeffectiveandcanbegivena conditional recommendation for managing IBS (12). Wheat bran or corn bran is no more effective than placebo in the relief of global symptoms of IBS and cannot be recommended for routine use (12). Certain antispasmodics (hyoscine, cimetropium, pinaverium, and peppermint oil) may provide short term relief of abdominal pain and discomfort (12). However, evidence of longterm efficacy, safety, and tolerability is limited (12).ProbioticspossessanumberofpropertiesthatmayprovetobebeneficialforpatientswithIBS (12).AlthoughstudiesofLactobacillihaverepeatedlyshownnoeffectonsymptoms,probioticscombinations includingBifidobacteriamayimprovesymptomsofIBS (12).ApositionstatementfromtheAmericanDietetic AssociationsuggeststhatfiberintakeshowsinconsistentresultsinIBS.Dietaryfibershouldbeconsideredas a therapy for bowel syndromes, but it should not be regarded as a proven therapy that is suitable for all individualswithbowelsyndromes(1). Cardiovasculardiseaseandhypercholesterolemia:Dietaryfiberintakefromwholefoodsorsupplements may lower blood pressure, improve serum lipid levels, and reduce indicators of inflammation such as C reactiveprotein (GradeII)(1).Benefitsmayoccurwithdailyfiberintakesof12to33gfromwholefoodsorup to 42.5 g from supplements (Grade II) (1). The DRI recommendations for dietary fiber intake are based on protection against cardiovascular disease (1). The one characteristic common to all cholesterollowering fibersisviscosity (13).Fiberthatlowersbloodcholesterolisfoundinfoodssuchasapples,barley,beansand other legumes, fruits, vegetables, oatmeal, oat bran and rice hull. Purified sources of cholesterollowering fiberincludebeetfiber,guargum,karayagum,konjacmannan,locustbean,gum,pectin,psylliumseedhusk, soy polysaccharide, and xanthan gum (1,14). The US Food and Drug Administration has studied two fibers, betaglucaninoatsandpsylliumhusk,toauthorizeahealthclaimthatfoodsmeetingspecificcompositional requirementsandcontaining0.75gofbetaglucanor1.7gofpsylliumhuskperservingcanreducetheriskof heartdisease(15).Viscousfiberslowercholesterolbecausetheirviscosityinterfereswithbileacidabsorption fromtheileum.Inresponse,lowdensitylipoproteincholesterolisremovedfromthebloodandconverted intobileacidsbythelivertoreplacethebileacidslostinthestool.Evidencealsoindicatesthatcholesterol synthesisisdampenedbychangesinthecompositionofthebileacidpoolthataccompanytheingestionof viscousfibers(1,16).FiberingestionalsoaffectsthelevelsofbloodpressureandCreactiveprotein,whichare bothbiomarkerslinkedtotheriskofcardiovasculardisease (Grade II) (1).Asecondarybenefitofahighfiber diet is a lower dietary content of energy, fat, and simple sugars; these reductions are effective dietary intervention strategies for weight management and hypertriglyceridemia associated with cardiovascular disease(1,17). Diabetesmellitus:Dietsproviding30to50goffiberperdayfromwholefoodsourcesconsistentlyproduce lowerserumglucoselevelscomparedtoalowfiberdiet.Dailyfibersupplementsproviding10to29gmay havesomebenefitintermsofglycemiccontrol(GradeIII)(1).Theadditionofviscousdietaryfibersslowsgastric emptying rates, digestion, and the absorption of glucose to benefit immediate postprandial glucose metabolism and longterm glucose control in individuals with diabetes mellitus (1). The American Diabetes Association has determined that the consumption of soluble fiber independent of total fiber has limited documentedeffectsonglycemiccontrolinindividualswithdiabetes (18).Althoughlargeamountsofdietary fiber(>50g/day)mayhavebeneficialeffectsonglycemia,insulinemia,andlipemia,itisnotknownwhether such high levels of fiber intake can be maintained longterm (18). According to the American Diabetes Association and evidencebased nutrition practice guidelines, fiber consumption recommendations for peoplewithdiabetesarethesameasforthegeneralpopulation (1,18).TheDRIrecommendsconsumptionof 14 g of dietary fiber per 1,000 kcal, or 25 g for adult women and 38 g for adult men. For general health benefits,thedailyconsumptionofdietaryfiberisencouragedfromfoodsourcessuchaswholegrains,fruits, andvegetables(18).
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Weight management: Dietary fiber intake from whole foods or supplements may have some benefit in termsofweightlossandotherhealthoutcomesassociatedwithweightloss (Grade III) (1). Benefitsmayoccur withdailyfiberintakesof20to27gfromwholefoodsorupto20gfromsupplements(GradeIII)(1).Fiberacts asaphysiologicalobstacletoenergyintakebydisplacingenergyandnutrientsfromthediet,increasingthe expansion of the stomach leading to increasedsatietyandfeelingsoffullness,andreducingtheabsorption efficiency of the small intestine (1). Highfiber foods promote energy balance by providing a significant amountofvolumeandlowenergydensity(1).
Cancer:Peoplewhoeatagreateramountoffruitsandvegetableshaveaboutonehalftheriskofdeveloping cancerandalowermortalityratefromcancer (19).Evidencethathighfiberdietsdecreasetheriskofcertain cancers, including large bowel cancers (colon and rectum) and breast cancer, remains inconclusive (1). Althoughdietaryfiberintakemaynotprotectagainstcolorectalcancerinprospectivestudies,somesupport existsfortheprotectivepropertiesofwholegrainintake (1,20). Thereisevidencethatvegetables,fruits,and whole grains reduce the risk of chronic diseases including cancer, which provides support for the use of a highfiberdietinreducingcancerrisk(1,19).
Useinenteralformulas:Twotypesofenteralformulasthatcontaindietaryfiberarecurrentlymarketed: blended formulas made from whole foods and formulas supplemented with purified fiber sources (eg, oat, pea,hydrolyzedguargum,andsugarbeetfiber) (1).Dietaryfiberaddedtoenteralformulasisthoughttoaid in normalizing bowel function and reduce the incidence of diarrhea. However, there is no conclusive evidencethatfibercontainingenteralformulaspreventdiarrheaintubefedpatients(1).Arecentadditionto enteral formulas is fructooligosaccharides, which are shortchain oligosaccharides (usually 2 to 10 monosaccharide units). Because they are not digested in the upper digestive tract, fructooligosaccharides havesomeofthesamephysiologiceffectsassolublefiber (21).Fructooligosaccharidesarerapidlyfermented byintestinalbacteriathatproduceshortchainfattyacids,whichstimulatewaterandelectrolyteabsorption and should aidinthetreatmentofdiarrhea.Althoughfructooligosaccharidesareapreferredsubstratefor Bifidobacteria,theyarenotusedbypotentiallypathogenicbacteria,thushelpingtomaintainandrestorethe balance of healthy gut flora (1). Fructooligosaccharides are not isolated by currently accepted methods to measuredietary fiber, so they cannot technically be called dietary fiber (5). The Association of Official AnalyticalChemistshasdevelopednewermethodstoanalyzefructooligosaccharides(1). Contraindications Diverticulitis: A highfiber diet may be contraindicated when inflammation has caused the narrowing or blockageoftheintestinallumenorduringacutediverticulitis (9).However,thisrecommendationisbasedon individualtolerance.
Infants and children: The American Academy of Pediatrics does not encourage the addition of highfiber foods to the diets of infants younger than 1 year old. Highfiber foods are filling but contain little energy, potentially causing reduced energy intakes in infants, whose stomach capacities are naturally small. AccordingtotheAmericanAcademyofPediatrics,thedailyfiberintakeofchildren2yearsandoldershould beanamountequaltoorgreaterthantheirageplus5g(1).
Phytobezoarformation:Phytobezoarsaremassesofvegetablematterthatbecometrappedinthestomach. Individuals who experience decreased gastric motility or emptying, such as diabetic gastroparesis, or individuals who have undergone surgical procedures for stomach cancer or peptic ulcer disease may be susceptible (1,22,23). These individuals should be advised to avoid the following foods implicated in phytobezoarformation:apples,berries,brusselssprouts,coconuts,figs,greenbeans,oranges,persimmons, andpotatopeelsorhighlyviscousoverthecounterfibersupplementssuchasglucomannan(1,22,23).
NutritionalAdequacy ThedietcanbeplannedtomeettheDRIsasoutlinedintheStatementonNutritionalAdequacyinSectionIA.
HowtoOrdertheDiet OrderasHighFiberDiet.
PlanningtheDiet Promotefoodintakepatternsconsistentwiththe2005DietaryGuidelinesforAmericansandMyPyramid thatencourageawidevarietyofplantfoodstoachievefiberintakesgoals.Emphasizefruits,vegetables, andwholegrainbreadsandcereals.

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Foodsmadewithwholegrainfloursaresubstitutedforfoodsmadewithrefinedfloursandstarches. People who experience difficulty in chewing fruits and vegetables may increase fiber in their diet by consuming one or more servings daily of a highfiber cereal, such as bran; substituting wholewheat breadforwhitebread;andconsumingsoftorcookedfruitsandvegetables. Ifunprocessedbranisconsumed,itmustbeservedthoroughlymoistenedandmixedwithfoodandbe incorporated gradually into the diet. One tablespoon of bran contains 4.5 g of dietary fiber. To incorporatebranintothediet,beginwith1tsp/dayandgraduallyincreaseindivideddoses,astolerated, to4to6tbsp/day.Threetablespoonsofbran,consumeddailyindivideddoses,isadequatetopromote normalbowelfunctioning. Highfiber foods should be addedto the diet gradually. An increase infiberconsumptionmayinitially generate bloating and flatulence. Patients should be advised that these conditions may occur but will generallysubsideasthedigestivesystemadjuststoincreasedfiberconsumption. Fiber gathers water in the colon, hence its stoolbulking property. For this reason, a highfiber diet shouldalsoincludealiberalintakeoffluids,consistingofatleast8cupsor64ozofextrafluidperday(1). Consumingincreasedamountsoffiberwithoutincreasingfluidconsumptioncanleadtotheformationof hard,drystoolsthataredifficulttoeliminate.
References 1. Slavin,JL.PositionoftheAmericanDieteticAssociation:healthimplicationsofdietaryfiber.JAmDietAssoc.2008;108:17161731. 2. Institute of Medicines Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. National Academy of Sciences, 2002:265334. Preprint available at: http://www.nap.edu.books/0309085373/html/index.html.AccessedSeptember16,2002. 3. FungweTV,BenteL,HizaH.USDACenterforNutritionPolicyandPromotion.TheFoodSupplyandDietaryFiber:ItsAvailabilityand EffectonHealth.Availableat:http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight36.pdf.AccessedJuly28,2008. 4. SlavinJL.Dietaryfiber:classification,chemicalanalyses,andfoodsources.JAmDietAssoc.1987;87:11641171. 5. DietaryReferenceIntakes:ProposedDefinitionofDietaryFiber.Washington,DC:NationalAcademyPress;2001:164. 6. Cummings JH. The effect of dietary fiber on fecal weight and composition. In: Spiller GA, ed. CRC Handbook of Dietary Fiber in HumanNutrition.2nded.BocaRaton,Fla:CRCPress;1993:263349. 7. Kurasawa S, Haack VS, Marlett JA. Plant residue and bacteria as bases for increased stool weight accompanying consumption of higherdietaryfiberdiets.JAmCollNutr.2000;19:426433. 8. SalzmanH,LillieD.Diverticulardisease:diagnosisandtreatment.AmFamPhysician.2005;72:12291234. 9. National Digestive Diseases Information Clearinghouse. Diverticulosis and Diverticulitis. 2008. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/index.htm.AccessedSeptember4,2008. 10. Strate LL, Liu YL, Syngal S, Aldoori WH, Biovannucci EL. Nut, corn, and popcorn consumption and the incidence of diverticular disease.JAMA.2008;300:907914. 11. MarcasonW.Whatisthelatestresearchregardingtheavoidanceofnuts,seeds,cornandpopcornindiverticulardisease?JAmDiet Assoc.2008;108:1956. 12. American College of Gastroenterology Task Force on IBS. An evidencebased systematic review on the management of irritable bowelsyndrome.AmJGastroenterol.2009;104(suppl1):S1S35. 13. MarlettJA.Sitesandmechanismsforthehypocholesterolemicactionsofsolubledietaryfibersources.In:KritchevskyD,BonfieldC, eds.DietaryFiberinHealthandDisease.NewYork,NY:PlenumPress;1997:109121. 14. MarlettJA.Dietaryfiberandcardiovasculardisease.In:ChoSS,DreherML,eds.HandbookofDietaryFiber.NewYork,NY:Marcel Dekker;2001:1730. 15. US Food and Drug Administration. Health claims: soluble fiber from certain foods and risk of heart disease. Code of Federal Regulations.2001;21:101.81. 16. Marlett JA, Hosig KB, Vollendorf NW, Shinnick FL, Haack VS, Story JA. Mechanism of serum cholesterol reduction by oat bran. Hepatology.1994;20:14501457. 17. AHA Diet and Lifestyle Recommendations Revision 2006: a scientific statement from the American Heart Association Nutrition Committee.Circulation.2006;114:8296. 18. AmericanDiabetesAssociation.Nutritionrecommendationsandinterventionsfordiabetes:apositionstatementoftheAmerican DiabetesAssociation.DiabetesCare.2008;31(suppl1):61S78S. 19. CraigWJ.Phytochemicals:guardiansofourhealth.JAmDietAssoc.1997;97(suppl2):S199S204. 20. Schatzkin A, Houw T, Park Y, Subar AF, Kipnis V, Hollenbeck A, Leitzmann MF, Thompson FE. Dietary fiber and wholegrain consumptioninrelationtocolorectalcancerintheNIHAARPDietandHealthStudy.AmJClinNutr.2007;85:13531360. 21. RoberfroidM,SlavinJL.Nondigestibleoligosaccharides.CritRevFoodScienceNutr.2000;40:461480. 22. VanderbeekPB,FasanoC,OMalleyG,HornsteinJ.Esophagealobstructionfromahygroscopicpharmacobezoarcontaining glucomannan.ClinToxicol(Phila).2007;45:8082. 23. Gastroparesis. In: Nutrition Care Manual. American Dietetic Association; 2004. Available at: www.nutritioncaremanual.org. AccessedJanuary25,2009.
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FOODGUIDEHIGHFIBERDIET
Thislistisnotmeanttobeallinclusive.Onlythefoodshighestandlowestinfiberineachcategoryarelisted inthecategoriesHigherFiberandLowerFiberFoods,respectively.
FOODGROUP BeveragesandMilk BreadsandCrackers
Emphasize HIGHERFIBERFOODS 100%wholewheatbread,rolls,muffins Wholewheatcrackers Branmuffins Pumpernickelandryebread 100% and 40% bran cereal, whole wheatandoatcereals,includingpuffed wheat, shredded wheat, granola,* GrapeNuts, oatmeal,* oat bran,* rolled wheat, and Wheatena Brown rice, barley Desserts made from wholegrain flour, nuts,fruits,coconut,orvegetables
Minimize LOWERFIBERFOODS Beveragesandmilk Whitebreadandrolls Saltineandotherrefinedcrackers
CerealsandGrains
Cereals from refined wheat flours, corn, or rice, including farina, grits, cream of rice, cornflakes, puffedrice,andcrisprice Whiterice,pasta,noodles
Desserts
Fats
Peanuts,*treenuts,seeds
Fruits Meat,Fish,Poultry, Cheese,Eggs,Legumes Soups SugarsandSweets
Allexceptjuices
Cake, cookies, and pastry made from whiteflour Icecream,sherbet Creamorcustardpies Pudding,custard Gelatin Butter, margarine, oils, mayonnaise, saladdressings,gravy Juices
Chili and other entrees containing Meat,fish,poultry,eggs,cheese legumes* Peanutbutter* Broth,meat,rice,noodlesoups Vegetableandotherlegume*soups Candy made primarily from coconut, Hard, chocolate, or caramel candy; raisins,orotherfruitornuts honey, jam, jelly, molasses, sugar, syrup All, especially broccoli, corn, greens, legumes,*peas,*sweetpotatoes,winter squash Snack Milk Grapes
VegetablesandPotatoes
*
Foodscontainingsolublefibers.
Breakfast Freshorange 40%brancereal Softcookedegg Wholewheattoast Margarine Jelly Milk Coffee
SAMPLEMENU(23gfiber) Noon Evening Splitpeasoup Cranberryrelish Roastbeefsandwichonwhole Roastturkey wheatbreadwithlettuceand Sweetpotatoes tomato Broccoli Relishplate Tossedsaladwithdressing Apricothalves Wholewheatbread Coffeeortea Margarine Freshapple Coffeeortea
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HighFiberDiet
DIETARYFIBERCONTENTOFFOODS
FoodGroup Breads 1g Bagel() Dinnerroll Frenchbread Hamburger/hotdog roll() Hardroll Italianbread Pancake(1) Graham crackers (2) Whitebread Puffedrice Cereals (3/4cupcooked;1oz Puffedwheat RiceKrispies dry,unlessnoted) 11.9g Wholewheat bread (5inches) Raisin Rye Tortilla 22.9g pita Pumpernickel Branmuffin 33.9g 44.9g 55.9g >6g Ryewafers (3)
Oatmeal Cornflakes Granola Grits
GrapeNuts ShreddedWheat WheatChex
Cheerios Raisinbran Wheatgerm Wheaties
Pasta,rice
Vegetablesand legumes(cup cookedunlessnoted)
Fruits,canned (unlessnoted)
Miscellaneous
Asparagus Brusselssprouts Cabbage Carrots,raw Cauliflower Greenbeans Summersquash Tomatoes,raw Turnips Zucchinisquash Applesauce Grapefruit,raw Appleslices Grapes,raw Apricots Pineapple Cantaloupe Plums Cherries, raw or Watermelon Fruit juices cooked (includingnectars) Cherries,raw Fruitcocktail Peaches Pineapple,raw Prunes(3) Raisins,dried(2tbsp) Strawberries,raw Olives Filberts Popcorn Walnuts
Macaroni Spaghetti Eggnoodles Rice,white Cabbage,raw Beansprouts Celery,raw Cucumber,raw Greenpepper Lettuce,raw Mushrooms,raw
Rice,brown
Unprocessed bran 40% bran flakes Oatbran Ralstoncereal
AllBran BranBuds
Bakedbeans Broccoli Sweetpotato Carrots Corn Mixedvegetables Okra Potato,noskin Spinach
Bakedpotato, Chickpeas Pinto noskin Kidneybeans beans Limabeans Peas Wintersquash
Lentils
Banana Nectarine Papaya Pears
Apple,raw Dates(5) Mango Orange,raw
Pear,raw Raspberries, raw
Almonds Avocado Fruitpie Peanuts Peanutbutter
Source:PenningtonJ.BowesandChurchsFoodValuesofPortionsCommonlyUsed.17thed.Philadelphia,Pa:JBLippincott;1998.
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High-Fiber Diet
DietaryFiberContentofCommonFoods
Grams BeveragesandMilk Milk,white,nonfatorlowfat 0.0 (8oz) Buttermilk 0.0 Coffee,tea 0.0 Bread Bagel(1whole) 1.6 Branmuffin(1averagesize) 2.5 Biscuit 0.5 Cornbread 1.0 Dinnerroll(1) 0.9 Doughnut 0.7 Frenchbread(1slice) 0.8 Hamburger/hotdogroll() 0.6 Hardroll(1white) 0.9 Italianbread(1slice) 0.9 Pancakes 1.0 Pitabread(5inches) 1.0 Pumpernickelbread(1slice) 2.1 Raisinbread(1slice) 1.1 Ryebread(1slice) 1.9 Tacoshell(1) 1.3 Tortilla,flour 1.2 Whitebread(1slice) 0.6 Wholewheatbread(1slice) 1.9 Crackers Graham 0.25 Ryewafers(3) 5.7 Saltines(2) 0.1 Triscuits(7) 4.0 WheatThins(24) 1.0 Snacks Cornchips(1oz) 1.4 Popcorn(1cup) 1.0 Potatochips(1oz) 1.0 Pretzels(1oz) 0.9 CerealsandGrains (Cookedcereal3/4cupunlessnoted) Creamofrice 1.0 Farina 2.4 Grits 1.5 Oatmeal 3.0 Ralston 4.6 Dry,ReadytoEatCereal (1ozunlessnoted) AllBran 10.0 BranBuds(1/3cup) 12.0 Bran,unprocessed(1tbsp) 4.6 40%branflakes 4.0 Grams Cheerios 3.0 Cornflakes 1.1 Granola(1/3cup) 1.8 GrapeNuts 2.5 Oatbran(1/3cup) 4.8 Puffedrice(1cup;14g) 0.1 Puffedwheat(1cup;14g) 0.5 Raisinbran 4.0 RiceKrispies 0.5 Shreddedwheat 2.8 Wheaties 3.0 Wheatgerm(1/4cup) 3.8 Pasta,Rice,etc(cupcooked) Barley 3.0 Macaroni;spaghetti 0.9 Rice,white 0.5 Rice,brown 1.7 Desserts Cake, plain, iced (1/12 of 9 0.5 inches) Carrotcake(1/12of9inches) 1.4 Coffeecake(1/6of16oz) 0.8 Cookies(1oz) 0.5 Gelatindessert 0.0 Icecream(cup) 0.0 Pie,fruit(1/8of9inchpie) 2.0 Pudding 0.0 Yogurt(8oz)plainorfruit 0.0 FatsandNuts Avocado(1/4) 2.1 Butter;margarine(1tsp) 0.0 Cream, dairy and nondairy, all 0.0 types Mayonnaise;smoothsalad 0.0 dressing(1tbsp) Oil;shortening(1tbsp) 0.0 Olives(5medium) 0.5 Tartarsauce;thousandisland 0.0 dressing(1tbsp) Nuts(1oz) Almonds,roasted 3.0 Filberts 1.7 Peanuts,roastedandsalted 2.3 Peanutbutter,chunky(2tbsp) 2.0 Walnuts(1oz) 1.4 FruitsandJuices (cupportionunlessnoted) Apple,rawwithpeel 3.7 (2inchdiameter) Apple,canned,sliced 1.7 Grams Applesauce,canned 1.0 Apricots,canned(3halves) 1.4 Banana(1medium) 2.7 Cantaloupe(1/4melon) 1.3 Cherries,sweet(10) 1.6 Cherries,canned 1.9 Dates,dried(5) 3.1 Fig,dried(3) 6.8 Fruitcocktail 1.2 Grapefruit() 1.4 Grapefruitsections,canned 0.5 Grapes,European(10) 0.8 Honeydewmelon 0.5 Mandarinoranges 0.9 Mango(1medium) 3.7 Nectarine(1medium) 2.2 Orange(1small) 3.1 Papaya(medium) 2.5 Peaches,canned(2halves) 1.6 Peach,raw(1medium) 1.7 Pear,canned(2halves) 2.0 Pear,raw(2perpound) 4.0 Pineapple,canned 1.0 Pineapple,raw 1.8 Plums,raw,1medium 1.0 Plums,canned(3) 0.9 Prunes(3) 1.8 Raisins(2tbsp) 1.6 Raspberries,raw 4.2 Strawberries,raw 1.6 Tangerine 1.9 Watermelon 0.4 FruitJuices(cup) Apple 0.0 Apricotnectar 0.8 Cranberry 0.0 Grapefruit;orange 0.0 Grape 0.0 Pineapple 0.0 Prune 1.3 Meat,Fish,Poultry,Cheese,Eggs 0.0 SugarandSweets Jam;preserves(1tbsp) 0.7 Jelly(1tbsp) 0.0 Sugars;honey;syrups 0.0 Cranberrysauce(1/4cup) 0.7
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HighFiberDiet
DietaryFiberContentofCommonFoods(Cont.)
Grams Soups(cup) Beanwithbacon 7.0 Beefbarley 2.0 Beefnoodle 1.0 Celery,creamof 1.0 Cheddarcheese 1.0 Chickengumbo 1.0 Chickennoodle 1.0 Chickenrice 0.0 Chickenvegetable 2.0 Clamchowder,Manhattan 2.0 Clamchowder,NewEngland 1.0 Cornchowder 2.0 Minestrone 4.0 Mushroom,creamof 1.0 Pea,green 2.5 Pea,split 5.0 Potato,creamof 1.0 Tomato 2.0 Turkeynoodle 1.0 Vegetable 2.0 Vegetablebeef 2.0 Vegetables (cupportioncookedorrawunlessnoted) Asparagus 1.4 Bakedbeans(1/3cup) 3.0 Beansprouts 0.6 Beans,green,freshcut 2.0 Beans,green,cut 1.3 Beans,kidney 4.9 Beans,lima,baby 4.9 Beans,navy 6.7 Beets 1.4 Broccoli,raw(1spear) 1.3 Broccoli,spears 2.8 Broccoli,chopped 2.3 Brusselssprouts 2.0 Cabbage,cooked 1.7 Cabbage,raw 0.8 Carrots,cooked 2.6 Carrots,raw(1medium) 2.2 Cauliflower,cooked 1.7 Cauliflower,raw 1.3 Celery,raw(1stalk) 0.7 Chard 1.7 Chickpeas(garbanzobeans) 5.3 Collardgreens 2.4 Coleslaw 0.9 Cornkernels 2.3 Cowpeas(blackeyedpeas) 3.7 Cucumber,raw 0.4 Grams Greenpepper 0.9 Kale 1.3 Lentils 7.8 Lettuce,iceberg(shredded) 0.5 Mixedvegetables 2.5 Mushrooms,raw 0.4 Mushrooms,canned 1.9 Okra 2.2 Onions,raw,chopped 1.4 Peas,green,frozen 4.4 Pintobeans 5.5 Potato,baked,withskin 4.6 Potato,boiled(140g) 2.3 Potato,frenchfried(20) 1.6 Potato,mashed 1.9 Radishes 0.7 Sauerkraut 2.9 Spinach 2.8 Spinach,raw 0.8 Squash,summer 1.3 Squash,winter 4.5 Squash,zucchini 1.8 Sweetpotatoes,mashed 3.0 Tomato,raw(1medium) 1.4 Tomatojuice 0.7 Tomatosauce 1.7 Turnips 1.6 Turnipgreens 2.5 Miscellaneous Ketchup(1tbsp) 0.2 Mustard(1tsp) 0.1 Pickle,dill(1medium) 0.3 Pickle,sweet(4slices) 0.5 Picklerelish,sweet(1tbsp) 0.5

Source:PenningtonJ.BowesandChurchsFoodValuesofPortionsCommonlyUsed.17thed.Philadelphia,Pa:JBLippincott;1998.
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GASTROINTESTINALSOFTDIET
Description The Gastrointestinal Soft Diet limits most raw, highly seasoned, and fried foods. The diet contains only moderateamountsoffiber. Indications Thisdietisusedasatransitionaldietforpatientswhohaveundergonesurgerythatirritatesorcausesmajor discomforttothegastrointestinaltract. Contraindications The diet does not necessarily limit fat or the size of meals and may be counterproductive in patients with gastroesophagealreflux(seeSectionIII:GastroesophagealReflux). The diet is low in fiber and may be contraindicated in disorders, such as diverticulosis, requiring a liberal fiberintake.SeeSection1D:FiberRestrictedDietsandHighFiberDiet. Thedietmayinappropriatelylimitmealtimevarietyandtherebylimitenjoymentandoralintake. NutritionalAdequacy The diet can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in the Statement on NutritionalAdequacyinSection1A. HowtoOrdertheDiet OrderasGastrointestinal(GI)SoftDiet.Ifbetweenmealfeedingsarerequired,theyshouldbespecifically ordered. SAMPLEMENU Breakfast Noon Evening Orangejuice Roastbeef Creamoftomatosoup Oatmeal Whippedpotatoes Bakedchicken Scrambledegg Cookedcarrots Steamedrice Toast Plainroll Greenbeans Margarine Margarine Plainroll Jelly Sugarcookies Margarine Milk IcedTea Slicedpeaches Coffee Milk
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GastrointestinalSoftDiet
FOODGUIDEGASTROINTESTINALSOFTDIET
Since the food tolerances of patients with gastrointestinal disorders and symptoms can vary considerably, attentionshouldbegiventoindividualfoodtolerances. FOODGROUP FOODALLOWED FOODSEXCLUDED Alcohol Beveragesand Milkandmilkdrinks Milk Cerealbeverages Carbonatedbeverages Coffee,tea Breadsand Crackers Cerealsand Grains Desserts White,seedlessrye,finewholewheatbread Plaincrackers Grahamcrackers Cookedanddrycerealsunlesslistedasexcluded Plainspaghetti,macaroni,noodles,rice Plaincake,cookies,pudding,custard,icecream, sherbet,gelatin,fruitwhips Butter Cream;creamsauce Bacon Margarine Mayonnaise;mildsaladdressing Allfruitjuices Avocado Banana Grapefruitandorangesectionswithout membrane Bakedpeeledapple;applesauce Canned:apricots,cherries,peaches,pears, pineapple Peeledripepeachesorpears Meat,fish,orpoultry,notfried Plaincheeses Eggs,exceptfried Smoothpeanutbutter Creamsoupsmadefromfoodsallowed;meat, rice,noodlesoups Sugar,syrup,honey,clearjelly;plain,sugarcandy inmoderation Tomatojuice Cookedasparagus,beets,carrots,greenorwax beans,greenpeas,mushrooms,potatoes, spinach,summersquash,sweetpotatoes, tomatoes,wintersquash Salt,allspice,cinnamon,paprika,herbs,flavoring extracts,ketchup Coarsewholegrainbreads Breadswithseeds,nuts,orraisins Highlyseasonedcrackers Brancereals Cerealswithraisins Brownorwildrice Pastries,pies,dessertscontainingnuts, coconut,driedfruits,fruitwithseedsor toughskins Friedfoods Gravy Nuts Olives Spicysaladdressings Rawfruitnotlistedasallowed Driedfruits Fruitswithedibleseedsortoughskins
Fats
FruitsandJuices
Meat,Fish, Poultry,Cheese, Eggs,Legumes Soup SugarandSweets Vegetablesand Potatoes
Friedmeat,fish,orpoultry Highlyseasonedcoldcutsorsausage Friedeggs Vegetablesoupsunlessmadefromfoods allowed Jam,marmalade,andcandiesthatcontain toughskins,seedsornuts Rawvegetables Allothercookedvegetables Deepfriedvegetables
Miscellaneous
Red,black,whitepepper;horseradish, mustard,pickles,popcorn,potatochips
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NUTRITIONMANAGEMENTOFTHEFULLTERMINFANT
Growth and nutrient needs during the first year of life exceed those at any other stage of the life cycle. However,sincetheorgansystemsarenotfullydevelopedininfancy,specialconsiderationsshouldbegiven to when and how foods are introduced. While supplying sufficient nutrients to promote growth and maintenance,itisimportantfortheinfantsdiettonotexceedtherequirementsorcapabilitiesoftheinfants digestiveorexcretorysystems.Theoptimalfeedingregimenistoexclusivelybreastfeedforsixmonthsand breastfeedwithcomplementaryfoodsforatleasttwelvemonths(1,2). Breastfeeding Breastfeeding is the optimal way to provide food for the health, growth, and development of the infant. In additiontoitsuniquenutrientcomposition,itoffersimmunologicandpsychosocialbenefitsthatarenotprovided byanyotherfeedingsubstance.Humanmilkisuniqueinthatitprovidesdocosahexaenoicacid(DHA),along chainfattyacidthatisessentialforinfantbrainandeyedevelopment (3,4).Lactoferrin,anironbindingprotein foundinwheyofhumanmilk,hasbeenobservedtoinhibitthegrowthofcertainirondependentbacteriainthe gastrointestinaltract (5).Infantswhoarebreastfedusuallyhavefewergastrointestinalandnongastrointestinal infections, including otitis media, pneumonia, bacteremia, diarrhea, and meningitis. They have fewer food allergies and a reduced risk of certain chronic diseases throughout life (eg, type 1 diabetes, lymphoma, and Crohnsdisease)(1,2,69). InfantsnursedbyaveganmothermaybeatriskforvitaminB12deficiency.ThedietaryvitaminB12intake ofthemothershouldbeassessedtodetermineadequacy.Veganmothersshouldbeinstructedtosupplement theirdietswithfoodsfortifiedwithvitaminB12(10). ContraindicationsforBreastFeeding Infants with certain inborn metabolism errors, such as phenyalamine, maple syrup urine disease, or galactosemiashouldnotbebreastfed(2). Breastfeedingiscontraindicatedforwomenwho: useaddictivedrugs,suchascocaine,marijuana,andphencyclidine(PCP) drinkmorethanaminimalamountofalcohol receivecertaintherapeuticordiagnosticagents,suchasradiationorchemotherapy(11,12) areinfectedwiththehumanimmunodeficiencyvirus(HIV)(2) Womenshouldnotbreastfeedwhentheyarereceivingcertaintherapeuticmedications.Notonlyistoxicity totheinfantaconcern,butresearchhasindicatedthatsomemedicationsaffecttheinfantsmetabolism.In addition, some agents (eg, bromocriptine) decrease milk production. Whereas most medications are consideredcompatiblewithbreastfeeding,therearesubstancesforwhichtheriskoftoxicitytotheinfantis consideredtobegreaterthanthebenefittothemother.Themostfrequentlyusedofthesemedicationstobe awareofinclude(12): amphetamine bromocriptine cyclophosphamide cyclosporine doxorubicin ergotamine lithium methotrexate nicotine phenindione FormulaFeeding The use of commercially prepared infant formula is an acceptable alternative to breastfeeding. These formulas are designed to approximate the composition of human milk as closely as possible. Most commercialinfantformulasarecomposedofmilkproteinsorsoyproteinisolate.
E1
NutritionManagementoftheFullTermInfant
Milkbasedformulasaregenerallyappropriateforusewiththehealthyfullterminfant.Standardformulas have a 60:40 wheytocasein ratio, which is desirable in a formula; they provide 20 kcal/oz. Breast milk yields an 80:20 whey: casein ratio with about the same number of calories. Soybased formulas are often usedfrombirthtopreventallergicdiseaseininfantswithastrongfamilyhistoryofallergies(13). Aslongasthecommerciallypreparedinfantformulawithironisdeliveredintheappropriatevolumesfora term infant, it is not necessary to supplement with additional vitamins or iron. The American Academy of Pediatricsrecommendsthatformulafedinfantsbegivenanironfortifiedcerealorsupplementedwithiron by6monthsofage.Whenfoodisintroducedduringthesecond6monthsoflife,thecombinationoffoodand formula will meet the infants nutrient requirements (14). Fluoride supplementation may be required if powderedorconcentratedformulaisusedandifthecommunitywatersupplycontainslessthan0.3ppmof fluoride.Fluorideshouldnotbesupplementedbefore6monthsofage(2). Therapeutic or specialized formulas are indicated for use with premature infants, aswellasinfantswith cows milk allergy or intolerance, intact protein allergy, or generalized malabsorption. Prematureinfant formulasaremodifiedintermsoftheirenergy,macronutrient,andmicronutrientcontentinordertomeet the specialized physiologic and gastrointestinal needs of these infants. Premature infants should be discharged home on prematureinfant formula and remain on it until 12 months of age. Human milk fortifiers(HMFs)arespeciallydesignedtobeaddedtoexpressedbreastmilkfortheprematureinfant.HMFs provideprotein,energy,calcium,phosphorus,andothermineralsneededforrapidgrowthandnormalbone mineralizationintheprematureinfant.Hydrolysateformulasareindicatedforthenutritionmanagementof infants with allergies to intact protein from either cows milk or soy. These hydrolyzed formulas, some of which also contain part of the fat as medium chain triglycerides, may also be used for infants with generalizedmalabsorptionofbothproteinandfat(eg,shortgutsyndromeandcysticfibrosis).Fatmodified formulas are indicated for nutrition management of infants with steatorrhea due to their limited bile salt pool,suchasthosewithbiliaryatresiaorotherformsofmalabsorptionorintolerance.Medicalformulasfor various disorders of inborn errors of metabolism are also available fromthemajorformulamanufacturers fordisorderssuchasphenylketonuriaandmaplesyrupurinedisease. Water Iftheinfantconsumesanadequateamountofbreastmilk,formula,orboth,theinfantwillhaveanadequate intakeofwater. CowsMilk Cows milk should notbeintroduceduntilachildis1yearofage.Thenutrientcompositionofcowsmilk variessubstantiallyfromthatofhumanmilk.Feedingswithcowsmilkcausesamarkedlyhighrenalsolute loadduetoitsproteinandsodiumcontent,andinfantsarenotgenerallyabletoconcentrateurinewell.The ingestionofcowsmilkincreasestheriskforgastrointestinalbloodlossandallergicreactions.Wholemilk canbeintroducedafterthefirstyearandcontinuedthroughthesecondyear.Afterthesecondyear,reduced fatmilkcanbeserved(2). TableE1:NutrientComparisonofBreastMilk,Formula,andCowsMilk Productsper100cc Energy Protein Calcium Phosphorus Iron Sodium (kcal) (g) (mg) (mg) (mg) (mg) Breastmilk 70 1.0 32 14 0.3 8 Milkbasedformula 67 1.5 4251 2839 1.2 1520 (20kcal/oz) Soybasedformula 67 1.82.1 6071 4251 1.2 2030 (20kcal/oz) Wholecowsmilk 64 4.9 120 95 Trace 51 (homogenized) IntroductionofSolidFood There is no nutritional need to introduce solid food to infants during the first 6 months of age (1,2). The infantsindividualgrowthanddevelopmentpatternisthebestindicatorofwhentointroducesemisolidand solidfoods.Generally,aninfantwilldoublehisbirthweightandbeabletosituprightwithoutsupportbythe timesemisolidfoodsareintroduced.By4to5months,theinfanthastheabilitytoswallownonliquidfoods.
E2
NutritionManagementoftheFullTermInfant
Ifsolidsareintroducedbeforethistime,thesefoodsmaydisplacebreastmilkorformulaandtheinfantmay receiveinadequateenergyandnutrientneeds. Nospecificscheduleofintroductionoffoodotherthanbreastmilkorformulamustbefollowed,butcertain recommendationsexist: Ironfortifiedinfantcerealiscommonlysuggestedasthefirstfoodoffered.Startwithafewspoonfulsof asinglegrain,ironfortifiedinfantcerealsuchasrice,onceortwiceaday. Introducesingleingredientfoods,oneatatime,sothattheoffendingfoodcanbeidentifiedifanadverse reactionoccurs. Vegetablesmightbeacceptedmorereadilyifintroducedbeforefruits,sincefruitstastesweeter. Allowatleast3daysbetweentheintroductionofeachnewfood. Beginwithsmallamountsoffoods,offeringsecondsasnecessary. Avoid early introduction of the following common allergens: egg white, cows milk, citrus, wheat, chocolate, fish, shellfish, tree nuts, and nut butters (eg, no peanut butteruntil18to24monthsofage) becausesusceptibleinfantswithafamilyhistoryofallergiesmayexperienceallergicreactions. Takecaretoavoidspoilageofhomepreparedfoodsandjarsoffoodoncetheyareopened.Donotfeed infantsdirectlyfromthejar,assalivaaddedtothejarcausesfasterspoilage. Select appropriate solid foods that require minimal chewing. Foodssuchashotdogs,peanuts,grapes, berries,rawcarrotsandslicedapples,raisins,potatoorcornchips,popcorn,seeds,round,hardcandies, andgummaycausechokingandaspirationininfantsandchildren. TableE2:InfantFeedingGuidelines Age(months) Food 02 24 46 68 910 1112 Humanmilk/formula(oz) 1828 2532 2745 2432 2432 2432 Ironfortifiedcereal(tbsp) 48 46 46 46 Zwieback,drytoast 1 1 12 Vegetable,plain,strained(tbsp) 34 68 78(soft,
cooked, chopped)
Fruit,plainstrained(tbsp) Meat,plain,strained(tbsp) Eggyolk(tbsp) Fruitjuice(oz) Potato,rice,noodles(tbsp)
34 12 24
68 46 1 4
8(soft,
chopped)
45 (groundor
chopped)
1 4 8
References 1. PositionoftheAmericanDieteticAssociation:breakingthebarrierstobreastfeeding.JAmDietAssoc.2001;101:12131220. 2. AmericanAcademyofPediatricsCommitteeonNutrition.Breastfeedingandtheuseofhumanmilk(policystatement).Pediatrics. 1997;100(6):10351039. 3. Jorgensen MH, Hernell O, Lund P, Holmer G, FleisherMichaelsen K. Visual acuity and erythrocyte docosahexaenoic acid status in breastfedandformulafedinfantsduringthefirstfourmonthsoflife.Lipids.1996;31:99105. 4. MakridesM,NeumannMA,ByardRW,SimmerK,GibsonRA.Fattyacidcompositionofbrain,retina,anderythrocytesinbreastand formulafedinfants.AmJClinNutr.1994;60:189194. 5. LawrenceRA.Breastfeeding:AGuidefortheMedicalProfession.4thed.StLouis,Mo:MosbyYearBook;1994. 6. ForsythJS.Therelationshipbetweenbreastfeedingandinfanthealthanddevelopment.ProcNutrSoc.1995;54:407418. 7. BrunoG.Preventionofatopicdiseaseinhighriskbabies(longtermfollowup).AllergyProc.1993;14:181186. 8. KoletzkoS.RoleofinfantfeedingpracticesinthedevelopmentofCrohnsdiseaseinchildhood.BrMedJ.1989;298:16171618. 9. American Academy of Pediatrics Work Group on Cows Milk Protein and Diabetes Mellitus. Infant feedings and their possible relationshiptotheetiologyofdiabetesmellitus.Pediatrics.1994;94:752754. 10. Darby ML, Loughead JL. Neonatal nutritional requirements and formula composition: a review. J Obstet Gynecol Neonatal Nurs. 1996;25:209217. 11. Anderson PO. Drug use during breastfeeding. Clin Pharm. 1991;10:594624. (Cited in: Nutrition Management in the FullTerm Infant.PediatricManualofClinicalDietetics.Chicago,Ill:TheAmericanDieteticAssociation;1997.) 12. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 1994;93:137150. 13. Iyngkaran N, Yadav M, Looi LM. Effect of soy protein on the small bowel mucosa of young infants recovering from acute gastroenteritis.JPediatrGastroenterolNutr.1988;7:6875. 14. AmericanAcademyofPediatricsCommitteeonNutrition.Ironsupplementationforinfantformulas(policystatement).Pediatrics. 1999;104(1):119123. ManualofClinicalNutritionManagement
E3
Infant Formula Comparison Chart Nutrient Content of Infant Formulas (per 100 cal)
Formula Indications Calorie/O z CHO Protein Fat g CHO % of cal g Fat % of cal Protein g % of ca l 2.1 8 Na K Minerals mg Cl P Ca Fe OSM mOsm/Kg PRSL, H2O mOsm
Cows Milk-Based Breast Milk
Normal infant feeding
20
Lactose
Lactalbumin 65% Casein 35% Casein 81% Lactalbumin 19% Nonfat milk
High in oleic; low in volatile fatty acids
9.9
40
5.8
52
37
85
82
19
37
0.1 8
343
24.5
Cows Milk, Whole
Enfamil PREMIUM
Normal feeding >1yr old Normal infant feeding
19
Lactose
20
Lactose
Enfamil A.R.
Need for thickened formula
20
Lactose, rice starch, maltodextrin
Nonfat milk
Enfamil Gentlease
Reduced lactose
20
Corn syrup solids
Similac Advance
20
Lactose, Galactooligosaccharides (GOS) Organic Corn Maltodextrin, Organic Lactose, Organic Sugar
Partially hydrolyzed nonfat milk and whey protein concentrate Nonfat milk, whey protein concentrate Organic nonfat milk
Palm olein, soy, coconut, sunflower oils Palm olein, soy, coconut, sunflower oils Palm olein, soy, coconut, sunflower oils Safflower, soy coconut oils Organic sunflower, soy, coconut oils Palm olein, soy, coconut, sunflower oils High Oleic Safflower, Soy oil, Coconut Oil Safflower, soy coconut oils MCT oil, soy, sunflower, safflower oil MCT oil, soy, sunflower, safflower oil
11.2
43. 5
5.3
48
2.1
8. 5
27
108
63
43
78
1.8
300
19.1
11
44
5.1
46
2.5
10
40
108
75
53
78
1.8
230
23
10.8
43
5.3
48
2.3
36
108
63
46
82
1.8
230
21
E4
10.7
43
5.6
49
2.0 7
24
105
65
42
78
1.8
310
18.7
Similac Advance Organic
20
10.6
42
5.5
49
2.0 7
24
105
65
42
78
1.8
225
18.8
Soy-Based Enfamil Prosobee
Normal infant feeding soy, lactose and sucrose free Normal infant feeding soy
20
Corn syrup solids
Soy protein isolate
10.6
42
5.3
48
2.5
10
36
120
80
69
105
1.8
180
23
Similac Sensitive Isomil Soy (concentrate)
20
Corn syrup solids, sugar
Soy protein isolate, Lmethionine
10.4
41
5.46
49
2.4 5
10
44
108
62
75
105
1.8
200
154.5
Similac Sensitive
Lactose intolerance
20
Corn Maltodextrin, Sugar, Galactooligosaccharide s (GOS) Corn syrup solids, lactose
Milk protein isolate
11.1
43
5.4
49
2.1 4
30
107
65
56
84
1.8
200
19.9
Premature (NICU only) Enfamil Premature 20 Cal Low Iron (RTF)
Prematurity
20
Nonfat milk, whey protein concentrate
11
44
5.1
44
12
58
98
90
83
165
0.5
240
27
Enfamil Premature 20 Cal Iron Fortified (RTF)
Prematurity
20
Corn syrup solids, lactose
11
44
5.1
44
12
58
98
90
83
165
1.8
240
27
Formula Indications Calorie/O z CHO Protein Fat g CHO % of cal 44 g Fat % of cal 44 Protein g % of ca l 3 12 Na K Minerals mg Cl P Ca Fe OSM mOsm/Kg PRSL, H2O mOsm
Enfamil 24 Premature 24 Cal Low Iron (RTF)
Prematurity
24
MCT oil, soy, sunflower, safflower oil MCT oil, soy, sunflower, safflower oil MCT oil, soy, sunflower, safflower oil MCT oil, soy, coconut oils MCT oil, soy, coconut oils MCT oil, soy, coconut oils MCT oil, soy, coconut oils Sunflower , safflower, soy, coconut oils, MCT oil MCT oil, soy, safflower, coconut oils MCT oil, soybean oil MCT oil
11
5.1
58
98
90
83
165
0.5
300
27
Enfamil 24 Premature 24 Cal Iron Fortified (RTF)
Prematurity 24 Corn syrup solids, lactose Nonfat milk, whey protein concentrate 11 44 5.1 44 3 12 58 98 90 83 165 1.8 300 27
Enfamil Premature High Protein 24 Cal (RTF)
Prematurity
24
10.5
42
5.1
44
3.5
14
58
98
90
83
165
1.8
300
30
Similac Special Care 20 with Iron (RTF)
Prematurity
20
Nonfat milk, whey protein concentrate Nonfat milk, whey protein concentrate Nonfat milk, whey protein concentrate Nonfat milk, whey protein concentrate
10.3
41
5.4
47
12
43
129
81
100
180
1.8
235
27.8
Prematurity
24
10.3
41
5.4
47
12
43
129
81
100
180
1.8
280
27.8
E5
Similac Special Care 24 High Protein (RTF)
Prematurity
24
10
40
5.4
47
3.3
13
43
129
81
100
180
1.8
280
29.5
Prematurity, formula or breast milk supplement Premature Discharge/Transitional Enfamil EnfaCare Premie discharge formula
30
7.7
31
6.6
57
12
43
129
81
100
180
1.8
325
27.8
22
10.4
42
5.3
42
2.8
11
37
105
78
66
120
1.8
310
25
Similac Expert Care Neosure
Premie discharge formula
22
10.1
40
5.5
49
2.8
11
33
142
75
62
105
1.8
250
25.2
Human Milk Fortifiers Enfamil Human Milk Fortifier (powder) per 4 packets Similac Human Milk Fortifier (powder) per 4 packets Special Formulas Nutramigen
Prematurity
n/a
Corn syrup solids
Prematurity
n/a
Corn syrup solids
Milk protein isolate, whey protein isolate Nonfat milk, whey protein concentrate Casein hydrolysate (from milk)
<0.4
62
1.1
32
16
29
13
50
90
1.4 4
35
9.8
1.8
51
0.36
23
1.0
28
12
63
33
79
138
0.4 2
95
10.6
Cows Milk Protein Allergy
20
Corn syrup solids, modified corn starch
Palm olein, soy, coconut, sunflower oils
10.3
41
5.3
48
2.8
11
47
110
86
52
94
1.8
260-320
25
Formula Indications Calorie/O z CHO Protein Fat g CHO % of cal 41 g Fat % of cal 48 Protein g % of ca l 2.8 11 Na K Minerals mg Cl P Ca Fe OSM mOsm/Kg PRSL, H2O mOsm
Nutramigen with Enflora LGG
Allergy
20
Casein hydrolysate (from milk)
Pregestimil
Fat malabsorptio n
20
Casein hydrolysate (from milk)
Similac Expert Care Alimentum
Fat malabsorptio n
20
Corn maltodextrin, sugar
Nutramigen AA
Protein allergy
20
Corn syrup solids, modified tapioca starch
Casein Hydrolysate, L-Cystine, LTyrosine, LTryptophan Amino acids
Palm olein, soy, coconut, sunflower oils MCT oil, soy, corn, safflower or sunflower oils MCT oil, safflower, soy oils, DATEM Palm olein, soy, coconut, sunflower oils MCT oil, safflower, soy oils MCT oil palm, coconut, sunflower oils Safflower, coconut, soy oils Safflower, soy, and coconut oils MCT oil and soy oil
10.3
5.3
47
110
86
52
94
1.8
300
25
10.2
41
5.6
41
2.8
11
47
110
86
52
94
1.8
290-320
25
10.2
41
5.5
48
2.7 5
11
44
118
80
75
105
1.8
320
25.3
10.3
41
5.3
48
2.8
11
47
110
86
52
94
1.8
350
25
EleCare
Allergy
20
Corn syrup solids
Free Lamino acids Free Lamino acids
10.7
43
4.8
42
3.1
15
45
150
60
84
116
1.5
350
28
E6
Neocate Infant
Allergy, GI 5% MCT oil
20
Corn syrup solids
11.7
47
4.5
41
3.1
12
37
155
77
93
124
1.8
375
Not noted
Neocate Infant DHA and ARA Similac PM 60/40
33% MCT oil
20
Corn syrup solids
Free Lamino acids Whey Protein Concentrate , Sodium Caseinate Calcium caseinate and sodium caseinate (from milk) Sodium caseinate None None
11.7
47
4.5
41
3.1
12
37
155
77
93
124
1.5
375
Not noted 18.3
Enfaport
Lower phosphorus and potassium content Chylothorax, LCHAD Deficiency
20
Lactose
10.2
41
5.6
50
2.2
24
80
59
28
56
0.7
280
30
Corn syrup solids
10.2
41
5.4
45
3.5
14
30
115
87
52
94
1.8
280
28
Portagen Rehydration Solutions Enfamil Enfalyte per 8 ounces Pedialyte per 8 ounces
Chylothorax
30
Corn syrup solids, sugar
MCT and corn oils None None
11.5
46
4.7
40
3.5
14
55
126
87
70
94
1.8
350
33
Light cherry flavor Unflavored
3.4 3
Rice syrup solids Dextrose
7.2 5.9
0 0
0 0
12 mEq 10.6 mEq
6 mEq 4.7 mEq
10.8 mEq 8.3 mEq
170 250
NUTRITIONMANAGEMENTOFTHETODDLERANDPRESCHOOLCHILD
Description TheRegularDietfortheToddler(1to3yearsofage)andthePreschoolChild(4to5yearsofage)includesa wide variety of foods to promote optimal growth and development. The diet consists of foods of different textures,tastes,andcolorsprovidedthroughouttheday.Snacksmayberequiredtomeetthenutrientneeds, sincethetoddlerandpreschoolerhavesmallstomachcapacities.
Indications Thedietisservedwhenspecificdietarymodificationsarenottherapeuticallyrequired.
NutritionalAdequacy ThedietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)forthespecificageasoutlinedinthe Statement on Nutritional Adequacy in Section IA. Actual nutrient requirements may vary widely among children of the same age, depending on the rate of growth and stage of development. Critical nutrition concernsofUSchildrenincludeexcessiveintakeofdietaryfat,especiallysaturatedfatsaswellasinadequate intakesoffoodsrichincalcium,fiber,vitaminE,folate,iron,magnesium,andpotassium (1).Themostrecent prevalence estimates from the National Health and Nutrition Examination Survey 20032004 indicate that 33.6%ofindividualsage2to19yearswereatriskofoverweightand17.1%wereoverweightcomparedto 28.2% and 13.9 % respectively in 19992000 (1,2). This trend has led for the need to broaden dietary guidance from not only focusing on underconsumption but also overconsumption and decreased energy expended as a result of decreased physical activity (1). The attainment of optimal health by improving the quality of the diet an increasing physical activity will promote decreases in chronic disease in children 2 yearsandolder(1).
HowtoOrdertheDiet Order as Pediatric Regular Diet or Regular Diet for Age ______. The age of the patient will be taken into considerationinimplementingthedietorder.Anyspecificinstructionsshouldbeindicated.
PlanningtheDiet Energyneedsvarywiththegrowthrate,bodysize,andphysicalactivityofthechild.Theaveragedailyenergy requirementforages13yearsis1046kcalformalesand992kcalforfemales(3).Theestimateddailyenergy needsforages4to5yearsis1742kcalformalesand1642kcalforfemales (3).TheInstituteofMedicines Food and Nutrition Board have established acceptable macronutrient distribution ranges (ADMR) for childrenandinclude45to65%oftotalcaloriesfromcarbohydrates,5to20%oftotalcaloriesfromprotein for young children, and 30% to 40% of total calories from fat for 1 to 3 years and 25% to 35% of total caloriesfromfatfor4to18yearolds(1,3). Therecommendedprotein(RDA)intakeis13g/day(or1.1g/kg)for1to3yearoldsand19g/day(or 0.95 g/kg) for 4 or 5yearolds (3). Adequate protein intake may be difficult to obtain if chewing skills are limitedormilkintakeisinadequate.Cheese,peanutbutter,andyogurtmaybeconsideredtohelppromote adequateproteinintake.Dietaryreferenceintakesthatlimitaddedsugars,definedassugarsandsyrupsthat are added to food during processing or preparation, have been established (1,3). The daily intake of added sugars should be limited to 25% of the total energy consumed by a child (3). Twentyfive percent is a maximumlimit;therecommendedamountofaddedsugarinahealthydietis6%to10%oftotalenergy(1,3). Fruit juices can provide a substantial amount of sugar and energy in the diet of children. Currently it is recommendedthatdailyfruitjuiceconsumptionbelimitedto4to6ouncesperdayforchildren1to6years ofage(4).
Thetoddlerandpreschoolchildhavedistinctdevelopmentalandnutritionneeds.Afterthefirstyearoflife, atimeofrapidgrowthanddevelopment,thegrowthrateslows,butthereisasteadyincreaseinbodysize. Along with the decrease in growth rate, the appetite decreases. However, there is an increased need for protein and many vitamins and minerals (1). Failure to meet calcium requirements in combination with sedentary lifestyle in childhood can impede the achievement of maximal skeletal growth and bone mineralization,therebyincreasingriskforosteoporosislaterinlife(1).
Thetoddlerandpreschoolchildisstrivingforindependence.Selffeedingisimportant,althoughthechild maynotphysicallybeabletohandlefeedingutensilsorhavegoodhandeyecoordination.Atthisage,food likes and dislikes become prominent, and food acquires a greater social significance. Childrens food preferencesarelearnedthroughrepeatedexposuretofoods.Aminimumof8to10exposurestoafood,is oftenrequiredforachildtoovercometheirneophobicresponseanddevelopanincreasedpreferenceforthat
E7
NutritionManagementofTheToddlerandPreschoolChild
food (1,5). Family involvement and family mealtimes play a key factor affecting childrens nutrition, health, andoverallwellbeing(1). Beginningat2yearsofage,recommendationsfromtheDietaryGuidelines (6)andMyPyramidforKids(2to 5years)(7)shouldbeappliedforhealthychildren(1,6,7).SeeTableE3.Currentguidelinesrecommendtotalfat intakebetween30to35percentofcaloriesforchildren2to3yearsofageandbetween25to35percentof calories for children 4 years and older (6). Most fats should come from sources of polyunsaturated and monounsaturatedfattyacids,suchasfish,nuts,andvegetableoils (6)TheDRIshaveestablishedanadequate intake(AI)offiberwhichrepresentsahigherthanestimatedrequirementsduetotheknownhealthbenefits offiber.Forchildren1to3years19gfiber/dayisrecommendedandforages4to8years25g/dayoffiber isrecommended(3).
TableE3:FoodGroupsandRecommendedPortionSizesforToddlerandPreschoolChild FoodGroup DailyServings PortionSize PortionSize 13years 45years Grains,Breads, >6servings Cereals Bread 1slice slice Drycereal cup 1/3cup 1/3cup 1/3cup Cookedcereal,noodles,rice 23 46 Crackers Fruits >2servings Freshfruit Cooked,canned,orraw,(chopped) Juice >3servings Cooked,canned,orraw,(chopped) Whole Juice 34servings Milk Yogurt Cheese 2servings Egg Cookedmeat Driedbeans,peas 34servings Margarine;butter;oil small 1/3cup cup cup piece cup cup oz(24 tbsp) 1 13tbsp 13tbsp 1tsp 1small cup cup cup 1piece cup
Vegetables
Milk
cup oz(46 tbsp) 1 35tbsp 24tbsp 1tsp
Meat
Fat
Childrenshouldbesupervisedduringmealsandsnacks.Achildwhoischokingmaynotbeabletomake noiseortoattractattention.Foodsthatmaycausechokingincludehotdogs,chunksofmeat,nuts,peanut butter,rawapples,jellybeans,hardcandy,gumdrops,popcorn,rawcarrots,raisins,grapes,berries,and potato or corn chips. By changing the form of some of these items, these foods are less likely to cause choking, such as serving peanut butter with jelly, not by the spoonful, or cutting hot dogs or grapes in smallpieces.
References 1. Position of the American Dietetic Association. Nutrition guidance for healthy children aged 2 to 11 years. J Am Diet Assoc. 2008;108:10381047. 2. OgdenCL,CarrollMD,CurtinLR,McDowellMA,TabakCJ,FlegalKM.PrevalenceofoverweightandobesityintheUnitedStates, 19992004.JAMA.2006;295:15491555. 3. Institute of Medicines Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,ProteinandAminoAcids(Macronutrients).Washington,DC:NationalAcademyofScience;2002. 4. CommitteeonNutritionoftheAmericanAcademyofPediatrics.PolicyStatement:theuseandmisuseoffruitjuiceinpediatrics. Pediatrics.2001;107:12101213. 5. BirchLL,MarlinDW.Idontliketo;Inevertriedit:Effectsofexposureontwoyearoldchildrensfoodpreferences.Appetite. 1982;3:353360. 6. DietaryGuidelinesforAmericans2010.Availableat: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.AccessedJan31,2011. 7. MyPyramidforKids.USDepartmentofAgriculture.Availableathttp://mypyramid.gov/kids/(2to5years).AccessedJanuary 23,2009. E8 Copyright2011MorrisonManagementSpecialists,Inc. ManualofClinicalNutritionManagement Allrightsreserved.
NUTRITIONMANAGEMENTOFTHESCHOOLAGEDCHILD
Description TheRegularDietfortheSchoolAgedChild(6to11yearsold)includesawidevarietyoffoodstopromote optimal growth and development. Nutrition during this stage should supply adequate nutrients to support physicalactivity,attainahealthyweight,andensurethatthegrowthdemandsofadolescencearemet(1).The most recent prevalence estimates from the National Health and Nutrition Examination Survey 20032004 indicatethat33.6%ofindividualsage2to19yearswereatriskofoverweightand17.1%wereoverweight comparedto28.2%and13.9%respectivelyin19992000 (1,2).Thistrendhasledfortheneedtobroaden dietary guidance from not only focusing on underconsumption but also overconsumption and decreased energyexpendedasaresultofdecreasedphysicalactivity(1). Healthyeatinghabitsandregularparticipation inphysicalactivityshouldbeestablishedtoreducetheriskofchronicdiseaseandachieveoptimalphysical and cognitive development (1). Foods are provided based on the Dietary Guidelines (3) and MyPyramid for Kids(6to11years) (4) andtheNationalCholesterolEducationProgram (5).Threemealsperdayplusoneto threeplannedsnacksarerecommended. Indications Thisdietisservedwhenspecificdietarymodificationsarenottherapeuticallyrequired.
NutritionalAdequacy The Regular Diet for the SchoolAged Child meets the Dietary Reference Intakes (DRIs) for specific ages as outlinedintheStatementonNutritionalAdequacyinSectionIA,providedthatavarietyoffoodsisconsumed. Energy and protein requirements vary with the childs age, growth rate, and physical activity. Nutrition concernsofUSchildrenincludeexcessiveintakeofdietaryfat,especiallysaturatedfatsaswellasinadequate intakesoffoodsrichincalcium,fiber,vitaminE,folate,iron,magnesium,andpotassium(1).
HowtoOrdertheDiet Order as Pediatric Regular Diet or Regular Diet for Age ______. The patients age will be taken into considerationinimplementingthedietorder.Anyspecificinstructionsshouldbeindicated. PlanningtheDiet Energy needs vary with the growth rate, body size, and physical activity of the child. The average energy requirementforchildrenaged4to8yearsis1,742kcalforboysand1,642kcalforgirls.Forchildrenaged9 to 11 years, the average daily energy requirement is 2,279 kcal for boys and 2,071 kcal for girls (6). The Institute of Medicines Food and Nutrition Board has established acceptable macronutrient distribution rangesforschoolagedchildren.Theseguidelinesindicatethatcarbohydratesshouldprovide45%to65%of totalenergy,proteinsshouldprovide10%to30%oftotalenergy,andfatshouldprovide25%to35%oftotal energy (6). The recommended dietary allowance (RDA) for protein is 0.95 g/kg for children aged 4 to 13 years.ThisRDAismetbychildrenaged4to8yearswhoconsume19gofproteinperdayandchildrenaged 9 to 13 years who consume 34 g of protein per day (6). Dietary reference intakes that limit added sugars, definedassugarsandsyrupsthatareaddedtofoodduringprocessingorpreparation,havebeenestablished (1,6).Thedailyintakeofaddedsugarsshouldbelimitedto25%ofthetotalenergyconsumedbyachild (6). Twentyfivepercentisamaximumlimit;therecommendedamountofaddedsugarinahealthydietis6%to 10% of total energy (1,6). Fruit juices can provide a substantial amount of sugar and energy in the diet of schoolagedchildren.Currentlyitisrecommendedthatdailyfruitjuiceconsumptionbelimitedto4to6oz forchildrenaged1to6yearsand8to12ozforchildrenandadolescentsaged7to18years(7). The DRI for calcium in children aged 8 years or younger is 500 mg. The DRI increases to 1,300 mg for childrenaged9yearsorolder(8).Therequirementforcalciumincreaseswiththegrowthofleanbodymass andtheskeleton.ThehigherDRIforcalciumwasestablishedbecauseevidenceindicatesthatcalciumintakes at this level can increase bone mineral density in children, thus decreasing their risk of developing osteoporosislaterinlife (1).Failuretomeetcalciumrequirementsincombinationwithsedentarylifestylein childhood can impede the achievement of maximal skeletal growth and bone mineralization, thereby increasingriskforosteoporosislaterinlife(1). Olderchildren(9to11years)willhaveanaturalincreaseinappetite.Betweentheagesof8and11years some children (primarily girls), may be at risk for developing eating disorders due to an overemphasis on bodyimageandlowintake(9).
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Copyright 2011 Morrison Management Specialists, Inc. All rights reserved.
NutritionManagementofTheSchoolAgedChild
RecommendationsfromtheDietaryGuidelines,NationalCholesterolEducationProgram,andtheAmerican AcademyofPediatricsshouldbeappliedtothedietofhealthychildren.Theserecommendationsincludean intake of fat between 25 to 35% of total energy, limiting saturated fat to less than 10% of total energy, limitingdietarycholesteroltolessthan300mg/day,andlimitingtheintakeoftransfattyacidstoaslowas possible (3,5,10). Lower targets may need to be achieved based on risk factor assessment of the childs cardiovascularriskprofile (10).Therecommendeddailyfiberintakeforchildrenaged6to11yearsisequal toorgreaterthanthechildsageplus5g (11).TheDRIshaveestablishedadequateintakesoffiberthatare higherthantheestimatedrequirementsduetothehealthbenefitsoffiber.Theadequateintakeoffiberis25 g/dayforchildrenaged4to8years,31g/dayforboysaged9to13years,and26g/dayforgirlsaged9to13 years(6). TableIE4:FoodGroupsandRecommendedPortionSizesfortheSchoolAgedChild(3) FoodGroup DailyServings PortionSize Grains,Breads,Cereals Morethansixservings Bread 1slice Drycereal 1ozorcup Cookedcereal cup Noodles 46 Rice cup Crackers 4to6 Fruits Twoormoreservings Freshfruit 1wholemedium Cooked,canned,orraw cup (chopped) Juice cup Vegetables Threeormoreservings Cooked,canned,orraw cup (chopped) Juice cup Milk Threeservings Milk 1cup Yogurt 1oz Cheese 1oz Meat Twotothreeservings (atotalof56oz/day) Egg 1 Cookedmeat 23oz Driedbeans,peas cup Peanutbutter 2tbsp Fats,Sweets Asneededtoprovide energy SeeSectionIII:ClinicalNutritionManagement
OBESITYANDWEIGHTMANAGEMENT
References 1. Position of the American Dietetic Association. Nutrition guidance for healthy children aged 2 to 11 years. J Am Diet Assoc. 2008;108:10381047.. 2. OgdenCL,CarrollMD,CurtinLR,McDowellMA,TabakCJ,FlegalKM.PrevalenceofoverweightandobesityintheUnitedStates, 19992004.JAMA.2006;295:15491555. 3. DietaryGuidelinesforAmericans2010.Availableat: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.AccessedJan31,2011. 4. My Pyramid for Kids. US Department of Agriculture. Available at http://mypyramid.gov/kids/ (6 to 11 years). Accessed January23,2009. ManualofClinicalNutritionManagement
E10
Nutrition Management of the School-Age Child National Cholesterol Education Program. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Washington,DC:USDeptofHealthandHumanServices;1991.NIHpublication912732. 6. Institute of Medicines Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,ProteinandAminoAcids(Macronutrients).Washington,DC:NationalAcademyofScience;2002. 7. American Academy of Pediatrics Committee on Nutrition. Policy statement: the use and misuse of fruit juice in pediatrics. Pediatrics.2001;107:12101213. 8. InstituteofMedicine,FoodandNutritionBoard.DietaryReferenceIntakesforCalcium,Phosphorus,Magnesium,VitaminD,and Fluoride.Washington,DC:NationalAcademyPress;1997. 9. Nutrition Management of the SchoolAge Child. Pediatric Manual of Clinical Dietetics. 2nd ed. Chicago, Ill: American Dietetic Association;2003. 10. Daniels SR, Greer FR, and the Committee on Nutrition. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122:198208. 11. PositionoftheAmericanDieteticAssociation:Healthimplicationsofdietaryfiber.JAmDietAssoc.2008;108:17161731. 5.
E11
NUTRITIONMANAGEMENTOFTHEADOLESCENT
Description The Regular Diet for the Adolescent (11 to 19 years of age) includes a wide variety of foods to promote normal growth and development during puberty and to maintain a good nutritional status for health and disease prevention after the physiological growth has occurred. Foods are provided based on the Dietary GuidelinesforAmericans,theAmericanHeartAssociation,theAmericanCancerAssociation,andtheNational CholesterolEducationProgram(12). Indications Thedietisservedwhenspecificdietarymodificationsarenottherapeuticallyrequired.
NutritionalAdequacy TheDietfortheAdolescentisadequatetomeettheDietaryReferenceIntakes(DRIs)forthespecificageas outlinedintheStatementonNutritionalAdequacyinSectionIA,providedthatavarietyoffoodsisconsumed. Energyandproteinrequirementsvarywiththeadolescentsage,sex,stageofgrowth,andphysicalactivity. Specialattentionmayberequiredtoensureadequateintakeofiron,zinc,andcalcium.
HowtoOrdertheDiet OrderasRegularDietorRegularDietforAge______.Theageofthepatientwillbetakenintoconsideration inimplementingthedietorder.Anyspecificinstructionsshouldbeindicated. PlanningtheDiet Energy needs vary with the sex, stage of growth, and physical activity of the adolescent. See Section IA: Estimated Energy Requirement (EER) for Male and Females Under 30 Years of Age. An initial estimate for energy thatrelatesmorecloselytophysiologicalagecanbeobtainedbycalculatingkilocaloriesdividedby heightincentimeters (3).ThisisdeterminedbydividingtheDRIforenergyforthechildsageandsexbythe referenceheight(listedontheEstimatedEnergyRequirement(EER)forMaleandFemalesUnder30Yearsof Age table and then multiplying kilocalories per centimeter by the adolescents height (4). If the height is unavailableorcannotbemeasuredaccurately,theDRIforthekilocaloriesperdaymaybeused(4).Therefore, periodicadjustmentsinenergyintakemaybenecessarytomaintainanappropriateweightforheight. Proteinneedsforadolescentsalsorelatemoretothephysiologicalagethanchronologicalage.TheRDAfor protein is 0.95 g/kg weight for ages 1113 then decreases slightly to 0.85 g/kg/day at the age of 14 to 18. Adequateintakerangesfrom34g/day(9to13years)to52g/day(14to18years)(4).SeeSectionIA:Dietary ReferenceIntakes(DRIs);RecommendedIntakesforindividuals,Macronutrients. Girlsgenerallybeginpubertyaround10to12yearsofageandboysbeginbetween11and13yearsofage. Likewise,girlsusuallyhaveapeakheightvelocityaroundage12andboysaroundage14.Youngmenoften achieveanadultheightgreaterthanyoungwomendobecauseboysgrowprepubertally2yearsmorethan girlsdoandhavealongerperiodofgrowthoncepubertystarts.Girlsgenerallystopgrowthat16yearsofage andboysat18yearsofage.
Duringpuberty,bodycompositionchanges.Boysdoubletheirleanbodymassbetween10and17yearsof ageandmaintainabout12%bodyfatbylatepuberty.Girlsgainmorefatduringpubertyandusuallyhave 23%bodyfatbylatepuberty. Vitamins and mineral needs increase as the adolescent grows. Calcium, iron, and zinc are particularly importantforgrowth,anddietaryintakeisfrequentlyinadequate.Carefulfoodselectionisrequiredtomeet theDRIs.Acceptingchangesthatwillimprovenutrientintakeseemstobemostsuccessfulwhenthechangeis relatedtophysicaldevelopment,appearance,andsportsperformance. The DRI for calcium is 1,300 mg for both sexes between the ages of 9 and 18 years (5). The accelerated skeletalandmusculardevelopmentduringadolescencemakesthisstageoflifeacriticaltimeforbonegrowth anddepositionofcalcium. TheDRIforiron14to18yearoldsis11mg/dayformalesand15mg/dayforfemales (4).Theneedfor ironincreasesduringpubertywiththeincreaseinmusclemassandbloodvolume.
E-12
Nutrition Management of the Adolescent
TheRDAforzincformalesandfemales14to18yearsis11mg/dayand9mg/day,respectively (4).Zincis especiallyimportantduringadolescencebecauseofitsroleingrowthandsexualmaturation. Recommendations from the Dietary Guidelines, the American Heart Association, the American Cancer Association,andtheNationalCholesterolEducationProgramshouldbeappliedforhealthyadolescents.Refer totheRegularDietAdultinSectionIAforrecommendationsandguidelines. SeeSectionIA:REGULARDIETINPREGNANCYANDLACTATION SeeSectionIII:ClinicalNutritionManagement OBESITYANDWEIGHTMANAGEMENT
References 1. DietaryGuidelinesforAmericans2010.Availableat: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.AccessedJan31,2011. 2. National Cholesterol Education Program. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Washington,DC:USDeptofHealthandHumanServices;1991.NIHpublication912732. 3. Nutrition Management of the Adolescent. Pediatric Manual of Clinical Dietetics. 2nd ed. Chicago Ill: The American Dietetic Association;2003. 4. Institute of Medicines Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,ProteinandAminoAcids(Macronutrients),Washington,DC,NationalAcademyofScience,2002. 5. InstituteofMedicine,FoodandNutritionBoard.DietaryReferenceIntakesforCalcium,Phosphorus,Magnesium,VitaminD,and Fluoride.Washington,DC:NationalAcademyPress;1997.
E13
KETOGENICDIET
Description The ketogenic diet is designed to establish and maintain ketosis. The diet is very high in fat and severely restrictedincarbohydrates.Thisisdonebycalculatingthediettoprovide3to4gramsoffatforeach1gram ofproteinandcarbohydratecombined,thusconvertingthefuelburnedbythebodyfromcarbohydratetofat. Aphysicianprescribestheratioof3:1or4:1asappropriateforeachindividualpatient.Thedietiscalculated tomeetthespecificneedsofeachindividualforcaloriesandprotein,andprovideslittletonocarbohydrate dependingonproteinrequirements.Evenwiththehighfatcontentofthediet,weightisusuallymaintained with very little gain. This is possible because calories are calculated to meet only 75% of the individuals DietaryReferenceIntake(DRI)forenergy.ThefoundationofthedietiseitherheavywhippingcreamorMCT oil.Thedietusingwhippingcreamisdescribedbelow. Indications Thedietservesasanadjuncttoanticonvulsantmedicationsincontrollingintractableseizures.Itisusedin cases of resistance to medications or drug toxicity (1,2). Sustained ketosis appears to be important in modifying the convulsive threshold (1,3). The diet seems to be most effective in children 18 months to 10 yearsofage (4),althoughitcanbeusedwitholderchildrenandadultswithvaryingdegreesofsuccess.The dietisadministeredtothosewhohavemyoclonicabsence(drop)andatonicseizures,whicharedifficultto controlwithmedications.Itmayalsobenefitchildrenwithgeneralizedtonicclonic(grandmal)seizuresand seizuresoftheLennoxGestaultSyndrome.Theketogenicdietcanbeusedforalltypesofseizures,especially ifmedicationtherapyisnoteffective(5). The diet requires a trial period of 2 to 3 months during which effectiveness is assessed and the diet is adjusted to maintain strong ketosis. Once it is determined that the diet is effective on controlling seizure activity, a commitment of 1 to 2 years is required after which weaning is done gradually. Because of the extremedietaryregimensinvolvedinthisdiet,theJohnsHopkinsPediatricEpilepsyCenterrecommendsuse oftheketogenicdietforthoseindividualswhohavemorethan2seizuresaweekdespitetreatmentwithat least2differentanticonvulsantmedications(6). NutritionalAdequacy TheketogenicdietisinadequateinvitaminBcomplexvitamins,folate,iron,calcium,andzinc.Thedietmust besupplementedwithvitamins,ironandcalciuminformsthataresugarfree. HowtoOrdertheDiet OrderasKetogenicDiet.Anutritionconsultbyaregistereddietitianmustaccompanythedietorder,asthe diethastobepreciselycalculated.Allmedicationsmustbecarbohydratefree,aswellastoothpaste.Thediet mustbeinitiatedinahospitalizedsettingunderclosesupervision. PlanningtheDiet A gram scale and a copy of the Epilepsy Diet Treatment book (6) are paramount in administering this diet effectively. Calculation(5) 1. Samplepatient:ageandweight Age 5 Height 43inches Weightinkilograms 18.46(40.6lb) Idealweight 18.46(50thpercentile)
KetogenicRatio(fatcalories:nonfatcaloriesratio)
Upto2years 3:1 2yearsto12years 4:1 Over12years 3:1
A4:1Ketogenicdietisprescribedforthepatient,whichat50thpercentilematchestheidealweightfor hisageandsize. 2. Caloriesperkilogram:CalculatetheidealbodyweightforthechildsheightusingtheNCHSgrowthcharts.

E-14
Ketogenic Diet
Determinethenumberofcaloriesperkilogrambasedonthechildsageandidealweightfromthefollowing chart(7).Additionaladjustmentsforcaloricneedswillneedtobeindividualizedbasedonpatientsactivity level. Upto1year 80kcal/kg 1218months 75kcal/kg 18months3years 70kcal/kg 46years 65kcal/kg 78years 60kcal/kg 910years 55kcal/kg 1114years 40kcal/kgorless 3. Totalcalories:Determinethetotalnumberofkcalinthedietbymultiplyingthechildsidealweightby thenumberofcaloriesrequiredperkilogram.
Thepatient,age5andweighing18.46kg,needsatotalof65x18.46or1,200kcalperday.
4. Dietary unit composition: Dietary units are the building blocks of the ketogenic diet. A 4:1 diet has dietary units made up of 4 gm of fat to each 1 gm of protein plus carbohydrates. Because fat has 9 calories/g(9x4=36),andproteinandcarbohydrateseachhave4kcal/g(4x1=4),adietaryunitata 4:1 diet ratio has 36 + 4 = 40 kcal. The caloric value and breakdown of dietary units vary with the ketogenicratio.
Ratio 2:1 3:1 4:1 5:1

FatCalories Carbohydratesplus Caloriesper ProteinCalories DietaryUnit 2gx9kcal/g=18 3gx9kcal/g=27 4gx9kcal/g=36 5gx9kcal/g=45 1gx4kcal/g=4 1gx4kcal/g=4 1gx4kcal/g=4 1gx4kcal/g=4 18+4=22 27+4=31 36+4=40 45+4=49
________________________________________________________________________________________________________
Thepatientsdietaryunitswillbemadeupof40calorieseachbecauseheisona4:1ratio. 5. Dietaryunitquantity:Dividethetotalcaloriesallottedbythenumberofcaloriesineachdietaryunitto determinethenumberofdietaryunitstobealloweddaily.
Eachofthepatientsdietaryunitsona4:1ratiocontains40calories,isallowedatotalof1200kcal/day, sohereceives1200/40=30dietaryunitsperday.
6. Fat allowance: Multiply the number of dietary units times the units of fat in the prescribed ketogenic ratiotodeterminethenumberoffatgramspermitteddaily.
Onhis4:1diet,with30dietaryunitsperday,thepatientwillhave30x4or120goffatperday.
7. Proteinandcarbohydrateallowance:Multiplythenumberofdietaryunitstimesthenumberofprotein pluscarbohydrateintheprescribedketogenicratio,usuallyone,todeterminethecombineddailyprotein pluscarbohydrateallotment.
Onhis4:1diet,thepatientwillhave30x1or30gofproteinandcarbohydrateperdiet.
8. Protein allowance: To maintain health, a 5yearold child should eat a minimum of 1 g of protein for everykilogramofweightand/ormeettheDRIforproteinforage.
At 18.56 kg, the patient should eat 18.5 g of protein per day out of his total protein and carbohydrate allotmentof30g.
9. Carbohydrate allowance: Determine the grams of carbohydrate allotted by subtracting the protein allotmentfromthetotalproteinpluscarbohydrateallotment.Carbohydratesarethedietsfillerandare alwaysdeterminedlast.
Thepatientscarbohydrateallotmentis3018.5=11.5gmcarbohydratedaily. 10. MealOrder:Dividethedailyfat,proteinandcarbohydrateallotmentsinto3equalmeals.Itisessential thattheproperratiooffattoproteinpluscarbohydratebemaintainedateachmeal.

E15
Ketogenic Diet
Thepatientsdietorderreads: Protein Fat Carbohydrate Kcal
Daily 18.5g 120g 11.5g 1,200
PerMeal 6.2g 40g 3.8g 400
11. Liquids: Multiply the childs ideal weight by 65 to determine the daily cubic centimeter allotment of liquid.Asfewas60cc/kgbutasmanyas70ccmaybeadequate,dependingonthechildsactivitylevel andtheclimateinwhichtheylive.Liquidintakeshouldbespacedthroughoutthedaywithnomorethan 120 150 cc being given at any one time. Liquids should be noncaloric such as water, herbal or decaffeinated tea or decaffeinated sugarfree diet soda. Sugar free soda should be limited to no more than1calorieperday.Inhotclimates,thecreammaybeexcludedfromthefluidallotment.Theliquid allotmentmayalsobesetequaltothenumberofcaloriesinthediet.
Thepatient,wholivesinNewYorkandgets1200kcalperdayonthediet,isallowed1200ccoffluidper day,includinghisallottedcream.
12. Everychildontheketogenicdietshouldtakeadailydoseofasugarfreevitamin/mineralsupplement. Forinfantsorchildrenwhohavedifficultychewing,600to650mgoforalcalcium,inasugarfreeform, such as calcium gluconate or calcium carbonate or calcium magnesium liquid and a sugarless multi vitaminwithiron,suchasPolyViSolliquidordropscanbeused.Asugarfreemultivitaminmineral ChewTabisabetterchoiceforchildrenover1yearofagethatcanchew.
IntroducingTheKetogenicDiet The diet must be introducedinthehospitalizedcaresetting.Initiallyketogeniceggnogisgivenafterthe initialtwodayfastorwhentheketoneshavereachedthe160level(4+).
Tointroducetochildren,aketogeniceggnogisprovidedasamplefullmealrecipefollows.Thechildshould receive 1/3 of the childs full meal recipe first meal, 2/3s of the full meal recipe the second meal, and progresstothefullrecipebythethirdmeal.
CalculatingTheKetogenicEggnog Step1: Calculatetherecipebasedon1/3ofthechildstotalallottedcalories.Selectanamountofcream thatcontainsclosebutnotequaltotheamountoftotalallottedfat.
Weight Protein Fat Carbohydrate _____________________________________________________________________ Cream 97g 1.9g 34.9g 2.9g Egg _____________________________________________________________________ Shouldbe 6.2g 40.0g 3.8g
Subtractthecarbohydrateinthecreamusedfromthetotalallottedcarbohydrate:3.8g2.9g= 0.9g. Step3: Addtheremainingamountofcarbohydratetothetotalallottedprotein:6.2g+0.9g=7.1g. Step4: SubtracttheproteinusedinthecreamfromthesuminStep3.7.1g1.9g=5.2g. Step5: Usingthefoodvalueschart(8),givetheamountofeggthatcontains5.2gofprotein.

Step2:
E-16
Ketogenic Diet
Recipefor1FullMeal Weight Protein Fat Carbohydrate _____________________________________________________________________ Cream 97g 1.9g 34.9g 2.9g Egg 43g 5.2g 5.2g _____________________________________________________________________ Actualtotal 7.1g 40.1g 2.9g Shouldbe 6.2g 40.0g 3.8g
In the ketogenic eggnog, the carbohydrate will be lower than the allotment and the protein will be higher than the allotment. The amount of fat should always be within a close proximity to the allotment. On occasion,dependingondifferentketogenicratiosused,smallamountsofoilmaybeneeded. The4:1ketogenicratiomaybedoublecheckedbyaddingthegramsofproteinandcarbohydrateinthemeal andmultiplyingbyfour(4).Thesumshouldbetheamountoffatinthemeal,inthiscase,40.0g.Since(7.1g +2.9g)x4=40.0g,theratioiscorrect. Whenthefullquantityisreached,realfoodmaybeservedorthechildmaybegiveneggnogagain. TheKetogenicEggnogRecipe Ketogenic eggnog is the only meal that does not need to be eaten all at once. This way the child sipping eggnogwillnotbeunderasmuchpressureaswhenhe/sheisfacedwithaplateofunfamiliarfood.Athome, the parents can prepare more appetizing, familiar meals. However, it is important that parents be given enoughtraininginpreparingsolidfoodmealssotheywillbeabletodoitcomfortablyathome.Ingredients requiredfortheketogeniceggnogare: HeavyCream Egg VanillaExtract Saccharin(optional) Thepatientsfirstmealofeggnogwillbe1/3ofthefullmealrecipe: 32g HeavyCream 14g Egg upto5drops Vanilla uptograin Saccharin ______ _______ 46cc Total Thepatientssecondmealofeggnogwillbe2/3ofthefullmealrecipe: 64g HeavyCream 28g Egg upto5drops Vanilla uptograin Saccharin _______ _______ 92cc Total

E17
Ketogenic Diet
Thepatientsthirdmealofeggnogwillbethefullmealrecipe. 92g HeavyCream 14g Egg upto5drops Vanilla uptograin Saccharin _______ ________ 140cc Total Regularmealsareprovidedtothepatientusuallybythethirdmealand/orpriortodischarge. CalculatingMealPlans Whencalculatingthemealplan,dividethetotalprotein,fatandcarbohydrateallottedforthedaybythree andprovide1/3oftheallotmentpermeal.Forexample: Weight Protein Fat Carbohydrate _____________________________________________________________________ Cream 65g 1.3g 23.4g 1.9g
Fruit 19g 0.2g 1.9g
Meat 20g 4.7g 3.3g
Fat 18g 13.3g _____________________________________________________________________ ActualTotal 6.2g 40.0g 3.8g Shouldbe 6.2g 40.0g 3.8g Calculatethewhippingcreamfirst.Heavywhippingcream(36%)shouldtakeupnomorethanhalfofthe carbohydrateallotmentinthemeal. Thepatientisallowedatotalof3.8gcarbohydratespermeal.Referringtothefoodvaluecharts (9),touse halfofthisallotmentofcream,heshouldeat65gof36%cream,whichcontains1.9gcarbohydrates. Calculatetherestofthecarbohydrate(fruitsorvegetables)bysubtractingthecarbohydratecontainedin thecreamfromthetotalcarbohydrateallotment. Referring to the food valuecharts,thepatientcaneattheremaining1.9gcarbohydratesas19gof10% fruits.Thepercentequalsthepercentofcarbohydrateinthefruit(7). 10%CarbohydrateFruits 15%CarbohydrateFruits Applesauce Apple Cantaloupe Apricot Grapefruit Blackberries Tangerine Blueberries Honeydew Figs Orange Nectarine Papaya Pear Peach Pineapple Strawberries Plums(Damson) Watermelon Raspberries(black) Raspberries(red) Grapes Mango

E-18
Ketogenic Diet
Calculatetheremainingprotein(meat/fish/poultry,cheeseoregg)bysubtractingtheproteininthecream andvegetablefromthetotalproteinallotment.The65gof36%creamandthe19gof10%fruitscontaina totalof1.5gofprotein. Thepatientisallowed6.2gmofproteinpermeal,sohecaneat4.7gofproteinfrommeat,fishorpoultry. Referringtothefoodvaluecharts(9),thiscalculatestobe20gofmeat,fishorpoultry. Calculatetheamountoffattobeallowedinthemealbysubtractingthefatinthecreamandproteinfrom thetotalfatallotment. Thepatienthastoeat40goffatwitheachmeal.Thecreamandmeatcontain26.7goffat,leaving13.3gof fattobemixedwithhismeal. Butter, margarine or mayonnaise are more frequently used because of their palatability. However, they containonly74%fat.Therefore,theremaininggramsoffataredividedby0.74.13.3/.74=17.9or18gof butter,margarineormayonnaise Oilisnotincludedbutcanbeused.Oilwouldraisetheaverageuphigherbutisnotusedasoftenasbutter, margarineormayonnaise. OtherConsiderations Because the diet may induce hypoglycemia, blood glucose levels need to be monitored during the fasting period (3). All IVs must be glucose free. If the blood sugar drops at or below 25mg % with symptoms of hypoglycemia, administer 15 to 30 cc (1.8 to 3.75 g carbohydrate) of orange juice. Monitor closely and administer more juice if necessary, but be aware that too much carbohydrate will delay ketosis. (See reference5forcompletehypoglycemiaplan.)Anotheralternativeistoadminister1oz.Pulmocareplus5 cc corn/safflower oil. This provides a 4.3:1 ratio and 1.25 g carbohydrate in 30 cc, therefore, treating the hypoglycemiabutnotinterruptingketosis(7). FoodGuide All foods must be weighed precisely on a gram scale. Bowes & Churchs Food Values of Portions Commonly Used(9)isausefulreferenceformealplanning. Thefollowingfoodsandproductsareeliminatedfromthedietbecausetheycontainanappreciableamount ofcarbohydrates. FoodstoAvoid Bread Jam Potatoes Cake SugarsweetenedKetchup Puddings Candy Marmalade Rice Carbonatedbeverages, Medicinescontainingsugar Rolls Cereals,sugarcoated Molasses Sherbet Chewinggum Muffins Sugar Cookies Pancakes Syrup Coughdropsorcoughsyrupsthatcontain Pastries Toothpaste sugar Peas Waffles Crackers Pies Honey JellyPreserves Icecream,commercial

E19
Ketogenic Diet References 1. ClarkBJ,HouseFM.MediumChainTriglycerideOilKetogenicDietsintheTreatmentofChildhoodEpilepsy.J.HumNutr,1978; 32:111. 2. Withrow, CD. The Ketogenic Diets: Mechanism of Anticonvulsant Action. In: Glaser GH, Penry JK, Woodbury DM. Antiepileptic Drugs:MechanismsofAction.NewYork,NY:RavenPress;1980. 3. HuttenlocherPR,WilbournAJ,SignoreJM.MediumChainTriglyceridesasaTherapyforIntractableChildhoodEpilepsy.Neurology 1971;21:1097. 4. GordonN.MediumChainTriglyceridesinaKetogenicDiet.DevMedChildNeurol.1977;19:535. 5. CalculatingandAdministeringtheKetogenicDietintheTreatmentofPediatricEpilepsy.UniversityofCaliforniaConference,Redondo Beach,CA:September2223,1995. 6. GershoffSNed.Adietforepilepsyprovidesnewhope.TuftsUniversityHealth&NutritionLetter.1997;15:6. 7. FreemanJM,KellyMT.TheEpilepsyDietTreatment,AnIntroductiontotheKetogenicDiet.NewYork,NY:DemosPublication;1996. 18005328663. 8. PersonalCommunications.St.JosephHospitalandMedicalCenterNutritionService,HospitalandMedicalCenter,Phoenix,Az:1996. 9. PenningtonJA.BowesandChurchsFoodValuesofPortionsCommonlyUsed.17thed.Philadelphia,PA:Lippincott;1998.
E20
SODIUMCONTROLLEDDIET
Description The SodiumControlled Diet limits sodium intake. Foods and condiments high in sodium are eliminated or restricted at suggested levels to optimally manage blood pressure and underlying medical conditions associatedwithhypertensionorchronicorgandamage. The average dietary sodium intake is approximately 4,100 mg/day for American men and 2,775 mg/day forAmericanwomen(1).Theconsumptionofprocessedfoodsaccountsfor75%ofthedailysodiumintake(2). The minimum daily sodium requirement for healthy adults is 500 mg (3). In 2002, The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National ResearchCouncil(JNC7)recommendeddailyintakeofsodiumbelimitedto2,400mg.(4).However,basedon emerging data and evaluation of scientific data, more recent recommendations from The American Heart Association, Dietary Guidelines for Americans, and National Institutes of Health National Heart Lung and Blood Institute (NIH/NHLBI), and Dietary Approaches to Stopping Hypertension study outcomes suggest targeting less than 2,300 mg/day for healthy adults. High risk populations including African Americans, middleage,olderadultsandpersonswithexistinghypertensionshouldtargetalowersodiumintakeof1,500 mg/dayinadults(2,4,5,6).RefertoSectionIII:Hypertension. Indications TheSodiumControlledDietisusedinthetreatmentofconditionscharacterizedbyedema(waterretention), includingthefollowing: cirrhosisoftheliverwithascites heartfailure hypertension renaldisease Under normal physiologic conditions, the body responds to an increase in sodium consumption with an increaseinsodiumexcretion,generallyeliminatingtheexcesssodiumwithin24hours(3,7).However,certain diseases or conditions impair the bodys ability to maintain a normal sodium and water balance, necessitatingareductioninsodiumintake.Excesssodiuminthebodycausedbyoneoftheconditionslisted abovecanleadtoedema,increasedbloodpressure,thirst,andshortnessofbreath. Cirrhosisoftheliverwithascites:Ascites,anaccumulationofnutrientrichfluidintheperitonealcavity, oftenoccursasaresultofhepaticcirrhosis.Asmallpercentageofpatientswiththisconditionloseweight andreducetheirfluidvolumebyadheringtoasodiumcontrolleddiet(8).Almost90%ofpatientsrespondto combinationtherapyconsistingofasodiumcontrolleddietanddiuretics, whereastheother10%ofpatients areresistanttocombinationtherapyandrequirefurthermedicalintervention (9).Althoughfluidrestrictions often accompany sodiumcontrolled diets, the efficacy of this practice in the treatment of patients with ascites has been challenged. Fluid restriction may not be necessary unless the serum sodium level drops below128mEq/L (8,9).Inpatientswithascites,thetreatmentgoalistoachieveanegativesodiumbalance andaweightlossof0.5kg/day (8).Sodiumcontrolleddietsthatprovidelessthan2,000mgofsodiumper day,dependingonthepatientsfluidvolume,arerecommended(8). Heart failure: In patients with heart failure, the kidneys respond to a decrease in systemic blood flow by increasingtheabsorptionofsodiumandfluids,leadingtoedemaandworseningheartfailure.Topromote diuresis,asodiumcontrolleddietaccompaniedbydiureticuseisthepreferredmethodoftreatment (2,3,10,). Inheartfailure,sodiumintakeshouldbelessthan2,000mg(2g)perday.Sodiumrestrictionwillimprove clinical symptoms and quality of life (Grade II) (10) According to the Comprehensive Heart Failure Practice Guidelines, dietary sodium restriction of 2 to 3 g daily is recommended for patients with the clinical syndrome of heart failure and a preserved or depressed left ventricular ejection fraction (LVEF). Further restriction(<2gdaily)maybeconsideredinmoderatetosevereheartfailure (13).(SeeSectionIII:Heart Failure.)Thefluidintakeofpatientswithhyponatremia(plasmasodiumconcentration<130mEq/L)maybe restrictedto1.4to1.9L/day,dependingontheclinicalsignsandsymptoms(GradeIII)(10). Hypertension: Sodiumsensitive individuals have an impaired ability to excrete large concentrations of sodium,leadingtoincreasedserumsodiumlevels,hypervolemia,andhypertension.Between20%and50% of individuals with hypertension, particularly the elderly and African Americans, respond to an increase in
F1
Sodium-Controlled Diet
sodium consumption with an increase in blood pressure (7). Other lifestyle modifications that can help prevent hypertension include losing excess body weight, following the Dietary Approaches to Stop Hypertension (DASH) eating plan, increasing physical activity, and avoiding excess alcohol intake (2). The DASH collaborative intervention studies have demonstrated that a reduced sodium diet of <2,400 mg/day, which includes increased intakes of fruits, vegetables, potassiumrich foods, and lowfat dairy foods and decreasedintakesoftotalfat(27%),saturatedfat(6%),andcholesterol(<150mg)hasasignificanteffecton loweringbloodpressure (12,13).PatientswhofollowedtheDASHeatingplanexperiencedan8to14mmHg reduction in systolic blood pressure (Grade IV) (12,13,14). The greatest blood pressure reductions occurred in patients who followed the DASH eating plan at a sodium intake level of 1,500 mg/day (12,14). The American Dietetic Associations Hypertension Evidence Based Nutrition Practice Guideline suggests that sodium intake belimitedtonomorethan2,300mg/day (Grade1)(15). Reductionofdietarysodiumtotherecommendedlevels lowerssystolicbloodpressureby2to8mmHg (GradeI)(14).Ifthepatientdemonstratesgoodadherencetoa 2,300 mg sodium diet but has not achieved the treatment goal, then the dietitian should recommend the DASHdietarypatternand/orareductionindailysodiumintaketo1,600mgtofurtherreducebloodpressure (Grade I)(14). Sodiumcontrolled diets also enhance the effectiveness of diuretic therapy (2,3) and may help individualsremainnormotensiveafterthecessationofpharmacologictherapy(2,16). If a potassiumwasting diuretic, such as thiazide or a loop diuretic, is prescribed, a diet containing increasedamountsofpotassiummaybenecessarytoavoidhypokalemia (3).Patientsshouldbeadvisedto consumeadequatefoodsourcesofpotassiumaspartofmedicalnutritiontherapytoreducebloodpressure. Research suggests that potassium intake lower than the recommended Dietary Reference Intakes is associatedwithincreasedbloodpressure(GradeII)(14).(SeeNutritionManagementofPotassiumIntakelaterin thissectionandHypertension,includingtheDASHEatingPlan,inSectionIII.) Renaldisease:SeeSectionIG:MedicalNutritionTherapyforChronicKidneyDisease. Contraindications Under normal conditions, the dietary restriction of sodium intake should not cause sodium depletion. However,asodiumcontrolleddietiscontraindicatedinthepresenceofthefollowing: conditionsthatpromotesodiumdepletion(profuseperspiration,vomiting,anddiarrhea) impairedmechanismsofsodiumconservation(colectomyandileostomyinthepostoperativeperiod) conditionsthatconservesodiumasanormalphysiologicadjustment(pregnancy) lithium carbonate therapy (The kidney does not always discriminate between sodium and lithium. Therefore, with a low sodium intake, the kidney may conserve both sodium and lithium, causing an increasedserumlithiumlevelandthepotentialforlithiumtoxicity(7)). NutritionalAdequacy SodiumcontrolleddietscanbeplannedtomeettheDietaryReferenceIntakesasoutlinedintheStatementon NutritionalAdequacyinSectionIA.
HowtoOrdertheDiet Orderthedietintermsofsodium,notsalt. Ordertheamountofsodiumthatshouldnotbeexceededinthediet.Differentlevelsofsodiumcontrolled dietslimitthedailysodiumintaketo1,500mg(65mEq),2,000mg(87mEq),3,000mg(130mEq)or 4,000mg(174mEq). The dietitian may allow certain higher sodium foods to be added to the patients diet if the patients sodiumintakefallsbelowtheprescribedrangeduetolowenergyintake. Notethatdietscontaininglessthan2,000mg/dayofsodiumaredifficulttosustainoutsideofthehospital environmentforreasonsofpalatabilityandconvenience(3).
PlanningtheDiet Saltsubstitutes:Saltsubstituteswillnotbeofferedunlessaphysician,standingorder,oranorganizations policydesignatestheiruse.Saltsubstitutesmaycontainpotassiumchloride,whichcouldbecontraindicated undercertainconditions.Somesaltsubstitutesalsocontainvariousamountsofsodium.
Sodiuminmedications:Patientsonasodiumrestricteddietshouldbemadeawarethatcertainoverthe countermedications(eg,seltzersandsomeantacids)containhighquantitiesofsodiumandthattheyshould consulttheirphysicianifthemedicationsareusedonaregularbasis.

