Lecture 1 Nutritional Basics, Micronutrients

1. Outline the fundamental differences between fat

soluble and water soluble vitamins, particularly as it
relates to practical implications such as potential for
losses prior to consumption, absorption and storage in the body.
a. Fat Soluble (A, D, E, K)
a.i. Found in foods containing fat
a.ii. Fat presence need for absorption
a.iii. Excess can be stored in body (cannot be excreted in urine; more likely toxic)
a.iii.1.
Stored in liver & fatty tissue
a.iii.2.
Deficiencies take much longer to develop
b. Water Soluble (B, C)
b.i. Very sensitive to heat (lost during cooking evaporate into air)
b.ii. Most excess can be excreted from body in urine (less likely toxic)
b.ii.1.
All are easily excreted in urine except B12
b.ii.2.
deficiency symptoms can develop quickly (a few days)
2. Describe the proper understanding of the various categories of the DRIs: RDA, AI, UL
a. Dietary Reference Intake (DRI)
a.i. Standards defined for:
a.i.1.
energy nutrients
a.i.2.
other dietary components
a.i.3.
physical activity
a.ii. Applies to healthy people, may be different for specific
groups
b. Nutrient level categories of DRI
b.i. Estimated Average Requirement (EAR)
b.i.1.
meets needs of 50% of population within
each group
b.ii. Recommended dietary allowance (RDA)
b.ii.1.
meets needs of 95% of population within
each group
b.ii.2.
EAR + margin of safety
b.iii. Adequate intake (AI)
b.iii.1.
similar to RDA but signifies the absence of
definitive data on which to base an RDA
b.iv. Tolerable Upper Intake Level (UL)
b.iv.1.
NOT recommended intake level
b.iv.2.
Maximum level not likely to pose health risks for most healthy people
c. Daily values based on RDAs/DRIs for essential nutrients (including vitamins) & Daily
Reference Values
c.i. Percentages based on 2000 kcal diet
3. Identify the current standard for food labeling of essential nutrients and other key food constituents
and the components of the standard
a. Use Daily values: Based on RDAs/DRIs for essential nutrients including vitamins + DRVs
(daily reference values) which cover compounds in foods we want to reduce (like cholesterol,
saturated fat, sodium/salt) .
b. These percentages are based on a 2000kCal diet
c. only vitamin C and A are required. And other information is voluntary
4. State the important considerations relative to mineral bioavailability in general, and with respect
specifically to calcium, phosphorus, iron, and zinc
major minerals need >100mg/day >.1% body weight
minor minerals need <100 mg day present >.1% body weight
always retain chem. identity
cannot be destroyed by heat, air ,acid, or mixing

Mineral
Calcium
(major)

Considerations
1. Blood calcium levels
2. Plasma levels increased at expense of bone
(Vit. D, PTH, Calcitonin) (All adults lose bone
with age beginning bw 30-40 yo
3. Higher fracture risk with reduced GI pH (w/
PPIs)
Most abundant mineral in the body 1-2% of
adult body weight

Bioavailability
- Cauliflower, watercress, cabbage (>50%
absorption)
- Yogurt, milk, cheese, sardines (higher
content, 30% absorbed)
- Spinach rhubarb swiss chard less than 5%
absorbed
-Almonds, seeds, beans, sweet potatoes
about 20% absorbed

Phosphoru 1. Component of Teeth and Bones

s
2. Higher levels contribute to bone loss,
(major)
weakness, & loss of appetite
3. often get excess

- Sunflower seeds, almonds, spinach, beans

-widely distributed in the food supply

Iron (trace) 1. Hb
2. Stored as Ferritin (small intestine)
3. Transported via Transferrin
4.Very common deficiency
5.Body conserves iron and balance is
maintained through absorption ( absorb more
when body is low)
6. Need depends on age, health, and iron status
7. RDA women >50 and men is 8mg
RDA women 19-50 18 mg

- Heme iron (more bioavailable than nonheme)

Iron cookware confers nonheme iron

Zinc
(trace)

- Beef, crab, yogurt, lentils

- Sunflower seeds, spinach, whole wheat
bread
-Phytate inhibits absorption

1. Most abundant intracellular trace element

2. In over 300 different enzymes
3. Absorption varies (due to mineral-mineral
interactions w/ iron and copper)
4. Transport via albumin & transferrin
5. RDA 8 mg women, 11 mg men

- Spinach, lentils, beef, sunflower seeds,

bread, broccoli
- Absorption enhancing: MFP, Vitamin C,
some acids & sugars
- Absorption inhibiting: phytates,
polyphenols, vegetable proteins, calcium

5. State the important considerations relative to mineral bioavailability in general, and with respect
specifically to calcium, phosphorus, iron, and zinc
Vitamin Key Functions
Vitamin A 1. Growth, Development, and
Reproduction: Growth activating
protein synthesis
2. Maintenance of Epithelial
Tissues: mucus production
3. Immune Function: deficiency
leads to infection
4. Vision (retinal)

Food Source
Beef liver, carrots,
spinach, mustard
greens, apricots,
eggs, milk

Deficiency States/High Risk Groups

-Can arise when there is fat
malabsorption
-Risk of infectious diseases
-Night blindness (xeropthalmia) (dry eyes
due to lack of mucous infections)
-Keratinization and hyperkeratosis
-Change in size and shape of epithelial
cells dry scaly skin + GI problems
affecting nutrient absorption + weakened
defenses in respiratory, urinary tracts,
and vagina
-Death

Vitamin D 1. Bone Growth

2. Enhances or Suppresses Gene
Activity
3. Immunity

Salmon, milk,
- Children: Rickets (bending of bones)
eggs, cheese, liver - Adults: Osteomalacia and eventually
osteoporosis
- Elderly at risk: low sun exposure, dietary
intake, and organ function decline

- Diseases and Surgery: Fat

malabsorption from lower GI, Liver and
Bariatric Surgeries
-40 deg latitude or above b/c of less
sunlight
-Men with deficient levels are 2X more
likely to have MI
-Cardiovascular disease higher risk of MI
and CVD death with low levels
-Higher blood pressure
-Multiple sclerosis linked to low levels
Vitamin K 1. Clotting and Coagulation
2. Metabolism of Bone Proteins:
Osteocalcin needs Vit K, otherwise
bones become brittle

mainly leafy
vegetables
mustard greens,
kiwi, and soybean
oil

- Primary deficiency is rare

- Secondary: fat malabsorption and some
drugs that disrupt vitamin K synthesis/
action (like blood thinners) and
antibiotics which kill gut bacteria which
help us get our vit K
- Newborn Infants need Vit K injections
because they have sterile guts
- High risk individuals: High intake/doses
can reduce the effectiveness of
anticoagulant drugs
-Consistency in intake is key get 50%
from gut and 50%diet

Vitamin C 1. Cofactor in Collagen Formation

2. Hydroxylates Carnitine
3. Converts Tryptophan to
Serotonin
4. Converts Tyrosine to NE
5. Hormone Synthesis
6. Antioxidant (protects tissues
from oxidative stress)
7. Important in stress and released
with stress hormones from adrenal
gland

Fruits and
vegetables,
potatoes, broccoli,
spinach

- Scurvy: gums bleed, hemorrhages in

subcutaneous skin, psychological signs,
and sudden death
- Smoking: increases need for Vitamin C
- Interferes with medical regimens/ drugs
like angioplasty and statins, niacin,
warfarin, aspirin, and chemotherapy