F2
SodiumControlledDiet
HEARTFAILURE CORTICOSTEROIDTHERAPY HYPERTENSION NEPHROTICSYNDROME
References 1. USDepartmentofAgriculture,AgriculturalResearchService.NutrientIntakesfromFood:MeanAmountsConsumedperIndividual, OneDay,20052006.Available:www.ars.usda.gov/ba/bhnrc/fsrg. 2. ChobanianAV,BakrisGL,BlackHR,CushmanWC,GreenLA,IzzoJLJr,JonesDW,MatersonBJ,OparilS,WrightJTJr,RoccellaEJ,and theNationalHighBloodPressureEducationProgramCoordinatingCommittee.SeventhreportoftheJointNationalCommitteeon Prevention,Detection,Evaluation,andTreatmentofHighBloodPressure.Hypertension.2003;42:12061252. 3. WhitmereS.Water,electrolytes,andacidbasebalance.In:MahanKL,EscottStumpS,eds.KrausesFood,NutritionandDietTherapy. 10thed.Philadelphia,Pa:WBSaunders;2000:159. 4. Whelton PK, He J, Appel LJ, Cutler JA et al. National High Blood Pressure Education Program Coordinating Committee. Primary preventionofhypertension:clinicalandpublichealthadvisoryfromTheNationalHighBloodPressureEducationprogram.JAMA 2002Oct16;288(15):18828. 5. AppelLJ;AmericanSocietyofHypertensionWritingGroup,GilesTDetal.DASHPositionPaper:Dietaryapproachestolowerblood pressure.JClinHypertens2009Jul;11(7):35868. 6. LloydJones DM. Cardiovascular risk prediction: basic concepts, current status, and future directions. Circulation 2010 Apr 20; 121(15):176877. 7. HaddyFJ,PamnaniMB.Roleofdietarysodiuminhypertension.JAmCollNutr.1995;14:428438. 8. GinesP,CardenasA,ArroyoV,RodesJ.Managementofcirrhosisandascites.NEnglJMed.2004;350:16461654. 9. AizaI,PerezGO,SchiffER.Managementofascitesinpatientswithchronicliverdisease.AmJGastroenterol.1994;89:19491956. 10. Heart Failure EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2008.Availableat:http://www.adaevidencelibrary.com.AccessedDecember3,2010. 11. LindenfeldJ,AlbertNM,BoehmerJP,etal.ExecutiveSummary:HFSA2010ComprehensiveHeartFailurePracticeGuideline.JCard Fail2010;16:475539. 12. Sacks FM, Svetkey LP, Vollmer WM, Obarzanek E, Conlin PR, Miller ER 3rd, SimonsMorton DG, Karanja N, Lin PH. DASHSodium Collaborative Research Group. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension(DASH)diet.NEnglJMed.2001;344:310. 13. SvetkeyLP,SimonsMortonD,VollmerWM,AppelLJ,ConlinPR,RyanDH,ArdJ,KennedyBM,fortheDASHResearchGroup.Effects of dietary patterns on blood pressure: subgroup analysis of the Dietary Approaches to Stop Hypertension (DASH) randomized clinicaltrial.ArchInternMed.1999;159:285293. 14. Hypertension EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2008.Availableat:http://www.adaevidencelibrary.com.AccessedJanuary10,2009. 15. VollmerWM,SacksFM,ArdJ,AppelLJ,BrayGA,SimonsMortonDG,ConlinPR,SvetkeyLP,ErlingerTP,MooreTJ,KaranjaN.DASH SodiumTrialCollaborativeResearchGroup.Effectsofdietandsodiumintakeonbloodpressure:subgroupanalysisoftheDASH sodiumtrial.AnnInternMed.2001;135:10191028. 16. AldermanMH.Nonpharmacologicaltreatmentofhypertension.Lancet.1994;344:307311.
F-3
NOADDEDSALTDIET (4,000mgSodiumDiet)
FOODSEXCLUDED Bacon* Barbecuesauce* Buttermilk,cultured(limitto1cup/day) Ketchup(limitto1tbsp/day) Cheese,processed Chilisauce Commerciallycannedproducts,frozenproducts,orconvenienceproducts(unless<600mgofsodiumper entreeor<350mgofsodiumpersinglefooditems) Cornedbeef* Fish,saltyorsmoked(eg,anchovies,saltedcod,herring,sardines) Frankfurters* Ham* Meatextracts Meat,luncheon* Meat,smoked,cured,canned,orpickled Meattenderizers Olives Partyspreadsanddips Saltedpotatochips,cornchips Saltpork Saltedbouilloncubes Saltedcrackers Saltednuts Soups,canned,frozen,ordehydrated(unlessreducedsodium) Sauerkrautorpickledvegetables Sausage* Spicesandherbsthatcontainsalt(eg,garlicsalt,celerysalt,onionsalt,andlemonpepper) Soysauce Tunacannedinoil(tunacanbeusedifrinsed)
*Maybecalculatedintothediet.Selectonlyoneservingdailyfromtheentirelist.
Note:Foodswithsodiumcontentsgreaterthan350mgperservingshouldbecalculatedintothediet.
F4
FOODGUIDE3,000MGSODIUMDIET
FOODGROUP Beverages
FOODSALLOWED Lowsodiumcarbonatedbeverages Coffee,tea
FOODSEXCLUDED
Breads,Cereals, GrainProducts (150mgsodium/ serving)
Enrichedwhite,wheat,rye,andpumpernickelbread Hardrolls,dinnerrolls Muffins,cornbread Waffles,pancakes Mostdryandhotcereals Crackersandbreadstickswithunsaltedtops Tortillas Enrichedunsaltedrice,barley,noodles,spaghetti,macaroni, andotherpastas Unsaltedtortillachips,pretzels,potatochips,orpopcorn Homemadebreadstuffing
Breads,rolls,andcrackers withsaltedtops Commerciallypreparedrice andpastamixes Saltysnackfoods Stuffingmixes
Vegetables (10mgsodium/ 1/2cserving)
Allfreshandfrozenvegetables Vegetables,canned,noaddedsalt Whiteandsweetpotatoes Squash Lowsodiumtomatosauceandtomatopaste
Sauerkraut,pickled vegetables,andothers preparedinbrine Vegetablesseasonedwith ham,bacon,saltpork, cheese,orcheesesauces Commerciallyprepared potatomixes Regulartomatosauceand puree
FruitsandJuices (10mgsodium/ 1/2cserving)
Allfruitsandfruitjuices Lowsodiumorsaltfreevegetablejuices
Fruitsdriedwithsodium sulfate Regularvegetablejuices
Milk (150mg sodium/serving)
Milk,buttermilk(limitto1cup/day),chocolatemilk Yogurt,frozenyogurt Regularricottacheese(1/4cup);Swissormozzarella cheese(1oz)
Instantmilkbeverages, instantcocoamix,malted milk
MeatsandMeat Substitutes (60mgsodium/ 1ozserving)
Freshorfrozenbeef,lamb,pork,andpoultry Fishandmostshellfish;cannedtunaorsalmon,rinsed Eggsandeggsubstitutes Lowsodiumcheese Regularpeanutbutter(3timesweekly) Driedpeasandbeans Frozendinners(<600mgsodium)
Smoked,cured,salted, koshered,orcannedfish, poultry,ormeat,including bacon,chippedbeef,cold cuts,ham,hotdogs, sausage,sardines, anchovies,marinated herring,andpickledmeats Frozenbreadedmeats Pickledeggs Processedcheese;cheese spreadsandsauces
Fats (100mg/tbsp)
Butterormargarine Vegetableoils Saladdressingsinlimitedamounts(2tbsp) Light,sour,andheavycream Mayonnaise Unsaltednuts
Bacon,saladdressings containingbaconfat, baconbits,andsaltpork Snackdipsmadewith instantsoupmixesor processedcheese Saltednuts Olives Cannedgravyandmixes
F-5
FOODGROUP Soups
FOODSALLOWED Homemadebroth Soupswithoutaddedsaltandmadewith allowedvegetables Lowsodiumcannedsoupsandbroths
FOODSEXCLUDED Regularcannedordehydrated soups Bouilloncubes
Dessertsand Sweets
All
None
Miscellaneous
Limitaddedsalttotsp/dayusedatthetable orincooking Useasaltsubstitutewithphysiciansapproval Pepper,herbs,spices Vinegar Ketchup(1tbsp),mustard(1tbsp) Lemonorlimejuice Hotpeppersauce,lowsodiumsoysauce(1tsp), Worcestershiresauce(1tsp) Salsa(cup)
Seasoningsmadewithsalt, includinggarlicsalt,celery salt,onionsalt,and seasonedsalt;seasalt;rock salt;koshersalt;lemonpepper Meattenderizers Monosodiumglutamate Olives Regularsoysauce,teriyaki sauce,barbecuesauce
SAMPLEMENU Breakfast OrangeJuice UnsaltedCreamofWheat UnsaltedScrambledEgg WheatToast Margarine,Jelly Milk(1cup) Coffee Sugar,Creamer Noon HoneyGlazedChicken SteamedRice SteamedBroccoli FruitedGelatin DinnerRoll Margarine FrostedBananaCake Milk(1cup) Tea Sugar Evening UnsaltedBeefTipsandNoodles SeasonedGreenBeans SlicedTomatoSalad FrenchDressing DinnerRoll Margarine PeachHalves IcedTea Sugar
2,000mgand1,500mgSodiumRestrictedDietPatterns(SamplePatterns) FoodGroup NumberofServings NumberofServings 2,000mgsodium 1,500mgsodium Bread,Cereals,andGrain 6regularbreadorcerealitems 5regularbreadorcerealitems Products(150mg/serving) Vegetables/Fruits 5 5 (10mg/cserving) Meat,Fish,PoultryandEggs 6 6 (60mg/1oz) MilkandDairy(150mg/serving) 2 2 Fats(100mg/1Tbspserving) 1 0 45tspunsalted 78tspunsalted Soup(unsaltedonly) Calculateintodiet Calculateintodiet DessertsandSweets Readlabelandcalculateintodiet Readlabelandcalculateintodiet Miscellaneous Calculateintodiet Calculateintodiet;noaddedsalt incookingorattable TotalSodium 1710mg 1460mg
F6
Breakfast OrangeJuice StewedPrunes UnsaltedCreamofWheat UnsaltedScrambledEgg WheatToast Margarine,Jelly NonfatMilk(1cup) Coffee Sugar,Creamer
SAMPLEMENU(2,000mgsodium) Noon Evening HoneyGlazedChicken UnsaltedBeefTipsandNoodles SteamedRice SeasonedGreenBeans SteamedBroccoli SeasonedCarrots TossedSaladwithFatFree SlicedTomatoSalad Dressing DinnerRoll DinnerRoll Margarine Margarine PeachHalves FreshBanana IcedTea NonfatMilk(1cup) Sugar Tea,Sugar SAMPLEMENU(1,500mgsodium) Noon Evening UnsaltedBeefTipsandNoodles HoneyGlazedChicken SeasonedGreenBeans,unsalted SteamedRice,unsalted SeasonedCarrots,unsalted SteamedBroccoli SlicedTomatoSalad TossedSaladwithFatFree, DinnerRoll LowsodiumDressing Margarine,unsalted DinnerRoll PeachHalves Margarine,unsalted IcedTea FreshBanana Sugar NonfatMilk(1cup) Tea,Sugar
Breakfast OrangeJuice StewedPrunes UnsaltedCreamofWheat UnsaltedScrambledEgg WheatToast Margarine,unsalted Jelly NonfatMilk(1cup) Coffee Sugar,Creamer
F-7
Sodium-Controlled Diet
FOODGUIDE1,000MGSODIUMDIET
FOODGROUP Beverages
FOODSALLOWED Coffee;tea Lowsodiumcarbonatedbeverages
FOODSEXCLUDED Gatorade
Breads,Cereals, GrainProducts
Hotcerealwithoutsalt Puffedrice,puffedwheat,shreddedwheat,and lowsodiumdrycereals Lowsodiumbread Lowsodiumcrackers,melbatoast,andmatzo Tortilla Enrichedunsaltedrice,barley,andpastas Unsaltedtortillachips,pretzels,potatochips,or popcorn
Breads,rolls,andcrackerswithsaltedor unsaltedtops Quickbreads;biscuits;cornbread;muffins Frozenwaffles;pancakes Regulardrycereal;instanthotcereals Selfrisingflour Commerciallypreparedriceorpasta mixes Potatochips;saltysnackfoods
Limitto2servingsperday: Enrichedwhite,wheat,rye,andpumpernickel breadorbreadsticks;hardrollsanddinnerrolls; homemadebreadstuffing
Vegetables
Allfresh,unsaltedfrozenvegetables Lowsodiumcannedvegetables Whiteorsweetpotatoes Squash Unsaltedtomatopaste
Regularcannedvegetables,sauerkraut, pickledvegetables,andothers preparedinbrine Vegetablesseasonedwithham,bacon,or saltpork Tomatosauce,puree,andregularpaste Commerciallypreparedpotatomixes Frozenpeas,limabeans,andmixed vegetables Allfrozenvegetablesinsauce
Fruitsand Juices
Allfruitsandfruitsjuices Lowsodium,saltfreevegetablejuices
Regularvegetablejuices Fruitsprocessedwithsaltorsodium compounds,eg,somedriedfruits
Milk
Limitto2servingsperday Milk Yogurt
Maltedmilk;milkshake;buttermilk; chocolatemilk
MeatsandMeat Substitutes
Anyfreshorfrozenbeef,lamb,pork,andpoultry Fishandmostshellfish;lowsodiumcannedtunaor salmon Eggs Lowsodiumcheese,cottagecheese,andricotta cheese Lowsodiumpeanutbutter Driedpeasandbeans
Anysmoked,cured,salted,koshered,or cannedmeat,fish,poultryincluding bacon,chippedbeef,coldcuts,ham,hot dogs,sausage,sardines,anchovies, marinatedherring,andpickledmeats Frozenbreadedmeats Eggsubstitutes;pickledeggs Regularhardandprocessedcheese; cottagecheese;cheesespreadsandsauces Regularpeanutbutter Frozendinners
Fats
Unsaltedbutterormargarine Vegetableoils Lowsodiumsaladdressing;lowsodium mayonnaise Nondairycreamer(1oz/day) Unsaltednuts Lowsodiumcreamcheese
Bacon,baconbits,andsaltpork;regular saladdressings;snackdipsmadewith instantsoupmixesorprocessed cheese;cannedgraviesandmixes; tartarsauce,saltednuts;olives
F-8
FOODGROUP Soups
FOODSALLOWED Noaddedsaltbrothsandsoupsmadewithallowed vegetables Lowsodiumcannedsoupsandbroths Lowsodiumcreamsoupsmadewithmilk allowance

FOODSEXCLUDED Regularcannedordehydratedregular soups
Dessertsand Sweets
Icecream Lowsodiumpudding Frozenyogurt(countaspartofmilkallowance) Fruitice Gelatinsandsherbet(nottoexceedcup/day) Jam;jelly Syrup
Instantpuddings Commercialcake,cookie,andbrownie mixes Cheesecake
Miscellaneous
Saltsubstitutewithphysiciansapproval Pepper;herbs;spices Vinegar Lowsodiumcondiments(ketchup,mustard) Lemonorlimejuice Hotpeppersauce Freshgroundhorseradish Salsa(cup)
Anyseasoningmadewithsalt, includinggarlicsalt,celerysalt, onionsalt,andseasonedsalt;kosher salt Meattenderizers Monosodiumglutamate Worcestershiresauce;regularandlow sodiumsoysauce;chilisauce, teriyakisauce;barbecuesauce Mostflavoredvinegars Regularcondiments Commercialsalsa
SAMPLEMENU Breakfast OrangeJuice UnsaltedCreamofWheat UnsaltedScrambledEgg MelbaToast Margarine,Jelly Milk(1cup) Coffee Sugar,Creamer Noon HoneyGlazedChicken SteamedRice SteamedBroccoli FruitedGelatin DinnerRoll UnsaltedMargarine FreshBanana Milk(1cup) Tea,Sugar Evening UnsaltedBeefTips&Noodles UnsaltedGreenBeans SlicedTomatoSalad DinnerRoll UnsaltedMargarine PeachHalves IcedTea Sugar
F-9
NUTRITIONMANAGEMENTOFPOTASSIUMINTAKE
Description The medical condition and nutritional requirements of the patient influence whether the dietary intake of potassiumisadequate.Theamountofpotassiuminthedietmayneedtobeeitherincreasedordecreased, dependingonthepatientscondition. Indications Adietwithanincreasedpotassiumcontentisprescribedtoretainbodypotassiumstoresinthefollowing: patientswhoselongtermuseofpotassiumlosingdiuretics,combinedwithamarginalpotassiumintake, contributestopotassiumdepletion patients who have increased urinary and gastrointestinal potassium losses resulting from certain diseasesorconditions,eg,edemaassociatedwithcertaincardiacorhepaticdisorders,dehydration,the diureticstageofnephritis A potassiumsupplemented diet may be used in conjunction with pharmaceutical potassium supplements,oralone,inindividualswithamildpotassiumdepletionwhoarenotabletotoleratepotassium supplements.However,withoutsupplements,itmaybedifficultforapatienttoconsistentlyincreasedietary potassiumintakeoverhisorherusuallevelofintake. Adietrestrictingpotassiumintakeisusuallyrequiredforpatientswithhyperkalemia,whichcommonly iscausedbyrenaldiseaseorcertainmedications.SeeDietaryManagementUsingtheHealthyFoodGuidefor People with Chronic Kidney Disease in Section IG. For patients requiring a Simplified Renal Diet, refer to SimplifiedRenalDietinSectionIG. NutritionalAdequacy Increasedpotassiumintake:ThedietisplannedasaRegularDietwithanincreaseinfoodsthatarehighin potassium.ThedietisplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedintheStatementon NutritionalAdequacyinSectionIA. Decreased potassium intake: See Dietary Management Using the Health Food Guide for People with ChronicKidneyDiseaseinSectionIG. HowtoOrdertheDiet To increase potassium intake: Order the diet as Regular Diet with high potassium foods. If a specific potassiumlevelisdesired,specifythelevelingrams. Individualpotassiumintakevaries.Todeterminethepatientscurrentpotassiumintake,thephysician should order a nutrition consult, including a diet recall of the patients intake of potassium. From this evaluation, the dietitian can make appropriate recommendations for the patient to increase potassium intake. To decrease potassium intake: See Dietary Management Using the Health Food Guide for People with ChronicKidneyDiseaseandSimplifiedRenalDietinSectionIG. PlanningtheDiet Toincreasepotassiumintake,refertotheTableF1:PotassiumContentofCommonFoods. SeeSectionIG:ModificationofProtein
DIETARYMANAGEMENTUSINGTHEHEALTHYFOODGUIDE FORPEOPLEWITHCHRONICKIDNEYDISEASE
F10
NutritionManagementofPotassiumIntake
TableF1:POTASSIUMCONTENTOFCOMMONFOODS
FOODITEM DairyProducts Cheese,American Cheese,Cheddar IceCream Milk Yogurt,Fruited DriedBeansandPeas GreatNorthernBeans LimaBeans PintoBeans Peas Fruits Apricots,Dried Banana Cantaloupe Dates Grapefruit HoneydewMelon OrangeJuice Orange PruneJuice Strawberries Watermelon Vegetables Broccoli BrusselsSprouts Mushrooms,Cooked Potato,BakedinSkin Potato,MashedWithMargarine Spinach SweetPotatoes Tomato,Fresh TomatoSauce BreadsandCereals BranBuds BranFlakes Oatmeal,Cooked RaisinBran WheatGerm WholeWheatBread Meats,Fish,Poultry Beef;Chicken Tuna Nuts PeanutButter Peanuts,DryRoasted Pecans SERVINGSIZE 1oz 1oz cup 1cup 1cup cup cup cup cup 5 medium 1cupofpieces cup small 1cupofpieces cup 1small,2inchdiameter cup cup 1cup cup cup cup 121/34inches cup cup cup 2slices cup 1/3cup cup cup 1oz(1box) 1tbsp 1slice 1oz cup 2tbsp 1oz 1oz POTASSIUM(mg) 101 127 192 422 441 344 369 397 216 241 226 494 290 156 461 236 237 353 185 185 227 247 278 609 244 419 348 109 226 421 123 200 184 134 26 79(average) 89 91 230 105
Source:USDAHandbookNo.8.Washington,DC:USDeptofAgriculture;1986. ManualofClinicalNutritionManagement .
F11
NUTRITIONMANAGEMENTOFPHOSPHORUSINTAKE
Description Phosphorusintakeislimitedtotheprescribedlevel. Indications Hyperphosphatemia can lead to secondary hyperparathyroidism, resulting in bone disease. To prevent hyperphosphatemia, a phosphorusrestricted diet may be adjunctive to the use of agents that bind phosphorusinthegastrointestinaltractforindividualswithchronicrenalfailure.Generally,phosphorusis restrictedto600to1200mg/day.However,whenasimultaneousrestrictionofproteinisordered,suchasin renal disease, the phosphorus level is generally lowered enough to be within the desired range. With a glomerularfiltrationof25mL/min,phosphatebindingsubstancesaloneareusuallysufficienttocontrolthe serumphosphoruslevel.SeeMedicalNutritionTherapyforChronicKidneyDiseaseinSectionIG. NutritionalAdequacy If the phosphorus level is restricted to a level below 800 mg, the Dietary Reference Intakes (DRIs) for phosphoruswillnotbemet.Ifmilkproductsarerestrictedinordertoachievethislevelofphosphorus,the DRIforcalcium,vitaminD,andriboflavinmaynotbemet;calciumsupplementationmaybeindicated.See MedicalNutritionTherapyforChronicKidneyDiseaseinSectionIGforadiscussionofnutritionaladequacy forpatientswithrenaldisease. HowtoOrdertheDiet Specify the desired intake of phosphorus in milligrams and any other restrictions, eg, ________ Diet, ___ mg phosphorus. PlanningtheDiet Generally,thephosphorusrestrictioncanbemetby: limitingtheintakeoffoodscontainingmilk eliminatinglegumes,nuts,chocolate,andcolafromthediet substitutingrefinedgrainsforwholegrains RefertoTableF2:PhosphorusContentofCommonFoods,foradditionalfoodsthatmaywarrantrestriction. SeeSectionIG:ModerationofProtein MEDICALNUTRITIONTHERAPYFORCHRONICKIDNEYDISEASE
F12
NutritionManagementofPhosphorousIntake
TableF2:PHOSPHOROUSCONTENTOFCOMMONFOODS
FOODITEM DairyProducts Cheese,American Cheese,Cheddar Cheese,Cottage IceCream Milk Yogurt,Fruited DriedBeansandPeas GreatNorthernBeans LimaBeans PintoBeans Peas BreadsandCereals BranBuds BranFlakes Oatmeal,Cooked RaisinBran WheatGerm WholeWheatBread Meats,Fish,Poultry Beef;Chicken Egg Tuna Nuts PeanutButter Peanuts,DryRoasted Pecans Miscellaneous Cola Chocolate SERVINGSIZE 1oz 1oz cup cup 1cup 1cup cup cup cup cup 1/3cup cup cup 1oz(1box) 1tbsp 1slice 1oz 1 cup 2tbsp 1oz 1oz 12oz 1oz PHOSPHORUS(mg) 112 143 69 101 250 271 145 100 136 94 218 96 122 132 162 64 65(average) 90 53 103 100 86 45 40
Source:USDAHandbookNo.8.Washington,DC:USDeptofAgriculture;1986.
ManualofClinicalNutritionManagement .
F13
NUTRITIONMANAGEMENTOFCALCIUMINTAKE
Description The medical condition and nutritional requirements of the patient influence whether the dietary intake of calcium is adequate. The amount of calcium in the diet may need to be either increased or decreased, dependingonthepatientscondition. Indications Calciumrestrictionmaybeindicatedforthefollowing: tocontrolhypercalciuria inconjunctionwithoveralltreatmentforurolithiasis An adequate intake of calcium has been associated with a reduced risk of osteoporosis. The Dietary Reference Intakes (DRIs) includes the amount of calcium needed to reduce the risk of osteoporosis (1). However,itisdifficultformanywomentoconsumetheselevelswithoutsupplementation.Inaddition,after gastricbypassprocedures,calciumsupplementationwillberequiredtomaintainserumlevelsandprevent metabolicbonedisease. NutritionalAdequacy CalciumRestrictedDiet:Thedietisinadequateincalcium,vitaminD,andriboflavin. CalciumEnhancedDiet:ThedietmeetstheDRIsasstatedintheStatementonNutritionalAdequacyinSection IA. HowtoOrdertheDiet Todecreasecalciuminthediet:Specifythedesiredlevelofcalciumintakeinmilligrams.Includeanyother necessaryrestrictions.Order______Diet,_____mgcalcium. ToincreasecalciuminthedietabovetheDRI:Specifythedesiredlevelofcalciuminmilligrams.TheDRI forcalciumformalesandfemalesisasfollows(1): Age(years) Calcium(mg/day) 9to18 1300 19to50 1000 51 1200 PlanningtheDiet Torestrictcalcium:Eliminatemilkandallmilkproducts. To encourage increase in calcium intake: Refer to Table F3: Calcium Content of Common Foods, for additionalfoodstoencourageeating.Ifsupplementationisrequired,recommendsupplementswithcalcium carbonate, since this form contains the most available amount of elemental calcium. Refer to the supplements label to determine the actual amount of calcium, which usually is referred to as elemental calcium (2,3) Elementalcalciumishighestincalciumcarbonate(40%).Othercalciumsupplementscontain lesser amounts of elemental calcium, eg, calcium phosphate (38%), calcium citrate (21%), calcium lactate (13%),andcalciumgluconate(9%).Tocalculatetheamountofelementalcalciuminasupplement,identify thenumberofmilligramsthesupplementcontains.Forexample:1pillof650mgofcalciumcarbonate[650 mgx40%]provides260mgofelementalcalcium (2).Approximately4tabletsperdayofcalciumcarbonate areneededtomeettheRDIformostagegroups.Calciumsupplementsof1200to1500mg/dayshouldbe providedtoallpatientsaftergastricbypasssurgery(RouxenYandbiliopancreaticdiversion(BPD)) (4).In the cases of gastric bypass, calcium citrate with vitamin D is the preferred preparation because it is more soluble than calcium carbonate in the absence of gastric acid production (5). For patients with the BPD procedurewhohaveclinicalsteatorrhea,ahighdosecalciumsupplementationregimen(2000mg/day)along withmonthlyintramuscularvitaminDisrecommendedtoreducetheriskofmetabolicbonedisease(1). F14
NutritionManagementofCalciumIntake
AdequateintakeorsynthesisofvitaminDiscriticaltoensureadequateabsorptionofcalcium.TheDRIfor vitaminDformenandwomenisasfollows(1):
Age(years) 19to50 51to70 71
VitaminD(IU) 200 400 600
AlthoughvitaminDissynthesizedintheskinfromexposuretosunlight,studieshaveshownthatolder adults usually do not have adequate exposure to sunlight to synthesize the necessary vitamin D. This problemiscompoundedbyincreaseduseofsunscreenswithhighsunprotectionfactorsandaninefficiency oftheskintomanufacturevitaminDasadultsage.Foradultsover50yearsofageandyoungeradultswho spend little time outside, it may be advised to take a daily multivitamin with vitamin D (which typically contains400IUofvitaminD)(68).
TableF3:CALCIUMCONTENTOFCOMMONFOODS
FOODITEM MilkandDairyProducts Cheese American Cheddar Cottage,Creamed Mozzarella,PartNonfat ParmesanCheese Swiss HotCocoa IceCream IceMilk Milk,Whole,Nonfat,Chocolate Pudding Sherbet Yogurt,FatFree Yogurt,Frozen Yogurt,FruitFlavored Yogurt,Plain
SERVINGSIZE 1oz 1oz 1oz 1oz 1tbsp 1oz 1cup cup cup 1cup cup cup 8oz 4oz 8oz 8oz 1oz 1oz cupcooked cupcooked cupcooked cupcooked 1cupcooked 1cupcooked 1cupcooked 5 1cup
CALCIUM(mg) 174 204 68 183 70 272 106300 88 102 287300 125187 52 314 105 415 415 101 74
Fish Sardines,CannedWithBones Salmon,CannedWithbones Vegetables Broccoli CollardGreens Kale TurnipGreens Legumes Greatnorthernbeans Navybeans Pintobeans Fruits Driedfigs Calciumfortifiedorangejuice
89 178 90 125
121 128 82
258 300
Sources:USDAHandbookNo.8.WashingtonDC:USDeptofAgriculture;1986. PositionofTheAmericanDieteticAssociationandDietitiansofCanada:vegetariandiets.JAmDietAssoc.003;103(6):748 765. ManualofClinicalNutritionManagement
F15
NutritionManagementofCalciumIntake References 1. InstituteofMedicine,FoodandNutritionBoard.DietaryReferenceIntakesforCalcium,Phosphorus,Magnesium,VitaminDand Fluoride.Washington,DC:NationalAcademyPress;1997. 2. CalciumSupplements(Systemic).MedlinePlusHealthInformationAvailableat http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202108.html.AccessedSeptember16,2002. 3. NationalOsteoporosisFoundation.Howcalciumhelps.Availableat:http://www.nof.org/other/calcium.html.AccessedApril,27, 1998. 4. KushnerR.Managingtheobesepatientafterbariatricsurgery:acasereportofseveremalnutritionandreviewoftheliterature. JPEN.2000;24:126132. 5. LevensonDI,BockmanRS.Areviewofcalciumpreparations.NutrRev.1994;52:221232. 6. NationalOsteoporosisFoundation.HowcanIpreventosteoporosis?Availableat:http://www.nof.org/PreventOsteo.html.Accessed April27,1998. 7. ThomasMK,LloydJonesDM,ThadhaniRI,ShawAC,DeraskaDJ,KitchBT,VamvakasEC,DickIM,PrinceRL,FinkelsteinJSNEnglJ Med.1998;338:777783. 8. MalabananA,VeronikisIE,HolickMF.Lancet.1998;351:805806.Letter.
F16
PROTEINCONTROLLEDDIETFORACUTE ANDREFRACTORYHEPATICENCEPHALOPATHY
Description Adjustment of the amount and type of protein characterizes the ProteinControlled Diet for Hepatic Encephalopathy.Energyandproteinareprovidedtoattemptmaintenance ofnitrogenbalance andsupport liverregeneration. Indications The diet is used in the treatment of acute and refractory hepatic encephalopathy associated with hepatic disorders,whichmayincludethefollowing: hepatitis cholestaticliverdisease cirrohosiswithacuteand/orchronicencephalopathy Liverdiseasecausesnumerousmetabolicproblemsthatcanaffectallmajornutrientsandtheassessment parameters commonly used to evaluate nutritional status of the patient with hepatic disease. The classic signs of liver disease are anorexia, weight loss, and nausea with marked deficiencies in energy, protein, vitamins, and minerals (1,2). Because of the high risk for malnutrition in persons with hepatic diseases the American Society for Enteral and Parenteral Nutrition (ASPEN) recommends protein restriction be no less than 0.6 to 0.8 g/kg and reserved to those patients during acute or refractory episodes of encephalopathy. Normal protein intake should be resumed of 1 to 1.2 g/kg after the cause of encephalopathy has been identifiedandtreated (3).Thewidespreadpracticeofproteinrestrictionforallpatientswithcirrhosisisnot justifiedandoftenleadstoiatrogenicproteinmalnutrition(3). Although malnutrition does not correlate with the type of liver disease, therapeutic modifications vary accordingtothetypeandseverityofhepaticinsufficiency.Generally,fattyliverrequireslittletononutrition intervention,whilecirrhosisnecessitatesmajorchangesinthepatientsfoodintake.Amajorgoalofmedical nutritiontherapyinliverdiseaseistopreventandtreathepaticencephalopathy(1,3).
Hepatic disease can profoundly affect the nutritional status of the patient because of its effects on carbohydrate, fat, protein, vitamin, and mineral metabolism. Metabolic disorders of the following are commonlyseenintheclinicalsettingofpatientswithhepaticinsufficiency:
Carbohydrates: Adverse effects can include hypoglycemia or hyperglycemia. Hypoglycemia is most frequentlyseeninacutehepatitisorfulminantliverdisease,probablyduetoimpairedgluconeogenesis (1,3). Hyperglycemia is commonly observed secondary to counteracting catabolic hormones and insulin resistancewhensuperimposedbyacutestressandinjury(1).Solublefibermaybebeneficialinmanaging hepatic encephalopathy. Soluble fiber is fermented in the colon by the same mechanism as lactulose, whicheliminatesammoniaintheformofammoniumionandbacterialproteins(3). Fats: Malabsorption may occur because of inadequate production of bile salts. This may lead to steatorrhea,whichcouldleadtodeficienciesinfatsolublevitaminandcalciumlevels.Researchershave foundanincreaseinserumlipids,reflectinglipolysis(1,3). Protein:Theeffectofhepaticinjuryonproteinmetabolismismoredramaticthaniscarbohydrateorfat metabolism.Thereisadecreaseinsynthesisofserumalbumin,thetransportationofproteins,andthe clottingfactors(1,3).Theabilityofthelivertosynthesizeureadecreases,whichresultsinanaccumulation of ammonia and a decrease in serum urea level. This derangement in metabolism elevates the serum aromatic amino acids (AAAs) (phenylalanine, tryptophan, and tyrosine) and methionine and decreases theserumbranchedchainaminoacids(BCAAs)(valine,isoleucine,andleucine).Theonlyenzymesthat metabolizeAAAsarelocatedinthehepatocytes.Inhepaticinsufficiency,thereisadecreaseinhepatic oxidation of AAAs, leading to an increase in circulation of AAAs in the plasma. In contrast, BCAAs are metabolizedprimarilybytheskeletalmuscle.ThereisanincreaseinBCAAoxidationinthe peripheraltissueduringstress,causingadropinplasmacirculation(1). Vitamins and minerals: Hepatic injury results in decreased absorption, transport, and storage and may alter the metabolism of vitamins and minerals. Cirrhotic livers have been reported to store decreased G1
Allrightsreserved.
ProteinControlledDiet
levelsofthiamin;folate;riboflavin;niacin;pantothenicacid;vitaminsB6,B12,andA;zinc;andcobalt (1,4). Inchronicliverdisease,thehydroxylationofdietaryandendogenousvitaminDtotheactiveform(25 hydroxy derivative) is impaired and may lead to a deficiency state with concomitant osteomalacia. Although there are possibilities of vitamin and mineral deficiencies, supplementation should be administered only when a specific nutrient deficiency is identified. Supplementation should be monitored. Vitamin K deficiency may be induced from malabsorption with steatorrhea, dietary deficiency, impaired hepatic storage, and/or decreased production of gut flora due to intake of antibiotics. If vitamin K deficiency occurs, the rate at which prothrombin is converted to thrombin is affected, thus hampering the coagulation process and producing inadequate clotting factors (1). Intravenousorintramuscular vitaminKoftenisgivenfor3daystoruleouthypopothrombinemiadueto deficiency(4).
NutritionalAdequacy Diets containing less than 50 g of protein may be inadequate in thiamin, riboflavin, calcium, niacin, phosphorus,andironbasedontheStatementonNutritionalAdequacyinSectionIA.Supplementationmaybe indicatedbut shouldbeassessed onanindividualbasis.This dietshouldbeconsideredatransitionaldiet. Normal protein intake should be resumed soon after the cause of encephalopathy has been identified and treated.Longtermproteinrestrictionshouldonlybeconsideredinpatientswithrefractoryencephalopathy (3). HowtoOrdertheDiet Thedietordershouldspecifythegramsofproteinrequiredfromfood.Basethegramsofproteinorderedon thepatientsactualweightoruseidealbodyweightincaseswhereweightcannotbemeasuredoraccurately accessed due to fluid issues (e.g, with ascites). To calculate weight, see Section II (Estimation of Energy Expenditures,orWeightforHeightCalculation5Rule).Ifaspecialformulaisrequested,theamountshould bespecified.Specifyanyrestrictionsuchassodium,fluid,orothernutrients. PlanningtheDiet Thetablebelowoutlinestherecommendednutrientprescriptionaccordingtotypeofhepaticdisease(3,5,6). TypeofHepaticDisease NutrientPrescription Fattyliver/steatosis Abstinencefromethanol Weightreduction,ifattributabletoobesity Reducedenergyanddextroseintake,especiallyifpatientisreceivingtotal parenteralnutrition(PN) Hepatitis (acute/chronic/alcoholic) Cirrhosis (uncomplicated) Cirrhosis (complicated) Esophagealvarices Ascites Energy:3035kcal/kg Protein:11.2g/kg Energy:3035kcal/kg Protein:11.2g/kg Energy:3035kcal/kg Protein:11.2g/kg(withmalnutrition) Liberaldietconsistency,normalconsistencyisencouragedastolerated Sodiumrestriction:2g/daywithdiuretics Fluidrestriction:useclinicaljudgment Fatsolublevitaminsupplementupto100%RDAmaybenecessaryin cholestaticcirrhosis(seesteatorrhea) Energy:35kcal/kg Protein:0.61.2g/kg.Startat0.6g/kgperdayandprogressto11.2 g/kgastolerated.Donotgiveproductsenrichedwithglutamine. Considerhighsolublefiberdiet
Hepaticencephalopathy
G2
TypeofHepaticDisease(Cont.) NutrientPrescription Hepaticcoma Usetubefeeding Protein:Startat0.6g/kgperdayandprogressto11.2g/kgdayas tolerated.Donotgiveproductsenrichedwithglutamine. Steatorrhea>10g/day or Cholestaticliverdiseasewith weightloss Fat:40g/day(longchaintriglycerides) Supplementwithmediumchaintriglyceridestoprovideadditionalenergy. Oralsupplementwithcalcium,1,25hydroxyvitaminD,andcalcitoninmay berequired. Mayrequiresupplementationoffatsolublevitamins.
Mealsizeandfrequency:Somepatientsrequiresmallportionsandfrequentfeedingsbecauseasciteslimits thecapacityforgastricexpansion.Studieshave shownthatthe metabolic profileafter anovernightfastin patients with cirrhosis is similar to normal individuals undergoing prolonged starvation without any associatedstress.Cirrhosiscanbeconsideredadiseaseofacceleratedstarvationwithearlyrecruitmentof alternativefuels.Asmallscalestudyshowedpatientswithcirrhosiswhoreceivedaneveningsnacktosupply energy during sleeping hours were able to maintain a greater positive nitrogen balance than did other patientswhowerefedlessfrequently(2). Commercialsupplements:Supplementationwithenteralformulasisoftennecessarytoincreasethepatients intake. Modular products of carbohydrates and fat can increase energy intake without increasing protein intake. The usefulness of special products containing BCAAs is controversial, and these products generally haveahighercost.TheguidelinesfornutritiontherapyinliverdiseasedevelopedbytheAmericanSociety for Enteral and Parenteral Nutrition (ASPEN) restrict the use of BCAA enriched formulas to patients with refractoryencephalopathynotrespondingtomedicaltherapy(7). SAMPLEMENU (50gofprotein) Breakfast Noon Evening CranberryJuiceCocktail(cup) GardenGreenSalad(1oz) OrangeJuice(c) OvenFriedChicken(2oz) withDressing(1Tbsp) Oatmeal(c) ButteredRice(c) RoastBeefSandwich Toast(2slices) SeasonedGreenBeans(c) RoastBeef,Shaved(1oz) Margarine(2tsp) DinnerRoll(1) Bread(2slices) Jelly(1Tbsp) Margarine(2tsp) Mayonnaise(2Tbsp) Milk(c) SlicedPeaches(c) SlicedTomato(1oz) Sugar Lemonade FreshFruitSalad(c) Coffee;Tea FruitPunch NondairyCreamer Snack Snack Snack HardCandy(6pieces) FruitIce(3oz) Banana(1) JellyBeans(1oz) DryCereal(oz) Milk(c)
Sources 1. WongK,KleinB,FishJ.NutritionManagementoftheAdultwithLiverDisease.In:SkipperA,ed.DietitiansHandbookofEnteraland ParenteralNutrition.2nded.Gaithersburg,Md:AspenPublishers;1998. 2. LevinsonM.Apracticalapproachtonutritionalsupportinliverdisease.Gastroenterologist.1995;3:234240. 3. TeranTC,McCulloughAJ.NutritionIn LiverDisease.In:GottschlichM,ed. TheScienceandPracticeofNutritionSupportACore BasedCurriculum.Dubuque,Ia:Kendall/HuntPublishingCompany;2001. 4. Hasse JM, Matarese LE. Medical nutrition therapy for liver, biliary system, and exocrine pancreas disorders. In: Mahan K, Escott StumpE,eds.KrausesFood,NutritionandDietTherapy.10thed.Philadelphia,Pa:WBSaunders;2000:710. 5. CorishC.Nutritionandliverdisease.NutrRev.1997;55:1719. 6. Shronts EP, Fish J. Hepatic failure. In: Merrit RJ, ed. The A.S.P.E.N. Nutrition Support Practice Manual. Silver Spring, Md: Aspen Publishers;1998. 7. ASPENBoardofDirectorsandtheClinicalGuidelinesTaskForce.Guidelinesfortheuseofparenteralandenteralnutritioninadult andpediatricpatients[publishederratumappearsinJPENJParenterEnteralNutr.2002;26:144].JPENJParenterEnteralNutr. 2002;26(suppl1):1SA138SA.
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PROTEINBASEDEXCHANGES
Exchange MeatandMeatSubstitutes Milk Starch/Bread Vegetables Fruit LowProteinProducts Sweets Fats Meatandmeatsubstitutes(7gprotein) Egg Cheese(naturalhardorsemisoft) Cheese,processed(eg,American) CottageCheese Meat,fish,poultry(leanportion,cooked) Meat(groundorflaked) Legumes(cooked): Blackbeans Garbanzobeans Kidneybeans Lentils Limabeans Pintobeans Blackeyedpeas(CowPeas) Peanutbutter Milk(4gprotein) Cream,HalfandHalf Cream,light Cream,heavy(whipping) Cream,heavy(fluid) Creamcheese Milk,whole,lowfat,nonfat,orchocolate Yogurt,fruited Yogurt,plain,lowfat,vanilla Custard Pudding Starch/Bread(2.5gprotein) Bread,white,rye,wholewheat Biscuit Cereal(cooked) Creamofrice Farina Grits Maltex Oatmeal Ralston Rolledwheat Wheatena Protein(g) 7 4 2.5 2 Negligible 0.2 Negligible Negligible Portion 1large 1oz 1oz cup 1oz cup(1oz) cup 2Tbsp cup cup cup cup 2Tbsp cup cup 1/3cup 1/3cup cup 1slice 1 6oz 6oz 6oz 4oz 4oz 4oz 4oz 4oz VariancesinPortionor ProteinContent(0.2g)Noted 1mediumegg=5.7g 6.6g 7.6g 7.3g 6.7g 8.9g 7.3g 7g 5.7g 7.9g 3.6g 3.3g 3.7g 3.6g 2.1g 4.5g Approx.1ozbiscuit=2g 1.6g 2.6g 2.7g 2.9g 3g 2.8g 2.5g 2.8g
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ProteinBasedExchanges(Cont.)
Portion
Starch/Bread(Cont) Cereal(readytoeat) 40%BranFlakes 1oz Cornflakes 1box(oz) Crisprice 1box(5/8oz Puffedrice oz Puffedwheat oz Shreddedwheat 1oz Crackers Graham 4squares Saltines 6 Muffin,corn 1 Pasta,rice,noodles(cooked) cup Icecream cup Icemilk cup StarchyVegetables(2.5gprotein) Corn cup Peas,green cup Potato(baked) 1(5oz) Potatoes,frenchfried(23incheslong) 10 Potato(mashed) cup Potato(peeledandboiled) 1small(5oz) Sweetpotatooryam(canned) cup Wintersquash cup OtherVegetables(2gprotein) Allothers(cooked) cup ExceptthoseinStarch/Breadand MeatandMeatSubstitutesgroups Fruits(negligibleprotein) All LowProteinProducts(eachexchangecontains0.2gprotein) Lowproteinbread 1slice(1oz) Lowproteinrusks 2slices Lowproteinmacaroniornoodles cup,cooked(cupdry) Lowproteingelatin cup,prepared(negligibleprotein) Lowproteincookies 2 Sweets(negligibleprotein) Fats(negligibleprotein) Candy:hardcandy,lollipops,jellybeans,gum ButterorMargarine drops,marshmallows OilorShortening Carbonatedbeverages Mayonnaise Lemonade;Limeade SaladDressing(exceptsourcreambasedorcream cheese) Noncarbonatedsoftdrinks Jam;jelly NondairyCreamer Popsicles;fruitice,italianice Gravy(meatdrippingswithfat,thickenedwith Sugar;syrup;honey cornstarch)
VariancesinPortionor ProteinContent(0.2g)Noted 3.6g 1.7g 1.2g 0.9g 2.1g 3.1g 2.3g 3g Approx.1oz=2.8g 2.4g 2.6g cup=4.1g 3.2g 3.2g 2g 1.5g
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MEDICALNUTRITIONTHERAPYFORCHRONICKIDNEYDISEASE
Description The approach to medical nutrition therapy for chronic kidney disease (CKD) is based on the stage and progression of kidney disease, comorbid conditions (eg, diabetes mellitus, hypertension, or cardiovascular disease), and renal replacement therapy (RRT). Medical nutrition therapy and nutrition intervention are providedbasedontheindividualizedneedsofthepatient.Thedietaryapproachismodifiedinoneormore ofthefollowingconstituents:protein,sodium,potassium,totalfluid,andphosphorus.Thedietmayalsobe modifiedtoprovideadequateamountsofenergy,vitamins,andminerals.TheAmericanDieteticAssociations ChronicKidneyDiseaseEvidenceBasedNutritionPracticeGuidelineandrecommendationsfromtheNational KidneyFoundationserveasaframeworkforprovidingcaretorenalpatientsbasedondiseasestageandthe requirement for RRT (1,2). These guidelines and resources, in addition to the guidelines cited below, are consistentwiththelanguageandtermsusedforreimbursementinMedicarebeneficiaries.
Indications ManagementofCKD:Thisdiseasecausesaprogressivereductioninrenalfunctionformorethan3months thatresultsinareducedabilitytocontrolbodywatervolume,acidbasebalance, hormonalregulation,and electrolyte concentrations (3). The five stages of CKD are described in Table G1: Definition and Stages of ChronicKidneyDisease (2).Stage1,whichistheleastseverestage,ischaracterizedbykidneydamagewitha glomerular filtration rate (GFR) greater than 90 mL/min per 1.73 m2; stage 5, the most severe stage, is characterizedbykidneyfailurewithaGFRlessthan15mL/minper1.73m2 (3).TheleadingcausesofCKD are diabetes mellitus and hypertension, which account for 65% to 70% of all new cases of endstage renal disease requiring RRT (3). Other causes of CKD include vascular disease, urologic disorders, and primary glomerularorinterstitialkidneydiseases(3).Symptomsofuremia,suchasnausea,anorexia,andalteredtaste sensation,canleadtoreducedoralintakeandanincreasedriskofmalnutritioninpatientswithCKD(3,4).The goalsfordietarymanagementinCKDaretominimizeuremictoxicity,preventwastingandmalnutrition,and complementtheprescribedRRTregimen.
TableG1:DefinitionandStagesofChronicKidneyDisease GFR WithKidneyDamage* (mL/min/1.73m2) WithHBP** WithoutHBP** 90 6089 3059 1529 <15(ordialysis) 1 2 3 4 5 1 3 3 4 5
WithoutKidneyDamage* WithHBP** WithoutHBP** HighBlood Normal Pressure HighBlood GFR Pressurewith GFR 3 3 4 4 5 5
Shadedarearepresentschronickidneydisease;numbersdesignatestageofchronickidneydisease. *Kidneydamageisdefinedaspathologicabnormalitiesormarkersofdamage,includingabnormalitiesinbloodorurinetestsorimaging studies.**Highbloodpressure(HBP)isdefinedas140/90mmHginadultsand>90thpercentileforheightandgenderinchildren. Maybenormalininfantsandtheelderly. Resource:DefinitionandStagesofChronicKidneyDisease.In:Part4.DefinitionandClassificationofStagesofChronicKidneyDisease. KDOQIClinicalPracticeGuidelinesforChronicKidneyDiseaseEvaluation,ClassificationandStratification.Availableat http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm.AccessedJanuary10,2011.
Typically, CKD progresses until treatment by RRT (dialysis) or transplantation is required. Dietary modificationsandpracticeguidelinesoutliningthescopeofnutritiontherapyarebasedontheclassification orstageofthedisease(1,2).PatientswithCKDaregenerallyclassifiedintwogroups(2,3): Patientsinstages1to5whodonotyetrequireRRT;managementisprimarilybydietmodificationsand medication,or Stage5patientswhorequireRRT(hemodialysis,peritonealdialysis,orothertypesofRRT).
This section focuses on medical nutrition therapy for CKD. The American Dietetic Associations Chronic Kidney Disease EvidenceBased Nutrition Practice Guideline provides the most current recommendations for CKDpatients(stages1to5)whoaremanagedprimarilybydietmodificationsanddonotrequiredialysis (1). Forstage5patientswhorequireRRT,theclinicianshouldrefertorecommendationsoutlinedintheNational KidneyFoundationsPocketGuidetoNutritionAssessmentofthePatientwithChronicKidneyDisease(2).Both oftheseresourcesprovidespecificguidelinesforthenutritioncareofadultkidneytransplantrecipients (1,2).
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MedicalNutritionTherapyforChronicKidneyDisease
The American Kidney Foundation has published diagnostic criteria and management strategies for acute kidneyinjury,whichreplacesthetermacuterenalfailure.Nutritioninterventionstrategiesforacutekidney injury are described in Table G3 of this section and in Section III: Nutrition Management of Acute Kidney InjuryandChronicKidneyDisease.
RRTs ThethreeprimarytypesofRRTsarehemodialysis,peritonealdialysis,andcontinuousRRT(2,3).
Hemodialysis:Hemodialysisaccountsfor80%ofallRRTsusedtomanagethecomplicationsofrenaldisease (3).Hemodialysisusesanartificialkidney(hemodialyzer)tocleansetheblood.Thisprocessreturnsthebody to a more normal state by removing excess fluid and waste products. However, it does not replace the endocrinefunctionsofthekidney.Theaveragetreatmentlasts3to5hoursandisperformedthreetimesa week.Treatmentisbasedonadequateureaclearancetoequalaureareductiongoalofgreaterthan65%ora Kt/V(clearanceofthedialyzertime/volume)ofgreaterthan1.2 (2,3).Hemodialysisremovessomewater soluble vitamins such as vitamin C, folic acid, and pyridoxine. Hemodialysis also removes certain minerals and electrolytes. Potassium is efficiently removed by hemodialysis, while phosphorus and magnesium are removed to a lesser degree (3). Hemodialysis may increase energy requirements because of lymphocyte stimulationandcomplementactivation (3).Hemodialysiscanbeperformedatadialysis center orathome. Therearetwotypesofmorefrequenthemodialysis,shortdailydialysisandnocturnaldialysis.Thesetypesof hemodialysis provide more treatment time with fewer side effects and risks; patients who receive more frequenthemodialysismayconsumeamoreliberaldietthanpatientswhoreceivethriceweeklyconventional hemodialysis(2).
Peritoneal dialysis: This type of dialysis involves the removal of waste products and water within the peritoneal cavity by using the peritoneal membrane as a filter. The dialysis solution (dialysate) is instilled through the peritoneal catheter into the peritoneal cavity or peritoneum. The many blood vessels and capillaries throughout the peritoneum are separated from the peritoneal cavity by a layer of mesothelium. Passive movement from the peritoneal capillaries into the dialysate removes the uremic toxins. The high osmolalityofthedialysateduetothehighdextroseconcentrationresultsintheremovalofextracellularfluid. ThistypeofRRTmayplacethepatientatincreasedriskforinfection(eg,peritonitis)andhyperglycemia (3). Therearetwomajortypesofperitonealdialysis: Continuousambulatoryperitonealdialysis(CAPD)isamanualdialysisprocess,wherebyacontinuous presenceofadialysateintheperitonealcavityisinterruptedintermittentlyfordrainageandinstillation of fresh dialysate. The dialysate is usually exchanged four times a day, with only a 30 to 35minute interruption ofdailyactivityduringeachexchange. Thedialysate remainsintheperitonealcavityfor 3to4hoursduringthedayand8to10hoursatnight. Continuous cyclic peritoneal dialysis (CCPD) or automated peritoneal dialysis provides more daytime freedomandadecreasedriskofinfectionbydecreasingthenumberofcatheterconnectionstotwoper day.Acyclermachinedeliversthreeorfourdialysateexchangeseachnight,lasting2to3hourseach. Approximately2Lofdialysateremainsintheperitonealcavityduringthedayfor12to15hoursandis thendrainedwhenthepatientbeginsthenightlyroutine. Intermittentperitonealdialysisisalsoavailable;however,itisnotastandardtreatment.
Patientswhoreceiveperitonealdialysismaydevelophypokalemia,sincecommerciallyavailablesolutions donotcontainpotassium (3).Potassiumcanbeliberalizedinthedietorsupplementedorallyifneeded.The peritonealdialysatecanprovideasubstantialamountofenergyfromglucosetothepatientwhenhypertonic solutions are needed for increased fluid removal (3). Diabetic patients may have a greater risk for hyperglycemia, and all patients can develop hypertriglyceridemia. A lowsodium, fluidrestricted diet can help eliminate the need for higher dextrose concentration solutions. The amount of total energy absorbed dependsontheinfusionvolume,dwelltime,anddextroseconcentration (3).(SeeDeterminationofGlucose Absorption in Peritoneal Dialysis later in this section.) The nutritional intake of patients who receive peritonealdialysismaybeaffectedbybloating,abdominalfullness,andlossofappetiteduetotheindwelling dialysate (3,4).Theproteinneedsofpatientswhoreceiveperitonealdialysisareincreased,anditisimportant to encourage a highprotein diet to minimize the risks of malnutrition and infection. Some patients may requireproteinorproteinenergysupplementationtomeettheirdailyestimatedproteinneedsof1.2to1.3 g/kg(2).
ContinuousRRT:ContinuousRRTsincludecontinuousvenovenoushemofiltration,continuousvenovenous hemodialysis, continuous hemodiafiltration, and slow continuous ultrafiltration (3). Each method uses a G7
different mechanism for fluid and solute clearance (3). Continuous arteriovenous hemofiltration and continuousarteriovenoushemodialysisrelyonarterialandvenouscannulationandthepatientsownblood pressure to provide the gradient for blood flow and dialysis (3). Although continuous RRT has a lower clearance rate than standard hemodialysis, it provides superior clearance of fluids, nitrogenous waste, and othermetabolicbyproductsandimprovedhemodynamicstabilitybecausetheprocessiscontinuous (3).This procedureisoftenusedinthecriticalcaresettingwhenpatientsarehemodynamicallyunstable.Inaddition, continuousRRThasbecomethepreferredmethodofdialysisforacutekidneyinjuryinsomecenters (3).As compared to hemodialysis, continuous RRT is more expensive, immobilizes the patient, and requires continuous anticoagulation (3). The amount of nitrogen loss is dependent on the type of continuous RRT; however, the differences in losses between methods are not significant (3). Daily protein requirements for adults on continuous RRT therapy are between 1 and 2.5 g/kg (3,4). The daily protein requirement for patientswhoreceivecontinuousarteriovenoushemofiltrationisfrom1.5to1.8g/kg,becausethelossesof small peptides and amino acids can be high (3,5). Fluid losses can be as great as 20 L/day, therefore fluid replacement is necessary to prevent hypovolemia, and electrolytes should be frequently monitored (3). EnergyneedsforacutekidneyinjurypatientsreceivingcontinuousRRTareapproximately1.3timesgreater than their resting energy expenditure requirements, or an average of 25 to 35 kcal/kg per day (3). The dialysateandreplacementfluidsusedinsometypesofcontinuousRRTprovidedextrose,thereforedextrose energyshouldbeincludedincalculationsdeterminingtotalenergy(3).
Transplantation A transplant offers a relatively favorable longterm outlook and improves the quality of life for many individualswithCKD,especiallyyoungchildren.Afunctioningtransplantedkidneyperformstheexcretory and regulatory functions of a normal kidney. Successful transplantation frees the patient from the time consuming demands of dialysis and a strict dietary regimen. Refer to the American Dietetic Associations Chronic Kidney Disease EvidenceBased Nutrition Practice Guideline and the National Kidney Foundations Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease for specific nutrition guidelinesbeforeandaftertransplantationforadults(1,2). NutritionalAdequacy Becauseindividualdietsforrenaldiseasevarywidelyastothenutrientscontrolled,ageneralstatementon nutritionaladequacyisnotgiven.Refertostatementsforeachconstituentintherespectivesections:
SectionIF:NutritionManagementofPotassiumIntake SodiumControlledDiet NutritionManagementofPhosphorusIntake
MANAGEMENTOFACUTEKIDNEYINJURYAND CHRONICKIDNEYDISEASE
HowtoOrdertheDiet Refer to the How to Order the Diet instructions for each of the components required in the respective chapters. See Nutritional Adequacy in this section. Also, refer to Nutrition Management of Fluid Intake in SectionIA.
NutritionAssessmentandNutritionIntervention PlanningtheDiet RefertoTableG3:DailyNutritionalRequirementsforAdultswithRenalDiseaseBasedonTypeofTherapy.
Body weight estimates are used to calculate the nutritional needs of patients with CKD (1). There are no standard reference norms in the CKD population (including kidney transplant recipients). Therefore, the registereddietitianshould useclinical judgmenttodetermine whichdata to includeinestimationsofbody weight, including actual measured weight; history of weight changes; serial weight measurements, and adjustmentsforthesuspectedimpactofedema,ascites,andpolycysticorgans(GradeIV)(1).Bodyweightcanbe difficult to determine because as kidney function decreases, the ability to regulate fluid balance may be compromised,andmultiplefactorsmustbeconsidered (1).Avarietyofpublishedweightnormscanbeused intheanthropometricassessmentofindividualswithCKD(includingkidneytransplantrecipients);however, eachnormhassignificantdrawbacksandshouldbeusedwithcaution(GradeIV)(1).Theassessmentofstandard body weight can be derived from National Health and Nutrition Examination Survey (NHANES II) weight table, which is based on sex, age, and frame size. (Refer to Section II: Standard Body Weight (SBW)
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DeterminationBasedonNHANESII.)Energy,protein,andtracemineralrecommendationsusestandardbody weight as the basis for determining the nutrient requirements for CKD patients (1,2,5,6). Although standard bodyweightdataisvalidatedandstandardizedandusesalargedatabaseofethnicallydiversegroups,data providesonlyactualweights,notidealweightsforthereductionofmorbidityandmortality(GradeIV)(5).
Energy CKD(stages1to5):TheenergyrequirementsofCKDpatientswhodonotreceivedialysisaresimilartothe requirements of healthy individuals and are influenced by age, sex, and physical activity level (1,5). Resting metabolicratesdeterminedbydirectandindirectcalorimetryaresimilarforpatientswithCKDandhealthy control subjects. Studies of individuals who consumed less than 0.8 g protein per kg of ideal body weight reportedaneutralorpositivenitrogenbalancewhenenergyintakeswerebetween35and45kcal/kgofideal bodyweightandanegativenitrogenbalancewhenenergyintakeswere15to25kcal/kgofidealbodyweight (1,7).Therefore,energyintakesshouldbegreaterforpatientswhoconsumelessthantheRecommendedDaily Allowance for protein (Grade I) (1). Five randomized controlled trials published between 2001 and 2007 examinedpatientswithanormalbodyweightandfoundthatatotalenergyintakeof23to35kcal/kgofbody weight (when consuming a proteinrestricted diet with a daily protein intake of 0.3 to 0.7 g/kg of body weight)isadequatetomaintainastablebodymassindexinadultnondiabeticpatientswithCKD (Grade II) (1). Overweight patients with CKD and type 1 or type 2 diabetes who receive a total energy intake of 1,780 to 1,823kcal(whenconsumingproteinrestricteddietswithadailyproteinintakeof0.68gto0.86g/kgbody weight) can decrease body weight without signs of malnutrition (Grade II) (5). When prescribing energy requirements for persons with CKD, the primary goals should be to provide an adequate amount of total energy to maintain or achieve a reasonable body weight and positive nitrogen balance (1). Based on this emergingevidence,the2010ChronicKidneyDiseaseEvidenceBasedNutritionPracticeGuidelinerecommends a daily energy intake of 23 to 35 kcal/kg body weight for all adults with CKD, including patients who have recovered from kidney transplantation surgery (Grade II)(1). The registered dietitian should consider weight status, nutrition goals, age, sex, physical activity level, and metabolic stressors when determining energy requirements(GradeII)(1).
Hemodialysis:Forpatients60yearsandolderwithstage5diseasewhoreceivedialysis,anenergyintakeof 30to35kcal/kgofidealbodyweightorstandardbodyweightissuggested (2,5,6).Forpatientsyoungerthan 60 years of age, energy needs should be calculated at a minimum of 35 kcal/kg of ideal body weight or standardbodyweight (2).TheAmericanDietetic Associationhasexploredevidenceregardingtheaccuracy and applicationof methodsto measure energyexpenditure. For additional information,referto SectionII: EstimatingEnergyExpenditure.
Peritoneal dialysis: In peritoneal dialysis, glucose is absorbed from the dialysate. Therefore, the dietary energyintakemayneedtobedecreasedtopreventexcessweightgainandobesity.Glucoseabsorptionvaries among patients due to differences in peritoneal permeability. Some patients who receive CAPD or CCPD absorb more than 800 kcal/day from the dialysate, depending on the exchange concentrations (5). (See DeterminationofGlucoseAbsorptioninPeritonealDialysislaterinthissection.)Energyabsorbedfromthe dialysateshouldbesubtractedfromthedailyenergyintakefromthediet(2,5,6).
Protein CKD(stages1to5):TheModificationofDietinRenalDisease(MDRD)trialfoundthatalowproteinintake reducesintraglomerularpressure,soluteload,andoverallnephronactivityandmaypreserverenalfunction or delay its progressive decline. (3,6,7). However, more recent trials with larger samples of subjects and a longerduration(upto2years)havedemonstratedthatalowproteindiet(0.6to0.897g/kgofbodyweight perdaywithoutketoacidsupplementation)didnotsignificantlyalterthedeclineinGFRwhencomparedtoa typicallevelofproteinintake(1.0to1.4g/kgperday),regardlessofthestageofCKDorthetypeofdiabetes among patients with diabetic nephropathy (Grade II)(1). A few studies have demonstrated that protein restricteddiets(0.7gdietaryproteinperkgofbodyweightperday)withadequatetotalenergyintakecan slowtheGFRdeclineandmaintainastablenutritionstatusinadultnondiabeticpatientswithCKD(GradeII)(1,7). Nutrition practice guidelines recommend that the protein intake be based on the patients creatinine clearance, estimated GFR, and urinary protein losses (1,2,4,6). A proteincontrolled diet with a daily protein intake of 0.6 to 0.8 g/kg of body weight is recommended for nondiabetic adults with CKD who are not on dialysis and have an estimated GFR that is less than 50 mL/minute/1.73 m2 (Grade II)(1). Clinical judgment shouldbeusedwhenrecommendinglowerprotein intakes; thepatientslevel of motivation,willingnessto participateinfrequentfollowuptesting,andriskforproteinenergymalnutritionshouldbeconsidered (Grade II)(1).
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Diabetic nephropathy: For adults with diabetic nephropathy, a proteincontrolled diet providing a daily proteinintakeof0.8to0.9g/kgofbodyweightisrecommendedbythe2010ChronicKidneyDiseaseEvidence BasedNutritionPracticeGuideline (Grade II)(1).Dietaryproteinintakeof0.7g/kgofbodyweightperdaymay cause hypoalbuminemia in some patients (Grade II)(1,7). However, a few studies have found that protein restricteddietsmayimprovemicroalbuminuria(1).
Hemodialysis: The recommended protein intake for patients who receive hemodialysis three times per weekisatleast1.2g/kgofstandardbodyweightperday(2,5,6).Anonfastingpatientloses10to13gofamino acidsandsmallpeptidesduringasinglehemodialysistreatment(3).Approximately30%to40%oftheamino acidslostduringhemodialysisareessential.Therefore,highbiologicalvalueproteinshouldprovideatleast 50%ofthetotalproteininthediet(2,57).Thereuseofartificialdialyzermembranesmayincreaseaminoacid losses,dependingonthecompositionofthedialyzer.
Peritonealdialysis:Theproteinrecommendationsforpatientswhoreceiveperitonealdialysisare1.2to1.3 g/kg of standard body weight (2,46). Protein requirements may be even higher, depending on the patients stress level or metabolic needs. When used for longterm management of CKD, peritoneal dialysis is associatedwithprogressivewastingandmalnutrition(3).Factorsthatcontributetowastinginclude:anorexia caused by inadequate dialysis, additional and secondary illnesses, discomfort, fullness, or severe dietary restriction; the loss of protein, amino acids, and vitamins to the dialysate; and peritonitis leading to catabolism.
Kidney transplant: For adult kidney transplant recipients who have recovered from surgery and have an adequatelyfunctioningallograft,adailyproteinintakeof0.8to1.0g/kgofbodyweightisrecommended(Grade IV)(1).Theregistereddietitianshouldconsiderthemedicalstatusofeachpatient,addressingindividualissues asneeded(1).Adequatebutnotexcessiveproteinintakesupportsallograftsurvivalandminimizestheimpact oncomorbidconditions(GradeIV)(1).
Fat Elevated levels of lipoproteins and abnormalities in lipid metabolism are common in patients with CKD (2). The National Kidney Foundation Task Force on Cardiovascular Disease has recommended the use of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III guidelines for patients with chronicrenaldisease,includingkidneytransplantrecipients (GradeII)(1,2).Forpatientswithrenaldisease,the target goals for cholesterol are modified slightly based on data from morbidity and mortality studies (2,5,8). For therapeutic lifestyle diet modifications, see Section C: Medical Nutrition Therapy for Disorders of Lipid Metabolism.
TableG2:RecommendedLipidLevelsforAdultswithChronicKidneyDisease(8) StageofRenalFailure RecommendedLipidLevelsa CKD(stage15) Cholesterol<200mg/dL Lowdensitylipoproteincholesterol<100mg/dL Highdensitylipoproteincholesterol>40mg/dL Triglycerides(fasting)<150mg/dL
CKDwithmaintenancedialysis(stage5)
Cholesterol180200mg/dL Lowdensitylipoproteincholesterol<100mg/dL
aLevelsmaybemeasuredasnonfastinglevelsexceptwhereindicated. Source:NationalKidneyFoundation,KidneyDiseaseOutcomesQualityInitiative.Guideline4:ManagementofDyslipidemiasinDiabetes andChronicKidneyDisease.NationalKidneyFoundation;2007.Availableat: www.kidney.org/professionals/kdoqi/guideline_diabetes/guide4.htm.AccessedFebruary20,2009.
SodiumandFluid CKD(stages1to5):ForadultswithCKD,includingkidneytransplantrecipients,the2010ChronicKidney Disease EvidenceBased Nutrition Practice Guideline suggests a sodium intake of less than 2.4 g/day with adjustments for blood pressure, medications, kidney function, hydration status, acidosis, glycemic control, catabolism, and gastrointestinal issues (eg, vomiting, diarrhea, constipation, or gastrointestinal bleeding) (GradeII)(1).Theprescribedfluidintakeshouldbesufficienttomaintainappropriatehydration(1,46).
Hemodialysis: The daily sodium allowance for patients who receive hemodialysis is 2 g/day with adjustments based on urine output (2,46). The more urine that the patient produces, the more sodium the patientmayeliminateviatheurine.Understeadystateconditions,urinaryoutputusuallyprovidesagood guideforfluidintake.Thevolumeofurineoutputperdayplus1,000mLoffluidisrecommendedtomaintain
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fluidweightgainoflessthan3%to5%oftheinterdialyticweightbetweenhemodialysistreatments (2,46).If thepatientisanuric,1,000to1,500mL/dayoffluidisrecommended(3,5,6).
Peritonealdialysis:SodiumbalanceandbloodpressurecanbewellcontrolledwithCAPDorCCPD.Asmuch as 5,700 mg/day of sodium can be removed with CAPD. Patients must understand the symptoms of hypotensionaswellasthemethodstoavoidit.Theappropriatesodiumrequirementforeachpatientshould be determined from an evaluation of parameters including weight (dry weight vs fluid weight), blood pressure (hypotension or hypertension), shortness of breath, and edema (5). The sodium intake for most patientsshouldbe2g/day (2).ThesuggestedfluidintakeforpatientswhoreceiveCAPDorCCPDitis2,000 mL/day(2).Patientsshouldmonitortheirweightandbloodpressureandadjusttheirsodiumandfluidintake as necessary. Adjustments in fluid balance can be made by altering the quantity or concentration of hypertonic solutions. Patients must measure their own blood pressure and weigh themselves regularly to determinetheglucoseconcentrationofdialysatenecessarytomaintainfluidbalance(2,5,6).
Potassium CKD(stages1to5):The2010ChronicKidneyDiseaseEvidenceBasedNutritionPracticeGuidelinesuggests thatCKDpatients(stages3and4),includingkidneytransplantrecipients)whoexhibithyperkalemiashould be prescribed less than 2.4 g/day of potassium, with adjustments based on serum potassium levels, blood pressure, medications, kidney function, hydration status, acidosis, glycemic control, catabolism, and gastrointestinalissues(eg,vomiting,diarrhea,constipation, orgastrointestinalbleeding) (Grade II)(1).Dietary andothertherapeuticlifestylemodificationsarerecommendedaspartofacomprehensivestrategytoreduce cardiovascular disease risk in adults with CKD (1). The degree of hypokalemia or hyperkalemia can have a directeffectoncardiacfunctionandshouldbecarefullymonitoredandadjustedbasedonbiochemicalvalues (1,2).
Hemodialysis: For patients who receive hemodialysis, a potassium intake of 40 mg/kg of standard body weightisrecommended;or,thepotassiumintakecanbedeterminedfromlaboratoryvalues (2,5,6).Anintake of 2 to 3 g/day has also been suggested (3,6). Hemodialysis removes potassium; therefore, monitoring potassiumlevelsandensuringadequateintakeisimportant(3).Inadequatedialysis,gastrointestinalbleeding, hyperglycemia,infection,andcatabolismcancausehyperkalemia,whichcanleadtolifethreateningmedical problems (2).Adjustmentsinpotassiumintake(eitherfromthedietorfromthedialysatebath)canbemade toachievetargetpotassiumlevels(2).
Peritonealdialysis:PatientswhoreceiveCAPDorCCPDmaynotneedpotassiumrestrictions;however,an assessmentshouldbebasedonthepatientslaboratoryvalues (2,5,6).Peritonealdialysiscanincreasetherisk for hypokalemia, since most commercially available solutions do not contain potassium (3). If needed oral supplementation and/or dietary intake can be adjusted to compensate for low potassium levels . A target intakeof3to4g/dayofpotassiumissuggested(3,5,6).
Phosphorus Alterations in calcium, phosphorus, and vitamin D metabolism result in secondary hyperparathyroidism, causingrenalosteodystrophyandcardiacandextraskeletalcalcification (5,6,9).Derangementsinmineraland bonemetabolismcommontoCKDareassociatedwithincreasedmorbidityandmortality(9).Thisassociation prompted the development of the KDOQI (Kidney Disease Outcomes Quality Initiative) Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease (9). These guidelines provide recommendations for the evaluation of phosphorus, calcium, plasma intact parathyroid hormone, and alkaline phosphorus and for the management and treatment of abnormalities with vitamin D, phosphate binders,anddialysatebaths (9).Phosphoruscontrolisthecornerstoneforthetreatmentandpreventionof secondaryhyperparathyroidism,bonedisease,andsofttissuecalcificationinCKD(1).
CKD (stages 1 to 5): The 2010 Chronic Kidney Disease EvidenceBased Nutrition Practice Guideline recommends that adults with CKD (stages 3 and 4) receive a lowphosphorus diet providing 800 to 1,000 mg/day or 10 to 12 mg/g of protein (Grade II) (1). Serum phosphorus levels are difficult to control with diet alone,thereforeaphosphatebinder may berequired (1,5,6).Foradultswith CKD(stages3and 4),the dose andtimingofphosphatebindersshouldbeindividuallyadjustedaccordingtothephosphatecontentofmeals andsnackstoachievethedesiredserumphosphoruslevels(GradeIV)(1).
Hemodialysisandperitonealdialysis:Phosphorusrequirementsshouldbeindividualizedorlimitedto10 12mg/kgofstandardbodyweightor8001000mgwhenserumphosphoruslevelsapproachtheupperlimit ofnormalrange(1,5,6).
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Aphosphorusrestrictionisadvisedwhentheintactparathyroidhormonelevelisgreaterthan70pg/mLin stage3CKDpatients;greaterthan110pg/mLinstage4CKDpatients;orgreaterthan300pg/mLinstage5 CKD patients (3,5,9). Controlofserum phosphoruslevels isusuallynot possiblebydiet alone (5,9). Calcium based, or noncalciumbased, nonaluminumbased phosphate binders are given at mealtimes to bind the phosphatefromfood.Theprescribedamountofphosphatebindersshouldbeindividualizedaccordingtothe amountofphosphatepresentinameal.Approximately60%to70%ofingestedphosphorusisabsorbed (10). However,100%ofadditivephosphorusfromfoodenhancersorpreservativesisabsorbed,andphosphorusis frequentlyaddedtomanyfoodsthatwereonceconsideredtobelowphosphorusfoods.Onegramofcalcium carbonate (CaCO3) binds roughly 39 mg of phosphorous, and 1 g of calcium acetate binds 40 to 60 mg of phosphorous. Whereas CaCO3 contains 40% elemental calcium, calcium acetate is composed of 25% elementalcalcium.Calciumacetatecontains167mgofelementalcalciumineachtablet,andCaCO3contains 500mg.Withanincreasedcalciumphosphorousproduct,sevelamerhydrochloride,sevelamercarbonate,or lanthanum carbonate may be more effective and will not contribute to elevated phosphorus and calcium levels. One 800mg tablet of sevelamer hydrochloride or sevelamer carbonate replaces a calcium acetate tablet (11,12).Typicalstartingdosesoflanthanumcarbonateare500to1,000mgwithadesignatedmeal.If calciumandphosphoruslevelsareatthehighendofthenormalrange,acalciumbindermayincreasethese levels to exceed the normal range and contribute to softtissue calcification. The goal is for the serum calciumphosphorusproducttobelessthan55mg2/dL2 (5,6,10).Aluminumcontainingphosphatebindersare not recommended due to the risk for aluminum toxicity, which can lead to osteodystrophy, anemia, and encephalopathy(3,9).
Calcium CKD (stages 1 to 4): The secretion of parathyroid hormone, which affects bone integrity and soft tissue calcification,isprimarilyregulatedbyserumcalcium (1).TheChronicKidneyDiseaseEvidenceBasedNutrition Practice Guideline recommends that the total elemental calcium intake in adults with CKD (stages 3 and 4, including kidney transplant recipients) not exceed 2,000 mg/day (including dietary calcium, calcium supplementation,andcalciumbasedphosphatebinders)todecreasethepredispositionformineralandbone disorders(GradeIV)(1).TheuseofvitaminDandothersupplementsthatimpactthecalciumlevelshouldalsobe consideredinthenutritionassessmentofcalciumneeds(1,5,6,9,13).
Hemodialysisandperitonealdialysis:Calciumintakeshouldbelessthan2,000mg/dayorindividualized based on calcium, phosphorus, and parathyroid hormone levels and the use of vitamin D supplementation (2,5,6,9).IntestinalabsorptionofcalciumisimpairedinuremiaduetothelackoftheactiveformofvitaminD (3). Also,dietsprescribedforpatientswithCKDtendtobelowincalciumbecauseoftherestrictionofdairy products (5). Calcium supplementation is not typically recommended due to an association between increasedcalciumloadandcardiovascularcalcificationinCKDpatients.AsinCKD(stages1to4),thegeneral dietaryrecommendationforpatientswhoreceiveRRTdependsonserumcalciumlevelsandotherfactors.If calcium supplements are needed, they should be taken between meals and not be confused with those supplementsusedtobindphosphorus.AnactivatedformofvitaminDcanalsobeusedtoenhancecalcium absorption.Itisimportanttouseanadjustedcalciumlevelinpatientswithlowalbuminlevels.
Magnesium The kidney is the organ primarily responsible for the maintenance of serum magnesium. Patients with uremia should be wary of laxatives, enemas, antacids, or phosphate binders (eg, MagneBindTM, which combinesmagnesiumandCaCO3)thatcontainmagnesium(3,4).Iftheseproductsareused,magnesiumlevels should be monitored (2). Excess magnesium mainly accumulates in bone tissue, where it is deleterious to bone metabolism. Symptoms of excess magnesium include muscle weakness, hypotension, electrocardiographic changes, sedation, and confusion. If the patients magnesium levels are too high, the levelofmagnesiuminthedialysatecanbedecreased.
GuidelinesforVitaminandTraceMineralSupplementationinCKD Vitamins:ThedietforCKDcontainslessthantheDietaryReferenceIntakes(DRIs)forseveralwatersoluble vitaminsbecauseoftherestrictedintakeoffoodshighinproteinandpotassium (5).Othercausesofvitamin deficienciesincludeimpairedfoodintakeasaresultofuremiaandalterationsintheabsorption,metabolism, or activity of some vitamins. The most common vitamin deficiencies in CKD include vitamin D, folic acid, vitamin B6, and vitamin C (5). Studies do not support the routine supplementation of fatsoluble vitamins other than vitamin D for patients consuming wellbalanced, adequate diets (5,9). Patients with CKD have a predispositionformineralandbonedisorders,aswellasotherconditionsthatmaybeaffectedbyinsufficient vitaminD (1).RegistereddietitiansshouldrecommendnutritionalvitaminDsupplementationtoadultswith
G12
CKD, including kidney transplant recipients, whose serum levels of 25hydroxyvitamin D are less than 30 ng/mL(75nmol/L) (GradeIV)(1).Supplementsof1,25dihydroxyvitaminD(calcitriol),theactivemetaboliteof vitamin D, can be provided to maintain normal calcium homeostasis and prevent osteomalacia (3). SupplementationwithvitaminDanalogs,paricalcitol(Zemplar)anddoxercalciferol(Hectorol),canbeusedto treat secondary hyperparathyroidism. The advantage of using the analogs as opposed to calcitriol is the decreased absorption of phosphorus and calcium in the gut (13). Supplementation with 1,25 dihydroxycholecalciferol,theactiveformofvitaminD,inthepresenceofCaCO3,mustbeindividualized,and its effects on calcium levels must be frequently monitored (9). Deficiencies of watersoluble vitamins, especially vitamin C, folate, and vitamin B6, may occur secondary to poor appetite, altered metabolism, uremia, removal by dialysis, and a restricted diet (3,5,6). Each patient should be evaluated and treated with vitaminsaccordingtoindividualneedandaftertheappropriateassessmentofbiochemicallevels (1,2,46,9).In adults with CKD (including kidney transplant recipients), the clinician should recommend vitamin B12 and folicacidsupplementationifthemeancorpuscularvolumeisgreaterthan100ng/mLandtheserumlevelsof thesenutrientsarelessthannormalvalues (GradeIV)(1).VitaminCsupplementationatalevelgreaterthanthe DRI is not recommended to manage anemia in patients with CKD (stages 1 to 4) due to the risk of hyperoxalosis(GradeIV)(1).IfvitaminCsupplementationisproposedtoimproveironabsorptioninstage1to4 CKD patients (including kidney transplant recipients) who are anemic, the registered dietitian should recommend the DRI for vitamin C (Grade IV) (1). Vitamin C supplementation (60 to 100 mg/day) is recommendedforadultswhoreceiveRRT(hemodialysisandperitonealdialysis)(5,6);however,dosesgreater than 200 mg/day increase blood oxalate levels, which can result in the deposition of oxalate in the heart, kidney,andbloodvessels (3).Thiaminsupplementationof1.5to2mg/dayissuggestedforpatientsonCAPD becauseofdialysisloss (5,6).Supplementationwithfolicacid(1mg/day),vitaminB6(2mg/day),andvitamin B12(3mcg/day)issuggestedforpatientswhoreceivehemodialysisorperitonealdialysis(3,5,6).
Trace minerals: Patients with CKD experience alterations in the metabolism of trace minerals, especially zinc and iron. Serum or tissue levels of these trace minerals can be high or low. Trace minerals should be supplemented or restricted only after performing the appropriate biochemical assessments (5). Zinc supplementation (15 mg/day) is suggested for patients who receive hemodialysis or peritoneal dialysis (5). Iron status should be routinely evaluated and supplemented based on individual need (5,6). In adults with CKD (stages 1 to 4, including kidney transplant recipients), the dietitian should recommend oral or intravenous iron administration if the serum ferritin level is less than 100 ng/mL and the transferrin saturation, referred to as TSAT, is less than 20% (Grade IV)(1). Sufficient iron should be recommended to maintainadequatelevelsofserumirontosupporterythropoiesis(GradeIV)(1).
MANAGEMENTOFACUTEKIDNEYINJURYAND CHRONICKIDNEYDISEASE
DiabetesManagementinPatientswithCKD Medical nutrition therapy for people with diabetes mellitus and kidney disease is complex and requires an individualizedapproach (1,2,5,6,8).ForadultswithdiabetesandCKD(includingkidneytransplantrecipients), theclinicianshouldimplementmedicalnutritiontherapytomanagehyperglycemiawithatargethemoglobin A1C level of approximately 7% (Grade I) (1). Intensive treatment of hyperglycemia, while avoiding hypoglycemia, prevents the development of diabetic kidney disease and may slow the progression of establishedkidneydisease (Grade I)(1). In additionto thenutrient modificationsrequired formanagingrenal disease,consistentcarbohydrateintakeisaprimarygoalforpersonswithdiabetesmellituscomplicatedby CKD.ThetreatmentapproachshouldfollowtheguidelinesoutlinedinSectionIC:MedicalNutritionTherapy forDiabetesMellitus.The2002versions(secondeditions)ofAHealthyFoodGuideforPeopleWithChronic KidneyDiseaseandAHealthyFoodGuideforPeopleonDialysisfocusoncomplementingthepatientsexisting diabetesmealplanningapproaches(eg,constantcarbohydratemealplan,carbohydratecountingmealplan, or exchange meal plan) (2,6). These publications also recommend strategies that best meet the nutritional needsofthepatientandthatpromoteormaintainglucosetolerance.

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Diagnosis/ Therapy
Acutekidney injury(5)
TableG3:DailyNutritionalRequirementsforAdultswithRenalDiseaseBasedonTypeof Therapy
Energy
2535 kcal/kga,or determine viaindirect calorimetry
Protein
0.81.2g/kga withno dialysis
Fluid
Sodium
Anuric/ oliguricphase: 23g; basedonblood pressureand edema
Potassium
Anuric/oliguric phase: 23g
Phosphorus
8to15mg/kga
Consider stresslevel.
Anuric/ oliguric phasec:500 mL+total 1.21.5g/kga output(urine, withdialysis vomitus,and orifcatabolic diarrhea)
Individualizebasedon serumvalues.
Include energyfrom continuous RRT,if applicable. Stage14 CKD(1) 2335 kcal/kga
Diureticphase: Largevolume offluidsmay beneeded. Assess frequently. 0.60.8g/kga without diabetes

(GradeII)(1)
(GradeII)(1)
Stage5CKD/ Hemodialysis (5,6,9,14)
3035 kcal/kgaif 0.80.9g/kga >60yearsold withdiabetic (6,14) nephropathy (GradeII)(1) >1.2g/kga 35kcal/kga <60yearsold with>50% 3035 HBVb kcal/kgaif >60yearsold
Individualize tomaintain appropriate hydration status.
Diureticphase: Replacebased onurine output,edema, needfor dialysis,and serumsodium levels. Individualizeor <2.4g(GradeII) (1)
Diureticphase: Replacelosses dependingon urinevolume, serumpotassium levels,andneedfor dialysisand medication.
Individualize basedon laboratoryvalues. Ifhyperkalemia, <2.4g(forstages3 and4)(GradeII)1) 23g Individualize basedon laboratoryvalues.
Basedonserumvalue
Forstages3and4,800 1,000mgor1012mg/gof protein(GradeII)(1)
Urineoutput +1,000mL 1,0001,500 mLifanuric
Individualizeor 2g
Doseandtimingof phosphatebinders individualized(GradeIV)(2) Individualize,or <1012mg/kgaor800 1,000mgwhenserum phosphoruslevels approachtheupperlimit ofnormalrange(2)
Usuallyrequires phosphatebinder(9) Stage5CKD/ Peritoneal dialysis (5,6,9,14) 35kcal/kga
3035 kcal/kgaif >60yearsold
1.21.3g/kga with>50% HBVb
Subtract energy absorbed from dialysate fromdaily energy prescription.
Individualize tomaintain fluidbalance andblood pressure.
Individualizeor 2g
34g Adjusttoserum levels.
Individualize,or <1012mg/kgaor800 1,000mgwhenserum phosphoruslevels approachtheupperlimit ofthenormalrange(2)
Usuallyrequires phosphatebinder(9)
aTocalculatetheserequirements,usestandardbodyweightderivedfromtheNHANESIIweighttablebasedonsex,age,andframesize.(See SectionII:StandardBodyWeight(SBW)DeterminationBasedonNHANESII.)Insomecases,actualbodyweightoradjusteddryweightmaybe moreappropriatethanstandardbodyweight(152).Inallcases,individualpractitionersshouldusetheirownclinicaljudgmentandexpertisein selectingamethod(1,2,5,9). bHBV,highbiologicalvalueprotein cAnuric/oliguricphasereferstolessthan500mLofurineoutputper24hours(1,14).
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EstimatesofCaloriesAbsorbedinPeritonealDialysis
Energy requirements and nutrient intake calculations for patients who receive peritoneal dialysis should include carbohydrate absorption from the dialysate. The most accurate method of determining the energy loadistomeasurethegramsofglucoseintheeffluentandcomparethatwiththegramsofglucoseinfused(2).
Simple estimate of glucose absorption in peritoneal dialysis: The following quick estimate does not considertheperitonealequilibrationtest(2) ForCCPD:[(dextrose%xL)x3.4]x40%=energy(kcal)(2) ForCAPD:[(dextrose%xL)x3.4]x60%=energy(kcal)(2) Glucoseabsorbed(kcal)(2) =Glucoseinfused(mL)x40%APD*orGlucoseinfused(mL)x60%absorption (CAPD).Fora1LvolumeofdialysateinCAPD: 1.5%=15gx3.4kcal/g=51kcalx60%=31kcal/L 2.5%=25gx3.4kcal/g=85kcalx60%=51kcal/L 4.25%=42.5gx3.4kcal/g=144.5kcalx60%=86.7kcal/L
*APDautomatedperitonealdialysis
Example(2):ApatientonCAPDuses4Lof1.5%solutionand4Lof4.25%solution. 4L,1.5%=124kcal 4L,4.25%=346kcal Total=470kcal

References 1. Chronic Kidney Disease EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. AmericanDieteticAssociation;2010.Availableat:www.adaevidencelibrary.com.AccessedOctober25,2010. 2. McCannL,ed.PocketGuidetoNutritionAssessmentofthePatientwithChronicKidneyDisease.4thed.NewYork,NY:NationalKidney Foundation;2009.Availableatwww.kidney.org/professionals/crn/pocketGuide/index.cfm. 3. WolkR,MooreE,FoulksC.Renal disease.In:Gottschlich MM,ed. TheA.S.P.E.N.NutritionSupportCoreCurriculum: ACaseBased ApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyForParenteralandEnteralNutrition;2007:575598. 4. KoppleJD,MassrySG,eds.NutritionManagementofRenalDisease.2nded.Philadelphia,Pa:LippincottWilliams&Wilkins;2004. 5. Chronic kidney disease. In: The American Dietetic Association Nutrition Care Manual. Updated annually. Available at: www.nutritioncaremanual.org.AccessedOctober25,2010. 6. Renal Practice Group of the American Dietetic Association. National Renal Diet: Professional Guide. 2nd ed. Chicago, Ill: American DieteticAssociation;2002. 7. CaggiulaAW,LeveyAS.MDRDStudydatasuggestbenefitsoflowproteindiets.JAmDietAssoc.1995;95:1289. 8. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic KidneyDisease.AmJKidneyDis.2007;49(suppl2):S12S154. 9. NationalKidneyFoundation.KDOQIClinicalPracticeGuidelinesforBoneMetabolismandDiseaseinChronicKidneyDisease.AmJ KidneyDis.2003;42(suppl3):S1S201. 10. HsuCH.Arewemismanagingcalciumandphosphatemetabolisminrenalfailure?AmJKidneyDis.1997;29:641649. 11. Malluche HH, MonierFaugere MC. Hyperphosphatemia: pharmacologic intervention yesterday, today and tomorrow. Clin Nephrol. 2000;54:309317. 12. Renagel[packageinsert].Cambridge,Mass:GenzymeCorp;2001. 13. Slatopolsky E., Martin KJ, Sherrard DJ. Should vitamin D analogs be the therapy of preference for ESRD patients with secondary hyperparathyroidism?DialTransplantation.2001;30:190195. 14. WigginsKL,ed.GuidelinesforNutritionCareofRenalPatients.3rded.Chicago,Ill:AmericanDieteticAssociation;2002. Bibliography CentersforMedicare&MedicaidServices.EndStageRenalDisease(ESRD)ProgramInterpretiveGuidanceVersion1.1.October2008 update.BaltimoreMd:DeptofHealthandHumanServices;2008.Ref:S&C0901. National Kidney Foundation. KDOQIClinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification.AmJKidneyDis.2002;39(suppl1):S1S266.
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DIETARYMANAGEMENTUSINGTHEHEALTHYFOODGUIDEFOR PEOPLEWITHCHRONICKIDNEYDISEASE
Before determining a patients diet prescription and calculating his or her meal plan, the dietitian should performacompletenutritionassessment,withspecialattentiontothefollowingfactors: 1. Medicalhistory. 2. Physiciansorders. 3. Treatment modality (preendstage renal disease [preESRD], hemodialysis, or peritoneal dialysis). Nutritionmanagementoftherenalpatientdependsonthemethodoftreatmentaswellasonmedicaland nutritionalstatus.Acomparisonoftreatmentmethodsandprimaryconcernsineachissummarizedin thetablebelow. 4. Presenceofotherchronicdiseasesthatmayaffectthenutritionalstatus.Asaresult,thedietprescription alsowillbeaffected.
ComparisonofTreatmentApproachesforPatientsWithCKD RenalReplacementTherapy StageofCKD Treatment (RTT) CKDStage1 Dietand None 5(without medications dialysis)
Duration Indefinite
MetabolicConcerns Glomerular hyperfiltration;rise inBUN;bone disease Hypertension; glycemiccontrolin diabetes Aminoacidloss; interdialytic electrolyteandfluid changes Bonedisease; hypertension Proteinlossinto dialysate;glucose absorptionfrom dialysate Bonedisease;weight gain;hyperlipidemia; glycemiccontrolin diabetes
Hemodialysis
Dietand medications; hemodialysis
Dialysisusingvascularaccessfor wasteproductandfluidremoval
35h 23d/wk
CAPDor CCPD
Dietand medications; peritoneal dialysis
Dialysisusingperitoneal membraneforwasteproductand fluidremoval
35 exchanges 7d/wk
ThesecondeditionoftheNationalRenalDiet(1)andeducationalguides,HealthyFoodGuideForPeopleWith Chronic Kidney Disease (2), and Healthy Food Guide for People on Dialysis (3) is recommended by the Renal PracticeGroupoftheAmericanDieteticAssociationasthemealplanningapproachforpersonswithCKD(13). Thiseditionusesanapproachthatisflexibleandencouragesselfmanagementtrainingandindividualization for both the patient and registered dietitian (1). Foods are divided into groups or choices according to nutrient content and are categorized based on the amount of protein, energy, sodium, potassium, and phosphoruscontent. The following information and tables are reprinted with permission from the American Dietetic Association, National Renal Diet: Professional Guide (1), Healthy Food Guide for People With Chronic Kidney Disease(2),andHealthyFoodGuideforPeopleonDialysis(3),2002.
aCAPD indicates continuous ambulatory peritoneal dialysis; CCPD, continuous cyclic peritoneal dialysis; and BUN, blood (serum) urea nitrogen.
OverviewoftheNationalRenalDiet TheNationalRenalDiet,secondedition, version2002,simplifiestheapproachtomedicalnutritiontherapy managementforpersonswithCKD.Thenewerversionsfocusontwoprimarydietapproaches,oneforuse withCKDpatientsstages15withoutdialysis(HealthyFoodGuideforPeoplewithChronicKidneyDisease[Pre
G16
Allrightsreserved.
ESRD)(2)andoneforusewithpatientsondialysis(HealthyFoodGuideforPeopleonDialysis)(3).Theintentof the revised version is to simplify the diet approach and allow for more flexibility and selfmanagement training opportunities with the patient. The National Renal Diet Professional Guide, second edition, can be usedtoprovidedetailreviewofthesetwodietapproaches(1).
TheguidesforCKD(stages15withoutdialysis)anddialysisareverysimilarbutdiffersomewhatinhow foodsaregroupedandcategorized.Differencesinhowfoodsaregroupedarebasedontheuniqueneedsof personswithstage15CKDcomparedwiththosewithCKDstage5ondialysis.Asummarycanbereviewed inTablesG3.1toG3.5:HealthyFoodGuideforPeopleWithChronicKidneyDisease(stage15)(1,2)andTables G4.1toG4.6:HealthyFoodGuideforPeopleonDialysis (1,3).Inbothguides,foodliststhatareprovidedare limitedtothemostcommonfoods.Thedietitianwillneedtoworkwiththepatienttoaddressservinglimits, servingsizes,andadditionalfoodchoicesthatmaynotbeincludedonthelistsprovided.Foodchoicesinboth guides are grouped according to the amount of protein, calories, sodium, potassium, and phosphorus. Nutrient composition of foods can vary greatly, depending on the size, variety, growing conditions, processing,packaging,andfinalpreparation(1).NutritionistsIVandV(FirstDataBank)wereusedtoupdate foodlistsfortherevisedNationalRenalDietguides(1).
TablesG3.13.5:HealthyFoodGuideforPeoplewithChronicKidneyDisease(PreESRD)
TableG3.1:HighProteinFoods HighProteinFoodChoices:Thehighproteinfoodlistincludessourcesofproteinfrombothanimalsand vegetables that provide a highbiological source of protein (providing 6 to 8 g protein per serving). Foods thatprovideahighsourceofphosphorusandsodiumareidentified(seefootnotes).
FoodList Highprotein Higher phosphorus proteins Higher sodium proteins
Protein (g/serving) 68 68
Calories (kcal/serving) 50100 50100
Sodium (mg/serving) 20150 20150
Potassium (mg/serving) 50150 50350
Phosphorus (mg/serving) 50100 100300(ifmarked a*) 50100
68
50100
200450(if markedwith b**)
50150
*afoodcontains100300mgphosphorusperserving. **bfoodcontains200450mgsodiumperserving.
TableG3.2:LowProteinFoods LowerProtein Food Choices: The lowprotein food choices include vegetables as well as breads, cereals, and other grain foods, and desserts that provide 2 to 3 g protein per serving. The foods contained in this grouphelptocompletetheprotein,nutrient,andcalorieneedsofthepatient.MostCKDpatientsdonotneed tomonitorpotassiumintake,butifnecessary,vegetablesaregroupedbypotassiumcontent.
FoodList Vegetables (separatedby potassium content) Breads,rolls, cereals,grains, crackers, snacks, desserts Highersodium and/or phosphorus grainfoods
Protein (g/serving) 23
Calories (kcal/serving) 10100
Sodium (mg/serving) 050
Potassium (mg/serving) 1)20150 2)150250 3)250550 10100
Phosphorus (mg/serving) 1070
23
50200
0150
1070
23
50200
10100
100200(ifmarked witha*)
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TableG3.3:FruitChoices FruitChoices:Fruitsaddverylittleproteintothediet(0to1gperserving)butprovidenecessaryvitamins, calories, fiber, and flavor. The fruit lists are grouped according to potassium content for those needing to monitorpotassiumintake. Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) 01 20100 010 1)20150 120 Fruits 2)150250 (groupedby 3)250550 potassium content)
TableG3.4:CalorieandFlavoringChoices CalorieandFlavoringChoices:Foodsgroupedinthiscategoryhelptoaddextracaloriesandflavortofoods tohelpenhancecaloricintakeandcanbeaddedtothediettopreventweightloss. Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Calorie 01 100150 0100 0100 0100 choices Flavorchoices 0 020 250300 0100 020
TableG3.5:VegetarianProteinChoices VegetarianChoices:Thesectiononvegetarianchoicesisintendedforpatientswhoavoidanimalfoods.It canreplacetheproteinchoicessection(Tables3.1to3.2).Table3.5providesnutrientvaluesofvegetarian proteinsandfoodscategorizedinthisgroup.Choosingvegetarianproteinsoveranimalproteinsmayresult inahigherphosphorusload.Ifthisisaconcern,phosphorusbindersmaybeneeded,orthepatientmayneed to limit other highphosphorus foods (See the dairy and phosphorus choices, Table 4.3, in A Healthy Food GuideforPeopleonDialysis.) Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Proteinfoods 68 70150 10200 60150 80150 Higher 68 70150 250400 250500 200400(marked sodium, (markedwith (markedwith witha*) potassium,or b**) c***) phosphorus proteins
*afoodcontains200400mgphosphorusperserving. **bfoodcontains250400mgsodiumperserving. ***cfoodcontains250500mgpotassiumperserving.
CalculatingFoodChoicesforPeoplewithCKD(Stages15)(1,2) 1. RefertoSectionIG,TableG2:NutritionalRequirementsforAdultswithRenalDiseaseBasedonTypeof Therapytodeterminenutritionneeds. 2. Oncenutritionneedsareknown,calculateandidentifyproteinneedsanddeterminechoicesfromTables G3.1toG3.2.Atleast50%oftheproteinshouldcomefromtheHighProteinFoodList(TableG3.1)to ensurehighbiological proteinsareconsumed.Choicesfromthehigherphosphorusandsodiumgroups canbeincludedasneededbythedietitiansdiscretiontomeetthepatientsnutritionneeds. 3. Lowerprotein foods can then be selected to fulfill protein and nutrient requirements (refer to Table G3.2). Most CKD patients do not need to monitor potassium intake, but if necessary, vegetables are groupedbypotassiumcontent. 4. Afterproteinneedshavebeenmet,fruitchoices(alsogroupedbypotassiumcontent)andcalorieand flavoringchoicescanbeusedtoprovidebalance,flavor,andadditionalcaloriestomeetnutritionneeds andcompletethepatientsmealplan(refertoTablesG3.3toG3.4).
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HIGHPROTEINFOODLIST Serving1oz Protein Calories (g/serving) (kcal/serving) 68 50100 Beef(1oz) Eggsubstitutes(cup) Eggs(1large) Fish(1oz) Lamb(1oz) Pork(1oz) Poultry(1oz) Shellfish(1oz) Veal(1oz) Wildgame(1oz)
Potassium (mg/serving) 50150
Phosphorus(mg/serving) 50100
HighProteinandHighPhosphorusFoodLists Protein Calories Sodium (g/serving) (kcal/serving) (mg/serving) 68 50100 20150 Cheese(1oz)a Cookeddriedbeansandpeas(cup)a Evaporatedmilk(cup)a Milk,allkinds(1cup)a Nutbutters(2tbsp)a Nuts(cup)a Organmeats(1oz)a Soymilk(1cup)a Sweetenedcondensedmilk(cup)a Tofu(cup)a Yogurt(1cup)a
*afoodcontains100300mgphosphorusperserving.
Phosphorus(mg/serving) 100300(ifmarkeda*)
HighProteinandHighSodium(Salt)FoodLists Protein Calories Sodium Potassium (g/serving) (kcal/serving) (mg/serving) (mg/serving) 68 50100 200450(ifmarked 50150 withb**) Bacon(4slices)b Breakfastsausage(3linksor1patties)b Cannedtuna,salmon(1ozorcup)b Cottagecheese(cup)b Delistyleroastbeef,ham,turkey(1oz)b Frankfurters,bratwurst,Polishsausage(2oz)b Luncheonmeats,bologna,liverwurst,salami,etc(2oz)b
**bfoodcontains200450mgsodiumperserving.
LOWERPROTEINFOODLISTS:VEGETABLES Serving:cupunlessotherwisenoted Protein Calories Sodium (g/serving) (kcal/serving) (mg/serving) 23 10100 050
Potassium (mg/serving) 1)20150 2)150250 3)250550