Vitamin
B12

1. Brain, Nervous System, and

Blood Formation
2. DNA Synthesis and Regulation
3. Fatty Acid Synthesis
4. Required for Iron Absorption

Trout, beef, pork,

milk, cheese,
chicken, orange
juice

- Deficiency >15% among older adults

- Atrophic Gastritis
- Fatigue, Poor appetite, mucosal and skin
pallor, difficulty concentrating
- Megaloblastic Anemia (pernicious
-Vegan diets
anemia)
require
-High folate masks the B12 Deficiency,
supplementation but neurologic symptoms continue
- more available
from animal
- Bariatric Surgery and Diseases of the
products (almost Small Intestine (Crohns)
exclusive source) - Vegans

Vitamin
B9
(Folate)

1. THF: Transfers single-carbon

Lentils, spaghetti,
compounds during metabolism
asparagus,
- Linked to CVD via homocysteine
(primary coenzyme form THF)
spinach
metabolism
2. Converts B12 to coenzyme form
-Autism and neural tube defects in babies
3. DNA synthesis
-Impairs cell division: red blood cells and
4. Regenerates Methionine from
anemia
Homocysteine
-GI tract deterioration due to impaired
protein synthesis
-Sensitive to heat, oxidation
-Primary deficiency: sensitive to heat,
oxidation Synthetic form more
bioavailable than natural form
-Secondary deficiency from drugs

6. Outline the key functions, at least 3 significant food sources, and deficiency states/high risk groups
for the minerals calcium, iron, phosphorus, iron, and zinc
Mineral
Calcium

Functions
Food Source
Deficiency States/High Risk Groups
1. Participates in Blood Yogurt, 1 % milk, cheese, - Osteoporosis
Clotting (extracellular) sardines
- Atrophic Gastritis: Acid required for
2. Nerve Transmission
absorption
3. Muscle contraction
- Estrogen Deficiency
4. Blood Pressure
- Vitamin D Deficient
Regulation
-most likely to be deficient
5. Release of Hormones
- Female
- Cigarettes
- Alcohol
chronic disease links to
-CVD
-Diabetes
-obesity
-colon cancer

Phosphoru 1. Component of Teeth

s
and Bones (85% is here)
2. Regulatory
(1% of an adults body
weight)
Iron

-widely distributed in the

food supply (most
significant source as an
additive)

1. Hb
Spinach, lentils, beef,
2. Cofactor for oxidation- sunflower seeds, bread,
reduction reactions
broccoli
3. Electron Carriers

- Bone loss
- Weakness
- Loss of Appetite
- Must be restricted in kidney disease:
difficult time controlling phosphorus
-more likely to be in excess
- most common deficiency world wide (80%
population)
- Iron Deficient Anemia (Hb cannot be
produced) red blood cells become
microcytic and hypochromic

-Lethargy and weakness

-can arise from: inadequate intake, blood
loss, or disease
-Stages: Iron stores diminish (serum
ferritin), decrease in transport iron
(transferrin), and iron deficiency
(hemoglobin and hematocrit values)
- Vulnerable: women in reproductive years,
pregnancy, infants and young children, and
adolescence
-Link to disease as a catalyst for oxidation
(heart disease and cancer)
Zinc

1. Gene expression
2. Blood Clotting
3. Cell Membranes
4. Immune Fct.
5. Growth and
Development
6. Synthesis, Storage,
and release of Insulin
7. Thyroid Hormone
Function
8. Behavior and
Learning Performance
9. Visual Pigment
10. Taste Perception
11. Sperm Production
12. enzymes (300 dif
types; including
superoxide dismutase)

Beef, crab, yogurt, lentils, sunflower seeds

-

Hypogonadism
Short Stature
Impaired Immune Response
Delayed wound healing
Impaired Taste Acuity
Damage to CNS
Alopecia, skin lesions

7. Identify the types of individuals/groups who may need nutrient supplementation

- Specific nutrient deficiencies
- low energy intakes
- vegans Older adults with atrophic gastritis
- lactose intolerance
- certain medications
- certain stages of life cycle (pregnancy)
- inadequate milk intake, sun exposure, or dark skin
- medical conditions that interfere with nutrients in the body
8. Identify four categories of dietary supplements
a. Essential Nutrients (Vit/Min, AAs, FAs), Herbs, Phytochemicals (phenols), Functional Food
(may contain added essential nutrients (vitamins) or phytochemicals)
9. Select three modes of action through which food components/nutrients may modulate chronic
disease development or progression
a. Promote/fight inflammation
b. Antioxidants (C,E carotenoids, phenols, phytochemicals)
c. Hemodynamics (blood sugar, cardiovascular, clotting, etc)
10. Define nutrient density as it relates to foods
a. More vitamins, minerals, & protein per calorie *ex. 100 Cal= 2.5c of broccoli which has vit c,
iron, protein and fiber compared to 100 Cal= 8oz soda which has no nutrients at all
b. Superfoods
c. fewer calories with more nutrients and phytochemicals (can help fight chronic disease and
increases antioxidant intake

Lecture 2: Nutritional Assessment Width

1. Describe the purpose of and differences between Nutrition Screening and Nutrition Assessment,
and discuss the 4 categories covered in a nutrition assessment
a. Nutrition Screening
a.i. Quick, easy and include data that is readily available
a.ii. May be done by a health care professional and paraprofessionals, dont necessarily
need trained nutritionist
a.iii. Quickly identify people at nutritional risk who may need comprehensive nutritional
assessment
a.iv. Utilizes weight, diet, skin integrity, appetite, GI disturbances, dentition
b. Nutrition Assessment
b.i. Comprehensive, evaluates problems, needs, status, and used in formulating
treatment plan
b.ii. 4 Categories
b.ii.1.
Anthropomerics: physical measurements for determining body
composition
b.ii.2.
Biochemical: blood & urinalysis (protein status mainly)
b.ii.3.
Nutrition-Focused exam: look for clinical nutrition risk factors
b.ii.4.
History: PMH/SH for nutritional relevance
2. Describe the characteristics, complications and treatment of the types of Protein Energy
Malnutrition
a. Kwashiorkor: condition that results primarily from protein deficiency
a.i. Children weaned off breast milk high carbohydrate diet low in protein (acute)
a.ii. Symptoms: edema, fatty liver (lipids remain in liver because proteins for signaling
not being processes), patch and scaly skin, loss of hair and skin pigment, stunted
growth, muscle wasting
a.iii. Characteristics:
a.iii.1.
Children of 1-3 years
a.iii.2.
Inadequate protein intake, typically with high carbohydrate intake
a.iii.3.
Rapid onset
a.iii.4.
Some weight loss; some muscle wasting with retention of body fat
a.iii.5.
Growth: 60-80% wt-for-age
a.iii.6.
Edema and fatty liver
a.iii.7.
Apathy, misery, irritability, sadness
a.iii.8.
Skin becomes discolored and develops lesions
a.iii.9.
Hair is dry, brittle, pulls out easily, changes color, becomes straight
b. Marasmus: primarily from protein deficiency (chronic PEM, protein energy malnutrition)
b.i. Symptoms: severe muscle wasting, stunted growth, impaired learning ability, low
body temp, lethargy, GI tract atrophy
b.ii. Chronic effects of protein malnutrition and body adaptation
b.iii. Characteristics
b.iii.1.
Infancy <2 yrs
b.iii.2.
Severe deprivation of energy protein vit minerals
b.iii.3.
Develops slowly over time
b.iii.4.
Severe weight loss and muscle wasting with no body fat
b.iii.5.
Growth <60 weight for age
b.iii.6.
No detectable edema or fatty liver
b.iii.7.
Anxiety, apathy
b.iii.8.
Skin is dry, thin, easily wrinkles
b.iii.9.
Hair is sparse thin dry pulls out easily
c. Complications
c.i. Degradation of antibodies: prone to infection
c.ii. Dysentery: diarrhea
c.iii. Anemia

c.iv. Combination of infections, fever, fluid imbalance, and anemia can lead to heart
failure and death
d. Treatment
d.i. Rehydration and nutrition intervention: add protein slowly
d.ii. Antibiotics help with recovery
3. Calculate ideal body weight using the Hamwi method, including adjustments for frame size,
amputation, and/or spinal cord injuries (adjustment factors for amputation or spinal cord injuries
would be given)
a. Females = 100 lbs. for 5 feet + (5 lbs/inch over 5 feet)
b. Males = 106 lbs. for 5 feet + (6 lbs/inch over 5 feet )
c. % IBW =
d. Adjustments:
d.i. Frame Size: measure wrist circumference distal to the styloid process on the left
hand and compare to chart
d.i.1.
Subtract 10% from IBW for
small frame
d.i.2.
Add 10% to IBW for large
frame
d.ii. Amputation:
d.ii.1.
d.ii.2.
Paraplegia: subtract 5-10%
from IBW
d.ii.3.
Quadriplegia: subtract 10-15% from IBW
e. Adjusted Body Weight: based on the assumption that 25% of excess weight is
metabolically active lean body mass and 75% is metabolically inert adipose tissue; used by
many clinicians for a patients >120 %IBW (although not evidence based)
e.i.
4. Discuss the purpose and cautions of using Body Mass Index (BMI) in nutrition assessment
a. Diagnosis of obesity (overweight 25-29, underweight <18.5, starvation <15, obesity 3034.9, obesity II 35-39.9, extreme obese (class III) >40)
b. Originally intent was actually for population studies not individual
c. Does not take into account muscularity, frame size, bone proportions, cartilage, water
weight
d. For all ages, separate for children
5. Describe the purpose of the different methods of evaluating body weight changes in hospitalized
patients when completing a nutrition assessment (%IBW, % weight change). Calculations would be
given if used in a question
a. % IBW: tells you how far off a person is from their ideal weight, but nothing about current
weight status
b. Weight change: a more meaningful parameter to assess weight
change
b.i.
b.ii. Can pick up on involuntary weight loss: burn victims,
spinal injury rehab, outpatient rehab post injury/surgery,
and nursing home patients
b.ii.1.
consider the hydration status, which can
falsely affect actual weight: edema and ascites
b.iii. Adjusted Body Weight: based on the assumption that 25% of excess weight is
metabolically active lean body mass and 75% is metabolically inert adipose tissue;
used by many clinicians for a patients >120 %IBW (although not evidence based)
b.iii.1.
b.iii.2.
Used when patient is >120% IBW
b.iv. Skin fold and arm measurements
b.iv.1.
Widely used technique for estimating body composition
b.iv.2.
Used more often in outpatient and community settings but useful in
determining malnutrition in a clinical setting

b.iv.3.
Principle: amount of total body adipose well represented by
subcutaneous fat (50%)
b.iv.4.
Inexpensive and non-invasive
b.iv.5.
Sites include triceps, subscapular, suprailiac
b.iv.6.
Provides data on adipose stores and is a good indicator of muscle and
protein reserves
b.iv.7.
You measure: midarm circumference MAC and triceps skin fold TSF
b.iv.8.
You calculate: arm muscle area (AMA) AMA= [MAC (3.14 X TSF)]2/ 4 X
3.14
b.iv.9.
Compare to standards. Serial measurements work best to monitor
changes
b.v. Waist circumference and waist to hip ratio
b.v.1.
Presence of excess fat in the abdomen, out of proportion to total body
fat is a risk factor for heart disease and diabetes
b.v.2.
Waist circumference= measure waist at the top of the hip bone level
with the navel
b.v.2.a.
>35 inches (88cm) for a woman, >40 inches (102cm) for a man
is considered high risk
b.v.3.
waist to hip ratio: measure hip circumference at widest pt. then divide
waist circumference by hip circumference.
b.v.3.a.
Below .8 women
b.v.3.b.
Below 1.0 for a man
6. Describe the biochemical tests used to assess both somatic and visceral protein status, including
half -life, when each test should or should not be used, and other factors that might affect test
results
a. Nitrogen Balance: somatic/visceral protein
a.i. Normal healthy adults are in nitrogen balance
a.ii. This is the best assessment tool for determining adequacy of nutrition support
b. Negative NB:
b.i. Protein catabolism exceeds protein anabolism
b.ii. Immobilization
b.iii. Malnutrition
c. Positive NB:
c.i. Protein anabolism exceeds protein catabolism
c.ii. Pregnancy
c.iii. Growth in childhood
d. Calculating Nitrogen Balance:
d.i. Monitor dietary intake of PRO:
d.ii.
d.iii. collect 24 hr urine: obtain UUN
d.iv.
d.iv.1.
NB = NI (UUN (g) + 3-4g)
d.iv.2.
3-4g represent insensible losses or non-urea nitrogen
d.v. Goal in nutritional support is a +NB of at least 2g nitrogen/day
e. Pre-albumin: visceral/recent protein intake
e.i. Has a half-life of 48 hours (extremely short)
e.ii. Highly sensitive marker of recent nutrition status
f. Albumin: visceral protein/iron status; most widely used
f.i. Has a half life of 14-20 days (long)
f.ii. Not sensitive to recent changes, but is a good marker of long term nutritional status
f.iii. Correlates well with patient outcomes and length of stay
g. Transferrin: visceral protein
g.i. Has a half life of 8-10 days
g.ii. Although half-life is just right to reflect protein status, it is a poor marker for protein
malnutrition in older adults
g.iii. Levels are increased with iron deficiency
h. Acute Phase Proteins (e.g. CRP)
h.i. Plasma proteins that respond to inflammation by decreasing (negative APP) or
increasing (positive APP)

h.ii. Mediated by cytokines released by inflammatory cells, which stimulate hepatocytes

to produce positive APP concomitant with reduced synthesis of negative APP
h.iii. Note: albumin, prealbumin and transferrin are all negative acute phase proteins
(decrease during inflammation due to action of cytokines on hepatocytes); therefore,
you must use caution when using these tests to evaluate protein status in
stress/trauma situations
Normal

> 100

Mild

97.5 100

Moderate

83.5 97.5

Severe

< 83.5
i.

Nutrition Risk Index

i.i. Calculates the risk of malnutrition using weight and albumin levels
i.ii.