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LowerProteinFoodLists:Vegetables(Cont.) Group1:20150mg Group2:150250mg Alfalfasprouts Asparagus Bambooshoots(canned) Broccoli Beansprouts Celery Beets Kale Cabbage Mixedvegetables Carrots Peas Cauliflower Peppers Corn Summersquash,boiled Cucumber Turnips Endive Zucchini Eggplant Greenbeans Lettuce Mushrooms Onions Radishes Summersquash,raw Waterchestnuts(canned) Watercress
Group3:250550mg Artichokes Avocado Bambooshoots(fresh,raw) Beets(fresh) Brusselssprouts Chard Greens(beet,collard,mustard,etc) Kohlrabi Okra Parsnips Potatoes Pumpkin Rutabagas Spinach Sweetpotatoes Tomatoes Tomatosauce,puree V8juice Waxbeans Wintersquash Yams
LOWERPROTEINFOODLISTS:BREADSANDROLLS,CEREALSANDGRAINS,CRACKERSANDSNACKS, ANDDESSERTS Protein Calories Sodium(mg/serving) Potassium Phosphorus (g/serving) (kcal/serving) (mg/serving) (mg/serving) 23 50200 0150 10100 1070 23 50200 150400(ifmarkedwithb**) 10100 100200(ifmarkedwitha*) Cereals: BreadsandRolls: Lowsaltcereals(CornPops,CocaPuffs,SugarSmacks,Fruity Bagel(small) Pebbles,PuffedWheat,PuffedRice)(1cupor1oz) Bread,allkinds(1sliceor1oz) Cereals,cooked(CreamofRiceorWheat,Farina,MaltoMeal)(cup) Bun,hamburgerorhotdogtype() Cornbread,homemade(1pieceor2oz) Grits,cooked(cup) Pasta,cooked(noodles),macaroni,spaghetti)(cup) Danishpastryorsweetroll(small) Rice,cooked(cup) Dinnerrollorhardroll(1small) Crackers,unsalted(42inchcrackers) Doughnut(1small) Grahamcrackers(3squares) Englishmuffin() Melbatoast(3oblong) Pitaorpocketbread(6inch Popcorn,unsalted(1cups,popped) diameter) Pretzel,unsaltedsticksorrings(3/4oz,10sticks) Tortilla,flour(1to6inchdiameter) Tortillachips,unsalted(3/4oz,9chips)
Desserts: Sugarcookie(4cookies) Shortbreadcookie(4cookies) Sugarwafer(4cookies) Vanillawafer(10cookies)
Addedsaltandphosphorus: Biscuits,muffins(1small)a,b Cake(1/20roundcakeor22inchsquare)a,b Cornbread,frommix(1pieceor2oz)a,b Fruitpie(1/8pie)b Granola,oatmeal(cup)a Pancakes,waffles(14inches)a,b Pretzels,saltedsticksorrings(3/4ozor10sticks)b Drycereals,mostbrands(3/4cup)b RyKrisp(3crackers)b Sandwichcookie(4cookies)b Wholewheatcereals,brancereals(1/2cup)a,b
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FRUITLISTS Serving:cupunlessotherwisenoted Protein Calories Sodium FoodList (g/serving) (kcal/serving) (mg/serving) Fruits 01 20100 010 (groupedby potassium content) Group1:20150mg Group2:150250mg Apple,raw(withoutskin) Apple,raw(withskin) Applejuice(cup) Grapejuice(canned/bottled) Applesauce Peach,raw(withskin) Apricotnectar Pear,raw(withskin) Blackberries Cherries,raw(10) Blueberries Cantaloupe Cranberries Figs(2whole) Cranberryjuicecocktail Grapefruit,raw Fruitcocktail Grapefruitjuice Gooseberries,canned Mango Grapejuice(frozen Papaya concentrate) Grapes Rhubarb Lemon,lime(1raw) Lemon,limejuice Papayanectar Peachnectar Peach,canned Pear,canned Pearnectar Pineapple,freshorcanned Plum,raworcanned Raspberries,raworfrozen Strawberries,raworfrozen Tangerine,raw Watermelon,raw
Potassium (mg/serving) 1)20150 2)150250 3)250550
Group3:250550mg Gooseberries(raw) Peach,dried(5) Pear,dried(5) Figs,dried(5) Apricots,dried(10) Apricots,raw(3) Banana(1small) Dates(cup) Honeydewmelon Kiwifruit Nectarine Orangejuice Orange Prunejuice Prunes(5) Raisins
CALORIEANDFLAVORINGCHOICESFOODLISTS Protein Calories FoodList (g/serving) (kcal/serving) Caloriechoices 01 100150 Flavorchoices 0 020 Chewyfruitsnacksandcandies(1oz) Cranberrysauceorrelish(cup) Creamcheese(2tbsp) Fruitchews(4or1oz) Fruitdrinks(1cup) Fruitrollup(2) Gumdrops(8) Hardcandy(4pieces) Honey(2tbsp) Jamorjelly(2tbsp) Jellybeans(15) Lifesavers(13) Margarineorbutter(1tbsp) Marmalade(2tbsp) Marshmallows(5large) Mayonnaise(1tbsp)
Sodium Potassium Phosphorus (mg/serving) (mg/serving) (mg/serving) 0100 0100 0100 250300 0100 020 Mints,peppermintpatties(13mintsorlarge) Nondairycreamers,halfandhalf(cup) Nondairycreamers,halfandhalf Nondairywhippedtopping(cup) Popsicles,juicebars(1bar) Saladdressing(1tbsp) Sodapop(1cup) Sorbet(cup) Sourcream(cup) Sugar,brownorwhite(2tbsp) Sugar,powdered(3tbsp) Syrup(2tbsp) Tartarsauce(2tbsp) Vegetableoil(1tbsp) Whippedcream(cup)
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VEGETARIANPROTEINFOODLISTS(ALSOREFERTOLOWERPROTEINFOODLISTS) Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Proteinfoods 68 70150 10200 60150 80150 Highersodium, 68 70150 250400 250500 200400(markedwith potassium,or (markedwith (markedwith a*) phosphorus b**) c***) proteins Cheese,allkinds(1oz) Okra(1cup)c Eggs(1large) Soycheese(1oz)a,b Nutbutters(1tbsp) Soymilk(1cup)c Tempeh(cup) Soynuts(2tbsp)b Tofu,firmtype(cup) Soyproteinisolate(oz)c Tofu,softtype(cup) Soysprouts(1cup)c Soyyogurt(1cup)c Higherphosphorus(a),sodium(b),orpotassium Tofuhotdog(1oz)b (c): Tuno(1/3cup)b b Cottagecheese(cup) Vegetarianmeatanalogs(Gardenburgers,Bocaburgers)(2 Driedbeans,peas(cup)c oz)b a,c Yogurt(1cup)a,c Milk(1cup) b Miso(cup) Natto(cup)c Nuts(cup)b,c *afoodcontains200400mgphosphorusperserving.
**bfoodcontains250400mgsodiumperserving. ***cfoodcontains250500mgpotassiumperserving.
TablesG4.1G4.6:HealthyFoodGuideforPeopleonDialysis
TableG4.1:ProteinChoices ProteinChoices:Thefoodsincludedinthislistincludesourcesofproteinfrombothanimalsandvegetables thatprovideahighbiologicalsourceofprotein(generally6to8gproteinperserving).Foodsthatprovidea highsourceofsodium,potassium,and/orphosphorusareidentified. Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Animalprotein 68 50100 20150 50150 50100 Highersodium, 68 50100 200500(if 250450(if 100300(if potassium,or markedb**) markedc***) markeda*) phosphorus proteins
a*foodcontains100300mgphosphorusperserving. **bfoodcontains200500mgsodiumperserving. ***cfoodcontains250450mgpotassiumperserving.
TableG4.2:FruitandVegetableChoices(groupedbypotassiumcontent) FruitandVegetableChoices:Fruitsandvegetablesaregroupedbypotassiumcontent.Mostpatientscan chooseonehighpotassiumfood,twomediumpotassiumfoods,andthreelowpotassiumfoodsperday. Choiceswillvarydependingontheserumpotassiumlevelanddialysistherapy. Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Lowpotassium 03 10100 150 20150 070 Mediumpotassium 03 10100 150 150250 070 Highpotassium 03 10100 150 250550 070
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TableG4.3:DairyandPhosphorusChoices DairyandPhosphorusChoices:Thefoodsinthisgroupcontain100to120mgphosphorusperserving,and 2to8gproteinperserving.Mostpatientscanchooseoneortwohighphosphorusfoodsaday,dependingon labvalues,useofphosphatebinders,andtype/frequencyofdialysistherapy. Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Dairyand 28 100400 30300 50400 100120 phosphorus TableG4.4:Bread,Cereal,andGrainChoices Bread,Cereal,andGrainChoices:Thisgroupoffoodsgenerallyprovides2to3gproteinperserving.Grain foods with higher values of sodium, potassium, and/or phosphorus are identified. These foods can be integrated in the meal plan to meet nutrition needs. Laboratory values, use of phosphate binders, and type/frequencyofdialysistherapyshouldbeconsideredtodetermineservingsrecommendedperday. Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Breads,rolls, 23 50200 0150 10100 1070 cereals,grains, crackers,snacks, desserts Highersodium 23 50200 150400(if 10100(if 100200(if and/orphosphorus markedwith markedwith markedwith grainfoods b**) c***) a*)
a*foodcontains100200mgphosphorusperserving. **bfoodcontains150400mgsodiumperserving. ***cfoodcontains10100mgpotassiumperserving.
TableG4.5:CalorieandFlavoringChoices CalorieandFlavoringChoices:Foodsgroupedinthiscategoryhelptoaddextracaloriesandflavortofoods tohelpenhancecaloricintakeandcanbeusedtohelppreventweightloss. Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Caloriechoices 01 100150 0100 0100 0100 Flavorchoices 0 020 250300 0100 020 TableG4.6:VegetarianProteinChoices VegetarianChoices:Thesectiononvegetarianchoicesisintendedforpatientswhoavoidanimalfoods.It can replace the protein choices section (Table G4.1). Table G4.6 provides nutrient values of vegetarian proteinsandfoodscategorizedinthisgroup.Choosingvegetarianproteinsoveranimalproteinsmayresult in higher intakes of potassium and phosphorus per gram of protein. Higher sodium, potassium, and phosphorusfoodsareidentifiedandoftencanbeusedonceortwiceperweekdependingonlabvalues,fluid weightgains,anddialysistherapy. Protein Calories Sodium Potassium Phosphorus FoodList (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Proteinfoods 68 70150 10200 60150 80150 Highersodium, 68 70150 250400 250500 200400 (markedwithb) (markedwitha) potassium,or phosphorus proteins CalculatingFoodChoicesforPeopleonDialysis(1,3) 1. RefertoTableG2:NutritionalRequirementsforAdultsWithRenalDiseaseBasedonTypeofTherapyto determine nutrition needs. Priorities in meal planning for people on dialysis will vary with their nutrition status, laboratory values and type/frequency of dialysis therapy. Once nutrition needs are
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known,calculateandidentifyproteinneedsanddeterminechoices.Atleast50%oftheproteinshould comefromtheProteinChoicesFoodList(TableG4.1)toensurehighbiologicalproteinsareconsumed. Choices from the higher sodium, potassium, and phosphorus groups can be included as needed by the dietitiansdiscretiontomeetthepatientsnutritionneeds. 2. Otherproteinfoodscanthenbeselectedtofulfillproteinandnutrientrequirements(refertoTablesG4.2 to G4.4.). The amount of sodium, potassium, and phosphorus should be determined based on the patientslaboratoryvalues,medications(eg,phosphorusbinders)andtype/frequencyofdialysis. 3. Calorieandflavoringchoicescanbeusedtoprovidebalance,flavor,andadditionalcaloriestomeet nutritionneedsandcompletethepatientsmealplan(refertoTableG4.5).
PROTEINCHOICESFOODLIST AnimalProtein:Serving1oz Protein Calories Sodium Potassium Phosphorus (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) 68 50100 20150 50150 50100 Beef(1oz) Poultry(1oz) Eggsubstitutes(cup) Shellfish(1oz) Eggs(1large) Veal(1oz) Fish(1oz) Wildgame(1oz) Lamb(1oz) Pork(1oz)
HighSodium,Potassium,Phosphorus,ProteinFoodLists Protein Calories Sodium Potassium Phosphorus (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) 68 50100 200500(if 250450(ifmarked 100300(ifmarkeda*) markedb**) c***) Bacon,breakfastsausageb(4slices,1patties,or3links) Cannedtuna,cannedsalmon,orsardinesa,b(cup) Cheeses,allkindsa,b(1oz) Cooked,driedbeansandpeasa,c(cup) Cottagecheeseb(cup) Delistyleroastbeef,ham,turkey(1oz)b Frankfurters,bratwurst,polishsausage(2oz)b Luncheonmeats,bologna,liverwurst,salami,etc(2oz)b Milk(1cup)a,b Nutbutters(2tbsp)a Nuts(cup)a,c Organmeats(1oz)a Soymilk(1cup)c Tofu(cup)a Vegetarianmeatanalogs(gardenburgers,soyburgers,etc)(2oz)b Yogurt(1cup)a,b,c *afoodcontains100300mgphosphorus/serving **bfoodcontains200500mgsodium/serving ***cfoodcontains250450mgpotassium/serving FRUITANDVEGETABLECHOICESFOODLISTS(groupedbypotassiumcontent) Protein Calories Sodium Potassium Phosphorus FoodList* (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) Lowpotassium 03 10100 150 20150 070 Mediumpotassium 03 10100 150 150250 070 Highpotassium 03 10100 150 250550 070
*RefertoVegetableListsandFruitListsunderHealthyFoodGuideforPeopleWithChronicKidneyDisease(PreESRD),thissection.
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DAIRYANDPHOSPHORUSCHOICESFOODLISTS Protein Calories Sodium Potassium Phosphorus (g/serving) (kcal/serving) (mg/serving) (mg/serving) (mg/serving) 28 100400 30300 50400 100120 Organmeats(1oz) Biscuits,muffins(1small) Pancakes,waffles(14inches) Cake(1slice,22inches) Pudding,custard(cup) Cheese(1oz) Sardines(1oz) Cookeddriedbeansandpeas(cup) Soymilk(1cup) Condensedandevaporatedmilk(cup) Tofu(cup) Cottagecheese(cup) Tortillas,corn(2to6inchdiameter) Granola,oatmeal(cup) Vegetarianmeatanalogs(Gardenburgers,Bocaburgers,etc) Icemilkoricecream(cup) (2oz) Lightcreamorhalfandhalf(cup) Wholewheatcereals,brancereals(cup) Milk,allkinds(cup) Yogurt,plainorfruitflavored(cup) Milkshake(cup) Nondairymilksubstitutes(1cup) Nutbutters(2tbsp) Nuts(cup)
BREAD,CEREAL,ANDGRAINCHOICESFOODLISTS Protein Calories FoodList*** (g/serving) (kcal/serving) Breads,rolls, 23 50200 cereals,grains, crackers,snacks, desserts Highersodium 23 50200 and/orphosphorus grainfoods
10100
100200(if markedwitha*)
*afoodcontains100200mgphosphorusperserving. **bfoodcontains150400mgsodiumperserving. ***RefertoBread,Cereal,andGrainChoicesFoodListsunderHealthyFoodGuideforPeopleWithChronicKidneyDisease (PreESRD),thissection.
CALORIEANDFLAVORINGCHOICES Protein FoodList* (g/serving) Caloriechoices 01 Flavorchoices 0
Potassium (mg/serving) 0100 0100
Phosphorus (mg/serving) 0100 020
*RefertoCalorieandFlavoringChoicesFoodListunderHealthyFoodGuideforPeopleWithChronicKidneyDisease(Pre ESRD),thissection.
VEGETARIANPROTEINCHOICES Protein FoodList**** (g/serving) Proteinfoods 68 Highersodium, 68 potassium,or phosphorusproteins
Potassium (mg/serving) 60150 250500 (markedwith c***)
Phosphorus (mg/serving) 80150 200400 (markedwith a*)
*afoodcontains200400mgphosphorusperserving. ***cfoodcontains250500mgpotassiumperserving. ****RefertoVegetarianProteinFoodChoicesListsunderHealthyFoodGuideforPeopleWithChronicKidneyDisease(PreESRD),this section.
References
1. 2. 3.
NationalRenalDietProfessionalGuide.2nded.Chicago,Ill:RenalPracticeGroupoftheAmericanDieteticAssociation;2002. SchiroHarveyK.AHealthyFoodGuideforPeopleWithChronicKidneyDisease.2nded.Chicago,Ill:RenalPracticeGroupofthe AmericanDieteticAssociation;2002 SchiroHarveyK.AHealthyFoodGuideforPeopleonDialysis.2nded.Chicago,Ill:RenalPracticeGroupoftheAmericanDietetic Association;2002.
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MEALPATTERNSUSINGHEALTHYFOODGUIDE(SAMPLE)
SampleMealPatternforCKD(PreESRD) Basedon70kgreferenceperson FoodChoice Numberof Breakfast Choices HighProtein 3 1 Choices HighProtein,High 1 1 PhosphorusChoices VegetableChoices Group1 1 Group2 1 Group3 1 Bread,Cerealand 8 3 GrainChoices FruitChoices Group1 1 Group2 1 Group3 1 1 Calorieand 67 23 FlavoringChoices ApproximateTotals: 61gProtein 2,130calories 2,090mgsodium 2,160mgpotassium 840mgphosphorus Noon 1 1 1 2 1 2 Evening 1 1 3 1 2
SampleMealPatternforCKD(Dialysis) Basedon70kgreferenceperson FoodChoice Numberof Breakfast Choices HighProtein 8 2 Choices Dairyand 1 1 PhosphorusChoices VegetableChoices Group1 1 Group2 2 Group3 Bread,Cerealsand 9 3 GrainChoices FruitChoices Group1 1 Group2 1 Group3 1 1 Calorieand 67 23 FlavoringChoices FluidChoices 3 ApproximateTotals: 84gProtein 2350calories 2150mgsodium 2220mgpotassium 1100mgphosphorus 960ccfluid Noon 3 1 1 3 1 2 3 1 3 1 2 Evening
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SIMPLIFIEDRENALDIET
Description TheSimplifiedRenalDietmildlyrestrictssodium,potassium,phosphorus,andfluidintake. Indications patientsinpredialysisstage patientsreceivinghemodialysisandhavingdifficultyadheringtotheRenalDiet NutritionalAdequacy The diet is inadequate in calcium according to the Dietary Reference Intakes (DRIs) as outlined in the StatementonNutritionalAdequacyinSectionIA. HowtoOrdertheDiet ThedietshouldbeorderedNoAddedSaltDiet(NAS)______ccfluidrestriction,SimplifiedRenalDiet.For patientswhorequirearenaldiabeticrestriction,orderConsistentCarbohydrate,NASDietwith______ccfluid restriction,SimplifiedRenalDiet. PlanningtheDiet GuidelinesfortheSimplifiedRenalDietfollow: 1. Limitmilkandmilkproductstocup/day. 2. Limit foods high in potassium to one serving per day. Such foods include cantaloupe and honeydew, potatoes, prunes, oranges, orange juice, prune juice, dried beans and peas, nuts and peanut butter, chocolate,bananas,apricots,andtomatoes.(Therenalchoicelistmaybeusedforguidelinesofaserving.) 3. Eliminatesaltsubstitutesandlightsalt. 4. Ifphosphorusrestrictionisrequired,limitbrancereal,wholewheatbread,nuts,anddriedbeanstoone servingperday. 5. Forproteinrequirements,provide6ozofmeatormeatentreeperday.Offeraneggforbreakfastatleast everyotherday.
Bibliography EcklundK.Handlingthedialysisdietinlongtermcare.ConsultantDietitian.1992;17(1):1.
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GLUTENFREEDIET
Description The GlutenFree Diet is the primary treatment for celiac disease, which is also called glutensensitive enteropathyorceliacsprue.Theonlytreatmentforceliacdiseaseislifelongadherencetoaglutenfreemeal pattern,includingstrictavoidanceofprolamins,whichareproteinsfoundinwheat,rye,barley,andtriticale (1).Dermatitisherpetiformisisthetermfortheskinmanifestationofceliacdisease.TheGlutenFreeDietalso helpstocontrolmostcasesofdermatitisherpetiformisassociatedwithglutensensitiveenteropathy(16).
Indications Celiacdiseaseisanimmunemediateddiseasecharacterizedbychronicinflammationofthesmallintestine mucosathatresultsinmalabsorptionduetoatrophyoftheintestinalvilla (16).Althoughceliacdiseasewas oncethoughttobeararechildhooddisease,itisnowrecognizedasafairlycommonmultisystemdisorder that occurs in one in 133 people (1,6). Individuals with celiac disease have an immunologic reaction to proteinstermedprolamins,whicharefoundinwheat,rye,andbarley (1).Whenfoodscontainingglutenare consumedbyapersonwithceliacdisease,thedigestiveprocessfailsandanimmunologicallyreactiveprotein fragment remains (1). Research suggests that a 33amino acid molecule may be the cause of the inflammatory response (1,46). This molecule enters the intestinal mucosa and cannot be degraded by digestiveenzymesorpancreaticenzymes.Themoleculethenentersthelaminapropria,whereitcausesthe releaseofTcells (1).ThepresenceoftheTcellsinthelaminapropriatriggerscytokineactivation,antibody production,andinflammatoryresponses (1).Theresultingvillousatrophyandinflammationofthemucosa resultinmalabsorption (16).Theproximalbowel(duodenum)isthefirstareaofthegastrointestinaltractto beexposedtotheimmunologicallyreactivepeptide.Therefore,itisexposedtothehighestconcentrationof the peptide and is often the most severely injured section of the small intestine. The jejunum and occasionallytheileummayalsobeaffected.
Although the classic presentation of celiac disease is diarrhea, wasting, malabsorption, failure to grow, bloating, and abdominal cramps, not all individuals with celiac disease have these symptoms. Many individualswithceliacdiseasearediagnosedwhenseekingmedicalcareforotherproblemssuchasanemia, osteoporosis, peripheral neuropathy, and fatigue (1,6). Celiac disease is categorized into four main classes accordingtotheNationalInstitutesofHealthConsensusConferenceStatement(6):
Classicalceliacdisease:Thisclassischaracterizedbypredominantgastrointestinalsymptomsandsequelae includingmalabsorption,significantweightlossorgain,failuretogrow(inchildren),diarrhea,constipation, excessivegas,bloating,andabdominalpain.Thediagnostictestingrevealspositiveserologictestresultsand biopsyprovenintestinalatrophy.Symptomsimproveafterapatientadoptsaglutenfreediet.
Celiac disease with atypical symptoms: This class is characterized by predominantly extraintestinal manifestations and few or no gastrointestinal symptoms. Nongastrointestinal symptoms include anemia, osteoporosis, peripheral neuropathy or neurological symptoms, dental enamel defects, and fatigue. The diagnostictestresultsandtreatmentresponseareconsistentwithclassicalceliacdisease.
Silent celiac disease: This disease is characterized by a lack of clinical symptoms in spite of positive serologic test results and biopsyproven villous atrophy. Diagnosis of silent celiac disease usually results fromscreeninghighriskindividuals,eg,familymembersandindividualswithassociatedconditionssuchas typeIdiabetesmellitus,Downsyndrome,orWilliamssyndrome.Aclearoutcomebenefitoftreatingthese individualshasnotemergedfromcurrentdataanalysis.
Latent celiac disease: This class is characterized by positive serologic test results, the absence of villous atrophy on intestinal biopsy, and no clinical symptoms of celiac disease. These individuals may develop intestinalchangesandsymptomsofceliacdiseaselaterinlife.
Dermatitisherpetiformis:Thisconditionistheskinmanifestationofceliacdisease,whichischaracterized by a bilateral, symmetric rash or eruptions primarily on pressure points of the skin that may evolve into blisters or bullae (fluidfilled sacs). These lesions are painfully itchy and do not respond well to topical treatment. Dermatitis herpetiformis is diagnosed from a skin biopsy taken from a site next to a lesion. Ninetypercentofindividualswithdermatitisherpetiformishavenogastrointestinalsymptomscharacteristic of celiac disease, but 75% have biopsyproven villous atrophy that responds well to a glutenfree dietary pattern.Topicaltreatmentofthelesionswithsulfapyridineiseffectiveintreatingthisformofbullousatopic
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GlutenFreeDiet
dermatitis.Althoughoralmedicationsmayalsobeused,adherencetoaglutenfreedietisthemosteffective waytopreventdermatitisherpetiformis. Compliancewithaglutenfreedietarypatternreducestheprevalenceofdiarrhea,constipation,abdominal painandbloating,nauseaorvomiting,reducedgutmotility,delayedgastricemptying,andprolongedtransit time (Grade II) (7). Evidence is limited regarding the effect of a glutenfree dietary pattern on indigestion, dysphagia,andreflux (GradeII)(7).Individualswhocomplywithaglutenfreedietarypatternhavesubstantial improvementinvillousatrophy;however,mucosalabnormalitiesmaypersistinsomeindividuals (GradeII)(7). Althoughnormalizationofabnormalitiesmayoccurwithin1year,itgenerallytakeslonger,dependingonthe severity of villous atrophy, level of compliance, and age at diagnosis (Grade II) (7). Recovery in children may progressfasterandmorecompletelythaninadults(GradeII)(7).Peoplewithceliacdiseasearemorelikelythan healthy controls to experience neurological symptoms such as depression, cerebellar ataxia, headaches, migraines,andneuropathy(GradeII)(7).Earlydiagnosisandcompliancewithaglutenfreedietarypatternmay reduce the prevalence of symptoms related to cerebellar ataxia, headaches, and migraines (Grade II) (7). The evidence is less conclusive or limited regarding the effect of a glutenfree diet on depression, anxiety, and epilepsy(GradeII)(7). NutritionAssessmentandDiagnosis Biopsyofthesmallintestineisthegoldstandardfordiagnosingceliacdisease (16). Severalbiopsiesshould be taken because mucosal abnormalities may be localized (6). Criteria for diagnosis include mucosal abnormalities(eg,increaseddensityofintraepitheliallymphocytes,partialtototalvillousatrophy,andcrypt hyperplasia) and clinical improvement after a period of time on a glutenfree nutrition prescription (6,8). Testsforgeneticmarkersareavailabletodeterminethelikelihoodthatapersonhasceliacdisease (1).The DQ2andDQ8markersarehighlycorrelatedwithceliacdiseaseandaretoolsforassessingapersonsriskfor celiac disease (6). Persons who exhibit symptoms of irritable bowel syndrome or who have undiagnosed gastrointestinal complaints (eg, diarrhea, bloating, gas, and abdominal pain), especially when accompanied by fatigue and weight loss, should be assessed for celiac disease. In a survey of adults with celiac disease, 37%ofcasesreportedaninitialdiagnosisofirritablebowelsyndrome(9).Serologicmarkersthatcanbeused bydietitianstoscreenforceliacdiseaseincludeimmunoglobulinA,antihumantissuetransglutaminase,and immunoglobulin A endomysial antibody (1). Tests for these markers have a high sensitivity and specificity andarethebestavailabletestsintermsofdiagnosticaccuracy(1,6). Acomprehensivenutritionalassessmentiscriticalindeterminingwhetherrecurrentsymptomsarerelated toglutensensitivityortoanunrelatedproblem.Damagetotheintestinalmucosamaycausevariousdegrees ofmalabsorptionthatleadstodeficienciesofkeyvitaminsandminerals,includingcalcium,vitaminD,iron, andfolate (4).Thefollowingdiscussionreviewstheevidenceregardingthelongtermeffectsoffollowinga glutenfreedietarypatternafteradiagnosisofceliacdisease(7). Calcium: Clinical trials and crosssectional studies have found reduced bone mineral content and bone mineral density in untreated children, adolescents, and adults (7). Both of these parameters improve significantlywithcompliancetoaglutenfreedietarypatternforatleast1year (Grade I) (7).Compliancewith dietary treatment initiated during childhood or adolescence allows the achievement of normal bone mineralization(GradeI)(7).However,inadultswhoreceivednotreatmentordelayedtreatmentinchildhoodor adolescence,aglutenfreemealpatternmayimprovebonedensitybutnotnormalizebonemineraldensity (GradeI)(7).Successfultreatmentdependsontheageatdiagnosis,aspatientswhodonotreceivetreatmentin childhood and adolescence may never reach peak bone mass (Grade I) (7). Further studies are needed to evaluate the effects of calcium and vitamin D supplementation on bone mineral content and bone mineral density,aswellastheeffectsofhormonereplacementtherapyforpostmenopausalwomen (7).Adultswith celiac disease should have a bone density test (dual energy Xray absorptiometry scan) at the time of the diagnosis(6). Iron:Formostchildrenandadultswithceliacdisease,compliancewithaglutenfreedietarypatternresults in significant improvement in hematological parameters including serum hemoglobin, iron, ferritin, mean corpuscularvolume,meancorpuscularhemoglobin,andredcelldistributionwidth(GradeII)(7).Recoveryfrom anemia,asindicatedbythenormalizationofhemoglobinconcentrations,generallyoccurswithin6months; recoveryfromirondeficiency,asindicatedbythenormalizationofferritinconcentrations,maytakelonger than 1 year (Grade II) (7). Iron supplementation in the form of a multivitamin with iron may be necessary to achievenormalvaluesforthesehematologicalvariableswithinthesetimeperiods(GradeII)(7).
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Lactose: Patients may need to be evaluated for lactose intolerance, which can appear secondary to celiac disease. If the patient is lactose intolerant, see the discussion of the LactoseControlled Diet later in this section. Usually lactose intolerance will normalize within weeks to months of adopting a glutenfree diet pattern(1). Contraindications Oneformofceliacdisease,refractorysprue,doesnotrespondtotheGlutenFreeDietorrespondsonly temporarily. NutritionalAdequacy TheGlutenFreeDietcanbeplannedtomeettheDietaryReferenceIntakesasoutlinedintheStatementon Nutritional Adequacy in Section IA. Compliance with a glutenfree dietary pattern results in significant improvementsinnutritionallaboratoryvalues,suchasserumhemoglobin,iron,zinc,andcalcium,asaresult of intestinal healing and improved absorption (Grade II) (7). Often, supplementation may be required totreat deficienciessecondarytoceliacdisease (1).Anemiamaybetreatedwithfolate,iron,orvitaminB12.Patients whoaredehydratedduetoseverediarrhearequireelectrolytesandfluids.VitaminKmaybeprescribedfor patients who develop purpura, bleeding, or prolonged prothrombin time. Calcium and vitamin D supplementationmaybenecessarytocorrectosteomalacia.VitaminsAandDmaybenecessarytoreplenish stores depleted by steatorrhea. Daily consumption of a glutenfree, multivitaminmineral supplement containing the Dietary Reference Intakes is recommended for patients who continue to have suspected deficienciesormalabsorption(1,7).
HowtoOrdertheDiet OrderasGlutenFreeDiet.
NutritionInterventionandPrescription TheGlutenFreeDietisbasedontheavoidanceofthegrains,chemicals,andnaturalorartificialingredients that are toxic for patients with celiac disease or dermatitis herpetiformis (1). This diet eliminates all foods containingwheat,rye,barley,triticale,andtheirderivatives (1,6).Derivativesofthesegrainsincludewheat basedspelt,semolina,andkamut.Quinoa,buckwheat,amaranth,andteffareallowedonaglutenfreediet, based on plant taxonomy and limited scientific evidence for the need to exclude these items (1). Millet, sorghum,Jobstears,teff,ragi,andwildricearemorecloselyrelatedtocornthantowheat.TheAmerican DieteticAssociation,DietitiansofCanada,andotherorganizationssuchastheGlutenIntoleranceGroupand the Celiac Disease Foundation consider these plants to be acceptable in a glutenfree diet (1,6,10). The followinggrainsandplantfoodscanbeincludedinaglutenfreeprescription(1): Rice,corn,amaranth,quinoa,teff(ortef),millet,fingermillet(ragi),sorghum,Indianricegrass(Montina), arrowroot, buckwheat, flax, Jobs tears, sago, potato, soy, legumes, tapioca, wild rice, cassava (manioc), yucca,andnuts Nonmaltvinegars,includingcidervinegar,winevinegar,anddistilledvinegar Oats:Studieshaveshownthatincorporatingoatsuncontaminatedwithwheat,barley,orryeintoagluten freedietarypatternatintakelevelsofapproximately50gofdryoatsperdayisgenerallysafeforpeoplewith celiacdiseaseandimprovestheircompliance (GradeII)(7,1115).However,theintroductionofoatsmayresultin gastrointestinal symptoms such as diarrhea and abdominal discomfort (7,1618). Additional adverse effects include dermatitis herpetiformis, villous atrophy, and an increased density of intraepithelial lymphocytes, indicatingthatsomepersonswithceliacdiseasemaybeunabletotolerateoats (GradeII)(7).Theriskofcross contamination with glutencontaining products remains a substantial concern in the United States. Some foodcompaniessuchasGlutenFreeOatsandCreamHillEstatesareattemptingtoimprovethepurityofoat productionandmaybearesourceforpersonswithceliacdisease(1).Untiloatsareprovensafe,theinclusion ofoatsinaglutenfreedietshouldbeatthediscretionofpatientsinconsultationwiththeirphysiciansand dietitians(1).Patientswhoconsumeoatsshouldbeadvisedtolimittheirdailyconsumptiontoapproximately 50gofdryoats,anamountfoundtobesafeinstudies (19).Ideally,patientsshouldonlyconsumeoatsthat havebeentestedandfoundtobefreeofglutencontamination(1,19). Wheatstarchbasedglutenfreefoods:Bothnaturalandwheatstarchbasedglutenfreefoods(asdefined bytheCodexAlimentarius(20))producesimilarhistologicalandclinicalrecoveryinpeoplewithceliacdisease (Grade III) (7).Overallcompliancewithaglutenfreedietmaybemoreimportantthanthespecifictypeofdiet
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(eg, natural or wheat starchbased), as evidenced by the incomplete bowel mucosal recovery and positive serologicaltestresultsgenerallyseeninstudysubjectswhohavedietarylapses(GradeIII)(7). Alcohol:Beer,ale,porter,stout,andotherfermentedbeveragesshouldbeavoidedbecausetheyarederived frombarley (1).Distilledalcoholicbeverages(eg,ginandvodka)maybeincludedinaglutenfreenutrition prescription. Although these beverages may be derived from glutencontaining grain, the process of distillationshouldpreventanyproteinfromremaininginthefinaldistillate (1). Checkingthemanufacturers labelisimportantwithalltypesofalcoholicproductsbecauseglutencontainingadditivesmaybeaddedafter thealcoholisdistilled.
Thefollowingguidelinesshouldbeconsideredwhendeterminingthenutritionprescription(1): The daily protein intake for adults should be 1 to 2 g/kg of body weight (1). Use highbiological value proteins. AdequateenergyintakeshouldbedeterminedbyusingtheIretonJonesorMifflinSt.Jeorequations,oras outlinedinSectionII:EstimationofEnergyExpenditures.Considertheneedforweightgainifweightlossis unintentionalandassociatedwithdisease. Evaluatetheneedforglutenfreevitaminandmineralsupplementation. Evaluate the need for a mediumchain triglyceride supplement in adults who are diagnosed with steatorrhea.
Thelongtermnutritionaladequacyofaglutenfreediethasbeeninvestigated.Adherencetothegluten freedietarypatternmayresultinadietthatishighinfatandlowincarbohydratesandfiber,aswellaslowin iron,folate,niacin,vitaminB12,calcium,phosphorus,andzinc(GradeII)(7).Afoodintakesurveyofpersonswith celiacdiseasefoundthatlessthan50%ofthefemaleparticipantsconsumedtherecommendedamountsof fiber, iron, and calcium (21). A small number of studies of adults show a trend toward weight gain after diagnosis (Grade II) (7).Thesefactorsmayneedtobeconsideredduringlongtermpatientmanagement.The followingdietaryguidelinesmaybesuggestedtopersonswithceliacdisease(1): Consume5to10ozequivalentservingsfromthegrainfoodgroupeachday. Choosewholegrain,glutenfreeproductswheneverpossible. Chooseenriched,glutenfreeproductsoverrefined,unenrichedproductswheneverpossible. Increaseintakeofglutenfreeproductsmadefromalternativeplantfoods(eg,amaranth,buckwheat, quinoa,teff,andflaxseed)toprovidegoodsourcesoffiber,iron,andsomeBvitamins. Increaseintakeofotherenriched,glutenfreefoods,suchasriceandenergybars. Increaseintakeofnoncerealsourcesofthiamin,riboflavin,niacin,folate,iron,andfiber. Considertakingaglutenfreemultivitaminandmineralsupplement.GlutenfreebrandsincludeFreeda (www.freedavitamins.com)andNaturesBounty(www.naturesbounty.com). Crosscontamination with glutencontaining grains or glutencontaining products during processing, preparation,orfoodhandlingshouldbeavoided.Patientswillneedtobecomeproficientintheevaluationof food and manufacturers labels to screen the ingredients in food products, dietary or medical food supplements, and medications. Hidden sources of gluten in food products include: hydrolyzed vegetable protein,flavorings,maltflavoring(includesmaltsyrup,maltextract,maltmilk,andmaltvinegar),brownrice syrup, modified food starch, dextrin, caramel color, vegetable gum, soy sauce, monoglycerides and diglycerides in dry products, emulsifiers, alcoholbased extracts (eg, vanilla extract), prepared meats, and flavored coffees. The following additional components contain gluten and are often overlooked: broth, breading,croutons,pasta,stuffing,flours,sauces,coatingmixes,marinades,thickeners,roux,soupbase,self basting poultry, imitation seafood, and imitation bacon (1). According to the U.S. Food and Drug AdministrationsCodeofFederalRegulations(21CFR137),thefollowingtermsonafoodlabeloringredient listindicatethepresenceofwheat(22): flour,whiteflour,plainflour,bromatedflour,enrichedflour,phosphateflour,selfrisingflour,durumflour, farina,semolina,andgrahamflour(1)
Effective January 1, 2006, under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA),ifafoodoraningredientcontainswheatorproteinderivedfromwheat,thewordwheatmustbe clearly stated on the food label (1,22). FALCPA applies not only to food products but also to dietary supplements, infant formulas, and medical foods. This regulation includes products that contain dextrin, caramelcolor,ormodifiedfoodstarchfoundinfoodproductscontainingproteinderivedfromwheat (1,22). All prescribed and overthecounter medications should be evaluated by a knowledgeable pharmacist or physician prior to use. Ingredients used as part of the packaging are not required to be listedonthelabel.
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Personswithceliacdiseaseshouldbeawareofthepotentialforcrosscontaminationwithglutencontaining foodsthatmayoccurasresultofpreparingorcookingfoods(eg,fryingorgrilling).
NutritionEvaluationandMonitoring Personswithceliacdiseasemayexperienceanimprovementinsymptomsafter3to6daysofconsuminga glutenfreediet,withfullimprovementoftheintestinalmucosawithin6months (23).Individualswithceliac diseasedemonstrateimprovedqualityoflifeaftercompliancewithaglutenfreedietarypatternforatleast1 year (GradeII)(7).Celiacdiseaseisachronicdisease.Anasymptomaticstatedependsonlifelongmaintenance oftheGlutenFreeDiet.Patientsshouldbecautionedagainstingestingglutenoncetheystarttogainweight and feel better. The ingestion of gluten damages the mucosa and causes recurrent symptoms, although several weeks maylapsebeforethepatientobservessymptoms.Villousatrophyissignificantlyassociated withdietarycompliance (GradeII)(7).Therefore,anassessmentofdietaryadherenceiscriticalindetermining whetherrecurrentsymptomsarerelatedtoglutensensitivityortoanunrelatedproblem.Individualswho arediagnosedwithceliacdiseaseandarenottreatedordonotadheretoaglutenfreedietareatgreaterrisk of developing osteoporosis and benign and malignant complications including lymphoma and other autoimmunediseasessuchastype1diabetesmellitus(16).

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FOODGUIDEGLUTENFREEDIET
FOODGROUP Beverages FOODSALLOWED Brewedcoffee(regularanddecaffeinated),tea InstantandfreezedriedSanka,Maxwell House,andBrimcoffee Cocoa Carbonatedbeverages,exceptsomerootbeer Artificiallyflavoredfruitdrinks,cider Wine,rum
FOODSEXCLUDED Someherbalteas Otherinstantcoffees Somefruitflavoreddrinksa Somecocoaorchocolatemixesa Somerootbeer Beera,ale,andotherdistilledspiritsmadefrom cerealgrainsb
Breads, Cereals,and Grain Products
Speciallypreparedbreads,crackers,cakes, cookies,pasta,andotherproductsmade withthesefloursandstarches:cornflower, cornstarch,cornmeal,potatostarch,rice flour,soyflour,soybeanstarch,tapioca, arrowrootstarch,wholebeanflour,sago, ricebran,buckwheat,millet,flax,teff, sorghum,amaranth,andquinoa Purecorntortillas Potatochipsmadeonlyofpotato;cornchips madeonlyofcorn Plainpopcorn Ricecakes(checklabel) Hominygrits Rice,ricenoodles Cornmeal Cornorricecerealscontainingmaltflavoring derivedfromcorn;creamofrice;puffed rice;puffedmillet
Breadedfoods Breads,crackers,muffins,pizzacrust,andother productsmadefrombarley,oata,rye,orwheat flour;triticale;grahamflour;glutenflour;bulgur; farina;wheatbasedsemolina;spelt;kamut Branorwheatgerm Commercialglutenbread Commerciallypreparedmixesforbuckwheat pancakesorcornbread Crackercrumbs Pretzels,chips,andothersnackfoods,exceptthose allowed Pastaandnoodlesmadefrombarley,oat,rye,or wheatflour Communionwafers
Vegetables
Plain,fresh,frozen,orcannedvegetables, exceptthoseexcluded
Commerciallypreparedvegetablesandsalads(eg, somerestaurantfrenchfriesorbattered vegetables)a Vegetablespreparedwithsauces Cannedbakedbeans
Fruitsand Juices
Milk
Fresh,frozen,canned,ordriedfruit Fruitjuices Milk Chocolatemilk(checklabel)
Preparedfruitswithexcludedfloursorgrains(eg, somepiefillingsandthickenedfruits) CerealbeveragessuchasOvaltine Somecommercialchocolatemilkb,maltedmilk, instantmilkmixes
MeatandMeat Puremeat,fish,poultry,eggs,bacon,andham Substitutes Purecottagecheese;naturalhardand semisoftcheeses Peanutbutter,soybeans,driedbeans,and otherlegumes;tofu Coldcuts,frankfurters,orsausagewithout fillersa
Breadedmeat,fish,orpoultry Cannedorfrozenmeatdishes,stews,chili Patties,loaves,andcroquettesmadewithbread crumbsorflour Somepreparedmeatssuchascoldcuts,frankfurters, sausages,andsomehamburgersab Processedcheese,cheesefood,andcheesespreads Texturedorhydrolyzedvegetableorplantprotein products(TVP,HVP,HPP) SelfbastingturkeywithHVPadded Cheeseproductscontainingoatgumasaningredient Imitationcrabcontainingwheat,starch,orother unacceptablefillers
a b
Itemsmayormaynotcontainglutenorharmfulprolamins.Verifyingredientlistandpurityofproductwithsupplier. Checkproductlabelandcontactmanufacturertoclarifyquestionableingredients,especiallythesourceofflavoringinmeatandpoultryproducts.
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FOODGROUP FOODSALLOWED MeatandMeat Substitutes
FOODSEXCLUDED Frozenindividualfish(maybedustedwithflour); tunacannedwithhydrolyzedprotein
Fats
Butter,margarine,lard,cream,shortening,oils Mayonnaise Nuts Olives Gravyandsaucemadewithallowed thickeningagents Saladdressingsthatdonotcontainagluten stabilizer Creamcheese
Somecommercialsaladdressings (consultlabel) Creamsaucethickenedwithflour Nondairycreamsubstitute Commerciallypreparedgravyandsauce Coatedandflavorednuts
Soups
Homemadebroths;vegetableorcreamsoups madewithallowedingredients
Commerciallypreparedsoups,bouillon,orbroth withHVPorHPPb Soupscontainingbarley,pasta,noodles,HVP,orHPP
Dessertsand Sweets
Cakes,cookies,orpastriesmadefromallowed floursorstarchesandcerealfreebaking powder Custard Cornstarch,rice,andtapiocapuddings Gelatindesserts KozyShackpuddingsandflans Icecreamwithafewsimpleingredients (usuallybrandsthatareexpensive) Sorbet,frozenyogurt,andsherbet(check labels) Coconut Marshmallows Hardcandy Commercialandhomemadecandiesfreefrom excludedgrains Sugar,honey,cornsyrup,maplesyrup,jam, jelly,molasses
Icecreamcontainingstabilizersa Commerciallymadepuddings Cookies,cakes,pies,pastry,andotherbakeditems, unlessspeciallyprepared Doughnuts Breadpudding Productsmadewithbrownricesyruppreparedwith barleymaltenzyme Flavoredsyrups Chocolateandothercandycontainingexcluded ingredients Dessertswithmalt,maltflavoring,ornatural flavoring Chocolatecoverednutsthatmayhavebeenrolledin wheatflour
Miscellaneous
Salt,monosodiumglutamate,tamari,spices, herbs,flavoringextracts,drymustard Dryyeast Purecocoaandchocolate Cider Vinegar,exceptmaltvinegar Pickles,olives
Soysauceb,commercialcatsupb,chilisauceb, barbecuesauce,Worcestershiresauce, horseradish,seasoningmixes Cakeyeast,bakingpowder Somepizzasa Licorice Chewinggumb Maltvinegar
Itemsmayormaynotcontainglutenorharmfulprolamins.Verifyingredientlistandpurityofproductwithsupplier. Checkproductlabelandcontactmanufacturertoclarifyquestionableingredients,especiallythesourceofflavoringinmeatandpoultryproducts.
SAMPLEMENU Breakfast OrangeJuice CreamofRice SoftCookedEgg GlutenfreeBread Margarine,Jelly Milk Coffee Sugar,Creamer
Noon BakedChicken SteamedRice SteamedBroccoliWithCarrots GlutenfreeBread Margarine PineappleChunks Milk IcedTea,Sugar H7
Evening BraisedBeefTips WhippedPotatoes GreenBeans SlicedTomatoSalad PeachHalves GlutenfreeBread Margarine IcedTea,Sugar
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SubstitutionsforWheatFlour Mostpatientsfindspecialcookbookshelpful.Recipescanbemodifiedbythefollowingsubstitutions:
Forbaking,1cupwheatflourmaybereplacedby: 1cupcornflour(finelymilled) 1scantcupfinecornmeal cupcoarsecornmeal 5/8cup(10tbsp)potatostarchflour 7/8cup(14tbsp)riceflour(whiteorbrown) 1cupsoyflourpluscuppotatostarchflour cupsoyflourpluscuppotatostarchflour
Forthickening,1tbspofwheatflourmaybereplacedby: 1teaspoonsofcornstarch,potatostarch,rice,flourarrowrootstarch,orgelatin 2teaspoonsofquickcookingtapioca 1tbspriceflour(whiteorbrown) SupportGroups CeliacDiseaseFoundation AmericanCeliacSociety 13251VenturaBlvd.,#1 POBox23455 StudioCity,CA91604 NewOrleans,LA70183 (504)7373293 (818)9902354 www.americanceliacsociety.org www.celiac.org CeliacSprueAssociation GlutenIntoleranceGroupofNorthAmerica POBox31700 31214124thAveSE Auburn,WA980923667 Omaha,NE681310700 (253)8336655 (877)CSA4CSA www.gluten.net www.csaceliacs.org SuppliersofGlutenFreeProducts EnerGFoods* BobsRedMill EnjoyLifeFoods* (800)5532258 (800)3315222 (888)5036569 www.bobsredmill.com www.energ.com www.enjoylifefoods.com GlutenSolutions GlutenFreeMall TheGlutenFreePantry/Glutino (888)8458836 (866)5753720 (800)2918386 www.glutensolutions.com www.glutenfreemall.com www.glutino.com HealthValley* HeartlandsFinest KingsmillFoods (800)4344246 (888)6588909 (416)7551124 www.healthvalley.com www.heartlandsfinest.com www.kingsmillfoods.com KinnikinnickFoods* MapleGroveFoodandBeverage* MedDiet (877)5034466 (323)3220501 (800)6333438 www.kinnikinnick.com www.maplegrovefoods.com www.meddiet.com MissRobens PamelasProducts PerkysNaturalFoods* (800)8910083 (707)4626605 (888)4737597 www.missroben.com www.pamelasproducts.com www.perkysnaturalfoods.com *Providesenrichedglutenfreebreadproductsorbakingmixes
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GlutenFreeDiet References 1. Celiacdisease.TheAmericanDieteticAssociationNutritionCareManual.UpdatedAnnually.Availableat:nutritioncaremanual.org. AccessedOctober26,2010.. 2. AbdulkarimAS,MurrayJA.Reviewarticle:thediagnosisofcoeliacdisease.AlimentPharmacolTher.2003;17:987995. 3. Alaedini A, Green PH. Narrative review: celiac disease: understanding a complex autoimmune disorder. Ann Intern Med. 2005;142:289298. 4. FarrellRJ,KellyCP.Celiacsprue.NEnglJMed.2002;346:180188. 5. Fasano A, Catassi I. Current approaches to diagnosis and treatment of celiac disease:anevolvingspectrum.Gastroenterology. 2001;120:636651. 6. NationalInstitutesofHealthConsensusDevelopmentConferenceStatement.NIHConsensusDevelopmentConferenceonCeliac Disease.June2830,2004;Bethesda,Md.FinalStatementAugust9,2004. Availableat:http://consensus.nih.gov/2004/2004CeliacDisease118html.htm.AccessedNovember27,2007. 7. CeliacDiseaseEvidenceBasedNutritionPracticeGuidelines.AmericanDieteticAssociationEvidenceAnalysisLibrary.The AmericanDieteticAssociation;2009.Availableat:http://www.adaevidencelibrary.org.AccessedOctober25,2010. 8. MakiM,CollinP.Coeliacdisease.Lancet.1997;349:17551759. 9. ZipserRD,PatelS,YahyaKZ,BaischDW,MonarchE.Presentationsofadultceliacdiseaseinanationwidepatientsupportgroup. DigDisSci.2003;48:761764. 10. ThompsonT.CaseProblem:questionsregardingtheacceptabilityofbuckwheat,amaranth,quinoa,andoatsfromapatientwith celiacdisease.JAmDietAssoc.2001;101:586587. 11. JanatuinenEK,KemppainenTA,PikkarainenPH,HolmKH,KosmaVM,UusitupaMIJ,MakiM,JulkunenRJK.Lackofcellularand humoralimmunologicalresponsestooatsinadultswithcoeliacdisease.Gut.2000;46:327331. 12. Hoffenberg EJ, Haas J, Drescher A, Barnhurst R, Osberg I, Bao F, Eisenbarth G.A trial of oats in children with newly diagnosed celiacdisease.JPediatr.2000;137:361366. 13. JanatuinenEK,KemppainenTA,JulkunenRJK,KosmaVM,MakiM,HeikkinenM,UusitupaMIJ.Noharmfromfiveyearingestion ofoatsincoeliacdisease.Gut.2002;50:332335. 14. StorsrudS,OlssonM,ArvidssonLR,NilssonLA,KilanderA.Adultcoeliacpatientsdotoleratelargeamountsofoats.EurJClin Nutr.2003;57:163169. 15. Hogberg L, Laurin P, FaithMagnusson K, Grant C, Grodzinsky E, Jansson G, Ascher H, Browaldh L, Hammersjo JA, Lindberg E, Myrdal U, Stenhammer L.Oats to children with newly diagnosed coeliac disease: a randomised double blind study.Gut.2004;53:649654. 16. LundinKE,NilsenEM,ScottHG,LobergEM,GjoenA,BratlieJ,SkarV,Mendez,E,LovikA,KettK.Oatsinducedvillousatrophyin coeliacdisease.Gut.2003;52:16491652. 17. PeraahoM,KaukinenK,MustalahtiK,VuolteenahoN,MakiM,LaippalaP,CollinP.Effectofoatscontainingglutenfreedieton symptomsandqualityoflifeincoeliacdisease:arandomizedstudy.ScandJGastroenterol.2004;39:2731. 18. ArentzHansenH,FleckensteinB,MolbergO,ScottH,KoningF,JungG,RoepstorffP,LundinKEA,SollidLM.Themolecularbasis foroatintoleranceinpatientswithceliacdisease.PLoSMed.2004;1:e1. 19. ThompsonT.Oatsandtheglutenfreediet.JAmDietAssoc.2003;103:376379. 20. Joint FAO/WHO Food Standards Program. Codex Committee on Nutrition and Foods for Special Dietary Uses.Draft revised standardforglutenfreefoods.CX/NFSDU98/4.July1998:14. 21. Thompson T, Dennis M, Higgins L, Lee A, Sharrett M.Glutenfree diet survey: are Americans with coeliac disease consuming recommendedamountsoffibre,iron,calciumandgrainfoods?JHumNutrDiet.2005;18:163169. 22. USFoodandDrugAdministrations(FDA)CodeofFederalRegulations(21CFR137).Availableat: http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=108_cong_bills&docid=f:s741es.txt.pdf. Accessed November 29, 2007. 23. GodkinA,JewellD.Thepathogenesisofceliacdisease.Gastroenterology.1998;115:206210. Bibliography GreenPH,JabriB.Coeliacdisease.Lancet.2003;362:383391. FasanoA,BertiI,GerarduzziT,NotT,CollettiRB,DragoS,ElitsurY,GreenPH,GuandaliniS,HillID,PietzakM,VenturaA,ThorpeM,Kry D,FornardiF,WassermanSS,MurrayJA,HorvathK.PrevalenceofceliacdiseaseinatriskandnotatriskgroupsintheUnitedStates:a largemulticenterstudy.ArchInternMed.2003;163:286292. MurrayJA.Thewideningspectrumofceliacdisease.AmJClinNutr.1999;69:354365. ThompsonT.Thiamin,riboflavin,andniacincontentsoftheglutenfreediet:istherecauseforconcern?JAmDietAssoc.1999;99:858 862.AmericanGastroenterologicalAssociationmedicalpositionstatement:CeliacSprue.Gastroenterology.2001;120:15221525.
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TYRAMINERESTRICTEDDIET
Description Foods containing tyramine and other vascoconstrictive amines are eliminated from the TyramineRestricted Diet.
Indications TheTyramineRestrictedDietisindicatedwhenpatientsarereceivingmonoamineoxidaseinhibitors(MAOIs) and the medication Zyvox (Linezolid), an oxazolidinone antibiotic possessing weak, reversible monoamine oxidative inhibitor activity (1,2). MAOIs treat anxiety and depression by inhibiting the inactivation of neurotransmitters.TherapywithMAOIsisusedtopreventthecatabolismofdietarytyramine,whichnormally is metabolized in the gastrointestinal tract.Theresultisanincreasedconcentrationoftyramineinthebody, causingthereleaseofnorepinephrineandanelevationofmood.Increaseamountsoftyramine,however,can cause an excess amount of norepinephrine to be released, which may result in a hypertensive crisis. This is characterizedbysevereheadaches,palpitation,neckstiffnessorsoreness,nauseaorvomiting,sweating,fever, andvisualdisturbances.
Manyfoodsnormallycontainsmallamountsoftyramineandothervasopressoramines.Largeamountshave been reported only in aged, fermented, pickled, smoked, or bacterially contaminated products. When fresh foods are stored, especially meat, poultry, fish, and related items such as pt, gravy, and soup stock, fermentationoccursandthetyraminecontentofthefoodincreases.Sinceheatdoesnotdestroytyramine,all foodsshouldbefresh,freshfrozen,orcannedandshouldbehandled,prepared,stored,andservedinwaysthat maximizefreshness.
Theconsequencesoftyramineintakearedoserelated.Therefore,reactionscanbepreventedwithouttotal abstinencefromtyraminecontainingfoods.Asanexample,Zyvox(Linezolid)isusuallyadministeredasanIV antibioticinthehospitalsettingwhentypicallylowertyraminefoodsareconsumed.Arecentstudyshowed dietaryrestrictionwasnotnecessaryduetolowertyraminecontentofthehospitalmeals (3).However,the FDAcontinuestorecommendavoidingconsuminglargeamountsoffoodsorbeverageswithhightyramine content while consuming Zyvox (2). A rational approach to diet compliance could best be achieved by emphasizingthemostcrucialitemstoavoid.
Caffeine does not contain tyramine, but excessive amounts may precipitate hypertensive crisis. Therefore, foods containing caffeine such as chocolate (1) should be ingested with caution. In addition, using the herb ginsengwithMAOinhibitorssuchasNardilorParnatemaycauseheadache,troublesleeping,nervousness,and hyperactivity(1).
NutritionalAdequacy The diet, a variation of the Regular Diet, can be planned to meet the DRIs as outlined in the Statement on NutritionalAdequacyinSectionIA.
HowtoOrdertheDiet Orderas____________________Diet,TyramineRestricted.
PlanningtheDiet GuidelinesfordietarycounselinginMAOIuseincludethefollowing: 1. Beginnutritioncounselingbeforemedicationtherapy. 2. Monitorpatientcompliance. 3. Recommendpreparationandconsumptionofonlyfreshfoods. 4. Continuethediet4weeksbeyondmedicationtherapy.
Resynthesis of monoamine oxidase occurs slowly, and food interactions may occur up to 3 weeks after withdrawal of some MAOI medications. Prudent practice is to start the tyraminerestricted diet when the medicationtherapyisbegunandtocontinuethedietfor4weeksafterthemedicationregimeniswithdrawn.
Reference 1. Drugsafetydata:Linezolid.Availableat: http://www.accessdata.fda.gov/drugsatfda_docs/label/2005/021130s008,009,021131s009,010,021132s008,009lbl.pdf (2005datareport).AccessedAugust6,2010. 2. ZyvoxIn:DrugLibrary.DrugDigest.ExpressScripts,Inc.@www.drugdigest.org,accessedOctober1,2005. 3. RumoreMM,RothM,OrfanosA.Dietarytyraminerestrictionforhospitalizedpatientsonlinezolid:anupdate.NutrClinPract. 2010;25:265269. Bibliography Tyraminecontrolleddiet.In:TheAmericanDieteticAssociationNutritionCareManual.Updatedannually.Availableat: http://www.nutritioncaremanual.org.AccessedOctober26,2010. ManualofClinicalNutritionManagement
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Tyramine-Restricted Diet
FOODGUIDE
FOODSEXCLUDED Beverages
Wine;beer;champagne(regular,alcoholfree,orreducedalcohol) Caffeinecontaining beverages (eg, coffee, tea, or soft drinks) should be limitedtotwo8ozservingsperday Cheeseorcheeseproductsexceptcottagecheese,cream,ricotta,orprocessed (American)
Milk
Meats&Fish Aged,cured,smoked,pickled,orsaltedmeatsandfish Liver;pate Hotdogs;sausage;salami;pepperoni;bacon Vegetables Sauerkraut Pickledvegetablessuchaspickles;chilipepper Broadbeans Fruits None Miscellaneous Soysauce;teriyakisauce;blackbeansauce Meattenderizers Bleucheese,ranch,orothercheesecontainingsaladdressings Brewersyeast Olives Chocolate Note: Patients should be reminded to consult their physician or pharmacist before taking new medications, especially cold tablets, decongestants, most allergy and asthma medications, hypertensivemedications,dietpills,andsleepingpills. MONOAMINEOXIDASEINHIBITOR(MAOI)DRUGS
GENERICNAME Tranylcyprominesulfate Phenelzinesulfate Isocarboxazid Furazolidone Procarbazinehydrochloride GENERALUSE Antidepressant Antidepressant Antidepressant Antimicrobial Anticancer
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LACTOSECONTROLLEDDIET
Description TheLactoseControlledDietlimitsintakeofmilkandmilkproductstotheamounttoleratedbytheindividual. RefertoLactoseMaldigestionmedicalnutritiontherapyprotocolformedicalnutritioninterventionstrategies(1). Indications TheLactoseControlledDietisindicatedinpatientswhoarelactoseintolerant;theyaredeficientintheenzyme lactase and are unable to tolerate ingested lactose. Lactose maldigestion occurs when digestion of lactose is reduced as a result of low activity of the enzyme lactase, as determined by the breath hydrogen test (2). Interpretationofthetermsusedtodescribelactosemaldigestionvaries.Forexample,lactoseintolerancerefers tothegastrointestinalsymptomsresultingfromconsumptionoftoomuchlactoserelativetothebodysabilityto breakitdownbytheintestinalenzymelactase (1).Lactosemaldigestionoritssymptoms(lactoseintolerance) should not be confused with a milk allergy, which is an allergy to milk proteins, not lactose. Lactose maldigestionispresentin70%oftheworldsadultsand20%to25%oftheUSpopulation.Itismostprevalent among AfricanAmericans, Asians, Hispanics, Native Americans, and people of Jewish descent. Lactose not hydrolyzedbylactaseinthesmallintestinepassesintothelargeintestine,whereitisbrokendownbybacteria. Theproductsofbacterialdegradationcanirritatethemucosaandraisetheosmolalityoftheintestinalcontents, causing a net secretion of fluid. Symptoms includebloating,abdominalpain,flatulence,anddiarrhea,usually within30minutesafteringestionoflactosecontainingfoods. Lactosemaldigestionisnotadisease,butanormalphysiologicpattern (3).Primarylactasedeficiencyisthe most common type and occurs as a normal physiological process in which lactase production in the brush borderofthesmallintestineisreduced (3).Lactasedeficiencymaybesecondary(secondarylactasedeficiency) to significant proteinenergy malnutrition, acquired immunodeficiency syndrome (AIDS), or iron deficiency anemia. Secondary lactase deficiency has also been observed following the use of antibiotics and anti inflammatory drugs for arthritis. A transient secondary lactase deficiency may occur following viral gastroenteritis.Ithasbeenobservedfollowingsurgicalresectionofthestomachorsmallbowelwhenthereisa decrease in the absorptive area, following radiation therapy to the gastric or pelvicarea,andafterprolonged disuseofthegastrointestinaltract(eg,withtotalparenteralnutrition).However,thelactaseactivitymayreturn to normal in the latter conditions over time. In children, it is typically secondary to infections or other conditions,suchasdiarrhea,AIDS,orgiardiasis.Lactoseintolerancemayalsobesecondarytoconditionsthat produce intestinal damage, such as celiac sprue, regional enteritis, Crohns disease, and glutensensitive enteropathy. Treatment is aimed at the underlying disorder in order to restore the patients tolerance to lactose and to eliminatelactoserestrictions.Evidencesuggeststhatpeoplewithmedicallyconfirmedlactasemaldigestioncan include the recommended number of servings of milk and other dairyfoodsintheirdiet,whichmayactually improvetheirtolerancetolactose(13). Infeedingmalnourishedhospitalizedpatientsandotherpatientswithlactoseintolerance,intoleranceto12g oflactosecanbeclinicallyrelevant.Thefollowingareusedtodeterminethepresenceoflactoseintolerance: Adiethistorycanrevealsymptomsoflactoseintolerancefollowingingestionoflactose.Reliefofsymptoms followingtrialofareducedlactoseintakealsoindicateslactoseintolerance. Abreathhydrogenanalysistestisthegoldstandard,ormethodofchoice,todiagnoselactosemaldigestion, especially in children. An increase in breath hydrogen concentration, generally 10 to 20 ppm above baseline,warrantsadiagnosisoflactosemaldigestion. Alactosetolerancetestgivesanoraldoseoflactoseequivalenttotheamountof1quartofmilk(50g).Inthe presence of lactose intolerance, the blood glucoselevelincreaseslessthan25mg/dLofserumabovethe fastinglevel,andgastrointestinalsymptomsmayappear. Abiopsyoftheintestinalmucosatodeterminelactaseactivity. Congenitallactoseintoleranceisararecondition.Itiscommonlydiagnosedduringthenewbornperiodby intestinal biopsy and enzyme assay. Congenital lactose intolerance can cause lifethreatening diarrhea and dehydrationinthenewborn.Alactosefreeformulaisindicatedassoonasthediagnosisismade.
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Lactose-Controlled Diet
NutritionalAdequacy TheLowLactoseDietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedintheStatement on Nutritional Adequacy in Section IA. Adequate calcium can be obtained through the inclusion of dairy products,includingcheese,yogurt,andmilkorlactosehydrolyzedmilk. When dairy products are limited, adequate intake of calcium, phosphorus, vitamins AandD,andriboflavin may be difficult to obtain. Because of the increased importance of calcium and its relationship to various diseases (eg, osteoporosis, hypertension) maintaining calcium intake of 1000 to 1300 mg/day for adults is a primarygoal (4).VitaminDfortifiedmilkisthemostdependablesourceofvitaminD.AvitaminDsupplement may be indicated if exposure to sunlight is not ensured and if other foods fortified with vitamin D are not includedinthediet. HowtoOrdertheDiet OrderasLactoseControlledDiet. PlanningtheDiet Theimportantconsiderationishowmuchlactosecanbetoleratedwithoutdevelopingintestinalsymptoms. Between80%and100%ofpeoplewithlactasedeficiencyexperiencethesymptomsdescribediftheydrink1 quart of milk a day. Research indicatesthatmostpeoplewithlowlevelsoflactasecancomfortablyingestat least1cup(8oz)ofmilk(12goflactose)withamealandeven2cupsofmilkinaday(5,6).Onestudyhasfound that people with lactose maldigestion can consume 1500 mg of calcium per day if the dairy products are distributedbetweenthethreemealsandprovidedpartiallyintheformofyogurtandcheese(2cupsofmilk,2oz of cheese, and 8 oz of yogurt) (7). Tolerance to milk products is greater when they are consumed with other foodsandspacedthroughouttheday.Wholemilkisbettertoleratedthanlowerfatmilk,andchocolatemilkis better tolerated than unflavored milk (8,9). Generally, cheeses and ice cream are better tolerated than milk becauseofitslowerlactosecontent.Adultswithlactoseintolerancecanusuallytoleratetheamountsofmilkin manypreparedfoods,suchasbreads,luncheonmeats,andcreamedfoods,ifthesefoodsaregivenatintervals throughouttheday. Milk contributes a number of important nutrients to the diet, and dairy products are a major source of calcium, protein, and riboflavin. The maximum amount of milk products that can be taken without adverse effectsshouldbeincludedinthedietofpersonswithlactosemaldigestion.Tolerancetolactosecanbeimproved bygraduallyincreasingintakeoflactosecontainingfoodssuchasdairyproducts(3). Commercial lactase enzyme preparations (eg, Lactaid and Dairy Ease) will hydrolyze 70% to 90% ofthe lactoseinmilkdependingontheamountadded.Lactosereducedmilks(reducedfat,nonfat,calciumfortified, and chocolate) with 70% to 100% of their lactose hydrolyzed are available. Lactosereduced cottage cheese, pasteurizedprocessedcheese,andsomeicecreamsareavailableinsomemarkets.LactaidcapletsandDairy Easetablets,whichcanbetakenbeforeingestionofmilkormilkproducts,arealsoavailable.Productsmade fromsoy,eg,tofu,calciumandvitaminfortifiedsoymilk,tofubasedicecreamsubstitutes,andpastaentrees,are alsoavailable. The following ingredients contain lactose and can be identified on the products food label: (dry) milk solids/curds,casein,whey(solids),andlactose. Other compounds that may appear on the food label but do not contain lactose are calcium compounds, kosherfoodsmarkedpareveorparve,lactate,andlacticacid.
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LACTOSECONTENTOFMILKPRODUCTS
1015g Milk,fluid,1cup 16g Pudding,cup IceCream,cup IceMilk,cup Sherbet,cup ProcessedCheeseSpread,1oz CottageCheese,cup LactaidandDairyEaseMilk(100% reduced),1cup 1ga ProcessedAmericanCheese,1oz Creamcheese,1oz NaturalHardandSemisoftCheeses,1 oz HalfandHalf,1tbsp SourCream,1tbsp
Yogurtb,1cup
Thesefoodsareprocessedwithsmallamountsofmilk,milkproducts,milksolids,orlactoseandcanbeconsideredtohaveminimalto undetectableamountsoflactose. bOnlyyogurtwithactiveculturesiswelltoleratedbypersonswithalactasedeficiency.Yogurtwithactiveculturesislabeledliveandactive culture.

a
FOODGUIDELACTOSECONTROLLED
FOODGROUPS
FOODSTHATMAYCAUSEDISTRESS
BeveragesandMilk
Milk(includingacidophilusmilk)andmilkproductsexceptyogurta;however, 4to8ozofmilkcanusuallybetoleratedwithmealsseveraltimesperday Mochamix
FruitsandJuices
None
Vegetables
Anypreparedwithmilkorcheese Instantmashedpotatoescontaininglactose Creamed,scalloped,orcommercialproductscontainingmilk
BreadsandCereals
InstantCreamofWheat;highproteincereals;cerealswithmilk
Meat,Fish,Poultry,Cheese
Meatsandmeatsubstitutesincreamsauce Coldcuts,luncheonmeats,sausage,processedmeatsthatcontainmilk,nonfat milksolidsorlactosefiller Cottagecheese;processedcheesespread(Hard,agedcheeses,eg,bleu,brick, Camembert,cheddar,Colby,Edam,provolone,andSwiss,andprocessed cheeses,eg,American,Swissarelowinlactoseandusuallydonotpresenta problem.)
Fats
Cream;halfandhalf;whippingcream Graviesmadewithmilk
Soups
Creamsoups;chowder;commerciallypreparedsoupsthatcontainmilkor milkproducts
Desserts
Icecream Pudding,custard,andotherdessertscontainingmilkormilkproducts
SugarandSweets
Candycontainingmilkorcocoa Butterscotchcandies,caramels,chocolate
Onlyyogurtwithactiveculturesiswelltoleratedbypersonswithalactasedeficiency.Yogurtwithactiveculturesislabeledliveandactive culture.
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Lactose-Controlled Diet
SAMPLEMENU Breakfast OrangeJuice Oatmeal HardCookedEgg Biscuit Margarine;Jelly Coffee Sugar;Nondairycreamer Milk(cupiftolerated)or LactoseReducedMilk Noon HoneyGlazedChicken BakedPotatoWithMargarine SteamedBroccoli FruitedGelatin DinnerRoll Margarine FrostedBananaCake Milk(cupiftolerated) Tea;Sugar Evening BraisedBeef&Noodles SeasonedGreenBeans SlicedTomatoSalad FrenchDressing PeachHalves DinnerRoll FruitedYogurt Margarine Tea;Sugar
References 1. InmanFeltonA.Overviewoflactosemaldigestion(lactosenonpersistence).JAmDietAssoc.1999;99:481489. 2. LactoseIntolerance.Washington,DC:NationalDigestiveDiseaseInformationClearinghouse;1994.NIHPublicationNo.942751. 3. McBeanLD,MillerGD.Allayingfearsandfallaciesaboutlactoseintolerance.JAmDietAssoc.1998;98:671676. 4. Yates AA, Schlicker SA, Suitor CW. Dietary Reference Intake: The new basis for recommendations for calcium and related nutrients, B vitaminsandcholine.JAmDietAssoc.1998;98:699706. 5. SuarezF,SavaianoD,LevittMD.Acomparisonofsymptomsaftertheconsumptionofmilkorlactosehydrolyzedmilkbypeoplewithself reportedseverelactoseintolerance.NEnglJMed.1995;333:14. 6. SuarezF,SavaianoD,ArbisiP,LevittMD.Tolerancetothedailyingestionoftwocupsofmilkbyindividualsclaiminglactoseintolerance.Am JClinNutr.1997;65:15021506. 7. SuarezF,AdsheadJ,FurneJ.LevittMD.Canlactosemaldigesterstoleratetheingestionofadairyrichdietcontainingapproximately1500 mgcalcium/day?NewOrleans,La:AmericanGastroenterologicalAssociationDigestiveDiseaseWeekSyllabus.1998;A520,#2086. 8. DehkordiN,RaoDR,WarrenAP,ChawanCB.Lactosemalabsorptionasinfluencedbychocolatemilk,skimmilk,sucrose,wholemilk,and lactosecultures.JAmDietAssoc.1995;95:484486. 9. HertzlerSR,LevittMD,SavaionoPA.Colonicadaptationinthedailylactosefeedinginlactosemaldigestersreduceslactoseintolerance.JAm ClinNutr.1996;64:12321236.
Bibliography EscottStumpS.NutritionandDiagnosisRelatedCare.5thed.Baltimore,Md:LippincottWilliams&Wilkins;2002. HermansMM,BrummerRJ,RuijgersAM,StockbruggerRW.Therelationshipbetweenlactosetolerancetestresultsandsymptomsof lactoseintolerance.AmJGastroenterol1997;92:981984. HetzlerS,HuynhBL,SavaianoDA.Howmuchlactoseislowlactose?JAmDietAssoc.1996;96:243246. Lactosecontrolleddiet.ManualofClinicalDietetics.Chicago,Ill:AmericanDieteticAssociation;1996. Lactaid.Availableat:http://www.jnj.merck.com.AccessedApril28,1998. LeeMF,KrasinskSD.Humanadultonsetlactasedecline:anupdate.NutrRev.1998;98:18. LinMY,YenCI,ChenSH.Managementoflactosemaldigestionbyconsumingmilkcontaininglactobacilli.DigDisSci.1998;43:133137. BeyerPL.Medicalnutritiontherapyforlowergastrointestinaltractdisorders.In:MahanKL,EscottStumpS,eds.KrausesFood,Nutrition andDietTherapy.10thed.Philadelphia,Pa:WBSaunders;2000:679680. NationalDigestiveDiseasesInformationClearinghouse.Lactoseintolerance.Availableat:http://www.gastro.com.AccessedApril28, 1998. RamirezFC,LeeK,GrahamDY.Alllactasepreparationsarenotthesame:resultsofaprospective,randomized,placebocontrolledtrial. AmJGastroenterol.1994;89:566570. SavaianoDA,AbouA,AnouarEI,SmithDE,LevittMD.Lactosemalabsorptionfromyogurt,pasteurizedyogurt,sweetacidophilusmilk, andculturedmilkinlactasedeficientindividuals.AmJClinNutr.1984;40:12191223. VesaTH,KorpelaRA,SahiT.Tolerancetosmallamountsoflactoseinlactosemaldigesters.AmJClinNutr.1996;64:197201.
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NUTRITIONMANAGEMENTOFFOODHYPERSENSITIVITIES
Description This diet eliminates the offending food or foods that cause an adverse reaction. Generally, the diet is the RegularDietwiththeomissionoftheoffendingfood.Eachindividualssensitivitytothefooddeterminesthe degreetowhichtheparticularfoodmustbeomitted.
Indications Foodhypersensitivityisanimmuneresponse,generallyfromIgE,tofoodcomponents.Thereactionresults fromanantigenoffoodsource(usuallyprotein)andmayoccurimmediately(1minuteto2hours)orasa delayed reaction (2 to 48 hours) (1). Allergic tendencies are inherited, but not necessarily to a specific antigen.Foodsmostcommonlyreportedtocauseallergicreactionsinchildrenarecowsmilk,chickeneggs, peanuts,soy,andfish;inadults,themostcommonaretreenuts,peanuts,fish,shellfishandwheat (24).The mostcommonreactionstofoodallergiesaregastrointestinal(eg,diarrhea,nausea,vomiting,cramping,and abdominaldistentionandpain),skinrelated,andrespiratoryresponsesaswellassystemicanaphylaxiswith shock.
No simple test can be used to accurately diagnose the presence of a true food hypersensitivity. Unidentified or misdiagnosed food hypersensitivities can cause fatal reactions, result in inappropriate treatments, and threaten nutritional status. For the diagnosis of hypersensitivity, the following measures shouldbetaken:afoodreactionhistory,aphysicalexamination,a1to2weekdiaryrecordingfoodseaten and symptoms, biochemical testing, immunologic testing, eg, skin tests such as, radioallergosorbent test (RAST) and the enzymelinked immunosorbent assay (ELISA), a trial elimination diet for 2 weeks or until symptomsareclear,andafoodchallenge(2,5,6).
Thehistory,usedtoidentifythesuspectedfood,shouldincludedetaileddescriptionsofsymptoms,amount offoodingested,timeofintake,andtimeofonsetofsymptoms.
Atrialeliminationdietremovesallsuspectedfoodsandreintroducesthemoneatatime;ifthesymptoms arereducedby50%ormorewhilethepatientisonthediet,thatfoodissuspected (5).Thefoodchallengeis madeaftersymptomsarecleared.Althoughchallengescanbeopen,singleblind,ordoubleblind,thedouble blind, placebocontrolled food challenge (8) is the preferred method for diagnosis of food hypersensitivity. Foodsareprovidedinapureform,andchallengedoneatatime,oneperday.Afterthetrialeliminationdiet andfoodchallenge,thepatientsdietshouldbealteredeliminatingtheresponserelatedfoodfor6to8weeks (5).Thesefoodsarechallengedagain,andifthepatientdoesnotreacttothem,thefoodsarereturnedtothe dietonanoccasionalbasis.
NutritionalAdequacy Thetrialeliminationdietisintendedtobeshorttermbecauseofitsnutrientinadequacies.Mosteliminations that involve a single food can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in the Statement on Nutritional Adequacy in Section IA. However, diets that eliminate cows milk may be low in calcium,vitaminD,andriboflavin.Ifchildrenmusteliminatecowsmilk,thedietmayalsobelowinprotein andvitaminA.Dietsthatrestrictoreliminateeggs,meats,andfishmaybedeficientinprotein.Grainfree diets may be deficient in B vitamins, iron, energy, and carbohydrates.Citrusfreedietsmaybedeficientin vitaminCandfolicacid.Dietsthateliminatemultiplefoodscanbedeficientincertainnutrientsandshould beevaluated,sothatappropriatealternativesarerecommendedtosupplynutrientsthatarelacking.Nofood groupshouldbecompletelyeliminatedonapermanentbasisunlessabsolutelynecessary.
HowtoOrdertheDiet Orderas______FreeDiet(specifyfoodtoeliminate).
PlanningtheDiet The basic diet should be the appropriate diet for the patients age. Only foods confirmed by the food challenge should continue to be restricted. It is important to personalize the patients diet based on food preferences.
Labelsandrecipesshouldbecarefullyreadtoavoidingestionofthefoodthatcausesareaction.Teaching the patient to read food labels, make appropriate substitutions, and purchase foods free of the suspected allergen, is the most helpful component to the selfmanagement training. Often this training will require morethanonesession.Patientsshouldbeencouragedtocontactfoodmanufacturerswithquestionsabout
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Nutritional Management of Food Hypersensitivities
ingredients.TheFoodAllergy&AnaphylaxisNetwork(FAAN)hasaGroceryManufacturersDirectoryand small, pocketlaminated cards listing food terminology. These resources are available for purchase directly from FAAN (10400 Eaton Place, Suite 107, Fairfax, VA 22030, 703/6913179, Fax, 703/6912713, email: fan@worldweb.net)(5).
The following section lists ingredients and terms found on food labels, which indicate the presence of specificfoodallergens.
CornFreeDiet Ingredientstoavoid: Bakingpowder Corn,alltypes Cornflour Corngrits Cornmalt Cornmeal Cornstarch Cornsugar;cornsweeteners Cornsyrups Dextrin;dextrose Equalsugarsubstitute
Fructose Glucose Hominy Lacticacid Maize Maltodextrin Modifiedfoodstarch Popcorn Sorbitol Vegetablegum;vegetablestarch
EggFreeDiet Ingredientstoavoid: Albumin Apovitellin Cholesterolfreeeggsubstitute Egg Eggpowder Eggwhites,allforms Globulin Livetin Mayonnaise
Meringue(meringuepowder) Ovalbumin Ovoglobulin Ovomucin Ovomucoid Ovovitellin Simplesse Surumi
MilkFreeDiet Ingredientstoavoid: Artificialbutterflavor;butterflavoredoil Maltedmilk Butter,buttersolids Milk:whole,lowfat,reducedfat,andnonfat Buttermilk Milkchocolate Casein;caseinates(ammonium,calcium, Milkderivative;milkpowder;milkprotein;milk magnesium,potassium,sodium) solids;milksolidpastes Cheese,alltypes;cheeseflavor;cheesesauce; Nonfatmilksolids;nonfatdrymilk cottagecheese;creamcheese Nougat Cream;sourcream;whippedcream Pudding Curds Rennetcasein Custard Simplesse Ghee Sourmilksolids Goatsmilk Sweetenedcondensedmilk Halfandhalf Whey:curd,lactosefree,demineralized,sweet dairy;wheyproteinconcentrate;whey Hydrolysates(casein,milk,protein,whey,whey solidsYogurt;frozenyogurt;yogurtpowder protein) Icecream Foodsthatmayindicatethepresenceofmilk protein:caramelcandies,highproteinflour,non Lactalbumin;lactalbuminphosphate; dairyproducts lactoglobulin Lactatesolids Lactose Lactulose Note:Thedesignationpareveonfoodlabelsindicatesthattheproductdoesnotcontainmilk.
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PeanutFreeDiet Ingredientstoavoid: Artificialnuts Beernuts Coldpressedorextrudedpeanutoil Groundnuts Mandelonas Mixednuts
Nuts;flavorednuts,nutmeat,pieces Peanuts Peanutbutter;peanutbutterchips Peanutflour Peanutsyrup Foodsmayhavepeanutproteinpresence:baked goods,candy(includingchocolate,eggrolls,chili, enchiladasauce,flavoring,marzipan,nougat
SoyFreeDiet Ingredientstoavoid: EdaMame(soybeansinpods) Hydrolyzedsoyprotein Kinnokoflour Kyodofu(freezedriedtofu) Miso;soymiso Modifiedfoodstarch Natta Okara(soypulp) Shoyusauce Soyalbumin Soyconcentrate Soyflour;soybeanflour
Soymilk;soybeanmilk Soynuts Soyprotein;soyproteinisolate Soysauce Soysprouts Soybeangranules Supro Tamari Tempeh TexturedVegetableProtein(TVP) Tofu Yakidofu
WheatFreeDiet Ingredientstoavoid: Allpurposeflour,enrichedflour Noodles Bran Pasta Bread;breadcrumbs Pastryflour Bulgur Semolina Cakeflour Spelt Cerealextract SoySauce Couscous Starch Crackers;crackermeal Surumi Durum;durumflour;durumwheat Wheat;wheatbran;wheatflour Farina Wheatgerm Flour,wheat,bran,graham Wheatgluten Foodstarch Wheatmalt Gluten;highglutenflour Wheatstarch Grahamflour Wholewheatberries Malt;maltextract Note: Alternatives to wheat flour include rice flour, potato flour, rye flour, oat flour, barley flour, and buckwheatflour.SeeGlutenRestrictedDietearlierinthissectionforfloursubstitutionrecipes.
ShellfishFreeDiet IngredientstoAvoid: Abalone Clams Crab Crawfish Lobster Mollusks Oysters

Prawns Scallops Shrimp Foodsthatmayindicatethepresenceofshellfish protein:fishstock,flavoring(includingnaturalor artificial),seafoodflavoring(suchascraborclam exgtract),surimi
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TreeNutFreeDiet IngredientstoAvoid: Almonds Artificialnuts Brazilnuts Caponata Cashews Filbert/hazelnuts Gianduja(nutmixturefoundinchocolate) Hickorynuts Nougat Naturalnutextract(i.e,almond,walnut)
Nutmeal Nutoil Nutpaste(i.e,almondpaste) Nutpieces Pecans Pesto Pine nuts (also known as Indian, pinon, pinton, pignoli,pignoliaandpignonnuts Pralines Walnuts
Bibliography 1. EscottStumpS.NutritionandDiagnosisRelatedCare.5thed.Baltimore,Md:LippincottWilliams&Wilkins;2002:76. 2. Wilson SH. Medical nutrition therapy for food allergy and food intolerance. In: Mahan KL, EscottStump S, eds. Krauses Food, NutritionandDietTherapy.10thed.Philadelphia,Pa:WBSaunders;2000.p916924. 3. AmericanAcademyofAllergy,Asthma,andImmunology.Positionstatementonanaphylaxisinschoolandotherchildcaresettings.J AllergyClinImmunol.1998;102:173. 4. Nutrition management of food hypersensitivities. In: Pediatric Manual of Clinical Dietetics. 2nd ed. Chicago, Ill: American Dietetic Association;2003. 5. WatsonWT.Foodallergyinchildren.ClinRevAllergyImmunol.1995;13:347359. 6. Bischoff SC, Mayer J, Wedemeyer J, Meier PN, ZeckKapp G, Wedi B, Kapp A, Cetin Y, Gebel M, Manns MP. Colonoscopic allergen provocation(COLAP):anewdiagnosticapproachforgastrointestinalfoodallergy.Gut.1997;40:745753. 7. PlantM.Newdirectionsinfoodallergyresearch.JAllergyClinImmunol.1997;100:710.
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BODYWEIGHTEVALUATIONandNUTRITIONALINDICATORSOF NUTRITIONRELATEDPROBLEMS
Weightevaluationispartofthenutritionassessment.Weightshouldalsoberoutinelyevaluatedtodetermine theoutcomeofnutritioninterventions.Ifpossible,apatientshouldbeweighedonthesamescaleforeach evaluation, preferably by using a beam scale with nondetachable weights. For the most reliable weight evaluation, the patient should be weighed while fasting, after voiding, and without drainage bags and dressings. If drainage bags and dressings cannot be removed, weigh them separately and deduct their weight. BodyWeightasanIndicatorofNutritionRelatedProblems Body weight and changes in body weight are two of the most reliable indicators of declining or improving nutritional status. The three means of evaluatingbodyweight describedbyBlackburnarelistedbelow (1). Thepercentusualweight,percentofrecentweightchange,andthebodymassindex(BMI)arestrongly correlated with morbidity, mortality, and severity of illness in hospitalized patients and longterm care residents (1,2).Involuntaryweightlossisareliableindicatorofnutritionalcompromiseandcanbeusedto diagnose nutritionrelated problems, such as malnutrition (13). The criteria listed in Tables II: 13 can be used to determine ICD9CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnosticcodesandthenutritiondiagnosisofmalnutritionorothernutritionrelateddiagnosesbyusingthe AmericanDieteticAssociationsInternationalDietetics&NutritionTerminology(IDNT)ReferenceManual (4). BMI levels less than 19 kg/m2 for adults and less than 23 kg/m2 for older adults (>65 years of age) are indicators of lower than recommended weight levels (4). For the most complete evaluation, the dietitian should use the three assessment parameters described below in addition to the BMI level (3,4). For the dehydrated or edematous patient, the measured weight must be intuitively increased or decreased, respectively,priortoevaluation. Actualweight 1. Percentidealbodyweight(1)= 100 Idealweight SeeDeterminingIdealBodyWeightBasedonHeighttoWeight:TheHamwiMethod(pageII6).
2. Percentusualbodyweight(1)=
Actualweight Usualweight
100 100
3. Percentrecentweightchange(1)=
(UsualweightActualweight) UsualWeight
TableII1:WeightLossasanIndicatorofMalnutrition(1,2) Time SignificantWeightLoss(%) SevereWeightLoss(%) 1week 1to2 >2 1month 5 >5 3months 7.5 >7.5 6months 10 >10 TableII2:BodyMassasanIndicatorofMalnutrition(3) LevelofMalnutrition BodyMassIndex (kg/m2) Mildmalnutrition 17.018.4 Moderatemalnutrition 16.016.9 Severemalnutrition <16.0

ManualofClinicalNutritionManagement II1 Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.
BodyWeightEvaluation
TableII3:IndicatorsaoftheNutritionDiagnosisofMalnutrition(4)
NutritionDiagnosis Etiologies(Causes) NutritionAssessmentIndicators
Malnutrition(NI5.2) Inadequateintakeof proteinand/or energyover prolongedperiodsof timeresultinginloss offatstoresand/or musclewasting
Physiologicalcauses Lackoffoodor limitedaccessto food Foodandnutrition relatedknowledge deficitconcerning theamountof energyandprotein required Psychological(eg, depression,eating disorders)
Biochemicalb: Anthropometric: BMI<18.5kg/m2adults(<23kg/m2foradults65years andolder) Inadequatematernalweightgain BMI<5thpercentileinchildren Weightloss(>10%in6months,>5%in1month) Underweightwithmusclewasting Nutritionfocusedphysicalfindings: Uncomplicatedmalnutrition:thin,wastedappearance; severemusclewasting;decreasedbloodpressure,body temperature,andheartrate;changesinhairandnails, thin/sparsehair Disease/traumarelatedmalnutrition:thintonormal appearancewithperipheraledema,ascites,or anasarca;edemaoflowerextremities;somemuscle wastingwithretentionofsomebodyfat; dyspigmentationofhairandskin Food/nutritionandclienthistory: Delayedwoundhealing Intakeanalysislessthanenergy/proteinrequirements Excessiveconsumptionofalcoholorothersubstances preventingadequateenergy/proteinintake
Biochemical:
Inadequateprotein energyintake(NI 5.3) Inadequateintakeof proteinand/or energycomparedto establishedreference standardsor recommendations basedon physiologicalneeds ofshortorrecent duration
Sameasmalnutrition
Normalalbumin(inthesettingofnormalliverfunction despitedecreasedproteinenergyintake) Anthropometric: Inadequatematernalweightgain Weightlossof7%duringpast3months,>5%inone month,1to2%inoneweekinadults,anyweightloss orfailuretogainweightinchildren. Nutritionfocusedphysicalfinding: Slowordelayedwoundhealing Food/nutritionandclienthistory: Intakeanalysislessthanestimatedormeasuredenergy requirements Restrictionoromissionoffoodgroupssuchasdairyor meatgroups(protein)orbreadormilkgroup (energy) Nutrientmalabsorption(eg,bariatricsurgery)
Oneormoreindicatorsmustbepresenttodetermineanutritiondiagnosis. bADAandASPENareintheprocessofdevelopingandsubmittinganetiologybasednomenclaturefordescribingandcodingadult malnutrition(JParentEnteralNutr.2010;34(2):156159)totheNationalCenterforHealthStatistics(NCHSICD9CM)inSeptember 2010.Inthepast,hepatictransportproteinmeasure(albuminandprealbumin)wereusedasindicatorsofmalnutrition.Thesensitivity ofthesemeasuresispresentlyunderinvestigation(4). Adaptedfrom:InternationalDietetics&NutritionTerminology(IDNT)ReferenceManual.3rded.Chicago,Ill:AmericanDietetic Association;2010.

a
BodyWeightEvaluation
Table II-4: ICD9CMCodesForNutritionRelatedDisorders Criteriab ICD9CM Diagnosisa CodeNumber 260.0 Kwashiorkor Nutritionaledemawithdyspigmentationofskinand hair 261.0 Nutritionalmarasmus Nutritionalatrophy;severe,chroniccaloriedeficiency; severemalnutrition 262.0 Othersevereproteinenergy Nutritionaledemawithoutmentionof malnutrition dyspigmentationofskinandhair 263.0 Proteinenergymalnutrition RefertoTablesII:13fornutritionalindicatorsof ofmoderatedegree malnutrition. 263.1 Proteinenergymalnutrition RefertoTablesII:13fornutritionalindicatorsof ofmilddegree malnutrition. 263.8 Otherproteincalorie Criteriaisnotavailable.RefertoTablesII:13for malnutrition nutritionalindicatorsofmalnutrition. 263.9 Unspecifiedproteincalorie Adisordercausedbyalackofpropernutritionoran malnutrition,calorie inabilitytoabsorbnutrientsfromfood malnutrition Animbalancednutritionalstatuscausedby insufficientintakeofnutrientstomeetnormal physiologicalrequirements 579.3 Otherandunspecified Hypoglycemiaormalnutritionfollowing postsurgicalnonabsorption gastrointestinalsurgery 783.2 Abnormallossofweightand BMI<19kg/m2(<23kg/m2inolderadults65+ underweight years)(4) 783.21and/or Lossofweight BMI<19kg/m2;alsorefertoTableII:1 V85.0 783.22and/or Underweight BMI<19kg/m2 V85.0
MalnourishedindividualsmaymeetcriteriaforthesebillableICD9CMcodes. Acutephasehepaticproteins(albumin,prealbumin,transferrin,andretinolbindingprotein)shouldnotbeusedasindicatorsof malnutritioninpatientswhohaveaninflammatorymetabolismduetoacuteorchronicdiseaseorinpatientsinwhichtheevaluationofC reactiveproteinorothermarkersindicatesaninflammatorymetabolism(46).ADAandASPENareintheprocessofdevelopingand submittinganetiologybasednomenclaturefordescribingandcodingadultmalnutrition(JParentEnteralNutr.2010;34(2):156159)to theNationalCenterforHealthStatistics(NCHSICD9CM)inSeptember2010.
a b

References 1. BlackburnGL,BistrianBR,MainiBS,SchlamnHT,SmithMF.Nutritionalandmetabolicassessmentofthehospitalizedpatient.J ParenterEnteralNutr.1977;1:1122. 2. SplettPL,RothYouseyLL,VogelzangJL.Medicalnutritiontherapyforthepreventionandtreatmentofunintentionalweightlossin residentialhealthcarefacilities.JAmDietAssoc.2003;103:352362. 3. KrystofiakRussellM,MuellerC.Nutritionscreeningandassessment.In:GottschlichM,ed.TheA.S.P.E.N.NutritionSupportCore Curriculum:ACaseBasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofParenteralandEnteralNutrition; 2007:168. 4. InternationalDietetics&NutritionTerminology(IDNT)ReferenceManual.3rded.Chicago,Ill:AmericanDieteticAssociation;2010. 5. CriticalIllnessEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociationEvidenceAnalysisLibrary.American DieteticAssociation;2006.Availableat:http://www.adaevidencelibrary.com.AccessedJanuary5,2009. 6. FurhmanMP,CharneyP,MuellerCM.Hepaticproteinsandnutritionassessment.JAmDietAssoc.2004;104:12581264.
Bibliography AmericanMedicalAssociation.AMAICD9CM2007:Physician,InternationalClassificationofDiseases:ClinicalModification.9threv.ed. Chicago,IL:AmericanMedicalAssociation,2006.
STATUREDETERMINATION
Method1:Height Height should be taken with the subject in stocking feet and standing against a vertical measuring board. (Forpatientswithseverecurvatureofthespine,othermeasurementsofstaturemaybemoreaccurate.) Procedure:Havethesubjectstanderectwithweightequallydistributedonbothfeetandtheheelstogether and touching the vertical board. Where possible the head, shoulder blades, buttocks, and heels should all touch the vertical board. Arms should be hanging free at the sides with palms facing the thighs. Subject shouldlookstraightahead,takeadeepbreath,andholdpositionwhilethehorizontalheadboardisbrought downfirmlyontoptothehead.Measuretothenearest0.1cm.
Method2:ArmSpan Measurement of arm span is roughly equal to height. The span measurement remains constant despite decreasingheightwithageandisanacceptablealternativemethodforestablishingheight.
Procedure: Position the subject with his or her feet against a flat surface, usually a wall. Fully extend the subjects upper extremities (including hands) at shoulder level with palms facing forward. Place a tape measureagainstthewalltomeasurethedistancebetweenthetipofonemiddlefingertothetipoftheother middlefinger(excludefingernails).Armspanmustbedonesupinebetweenbirthandthreeyearsofage.
Note:Measurementofarmspanmaybedifficultinelderlypersonsduetoaninabilitytoadequatelystretch outtheirarms,andchestmeasurementsmaybealteredbylungdiseaseorosteoporosis.Armspanmaybe usedintheelderlytoestimatemaximumstatureatmaturitybeforeoccurrenceofagerelatedboneloss.
Method3:KneeHeight Knee height provides a method to measure stature of persons who cannot stand upright. Unlike overall height,kneeheightchangeslittlewithage.Themeasurementishighlycorrelatedwithstature.
Thefollowingformulasareusedtocomputestaturefromkneeheight: EstimationofStatureFromKneeHeight Whitemale 618years 2.22(KneeHeight)+40.54 1860years 1.88(KneeHeight)+71.85 6080years 2.08(KneeHeight)+59.01 Blackmale 618years 2.18(KneeHeight)+39.60 1860years 1.79(KneeHeight)+73.42 6080years 1.37(KneeHeight)+95.79 Whitefemale 618years 2.15(KneeHeight)+43.21 1860years 1.87(KneeHeight)+70.25(0.06age) 6080years 1.91(KneeHeight)+75(0.17age) Blackfemale 618years 2.02(KneeHeight)+46.59 1860years 1.86(KneeHeight)+68.10(0.06age) 6080years 1.96(KneeHeight)+58.72
*
Factor* +8.42cm +7.94cm +15.68cm +9.16cm +7.2cm +16.8cm +7.8cm +7.2cm +17.64cm +8.78cm +7.6cm +16.5cm
Thestatureofanindividualwillhavea95%chanceoffallingwithintheboundariesrepresentedbytheformulawiththeappropriate correctionfactor.
Adapted from: Chumlea W, Guo S, Steinbaugh M. Prediction of stature from knee height for black and with adults and children with application to mobilityimpaired or handicapped person. J Am Diet Assoc. 1994;94:13851388. From: Grant A, DeHoog S. Nutrition AssessmentSupportandManagement.Seattle,Wash:DeHoog/Grant;1999.Reprintedbypermission.
Procedure:Thekneelengthmeasurementismadewithasliding,broadbladecalipersimilartotheapparatus usedtomeasurethelengthofinfants.
Bibliography GrantA,DeHoogS.NutritionalAssessmentSupportandManagement.5thed.Seattle,Wash:Grant/DeHoog;1999.
BODYMASSINDEX(BMI)
Height 50 51 52 53 54 55 56 57 58 59 510 511 60 61 62 63 64
100 20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 12 12 105 21 20 19 19 18 17 17 16 16 16 15 15 14 14 13 13 13 110 21 21 20 19 19 18 18 17 17 16 16 15 15 15 14 14 13 115 22 22 21 20 20 19 19 18 17 17 17 16 16 15 15 14 14 120 23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15 125 24 24 23 22 21 21 20 20 19 18 18 17 17 16 16 16 15 130 25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16 135 26 26 25 24 23 22 22 21 21 20 19 19 18 18 17 17 16 140 27 26 26 25 24 23 23 22 21 21 20 20 19 18 18 17 17
Weight(lb)
145 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18 150 29 28 27 27 26 25 24 23 23 22 22 21 20 20 19 19 18 155 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19 160 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 19 165 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 170 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 175 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 180 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 185 190 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 37 36 35 34 33 32 31 30 29 28 27 26 26 25 24 24 23 195 38 37 36 35 33 32 31 31 30 29 28 27 26 26 25 24 24 200 39 38 37 35 34 33 32 31 30 30 29 28 27 26 26 25 24 205 40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 26 25
TheBMIscoremeansthefollowing: Underweight Normal Overweight Obesity Extremeobesity Below18.5 18.524.9 25.029.9 30.039.9 >40
BMI levels less than 19 kg/m2 for adults and less than 23 kg/m2 for older adults (>65 years of age) are indicatorsoflowerthanrecommendedweightlevels(1).
Source: National Heart, Lung, and Blood Institute Obesity Education Initiative. Expert Panel. Clinical guidelines on the identification, evaluationandtreatmentofoverweightandobesityinadults.Availableat:http://www.nhlbi.nih.gov.AccessedNovember8,1999.
Reference 1. InternationalDietetics&NutritionTerminology(IDNT)ReferenceManual.3rded.Chicago,Ill:AmericanDieteticAssociation;2010.
DETERMININGIDEALBODYWEIGHT(IBW)BASEDONHEIGHTTO WEIGHT:THEHAMWIMETHOD
FrameSize Medium Females Males Allow100lbforfirst5ftofheightplus5lbfor Allow106lbforfirst5ftofheightplus6 eachadditionalinch.Subtract2.5lbforeach lbforeachadditionalinch.Subtract2.5 inchlessthan5ft. lbforeachinchunder5ft. Subtract10% Add10% Subtract10% Add10%
Small Large
Source: Nutrition and Your Health: Dietary Guidelines for Americans. 3rd ed. Washington, DC: US Depts of Agriculture and Health and HumanServices;1990.HomeandGardenBulletinNo.232. HamwiGJ.Changingdietaryconcepts.In:DanowskiTS(ed).DiabetesMellitus:DiagnosisandTreatment,Vol.1.NewYork: AmericanDiabetesAssociation,Inc;1964:7378.
TheabovemethodofcalculatingIdealBodyWeight(IBW)isalsoreferredtoasthe5footrule.
HEALTHYWEIGHTCHART
**
WithoutShoes WithoutClothes
Source:ReportoftheDietaryGuidelinesAdvisoryCommitteeontheDietaryGuidelinesforAmericans,2000.Availableat: http://www.ars.usda.gov/dgac/dgacguideexp.pdf.AccessedFebruary23,2000.
STANDARDBODYWEIGHT(SBW)DETERMINATIONBASEDON NHANESII
BasedonNHANESIIweighttable,50thpercentile,kg Men 2554Years Height(in) Small Medium Large 62 64 68 82 63 61 71 83 64 66 71 84 65 66 74 79 66 67 75 84 67 71 77 84 68 71 78 86 69 74 78 89 70 75 81 87 71 76 81 91 72 74 84 91 73 79* 85 93 74 80* 88 92 Women 2554Years Height(in) Small Medium Large 58 52 63 86 59 53 66 78 60 53 60 87 61 54 61 81 62 55 61 81 63 55 62 83 64 57 62 79 65 60 63 81 66 58 63 75 67 59 65 80 68 62 67 76 69 63* 68 79 70 64 70 76 5474Years Medium 68 70 71 72 74 78 78 77 80 84 81 88 95 5474Years Medium 57 62 65 64 64 65 66 67 66 72 70 72* 73*
Small 61 62 63 70 68 69 70 75 76 69 76* 78* 77*
Large 77* 80 77 79 80 85 83 84 87 84 90 88 89
Small 54 55 54 56 58 58 60 60 68 61* 61* 62* 63*
Large 92 78 78 79 82 80 77 80 82 80 79 85* 85*
Note:Thecliniciansjudgmentshouldbeusedinassigningtheseweights.Somecategoriesarebasedonasmallsamplesizeofpatientsor estimated*bylinearregressionequation. Reference FrisanchoAR.NewStandardsofweightandbodycompositionbyframesizeandheightforassessmentofnutritionalstatusofadultsand theelderly.AmJClinNutr.1984;40:808819.McCannL(ed)PocketGuidetoNutritionAssessmentofthePatientwithChronicKidney Disease(3rdEd).NationalKidneyFoundationCouncilonRenalNutrition,2002:11.
DETERMINATIONOFFRAMESIZE
Method1:WristMeasurement FrameSize(rvalues)=
Height(cm) WristCircumference(cm) Method 1. Measureindividualheightincentimeters(cm) 2. Measurethesmallestpartoftheindividualswristincentimeters. 3. Dividetheheightbythewristcircumferencetoderivervaluefor framesize.Lookattabletothelefttointerpretframesizeof individual.
rvalues Females Males
Interpretatio n >11.0 >10.4 Smallframe 10.111 9.610.4 Medium frame <10.1 <9.6 Largeframe
Method2:ElbowBreadth(1,2) Framesizeisinfluencedbysofttissueandfatbutelbowbreadthisagoodindexofskeletalorframesizeandis lessaffectedbyfatthanwristcircumference.Itisalsocloselyassociatedwithleanbodymass.Elbowbreadthis thedistancebetweentheepicondylesofthehumerusandshouldbemeasuredwitheitherslidingorspreading calipers.Tomeasure:
1. 2.
3.
4.
5.
Extendonearminfrontofthebodyandbendtheforearmupwardata90angle.Keepthefingersstraight andturntheinsideofthewristtowardthebody. Place the thumb and index finger of the other hand on the two prominent bones (epicondyles of the humerus)ontherightsideoftheelbow.Forgreatestaccuracy,useslidingcalipers.(Slidingcaliperscanbe obtainedfromLafayetteInstrument,POBox5729,3700SagamorePkwyN,Lafayette,IN47903;telephone: 800/4287545;fax:7654234111;email:rehab@licmef.com.) Place the blades of the sliding caliper (blades pointing up) or the tips of the spreading caliper on the epicondyles.Exertfirmpressuretocompressthesofttissuesandrecordinthemeasurementtothenearest 0.1cm. Frisanchodevelopedaframeindexbasedonelbow,breadth,height,andage.FrameIndex2wasderived usingdatafromtheNationalHealthandNutritionExaminationSurveyIII(NHANES)andaccountsforage relatedchangestoheightandweight.Plugthevalueintothefollowingformula: FrameIndex2=ElbowBreadth(mm)dividedbyHeight(cm)100 Usethetablebelowtoidentifyframesizeforage.
FrameSizeBasedonStatureandAge Men Age(yr) Small Medium 1825 <38.4 38.441.6 2530 <38.6 38.641.8 3035 <38.6 38.642.1 3540 <39.1 39.142.4 4045 <39.3 39.342.5 4550 <39.6 39.643.0 5055 <39.9 39.943.3 5560 <40.2 40.243.8 6065 <40.2 40.243.6 6570 <40.2 40.243.6 7075 <40.2 40.243.6
Large >41.6 >41.8 >42.1 >42.4 >42.5 >43.0 >43.3 >43.8 >43.6 >43.6 >43.6
Small <35.2 <35.7 <35.7 <36.2 <36.7 <36.7 <37.2 <37.8 <38.2 <38.2 <38.2
Women Medium 35.238.6 35.738.7 35.739.0 36.239.8 36.740.2 37.240.7 37.241.6 37.841.9 38.241.8 38.241.8 38.241.8
Large >38.6 >38.7 >39.0 >39.8 >40.2 >40.7 >41.6 >41.9 >41.8 >41.8 >41.8
Adaptedfrom:FrisanchoAR.AnthropometricStandardsfortheAssessmentofGrowthandNutritionalStatus.AnnArbor,Mich:University ofMichiganPress;1990.In:GrantA,DeHoogS.NutritionAssessmentSupportandManagement.5thed.Seattle,Wash:Grant/DeHoog; 1999.Reprintedbypermission. Bibliography FrisanchoR.Newstandardsofbodyweightandcompositionbyframesizeandheightforassessmentofnutritionalstatusofadultsand elderly.AmJClinNutr.1984;40:808 GrantA,DeHoogS.NutritionAssessmentSupportandManagement.5thed.Seattle,Wash:Grant/DeHoog;1999. GrantJ.HandbookofTotalParenteralNutrition.2nded.Philadelphia,Pa:WBSaundersCo;1992:19. ManualofClinicalNutritionManagement II8 Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.
ESTIMATIONOFIDEALBODYWEIGHTANDBODYMASSINDEXFOR AMPUTEES
Inthecasewhereapatienthadanamputation,idealbodyweight(IBW)cannotbecomparedtothestandardsfor normaladults.Althoughbodyproportionsvaryfromindividualtoindividual,segmentalweightscanbeusedto proveanapproximationofIBW.
PercentTotalBodyWeightbyIndividualBodyParts(1)
Source:Osterkamp,Linda.Currentperspectiveonassessmentofhumanbodyproportionsofrelevancetoamputees.JAmDiet Assoc.1995:95;215218.
DeterminingAdjustedBodyWeightfortheAmputee Using the IBW of the patient before the amputation, subtract the percentage of the body limb or part that was removedtoobtainanadjustedIBW.ForamethodofdeterminingIBW,seeSectionII:DeterminingIdealBody Weight(IBW)BasedonHeightandWeight:TheHamwiMethod.
Example:DeterminetheadjustedIBWforawoman55withabelowkneeamputationoftherightleg. IBW(female55).......................................................................... 125lb Rightbelowtheknee(calf4.4%+foot1.5%=(5.9%) 7.5lb AdjustedIBW.................................................................................... 117.5lb
FormulaforBodyMassIndex(BMI)forAmputees(2) BodymassindexcanbecalculatedforpersonswithamputeesbyusingthefollowingformuladescribedbyHimes (2).Totalbodyweight(TBW)orreferredtoasWtEiscalculatedbytakingtheWtOorobservedbodyweight whichisthecurrentmeasuredbodyweight(aftertheamputation)anddividebyoneminusthetotalpercentage oflimb(s)removed.ThepercentageoflimbsmissingcanbederivedfromtheTableabove.
FormulaforBMIinAmputees:WtE=WtO/(1P)(2)
WtE is estimated total body weight (TBW); WtO is the observed body weight (measured weight after the amputation);andPisthepercentageofthemissinglimbsegment(s)whichcanbeestimatedbasedontheTable above.
Example:Abelowthekneeamputationis5.9%or0.059ofTBW.Observed(measured)weightis70kg. WtE=70kg/(10.059) =70kg/(0.941) =74.4kg