7. Identify types of nutritional anemias

a. Hematological assessment can determine the presence of nutritional anemias
b. Iron: hypochromic (low mean cell Hb), microcytic (low mean cell volume); iron deficiency is
the most common cause of anemia worldwide
c. B12: normochromic (normal MCH), macrocytic (high MCV)
d. Folate: normochromic (normal MCH), macrocytic (high MCV)
e. Therefore, if iron and B vitamin deficiencies coexist, values may be normal (further tests
needed)
8. Discuss common drug-nutrient interactions (antibiotics, diuretics, antineoplastics, corticosteroids,
warfarin, MAOIs, problems with grapefruit juice)
a. Antibiotics:
a.i. GI disturbances, diarrhea
a.ii. Dairy products (Ca++) interfere with tetracycline absorption
b. Diuretics:
b.i. Excess mineral excretion (esp. K+)
c. Antineoplastics:
c.i. Taste changes/loss of appetite
c.ii. GI disturbances
c.iii. Mouth sores
d. Corticosteroids:
d.i. Weight gain/appetite increase
d.ii. Glucose homeostasis
e. Oral Contraceptives:
e.i. Reduced serum vitamin C and possibly some B vitamins
e.ii. Increased copper
f. NSAIDS:
f.i. GI irritation (bleeding, ulceration)
g. Warfarin:
g.i. Monitoring INR/PT (clot formation times) and consistency in vitamin K
intake is ESSENTIAL
g.ii. Sudden increases in vitamin K intake can decrease effectiveness of warfarin; sudden
decreases can increase effect
g.iii. Need to limit high vitamin K foods to 1 serving/day
g.iii.1.
Raw: kale, parsley
g.iii.2.
Boiled: spinach, turnips, collards, Swiss chard, mustard greens
g.iv. Need to limit moderate vitamin K foods to 3 servings/day
g.iv.1.
Raw: spinach, turnips, green leaf lettuce, broccoli, romaine, endive
g.iv.2.
Boiled: brussels sprouts
g.v. Avoid alcohol and caution with herbal supplements
g.v.1.
Increase warfarin effects: garlic, ginger, ginko, feverfew

g.v.2.
Decrease warfarin effects: ginseng
h. MAOIs:
h.i. MAO (monamine oxidase) is an endogenous enzyme in the GI tract that normally
metabolizes pressor vasoactive amines (VA,tyramine), keeping them at safe levels
h.ii. MAOI drugs suppress MAO increasing the sensitive to tyramine and possibly
precipitating hypertensive crises
h.iii. When using MAOIs, need to limit tyramine (VA) intake
h.iv. MAOIs can increase sensitivity to tyramine, possibly precipitating a hypertensive
crisis
h.v. Sources of Tyramine: aged cheese, aged/cured meats, soybean products, tap beer,
sauerkraut, fava or broad bean pods, Chianti, Vegemite
i. Grapefruit Juice:
i.i. Can block hepatic enzymes that normally metabolize drugs, enhancing the drug
action
i.ii. Examples of Drugs Affected: anti-arrhythmia, anti-convulsants, antidepressants,
antifungals, anti-histamines, antiretrovirals, anti-seizures, calcium channel blockers,
immunosuppressants, impotence drugs, statins
j. Dietary supplements
j.i. May interact with medications and adversely affect surgeries (ex Echinacea can slow
wound healing)
9. Describe the different methods available to estimate energy, protein and fluids needs (equations
and factors would be given if needed)
a. Energy Needs
a.i. Indirect Calorimetry is the gold standard
a.i.1.
measures oxygen consumption VO2 and carbon dioxide production
VCO2
a.i.2.
calculates the resting energy expenditure (REE)
a.i.3.
metabolic cart:
a.i.4.
advantages: portable, practical, eliminates variability and prediction
errors
a.i.5.
disadvantages: requires constant calibration
a.ii. Med Gem (hand-held)
a.ii.1.
Uses sensors to measure O2 consumption and calculates resting
metabolic rate (RMR)
a.ii.2.
Option in outpatient
a.ii.3.
Still questioning accuracy (studies)
a.iii. Harris-Benedict Equation
a.iii.1.
measures resting energy expenditures and is not very accurate
a.iii.2.
Total Daily Energy Expenditure = TDE x AF ( activity factor: sedentary
vs. ambulatory) and/or SF (stress factor: burns, sepsis, surgery, trauma)
a.iv. Calories per kilogram
a.iv.1.
Fast and easy to use
a.iv.2.
Uses actual or ideal body weight (if patient >120% IBW use IBW vs
actual)
a.iv.3.
Normal= 25-30 kcal/kg, stress (mild)=30-35 kcal/kg, stress (moderatesevere)= 35-45 kcal/kg
b. Protein Needs: based on actual body weight

c. Fluid Needs

Lecture 3: Maternal and Infants, Children, Adolescents Reinhard

1. Identify the risk factors for poor pregnancy outcome
a. Non nutrition related
a.i. Gynecologic Age: pregnancy age age of menses onset (low GA is high risk)
a.ii. Race/Ethnicity: African Americans are highest risk (double that of Caucasians)
a.iii. Socioeconomic Status
a.iv. Social Support
a.v. Use of Specific Substances: smoking, alcohol, drugs (prescription, OTC, illegal)
a.vi. Adequate Prenatal Care: timing and frequency
a.vi.1.
300% higher risk with no prenatal care; higher risk with delayed care
a.vii. Chronic Disease: disease process, impact on nutritional status and medications can
all be problematic
a.viii. Parity: number of previous births and the spacing between them (high parity with
close spacing can be problematic: depletion of nutrient stores)
b. Nutrition related
b.i. Preconception nutritional status
b.ii. Underweight (BMI <18.5) need to gain bw 28-40 lbs
b.iii. Obese BMI >29.9 need to gain 11-20lbs
b.iv. Nutrient intake during pregnancy
b.v. Weight gain during pregnancy
2. Define low birthweight and outline the implications; Related to low birthweight, distinguish between
small for gestational age versus pre-term
a. Low Birth Weight = 5.5 lbs at birth. = 25% higher infant mortality and morbidity: having
physical and mental birth defects, higher complications during delivery, and contracting
infectious disease, 400% greater risk for autism, chronic kidney disease in childhood, higher
health care costs, and higher risk for chronic disease as an adult
b. Small for Gestational Age = made it to full term but is not > 5.5 lbs; probably had a
problem during gestation that accounts for the low birth weight; higher risk
c. Premature/Pre-Term= born before term (before 37 weeks) and as a result has a low
birthweight
3. Select accurate descriptors related to infant mortality rate
a. Infant Mortality Rate: Number of deaths among birth to 12 months per 1000 live births
b. Decrease in IMR 1900-1950 due to improvements in sanitation and housing, as well as
income and education
c. US is poorly ranked among other developed nations (6.1), with Michigan tied for 15th among
other states (7.1) and Detroit being at higher risk versus most cities (15)
4. Outline the recommendation for total weight gain during pregnancy based on prepregnancy weight
(Institute of Medicine Recommendations 2009)
Maternal Weight Gain
Category

BMI

Weight Gain
(lbs)

Twins (lbs)

Underweig
ht

< 18.5

28 40

Ask

Normal

18.5
24.9

25 35

37 54

Overweigh
t

25 29.9

15 25

31 50

Obese

30

11 - 20

25 42

Weekly Maternal Weight Gain (2nd & 3rd Trimester)

33% weight gain within in current guidelines

excessive gain increases risk for overweight child
weight gain is influenced by psychosocial factors (cultural ideas about women, lack of support)
restrained eaters fain more weigh that non restrained eaters
underweight RE gained less weight than non-RE underweight women
5. Select the risk factors for adolescent (teen) pregnancy
a. Risk Factors:
a.i. High nutritional risk group (still growing themselves, often have poor diets)
b. Social Risk:
b.i. Leave home, abandoned by significant other
b.ii. No social support or income
b.iii. Late and/or poor prenatal visit attendance (denial)
b.iv. Body image problems (poor diet)
c. Gynecologic Age: pregnancy age age of menses (they have low GA= high risk)