EstimationofIdealBodyWeightandBodyMassIndexforAmputees
ToobtainheightforuseintheBMIequation,useheightpriortoamputation,currentheightifitcanbeobtained, or derived from the arm span (for formula see, Section II: Stature Determination). The WtE or adjusted Total BodyWeight(TBW)derivedfromthisformulacanbethenusedintheBMIformula.Alowbodymassindexhasa predictorofmortalityina15monthperiodafteranamputationintheelderlypopulation(3).
References 1. OsterkampL.Currentperspectiveonassessmentofhumanbodyproportionofrelevancetoamputees.JAmDietAssoc.1995;95:215 218. 2. HimesJH.Newequationtoestimatebodymassindexinamputees{letter]JAmDietAssoc.1995;95:646. 3. ColettaEM.Careoftheelderlypatientwithlowerextremityamputation.JAmBoardFamPract.2000;13:2334.
ESTIMATIONOFENERGYEXPENDITURES
Discussion Since the early 1900s, various formulas have been employed to estimate energy expenditure. Since the adventofthedoublylabeledwater(DLW)techniqueinthe1980s,scientistshavebeguntomoreaccurately determinetotalenergyexpenditure(TEE)infreelivingpersons (1).Unfortunately,duetoitshighcostand the limited number of laboratories that perform the DLW technique, this application is not currently accessibleintheclinicalsetting.Mostrecently,theAmericanDieteticAssociation(ADA)exploredevidence that reported the accuracy and application of various methods used to measure energy expenditure, particularlyindirectcalorimetryandpredictiveformulasforvariouspopulationgroups (2,3).Thesereports provide evidence that can be used by dietetic professionals to make informed clinical decisions regarding whether to measure or estimate resting energy expenditure (REE) in patients(2). The predictive equations that have been evaluated include: the HarrisBenedict equation (4), MifflinSt. Jeor equation (5), Owen equations(6,7),andequationsusedbytheWorldHealthOrganizationandtheDietaryReferenceIntakes(8).In 2006, the Swinamer equation, IretonJones equations, Penn State equations, and other equations were evaluatedfortheirapplicationinestimatingenergyexpenditureincriticallyillpatients(3). The Dietary Reference Intakes for energy, which are based on studies using the DLW technique, are considered the most accurate references for estimating TEE in freeliving persons (2,9). These values can serveasaresourcefortheassessmentofpatientswhoarenotcriticallyillordonothavemultipledisease processes (2,8). (Refer to Section A: Estimated Energy Requirements (EER) for Male and Female Under 30 YearsofAge.)TheMifflinSt.JeorequationpredictsREEwiththemostconsistencyandtheleastpercentage oferrorintheambulatorypopulation (2).MultiplestudieshavereportedvariableaccuracywiththeHarris Benedictequation;thisequationaccuratelypredictsREEonly45%to81%ofthetimeinhealthynonobese subjects (2). The accuracy of all predictive equations decreases when applied to the obese population. In studies of obese patients, the HarrisBenedict equation accurately predicted REE only 33% to 64% of the time, while the MifflinSt. Jeor equation accurately predicted REE 70% of the time (2). Because of the variationsreportedwiththeuseoftheHarrisBenedictformula,evidenceprovideslimitedsupportforitsuse in estimating the energy expenditure of ambulatory or hospitalized population groups (2,9). Energy expendituredependsonfactorsincludingage,gender,height,weight,andphysicalactivity.Inthehospital settingwherepatientsgenerallyhavemultiplecomplicationsandthepotentialforrapidchangesinmedical status,predictiveformulasthatincludenotonlydeterminantsofREE,butalsomodifiersforillnessseverity, inflammatorystate,andrespiratorydemandsmaybeneeded (9,10).RefertotheIretonJonesequationsand PennStateequationsdiscussedbelow (3,9,10).Theclinicianshouldrealizethatanymethodusedtoestimate energy expenditure only provides an approximation (2). These equations should be used onlyasaguideor startingpoint,afterwhichthepatientmustbecloselymonitoredandinterventionsmustbedevisedbasedon individualneedsthatpromotetheattainmentofnutritionalstatus.
RecommendedFormulastoCalculateREEinCriticalCarePatients IndirectcalorimetryisthestandardfordeterminationofREEincriticallyillpatientsbecauseREEbasedon measurementismoreaccuratethanestimationusingpredictiveequations (GradeI)*(3).Ifpredictiveequations are needed in nonobese critically ill patients, the best prediction accuracy of equations studied (listed in order of accuracy) include the Penn State equation (2003a version) (79%), Swinamer (55%) and Ireton Jones equation (1992 version), (Grade III) (3,9,11). The HarrisBenedict equation (with or without activity and stressfactors),IretonJonesequation(1997version),andFickequationshouldnotbeusedtodetermineREE incriticallyillpatients,astheseequationsdonothaveadequatepredictionaccuracy (Grade I) (3).Inaddition, theMifflinSt.Jeorequationshouldnotbeusedincriticallyillpatients,asitwasdevelopedforhealthypeople andhasnotbeenwellresearchedinthecriticallyillpopulation (GradeI)(3).Ifpredictiveequationsareneeded forcriticallyill,mechanicallyventilatedindividualswhoareobese,considerusingtheIretonJonesequation (1992version)orthePennStateequation(1998version),astheyhavethebestpredictionaccuracyofthe equations that have been studied (Grade III) (3). Refer to the Critical Illness EvidenceBased Nutrition Practice Guideline(2006)intheADAEvidenceAnalysisLibraryfordetailedinformation(3).
*TheAmericanDieteticAssociationhasassignedgrades,rangingfromGradeI(good/strong)toGradeV(insufficientevidence),toevidence andconclusionstatements.ThegradingsystemisdescribedinSectionIII:ClinicalNutritionManagement,AReferenceGuide,pageIII1.
The IretonJones equations were developed specifically for critically ill patients and hospitalized burn patients. These formulas are the most widely used formulas for patients in the critical care and hospital setting (9, 10, 1215). These equations have easily measured variables (height, weight, age, gender, diagnosis, ManualofClinicalNutritionManagement II11 Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.
EstimationofEnergyExpenditures
presenceofobesity,andventilatorystatus)thatareusedintheequationtoestimateREE.Forthediagnosis variable, patients are assigned as burn, nonburn trauma, or other. Different than most guidelines and definitions,theIretonJonesequationconsidersobesitytobepresentifthebodymassindex(BMI)isgreater than 27 kg/m2 (12,14). If a patient is mechanically ventilated, the ventilator equation should be used regardless of the presence of obesity. The variables in these equations take into account the health and mobilitystatusofacriticalcarepatient.Thecommonpracticeofmultiplyingadditionalphysicalactivitylevel (PAL)factorsorinjuryfactorsisnotvalidatedwiththeseformulas. With the exception of the Penn State Equation, all equations below were developed using actual weight. For the Penn State equation, actual weight was adjusted using the following formula (ideal body weight x 125%)forpatientswithaBMIof>30.WiththeexceptionofthePennStateEquation,thereisnoevidence thatsubstitutingadjustedoridealweightinthesecalculationsresultsinimprovedaccuracy(2,9) PennStateequations(3): The1998versionisrecommendedformechanicallyventilated,obese,criticallyillpatients(GradeIII)(3): REE=BEE(1.1)+VE(32)+Tmax(140)5340 The2003aversionisrecommendedformechanicallyventilated,nonobese,criticallyillpatients(GradeIII)(3): REE=BEE(0.85)+VE(33)+Tmax(175)6433,where BEE=basalenergyexpenditurecalculatedusingtheHarrisBenedictequationa(4) VE=minuteventilation(L/min) Tmax=maximumtemperature(degreesCelsius)
aHarrisBenedictequation(4)foruseinPennStateequationonly:
kcal/day(male)=66+13.8(W)+5.0(H)(6.8xA) kcal/day(female)=655+9.6(W)+1.8(H)(4.7xA),where W=actualweight(kg) H=height(cm) A=age(years)
AnewerversionofthePennStateequations(2003b),inwhichtheMifflinSt.Jeorequationisusedto calculateBEE,isbeingevaluated(3). SwinamerEquation(16) Publishedin1990,wasbasedonobservationsin112mechanicallyventilated,criticallyilltrauma,surgical, andmedicalpatientswithinthefirst2daysofadmissiontocriticalcareunit(GradeIII)(16). EnergyExpenditure=945(BSA)6.4(age)+108(T)+24.2(breaths/min)+81.7(VT)4349 Equationincludesbodysurfacearea(BSA)insquaredmeters(m2),temperature(T)indegreesCelsius,and tidalvolume(VT)inlitersperminute(L/min). IretonJonesequations(1992version)(3,14): IJEE(ventilatordependent)=192510(A)+5(W)+281(S)+292(T)+851(B) IJEE(spontaneousbreathing)=62911(A)+25(W)609(O),where IJEE=estimatedenergyexpenditure(kcal/day) A=age(years) T=trauma(present=1,absent=0) W=weight(kg) B=burns(present=1,absent=0) S=sex(male=1,female=0) O=BMI>27kg/m2(present=1,absent=0) MifflinSt.JeorEquationandRecommendedFormulastoCalculateREEinAmbulatoryPatients TheMifflinSt.JeorequationwasdesignedtoestimateREEintheambulatorypopulation (5,10).Actualbody weight is used in these equations, regardless of BMI (5). It is generally recommended that a PAL factor be multiplied to obtain TEE. It has been recommended that the REE be multiplied by a PAL factor of 1.3 for sedentaryindividuals;however,thisrecommendationhasnotbeenvalidatedinstudies (9).Ifneeded,usea higher activity factor to correct for active individuals engaging in purposeful activity (9). See the following table as a guideline, or refer to PAL described in Dietary Reference Intakes in Section A to determine appropriate PAL estimate (17). Injury factors have not been validated for use with these equations and thereforearenotrecommendedaspartofTEEcalculations. ManualofClinicalNutritionManagement II12 Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.
TheMifflinSt.Jeorequationformenis: REE=10(weightainkg)+6.25(heightincm)5(ageinyears)+5 Thecorrespondingequationforwomenis: REE=10(weightainkg)+6.25(heightincm)5(ageinyears)161

aUsetotalbodyweight,regardlessofBMI.
PALFactor PhysicalActivityLevel(17) Confinedtobed 1.2 Outofbed,ambulatory 1.3 Seatedwork,littleornostrenuousleisure 1.61.7 activity Standingworkorsignificantamountsof 1.81.9 sportorstrenuousleisureactivity(30to 60minutesfourorfivetimesperweek) Strenuousworkorhighlyactiveleisure 2.02.4 EstimatingEnergyExpenditureintheObesePopulation Ideally,theREEofanobesepatientshouldbebasedonleanbodymassthatisdeterminedbymethodssuch asdualxrayabsorptiometry,underwaterweighing,orgoldstandardenergyexpenditurepredictionmodels (eg, DLW technique) (9). However, these methods are not practical in most clinical settings. The common clinicalpracticeofusinganadjustedbodyweighttoestimatethemetabolicallyactivetissuemassdoesnot improvetheaccuracyofpredictingthemetabolicrateinobesepatients (10).TheAdjustedBodyWeightfor Obesity formula, a wellknown formula developed by Cunningham (18,19), is not considered applicable in currentclinicalpracticeandthereforeshouldnotbeusedinanypredictiveequations(5,9,10,19).Theconsensus of literature supports the use of actual body weight in predictive formulas for estimating REE in obese patients (19,20).FormulasliketheMifflinSt.Jeor,IretonJones(1992version),andPennState(1998version) equations have utilized obese subjects in the validation of the equations and therefore are an option for predicting REE in obese patients (3,5,10). According to the ADAs Weight Management Practice Guidelines, estimatedenergyrequirementsshouldbebasedonrestingmetabolicrate(RMR)(21).Ifpossible,RMRshould bemeasured(eg,indirectcalorimetry).IfRMRcannotbemeasured,thentheMifflinSt.Jeorequationusing actual body weight is the most accurate formula for estimating RMR for overweight and obese healthy individuals(GradeI)(21). EstimatingApproximateEnergyRequirementsforAdults Asanalternativetotheabovecalculations,ausefulinitialapproximationoftheenergyneedsofpatientsin theclinicalsettingcanbeobtainedasfollows(8,22):
Obeseorveryinactivepersonsandchronicdieters 1012kcal/lb(20kcal/kg) Personsolderthan55years,activewomen,sedentarymen 13kcal/lb(25kcal/kg) Activemen,veryactivewomen 15kcal/lb(30kcal/kg) Thinorveryactivemen 20kcal/lb(40kcal/kg) EstimatingEnergyRequirementsforSpinalCordInjury Peoplewithspinalcordinjurytendtohavereducedmetabolicactivityduetodenervatedmuscle.Measured energyexpenditureisatleast10%belowpredicted;therefore,caloricneedsofspinalcordinjuredpatients shouldbebasedonmeasuredenergyexpenditure(GradeIII)(23).Ifindirectcalorimetryisnotavailableduring the acute phase (0 4 weeks postinjury using prediction equations based on critical care level using admission weight and multiplying by an injury/stress factor of 1.2 has been suggested (23). During the rehabilitationphase,onestudyreportsinitialcaloricneedscanbeestimatedusing22.7kcal/kgbodyweight forindividualswithtetraplegiaand27.9kcal/kgforthosewithparaplegia(23).Whenestimatingcaloricneeds ofindividualswithspinalcordinjury,acutenessofinjury,levelofinjury,gender,andphysicalactivitylevel shouldbetakenintoconsideration(GradeIII)(23). MeasuringREEbyIndirectCalorimetry IndirectcalorimetryisanindirectmeasurementofREEbasedonquantificationofanindividualsrespiratory gas exchange (ratio of oxygen consumed to carbon dioxide produced). From respiratory gas exchange
measurements, a respiratory quotient can be obtained that can provide additional information about individual substrate utilization (10). Many stress factors and kilocalorie ranges proposed for estimating energy expenditure for specific disease states are based on indirect calorimetry studies; however, the accuracyoftheseformulasforestimatingexpenditurefortheindividualpatientcanvary (9,10).Factorsthat affect energy expenditure and impact the outcome of indirect calorimetry results include: changes in medicationsthatactasastimulantorasedative,changesinthedegreeortypeofventilatorsupport,andday todayvariationsinthemetabolicstresslevel (10).Thesefactorsshouldbeconsideredwhenmonitoringand interpretingmeasuredREE.Indirectcalorimetryremainsaviableoptionforestimatingenergyrequirements inthecriticalcaresettingandcanbeusefulinthepreventionofoverfeedingthecriticalcarepatient.Precise guidelinesandmoreindepthconsiderationsfortheuseofindirectcalorimetryhavebeenpublished(2,1012).
References 1. Black AE, Coward WA, Cole TJ, Prentice AM. Human energy expenditure in affluent societies: an analysis of 574 doublylabelled watermeasurements.EurJClinNutr.1996;50:7292. 2. Indirect Calorimetry Evidence Analysis Project. American Dietetic Association Evidence Analysis Library. American Dietetic Association;2005.Availableat:http://www.adaevidencelibrary.org.AccessedOctober15,2007. 3. Critical Illness EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2006.Availableat:http://www.adaevidencelibrary.com.AccessedOctober15,2007. 4. Harris J, Benedict F. A Biometric Study of Basal Metabolism in Man. Washington, DC: Carnegie Institute of Washington; 1919. PublicationNo.279. 5. MifflinMD,StJeorST,HillLA,ScottBJ,DaughertySA,KohYO.Anewpredictiveequationforrestingenergyexpenditureinhealthy individuals.AmJClinNutr.1990;51:241247. 6. OwenOE,HolupJL,DAlessioDA,CraigES,PolanskyM,SmalleyKJ,KavleEC,BushmanMC,OwenLR,MozzoliMA.Areappraisalof thecaloricrequirementsofmen.AmJClinNutr.1987;46:875885. 7. Owen OE, Kavle E, Owen RS, Polansky M, Caprio S, Mozzoli MA, Kendrick ZV, Bushman MC, Boden G. A reappraisal of caloric requirementsinhealthywomen.AmJClinNutr.1986;44:119. 8. Institute of Medicines Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. National Academy of Sciences; 2002:265334. Preprint available at: http://www.nap.edu.books/0309085373/html/index.html.AccessedApril20,2005. 9. Calculations for nutrition assessment. In: Nutrition Care Manual. American Dietetic Association; 2007. Available at: http://www.nutritioncaremanual.org.AccessedOctober15,2007. 10. WooleyJA,FrakenfieldDC.Energy.In:.In:GottschlichMMed.TheA.S.P.E.N.NutritionSupportCoreCuriculum:ACasedBased ApproachTheAdultPatient.SilverSpring,MD:AmericanSocietyofEnteralandParenteralNutrition;2007:1932.. 11. FrankenfieldD,HiseM,MaloneA,RussellM,GradwellE,CompherC,FortheEvidenceAnlaysisWorkGroup.Predictionofresting metabolicrateincriticallyilladultpatients:Resultsofasystematicreviewoftheevidence.JAmDietAssoc.2007;107:15521561. 12. IretonJonesC.Indirectcalorimetry.In:SkipperA,ed.DietitiansHandbookofEnteralandParenteralNutrition.Gaithersburg,Md: AspenPublishers;1998:148164. 13. Kemper MS. Indirect calorimetry equipment and practical considerations of measurement. In: Weissmen C, ed. Problems in RespiratoryCare:NutritionandRespiratoryDisease.Philadelphia,Pa:JBLippincottCo;1989:479490. 14. IretonJonesCS,TurnerWWJr,LiepaGU,BaxterCR.Equationsforestimationofenergyexpendituresinpatientswithburnswith specialreferencetoventilatorystatus.JBurnCareRehabil.1992;13:330333. 15. IretonJonesCS,JonesJD.Whyusepredictiveequationsforenergyexpenditureassessment?JAmDietAssoc.1997;97(suppl):A44. 16. Swinamer DL, Grace MG, Hamilton SM, Jones R, Roberts P, King EG. Predictive equation for assessing energy expenditure in mechanicallyventilatedcriticallyillpatients.CritCareMed.1990;18:657661. 17. ShettyPS,HenryCJ,BlackAE,PrenticeAM.Energyrequirementsofadults:anupdateonbasalmetabolicrates(BMRs)andphysical activitylevels(PALs).EurJClinNutr.1996;50(suppl1):S11. 18. CunninghamJJ.Anindividualizationofdietaryrequirementsforenergyinadults.JAmDietAssoc.1982;80:335338. 19. FrankenfieldDC,MuthER,RoweWA.TheHarrisBenedictstudiesofhumanbasalmetabolism:historyandlimitations.JAmDiet Assoc.1998;98:439445. 20. IretonJonesCS,TurnerWWJr.Actualoridealbodyweight;whichshouldbeusedtopredictenergyexpenditure?JAmDietAssoc. 1991;91:193195. 21. Adult Weight Management EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. AmericanDieteticAssociation;2006.Availableat:http://www.adaevidencelibrary.com.AccessedOctober15,2007. 22. Franz MJ, Reader D, Monk A, eds. Implementing Group and Medical Nutrition Therapy for Diabetes. Alexandria, Va: American DiabetesAssociation;2002:b4. 23. Spinal Cord Injury Evidence Analysis Project. American Dietetic Association Evidence Analysis Library. American Dietetic Association;2007.Availableat:http://www.adaevidencelibrary.com.AccessedNovember7,2007.
ESTIMATIONOFPROTEINREQUIREMENTS
Thefollowingmethodscanbeusedtoestimateproteinrequirementsbasedonlifestage.Useofactualbody weightorwhenweightcannotbeobtained,idealbodyweight(IBW),issuggestedforallequationsbecause proteinrequirementsrelatetoleanbodymass.Intheunderweight,malnourishedpatient,useofactualbody weighthasbeensuggestedinequationsusinganabolicproteinlevelsinordertoavoidtheconsequencesof overfeeding in these patients. A nitrogen balance test may be employed to evaluate adequacy of protein intakeineitherobeseorundernourishedpatients.RefertoSectionIII:Burnsforinformationonthenitrogen balancetest. AdultMaintenance:RecommendedDietaryAllowances(RDA):0.8to1.0g/kgidealbodyweight(1) OlderAdultsMaintenance:Emergingevidencerecommendsproteinbeincreasedto1.0to1.25g/kgdaily (25)or12%to14%oftotalenergyintakefortheelderly. AdultCriticalIllnessNormalWeightandObesity Critical illnessandthestressresponsetoillnessandtraumaisassociatedwithincreasedproteinturnover, protein catabolism, and negative nitrogen balance (6). Protein requirements double in critical illness to approximately 15% to 20% of total calories (6). In critically ill patients with a body mass index (BMI) < 30, proteinrequirementsshouldbeintherangeof1.2to2.0g/kgactualbodyweightperday.Proteinrequirements maybeevenhigherinburnormultitraumapatients(3,6).2009ASPENguidelinessuggestevenhigherranges fortheobesecriticallycareICUadultpatient.Theguidelinesrecommendproteininarangeof>2.0g/kgideal bodyweightperdayforClassIandIIobesepatients(BMI30to40),>2.5g/kgidealbodyweightperdayfor Class III obese patients (BMI > 40) (6). The best nutrition assessment indicator to determine adequacy of protein intake in critical illness is nitrogen balance evaluation (6). Refer to Section III: Burns for detailed overviewforwhennitrogenbalancemaybewarranted.

SpinalCordInjury: The acute phase of spinal cord injury results in an obligatory negative nitrogen balancethatmaypersistfor7weeksormore,asnitrogenexcretionincreaseswithchangesinbodyweight andlossofleanbodymass (7).Effortstoachievepositivenitrogenbalancewithaggressivenutritionsupport are generally unsuccessful and may result in overfeeding (7). Although a protein intake of 2.4 grams/kg IBW/daymaylessenthenegativenitrogenbalance,2gprotein/kgIBW/daymaybemoreappropriategiven potentialconcernsofsubstrateoverload (GradeIII)(7).Acutephasehypoalbuminemiamaynotbeindicativeof malnutrition, but a rising albumin level within 3 weeks of injury generally indicates adequate nutritional intake (7).Forapersonwithspinalcordinjury,0.81.0gprotein/kgbodyweight/daymayberequiredfor maintenance,withanincreaseto1.01.5gprotein/kgbodyweight/dayifpressureulcersorinfectionare present(GradeIII)(7). RefertoDietaryReferenceIntakes(DRIs):RecommendedIntakesforIndividuals,MacronutrientsinSection 1AorSectionIIIfordiseasespecificinformation.
References 1. InstituteofMedicinesFoodandNutritionBoard.DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids, Cholesterol,Protein,andAminoAcids.NationalAcademyofSciences,2002:265334;preprintat http://www.nap.edu.books/0309085373/html/index.html.AccessedSeptember16,2002. 2. Institute of Medicines Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,Protein,andAminoAcids.(Macronutrients).Washington,DC:NationalAcademyofSciences,2005:107180. 3. Campbell WW, Crim MC, Dallal GE, Young VR, Evans WJ. Increased protein requirements in elderly people: new data and retrospectivereassessments.AmJClinNutr.1994;60:501509. 4. HarrisNG.Nutritioninaging.In:MahanLK,EscottStumpS.KrausesFood,Nutrition,andDietTherapy.10thed.Philadelphia,Pa:WB SaundersCo;2000:294. 5. EvansWJ,CyrCampbellD.Nutrition,exercise,andhealthyaging.JAmDietAssoc.1997;97:632638. 6. McClaveSA,MartindaleRG,VanekVW,McCarthyM,RobertsP,TaylorB,OchoaJB,NapolitanoL,CresciG;A.S.P.E.NBoardof Directors;AmericanCollegeofCriticalCareMedicine.Guidelinesfortheprovisionandassessmentofnutritionsupporttherapyin theadultcriticallyillpatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition(A. S.P.E.N.).JPENJParenterEnteralNutr.2009;33:277316. 7. SpinalCordInjuryEvidenceAnalysisProject.AmericanDieteticAssociationEvidenceAnalysisLibrary.AmericanDietetic Association;2007.Availableat:http://www.adaevidencelibrary.com.AccessedNovember7,2007.
LABORATORYINDICESOFNUTRITIONALSTATUS
Laboratory values can be useful in assessing nutritional status or identifying those at high risk that may require nutrition intervention. However, caution is necessary when interpreting laboratory values, and resultsfromsinglelaboratoryvaluesshouldbeinterpretedcarefully.Thelaboratorytestslistedbeloware commonly used to evaluate either a direct or indirect relationship to a patients nutritional status. The negativeacutephasehepaticproteinsalbumin,prealbumin,transferrinandretinolbindingproteinarenow considered better indicators of inflammatory metabolism, morbidity, mortality and severity of illness than nutritional status (14). These proteins can decrease by as much as 25% as a result of inflammatory metabolism caused by acute or chronic disease (1). In addition, these proteins are not directly linked to nutritiondeprivationasoncethought(14).Thesensitivityofthesemeasuresispresentlyunderinvestigation (5). Because of their ability to predict severity of illness, they can be used to indirectly identify the sickest patientswhomostlikelywillrequirenutritionalinterventionsandmedicalnutritiontherapy(1,2,4).
Test
ProteinStatus Albumin
Purpose/Definition
Indicatorofinflammatory metabolism,morbidity,mortality, orseverityofillness(14)
NormalRange
3.55.0g/dL
Discussion
Shouldnotbeusedasanindicatorofnutritionalstatus Useasanindicatorofinflammatorymetabolism, morbidity,mortality,orseverityofillness(14)Elevated levelsoccurindehydration. Lowinuncomplicatedmalnutrition(withoutexisting acuteorchronicdisease)(1) Shouldnotbeusedasanindicatorofnutritionalstatus Useasanindicatorofinflammatorymetabolism, morbidity,mortality,orseverityofillness(14)More sensitivetodietarychangethanalbuminpostfasting,(4,6). Lowinuncomplicatedmalnutrition(withoutexisting acuteorchronicdisease)(1) Decreasedvaluesoccurwith: nephrosis severeburns malnutrition overhydration hepaticinsufficiency
Prealbumin
1943mg/dL
Protein,total
Totalproteinisoflittlevalueasa sensitiveindexforestimating proteinnutritionalstatus
Serumvalue 6.48.3g/dL
Transferrin
200400mg/dL
Increasedvaluesoccurwith: multiplemyeloma dehydration Shouldnotbeusedasanindicatorofnutritionalstatus Useasanindicatorofinflammatorymetabolism, morbidity,mortality,orseverityofillness(14) Decreaseswithanemiaandproteinenergymalnutrition (uncomplicatedbyacuteorchronicdisease)
Ureanitrogen
Ureaistheprincipalendproductof proteincatabolism
1020mg/dL Valuesmaybe slightlyhigherinthe elderly
Increaseswithirondeficiency,infection,oral contraceptives,andpregnancy Decreasedvaluesoccurwith: liverimpairment decreasedproteinintake overhydration malabsorption highcarbohydrate,lowproteindiets
Increasedvaluesoccurwith: renalinsufficiency GIbleeding dehydration lowerurinarytractinfection diabetesmellitus obstruction starvation congestiveheartfailure excessiveproteinintakeorproteincatabolism HematologicStatus Redbloodcells MeasuresthenumberofRBCsin (RBCs) wholeblood M:4.56.0 million/mm3 F:4.05.5 million/mm3 Decreasedvaluesoccurwith: anemia chronicinfection leukemia
Increasedvaluesoccurwith:dehydration

Test
Hemoglobin (Hgb)
Purpose/Definition
Partoftheredbloodcellsthat carriesoxygenandcarbondioxide intheblood
LaboratoryIndicesofNutritionStatus
NormalRange
M:1318g/100dL F:1216g/100dL
Discussion
MensHgbmaydrop12g/100mLwithage.Women havenodocumentedchange.AlthoughHgbdeclineswith age,othersignsshouldbereviewed,eg,paleskin,pale conjunctiva. Valuesmaydecreaseslightlyintheelderly Values<30indicateadvancedirondeficiencyanemia
Hematocrit(HCT) Meancorpuscular hemoglobin concentration (MCHC) Meancorpuscular volume(MCV) Ferritin
MeasuresthepercentofRBCsin thetotalbloodvolume MeasurestheconcentrationofHgb perunitofredbloodcells
M:42%52% F:37%47% 32%36%
Measurestheaveragesizeofthe RBC Providesanindexofironstoresin irondeficiencyandironoverload Measuresvelocityofbloodclotting andisanindirectmeasureof vitaminKstatus
8095mm3 M:12300g/L F:10150g/L Adults:1112.5 seconds85%100% ofcontrol
Prothrombintime (PT)
Increasedvaluesindicateperniciousanemia.Decreased valuesindicateirondeficientanemia. Significantlyhigherinmendandpostmenopausalwomen. Decreasedvaluesoccurwithironorproteindeletion. Increasedvaluesoccurwithironexcess. Increasedvaluesoccurwith: vitaminKdeficiency(commoninelderlyand hospitalized) liverdisease fatmalabsorption medicationtherapy(antibodies,anticoagulants, aspirin)
PT>25secondsisassociatedwithmajorbleeding

References 1. KrystofiakRussellM,MuellerC.NutritionScreeningandAssessment..In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupport CoreCurriculum:ACasedBasedApproachTheAdultPatient.SilverSpring,MD:AmericanSocietyofEnteralandParenteral Nutrition;2007:170181. 2. FuhrmanMP,CharneyP,MuellerCM.Hepaticproteinsandnutritionassessment.JAmDietAssoc.2004;104:12581264. 3. GabayC,KushnerI.Acutephaseproteinsandothersystemicresponsestoinflammation.NEngJMed.1999;340:448454. 4. MuellerC.Trueorfalse:serumhepaticproteinconcentrationsmeasurenutritionalstatus.SupportLine.2004;26:816. 5. InternationalDietetics&NutritionTerminology(IDNT)ReferenceManual.3rded.Chicago,Ill:AmericanDieteticAssociation;2010. 6. ScalfiL,LavianoA,ReedLA,BorrelliR,ContaldoF.Albuminandlabileproteinserumconcentrationsduringverylowcaloriediets withdifferentcompositions.AmJClinNutr.1990;51:338342.
CLASSIFICATIONOFSOMEANEMIAS
Test RBCcount Hemoglobin Hematocrit MCV MCH MCHC Reticulocytecount RDW Serumferritin TIBC Transferrin Transferrin saturation(%) Serumiron Serumfolate Redcellfolate VitaminB12 Redbloodcells Other B12Deficiency D D D I I N NorD NorI I N N N N NorI D D Normochromic, macrocytic Hypersegmented neutrophils, macroovalocytes FolateDeficiency D D D I I N NorD NorI I N N N N D D N Normochromic, macrocytic Hypersegmented neutrophils, macroovalocytes IronDeficiency D D D D D D NorD I D NorI NorI D D N N N Hypochromic, microcytic Anisocytosis AnemiaofChronicDisease D SlightD D N N N NorD N NorI NorD NorD NorD D N N N Hypochromic,microcytic (bothmild) Poikilocytosis(slight), anisocytosis(moderate)
I=increased;N=normal;D=decreased;TIBC=totalironbindingcapacity
Source:GrantA,DeHoogS.NutritionAssessmentSupportandManagement.5thed.Seattle,Wash:Grant/DeHoog;1999:183.Reprintedby permission.
DIAGNOSTICCRITERIAFORDIABETESMELLITUS
ThediagnosticcriteriafordiabetesareissuedbytheExpertCommitteeontheDiagnosisandClassificationof Diabetes Mellitus (1). In 2009, the Expert Committee on Diagnosis and Classification of Diabetes Mellitus approvedtheuseoftheA1Ctestfordiagnosingdiabetesmellitusafterextensivereviewoftheliteratureand improvedstandardizationoftheassay (1).Thissystemofclassificationofdiabetesisbasedonthecauseof thedisease,asopposedtothetherapyusedtotreatthehyperglycemia. DiagnosisofDiabetes TheExpertCommitteeontheDiagnosisandClassificationofDiabetesMellitusadvocatesuseofthefollowing laboratorycriteriafornonpregnantadults(1):
1.
2. 3.
4.
Symptoms of diabetes plus casual plasma glucose concentration greater than or equal to 200 mg/dL (11.1mmol/L).Casualisdefinedasanytimeofthedaywithoutregardtothetimesincethelastmeal. Theclassicsymptomsofdiabetesincludepolyuria,polydipsia,andunexplainedweightloss. Fastingplasmaglucose(FPG)concentrationgreaterthanorequalto126mg/dL(7.0mmol/L).Fasting isdefinedasnoenergyintakeforatleast8hours. Plasmaglucoseconcentration2hoursafterglucoseingestiongreaterthanorequalto200mg/dLduring anoralglucosetolerancetest(OGTT).Thetestshouldbeperformed,asdescribedbytheWorldHealth Organization (WHO), using a glucose load containing the equivalent of 75 g of anhydrous glucose dissolvedinwater. A1Ctestgreaterthanorequalto6.5%.Testshouldbeperformedinalaboratoryusingamethodthatis NationalGlycohemoglobinStandardizationProgram(NGSP)certifiedandstandardizedtotheDiabetes ControlandComplicationsTrial(DCCT)assay.
Intheabsenceofunequivocalhyperglycemiawithacutemetabolicdecompensation,thesecriteriashouldbe confirmedbyrepeatedtestingonadifferentday.TheOGTTisnotrecommendedforroutineclinicaluse(1). ImpairedFastingGlucose(IFG)andImpairedGlucoseTolerance(IGT) TheExpertCommitteeontheDiagnosisandClassificationofDiabetesMellitusendorsesthefollowingcriteria forthediagnosisofdiabetesmellitus(1). TheExpertCommitteerecognizesanintermediategroupofpatients whose glucose levels, although do not meet thecriteriafordiabetes,aretoohightobeconsiderednormal. Thisgroupisnowreferredtoasprediabetesindicatingtherelativelyhighriskfordevelopmentofdiabetes inthesepatients(1):
Fastingplasmaglucose
Normal <100mg/dL
Glucose tolerance, at 2 hours >200mg/dL after glucose load (during <140mg/dL OGTT) A1CTest 4.5to5.5% 5.7%to6.4% >6.5% ScreeningandDiagnosisSchemeforGestationalDiabetesMellitus(GDM)(2,3) PlasmaGlucose 50gScreeningTest(mg/dL) 100gDiagnosticTest*(mg/dL) Fasting 95 1hpostprandial 130140 180 2hpostprandial 155 3hpostprandial 140
Prediabetes ImpairedFastingGlucose(IFG) >100and<126mg/dL(IFG) ImpairedGlucoseTolerance(IGT) >140and<200mg/dL(IGT)
Diabetes >126mg/dL
Note: High risk women (e.g., marked obesity, history of GDM, glycosuria, or strong family history of diabetes) should undergoglucose testingduringtheinitialprenatalcarevisit,iffoundtonothaveGDMshouldberetestedat24and28weeksgestation.Screeningshould beperformedbetweenthe24thand28thweeksofgestationinwomenwithaverageriskmeetingoneormoreofthefollowingcriteria: >25yearsofage;abodymassindex(BMI)>25kg/m2);familyhistoryofdiabetesinfirstdegreerelatives;historyofabnormalglucose tolerance,and/ormemberofanethic/racialgroupwithahighprevalenceofdiabetes(eg,HispanicAmerican,NativeAmerican,Asian American,AfricanAmerican,orPacificIslander).
*The100gdiagnostictestisperformedonpatientswhohaveapositivescreeningtest.ThediagnosisofGDMrequiresanytwoofthefour plasmaglucosevaluesobtainedduringthetesttomeetorexceedthevaluesshownabove.Thetestshouldbedoneinthemorningafter anovernightfastofbetween8and14hoursandafteratleast3daysofunrestricteddiet(>150gCarbohydrateperday)andunlimited physicalactivity.
DiagnosticCriteriaforDiabetesMellitus References 1. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus: position statement. Diabetes Care. 2010;33 (suppl1):62S69S. 2. AmericanDiabetesAssociation.Gestationaldiabetesmellitus:positionstatement.DiabetesCare.2004;27(suppl1):88S90S. 3. ACOG Practice Bulletin. Clinical management guidelines for obstetriciangynecologists. Number 30, September 2001 (replaces TechnicalBulletinNumber200,December1994).GestationalDiabetes.ObstetGynecol.2001;98:525538. Bibliography The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on Diagnosis and ClassificationofDiabetesMellitus.DiabetesCare.1997;20:11831197. AmericanDiabetesAssociation.Implicationsofthediabetescontrolandcomplicationstrial:positionstatement.DiabetesCare.2002;25 (suppl25S27S. AmericanDiabetesAssociation.ImplicationsoftheUnitedKingdomProspectiveDiabetesStudy.DiabetesCare.2002;25:(suppl1):28S 32S.
MAJORNUTRIENTS:FUNCTIONSANDSOURCES
FatSoluble Vitamins VitaminA (retinol,beta carotene) ImportantSources Milk,butter,fortifiedmargarine,wholemilk Cheese,liver,eggyolk(retinol) Greenleafyandstemvegetables,yellowfruits andvegetables(carotene),eg,spinach, asparagus, broccoli,carrots,apricots,andcantaloupe Exposuretosunlight,fortifiedfoods,fishliver oils Vegetableoils Wholegrains,wheatgerm Leafyvegetables Eggyolk Legumes,nuts(especiallyalmonds,peanuts, pecans,walnuts),sunflowerseeds Lettuce,spinach(greenleafyvegetables), kale,cauliflower,cabbage Eggyolk Soybeanoil Liver ImportantSources Citrusfruits,strawberries,cantaloupe, tomatoes,sweetpeppers,cabbage,potatoes, kale,parsley,turnipgreens,broccoli PhysiologicalRoles Maintainsnormalvisionindimlight,healthyskin, andmucousmembranes Essentialfornormalskeletalandtoothdevelopment
VitaminD (calciferol) VitaminE (tocopherol)
Maintainsbloodcalciumandphosphoruslevels Requiredforproperbonedevelopment Protectstheintegrityofnormalcellmembranes Assistsinpreventionofhemolysisofredbloodcells ProtectsvitaminA,actingasanantioxidant
VitaminK
Producesprothrombininnormalbloodclotting
WaterSoluble Vitamins Ascorbicacid (vitaminC)
PhysiologicRoles Maintainsintegrityofcapillaries Promoteshealingofwoundsandfractures Aidstoothandboneformation Increasesironabsorption Protectsfolicacid Helpsformcollagenforhealthyconnectivetissue Metabolizescarbohydratesforenergy Providesfunctionofnervecellmembranes
Thiamin (vitaminB1)
Riboflavin (vitaminB2)
Niacin
Pyridoxine (vitaminB6)
Pork,liver,chicken,fish,beef Wholegrains,wheatgerm,driedyeast, enrichedcerealproducts Nutsandlentils Milk Liver,meat,fish,eggs Enrichedcerealproducts Greenleafyvegetables Liver,poultry,meat,fish,eggs Wholegrains,enrichedcerealproducts Peanuts,peanutbutter Pork,organmeats,meat,poultry,fish,legumes, seeds Wholegrains
Metabolizescarbohydrates,proteins,andfatsfor energy Closelyrelatedtothemetabolismofprotein Metabolizescarbohydrateforenergy
Metabolizesprotein Convertstryptophantoniacin Synthesizeshemoglobin Maintainsintegrityofcentralnervoussystem
MajorNutrients:FunctionsandSources
WaterSoluble Vitamins VitaminB12 (cyanocobalamin)

ImportantSources
PhysiologicRoles Essentialforredbloodcellmaturationandnormal functionofallbodycells(especiallynervous system,gastrointestinaltractandbonemarrow)
Animalfoodsonly:liver,meat,saltwater fish,oysters,eggs Milk
Folate
Greenleafyvegetables Liver,beef,fish,drybeans,lentils Wholegrains

EssentialforDNAsynthesisandsynthesisand maturationofredbloodcells Responsibleformetabolismofcarbohydrates, proteins,andfatsforenergy;formationofsome hormones,hemoglobin,andnerveregulating substances Synthesizesfattyacids Helpsinmetabolismofcarbohydratesforenergy PhysiologicRoles
Pantothenicacid
Animalsources(esp.organmeats,eggyolk, andmeat) Wholegrains Legumes Yeast
Biotin Minerals
Organmeats,egg,yolk,legumes,nuts ImportantSources
Calcium
Milk Hardcheeses,eg,cheddar,Swiss, mozzarella,andprovolone Yogurt,icecream,cottagecheese Turnipandmustardgreens,collards,kale, broccoli,cabbage

Maintainsstrengthofbonesandteeth Involvedwithtransmissionofnerveimpulses, musclecontractionsandrelaxation,blood clotting,structureandfunctionofcell membranes,andabsorptionofvitaminB12 Essentialforstructureofbonesandteeth;release ofstoredenergy;structureofRNAandDNA;cell permeability;andmetabolismofcarbohydrates, fats,andproteins
Phosphorus
Milkandmilkproducts Meat,poultry,fishandeggs Wholegraincerealsandflours Nutsandlegumes
Magnesium
Wholegrainbreadsandcereals Soybeans,nuts,drybeansandpeas,green leafyvegetables
Fundamentaltotheproductionofenergy,calcium, andphosphorusmetabolisminbone;maintenance ofthefunctionandstructuralintegrityofheart muscleaswellasothermusclesandnerves
Sodium
Useofsaltatthetableandincooking Processedfoods Milk Eggs,meat,poultry,fish Smokedmeats Olives,pickles,soysauce
Maintainsnormalosmoticpressurewaterbalance, normalirritabilityofnervecellsandcontractionof muscles,andpermeabilityofthecellmembrane
Potassium
Meats,poultry,fish,(especiallyvealand salmon) Fruitsandvegetables(especiallybananas, potatoes,tomatoes,andcitrusfruits) Wholegraincereals
Maintainsnormalosmoticpressureandfluid balance Requiredtostoreenergywithinthecell Keytotransmissionofnerveimpulseand contractionofmusclefibers,especiallytheheart muscle
Chloride
Useofsaltatthetableandincooking
Regulatesosmoticpressure,waterbalance,and acidbasebalanceofextracellularfluid Isacomponentofhydrochloricacidinthegastric juice
MajorNutrients:FunctionsandSources
TraceElements Iron
Zinc
Copper
Iodine
ImportantSources Liver,meat,fishandpoultry Wholegrainandenrichedcereals Legumes Greenleafyvegetables Eggs Driedfruit Foodscookedinironpotsandskillets (especiallyfoodswithahighacidcontent) Animalproducts(especiallyliverandoysters) Beef,lamb,pork Wholegraincereals Legumes Peanuts Peanutbutter Organmeats Shellfish(especiallyoystersandcrabs) Wholegraincereals Hickoryandbrazilnuts,sesameandsunflower seeds Legumes(soybeans,kidney,navy,limabeans) Iodizedsaltusedatthetableandincooking
PhysiologicRoles Essentialtotheformationofhemoglobinin bloodandmyoglobininmuscles,which supplyoxygentocells
Essentialinwoundhealing,synthesisof proteins,mobilizationofvitaminAfrom liver,normalcellularimmunefunctions, andnormalgrowthofgenitalorgans
Essentialforformationofredbloodcells andtheutilizationofiron,productionof energy,cellprotectionagainstoxidative damage,andsynthesisofconnectivetissue
Fluoride
Fluoridatedwater Seafood Presentinverysmallamountsinplantfoods (ie,wholegrains,driedbeansandpeas,nuts, seeds,freshfruitsandvegetables) Animalfoods(meat,fish,poultry,eggs)
Partofthyroidhormones Influencesphysicalandmentalgrowth, functioningofnervousandmuscletissues, circulatoryactivity,andmetabolismofall nutrients Increasesdepositofcalcium,which strengthenstheboneandreducestheacid inthemouth,thereforedecreasingtooth decay Essentialascomponentsofenzymesand hormones
Chromium Manganese Molybdenum Selenium Nickel Silicon Vanadium
II-23
PHYSICALSIGNSOFNUTRITIONALDEFICIENCIES
BodyPart
Signs
Deficiencies
Hair
Colorchange Easypluckability,sparseness Alopecia Brittle Dryness
Proteinenergymalnutrition Biotin,zinc,vitaminsAandE
Skin
Acneiformlesions Follicularkeratosis(scalelikeplaques) Xerosis(dryskin) Ecchymoses;petechiae(hemorrhagicspots) Thickeningandhyperpigmentationofpressurepoints Scrotaldermatosis
VitaminA VitaminAoressentialfattyacids VitaminA VitaminsCandK Niacin Niacinandriboflavin
Eyes
Paleconjunctiva(palecoloringofeyelidliningandwhitesofthe eyes) Bitotsspots(foamyspotsonthewhitesoftheeyes) Conjunctivalxerosis(innerlidsandwhitesappeardull,rough) Angularpalpebritis(cornersofeyesarecracked,red)
Iron,folate,orvitaminB12 VitaminA VitaminA Riboflavinandniacin
Mouth
Decreasedproductionofsalivaryfluids Angularstomatitis(cracked,red,flakyatcornerofmouth) Bleedinggums Cheilosis(verticalcracksoflips)
VitaminA VitaminB12 VitaminC Riboflavin
Tongue
Atrophicpapillae(smooth,pale,slicktongue) Glossitis(red,painfultongue) Magentatongue(purplish,redtongue)
Folate,niacin,riboflavin,iron,or vitaminB12 Folate,niacin,andvitaminB12 Riboflavin
Nails
Koilonychia(concave,spoonshaped)
Iron
Extremities
Genuvalgumorvarum(knockedkneesorbowedlegs) Lossofdeeptendonreflexesoflowerextremities
VitaminDorcalcium ThiaminandvitaminB12
II-24
FOODANDMEDICATIONINTERACTIONSa
Medication Classification
Analgesic Acetaminophen (Tylenol) Ibuprofen (Motrin) Aspirin/salicylate
EffectofFood onMedication
Fooddelaysbut doesnot absorption
EffectofMedicationon NutritionalStatus
GIbleedingispossible DecreasedplateletlevelsofvitaminC Decreasedserumfolatedueto competingforserumprotein bindingsites Fecalironloss;potassiumdepletion
PatientGuidelines
Ifmedication(anyanalgesic)upsets stomach,takewithmeals
None
Antacid Magnesium trisilicate (Trisogel) Calciumcarbonate (Tums) Sodium bicarbonate Anticonvulsant Diphenylhydantoin (Dilantin)
None
Mayironabsorption thirst;weight(edema) Possiblemegaloblasticanemiawith longtermtherapy(respondsto25 g/dayoffolate) IncreasedturnoverofvitaminD BlocksconversionofvitaminDby liver;osteomalaciamayresult (respondstovitaminD) IncreasedvitaminCrequirements ReductioninvitaminKdependent coagulationfactors ReducedserumB12status Cantasteacuity Hyperglycemiahasbeenreported Folateneedwithlongterm therapy;however,folatewill absorption Anorexia;oralcandidiasis; abdominalstress
VitaminCsupplementationis recommendedforindividuals receivingsalicylatesfortreatmentof rheumatoidarthritis Maytakewithlowmineral carbohydratesnack Takeaftermealswithwater Evaluateironstatusregularly Takeironsupplementsseparately1 hourbeforeor2hoursaftereating Takewithfoodormilk(medication maycausegastricirritation) Stoptubefeeding1hourbeforeand 1houraftermedicationintake(1) Liberalintakeofdairyproductsis advised VitaminDorfolatesupplementmay beneeded TakeCaorMgsupplementor antacids2hoursbeforeorafter medication Ifpatienthaslossofseizurecontrol, mayneedtofolicacidsupplement
Administer separatelyfrom tubefeedingdue topossibleeffects ofbioavailability
Antibiotic/Anti Infective Erythromycin Penicillinor Ampicillin
Delayed absorptionwhen takenwithfood
Takeonemptystomachwithfull glassofwater Allow1hourtoelapsebetween penicillindoseandconsumptionof fruitjuiceorotheracidicbeverage Takeonemptystomachwithfull glassofwatertoavoidnausea. Avoidmilkproducts,ironfortified cereals,andironsupplementswithin 2hoursofdosage
Tetracycline (Achromycin)
Absorption impairedby concurrent intakeoffoodand antacids containing
Canpromotenegativenitrogen balance
GIindicatesgastrointestinal;,increase;and,decrease ManualofClinicalNutritionManagement II25 Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.
Food and Medication Interactions
Linezolid(Zyvox)
Possible interactionwith foodsand beverageswith hightyramine content(2)
Linezolidisanoxazolidinone antibioticpossessingweak, reversiblemonoamineoxidative inhibitoractivity.
PatientGuidelines
Avoidhightyraminecontaining foodsduringuse.ThisIVantibiotic isprimarilyusedinthehospital settingwhentypicallylowertyra minefoodsareconsumed.Arecent studyshoweddietaryrestrictionis oftennotnecessaryduetolower tyraminecontentofthehospital meals(3).However,FDArecom mendsavoidingconsuminglarge amountsoffoodsorbeverageshigh intyraminecontentduringuse(2). Takemultivitaminswithminerals, Ca,Fe,Mgseparatelyby2hours Stoptubefeeding2hoursbeforeand 2hoursaftermedicationintake
Ciprofloxacin (Cipro) Sulfasalazine
Antifungal Griseofulvin (Fulvicin)
Antihyperlipidemic Clofibrate (AtromidS) Colestipol (Cholestid; Probucol) Cholestyramine (Questran, Cuemid)
Fulvicin absorption improveswitha fattymealor wholemilk
Patientstakingsulfasalazinemay requireasupplementof1mg/dayof folicacidtopreventvitamin deficiencyassociatedwith competitionofthemedicationfor absorptionoffolate PossiblevitaminKandvitaminB absorption Tasteloss;oralcandidiasis;dry mouth;stomachpain
Takewithwholemilkormeal
Nausea Reporteddecreasedabsorptionof vitaminsA,D,K,B12,folate,andFe
Takewithfoodormilk Followalowcholesterolandlowfat diet
Constipationcommon
Atorvastatin (Lipitor) Lovastatin, (Mevacor,Altocor) Simvastatin (Zocor)
Consuminghigh fiberfoodsatsame timemedicationis taken absorptionof medication Grapefruitjuice mayincrease medication availabilityand absorption(47)
Increaseintakeofwaterandhigh fiberfoods Takewithmeals Takevitamin/mineralsupplements1 hourbeforeor4hoursafter medicationintake Mevacor:Donotconsumewithhigh fiberfoods Avoidgrapefruitjuice(47). MevacorandAltocor: AvoidSt.JohnsWort(8)
St.JohnsWort canreducethe concentrationof medicationsin blood(8)

a
GIindicatesgastrointestinal;,increase;and,decrease
II-26
Antihypertensive Propranololbeta blockers (Inderal, Lopressor)
Foodmay increase, decrease,or delayabsorption (dependingon whichbeta blockerisused) Grapefruitjuice mayincrease medication availabilityand absorption(47)
Drymouth;diarrhea;nausea; vomiting;constipation Maypreventtheappearanceof certainpremonitorysignsand symptomsofacutehypoglycemiain type1diabetes
PatientGuidelines
Takewithfood Followasodiumrestricteddiet Avoidnaturallicorice
Calciumchannel blockers (Nifedipine, Felodipine, Nicardipine, Nimodipine, Isradipine, Nisoldipine)and Phenylalkylamine betablocker (Verapamil) Bronchodilator Theophylline (Theo24, TheoDur, Theolair, Slobid)
Avoidgrapefruitjuice(47).
Medicationeffect isincreasedby caffeine;toxicity canresult Whenplasma levelsare measured,coffee, tea,cola, chocolate,and acetaminophen andxanthine contributeto highvalues;may riskof cardiovascular andcentral nervoussystem sideeffects Medicationeffect maybe decreasedby ingestionof charcoalbroiled meats High protein/low carbohydrate dietisassociated withdecreased medicationlevel
MayoccasionallyactasaGIirritant Anorexia Bitteraftertaste Raisesglucosewithhighdosage
Avoidlargeamountsofcaffeineand chocolate TakewithfoodtohelpreduceGI irritation Avoidmajorchangesin carbohydrateandprotein compositionofdiet Avoidexcessiveintakeof charbroiledmeats
II-27
Cardiovascular Digoxin(Lanoxin) Arrhythmia Specific: Amiodarone (Cordarone) Disopyramide (Norpace) Diuretic Thiazides (Diuril, Hydrodiuril) Furosemide (Lasix)
Fooddelaysbut doesnotinhibit absorption exceptforbran, whichmay reduce absorption. AvoidLicorice(8). St.JohnsWort canreducethe concentrationof medicationsin blood(8) Grapefruitjuice mayincrease medication availabilityand absorption(47) Foodincreases absorption.
Digitalismayexacerbatemetabolic effectsofhyperkalemia,especially withrespecttomyocardialactivity MaycauseGIirritation Anorexia;weightloss Diarrhea.Someformsoflicorice mayincreaseriskfortoxicity(8).
PatientGuidelines
Take2hoursaftermealstolessen gastricirritation Takemedicationbetweenmealsif mealsarehighinbran;bran decreaseseffectsandlevelof medication Dietshouldprovideliberal potassium,Mg,andCaintake Avoidnaturallicorice(8) (imported)bandlowNaintake AvoidtakingSt.JohnsWort(8) Avoidgrapefruitjuice(47)
Natriuresismaybeaccompaniedby lossofpotassium AlsoincreasesK,Mg,Zn,andB6 excretion Willutilizationoffolate
Triamterenewith hydrochloro thiazide (Dyazide, Maxzide)
Mgsupplement willabsorption ofmedication
Hypokalemiaisuncommon,but hyperkalemiamayoccur
GIStimulant Cisapride (Propulsid)
Laxative Bisacodyl (Dulcolax)
Bisacodyl (Dulcolax)
Licoricemay reduceeffects(8), particularly hydrodiuruiland aldactone(8) Grapefruitjuice mayincrease medication availabilityand absorption(4,5). MilkcanraisepH ofstomach sufficientlyto dissolveenteric coating prematurely MilkcanraisepH ofstomach sufficientlyto dissolveenteric coating prematurely
Donottakewithmagnesium supplement Takewithmealormilk Limitintakeoffoodshighinsodium; sodiumrestricteddietmaybe preferred Increaseintakeoffoodshighin potassiumandfolate Limituseofnaturallicorice(8) (imported)b Avoiduseofsaltsubstitutes Increasepotassiumintakeonly whennecessaryandthencautiously Avoidgrapefruitjuice(4,5).
Misusemaycausehypokalemiaand weightloss
Takeonemptystomachwith8ozof waterorjuice Drinkplentyoffluids
Misusemaycausehypokalemiaand weightloss
Takeonemptystomachwith8ozof waterorjuice Drinkplentyoffluids
II-28
Thyroid Preparation Synthroid

Goitrogenicsubstancesnaturally presentinsomefoodscaninterfere withiodineuptakebythethyroid
PatientGuidelines
Takeironsupplementseparatelyby 4hours Takeonemptystomach Ifhypothyroidismisinducedby goitrogenicfoods,oneshould encouragethoroughcookingto inactivatethegoitrogensinsome vegetables TakeFesupplementseparatelyby4 hours Avoidconsumptionofcoffee,tea,or fruitjuice1hourbeforeor2hours aftertakingliquidform Takewithfoodormilk
Haloperidol (Haldol)
Miscellaneous Cimetidine (Tagamet)
Maycause additive hypotensionwith alcohol Coffeeorteamay precipitateliquid formof medication Fooddelays medication absorptionand allows maintenanceof aneffective blood concentration betweendoses Grapefruitjuice mayincrease medication availabilityand absorption(4,5). Grapefruitjuice mayincrease medication availabilityand absorption(4,5,8). Adequatefat, protein,and vitaminE neededfor absorption caloriesfor carbohydrate intake; thiamin requirement
Appetite;weightloss;anorexia Drymouth Constipation
Aplasticanemia;absorptionof vitaminB12
Takewithordirectlyaftermeals Adviseconcerningtastechanges
ProteaseInhibitor (Fortorase)
Avoidgrapefruitjuice(4,5).
Benzodiazepines Midazolam,and Triazolam (Halcion, Clomipramine, Anafranil) Vitamin Supplements VitaminA

a b
Avoidgrapefruitjuice(4,5,8).
Toxicinexcessdoses
Avoidexcessiveintakeofrawfish
GIindicatesgastrointestinal;,increase;and,decrease Naturallicoricecontainsacorticosteroidpressorsubstance(carbenoxolone),whichcaninterferewiththeeffectofantihypertensivemedications(beta blockers/hydralazine/thiazides/spironolactone).Advisepatientsreceivingantihypertensivetherapytoeatnomorethananoccasionalpieceofnatural licorice.SeeSectionII:HerbandMedicationInteraction. Manual of Clinical Nutrition Management
II-29
Thiamin(B1) Niacin(B3) Pyridoxine(B6)
Foodshighin thiaminasemay thiamin activity
Largedosesmaybloodglucose andcausejaundiceandGI disturbances;39g/dayproduces toxicity
PatientGuidelines
TakewithfoodormilktoGI distress Forcapsules,donotmixcontents withjamorjelly
VitaminC VitaminD VitaminE
Largedosesmayredbloodcell hemolysisanddestroydietary vitaminB12whentakenwithfood Mayberelevanttokidneystone formation Toxicinexcessdoses LargedosesmayinducevitaminK deficiency 20mg/daywillproducesevere skeletalfluorosis Ca,vitaminC,orproteindeficiency willfluorosis
Mineral Supplements Fluoride Potassium (KDur,KLor, KLyte)

a
Decreased absorptionwhen takenwithdairy products
TakevitaminB12supplement separatelyby1hour Takewithironsupplementto ironabsorption Donottakewithhighfat,lowsugar (rich)foods KeepCasupplementandalbumin hydroxideseparateoffluorideby2 hours Donottakewithdairyproducts
Alsofindreferencetothefollowingmedications: Anticoagulants SeeSectionIII:AnticoagulantTherapy Corticosteroids SeeSectionIII:CorticosteroidTherapy Calciumsupplements SeeSectionIF:NutritionManagementofCalciumIntake Chemotherapeuticagents SeeSectionIII:Cancer Monamineoxidaseinhibitors SeeSectionIH:TyramineRestrictedDiet OralglucoseloweringmedicationsSeeSectionIII:Diabetes:OralGlucoseLoweringMedicationsandInsulin
References 1. DoakKK,HaasCE,DunniganKJ,ReissRA,ReiserJR,HuntressJ,AHavelaJL.Bioavailabilityofpheyntoinacidandpheyntoinsodiumwith enteralfeeding.Pharmacotherapy.1998;18:636645. 2. Drugsafetydata:Linezolid.Availableat http://www.accessdata.fda.gov/drugsatfda_docs/label/2005/021130s008,009,021131s009,010,021132s008,009lbl.pdf (2005datareport).Accessed8/6/2010. 3. RumoreMM,RothM,OrfanosA.Dietarytyraminerestrictionforhospitalizedpatientsonlinezolid:anupdate.NutrClinPract. 2010;25:265269. 4. BailyDG,MalcolmJ,ArnoldO,SpenceJD.Grapefruitjuicedruginteractions.BrJClinPharmacol.1998;46:101110. 5. HuangSM,HallSD,WatkinsP,LoveLA,SerabjitSinghC,BetzJM,HoffmanFA,HonigP,CoatesPM,BullJ,ChenST,KearnsGL,MurrayMD. Druginteractionswithherbalproductsandgrapefruitjuice:Aconferencereport.ClinPharmacolTher.2004;75:112. 6. StumpAL,MayoT,BlumA.Managementofgrapefruitdruginteractions.AmFamPhy.2006;74:605608. 7. MertensTalcottSU,ZadezenskyI,DeCastroWV,DerendorfH,ButterweckV.Grapefruitdruginteractions:caninteractionswithdrugsbe avoided.JClinPharm.2006;46:13901416. 8. U.S.DepartmentofHealthandHumanServicesandU.S.Food&DrugAdministration.DrugswithFoodandBeverages.Availableat http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm096386.htm.AccessedOctober1,2010. Bibliography U.S.DepartmentofHealthandHumanServicesandU.S.Food&DrugAdministration.DrugswithFoodandBeverages.Availableat http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm096386.htm.AccessedOctober1,2010. Manual of Clinical Nutrition Management
II-30
HERBANDMEDICATIONINTERACTIONS
Herb Classifications
Germanchamomile Matricariarecutita (Note:Various typesareavailable, suchasEnglish chamomile,with varying properties.)
Common Indications
Internal: *Cough/bronchitis(2) *Feversandcolds(2) *Inflammationor spasmsofthe gastrointestinaltract(2) *Inflammationofthe mouthandpharynx(2) *Tendencyforinfection (2) Topical: Mildinflammationof theskin(2) Contraindications: Pregnancyand lactation(3) Internal: *Preventionand treatmentofcolds, cough/bronchitis,and urinarytractinfections *Inflammationofthe mouthandpharynx *Stimulatesimmune system(2) Topical: Promoteswound healing(13) Contraindications: Multiplesclerosis, leukosis,collagen disease,AIDS, tuberculosis,and pregnancy Preventionand treatmentofmigraines andmigraine associatednauseaand vomiting(2) Antiarthritic(1)
PossibleSide Effects
Allergy(rare)(1) Patientswithsevere allergiestoragweed shouldbewarned aboutpossiblecross reactivityto chamomileandother membersoftheaster family(eg,echinacea, feverfew,andmilk thistle)(2).
Herb Medication Interactions

Avoidusewith coumarin anticoagulants(2). Chamomilemay exacerbatethe anticoagulant effectsofwarfarin (4). Avoidusewith alcoholand benzodiazepines (2).
PatientGuidelines
Avoidtakingwithother sedatives,suchas benzodiazepinesand alcohol(1). Recommendeddailydosage forinternaluse:3g(2)asan infusion;3gin150mL water3timesdailyfor gastrointestinalcomplaints (8);1to4mLofliquid extractor1cupoftea administeredthreetofour timesdaily(2).
Echinacea Echinacea purpurea, Echinacea angustifolia, Echinaceapallida
Possiblesuppression ofimmunitywith habitualuse(12) Parenteraldosesmay causefever,nausea, andvomiting(2). Patientswith diabetesshould avoidparenteral administration(2).
Immunostimulatin geffectsof echinaceaoffset the immunosuppressiv eeffectsof corticosteroids andcyclosporine (2,3).
Dosageisdependenton variationtype.Safedosages forshorttermuse(<8 weeks)(1,2,4)areto1tsp liquid(expressedjuiceof theherbstabilizedin22% alcohol)orone88.5mg capsuleofdriedjuiceTID(3) or900mgdaily(2).
Feverfew Tanacetum parthenium
Potential sensitizationviaskin contactwith medication(2) Inflammationof mouthandtongue(3)
Contraindications: Pregnancyand lactation
Mayinteractwith thrombolytics, anticoagulants, andmedications thatdecrease platelet aggregation(eg, aspirin)(2).
Recommendeddailydosage: Recommendeddailydosage: 200to250mgorally, standardcontentof0.2% parthenolide(3).A4to6 weekcourseofcontinual useoftheherbalmedication issuggestedtoimprove migraines. A4to6weekcourseof feverfewissuggestedto improvemigraines.
II-31
Herb and Medication Interactions
Garlic Alliumsativum
Common Indications
*Antiatherosclerosis (lipidloweringanti thrombotic, fibrinolytic, antihypertensive)(12) Contraindications: Lactation;prolongs bleedingtime,and shouldbediscontinued 12weeksprior surgery(3) *Lossofappetite, nausea,travelsickness, anddyspeptic complaints(1,2)
Stomachupset, headache,myalgia, fatigue,andvertigo (2) Sulfuricodor,contact irritation,and dermatitis(2)
Herb Medication Interactions

Mayincreasethe effectof antihypertensive medicationsand anticoagulant medications,such asaspirin,NSAIDs, orwarfarin(2,5)
PatientGuidelines
Recommendeddailydosage: acommercialpreparationof 600to900mg(containing3 mgofallicinoratotalallicin potentialof5,000g)inan entericcoatedformQD(2) oronecloveofrawgarlic (equalto4g)QDorBID(2).
Ginger Zingiberofficinale
Heartburn(1)
Doses>6g/daymay leadtoulcer formation(2). Contraindications: GermanysCommission Allergicreaction Econtraindicatesthe (rare)(1) useofgingerfor morningsickness associatedwith pregnancy(2);gallstone conditions;and personsatriskfor hemorrhage(2).
Ginkgo Ginkgobiloba
*Symptomaticreliefof organicbrain dysfunctionand intermittent claudication(dementia, peripheralocclusive arterialdisease [POAD])(1,2);improves memory *Vertigo(vascular origin)(2) *Tinnitus(vascular origin)(2)
Gastrointestinaltract disturbance, headache,and (rarely)contact dermatitis(13);blood pressure irregularities(2); bloodglucoselevel changes(3)
Patientswithknown riskfactorsfor intracranial hemorrhage(eg, systemicarterial hypertension, diabetesamyloid senileplaques) shouldavoiduseof ginkgo(2).
Mayexacerbate theanticoagulant effectsofwarfarin (2,3) Maydecrease effectivenessof antacids,H2 blockers,and protonpump inhibitors Mayinterferewith diabeticandblood pressure medicines(3) Mayexacerbate theeffectsof antithrombolytic agents(eg, anticoagulants, antiplatelets, aspirin,or acetaminophen)as aresultofapotent inhibitoryeffecton plateletactivating factor(2,4) Maycause hypomaniaiftaken withfluoxetine Mayinteractwith medicinesthat lowerseizure thresholdand thiazidediuretics
(3)
Useonlybrieflyduring pregnancy. Mayprolongbleeding,sodo notuseaftersurgery. Patientsreceiving anticoagulantmedications orpatientswithahistoryof gallstonesshouldnottake ginger(2,3,4).
Usualdoseforantiemeticis 1to2gfreshlyground gingertakenwithliquidand intwodivideddoses(2)
Ginkgoisavailableina capsule,tablet,orliquid form.Absorptionis unaffectedbyfoodintake(1). Recommendeddailydosage forcerebrovascular insufficiency(eg,dementia, POAD,andequilibrium disorders)is 120to240mgof standardizeddriedextract in2or3oraldoses(2,6).A6 to8weekcourseisadvised todetermineeffectiveness oftherapy. AvoidtakingwithTegretol, Equetro,Carbatrol (cabamazepine),and Depakote(valproicacid)(7)
II-32
HerbandMedicationInteractions
Ginseng Panaxginseng Panaxquinquefolius
Common Indications
*Stimulatesthecentral nervoussystem, reducesfatigue,and improves concentration(13)
Tachycardiaand hypertension(1,2)
HerbMedication Interactions
Avoidconcomitant usewithwarfarin, NSAIDs,and antiplateletagents (2,5)dueto anticoagulanteffects. Cautionshouldbe takenwithdiabetic agents/insulindueto hypoglycemiceffects (2). Patientstaking steroids,MAOIs,or loopdiureticsshould notuseginseng(2,4).
PatientGuidelines
Recommendeddaily dosage(usuallycapsule form)forcognitive functionis400mg(2);for hypoglycemiceffects,100 to200mg(2);forantiviral effects,100to200mg(2); forphysicaland psychological performance,100mg twiceaday(2).
Anticancereffects(1,2); antioxidanteffects(2); antiplateleteffects(2); antiviraleffects(2); hypolipidemic/cardiac effects(2);and hypoglycemiceffects(2)
Insomnia,epistaxis, headache, nervousness,and vomiting(2)
Reportsofmastalgia andpostmenopausal vaginalbleeding(2)
Greentea Camelliasinensis
Cautioninusewith: Cardiacdisorders, includinghypertension (6),anddiabetes(2,4) Contraindications: Pregnancyand lactation(2). Preventscancersofthe pancreas,colon,small intestine,stomach, breast,andlung(2)
Overdosecancause hypertension, insomnia,hypertonia, andedema(2).
Otherrecommendations: 100mgQDorBIDof4% to7%ginsengosides(3)
Limitcontinuoususeto lessthan3months(3).
Dentalcaries(2)
Diarrhea(2)
Excessconsumption (>5cups/day)can causegastrointestinal tractirritation (relatedto hyperacidity)and excitabilityoranxiety (relatedtocaffeine) (2).
Resorptionofalkaline medicationscanbe delayedbecauseof chemicalbonding withtannins(2).
Availableasaninfusion orcapsuleformfor internaluse.
Mayincreaseriskof bleedingwith anticoagulant medications
Recommendeddaily dosageis300to400mg ofpolyphenolsor3cups ofgreentea(which contains240to320mg ofpolyphenols)(2).
Pregnantwomen shouldnotexceeda dosageof300 mg/day(2).
Mayinteractwith verapamilby increasingplasma caffeinelevels(3)
Avoidconcomitantuse withgrapefruitjuice(3).
Englishhawthorn Crataeguslaevigata
*Decreasedcardiac output,senileheart, chroniccorpulmonale, andmildformsof bradycardial arrhythmias(2)
Contraindications: Acuteangina(because herbactionistooslow) (1,2);avoidduringfirst trimesterofpregnancy; childrenyoungerthan 12yearsshouldavoid thisproduct

Microcyticanemia hasbeenreportedin infantsfed250mLof greenteadaily(2). Hawthorn supplementsshould beprescribedand monitoredbya physician(2).During treatment,heartrate andbloodpressure shouldbemonitored onaregularbasis(2).
Usewith antiarrhythmicsis discourageddueto similarmodesof action(2).
Englishhawthorn maypotentiatethe effectsofcardiac glycosides.Therefore, ifinitiatedinpatients Treatmentdurationisa takingdigoxin, minimumof6weeks(2). digitoxin,org strophanthin,the glycosidedosage shouldbeadjusted(2).
Recommendeddaily dosageis5gof medicationor160to900 mgofhawthornextract (standardizedto20% procyanidinsor2.2% flavonoidcontent) administeredindivided dosesthreetimesdaily (2,3).
II-33
Englishhawthorn Crataeguslaevigata (Continued)
Common Indications
HerbMedication Interactions
Cancausea hypertensiveeffect whenusedin combinationwith betablockers(2)
PatientGuidelines
Kavakava Pipermethysticum
*Suppressesanxiety andthecentral nervoussystem(2) *Mayrelievemild anxietyand sleeplessness/ restlessness(2,3)
Inrarecases,kava kavamaycausedry patchyskinanda temporaryyellow discolorationofskin, hair,andnails(1).
Contraindications: Pregnancyand lactation;patients withendogenous depression(2,8)
Licorice Glycyrrhizaglabra
*Soothingstomach irritations/gastritis (2) *Coughremedyand expectorant/bronchi tis(2)
Overdosecanresult indisordersof complexmovement (withouta disturbanceof consciousness), followedbytiredness andtendencytosleep (2). Largeamountsmay leadtopotassium loss,sodium retention,edema, highbloodpressure, andcardiac complaints(2,5).
Shouldbeavoided withcisaprideand othermedicationsin asimilarmedication classascisapride(2) Maypotentiatethe effectivenessof substancesthataffect thecentralnervous system(eg,alcohol, barbiturates,and psychopharmacologic agents)(2) Kavakavaisreported toantagonizethe effectofdopamine. Patientswith Parkinsondisease whotakelevodopa shouldavoidkava kava(2). Avoidwiththiazide medications,as licoricemay counteracttheeffects ofthiazide medications(2). Increasespotassium losses,whichmay increasetoxicityto digitalisglycosides (2,4) Mayinterferewith aniarrhythmic agents(eg, procainamide, quinidine)(2). Prolongshalflifeof cortisol,whichmay leadtohypokalemia, highbloodpressure, andedema(2)
Recommendeddosageis 150to300mgofroot extracttakentwicedaily, withadailydoseof preparationsequivalent to50to240mgkava pyrones(2). Theherbshouldbetaken withfoodorliquiddueto itslipidsolubility(2). Avoidconcomitantuseof kavakavawithalcohol(3)
Contraindications: Naturallicorice (except deglycyrrhizinated licorice)isnot recommendedfor peoplewithhigh bloodpressure,heart disease,diabetes, cholestaticliver disorders,liver cirrhosis,hypertonia, hypokalemia,or severekidney insufficiency(6);or forpregnantor lactatingwomen(2,3);
Recommendeddaily dosageis5to15g(1to2 tsp)ofdriedroot, containing200to600mg ofglycyrrhizin(2). Shouldnotbeusedmore than4to6weeks, otherwisetheriskofside effectsandoverdose increases(2,9) Avoidconcomitantuse withgrapefruitjuice(3).
II-34
Milkthistle Silybummarianum
Common Indications
*Dyspeptic complaints(2)*Used asatonic,asa stimulant,andfor reliefoffunctional disordersoftheliver andgallbladder(2) *Prostatecomplaints (relievesthe difficultiescausedby anenlargedprostate withoutreducingthe enlargement)(2) *Irritablebladder(2) Inhibitsmale hormones;hassome effectsonestrogen; maybeanti inflammatory(3)
HerbMedication PatientGuidelines Interactions

Recommendeddaily dosageisa140mgto 420mgcapsule (standardizedto70% silymarin)BIDorTID (1,2);or400mgof concentratedextract (whichequals140mg ofsilymarin). Prostateenlargement requiresdiagnosisand followupbya physician(5).
Sawpalmetto Serenoarepens
Contraindications: Pregnancyand lactation(dueto potentialhormonal effects)(2) Valerian Valerianofficinalis *Nervousnessand insomnia(1,2)
Relievespain, reducesspasms(6), andstimulates appetite(6) Contraindications: Pregnancyand lactation
Noknownsideeffects Concomitantusewith butyrophenonesor ifproperly phenothiazines administered(2) resultsinreduced lipidperoxidation(2) Antagonisticeffect withyohimbineand phentolamine(2) Mayexertestrogen, Rarecasesof gastrointestinaltract androgen,andalpha adrenergicblocking upset(1,2) effects;therefore,the concomitantuseof hormones,hormone likemedications,or adrenergic medicationsmay needtobeadjusted (2) Nosignificant adverseeffectshave beenreportedin clinicaltrials(2). Mightincreaseriskof bleedingiftakenwith anticoagulant medications(3) Avoidusewith Heartpalpitations alcohol(2). andinsomniaoccur rarelywithlongterm Potentiatestheeffect ofcentralnervous use(1,2). systemdepressants andnot recommendedforuse withsedativesor antidepressants(2). Mayexacerbatethe sideeffects (drowsinessand fatigue)of medicationsusedto treatallergiesor anxiety(eg, antihistamines)(5)
Recommendeddaily dosageis160mgBID or320mgonetimeper dayofanextract standardizedtocontain 85%to95%fattyacids andsteroids(2,4).
Recommendeddaily dosageis400to900 mgofstandardized valerianroot30 minutesbeforebedtime totreatinsomniaor 220mginextractthree timesdailytotreat restlessness(2).
*IndicationsforusehavebeenapprovedbytheCommissionE,Germanysregulatoryauthorityonherbalandbotanicalproducts,whichis currentlyrecognizedasthebestexpertconsensusonmedicinalherbs(2). NSAIDs=nonsteroidalantiinflammatorydrugs;MAOI=monoamineoxidaseinhibitor;SSRI=selectiveserotoninreuptakeinhibitor;TID=three timesaday;BID=twotimesaday;QD=everyday;a.m.=morning;p.m.=evening. References 1. OHareM,KieferD,FarrellM],KemperK.Areviewof12commonlyusedmedicinalherbs.ArchFamMed.Availableat: http://www.amaassn.org/scipubs/journals/archive/fami/vol_7/no_6/fsa8005.htm.AccessedFebruary12,1999. 2. PDRforHerbalMedicines.2nded.Montvale,NJ:ThomsonMedicalEconomicsCo;2000. Manual of Clinical Nutrition Management
II-35
Herb and Medication Interactions 3. 4. 5. 6. 7. TherapeuticResearchFaculty.NaturalMedicines:ComprehensiveDatabase.Stockton,Ca.;2004. MathaiK.Integrativemedicineandherbaltherapy.In:MahanK,EscottStumpS,eds.KrausesFood,Nutrition,andDietTherapy. 10thed.Philadelphia,Pa:WBSaundersCo;2000.;415429. Ginseng,cardiacdrugsdontmix:herbalinteractionsyoushouldknow.EnvironNutr.1999;22:1,45. BlumenthalM,GoldbergA,BrinckmannJ.HerbalMedicine:ExpandedCommissionEMonographs.Newton,Mass:IntegrativeMedicine Communication;2000. U.S.DepartmentofHealthandHumanServicesandU.S.Food&DrugAdministration.DrugswithFoodandBeverages.Availableat http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm096386.htm.AccessedOctober1,2010. ENsherbalmedicinecabinet:top10herbsyoucantrust.EnvironNutr.1998;21:1,4. Licorice:sweetcandy,soothingremedy,buteasytooverdo.EnvironNutr.1999;22:8.
8. 9. Bibliography AHealthcareProfessionalsGuidetoEvaluatingDietarySupplements.Chicago,Ill:TheAmericanDieteticAssociationandAmerican PharmaceuticalAssociation;2000.
II-36
CLINICALNUTRITIONMANAGEMENT AREFERENCEGUIDE
INTRODUCTION
Thematerialinthissection: provides the dietitian with relevant evidencebased information to consider in the development of the nutritioncareplan forms the basis for the development of disease or conditionspecific nutrition interventions and protocolsasrequiredbytheorganization As part of Morrison Management Specialists strategic plan to support and assimilate evidencebased researchintoclinicalpractice,theManualofClinicalNutritionManagementintegratestheAmericanDietetic Associations(ADAs)recommendationsandconclusiongradingstatementsestablishedaspartoftheADAs Evidence Analysis Library and evidencebased analysis process. The ADAs Evidence Analysis Library (www.adaevidencelibrary.com) is an online library that includes a synthesis of the best, most relevant researchonimportantdieteticpracticequestions.Thelibrarysresourcesincludeconclusionstatementsthat provideaconcisesummaryoftheresearchonagivenquestion.TheADAhasassignedgrades,rangingfrom Grade I (good/strong) to Grade V (insufficient evidence), to evidence and conclusion statements. These grades, which are based on the quality and extent of the research, are a tool for practitioners to use when determiningthecertaintyofinformation. TheADAsgradesareintegratedthroughouttheManualtoassistthedietitianininterpretingthestrength and relevance of evidence on a particular topic. The criteria and characteristics of the five grades are describedinTableIII1. TableIII1:ConclusionGradingCharacteristicsa GradeI Qualityofstudiesisstrongandfreefromdesignflaws,bias,and Good/strong executionproblems.Useslargenumberofsubjects;outcomes directlyrelatedtoquestion;statisticaldifferenceislargeand meaningful;canbegeneralizedtopopulationofinterest. GradeII Qualityofstudiesisstrong,however,withminormethodological Fair concerns;inconsistencyamongresultsofstudies,orstudies evaluatedhaveweakerdesign;doubtsaboutadequatesamplesize; doubtsaboutstatisticalsignificance;minordoubtsabout generalizabilitytopopulationofinterest. GradeIII Studiesofweakdesign;inconclusivefindingsduetodesignflaws,bias, Limited/weak orexecutionproblems;inconsistencyamongresultsthatcannotbe explained;inadequatesamplesize;seriousdoubtsabout generalizabilitytopopulationofinterest. GradeIV Nostudiesavailable;conclusionbasedonusualpractice,expert Expertopiniononly consensus,clinicalexperience,opinion,orextrapolationfromthe research. GradeV Noevidencepertainstothequestionbeingaddressed. Insufficientevidence
aThegradingsystemisbasedonthegradingsystemfrom:GreerN,MosserG,LoganG,HalaasGW.Apracticalapproachtoevidence grading.JtCommJQualImprov.2000;26:700712.InSeptember2004,theADAResearchCommitteemodifiedthegradingsystemto thiscurrentversion.
Whennecessary,thepractitionercanusegradinginformationtoassistinclinicaldecisionmakingas describedinTableIII2.
III1
Introduction
TableIII2:GradingImplicationsforPracticea GradeI Practitionersshouldfollowrecommendationunlessaclearand Good/strong compellingrationaleforanalternativeapproachispresent. GradeII Practitionersshouldgenerallyfollowrecommendationbutremain Fair alerttonewinformationandbesensitivetopatientpreferences. GradeIII Practitionersshouldbecautiousindecidingwhethertofollow Limited/weak recommendation,andshouldexercisejudgmentandbealertto emergingpublicationsthatreportevidence.Patientpreference shouldhavesubstantialinfluencingrole. GradeIV Practitionersshouldbeflexibleindecidingwhethertofollow Expertopiniononly recommendation,althoughtherecommendationmayset boundariesonalternatives.Patientpreferenceshouldhavea substantialinfluencingrole. GradeV Practitionershouldexercisejudgmentandbealerttoemerging Insufficientevidence publicationsthatreportevidencethatclarifiesthebalanceof benefitvs.harm.Patientpreferenceshouldhaveasubstantial influencingrole.
aAdaptedbytheADAfrom:AmericanAcademyofPediatricsSteeringCommitteeonQualityImprovementandManagement.Classifying recommendationsforclinicalpracticeguidelines.Pediatrics.2004;114:874877.
GradinginformationintheManualappearsinparentheses,asseeninthefollowingexample: Evidence shows that physical activity at any level, light, moderate, or vigorous, as well as food patterns emphasizing a diet high in fruits, vegetables, and whole grains is associated with reduced incidence of metabolicsyndrome(GradeII)(1).
1.
DisordersofLipidMetabolismEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociation EvidenceAnalysisLibrary.AmericanDieteticAssociation;2005.Availableat: http://www.adaevidencelibrary.com.AccessedJune1,2006.
BecausetheADAsEvidenceAnalysisLibraryisanevolvingproject,notallsectionsandrecommendations in the Manual contain grading information. Also, the recommendations that are graded may be frequently updatedasevidenceemerges.ThepractitionerisencouragedtorefertotheADAsonlinelibraryforupdates on emerging topics. The grading information is provided to assist practitioners in making decisions about clinicalcareandinterventions.Gradinginformationshouldcomplementclinicaldecisionmaking,notreplace soundclinicaljudgmentorexpertise. This section also contains information (eg, medical diagnostic tests or laboratory indexes) that may not necessarily be mentioned in the nutrition assessment care plan. The evidence that supports the nutrition specificinformationisincludedtostrengthenthedietitiansroleasaparticipatingmemberofthehealthcare team. In developing the individual patient care plan, the dietitian selectively discusses the assessment parametersandinterventionsthatarepertinenttoimprovingthepatientsnutritioncare. Inconclusion,theapproachesmentionedforeachconditionaresuggestionsthatshouldnotbeinterpreted as definitive nutrition therapy for the given condition. The evidence grades are provided to guide clinical decisionmaking and the selection of optimal nutrition approaches. Medical approaches are listed with medical nutrition therapy approaches to create an awareness of coordinated therapies. Diets approved by the organizations medical staff are included in Section I. Conditionspecific protocols, if developed by the organizationfromthefollowingmaterial,shouldbeapprovedbytheappropriatecommitteeandplacedinthe organizationspracticeguidelinesmanual. Additionalinformationcanbeobtainedatwww.adadevidencelibrary.com Thematerialinthissectionisintended:
Toprovidethedietitianwithrelevantinformationthatmaybeconsideredinthedevelopmentofthe nutritioncareplan. To form the basis for the development of disease or conditionspecific protocols and nutrition prescriptionsasrequiredbytheorganization. III2
Introduction
Formanyofthediseasesandconditions,informationisincludedthatwouldnotnecessarilybementioned in the nutrition assessment care plan (eg, diagnostic laboratory indexes). This information is included to provideamorecompletepictureofthemultidisciplinarymanagementinordertostrengthenthedietitians role as a participating member of the health care team. In developing the individual patient care plan, the dietitianselectively discusses onlythoseassessment parametersthatare pertinenttothe specific nutrition careapproach. Theapproachesmentionedforeachconditionaresuggestionsandarenottobeinterpretedasdefinitive nutrition therapy for the given condition. Medical approaches are listed with medical nutrition therapy approaches, so as to create an awareness of coordinated therapies. Diets approved for the organizations implementationareincludedinSectionI.Conditionspecificprotocols,ifdevelopedbytheorganizationfrom thefollowingmaterial,shouldbeapprovedbytheappropriatecommitteeandplacedintheorganizations practiceguidelinesmanual.
III3
ANTICOAGULANTTHERAPY
Discussion OralanticoagulantsareusedtocreateapartialdeficiencyoftheactiveformofvitaminK,whichisresponsible for maintaining normal blood coagulation. By inhibiting the action of vitamin K, there is a reduced risk of abnormalbloodclotting. Indications Oral anticoagulants are typically prescribed for the primary and secondary prevention of the following conditions: venousthrombosis pulmonaryembolism myocardialinfarction Personswithprostheticheartvalves,atrialfibrillationwithembolization,orhereditydisordersthatresult inahypercoagulantstatemaybetreatedwithanticoagulantsindefinitely(1,2). A major complication of anticoagulant therapy is hemorrhage. The therapeutic index and safety of anticoagulation therapy is assessed through the measurement of the prothrombin time (PT), which is expressedastheinternationalnormalizedratio(INR) (2).AnINRof2.0to3.0isgenerallyconsideredinthe therapeuticrangeandtheriskofbleedingincreaseswhentheINRexceeds4.0(2). NutritionImplicationsofAnticoagulantTherapy Thegoalofmedicalnutritiontherapyforpersonsreceivinganticoagulanttherapyistoprovideaconsistent intakeofvitaminK.TheDailyValueforvitaminKis80mcgforadults (3).TheDailyValuecanbeusedasan appropriategoalforpersonsonanticoagulanttherapy(3,4).TheaveragedietaryintakeofvitaminKforadults intheUnitedStatesisestimatedtobe90to118mcg/day (57).Althoughmostpatientsintakewillfallinto thisacceptablerange,allpatientsshouldhavetheirdietsassessedfortypicalsourcesandpatternsoffoods containing vitamin K. Persons who receive anticoagulant therapy should limit their consumption of foods thathaveahighlevelofvitaminK. ThelistofdrugsthatinteractwithvitaminKantagonistsisconstantlyexpanding(7).Drugdruginteractions that increase or decrease the effect of anticoagulant therapy should be evaluated before concluding that dietary intake is responsible for a change in the anticoagulant response (2,5,7). Drugs that increase the anticoagulant effect are agents for gout treatment, anabolic steroids, antiarrhythmic agents, antibiotics, antifungalagents,antihyperlipidemicagents,cimetidine,disulfiram,isoniazid,omeprazole,sulfonylureas,and tamoxifen citrate. Drugs that decrease the anticoagulant effect are anticonvulsant agents, cholestyramine, griseofulvin,oralcontraceptives,rifampin,sucralfate,andvitaminK(5,8). NutritionAssessmentandDiagnosis TheoralanticoagulantdoseshouldbeestablishedbasedonthepatientsnormalvitaminKintake.Afterthe doseisestablished,areasonablegoalistomaintainthedailyvitaminKintakewithin250mcgofbaseline(1,9). Ifmajorchangesinfoodintakeoccur,theanticoagulantlevelmayneedtobereestablished.VitaminKintake mayincreasewhenapatientstartsaweightreductiondietandincludesagreaternumberofvegetablesthat arehighinvitaminKorbeginsahighprotein,lowcarbohydratediet(seediscussionbelow).Otherreasons foranincreasedvitaminKintakemayincludeanadjustmentindietbecauseofhospitalizationorachangein seasonal eating patterns (1). Unlike other fatsoluble vitamins, stores of vitamin K are rapidly depleted if intakeisdeficient(1). ThisinformationshouldbeconsideredwhenassessingthevitaminKlevelofapatient whohashadalowintakeoffoodforaweekorlonger,asmayoccurinthehospitalsetting. NutritionInterventionandMonitoring Patientsshouldbeeducatedaboutthedietarychangesthatimpactanticoagulanttherapy.Theyalsoshould beinformedoffoodsthatarehighinvitaminK(III3andIII4).Alimitedintakeoffoodsthatprovidemore than 60% of the Daily Value (80 mcg) for vitamin K can help keep the INR/PT in the desired range (9). Patientsshouldbeencouragedtokeeptheirdietconsistentwiththeirpresentpattern.However,ifthereisa change in diet that includes vitamin Krich foods, patients should contact their physician and have their INR/PTmonitored.
III4
AnticoagulantTherapy
TableIII3:FoodsModeratelyHighinVitaminK(60%to199%ofDailyValue)(9) Fooda ServingSize %DailyValue Brusselssprouts,frozen,boiled cup 190 Spinach,raw 1cup 180 Turnipgreens,raw,chopped 1cup 170 Greenleaflettuce,shredded 1cup 125 Broccoli,raw,chopped 1cup 110 Endivelettuce,raw 1cup 70 Romainelettuce,raw 1cup 70 aRecommendednottoconsumemorethanthreeservingsperday
Adaptedfrom:DrugNutrientInteractions:CoumadinandVitaminK.Bethesda,Md:WarrenGrantMagnusonClinical Center,NationalInstitutesofHealth;2003.
TableIII4:FoodsHighinVitaminK(200%ofDailyValue)(9) Fooda ServingSize %DailyValue Kale,fresh,boiled cup 660 Spinach,fresh,boiled cup 560 Turnipgreens,frozen,boiled cup 530 Collards,fresh,boiled cup 520 Swisschard,fresh,boiled cup 360 Parsley,raw cup 300 Mustardgreens,fresh,boiled cup 260 aRecommendednottoconsumemorethanoneservingperday
Adapted from: DrugNutrient Interactions: Coumadin and Vitamin K. Bethesda, Md: Warren Grant Magnuson Clinical Center,NationalInstitutesofHealth;2003.
Someevidencesuggeststhatcranberryproductsinteractwithanticoagulantstoincreasetheireffects (10). However, a prospective randomized study of patients taking warfarin demonstrated that their INR levels werenotadverselyaffectedbyconsumptionof1cupofcranberryjuicedaily (11).Untilfurtherevidenceis available on a variety of cranberry products, patients consuming cranberry juice or products should be educated,andtheirINR/PTshouldbemonitoredforthepotentialinteraction.Althoughiceberglettuce,red cabbage, asparagus, cauliflower, and soybean oil areoften reportedas being highin vitamin K,these foods containmuchsmalleramountsofvitaminKthanthefoodslistedinTablesIII3andIII4.Therefore,these foodsandotherfoodsandbeveragesnotlisted(includingcoffeeandtea)maybeconsumedasdesired(9). SpecialConsiderations Alcohol: Alcohol has shown to adversely affect the PT/INR ratio (5). Consuming more than 3 servings of alcoholic beverages per day can increase the effect of warfarin (9). Limiting or avoiding alcohol may be advised,andpersonswhodoconsumealcoholshouldconsultwiththeirphysician. Highprotein, lowcarbohydrate diets: A highprotein, lowcarbohydrate diet pattern decreases the INR/PTratio (12).CasereportshavedemonstratedadecreaseintheINR/PTratioafterinitiationofahigh protein,lowcarbohydratediet (12).TheINR/PTratioreturnedtoanormallevelafterthedietwasstopped andthewarfarindosewasdecreasedtotheoriginaldose.Highproteindietsrapidlyincreaseserumalbumin levels. This increase may result in more warfarin binding to serum albumin, thereby decreasing the anticoagulanteffectofwarfarin (12).Patientsreceivingwarfarintherapyshouldbemonitoredandeducated aboutthepotentialinteractionthatoccurswithwarfarinandhighprotein,lowcarbohydratediets(12). Dietaryandherbalsupplements:Severaldietaryandherbalsupplementscaninteractwithanticoagulants and alter the INR/PT ratio (9). Dietary supplements that affect the INR/PT ratio include arnica, bilberry, butchers broom, cats claw, dong quai, feverfew, forskolin, garlic, ginger, ginkgo, ginseng, horse chestnut, inositol hexaphosphate, licorice, melilot (sweet clover), pau darco, red clover, St. Johns wort, sweet woodruff, turmeric, willow bark, and wheat grass (9). In addition, persons who take vitamin and mineral supplements containing vitamin K should be monitored. Vitamin and mineral supplements that are taken consistently pose less of a problem than supplements that are taken sporadically (9). Vitamin E intakes greaterthan1,000InternationalUnits(IU)mayincreasetheriskofexcessbleeding.Researchsuggeststhat dosesupto800IUmaybesafeforindividualstakingwarfarin,buttheevidenceisnotconclusive(9).Persons takingorconsideringtakingvitaminEsupplementsshouldconsultwiththeirphysician.
III5
AnticoagulantTherapy
Enteral nutrition: Patients who are receiving enteral nutrition support while on anticoagulant therapy shouldbemonitoredclosely.SignificantvitaminKintakefromenteralformulascanantagonizetheeffectof theanticoagulantdrugwarfarinandresultintreatmentfailure(6).Mostenteralformulationscontainmodest amountsofvitaminKandprovidedailyvitaminKintakesimilartotheaveragedietaryintakefromfoods (6). Consistentintakeofanenteralformulationcontaininglessthan100mcgofvitaminKper1,000kcalisnot expected to cause warfarin resistance (6,8). However, warfarin resistance can occur in patients on enteral nutritionsupportwhoseintakeofvitaminKissubstantiallylow (13).Thisresistancemayoccurasaresultof warfarin binding to protein contained in the enteral formula; however, this mechanism has not been substantiatedbyclinicaldata (13,14).Areasonableapproachtotreatingwarfarinresistanceassociatedwitha lowvitaminKintakeistoinitiateatrialofholdingtheenteralnutritionregimenforatleast1hourbeforeand afterthewarfarindose(13,14).
References 1. HarrisJ.Interactionofdietaryfactorswithoralanticoagulants:reviewandapplications.JAmDietAssoc.1995;95:580584. 2. Levine MN, Raskob G, Landfeld S, Kearon C. Hemorrhagic complications of anticoagulant treatment. Chest. 2001; 119 (suppl 1):108S121S. 3. Reference values for nutrition labeling. In: A Food Labeling Guide. US Food and Drug Administration Center for Food Safety and AppliedNutrition;1994(Editorialrevisions,1999).Availableat:www.cfsan.fda.gov/~dms/flg7a.html.AccessedOctober8,2007. 4. BoothSL,CenturelliMA.VitaminK:apracticalguidetothedietarymanagementofpatientsonwarfarin.NutrRev.1999;57(9pt 1):288296. 5. Coumadin[packageinsert].Princeton,NJ:BristolMyersSquibbCompany;2006. 6. RollinsCJ.DrugNutrientinteractions.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum.SilverSpring,Md: AmericanSocietyforParenteralandEnteralNutrition;2007. 7. Vitamin K intake in micrograms by sex, age, and race/ethnicity: United States, 198894. In: Dietary Intake of Macronutrients, Micronutrients,andOtherDietaryConstituents:UnitedStates,198894.NationalCenterforHealthStatistics.VitalHealthStat.2002; 11(245):102.Availableat:www.cdc.gov/nchs/data/series/sr_11/sr11/245.pdf.AccessedOctober7,2007. 8. SchulmanS.Careofpatientsreceivinglongtermanticoagulanttherapy.NEnglJMed.2003;349:675683. 9. DrugNutrientInteractions:CoumadinandVitaminK.Bethesda,Md:WarrenGrantMagnusonClinicalCenter,NationalInstitutesof Health;2003.Availableat:http://dietarysupplements.info.nih.gov/factsheets/cc/coumadin1.pdf.AccessedOctober2007. 10. Committee on Safety of Medicine and the Medicines and Healthcare Products Regulatory Agency. Possible interaction between warfarinandcranberryjuice.CurrProblPharmacovigilance.2003;29:8. 11. LiZ,SeeramNP,CarpenterCL,ThamesG,MinuttiC,BowermanS.Cranberrydoesnotaffectprothrombintimeinmalesubjectson warfarin.JAmDietAssoc.2006;106:20572061. 12. BeattySJ,MehtaBH,RodisJL.Decreasedwarfarineffectafterinitiationofhighprotein,lowcarbohydratediets.AnnPharmacother. 2005;39:744777. 13. PetretichDA.Reversalofosmolitewarfarininteractionbychangingwarfarinadministrationtime.ClinPharm.1990;9:93.Letter. 14. PenrodLE,AllenJB,CabacunganLR.Warfarinresistanceandenteralfeedings:twocasereportsandasupportinginvitrostudy. ArchPhysMedRehabil.2001;82:12701273.
III6
BURNS
Discussion
Thermaltraumaresultsinmarkedhypermetabolismandhypercatabolism.Aggressivenutritionalsupportis required to meet metabolic demands, prevent the depletion of body energy and nitrogen stores, support wound healing, enhance immunity, and improve survival (13). Energy requirements increase linearly in proportiontoburnsizetoamaximumofapproximatelytwicethenormallevels (1).Factorssuchasagitation, pain,andheatlossduringdressingchangesareassociatedwithalargeincreaseinenergyexpenditure(1).
Approaches
Energy requirements in adults: Many formulas are available to determine energy requirements. Unfortunately, many of these formulas have not been validated for the burn population (1,3). The expert consensus is that indirect calorimetry should be used to evaluate resting energy expenditure (REE) on admission to the hospital and at least once weekly until the patient is stabilized (1,3). Indirect calorimetry shouldbeperformedlateatnightorearlyinthemorning(beforedailyactivities)toobtainamoreaccurate assessment of REE (1). In addition, indirect calorimetry is recommended when the patients condition is complicatedbyinfection,sepsis,poorwoundhealing,obesity,orventilatordependency(1).TheREEobtained fromindirectcalorimetryshouldbemultipliedbyafactorof1.3(or20%to30%)toaccountforactivityand stress of treatments (1,4,5). This figure provides the total energy expenditure for which the clinician would basethenutritionprescription.
Ifindirectcalorimetryisnotavailable,evidencebasedguidelinesrecommendusingthefollowingpredictive equations (listed in order of accuracy) Penn State, Swinamer, and IretonJones equations for use in calculating the REE in nonobese critical care patients (6). (See Section II: Estimation of Energy Requirements.)TheCurreriformulahasalsobeensuggestedforburnpatients (3).Thevaluesobtainedfrom theseequationsareapproximateandshouldbeusedonlyasguidelinesinpredictingenergyrequirementsin burnpatients(13).
Based on the REE equation and the parameters accounted for in the equation (eg, burn, nonburn, ventilatordependent,orspontaneousbreather),aninjuryfactor,whichisbasedonthepercentoftotalbody surfaceareaburned(TBSAB),andanactivityfactormayneedtobemultipliedwiththebaselineREEtoobtain total energy expenditure (14).The clinician should be aware that the practice of adding injury and stress factorshasnotbeenvalidatedandmayleadtotheoverestimationofthepatientsneeds (6).Patientswho aremechanicallyventilated,sedatedorparalyzedduetoseverityofinjuryoftenhavereducedenergyneeds (3).Chemicalneuromuscularparalysisdecreasesenergyrequirementsofcriticallyillpatientsbyasmuchas 30%(3). PhysicalActivityLevel ActivityFactor PercentTBSAB InjuryFactor(1,5) Bedrest 1.2 <20% 1.21.4 Ambulatory 1.3 20%25% 1.6 26%30% 1.7 31%35% 1.8 36%40% 1.9 41%50% 2.0 As previously mentioned, The Curreri formula isatool for specifically deriving the energy needs of burn patients (7,8).However,itmayoverestimatethepatientsnutritionneeds,particularlyduringconvalescence (1,3).TheCurreriformulaappearstobemostusefulduringtheearlypostburnphase(7to10dayspostburn), whenenergyexpenditureisatitsmaximum.Thisformulaalsoprovidesguidelinesforuseintheoverweight andobesepopulations(8).
Curreriformulaforpatientsaged16to59years: 25kcalaxkgactualbodyweight+(40kcalx%TBSABbbasedonactualweightinkg)
Forexample,a190lbmanwith35%TBSAB: 25kcalx86kg+[40kcalx30kg(35%of86kgis30kg)]=3,350kcal/day Curreriformulaforpatientsaged60yearsandolder: 20kcalaxkgactualbodyweight+(65kcalx%TBSABbbasedonactualweightinkg)
aIfBMI>27,use15to18kcal bIfthepercentTBSAB>50%,useamaximumvalueof50%
III7
Burns
Energyrequirementsinchildren:Indirectcalorimetry,ifavailable,shouldbeusedonadmissiontothe hospitalandtwiceweeklythereafteruntilthepatientishealed.TheREEshouldbemultipliedbyafactorof 1.3(or20%to30%)toprovidetotalenergyneeds(1,9). For less than 30% TBSAB, use the Dietary Reference Intakes (DRI) for energy, per age group, as a starting pointtoprovideadequateenergyintake (5).(SeeDietaryReferenceIntakesinSectionIA.)Forgreaterthan 30% TBSAB, use the following formulas, where BSA = Body Surface Area and BSAB = Body Surface Area Burned(10): Galvestoninfant 0to12months 2,100kcal/m2BSA+1,000kcal/m2BSAB RevisedGalveston 1to11years 1,800kcal/m2BSA+1,300kcal/m2BSAB Galvestonadolescent 12to18years 1,500kcal/m2BSA+1,500kcal/m2BSAB
The Curreri formula, which was proposed to calculate the energy needs of the burned adult, has been modifiedforpediatricpatientsbyusingbalancestudiesofweightinburnedchildren (11).TheCurrerijunior formula is designed for burns of less than 50% total body surface area. It typically overestimates energy requirementsinburnsexceeding50%. Age0to1year:Basalkcal+15kcalx%Burn Age1to3years:Basalkcal+25kcalx%Burn Age3to15years:Basalkcal+40kcalx%Burn Proteinrequirements:Proteinneedsofburnpatientsaredirectlyrelatedtothesizeandseverityofthe burn. The increased protein demand is necessary to promote adequate wound healing and to replace nitrogen losses through wound exudate and urine. Failure to meet heightened protein needs can yield suboptimalclinicalresultsintermsofwoundhealingandresistancetoinfection.Infantsandchildrenfurther adapt to inadequate protein intake by curtailing growth of cells, conceivably sacrificing genetic growth potential. Adults(1,12,13) <10%TBSAB 1.2to1.5g/kgofactualoridealbodyweighta 10%to15%TBSAB 1.5to2.0g/kgofactualoridealbodyweighta 15%to35%TBSAB 2.0to2.5g/kgofactualoridealbodyweighta >35%TBSAB 23%to25%oftotalenergy
aConsiderusingidealbodyweightwhenanactualweightcannotbeevaluatedormeasured,orincasesofsevereobesityinwhichprotein requirementsmaybeoverestimatediftheactualbodyweightisused.
Children(9,14,15) <1%TBSAB 1%to10%TBSAB >10%TBSAB
3to4g/kg 15%oftotalenergyornonproteincaloriestonitrogenratio(NPC:N)of 150:1 20%oftotalenergyorNPC:Nof100:1
Otherestimatesofproteinneedsoftheburnpatientinclude(1,12): Forpatients1yearofagetoadults,useatotalcalorietonitrogenratioof120:1. 20%to25%ofcalories(1) 2to3g/kgofactualweight(considerrenalfunction)(1) 1.2g/kgif<10%burnorifobese(1) Calculatenitrogenbalancefroma24hoururinecollectionanalyzedforureaurinarynitrogen(UUN): Nitrogenbalance=NitrogenIn(Intakeanalysis)NitrogenOut(seebelow) Nitrogenoutcanbeestimatedusingthefollowingformulaforchildren(12): [(24hourUUNcollection1.1a)+(1gforstoollosses)+(estimatedwoundnitrogenlossb)] dividedby 6.25gofproteinpergramofnitrogen(9)=estimatednitrogenlosses(output)perday
arepresentsobligatorylosses(skin,sweat,epithelial) bwoundnitrogen(N)loss:

10%openwound=0.02gN/kgactualweightperday 11%to30%openwound=0.05gN/kgactualweightperday 31%openwound=0.12gN/kgactualweightperday III8

Burns
Nitrogenbalanceinadultpatientsusingthestandardequationofnitrogenintake(g)urinaryureanitrogen + 4 (for obligatory losses of skin, sweat, epithelial) is a reasonable indicator of adequacy of protein and energy intake as long as normal renal status is maintained and accurate intake and output of nitrogen is collected and analyzed (3). The clinician should realize daily variances causing protein breakdown such as surgery,infectionsandsepsis.Duringthefirst7weekspostburntheadultpatientsnitrogenbalanceresults should target an anabolic range +5 to +10 g/day (3). Most likely, aggressive nutrition support (eg, enteral nutritionfeedings)willbenecessarytoachievethisgoal.Overtimeaswoundclosureisachieved,proteincan taperandrangeof+2to+4isacceptableforawound<5%open(3).
ParenteralNutrition Carbohydrate(3,4,13,16) Adults 3to4mg/kgperminuteparenteralglucoseinfusion orapproximately50to60%oftotal energyrequirementsincriticallyillburnpatients(3,17).Insulinshouldbeusedtomaintain normoglycemia(3,1819). Children Initiatedextroseat7to8mg/kgperminuteandadvanceasneededtomaximumof20% dextrosesolution. Infants Initiate dextrose infusion at 5 mg/kg per minute and advance to 15 mg/kg per minute overa2dayperiod.
Forallburnpatients,carbohydratesshouldaccountforapproximately50%oftotalenergy.
Fat(3,15,16) Adults Children>1year Children<1year
10%to30%oftotalenergyincriticalcarewith2%to4%asessentialfattyacids topreventdeficiency(3). 30%to40%oftotalenergy Upto50%oftotalenergy
Replacingomega6fattyacidwithomega3fattyacidmayhelpavoidorreversepostburn immunosuppression(3,4). PercentTBSAB FeedingApproach <20%(ifnotcomplicatedby Highenergy,highproteinoraldietisgenerallysufficient. facialinjury,inhalationinjury, orpreburnmalnutrition) >20%
Nocturnaltubefeedingtosupplementdietaryintakeduringthedaymay beadequatetomeetneeds;usenutrientintakeanalysistoensure adequateintake.
If feeding is to be given totally by nutrition support, the enteral route is preferred over total parenteral nutrition (3). Starting an intragastric feeding immediately after the burn injury (6 to 24 hours) has been shown to be safe and effective. Total parenteral nutrition should be reserved for only those patients with prolongedalimentarytractdysfunction.Gastricileusiscommonincentrallyinjuredburnpatients.Forthese patients,atranspyloricfeedingmaybeindicated.
MicronutrientRequirements(1,16) Electrolytes Minerals Traceelements Minorburns(<10%TBSAB)inallchildrenandadults Majorburns(10%to20%TBSAB)inchildren youngerthan3years
Majorburns(>20%TBSAB)inadultsandchildrenat least3yearsold
Providebasedonserumandurinedataandfluid needs. DRI DRI Onemultivitamindaily Onemultivitamindaily VitaminC250mgtwicedaily VitaminA5,000IUdaily Zincsulfate110mgdaily Onemultivitamindaily VitaminC500mgtwicedailya VitaminA10,000IUdaily Zinc4550mgdailyaor220mg(oncedaily)
aRecommendeddeliveryinsuspensionfortubefeedingbecauseoralvitaminCandzincinlargedosesmayprecipitate nauseaorvomiting(3).
III9
Burns References 1. Burns.In:NutritionCareManual.AmericanDieteticAssociation;2008.Availableat:nutritioncaremanual.org.AccessedDecember13, 2008. 2. MayesT,GottschlichMM.Burnsandwoundhealing.In:GottschlichMM,ed.TheScienceandPracticeofNutritionSupport:ACase BasedCoreCurriculum.Dubuque,Iowa:AmericanSocietyofEnteralandParenteralNutrition;2001:338341. 3. CresciGA,GottschlichMM,MayesT,MuellerC.Trauma,Surgery,andBurns.In:GottschlichMMed.TheA.S.P.E.N.Nutrition SupportCoreCurriculum:ACasedBasedApproachTheAdultPatient.SilverSpring,MD:AmericanSocietyofEnteraland ParenteralNutrition;2007:455476. 4. WaymackJP,HerndonDN.Nutritionalsupportoftheburnedpatient.WorldJSurg.1992;16:8086. 5. RodriguezDJ.Nutritioninmajorburnpatients:stateoftheart.SupportLine:APublicationofDietitiansinNutritionSupport. 1995;7:18. 6. CriticalIllnessEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociationEvidenceAnalysisLibrary.American DieteticAssociation;2006.Availableat:http://www.adaevidencelibrary.com.AccessedOctober10,2007.. 7. CurreriPW,RichmondD,MarvinJ,BaxterCR.Dietaryrequirementsofpatientswithmajorburns.JAmDietAssoc.1974;65:415 417. 8. GottschlichMM,IretonJonesCS.TheCurreriformula:alandmarkprocessforestimatingthecaloricneedsofburnpatients.Nutr ClinPract.2001;16:172173. 9. MayesT,GottschlichM,KhouryJ,WardenGD.Evaluationofpredictedandmeasuredenergyrequirementsinburnedchildren.J AmDietAssoc.1996;96:2429. 10. HildrethM,HerndonDN,DesaiMH,BroemelingLD.Caloricrequirementsofpatientswithburnsunderoneyearofage.JBurnCare Rehabil.1993;14:108112. 11. CurreriPW,RichmondD,MarvinJ,BaxterCR.Dietaryrequirementsofpatientswithmajorburns.JAmDietAssoc.1974;65:415417. 12. HildrethM,GottschlichM.Nutritionalsupportoftheburnedpatient.In:DNHerndon,ed.TotalBurnCare.Philadelphia,Pa:WB Saunders;1996. 13. DeitchEA.Nutritionalsupportoftheburnpatient.CritCareClin.1995;11:735750. 14. O'NeilCE,HutslerD,HildrethMA.Basicnutritionalguidelinesforpediatricburnpatients.JBurnCareRehabil.1989;10:278284. 15. FarrellK,BradleyS.Estimationofnitrogenrequirementinpatientswithburns.JBurnCareRehabil.1994;15:174. 16. GottschlichMM,WardenGD.Vitaminsupplementationinthepatientwithburns.JBurnCareRehabil.1990;11:257279. 17. A.S.P.E.N.BoardofDirectors.Guidelinesfortheuseofparenteralandenteralnutritioninadultandpediatricpatients.JParenter EnteralNutr.2002;26(suppl):88SA93SA. 18. HansenT,ThielS,WoutersP,ChristiansenJS,VandeBergheG.Intensiveinsulintherapyexertsantiinflammatoryeffectsin criticallyillpatients,asindicatedbycirculatingmannosebindinglectinandCreactiveproteinlevels.JClinEndocrinolMetab. 2003;88:10821088. 19. VandenBergheG,WoutersPJ,WeekersF,VerwaestC,BruyninckxF,SchetzM,VlasselaersD,FerninandeP,LauwersP,BouillonR. Intensiveinsulintherapyincriticallyillpatients.NEnglJMed.2001;345:13591367.
III10
CANCER
A cancer patients nutritional status and wellbeing are greatly impacted by the type of cancer and the treatmentmethods(TableIII5). In turn, nutritional status and overall health affectthe patientsability to toleratetreatmentandachievethedesiredclinicaloutcome.Tooptimizeclinicaloutcomes,patientswhoare diagnosed with cancer should receive early nutrition intervention with a complete nutritional assessment and a plan of care (1). When patients with colorectal cancer who are undergoing pelvic radiation receive individualizednutritioncounseling,theyexperienceimprovementsinenergyandproteinintake,nutritional status,andqualityoflifeandreductionsinsymptomsofanorexia,nausea,vomiting,anddiarrhea (1)(GradeII). Similarfindingsareseeninpatientswhoarereceivingchemotherapyforesophagealcancer,headandneck cancer, lung cancer, or acute leukemia (1). Patients who receive a pretreatment nutrition evaluation and weekly visits during chemoradiation and chemotherapy experience reduced weight loss, improved energy and protein intake, and improved quality of life; these patients may also have fewer unplanned hospitalizations,shorterhospitalstays,andimprovedtolerancetotreatmentsforavarietyofcancers(1)(Grade III). The American Dietetic Association has published evidencebased guidelines that address the nutrition interventionsthatareusedinthemanagementofspecifictypesofcancersincluding: breastcancer colorectalcancer esophagealcancer headandneckcancer lungcancer pancreaticcancer Becausetheevidenceislimited(GradeIIIorIV)formanyofthecurrentrecommendations,acomprehensive overview is not presented; rather, a summary is provided in the following paragraphs. The clinician, however, can refer to this resource for guidance when determining if specific therapeutic nutrition interventions should be initiated or discontinued (1). Parenteral nutrition support is generally not recommended for patients with the types of cancer listed above because of the risks of metabolic and infectiouscomplicationsandthelimitedevidencethatparenteralnutritionaffectsthelengthofhospitalstay orpatientsurvival (1) (Grade III).Enteralnutritionmaybeusedtoincreasetheenergyandproteinintakeand maintain the weight of esophageal cancer patients undergoing chemoradiation therapy (1) (Grade III). In addition, the use of enteral nutrition to increase the energy and protein intake of outpatients who are undergoingintensiveradiationtherapyforstageIIIorIVheadandneckcancermaintainsnutritionalstatus andimprovestolerancetotherapy(1)(GradeII).Medicalfoodsupplementsthatareusedtoimprovetheenergy andproteinintakeofpatientswhoareundergoingradiationtherapyforheadandneckcancerareassociated withfewertreatmentinterruptionsandreducedmucosaldamageandmayminimizeweightloss(1)(GradeII). Vitaminandmineralsupplements,specialfoods,andalternativehealthproductssuchasherbalproductsare commonly used by patients diagnosed with cancer. The following discussion is based on the Oncology EvidenceBased Nutrition Practice Guideline from the American Dietetic Association (1). Limited evidence supportstheuseoftopicalhoneyforthetreatmentofmouthsoresinpersonswhoarereceivingradiationfor head and neck cancer (1) (Grade III). The limited evidence shows that the topical use of honey has been associated with a decreased incidence of severe mucositis as well as weight gain and fewer treatment interruptions (1) (Grade III). Oral arginine supplements, which are used in an attempt to improve the clinical response,arenotrecommendedpriortoneoadjuvantchemotherapyforbreastcancer(1)(GradeIII).Inaddition, arginineenhanced medical food supplements or enteral nutrition is not recommended for head and neck cancer patients, because data have demonstrated no improvements in nutritionrelated outcomes or treatmentcomplications(1)(GradeII). VitaminE(intheformof670to1,000mgofalphatocopherol)hasnotbeenshowntopromotetoleranceor reducethelateeffectsofradiationinpatientswithbreastcancer;rather,vitaminEmayhaveadverseeffects such as nutrientnutrient interactions, drugnutrient interactions (eg, anticoagulant and antihypertensive medications or herbal supplements), and diseaserelated complications (1) (Grade III). Vitamin E oral supplements are not recommended for persons with head and neck cancer who are receiving radiation therapy, because these supplements increase the risk of developing a second primary cancer and decrease thesurvivalrate(1)(GradeIII).Dosesofantioxidants(eg,vitaminC,vitaminE,betacarotene,andselenium)that ManualofClinicalNutritionManagement III11 Copyright2011MorrisonManagementSpecialists,Inc.
Allrightsreserved.
Cancer
are greater than the tolerable upper intake level, which are used in an attempt to improve treatment outcomes, are not recommended for patients who are receiving chemotherapy for advanced nonsmall cell lung cancer. Multiple, highdose oral antioxidants do not significantly influence the treatment response, survival rate,survival time, ortoxicity in thispatientpopulation (1) (Grade III). Supplementsofomega3fatty acids, which are used in an attempt to improve weight gain, are not recommended for pancreatic cancer patientsduetolimiteddataandthepotentialfordrugnutrientinteractions(1)(GradeIII).RefertoTableIII6for suggestednutritioninterventionsandapproachestocommonproblemsexperiencedbycancerpatientsasa resultofthediseaseoradjunctivetreatments. TableIII5:CancerTreatmentsWithPotentialtoNegativelyAffectNutritionalStatus Treatment NutritionRelatedAdverseEffects Chemotherapy Abdominaldistention,anorexia,increasedappetite, Corticosteroids(eg,cortisone, diarrhea,ulcerativeesophagitis,gastrointestinal hydrocortisone,methylprednisolone, bleeding,hypocalcemia,hyperglycemiaor prednisone,prednisolone,triamcinolone) hypoglycemia,hypokalemia,hypertension,muscle massloss,nausea,osteoporosis,pancreatitis,sodium andfluidretention,vomiting,weightgain Hormones/analogs(eg,androgens,estrogens, Anorexia,anemia,increasedappetite,diarrhea,edema, progestins) fluidretention,glossitis,nausea,vomiting,weight gain Immunotherapies(eg,Bcellgrowthfactor, Anorexia,diarrhea,edema,nausea,vomiting,stomatitis, interferon,interleukin) tasteperversion,weightloss Abdominaldiscomfort,anorexia,diarrhea,oraland Generalchemotherapeuticagents(eg, gastrointestinalulceration,nausea,stomatitis, alkylatingagents,antibiotics, vomiting(Premedicationwithantiemeticswill antimetabolites,mitoticinhibitors, radiopharmaceuticals,othercytotoxic sometimesrelieveordecreaseseverityof agents) symptoms.) Radiationtherapy Head,neck,chest Dysgeusia,dysosmia,dysphagia,esophagus,fibrosis, fistula,hemorrhage,odynophagia,stomatitis, stricture,trismus,xerostomia,toothdecay,toothloss (Toothdecayandlosscanbepreventedbyan aggressiveprogramofdentalhygiene.) Abdomen,pelvis Boweldamage,diarrhea,fistulization,malabsorption, nausea,obstruction,stenosis,vomiting Surgery Radicalhead/neck Alteredappearance,chewingorswallowingdifficulty, chronicaspiration,dysgeusia,dysphagia,impaired speech,odynophagia,voiceloss Diarrhea,earlysatiety,gastricstasis,hypochlorhydria, regurgitation,steatorrhea Abdominalbloatingandcramping,achlorhydriawith lackofintrinsicfactor,diarrhea,dumpingsyndrome, earlysatiety,hypoglycemia,mineraldeficiencies,fat malabsorption,fatsolublevitamindeficiency VitaminB12deficiency,dehydration,diarrhea,fluidor electrolyteimbalance,hyperoxaluria,malabsorption, mineraldepletion,renalstoneformation,steatorrhea
Esophagectomy Gastrectomy
Intestinalresectiona
aProblemsthatdeveloparedeterminedbythenatureandextentofresection;nutritionalinterventionmustbehighlyindividualized.
Source:BarrocasA.Cancer.In:WhiteJ,ed.TheRoleofNutritioninChronicDiseaseOutcome.Washington,DC:NutritionScreeningInitiative;1997. ReprintedbypermissionfromtheNutritionScreeningInitiative,aprojectoftheAmericanAcademyofFamilyPhysicians,theAmericanDieteticAssociation, andtheNationalCouncilonAging,andfundedinpartbyagrantfromRossProductsdivision,AbbottLaboratories.
III12
Cancer
TableIII6:SuggestedNutritionIntervention(1,2) Problem(SignsandSymptoms) NutritionIntervention Chewingorswallowingdifficulty Modifyconsistency(SeeFullLiquidBlenderizedDiet; (secondarytosurgery,radiationtherapy) DysphagiaFeedingPlaninSectionIB). Dryness,soreness,orinflammationoforal mucosa(secondarytotumor, chemotherapy,radiationtherapy) Evaluateeffectofmedications. Consumefluidswithmeals. Avoidacidicfoods. Avoidverycoarsefoodsthatdonotsofteninthemouth. Cutfoodsintosmallpieces. Moistendryfoods;modifydietconsistency. Useoralmouthrinses. Evaluateuseofglutamine(10gorallythreeorfourtimesper day)(3). Patientsapplyingtopicalhoneyexperiencedasignificant reductioningrade3/4mucositiswith54%either maintainingorgainingweight(1,4)(GradeIII). Tryartificialsalivaproducts. Forpreventionofdentalcaries,betweenmealcandiesand gumshouldbesugarless. Avoidhotfoodstoreducetheriskofburningthemouth. Coldfoodsmaybesoothing. Avoidalcohol. Lidocaine(Xylocaine)canbeusedtorelievepainbefore eating. Useastraworspoonforconsumingliquids. Salivastimulants,suchassugarlesscandyorgum,maybe beneficial. Anorexiaandalteredtasteperception Determineifotherproblems,suchaspain,fearofvomiting, (secondarytosystemiceffectsofcancer, medication,orconstipation,couldbefactors. radiationtherapytoheadandneck, Recommendmodificationsindietorderasnecessary. chemotherapeuticagents) Monitorintake. Takeanutritionhistorytoidentifywelllikedfoods. Vigorousnutritioninterventionmayreversesomeofthe factorscausinganorexiaandtasteabnormalities. Considertheuseofpharmacotherapy(eg,progestational agents,cannabinoids,anabolicagents,prokineticagents, antiserotonergicagents)(2). Coldfoodsmaybemoreacceptablethanwarmfoods. Chocolateandfruitflavoredsupplementsarewellaccepted. Recommendwellseasonedfoods(liberaluseofherbs,spices, flavorings). Patientshouldrinsemouthwithtea,gingerale,orsaltwater beforeandaftereating. Usezincsupplementationonlyifthereisaclinicallyvalidated deficiency(5). Lowerthresholdforbitterness(meatrejection, Usenonmeatsourcesofprotein:eggs,dairyproducts, especiallybeef) poultry,orvegetablesources;poultryorfishmaybebetter toleratedthanredmeat;fishwithastrongaromamaynot beaccepted. Eatwithplasticutensilsratherthanmetalutensils. Elevatedthresholdforsweetness Addsugartofoods(sweetsauces,marinades).
III13
Cancer
TableIII6:SuggestedNutritionIntervention(1,2)(Cont.) Problem(SignsandSymptoms) NutritionIntervention Earlysatiety Eatsmall,frequentmealswith highenergy,nutrientdense (secondarytomalnutrition,obstruction, foods(additionofglucosepolymers). pain,effectsofdecreasedsecretionsand Drinkliquidsbetweenmealsratherthanwithmeals. peristalsis,chemotherapeuticeffectson Keepheadelevatedfollowingameal;avoidmealsatbedtime. digestivetract) Lowfatfoodsmaybebettertolerated;avoidfatty,greasy foods. Lightexerciseisallowediftolerated. Intakemaybebestatbreakfast. Keephighprotein,highenergysnacksonhandfornibbling. Chewthoroughlyandeatslowly. Nauseaandvomiting(associatedwith Evaluateeffectsandtimingofmedications. chemotherapy,radiationtherapyto Useantiemeticdrugshourbeforemeals. abdominalandgastricareas,partial Takedeepbreaths,sipacarbonatedbeverage,orsuckonice obstructionofthegastrointestinaltract) chips.Tryadrydiet(liquidbetweenmeals). Decreaseintakeoffattyfoods. (Note:Nauseaandvomitingareusuallyover Avoidcookingodors. within2448hoursafterchemotherapyand Avoidfavoritefoodswhennauseatedtopreventdevelopment 24hoursaftertotalbodyirradiation.) ofpermanentdislikeforsuchfoods. Eatfoodswithoutstrongodors. Coldfoodsareoftenbetteracceptedthanhotfoods. Vigorousnutritionalinterventionmayreverseatrophydueto malnutrition. Enteralroutemaybepreferabletotheparenteralroute,asit suppliesnutritiondirectlytomucosalcells. Uselactosefreesupplements. Decreasefibercontent. Steatorrheaanddiarrhea(secondaryto Decreaseproportionofenergyfromfat. thoracicesophagealresection,gastric Usemediumchainorlongchaintriglyceridesifdiarrhea resection,cancerousinvolvementof relatedtomalabsorption(2). Decreasefibercontentasneeded;however,bulkingagents lymphatics,blindloopsyndrome, andfoodshighinwatersolublefibermaybehelpfulif obstructionofthepancreaticorbileducts) diarrheaissecondarytoradiation. Promoteadequatefluidintake. Recommendalactosecontrolleddiet,ifrequired. Evaluateallmedications(eg,magnesiumcontaining medications,prokineticagents)andherbalsupplements (especiallymilkthistle,aloe,cayenne,sawpalmetto,and ginseng)thatcancausediarrhea(2). Evaluateintakeoffoodshighinsugarandsorbitol,asboth maycausediarrheaifconsumedinlargeamounts. Probioticsupplementation(yogurtwithlivecultures)maybe appropriateifdiarrheaisrelatedtoalteredmicroflora fromantibiotics(2,6). Glutamine,apowderedproteinsupplement,hasbeen recommendedtohelpcontrolcancertreatmentrelated diarrhea.Notallstudieshavedemonstratedefficacy,butit mayberelatedtothedose(7,8).Ingeneral,adoseof10g threetimesperdayhasbeenrecommended(2,7,8). Proteinlosingenteropathy Recommendahighproteinintake. (secondarytofistula,disruptionofintestinal Monitornutritionalstatus. epitheliumorlymphatics)
III14
Cancer
TableIII6:SuggestedNutritionIntervention(1,2)(Cont.) Problem(SignsandSymptoms) NutritionIntervention Providehighenergy,nutrientdensefoods. Weightloss(secondarytoincreasedbasal Useabovestrategiestopromotefoodintake. metabolicrate,catabolism,decreasedfood Consideruseofpharmacotherapy(eg,progestationalagents, intake,decreasedabsorption) cannabinoids,anabolicagents,prokineticagents, Anorexiacachexiasyndrome(9) antiserotonergicagents,branchedchainaminoacids, melatonin)withanorexiacachexiasyndrome(2). Note:Energyexpendituremaybeincreasedordecreased; diseasesoflongdurationareassociatedwith hypermetabolism. Constipation Increasefiberandfluidintake;limitgasformingfoods. Lightexerciseisadvised,iftolerated. Evaluatemedicationsasunderlyingcause(eg,narcotics). Heartburn SeeGastroesophagealRefluxDiseaselaterinthissection. Bowel obstruction: Patients who have had radiation or surgery to the pelvic area are at risk for bowel obstruction. Symptomsofbowel obstruction includecramping abdominalpain,diarrhea, andconstipation. Patientswhohaveapartialbowelobstructionmayhavethin,pencillikestoolsorsloughingofnecrotictissue, which may be mistaken for diarrhea. Patients should not take overthecounter medications without their physicians approval (2). Patients should consume a lowresidue diet and reduce their intake of bowel stimulating foods, such as caffeine and sorbitol (2). Symptoms of complete bowel obstruction include crampingthatisoftenaccompaniedbynauseaandvomiting.Diarrheamayprecedethecompletecessationof bowelmovements.Thephysicianshouldbecontactedimmediately.
References 1. OncologyEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociationEvidenceAnalysisLibrary.Chicago,Ill:American DieteticAssociation;2008.Availableat:http://www.adaevidencelibrary.com.AccessedJanuary16,2008. 2. Oncology.In:NutritionCareManual.AmericanDieteticAssociation;2004.Availableat:nutritioncaremanual.org.AccessedAugust23, 2006. 3. CoghlinDicksonTM,WongRM,OffrinRS,ShizuruJA,JohnstonLJ,HuWW,BlumeKG,StockerlGoldsteinKE.Effectoforalglutamine supplementationduringbonemarrowtransplantation.JParenterEnteralNutr.2000;24:6166. 4. BiswalB,ZakariaA,AhmadN.Topicalapplicationofhoneyinthemanagementofradiationmucositis:apreliminarystudy.Support CareCancer.2003;11:242248. 5. RipamontiC,ZeccaE,BrunelliC,FulfaroF,VillaS,BalzariniA,BombardieriE,DeConnoF.Arandomized,controlledclinicaltrialto evaluatetheeffectsofzincsulfateoncancerpatientswithtastealterationscausedbyheadandneckirradiation.Cancer. 1998;82:19381945. 6. DelPianoM,BallareM,MontinoF,OrselloM,GarelloE,FerrariP,MasiniC,StrozziG,SforzaF.Clinicalexperiencewithprobioticsin theelderlyontotalenteralnutrition.JClinGastroenterol.2004;38(6Suppl):S111S114. 7. KozelskyT,MeyersG,SloanJ,ShanahanT,DickS,MooreR,EngelerG,FrankA,McKaneT,UriasR,PilepichM,NovotnyP,Martenson J.PhaseIIIdoubleblindstudyofglutamineversusplaceboforthepreventionofacutediarrheainpatientsreceivingpelvic radiationtherapy.JClinOncol.2003;21:16691674. 8. SavareseD,SavyG,VahdatL,WischmeyerP,CoreyB.Preventionofchemotherapyandradiationtoxicitywithglutamine.Cancer TreatRev.2003;29:501513. 9. InuiA.Canceranorexiacachexiasyndrome.Currentissuesinresearchandmanagement.CACancerJClin.2002;52:7291.
III15
CHRONICOBSTRUCTIVEPULMONARYDISEASE
Discussion Chronic obstructive pulmonary disease (COPD) is an incurable condition that results in progressive obstructionandinflammationoftheairways.COPDistheumbrellatermforchronicbronchitis,emphysema, and a range of lung disorders. COPD results from airway obstruction and reduced expiratory flow (1). As COPD progresses, the work of breathing increases to 10 to 20 times that of a person with normal lung function (2). The main symptoms of COPD include dyspnea, possibly accompanied by wheezing, and a persistentcoughwithsputumproduction (2).Othersymptomsincludephysicalsigns,suchasabarrelchest relatedtohyperinflationofthelungs,andhypoxemiaandhypercapnia (2).SevereCOPDcanleadtocyanosis causedbyalackofoxygenintheblood.Insomecases,cyanosiscanleadtoheartfailureasaresultofthe extra work required by the heart to get blood flow to the lungs (3). Patients with COPD often experience compromised nutrition status caused by inadequate nutritional intake and the inability to meet energy expenditurerequirements (2).Inaddition,fatfreemassandbonemineraldensityarelowerinpeoplewith COPD (4). The malnutrition associated with COPD has been termed pulmonary cachexia syndrome (2). Patientswithpulmonarycachexiasyndromehaveaprogressivereductioninleanbodymassduetofactors associatedwithmedicalmanagement,includingmedications,andchangesinmetabolismandenergyintake (2).Theprevalenceofmalnutrition,asindicatedbyabodymassindex(BMI)lessthan20kg/m2,maybeas highas30%inpersonswithCOPD,andtheriskofCOPDrelateddeathdoubleswithweightloss(5).
The most common cause of COPD is exposure to tobacco smoke. Tobacco smoking accounts for an estimated80%to90%oftheriskfordevelopingCOPD (68).Otherriskfactorsaresecondhandsmoking,air pollution,andoccupationalexposure.Alpha1antitrypsindeficiency,theonlyknowngeneticabnormalitythat causesCOPD,accountsforlessthan1%ofCOPDcasesintheUnitedStates (7).Pulmonaryfunctiontests,or spirometry, are used to diagnose COPD (2). Forced vital capacity (FVC) is the amount of air that can be forciblyblownoutafterfullinspiration,andforcedexpiratoryvolumeinonesecond(FEV1)istheamountof air that can be forcibly blown out in one second. Both measurements are used to determine airway obstruction.AratioofFEV1toFVCthatislessthan0.70isadiagnosticindicatorofCOPD(8).
ThemajortreatmentgoalsforpersonswithCOPDaretomaximizefunctionalcapacity,preventsecondary medical complications, and improve quality of life (2,8). To achieve these treatment goals, medical management of COPD includes smoking cessation or avoidance of environmental smoke and pollution; pharmacologic therapy (eg, bronchodilators, corticosteroids or steroids, antibiotics, and diuretics); pulmonaryrehabilitationthroughaerobicexerciseandupperextremitystrengthtrainingoroxygentherapy; andmaintenanceofnutritionalstatus(2,79). NutritionAssessmentandDiagnosis Malnutrition is associated with the wasting and subsequent weakness of respiratory muscles (2,8). Eight studiesoftheweightandbodycompositionofpersonswithCOPDwererecentlyreviewed(9).Theprevalence of malnutrition (as defined by a BMI <20 kg/m2) was as high as 30%, and the risk of COPDrelated death doubledwithweightloss (GradeII)(9).Eveninthe70%ofCOPDpatientswithBMIsgreaterthan20kg/m2,the fatfree mass index and bone mineral density were lower than in healthy controls (Grade II) (9). Longterm corticosteroid therapy, which compromises immune function, combined with respiratory muscle weakness caused by malnutrition predisposes patients with COPD to respiratory tract infections such as pneumonia. Corticosteroidsplayanimportantroleinwastingsyndromesbyinhibitingproteinsynthesisandpromoting protein catabolism (2). The wasting effects of steroids seem to be dose dependent; doses greater than 60 mg/day lead to reduced respiratory muscle strength and delayed recovery of muscle function (2). Patients with COPD who are malnourished may have lower lung function measurements, more dyspnea, and lower nutritionalintakesthanpatientswhoarenotmalnourished (GradeII)(9).Lastly,patientswithCOPDmayhave moreimpairmentwithactivitiesofdailyliving(GradeII)(9). A comprehensive nutritional assessment that includes a physical assessment and assessments of energy intake (by using indirect calorimetry), biochemical values, medications, and anthropometrics is needed to identifyrelevantnutritiondiagnoses(2).AnevaluationofBMIandmusclemassormusclestrengthisauseful indicatorofmalnutritioninCOPDpatients(2,9).Clubbing,whichisathickeningofthefleshunderthetoenails andfingernails,isacommonphysicaltraitfoundinpatientswithCOPD.Thenailcurvesdownward,similarto theshapeoftheroundpartofanupsidedownspoon.Althoughthecauseofclubbingisstillunknown,itis thoughtthatCOPDcausesvasodilationinthedistalcirculationthatleadstohypertrophyofthetissueofthe nailbeds(2).AnotherphysicalsignofCOPD,cyanosis,isabluecolorationoftheskinandmucousmembranes
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ChronicObstructivePulmonaryDisease
causedbythepresenceofdeoxygenatedhemoglobininbloodvesselsneartheskinsurface(2).Anassessment ofmusclemass(eg,armcircumference)andanevaluationofsignsofmusclewastingoratrophyshouldbe performed. Patients who take steroids may have decreased respiratory strength, decreased bone mineral density,increasefracturerisk,andhyperglycemia (2).Adetailedfoodandnutritionhistoryfocusingontotal energy and carbohydrate intake; intake of omega3 fatty acids, calcium, and vitamin D; and use of medical food or other supplements is relevant in the COPD patient population (2,9). Refer to Chronic Obstructive PulmonaryDiseaseAcuteCareNutritionProtocolforareviewofcommonassociatednutritiondiagnosesin theacutecaresetting(10). NutritionIntervention TheprimarygoalsofmedicalnutritiontherapyinthemanagementofCOPDaretopreserveleanbodymass, preventinvoluntaryweightloss,andmaintainnutritionalstatus(2,9).Nutritioninterventionstrategiesshould be determined based on the patients nutrition diagnosis, primary medical diagnosis, coexisting diseases, levelofcare,andriskfactorsidentifiedduringthecomprehensivenutritionassessment.RefertotheCOPD AcuteCareNutritionProtocol (10)fordetailednutritionassessmentandnutritioninterventionstrategiesfor the acute care setting. Nutritional supplementation with medical food supplements increases the energy intake and promotes the weight maintenance of hospitalized patients with malnutrition or compromised nutritional status (Grade II) (9). In the ambulatory care setting, nutritional supplementation may result in increased energy intake, with weight gain more likely when combined with exercise (Grade II) (9). The ideal macronutrientcompositionofmedicalfoodsupplementstosupportlungfunctionhasnotbeenvalidated (9); therefore,theselectionofsupplementsshouldbebasedonthepatientstastepreferenceandtheadequacyto meetindividualizednutritionalneeds(2,9).
AcuterespiratorydistresssyndromeisasecondarycomplicationofCOPDthatrequireshospitalization(2,8). Mechanicalventilationistheprimarymanagement,withtheobjectivetokeepthelungsathighvolumeand prevent airway closure (2). Acute respiratory failure or distress syndrome occurs frequently in patients undergoing complicated surgery or as a result of trauma, septic shock, or multiorgan failure (2). Early nutrition intervention and access for enteral feeding support are recommended to prevent further deterioration of the nutritional status of patients who receive mechanical ventilation. Depending on the functional status of the gastrointestinal tract, parenteral nutrition may be indicated. (Refer to Enteral NutritionSupportandParenteralNutritionSupportinSectionIB.)
Energyexpenditure:ThetotaldailyenergyneedsofpeoplewithCOPDarehighlyvariableduetodifferences inrestingenergyexpenditureandphysicalactivitylevels (GradeIII)(9).Inflammationpresentduringstableor exacerbatedCOPDincreasestherestingenergyexpenditure (GradeIII)(9).Onesmallstudyoftenpatientswith severe COPD demonstrated that the measured energy expenditure was 50% higher than the World Health Organizationpredictiveequationandthatthetotaldailyexpenditurewaswidelyvariable,rangingfrom26to 48kcal/kg (11).TheAmericanDieteticAssociationperformedacomprehensivereviewoftheliteratureand concluded that further research on the influences of the thermic effect of food, breathing efficiency, and medications on the energy needs of COPD patients is needed (9). Indirect calorimetry is the best available method for assessing energy expenditure and establishing energy requirements in COPD patients (2,9). If indirectcalorimetrycannotbeperformed,energyrequirementsshouldbeestimatedbypredictiveequations based on the level of care (2). The energy requirements of most adult COPD patients range from 25 to 35 kcal/kg, depending on weight, coexisting disease processes, and nutritional deficits (2). Patients who are clinicallyoverfeddevelophypercapniaduetoincreasedcarbondioxideproduction.Hypercapniaincreases the demands of ventilation, which worsens the respiratory status, delays weaning from mechanical ventilation,orboth.Overfeeding,definedasenergyintakeinexcessofmetabolicdemands,shouldbeavoided (2).WeightlossisrecommendedforoverweightpatientswithCOPD.Inthesepatients,weightlossimproves respiratorymusclefunctionanddecreasesshortnessofbreath(2).
Protein: Provide enough protein to maintain visceral protein status and meet the demands of metabolic stress. Protein requirements do not increase with COPD (2). Protein increases minute ventilation, oxygen consumption, and ventilatory response to hypoxia and hypercapnia. In patients with Acute Respiratory DistressSyndrome,highlevelsofproteinmaycausefurtherfatigue,andproteinrequirementsmayneedtobe temporarilyreduced(6).
Carbohydrate and fat: It has been proposed that patients with COPD might benefit from a highfat, moderatecarbohydratediet(eg,40%to55%carbohydrate,30%to40%fat,and15%to20%protein) (12). The rationale is that carbohydrate as a fuel substrate increases the respiratory quotient. This quotient representsgasexchangeandisdefinedascarbondioxideproduceddividedbyoxygenconsumed.Alower
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ChronicObstructivePulmonaryDisease
respiratoryquotientindicatesbettergasexchangeandaneasiercapacityforapatienttobreathe.Thetypeof energy substrate (fat, protein, or carbohydrate) and how the body utilizes the substrates determine the respiratoryquotient (2).Whenoxidizedforenergyproduction,proteinhasarespiratoryquotientof0.8,fat hasanrespiratoryquotientof0.7,andcarbohydratehasanrespiratoryquotientof1 (2).Theclinicalbenefits ofalteringfattocarbohydrateratiosinpatientswithCOPDwhentheenergysuppliedisappropriatehavenot been demonstrated (2,9,13). The respiratory quotient can be affected by a number of variables other than substrate utilization (13,14). Current practice emphasizes the provision of measured or estimated energy requirementswiththeemphasisofpreventingoverfeedingratherthanalteringsubstratebyprovidinghigh fatorlowcarbohydrateformulations(13).
Omega3fattyacids:Areviewofstudiesontheinfluenceofomega3fattyacidsonairwayresponsiveness demonstratedinconclusivefindingsregardingarelationshipbetweenoverallfishintakeandCOPDmortality, pulmonary function, and symptoms (Grade III) (9). In one study, dietary fish oil consumption by cigarette smokersprovidedprotectiveeffectsagainstCOPD (Grade III) (9,15).Furtherinvestigationisrequiredtoassess the relationship between omega3 fatty acids and COPD. Currently, supplementation with fish oil is not recommended(GradeIII)(9).
Electrolytes and trace elements: Disturbances of electrolytes are common in critically ill patients with COPD. Patients with cor pulmonale or pulmonary edema may require sodium and fluid restriction. Hypophosphatemia, hypokalemia, hyperkalemia, hypocalcemia, and hypomagnesemia are associated with diminisheddiaphragmaticfunction (8).Respiratoryfunctionimproveswiththerepletionofthesenutrients. Phosphorusdeficiencyreducesthebloodsabilitytodeliveroxygentotissuesanddecreasesthecontractility ofrespiratorymuscles.Magnesiumdeficiencycompromisesrespiratorymusclestrength.Thedietaryintake of these key nutrients should be monitored (2). Reduced bone mass, as measured by dualenergy xray absorptiometry,hasbeendemonstratedinpatientswithCOPD;thisfindingprovidesevidencefornutritional concerns related to bone mineral density, fracture risk, and osteoporosis (Grade II) (9). The prevalence of osteoporosisand/orvertebralfracturesrangesfrom25%to60%inCOPDpatients (GradeII)(9). Patientswho aretreatedwithsteroids(greaterthan1,000mg/dayofinhaledororalsteroids)areatanincreasedrisk; changes in biochemical bone markers, decreased bone mineral density, and increased fracture risk are associatedwithhighersteroidintake(GradeII)(9).LowbodyweightandlowBMIarepositivelycorrelatedwith decreased bone density in patients with COPD (Grade II) (9). Emerging research shows associations between hypercapnia, vitamin D status, and bone mineral density (Grade II) (9). Until further research is available, the dietitian should carefully assess the patients risk factors (eg, older age, corticosteroid use, low BMI, and smoking) and dietary intake of calcium, phosphorus, and vitamin D. In consultation with the physician, supplementationwiththesekeyvitaminsandmineralsshouldbeconsideredbasedonthepatientsrisklevel assessmentorevidenceofneed.
Antioxidants: The effects of antioxidants (flavonoids and vitamins A, D, and E) on the pathogenesis and exacerbationofCOPDhaverecentlybeenreviewed(9).Sevenstudiesfoundreducedserumortissuelevelsof antioxidant vitamins in people with COPD (Grade III) (9). However, studies of supplementation report insignificanteffects(GradeIII)(9).Ongoingstudiesareinvestigatingtherelationshipbetweennutrientsandlung functionandCOPD (9).Foodsourcesrichinantioxidants,vitamins,andmineralsarecurrentlyrecommended inplaceofsupplementation(2). Mucus production and dairy consumption: Some patients with COPD perceive increased mucus productionafterconsumingmilkanddairyproducts.However,anarrativereviewconcludedthatmilkand dairyproductconsumptiondoesnotsignificantlyaffectlungfunctionparameters (GradeIII)(9).Moreresearch isneededonthistopic(GradeIII)(9).
References 1. 2. 3. 4. Snider GL. Nosology for our day: its application to chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2003;167:678683. Chronic obstructive pulmonary disease. In: Nutrition Care Manual. American Dietetic Association; 2004. Available at: http://nutritioncaremanual.org.AccessedJanuary5,2009. BauldoffGS,DiazPT.ImprovingoutcomesforCOPDpatients.NursePract.2006;31:2643. VestboJ,PrescottE,AlmdalT,DahlM,NordestgaardBG,AndersenT,SorensenTI,LangeP.Bodymass,fatfreebodymass,and prognosisinpatientswithchronicobstructivepulmonarydiseasefromarandompopulationsample:findingsfromtheCopenhagen CityHeartStudy.AmJRespirCritCareMed.2006;173:7983. Chailleux E, Laaban JP, Veale D. Prognostic value of nutritional depletion in patients with COPD treated by longterm oxygen therapy:datafromtheANTADIRobservatory.Chest.2003;123:14601466. AmericanThoracicSocietyBoardofDirectors.Standardsforthediagnosisandcareofpatientswithchronicobstructivepulmonary disease.AmJRespirCritCareMed.1995;152:S77S120.
5. 6.
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ChronicObstructivePulmonaryDisease 7. 8. 9. 10. Global Initiative for Chronic Obstructive Lung Disease. Executive Summary: Global Strategy for the Diagnosis, Management, and PreventionofCOPD.Availableat:www.goldcopd.com.AccessedJanuary10,2009. Celli BR, MacNee W.Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.EurRespirJ.2004;23:932946. ChronicObstructivePulmonaryDiseaseEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociationEvidenceAnalysis Library.AmericanDieteticAssociation;2008.Availableat:http://www.adaevidencelibrary.com.AccessedJanuary10,2009. ChronicObstructivePulmonaryDiseaseAcuteCareNutritionProtocol.In:InmanFeltonA,SmithKG.NutritionCareProtocolsfor theAcuteCareSetting.Atlanta,Ga:MorrisonManagementSpecialistsInc;2009.Availableat: https://www.morrisontoday.com/Documents/Forms/AllItems.aspx?RootFolder=%2fDocuments%2fNutrition%2fMHFS%20NUTR ITION%2fNutrition%20Care%20Process&FolderCTID=0x01200076035A4CEC8A4B4B827A74CE5B3B1A44&View=%7b1F2F11D B%2d2030%2d4BBC%2dB712%2dEFE12EF45909%7d. SlindeF,EllegardL,GronbergAM,LarssonS,RossanderHulthenL.Totalenergyexpenditureinunderweightpatientswithsevere chronicobstructivepulmonarydiseaselivingathome.ClinNutr.2003;22:159165. KuoCD,ShiaoGM,LeeJD.TheeffectsofhighfatandhighcarbohydratedietloadsongasexchangeandventilationinCOPDpatients andnormalsubjects.Chest.1993;104:189196. SchwartzDB,DiMariaR.Pulmonaryandcardiacfailure.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:A CasedBasedApproachTheAdultPatient.SilverSpring,MD:AmericanSocietyofParenteralandEnteralNutrition;2007:496501. McClave SA, Lowen CC, Kleber MJ, McConnell JW, Jung LY, Goldsmith LJ. Clinical use of the respiratory quotient obtained from indirectcalorimetry.JParenterEnteralNutr.2003;27:2126. BritonJR,PavordID,RichardsKA,KnoxAJ,WisniewskiAF,LewisSA,TattersfieldAE,WeissST.Dietaryantioxidantvitaminintake andlungfunctioninthegeneralpopulation.AmJRespirCritCareMed.1995;151:13831387.
11. 12. 13. 14. 15.
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CORTICOSTEROIDTHERAPY
Discussion Corticosteroids, in the synthetic forms of natural hormones, are potent antiinflammatory medications that canbegivenorallyorbyinjection.Theycanproduceseveresideeffects,suchashypertension,highblood glucoselevels,anincreasedriskofinfection,osteoporosis,fluidretention,decreasedabilitytohealwounds and fragile skin. Widely used corticosteroid preparations are prednisone, prednisolone, hydrocortisone, methylprednisone,anddexamethasone(1). Indications Corticosteroidsareusedas(1): immunosuppressivetherapyfororgantransplantrecipients treatment of numerous short term management of various inflammatory and allergic disorders: rheumatoidarthritis,collagendisease,dermatologicdiseaseandautoimmunedisorders(eg,systemic lupuserythematosus) treatment of ulcerative colitis, acute exacerbations of multiple sclerosis; and palliation in some leukemiasandlymphomas Approaches Dietaryinterventionsmaybeneededforsideeffectsofcorticosteroids. Problem Recommendation Decreasedcalciumabsorption Ensurecalciumintake(dietaryorby supplementation)tomeetDietaryReference Osteroporosis(glucocorticoidarthritis),thoughttoresult Intakeforage. fromdecreasedintestinalabsorptionandincreasedrenal excretionofcalcium IncreasesunshineexposureordietaryvitaminD. Hyperglycemia(steroidinducedglucoseintolerance) Adjustdietaccordingly. Mayrequireinsulinororalglucoselowering medication. Mayneedsodiumrestricteddiet(2). Behavioralstrategiesfordealingwithincreased appetite. SeeCalorieControlledDiet,inSectionIC. Exercise. Highproteindiet:1to2g/kg Adequateenergy:30to35kcal/kg
Edema;hypertensionduetowaterretention Weightgainduetoincreasedappetite
Negativenitrogenbalancesecondarytoincreasedprotein catabolism
References 1. 2.
Corticosteroids.Nursing2003DrugHandbook.23rded.Philadelphia,Pa:LippincottWilliams&WilkinsPublishers2003:701721. EscottStumpS.NutritionandDiagnosisRelatedCare.5thed.Baltimore,Md:Williams&Wilkins;2002:317.
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MONITORINGINDIABETESMELLITUS
NutritionEvaluationandMonitoring Thefollowinginformationprovidesrelevantoutcomesusedinthedeterminationofnutritiondiagnosisand evaluation and monitoring of medical nutrition therapy. The comprehensive list provides the suggested monitoring parameters used to assess and evaluate the management and progression of diabetes mellitus (type 1, type 2, or gestational diabetes mellitus [GDM]). The information below provides the objective outcomesthatsupporttherationaleforprovidingmedicalnutritiontherapyandselfmanagementtrainingto personswithdiabetesmellitus.Theoutcomeparametersthatthedietitianwillselecttoevaluateandmonitor are determined by the patients stage of disease (new diagnosis vs. followup), type of diabetes, and presentingsignsandsymptoms.Thedietitiancanstrengthenhisorherroleasaparticipatingmemberofthe healthcareteambyunderstandingtheimpactandinterpretationoftheseoutcomes.Whendevelopingthe individual patient care plan, the dietitian selectively discusses only those assessment and monitoring outcomeparametersthatarepertinenttothepatientssignsandsymptomsornutritionrelateddiagnosis. Laboratorystudies Fastingplasmaglucose(plasmaglucosevaluesare10%to15%higherthan (1): wholebloodglucosevalues) Serialbloodglucoselevelsbeforeeachmeal,beforeeveningsnack,3AM, postprandial Glycatedhemoglobin(GHb),*alsoreferredtoasA1Ctest,glycohemoglobin, glycosylatedhemoglobin,HbA1c,orHbA1. Glycatedserumprotein(GSP;shorterhalflife[1to2weeks]thanGHb[2to3 months];preferredtoGHbwhenanemiaispresent) Fasting lipid profile, including highdensity lipoprotein (HDL), lowdensity lipoprotein(LDL),verylowdensitylipoprotein(VLDL),triglycerides,andtotal cholesterol Renal function indexes (microalbuminuria, serum creatinine in adults,inchildrenifproteinuriaispresent) Testformicroalbuminuria(eg,timedspecimenoralbumintocreatinineratio) Glucoseinurine(limiteduseandnotrecommendedforuseinGDM), Urineandbloodketonetesting(recommendedintype1diabetes,pregnancy withpreexistingdiabetesandGDM) Electrolytes Thyroidfunctiontests(fortype1diabetesatdiagnosisandthenevery12 years) Cpeptide ImmunoglobulinA(IgA),tissuetransglutaminase(tTg)antibodiesor antiendomysialantibodies(antiEMA)forpersonswithtype1diabeteswho presentwithsignsorsymptomsofceliacdisease Medicalclinical(1): Insulinregimenand/ororalagent Bloodpressure Comprehensivemedicalreview Reviewofcoexistingmedicalconditions Current weight, body mass index, weight history, desirable weight (mutually agreed on goal) goal weight, growth and development pattern (children, adolescents) Activitylevel(exercisepattern) Nutrition history and typical food intake (meal and snack times; percent of kilocaloriesfromprotein,carbohydrate,andfat) Selfmonitoringofbloodglucose(SMBG)levelandpattern(Plasmaglucose valuesare10%to15%higherthanwholebloodglucosevalues,anditiscrucial thatpeoplewithdiabetesknowwhethertheirmonitorandstripsprovide wholebloodorplasmaresults.) Social: Relevantsocialfactors,suchasaccesstohealthcare,employmentschedule/school, culture,literacylevel,familysupport,financialresources,possiblyalcoholorother substanceabuse,selfmonitoringstrategies(eg,SMBGrecords),andprevious treatmentprograms,includingnutritionanddiabetesselfmanagementtraining *ValuesinthereferencerangearedifferentforHbA1vsHbA1c(2).
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DiabetesMellitus
Formedicalnutritiontherapyapproaches,seeMedicalNutritionTherapyforDiabetesMellitusinSectionIC. RoutineMonitoring(outcomeassessmentparameters)(1): Bodyweight Foodrecords Bloodpressure Selfmonitoringofbloodglucose(SMBG)records Selfmonitoringofbloodglucose(SMBG)shouldbecarriedoutthreeormoretimes dailyforpatientsusingmultipleinsulininjectionsorinsulinpumptherapy(1). Fastinglipidprofile Formostadultswithdiabetesevaluateannually(1). Glycatedhemoglobin,*alsoreferredtoasA1Ctest PerformA1Ctesttwiceperyearinstablepatientsmeetingtreatmentgoals.Assess quarterlyinpatientswhosetherapyhaschanged,orarenotmeetinggoals(1). Serumcreatinine Measureserumcreatinineatleastannuallyinalladultswithdiabetesregardlessof thedegreeofurinealbuminexcretion.Theserumcreatinineshouldbeusedto estimateglomerularfiltrationrate(eGFR)andstagethelevelofchronickidney disease(CKD)(1). Urine(ketones,glucose[exceptwithGDM],protein Annualscreeningformicroalbuminuria,withrandomspoturinesamplefor microalbumintocreatinineratioshouldbeinitiatedoncethechildis10yearofage andhashaddiabetesfor5years(1). *ValuesinthereferencerangearedifferentforHbA1vsHbA1c(2). Education and selfmanagement training as appropriate: See Section IC, Medical Nutrition Therapy for Diabetes,DiabetesNutritionManagement:MealPlanningApproaches,fordiscussionofteachingmaterialsto usewithvariousmealplanningapproaches.AlsorefertoDiabetesMellitus(UncontrolledandComplications) and Gestational Diabetes Mellitus: Medical Nutrition Therapy Protocols (4) for acute care; and Type 1 and Type2DiabetesMellitusevidencebasednutritionpracticeguidelinesforadultsinADAsEvidenceAnalysis Library(5).
References 1. AmericanDiabetesAssociation.Standardsofmedicalcareindiabetes2010.DiabetesCare.2010;33(suppl1):11S61S.. 2. SantiagoJ.LessonsfromtheDiabetesControlandComplicationsTrial.DiabetesCare.1993;42:1549. 3. AmericanDiabetesAssociation.Nutritionrecommendationsandinterventionsfordiabetes.DiabetesCare.2008;31(suppl1):61S 78S. 1. Diabetes(UncontrolledandComplications)AcuteCareProtocol.In:InmanFeltonA,SmithK,eds.NutritionCareProtocolsinthe AcuteCareSetting.Atlanta,Ga:MorrisonManagementSpecialists;2009.Availableat: https://www.morrisontoday.com/Documents/Forms/AllItems.aspx?RootFolder=%2fDocuments%2fNutrition%2fMHFS%20NUTR ITION%2fNutrition%20Care%20Process&FolderCTID=0x01200076035A4CEC8A4B4B827A74CE5B3B1A44&View=%7b1F2F11D B%2d2030%2d4BBC%2dB712%2dEFE12EF45909%7d. 4. Type 1 and Type 2 Diabetes Evidence-Based Nutrition Practice Guideline for Adults. The American Dietetic Association, 2008. In: The American Dietetic Association Evidence Analysis Library at http://www.adaevidencelibrary.com. Accessed December 2, 2008. Bibliography AmericanDiabetesAssociation.Diagnosisandclassificationofdiabetesmellitus.DiabetesCare.2010;33(suppl1):S62S69. AmericanDiabetesAssociation.Testsofglycemiaindiabetes:positionstatement.DiabetesCare.2004;27(suppl1):91S93S. AmericanDiabetesAssociation.Nephropathyindiabetes:positionstatement.DiabetesCare.2004;27(suppl1):79S83S. AmericanDiabetesAssociation.Gestationaldiabetesmellitus:positionstatement.DiabetesCare.2004;27(suppl1):88S90S. AmericanDiabetesAssociation.Diabetesnutritionrecommendationsforhealthcareinstitutions:positionstatement.DiabetesCare. 2004;27(suppl1):55S57S. AmericanDiabetesAssociation.Hypertensionmanagementinadultswithdiabetes:positionstatement.DiabetesCare.2004;27(suppl 1):65S67S.
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DiabetesMellitus
DIABETESMELLITUS:CONSIDERATIONSFOREXERCISE
Itisbecomingincreasinglyclearthatexercisemaybeatherapeutictoolinavarietyofpatientswith,oratrisk fordiabetes(1).Beforebeginninganexerciseprogram,theindividualwithdiabetesshouldundergoadetailed medicalevaluationwithappropriatediagnosticstudies (1).Sometypesofactivitiesmaybecontraindicated for people with hypertension, retinopathy, neuropathy, foot ulcers, and other complications of diabetes mellitus.Adetaileddiscussionofissuesrelatedtoeachtypeofcomplicationispresentedinreference1.For individuals with type 2 diabetes, exercise in the amount of 90 to 150 minutes a week (both aerobic and resistance/strength training) reduces A1C, improves insulin sensitivity, decreases dyslipidemia, and decreasesbloodpressure (2,3) (Grade I). Regularphysicialactivityalsohasshowntohelppersonswithtype2 diabetes achieve and maintain weight loss goals (2,3). Physical activity provides a way to create an energy deficitwhichcanfacilitateandmaintainweightloss.Researchhasshownthecombinationofdiet,exercise, and behavior modification to be the most effective method for reaching and maintaining weight loss goals (1,2,3).
AlterationinEnergyandNutrientRequirements Forindividualswishingtomaintaintheirweight,increasesinactivityrequireincreasesincaloricintake.For adultmenengaginginlightactivities,30kcal/kgbodyweightmaysuffice,whilethosewhoengageinheavy activitymayneed50kcal/kg.Forwomen,lightactivitymayincreaseneedto30kcal/kg,whileheavyactivity mayelevateneedsto44kcal/kg (4).Proteinneedsmaybeincreasedwithphysicalactivitiestoalevelof1.2 grams protein/kg body weight for both men and women (4). Fluid replacement is also an important consideration(4).
PreventionofExerciseInducedHypoglycemia
Type 1 Diabetes: Because physical activity may vary considerably from day today, adjustments in energy intakeandinsulindosagemayberequiredtoavoidhypoglycemiainindividualswithtype1diabetes.Several strategiesmaybeusedtoaverthypoglycemiaduringorafterexercise.Whenexerciseisplanned,insulindose should be adjusted to prevent hypoglycemia (1,2). If exercise is not planned, additional carbohydrate may needtobeconsumed(1,2).Carbohydratesupplementationisbasedonthebloodglucoselevelbeforeexercise, previousexperiencewiththeparticularformofexercise,andtheindividualsinsulinregimen (1,2).Moderate intensity exercise increases glucose uptake by 23 mg/kg/min above usual requirements. Thus, a 70 kg personwouldneed8.4to12.6[10to15]gofcarbohydrateperhourofmoderatephysicalactivity (2).More carbohydratemaybeneededforhigherintensityactivitiesorprolongedexercise(eg,>60minutes) (1,2).An individualmaybeatriskforhypoglycemiaupto24hoursaftertheexercisebout(1,2).Individualswhoprefer toconsumecarbohydratestopreventhypoglycemiaduringexerciseshouldtesttheirbloodglucosepriorto exercising,and consume an amount offood(15 grams carbohydrate) which will prevent hypoglycemia but not cause hyperglycemia (2). The following general guidelines can be helpful in regulating the glycemic responsetoexerciseintype1diabetes(1): Avoid exercise if fasting glucose levels are > 250 mg/dL and ketosis is present, and use caution if glucoselevelsare>300mg/dLandnoketosisispresent. Ingestaddedcarbohydrateifglucoselevelsare<100mg/dL
Type2Diabetes:Supplementalfoodbeforeandduringexerciseisnotneededtopreventhypoglycemiaand isnotrecommended,exceptunderconditionsofstrenuous,prolongedexercise,suchasendurancesports (2). For individuals taking sulfonylureas, there is a slightly increased risk of hypoglycemia during exercise, and supplementalenergyintakemayberequiredinsomecases (2).Theneedmaybedeterminedbyglucoseself monitoring.Individualswithtype2diabeteswhouseinsulinshouldalsomonitortheirbloodglucoselevels closely during and after exercise. Several strategies may be used to avert hypoglycemia during or after vigorous,prolonged,ornonhabitualexercise.Theseinvolvetheconsumptionofsupplementalcarbohydrate containingfoodsbefore,during,andafterexercise,aswellasadjustmentofinsulindosageandtiming(1,2).
References 1. AmericanDiabetesAssociation.Physicalactivity/exerciseanddiabetesmellitus:positionstatement.DiabetesCare.2004;27:58S 62S. 2. AmericanDiabetesAssociation.Nutritionrecommendationsandinterventionsfordiabetes.DiabetesCare.2008;31(suppl1):61S 78S. 3. American Dietetic Association Type 1 and Type 2 Diabetes Evidence-Based Nutrition Practice Guideline for Adults. The American Dietetic Association, 2008. In: The American Dietetic Association Evidence Analysis Library at http://www.adaevidencelibrary.com. Accessed December /2, 2008. 4. DelvinJT,RudermanN.Diabetesandexercise:theriskbenefitprofilerevisited.InHandbookofExerciseinDiabetes.RudermanN, DevlinJT,ShcneiderSH,KrisraA,eds.Alexandria,Va:AmericanDiabetesAssociation;2002. ManualofClinicalNutritionManagement
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Diabetes Mellitus
DIABETESMELLITUS:CONSIDERATIONSFORACUTEILLNESS
Monitoring Achieving stringent glycemic control during concurrent illness (eg, acute illness, trauma, or surgery) may reducemortalityandmorbidityinthehospitalsetting(1).Therefore,targetingglucosecontrolinthehospital settinghasthepotentialforimprovedmortality,morbidity,andhealthcareoutcomes(1).
Duringacuteillness,recordsshouldbekeptofbloodglucoselevelsandketonetestsaswellasweightloss, temperature,insulindoseandtimegiven,andanyothermedicationsthatweregiven(1).
Individualswithdiabetesmustbeappropriatelymonitoredfordiabeticketoacidosis(acidosisaccompanied bytheaccumulationofketonebodiesinthetissuesandfluids).Althoughdiabeticketoacidosisoccursmost ofteninpeoplewithtype1diabetes,peoplewithtype2diabetescandevelopketoacidosisduringillness.Ill patients with type 1 diabetes should check urine ketones and blood glucose every 3 to 4 hours, more frequentlyifthebloodglucoselevelishighorifthepatientispregnant.Ifpatientswithtype1diabeteshave bloodglucoselevelsthatarehigherthan240mg/dLtwotimesinarow,theurineorbloodshouldbetested for ketones. Blood glucose readings >240 mg/dL and moderate to large amounts of ketones are a danger signal for diabetic ketoacidosis. Patients with ketoacidosis require additional insulin and immediate managementoffluidsandelectrolytes(2).
ApproachesfortheHospitalSetting Guidelinesforpatientswithtype1ortype2diabetesmellitus: 1. Contactphysicianwhenvomitingordiarrheacontinuesfor3to4hours(1). 2. For insulinrequiring patients or patients who are pregnant, test urine for ketones. Contact physician whentestshowsamoderatetolargeamountofketones(1,2). 3. Fordiabeticcriticalcarepatients,contactphysicianwhenbloodglucoselevelremainsabove180mg/dL even after supplemental insulin (as arranged with physician). In critically ill patients insulin therapy shouldbeinitiatedfortreatmentofpersistanthyperglycemiastartingatathresholdofnogreaterthan 180mg/dL(1).Onceinsulintherapyisstarted,aglucoserangeof140to180mg/dLisrecommendedfor the majority of critically ill patients (1). Criticalcare patients will usually require intravenous insulin protocolthathasdemonstratedefficacyandsafetyinachievingdesiredglucoserangewithoutincreasing riskforhypglycemia(1). 4. For diabetic noncritically ill patients there is no clear evidence for specific blood glucose goals (1). If treated with insulin, the premeal blood glucose levels should generally be < 140 mg/dL with random bloodglucose<180mg/dLprovidedthesetargetscanbesafelyachievedwithoutriskinghypoglycemia (1). More stringent targets may be appropriate in stable patients with previous tight control. Less stringenttargetsmaybeappropriateinthosewithseverecomorbidities(1). 5. Contact physician when signs of ketoacidosisdehydration, drowsiness, abdominal or chest pain, difficultybreathing,sunkeneyes,orfruitybreatharepresent(2). 6. Contactphysicianwhentemperatureisgreaterthan100Forwhenthepatientisunabletotakefluidsfor 3to4hours(1). 7. Thepatientshouldavoidphysicalexertionandrestatacomfortableroomtemperature. Management Medication:Thepatientshouldtakeinsulinororalglucoseloweringmedicationregardlessoftheabilityto eatnormalamounts (1).Duringacuteillness,anassociatedincreaseinlevelsofcounterregulatoryhormones mayincreaseinsulinrequirements (1).Scheduledprandialinsulindosesshouldbegiveninrelationtomeals and should be adjusted according to pointofcare glucose levels. The traditional slidingscale insulin regimens are ineffective and not recommended (1). For people with type 2 diabetes who normally do not needinsulin,thepresenceofinfectionmaynecessitateshorttermuseofinsulin.Recordsshouldbekeptof bloodglucoselevelsandketonetestsaswellasweightloss,temperature,insulindoseandtimegiven,andany othermedicinesthatwere given (1).Thepatientshouldfollowthe physiciansinstructionsforchangingthe insulinormedicationregimen.
Intakeoffoodandfluid:Ingestionofcarbohydrate,especiallyifthebloodglucoselevelislessthan100 mg/dL,isimportantduringacuteillness (1).Inadults,ingestionofapproximately150to200gcarbohydrate daily(atleast50g,orthreetofourcarbohydratechoices,every3to4hours)shouldbesufficient,alongwith medication adjustments to keep glucose in the goal range, prevent hypoglycemia, and prevent starvation ketosis (1). (See Carbohydrate Replacement When Meals Are Missed or Delayed in Section IC.) Adequate
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intake of fluids is also very important. Persons with type 2 diabetes are vulnerable to nonketotic hyperosmolarcomaanddehydrationifthereispersistentglycosuria(1).
Electrolytes,especiallysodiumandpotassium,maybelostaftervomiting,diarrhea,anddiaphoresis.Salty liquids,suchassoupandbroth,canreplenishsodium.Fruitjuices,milk,yogurt,icecream,andcreamsoups (made with milk) can supply potassium. Caffeinated beverages should be avoided, as these can worsen dehydration.
References 1. AmericanDiabetesAssociation.Standardsofmedicalcareindiabetes2010.DiabetesCare.2010;33(suppl1):11S61S. 2. AmericanDiabetesAssociation.Hyperglycemiccrisesindiabetes:positionstatement.DiabetesCare.2004:27(suppl1):S94S102.
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Diabetes Mellitus
DIABETESMELLITUS:GASTROINTESTINALCOMPLICATIONS Gastroparesis Gastroparesis,alsoknownasdiabeticgastropathy,ischaracterizedbyanabnormaldelayintheemptyingof foods, particularly solid foods, from the stomach (1). Gastroparesis occurs when the vagus nerve, which controlsthemovementoffoodfromthestomachthroughthedigestivetract,isdamaged (1).Asaresult,the musclesofthestomachandintestinesdonotworknormallyandfoodmovesslowlyorstopsmovingthrough the digestive tract (1). The most common cause of gastroparesis is diabetes mellitus, and it is usually attributed to autonomic neuropathy (1). Symptoms associated with gastroparesis include nausea, vomiting undigestedfood,earlysatiety,bloating,abdominalpain,andwidefluctuationsinbloodglucoselevels(2). Approaches:Thefollowingapproachesareusedforthemedicalmanagementofgastroparesis(1). Improvethepatientsglycemiccontrol,ashyperglycemiaslowstherateofgastricemptying(1,2). Makechangestothepatientsinsulintherapy,suchasprovidingabolusofinsulinaftereatinginsteadof beforeeating(3). Consider the use of metoclopramide (Reglan), a dopamine antagonist with a central antiemetic effect. This medication stimulates stomach muscle contractions to assist in stomach emptying and reduces nauseaandvomiting(1).Gastrointestinalsideeffectsassociatedwithmetoclopramideincludediarrhea. Consider the use of erythromycin (EryPed), an antibiotic and motilin receptor agonist that increases stomachmusclecontractions.Sideeffectsassociatedwitherythromycinarenausea,vomiting,diarrhea, abdominalpainandcramps,increasedliverfunctiontests,andjaundice. Inseverecases,considerjejunostomyenteralfeedingorgastricneurostimulators(1). Recommendpostprandialexercise,suchwalking,becauseexerciseincreasessolidmealgastricemptyingin healthyindividuals(1). Because of limited evidence for the nutrition management of gastroparesis, dietary approaches and recommendations are based on professional judgement and logical interpretation of gastric physiology (1). Patientsvarytremendouslyintheirabilitiestotoleratedifferenttypesoffoods,sorecommendationsmustbe individualized.Acertainamountoftrialandlearningisinvolved.Commonfoodmodificationsforpatients withgastroparesisaredesignedtospeedupgastricemptying.Thesemodificationsinclude: Lowerthefibercontentofthediet;especiallyavoidfibrousvegetables(suchasorangesandbroccoli)and poorlydigestiblesolidswithlimitedgastricmotilitytoreducetheriskofbezoarformation(1).Eatsmall, frequent,balancedmeals(sixtosevenperday)andavoidlargemeals. Replace solid foods with liquid foods or blenderized meals (4). Puree or grind up solid foods, such as meats,sothattheymaybebettertolerated.Someindividualstoleratesolidsforthefirstonetotwosmall mealsandthendobetterwithliquidsfortheremainderoftheday. Avoid highfat foods and extra fats such as butter, margarine, gravy, or mayonnaise that are added to foods.Someindividualstoleratehighfatliquidssuchaswholemilkandicecream.Fatappearstobea potentinhibitorofgastricemptying(1). Situpwhileeatingandfor30minutesaftermeals.Walkingaftermealsmayenhancestomachemptying. NauseaandVomiting Possible causes of nausea and vomiting include neuropathy (gastroparesis), ketosis, and morning nausea secondarytonocturnalhypoglycemia. Approaches:Thefollowingapproachesareusedtorelievenauseaandvomiting. Morningnauseacausedbyovernighthypoglycemiawillusuallyberelievedbyeatingbreakfast. Nauseaandvomitingcausedbyketosiswillimprovewithmetabolicstabilization. Forpatientswithnauseaandvomitingcausedbygastroparesis,anantiemeticdrugshouldbepartofthe treatmentplan. Constipation Theincidenceofconstipationisbelievedtobemuchhigherinindividualswithdiabetesthaninnondiabetic individuals.Constipationindiabetesisrelatedtoproblemswiththeautonomicnervoussystem(5).The NutritionCareManualfromtheAmericanDieteticAssociationprovidesadetaileddiscussionofconstipation inpeoplewithdiabetes(3).
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Approaches:Thefollowingapproachesshouldbeusedfordiabeticpatientswithconstipation. Todeterminethecauseofconstipation,assessthepatientsfluidintakeandtheinsolublefibercontentof thepatientsdiet.Also,assessthephysicalactivitylevelandgeneralphysicalandmentalwellbeingofthe patient. Review the patients list of medications (prescription and nonprescription) for medicines that cause constipation.Noteahistoryoflaxativeuse(frequencyandduration). Consider recommending a formal evaluation if constipation is potentially secondary to other endocrinologic,neurologic,orgastrointestinaldisorders. Iflaxativesarerecommended,carefullyconsiderwhichtypetorecommend.RefertothepaperbyHainesfor adiscussionoftreatingconstipationinpatientswithdiabetes(5).
References 1. Gastroparesis in diabetes mellitus. In: Nutrition Care Manual. American Dietetic Association; 2008. Available at: http://www.nutritioncaremanual.org.AccessedDecember10,2008. 2. CamilleriM.Diabeticgastroparesis.NEnglJMed.2007;356:820829. 3. Pharmacotherapy in type 1 and type 2 diabetes. In: Nutrition Care Manual. American Dietetic Association; 2008. Available at: http://www.nutritioncaremanual.org.AccessedJanuary16,2009. 4. National Digestive Disease Information Clearinghouse. Gastroparesis. Available at: http:www.digestive.niddk.nih.gov. Accessed December12,2008. 5. HainesS.Treatingconstipationinthepatientwithdiabetes.DiabetesEduc.1995;21:223232.
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Diabetes Mellitus
DIABETESMELLITUS:ORALGLUCOSELOWERING MEDICATIONSANDINSULIN
TableIII7:GlucoseLoweringAgents(13) GenericName Trade Classification Name(s)a Chlorpropamideb Diabinese Sulfonylurea Glyburideb DiaBeta, Sulfonylurea Micronase, Glynase Glucotrol, Sulfonylurea Glipizideb GlucotrolXL Amaryl Sulfonylurea Glimepirideb Starlix Nonsulfonylurea Nateglinideb Prandin Nonsulfonylurea Repaglinideb Metformin Glucophage Biguanide GlucophageXR Biguanide GlyburideMetformin Glucovance SulfonylureaBiguanide (combinationdrug) Pioglitazone Actos Thiazolidinedione Rosiglitazone Avandia Thiazolidinedione Acarbose Precose glucosidaseinhibitor Miglitol Glyset glucosidaseinhibitor Sitagliptin Januvia DipeptidylpeptidaseIV inhibitor Exenatide Byetta Incretinmimetic Pramlintide Symlin Amylinomimetic
aAllproductnamesareregisteredtrademarksoftheirrespectivecompanies. bTheseoralhypoglycemicagentshavethepotentialtocausehypoglycemia,sincetheirmodeofactionincreasesthereleaseofinsulin
Onset(h) 1 1.5 1.5 1.5 1 1 23 0.33 0.250.5 13 0.53 Halflife,6.2 0.5,peak24 1 Immediate Immediate 1 0.51 0.5
Duration(h) 2472 1224 1224 24 1216 24 1224 14 1 612 1224 2448 24 1224 6 6 24 6 6
fromthepancreas.Patientswhotaketheseoralagentsmayrequiresnacksifthereismorethan4to5hoursbetweenmeals.Abedtime snackmayalsobenecessaryandshouldbeevaluatedaspartoftheindividualizedmealplan(4).
Discussion Neweroralorinjectableglucoseloweringmedications,aloneorincombination,providenumeroustreatment options for achieving glycemic control (1,2). A combination of two or three medications may be used by personswithtype2diabetesthatisnotadequatelycontrolledbynutritiontherapy(1,2).Ifglycemiccontrolis notattained,insulin,eitheraloneorincombinationwithoralmedication,maybenecessary.Thetransitionto insulin often begins with longacting insulin given at bedtime to control fastingglucose levels and glucose lowering medication given during the day to control daytime and postprandial glucose levels (1,2). Many patients with type 2 diabetes require two or more insulin injections daily to achieve glycemic control (1). Someofthesepatientswillattainbetterglycemiccontrolwiththreeorfourdailyinsulininjectionsorwithan insulinpump (13).Analgorithmforthetreatmentoftype2diabeteshasbeenestablishedbytheAmerican Diabetes Association and European Association for the Study of Diabetes. This algorithm recommends the initiationofmetformintherapyatdiagnosis,alongwithlifestyleinterventionthatincludesmedicalnutrition therapy (1,5). The algorithm calls for the addition of another oral agent or insulin if the percentage of hemoglobinA1cgoalexceeds7%(1,5). GlucoseLoweringMedications Commonly used glucoselowering medications and their onset and duration are listed in Table III7. Each classofdrughasadifferentmechanismofaction,asdescribedbelow(13). Insulinsecretagogues (sulfonylureas andnonsulfonylureas): These drugspromote insulin secretion by thebetacellsofthepancreas.Sulfonylureasaremetabolizedbytheliverandclearedbythekidney(except glimepiride);therefore,cautionisneededforpatientswhohaveimpairedrenalfunction (2).Patientsshould be informed that missed meals or snacks could cause hypoglycemia (2). In addition, these medications are associated with an increase in appetite and possible weight gain (2). Compared with sulfonylureas, nonsulfonylureas cause less weight gain and have an earlier onset, shorter duration (1 to 6 hours), and a III-28 Copyright 2009 Morrison Management Specialists, Inc. Manual of Clinical Nutrition Management
Diabetes Mellitus
reduced risk of hypoglycemia (2). Nonsulfonylureas are an option for patients who have erratic meal schedulesandareconcernedaboutweightgain(2). Insulinsensitizers(biguanides,thiazolidinediones,andglucosidaseinhibitors):Thesedrugsenhance insulinaction.Tobeeffective,thesedrugsrequirethepresenceofendogenousorexogenousinsulin. Biguanides provide enhanced insulin sensitivity by inhibiting hepatic gluconeogenesis and, to a lesser extent,glycogenolysis.Metformin,theonlybiguanide,causesweightlossanddoesnotcausehypoglycemia when it is used as a monotherapy (2). Metformin can cause gastrointestinal sideeffects such as abdominal pain,nausea,diarrhea,andmetallictaste.Startingwithsmalldosesofmedicationandlimitingfoodssuchas cauliflower, cabbage, broccoli, lentils, and legumes may lessen these side effects (2). Patients who have compromised renal function or who are at risk for dehydration or chronic heart failure should be closely monitoredfortheriskoflacticacidosisassociatedmetformin(2). Thiazolidinediones enhance insulin sensitivity by increasing the efficiency of the glucose transporters. Thiazolidinediones, particularly pioglitazone, beneficially affect lipids by decreasing triglyceride levels, increasing the highdensity lipoprotein cholesterol level, and increasing the particle size of lowdensity lipoprotein cholesterol (2). The main side effects of thiazolidinediones are weight gain and mild edema; therefore,anenergycontrolleddietandsodiummodificationmaybewarranted(2). The glucosidase inhibitors inhibit enzymes that digest carbohydrates in the small intestine. This inhibitionresultsindelayedcarbohydrateabsorptionandloweredpostprandialglucoseresponses.The glucosidase inhibitors should be taken before carbohydratecontaining meals or snacks and should not be takenwhenmealsaremissed (2).Thesemedicationsshouldbeavoidedbypersonswhohavesevererenalor hepatic impairment or any gastrointestinal disease. The side effects of glucosidase inhibitors include bloating,abdominalcramps,flatulence,anddiarrhea(2). DipeptidylpeptidaseIVinhibitors:ThesedrugsinhibitdipeptidylpeptidaseIV,theenzymethatdegrades endogenouslysecretedincretins (2).Becauseofthismechanism,increasedlevelsofincretinhormonesresult in increased insulin secretion. The most common side effects are headaches and nasopharyngitis (2). Sitagliptin,thefirstdipeptidylpeptidaseinhibitorIVapprovedforuseasamonotherapyorincombination withathiazolidinedioneormetformin,ismetabolizedintheliverbutexcretedintheurine.Inpatientswith renalinsufficiency,thedoseshouldbedecreasedby50%to75%(2). Incretinmimetics:Thesedrugsmimictheglucoseloweringeffectsoftheincretinhormone,aglucagonlike peptidethatoccursnaturallyinthebody.Exenatide(Byetta)representsanewclassofinjectablemedications for people with type 2 diabetes who take metformin or sulfonylurea agents. Exenatide is an aminoacid peptide that has many of the glucoselowering effects of incretin (1,3). The glucoselowering effects of this drugresultfromadelayingastricemptyingandenhancedglucosedependentinsulinsecretionfromthebeta cells.But,theseeffectsoccuronlyinthepresenceofelevatedglucoselevelsanddecreasedinsulinproduction (3). Exenatide is usually injected twice a day, at breakfast and the evening meal. It can be taken up to 60 minutesbeforeameal,buttakingthemedication30ormoreminutespriortoamealmayincreasethesense ofsatietyearlyinthemeal,resultingindecreasedenergyintake (1,3).Becausethemechanismslowsgastric emptying, a feeling of fullness may be experienced during meals and can cause nausea or early satiety (2). Exenatideisassociatedwithadegreeofweightlossovera2yearperiod(3). Amylinomimetics:Thesedrugscountertheeffectsofamylindeficiency.Amylinisahormonesecretedwith insulin by the pancreatic beta cells in response to food intake. Amylin lowers glucose levels by slowing gastric emptying and decreasing postprandial hepatic glucose release, which is related to a decrease in glucagonproductionfromthepancreaticalphacellsandisdependentontheglucoselevel (2,3).Pramlintide (Symlin), an injectable drug, is a form of amylin. Pramlintide is approved as an adjunct therapy to insulin therapy in patients who have type 1 or type 2 diabetes and have not achieved optimal glucose control (3). Pramlintide, which must be injected separately from insulin, should be given with each meal or snack that exceeds250kcalofenergyor30gofcarbohydrate(3). III-29
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TableIII8:HumanInsulins(13) Insulina RapidActing: Lispro(Humalog) Aspart(NovoLog) Glulisine(Apidra) ShortActing: Regular IntermediateActing: NPHb(HumulinN) LongActing: Glargine(Lantus)(3) Detemir(Levemir) Mixtures: NPHb/Regular:70/30;50/50 Aspart(NovoLogMix)70/30 Lispro(HumalogMix)70/30
theirrespectivecompanies.
Onset(h)
Peak(h)
Effective Duration(h) 14 14 14 6 1016 24 1423 1016 35 35
Maximum Duration(h) 4 4 4 68 1216 24+ 1423 1418 5 5
0.250.5 0.250.5 0.250.5 0.51 24 1.1 12 0.51 0.10.2 0.10.2
12 12 12 23 610 None 514 Dual 13 13
aGenericnamesarelistedfirst,andrepresentativetradenamesarelistedinparentheses.Allproductnamesareregisteredtrademarksof bNPH(neutralprotamineHagedorn)isalsocalledisophaneinsulinsuspension.
Insulins Personswithtype1diabetesobtainthebestglycemiccontrolwithreplacementinsulinthatmimicsnormal insulin action (1). The basal or background insulin dose is the amount of insulin required in the postabsorptive state to restrain endogenous glucose output, primarily from the liver (1). The bolus (mealtime)insulindosesmimicwhathappenswhenindividualswithoutdiabeteseatthenormalphysiologic patternofinsulinsecretion;theplasmaglucoseandinsulinconcentrationsincreaserapidly,peakin30to60 minutes,andreturntobasalconcentrationswithin2to3hours(1). Insulinglargine(Lantus)isabasalinsulinthatisinjectedonceaday,oftenatbedtime (3).However,itcan be injected at any time during the 24hour period if it is given consistently at the chosen time. Glargine cannotbemixedwithotherinsulins.Insulindetemir(Levemir)hasadurationofactionofapproximately17 hours, and therefore may need to be given twice a day. Detemir does have a slight peak, but the peak is extremely predictable, unlike the sometimes erratic peak of NPH (1,3). Rapidacting insulins are given at meals,oftenwiththeuseofaninsulinpen.Onoccasion,rapidactinginsulinmaybegivenaftermeals,most often for children with unpredictable eating habits or adults with gastroparesis (1). Insulinpump therapy provides basal rapidacting or shortacting insulin pumped continuously by a mechanical device in micro amountsthroughasubcutaneouscatheter.Inaddition,bolusdosesaregivenbeforemeals. Intensive insulin therapy increases the risk of hypoglycemia and weight gain in persons with type 1 diabetesmellitus (6).Skippedordelayedmeals,reducedcarbohydrateintakeatmeals,orincreasedphysical activitywithouttheappropriateinsulinadjustmentsarethemajorcausesofhypoglycemia (6).Alcoholmay alsoinducehypoglycemiaandmasksymptomsrelatedtohypoglycemia(6).Weightgainoccurswithintensive insulin therapy because less energy is lost from glycosuria as glycemic control improves (6). Frequency of hypoglycemiaandtheextraenergyusedforitstreatmentmayalsocontributetoweightgain(6).Strategiesto prevent weight gain include more frequent weight checks, a decreased daily energy intake, additional physicalactivity,andreviewoftheappropriatetreatmentofhypoglycemia.
References 1. Pharmacotherapyintype1andtype2diabetes.In:NutritionCareManual.AmericanDieteticAssociation;2008.Availableat: http://www.nutritioncaremanual.org.AccessedJanuary16,2008. 2. FonsecaVA,KulkarniKD.Managementoftype2diabetes:oralagents,insulin,andinjectables.JAmDietAssoc.2008;108:S29S33. 3. StuartN,ed.Medicationsanddiabetes:newhelpsandoldfriends.OntheCuttingEdge.[DiabetesCareandEducationnewsletter.]2006; 27:132. 4. AmericanDiabetesAssociation.Standardsofmedicalcareindiabetes2009.DiabetesCare.2009;32(suppl1):13S61S. 5. NathanDM,BuseJB,DavidsonMB,HeineRJ,HolmanRR,SherwinR,ZinmanB.Managementofhyperglycemiaintype2diabetes:a consensusalgorithmfortheinitiationandadjustmentoftherapy:aconsensusstatementfromtheAmericanDiabetesAssociationand theEuropeanAssociationfortheStudyofDiabetes.DiabetesCare.2006;29:19631972. 6. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progressionoflongtermcomplicationsininsulindependentdiabetesmellitus.NEnglJMed.1993;329:977986. Manual of Clinical Nutrition Management
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DIABETESMELLITUS:FATREPLACERS ANDNUTRITIVE/NONNUTRITIVESWEETENERS
Thegoalofmedicalnutritiontherapyfordiabetesmellitusistoimproveoverallmetabolicoutcomes(glucose andlipidslevels),provideappropriateenergytomaintaindesirablebodyweight,andimproveoverallhealth throughoptimalnutrition (1).Theappropriatenessofspecificmodifiedfoodproductsforagivenindividual shoulddependontherelativepriorityoflipidmanagement,controlofcarbohydrateintake,andtheneedfor weightmanagement(2). FatReplacers Fat replacers are compounds that replicate the functional and sensory properties of fats or mimic one or morecharacteristicsoffatinafood.Therearefourcategoriesoffatreplacers:carbohydratebasedmolecules composed of simple or complex carbohydrate, gums, and gels (also carbohydratebased); proteinbased molecules composed of whey protein or milk and egg protein; fatbased molecules, which may include chemical alteration of fatty acids to provide fewer calories or no calories; and a combination, usually consistingofacarbohydrateandproteinorcarbohydrateandlipids(2,3).Fatreplacersvaryinenergydensity. Carbohydratebasedfatreplacersprovideuptofourkcal/g,butbecausetheyareoftenmixedwithwaterthey typicallyprovideonetotwokcal/g (3).Proteinbasedreplacersprovideonetofourkcal/g,whilefatbased replacers provide zero to nine kcal/g (3). Olestra, a noncaloric fatbased ingredient, was approved by the Food and Drug Administration (FDA) in January 1996 as a fat substitute. Because the molecule used in olestraistoolargetobeabsorbedbythegastrointestinaltract,itaddsnoenergytofood.Foraperiodoftime, productsthatcontainedolestra,suchaspotatochips,wererequiredtodisplayalistofpossiblesideeffects. These possible side effects included decreased absorption of certain nutrients (vitamins A, D, E, and K and carotenoids), loose stools, and abdominal cramping (3). However, scientific review has led the FDA to concludethatthewarningisnolongerwarranted(3,4). ItisthepositionoftheAmericanDieteticsAssociationthat,withinthecontextofahealthydietarypattern, fatsubstitutes,whenusedjudiciously,mayprovidesomeflexibilityindietaryplanning,althoughadditional researchisneededtofullydeterminetheirlongtermhealtheffects (2,3).Fatreplacersthatarefibers,suchas inulin,lupinfiber,orBglucan,mayincreasedietqualityinthattheyaddtotheintakeofdietaryfiber (3).In one study of men with diabetes, diets encouraging foods containing fiberbased fat and sugar replacers, togetherwithlifestylechanges,causedagreaterincreaseinhighdensitylipoproteincholesterolandlarger decreasesinhemoglobinA1C,weight,andbodymassindexthanwereseenwiththestandardtreatmentplan (5). On a population level, replacing one to two g fat/day with fat replacers and fatmodified foods can potentially prevent weight gain and associated chronic disease and assist in promoting healthful eating behaviors (2,3).Althoughfatreplacersareusedtoreplacethefatcontentoffoods,thesefoodsarenotalways consistentlylowerinenergycontentbecausesomeofthefatinthefoodsmaybereplacedbyincreasingthe sugarcontentofthefood (3).Individualswithdiabetesshouldbeencouragedtoselfmonitortheirintakeof fatmodified foods and become educated as to how these foods should be used in the context of a well balancedeatingprogram(3). Sweeteners Sweeteningagentsmaybecategorizedasnutritive(thosecontainingenergy)andnonnutritive(thosethatdo not contain energy). Nutritive sweeteners include sucrose, fructose, and sugar alcohols (eg, sorbitol, mannitol,xylitol,isomalt,maltitol,lactitol,andstarchhydrolysates).Fivenonnutritivesweetenershavebeen approvedbytheFDA:aspartame,saccharin,acesulfameK,sucralose,andneotame(6). Nutritive sweeteners: The available evidence from clinical studies demonstrates that sucrose does not increase glycemia any more than isocaloric amounts of starch (2,6). People with diabetes do not need to restrict sucrose and sucrosecontaining foods based on a concern about aggravating hyperglycemia. However, if sucrose is included in the food or meal plan, it should be substituted for other carbohydrate sourcesor,ifadded,beadequatelycoveredwithinsulinorotherglucoseloweringmedication(2). Fructoseproducesasmallerriseinplasmaglucosethansucroseandotherstarches (2).Fructosereduces postprandial glycemia when it replaces sucrose or starch in the diabetic diet (2). However, fructose sweetenedproductsmaymakeamajorcontributionofenergytothedailyintakeandcannotbeconsidered freefoods.Consumptionoflargeamountsoffructose(15%to20%ofdailyenergyintake[90thpercentile of the usual intake]) has been shown to increase fasting total and lowdensity lipoprotein cholesterol in
III-31
Diabetes Mellitus
subjectswithdiabetes (2).Therefore,consumptionoffructoseinlargeamountsmayhaveadverseeffectson plasmalipids.Usingfructoseasasweeteningagentisnotrecommendedforpeoplewithdiabetesbecauseof thiseffect (2).Somepersonsexperiencealaxativeresponsefromaloadoffructose(50g) (6).Thelaxative effectmaybeincreasediffructoseisingestedwithotherindigestiblecarbohydratesandsorbitol(6). Sorbitol, mannitol, isomalt, maltitol, lactitol, and starch hydrolysates are considered polyols and are frequentlylistedontheproductsnutritionfactslabelassugaralcohols(2).Sugaralcoholsareusedinfood as sweeteners and bulking agents. Because sugar alcohols are only partially absorbed from the small intestine, the claim of reduced energy values per gram is allowed (2). In some studies, ingestion of sugar alcohols (approximately 50 g) by healthy and diabetic patients produced a lower glycemic response after ingestionoffructose,sucrose,orglucose (2).Consumptioninlargeamounts(eg,>50gofsorbitolor20gof mannitol)hasbeenreportedtocauseosmoticdiarrhea,especiallyinchildren (2,6).Useofsugaralcoholsas sweetners has also shown to reduce the risk of dental caries (2). Kilocalories from sugar alcohols vary but averageabouttwokcal/gonfoodlabels.Whencalculatingcarbohydratecontentoffoodscontainingsugar alcohols,substractionofhalfthesugaralcoholgramsfromtotalcarbohydrategramsisappropriate(2,7). Nonnutritive sweeteners: Aspartame (NutraSweet, Equal, Sugar Twin), saccharin (Sweetn Low, Sweet Twin,NectaTwin),acesulfameK(Sunette,SweetOne,Sweet&Safe),sucralose(Splenda),andneotameare approved by the FDA for use in the United States (6). The FDA also establishes the acceptable daily intake (ADI)forallfoodadditives.Itisdefinedastheamountofafoodadditivethatcanbesafelyconsumedona dailybasisoverapersonslifetimewithoutanyadverseeffectsandincludesa100foldsafetyfactor.Actual intakebyindividualswithdiabetesforallnonnutritivesweetenersiswellbelowtheADI (2).Itisunknown whetheruseofnonnutritivesweetenersimproveslongtermglycemiccontrolorassistsinweightloss(2).Ina limited number of studies, nonnutritive sweetners had no effect on changes in blood lipid profiles and glycemic response in adults with diabetes (Grade III)* (8). No studies in children were identified (Grade III) (8). Studies to determine the effects of nonnutritive sweeteners during pregnancy and lactation have been conducted in animals. No adverse effects have been reported (6,9). Nonnutritive sweeteners are safe for people with diabetes when consumed within the ADI levels established by the FDA (Grade II) (2,8). Limited research in humans, from peer reviewed journals, supports the safety of nonnutritive sweeteners for the general population. Considering the lack of high quality studies, continuing postmarket surveillance of the safetyofnonnutritivesweetenersisprudent (Grade III) (8).Usingnonnutritivesweetenersineitheracalorie restricted or ad libitum diet will affect overall energy balance only if the nonnutritive sweeteners are substitutedforhighercaloriefoodorbeverages(GradeII)(8). Technically,aspartameshouldnotbelistedasanoncaloricsweetenersinceitisequivalentinkilocalories totablesugar.However,aspartameissosweet(about160to220timessweeterthansucrose)thatthesmall amountconsumedinnormalusehasvirtuallynokilocaloriestoconsider(6).Aspartameisadipeptideformed by the synthetic combination of two amino acids. After it has been metabolized, aspartame converts into phenylalanine, aspartic acid, and methanol. Because aspartame is a phenylalanine source, it should not be consumed by individuals with phenylketonuria (6). Neotame is similar to aspartame but is 30 to 50 times sweeter and does not require special labeling for phenylketonuria since a small percentage (<20%) of the phenylalaninefromtheingestedneotamemaybereleasedintotheplasma(6,10). Use in pregnancy: The FDA has approved five nonnutritive sweeteners for general use: saccharin, aspartame, acesulfameK, neotame, and sucralose. The studies of the effects of these sweeteners on the reproductiveabilitiesofwomenandmen,aswellasonthedevelopingfetus,havebeenreviewedanddeemed safe by numerous regulatory bodies and expert committees around the world (6). Thus, consumption of acesulfameK, aspartame, saccharin, sucralose, and neotame within the ADI levels is safe during pregnancy (1,6). Although saccharin can cross the placenta and remain in fetal tissues because of slow fetal clearance, there is no evidence that saccharin causes ill effects (11). If a woman chooses to use saccharin during pregnancy,theevidencesuggestsitissafe (1,6).Aspartamedoesnotcrosstheplacentaatintakelevelsless thanenormousamounts(100timesnormal) (12).UseofaspartamewithintheFDAguidelinesappearssafe forpregnantwomen(6).MultigenerationalstudiesofratsthatreceivedacesulfameK,neotame,andsucralose have shown no adverse effects on fertility, number of offspring, birth weight, mortality, and fetal development,andthusbothsweetenersareconsideredsafeduringpregnancy(13).
*TheAmericanDieteticAssociationhasassignedgrades,rangingfromGradeI(good/strong)toGradeV(insufficientevidence),toevidence andconclusionstatements.ThegradingsystemisdescribedinSectionIII:ClinicalNutritionManagement,AReferenceGuide,pageIII1. Manual of Clinical Nutrition Management
III-32
Diabetes Mellitus References 1. AmericanDiabetesAssociation.Standardsofmedicalcareindiabetes2010.DiabetesCare.2010;33(suppl1):11S61S. 2. AmericanDiabetesAssociation.Nutritionrecommendationsandinterventionsfordiabetes.DiabetesCare.2008;31(suppl1):61S 78S. 3. PositionoftheAmericanDieteticAssociation:fatreplacers.JAmDietAssoc.2005;105:266275. 4. US Food and Drug Administration. FDA Talk Paper. FDA Changes Labeling Requirement for Olestra, 2003. Available at: http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01245.html.AccessedApril18,2005. 5. Reyna NY, Cano C, Bermudez VJ, Medina MT, Souki AJ, Ambard M, Nunez M, Ferrer MA, Inglett GE. Sweeteners and Bglucans improvemetabolicandanthropometricsvariablesinwellcontrolledtype2diabeticpatients.AmJTher.2003;10:438443. 6. PositionoftheAmericanDieteticAssociation:useofnutritiveandnonnutritivesweeteners.JAmDietAssoc.2004;104:255275. 7. WheelerM,FranzM,BarrierP.Helpfulhints:usingthe1995exchangelistsformealplanning.DiabetesSpectrum.1995;8:325326. 8. Nonnutritive Sweetner Evidence Analysis Project. Chicago, Ill: The American Dietetic Association, 2008. In: American Dietetic AssociationEvidenceAnalysisLibraryathttp://www.adaevidencelibrary.com(accessed1/16/08) 9. World Health Organization Expert Committee on Food Additives. Toxicological Evaluation of Certain Food Additives and Food Contaminants.Geneva,Switzerland:WorldHealthOrganization;1981,1983:16:1127,18:1214. 10. Stargel WW, Mayew DA, Comer P, Andress SE, Butchko HH. Neotame. In: Nabors LO, ed. Alternative Sweeteners. New York, NY: MarcelDekker;2001:129145. 11. Pitkin RM, Reynolds WA, Filer LJ, Kling TG. Placental transmission and fetal distribution of saccharin. Am J Obstet Gynecol. 1971;111:280286. 12. London RS, Rorick JT Jr. Safety evaluation in pregnancy. In: Tschanz C, Butchko HH, Stargel WW, Kotsonis FN, eds. The Clinical EvaluationofaFoodAdditive:AssessmentofAspartame.NewYork,NY:MarcelDekker;2001:115123. 13. GriceHC,GoldsmithLA.Sucralose:anoverviewofthetoxicitydata.FoodChemToxicol.2000;38(suppl2):1S6S.
III-33
DYSPHAGIA
Discussion Causesofdysphagiaareclassifiedasmechanical(traumaorsurgicalresectionofoneormoreoftheorgansof swallowing)orparalytic(lesionsofthecerebralcortexorlesionsofcranialnervesofthebrainstem).
Diseasesandconditionsinwhichdysphagiamayresultincludethefollowing: Cancerofheadorneck Headinjury Braintumors Cerebralpalsy Stroke Multiplesclerosis Parkinsonsdisease Alzheimersdisease Amyotrophiclateralsclerosis(ALS) Huntingtonschorea Myastheniagravis Auds(oralcandidiasis) Dementia Laryngectomy(fullorpartial)
Signsandsymptomsofdysphagiainclude: Drooling Retentionoffoodinmouth Coughingbefore,during,orafterswallowing Gurglyvoicequalities Feelingofalumpinthethroat Pneumonia Aspirationoffoodorsaliva
Choking Squirrelingoffoodincheeks Anorexia,weightloss,ormalnutrition Fatigueduringmeals Spikingtemperatures Dehydration
To define the therapeutic regimen, the multidisciplinary care team performs a comprehensive patient evaluation,whichmayincludeassessmentofthefollowing:
Diagnosis,treatments,surgicalreports,andmedications Proteinenergymalnutritionandothernutrientdeficits Energyandproteinneeds Indicationsforenteralfeeding Olfactoryandgustatorysensation Excessivesalivation Foodpreferencesanddislikesandtypicalmealpattern,elicitedthroughpatientand/orfamilyinterviews Abilitytoselffeed Dentition Visualacuity Paralysisorparesis Obstruction Respiratorystatus Orientation, alertness, comprehension, memory, cooperation, motivation, emotional state, and fear of choking Structureandfunctionofallmusclegroupsinvolvedinchewingandswallowing Painassociatedwithfoodingestionorswallowing Onset,duration,andseverityofswallowingproblems Food consistencies that can be consumed safely, as determined by clinical evaluation at bedside or by videoswallowanalysis
Approaches SeeNutritionManagementofDysphagiainSectionIB. OtherConsiderations Insomepatientswithmuscleweakness,avoidstickyfoods,astheycanadheretotheroofofthemouth, thuscausingfatigue.Forexample,breadmaytendtoballupinthemouth.Ifthishappens,breadcan be torn into small pieces and sprinkled into foods. Note: For some patients, sticky foods (eg, peanut butter,caramels)maybeusedforexercisetoimprovetonguecontrol,asrecommendedbythespeech language pathologist (SLP). Concentrated sweets may cause increased salivation. Certain foods (eg, Popsicles)maybeusedtopracticesucking,asprescribedbytheSLP. Offeravarietyoffooditemstoreduceboredomandpossiblerelianceoncertainfoods. Manual of Clinical Nutrition Management III-34 Copyright 2009 Morrison Management Specialists, Inc.
Dysphagia
Foodsshouldbeservedeitherwarm(nottepid,butnothotenoughtoriskburningthemouth,secondary tolossofsensations),orcold(forincreasedstimulation). Offer foods in small amounts so the sight of large quantities of food does not overwhelm the patient. Selectnutrientdensefoods. Donotuseliquidstoclearthemouthoffood;thepatientshoulddrinkliquidsonlyafterfoodhasbeen cleared. TheSLPshoulddetermineproperpositioning:Somepatientswithneurologicimpairmentsshouldsitin an upright position with hips flexed to a 90o angle, back straight, feet flat on the floor, and head bent slightly forward. This allows the tongue to facilitate laryngeal elevation and subsequently protect the airway.Anuprightpositionalsohelpstoclosetheglottis,decreasingriskofaspiration.Patientshouldbe sitting up for 15 to 30 minutes before and after meals to prevent aspiration of any residue potentially remainingintheglottisarea. Ensureaquietatmosphere,freeofdistractionswhilethepatienteats. Ensurepatientcomfort.Somepatientsmayrequiremedicationtoalleviatepainfulswallowing. Itisimportantthatthepatientbeencouragedtocommunicateproblemsandsuccesseswiththestaff. Itmaybebeneficialtostirmedicationsintopuddingifthepatienthasfluidrestrictions. Allowthepatienttosethisorherownpacewhileeating. Havethepatientorcaregivercleansethepatientsmouthbeforeeating.
Bibliography Dysphagia.In:NutritionCareManual.AmericanDieteticAssociationUpdatedAnnually.Availableat:nutritioncaremanual.org.Accessed September20,2010. MahanK,EscottStumpS.Medicalnutritiontherapyforneurologicdisorders(Chapter41).Krause'sFood&Nutritiontherapy,12th Edition.St.Louis,MO:Saunders;2008:10741077.
III-35
Dysphagia
RELATIONSHIPOFDYSPHAGIATOTHENORMALSWALLOW
Phase 1.
DescriptionofNormalSwallowing Oralpreparatoryphase:foodis manipulatedinthemouthand masticatedifnecessary
DysphagiaSignsand Symptoms Drooling
DietaryConsiderations Usesemisolidconsistencies thatformacohesivebolus; avoidthinliquids
2.
Oralorvoluntaryphase:thetongue propelsthefoodposteriorly
Inabilitytoformbolus
Usesemisolidconsistencies toformabolus;usemoist, welllubricatedfoods
Pocketingfood
Avoidfoodswithmorethan onetexture;positionfoodin sensitiveareas;usecold, highlyseasoned,flavorful food;trydensefoods.
Prolongedchewingand swallowinglatency
Usehighlytexturedfoods (eg,diced,cookedvegetables anddicedfruit);trydense cohesivefoods;avoidsticky orbulkyfoods;assessability tocontrolliquids
3.
Pharyngealphase:beginswiththe triggeringoftheswallowreflex
Markedprolongationofthe Usecohesivefoods feedingprocess Usecohesivefoods Chokingorcoughingon liquidand/orsolids

a.
Elevationandretractionofthe softpalateandcompleteclosure ofthevelopharyngealportto preventmaterialfromentering thenasalcavity Initiationofpharyngeal movement Elevationandclosureofthe larynxandallthreesphincters (epiglottis,falsefolds,andtrue folds)
Wetandgurglyvocal quality
Nasalregurgitation
Includecohesivesemisolid foodsandthickenedliquids
b.
Strugglebehavior(feelfor laryngealelevation)
c.
Usesoftsolidsandthickto spoonthickliquids;avoid stickyandbulkyfoodsthat tendtofallapart
4.
Relaxationofthe crycopharyngealsphincterto allowthematerialtopassfrom thepharynxtotheesophagus Esophagealphase:bolusmovesfrom theesophagustothestomach

Note:Theesophagealphaseoftheswallowis notamenabletoanykindoftherapeutic exerciseregimen.Thevideofluoroscopicstudy ofdeglutitiongenerallydoesnotinvolve examinationoftheesophagus.
d.
Indigestion
Reflux
Avoidstickyanddryfoods; trydensefoodfollowedby liquids
Sensationoffoodlodgedin thechest
Usesemisolid,moistfoods thatmaintainacohesive bolus
Bibliography DietforDysphagia.In:ManualofClinicalDietetics.Chicago,Ill:AmericanDieteticAssociation;2000. OGaraJ.Dietaryadjustmentsandnutritionaltherapyduringtreatmentfororalpharyngealdysphagia.Dysphagia.1990;4:209212. Manual of Clinical Nutrition Management
III-36
ENTERALNUTRITION:MANAGEMENTOFCOMPLICATIONS(15)
Problem Diarrhea
Approaches Evaluatemedicationprofile(eg,laxatives,stoolsofteners,antibiotics, medicationscontainingmagnesium,orelixirscontainingsorbitol,suchasacetaminophenor theophylline) CheckforClostridiumdifficile. Try soluble fibercontaining formula (4), or add soluble fiber to the medication regimen (1) for patientswithalowriskforbowlischemiaorboweldysmotility. Considerantidiarrhealmedicationssuchasloperamide,diphenoxylate,orparegoricifC.difficileor otherinfectiouscomplicationsareruledout(1). Usecontinuousinfusionadministration.Implementcontinuousenteralfeedings(4). Tryisotonicorpeptidebasedformula(4). Observepropersanitation.
Nausea, gastroparesis/ delayedgastric emptying(16)
Evaluatemedicationprofile(eg,opiateanalgesicsoranticholinergics). Considerlowfatorisotonicformula. Reducetherateofinfusionby20to25mL/hour,ortrysmallbolusfeedingsof50to100mL(1,6). Trymotilitymedicationssuchasaprokineticagent(eg,metoclopramideorerythromycin)(4). Administerformulaatroomtemperature(4). Check and evaluate gastric residual volume prior to each bolus feeding or every 4 hours for continuousfeeding(1,4). Checkforfecalimpaction. Tryantiemeticmedicationsifgastricresidualvolumesarenormal.
Hyperglycemia
Monitorbloodglucoselevels.Thetargetglucosegoalis100to150mg/dLfornondiabeticcritically illpatients (4)and140to180mg/dLfordiabeticcriticallyillpatients (7).Thetargetglucosegoal for medically stable patients with diabetes is <140 mg/dL with random blood glucose levels <180mg/dL (7). Mostcriticallyillpatientswithdiabetesrequireintravenousinsulintoachieve the desired glucose range without increasing the risk for hypoglycemia (4,7). More stringent targets may be appropriate in stable patients with previously tight glycemic control (7). Less stringenttargetsmaybeappropriateinpatientswithseverecomorbidities(7). Avoidoverfeeding.Evaluatetotalenergycomparedtoestimatedrequirements(4). Consultwithphysicianregardingtheneedforintravenousinsulinadministrationinpatientswho experiencepersistenthyperglycemia(4).
Dehydration
Uselessconcentratedformula. Supplementwithadditionalwaterasneeded.
Cloggedtube
Checkforpropertubesize(viscousformulasshouldbeadministeredthrougha>10French catheter). Flushtubewithwarmwater(usually20to30mL)regularlyandbeforeandafteradministration ofmedicines.
Constipation
Monitorhydrationstatus. Addfreewater. Considerfibercontainingformulawithextrafreewater(>1mLfreewater/kcal)(1). Consideraddingsolubleorinsolublefibermedicationwithextrafreewater(1). Increasephysicalactivityifpossible. Ifhydrationisadequateandothercausesareruledout,considerastoolsoftener(docusatesodium ordocusatecalcium),emollients,orlaxative(1).
Essentialfatty aciddeficiency
Add5mLofsaffloweroildaily(1),orprovideatleast4%ofenergyneedsaslinoleicacid(1). Changeformulatoonethatcontainsessentialfattyacid.
Overhydration, rapid/excessive weightgain

Checkfluidinputandoutput. Aweightchangeof0.2kg/dayormorereflectsachangeinextracellularfluidvolume(1). Considerfluidrestrictedformulabasedonfluid/volumestatusandmedicalissues.