6. Describe fetal alcohol syndrome

a. Congenital defect caused by alcohol intake of 3oz/day during pregnancy that typically
involves:
a.i. Low birth weight
a.ii. Limb, face/head deformities
a.iii. Impaired physical and cognitive development
a.iv. Leading cause of developmental defects
a.v. There is no safe limit: get rid of alcohol during pregnancy
7. Characterize the benefits of breastfeeding, both short-term breast-feeding and longer term
breastfeeding
a. Reduced infant mortality/morbidity
b. Emotional Bonding
c. Jaw and tooth alignment
d. Microbial Safety
e. Nutrient Content (similar to formula)
f. Hormones: Leptin, adiponectin, ghrelin-may protect against adult obesity
g. Antibacterial Compounds
g.i. high in colostrum
g.ii. lower rate of respiratory infection
g.iii. microbiome of breast milk >700 species
h. Allergy Development (conflicting research)
i. Cost
8. Outline the infant feeding guidelines of the Am. Academy of Pediatrics related to; Age to begin solid
foods, breast-feeding versus infant formula, use of cows milk in infancy, age to begin American
Heart Association dietary recommendations
a. Breastfeeding is preferred to one year
a.i. No cows milk until 1 year, and only whole milk until 2 years (unless high risk case
see below)
a.ii. Not applicable to CVD risk families
b. If not breast feeding, use only infant formula for the first year
c. Only use soy if allergy to standard formula
d. Fat free milk beyond 2yrs
e. Reduced fat milk can be used bw 1-2 yrs based on childs diet and risk for obesity/CVD and
should only be used in an overall dies that supplies 30% of calories from fat
f. Vitamin D supplementation for breastfed and partially breastfed infants (400 IU/day)
g. Solid foods can be added between three and six months
g.i. Dont stary before 17wks do start before 26 wks
g.ii. Need a source of iron bc maternal stores are depleted by 3 mo
g.iii. Formula fed possibly sooner (3-4 mo) and breast fed later (up to 6 mo)
h. Look for signs of readiness to feed solids
h.i. Important for both formula and breast-fed
h.ii. Taking >32oz formula and still hungry
h.iii. Holds head steady and sits up with support
h.iv. Keeps food in mouth (loss of extrusion reflex)
i. Delaying solid food could increase risk for allergies
j. First solid food should be infant rice cereal (iron-fortified)
j.i. Cereal before 3 months or after 7 months increase T1DM antibodies
j.ii. MIX with formula or breast milk NOT WATER
j.iii. From a spoon not a bottle
k. AHA dietary recommendations can begin after the age of two
9. For the various age groups (infants, toddler-aged children, adolescents), identify the most common
nutrient deficiencies, or specific nutrients likely to present concerns
a. Infants: Iron, Vit D (for breastfed infants not receiving supplement)
a.i. Toddlers: Iron (particularly for those who continue a high intake of milk: Iron
deficiency anemia
a.ii. Early childhood: dental caries, ADHD (deficits in n-3 FAs, Fe, Zn, Mg and also Cu)
a.iii. Adolescents: Ca, Mg, K, Vit E, Fiber

a.iii.1.
a.iii.2.
a.iii.3.
proper

Most common is Ca
Fe for females can be a concern
Bone density: often have low ca/ vit D and K, Cu, Mn, Zn, P are not in
ratio.

10. Select the BMI categories (percentiles) from the National Center for Health Statistics for children
related to overweight and obesity
a. BMI Assessment in Children:
a.i. Obesity: 95th percentile and up
a.ii. Overweight: 85th-95th percentile
a.iii. Underweight: less than 5th percentile
11. Outline the Screening Guidelines from the Am. Academy of Pediatrics for cholesterol in children
b. Screening:
b.i. Over the age of 2 with a positive family history of dyslipidemia or premature CVD
b.ii. Over the age of 2 without a family history but with risk factors (overweight, obesity,
diabetes, HTN)
b.iii. If lipids are normal in these individuals, screen again in 3-5 years
b.iv. Lipids Tested in all ages from 9-11 years
b.iv.1.
if normal, follow up at 18-21 years
b.iv.2.
Lipids tested from ages 2-8 yrs if high risk
b.v. Glucose testing at 10 years or at the onset of puberty if overweight and there is a
family history of T2DM
c. Intervention:
c.i. if LDL >130-189 mg/dL diet and lifestyle changes
c.ii. Nutrition counseling, exercise and weight management are the first treatments
c.iii. Medication (statins) at 10 years of age if higher LDL or other risk factors
c.iv. Medication should not be used <10 yrs unless severe primary hyperlipidemia or high
risk conditon associated with severe morbidity
Lecture 4: Aging, Obesity Reinhard
1. Identify the cut-off points for BMI (normal, overweight, obesity)
Category

BMI

Underweight

< 18.5

Healthy Weight /

20 24.9

Overweight

25 29.9

Obesity I

30 34.9

Obesity II

35 39.9

Obesity III
(Extreme)

> 40

2. Select the long-term effectiveness of weight loss (based on data from National Institutes of Health)
a. Of those who lose 10% of body weight:
a.i. 66% of people regain the weight within 1 year (of those who lose 10%)
a.ii. >95% regain the weight within 3-5 years
3. State the current recommended rate of safe weight loss for adults (pounds per week)
a. 0.5-1 lb/week (safe and effective recommendation)
4. Identify the waist circumferences for males and females associated with higher disease risk
a. >40 for men
b. >35 for women

c. Represent higher risk for diseases such as CVD (MI and HTN), gall bladder disease, and type
2 diabetes
5. Describe characteristics of the American lifestyle that contribute to the toxic environment obesity
theory and also to classic eating disorders; Outline the role of the cultural ideal with respect to the
toxic environment theory
a. Availability and Types of Foods:
a.i. Fast food restaurants (foods high in fat, low in fiber and other protective nutrients)
a.ii. McDonalds goal: 4 minutes from a restaurant
a.iii. Taco Bell open until 3am to get food
b. Less Energy Expenditure:
b.i. Low energy cost to obtain food
b.ii. Appliances have reduced energy cost for daily routine
b.iii. Hunter gatherer cultures vs the US
b.iv. Chewing gum and the importance of NEAT as well as intentional physical activity
b.v. Coach potato: there is an app for tracking TV viewing; rewards for TV time and the
phone rewards can be scanned at places like burger king and starbucks
c. Increased Portion Size
d. Societal Attitudes Against Obesity
d.i. Biggest Loser effect: after viewing subjects actually have more negative views
towards obese individuals; lower BMI subjects has highest aversion
d.ii. Employment Discrimination: hiring discrimination, lower salaries for overweight
workers (women 6.2%, men 2.3% lower)
d.iii. Physician Discrimination: doctors more compassionate to thinner patients
d.iv. Weight Teasing in Adolescence: Predicts disordered eating at 5 yr follow up
e. Eating Disorders: cultural ideals affect body image and begin the cycle of
restrained/disordered eating; can lead to eating disorders
e.i. Obsession with diet, exercise and weight loss attempts coexist with the highest
prevalence of obesity
e.ii. Cultural standards for beauty have changed
6. State the current guidelines for consideration of bariatric surgery (BMI with no co-morbidities)
a. Candidates for Surgery:
a.i. BMI between 30-40 with one co-morbidity (dont memorize)
a.i.1.
DM Type II at 35
a.i.2.
DM Type II at 30 if cant control with meds/lifestyle
a.ii. BMI greater than or equal to 40 without co-morbidities
a.iii. Full awareness of complications and lifelong dietary changes
7. Outline reasons for an elderly persons higher risk for dehydration
a. Body composition changes (higher adipose, lower lean body mass; therefore, less water)
b. Weakened thirst signal
c. Medications (diuretics)
d. Constipation (if using bulk forming laxatives need higher fluid intake)
e. Dementia
8. Identify several key nutrients most likely to be of concern in an elderly population
a. B Vitamins
a.i. Folate (B9), B6, & B12
a.i.1.
lower blood levels with aging
a.i.2.
higher intake linked to lower levels of homocysteine
a.i.3.
lower risk for Alzheimers, CVD, Cognitive Function, Hearing
a.i.4.
B12 is particularly of concern because there is a reduced synthesis of
intrinsic factor in the elderly
a.i.4.a.
atrophic gastritis, achlorhydria/hypochlorhydria
a.ii. Protein: Maintain the nitrogen balance
a.ii.1.
maintains lean body mass in combination with resistance exercise
a.iii. Vitamin D
a.iii.1.
inadequate sunlight exposure
a.iii.2.
decline in efficiency of synthesis of skin precursor compound

a.iv.

a.v.
a.vi.

a.vii.
a.viii.

a.ix.

a.iii.3.
decline in liver and kidney activation
a.iii.4.
Post menopause interferes with its intestinal absorption
a.iii.5.
low levels linked to depression in adults
Calcium
a.iv.1.
decline in Vit D leads to less Ca absorption in men and women
a.iv.2.
In addition in women poor intake is related to other hormones (DRI
1500 mg)
Magnesium
a.v.1.
lower dietary intake and also take drugs that inhibit absorption
Sodium and Salt
a.vi.1.
Aging affects the kidneys ability to respond to perturbing conditions in
maintaining fluid and electrolyte balance
a.vi.2.
Sodium restriction is common in the elderly
a.vi.2.a. Heart failure, hypertension, stroke, or with certain medications
a.vi.2.b. Restrictive diets of less than 3g per day are not likely to
improve disease condition
a.vi.2.b.i. More likely to cause protein calorie malnutrition due to a
reduction in food intake
a.vi.3.
Dietary guidelines: 2300 mg for healthy adults, 1500 mg for those over
age 51
Immunity: Zinc, Vitamin E, Probiotic (Bifidobacterium), Multivitamin supplement
Mortality:
a.viii.1.
Omega 3 FAs : mortality is lower for elderly who take it, if you are sick
take it to lower mortality
a.viii.2.
Blood Glucose Control: in older T2 Diabetes patients, A1C levels <6%higher mortality
Preservation of lean Body mass
a.ix.1.
an alkaline diet can help preserve lean body mass
a.ix.2.
arises from a higher intake fruits/vegetables

9. State how a chronic disease, other than the disease process itself, may adversely affect an elderly
patients food intake
a. Besides disease process itself, many people with chronic diseases take medications for it
b. Chronic use of medications can lead to problems with appetite and food intake in the elderly
b.i. >30% of all medications are used by the elderly population
b.ii. average older person receives more than 13 prescriptions/ year
b.iii. May take as many as 6 drugs at one time
b.iv. Several drugs have side effects that include anorexia, nausea and vomiting,
malabsorption of nutrients and increased excretion of nutrients
b.v. There are also cognitive effects that lead to falls and there is a higher risk of
mortality following a fracture
b.vi. Drug nutrient interactions: reduced antibiotic absorption leading to suboptimal drug
concentrations
10. Outline the rationale for the recommendation that as one ages, the diet should be more nutrient
dense than that of a younger person
a. Poor food intake
a.i. Diet needs to be more nutrient-rich since their energy needs are lower
a.ii. Decrease absorption: need micro nutrients
a.iii. Chronic Disease inhibit ability to eat or absorb food
b. Energy needs decline due to:
b.i. Loss of lean tissue, increased adipose (especially visceral)
b.ii. Drop in metabolic rate and physical activity
b.iii. an increase in weight in the elderly indicates a lower mortality
b.iv. Reduced organ function and body composition changes may require a higher amount
of some nutrients
c. Psycho-Social/Physical
c.i. Elderly are more likely to be socially isolated and depressed: may be linked to
nutrients
c.ii. Poverty: buy less nutrient-rich food sources

c.iii. Dementia and physical disabilities

c.iv. Skip meals often
d. Multiple drugs, some with effects on nutrition
e. Age related physical changes
e.i. Decline in organ system function
e.ii. Body composition: increase in adipose decrease in water and muscle mass
e.iii. Weakened thirst response
e.iv. Decline in acuity of taste and smell reducing food intake
Lecture 5: Diabetes Width
1. Describe the risk factors (including those used as screening parameters for diabetes), and the
warning signs/symptoms for type 1 and type 2 diabetes
Type I

Type II

Risk Factors

- No Major Risk Factors

- But their is an environmental and
genetic role

- Genetic disposition (strong family

history)
- Age (>40 yrs)
- Ethnicity: American Indian, AA,
Mexican American, and Pacific
Islander
- Obesity
- Sedentary lifestyle
- Low birth weight: lower birth weight
association (fetal programming)
- Diet: high saturated fat, low
fiber/high CHO

Warning
Signs/Sympt
oms

- Very rapid onset that worsens over

days/weeks
- Polyuria, polydipsia, polyphagia,
-fatigue, weakness, weight loss
(noticeable) , and blurred vision
-glycosuria occurs when renal
threshold exceeds 180/200 mg/dl

- Usually worsen over weeks, months,

or years
- Polyuria and polydipsia
- Fatigue and weakness
- Frequent infections and/or slowhealing sores
- Neuropathy
- Gradual weight loss
(less noticeable than type I)
- Acanthosis Nigricans
- present in flexural areas
- insulin overproduction; spills out
into skin

Characteristi
cs

- Have a thin to normal body weight

- Initial onset is in children and
adolescents
-need exogenous insulin
-autoimmune destruction of
pancreatic beta cells
-5-10% of diabetes cases

- Blurred vision is the result of

microvascular disease
- >85% of diabetes cases
-insulin resistance
-onset usually >40 yrs of age
-Treated with healthy diet, exercise,
oral meds, and/or insulin
-insulin resistance may improve with
weight reduction and/or drug
treatment

2. Describe the laboratory tests used for diagnosis of diabetes, and identify the diagnostic criteria for
pre-diabetes and diabetes using the fasting plasma glucose and A1C tests
a. HbA1c: assessment of time-averaged glycemic control over the previous 2-3 months
a.i. gold standard for long-term control
a.ii. no fasting required

a.iii. Indicates compliance/adherence to medications and diet, efficacy of drug regimen,