III37
EnteralNutrition
Problem Abdominal distention
Approaches Checkgastricresidualvolume.Iftwoconsecutivemeasurementsare>250to500mL,decreaseor hold feedings until possible causes are assessed (2)(Grade III), or follow organizationspecific protocolsforgastricresidualvolumetargetsandinterventionstrategies(25). Checkforconstipation,fecalimpaction,orobstruction. Placefeedingtubeindistalduodenumorproximaljejunum(1).
Aspirationrisk
Maintaintheheadofthepatientsbedata30to45angleduringfeedings(GradeIII)(35). PostpyloricplacementofthefeedingtubetipatorbelowtheLigamentofTreitzmaybebeneficial forpatientswhoaresupineorheavilysedated (35).Considertheuseofmotilityagentssuchas prokinetic medications (metoclopramide and erythromycin) or narcotic agonists if clinically feasible(5). Implementcontinuousenteralfeedings(4).
References 1. MaloneAM,SeresDS,LordL.Complicationsofenteralnutritiontherapy.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupport Core Curriculum: A CaseBased ApproachThe Adult Patient. Silver Spring, Md: American Society of Enteral and Parenteral Nutrition;2007:246263. 2. Critical Illness EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2006.Availableat:www.adaevidencelibrary.com.AccessedOctober5,2010. 3. KattelmannK,HiseM,RussellM,CharneyP,StokesM,CompherC.Preliminaryevidenceforamedicalnutritiontherapyprotocol: enteralfeedingsforcriticallyillpatients.JAmDietAssoc.2006;106:226241. 4. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; ASPEN Board of Directors;AmericanCollegeofCriticalCareMedicine.Guidelinesfortheprovisionandassessmentofnutritionsupporttherapyin theadultcriticallyillpatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition (A.S.P.E.N.).JParenterEnteralNutr.2009;33:277316. 5. BankheadR,BoullataJ,BrantleyS,CorkinsM,GuenterP,KrenitskyJ,LymanB,MethenyNA,MuellerC,RobbinsS,WesselJ;ASPEN Board of Directors. Enteral Nutrition Practice Recommendations. J Parenter Enteral Nutr. 2009;33:122167. Also available at: www.eatright.org(EvidenceBasedPracticelink).AccessedSeptember20,2010. 6. MaloneAM,BrewerCK.Monitoringforefficacy,complicationsandtoxicity.In:RolandelliRH,ed.ClinicalNutrition:Enteraland TubeFeeding.4thed.Philadelphia,Pa:Saunders;2005:276290.Executivesummary:standardsofmedicalcareindiabetes 2010.DiabetesCare.2010;33(suppl1):S4S10.
III-38
GASTROESOPHAGEALREFLUXDISEASE(GERD)
Discussion GERDinvolvesthesymptomaticrefluxofgastriccontentsparticularlyacid,pepsin,andbileintotheesophagus which results in damage to the esophageal mucosa and leads to esophagitis, regurgitation, and heartburn. Heartburnisoftenelicitedbylyingflatorbendingover.Iftherefluxissevereenough,thesamepositionsmay evokeactualregurgitationofgastricfluidintothemouth,causingchoking,coughing,andpossiblepulmonary aspiration. Other symptoms may include dysphagia, pain on swallowing and water brash (when the mouth suddenlyfillswithalargeamountoffluidsecretedfromthesalivaryglands)(1). Ordinarythe esophagusis protectedfromrefluxofgastriccontents bycontractionoftheloweresophageal sphincter (LES). In persons with chronic esophageal reflux, the sphincter pressure tends to be lower. Either increasedintragastricpressureordecreasedLESpressurecausesGERD. Treatmentisaimedatmodifyingthefactorsthatpromotegastroesophagealrefluxandirritation.Treatment requiresamultifactorialapproachandisaimedatnutritionandlifestylemodifications,drugtherapy,consisting ofantacidsandhydrogenantagonistsand,rarely,surgery.
Managementgoalsareasfollows: 1. Limitintragastricpressure. 2. AvoidsubstancesthatdecreasetheLES. 3. Decreaseacidityofrefluxedmaterialtopreventirritationoftheesophagus. Therapeutictreatmentisusuallyprovidedinthreephases. Phase1 Approaches Rationale Consumesmallvolumemeals;thismaynecessitate dividingmealsintosmallermealsandmidmorning andmidafternoonsnacks,orconsumingfluids betweenmeals Maintainuprightpostureduringandaftereating Intragastricpressureisincreasedbymechanicaland posturalfactors Reduceweightifneeded(seeCalorieControlledDiet inSectionIC) Avoidtightfittingclothing,frequentbending
Regressionofsymptomsislikelytoaccompany weightloss
Avoidlyingdownaftereating;consumebedtime snacksormealsatleast2hoursbeforeretiring
Elevateheadofbedatleast6incheswhensleeping Limitfatindiet(seeFatControlledDietinSection IC) Avoidpeppermintandspearmint Avoidgastricstimulants: Cigarettesmoking Alcohol Chocolate Coffee,regular Caffeine
Intragastricpressurecanbereducedifstomach emptyingisenhanced;fatdecreasesLESpressure. ThesesubstancesdecreaseLESpressure Goal:decreaseacidproduction;thesesubstancesalso decreaseLESpressure
III39
GastroesophagealRefluxDisease(GERD)
Phase1(cont.) Approaches Rationale Limitfoodconstituentsthatthepatientclaimscause discomfort;thesemayincludecitrusfruitsandjuices, tomatoproducts,andcarbonatedbeverages Treatwithantacidscontainingaluminumhydroxide Mayreducesymptomsbyformingaviscousbarrier andMagnesiumtrisilicate(Gaviscon) inthestomachthatimpedesreflux Phase2 Approaches Rationale MedicalApproaches Prescribedtodecreaseacidity TreatwithHistamineH2antagonists Cimetidine,rantidine Omeprazole(Prilosec) IncreasesLESpressure Bethanechol(Urecholine) Metoclopramide(Reglan) Phase3 Rationale Approaches Antirefluxsurgery Occasionaluseforthepatientinwhichmaximal medicaltherapyisnotsuccessful,andpersistent severesymptomsandcomplicationsarepresent. Although,significantimprovementisseen postoperatively,recurrenceofsymptomsaswellas histologicevidenceofesophagitisisreportedas timeprogresses(1).
Reference 1. DraganescuJM,LipshutzWH.Esophagus,stomach,andintestines.In:SkipperA,ed.DietitiansHandbookofEnteralandParenteral Nutrition.2nded.Gaithersburg,Md:AspenPublishers;1998. Bibliography EscottStumpS.NutritionandDiagnosisRelatedCare.5thed.Baltimore,Md:Williams&Wilkins;2002. Beyer PL. Medical nutrition therapy for upper gastrointestinal tract disorders. In: Mahan KL, EscottStump S, eds. Krauses Food, NutritionandDietTherapy.10thed.Philadelphia,Pa:WBSaunders;2000:650652. Gastroesophagealrefluxdisease.In:ManualofClinicalDietetics.Chicago,Ill:AmericanDieteticAssociation;2000. RichterJE.Acriticalreviewofcurrentmedicaltherapyforgastroesophagealrefluxdisease.JClinGastroenterol.1986;8:7280.
III-40
HEARTFAILURE
Discussion Heart failure, which is a syndrome characterized by left ventricular dilation or hypertrophy, is caused by cardiac dysfunction that results from myocardial muscle dysfunction or loss (1). Heart failure leads to neurohormonalandcirculatoryabnormalitiesthatcausefluidretention,shortnessofbreath,andfatigue (1). The leading causes of heart failure include hypertension, coronary heart disease, and diabetes mellitus (1). Othercausesincludecardiomyopathy,valvularheartdisease,arrhythmias,congenitalheartdisease,thyroid disease,obesity,alcoholabuse,humanimmunodeficiencyvirus,acquiredimmunedeficiencysyndrome,and illicitdruguse(1,2).Heartfailureiscommoninolderadults;theprevalenceincreasesfrom2%to3%atage65 to more than 80% in persons older than 80 years (2). Heart failure is the most common reason for hospitalization, morbidity, and mortality in the elderly (1,2). Referral to a registered dietitian for medical nutritiontherapyisrecommendedforindividualswhohaveheartfailure(GradeII)(3).Aminimumoffourvisits witharegistereddietitiancanleadtoanimproveddietarypatternandqualityoflifeanddecreasededema andfatigue (Grade II) (3).Medicalnutritiontherapyinconjunctionwithoptimalpharmacologicalmanagement mayalsoreducehospitalizations(GradeII)(3). Indications Heartfailureprecipitatestheonsetofsodiumretentionandedemaduetotheinabilityofthebodytoexcrete sodiumatarateinequilibriumwithdietarysodiumintake(1).Theprimaryobjectivesinmanagingthesigns and symptoms of heart failure include the achievement of fluid homeostasis by using medications such as loop diuretics and the implementation of dietary interventions to reduce fluid retention and increase the excretionofsodiumandwater(1). Signsandsymptomsofheartfailureinclude(1): difficultybreathing,especiallywhenlyingflatinbedorwithexertion wakingupbreathlessatnight frequent,dry,hackingcough poortolerancetoexercise,ordyspneaonexertion suddenweightgaincausedbyedemaorascites frequenturination swellinginthelowerextremities(especiallytheankles) fatigue,dizziness,weakness,orfainting earlysatiety,nausea,andabdominalswellingorbloating The medical diagnosis is verified by echocardiography or the assessment of left ventricular function by measuringtheejectionfraction.AlaboratorytestforBtypenatriureticpeptidecanindicateadiagnosisof heartfailureintheclinicalsetting(2).Heartfailureisclassifiedintooneoffourstages(withstageIVbeingthe mostsevere)basedonitsseverityandphysiologicalimpact (1). Medical management of heart failure involves a combination of drugs including diuretics, angiotensin converting enzyme inhibitors, and beta blockers; dietary modifications; exercise recommendations; and symptom and risk factor management (eg, blood pressure control and lipid management) (14). Behavioral compliancetothetreatmentregimen,especiallyphysicalexercise,iscorrelatedwithsuccessfuloutcomes.A multidisciplinary approach to treatment, including medical nutrition therapy, decreases hospital utilization andmedicalcostsandimprovesthequalityoflifeofelderlypersonswhohaveheartfailure(13). Adversehealthoutcomesassociatedwithheartfailureare(5): reducedtolerancetoexerciseoractivity stroke peripheralvasculardisease renalfailure NutritionAssessmentandDiagnosis Referral to a registered dietitian for medical nutrition therapy is recommended for individuals who have heart failure (Grade II) (3). The initial assessment should include a comprehensive evaluation of nutritional
III-41
Heart Failure
statusthatevaluatesthepatientsweightand/ormusclemass(especiallyifweightisdifficulttoassess)by using skinfold measurements or grip strength evaluation (4). A careful analysis of biochemical parameters andnutritionalintakeshouldassesstheadequacyofenergyandproteinintake,thesodiumandfluidbalance, andtheadequacyofvitaminsandmineralsthatcanbeimpactedbypolypharmacy.Folate,thiamine,vitamin B12, calcium, and magnesium are key nutrients compromised by medications such as diuretics and digoxin (1,3). Patientswhohaveheartfailurerequirelimitedsodiumandfluidintakeandadequatetotalenergyintaketo meet their increased energy expenditure.Patients whohave severe heartfailure maydevelop malnutrition andcardiaccachexiaduetotheincreasedenergyrequirementsassociatedwiththeincreasedlungfunction neededtoproduceoxygen (2,3).Compromisednutritionalintakeisalsorelatedtothefatigueandshortnessof breath associated with fluid retention (2,3). The mechanism of cardiac cachexia includes hypermetabolism, musclewasting,alteredintake,andfunctionalimpairments(4).Involuntaryweightlossassociatedwithheart failure may be masked by chronic fluid retention. The use of weight as the only parameter to diagnosis a nutritionrelated problem may underestimate the incidence of malnutrition (4,5). Intestinal malabsorption, especiallyoffat,iscommoninheartfailureasaresultofmucosalandintestinalcongestionrelatedtoedema inthelargeintestine (6).Patientsshouldbemonitoredforsignsandsymptomsofmalabsorptionaspartof thenutritionassessment(4). NutritionIntervention Specificnutritioninterventionsareeffectiveinmanagingthesignsandsymptomsofheartfailure(GradeII)(13). Theprimaryobjectiveofmedicalnutritiontherapyistocomplementpharmacotherapyinmaintainingfluid andelectrolytebalancewhilepreventingmalnutritionandcardiaccachexia.Nutritioninterventionsshould be customized based on the patients individualized needs and the nutrition diagnoses identified by the comprehensivenutritionassessment.RefertoHeartFailureAcuteCareNutritionProtocolandheartfailure evidencebased nutrition practice guidelines as needed (3,7). Hypertension is often associated with heart failure;therefore,dietaryandlifestylemanagementstrategiesfortreatinghypertensionshouldbeappliedto heartfailurepatientswhohavehypertension(13,8).(RefertoHypertension,SectionIII.) Energyexpenditure:Indirectcalorimetryisthebestmethodtodeterminetheenergyneedsofpatientswho haveheartfailure (Grade III) (3).Whenindirectcalorimetryisnotpossible,theclinicianshouldusepredictive equationsbasedonthepatientslevelofcareandadjustforanincreasedcatabolicstate(GradeIII)(3).Aprimary goalistoprovideenoughenergytomaintainareasonablebodyweightandvisceralproteinstatus.Insome cases, the basal metabolic needs may be 18% higher than agematched controls; this increased metabolic needcancontributetomalnutritionandcardiaccachexia (9).Inobesepatients,weightlossimprovescardiac outputandshortnessofbreath(4). Protein:Thedailyproteinintakeshouldbeatleast1.37g/kginclinicallystabledepletedpatientsand1.12 g/kg in normally nourished patients to preserve their actual body composition or limit the effects of hypercatabolism (GradeIII)(3).Theliteraturesuggeststhatpatientswithheartfailurehavesignificantlyhigher proteinneedsthanpatientswithoutheartfailure,asmeasuredbynegativenitrogenbalance (GradeIII)(3).The patientsnitrogenbalanceshouldbeevaluatediftheadequacyofproteinintakeisinquestion(3,4). Sodium:Limitsodiumto2,000mg/day (GradeIII)(3)anddonotexceed3,000mg/day (1).Severeheartfailure maywarrantalowersodiumintake.(RefertoSodiumControlledDietinSectionIF.)Sodiumrestrictionwill improve the patients quality of life and clinical symptoms such as edema and fatigue (Grade III) (3). Urinary sodium levels can be assessed to determine the adherence to a lowsodium diet (2). Severely restricted sodium intake (1,000 mg or less) is discouraged for home use. Dietary restriction at this extreme may be unrealistic,leadingtoreducedpatientcomplianceandcompromisednutritionalintake. Fluid: Fluid requirements are based on the presence of edema, ascites, shortness of breath, and hyponatremiaandthefrequencyofweightfluctuations.Fluidrestrictionimprovestheseclinicalsymptoms andthepatientsqualityoflife(GradeII)(3).Forpatientswithheartfailure,dailyfluidintakeshouldbebetween 1.4and1.9L(48to64oz),dependingonclinicalsymptoms (Grade III) (3).Fluidshouldberestrictedifserum sodiumlevelsfallbelow130mEq/L (1).Suddenincreasesinbodyweightof3to5lbsuggestmarkedfluid retention(4).(RefertoNutritionManagementofFluidIntakeinSectionIB.) Alcohol:Alcoholprovideslimitednutrientsandshouldbeavoidedorlimitedtoonedrinkperdayforwomen andtwodrinksorlessperdayformen;eachdrinkistheequivalentof1ozofalcohol (GradeII)(3).Research
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Heart Failure
demonstrates that this level of alcohol consumption is not harmful to heart failure patients (Grade II) (3). Patientswhohavealcoholismshouldavoidalcoholandseekalcoholrehabilitation. Thiamin:Individualswhotakemorethan80mg/dayofloopdiuretics,suchasfurosemide,haveincreased urinaryexcretionofthiaminandmaydevelopclinicallysignificantthiaminedeficiency.Thiamindeficiency causeshighoutputcardiacfailure(beriberi)andmayexacerbatecardiacfunctioninpatientswhohaveheart failure(10).ThepatientshouldconsumeatleasttheDietaryReferenceIntake(DRI)forthiaminthroughfood orsupplements(GradeIII)(3).Foodsourceshighinthiaminincludefortifiedcereals,bran,bread,andmeats. Folate:HeartfailurepatientsshouldconsumeatleasttheDRIforfolatethroughfoodoracombinationof vitaminB6,vitaminB12,andfolatesupplementation.Folatesupplementationgivenwithothervitaminsand mineralshasbeneficialclinicaloutcomesforpatientswhohaveheartfailure(GradeII)(3). VitaminB12:AmultivitaminandmineralsupplementcontainingvitaminB12oracombinationofvitaminB6, vitaminB12,andfolateisrecommendedforheartfailurepatients.VitaminB12supplementation(200to500 mcg/day) provided with other vitamins and minerals has beneficial clinical outcomes for heart failure patients(GradeII)(3). Minerals:Dietaryminerals,includingpotassium,magnesium,andcalcium,maybedepletedduetodiuretic therapy.Foodsourcesofthesemineralsincludelowfatdairyproducts,fruits,vegetables,andwholegrain products. Heart failure patients should consume at least the DRI for these minerals from food sources or supplements and should place a special emphasis on their magnesium intake (Grade II) (3). Low levels of magnesiummaybepresentinpatientswhohaveheartfailureandcanresultinirregularheartrhythms (Grade II)(3).Therecommendedpotassiumintakeis2to6g/day,unlessthepatienthasrenalimpairmentorreceives a potassiumsparing diuretic such as spironolactone. The need for additional magnesium requirements in heartfailurepatientsisbeingevaluated(3). Herbal supplements and overthecounter dietary supplements: Heart failure patients should be carefullyevaluatedfortheiruseofherbalsupplementsandoverthecounterdietarysupplements.Themost commonlyusedsupplementsusedbyheartfailurepatientsincludeLarginine,carnitine,coenzymeQ10,and hawthorn (3). Limited evidence is available regarding clinical heart failure outcomes and the use of these supplements(GradeIII;exceptcoenzymeQ10,gradeII)(3).Therisksandharmsoftakingsupplementsindifferentdisease states and with various medications should be thoroughly examined (3). For example, patients who take warfarin(Coumadin)shouldbeawarethatcoenzymeQ10ischemicallysimilartovitaminKandcandecrease theeffectivenessofwarfarin (3).Hawthornshouldbeusedcautiouslyinpatientswhotakebetablockersand calcium channel blockers, as hawthorn may decrease blood pressure (3). In addition, hawthorn in combination with digoxin can increase digoxin levels and increase the risk of side effects. Hawthorn in combinationwithnitrates,whichincreasebloodflow,maycauseorworsendizzinessandlightheadedness(3). Lastly, ephedra (ma huang), ephedrine, or its metabolites should be avoided due to an increased risk for mortality and morbidity in heart failure patients (1). The clinician should use additional resources in conjunction with evidence analysis documents for information regarding the potential side effects of these supplements(3).RefertoSectionII:FoodandDrugInteractionsandHerbandDrugInteractionsasneeded. Caffeine: Some studies have demonstrated that caffeine increases the heart rate and blood pressure and causes dysrhythmias. More research is needed to assess the effect of caffeine on specific conditions. The effectsofcaffeineintakeonheartfailureoutcomeshavenotbeenstudied.Inaddition,thelatestguidelines forbloodpressuremanagementdonotaddresslimitingcaffeineasarecommendedmodifiablelifestylefactor toreducebloodpressure(8).Becauseinformationislimited,itisrecommendedthatheartfailurepatientsuse caffeineinmoderationanddonotexceed300mg/day.
References Adams KF, Lindenfield J, Committee Members of the Heart Failure Society of America. Heart Failure Society of America 2006 ComprehensiveHeartFailurePracticeGuideline.JCardFail.2006;12:e1e122. 2. Heart failure. In: Nutrition Care Manual. American Dietetic Association; 2004. Available at: www.nutritioncaremanual.org. AccessedJanuary5,2009. 3. Heart Failure EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2008.Availableat:http://www.adaevidencelibrary.com.AccessedJanuary5,2009. 4. SchwartzDB,DiMariaR.Pulmonaryandcardiacfailure.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:A CaseBasedApproachTheAdultPatient.SilverSpring,MD:AmericanSocietyofParenteralandEnteralNutrition;2007:496501. 5. Schwengel RH, Gottlieb SS, Fisher ML. Proteinenergy malnutrition in patients with ischemic and nonischemic dilated cardiomyopathyandcongestiveheartfailure.AmJCardiol.1994;73:908910. III-43 Copyright 2011 Morrison Management Specialists, Inc. Manual of Clinical Nutrition Management All rights reserved. 1.
Heart Failure 6. NicolSM,CarrollDL,HomeyerCM,ZamagniCM.Theidentificationofmalnutritioninheartfailurepatients.EurJCardiovascNurs. 2002;1:139147. 7. HeartFailureAcuteCareNutritionProtocol.In:InmanFeltonA,SmithKG.NutritionCareProtocolsfortheAcuteCareSetting. Atlanta,Ga:MorrisonManagementSpecialistsInc;2009..Availableat: https://www.morrisontoday.com/Documents/Forms/AllItems.aspx?RootFolder=%2fDocuments%2fNutrition%2fMHFS%20NUTR ITION%2fNutrition%20Care%20Process&FolderCTID=0x01200076035A4CEC8A4B4B827A74CE5B3B1A44&View=%7b1F2F11D B%2d2030%2d4BBC%2dB712%2dEFE12EF45909%7d. 8. ChobanianAV,BakrisGL,BlackHR,CushmanWC,GreenLA,IzzoJLJr,JonesDW,MatersonBJ,OparilS,WrightJT,RoccellaEJ,the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention,Detection,Evaluation,andTreatmentofHighBloodPressure.Hypertension.2003;42:12061252. 9. PoehlmanET,ScheffersJ,GottliebSS,FisherML,VaitekeviciusP.Increasedrestingmetabolicrateinpatientswithcongestiveheart failure.AnnInternMed.1994;121:860862. 10. BradyJA,RockCL,HornefferMR.Thiaminstatus,diureticmedications,andthemanagementofcongestiveheartfailure.JAmDiet Assoc.1995;95:541544.
III-44
HIVINFECTIONANDAIDS
Discussion Thehumanimmunodeficiencyvirus(HIV)isaretrovirusthatistransmittedthroughcontactwithbloodor bodyfluids(semen,vaginalsecretions,orbreastmilk)fromaninfectedperson(1).ThisvirusattackshelperT lymphocytesintheblood,oftenreferredtoasCD4+Tcells.Thesystematicdestructionofthesecellsweakens the bodys immune system, which increases the hosts vulnerability to opportunistic infections. Acquired immunodeficiencysyndrome(AIDS)isaspecificstageofHIVinfectioninwhichtheprogressionofthevirus hasadvancedandtheimmunesystembecomescompromised.Duetoeffectiveprimarypreventionandthe lifeprolonging effects of antiretroviral therapies (ARTs), the number of reported HIV and AIDS cases has leveledoffatlessthan1%oftheglobalpopulation,accordingtothe2008ReportontheGlobalAIDSEpidemic (1,2).IntheUnitedStates,prevalenceratesincreasedbetween2003and2006asaresultofimprovedsurvival andeffortstoencouragetestingandawarenessofHIVinfectionstatus (1,3,4).RecentdataonHIVinfectionin theUnitedStatesindicatethatmorethantwothirdsofHIVinfectedpeoplearebetween25and49yearsof age,whileonequarterofinfectedpeopleareolderthan50years,and5%ofinfectedpeoplearebetween13 and 24 years of age (5). The most vulnerable groups at risk for infection are ethnic minorities, women, children,andadolescents(1). OverviewandClassificationofAIDS TheCentersforDiseaseControlandPrevention(CDC)definesAIDSbythefollowingcriteria(6): apositiveantibodytestforHIV,and aCD4countlessthan200/mm3orlessthan14%ofthetotalwhitebloodcellcount,or aclinicaldiagnosisofoneofthe25AIDSdefiningdiseases(7) In addition to the CDC system, the World Health Organization Clinical Staging and Disease Classification SystemcanbeusedreadilyinresourceconstrainedsettingswithoutaccesstoCD4cellcountmeasurements orotherdiagnosticandlaboratorytestingmethods(8).
AvarietyofmetabolicandphysiologicchangesarecausedbytheeffectofHIVontheimmunesystem (1). As a result, persons with HIV infection or AIDS are susceptible to disorders, including opportunistic infections, wasting syndrome, neurological dysfunctions, and gastrointestinal ailments, that challenge their nutritional status and quality of life(9). When AIDS is advanced, it increases the patients susceptibility to neoplasmssuchasKaposisarcomaandnonHodgkinlymphoma(9).TheCD4cellcountisusedasamarkerof HIVdiseaseprogression.TheHIVviralload,whichisexpressedascopiesofHIVribonucleicacidpermilliliter ofblood,isusedtoevaluatetheamountofvirusinthebody (9).Theviralloadtestreflectsthelevelofactive virusreplicationthroughoutthebodyandisusedforevaluatingtheefficacyofHIVtherapies,predictingthe progressionofHIVinfectiontoAIDS,andassessingtheefficacyofnewantiviralmedications (9).Astheviral load increases, the risk for clinical deterioration also increases (7,9). Although a person at the onset of HIV infectionmaybeasymptomatic,theHIVisnotdormant;rather,thevirusisactivelyreproducing.Inaddition to decreasing CD4 counts, symptoms of HIV disease progression include fatigue, weight loss, body composition changes, and diarrhea. Other signs of disease progression are associated with opportunistic symptomsandincludenightsweats,mouthsores,rashes,andfever (9).Highlyactiveantiretroviraltherapy (HAART), which isa combination therapy consisting of severalantiretroviraldrugs, is effectivein reducing andcontrollingviralburdenandimprovingimmunefunction.TheuseofHAARThasdramaticallyreducedthe mortalityrateofHIVinfectedpersonsandtheincidenceofAIDSwastingsyndrome (10).However,thelong term use of HAART has increased the prevalence of complications such as insulin resistance, diabetes, cardiovasculardisease,renaldisease,cancers,neurologicdisease,andbonedensityloss(1,9). NutritionalImplicationsofHIVandAIDS TheimpactofnutritiononHIVandAIDSissignificantandmultifactorial (1,9).TheHIVinfectionpromotesa vicious cycle, as the infection can cause malnutrition, which exacerbates immune dysfunctions and thus increasesthevulnerabilitytoopportunisticinfections(1,9).TheHIVinfectionanditstreatmentsmayinitiatea complex dysregulation of the metabolism associated with changes in nutritional status, such as energy expenditure, lipid metabolism, hormonal balances, and immune function (1,1114). Even in wellnourished individuals, the hormonal response to infection can lead to changes in hormonal sensitivity (eg, insulin, growthhormone,andsexhormones),tissuecatabolism,andareductioninappetiteandfoodintake(1,9).Poor nutritionalstatus,includingbothundernutritionandovernutrition,canaffectimmunefunctionindependent
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of HIV infection (1). Reducing or eliminating malnutrition has the potential to significantly slow the progression of disease, decrease the disease severity, and improve longevity (1). The treatment and managementofHIVwithARTspresent manynutritionalchallengesastheantiretroviralmedicationscanalter body composition and metabolic pathways (1,9). Common nutrition diagnosis and nutrient deficiencies that occur in HIV and AIDS include proteinenergy malnutrition, various forms of anemia, and alterations in nutrientssuchaszinc,iron,selenium,vitaminB12,carbohydrate,andfat (1,1517).Nutritionisparamountin supportingthehealthandqualityoflifeofHIVinfectedpersons (1).Theregistereddietitianshouldcomplete routine comprehensive nutrition assessments to identify nutrition alterations and manage the diverse complicationsassociatedwithHIVorAIDSanditstreatments (1).Themostcommonnutritioncomplications experiencedbypersonswithHIVorAIDSarecomprehensivelydiscussedhere. Weight,BodyComposition,andAIDSrelatedWastingSyndrome OneoftheleadingnutritionindicatorscorrelatingwithsurvivalinHIVisweightstatus (1).Bodymassindex (BMI)andadequatebodycellmass(BCM)arereliableindicatorsusedtodetermineacutechangesinweight and lean tissue in persons with HIV infection or AIDS (1,9,18). The HIV infection leads to an inflammatory response and challenges to the maintenance of weight and lean tissue stores (9). Even small losses of lean tissueareassociatedwithanincreaseinmorbidityandmortalityforHIVinfectedpersons(9,10,19).Withaloss ofBCMtoalevelof54%oftheexpectedvaluebasedonheight,deathislikelytooccurinpatientswithHIV infection regardless of the presence or absence of infectious complications (20). A major component of the clinicalsyndromeinHIVinfectionandAIDSisAIDSrelatedwastingsyndrome(6). The CDC defines AIDSrelated wasting syndrome as an involuntary weight loss of greater than 10% of baselinebodyweightaccompaniedbyoneofthefollowingcriteria(6): chronicdiarrhea(atleasttwodiarrhealstoolsperdayfor30daysorlonger),or chronic weakness and documented fever for 30 days or longer in the absence of a concurrent illness or conditionotherthanHIVinfectionthatcouldexplainthefindings Although the number of AIDS cases has dramatically decreased since the introduction of ARTs, the wasting syndrome continues to occur in approximately 20% of AIDS cases in the United States (9,10). More recent information suggests that weight loss or wasting syndrome occurs in more than 30% of HIVinfected patients regardlessofantiHIVtreatmentwithatotalprevalencerateofnearly40%intheinfectedpopulation (9,10).The causes of wasting syndrome and malnutrition in HIV disease are complex and multifactorial (1,9). Suspected mechanisms of weight and protein losses include compromised food intake caused by anorexia and increased utilizationofnutrientsassociatedwithinflammatoryresponses (1).Othercausesmayincludereducedintestinal absorption,whichcanaffecttheabsorptionofcarbohydrateandfat,resultinginlactoseandfatmalabsorption. Diarrhea,asymptomofmalabsorption,isassociatedwiththeAIDSrelatedwastingsyndrome (6).Diarrheaand malabsorption can lead to nutrient deficiencies and compromised energy intake that adversely affect weight status,immunefunctions,andothernormalbodyprocesses(1).Furtherresearchtosupportdietarytreatmentof diarrheaandmalabsorptioninHIVandAIDSisneeded (Grade II) (1,21).Researchoneffectivetreatments,suchas aminoacidbasedelementaldiets,probiotics,pancreaticenzymetherapy,calciumcarbonate,glutamine,andthe BRATdiet(bananas,rice,applesauce,andtoast),aswellastheeffectsofmedicationsiswarrantedbasedon a reviewofcurrentevidence (GradeII)(1,21).ForpeoplewithHIVinfectionwhohavediarrhea/malabsorption,the registereddietitian(RD)shouldencouragetheconsumptionofsolublefiber,electrolyterepletingbeverages andmediumchaintriglycerides(MCT)anddecreasetheconsumptionoffoodsthatmayexacerbatediarrhea (Grade II) (21). Studies of fat malabsorption reported that consumption of MCT resulted in fewer stools, decreased stool fat and weightand increasedfat absorption (Grade II) (21).Bothunintentionalweightlossand lean tissue loss require strategies to ensure that adequate macronutrients are consumed, absorbed, and assimilatedtopreventandreverseweightlossandwastingsyndrome(1).Consideringthecriticalimportanceof weight and maintenance of lean body stores, the routine monitoring of body composition by using anthropometricandothermeasuresisrecommendedindeterminingnutritionalriskandapplyingappropriate nutritioninterventions(GradeI)(1,21). LipodystrophyandMetabolicDiseaseinHIVandAIDS WiththedevelopmentofnewcombinationsofmedicationsreferredtoasARTs,peoplewithHIVorAIDSare living longer (15,9). These medication regimens, however, create nutritional challenges including dyslipidemia,insulinresistanceandglucoseintolerance,andvarioustypesofanemias(1,22,23).Lipodystrophy, theabnormalmetabolismanddepositionoffat,isacommonsideeffectofARTs (1).Lipodystrophyincludes lipoatrophy,whichisthelossofsubcutaneousfat,andlipohypertrophy,whichisthegainoftruncalfat (24). The lipodystrophyassociated alterations in body composition have metabolic consequences that lead to Manual of Clinical Nutrition Management III-46 Copyright 2011 Morrison Management Specialists, Inc.
HIVInfectionandAIDS
dyslipidemia and insulin resistance (1,24). A higher prevalence of risk factors for cardiovascular disease relatedtoARTislikelytorequireexerciseandlipidloweringmedicationsinadditiontodietarymodifications (1).AhearthealthydietandregularexercisereducebloodlipidlevelsinHIVpositivepatients(1,25).Research on several lifestyle modification interventions for the treatment of hyperlipidemia in people with HIV infectionfoundimprovementsinserumlipidprofiles(GradeI)(1,21).Patientswithlipodystrophyoftenrequire nutritioninterventiontosupportahealthybodyweightandreducetheirintakeofsaturatedfat,transfatty acids, salt, and dietary cholesterol (1). Patients with HIV and hypertriglyceridemia benefit from increasing fiber intake, limiting simple carbohydrates, and avoiding alcohol (1,25). Routine anthropometric measures, bloodlipidlevels,andbloodpressuremonitoringshouldbeusedtoevaluateandmonitorlipodystrophyin HIVinfectedpatients.Applyingpracticeguidelinesforcardiovasculardiseaseriskfactormanagementisthe currentrecommendedapproachfortreatment(1). AbnormalglucoseintolerancehasbeenassociatedwithHIVandAIDSmedicationtherapies(1,26).Patients with insulin resistance may benefit from diabetes education programs, which provide strategies for regulating blood glucose levels through diet and exercise (1). The treatment of insulin resistance with oral antidiabetic medications has been explored with mixed results (1). Metformin and glitazones are being investigatedfortheirpotentialtoimproveinsulinsensitivity,buttheireffectonperipheralsubcutaneousfat losses in patients receiving ART is still being researched (2729). In addition to nutrition therapy strategies, medicationsupportmaybeindicatedtohelpreduceinsulinresistanceandincreaseleanbodymass(LBM)(1). NutritionAssessmentandDiagnosis AllpatientswhoarenewlydiagnosedwithHIVinfectionshouldreceiveacomprehensivenutritionassessment. Early referral of HIVinfected patients to medical nutrition therapy can improve their nutritional status and outcomes(1).Areviewofevidencehasshownthatmedicalnutritiontherapy(intheformofanincreasednumber of nutrition counseling sessions) prevents progressive weight loss, improves cardiovascular risk indexes, and improvesenergyintakeandothersymptoms(GradeI)(1).Studieshavealsoreportedimprovedoutcomesrelatedto weight gain, CD4 count, and quality of life with nutrition counseling (Grade I) (1). Symptoms that may affect nutritionalstatusandthatareusedasindicatorsforidentifyingnutritiondiagnosesincludenausea,vomiting, diarrhea,anorexia,pain,chewingorswallowingdifficulties,tastechanges,andweightchanges(1,9).Providing specific nutrition intervention strategies to resolve the nutrition diagnoses and support patients through these challenges is an important part of medical nutrition therapy (1,9). The following types of nutrition assessmentdatashouldbecollectedandusedtodeterminenutritiondiagnoses,nutritioninterventions,and counselingstrategies. Biochemicalassessment:Thelevelsofserumproteins,fastinglipids(totalcholesterol,lowdensitylipoprotein cholesterol,highdensitylipoproteincholesterol,andtriglycerides),fastingglucose,andmicronutrientsshouldbe routinelyevaluatedduetometabolicandimmuneabnormalitiesassociatedwithHIVandAIDS(1,9).Alteredlevels of plasma proteins, micronutrients, and other nutritionrelated markers have been documented early in the diseaseprocessandareassociatedwithincreasedriskofmortalityinHIVinfection (1).Alterationsinzinc,iron, selenium,vitaminB12,carbohydrate,andfathavebeenreportedinsymptomaticandasymptomaticdiseasestates (1,30,31). Indicators of disease complications and prognosis include nutritionrelated laboratory values such as albumin,transthyretin,hemoglobin,hematocrit,creatinine,ureanitrogen,transferrin,glucose,vitaminB12,andC reactive protein (1,32,33). Serum iron, total ironbinding capacity, folate, and vitamin B12 are measured to distinguishtypesofanemias,includinganemiaofchronicdiseaseoranemiarelatedtomedicationtherapy (1,34). Serumlipidsinmenandwomenandlevelsoftotalandfreetestosteroneinmenshouldbemonitoredregularly for changes indicative of lipodystrophy and decreases in LBM (1). Alterations in nutritionrelated laboratory values may reflect inflammatory responses rather than purely nutritional compromise (1). Levels of zinc and albumin,whicharebothacutephasereactants,mayfallrapidlyduringthephysicalstressofinfectionandquickly increase when the infection is resolved (1). Therefore, biochemical values should be used in conjunction with othernutritionassessmentparameters,suchasweight,bodycomposition,andnutrientintake(1). Anthropometry: Routine anthropometric measures, including height, weight, BMI, waisttohip ratio, waist circumference, hip circumference, and other circumference measures, should be used to evaluate and monitor risk for wasting syndrome and lipodystrophy (1,9). Body composition measures such as skin folds and BCM, a component of LBM composed of highly functional protein stores (muscles and organs), are also important to monitor (1,9). In a review of 27 studies evaluating the assessment of body composition in persons with HIV infection, the majority of studies reported that fatfree massand fat mass are generally lower in people (men, women,children,andadolescents)withHIVinfection(GradeI)(1,21).AssessmentofBCMcandetectearlychangesin LBMandalterationsinfatpatternsandpotentialmusclewastingthatmaynotbereflectedbyweightchangeor
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weightrecords (1,9).Bodycomposition,particularlyBCM,canbeevaluatedbybioelectricimpedanceanalysis, bioimpedance spectroscopy, skinfold thickness measurements, and dual energy xray absorptiometry (Grade II) (1,21).Furtherresearchisneededtodeterminetheoptimalmethodologyforbodycompositionmeasurementin women,children,differentethnicgroups,andpatientswithlipodystrophy (Grade II) (1,21).Resultsofbioelectrical impedanceanalysismayvarywiththepredictionequationusedandtheequipmentmanufacturer (1).Skinfold thicknessmeasurementsmayalsovarywiththenumberofsitesmeasuredandthepredictionequationused (1). RefertoTableIII9:EvaluationCriteriaforWeightandBodyCompositionChangesinHIVandAIDS(9). TableIII9:EvaluationCriteriaforWeightandBodyCompositionChangesinHIVandAIDS(9) Anthropometric CriteriaforEvaluation Measure BMI NormalBMIis18.5to24.9kg/m2. 2 suggestshighriskformorbidity,mortality,andthedevelopmentor <18.5kg/m presenceofwastingorlipoatrophy >24.5kg/m2 suggestspotentialforobesityrelateddiseasesandcentralfat accumulation BCM IdealBCMis100%. <95%suggestswastingandassociatedcomplicationsofreducedbodyfunctions relatedtomuscledegenerationandmass(eg,abilitytosit,swallow,andbreathe) andreflectschangesinhormonalstasis <55%isassociatedwiththetimingofdeath(9,20) WeightChange >5%unintentionalweightlossisassociatedwithincreasedriskofmorbidityand mortality >5%unintentionalweightgainis associatedwithincreasedriskforcentralfat accumulation
AdaptedwithpermissionfromtheAmericanDieteticAssociationfrom:NutritionfocusedphysicalfindingsinHIV/AIDS.In:TheAmerican DieteticAssociationNutritionCareManual.Updatedannually.Availableat:www.nutritioncaremanual.org.AccessedNovember15,2010.
Energyrequirements:Therestingenergyexpenditure(REE)isincreasedwithHIVinfection,andthisincrease may contribute to weight loss. Numerous studies have found that HIVinfected adults have greater REE as compared to healthy controls (1,21,35). However, the total energy expenditure was similar to that of control subjects (Grade II) (1, 21). Higher REE has been correlated with fatfree mass, but it has not been consistently correlatedwithweightordiseasestatus. (1,21,36).FactorsrelatedtoenergyneedsinpeoplewithHIVinfection include stage of disease, opportunistic infections and comorbidities, inflammation, and effects of medications (Grade II) (1,21).Alterationsinendocrinefunctionandreductionofenergyintakeareassociatedwithwasting (37). The impact of ARTs on energy requirements is related to the patients response to treatment. Successful treatment with ART decreases REE and promotes weight gain, whereas a lack of response to treatment is associated with wasting (1,38,39). Further research is needed to determine the exact energy requirements of patientswithHIVorAIDS (GradeII)(1,21).TheREEcanbeestimatedbyusingpredictiveformulasandconsidering additionalenergyneedsassociatedwithfever,infection,diarrheaormalabsorption,weightlossorlossofBCM, and physical activity (1,9). The energy requirements of patients who receive ART and patients who have lipodystrophy, glucose intolerance, or obesity may need to be decreased (1,9). (Refer to Section II: Estimating EnergyExpenditure.) Protein requirements:Protein isessentialforthemaintenanceofBCMand normalbodyfunctions,including immunity (1,40).Althoughincreasedproteinintakemayhavebeneficialeffects(eg,themaintenanceofBCM)for individuals with HIV; the specific protein requirements, protein turnover, and the effects of increased protein intakeinpersonswithHIVhavenotbeenadequatelystudied(GradeIII)(1,21).Proteinrequirementsshouldbebased onthediseasestage,BCM,nitrogenbalancestudies,andphysicalactivitylevel (1,9).Coexistingcomplicationsto HIVorAIDSshouldalsobeconsidered;thesecomplicationsincludemalabsorption,infection,wastingsyndrome, impairedrenalfunction,andimpairedhepaticfunction. Fat requirements: Highfat, lowfiber diets are fairly common in both the general population and in HIV infectedpersons (1).StudieshavefoundthatHIVinfectedpeoplegenerallyconsumedietsthatarehighintotal fat, saturated fat, and cholesterol (Grade II) (1,21). Evidence supports a relationship between diets that are high in saturated fat and total fat and hyperlipidemia, particularly hypertriglyceridemia (1). Studies indicate that diets thatarelowinsaturatedfatandtotalfatandthatincludeomega3fattyacidsresultinreducedtriglyceridelevels, increasedhighdensitylipoproteincholesterollevels,andlowerriskoflipodystrophy(GradeII)(1,21,25).Althoughthe
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typeoffatconsumedmayberelatedtolipodystrophy,furtherresearchisneededtoexaminethispossibility(Grade
II) (1,21). Omega3 fatty acid supplementation may affect several types of metabolic modulations, but additional
research is needed to determine its role in the management of hypertriglyceridemia (Grade II) (1). Research has shown that lifestyle modifications adopted by HIVinfected persons with hyperlipidemia result in improved serumlipidprofiles(GradeI)(1,21).BecauseoftheincreasedprevalenceoflipodystrophyinHIVpatients,especially patients who receive ART, the National Cholesterol Education Panel recommends comprehensive lifestyle modificationsincludingloweredfatintake,increasedphysicalactivity,andtheuseoflipidloweringmedications (1,9).Inaddition,forpersonswithdiarrheaandmalabsorptionstudiesoffatmalabsorptionhaveshownthat consumptionofmediumchaintriglycerides(MCTs)resultedinfewerstools,decreasedstoolfatandweight andincreasedfatabsorption(GradeII)(21). Carbohydrateandfiberrequirements:Recommendationshavebeenmadeforincreasingfiberintaketoward the levels suggested in general nutrition guidelines because of the association with lower prevalence of lipodystrophy (1,41). Limited evidence supports a relationship between lowfiber diets or highglycemic index diets and increased risk of fat deposition (Grade III) (1,21). Further investigation regarding the dietary intake of carbohydrateinpeoplewithHIVinfectioniswarranted(1,21). Fluidrequirements:WaterrequirementsforpatientswithnormalfluidstatuscanbeestimatedfromtheDietary Reference Intakes (9). It may be prudent for patients with HIV or AIDS to avoid carbonated beverages and alcoholic beverages, as well as caffeinated beverages because they act as gastrointestinal stimulants and may contributetodehydrationanddiarrheaorinteractwithARTs.Considerincreasingfluidrequirementsinpatients whodevelopfever,nausea,vomiting,ordiarrhea;theinitiationofmedication,physicalactivity,andinclementhot ordryweathermayalsonecessitateincreasedfluidintake(9).Fluidrestrictionsmaybeindicatedforpatientswith renalorhepaticfailure(9).
Vitaminandmineralrecommendations:Micronutrients,includingbothvitaminsandminerals,playakeyrole in the maintenance of immune function, reduction of mortality from disease and treatmentrelated symptoms, and rehabilitation of nutritional status in HIVinfected persons (1). Studies have found that micronutrient deficienciesarecommoninindividualswithHIVinfection(GradeII)(1,21).Zinc,selenium,Bvitamins,vitaminC,and vitamins A, E, and D may be at risk for deficiency due to inflammatory and metabolic responses and/or interactionswithARTs (1,1517,21,42).However,itisdifficulttoadequatelystudythesenutrientseffectivelydueto theinabilitytoseparatetheeffectsofindividualnutrientdeficienciesfromtheeffectsofgeneralizedmalnutrition on the immune system (1,21,42). A recent review yielded no conclusive evidence to show that micronutrient supplementation reduces morbidity and mortality among HIVinfected adults; however, there is evidence that vitaminAsupplementationisbeneficialforHIVinfectedchildren (GradeII)(1,21).Furtherresearchregardingtype, dose, and duration of micronutrient supplementation is needed before recommendations can be provided to persons with HIV or AIDS (Grade II) (1,21). Routine biochemical assessment of vitamin and mineral levels is recommendedtodeterminethebesttreatmentoptionsifsymptomsarepresentanddeficienciesaresuspected (1,9).SupplementationbasedonlevelsdescribedintheDietaryReferenceIntakesthatremainbelowtheupper limitsofsafetyseemsprudentintheabsenceofsufficientevidence(9). Bonemineraldensityrecommendations:PatientswithHIVmayexperienceaprogressivelossofbonemineral densitythatleadstoosteopeniaorosteoporosis(1).PatientswithHIVoftenhavemultipleriskfactorsfortheloss ofbonemineraldensity,includinglowBMI,weightloss,steroiduse,nucleosidereversetranscriptaseinhibitor use,andsmoking (1,21).Bonedensityshouldbemonitoredwithroutinebonedensitytests (1Bonedensitycanbe preserved through the maintenance of optimal weight and the prevention of rapid weight loss (1). Diet modificationsthatpromotethemaintenanceofbonedensityinclude:reducingalcoholandcaffeineconsumption; choosingcalciumrichbeverages(suchasmilkorfortifiedsoybeverages)insteadofhighphosphoruscarbonated beverages;eatingavarietyofproteinfoods;eatingcalciumrichandvitaminDfortifiedfoods,andtakingadaily calcium supplement of 500 to 1,200 mg (1,9,43). Vitamin K, vitamin C, and zinc are also important for bone formationandshouldbeincludedinanadequatediet (1,43).AssesstheARTregimenandsuggestadjustmentsto regimens so as to minimize side effects In addition, encourage physical activity and regular weightbearing or resistanceexercise(1). Useofherbalsupplementation:Supplementalnutrients,herbs,andothermedicationsmaybeprocessedby thepathwaysusedbyantiretroviralmedications.Asaresult,thelevelsofthesupplementsormedicationsmaybe greaterorlessthantheexpectedlevels(1).Potentialinteractionsincludethereductionofdrugefficacyduringthe concomitant use of St. Johns wort, garlic, and echinacea with protease inhibitors or nonnucleoside reverse transcriptase inhibitor antiretroviral drugs (1). Other herbal substances with a potential for drug interactions
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include ginseng, melatonin, milk thistle, geniposide, and skullcap (44). Unless carefully tested for safety and medicationinteractionsinpersonswithHIVorAIDS,herbalsupplementationshouldnotberecommendedinthis population(1,9).(RefertoTableII:HIVMedications:Names,Forms,Interactions,andPotentialSideEffects(9).) Physicalactivityrecommendations:Exercisehasbeenrecommendedasastrategytomaintainbodyfunction, restoreandmaintainadequatenutritionalstatus,andassistinthemanagementofalteredglucose,lipid,andbone mineral metabolism (1). A review of evidence found that 20 or more minutes of constant or interval aerobic exercise, progressive resistant exercise, or a combination of both at a frequency of three times per week appearedtobesafeinadultswithHIVinfectionandmayleadtosignificantimprovementsincardiopulmonary fitnessandareductionindepressivesymptoms (Grade I) (1,21).Theimpactofphysicalactivityonimmunestatus remains unclear (1). Special considerations should be given to patients with HIV who have active infection, reduced aerobic capacity, metabolic changes, or increased pain, fatigue, or impairment while exercising (1). Further research is needed on the effects of exercise on the serum lipid profiles of persons with HIV infection (GradeI)(1,21). HIV and AIDS in children and adolescents: Children with HIV experience the same nutritional issues as adults who have the disease, but because of the added demands of growth and development,the effects in childrenareoftenmoredevastating (1).Earlynutritioninterventionisveryimportant,androutinenutrition assessmentshouldincludemonitoringofheight,weight,andheadcircumferencewithcomparisontogrowth standardsforageandsex(1).Additionalserialmeasuresforanthropometrymayincludethighcircumference andmidupperarmcircumference (1).Deleteriousnutritionaloutcomescommonlyexperiencedbychildren withHIVorAIDSincludetheinabilitytoachieveanormalweightforheight,growthstunting,failuretothrive, malnutrition, impaired cognitive development or developmental and oralmotor feeding skill delay due to HIVencephalopathy,andwasting (1).ChildreninfectedwithHIVareconsideredathighnutritionalriskand shouldbereferredforongoingnutritionassessmentandcounseling(1). Medications TherehavebeenmanyadvancesinthepharmacologictreatmentofHIVinfection(1,9).TheadventofHAARTs andcombinationmedicationtherapieshasreducedviralloadsandincreasedthequalityandlengthoflifein patientswithHIVorAIDS (1,10).TreatmentofHIVinfectionwithcombinationARThasbeenassociatedwith improvednutritionalindicators,suchasBMIandBCM,aswellasnegativeconsequencessuchasdetrimental toxicities and compromised bone mineral density affecting nutritional status (1,4547). The benefits of ARTs (eg, maintaining BMI and BCM) must beevaluatedagainstthe potentialfor negative healthoutcomes. The registered dietitian must consider the adverse influences of various medications on indicators of nutrition statusandmetabolicindicatorsofdiseaserisk(1).Theclinicianmustrecognizethatnutrientsandnutritional status can affect medication absorption, utilization, elimination, and tolerance (1,48). Potential nutrition related adverse effects that are related to ART include dyslipidemia, insulin resistance and glucose intolerance,andanemias(1,22,23).(RefertothediscussionofLipodystrophyandMetabolicDiseaseinHIVand AIDS earlier in this section.) Patient adherence to prescribed medication regimens is needed to optimize treatmentoutcomesandshouldbeassessed (1).Patientadherencetotheprescribedmedicationregimenis affectedbynegativesideeffects,changesinbodycomposition(eg,bodyfatchangesasseeninlipodystrophy), and body image issues (1). (RefertoTableIII10:HIV Medications: Names,Forms,Interactions, andPotential SideEffects(9).) Therearecurrentlysixclassesofantiretroviralmedications(1,9): Nucleosidereversetranscriptaseinhibitors Nonnucleosidereversetranscriptaseinhibitors Proteaseinhibitors Fusioninhibitors Entryinhibitors Integraseinhibitors Therearealsodualclass,fixeddose,combinationdrugsthatallowforfewerpillsoroncedailydoses (1). Emergingdrugsunderinvestigationincludeaclassofmaturationinhibitorsandothermedicationsthatboost thelevelsofantiretroviralmedications(1).MostHIVinfectedpatientswillrequirelifelongpharmacotherapy for disease management (1). Response to ART can vary according to sex, and men and women with HIV infection may experience problems associated with medication interactions differently (1). For example, as compared to men, women experience greater increases in blood lipid levels with certain medications (1). When using ritonavir and nelfinavir, men experience more diarrhea, while women experience nausea, Manual of Clinical Nutrition Management III-50 Copyright 2011 Morrison Management Specialists, Inc.
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vomiting,andabdominalpainmorefrequentlythanmen(1).Itisimportantforthecliniciantoconsiderthese differenceswhenassessingnutritionalstatusandmedicationtherapies. TableIII10:HIVMedications:Names,Forms,Interactions,andPotentialSideEffects(9) GenericName(commercialname); ClassofDrug(manufacturer); Forms(tablets,capsules,oral solutions,orinjections) Abacavir(Ziagen); NRTI(GlaxoSmithKline); Tablets,oralsolution(strawberry banana) Abacavir/Lamivudine/Zidovudine (Trizivir);NRTI1combination(Glaxo SmithKline); Tablets Amprenavir(Agenerase); Proteaseinhibitor(GlaxoSmithKline); Capsules(containssorbitol,vitaminE), oralsolution(grape,bubblegum, peppermint)containsacesulfame potassium,saccharin,vitaminE Food,Drink,andOther Interactions PotentialSideEffects
Takewithorwithoutfood; usecautionwithalcohol (increasesamountoftimea drugisactiveinyourbody) Takewithorwithoutfood
Nauseaandvomiting,lossofappetite, abdominalpain,diarrhea,anemia, pancreatitis,lacticacidosis(rare) Seesideeffectsondruglabelsfor Abacavir,Lamivudine,Zidovudine
Takewithorwithoutfood; donottakewithhighfat meal;donottakewitha vitaminEsupplement;if takingantacids,take Amprenavir1hourbefore orafter;avoidgrapefruit juice;increasefluidintake
Diarrhea,nauseaandvomiting,taste changes,stomachupset,diabetes, fatigue,increasedcholesterollevels, increasedtriglyceridelevels,fat maldistribution,anemia.Donottakeif youhavekidneyorliverfailure.
Nausea,increasedindirectbilirubin, lacticacidosis(rare) Becarefulifyouhaveliverproblems, mayrequiredosechange Nausea,diarrhea,headache,coldlike Darunavir(Prezista)Proteaseinhibitor Takewithorwithoutfood symptoms(runnynoseandsore (TibotecTherapeutics)capsules throat) Delavirdine(Rescriptor); Takewithorwithoutfood; Increasedthirst,lossofappetite,dry NNRTI2(Agouron); donottakewithantacidsor mouth,nauseaandvomiting,inflamed Tablets(containlactose); magnesiumcontaining stomach,diarrhea,constipation, supplements;maytakewith passinggas; acidicdrinks(suchas becarefulusingthisdrugifyouhave cranberryjuice);avoid liverproblems drinkingalcohol Didanosine,ddI(Videx,VidexEC); Takewithoutfoodonan Lossofappetite,diarrhea,nauseaand emptystomachhour NRTI(BristolMyersSquibb); vomiting,abdominalpain, Videx:chewabletablets(orange, beforeor2hoursaftera constipation,drymouth,tastechanges, containssorbitol,aspartame);powder; meal;donottakewith pancreasinfection,(increasedriskif VidexEC:capsules acidicdrinksorfoods, youdrinkalcohol),lacticacidosis aluminumcontaining (rare),problemswithfeelinginyour antacids,ormagnesium armsandlegs; containingsupplements; becarefulifyouhavekidneyproblems avoiddrinkingalcohol Efavirenz(Sustiva); Takeonanemptystomach; Lossofappetite,nauseaandvomiting, NNRTI(BristolMyersSquibb); ahighfatmealincreasesthe diarrhea,tastechanges,increasedgood Capsules,tablets(bothcontainlactose) riskforsideeffects;avoid andbadcholesterollevels,increased drinkingalcohol triglyceridelevels
Tipranavir(Aptivus);Proteaseinhibitor (BoehringerIngelheim Takewithahighfatmeal Pharmaceuticals);Capsules Atazanavir(Reyataz)Proteaseinhibitor Takewithfood (BristolMyersSquibb) capsules(containlactose)
Hypertriglyceridemia,hyperglycemia, fatmaldistribution
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GenericName(commercialname); ClassofDrug(manufacturer); Forms(tablets,capsules,oral solutions,orinjections) Emtricitabine(Emtriva); NRTI(Gilead); Capsules
Food,Drink,andOther Interactions
PotentialSideEffects
Nauseaandvomiting,diarrhea,lactic acidosis(rare); Becarefulifyouhavekidney problems;mayrequireadosechange Enfuvirtide(Fuzeon);Fusioninhibitor Diarrhea,nausea,fatigue,lossof (HoffmanLaRoche); appetite,constipation,inflamed Powderforinjection pancreas,increasedtriglyceridelevels, increasedlipase,increasedamylase; Lowweightdecreasesclearanceof drugfromyourblood,butnodose adjustmentisrecommended Fosamprenavir(Lexiva);Protease Takewithorwithoutfood; Nausea,vomiting,diarrhea,increased inhibitor(GlaxoSmithKline); avoidvitaminE triglyceridelevels,fatmaldistribution Tablets supplementation Indinavir(Crixivan); Takeonanemptystomach Nausea,vomiting,acidreflux, Proteaseinhibitor(Merck); orwithverylow increasedordecreasedappetite, Capsules(containlactose) calorie/lowproteinsnack abdominalpain,tastechanges, (Note:nofoodrestriction diarrhea,kidneystones,diabetes whentakenwithritonavir); (rare),increasedbloodliverenzyme takewithplentyoffluids(at levelsorpancreasenzymes,increased least1.5litersperday); muscledamage,redbloodcellsare avoidgrapefruitjuice destroyedfasterthanyourbodycan makethem,impairedliverfunctioning; Doseischangedincirrhoticliver disease;hyperlipidemia;fat maldistribution Lamivudine,3TC(Epivir); Takewithorwithoutfood Nauseaandvomiting,abdominal NRTI(GlaxoSmithKline); cramps,diarrhea,pancreatitis,lactic Tablets;oralsolution(strawberry acidosis(rare); bananaflavor) Doseischangedforkidneyproblems; Note:alsousedforhepatitisBinlower dosesasEpivirHBV Lamivudine/Zidovudine,3TC/ZDV, Takewithorwithoutfood Seesideeffectsondruglabelsfor 3TC/AZT(Combivir);NRTIcombination Lamivudine,Zidovudine (GlaxoSmithKline);Tablets Lopinavir/Ritonavir(Kaletra); Takewithfood Abdominalpain,diarrhea,nausea, Proteaseinhibitor(Abbott); increasedtriglyceridelevels;increased Softgelcapsules(containsorbitol),oral cholesterollevels,fatmaldistribution; solution(cottoncandyorvanilla; inflamedpancreas;hyperglycemia; containsalcoholandsaccharin) Becarefulifyouhaveliverproblems;if takenwithDidanosine,mustbetaken 2hoursapart Nelfinavir(Viracept); Takewithfattyfood;may Diarrhea,gaspassing,nausea, Proteaseinhibitor(Agouron); crushtablets,mixwith abdominalpain,hyperlipidemia;fat Tablets;powder(containsaspartame) water,andtakeimmediately maldistribution;diabetes(rare), aftermixing;mixingpowder increasedliverenzymes; withacidicfoodordrink Becarefulifyouhaveliverproblems resultsinbittertaste Nevirapine(Viramune); Takewithorwithoutfood Nauseaandvomiting,abdominalpain, NNRTI(Roxane); fatigue,toxictotheliver Tablets;oralsuspension(contains sorbitol)
Takewithorwithoutfood; Eatingahighfatmeal lowersthehighestdrug levels Nodietrestrictions
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GenericName(commercialname); Food,Drink,andOther ClassofDrug(manufacturer); Interactions Forms(tablets,capsules,oral solutions,orinjections) Ritonavir(Norvir); Takewithfood Proteaseinhibitor(Abbott); Softgelcapsule;oralsolution(contains saccharin,alcohol;peppermint, caramel) Saquinavir(Invirase,Fortovase); Proteaseinhibitor(Roche); Invirase:capsules;Fortovase:softgel capsules Stavudine,d4T(Zerit,ZeritXR); NRTI(BristolMyersSquibb); Zerit:capsulesorpowder(fruit);Zerit XR:capsules Takewithin2hoursofa highcalorie,highfatmeal
PotentialSideEffects
Takewithorwithoutfood; avoiddrinkingalcohol
Tenofovir(Viread); NRTI(Gilead); Tablets(containlactose)
Takewithfood;avoidSt John'swort,garlic supplements,andmilk thistle
Zalcitabine,ddC(Hivid); NRTI(Roche); Tablets(containlactose)
Takeonanemptystomach; avoiddrinkingalcohol
Zidovudine,AZT,CompoundS, Azidothymidine(Retrovir); NRTI(GlaxoSmithKline); Tablets,capsules,syrup(strawberry), injections
Takewithorwithoutfood; donottakewithahighfat meal
Nauseaandvomiting,diarrhea,taste changes,lossofappetite,upset stomach,diabetes,inflamedpancreas, increasedtriglyceridelevels,increased liverenzymes,increasedmuscle damage,increaseduricacid Nausea,abdominaldiscomfort,gas, diarrhea,lowbloodsugar, mouth/esophagealulcers;Becarefulif youhaveliverdisease,check triglyceridelevels Nauseaandvomiting,diarrhea,lossof appetite,mouth/esophagealulcers, lipoatrophy,hyperlipidemia,problems withfeelinginyourarmsandlegs, increasedliverenzymes,increased pancreasenzymes; Maychangedoseforkidneyproblems Nausea,vomiting,diarrhea,passing gas,abdominalpain,lacticacidosis (rare),increasedmuscledamage, increasedtriglyceridelevels; Donottakeifyouhavekidney problems Lossofappetite,mouthsores,nausea andvomiting,diarrhea,constipation, problemswithfeelinginyourarms andlegs,lacticacidosis(rare), inflamedpancreas(rare),increased triglyceridelevels,anemia Dosemaybechangedforkidney problems Lossofappetite,nauseaandvomiting, upsetstomach,constipation,taste changes,anemia,musclediseasein longtermuse; Dosemaybechangedinimpairedliver orkidneyfunction
NRTI=nucleosidereversetranscriptaseinhibitor NNRTI=nonnucleosidereversetranscriptaseinhibitor Sources:Compiledfrommanufacturerinformation DrugFactsandComparisons.DrugFactsandComparisons2004.58thed.2003. PronskyZM,MeyerSA,FieldsGardnerC.HIVMedicationsFoodMedicationInteractionGuide.2nded.2001. DHHSPanelonAntiretroviralGuidelinesforAdultsandAdolescentsAWorkingGroupoftheOfficeofAIDSResearchAdvisoryCouncil. GuidelinesfortheUseofAntiretroviralAgentsinHIV1InfectedAdultsandAdolescents.October10,2006.

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American Dietetic Association. Reprinted with permission. HIVmedicationsinHIV/AIDS.In:TheAmericanDieteticAssociationNutrition CareManual.Updatedannually.Availableat:www.nutritioncaremanual.org.AccessedNovember15,2010.
Medications for symptom management: Symptom management is a key strategy in maintaining both nutritional status and ART regimen adherence (1). Medications may be used to control symptoms and conditions including nausea, vomiting, diarrhea, mouth and throat sores, and organ diseases (1). Two commonlyusedmedications,megestrolacetate(Megace)anddronabinol(Marinol),arecurrentlyapproved
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for appetite stimulation. It should be noted, however, that the weight gain associated with these appetite stimulantsistypicallyintheformoffatmassandnotthedesiredLBM (9).Megestrolacetatealsocompromises testosterone balance, making it difficult to maintain and restore BCM and possibly exacerbating diabetes mellitus (9). Coadministration of testosterone with megestrol acetate has not been shown to increase lean tissue accrual. Testosterone replacement and anabolic steroids have been explored to assist with the restoration of body weight and BCM in addition to improving strength and quality of life (49). However, anabolic steroids can cause liver toxicityand negativechanges in lipid profiles (1). The use of testosterone and recombinant human growth hormone to treat wasting and central fat accumulation has been explored (50).HigherdosesofgrowthhormonepromoterecoveryfromHIVrelatedwastingbyrestoringBCM,while lower doses of growth hormone reduce central fat accumulation (1). Anticytokine therapies, such as thalidomide, have been explored for treatment of tuberculosis and HIVrelated wasting (1). More recently, thalidomide has been used to treat recurrent aphthous ulcers and HIVrelated colitis; however, its use is limitedduetoteratogenicity,peripheralneuropathy,andotheradverseeffects(51). NutritionInterventionandMonitoring Symptom management is an important component of nutrition intervention and monitoring (1). Nutrition interventionsshouldsupportthepatientsmedicaltreatmentgoalswhilereducinganynegativenutritionrelated health effects of the disease and medication regimens (1). Complications are diverse and develop frequently, interferingwithnutritionalintakeandoutcomes.Someofthemorecommoncomplications,aswellasnutrition managementstrategiestooptimizenutritionalstatus,arelistedinTableIII11:NutritionManagementStrategies forPeopleWithHIVInfectionorAIDS. TableIII11:NutritionManagementStrategiesforPeopleWithHIVInfectionorAIDS(1) Complication PossibleCauses NutritionInterventions Anorexia Medication Reviewmedications. Infection Considerappetitestimulants. Fever Recommendsmall,frequent, Nausea nutrientdensefoods;eatinginapleasant Vomiting atmosphere;andeasytopreparefoodor Diarrhea assistancewithmeals. Pain Considermedicalnutritionalsupplements. Anxiety Considervitaminandmineralsupplementsif Depression symptomsorbiochemicaltestsindicate Othermedicaltherapies deficiency. Nauseaandvomiting Medication Reviewmedications. Infection Considerantiemetics. Anxiety Consideralteringmedicationtimes. Fever Recommendsmall,frequentfeedings;dry Medicaltherapies foods,softfoods,coldorroom temperaturefoods,andsaltyfoods; elevationofupperbodyduringandafter meals;andliquidsbetweenmeals. Ensureproperfoodmedicationschedule. Considermedicalnutritionalsupplements. Considervitaminandmineralsupplementsif symptoms or biochemical tests indicate deficiency. Recommendoralrehydration. Diarrhea Medication Reviewmedications. Antibiotictherapy Recommendoralrehydration;replace Infection electrolytes;increasesolublefiberfoods; Foodborneorwaterborneillness evaluatetolerancetogasformingfoods, Foodintolerance fat,andlactose. Othermedicalconditions Considerintravenousrehydration. Medicaltherapy Consideryogurtorprobioticsiflongterm Anxiety antibiotictherapyisrequired. Stress Considervitaminandmineralsupplementsif Manual of Clinical Nutrition Management III-54 Copyright 2011 Morrison Management Specialists, Inc.
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Complication Diarrhea(cont.) Oralandesophageallesions
Earlysatiety
Foodintolerances
Tasteandsmellchanges
NutritionInterventions symptomsorbiochemicaltestsindicate deficiency. Considerpancreaticenzymes. Medication Reviewmedications. Infection Recommendsoft,nonspicy,nonacidicfoods; Malnutrition pureedfoodsorthickenedliquids;andoral Oral and esophageal candidiasis supplements. Kaposisarcomaandother Consideratopicalanalgesictodecrease malignancies mouthpain. Considermedicalnutritionalsupplements. Considervitaminandmineralsupplementsif symptoms or biochemical tests indicate deficiency. Medication Reviewmedications. Infection Recommend,small,frequentfeedings; Nausea nutrientdensefoods;liquidsbetween meals;andavoidanceofgreasy,friedfoods andgasformingfoods. Considermedicalnutritionalsupplementsas betweenmealssnacks. Considervitaminandmineralsupplementsif symptomsorbiochemicaltestsindicate deficiency. Medication Reviewmedications. Infection Recommendalternativefoodsandtextures; Gastrointestinaldisturbance evaluatepatientfornutrientdeficiencies. Poordentition Considermedicalnutritionalsupplements Geneticcause astolerated. Considervitaminandmineralsupplementsif symptomsorbiochemicaltestsindicate deficiency. Medication Investigateandtreatcause. Change,initiate,ordiscontinuemedication. Recommendsmall,frequentfeedings; experimentwithawidevarietyoffoods andseasoningsandalternativeprotein sources.
PossibleCauses
Nutritionprescription:Theregistereddietitianshoulddeterminetheappropriatemodeofnutritionsupport basedonthenutritionassessmentanddiagnosis.Acombinationofapproachesmaybenecessarytoaddressthe nutritionrelated problems faced by persons with HIV (1). Meal planning using guidelines established for lipid managementanddiabetesmanagementmayalsobenecessaryinpatientswhodeveloplipodystrophyorglucose intolerance related to medication management (1,9). For these patients refer to Section C: Modification of CarbohydrateandFat.Considerthefollowinginformationwhendeterminingthenutritionprescription: Oralfeedingsarepreferredoveranyotherfeedingmethod.Effortstomaintaintheoralfeedingrouteshould be maximized. Nutrientdense foods and supplements should be used to support maintenance and restoration of nutritional status and body weight. Appetite stimulants may be indicated for patients who experienceanorexia(1,9). Theenteralfeedingrouteispreferredoverparenteraladministrationinordertopreservegutstructureand function.Assesspatientscarefullyandreassessthemonaregularbasis.PatientswithAIDSrelatedwasting syndromeshouldbecarefullymonitoredforrefeedingsyndrome (1,9).(SeeSectionB:SpecializedNutrition Support.)
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Parenteralnutritionmaybecomenecessarywhenapatientmeetsthecriteriaforinitiationoftotalparenteral nutrition (9). Continual assessment and routine monitoring of laboratory values is essential. Patients with AIDSrelatedwastingsyndromeshouldbecarefullymonitoredforrefeedingsyndrome (9).(SeeSectionB: SpecializedNutritionSupport.)
Pediatricspecific interventions: The goals of intervention for children with HIV infection are similar to the goalsforadultswiththeaddeddimensionofsupportingadequategrowthanddevelopment(1).MotherswithHIV should be made aware of the risks and benefits of different infantfeeding options, including the risk of HIV transmissionthroughbreastfeeding (1).TheWorldHealthOrganizationhas issued recommendationsfor infant feeding (52). The WorldHealthOrganizationrecommendsthecontinueduseofprophylacticantiretroviralsfor mothersandchildrentoreducetheriskofHIVtransmissionthroughbreastmilk(52). Patienteducationandfoodsafety:Educationandcounselingareessentialfeaturesofmedicalnutritiontherapy for people infected with HIV (1). Patients infected with HIV have weakened immune systems and are more susceptibletocontractingfoodborneillnesses,asshownbyarecentreviewbytheAmericanDieteticAssociation EvidenceAnalysisLibrary (Grade I) (1,21).Foodborneillnessesoftencausesymptomssimilartothoseofinfluenza (diarrhea,nausea,vomiting,fever,andcramping).Theseverityofsymptomsrangesfrommildtolifethreatening. One study demonstrated a decrease in the number of symptoms and eating difficulties in people with HIV infectionwhenfoodborneillnesseducationwasacomponentofanHIVhealthmanagementprogram(GradeI)(1,21). In addition, two studies showed that when education was part of a homedelivered meal program, there was strongadherencetofoodsafetyguidelines(GradeI)(1,21).Foodandwatersafetyeducationisofspecialimportance topatientsexperiencingimmunedysfunction,especiallyforpatientswithlowCD4counts (9,21).Patientsshould beprovidedwithinformationthatfitstheirindividuallifestylesintermsofshopping,cooking,storingfood,and diningout(9).Practicalfoodsafetyguidelinesforpatientsareasfollows(53): ShoppingforGroceries Payattentiontosellbyandusebydatesonperishableproducts.Donotpurchaseoruseoutdatedfoods. Putrawmeat,fish,andpoultryinseparateplasticbagsbeforeplacingtheminyourgrocerycartwithother foods. Avoidcansthathavedents,bulges,orleaks. Avoidluncheonmeatsandcheesesfromthedelicase,astheymayhavebeencontaminatedfromimproper foodhandling.Instead,useprepackagedprocessedmeatsandcheeses. Selectfooditemsthatrequirerefrigerationimmediately beforecheckingout.Iffoodwill be inthecarfor longerthan30minutes,useacoolertokeepitcold. Buyonlypasteurizeddairyproducts. StoringandSavingFoodatHome Check refrigerator and freezer temperatures. Refrigerators should be kept at or below 40F, and freezers shouldbekeptatorbelow0F. Keeptheinterioroftherefrigeratorandfreezerclean. After returning home from grocery shopping, immediately place perishable foods in the refrigerator or freezer. Placeuncookedmeat,fish,andpoultryproductsinseparateplasticbags,andthensetthemonaplateonthe lowestshelfoftherefrigeratortopreventrawjuicesfromdrippingontootherfoods. Use ground beef, ground poultry, and fresh fish within 1 to 2 days. Use beef steaks, roasts, and poultry within3or4days. Labelallleftoverswiththedate.Wrapleftoversorstoreinaclosedcontainer. Refrigerate leftovers as soon as possible. Foods left at room temperature for longer than 2 hours are susceptibletobacterialgrowth. Store leftovers in shallow containers rather than narrow, deep bowls. Shallow containers will help the leftoverscoolmorequicklytothepropertemperature. Leftoversshouldbewrappedsecurelybeforerefrigerationandshouldbeeatenwithin3or4days. FreezingandDefrostingFoods Thawallfrozenfoodsintherefrigerator.Placethefrozenfoodsinaplasticbagoronaplatetopreventjuices from dripping onto other foods. Frozen food can be defrosted in the microwave oven, according to the manufacturersdirections,andthencookedimmediately.
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Thawingfoodonthekitchencounterorinwarmwaterisdangerous.Manyharmfulbacteriagrowrapidly between70Fand120F. Ifindoubtaboutthesafetyofafood,throwitout.
PreparingFood Wash hands with antibacterial soap and warm water before and after handling food, and especially after handlingrawmeat,poultry,andfish.Washhandsaftersneezingorcoughing. Use separate cutting boards, platters, trays, and utensils for cooked and uncooked meat, poultry, and fish. Alwayswashcontactsurfacesandutensilswithadilutebleach solutionimmediatelyafterpreparingthese products. Scruballfreshfruitsandvegetablesinhot,soapywaterbeforeeating. Avoid sushi, sashimi, seviche, raw oysters and clams, Caesar salads, homemade salad dressings and mayonnaise,homemadeicecream,homemadeeggnog,homemadecheeses,andcookiedoughorcakebatter. These foods contain raw seafood, meat, poultry, or eggs and therefore may contain harmful pathogens (bacteria). Cooking Cook ground beef to a minimum internal temperature of 160F. Cook poultry to a minimum internal temperatureof165F,andcookfishtoaminimuminternaltemperatureof145F.Steaksandroastsshould becookedtoaminimuminternaltemperatureof145F.Meetingthesetemperaturerequirementsdoesnot necessarilymeanthatthefoodiswelldone. Useaninstantreadthermometerforalltypesofmeat,includingporkandfish,toaccuratelydeterminethe internaltemperature.Aninstantreadthermometerisdifferentfromameatthermometerinthatitdoesnot stayinthemeatwhilecooking.Ithasasmall,roundtemperaturedisplayand. Avoidcookingmeatsataverylowoventemperature(lessthan300F)orovernight,asthismayencourage bacterialgrowthbeforecookingiscomplete. Cookallgroundmeatsuntiltheyarebrownallthewaythrough.Thisisespeciallyimportantinarestaurant whereyoumaynotbeabletochecktheinternaltemperature. Cookstuffingseparatelyfrommeat. Tomarinatefoods,keepthemintherefrigeratorincoveredcontainers. Cookeggsuntilwelldone.Eggsthatarecookedovereasyorundercookedincreasetheriskofsalmonella infection.Eggdishesshouldbecookedtoaminimumtemperatureof160F. Cookrawseafoodwithin24hoursofpurchase.
MicrowaveOvenCooking Donotcookmeatthatcontainsbonesinthemicrowave.Bonescanshieldthesurroundingmeatfromthe microwavesandthereforeleavesomemeatundercooked. Becausemicrowavesdonotalwayscookfoodsevenly,tryusingaturntabletohelpincreasetheconsistency. Checkmeatinseveralplacestoensurethatiscookedtothepropertemperaturethroughout.
WaterSafety Bacteria that may contaminate a water supply include Giardia, Cryptosporidium, Microsporidia, and Mycobacteriumaviumintracellulare. Fordrinkingwater,boiltapwaterfor1to5minutes. Onlybottledwaterthathasbeenpurifiedbydistillation,reverseosmosis,orabsolute1mfiltrationcanbe consideredsafe. Homewaterfiltersshouldusereverseosmosisorabsolute1mfiltration.Safewaterfilterswillbelabeled NSFStandard53forCystRemovalonthebox. Iceissafeonlyifitismadefromwaterthathasbeenboiledorproperlydistilledorfiltered.
EatingAwayFromHome Makesuremeat,fish,andpoultryarecookedthoroughly.Checktoseethatburgersarenolongerpinkinthe middleandthejuicesrunclear.Sendbackundercookedmeatsforfurthercooking. Wheneatingfromabuffet,makesurecoldfoodsarecold(atorbelow41F)andhotfoodsarehot(ator above140F).Avoidbuffetswhenpossible. Orderfriedeggscookedonbothsides.Sendbackscrambledeggsthatlookrunny. Lookforcleanlinessatsaladbarsandatmeatanddelicounters.Immunecompromisedindividualsareat riskwhentheyeatfromsaladbars.Oftenfruitsandvegetablesarenotwashedthoroughly,andprepared foodsarenotkeptatpropertemperaturestopreventbacteriafromthriving.

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HIVInfectionandAIDS
Confirmthatsoapandtowelsareavailableintherestroom.Ifnot,itmaymeanthatthewaitstaffandcooks cannotwashtheirhandsproperlyafterusingtherestroom. Consumptionoffoodspurchasedfromstreetvendorsisriskyandshouldbediscouraged. ForeignTravel Donotpurchasefoodsfromstreetvendors. Choosecookedfoodsoversalads,fruits,andrawvegetables. Bringdrinkingwaterwithyou,ordrinkonlyboiledwaterthathasbeencooled.Beveragesmadewithboiled water,suchascoffeeortea,aresafertodrink,asarecannedorbottledcarbonatedbeverages,beer,andwine. Donotdrinkbeveragescontainingicecubes. NotethattheUnitedStateshasoneofthesafestfoodsuppliesintheworld.Beawarethatnotall countrieshavethesamehighstandardsforsanitationandfoodsafety.
References 1. PositionoftheAmericanDieteticAssociation:nutritioninterventioninhumanimmunodeficiencyvirusinfection.JAmDietAssoc.2010; 110:11051119. 2. Joint United National Programme on HIV/AIDS. Report on the Global AIDS Epidemic. Executive Summary. Available at: http://data.unaids.org/pu/GlobalReport/2008/JC1511_GR08_ExecutiveSummary_en.pdf.PostedJuly2008.AccessedOctober1,2010. 3. CentersforDiseaseControlandPrevention.HIV/AIDSdatathroughDecember2006.HIV/AIDSSurveillanceSupplementalReport.2009;14 (No.1).Availableat:www.cdc.gov/hiv/topics/surveillance/resources/reports/2009supp_vol14no1/pdf/HIVAIDS_SSR_Vol14_No1.pdf. AccessedJuly23,2009. 4. Hall HI, Song R, Rhodes P, Prejean J, An Q, Lee LM, Karon J, Brookmeyer R, Kaplan EH, McKenna MT, Janseen RS. Estimation of HIV incidenceintheUnitedStates.JAMA.2008;300:520529. 5. Centers for Disease Control and Prevention. CDC HIV/AIDS Facts: New Estimates of U.S. HIV Prevalence, 2006. Available at: www.cdc.gov/hiv/topics/surveillance/resources/factsheets/pdf/prevalence.pdf.PostedOctober2008.AccessedJuly23,2009. 6. CentersforDiseaseControlandPrevention.1993revisedHIVclassificationandexpandedAIDSsurveillancedefinitionforAIDSamong adolescentsandadults.MMWRMorbMortalWklyRep.1992;41:119. 7. Cohen PT, Sande MA, Volberding PA, eds. The AIDS Knowledge Base: A Textbook on HIV Disease From the University of California, San Francisco, and the San Francisco General Hospital. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999. Available at: hivinsite.ucsf.edu.[UniversityofCalifornia,SanFranciscowebsite].AccessedMarch30,2005. 8. WorldHealthOrganization.WHOCaseDefinitionsofHIVforSurveillanceandRevisedClinicalStagingandImmunologicalClassificationof HIVRelatedDiseaseinAdultsandChildren.WorldHealthOrganization;2007.Availableat: www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf.AccessedOctober28,2010. 9. HIV/AIDS.In:TheAmericanDieteticAssociationNutritionCareManual.Updatedannually.Availableat:www.nutritioncaremanual.org. AccessedNovember1,2010. 10. MangiliA,MurmanDH,ZampiniAM,WankeCA.NutritionandHIVinfection:reviewofweightlossandwastingintheeraofhighly activeantiretroviraltherapyfromthenutritionforhealthylivingcohort.ClinInfectDis.2006;42:836842. 11. Lo J, You SM, Wei J, Canavan B, Grinspoon S. Relationship of peak growth hormone to cardiovascular parameters, waist circumference,lipidsandglucoseinHIVinfectedpatientsandhealthyadults.ClinEndocrinol(Oxf).2009;71:815822. 12. SlamaL,LeCamusC,SerfatyL,PialouxG,CapeauJ,GharakhanianS.Metabolicdisordersandchronicviraldisease:thecaseofHIV andHCV.DiabetesMetab.2009;35:111. 13. LlibreJM,FlacoV,TuralC,NegredoE,PinedaJA,MunozJ,OrtegaE,VidelaS,SireraG,MartinezE,MirallesC,IribarrenJ,GalindoMJ, DomingoP,dArminioMonforteA,MiroJM,ClotetB.ThechangingfaceofHIV/AIDSintreatedpatients.CurrHIVRes.2009;7:365 377. 14. FaintuchJ,SoetersPB,OsmoHG.NutritionalandmetabolicabnormalitiesinpreAIDSHIVinfection.Nutrition.2006;22:683690. 15. KruzichLA,MarquisGS,CarriquiryAL,WilsonCM,StephensenCB.USyouthsintheearlystagesofHIVdiseasehavelowintakesof somemicronutrientsforoptimalimmunefunction.JAmDietAssoc.2004;104:10951101. 16. Butensky E, Harmatz P, Lee M, Kennedy C, Petru A, Wara D, Miaskowski C. Altered iron metabolism in children with human immunodeficiencyvirusdisease.PediatrHematolOncol.2009;26:6984. 17. SchaibleUE,KaufmannSH.Malnutritionandinfection:complexmechanismsandglobalimpacts.PLoSMed.2007May;4:e115. 18. SrasuebkulP,LimPL,LeeMP,KumarasamyN,ZhouJ,SirisanthanaT,LiPC,KamarulzamanA,OkaS,PhanuphakP,VonthanakS, MeratiTP,ChenYM,SungkanuparphS,TauG,ZhangF,LeeCK,DitangeoR,PujariS,ChoiJY,SmithJ,LawMG.Shorttermclinical disease progression in HIVinfected patients receiving combination antiretroviral therapy: results from the TREAT Asia HIV observationaldatabase.ClinInfectDis.2009;48:940950. 19. Siddiqui J, Phillips AL, Freedland ES, Sklar AR, Darkow T, Harley CR. Prevalence and cost of HIVassociated weight loss in a managedcarepopulation.CurrMedResOpin.2009;25:13071317. 20. KotlerDP,TierneyAR,WangJ,PiersonRNJr.MagnitudeofbodycellmassdepletionandthetimingofdeathfromwastinginAIDS. AmJClinNutr.1989;50:444447. 21. HIV/AIDSEvidenceBasedNutritionPracticeGuidelines.AmericanDieteticAssociationEvidenceAnalysisLibrary.AmericanDietetic AssociationDecember2010.Availableat:http://www.adaevidencelibrary.com/topic.cfm?cat=4248.AccessedDecember31,2010. 22. 13thannualHIVdrugguide.PositivelyAware.March/April2009;20:2855. Availableat:positivelyaware.com/2009/09_02/09_02.pdf.AccessedApril21,2009. 23. FichtenbaumCJ.MetabolicabnormalitiesassociatedwithHIVinfectionandantiretroviraltherapy.CurrInfectDisRep.2009;11:84 92. 24. Visnegarwala F, Shlay JC, Barry V, Gibert CL, Xiang Y, Wang J, Kotler D, Raghavan S, ElSadar WM; for Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). Effects of HIV infection on body composition changes among men of different racial/ethnicorgins.HIVClinTrial.2007;8:145154. Manual of Clinical Nutrition Management
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The effect of rosiglitazone on insulin sensitivity,betacellfunction,bonemineraldensity,andbodycompositioninHIVpositivepatientsonhighlyactiveantiretroviraltherapy (HAART).HormMetabRes.2009;41:573579. 29. MulliganK,YangY,WiningerDA,KoletarSL,ParkerRA,AlstonSmithBL,SchoutenJT,FieldingRA,BasarMT,GrinspoonS.Effectsof MetforminandrosiglitazoneinHIVinfectedpatientswithhyperinsulinemiaandelevatedwaist/hipratio.AIDS.2007;21:4757. 30. RawatR,StoltzfusRJ,NtoziniR,MutasaK,IliffPJ,HumphreyJH.Influenceofinflammationasmeasuredbyalpha1acidglycoproteinon ironstatusindicatorsamongHIVpositivepostpartumZimbabweanwomen.EurJClinNutr.2009;63:787793. 31. MburuAS,ThurnhmDI,MwankikiDL,MuniuEM,AlumasaF,deWagtA.Theinfluenceandbenefitsofcontrollingforinflammationon plasmaferritinandhemoglobinresponsesfollowingamultimicronutrientsupplementinapparentlyhealthy,HIV+Kenyanadults.JNutr. 2008;138:613619. 32. FeldmanJG,GoldwasserP,HolmanS,DeHovitzJ,MinkoffH.Creactiveproteinisanindependentpredictorofmortalityinwomenwith HIV1infection.JAcquirImmuneDeficSyndr.2003;32:210214. 33. Salomon J, de Truchis P, Melcior JC. Body composition and nutritional parameters in HIV and AIDS patients. Clin Chem Lab Med. 2002;40:13291333. 34. NorthropClewes CA. Interpreting indicators of iron status during an acute phase responselessons from malaria and human immunodeficiencyvirus.AnnClinBiochem.2008;45:1832. 35. BatterhamMJ.InvestigatingheterogeneityinstudiesofrestingenergyexpenditureinpersonswithHIV/AIDS:ametaanalysis.AmJClin Nutr.2005;81:702713. 36. FitchKV,GugginaLM,KeoughHM,DonalLoobySE,HadiganC,AndersonEJ,HubbardJ,LiebauJG,JohnsenS,WeiJ,MakimuraH,Stanley TL,LoJ,GrinspoonSK.DecreasedrespiratoryquotientinrelationtorestingenergyexpenditureinHIVinfectedandnoninfectedsubjects. Metabolism.2009;58:608615. 37. KulstadR,SchoellerDA.Theenergeticsofwastingdisease.CurrOpinClinNutrMetabCare.2007;10:488493. 38. Mwamburi DM, Wilson IB, Jacobson DI, Spiegelman D, Gerbach SL, Knox TA, Wanke CA. Understanding the role of HIV load in determiningweightchangeintheeraofhighlyactiveantiretroviraltherapy.ClinInfectDis.2005;40:167173. 39. CampaA,YangZ,LaiS,XueL,PhillipsJC,SalesS,PageJB,BaumMK.HIVrelatedwastinginHIVinfecteddrugusersintheeraofhighly activeantiretroviraltherapy.ClinInfectDis.2005;41:11791185. 40. WilliamsSB,BartschG,MuurahainenN,CollinsG,RaghavanSS,WheelerD.Proteinintakeispositivelyassociatedwithbodycellmassin weightstableHIVinfectedmen.JNutr.2003;133:11431146. 41. ShahM,TierneyK,AdamsHuetB,BoonyavarakulA,JacobK,QuittnerC,DingesW,PetersonD,GargA.Theroleofdiet,exerciseand smokingindyslipidaemiainHIVinfectedpatientswithlipodystrophy.HIVMed.2005;6:291298. 42. WoodsMN,SpeiglemanD,KnoxTA,ForresterJE,ConnorsJL,SkinnerSC,SilvaM,KimJH,GorbachSL.Nutrientintakeandbodyweightin alargeHIVcohortthatincludeswomenandminorities.JAmDietAssoc.2002;102:203211. 43. MondyK,TebasP.Emergingboneproblemsinpatientsinfectedwithhumanimmunodeficiencyvirus.ClinInfectDis.2003;36(suppl2): S101S105. 44. ProjectInform.Herbs,recreationaldrugsandHIVmedications.Janauary2010. Availableat:http://www.projectinform.org/info/herbs/index.shtml.AccessedDecember31,2010. 45. FerrandoSJ,RabkinJG,LinSH,McElhineyM.Increaseinbodycellmassanddecreaseinwastingareassociatedwithincreasingpotencyof antiretroviraltherapyforHIVinfection.AIDSPatientCareSTDS.2005;19:216223. 46. DuvivierC,KoltaS,AssoumouL,GhosnJ,RozenbergS,MurphyRL,KatlamaC,CostagliolaD,ANRS121Hippocampestudygroup.Greater decrease in bone mineral density with protease inhibitor regimens compared with nonnucleoside reverse transcriptase inhibitor regimensinHIV1infectednavepatients.AIDS.2009;27:817824. 47. BoesckeC,CooperDA.ToxicityofHIVproteaseinhibitors:clinicalconsiderations.CurrOpinHIVAIDS.2008;3:653659. 48. LopezJC,MorenoS,JimenezOnateF,ClotetB,RubioR,HernandezQueroJ.Acohortstudyofthefoodeffectonvirologicalfailureand treatment discontinuation in patients on HARRT containing didanosine entericcoated capsules (FOODDIe Study). HIV Clin Trials. 2006;7:155162. 49. Hengge UR, Stocks K, Wiehler H, Faulkner S, Esser S, Lorenz C, Jentzen W, Hengge D, Goos M, Dudley RE, Ringham G. Doubleblind, randomized,placebocontrolledphaseIIItrialofoxymetholoneforthetreatmentofHIVwasting.AIDS.2003;17:699710. 50. Cofrancesco J Jr, Freedland E, McComsey G. Treatment options for HIVassociated central fat accumulation. AIDS Patient Care STDS. 2009;23:518. 51. MatthewsSJ,McCoyC.Thalidomide:areviewofapprovedandinvestigationaluses.ClinTher.2003;25:342395. 52. World Health Organization. Rapid advice: revised WHO principles and recommendations on infant feeding in the context of HIV November 2009. World Health Organization; 2009. Available at: whqlibdoc.who.int/publications/2009/9789241598873_eng.pdf. AccessedJanuary18,2010. 53. USDeptofAgriculture,FoodSafetyandInspectionService.FoodSafetyforPeopleWithHIV/AIDS:ANeedtoKnowGuideforThoseWho HaveBeenDiagnosedWithHIV/AIDS.USDeptofAgriculture;2006.Availableat: www.fsis.usda.gov/PDF/Food_Safety_for_People_with_HIV.pdf.AccessedNovember16,2010.
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HYPERTENSION
Discussion Atleast50millionadultsintheUnitedStateshavehypertension (1).AccordingtotheSeventhReportofthe JointNationalCommitteeonPrevention,Detection,Evaluation,andTreatmentofHighBloodPressure(referred toastheJNC7),30%oftheseadultsareunawarethattheyhavehypertension,andmorethan40%ofadults withhypertensionarenotreceivingtreatment (2).Theprevalenceofhypertensionincreaseswithadvancing age.Morethanhalfofpeopleaged60to69yearsandapproximatelythreefourthsofpeopleaged70years and older have hypertension (1). Based on data from the Framingham Heart Study, people who are normotensive at 55 years of age have a 90% lifetime risk of developing hypertension (3). In African Americans,hypertensionismorecommonandmoresevere.Itdevelopsatanearlierageandleadstomore clinicalcomplications(2). Hypertensionisanincreasinglyimportantmedicalandpublichealthissue (2).Forevery20mmHgsystolic or 10 mm Hg diastolic increase in blood pressure, the mortality from ischemic heart disease and stroke doubles.DatafromtheFraminghamHeartStudyindicatethatbloodpressurevaluesintherangeof130to 139 mm Hg systolic and 85 to 89 mm Hg diastolic are associated with a more than 2fold increase in the relativeriskofcardiovasculardiseasewhencomparedwithbloodpressurelevelsbelow120/80mmHg (4,5). Basedonthisemergingdataonthelifetimeriskofhypertensionandtheimpressiveincreaseintheriskof cardiovascularcomplicationsassociatedwithlevelsofbloodpressurepreviouslyconsiderednormal(140/90 mm Hg), the JNC 7 has established a blood pressure classification system that contains a prehypertension categoryandrangesforstaginghypertension(2).(RefertoTableIII12.) TableIII12:JNC7ClassificationofBloodPressureforAdultsAged18YearsandOlder(2) Systolic(mmHg) Diastolic(mmHg) Category <120 and<80 Optimala 120139 or8089 Prehypertensionb Stage1hypertensionc 140159 or9099 Stage2hypertensionc >160 or100
Optimalbloodpressurewithrespecttocardiovascularriskislessthan120/80mmHg.Unusuallylowreadingsshouldbeevaluated. Prehypertensionisnotadiseasecategory,ratheritisadesignationthatidentifiesindividualsathighriskofdevelopinghypertension. Lifestylemodificationsarerecommendedtoreducetheriskfordevelopinghypertension.Forpatientswhohavediabetesmellitusor kidneydisease,drugtherapyshouldbeconsideredifatrialoflifestylemodificationsfailstoreducebloodpressureto130/80mmHgor less. cBasedontheaverageoftwoormoreproperlymeasuredbloodpressurereadingstakenwhileseatedduringtwoormorevisits
a b
ClassificationandApproachestoTreatment The classification system introduced by the JNC 7 includes a prehypertension category for individuals who havebloodpressurereadingsof120to139mmHgsystolicor80to89mmHgdiastolic.Prehypertensionis not a disease category, rather it is a designation that identifies individuals at high risk of developing hypertension (2). Individuals in the prehypertension category are advised to adopt lifestyle modifications, including dietary modifications and physical activity, to reduce their risk of developing hypertension. For patients who have prehypertension and diabetes mellitus or kidney disease, drug therapy should be considerediflifestylemodificationsfailtoreducebloodpressureto130/80mmHg(2). The JNC 7 does not stratify individuals with hypertension by the presence or absence of risk factors or targetorgandamage.TheJNC7suggestslifestylemodificationsasanadjunctivetherapytopharmacotherapy for all persons who have stage 1 or stage 2 hypertension (2). The treatment goal for individuals who have hypertension and no other medical conditions is a blood pressure of 140/90 mm Hg or less (2). For individualswhohavehypertensionanddiabetesmellitusorkidneydisease,thetreatmentgoalis130/80mm Hg (2). The JNC 7 indicates that greater attention should be provided to the monitoring and evaluation of systolic blood pressure as a major risk factor for cardiovascular disease (2). The increase in systolic blood pressurecontinuesthroughoutlife,incontrasttodiastolicbloodpressure,whichincreasesuntil50yearsof age and then tends to leveloff during the next decade. Systolic hypertension is the most common form of hypertensioninpeopleolderthan50years.Thediastolicbloodpressureisamorepotentcardiovascularrisk factor than systolic blood pressure prior to 50 years of age; thereafter, systolic blood pressure is more important (2). (Refer to Table III13: JNC 7 Classification and Management of Blood Pressure for Adults.)
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Hypertension
TableIII13:JNC7ClassificationandManagementofBloodPressureforAdults(6) Diastolica Lifestyle DrugTherapy BloodPressure Systolica DrugTherapyWith (mmHg) (mmHg) Modification WithNoMedical Classification ExistingMedical Conditions Conditionsb Normal <120 and<80 Encourage Notindicated Notindicated Prehypertension 120139 or8089 Yes Notindicated Indicatedincasesof diabetesorkidney diseasec Stage1 140159 or9099 Yes Thiazidetype Drugsspecificfor hypertension diureticsformost medicalconditions patients Otherantihypertensive ConsiderACEI, drugs(diuretics,ACEI, ARB,BB,CCB,or ARB,BB,CCB)as combination needed Stage2 >160 or>100 Yes Twodrug Drugsspecificfor hypertension combinationfor medicalconditions mostdpatients Otherantihypertensive (thiazidetype drugs(diuretics,ACEI, diureticandACEI, ARB,BB,CCB)as ARB,BB,orCCB) needed
ACEI,angiotensinconvertingenzymeinhibitor;ARB,angiotensinreceptorblocker;BB,betablocker;CCB,calciumchannelblocker aTreatmentisdeterminedbyhighestbloodpressurecategory. bMedicalconditionsinclude:heartfailure,postmyocardialinfarction,highriskofcoronarydisease,chronickidneydisease,andrecurrent strokeprevention cTreatpatientswhohavechronickidneydiseaseordiabetestoachievethebloodpressuregoalof<130/80mmHg. dInitialcombinedtherapyshouldbeusedcautiouslyinpatientsatriskfororthostatichypotension.