and also used for diagnosis
a.iv. Not accurate in children
a.iv.1.
Normal: <5.6%
a.iv.2.
Pre-Diabetic: 5.7 - 6.4%
a.iv.3.
Diabetes; >6.5%
a.v. Results must be confirmed on a subsequent day
b. Fasting Plasma Glucose (FPG)
b.i. 8-12 hour overnight fast
b.ii. check glucose in the blood after the long fast
b.iii. preferred for non pregnant adults and children
b.iii.1.
Normal: </=99 mg/dL
b.iii.2.
Pre-Diabetes: 100 -125 mg/dL
b.iii.3.
Diabetes: > 126
b.iv. Results must be confirmed on a subsequent day
c. Oral Glucose tolerance Test
c.i. 8-12 hour overnight fast
c.ii. Get baseline fasting plasma glucose
c.iii. Test again 1 and 2 hours after 75 g glucose load
c.iv. usually done in pregnant women
c.v. hard to do on children and non-pregnant adults
c.v.1.
Normal: 139 or below
c.v.2.
Pre-diabetic: 140-199
c.v.3.
Diabetes: 200 or above
d. Random Casual Blood glucose
d.i. Not the preferred diagnostic tool
d.ii. Must be >200 w/ obvious and significant signs of diabetes
d.ii.1.
Acanthosis Nigricans
d.ii.2.
HTN
d.ii.3.
Dyslipidemia
d.ii.4.
PCOS
3. Identify the most common nutritive and nonnutritive sweeteners and their effects on the blood
a. Nutritive
a.i. Sucrose (Table Sugar)
a.i.1.
May be substituted for another CHO
a.i.2.
Still must count and cover by insulin or meds as necessary
a.ii. Fructose
a.ii.1.
Occurs in fruits and vegetable
a.ii.2.
Less affect on postprandial BG than Sucrose
a.ii.3.
May have adverse effects on plasma lipids (can increase TGs)
a.ii.4.
Avoid added fructose in processed/packaged foods (60% of daily
intake)
a.iii. Sugar Alcohols
a.iii.1.
Half the calories of sucrose
a.iii.2.
Sorbitol, mannitol, xylitol, isomaltose
a.iii.3.
May cause diarrhea and GI discomfort
a.iii.4.
Still have calories; but may be only half metabolized (not considered
free food)
b. Non-Nutritive
b.i. Acesulfame-K (Sweet One)
b.ii. Aspartame (equal, Nutrasweet)
b.iii. Saccharin (sweet N Low)
b.iv. Sucralose (Splenda)
b.v. Neotame
b.vi. Stevia (SweetLeaf, Truevia, PureVia)
b.vii. All considered safe for people with diabetes when consumed at ADI levels established
by the FDA
b.viii. Still can cause weight gain and increases in blood sugar
4. Outline the major dietary recommendations for fat, protein and fiber in diabetes
a. Fat

a.i. Want 25-35% of total calories to come from fat; about 55-75 grams total
a.ii. Low-End: those who are overweight, obese, have metabolic syndrome, or those with
abnormal lipid profiles
a.iii. High-end: well-controlled patients with good lipid profiles and normal weight
a.iv. Limit Saturated fats <7% of total calories
a.v. Limit Trans fats < 1%
a.vi. Choose fats from mono- and poly-unsaturated sources: nuts, seeds, fish, and
vegetable oils
a.vii. Keep cholesterol under 200 mg per day
b. Protein
b.i. Same requirements as general population: 10-20 % of total calories: 50-100 g/day
b.ii. Low End: well-controlled patients with good protein stores and normal weight
b.iii. High End: Poorly controlled, newly diagnosed, overweight/obese, and those with
metabolic syndrome
b.iv. usually these patients are hyper-catabolic
b.v. patients with diabetes at risk for kidney disease
c. Fiber
c.i. Evidence is truly lacking
c.ii. DRI for women= 25g, men= 38g; average US intake is 14g
c.iii. May improve glycemic control, reduce hyperinsulinemia, decrease plasma lipids
c.iii.1.
hard to take in 50g though, mainly because of palatability and GI sideeffects
c.iv. Should tell patients to aim for 25-30g per day
c.iv.1.
10g from grains and cereals (whole grains, oatmeal, fiber cereals)
c.iv.2.
10g from fruits and vegetables (raspberries, blackberries, guava, pears
w/ skin artichokes, lima beans, brussels sprouts)
c.iv.3.
10g from legumes, nuts, and seeds: all beans, almonds, pistachios
c.iv.4.
drink plenty of water to avoid constipation
5. Describe the concept of Exchange Lists for meal planning and which food groups are considered
carbohydrates in this method
f. Exchange List
f.i. In the exchange system, foods are divided into three main groups based on the three
major nutrients
f.i.1.
Carbohydrates, Proteins and Fat
f.i.2.
CHO Subgroups: starches, fruits, milk, meat, sweets, fats and free
foods
f.ii. Within each group, there are equivalents of how much one can eat of various foods
for the same amount of calories, carbohydrates and other nutrients
f.iii. Can exchange within a group because they're similar in nutrient content and how
they affect blood sugar.
g. Carbohydrates
g.i. Starch, Milk, Fruit, non starchy Vegetables, Sweets

6.

7.

Describe Carbohydrate Counting, and calculate the number of carbohydrate choices allowed given
a total daily calorie level. Know specifics regarding fiber and carb counting
h. Carbohydrate Counting
h.i. 1 CHO Choice = 15 grams of CHO (starch, milk, fruit, other)
h.ii. 4 kcal/g CHO
i. Use Exchange Lists or Food labels to determine CHO grams
i.i. Total kCals x 0.55 (the percentage of calories coming from CHO during the Day) = #
kcals from CHO
i.ii. #kcals from CHO/ (4 kcals/g CHO) = # g of CHO per day
i.iii. # g of CHO per day/ 15 g/carbohydrate choice = # of carbohydrate choices
i.iv. 55% C, 20% P, 25% fat (percentage of calories from 3 groups)
j. CC and Fiber
j.i. If a food contains > 5 grams of fiber, subtract half of fiber grams from the total CHO
to get the available CHO
k.
Describe glycemic response, index, and load. Calculate glycemic load

l.

Glycemic Response: varying response of blood glucose and insulin to different types of
carbohydrates; affected by food form, degree of ripeness of fruits
m. Glycemic Index: the rise in blood glucose following ingestion of a food as a percentage of
the rise that follows a control food (glucose or white bread)
m.i. Issue: no standardized list of GIs
n. Glycemic Load: ranking system for CHO content in food portions based on glycemic index
and the portion size (most useful because it takes this into account)
o. Glycemic Load= net CHO x glycemic index / 100
p.
8.

Identify the uses of Insulin-to-Carbohydrate Ratio and Insulin Sensitivity/Correction Factor and be
able to use them in a calculation
q. Insulin-to-CHO Ratio: the amount of insulin needed to cover a specified number of CHO
grams
q.i. 500 Rule: 500 divided by the total daily dose (TDD) insulin, which equals all basal
plus bolus insulin
q.i.1.
Example: TDD=40 units, 500/40=12.5, therefore insulin-to-CHO ratio
is ~1:13
q.i.2.
So, eat 60 g CHO/ 13= 4.5 units of insulin to cover the meal
q.ii. Note: use 500 for rapid acting insulin and use 450 for regular insulin
r. Insulin Sensitivity/ Correction Factor: the mg/dL drop in blood glucose caused by 1 unit
of insulin
r.i. 1700 Rule:
r.i.1.
Correction factor= 1700/TDD
r.i.2.
Example: TDD=35 units, 1700/35= 48.5 (CF= ~50mg/dL)
r.i.3.
r.ii. Note: use 1700 for rapid acting insulin and use 1500 with regular insulin
9. Outline the causes, symptoms and treatment of hypoglycemic shock, and discuss the protocol for
handling illness for people with diabetes
s. Causes
s.i. BG < 70 mg/dL
s.ii. Missing a meal, excessive insulin or oral meds, prolonged duration or increased
intensity of exercise, alcohol intake without food, or vomiting/diarrhea
t. Symptoms
t.i. Sweating, Impatience, Double Vision, hunger, pallor, trembling, palpitations,
headache, faintness
t.ii. May lead to mental confusion or unconsciousness
u. Treatment: 15/15 Rule
u.i. Take 15 g CHO and Check BG after 15 minutes; repeat if necessary
u.ii. Usually 4-5oz soda regular or fruit juice;3-4 packs, tsp, cubes of sugar; 5-6 pieces of
hard candy; 3-4 tsp cake frosting; 3 glucose tablets