Evaluation AccordingtotheJNC7,theevaluationofpatientswithdocumentedhypertensionhasthreeobjectives (2):1) assesslifestyleandidentifyothercardiovascularriskfactorsorconcomitantdisordersthataffectprognosis andguidetreatment,2)revealidentifiablecausesofhighbloodpressure(refertoTableIII14),and3)assess thepresenceorabsenceoftargetorgandamageandcardiovasculardisease. TableIII14:CausesofHypertension(2) Sleepapnea Drugs such as cyclosporine, nonsteroidal antiinflammatory drugs, sympathomimetics (decongestants, anorectics),oralcontraceptivehormones,adrenalsteroidhormones,anderythropoietin Herbalsupplementssuchasephedra(mahuang)andbitterorange Chronickidneydisease Primaryaldosteronism Renovasculardisease ChronicsteroidtherapyandCushingssyndrome Pheochromocytoma Coarctationoftheaorta Thyroidorparathyroiddisease Causalfactorsforhypertensionincludeexcessbodyweight;excessdietarysodiumintake;reducedphysical activity;inadequateintakeoffruits,vegetables,andpotassium;andexcessalcoholintake (1,7,8).Accordingto theJNC7,theprevalenceofthesecharacteristicsishigh.Recentdataindicatethat64%ofAmericanadults are either overweight or obese (9). Mean sodium intake is 4,100 mg/day for men and 2,750 mg/day for women.Theconsumptionofprocessedfoodsaccountsfor75%ofthedailysodiumintake (2).Fewerthan 20%ofAmericansengageinphysicalactivity(10),andfewerthan25%consumefiveormoreservingsoffruits andvegetablesdaily(11). NutritionalAssessmentandEvaluation Routinenutritionalassessmentshouldincludebloodpressureevaluation (GradeIV)(12);assessmentforsignsof edema; and review of laboratory tests that assess blood glucose, hematocrit, serum potassium, calcium, creatinine or glomerular filtration rate, and lipid profiles (2). The patients height and weight should be measured,andthepatientsbodymassindexshouldbeevaluatedtoassesstheneedforweightmanagement
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Hypertension
asanadjuncttotreatment.Theseparametersshouldbeassessedtoestimateriskfordiseaseandtoidentify treatmentoptions (Grade IV) (12).Thefoodandnutritionhistoryshouldassessthepatientsintakeofsodium, potassium, and calcium and the frequency at which the patient consumes fruits, vegetables, lowfat dairy products,andprocessedfooditems.Thepatientshouldbeadvisednottouseherbalsupplements,suchas ephedra (ma huang) and bitter orange that increase blood pressure (2). Interactions between antihypertensive medications and nutrients or foods should be examined (Grade IV) (12). Patients who take monoamineoxidaseinhibitorsshouldbeadvisedthatconsumptionoflicoriceandtyraminecontainingfoods will increase their blood pressure (2). Based on the nutritional assessment and the patients concomitant conditions,refertothefollowingsectionsfornutritionalmanagement: SectionC:MedicalNutritionTherapyforDiabetesMellitus SectionC:CalorieControlledDietforWeightManagement SectionC:MedicalNutritionTherapyforDisordersofLipidMetabolism SectionG:MedicalNutritionTherapyforChronicKidneyDisease Atreatmentgoaloflessthan140/90mmHgisrecommendedforindividualswhodonothavecomorbidities (Grade IV) (12). This blood pressure level is associated with preventing target organ damage and decreasing cardiovascular risk factors and complications (Grade IV) (12). For individuals who have hypertension and diabetesor renal disease, atreatmentgoal of lessthan130/90 mm Hg isrecommended (Grade IV) (12). These individualsareatanincreasedriskforcardiovascularandrenalmorbidityandmortality(GradeIV)(12). AccurateBloodPressureMeasurement Theausculatorymethodofbloodpressuremeasurementwithaproperlycalibratedandvalidatedinstrument isrecommended(6,7).Thepatientshouldbeseatedquietlyforatleast5minutesinachair(ratherthanonan exam table), with feet on the floor and an arm supported at heart level. Caffeine, exercise, and smoking shouldbeavoidedforatleast30minutespriortobloodpressuremeasurement(2).Anappropriatesizedcuff (cuff bladder encircling at least 80% of the arm) should be used to ensure accuracy. At least two measurements should be made. The systolic blood pressure is the point at which the first two or more soundsareheard(phase1),andthediastolicbloodpressureisthepointbeforethedisappearanceofsounds (phase5)(6). HypertensioninChildrenandAdolescents In children and adolescents, hypertension is defined as elevated blood pressure that persists on repeated measurementatthe95thpercentileorgreaterforage,height,andsex (2).Chronichypertensionisbecoming increasinglycommoninadolescenceandisassociatedwithobesity,asedentarylifestyle,andafamilyhistory ofhypertensionorothercardiovasculardiseases (2).Lifestyleinterventionsshouldberecommendedforall childrenandadolescentswithhypertension (2).Pharmacologicaltherapyisrecommendedforchildrenand adolescents who have higher levels of blood pressure or who do not sufficiently respond to lifestyle modifications(2).
BenefitsofLoweringBloodPressureandLifestyleModificationIntervention Majorlifestylemodificationsthatlowerbloodpressureincludelimitingsodiumintaketonomorethan2,300 mg/day(GradeI)(12);weightreductionforindividualswhoareoverweightorobese(GradeIV)(12);adoptionofthe DietaryApproachestoStopHypertension(DASH)eatingplan,whichisadietrichinpotassiumandcalcium and lower in sodium, dietary cholesterol, saturated fat, and total fat (<27% of total energy) (Grade IV) (12,13); physicalactivity(GradeIV)(12);andmoderationofalcoholconsumption(GradeIV)(2,12).(SeeTableIII15:Evidence SupportingLifestyleModificationstoManageHypertension.)Lifestylemodificationsreducebloodpressure, prevent or delay the incidence of hypertension, enhance antihypertensive drug efficacy, and decrease cardiovascularrisk (GradeIV) (2,6,12).TheeffectsofaDASHeatingplanthatlimitsdailysodiumintaketo1,500 mgaresimilartotheeffectsofsingledrugtherapy (13).Combinationsoftwoormorelifestylemodifications can achieve even better results (2). Modifiable lifestyle factors have significant blood pressurelowering effects, and the adoption of a healthy lifestyle is an indispensable part of the management of hypertension (2,8).
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Hypertension
TableIII15:EvidenceSupportingLifestyleModificationstoManageHypertension LifestyleModification Rationale Factor Tobaccoavoidance Although not directly related to hypertension, tobacco use may impair the protective effectofantihypertensivemedicationsoncoronaryheartdisease(2). Weightreduction Research has shown a direct positive correlation between body weight or body mass (ifheavierthanideal indexandbloodpressure(2,14,15).Weightreductionbyenergyrestrictionmayresultina substantial decrease in blood pressure. As little as 4.5 kg of weight loss is associated weight) with reductions of 4 to 5 mm Hg systolic and 2 to 4 mm Hg diastolic pressure (16). Reductionsof5to20mmHgsystolicbloodpressureoccurwithevery10kgofweight loss(GradeIV)(1215). Moderatealcoholintake Moderateconsumptionofalcohol(<30gofethanolperdayortwodrinksperday)is notassociatedwithbloodpressureincreases (2).Largeramountsofalcoholingestion haveadoserelatedeffectonbloodpressureinbothhypertensiveandnormotensive subjects (8). Consumption of more than2 oz of ethanol per day may cause elevated blood pressure and resistance to antihypertensive treatment (2). Hypertensive patientsshouldlimittheiralcoholconsumption.Hypertensivemenshouldconsume no more than 1 oz of ethanol per day (equivalent to two drinks) (Grade IV) (2,12). Hypertensivewomenshouldconsumenomorethan0.5ozofethanol(onedrink)per day (Grade IV) (2,12). A reduction in alcohol consumption may reduce systolic blood pressurebyapproximately2to4mmHg(GradeIV)(12).Onedrinkisequivalentto12oz ofbeer,5ozofwine,or1.5ozof80proofliquor(2).Reboundhypertensionfrequently occurs during alcohol withdrawal, but it generally reverses within a few days to 6 weeks(17). Regular aerobic activities, such as walking, jogging, or swimming, may aid in the Physicalactivity prevention and treatment of hypertension (2). Regular physical activity can enhance weightloss,reducetheriskofcoronaryheartdisease(17),andpreventtheincreasein bloodpressurethatisassociatedwithaging (17).Regularexercisecanreducesystolic blood pressure by approximately 4 to 9 mm Hg (Grade IV) (12,17,18). Since exercise can initially increase blood pressure, patients should consult their physician before beginninganexerciseprogram (1,17).TheJNC7guidelinesareconsistentwithother national guidelines and recommend at least 30 minutes of aerobic activity on most daysoftheweek(GradeIV)(2,12).

Moderatesodiumintake
Adequatecalciumintake
Dietary sodium intake should be limited to 2,300 mg/day (100 mmol/day) or less (GradeI) (2,12).AfricanAmericans,olderpeople,andpatientswhohavehypertensionor diabetestendtobemoresensitivetodietarychangesinsodiumintake (2,13,19,20).The Dietary Guidelines for Americans suggests that persons who are 51 and older and thoseofanyagewhoareAfricanAmericanorhavehypertension,diabetes,orchronic kidneydiseaseshouldnotconsumemorethan1,500 mg/dayofsodium (21).Dietary sodium reduction is associated with a 2 to 8 mm Hg reduction in systolic blood pressure (Grade I) (12,13,19,20).AccordingtheAmericanDieteticAssociation,ifapatient demonstrates adherence to a 2,300 mg/day sodium diet but has not achieved the treatment goal, then the DASH dietary pattern or a reduction in sodium to 1,600 mg/daycanfurtherreducebloodpressure(GradeI)(12).(SeeSodiumControlledDietin SectionIF.) Population studies have shown an inverse association between blood pressure and calciumintake(2,13,22).However,noevidencesuggeststhatthecalciumintakeshouldbe increased beyond the Dietary Reference Intake (DRI) (2,12,20). Epidemiological studies have found that dietary patterns that do not meet the DRI for calcium are associated with increased blood pressure (Grade II) (12). The DASH eating plan, which significantly reduces blood pressure, provides 1,240 mg/day of calcium based on a 2,000 kcal combinationdiet(23). III-63
Hypertension
TableIII15:EvidenceSupportingLifestyleModificationstoManageHypertension(Cont.) LifestyleModification Rationale Factor Adequatepotassium Observationalstudiessuggestthatincreasedconsumptionofpotassiumisassociated intake with a lower incidence of stroke (17). High potassium intake may also be protective against hypertension (2,13,22). The diet should emphasize the consumption of foods richinpotassium,exceptwhencontraindicated(eg,patientswhoreceiveangiotensin converting enzyme inhibitors or who have renal insufficiency). The JNC 7 does not specify a potassium intake level. However, the JNC 6 recommended a potassium intake of 3,510 mg/day (90 mmol/day) from food sources such as fresh fruits and vegetables.ThelatestDRIsforpotassiumhavebeenincreasedto4,500mg/dayfor adultstoprovideaprotectiveeffectagainsthypertension (23).Potassiumintakesthat donotmeettheDRIsareassociatedwithincreasedbloodpressure (Grade II) (12).The DASHeatingplan,whichsignificantlyreducesbloodpressure,provides4,700mg/day ofpotassiumbasedona2,000kcalcombinationdiet(13,19,20,24).TheDietaryGuidelines for Americans suggests that individuals who have hypertension, African Americans, and middleaged and older adults should meet the potassium recommendation of 4,700mg/dayfromfoodsources (21).Thebestsourcesofpotassiumarefruitsfrom vines,leafygreenvegetables,androotvegetables (21).Althoughmeat,milk,andcereal products contain potassium, the form of potassium in these foods is not as readily absorbed(21). Adequatemagnesium intake
Because of its vasodilative properties, magnesium may have beneficial effects on hypertension (17).However,noevidencesuggeststhatpatientsshouldincreasetheir magnesium intake beyond the DRI (Grade II) (2,12,22). The DASH eating plan, which significantlyreducesbloodpressure,provides500mg/dayofmagnesiumbasedona 2,000 kcal combination diet (24). Dietary patterns that do not meet the DRI for magnesiummaybeassociatedwithincreasedbloodpressure(GradeII)(12).
DASHeatingplan
The DASH clinical study demonstrated that a diet (referred to as a combination diet) that is rich in fruits and vegetables (five to ten servings) and lowfat dairy food and reducestheintakeofsaturatedfat(6%),totalfats(<27%energy),andsodium(<2,400 mg/dayand1,500mg/day)significantlylowersbloodpressure (Grade I) (12,13,1925).The DASHeatingplanthatlimitssodiumintaketo1,500mg/dayprovidesthegreatestblood pressurereductions(13,19).FollowingtheDASHeatingplanisassociatedwithan8to14 mmHgreductioninsystolicbloodpressure (13,19).TheDASH2,000kcalcombination diet also provides 31 g/day of fiber (21). The JNC 7 and the American Dietetic AssociationrecommendtheDASHeatingplanforthetreatmentofhypertension(GradeIV) (2,12). The serving sizes from the Dietary Guidelines for Americans are used as the reference guide in the DASH eating plan (21). The DASH eating plan provides 2,000 kcal/day,howeveritcanbemodifiedtomeetlowerorhigherenergyneeds (26).(Refer toTablesIII16fordetailsregardingtheDASHeatingplan(23,26). ExamplesandNotes Significancetothe DASHEatingPlan Majorsourceof energyandfiber Selectunsaltedor lowersodium products.
TableIII16:DASHEatingPlan(26) FoodGroup DailyServings ServingSizes Grainsandgrain Sixtoeight products One sliceofbread 1ozdrycereala cupcookedrice, pasta,orcereal
Vegetables
Fourtofive
Wholewheatbread, Englishmuffin,pita bread,bagel,cereals, grits,oatmeal,crackers, unsaltedpretzelsand popcorn 1cuprawleafy Tomatoes,potatoes, Richsourcesof vegetables carrots,greenpeas, potassium, cupcooked squash,broccoli,turnip magnesium,and vegetables greens,collard,kale, fiber 6ozvegetablejuice spinach,artichokes, Selectlowersalt greenbeans,limabeans, cannedvegetables sweetpotatoes ortomatojuice. III-64
Hypertension
FoodGroup Fruits
DailyServings Fourtofive
ServingSizes cup fruitjuice Onemediumfruit cupdriedfruit cupfresh, frozen,orcanned fruit
ExamplesandNotes Apricots,bananas,dates, grapes,oranges,orange juice,grapefruit, grapefruitjuice, mangoes,melons, peaches,pineapples, prunes,raisins, strawberries, tangerines Fatfreeorlowfat(1%) milk,fatfreeorlowfat buttermilk,fatfreeor lowfatregularor frozenyogurt,fatfree orlowfatcheese
Significancetothe DASHEatingPlan Importantsourcesof potassium, magnesium,and fiber
Lowfatorfat freedairy
Twotothree
8ozmilk 1cupyogurt 1ozcheese
Meats,poultry, andfish
Twoorless
3ozcookedmeat, poultry,orfish
Nuts,seeds,and drybeans
Fourtofiveper week
Fatsandoilsb
Twotothree
Sweets
Fiveorlessper week
1/3cupor1oz nuts 2tbsporoz seeds cupcookeddry beansorpeas 1tspsoft margarine 1tbsplowfat mayonnaise 2tbsplightsalad dressing 1tspvegetableoil 1tbspsugar 1tbspjellyorjam ozjellybeans 8ozlemonade
Selectonlylean meats; trimawayvisiblefats; broil,roast,orboil, insteadoffrying; removeskinfrom poultry Almonds,filberts,mixed nuts,peanuts,walnuts, sunflowerseeds, kidneybeans,lentils
Softmargarine,lowfat mayonnaise,lightsalad dressing,vegetableoil (suchasolive,corn, canola,orsaffloweroil)
Majorsourcesof calciumandprotein Monitorsodium contentofprocessed cheeses(600mgof sodium)andnatural cheeses(110450 mgofsodium). Richsourcesof proteinand magnesium Limithamand processedmeats thatcontainsodium. Richsourcesof energy,magnesium, potassium,protein, andfiber Selectunsalted versions. DASHhas27%of totalenergyasfat, includingfatinor addedtofoods. Selectlowsalt versionsofdressing.
Maplesyrup,sugar,jelly, Sweetsshouldbelow jam,fruitflavored infat. gelatin,jellybeans, hardcandy,fruitpunch, sorbet,ices
Oneounceequalsto1cups,dependingonthetypeofcereal.ChecktheproductsNutritionFactslabel. Fatcontentchangesservingcountsforfatsandoils.Forexample,1tbspofregularsaladdressingequalsoneserving;1tbspoflowfat dressingequalsonehalfofaserving;and1tbspoffatfreedressingequalszeroservings.
References 1. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 19882000. JAMA.2003;290:199206. 2. ChobanianAV,BakrisGL,BlackHR,CushmanWC,GreenLA,IzzoJLJr,JonesDW,MatersonBJ,OparilS,WrightJTJr,RoccellaEJ,the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention,Detection,Evaluation,andTreatmentofHighBloodPressure.Hypertension.2003;42:12061252. 3. VasanRS,BeiserA,SeshadriS,LarsonMG,KannelWB,DAgostinoRB,LevyD,[fortheFraminghamHeartStudy.Residuallifetime riskfordevelopinghypertensioninmiddleagedwomenandmen:theFraminghamHeartStudy.JAMA.2002;287:10031010. 4. LewingtonS,ClarkeR,QizilbashN,PetoR,CollinsR,fortheProspectiveStudiesCollaboration.Agespecificrelevanceofusualblood pressuretovascularmortality:ametaanalysisofindividualdataforonemillionadultsin61prospectivestudies.Lancet.2002; 360:19031913. 5. Vasan RS, Larson MG, Leip EP, Evans JC, ODonnell CJ, Kannel WB, Levy D. Impact of highnormal blood pressure on the risk of cardiovasculardisease.NEnglJMed.2001;345:12911297. Manual of Clinical Nutrition Management
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Hypertension 6. 7. 8. JNC7Express:TheSeventhReportoftheJointNationalCommitteeonPrevention,Detection,Evaluation,andTreatmentofHighBlood Pressure.Bethesda,Md:USDeptofHealthandHumanServices;2003.NIHPublicationNo.035233. World Hypertension League. Measuring your blood pressure. Available at: http://www.mco.edu/org/whl/bloodpre.html. AccessedApril1,2003. Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, Roccella EJ, Stout R, Vallbona C, Winston MC, Karimbakas J, for the National High Blood Pressure Education Program Coordinating Committee. Primary prevention of hypertension: clinical and publichealthadvisoryfromtheNationalHighBloodPressureEducationProgram.JAMA.2002;288:18821888. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among U.S. adults, 19992000. JAMA. 2002;288:17231727. USDeptofHealthandHumanServices.PhysicalActivityandHealth:AReportoftheSurgeonGeneral.Atlanta,Ga:USDeptofHealth and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion;1996.Availableat:http://www.cdc.gov/nccdphp/sgr/contents.htm. DivisionofAdultandCommunityHealth,NationalCenterforChronicDiseasePreventionandHealthPromotion,CentersforDisease Control and Prevention. Five a day surveillance: behavioral risk factor surveillance system online prevalence data, 19952000. Availableat:http://apps.nccd.cdc.gov/5ADaySurveillance/.AccessedNovember2003. Hypertension EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2008.Availableat:http://www.adaevidencelibrary.com.AccessedJanuary5,2009. SacksFM,SvetkeyLP,VollmerWM,AppelLJ,BrayGA,HarshaD,ObarzanekE,ConlinPR,MillerER3rd,SimonsMortonDG,Karanja N,LinPH,fortheDASHSodiumCollaborativeResearchGroup.EffectsonbloodpressureofreduceddietarysodiumandtheDietary ApproachestoStopHypertension(DASH)diet.NEnglJMed.2001;344:310. TrialsofHypertensionPreventionCollaborativeResearchGroup.Effectsofweightlossandsodiumreductioninterventiononblood pressure and hypertension incidence in overweight people with highnormal blood pressure. The Trials of Hypertension Prevention,phaseII.ArchInternMed.1997;157:657667. HeJ,WheltonPK,AppelLJ,CharlestonJ,KlagMJ.Longtermeffectsofweightlossanddietarysodiumreductiononincidenceof hypertension.Hypertension.2000;35:544549. ErnstN,ObarzanekE,ClarkMB,BriefelR,BrownC,DonatoK.Cardiovascularhealthrisksrelatedtooverweight.JAmDietAssoc. 1997;97:S47S51. AldermanMH.Nonpharmacologicaltreatmentofhypertension.Lancet.1994;344:307311. WheltonSP,ChinA,XinX,HeJ.Effectofaerobicexerciseonbloodpressure:ametaanalysisofrandomized,controlledtrials.Ann InternMed.2002;136:493503. VollmerWM,SacksFM,ArdJ,AppelLJ,BrayGA,SimonsMortonDG,ConlinPR,SvetkeyLP,ErlingerTP,MooreTJ,KaranjaN,forthe DASHSodiumTrialCollaborativeResearchGroup.Effectsofdietandsodiumintakeonbloodpressure:subgroupanalysisofthe DASHsodiumtrial.AnnInternMed.2001;135:10191028. Chobanian AV, Hill M. National Heart, Lung, and Blood Institute Workshop on Sodium and Blood Pressure: a critical review of currentscientificevidence.Hypertension.2000;35:858863. DietaryGuidelinesforAmericans2010.Availableat: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.AccessedJan31,2011. Sacks F, Willett WC, Smith A, Brown L, Rosner B, Moore T. Effect on blood pressure of potassium, calcium, and magnesium in womenwithlowhabitualintake.Hypertension.1998;31:131138. SvetkeyLP,SimonsMortonD,VollmerWM,AppelLJ,ConlinPR,RyanDH,ArdJ,KennedyBM,fortheDASHResearchGroup.Effects of dietary patterns on blood pressure: subgroup analysis of the Dietary Approaches to Stop Hypertension (DASH) randomized clinicaltrial.ArchInternMed.1999;159:285293. Institute of Medicine. Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: National AcademyPress;2004. AppelL,MooreTJ,ObarzanekE,VollmerW,SvetkeyL,SacksFM,BrayAG,VogtTM,CutlerJA,WindhauserMM,PaoHwaL,Karanja N,fortheDASHCollaborativeResearchGroup.Aclinicaltrialoftheeffectsofdietarypatternsonbloodpressure.NEnglJMed. 1997;336:11171123. DASHEatingPlan.Bethesda,Md:USDeptofHealthandHumanServices;revisedApril2006.NIHPublicationNo.064082.
9. 10.
11.
12. 13.
14.
15. 16. 17. 18. 19.
20. 21. 22. 23.
24. 25.
26.
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HYPERTRIGLYCERIDEMIA
Discussion Elevatedserumtriglyceridelevelsarepositivelycorrelatedwiththeriskforcoronaryheartdisease (1).This relationshipiscomplexandmaybeexplainedbytheassociationbetweenhightriglyceridelevels,lowlevels of highdensity lipoprotein (HDL) cholesterol, and unusually atherogenic forms of lowdensity lipoprotein (LDL) cholesterol. A high triglyceride level may also reflect an increased level of triglyceriderich lipoproteins,knownasverylowdensitylipoproteins,whichhaveatherogeniceffects(1). TheNationalCholesterolEducationProgramAdultTreatmentPanelIII(ATPIII)developedaclassification systemfortriglyceridelevelstofacilitatecholesterolmanagement.Theclassificationsystemandguidelines forcholesterolmanagementarepresentedinMedicalNutritionTherapyforDisordersinLipidMetabolismin SectionIC(1). TriglycerideCategory SerumTriglycerides(mg/dL) Normal <150 Borderlinehigh 150199 High 200499 Veryhigh >500 Causesofhypertriglyceridemiainclude: obesity excessivealcoholintake uncontrolledtype1diabetesmellitus type2diabetesmellitus(degreeoftenparallelsobesity) nephroticsyndrome thiazidediuretics betaadrenergicblockingagents hypothyroidism chronicrenaldisease obstructiveliverdisease NutritionAssessmentandDiagnosis Medicalnutritiontherapyisindicatedinpatientswhohavetriglyceridelevelsgreaterthan150mg/dL (Grade III) (1,2). As part of the nutrition assessment, the patients lipid panel, which includes total cholesterol, LDL cholesterol, and HDL cholesterol, should be comprehensively evaluated. Individuals who have hyperlipidemiasecondarytofamilialdisordersorotherdiseasessuchasdiabetesoftenhaveborderlinehigh orhightriglyceridelevels (1).Causesofhypertriglyceridemiashouldbeevaluatedandnutritionintervention targetedtopromoteoptimalnutritionandmetabolicoutcomes.Complementarydrugtherapythatincludes LDLloweringmedications,fibrates,ornicotinicacidisindicatedtopreventacutepancreatitisorabdominal painwhentriglyceridelevelsareveryhigh(>500mg/dL)(1). NutritionIntervention(12) Anenergycontrolled,cardioprotectivedietarypatternthatavoidsextremesincarbohydrateandfatintake, limitsalcoholandrefinedsugar,increasestheintakeofcomplexcarbohydrates,andincludesphysicalactivity shouldbeusedforpatientswhohaveelevatedtriglycerides(>150mg/dL) (GradeIII)(2).Weightlossof7%to 10% of body weight should be encouraged, if indicated. Lifestyle changes that lower triglyceride levels include(GradeIII)(2):controlofbodyweight adietlowinsaturatedfatandcholesterol regularexercise limitingalcoholintake restrictionordietarymodificationofsimpleandrefinedsugars The ideal macronutrient composition for lowering triglyceride levels in patients who have hypertriglyceridemia is unclear (Grade III) (2). The dietitian should refer to the ATP III guidelines for the suggestednutritionandlifestyleinterventionsbasedonthetriglyceridelevelandtherapygoals(GradeII)(1,2).A
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Hypertriglyceridemia
verylowfatdiet(<15%ofenergy)inadditiontolifestylechangesreducestriglyceridelevlesandtheriskof pancreatitisinpersonswhohaveveryhightriglycerides(>500mg/dL)(GradeII)(2). TriglycerideLevel ATPIIIRecommendations (1) Borderlinehigh(150199 weightreduction mg/dL) increasedphysicalactivity High(200499mg/dL) weightreduction increasedphysicalactivity drugtherapy(LDLloweringdrugsand/ornicotinicacidorfibrates) Veryhigh(>500mg/dL) verylowfatdiet(<15%ofenergyintake)topreventacutepancreatitis weightreduction increasedphysicalactivity drugtherapy(LDLloweringdrugsand/ornicotinicacidorfibrates) ElevatedTriglyceridesandEicosapentaenoicAcid/DocosahexaenoicAcid(EPA/DHA)Supplements HighdosesofsupplementalEPA/DHAlowertriglyceridelevelsinpatientswhohaveelevatedtriglycerides.If apatienthasahightriglyceridelevel(>200mg/dL)thatisrefractorytootherlifestyletherapies,physician prescribedsupplementalEPA/DHAcapsules(2to4g)canbeconsidered(GradeII)(2).Refertothediscussionof omega3fattyacidsinSectionC:MedicalNutritionTherapyforDisordersofLipidMetabolism.
References 1. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation,andTreatmentofHighBloodCholesterolinAdults(AdultTreatmentPanelIII).JAMA.2001;285:24862497. 2. DisordersinLipidMetabolismEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociationEvidenceAnalysisLibrary. AmericanDieteticAssociation;2005.Availableat:http://www.adaevidencelibrary.com.AccessedJanuary5,2009.
III-68
HYPOGLYCEMIA
Discussion Therearetwoprimarycategoriesofhypoglycemia:fastingandpostprandial(reactive)hypoglycemia.True hypoglycemia(nondiabeticorigin)isaclinicalsyndromewithdiversecausesinwhichlowlevelsofplasma glucose eventually lead to neuroglycopenia (1). Hypoglycemia is defined as the presence of the following threefeatures,knownasWhipplestriad(1): alowlevelofplasmaglucose symptomsofhypoglycemia,suchassweating,shaking,weakness,hunger,headaches,andirritability,that occuratthesametimeasthelowbloodglucosevalues ameliorationofthesymptomsbytheingestionofcarbohydrate Maintainingbloodglucoselevelswithinanormalrangeisimportantbecausethebrainandcentralnervous systemmusthave a steady supply ofglucose to function properly. Symptoms can be recognized when the bloodglucoselevelis60mg/dL,andimpairedbrainfunctioncanoccuratalevelofapproximately50mg/dL (1). When blood glucose levels fall below normal limits within 2 to 5 hours after eating, this condition is referredtoasreactiveorpostprandialhypoglycemia (1).Postprandialhypoglycemiamostfrequentlyoccurs as alimentary hypoglycemia (dumping syndrome) in adults who have undergone gastric surgery, such as a Billroth gastrectomy. The episode of hypoglycemia usually occurs 1 to 5 hours after meals, especially carbohydraterichmeals.RefertotheDumpingSyndromeDietinSectionIB. Fastinghypoglycemiamayoccurinresponsetonoteatingfor8hoursorlonger.Otherlesscommoncauses are pancreatic tumors (insulinoma), pancreatic islet cell disease, severe heart failure, and critical organ failure.Certainmedications,suchasexogenousinsulin,sulfonylureas,ethanol,salicylates,pentamidine,and quinine,mayalsocausehypoglycemiainsomepatients.Diettherapyistheprimarytreatment,and,insome cases, adjustments in medications are also needed. Surgery may be required for some conditions, such as insulinoma.Themostfrequentcauseoffastinghypoglycemiaresultsfromtheuseofinsulinororalglucose loweringmedicationsinthetreatmentofdiabetesmellitus.RefertoMedicalNutritionTherapyforDiabetes MellitusinSectionIC. Therearecurrentlynoconsensusguidelinesforthediagnosisofreactivehypoglycemia (1).Thediagnostic techniquesrangefromconfirmingthatthebloodglucoselevelislowduringahypoglycemicreactionafteran ordinarymealtoperforminganoralglucosetolerancetest.However,10%ofasymptomatichealthypersons respondtotheoralglucosetolerancetestwithalowerthannormalglucoselevel. NutritionIntervention Thegoaloftreatmentisforthepatienttoadopteatinghabitsthatwillkeepbloodglucoselevelsasconsistent aspossible (1).Theseeatinghabitsincludeconsistentmealtimesandconsistentcarbohydrateintake (1).As partofmealplanning,determinethefrequencyandsymptomsofhypoglycemia,aswellasactivitylevelsand exercise frequency, and schedule appropriate times for meals and snacks. The treatment of reactive hypoglycemia depends on the specific cause. The treatment of alimentary hypoglycemia following gastric surgery is discussed in Section IB (Dumping Syndrome Diet). Provided below are guidelines for avoiding symptomsofhypoglycemia(1): Allowfiveorsixsmallmealsorfeedingsperday.Eatconsistentamountsofcarbohydrateatmealsand snacksfromdaytodayandavoidskippingmeals. Spread carbohydrate intake throughout the day. Most individuals need three to four carbohydrate servings at meals and one to two carbohydrate servings for snacks (one serving = 15 g carbohydrate). Includeproteinfoodsandvegetablesateachmealforsatietyandextraenergy. Avoid foods that contain a large amount of carbohydrates, because reactions can occur as a result of a highcarbohydrateload.Examplesofthesefoodsareregularsoftdrinks,syrups,candy,regularfruited yogurts,cookies,pies,andcakes. Avoidbeveragesandfoodscontainingcaffeine.Caffeinecancausethesamesymptomsashypoglycemia. Limitalcoholconsumptionbecauseitinhibitsgluconeogenesis.Ifanindividualchoosestodrinkalcohol, itshouldbelimitedtoonedrinkperdayforwomenandtwodrinksperdayformen.Drinkingalcoholon an empty stomach and without food can cause hypoglycemia. A carbohydrate food should always be consumedalongwiththealcoholicbeverage.
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Hypoglycemia
Glucagon injections are used to treatsevere hypoglycemia. The primary effect of glucagon is to increase bloodglucoselevelsbyacceleratinghepaticglycogenolysisandstimulatinghepaticgluconeogenesis (2).The mostcommonadverseeffectofglucagonisnauseaorvomiting(2). Educate the patient regarding fastacting carbohydrate foods that should be consumed or avoided dependinguponthepatientsbloodglucoselevel.RefertoMedicalNutritionTherapyforDiabetesMellitus, TreatmentofHypoglycemiainSectionIC.
References 1. Reactivehypoglycemia.In:AmericanDieteticAssociationNutritionCareManual.Chicago,Ill:AmericanDieteticAssociation;2008. Availableat:nutritioncaremanual.org.AccessedJanuary16,2008. 2. StuartN,ed.Medicationsanddiabetes:newhelpsandoldfriends.OnTheCuttingEdge[DiabetesCareandEducationnewsletter].2006; 27:132.
Bibliography International Diabetes Center. Reactive and Fasting Hypoglycemia. Minneapolis, Minn: International Diabetes Center, Park Nicollet Institute;2004.
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INBORNERRORSOFMETABOLISM
Discussion Inborn errors of metabolism are inherited disorders in which there is an absence or reduced activity of a specificenzymeorcofactor.Impairedmetabolismanddiseaseresult. A rational approach to the nutrition intervention of an inborn error of metabolism requires some understanding of the pathogenic mechanisms and resulting consequences. One or both of the following mechanismsmaybepresent,dependingonthetypeofdisorder: 1. Theaccumulatedsubstrateoritsmetabolitesmayhavetoxiceffects. 2. Aharmfuldeficiencymayresultfromthedecreasedsynthesisofanecessaryendproduct. Therationalefornutritioninterventiondependsonwhichofthesemechanismsisthoughttobeimportant. Forexample,ingalactosemia,thegoalistoreducetheaccumulationofsubstrate(galactoseandgalactose1 phosphate). In type I glycogen storage disease, the aim is to supply the deficient product (glucose). In phenylketonuriabothreductionofthesubstrate(phenylalanine)andprovisionsofadequateamountsofthe product(tyrosine)mustbeaccomplished. Successful nutrition intervention for patients with inborn errors requires a keen appreciation of the tremendous variability among individuals and a willingness to tailor the therapeutic approaches to the specificneedsofeachpatient. Approaches Thefollowingtablelistsgeneticdisordersinwhichnutritioninterventionhasbeenemployed.
MetabolicDisordersThatRespondtoDietaryTreatment Disorder EnzymeDefect Nutrition Intervention Dietlowin phenylalanine. Increasetyrosinein diet. Dietlowin phenylalanineand tyrosine SpecialFormulasa Lofenalac (MJ) Phenylfree(MJ), Phenex(RL), Maxamaid(SHS) Product3200AB (MJ),XYPHEN (SHS),Tyromex (RL) PossibleOutcomes WithoutEffective MedicalTreatment Growthdelay,mental impairment,seizures Death,growthdelay, mentalimpairment,renal disease,liverdysfunction, seizures,hypoglycemia, metabolicacidosis, hyperammonia Death,growthdelay, mentalimpairment, seizures,hypoglycemia, metabolicacidosis, hyperammonia
Phenylketonuria Phenylalanine (PKU)
Tyrosinemia
Cytosoltyrosine aminotransferase
Maplesyrup urinedisease (MSUD)
Ketoacid decarboxylase
Dietlowinleucine, isoleucine,and valine
MSUDDietPowder (MJ),MSUD Maxamaid(SHS), Ketonex(RL)
III-71
Inborn Errors of Metabolism
Disorder
EnzymeDefect
Nutrition Intervention Dietlow inprotein, +/Laminoacid(s) missingorinactive withdefect.All conditionsrequirea dietlowinsodium benzoate,exceptin thearginasedefect.
SpecialFormulasa
Ureacycle defects
Organic acidemia
Dependsondefect. Enzymesthatmay bedefectiveinclude carbamoylphosphat esynthetase, ornithine transcarbamoylase, angininosuccinic acidsynthetase, argininosuccinic acidlyase,arginase Dependsondefect. Enzymesthatmay bedefective include methlmalonyl coenzymeA(CoA) mutaseor coenzymeB12or propionylCoA carboxylase
UCD (MJ), Cyclinex(RL)
PossibleOutcomes WithoutEffective MedicalTreatment Death,growthdelay, mentalimpairment, seizures,hyperammonia
Galactosemia Galactose1 phosphateuridyl transferase Fructose intolerance
Diethighinenergy andlowinprotein, +/Laminoacid(s) missingorinactive withdefect.For methlmalonylCoA mutaseorcoenzyme B12,supplementwith B12.Inacutestate, giveIVfluidsand bicarbonate Dietfreeofgalactose andlactose
OS (MJ),XMTVI Maxamaid(SHS), Propimex(RL)
Death,growthdelay, mentalimpairment,renal disease,seizures, hypoglycemia,metabolic acidosis,hyperammonia
Death,growthdelay, mentalimpairment,liver dysfunction,hypoglycemia Death,growthdelay,renal disease,liverdysfunction, hypoglycemia,metabolic acidosis Death,growthdelay,renal disease,liverdysfunction, seizures,hypoglycemia, metabolicacidosis
Fructose1 Dietfreeoffructose, phosphatealdolase sucrose,andsorbitol
Glycogen storage diseases
TypeO:glycogen synthetase TypeI:glucose6 phosphatase TypeIII: debrancher enzyme TypeVI:hepatic phosphorylase
Diethigh inprotein, frequent carbohydrate feedings;high proteinfeedingat night Normaldietwith highcarbohydrate feedingsbetween meals;nasogastric dripatnight Dietwithnormal energyandhigh proteinintake;night feedinghighin protein Highproteindietand frequentfeedings
Medicalproductsaremadebythefollowingmanufacturers: (MJ)MeadJohnsonNutritionals,Evansville,Ind;800/7554805 (RL)RossLaboratories,Columbus,Ohio;800/9868755 (SHS)ScientificHospitalSupplies,Gaithersburg,Md;800/3657354 Bibliography TrahmsCM.Medicalnutritiontherapyformetabolicdisorders.In:MahanKL,EscottStumpS,eds.KrausesFood,NutritionandDiet Therapy.10thed.Philadelphia,Pa:WBSaunders;2000:9871009. Nutrition management of inborn errors of metabolism. Pediatric Manual of Clinical Dietetics.2nd ed. Chicago, Ill: American Dietetic Association;2003.
a
III-72
IRONDEFICIENCYANEMIA
Discussion Foradiscussionofassessment,seeClassificationofSomeAnemiasinSectionII. Treatmentshouldfocusprimarilyontheunderlyingdiseaseorsituationleadingtotheanemia.Thechief treatment of iron deficiency anemia is oral administration of inorganic iron in the ferrous iron form. The mostwidelyusedpreparationisferroussulfite,andthedoseiscalculatedintermsoftheamountofelemental ironprovided.Dependingontheseverityoftheanemia,dailydosageofelementalironshouldbe50to200 mgforadultsand6mg/kgforchildren.Ascorbicacidgreatlyincreasesironabsorption.Ittakes4to30days tonoteimprovementwithirontherapy,especiallythehemoglobinlevel.Irontherapyshouldbecontinued forseveralmonths,evenafterthehemoglobinlevelisrestored,sothatthebodyironreservesarereplete. In addition to medication, attention should be given to the amount of absorbable iron in food. Dietary modificationcanbeadjunctivetoironadministrationorcanbeprophylacticintheindividualwhoisatrisk forirondeficiencyanemia.Thedietcanbemodifiedtoincreasetheironintakeforanyindividual. Dietarystrategiesinvolve: 1. providingfoodsthathaveahigherirondensity 2. increasingtheironabsorptionfromfood IronDensity Thenormalmixeddiethasbeensaidtohaveanirondensityofaround6mg/1000kcal.Beef,legumes,dried fruit,andfortifiedcerealsarefoodsthatrankthehighestinironcontent. In general, foods that obtain most of their calories from sugar, fat, and unenriched flour have a low iron density.Foodsmadefromwholegrainandenrichedflour,aswellasunrefinedfoods(fruit,vegetables,and meats),haveahigherirondensity.Dairyproductshavealowirondensity. IronAbsorption Theironcontentofthebodyishighlyconservedandintheabsenceofbleeding,littleislosteachday.Formen and postmenopausal women, for whom the RDA is 8 mg/day of iron, 1 mg of absorbable iron per day will meetthisrequirement(1). Dietaryironisprovidedinthedietintwoforms:hemeandnonheme.Hemeironconstitutes40%ofthe ironpresentinmeat,fish,andpoultry.Nonhemeironconstitutesthebalanceoftheironinmeat,fish,poultry and allthe iron present in plantfood, eggs, milk,and cheese. Heme iron is better absorbedthan nonheme iron.Theabsorptionofnonhemeironisinfluencedbyseveraldietaryenhancingfactors,particularlyascorbic acidandmeat,fish,andpoultry.Ascorbicacidbindsirontoformareadilyabsorbedcomplex.Goodsources of ascorbic acid include, but are not limited to, citrus fruit and juices, tomatoes and tomato juice, greens, broccoli,strawberries,andsweetpotatoes. Ironabsorptionisalsoinfluencedbyotherfactors,suchas: Nutritional status with respect to iron: Individuals with an iron deficiency will have greater iron absorption. The presence of substances that decrease iron absorption: Phytates, tannic acid, carbonates, oxalates, phosphates, ethylenediaminetetraacetic acid (EDTA), phosvitin. Phytates found in unleavenedbread,unrefinedcereals,andsoybeansinhibitironabsorption.Tannicacidfoundintea andcoffeeandphosvitinfoundineggyolkhavebeenshowntodecreaseironabsorption.Calcium phosphatesaltsandEDTA,afoodpreservative,canalsoreduceironabsorption. Cookingutensils:Cookingwithanironskilletmaycontributeminuteamountsofirontothediet. Gastric acidity: Subnormal acidity of the gastric juices, fairly common in older persons, can cause them to absorblessdietaryiron. III-73
Iron Deficiency Anemia
Approaches Guidelinestoincreaseironintakeandabsorptionareasfollows: Increaseascorbicacidateverymeal. Includemeat,fish,andpoultryateachmeal,ifpossible. Avoiddrinkingteaorcoffeewithmeals. AvoidfoodswithhighquantitiesofEDTAbycheckingfoodlabels. Increasefoodselectionsthathaveahighirondensity. IRONCONTENTOFCOMMONFOODS Food Amount Iron(mg) Sourcesofhemeiron: Beef,cooked,lean 1oz 0.7 Chicken,cooked 1oz 0.4 Cod,cooked 1oz 0.14 Egg 1large 0.6 Liver,beef,cooked 1oz 1.9 Liver,chicken,cooked 1oz 2.4 Oysters,cooked 6medium 5.0 Pork,cooked,lean 1oz 0.33 Sourcesofnonhemeiron: Apricots,dried 4 0.6 Bread,enriched 1slice 0.7 Bread,wholewheat 1slice 0.8 Cereal,dry,fortified 1cup 4.5 18.0 Creamofwheat,cooked cup 9.0 Farina,cooked,enriched c 7.4 Greenbeans cup 0.9 Greens,turnip,cooked cup 1.0 Kale,cooked cup 0.6 Kidneybeans,cooked cup 2.6 Lentils,cooked cup 3.3 Molasses,blackstrap 1tbsp 3.5 Pasta,cooked,enriched cup 1.25 Peanutbutter 2tbsp 0.6 Prunes 5 1.0 Prunejuice cup 1.5 Raisins 1/3cup 1.0 Spinach,cooked cup 1.4
Source:PenningtonJAT.Bowes&ChurchsFoodValuesofPortionsCommonlyUsed.Philadelphia,Pa:Lippincott;1998.

Reference 1. InstituteofMedicine.DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine,Iron,Manganese, Molybdenum,Nickel,Silicon,Vanadium,andZinc.FoodandNutritionBoard,Washington,DC:NationalAcademiesPress,2002:290 292;athttp://www.nap.edu.books/0309072794/html/index.html,2002(accessed1/28/03).

Bibliography FoodandNutritionBoard,NationalResearchCouncil:RecommendedDietaryAllowances.10thed.Washington,DC:NationalAcademyof Sciences;1989. KasdanTS.Medicalnutritiontherapyforanemia.In:MahanKL,EscottStumpS,eds.KrausesFood,NutritionandDietTherapy.10thed. Philadelphia,Pa:WBSaunders;2000:781800.
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NEPHROTICSYNDROME
Discussion Nephrotic syndrome is characterized by urinary losses of albumin and other plasma proteins, resulting in hypoalbuminemia.Nephroticsyndromeiscausedbythefailureoftheglomerularcapillarywalltoactasan impermeablebarriertoplasmaproteins.A24hoururinaryproteinexcretionof3.0gorgreaterisindicative ofnephroticsyndrome (1,2).Nephroticsyndromeisassociatedwithothermetabolicdisturbancesincluding hyperlipidemiacausedbyincreasedlipidsynthesisanddecreasedlipidcatabolism (2,3).Edemaiscausedby sodium retention or imbalance, fluid retention, hypoalbuminemia, and underlying diseases such as renal, cardiac, or liver disease (3). Causes of nephrotic syndrome include diabetes mellitus, infections, certain medications,neoplasms,preeclampsia,andchronicallograftnephropathy(2). Approaches(2,3) Rationale Protein: In contrast to the treatment of proteinenergy malnutrition, the treatmentofnephroticsyndromedoesnotincludeahighproteindiet; Provide0.8to1.0g/kgofideal a highprotein diet would not replenish plasma protein levels and bodyweight. could cause further renal damage in patients who have nephrotic Highbiologicalvalueprotein syndrome (2,3). Mild protein restriction and provision of an shouldcontributeatleast50%of angiotensinconverting enzyme inhibitor diminish urinary protein proteinintake. losses and increase serum albumin levels (2,3). Soy protein decreases urinary protein excretion and blood lipid levels (2,4). Some studies suggest that a low or verylow protein diet with essentialaminoacid supplementation reduces proteinuria and improves protein nutriture (5).Therecommendedproteinintakeforchildrenwhohavenephrotic syndrome is the Dietary Reference Intake for age plus the amount of urinary protein loss. Children who have persistent proteinuria may require2.0to2.5g/kgofproteinperday(3). Sodium: Thelevelofsodiumprescribedisbasedontheseverityofedema and hypertension.Sodiumisusuallyrestrictedto1to2g/day,depending SeeSodiumControlledDietin on the severity of the patients signs and symptoms (3). Fluid SectionIF. restriction is often necessary and should be based on the patients symptoms.Diureticscanhelpmaintainfluidandsodiumbalance(3). Energy: The energy intake requirement is determined by the nutritional evaluationandcanbeashighas35kcal/kg(3).Complexcarbohydrates Calculateaccordingtoindividual shouldbetheprimarysourceofenergyintake (2).Weightlossmaybe needs. recommendedforobesepatients,becausetheyhaveanincreasedrisk ofcomorbiddiseasesandcomplications. Hypercholesterolemiaorhypertriglyceridemia)resultsfromincreased Fat: lipidsynthesisanddecreasedlipidcatabolism (3).Thisdisturbancein UsetheNationalCholesterol lipidmetabolismincreasestheriskforcardiovasculardisease,stroke, EducationProgramAdult TreatmentPanelIIIguidelines(2,3). andprogressiverenalfailure (2).Acombinationofstatintherapyand the Therapeutic Lifestyle Changes diet lowers serum lipid levels (2). RefertoSectionC:Disordersin Fish oil supplementation (12 g/day) may be beneficial for patients LipidMetabolismforthe who have IgA nephropathy, which is a caused by the deposition of TherapeuticLifestyleChanges immunoglobinAinthekidneys(3). (TLC)diet. Target<30%ofenergyfromfat, saturatedfat<7%oftotalfat,and cholesterol<200mg/dLperday(2).
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NephroticSyndrome
Approaches(2,3) Vitaminsandminerals: Baseintakeonfoodandnutrition assessmentandbiochemicallevels: Provideiron,basedonthe individualpatientsneed(2). EnsurepatientismeetingDietary ReferenceIntakesforBcomplex vitamins(niacin,riboflavin,and thiamin)andvitaminC. Supplementasneeded(2). Supplement1to1.5gofcalcium, nottoexceed2,000mg(2). Limitphosphorusto<12mg/kgper day(6).

Rationale (Cont.) Abnormalities in iron, copper, zinc, and calcium levels are directly related to the urinary loss of proteins that are involved in their metabolism (2,3).Forexample,theincreasedlossoftransferrincauses decreased plasma iron levels. Iron supplementation is important for patients who have nephrotic syndrome (3). Copper is also bound to protein, and serum copper levels are often compromised. However, clinicalmanifestationsdonotoccurasaresultofthelowcopperlevels; therefore, supplementation is not necessary (3). Supplemental zinc maybeneeded,aszincisboundtoalbumin (3).Inaddition,decreased levels of calcium and serum 1,25dihydroxycholecalciferol may occur as a result of being bound to albumin (3). Supplemental calcium, vitaminD,andironmaybeneededtonormalizeserumlevels.
References 1. Madaio M, Harrington J. The diagnosis of glomerular diseases: acute glomerulonephritis and nephrotic syndrome.Arch Intern Med.2001;161:2534. 2. Nephrotic syndrome. In: Nutrition Care Manual. American Dietetic Association; 2004. Available at: www.nutritioncaremanual.org. AccessedJanuary12,2009. 3. KoppleJD,MassrySG,eds.NutritionManagementofRenalDisease.2nded.Philadelphia,Pa:LippincottWilliams&Wilkins;2004. 4. D'Amico G, Gentile MG, Manna G, Fellin G, Ciceri R, Cofano F, Petrini C, Lavarda F, Perolini S, Porrini M.Effect of vegetarian soy diet on hyperlipidaemiainnephroticsyndrome.Lancet.1992;339:11311134. 5. GiordanoM,DeFeoP,LucidiP,DePascaleE,GiordanoD,CirilloD,DardoG,SignorelliSS,CastellinoP.Effectsofdietaryproteinrestriction onfibrinogenandalbuminmetabolisminnephroticpatients.KidneyInt.2001;60:235242. 6. McCann L, ed.Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. 3rd ed.New York, NY: National Kidney FoundationCouncilonRenalNutrition;2002.
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OBESITYANDWEIGHTMANAGEMENT
Discussion Recentdataindicatethat64%ofAmericanadultsareeitheroverweight(bodymassindex[BMI]of25.0to 29.9 kg/m2) or obese (BMI >30 kg/m2) (1). This figure has sharply increased since 1994 when 55% of American adults were overweight or obese. The rate of obesity has doubled from 15% in 1980 to 30% in 1999 (1,2).ThetrendissimilarinAmericanchildrenandadolescents.The1999to2000NationalHealthand Nutrition Examination Survey (NHANES) identified the prevalence of overweight as 15.5% among 12 through 19yearolds; 15.3% among 6 through 11yearolds; and 10.4% among 2 through 5yearolds. These percentages are greater than the corresponding values of 10.5%, 11.3%, and 7.2% in 1988 to 1994 (NHANES III) (2). Overweight children have a greater risk for becoming overweight adults (3). Obesity contributes to many adverse health outcomes, including type 2 diabetes, cardiovascular disease, hypertension, stroke, osteoarthritis, gallbladder disease, sleep apnea, respiratory problems, and cancers of the endometrium, breast, prostate, and colon (1,4). The total estimated cost of obesity in 1995 was $99.2 billion,whichincludes$51.6billionspentondirectmedicalcosts(5). Obesityisacomplexmultifactorialdiseasethatresultsfromthepositiveenergybalancethatoccurswhen energyintakeexceedsenergyexpenditure.Lifestyleandenvironmentalfactors,includingexcessiveenergy intake,highfatintake,andphysicalinactivity,areassociatedwiththepathophysiologyofobesity.Growing evidencesuggestsastronglinkbetweengeneticfactorsandthepathogenesisofobesity.Genesinvolvedin energy regulation such as leptin, a signal protein for satiety produced in the adipose tissue, and other hormones or peptides, such as neuropeptide Y, may have important implications for understanding the causes of obesity (6). Ongoing research is required to determine the role of genetic factors in obesity treatment.
Adults TheClinicalGuidelinesontheIdentification,Evaluation,andTreatmentofOverweightandObesityinAdults (4) provideguidelinesforclassifyingthedegreeofoverweightandobesityandtheassociatedhealthriskaswell as guidelines for developing treatment strategies. The BMI is used to classify the degree of overweight or obesityinadultsbecauseitishighlycorrelatedwithbodyfatness(4).TheBMIiscalculatedbydividingweight in kilograms by height in meters squared. Studies have identified a relationship between an elevated BMI (>25kg/m2)andanincreasedincidenceofmorbidityandmortality (1,4).TheBMIandwaistcircumference shouldbeusedtoclassifyoverweightandobesity,estimateriskfordisease,andidentifytreatmentoptions (GradeII)*(4,7).(RefertoTableIII17.)TheBMIandwaistcircumferencearehighlycorrelatedtoobesityorfat mass and risk of other diseases (Grade II) (4,7). Waist circumference is also used as an assessment parameter because excess fat in the abdomen is an independent predictor of increased risk and morbidity, even for individualswithanormalweight(4).Evidencefromepidemiologicstudiesshowswaistcircumferencetobea better marker of abdominal fat than the waisttohip ratio. Waist circumference also is the most practical anthropometricmeasurementforassessingapatientsabdominalfatcontentbeforeandduringweightloss treatment(4).Ahighwaistcircumferenceisassociatedwithincreasedriskfortype2diabetes,dyslipidemia, hypertension,andcardiovasculardiseaseinpatientswhoseBMIisbetween25.0and34.9kg/m2.However, forindividualswhoseBMIisgreaterthan35.0kg/m2,waistcircumferenceaddslittletothepredictivepower ofthediseaseriskclassificationofBMI(4).(RefertoTableIII18:AGuidetoSelectingTreatment.)
*TheAmericanDieteticAssociationhasassignedgrades,rangingfromGradeI(good/strong)toGradeV(insufficientevidence),toevidence andconclusionstatements.ThegradingsystemisdescribedinSectionIII:ClinicalNutritionManagementAReferenceGuide,pageIII1.

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Obesity and Weight Management
TableIII17:ClassificationofOverweightandObesityandAssociatedDiseaseRiskabyBMIandWaist Circumference Obesity DiseaseRiska BMI 2) Class (kg/m (RelativetoNormalWeightandWaistCircumference) >40inches(>102cm) Men<40inches(<102cm) Women<35inches(<88cm) >35inches(>88cm) Underweight <18.5 Normalb 18.524.9 Overweight 25.029.9 Increased High Obesity 30.034.9 I High Veryhigh 35.039.9 II Very high Veryhigh ExtremeObesity >40.0 III Extremelyhigh Extremelyhigh
aDiseaseriskfortype2diabetes,hypertension,andcardiovasculardisease bIncreasedwaistcircumferencecanalsobeamarkerforincreasedriskinpersonsofnormalweight.
TableIII18:AGuidetoSelectingTreatment Treatment Diet,exercise,and behaviortherapy Pharmacotherapy Surgery <24.9 25.026.9 With comorbidities BMI(kg/m2) 27.029.9 With comorbidities With comorbidities 30.034.9 + + 35.039.9 + + >40.0 + +
With + comorbidities +Optionsfortreatment(NotethatwhentheBMIis>29.9kg/m2,adjunctivetreatmentoptionsshouldbeconsidered.) PreventionofweightgainwithlifestyletherapyisindicatedinanypatientwithaBMI>25kg/m2,even withoutcomorbidities.However,weightlossisnotnecessarilyrecommendedforpatientswithaBMIof25.0to 29.9kg/m2orahighwaistcircumference,unlesstheyhavetwoormorecomorbidities. Combinedtherapywithalowenergydiet,increasedphysicalactivity,andbehaviortherapyprovidesthemost successfulinterventionforweightlossandweightmanagement. Considerpharmacotherapyonlyifapatienthasnotlost1lb/weekafter6monthsofcombinedlifestyletherapy.

SourceforTableIII17andTableIII18:ThePracticalGuidetotheIdentification,Evaluation,andTreatmentofOverweightandObesityin Adults.TheNationalInstitutesofHealth,NationalHeart,Lung,andBloodInstitute,andtheNorthAmericanAssociationfortheStudyof Obesity;October2000.NIHpublicationNo.004084.
ChildrenandAdolescents Overweight children have a greater risk for becoming overweight adults (3). Whether or not the child is obese, obesity of at least one parent more than doubles the risk of a child being obese as an adult (8). The latest statistics indicate that obesity is more prevalent among nonHispanic black and MexicanAmerican adolescents (2). Weight gain among children and adolescents is attributed to a combination of poor dietary habits, family lifestyle, physical inactivity, ethnicity, socioeconomic status, and genetic makeup (9,10). Early interventionisrecommendedtopreventoverweightandobesityfromcontinuinglaterinlife(9). Recommendationshavebeenestablishedfortheinterventionandtreatmentofoverweightandobesityin children and adolescents (9). The Expert Committee recommends evaluation and possible treatment for childrenwithaBMIgreaterthanorequaltothe85thpercentilewithcomplicationsofobesityandchildren withaBMIgreaterthanthe95thpercentilewithorwithoutcomplicationsofobesity (9).Theclassificationof overweightforchildrenisdeterminedbycalculatingtheBMIandplottingitontheappropriateBMIforage chartdevelopedbytheCentersforDiseaseControlandPrevention (11).TheCentersforDiseaseControland Prevention recommends that the BMIforage charts be used for all children and adolescents aged 2 to 20 years, instead of the weightforstature charts previously developed by the National Center for Health Statistics (11). Complications of obesity include hypertension, dyslipidemia, orthopedic disorders, sleep disorders, gallbladder disease, and insulin resistance (9). The use of weight maintenance vs weight loss to achieve weight goals depends on the patients age, baseline BMI percentile, and the presence of medical complications(9).
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The Expert Committee recommends that the first step in the assessment of an overweight child includes evaluation for underlying syndromes, including genetic causes (eg, PraderWilli syndrome) and endocrinologic causes (eg, hypothyroidism and Cushing syndrome). In addition, a complete medical and psychosocialhistoryshouldbegathered,andaphysicalexamshouldbeperformedtoidentifycomplications. These complications include sleep apnea, pseudotumor cerebri, orthopedic complications, and acanthosis nigricans (the coarse, hyperpigmented areas in the neck folds or axilla that are associated with insulin resistance and type 2 diabetes). Children with eating disorders or symptoms of depression require psychologicaltreatmentandshouldnotparticipateinaweightcontrolprogramwithouttheconcurrenceofa therapistorspecialist(9). Approaches ChildrenandAdolescents Theprimarygoalofaprogramtomanageuncomplicatedobesityinchildrenandadolescentsishealthyeating andactivity,notachievementofidealbodyweight (9).Forchildrenwithasecondarycomplicationofobesity (eg,hypertensionordyslipidemia),improvementorresolutionofthecomplicationisanimportantmedical goal.Thefirststepinweightcontrolforalloverweightchildren(85thto94thpercentile)olderthan2yearsis themaintenanceofbaselineweight.Prolongedweightmaintenance,whichallowsagradualdeclineinBMIas children grow in height, is a sufficient goal for many children (9). Weight maintenance is also the goal for childrenaged2to7yearswhohaveaBMIgreaterthanthe95thpercentileandnocomplications(9).However, ifcomplications(eg,hypertension,dyslipidemia,orinsulinresistance)areidentified,weightlossisindicated in this group. For children 7 years and older who are overweight (85th to 94th percentile), weight maintenance is the goal if no complications are present, and weight loss is indicated if complications are present (9).Weightlossisindicatedindependentofcomplicationsforchildrenaged7yearsandolderwho areatorabovethe95thpercentile(9). Weightlossachievedbylifestyleapproaches,includingalowenergydietandincreasedphysicalactivity,is recommended (Grade I) (12). Energy intake levels need to be individualized to meet the patients growth and developmentneeds.Approachestoweightlossshouldbebasedonfamilyreadinessandinvolvement(9).The dietarygoalsforpatientsandfamiliesshouldincludewellbalanced,healthymealsandahealthyapproachto eating.Alowenergydiet(900to1,200kcal/day)aspartofaclinicallysupervised,multicomponentweight lossprogramisassociatedwithbothshorttermandlongertermreductionsinadiposityamongchildrenages 6to12years (GradeI)(12).Areducedenergydiet<1,200kcal/day)intheacutetreatmentphaseofadolescent overweightisgenerallyeffectiveforshorttermimprovementinweightstatus.However,withoutcontinuing intervention weight is regained (Grade I) (12). Counting calories can be tedious and inaccurate (9). As an alternative,targetinghighenergyandhighfatfoodsandbeveragesintheexistingdietandfocusingononeor two small dietary changes at a time is suggested (9). Behavior modification approaches, such as the traffic lightdiet,areveryeffective (GradeI)(9,12).Childrenandadolescentsmustreceiveadequatevitamins,minerals, protein,andenergytomaintainhealthygrowth.Lineargrowthmayslowduringweightloss (9).However, most overweight children are tall and impact on adult stature appears to be minimal (13). Although pharmacologicalmeansoftreatmentarebeinginvestigated (9),theonlytreatmentoptioncurrentlyavailable isforadolescents(12yearsorolder)whomaybetreatedwithOrlistatforuptooneyear.SeeWeightContol Information Network information at http://www.win.niddk.nih.gov.. Bariatric surgery (eg, laparoscopic adjustablegastricband(LAGB)andRouxenYgastricbypass(RYGB))maybeatreatmentoptionforchildren and adolescents who are obese (> 95th percentile) for weight based on age in specialized centers when a severecomorbidityispresent(refertodiscussiononSurgeryinthissection). Likeadults,childrenandadolescentswhoareobesehaveanincreasedriskforvasculardisease (9,10).The characteristicpatternconsistsofelevatedserumlowdensitylipoproteincholesterolandtriglycerideslevels andloweredhighdensitylipoproteincholesterollevels (14).TheAmericanHeartAssociation(AHA)dietary guidelines for primary prevention of atherosclerotic heart disease recommend that children older than 2 yearsgraduallybegintoadoptadietthatcontainsnomorethan30%ofenergyfromfat.Adietlowinfat (<30% of total energy, but no less than 20% of total energy), saturated fat (<10% of energy per day), cholesterol (less than 300 mg/day), and low in trans fatty acids is encouraged (15,16). Similar to adult guidelines,theAHAsuggestsdailyconsumptionoffiveormoreservingsoffruitsandvegetablesandsixto eleven servings of whole grain foods. In addition, lowfat dairy products, fish, legumes, poultry, and lean meatsarerecommended (15,16).TheAHArecommendsthatchildrenconsumeadequateamountsofdietary fiber(equaltothechildsageplus5g)eachday(16,17).
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Adequate physical activity also is encouraged (9,15,16,18). The US Surgeon Generals Report on Physical ActivityandHealth recommends 30 minutes per day ofmoderate to vigorous physicalactivity forchildren andadults(18). Adults Weight management is defined as the adoption of healthful and sustainable eating and physical activity behaviorsindicatedforareduceddiseaseriskandimprovedfeelingsofenergyandwellbeing(6).Weightloss therapyshouldbebasedonacomprehensiveweightmanagementprogramincludingdiet,physicalactivity, andbehaviortherapy.Thecombinationtherapyismoresuccessfulthananyoneinterventionalone(GradeI)(7). A nonrestrictive approach to eating based on internal regulation of food (hunger and satiety), physical activity, and healthful eating habits should be emphasized (6). Data on lifestyle weight loss interventions indicatethattheyproducelowlevelsofsustainedloss.Typicallyreportedweightlossesremainingafter4to 5 years are about 3% to 5% of initial body weight (6). Based on data from the National Weight Control Registry, longterm maintenance of weight loss and goals is increased in persons who have specific health habitsandbehaviors.Thesehabitsincludeeatingalowerenergydiet(average=1,381kcal/day)thatislow infatandhighincarbohydrates,regularselfmonitoringoffoodintakeandactivitylevel,andparticipatingin regularphysicalactivitycomparableto1hourperdayofmoderateintensityphysicalactivity,suchasbrisk walking (4,19).TheNationalWeightControlRegistryregistrantswhohavedocumentedthesebehaviorshave demonstratedsustainedweightlossof10%ofinitialbodyweightforatleast1year(19).Weightlossof5%to 10% of initial body weight can lead to a substantial improvement in risk factors for diabetes and heart diseaseandcanleadtoreductionsinordiscontinuationsofmedicationsfortheseconditions (4).Theresults of the Diabetes Prevention Program have provided the most definitive evidence of the health benefits of modestweightloss (20).Inthisstudy,thelifestyleinterventiongrouphada58%reducedriskofdeveloping type 2 diabetes when compared to the placebo group and a 39% reduced risk when compared to the pharmacotherapy intervention group that used metformin (20). Individualized goals of weight loss therapy shouldbetoreducebodyweightatanoptimalrateof1to2lb/weekforthefirst6monthsandtoachievean initialweightlossgoalofupto10%frombaseline.Thesegoalsarerealistic,achievable,andsustainable(Grade I)(4,7).
Energy: Energy requirements should be based on individual needs to promote gradual and safe weight loss.Estimatedenergyrequirementsshouldbebasedonrestingmetabolicrate(RMR) (7).Ifpossible,RMR shouldbemeasured(eg,indirectcalorimetry).IfRMRcannotbemeasured,thentheMifflinSt.Jeorequation usingactualbodyweightisthemostaccurateforestimatingRMRforoverweightandobeseindividuals (Grade I) (7). The prescribed energy level should promote a weight loss of 0.5 to 1.5 lb/week (Grade I) (4,7). The recommendedminimumenergylevelsare1,200kcal/dayforwomenand1,400to1,500kcal/dayformen (4, 21). Evidence suggests that moderation in total energy is the key variable in promoting weight loss, rather than modification of the diets macronutrient composition (21). Consideration of a realistic energy goal is important for successful patient compliance with a weightmanagement program (4). Total energy intake should be distributed throughout the day, with the consumption of four to five meals/snacks per day including breakfast (Grade II) (6,7). Consumption of greater energy intake duringthe day may be preferable to eveningconsumption(GradeII)(6,7).(SeetheCalorieControlledDietforWeightManagementinSectionIC.)
Protein:Topreserveleanbodymass,dailyproteinintakeshouldbeintherangeof0.8to1.2g/kgofbody weight (22). During energy restriction, it is generally suggested that 72 to 80 g of highquality protein be consumedperday(23).Patientswhoingesttoolittleprotein(<40g/day)areatriskforventriculararrhythmias (23).
Fat:Fatshouldaccountfor20%to30%oftotalenergy.Saturatedfatsshouldbelimitedtolessthan6%to 8%oftotalfatenergy.TheUSDepartmentofAgriculturehasfoundthatdietswithlowtomoderatefatintake (15%to30%oftotalenergy)tendbelowerintotalenergyandhighestindietqualitywhencomparedtolow carbohydratediets(21).
Carbohydrates:Carbohydratesshouldaccount for 50% to 60% of total energy. Carbohydrates can help prevent the loss of lean tissue (23). It has been suggested that at least 100 g of carbohydrates should be consumed per day to minimize ketosis (23). Hyperuricemia can result from lowcarbohydrate diets (23). Maintaining a minimum level of carbohydrate intake (>100 g/day) reduces the risk of increased uric acid levelsthatmaypredisposethepatienttogout(23).Highfibercarbohydratesources,suchasfruits,vegetables, whole grain breads, cereals, and legumes, are recommended. The daily consumption of 20 to 35 g of fiber reducestheenergydensityoffoodsconsumedandpromotessatietybydelayinggastricemptying(17).TheUS DepartmentofAgriculturehasfoundthatdietshighincarbohydrate(>55%)andlowtomoderateinfat(15% III-80 Copyright 2011 Morrison Management Specialists, Inc. Manual of Clinical Nutrition Management
to30%)tendtobelowerintotalenergyandhigherindietqualitywhencomparedtolowcarbohydratediets (<30%) (19). Highcarbohydrates diets have been scrutinized basedon outcomes and personaltestimony of individuals who follow popular lowcarbohydrate diets. A randomized controlled trial published in 2003 investigated weight loss outcomes using a lowcarbohydrate diet compared to a lowfat, lowenergy high carbohydrate(conventional) diet. Although the initialweight loss outcome was significantly greater in the lowcarbohydrategroup,thedifferencebetweenthetwogroupswasnotstatisticallysignificantat1year(24). The difference in weight loss between the two groups in the first 6 months was attributed to an overall greater energy deficit in the lowcarbohydrate group (24). The lowcarbohydrate diet was associated with greaterimprovementinsomeriskfactorsforcoronaryheartdisease.Adherencewaspoorandattritionwas highinbothgroups (24).Resultsofthisstudyshouldbeinterpretedwithcaution,giventhestudysrelatively smallsamplesizeandthe1yearduration (24).Longerandlargerstudiesarerequiredtodeterminethelong termsafetyandefficacyoflowcarbohydratedietsthatarehighinproteinandfat(24).Thelowglycemicindex diet is not recommended for weight loss or weight maintenance, since studies have not shown it to be effectiveintheseareas(GradeI)(7).
Calcium: A review of evidence suggest calcium intake lower than the recommended level is associated withincreasedbodyweight (Grade II) (6,7).However,theeffectofcalciumatoraboverecommendedlevelson weightmanagementisnotclear (GradeII)(6,7).Incorporating3to4servingsoflowfatdairyfoodsadayaspart ofthedietcomponentofacomprehensiveweightmanagementprogramissuggested(6). Physical activity: The US Surgeon Generals Report on Physical Activity and Health recommends 30 minutes of moderate to vigorous physical activity per day for children and adults (18). Physical activity contributestoweightloss,maydecreaseabdominalfat,andmayhelpwithmaintenanceofweightloss(GradeI) (7).Increasedphysicalactivityshouldbeakeycomponentofaweightlossprogram (4,6,7).Acombinationof weightresistanceorstrengthtrainingandaerobicexerciseisrecommendedtopreserveleanbodymassand promote the loss of adipose tissue (4). Federal Physical Activity Guidelines for Americans make recommendationsinweeklyversusdailydoses (6, 25).Theseguidelinessuggestthatmanypeoplemayneed more than the equivalent of 150 minutes/week of moderateintensity physical activity to maintain their weightandmorethan300minutes/week(or42minutes/day)tomeetweightcontrolgoals (25).Longterm goalsshouldbetoaccumulateatleast30minutesofmoderateintensityphysicalactivityonmost,preferably all,days(unlessmedicallycontraindicated)(GradeI)(7).
Behavior modification: Behavior modification is an integral component of weight loss and weight management and, in addition to diet and physical activity, leads to additional weight loss (Grade I) (4,6,7). Behavior modification is based on the premise that eating is a conditioned response. A goal of behavior modificationistohelpthepatientrealizeandeliminatetheassociationsthatcontroleatingbehavior.Portion control, one method of behavior modification, at meals and snacks results in reduced energy intake and weight loss (Grade II) (6,7). A comprehensive weight management program should make maximum use of multiple strategies for behavior therapy (eg, selfmonitoring, portion control, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support) (7). Continuedbehaviorinterventionsmaybenecessarytopreventareturntobaselineweight(GradeI)(7).
Verylowcalorie diets (VLCD): These specialized feeding regimens provide 800 kcal/day (or 6 to 10 kcal/kg)orlessperday,isenrichedwithhighbiologicalvalueproteinandprovidesatleast100%oftheDaily Valueofessentialvitaminsandminerals (6).Thesedietsconsistofapremixedliquidormeat,fish,orpoultry (6). This type of diet is recommendedonly to patients who are ata very high health risk related to obesity. Criteria for these regimens generally are a BMI of at least 30 kg/m2 and previous failures from other treatment approaches (6). Individuals on a VLCD should be supervised by a physician and receive supplemental vitaminsand minerals (26). The typicaltreatmentdurationis4to6months.Becausepatients who consume less than 800 kcal/day are at risk for protein, vitamin, and mineral deficiencies, they should be metabolicallymonitored.Highqualityprotein(0.8to1.5g/kgofidealbodyweight)andaminimumof100gof carbohydrateshouldbeprovidedeachday (23).Peoplewithahistoryofgallbladderdisease,cardiacabnormality, cancer, renal or liver disease, type 1 diabetes, or HIV should use these regimens with caution. VLCDs produce weight losses of 15% to 25% in 8 to 16 weeks (27). Adherence to VLCDs results in lower calorie intakes and therefore significant intial weight loss than reducedcalorie diets (Grade I) (6,7). Despite the shortterm success of achievingsignificantweightlosses,thereispoorlongtermmaintenanceoftheweightloss (Grade I) (6,7,26).Several randomizedtrialsfoundVLCDstobenomoreeffectivethanlowenergydiets1yearaftertreatment,leadingthe NationalInstitutesofHealthExpertCommitteetonotrecommendVLCDs(4).
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Meal replacements: Meal replacements are growing in popularity as another category of energycontrolled diets (6). A meal is replaced with a liquid drink that contains approximately 200 kcal per serving and approximately 50% to 60% carbohydrate, 30% protein, and 10% fat, or a premeasured frozen meal of a set energyvalue (6).Themealreplacementhelpsthepatientcontrolenergyintakeandreducessensorystimulation and the need to make decisions about portion size (6). Weight loss outcomes using a meal replacement are dependentonthepatientsadherencetothemealplan.Studiesdemonstratesustainedweightlossof3.2%to8.4% over4yearsusingmealreplacements(2829).Forpeoplewhohavedifficultywithselfselectionorportioncontrol, mealreplacements(eg,liquidmeals,mealbars,energycontrolledpackagedmeals)maybeusedaspartofthediet componentofacomprehensiveweightmanagementprogram.Substitutingoneortwodailymealsorsnackswith mealreplacementsisasuccessfulweightlossandweightmaintenancestrategy(GradeI)(6,7).
Pharmacotherapy:Pharmacologicagentsforobesityinterventioncontributetoenergydeficitthrougha varietyofmechanisms (27).Therearecurrentlyfewpharmacotherapyoptionsavailableforlongtermuse (6). MedicationsapprovedbytheFoodandDrugAdministrationforthetreatmentofsignificantclinicalobesity includesibutramine(Meridia)andorlistat(Xenical) (6).Thegreatestbenefitofpharmacotherapymaybethe facilitationofweightlossmaintenance,ratherthantheinductionofweightloss (2930).Twoyearstudiesof sibutramine and orlistat showed that participants who remained on medication at the end of this time maintainedweightlossesthatwerenearlytwiceasgreatasthoseofparticipantswhoreceivedplacebo(30).It may be recommended that these medications be used longterm in the same manner as agents for hypertension,hyperlipidemia,anddiabetesmellitus(31).Criteriaforpharmacotherapyinterventionincludea BMIofatleast30kg/m2withnocomorbidconditions,oraBMIofatleast27kg/m2withcomorbidconditions or a very high health risk (4). Research indicates that pharmacotherapy may enhance weight loss in some overweightandobeseadults(GradeI)(6,7).
Sibutramineisacombinedcentrallyactingserotoninnorepinephrinereuptakeinhibitorthatisassociated withincreasedsatiation.Sibutramineseemstoreducebodyweightbymodifyingintakethroughincreased satiety,andanimaldatasuggestthatitmayalsoincreaseenergyexpenditurebystimulatingthermogenesis (31).Whencombinedwithalowenergydiet,10to15mg/dayofsibutramineproducesaclinicallysignificant greaterlossofinitialweight(7%)whencomparedtoalowenergydietplusplacebo (32).Weightlossof10% to 15% has been observed in studies that combine sibutramine with intensive lifestyle modification (33,34). Sibutramineisnotrecommendedforpatientswithuncontrolledhypertensionorahistoryofcoronaryartery disease,arrhythmias,heartfailure,orstroke.Inaddition,someantidepressants,suchasmonoamineoxidase inhibitors or selective serotonin reuptake inhibitors, may counteract with the mechanism of sibutramine; therefore, it is not recommended that these medications be taken concurrently (31). Complications of sibutramineincludedrymouth,nausea,headache,insomnia,increasedbloodpressure,andincreasedheart rate(4,6,29).
Amphetaminelikederivatives,suchasphentermineandphentermineresin(AdipexP,Fastin,andothers), mazindol, benzphetamine, and phendimetrazine, which are frequently approved and prescribed for short term use (< 3 months), have a different mechanism of action other pharmological medications. They decrease appetite and food intake by increasing the availability of norepinephrine in the brain. The complications of these drugs are similar to those of sibutramine. Fenfluramine (Pondimin) and dexfenfluramine(Redux)werevoluntarilywithdrawnfromthemarketbecauseofreportsoftheirassociation withvalvularheartdisease.Theyareserotoninergicagentsthatactprimarilybyincreasingserotoninlevels in the brain, leading to a decrease in appetite (6). Herbal preparations for weight loss do not have standardizedamountsofactiveingredientsandhavebeenreportedtohaveharmfuleffects(6).Certainover thecounter preparations containing phenylpropanolamine (eg, Dexatrim) and related compounds have no provenefficacyandhavebeenrecalledbecauseofreportedincidencesofhemorrhagicstroke(6).
Orlistat,apancreaticlipaseinhibitor,isthefirstobesitymedicationthatdoesnotactsystemically.Orlistat inhibitstheabsorptionofupto30%ofdietaryfatcontainedinameal,leadingtoalossof150to180kcal/day (35).Patientsshouldtakethismedicationwithmeals,asittakeseffectwithin2hoursofingestion.Patients receiving orlistat should followa moderately lowfat diet (less than 30% of total energy from fat), with fat distributedevenlyateachmeal.Consumptionofmorethan20goffatpermealor70goffatperdaycan induce adverse gastrointestinal events that include flatus, oily leakage or oily stools, and diarrhea (6). Supplementation with fatsoluble vitamins may be needed (6). In randomized trials, participants who received placebo plus diet lost 6% of their weight in 1 year, compared with a 10% weight loss for those treated with orlistat plus diet (36). Because longterm safety has been demonstrated, orlistat has been approvedbytheFoodandDrugAdministrationforoverthecountersalesatareduceddosage(6).
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Medical nutrition therapy, exercise, and behavior modification should be provided in adjunct to pharmacotherapy (Grade I) (4,6, 7, 29). With pharmacotherapy, weight loss plateaus by 6 months, and weight regainoccursaftermedicationtherapystops (31).Alimitednumberofstudieshaveevaluatedthesafetyand efficacy of anorexiant medications for more than 2 to3 years. The physician must continually assess drug therapyforefficacyandsafety(4).
Surgery: Weight loss surgery is one option for weight reduction in adult patients with severe obesity, definedasaBMIofatleast40kg/m2oraBMIofatleast35kg/m2withcomorbidconditions (Grade I) (4,6,37). RouxenYgastricbypassandlaparoscopicadjustablegastricbandarethemostcommonandwidelyaccepted surgicalprocedures forweightloss (6).Morerecentguidelinessuggestweightlosssugerymaybeanoption for children and adolescents over the 95th percentile for weight based on age who present with a severe comorbidity(36).Childrenandadolescentsshouldbemanagedinspecializedcentersandcurrentlyonlythe laparoscopic adjustable gastric band (LAGB) and RouxenY gastric bypass (RYGB) should be offered as surgicaloptionsinthispopulationgroup (37).Theprimarybenefitofsurgicaltherapyisdurableweightloss and maintenance of weight loss (4, 6). More than 90% of patients experience significant (>20% to 25%) weightloss,andbetween50%and80%ofpatientsmaintaintheweightlossformorethan5years (38).Most weightlossoccursinthefirst6monthsandcontinuesforupto18to24months.Theinitial6monthperiod is marked by the most rapid weight reduction and improvements in comorbid conditions (1). Prospective studies show that the average weight 10 years after surgery is approximately 55% of excess body weight, withaweightregainof10%to15%oftheinitialweightlost(39).Apreoperativebehaviorchangeprogramis highly recommended. Complications of weight loss surgery include gallstones, nutritional deficiencies requiringsupplementation,dumpingsyndrome,proteincaloriemalnutrition,andthecomplicationsthatare associatedwithanysurgery.(RefertoNutritionManagementofBariatricSurgeryinSectionB.)
References 1. 2. 3. 4. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among U.S. adults, 19992000. JAMA. 2002;288:17231727. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among U.S. children and adolescents, 1999 2000.JAMA.2002;288:17281732. SerdulaMK,IveryD,CoatesRJ,FreedmanDS,WilliamsonDF,ByersT.Doobesechildrenbecomeobeseadults?Areviewofthe literature.PrevMed.1993;22:167177. National Heart, Lung, and Blood Institute Obesity Education Initiative Expert Panel. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. National Institutes of Health; 1998. NIH publicationNo.984083.Availableat:http://nhlbi.nih.gov/nhlbi/htm. WolfA,ColditzGA.CurrentestimatesoftheeconomiccostofobesityintheUnitedStates.ObesityRes.1998;6:97106. PositionoftheAmericanDieteticAssociation:weightmanagement.JAmDietAssoc.2009;109:330346. Adult Weight Management EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. AmericanDieteticAssociation;2006.Availableat:http://www.adaevidencelibrary.com.AccessedFebruary10,2009. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parenteral obesity.NEnglJMed.1997;337:869873. BarlowSE,DietzWH.Obesityevaluationandtreatment:ExpertCommitteerecommendations.Pediatrics.1998;102:111 DietzWH.Healthconsequencesofobesityinyouth:childhoodpredictorsofadultdisease.Pediatrics.1998;101:518525. KuczmarskiRJ,OgdenCL,GrummerStrawnLM,FlegalKM,GuoSS,WeiR,MeiZ,CurtinLR,etal.CDCGrowthCharts:UnitedStates. AdvanceDataFromVitalandHealthStatistics.Hyattsville,Md:NationalCenterforHealthStatistics;2000.PublicationNo.314. Pediatric Weight Management Evidence Analysis Project. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2006.Availableat:http://www.adaevidencelibrary.com.AccessedAugust1,2006. EpsteinLH,ValoskiA,McCurleyJ.Effectofweightlossbyobesechildrenonlongtermgrowth.AmJDisChild.1993;147:1076 1080. Caprio S, Hyman LD, McCarthy S, Lange R, Bronson M, Tamborlane WV. Fat distribution and cardiovascular risk factors in obese adolescentgirls:importanceoftheintraabdominalfatdepot.AmJClinNutr.1996;64:1217. KaveyRE,DanielsSR,LauerRM,AtkinsDL,HaymanLL,TaubertK.AmericanHeartAssociationguidelinesforprimaryprevention ofatheroscleroticcardiovasculardiseasebeginninginchildhood.Circulation.2003;107:15621566. Williams CL, Hayman LL, Daniels SR, Robinson TN, Steinberger J, Paridon S, Bazzarre T. Cardiovascular health in childhood: a statementforhealthprofessionalsfromtheCommitteeonAtherosclerosis,Hypertension,andObesityintheYoung(AHOY)ofthe CouncilonCardiovascularDiseaseintheYoung,AmericanHeartAssociation.Circulation.2002;106:143160. PositionoftheAmericanDieteticAssociation:healthimplicationsofdietaryfiber.JAmDietAssoc.2002;102:9931000. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American CollegeofSportsMedicine.JAMA.1995;273:402407. WingRR,HillJO.Successfulweightlossmaintenance.AnnuRevNutr.2001;21:323341. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.NEnglJMed.2002;346:393403. Kennedy ET, Bowman SA, Spence JT, Freedman M, King J. Popular diets: correlation to health, nutrition, and obesity. J Am Diet Assoc.2001;101:411420. WaddenT,VanItallieT,BlackburnG.Responsibleandirresponsibleuseofverylowcaloriedietsinthetreatmentofobesity.JAMA. 1990;263:8385. NonasC.Amodelforchroniccareofobesitythroughdietarytreatment.JAmDietAssoc.1998;98(suppl2):S16S22. FosterGD,WyattHR,HillJO,McGuckinBG,BrillC,MohammedBS,SzaparyPO,RaderDJ,EdmanJS,KleinS.Arandomizedtrialofa lowcarbohydratedietforobesity.NEnglJMed.2003;348:20822090.
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
17. 18. 19. 20. 21. 22. 23. 24.
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Obesity and Weight Management 25. Physical activity guidelines advisory committee report to the Secretary of Health and Human Services, 2008. US Department of HealthandHumanServicesWebsite.http://www.health.gov/PAGuidelines/committeereport.aspx.AccessedFebruary10,2009. 26. National Task Force on the Prevention and Treatment of Obesity, National Institutes of Health. Very lowcalorie diets. JAMA. 1993;270:967974. 27. WaddenTA,OseiS.Thetreatmentofobesity:anoverview.In:WaddenTA,StunkardAJ,eds.HandbookofObesityTreatment.New York:GuilfordPress;2002:229248. 28. FlechtnerMors M, Ditschuneit HH, Johnson TD, Suchard MA, Adler G. Metabolic and weight loss effects of longterm dietary interventioninobesepatients:fouryearresults.ObesRes.2000;8:399402. 29. National Task Force on the Prevention and Treatment of Obesity. Longterm pharmacotherapy in the management of obesity. JAMA.1996;276:19071915. 30. FabricatoreAN,WaddenTA.Treatmentofobesity:anoverview.ClinDiabetes.2003;21:6772. 31. Fernstrom JD, Atkinson RL. Antiobesity agents: pharmacology and pharmacotherapy. In: Obesity as a Chronic Disease: New Implications for Management. Clinical Management Conference Proceedings. Minneapolis, Minn: University of Minnesota Office of ContinuingEducation;1998:1827. 32. LeanMEJ.Sibutramine:areviewofclinicalefficacy.IntJObes.1997;21:30S36S. 33. JamesWP,AstrupA,FinerN,HilstedJ,KopelmanP,RossnerS,SarisWH,VanGaalLF.Effectofsibutramineonweightmaintenance afterweightloss:arandomizedtrial.Lancet.2000;356:21192125. 34. Wadden TA, Berkowitz RI, Sarwer DB, PrusWisniewski R, Steinberg C. Benefits of lifestyle modification in the pharmacologic treatmentofobesity:arandomizedtrial.ArchInternMed.2001;161:218227. 35. SjostromL,RissanenA,AndersenT,BoldrinM,GolayA,KoppeschaarHP,KrempfM.Randomisedplacebocontrolledtrialoforlistat forweightlossandpreventionofweightregaininobesepatients.Lancet.1998;352:167172. 36. Davidson MH, Hauptman J, DiGiorlamo M, Foreyt JP, Halstead CH, Heber D, Heimburger DC, Lucas CP, Robbins DC, Chung J, HeymsfeldSB.Weightcontrolandriskfactorreductioninobesesubjectstreatedfor2yearswithorlistat:arandomizedcontrolled trial.JAMA.1999;281:235242. 37. Mechanick JI, Surgerman HJ, CollazoClavell ML, Spitz AF, Livingston EH, Anderson WA. Executive Summary of The Recommendations of The American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic&BariatricSurgeryMedicalGuidelinesForClinicalPracticeforThePerioperative,Nutritional,Metabolic,andNonsurgical SupportofTheBariatricSurgeryPatient.EndocrinePractice.2008;3:318336. 38. MacLeanLD,RhodeBM,NohrCW.Lateoutcomeofisolatedgastricbypass.AnnSurg.2000;231:524528. 39. PoriesWJ,SwansonMS,MacDonaldKG,LongSV,MorrisPG,BrownBM,BarakatHA,deRamonRA,IsraelG,DelezalJM,etal.Who wouldhavethoughtit?Anoperationprovestobethemosteffectivetherapyforadultonsetdiabetes.AnnSurg.1995;222:339352.
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PANCREATITIS
Discussion Thepancreasisamajororganinvolvedinthedigestionandabsorptionoffood.Thepancreasiscomprisedof twomajorglandseachprovidingauniquefunction.TheendocrineglandknownastheIsletsofLangerhansis responsibleforproducinginsulin,glucagon,andsomatostatin.Theexocrineportionofthegland(referredas the ductal system) is responsible for secretion of multiple digestive enzymes including amylase, lipase, carboxypeptidase,phospholipasealpha,chymotrypsin,aminopeptidase,trypsinogen,andcholesterase(1). Acute pancreatitis involves a systematic immunoinflammatory response to a localized process of autodigestionofthepancreaticglandandcanincludetheinvolvementofothertissuesandorgansystems(13). The onset of pain usually occurs 24 to 36 hours after the peak of cytokine production which leads to the inflammatoryresponse(4).Distantorganfailurecanoccurin1to3days(4). TheetiologyofacutepancreatitisintheU.S.involvesalcoholabusein75%ofcases(1,5).Approximately15% of caseare either idiopathic orcaused by biliary tractdiseases (passage ofcommon bile ductstone), while 10% is accounted for by a variety of disorders such as pancreas divisum, trauma, hypoparathyroidism, hyperclacemia,hyperlipidemia,postendoscopicretrogradecholangiopancreatography(ERCP),medications, and biliary dyskinesia (1,5). Treatment often depends on severity which is identified by objective scoring systemssuchasAcutePhysiologyandChronicHealthEvaluation(APACHE)IIscoreandRansonCriteria(1,69), and the presence of necrosis on CT scan (1,6). For severe cases the anticipated hospital length of stay is approximately1monthwithahighpercentageofpatientsdevelopingcomplicationssuchasinfection,sepsis, andorganfailure(1).Formildtomoderatecases,thereisalowriskforcomplications(<5%),withthechance for80%toadvancetoanoraldietsuccessfullywithin1week(1,69). NutritionalAssessmentandDiagnosis Acute pancreatitis produces a hypermetabolic response that alters carbohydrate protein, fat, and energy metabolism leading to rapid deterioration of nutritional status (1). Reduced oral intake can occur from abdominal pain, food aversion, nausea, vomiting, gastric atony, paralytic ileus, or partial obstruction of the duodenum from enlargement of the pancreatic gland (1). Pancreatitis can also produce a hemodynamic response, which is similar to that of sepsis (1). This response includes increased cardiac output, decreased peripheral resistance, and increased oxygen consumption, currently known as the systemic inflammatory response syndrome (SIRS) (1). Energy expenditure reportedly increases by 139% of that predicted by the HarrisBenedict equation and can further be increased by 15% if the pancreatitis is complicated by sepsis (1,10),. Patients with acute pancreatitis are more hypermetabolic when compared to those with chronic pancreatitis(10). Nutrientlossesareoftenincreasedbecauseofmaldigestionfromreducedenzymeoutput,malabsorptionof luminalnutrients,orexcessiveproteinlosscausedbydiarrheaorpancreaticfistulas(1).Proteincatabolicrate and urea production rates are significantly increased. Errors in carbohydrate metabolism leading to hyperglycemiaand insulinresistanceoccur in 40%to90% ofpatients (1,11). Errors in fat metabolism with hypertriglyceridemiaoccurin12%to15%ofcases(1,1213).Hypocalcemiahasbeenshowntobeprevalent(13) andoccursasaresultofreducedcalciumlevelsrelatedtodecreasedparathyroidhormonerelease,increased calcitonin, decreased magnesium levels, hypoalbuminemia, and saponification of calcium with unabsorbed fatty acids (1). Since longterm alcohol use is a primary cause of acute pancreatitis, decreases in zinc, magnesium, thiamin, and folate levels are often observed and should be evaluated (1,1113). Table III19 providescommonassessmentparametersthatmaybealteredasaresultofpancreatitisandcanbeusedin diagnosingnutritionrelatedproblems. TableIII19:CommonAssessmentParametersforPancreatitis Data ReferenceRange Discussion Serumamylase 30to95IU Elevatedwithpancreaticdysfunction,duetoliberationof digestiveenzymesfrompancreasintoneighboringtissuesand bloodstream Serumbilirubin 0.2to0.9mg/dL Elevatedvaluesmaybedueto compressionofthedistalcommon ductwithinthepancreas,biliarystones,orinflammationofthe liverandbileducts
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TableIII19:CommonAssessmentParametersforPancreatitis Data ReferenceRange Discussion Serumlipase <1.5IU/mL Elevatedwithliberationoflipasefromthepancreasintothe bloodstream Bloodglucose 70to110mg/dL Elevatedwithimpairedsecretionofinsulininresponsetoglucose loadbecauseofinflammatorydestructionofIsletsof Langerhans Glucagonreleasedfromalphacellsmaycontributetothe elevationofbloodglucose. Elevatedwithfatmalabsorptionsecondarytoimpaireddigestion offatduetoimpairedsecretionofpancreaticlipase Valuemayreach50g/24hours. Decreasedsecondarytofatmalabsorptionassociatedwith steatorrhea Thistestisrarelydone. Decreasedduetosaponification of calciumwithunabsorbedfatty acids,orasresultofincreasedcalcitonin,decreased magnesiumlevels,hypoalbuminemia,and/ordecreased parathyroidhormonerelease. Elevatedduetohemoconcentrationwhenserumexudesintothe abdomen Decreasedinseverehemorrhagicpancreatitis Identifieslevelofnecrosis of pancreas Hypoactivebowelsounds Abdominalpain, Nausea,vomiting Diarrheaorbulkyfoulsmellingstoolsandflatulenceindicatefat malabsorption.
Fecalfat
5to6g/100gof stool 90to280g/dL 100to300IU/dL 9to11mg/dL
Serumcarotene
Serumcalcium
Hematocrit
42to52%(males) 37to47%(females) Subjective
CTscan Physical examination
NutritionInterventioninAcutePancreatitis Treatment of acute pancreatitis has drastically changed over the past decade (1). Parenteral nutrition (PN) andbowelresthastraditionallybeentheprimarymanagementapproachbasedonthehypotheticalreasons thatenteralfeedingmaystimulatethesynthesisofpancreaticenzymesandworsentheseverityofdisease. However, current evidence suggests that the provision of enteral nutrition (EN) has a dramatic impact on patient outcome compared to the provision of parenteral nutrition (PN) (1415). Two recent metaanalyses demonstratedthatuseofENreducesinfectionbyasmuchas52%,hospitallengthofstaybyasmuchas4 days,needforsurgicalinterventionbyasmuchas52%,andtrendtowardreducedorganfailurebyasmuch as41%whencomparedtouseofPN (1415).Experiencefromtheliteraturesuggeststhateffortstopromote pancreaticrestasthesolemanagementstrategytotreatpancreatitisisineffectiveanddoesnothaveimpact onpatientoutcome(1). Thechoiceofnutritiontherapyshouldbedeterminedbydiseaseseverity,anticipatedlengthofintervention, andtolerancetotheintervention(1).Theoptionsfornutritioninterventioninpatientswithacutepancreatitis mayincludeprovisionofEN,placementonPN,oruseofaprogressiveoraldiet(eg,clearliquidsadvancingas tolerated) withoutspecialized nutrition support (1). The most recent evidence suggests enteral nutrition is the first choice over PN in patients with severe acute pancreatitis (1, 1415). Placement on PN should be reservedforonlythosepatientswithsevereacutepancreatitisinwhompoortolerancehasbeendocumented withENinterventionorincaseswhereENisnotfeasibleduetoaccessorothermedicalissues(1).Thetiming ofspecializednutritionsupportiscriticalforimprovingpatientoutcomes.ENshouldbeinitiatedwithin48 to72hoursofadmission,whilePNmayneedtobedelayeduntilafterthe5thdayofadmission(1). Promoting tolerance to enteral feeding regimen is critical. Several factors have been identified that influence toleranceto enteral feedings in patients with acute pancreatitis (1). Complications of pancreatitis suchaspresenceofpseudocyst,abscess,orascitesarenotacontraindicationtoEN(1).ENmaybeprovidedas longastoleranceisdemonstrated.EvidenceofintolerancetoEN(eg,increaseinabdominalpain,fever,or
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WBCcountinassociationwithincreasesinamylase,lipase)shouldberoutinelyevaluated.Ifintoleranceis documented,achangeinenteralformulamaybeindicated(1).ThefollowingTableIII20providesguidelines forinitiatingENinsevereacutepancreatitis. TableIII20:GuidelinesforUsingEnteralNutritioninSevereAcutePancreatitis(1) Tubeplacement: PositionfeedingtubetipjustbelowtheLigamentofTreitz(1,1518). Intragastricorintraduodenalinfusionofelementalformulascanprovokea clinicalexacerbationinacutepancreatitis(1). Feedingrate: Usecontinuousinfusionover24hoursperday(1) Formulaselection: Usestandardisotonic1kcal/mLformulaiffeedingtubetipispositioned belowtheLigamentofTreitz. Ifintolerancetostandardformuladocumented(1): Useelementalorsemielementalformula.Tryanelementalformulathatprovides<2to3%oftotal caloriesfromfatsuchasVivonexTM,CriticareTM,VitalHNTM;orswitchtosemielementalformulawith smallpeptidesandmediumchaintriglyceridessuchasPeptamenTMorSubdueTM. Ifdiarrheaorsteatorrheadocumented(1): UsesemielementalformulawithsmallpeptidesandmediumchaintriglyceridessuchasPeptamenTM orSubdueTM. ImplicationsofParenteralNutrition(PN) Patients who are placed on PN should be managed using hospital PN protocols and/or guidelines. If pancreatitisiscausedbyhypertriglyceridemia(>1,000mg/dL)orthepatienthasahistoryofhyperlipidemia, infusion of IV fat emulsion (IVFE) should be used with caution (1). Pancreatitis due to IVFEinduced hyperlipidemiaisrareunlessserumtriglyceridesexceed1000mg/dL (1).IVFEisconsideredsafeforusein patientswithpancreatitiswithouthypertriglyceridemia(1,19).However,IVFEshouldbewithheldfromthePN regimenifserumtriglycerideconcentrationsexceed400mg/dL(1). NutritionApproachesandInterventioninChronicPancreatitis Chronic pancreatitis is a chronic, persistent inflammatory state resulting in progressive, irreversible fibrosisanddestructionoftheendocrineandexocrinetissue.Whatdifferentiateschronicpancreatitisfrom acuteisevidenceofpermanentdamagetotheanatomyorfunctionofthegland (1).Theetiologiesthatcan lead to chronic pancreatitis are nearly identical to those for acute pancreatitis (1). A flare up of chronic pancreatitisisidenticaltoacutepancreatitis (1),however,aftertheacuteepisodepatientsmaygoontohave recurrentabdominalpaincomplicatedbydiarrhea,steatorrhea,andweightloss.Chronicpancreatitiscauses many digestive and metabolic disturbances and can compromise the patients nutritional status over time. Malnutritionoccurslateinthedisesasecourseandisaresultofareductioninnutrientabsorption,andan increaseinmetabolicactivity (20).Nutritioninterventionandmanagementshouldfocusonmaintainingthe patientsweight,nutritionalstatusandcontrollingabdominalpainthroughsymptommanagement(1). Mostchronicpancreatitispatientscanbemanagedwithdietaryrecommendationsandpancreaticenzyme supplementation(1,20).Enzymereplacementtherapyisusedtocontrolmalabsorptionandtorelievepain,and isusuallygivenwithmeals (1).Thereisnoevidencetosupportthecontentionthatafatrestricteddietwill influence the recurrence rate of pancreatitis, except in those patients with severe hypertriglyceridemia. Pancreatic lipase reserves are large; as much as 80% of pancreatic lipase secretion can be lost without interferingwithfatdigestion.Alowfatdietisnotroutinelyrequired,unlesssymptomsarepoorlycontrolled onenzymetherapyorifpainpersistsonbothenzymesupplementationandnarcoticanalgesia(1).Vegetable fatshavebeenshowntobebettertoleratedthananimalfats (1).Substitutingmediumchaintriglycerideoil for longchain fat has been shown to decrease cholecystokinin (CCK) levels and pancreatic stimulation and improvepersistentpaininpatientswithchronicpancreatitis (19).Onestudyfoundthatapproximately5%of those with chronic pancreatitis have severe and ongoing maldigestion and may enteral feeding support. Providing enteral nutrition using a route that provides feedings beyond the Ligament of Treiz is recommendedoverparenteralnutrition(20). The following table provides a summary of nutrition intervention strategies for patients with acute and chronicpancreatitis. III-87 Copyright 2011 Morrison Management Specialists, Inc. Manual of Clinical Nutrition Management
Pancreatitis
Approach Firstoralfeeding Totalenergy
Rationale Clearliquidstoestablishtolerance. Patientswhotolerateclearliquidsmaytoleratedietadvancement. 15%to39%greaterthannormal REEinacutepancreatitis(10) Patientswithexocrineinsufficiencymayrequiremoreenergytocompensatefor malabsorption(1). 35kcal/kg/dayforchronicpancreatitis(1) 1.5g/kg/daywith acutepancreatitis (1) 1.0to1.5g/kg/dayinchronicphase(1) 0.7to1.0g/kg/day(1,21) Patientswithexocrineinsufficiencyshouldreceivepancreaticenzymes(1). Alowfatdietisnotroutinelyrequired,unlesssymptomsarepoorlycontrolledon enzymetherapyorifpainpersistsonbothenzymesupplementationandnarcotic analgesia(1). Note:Duringmeasurementof72hour(quantitative)fecalfat,patientsneedtobeon a100gfatdietandhaveactualfatintakecalculated. Normalpercentageofcarbohydrates. Patientsmayhaveincreasedfluid,chloride,sodium,potassium,andcalciumneeds secondarytonasogastricsuction,diarrhea,oremesis. Avoidhighfiberdietsinpatientswithexocrineinsufficiency;largeamountsoffibercan increasesteatorrhea. Patientswithmalabsorptionmayneedsupplementationoffatsolublevitamins. Oralintake:Ifsteatorrheacontinues,monitorforserumdeficienciesoffolicacid,B12 andfatsolublevitamins. Ifabdominalpaincontinuesenzymesupplementsmayneedtobeincreasedto3to4 tabletswithmealsandatbedtime(1).Seetypicaldosebelow. Avoidalcohol. Smallfeedings. Inexocrineinsufficiency,pancreaticenzymesmustbetakenatthesametimeasfood,at allmealsandsnacks. Alowfatdietisnotroutinelyrequired,unlesssymptomsarepoorlycontrolledon enzymetherapyorifpainpersistsonbothenzymesupplementationandnarcotic analgesia(1). Typicaldoseis2tabletstakenorally(30,000IUoflipase)permealand/orsnacks(1,21 22)a. Mustbetakenwhileeating. Donotcrushentericcoatedenzymecapsules.TheuseofH2receptorantagonists(eg, cimetidine,ranitidine,famotidine)orprotonpumpinhibitors(omeprazole)increases theefficiencyofnonentericcoatedpancreaticenzymesupplementsbydecreasing gastricacidproduction(1).
Protein
Fat
Carbohydrates Fluids Fiber Vitamins Monitoring
Selfmanagement training
Pancreatic enzymes
Thedoseofenzymesusuallyrequiredtotreatsteatorrheashouldcontaintheconcentrationofenzymesthatapproximates10%ofwhat thepancreasnormallyproduce(1) References 1. Tiu Amy, McClave SA. Pancreatitis. In: Gottschlich MM ed. The A. S. P. E. N. Nutrition Support Core Curriculum: A CasedBased ApproachTheAdultPatient.SilverSpring,MD:AmericanSocietyofEnteralandParenteralNutrition;2007:558574. 2. BradleyEL3rd.Aclinicallybasedclassificationsystemforacutepancreatitis.ArchSurg.1993;128:586590. 3. Saluja AK, Steer MLP. Pathophysiology of pancreatitis. Role of cytokines and other mediators of inflammation. Digestion. 1999;60(suppl1):2733. 4. NormanJG.Newapproachestoacutepancreatitis:roleofinflammatorymediators.Digestion.1999;60(suppl1):5760. 5. HoltS.Chronicpancreatitis.SouthMedJ.1993;86:201207.
a
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Pancreatitis 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. BanksPA,FreemanML,PracticeParametersCommitteeoftheAmericanCollegeofGastroenterology.Practiceguidelinesinacute pancreatitis.AmJGastroenterol.2006;101:23792400. LarvinM,McMahonMJ.APACHEIIscoreforassessmentandmonitoringofacutepancreatitis.Lancet.1989;2:201205. Sax H, Warner B, Talawini M. Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects. Am J. Surg. 1987;153:117124. WilsonC,HeathDI,ImrieCW.Predictionofoutcomeinacutepancreatitis:acomparativestudyofAPACHEII,clinicalassessment andmultiplefactorscoringsystems.BrJSurg.1990;77:12601264. Dickerson RN, Vehe KL, Mullen JL, Feurer ID. Resting energy expenditure in patients with pancreatitis. Crit Care Med. 1991;19:484490. MarulendraS,KirbyD.Nutritionsupportinpancreatitis.NutrClinPract.1995;10:4553. HavalaT,ShrontsE,CerraF.Nutritionalsupportinacutepancreatitis.GastroenterolClinNorthAm.1989;18:525542. KohnCL,BrozenecS,FosterPF. Nutritional supportforthepatientwithpancreatobiliarydisease.CritCareNursClin North Am. 1993;5:3745. McClaveSA,ChangWK,DhaliwalR,HeylandDK.Nutritionsupportinacutepancreatitis:asystematicreviewoftheliterature.J ParenterEnteralNutr.2006;30:143156. Marik PE, Zaloga GPL. Metaanalysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ. 2004;328:14071412. Kudsk KA, Campbell SM, OBrien T, Fuller R. Postoperative jejunal feedings following complicated pancreatitis. Nutr Clin Pract. 1990;5:714. McClaveSA, GreeneLM,SnidarHL,MakkLJ,CheadleWG,OwensNA,DukesLG, Goldsmith, LJ. Comparisonofthe safetyofearly enteralvs.parenteralnutritioninmildacutepancreatitis.JParenterEnteralNutr.1997;121:1420. Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos, CA. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis:resultsofarandomizedprospectivetrial.BrJSurg.1997;84:16651669. SheaJC,BishopMD,ParkerEM,GelrudA,FreedmanSD.Anenteraltherapycontainingmediumchaintriglyceridesandhydrolyzed peptidesreducespostprandialpainassociatedwithchronicpancreatitis.Pancreatology.2003;3:3640. Stanga Z, Giger U, Marx A, DeLegge MH. Effect of jejunal longterm feeding in chronic pancreatitis. J Parenter Enteral Nutr. 2005;29:1220. MeierR.Nutritioninchronicpancreatitis.In:BuchlerM,FriessH,UhlW,eds.ChronicPancreatitis.Berlin:Blackwell;2002:421 427. ForsmarkCE.Chronicpancreatitis.In:FeldmanM,FriedmanLS,SleisengerMH,eds.SleisengerandFordtransGastrointestinaland LiverDisease:Pathophysiology/Diagnosis/Management.7thed.Philadelphia,PA:Saunders;2002:943969.
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PARENTERALNUTRITION(PN):METABOLICCOMPLICATIONS(14)
Complication Hyperglycemia(14)
Causes Trauma Infection Diabetesmellitus Excessivedextrose administration Corticosteroidsor immunosuppressive therapy
Symptoms Elevatedbloodglucose level
Hypoglycemia
SuddencessationofPN Excessiveinsulin administration
Lowbloodglucoselevel (<70mg/dL)(5,6) Headache Sweating Thirst Disorientation Convulsions Coma
Hyperglycemic hyperosmotic syndrome
Dehydrationfrom osmoticdiuresis(type 1diabetesmellitus) Poorintakeofwater (occursinelderly patientswithtype2 diabetesmellitus)
Lethargy Stupor Convulsions Bloodglucoselevel>600 mg/dL(67) Serumosmolality>350 mOsm/L
Azotemia
Dehydration Renalinsufficiency Excessiveprotein administrationor inadequatenonprotein energy
Highbloodureanitrogen level
Treatments Withpersistenthyperglycemia,provide insulinwhennecessarytomaintain bloodglucoselevelsof100to150 mg/dLincriticallyillpatients(4,5). Indiabeticpatients,theplasmagoalis 140to180mg/dLforthemajorityof criticallyillpatients(5)and<140 mg/dLfornoncriticallyillpatients withrandombloodglucosetargeting levels<180mg/dL(5).Morestringent targetsmaybeappropriateinstable patientswithpreviouslytightglycemic control.Lessstringenttargetsmaybe appropriateinpatientswithsevere comorbidities(5). Therateofdextroseinfusionin parenteralnutrition(PN)shouldnot exceed4to5mg/kgpermin(1,4). Ifmanagedoninsulin,decreaseinsulin administration. Giveintravenousdextrose. AvoidtheabruptcessationofPN. Studiesshowthathypoglycemiais equallyprevalentinnondiabetic patientsduetostress.TaperPN solutionfor1to2hours.IfPNmust bediscontinuedquickly,10% dextroseshouldbeinfusedfor1or2 hoursfollowingPNdiscontinuation (1).Checkthecapillarybloodglucose concentration30minto1hourafter thediscontinuationofPNtoidentify reboundhypoglycemia(1). DiscontinuePN. Initiaterateofhalfoftheestimated needsorapproximately150to200g (or100g/dayifsevere hyperglycemia)forthefirst24hours untiltoleranceisdocumented(1). Provideinsulintocorrecttheblood glucoselevel. Carbohydrateadministrationshould notexceedarateof4to5mg/kgper min(1). Increaseadministrationoffreefluid. Reduceaminoaciddose. Patientswithimpairedrenalorhepatic diseasemayrequiredialysis.
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Parenteral Nutrition
Complication Hypophosphatemia
Cholestasis
Steatosis (hepatic accumulation)
Causes Alcoholism Intractablevomiting Inadequateintake Refeedingsyndrome VitaminDdeficiency Hyperparathyroidism Disuseof gastrointestinaltract Overfeeding LongtermuseofPN Excessiveuseof intravenousfat emulsions(IVFE) Overfeeding Essentialfattyacid deficiency
Symptoms Anorexia Muscleweakness Paresthesias Longbonepain Coma Respiratorydistress Elevatedtotalbilirubin level>2mg/dL(1) Elevatedalkaline phosphataseleveland gammaglutamyl transpeptidaselevel Elevated aminotransferaselevel
Treatments IncreasephosphorusinPNsolution basedonindividualmedicalneeds (4). Ifrefeedingsyndromeoccurs,modify theamountofenergyprovidedby carbohydrates(15to20kcal/kgper day)untilelectrolytesarestable(1). Reducetotalenergyprovided. Decreasedextroseto<5mg/kgper min. DecreaseIVFEto<1g/kgperday(1). ConsidercyclicPNinfusion.
Hypomagnesemia
Malabsorption Massivesmallbowel resection Acutepancreatitis Prolongednasogastric suction Intestinalfistula Vomiting Refeedingsyndrome
Hypermagnesemia
ExcessiveMg administration Renalinsufficiency
Hyponatremia
Hypernatremia
Fluidoverload Excessive gastrointestinalloss Excessiveurinaryloss Adrenalinsufficiency Congestiveheartfailure Syndromeof inappropriate antidiuretichormone secretion Dehydration ExcessiveNaintake Osmoticdiuresis Hypoglycemia Hypocalcemia Headtrauma Antidiuretichormone deficiency
Muscleweakness Depression Apathy Nausea Vomiting Irritability Vertigo Ataxia Muscletremor Hypocalcemia Hypoparathyroidism Drowsiness Weakness Nausea Vomiting Cardiacarrhythmia Hypotension DecreasedserumNa levelsandosmolality Irritability Confusion Seizures
ConsidercyclicPNinfusion. Decreasetotalenergyprovided. Balancedextroseenergywithenergy fromfat. Decreasedextroseto<5mg/kgper min. Ifessentialfattyaciddeficiencyoccurs, treatwithlipidinfusions. IncreaseMginPN. Provideadditionalintravenous supplementation(4,7). Correctforhypoalbuminemia. Ifrefeedingsyndromeoccurs,modify thedeliveryofenergyfrom carbohydrates(15to20kcal/kgper day)untilelectrolytesarestable(1).
DecreaseMginPN.
Evaluatefreewaterintakeandtotal volumestatusconsideringdiseasestate andunderlyingcauses.Ifthevolumeis excessive(eg,freewater,intravenous fluids),decreasefluidintakeand/or adjustfreewatervolume.Ifthevolume isdeficient,increasewaterandNa. AdjustNaintakeasconditiondictates.
IncreasedserumNalevel Convulsions Irritability Restlessness Coma
Evaluatefordehydrationordeficitof waterortotalvolume.Increasefree waterorfluidintakeasappropriate. Evaluateintravenoussourcesand considerdecreasingNaifexcessive.
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Parenteral Nutrition
Complication Hyperphosphatemia
Hypokalemia
Hyperkalemia
Causes Renalinsufficiency Excessivephosphorous administration InadequateK+intake Diarrhea Intestinalfistula Anabolism Metabolicalkalosis K+wastingmedications Vomiting Refeedingsyndrome Renalinsufficiency ExcessiveK+ administration Medication (spironolactone) Hypoalbuminemia InadequatevitaminD intake Hypoparathyroidism InadequateCaintake Increased gastrointestinallosses Inadequatephosphorus intake Highproteindose Metabolicacidosis ExcessivevitaminD administration Prolonged immobilization Stress Hyperparathyroidism Malignancy Overfeedingwith dextrose Rapidadministrationof IVFE>110mg/kgper hour(1) Intravenousinfusionof propofol(Diprivan), whichhasthesame lipidcontentasIVFE providing1.1kcal/mL (10)
Symptoms Elevatedserum phosphorouslevel Ileus Cardiacarrhythmia
Treatments DecreasephosphorousinPN.
Cardiacarrhythmia Paresthesias
Hypocalcemia
Paresthesias Tetany Muscularcramping/ spasms
Hypercalcemia
Thirst Polyuria Decreasedappetite Nausea Vomiting Itching Muscleweakness Triglyceridelevel>400 mg/dL(1,3,9) Impairedimmune response Pancreatitis(riskoccurs whenthetriglyceride levelexceeds1000 mg/dL)(1)
Hypertriglyceridemia
CorrectK+priortostartingPNoradjust PNformula. Consideradditionalintravenous supplementation(8). Ifrefeedingsyndromeoccurs,modifythe deliveryofenergyfromcarbohydrates (15to20kcal/kgperday)until electrolytesarestable(1). DecreaseK+inPN(alsoconsider decreasingK+fromotherintravenous sources). ProvideK+binders. K+>5.5mEqwarrantsan electrocardiogram(8). IncreaseCa2+inPN.(Usecautionand followprotocolstoavoidCa2+ phosphorusprecipitation.Check adjustedserumCa2+if hypoalbuminemicorionizedCa2+prior toincreasingCa2+inPN.) Ensureadequatephosphorus(20to40 mmol)inPN(1,3). Evaluateprotein(>2g/kgperday associatedwithincreasedurinary excretionofcalcium)(1). EnsureadequateacetateandMginPN(1). EvaluateCa2+inPN. Ensureadequatehydration. Provideintravenoushydrationusing 0.9%sodiumchlorideat200to300 mL/hourwhencalcium>13mg/dL(8). Afteradequatehydration,furosemide canbeusedtoincreaserenalcalcium excretion(8). ReducedoseorlengthentheIVFE infusiontime(1). Provide<30%ofenergyfromIVFE,or provide1g/kgperdayandinfuse slowly(nolessthan8to10hours)(1,4). Avoidexcessivedextroseadministration.
References 1. KumpfVJ,GervasioJ.Complicationsofparenteralnutrition.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:A CaseBasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:323339. 2. CriticalIllnessEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociationEvidenceAnalysisLibrary.AmericanDietetic Association;2006.Availableat:www.adaevidencelibrary.com.AccessedOctober5,2010. 3. TaskForcefortheRevisionofSafePracticesforParenteralNutrition.Safepracticesforparenteralnutrition.JParenterEnteralNutr. 2004;28(6suppl):S39S70. 4. McClaveSA,MartindaleRG,VanekVW,McCarthyM,RobertsP,TaylorB,OchoaJB,NapolitanoL,CresciG;A.S.P.E.N.BoardofDirectors; AmericanCollegeofCriticalCareMedicine.Guidelinesfortheprovisionandassessmentofnutritionsupporttherapyintheadult Manual of Clinical Nutrition Management
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Parenteral Nutrition criticallyillpatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition(A.S.P.E.N.).J ParenterEnteralNutr.2009;33:277316. 5. Executivesummary:standardsofmedicalcareindiabetes2010.DiabetesCare.2010;33(suppl1):S4S10. 6. McDonnellME,ApovianCM.Diabetesmellitus.In:GottschlichMM,ed.TheA.S.PE.N.NutritionSupportCoreCurriculum:A CaseBasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:676694. 7. GarberAJ,MoghissiES,BransomeEDJr,ClarkNG,ClementS,CobinRH,FurnaryAP,HirschIB,LevyP,RobertsR,VandenBergheG, ZamudioV.AmericanCollegeofEndocrinologyTaskForceonInpatientDiabetesMetabolicControl.AmericanCollegeofEndocrinology positionstatementoninpatientdiabetesandmetaboliccontrol.EndocrPract.2004;10(suppl2):49. 8. LangleyG.Fluid,electrolytes,andacidbasedisorders.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum: ACaseBasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:112,116 117. 9. ASPENBoardofDirectorsandtheClinicalGuidelinesTaskForce.Guidelinesfortheuseofparenteralandenteralnutritioninadultand pediatricpatients.JParenterEnteralNutr.2002;26(1suppl):1SA138SA. 10. HiseME,BrownJC.Lipids.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACaseBasedApproachThe AdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:6364.
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CALCULATINGTOTALPARENTERALNUTRITION
I. StepsforCalculatingTPN. Assesscalorie,protein,andfluidrequirements. 1. Determinecaloriestobeprovidedasfat. 2. Convertfatcaloriestovolumeoflipidemulsionorlipidconcentrationin3in1solution(or totalnutrientadmixtureTNA) 3. Determinecaloriesprovidedfromprotein 4. Determineaminoacidconcentration. 5. Determinecaloriesprovidedfromcarbohydrate. 6. Determinecarbohydrate(dextrose)concentration. 7. Determineiffinalsolutioncanbecompounded. Thesestepswillbeoutlinedindetailbelow. Determineamountofeachsubstrate.Guidelinesforusualandmaximumsubstrateamounts areprovidedintheTable.Afterthesedeterminationshavebeenmadesubstrateconcentrations areeasilycalculatedbasedonTPNvolume.Endconcentrationsreflectgramsofsubstrateinthe finalvolumeofTPNsolution(seeTable). SubstratesinTPN SUBSTRATE USUSALAMOUNT MAXIMUMUNITSOFSUBSTRATE Carbohydrate(cho) 4060%oftotalKcal <5mg/kg/minute Protein(pro) 1.02.0gm/kg/day 2.02.5gm/kg/day Fat 2040%dailytotalKcal 2gm/kg/day <1gm/kg/dayinhighstress
Note:Samplecalculationsarebasedontotalcalorieneedsratherthannonproteincalorieneeds.Eithermethodmaybe used;however,theformeryieldsapproximately250to350caloriesmore.
II.
EstimatedNeeds:1,700calories(kcal),70gmprotein. Calculatingmacronutrientconcentrations. A. 2in1(traditional)solutioncalculations: Calculate2in1solutionusing2,000mLfluid(thisvolumewillincludelipidemulsion) 1. Determinekcaltobeprovidedasfat. Estimatedkcalxdesiredpercentoffat=kcalasfat 1,700kcalx30%=510kcalfromfat 2. Convertfatkcaltovolumeoflipidemulsion. Fatkcalkcal/mLlipidemulsion=volumeoflipidemulsion 510kcal1.1(10%emulsion)kcal/mL=463mLof10%lipid or 510kcal2.0(20%emulsion)kcal/mL=255mLof20%lipid Someinstitutionspreferlipidtobeorderedinvolumesaspackagedbythesupplier (250mLor500mL). Forthisexample,500mLof10%lipidwillbeusedleaving1,500MLfortheremaining TPNsolution. 3. Determinekcaltobeprovidedfromprotein. Estimatedproteinneedsxkcal/gmprotein=70gmproteinx4kcal/gm=280kcal protein 4. Determineaminoacidconcentration(AA). gmprotein x100=%aminoacids TPNvolume 70gm x100=4.7%aminoacids 1,500mL 5. Determinekcaltobeprovidedfromcarbohydrate. Estimatedkcalneeds(kcalasfat+kcalasprotein)=carbohydratekcal 1,700kcal(510kcal+280kcal)=910kcalcarbohydrate 6. Determinecarbohydrateconcentration. a. Carbohydratekcalkcal/gmdextrose*=gmdextrose 910kcal3.4kcal/gm=268gmdextrose *Dextrosesolutionsare3.4kcal/gmratherthan4kcal/gm b. gmdextrose x100=%dextrose volumeTPN 268gm x100=17.9%dextrose 1,500mL Manual of Clinical Nutrition Management III-94 Copyright 2011 Morrison Management Specialists, Inc. III.
Calculating Total Parenteral Nutrition
B.Calculatea2in1solutionwithafluidrestrictionof1,250mL. 1. Determinekcaltobeprovidedasfat. Estimatedkcalxdesiredpercent=kcalasfat 1,700kcalx30%=510kcalfat 2. Convertfatkcaltovolumeoflipidemulsion. A20%lipidsolutionispreferredforfluidrestrictedpatients. kcalasfatkcal/mLlipidemulsion=volumelipid 510kcal2kcal/mL(20%emulsion)=255mL Thiscanberoundedto250mL,leaving1,000mLfortheremainingTPNsolution. 3. Determinekcaltobeprovidedfromprotein. Estimatedproteinneedsxkcal/gmprotein=kcalprotein 70gmx4kcal/gm=280kcalprotein 4. Determineaminoacidconcentration(AA). x100=%AA gmprotein TPNvolume x100=7.0%AA 70gm 1,000mL 5. Determinekcaltobeprovidedfromcarbohydrate. Estimatedkcalneeds(kcalasfat+kcalasprotein)=carbohydratekcal 1,700kcal(510kcal+280kcal)=910kcalcarbohydrate 6. Determinecarbohydrateconcentration. a. Carbohydratekcalkcal/gmdextrose=gmdextrose 910kcal3.4kcal/gm=268gmdextrose b. gmdextrose x100=%dextrose volumeTPN x100=26.8%dextrose 268gm 1,000mL 7. Finalorder: 1liter7%AA,26.8%dextrose,and250mL20%lipid.Thissolutionwillnotcompound,so thedextrosewillhavetobereducedto17.5%untilfluidrestrictionsarelifted.* (SeecompoundingguidelinesforspecificcalculationsSectionIV.) *Ifyourpharmacyusesa15%aminoacidstocksolution,thiswillcompound. C. Calculatea3in1solutionwith2,000mLfluid. 1. Determinekcaltobeprovidedasfat. Estimatedkcalxdesiredpercent=kcalasfat 1,700kcalx30%=510kcalfat 2. Convertfatkcaltovolumeoflipidemulsion. a. kcalfatkcal/gm=gmfat 510kcal9kcal/gm*=56.7gmfat b. gmdextrose x100=%dextrose volumeTPN x100=26.8%dextrose 268gm 1,000mL *9kcal/gmisusedasanestimate;however,lipidemulsionsareactually10 kcal/gmbecauseofcomponentsotherthanfatwithintheemulsion. 3. Determinekcaltobeprovidedfromprotein. gmproteinxkcal/gm=kcalasprotein 70gmx4kcal/gm=280kcalprotein 4. Determineaminoacidconcentration(AA). x100=%AA gmprotein TPNvolume x100=3.5%AA 70gm 2,000mL 5. Determinekcaltobeprovidedfromcarbohydrate. Estimatedkcalneeds(kcalasfat+kcalasprotein)=carbohydratekcal 1,700kcal(510kcal+280kcal)=910kcalcarbohydrate 6. Determinecarbohydrateconcentration. a. kcaldextrosekcal/gmdextrose=gmdextrose 910kcal3.4kcal/gm=268gmdextrose
III-95
gmdextrose x100=%dextrose TPNvolume 268gm x100=13.4%dextrose 2,000mL 7. Finalorder: 2liters3.5%AA,13.4%dextrose,and2.8%lipid D. Calculatea3in1solutionwith1,250mLfluidrestriction. 1. Determinekcaltobeprovidedasfat. Estimatedkcalxdesiredpercent=kcalasfat 1,700kcalx30%=510kcalfat 2. Convertfatkcaltovolumeoflipidemulsion. a. kcalfatkcal/gm=gmfat 510kcal9kcal/gm=56.7gmfat b. gmfat x100%=%lipid TPNvolume 56.7gm x100%=4.5%lipid 1,250mL 3. Determinekcaltobeprovidedfromprotein. gmproteinxkcal/gm=kcalasprotein 70gmx4kcal/gm=280kcalprotein 4. Determineaminoacidconcentration(AA). gmprotein x100=%AA TPNvolume 70gm x100=5.6%AA 1,250mL 5. Determinekcaltobeprovidedfromcarbohydrate. Estimatedkcalneeds(kcalasfat+kcalasprotein)=carbohydratekcal 1,700kcal(510kcal+280kcal)=910kcalcarbohydrate 6. Determinecarbohydrateconcentration. a. kcaldextrosekcal/gmdextrose=gmdextrose 910kcal3.4kcal/gm=268gmdextrose b. gmdextrose x100=%dextrose TPNvolume 268gm x100=21.4%dextrose 1250mL 7. Finalorder: 1.25liters5.6%AA,21.4%dextrose,and4.5%lipid.Thissolutionwillnotcompound, thereforethedextrosewillhavetobereducedto12.3%dextroseuntilfluid restrictionsarelifted.* (Seecompoundingguidelinesforspecificcalculations.SectionIV) *Ifyourpharmacyusesa15%aminoacidstocksolution,thiswillcompound. IV. CompoundingParenteralNutrition Assumestocksolutionsof70%dextrose,10%aminoacids,and20%lipids. 1. DetermineTPNvolumeandgramsofcarbohydrate,protein,andfat. 2. Determinevolumeof70%dextrosestocksolution. 3. Determinevolumeof10%aminoacidstocksolution. 4. Determinevolumeof20%lipid. 5. Determinevolumeofsterilewaterandadditives. 6. Adjustdextroseorothersubstratesifsolutioncannotbecompoundedatthedesiredvolume. Samplecalculations: A. 2in1solutionwithfluidrestriction1,250mL 1. DetermineTPNvolumeandgramsofcarbohydrate,protein,andfat(seeIII.B.) 1,250mLvolume 250mL20%lipid 268gmcarbohydrate 70gmprotein 2. Determinevolumeof70%dextrosesolution. gmdextrosegm/100mLstocksolution=volumeofstocksolution 268gm70gm/100mL=383mL70%dextrosesolution 3. Determinevolumeof10%AAsolution. III-96 Copyright 2011 Morrison Management Specialists, Inc. Manual of Clinical Nutrition Management
b.
gmproteingm/100mLstocksolution=volumeofstocksolution 70gm10gm/100mL=700mL10%AAsolution. 4. Determinevolumeof20%lipid. 250mL(seeIII.B.2.) Ina2in1solution,thisisseparatefromtheTPNsolution.Thiswillleave1,000mL forAAanddextrose. 5. Determinevolumeofsterilewaterandadditives. DesiredvolumeTPNsolution(volumeofdextrose+volumeAA)=volumeforwater andadditives. 1,000mL(383mL+700mL)=83mL ThesevolumesofstocksolutiondonotfitintothedesiredTPNvolume. 6. Adjustsolution. a. Determinethevolumeavailablefordextrose. Desiredvolume(volumeofAAsolution+volumeforadditives*)=volume availablefordextrose. 1,000mL(700mL+50mL)=250mL *Ususally,50100mLisneededforadditives. b. Determinenewgramsofdextrose. Volumeofdextrosexsolutionconcentration=gmdextrosestocksolution 250mLx70gm/100mL=175gmdextrose c. Determinedextroseconcentration. gmdextrose x100=%dextrose TPNvolume 175gm x100=17.5%dextrose 1,000mL B. 3in1solutionwithfluidrestrictionof1,250mL. 1. DetermineTPNvolumeandgramsofcarbohydrate,proteinandfat(seeIII.D.). 1,250mL 268gmcarbohydrate 70gmprotein 56gmfat 2. Determinevolumeof70%dextrosesolution. gmdextrosegm/100mLstocksolution=volumeofstocksolution 268gm70gm/100mL=383mL70%dextrosesolution 3. Determinevolumeof10%AAsolution. gmproteingm/100mLstocksolution=volumeofstocksolution 70gm10gm/100mL=700mL10%AAsolution 4. Determinevolumeof20%lipid. gmfatgm/100mLstocksolution=volumeofstocksolution 5620gm/100mL=280mL20%lipid 5. Determinevolumeofsterilewaterandadditives. DesiredTPNvolume(volumedextrosesolution+volumeAAsolution+volume lipids=volumeofwaterandadditives 1,250mL(383mL+700mL+280mL)=113mL Thissolutionwillnotcompound. 6. Adjustsolution. a. Determinethevolumeavailablefordextrose. Desiredvolume(volumeofAAsolution+volumelipid+volumeadditives)= volumeavailablefordextrose 1,250mL(700+280+50)=220mL b. Determinenewgramsofdextrose. Volumeofdextrosexsolutionconcentration=gmdextrosestocksolution 220mLx70gm/100mL=154gmdextrose c. Determinenewdextroseconcentration. gmdextrose x100=%dextrose TPNsolution 154gm x100=12.3%dextrose 1,250mL
Reprintedbypermission:fromFishJ.Worksheetforcalculatingtotalparenteralnutrition.SupportLine.1995:17(6):1013. Manual of Clinical Nutrition Management
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PEPTICULCER
Discussion Pepticulcerdiseaseincludesesophageal,gastricandduodenualulcers.ResearchidentifiestheHelicobacter (H.) pylori bacteria as the primary cause in 95% of gastric and duodenal ulcers (13). The remaining 5% is caused by nonsteroidal antiinflammatory medication usage (eg, aspirin and ibuprofen) and excessive production of stomach acid. The treatment for individuals infected with the H. pylori bacteria includes healingtheulcerwithacidsuppressingmedicationandcuringtheinfectionbyusingantibiotics(36). Thereisnoevidencethatfood,beverages,orspicescauseorreactivateulcers(3,4). MedicalApproaches Rationale Avoidfoodsnottolerated. Eliminatefoodsthatcausepainordiscomforttothe (SeeSectionID:Gastrointestional(GI)SoftDiet) patientduringtheacutephases Antisecretorymedication(histamineH2antagonist Reducesgastricacidandpepsinsecretion blocker) Cimetidine(Tagamet),Ranitidine(Zantac) Famotidine(Pepcid),Nizatidine(Axid) Inhibitsgrowthanddestroysmicroorganisms,ie,H. Antibiotics pyloribacteria Buffersacidity Antacids Formsprotectivecoatingoverulcer Sucralfate(carafate)
References 1. NationalInstitutesofHealthConsensusStatement.HelicobacterPyloriinPepticUlcerDisease.Bethesda,Md:NIHOfficeofMedical ApplicationsofResearch.1994;12(1):115. 2. Marshall B, Warren J. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet. 1984;1:13111315. 3. Abreakthroughinulcertreatment.TuftsUniversityDietandNutritionLetter.1996;13(11):46. 4. Rubin,R,Cascade,E,PeuraD,etal.Diagnosisanderadicationofhelicobacterpyloriinthemanagementofpepticulcerdisease:a decisionanalysismodel.AmJManCare.1996;2(4):375383. 5. RubinR,CascadeE,BarkerR,etal.Managementofdyspepsia:adecisionanalysismodel.AmJManCare.1996;2(6):145153. 6. Sung J, Chung S, Ling T, et al. Antibacterial treatment of gastric ulcers associated with helicobacter pylori. N Engl J Med. 1995;332:139142.
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PNEUMONIA
Discussion Pneumoniaisdefinedasinflammationandconsolidationoflungtissueinresponsetoaninfectiousagent (1). Several organisms and disease conditions have been identified to infect or inflame the lungs. The epidemiologyofthediseasehaschangedduetochangesinthemicroorganismsandmodalitiesusedtotreat the condition. The incidence of pneumonia requiring hospitalization is highest among the elderly(2). Subgroups at risk for pneumonia include individuals with chronic obstructive pulmonary disease (COPD), diabetesmellitus,asthma,alcoholism,andheartfailureanddiseasesthataffecttheimmunesystem(eg,HIV disease/AIDSandcancer).Mechanicallyventilatedpatientsareatmostriskfordevelopinghospitalacquired pneumonia.
Approximately 50% of pneumonia cases are caused by viruses and tend to be less severe than those of bacterial origin (13). Pneumococcus (Streptococcus pneumoniae) is the most common cause of bacterial pneumonia (4). Aspiration pneumonia results when solid or liquid food passes into the lungs, causing infection. Aspiration pneumonia results in approximately 50,000 deaths per year, mostly in the elderly (1). NosocomialpneumoniaistheleadingcauseofdeathfromhospitalacquiredinfectionintheUnitedStates(2).
Preventionofpneumoniaprimarilyincludesmaintenanceofimmunestatusandpneumococcalvaccination. Treatment of pneumonia involves a combination of pharmacologic therapy (eg, antibiotics), pulmonary rehabilitation,andmaintenanceofnutritionalstatus.Proteinenergymalnutrition(PEM)isassociatedwith involuntary weight loss, functional impairment and impaired immunity (3). It has been demonstrated that nutritional status plays a critical role in the modulation of immune function. In a study of 277 patients admitted to the hospital for treatment of communityacquired pneumonia, the most important factor independentlyassociatedwithfataldiseasewasalowserumalbuminlevel (4).Inthesamestudy,aserum albumin level under 3.0 g/dL during treatment of the pneumonia was also associated with death due to pneumonia after discharge. Craven and colleagues identified malnutrition as a risk factor for nosocomial pneumoniainhospitalizedpatients(5). Approaches The primary goal of medical nutrition therapy in the management of pneumonia is to preserve lean body massandimmunefunction,preventunintentionalweightloss,andmaintainnutritionalstatus.Fordetailed intervention strategies, refer to the Pneumonia Medical Nutrition Therapy Protocol in Medical Nutrition TherapyAcrosstheContinuumofCare(6).
Energy:Provideenoughenergytomaintainreasonablebodyweight.Increasedenergymaybeneededfor patientswithinfection,fever,orweightloss.
Protein:Provideenoughproteintomaintainvisceralproteinstatusandmeetthedemandsofinfection. Fluid: Fluids are encouraged, unless contraindicated. From 3 to 3.5 L of fluid per day has been recommendedtoliquefysecretionsandhelplowertemperatureinfebrilepatients(7).
Nutrientsandtheimmunesystem:Severalnutrientshavebeenlinkedtothepreservationandmaintenance ofimmunefunction.NutrientsthathavebeenidentifiedincludevitaminsA,E,andB6,zinc,copper,selenium, the amino acids glutamine and arginine, and omega3 fatty acids. These nutrients all seem to modulate specificaspectsofhumanimmunefunction (8).Currentstudiesdonotdemonstrateadirectcauseandeffect relationshipwiththeincidenceofpneumonia.Thecurrentthoughtisthatthesenutrientsmayplayakeyrole in the immune function, leading to less of a risk of developing pneumonia (9). Currently, supplementation withtheseidentifiednutrientsisnotwarranted.However,itisrecommendedtoincreasetheconsumptionof foodsthatprovidethesenutrientsasgoodsources,suchasfruit,vegetables,grains,meats,andfish.
Aspirationriskreduction:Institutingfeedingtechniquesthatpreventriskforaspirationmaybeindicated inpatientswhodemonstratesymptomsofaspiration,suchascoughingbefore,during,orafterconsumption of solids, liquids or medications; drooling; pocketing food in the mouth; and repetitive movement of the tonguefromfronttobackofthemouth.Toreducetheriskofaspiration,considerthefollowingstrategies(10): Positionpatientata90oangleduringmeals. Servefoodatappropriatetemperatures. Limitmealtimedistractions. III-99 Copyright 2011 Morrison Management Specialists, Inc. Manual of Clinical Nutrition Management
Pneumonia
Encouragesmallbites. Avoidusingstrawssinceliquidswillberushedtothebackofthemouthbeforeswallowingissafe. Avoidservingthinliquids,astheycanbeeasilyaspirated.Thickenedliquidswillslowtransittime.
References MarrieTJ.Bacterialpneumonia.In:ConnRB,BorerWZ,SnyderJW,eds.CurrentDiagnosis9.Philadelphia,Pa:WBSaunders;1997: 307311. 2. Pneumonia.AmericanLungAssociation;1996.Factsheet. 3. WhiteJ,ed.TheRoleofNutritioninChronicDiseaseCare.Washington,DC:NutritionScreeningInitiative;1997:2235.. 4. Hedlund JU, Hansson LO, Ortqvist AB. Hypoalbuminemia in hospitalized patients with communityacquired pneumonia. Arch InternMed.1995;155:14381442. 5. CravenDE,StegerKA,BaratLM,DuncanRA.Nosocomialpneumonia:epidemiologyandinfectioncontrol.IntensiveCareMed.1992; 18(suppl1):S39. 6. InmanFelton A, Smith K, Johnson E, eds. Medical Nutrition Therapy Across the Continuum of Care. 2nd ed. Chicago, Ill: American DieteticAssociation;1998. 7. EscottStumpS.NutritionandDiagnosisRelatedCare.5thed.Baltimore,Md:LippincottWilliams&Wilkins;2002:199. 8. RomoreMM.VitaminAasanimmunomodulatingagent.ClinPharm.1993;12:506514. 9. Chandra RK. Effect of vitamin and trace element supplementation on immune responses in elderly subjects. Lancet. 1992;340:11241127. 10. NeidertKC,ed.NutritionCareoftheOlderAdult.Chicago,Ill:AmericanDieteticAssociation;1998:213. 1.
III-100
PRESSUREULCERS
Discussion A pressure ulcer is an area of localized injury to the skin and/or underlying tissue, usually over a bony prominence,asaresultofpressurealoneorpressurecombinedwithshearorfriction(1).Pressureulcerscan develop within 2 to 6 hours when normal capillary blood flow is obstructed, leading to tissue necrosis (1). Personswhohavecomorbiditiesorwhoareseverelyillaremorevulnerabletodevelopingpressureulcers(1). TheNationalPressureUlcerAdvisoryPanel(NPUAP)developedastagingsystemtoclassifypressureulcers in1989andrevisedthestagingsystemin2007.Thenewstagingsystemconsistsofsixcategories:stagesIto IV,unstageable,andsuspecteddeeptissueinjury(1,2). Stage I: Intact skin with nonblanchable rednessof localized area usually overa bony prominence. Darkly pigmentedskinmayhavevisibleblanching;itscolormaydifferfromthesurroundingarea.(Theareamaybe painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individualswithdarkskintones.) Stage II: Partial thickness loss of dermis presenting as a shallow, open ulcer with a redpink wound bed, withoutslough.Mayalsopresentasanintactoropen/ruptured,serumfilledblister.(Presentsasashinyor dry,shallowulcerwithoutsloughorbruising,whichindicatessuspecteddeeptissueinjury.Thisstageshould notbeusedtodescribeskintears,tapeburns,perinealdermatitis,maceration,orexcoriation.) Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.Sloughmaybepresentbutdoesnotobscurethedepthoftissueloss.Mayincludeunderminingand tunneling.(ThedepthofastageIIIpressureulcervariesbyanatomicallocation.Thebridgeofthenose,ear, occiput,andmalleolusdonothavesubcutaneoustissueandstageIIIulcerscanbeshallow.Incontrast,areas ofsignificantadipositycandevelopextremelydeepstageIIIpressureulcers.Bone/tendonisnotvisibleor directlypalpable.) StageIV:Fullthicknesstissuelosswithexposedbone,tendon,ormuscle.Sloughorescharmaybepresent onsomepartsofthewoundbed.Oftenincludeunderminingandtunneling.(ThedepthofastageIVpressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule), making osteomyelitis possible. Exposed bone/tendonisvisibleordirectlypalpable.) Unstageable:Fullthicknesstissuelossinwhichthebaseoftheulceriscoveredbyslough(yellow,tan,gray, green,orbrown)and/oreschar(tan,brown,orblack)inthewoundbed.(Untilenoughsloughand/oreschar is removed to expose the base of the wound, the true depth and, therefore, stage cannot be determined. Stable(dry,adherent,intactwithouterythemaorfluctuance)escharontheheelsservesasthebodysnatural biologicalcoverandshouldnotberemoved. Suspected deep tissue injury: Purple or maroon localized area of discolored intact skin or bloodfilled blisterduetodamageofunderlyingsofttissuefrompressureand/orshear.Theareamaybeprecededby tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injurymaybedifficulttodetectinindividualswithdarkskintones.Evolutionmayincludeathinblisterover a dark wound bed. The wound may further evolve and becomecovered by thin eschar. Evolution may be rapid,exposingadditionallayersoftissueevenwithoptimaltreatment. NutritionAssessmentandDiagnosis A number of contributing or confounding factors are associated with pressure ulcers, although the significance of these factors remains unknown (1). Surveys report a high prevalence of pressure ulcers in hospitalizedpatients(3%to4%)andinresidentsofnursinghomes(20%to33%)thatcoincideswithahigh prevalence of malnutrition (30% to 50% and 19% to 59%, respectively) (3). Although poor nutrition is commonlycitedasariskfactorforthedevelopmentofpressureulcers,thepreciseroleofnutritionalstatus remainscontroversial (3).Commoncausesofpressureulcersincluderestrictedmobilityandlimitedphysical activity, a compromised level of consciousness, incontinence, peripheral vascular disease that causes poor circulationandlackofoxygentothetissues,andconditionsthatcauseimpairedsensoryperception.Other
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Pressure Ulcers
conditions that place a patient at risk for the development of pressure ulcers include: diabetes mellitus; obesity; chronic obstructive pulmonary disease; sepsis; chronic or endstage renal, liver, or heart disease; diseases related to immunosuppression; hip fractures; and spinal cord injury. Medical treatments and medications that may contribute to the risk of pressure ulcer development include antikinetic drugs (eg, antidepressantsandsleepingpills),immunosuppressivedrugs,steroids,radiation,chemotherapy,andrenal dialysis. Malnutrition, dehydration, or unintentional weight loss (greater than 5% in 1 month, 7.5% in 3 months, or 10% in 6 months), whether secondary to poor appetite or another disease process, places the clientatriskoftissuebreakdownandpoorhealing(4).
Patientswithriskfactorsforpressureulcerdevelopmentshouldreceiveacompletenutritionassessment andcareplandesignedtoaddresseachnutritionproblemareathatisidentified (2). Itisimportanttoidentify andassesspatientswhoareatriskofdevelopingpressureulcers.Assessmentofpressureulcerriskshould bedocumentedwithavalidatedtool,suchastheBradenscale (25).Patientswhoareidentifiedtobeatrisk shouldbemonitoredatregularintervalsinapreventiveprogramwhenappropriate.Monitoringmayinclude a systematic skin inspection at least daily (paying particular attention to the bony prominences), daily physical activity or a mobility program (1), and routine evaluation of nutritional and hydration status accordingtotheorganizationsprotocols.Nationalguidelineshavebeenestablishedtoaddresstheissueof pressureulcersandthebestpracticeguidelinesforcare(2).
NutritionIntervention Patients who require treatment of pressure ulcers should receive adequate nutrition, including energy, protein,fluids,andvitaminsandminerals(1,2).Theassessmentshouldincludeareviewoftheexudatelosses from wounds, in consideration of fluid and protein losses. The following guidelines will usually meet the patientsneeds(2): Provide a wellbalanced diet adequate in energy, highbiological value protein, and fluid as well as vitaminsandmineralstomeettheestimatedrequirements.Thegoalistomaintainorregainlostweight (1).Ingeneral,thepatientshouldbeontheleastrestricteddietpossible(1). Theenergyrequirementforwoundhealingisnotknown.Recommendationsmustbeindividualizedwiththe goaltoprovideadequateenergyforanabolismandcollagensynthesis (6).Adequateenergyintakeshouldbe determined by using the appropriate prediction equation as outlined in Section II: Estimation of Energy Expenditures.Thegeneralrecommendationforpeoplewithpressureulcersis30to35kcal/kg (1,68).Inthe National Pressure Ulcer LongTerm Care Study, adequate nutrition support at 30 kcal/kg of actual body weightperdaywasastrongpredictorofstageIIIandIVpressureulcerhealing (9).TheNPUAPrecommends increasingtheenergylevelto35to40kcal/kgperdayforpeoplewhoareunderweightorlosingweight (1,6). Whenavailable,indirectcalorimetryisrecommendedtomorecloselyidentifytheindividualenergyneedsof patients who fail to achieve anabolism; exhibit delayed wound healing; require more energy to assist in healinglargerormultiplewounds;orneedamoreaggressiveapproachtothenutritioncareplan(3). Provideadequate protein for apositive nitrogen balance. Adequate protein is essential in allstagesof wound healing; but, without adequate energy intake, the protein will be used as an energy source (6). Dailyproteinintakeof1.25to1.5g/kgofactualbodyweightfromfoodsourcesofhighbiologicalvalue protein (1) is the most commonly cited recommendation in the literature (1,6) The European Pressure UlcerAdvisoryPanelrecommends1.0to1.5g/kgperday(6,7).Excessdietaryproteininamountsgreater than1.5to2.0g/kgperdaycanbeariskfactorfordehydration,especiallyintheelderly(6,8,10). Provide adequate fluid intake each day to keep the patient well hydrated and prevent dehydration (6). Theoptimalfluidintakeis30to35mL/kgofactualbodyweightoraminimumof1,500mL/day(2,6).Itis oftendifficulttomeetfluidneedswhenfluidsareonlyprovidedwithmeals.Ensuresupplementaryfluids are providedto meetfluidneeds. Patients whoareon thickened liquid mealplans should becarefully monitoredandsupplementedwithfluidsasneeded (6).Inaddition,patientswhoaremedicallymanaged on airfluidized beds may be at greater risk for dehydration and should be evaluated for greater fluid needs. Patients who require airfluidized beds set at a high temperature will need additional fluids, estimated to be approximately 10 to 15 mL/kg because of an increase in insensible water loss (6,10,11). Refer to Nutrition Management of Fluid Intake in Section IA for guidelines on fluid requirements for patientsbeingtreatedonanairfluidizedbed. Adailymultiplevitaminandmineralsupplementmeeting100%oftheRecommendedDailyAllowances (RDAs) (Dietary Reference Intakes [DRIs]) is given if energy intake is substantially below the required level,orifvitaminormineraldeficienciesareconfirmedbylaboratoryassessment(2,6).Supplementation should not be greater than 10 times the RDAs (DRIs) for watersoluble vitamins (2). However, this recommendation should be reevaluated in light of the most recent DRIs, in which the Tolerable Upper IntakeLevelsforvitaminsareoftenmuchlessthan10timestheRDA (6).Forpatientswithrenalfailure,
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Pressure Ulcers
currentguidelinesrecommendgivingnomorethan60to100mgofvitaminCperdayduetotheriskof renaloxalatestoneformation(3). SpecialConsiderations Vitamins:Allvitaminsareessentialinwoundhealing;however,vitaminsA,E,C,andK(especiallyvitaminsC andA)havebeengiventhemostattention (6).Limitedresearchisavailabletovalidatetherolesofspecific vitaminsinwoundhealing.Althoughtheresearchmayshowthatincreasedvitaminintakeimprovesblood assay results, there is no evidence that vitamins directly impact pressure ulcer healing rates (12). Studies demonstrate that a lack of adequate energy and protein intake places the patient at the greatest risk of pressureulcerdevelopment(6). Traceminerals:Thetraceelementspresentinthebody,zinc,copper,andiron,havetheclosestrelationship towoundhealing(6,12).However,studieshavenotdemonstratedasignificantimprovementinpressureulcer healing with routine zinc supplementation (13,14). No studies have shown improvement in wound healing after the administration of zinc to patients who are not zinc deficient (6). The European Pressure Ulcer AdvisoryPanelhasalsoconcludedthatthereisnoevidencetorecommendzincsupplementationforpatients withpressureulcers (7).Ifazincdeficiencyisconfirmedorsuspected,zincsupplementationiswarranted (6). TheTolerableUpperIntakeLevelofzincforhealthyadultsis40mg/day (6).Cliniciansshouldbeawareof adverse side effects of zinc supplementation, including an adverse effect on copper and calcium status, compromised immune responses, and gastrointestinal effects (eg, nausea, vomiting, and diarrhea) (3,6). To minimizetheriskofadverseeffects,zincsupplementationshouldnotbegivenlongerthan2to3weeks (3,6). Although low serum zinc concentrations have been associated with impaired healing and alterations in immunefunction (12,13),serumzinclevelsdecreasewithinflammationandmaynotaccuratelyrepresentthe totallevelofzincinthebody(6,15). AlthoughvitaminCandzincmayplayaroleinwoundhealing,theadequacyoftotalenergy,protein,and fluidtomaintainnutritionalstatusremainsthemostrelevantdietaryapproachtothepreventionandhealing ofpressureulcers (3,6).ThompsonandFuhrmansindepthreviewoftheliteratureonnutrientsandwound healing is recommended for further information (16). Table III21 lists guidelines for supplementation if a deficiencyissuspectedorconfirmed. TableIII21:GuidelinesforVitaminCandZincSupplementation(3) Zincb PressureUlcer VitaminCa Stage StagesIandII 100to200mg/day 15mgelementalzincperday(orRDA);if deficiency is suspected, supplement with up to 50 mg/day for no longer than10to14days. StagesIIIandIV Up to 1,000 to 2,000 mg/day in 25 to 30 mg elemental zinc per day for divided doses for stressed patientsatriskformarginalzincstatus; patients or patients at risk for reassess after 10 to 14 days; ongoing deficiency; reassess after 10 to losses may warrant longer 14days. supplementation.
aSome references suggest highdose vitamin C supplementation is warranted in conditions such as acute stress, smoking, and malnutritiontoensureadequatetissuestoresforwoundhealing.Thesedatahave notbeenvalidated.NotethattheTolerableUpper IntakeLevelis2,000mg/day.ThereisanincreasedriskofoxalatestoneformationwhenexcessivevitaminCisgiventopatientswith chronicrenalfailure.Therefore,doses>500mg/dayshouldbereviewedbyanephrologist(3). bA 220mg dose of zinc sulfate is equivalent to 50 mg of elemental zinc (a common oral supplement dosage). Continued zinc supplementation may be warranted with chronic losses (eg, highvolume fistula, ileostomy, or diarrhea losses). In some cases, the recommended supplementation may exceed the Tolerable Upper Intake Limit of 40 mg/day (3). Parenteral requirements are significantlylessthanoralorenteralrequirementsbecauseofthedifferentabsorptionrates(3).
Medicalnutritionsupplementsandenteralfeedings:Ifthepatientconsistentlyconsumeslessthan50% of the estimated energy and protein needs, the need for oral supplementation or enteral nutrition support shouldbeevaluated (3,6).Theuseoffoodalonehasshowntobeineffectiveinimprovingpressureulcers (6). For patients who are underweight (body mass index < 20) and have challenges meeting nutritional requirements,oralintakeofmedicalnutritionsupplementsisveryeffectiveinpromotingintakeandweight gainandimprovingfunctionalstatus (6).Medicalnutritionalsupplementsprovideabettersourceofenergy, protein,andmicronutrientsthanfoodsnacksanddonotinhibitmealintake (6,17).Ifthepatientistubefed, thefeedingshouldprovideaminimumof100%ofthepatientsenergy,protein,andRDAs(DRIs)forvitamins
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Pressure Ulcers
andminerals (2).Becausetheeffectivenessofspecializedenteralformulasforwoundhealinghasnotbeen validated,furtherstudyisneededbeforetheroutineuseofwoundhealingformulascanberecommended(3). Aminoacids:Theaminoacidsarginineandglutaminehavebeenstudiedfortheirpossibleroleinenhancing woundhealing.However,theliteraturedoesnotprovideevidencetosupportthesupplementationofthediet withtheseaminoacids(3). EvaluationandMonitoring Treatment of pressure ulcers should always be provided by a multidisciplinary team (2). Nutrition intervention is part of a multidisciplinary approach that also includes nursing intervention (reduction of pressure and shearing, skin and wound care, feeding assistance, and a bowel and bladder care program), medical intervention (treatment of infection and other medical conditions), and physical and occupational therapy(promotionofincreasedactivityandfeedingability).
References 1. National Pressure Ulcer Advisory Panel. Updated Staging System. 2007. Available at: www.npuap.org/pr2.htm. Accessed November5,2007. 2. PressureUlcerTreatmentClinicalPracticeGuidelines.Rockville,Md:USDeptofHealthandHumanServices,PublicHealthService, AgencyforHealthCarePolicyandResearch;1994.QuickReferenceNo.15,AHCPRpublication950650. 3. StechmillerJK,CowanL,JohnsP.Woundhealing.In:GottschlichMM,ed.TheA.S.P.E.N.NutritionSupportCoreCurriculum:ACase BasedApproachTheAdultPatient.SilverSpring,Md:AmericanSocietyofEnteralandParenteralNutrition;2007:405423. 4. Skinintegrity.In:NeidertKC,ed.NutritionCareoftheOlderAdult.Chicago,Ill:ConsultingDietitiansinHealthCareFacilities,A PracticeGroupoftheAmericanDieteticAssociation;1998. 5. Braden BJ, Bergstrom N. Predictive validity of the Braden Scale for pressure sore risk in a nursing home population. Res Nurs Health.1994;17:459470. 6. Pressure ulcers. In: Nutrition Care Manual. American Dietetic Association; 2007. Available at: nutritioncaremanual.org. Accessed November5,2007. 7. ClarkM,ScholsJM,BenatiG,JacksonP,EngferM,LangerG,KerryB,ColinD.Pressureulcersandnutrition:anewEuropeanguideline. JWoundCare.2004;13:267272. 8. ThomasDR.Improvingoutcomeofpressureulcerswithnutritioninterventions:areviewoftheevidence.Nutrition.2001;17:121 125. 9. BergstromN,HornSD,SmoutRJ, Bender SA, Ferguson ML,TalerG, Sauier AC,SharkeySS,VossAC. TheNationalPressure Ulcer LongtermCareStudy:outcomesofpressureulcertreatmentsinlongtermcare.JAmGeriatrSoc.2005;53:17211729. 10. AyelloEA,ThomasDR,LitchfordMA.Nutritionaspectsofwoundhealing.HomeHealthcNurse.1999;17:719729. 11. BreslowRA.Nutritionandairfluidizedbeds:aliteraturereview.AdvWoundCare.1994;7:5762. 12. WilliamsJZ,BarbulA.Nutritionandwoundhealing.SurgClinNorthAm.2003;83:571596. 13. GrayM.Doesoralzincsupplementationpromotehealingofchronicwounds?JWoundOstomyContinenceNurs.2003;30:295299. 14. Haggard J, Houston MS, Williford JH, Meserve LA, Shewokis P. Retrospective study of the effects of zinc supplementation in an elderlyinstitutionalizedpopulationwithdecubitusulcers.JAmDietAssoc.1999;99:A11.Abstract. 15. FuhrmanMP.Woundhealingandnutrition.TopClinNutr.2003;18:100110. 16. ThompsonC,FuhrmanMP.Nutrientsandwoundhealing:stillsearchingforthemagicbullet.NutrClinPract.2005;20:331347. 17. StrattonRJ,BoywerG,EliaM.Greatertotalenergyandproteinintakeswithliquidsupplementsthanfoodsnacksinpatientsatrisk ofmalnutrition.Posterpresentedat:EuropeanSocietyofParenteralandEnteralNutrition;October21,2006;Istanbul,Turkey.
III-104
MANAGEMENTOFACUTEKIDNEYINJURYANDCHRONICKIDNEY DISEASE(StageV)
AcuteKidneyInjury Aninternationalnetworkofkidneyandcriticalcarespecialists,theAcuteKidneyInjuryNetwork,developed consensusrecommendationsfortheterminology,diagnosticcriteria,andstagingofacutekidneyinjury(AKI). AKI replaces the term acute renal failure, as the condition does not always result in renal failure (1). The diagnosticcriterionforAKIisanabrupt(within48hours)reductioninkidneyfunctiondefinedasanabsolute increaseintheserumcreatininelevelofatleast0.3mg/dL,a50%increaseintheserumcreatininelevel,ora documentedurineoutputoflessthan0.5mL/kgperhourformorethan6hours (1).(RefertoTableIII22: Classification/StagingSystemforAKI.) TableIII22:Classification/StagingSystemforAKI(1) Stage CreatinineClearance UrineOutput 1 Serum creatinine increase of at least 0.3 mg/dL, or a <0.5 mL/kg per hour for more 150%to200%increase than6hours 2 Increaseinserumcreatinineleveltogreaterthan200% <0.5 mL/kg per hour for more to300%ofbaseline than12hours 3 Increaseinserumcreatinineleveltogreaterthan300% <0.3 mL/kg per hour for 24 ofbaseline,orserumcreatininelevelof4.0mg/dLwith hoursoranuriafor12hr anacuteincreaseofatleast0.5mg/dL CausesofAKIinclude: systemicshockduetoasuddenlossofbloodsupplytothekidneysfromtrauma,surgicalcomplications, orsepsis exposure to a nephrotoxic chemical or drug (eg, radiologic dyes, cleaning solvents, pesticides, and gentamicin) streptococcalinfection AKIisoftencomplicatedbysepsis,trauma,andmultipleorganfailure (2).Acutekidneyinjury(AKI)occurs in approximately 20% of hospitalized patients and is associated with a 40% to 80% mortality rate (24). Continuous renal replacement therapy (CRRT) is a type of dialysis used for hemodynamically unstable patients who have AKI, as it is better tolerated than conventional intermittent hemodialysis (2). CRRT removes fluids and solutes slowly, corrects electrolyte and metabolic abnormalities, and maintains fluid balanceuntilrenalfunctionreturnsoruntilthepatientcantoleratehemodialysis (3).Theprimarytypesof CRRT include continuous hemofiltration, continuous hemodialysis, continuous hemodiafiltration, and slow continuousultrafiltration.Peritonealdialysisisanotheroption,butitisoftencontraindicatedincriticallyill patients(2).
NutritionAssessmentandNutritionInterventioninAKI AKIcausesnutritionalimbalancesincludingacidosis,hyperkalemia,hyperphosphatemia,fluiddisturbances, impaired glucose utilization, protein catabolism, accumulation of metabolic waste, and a rapid decrease in urine output (4). Patients who have AKI should receive a comprehensive nutrition assessment to identify nutrition diagnoses and close monitoring to ensure that nutrition care outcomes and goals of therapy are achieved. The nutrition interventions should be based on the individualized patient assessment and identified nutrition diagnosis. Nutrition interventions should complement medical management strategies suchasCRRTtooptimizethepatientstreatmentresponse.PatientswhohaveAKIarehypermetabolicand hypercatabolic as a result of the neurohumoral response associated with acute injury (36). The primary goals of medical nutrition therapy are to provide adequate protein, energy, and nutrients and to minimize malnutrition (2,6).TheAmericanDieteticAssociationpublishedGuidelinesforNutritionCareofRenalPatients in 2002; however, this publication has not been updated to reflect the changes in medical management strategies (5). Specific nutrition intervention strategies for acute care management of AKI are found in the AcuteKidneyInjury(AKI)AcuteCareNutritionProtocol(7).Thefollowingsummaryincludesthemostrecent managementstrategiesandguidelinesformedicalnutritiontherapyinpatientswhohaveAKI(2,5,6,8). Energy:Individualizebasedonlevelofcare(eg,criticallyill)orindirectcalorimetry.Use25to35kcal/kgof actual body weight as an estimation of energy requirements. Energy expenditure and requirements will
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Management of Adult Kidney Injury and Chronic Kidney Disease
depend on the patients stress level, acuity level, and nutritional status and should include the energy obtainedfromCRRT(2).(RefertoSectionII:EstimationofEnergyExpenditures.) Protein: The optimal protein intake for patients who have AKI remains controversial and should be prescribedbasedonthedegreeofcatabolismandtypeofrenalreplacementtherapy(2,9).Withoutdialysisor catabolism, provide 0.8 to1.2 g/kg of actual body weight. Inthe presence ofcatabolism, provide 1.2 to 1.5 g/kgofactualbodyweight.CRRTcanremoveaminoacidsandproteins;therefore,aminimalproteinintake of1.5g/kgofrecommendedbodyweightperdayissuggested (4,9).IfCRRTisfrequentlyused,theprotein requirementsmaybehigher. Sodium: Sodium intake should be 2,000 to 3,000 mg/day based on the patients blood pressure and the presenceofedema.Duringthediureticphase,replacesodiumlossesbasedonurinaryoutput,edema,renal replacementtherapy,andserumsodiumlevels. Potassium: Provide 2,000 to 3,000 mg/day of potassium. During the diuretic phase, replace potassium losses based on urinary volume, serum and urinary potassium levels, renal replacement therapy, and drug therapy. Phosphorus:Provide8to15mg/kgofphosphorus.Closelymonitorthephosphoruslevelsofpatientswho receiverenalreplacementtherapy. Calcium: Maintain serum levels of calcium within normal ranges. Closely monitor the calcium levels of patientswhoreceiverenalreplacementtherapy. Fluids: The daily fluid intake should be 500 mL plus the volume of urine output. The fluid intake also dependsontheserumandurinarysodiumlevel,totalfluidoutput(includingurine),andtypeofdialysis. Vitamin and mineral supplementation: Individualize supplementation based on laboratory values, documented deficiencies, and the type of renal replacement therapy. Ensure that the Dietary Reference Intakes for vitamins and minerals are provided. Patients who receive CRRT must be carefully monitored becauseCRRTcausesasignificantlossofmagnesium,calcium,phosphorus,andpotassium(2,10).Patientswho have AKI require supplementation of watersoluble vitamins to prevent deficiency caused by renal replacement therapy losses, inadequate intake, drugnutrient interactions, and higher needs (2,6). Although theevidenceislimited,thesupplementationguidelinesinTableIII23havebeenproposedforpatientswho haveAKIandreceiveCRRT(specificallycontinuousvenovenoushemofiltration) (4).Inaddition,criticallyill patientswhostayintheintensivecareunitformorethan10daysareoftendeficientinvitaminDandhave increased bone turnover (11). Supplementation of vitamin D in AKI needs further research, because the mechanismofvitaminDmetabolismisnotthesameasinendstagerenaldisease(11). TableIII23:VitaminandMineralSupplementationinAKIManagedwithCRRT(2,4) Vitamin/Mineral Dose VitaminK 4mg/week VitaminE 10IU/day Niacin 20mg/day Thiamin 1.5mg/day Riboflavin 1.51.7mg/day Pantothenicacid(vitaminB5) 510mg/day VitaminC 60125mg/day Biotin 150300mcg/day Folicacid 1mg/day VitaminB12 4mcg/day Zinc 20mg?a VitaminA Avoid aThequestionmarkisincludedinthereferencearticle(4).
AlsorefertoSectionG:MedicalNutritionTherapyforChronicKidneyDiseaseforinformationandnutritional guidelinesassociatedwithCRRT.
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ChronicKidneyDisease Chronic kidney disease (CKD) is the result of the progressive deterioration of kidney tissue during several monthsoryearsasscartissueissubstitutedforviablekidneytissue.Patientswhohavelost85%ormoreof their kidney function have stage V CKD and require maintenance renal replacement therapy (dialysis) or renaltransplantation(5,6). CausesofCKDinclude: diseasesoftheglomeruli(glomerulonephritis) bloodvesseldamageinthekidneybynephrosclerosisfromhighbloodpressure inheriteddiseases,suchaspolycystickidneydisease obstructivediseases,suchaskidneystones congenitalbirthdefectsofthekidneyandurinarytract systemic or metabolic diseases, such as diabetic nephropathy, systemic lupus erythematosus, and hyperuricemia,inwhichthekidneysandurinarytractareirreversiblydamaged abuseofanalgesicorillicitdrugs NutritionAssessmentandNutritionInterventioninCKD When evaluating the patient for nutrition intervention, the dietitian should use established practice guidelines (5) and the norms established at the institutionspecific guidelines for a particular dialysis unit. Biochemical levels for dialysis patients will seldom be the same as for healthy individuals, since dialysis cannotcompletelyreplacekidneyfunction.Variousnephrologistsmaydefinenormallevelsdifferently,and thegoallevelsmaybedifferentbasedonthestage(IV)ofCKDandthemanagementtherapies.Thefollowing textoutlinesthebiochemicalparametersthatareaffectedbyCKD.Thesebiochemicalparametersshouldbe routinely evaluated following institutionspecific guidelines, especially guidelines that are certified by the CentersforMedicareandMedicaidServices. Albumin:Thepresenceofacuteorchronicinflammationlimitsthespecificityofalbuminandotheracute phase hepatic proteins as nutritional markers in CKD (12). The normalized protein catabolic rate may be a better marker of nutritional status in the CKD patient who receives renal replacement therapy. Uremia depressesalbuminmetabolism,whichcanaffectthealbuminconcentration.Meanalbuminlevelsarelower in CKD patients who have a glomerular filtration rate (GFR) that is less than 60 mL/min. Compared with normal levels, however, this decreased albumin level may be a reflection of decreased protein intake (5). Albumin losses are greater in patients who receive peritoneal dialysis. (See the discussion of protein requirementsinMedicalNutritionTherapyforChronicKidneyDiseaseinSectionIG.) Lipids: Increased lipid levels are associated with accelerated cardiovascular disease in patients who have renal failure. Cardiovascular disease is responsible for approximately 50% of all deaths in dialysis patients (13).Theprimaryabnormalityisareductioninthecatabolismoflipoproteinswithunchangedorlowhepatic synthesis. Dialysis patients commonly have increased levels of total cholesterol, very lowdensity lipid cholesterol, and triglycerides and decreased levels of highdensity lipoprotein cholesterol (5). The National Kidney Foundation Task Force on Cardiovascular Disease has recommended the National Cholesterol Education Program Adult Treatment Panel III guidelines for patients who have chronic renal disease. Individuals who have low, lownormal, or decreasing serum cholesterol levels should be examined for nutritionaldeficits(12). Blood(serum)ureanitrogen:Anitrogenouswasteproductofproteinmetabolism,thelevelofbloodurea nitrogenincreaseswithincreasedproteinintake,catabolism,gastrointestinalbleeding,glucocorticoiduse,or decreaseddialysisefficiency.Alowlevelofbloodureanitrogenmayindicatedecreasedproteinintake,loss ofproteinthroughemesisordiarrhea,frequentdialysis,proteinanabolism,oroverhydration.Valuesgreater than90to100mg/dLmayleadtoazotemia. Potassium:Hyperkalemia,whichisapotassiumlevelgreaterthan5.5mEq/L,ispotentiallylifethreatening andmayprecipitatecardiacarrestifnottreated.Whenhyperkalemiaoccursinpatientswhohavechronic renal failure, it is usually caused by oliguria (24hour urine output <500 mL); excessive potassium intake; acidosis; the catabolic stress of infection, surgery, or trauma; inadequate dialysis or renal replacement therapy; or hypoaldosteronism. Excessive potassium intake is frequently related to the use of potassium containingsaltsubstitutesanddietarynoncompliance.Hypokalemia,whichisapotassiumlevellessthan3.5 mEq/L, is caused by decreased dietary intake; vomiting; diarrhea; potassiumdepleting diuretics; excessive useofsodiumpolystyrenesulfonate(Kayexalate),apotassiumbinder;oralowpotassiumdialysate.
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Sodium: The evaluation of serum sodium levels must always include the patients hydration status. Hypernatremia can be caused by excessive water loss through diarrhea and vomiting (dehydration) and aggressive diuretic therapy without sodium restriction. Signs of hypernatremia include flushed skin, dry tongue and mucous membranes, and thirst. Hyponatremia can be caused by fluid overload and sodium depletion from sodium restriction along with sodiumlosing nephropathy. Symptoms of hyponatremia includeabdominalcramps,hypotension,andheadaches. Calcium: In CKD, calcium absorption decreases secondary to the abnormal metabolism of vitamin D. Hyperphosphatemia also leads to decreased serum calcium levels, which contribute to secondary hyperparathyroidismandrenalosteodystrophy(14).Derangementsinmineralandbonemetabolismcommon toCKDareassociatedwithincreasedmorbidityandmortality(14).Thisfindingpromptedthedevelopmentof Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease by the Kidney Disease Outcomes Quality Initiative (14). These guidelines provide recommendations for the evaluation of phosphorus,calcium,andplasmaintactparathyroidhormoneandmanagementandtreatmentwithvitamin D,phosphatebinders,andthedialysatebath(14).Serumlevelsofphosphorus,correctedcalcium,andplasma parathyroid hormone should be monitored, and the appropriate guideline recommendations should be implementedwhennecessary (14).Thegoaloftherapyistoachieveanormalrangeofserumcalcium,with the optimum level of 8.4 to 9.5 mg/dL (5,14). The presence of calcium in the dialysate helps to normalize serum calcium levels in patients who receive hemodialysis, along with the use of an activated source of vitaminD(calcitriol),anoralcalciumsupplement,avitaminDanalog(doxercalciferolorparicalcitol),anda phosphorus binder. The corrected calcium should be considered when the albumin levelnot the serum calciumislow (14).Thecorrectedserumcalciumisequalto:measuredtotalcalcium(mg/dL)+.8[ 4.0 albumin(g/dL)](2). Phosphorus:Lowlevelsofserumphosphatemayleadtophosphorusdepletionandosteomalacia.Thegoal oftherapyistomaintainthephosphoruslevelbetween2.7to5.0mg/dLinpatientswhohavestagesIIVCKD andbetween3.5to5.5mg/dLinpatientswhoreceiverenalreplacementtherapy (5,6). RefertotheClinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease by the Kidney Disease OutcomesQualityInitiative(14). Calciumphosphorus product: The calciumphosphorus product, which is the result of multiplying the serumvaluesofcalciumandphosphorus,shouldbelessthan55mg2/dL2topreventsofttissuecalcification (15).Researchregardingthecalciumphosphorusproductislimited.Therefore,atargetphosphoruslevelof lessthan5.0mg/dLissuggestedforpatientswhohaveCKD. Creatinine: Creatinine is a product of muscle metabolism that is used to assess renal function. A serum creatininelevelthatisdoublethenormallevelof0.5to1.5mg/dLsuggestsagreaterthan50%nephronloss, whereasaserumcreatininelevelof10mg/dLsuggestsa90%nephronlossorendstagerenaldisease.Serial serum creatinine levels can be used to determine the consistencyof dialytic therapy. Eventually, a normal creatininelevelcanbeestablishedforeachdialysispatientbasedonthepatientsmusclemassanddialysis prescription. The predialysis or stabilized serum creatinine and the creatinine index reflect the sum of dietary intake offoods rich in creatine and endogenous creatinine production minus the urinary excretion, dialyticremoval,andendogenousdegradationofcreatinine.Individualswhohavelowlevelsofpredialysisor stabilized serum creatinine (less than 10 mg/dL) should be evaluated for proteinenergy malnutrition and skeletalmusclewasting (12).Suddenincreasesinserumcreatininelevelsusuallycanbetracedtochangesin the dialysis regimen, such as skipped treatments, decreased dialysis time, or poor blood flow through an access.Increasedbloodureanitrogenandserumpotassiumlevelsaccompaniedbyasuddenincreaseinthe serum creatinine level and a decrease in carbon dioxide level usually indicate decreased waste product removal.
Glucose:Normalglucoselevelsshouldbemaintainedinalldialysispatientstopreventthecomplicationsof hypoglycemiaandhyperglycemia.Abnormalcarbohydratemetabolismresultinginhyperglycemiaoccursin individualswhoareapproachingendstagerenaldisease.Althoughthecauseofthisabnormalcarbohydrate metabolism is not known, the abnormality resolves after several weeks of dialysis therapy or after transplantation. High blood glucose levels can increase thirst, decrease serum sodium levels, and increase serum potassium levels. Acidosis, which is indicated by decreased carbon dioxide levels and an increased anion gap, increases protein catabolism and often accompanies increased blood glucose levels in patients whohavechronicrenalfailure(16,17).
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GlomerularFiltrationRate(CreatinineClearance)(2,5,18) CreatinineclearanceisthemostcommonlyusedmeasurementofGFR.ThenormalGFRis125mL/min. Directurinaryclearancemeasurementsareusefulindeterminingthedegreeofrenaldysfunctionatlower levelsofclearance(5).TheestimatedGFRprovidesausefulapproximationvalue(ie,<25mL/min)(12).
In principle, there is a reciprocal relationship between serum creatinine and creatinine clearance. To estimate creatinine clearance, factors such as body weight, age, and sex must be considered since creatinineincreaseswithbodyweightandmusculatureanddecreaseswithage.Therelationshipbetween serumcreatinineandcreatinineclearanceisnotvalidforpatientswhoreceivedialysis,patientswhohave acuterenalfailure,orpatientsinacatabolicstateinwhichmusclemassisbeingdestroyed.
ThemostwidelyusedmethodforestimatingGFRistheCockcroftGaultequation(2,18):
Weight(kg)(140Age) 72 Serumcreatinine(mg/dL) Weight(kg) (140 Age) GFR(Women)= 72Serumcreatinine(mg/dL) GFR(Men)=
0.85
For comprehensive guidance on the nutrition assessment, nutrition diagnosis, and nutrition intervention andthe monitoring parameters in the acute care setting refer to Chronic Kidney Disease (CKD) Acute Care NutritionProtocol(19).
References 1. MehtaRL,KellumJA,ShahSV,MolitorisBA,RoncoC,WarnockDG,LevinA,forAcuteKidneyInjuryNetwork.AcuteKidneyInjury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11:R31. Available at: http://ccforum.com/content/11/2/R31.AccessedJanuary12,2009. 2. Renal failure. In: Nutrition Care Manual. American Dietetic Association; 2004. Available at: www.nutritioncaremanual.org. AccessedJanuary12,2009. 3. PatonM.Continuousrenalreplacementtherapy:slowbutsteady.Nursing.2003;33:4850. 4. Marin A, Hardy G.Practical implications of nutritional support during continuous renal replacement therapy.Curr Opin Clin Nutr MetabCare.2001;4:219225. 5. WigginsKL,ed.GuidelinesforNutritionCareofRenalPatients.Chicago,Ill:AmericanDieteticAssociation;2002. 6. KoppleJD,MassrySG,eds.NutritionManagementofRenalDisease.2nded.Philadelphia,Pa:LippincottWilliams&Wilkins;2004. 7. AcuteKidneyInjuryAcuteCareNutritionProtocol.In:InmanFeltonA,SmithKG.NutritionCareProtocolsfortheAcuteCare Setting.Atlanta,Ga:MorrisonManagementSpecialistsInc;2009.Availableat: https://www.morrisontoday.com/Documents/Forms/AllItems.aspx?RootFolder=%2fDocuments%2fNutrition%2fMHFS%20NUTR ITION%2fNutrition%20Care%20Process&FolderCTID=0x01200076035A4CEC8A4B4B827A74CE5B3B1A44&View=%7b1F2F11D B%2d2030%2d4BBC%2dB712%2dEFE12EF45909%7d. 8. ByhamGray L, Wiesen K, eds. A Clinical Guide to Nutrition Care in Kidney Diseases. Chicago, Ill: American Dietetic Association; 2004. 9. WooleyJA,BtaicheIF,GoodKL.Metabolicandnutritionalaspectsofacuterenalfailureincriticallyillpatientsrequiringcontinuous renalreplacementtherapy.NutrClinPract.2005;20:176191. 10. Klein CJ, MoserVeillon PB, Schweitzer A, Douglass LW, Reynolds HN, Patterson KY, Veillon C.Magnesium, calcium, zinc, and nitrogenlossintraumapatientsduringcontinuousrenalreplacementtherapy.JParenterEnteralNutr.2002;26:7792. 11. VandenBergheG,VanRoosbroeckD,VanhoveP,WoutersP,DePourcqL,BouillonR.Boneturnoverinprolongedcriticalillness: effectofvitaminD.JClinEndocrinolMetab.2003;88:46234632. 12. National Kidney Foundation KDOQI. Clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis. 2000:35(suppl2):S1S104. 13. Block GA, Port FK. Reevaluation of risks associated with hyperphosphatemia and hyperparathyroidism in dialysis patients: recommendationsforachangeinmanagement.AmJKidneyDis.2000;35:12261237. 14. NationalKidneyFoundation.K/DOQIclinicalpracticeguidelinesforbonemetabolismanddiseaseinchronickidneydisease.AmJ KidneyDis.2003;42(suppl3):S1S201. 15. MoeSA.CalciumandPhosphorusBalanceinESRD:ImplicationsandManagement.Cambridge,Mass:GenzymeCorp;2001. 16. WeldyNJ.BodyFluidsandElectrolytes.7thed.St.Louis,Mo:Mosby;1996:104106,108112. 17. MitchWE,KlahrS.HandbookofNutritionandtheKidney.3rded.Philadelphia,Pa:LippincottRaven;1998:7980,170177. 18. CockcroftDW,GaultMH.Predictionofcreatinineclearancefromserumcreatinine.Nephron.1976;16:3141. 19. ChronicKidneyDisease(CKD)In:InmanFeltonA,SmithKG.NutritionCareProtocolsfortheAcuteCareSetting.Atlanta,Ga: MorrisonManagementSpecialistsInc;2009.Availableat: https://www.morrisontoday.com/Documents/Forms/AllItems.aspx?RootFolder=%2fDocuments%2fNutrition%2fMHFS%20NUTR ITION%2fNutrition%20Care%20Process&FolderCTID=0x01200076035A4CEC8A4B4B827A74CE5B3B1A44&View=%7b1F2F11D B%2d2030%2d4BBC%2dB712%2dEFE12EF45909%7d. Bibliography Centers for Medicare & Medicaid Services. End Stage Renal Disease (ESRD) Program Interpretive Guidance Version 1.1. October 2008 update.Baltimore,Md:DeptofHealthandHumanServices;2008.Ref:S&C0901. National Kidney Foundation. K/DOQIclinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.AmJKidneyDis.2002;39:S1S266.
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NUTRITIONCAREOUTCOMESandINTERVENTIONSINCKD(StageV) RENALREPLACEMENTTHERAPYBASEDONPATIENTASSESSMENT PARAMETERS

I.BiochemicalParameters Parameter ReferenceRangea Sodium Potassium 135145mEq/L 3.55.5mEq/L GoalforDialysisb (1,2) 135145mEq/L 3.55.5 mEq/L NutritionIntervention(13) Ifhigh,assesssodiumintakeandhydrationstatus. Iflow,assessfluidintake. Ifhigh,assessandlimitpotassiumintake;modify potassiumindialysateandmedications. Iflow,increasepotassiumintakeandevaluate dialysisandmedications. Ifhigh,avoidexcesscarbohydrateconsumption. Iflow,assesstotalenergyintake. Considerevidencebasedguidelinesonglycemic controlincriticalcarepatientsanddiabetic patients(3,4,5). Ifhigh,assessfortheoveruseofcalcium supplements,vitaminDsupplements,orother supplementsthatcanincreasecalciumlevels(6). Recommendavoidinghighcalciumandcalcium fortifiedfoodsortheuseofacalciumbinder Iflow,recommendthatcalciumbindersbetaken separatelyfrommeals,suchasatbedtime(4,6). Ifhigh, limittotalphosphorusintakeand evaluate theuseandtimingofaphosphorusbinder(6). Iflow,addoneservingofhighphosphorusfoodper dayoradjustbinder. Reduceserumphosphorusconcentrationsbefore increasingcalciumlevels.UtilizevitaminDor vitaminDanalogperprotocol. RefertoK/DOQIcguidelinesasneeded(6). Ifhigh,assess adequacyofdialysisandmedications (eg,steroids). Iflow,assessproteinandenergyintakeand residualrenalfunction. Iflow,assessandincreaseproteinintake. Considerimpactofinflammatorymetabolism. Lowtotalcholesterol(<150mg/dL)alsoindicates compromisednutritionalstatus,especiallyin adultsolderthan60years. Ifhigh,evaluatephosphorusandcalcium.Thegoal istoestablishlimitsincalciumrangewhile maintainingphosphoruslevels.Adjustdosageof calcitriol,paricalcitol,doxercalciferol,orSensipar (calcimimeticagent). Iflow,evaluatedosageofcalcitriol,doxercalciferol, orparicalcitol.Itmayneedtobereduced. RefertoK/DOQIguidelinesasneeded(6). Ifhigh,checkthedoseofepoetinorother erythropoiesisstimulatingagents.Iflow,check ferritinstores,transferrinsaturation,andiron stores;increaseepoetinorothererythropoiesis stimulatingagent.Ifnoresponse,checkfolateand vitaminB12levels(8).
Glucose
80100mg/dL
Calcium
8.510.5mg/dL
80200mg/dL,or <140to180mg/dL incriticallyill diabeticpatients (3,4) 8.49.5mg/dL (Correctedforlow serumalbumin)
Phosphorus
2.56.0mg/dL
3.55.5 mg/dL
Calcium phosphorus product(7) Blood(serum) urea nitrogen Albumin Prealbumin
notavailable
<55mg2/dL2 (7)
422mg/dL
<90100mg/dL
3.35.0g/dL 1943mg/dL
>4.0g/dL >30mg/dL (acutecare) >100300pg/mL
Plasmaintact parathyroid hormone BioIntact parathyroid hormone Hematocrit Hemoglobin
160pg/mL Institutionspecific referencerange
75-150 pg/mL
Men:38%50% Women:36%45% Men:1318g/dL Women:1216g/dL ManualofClinicalNutritionManagement
33%36% 1112g/dL III110
NutritionCareOutcomesandInterventionsinChronicKidneyDisease
I.BiochemicalParameters Parameter ReferenceRangea Transferrin saturation Ferritin II.Medications Drug Phosphatebinders Diuretics 20%50% 12800ng/L
GoalforDialysisb (1,2) 20%50% 100800ng/L
NutritionIntervention(13)
Ifhigh,decreaseironsupplementation;checkfor chronicinflammation.
Approaches Phosphatebindersmaydecrease levelof dietaryphosphorusrestriction. Ifeffective,diureticsmaydecreaselevelofsodiumrestriction.Diureticsmayincrease bloodureanitrogenlevelsanddecreasepotassiumlevels.
III.OtherParameters Parameter Interdialyticweightgain Dialysisadequacyassessedby ureakineticmodeling(1): Kt/V(URR)d nPNA(13) Glomerularfiltrationintakeand creatinineclearance Hypertension Heartfailure Edema
Goal 12lb/day 2%5%ofbodyweight(9) Kt/V>1.2orURR <65inhemodialysis(1) WeeklyKt/V>2.0, creatinineclearance>60 L/weekper1.73m2in CAPD(1) nPNA>1.2(2,3) BasedonstageofCKD(IIV) <130/80mmHg(GradeIV)(10) Individualizedbasedon symptoms Individualizedbasedon symptoms >90/60 Individualized basedon symptoms >80%estimatedenergy expenditure(1)
Approaches Ifhigh, limit fluidandsodiumintake. Iflow,modifyfluidintake. Evaluateadequacyofdialysisandprotein metabolism. Refertoguidelines(13)fordetaileddiscussionof ureakineticmodeling. Seediscussionofglomerularfiltrationrate earlierinthissection. Restrictsodium. Restrictsodiumandfluidasneeded Restrictsodiumandfluidasneeded
Hypotension Urineoutput
Assesssodium andfluidintake. Adjustfluidintakebasedonurineoutputto maintainstabledryweight. Modifynutritiontreatmentplananddiet restrictionstoincreasefoodintake. Exploreseasoningalternatives,assalt substitutesarecontraindicated;problemmay resolveasbloodureanitrogennormalizes.
Foodintake Alteredtastesensation
Biochemicalreferencerangesvarybasedontheinstitutionandtheanalyticalmethodsusedbytheindividuallaboratory. SuggestedgoalsfordialysisarebasedonCKDstageV(maintenancedialysis);goalsmayvaryforstagesIIV(13). cK/DOQI,kidneydiseaseoutcomesqualityinitiative dKt/V, clearance of the dialyzer time/volume; URR, urea reduction rate; CAPD, continuous ambulatory peritoneal dialysis; nPNA, normalizedproteinnitrogenappearance.
a b
SeeSection1G:MedicalNutritionTherapyforChronicKidneyDisease.
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NutritionCareOutcomesandInterventionsinChronicKidneyDisease References 1. WigginsKL,ed.GuidelinesforNutritionCareofRenalPatients.Chicago,Ill:AmericanDieteticAssociation;2002. 2. KoppleJD,MassrySG,eds.NutritionManagementofRenalDisease.2nded.Philadelphia,Pa:LippincottWilliams&Wilkins;2004. 3. Chronic kidney disease. In: Nutrition Care Manual. American Dietetic Association; 2004. Available at: www.nutritioncaremanual.org.AccessedJanuary12,2009. 4. Critical Illness EvidenceBased Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American DieteticAssociation;2006.Availableat:http://www.adaevidencelibrary.com.AccessedNovember29,2010. 5. Diabetescareinthehospital.In:ExecutiveSummary:StandardsofMedicalCareinDiabetes2010.DiabetesCare.2010;33(suppl 1):S4S10.. 6. NationalKidneyFoundation.K/DOQIclinicalpracticeguidelinesforbonemetabolismanddiseaseinchronickidneydisease.AmJ KidneyDis.2003;42(suppl3):S1S201. 7. MoeSA.CalciumandPhosphorusBalanceinESRD:ImplicationsandManagement.Cambridge,Mass:GenzymeCorp;2001. 8. NKFDOQI Clinical Practice Guidelines for Treatment of Anemia of Chronic Renal FailureQuick Reference Clinical Handbook. New York,NY:NationalRenalFoundation;1998. 9. Sherman RA, Cody RP, Rogers ME, Solanchick JC. Interdialytic weight gain and nutritional parameters in chronic hemodialysis patients.AmJKidneyDis.1995;25:579583.HypertensionEvidenceBasedNutritionPracticeGuideline.AmericanDieteticAssociation Evidence Analysis Library. American Dietetic Association; 2008. Available at: http://www.adaevidencelibrary.com. Accessed January5,2009.
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WILSONSDISEASE
Discussion Wilsons disease is an inherited disorder of copper metabolism that is characterized by the abnormal transportandstorageofcopper,resultinginhepatolenticulardegeneration,neurologicdamage,anddamage tothekidney,brain,andcornea.Onsetmayoccurfrom5to40yearsofage.Liverdiseaseisalwayspresent when a patient with Wilsons disease presents with any symptoms. Wilsons disease is a highly treatable condition;withpropertherapy,thediseaseprogresscanbehalted,andoftensymptomscanbeimproved.
Copperpromotesironabsorptionforhemoglobinsynthesis,formationofboneandmyelinsheath.Mostof copper in the copperalbumin complex is converted to ceruloplasmin in the hepatic tissues. In Wilsons disease,tissuedepositionoccursinsteadofceruloplasminformation.
Approaches Wilsons disease is treated with a copper chelating agent, such as penicillamine (Cuprimine, Depen) or trientine(Syprine),tokeepthepatientinanegativecopperbalance.Thechelatingagentbondswithcopper toformstablecomplexesthatareexcretedintheurine.Apatientinitiallytreatedwithachelatingagentmay receive maintenance therapy with zinc acetate (Galvin). This is particularly important for the patient who hasexperiencedadversereactionstochelatingagents.Zincacetateactsbyblockingtheabsorptionofcopper in the intestinal tract, which results in both the depletion of accumulated copper and prevention of its reaccumulation.
Chelating agents should be taken orally before meals. A vitamin B6 supplement is needed with this medication.Usually25mg/dayofvitaminB6isadequate.Zincmayalsobenecessary.Ifthetreatmentwith penicillaminealonedoesnotachieveanegativecopperbalance,alowcopperdiet(1to2mg/day)maybean appropriateadjunct. Anormaldietprovides2to5mg/dayofcopper.Toachieve1to2mg/dayofcopper,limitintakeofthe followingfoods: Organmeats,suchasliver,kidney,andbrain Shellfish,suchasoysters,crab,andlobster Driedlegumes,exceptpeas Wholewheatandbranbreadsandcereals Bakedpotatowithskin Sweetpotato Driedfruits,suchasraisins,dates,andprunes Mushrooms Chocolate Nutsandseeds Wildgame,suchasduckandgoose Mineralwater Noalcoholispermittedduetoitshepatotoxicaction. Zinc acetate (Galvin) is given in 50mg doses three times a day. Take separate fromfoodand beverages (otherthanwater)by1hour.Avoidliverandlimitshellfish(theonlyrestrictions).Checkthecoppercontent ofdrinkingwater.Ifcopperisgreaterthan1ppm,deionizedwatershouldbeused. Donotusecopperorbronzecookingutensils. Makesuresupplementsarecopperfree.
Bibliography EscottStumpS.NutritionandDiagnosisRelatedCare.5thed.Baltimore,Md:Lippincott,Williams&Wilkins;2002. HesseJM,MatareseLE.Medicalnutritiontherapyforliver,bilarysystem,andexocrinepancreasdisorders.In:MahanKL,EscottStumpS, eds.KrausesFood,Nutrition,andDietTherapy.10thed.Philadelphia,Pa:WBSaunders;2000:703. SkipperA,ed.DietitiansHandbookofEnteralandParenteralNutrition.2nded.Gaithersburg,Md:AspenPublishers;1998. PenningtonJ.BowesandChurchsFoodValuesofPortionsCommonlyUsed.17thed.City:Philadephia,Pa:LippincottRaven;1998. WilsonsDiseaseAssociation.Availableat:http://www.medhelp.org/wda/litAccessedApril28,1998.
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CAFFEINEANDTHEOBROMINECONTENTOFSELECTED FOODSANDBEVERAGES
Caffeine mgperserving Theobromine mgperserving 2 2 346 50 137 * 88 68 41 *
CarbonatedBeverages(12oz.) Cola,regularanddiet,unlesscaffeinefree 3137 Dr.Pepper,regularanddeit 37 FantaOrange,PatioOrange 0 Fresca 0 Hires 0 MountainDew 55 Mr.Pibb,regularandsugarfree 27 MellowYellow 35 Sprite,7Up 0 Kick 58 Coffeea(5oz.) Brewed,Percolator 103 Ground 59 Instant 57 Decaffeinated 2 Teaa(6oz.) Americanblack,3min.brew 36 Frominstant(1tsp) 30 Green,5min.brew 2636 Herb nonedetected ChocolateFoods Chocolate,baking(1oz.) 57 Chocolatecandy,milk(1oz.) 6 Chocolate,sweetdark(1oz.) 27 Chocolatemilk(1c) 5(27) Chocolatepudding(1/2c) 7 Chocolatesyrup(1oz.) 5 Carobpowder 0 Chocolateicecream(4oz.) 2 Cocoabeverage(6oz.) 5(28) aTheamountofcaffeinedependsupontheratioofcoffeeorteatowater,methodofpreparation,blendofcoffeeortea,andthelengthof
exposureofthecoffeeorteatohotwater. *Datanotavailable

Source PenningtonJ.Bowes&Churchs:FoodValuesofPortionsCommonlyUsed.17thed.Philadelphia,Pa:1998.
IV-1
Allrightsreserved.
METRIC/ENGLISHCONVERSIONSOFWEIGHTANDMEASURES
METRICEQUIVALENTS 1centimeter(cm) 1kilogram(kg) 1gram(g) 1milligram(mg) 1liter(L) 1mLliquid =10millimeters(mm) =1000grams(g) =1000milligrams(mg) =1000micrograms(g) =1000milliliters(mL) =1gram =1cubiccentimeter(cc) ENGLISHTOMETRIC 1inch(in) 1pound(lb) 1quart(qt) 1pint(pt) 1fluidounce(floz) METRICTOENGLISH 1centimeter 1kilogram 1gram 1milligram 1liter =0.39in =2.2lb =0.035ounce(oz) =0.015grain =1.057quarts =2.54centimeters =0.45kilograms =454grams(actualamountis453.6g) =0.946liter =946milliliters =480milliliters =30milliliters(actual28.35mL)
ENGLISHEQUIVALENTS 1bushel= 4pecks =8quarts 1gallon= 4quarts =2pecks 1peck =2quarts 1quart(qt) =2pints =4cups =32fluidounces 1pint(pt) =2cups =16fluidounces 1cup(c) =16tablespoons =8fluidounces 1tablespoon(tbsp) =3teaspoons =0.5fluidounce =15milliliters 1teaspoon(tsp) =1/6fluidounce =5milliliters
MILLIGRAM/MILLIEQUIVALENTCONVERSIONS
ATOMICWEIGHT VALENCE ELEMENT Calcium 40.08 2 Chlorine 35.45 1 Magnesium 24.31 2 Phosphorus 30.97 3 Potassium 40(39.10) 1 Sodium 23(22.98) 1 Sulfur 32.06 2 Conversions: mgtomEq:Dividethemilligramsbytheatomicweight;multiplybythevalence. Example: 200mgSodium Valence(1)=87mEq AtomicWeight(23) mEqtomg:Multiplymilliequivalentsbytheatomicweight;dividebythevalence. Example:90mEqSodium231=2070mg
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SALICYLATECONTENTOFSELECTEDFOODS
Therestrictionoffoodscontainingsalicylatesmaybeusedtotreaturticaria(hives).Berriesanddriedfruits are high in salicylates, as are most herbs and spices. Aspirin use or penicillin and food molds may also be restricted.Hivesmayappearwithinminutesoruptotwohoursaftereating,dependingonwherethefoodis absorbedinthedigestivetract. Note:Themostcommonfoodsthatcausehivesarechocolate,fish,tomatoes,eggs,freshberriesandmilk (1).Of thesefoods,onlyfish,eggs,tomatoesandfreshberriescontainsalicylatesTheirsalicylatecontentis<.1mg/100 mg,<.1mg/100mg,<.5mg/100mg,and1.04.99mg/100mgrespectively. FOODGROUP .50.99mgsalicylate/100 1.0 4.99mgsalicylate/100 5.010.0mgsalicylate/100 mg mg mg Fruits apple,cannedorgranny apricot raisins smith berries,allexceptfresh prunes,canned avocado raspberries(whichis raspberries,fresh cherries,sweet higher) figs,dried cantaloupe grapes,red cherries,canned grapejuice,dark cranberrysauce grapefruit currants,blackandred mandarinorange dates,freshanddried peach grapes,sultana tangelo orange pineapple plum,darkred Vegetables alfalfa chicory chilipeppers,red broadbeans endive broccoli peppers,sweetgreen chilipeppers,green/yellow radishes cucumberwithoutpeel tomatopaste eggplantwithpeel tomatosauce mushrooms,canned zucchini okra spinach,fresh squash sweetpotato,white tomato,canned watercress Nuts macadamianuts almonds pinenuts peanuts pistachios waterchestnuts Other sherry,sweet allspicesandherbsif wine usedinhighamounts
Reference 1.AmericanAcademyofDermatology.UrticariaHives.http://tray.dermatology.uiowa.edu(4/28/98). Bibliography PenningtonJ.BowesandChurchsFoodValuesofPortionsCommonlyUsed.17thed.Philadelphia,Pa:Lippinott;1998. EscottStumpS.NutritionandDiagnosisRelatedCare.4thed.Baltimore:Williams&Wilkins;1997:7576.
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MANUALOFCLINICALNUTRITIONMANAGEMENT

Manual of Clinical Nutrition Management

Copyright 2011 Morrison Management Specialists, Inc.

All rights reserved.

Manual of Clinical Nutrition Management

Copyright 2011 Morrison Management Specialists, Inc.

All rights reserved.

Manual of Clinical Nutrition Management

Copyright 2011 Morrison Management Specialists, Inc.

All rights reserved.

(g/d) (g/d) (g/d)

2.4* 3.3* 3.7* 3.7* 3.7* 3.7*

130 130 130 130 130 130

31* 38* 38* 38* 30* 30*

12* 16* 17* 17* 14* 14*

1.2* 1.6* 1.6* 1.6* 1.6* 1.6*

2.1* 2.3* 2.7* 2.7* 2.7* 2.7*

130 130 130 130 130 130

26* 26* 25* 25* 21* 21*

10* 11* 12* 12* 11* 11*

1.0* 1.1* 1.1* 1.1* 1.1* 1.1*

3.0* 3.0* 3.0*

175 175 175

28* 28* 28*

13* 13* 13*

1.4* 1.4* 1.4*

3.8* 3.8* 3.8*

210 210 210

29* 29* 29*

13* 13* 13*

1.3* 1.3* 1.3*

600 900 900 900 900 900

15* 15* 15* 15* 15* 20*

60* 75* 120* 120* 120* 120*

0.9 1.2 1.2 1.2 1.2 1.2

0.9 1.3 1.3 1.3 1.3 1.3

1.0 1.3 1.3 1.3 1.7 1.7

300 400 400 400 400 400

1.8 2.4 2.4 2.4 2.4i 2.4i

20* 25* 30* 30* 30* 30*

375* 550* 550* 550* 550* 550*

600 700 700 700 700 700

15* 15* 15* 15* 15* 20*

60* 75* 90* 90* 90* 90*

0.9 1.0 1.1 1.1 1.1 1.1

0.9 1.0 1.1 1.1 1.1 1.1

1.0 1.2 1.3 1.3 1.5 1.5

300 400i 400i 400i 400 400

1.8 2.4 2.4 2.4 2.4h 2.4h

20* 25* 30* 30* 30* 30*

375* 400* 425* 425* 425* 425*

Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150

750 770 770

15* 15* 15*

75* 90* 90*

1.4 1.4 1.4

1.4 1.4 1.4

1.9 1.9 1.9

600j 600j 600j

2.6 2.6 2.6

30* 30* 30*

450* 450* 450*

1,200 1,300 1,300