Lecture 6: Cardiovascular Disease (CVD) Khosla

1. State the main risk factors for CVD (gender, age, blood lipids, other diseases, etc).
a. Major Changeable Risk Factors:
a.i. High blood cholesterol
a.ii. Smoking
a.iii. Hypertension
b. Other Risk Factors:
b.i. Genetics (family history)
b.ii. Male (females actually have a higher rate of CHD than men after menopause)
b.iii. Age (males > 44, females > 54)
b.iv. Diabetes
b.v. Obesity
b.vi. Low HDL (<40)
b.vii. High triglyceride
b.viii. Inactivity

b.ix. Personality, stress, coping

2. Select the apolipoproteins associated with higher and lower risk for CVD (i.e. A E)
a. Apo A: found in chylomicra (A-I, A-IV) and HDL (A-I, A-II); protective
b. Apo B-100: found in VLDL, IDL and LDL; bad (atherogenic)
c. Apo E: found in VLDL and IDL; bad (atherogenic)
d. Note: different phenotypes for LDLs (phenotype A is large and low CVD risk while
phenotype B is small and has a high CVD risk)
3. Identify the diseases for which high waist circumference increases risk
a. CVD
b. Type II diabetes
c. Gall bladder disease
4. Outline the dietary fat sources for monounsaturated fat, polyunsaturated fat, and saturated fat
a. MUFA: canola oil, olive oil and peanut oil, soybean oil
b. PUFA: safflower oil, sunflower oil, corn oil and soybean oil (n-6 FAs)
c. SFA: mostly animal products (butter, beef fat, lard); palm oil (but not atherogenic; actually
good for blood lipids), palm kernel oil, and coconut oil
5. Identify which dietary fat sources should be recommended based on risks from blood lipid levels
a. PUFAs
a.i. Lowers LDL & HDL
b. Fish & Plant n-3 PUFAs
b.i. Lowers AA synthesis and improves hemodynamics
b.ii. Dilation of blood vessels, prevent platelet aggregation
b.iii. Lower enzymes that convert AA to LT
b.iv. Reduces blood viscosity
b.v. Reduces blood pressure
b.vi. Reduces triglycerides
b.vii. Counteract proliferative vascular response to atherogenic stimuli at the lesion level
b.viii. Reduces the number of small size LDL particles
c. N-6 PUFAs
c.i. Potent vasoconstriction and platelet aggregation
d. MUFAs
d.i. Lowers LDL, but does not lower HDL
d.ii. Also improve LDL resistance of oxidation compared to SFA and CHO
e. SFA (saturated fatty acid)
e.i. Reduction lowers LDL & HDL
e.ii. Not sure if benefit or harm
f. Monounsaturated > Saturated FA
f.i. But are all associated with either no increased risk of CVD (SFA) or lowering the risk
of CVD ( MUFA)
f.ii. Some evidence shows that PUFAs may raise the risk for CVD
g. ALA (-linoleic acid)
g.i. Converted to EPA and DHA
g.ii. Causes dilation of blood vessels and prevention of platelet aggregation
h. Trans-Fats (Avoid)
h.i. Increases LDL
h.ii. Lowers HDL
h.iii. Higher TC: HDL ratio
6. Based on the 2013 American Heart Association
CVD assessment, identify the 9 risk variables.
9 risk variables
Acceptable range
Sex
M or F
Age
20-79
Race
AA or W/H
Total Chol
130-320
HDL- chol
20-100

and American college of cardiology guidelines for

Ideal

170
150

systolic BP
Treatment of HTN
DM
Smoking

90-200
Y/N
Y/N
Y/N

110
N
N
N

7. Given a patients risk status relative to hypertension and the classification of the patients blood
pressure, select the correct intervention, based on JNC8 Lifestyle Modifications and Medical
Management of Hypertension
For ages 60 + Treat HTN is BP> 150/90 (strong evidence)
For ages <60 Treat HTN if BP >140/90 (expert opinion)
8. Outline the American Heart Association (AHA) dietary recommendations for either a patient with
risks (Therapeutic Lifestyle Changes), versus the general public, according to the ATP III and the
AHA
a. General Public:
a.i. Use up at least as many calories as you take in (at least 30 minutes of exercise on
most days)
a.ii. Eat a variety of nutrient rich foods from all groups:
a.ii.1.
Lots of fruits and vegetables
a.ii.2.
Whole grain, high fiber foods
a.ii.3.
Fish at least twice a week
a.iii. Eat less nutrient-poor foods:
a.iii.1.
Limit saturated fat, trans fat and cholesterol
a.iii.2.
Select fat-free, 1% or low fat dairy products
a.iii.3.
Cut back on beverages and food with added sugars
a.iii.4.
Aim for 1500 mg sodium/day
a.iii.5.
Drink alcohol only in moderation
a.iii.6.
Follow AHA recommendations when you eat out
a.iv. Avoid use and exposure to tobacco products
b. Therapeutic Lifestyle Changes (TLC):
b.i. For higher risk groups:
b.i.1.
High LDL or other dyslipidemias
b.i.2.
CHD or other CVD
b.i.3.
Diabetes
b.i.4.
Insulin resistance
b.i.5.
Metabolic syndrome
b.ii. Components:
b.ii.1.
LDL-Raising Nutrients:
b.ii.1.a. SFA: <7% (and low TFA)
b.ii.1.b. Dietary Cholesterol: <200mg/day
b.ii.2.
Therapy for LDL-Lowering:
b.ii.2.a. Plant Sterols: 2 g/day
b.ii.2.b. Soluble Fiber: 10-25 g/day
b.ii.3.
Total Energy:
b.ii.3.a.
Adjust total calories to maintain healthy weight (prevent gain)
b.ii.4.
Physical Activity:
b.ii.4.a.
Include moderate exercise to expend at least 200 calories/day
c. Step Diets (terms no longer used)
c.i. Step 1: <10% SFA, <1% Trans fat, <300 mg Cholesterol (similar to general public)
c.ii. Step 2: <7% SFA, <200 mg cholesterol (same as TLC)
Lecture 7: Kidney Disease Width
1. Identify and describe the three major biochemical parameters that are monitored in kidney disease,
including the levels used to diagnose ESKD
a. Blood Urea Nitrogen (BUN)
a.i. Nitrogenous waste product of protein metabolism
a.ii. Its a gross index of glomerular function

a.iii.
a.iv.

Correlates directly with protein intake, catabolism

Elevates during dehydration, GI bleeding, shock, CHF, steroids, burns, fever, and
stress
a.v. Decreases in liver disease, malnutrition, and overhydration
a.vi. 7-20 mg/dl = normal
a.vii. 60-80 mg/dl = normal on dialysis
a.viii. 100 = end-stage kidney disease
b. Creatinine (Cr)
b.i. Waste product of muscle catabolism
b.ii. May be 10-30% higher in a diet with high meat
b.iii. Commonly used indicator of renal function, but not suitable for detecting early stage
disease
b.iv. 0.6 - 1.2 mg/dL = Normal
b.v. 10 - 12 = end-stage kidney disease
c. Glomerular Filtration Rate (GFR)
c.i. Rate at which blood is filtered through the glomeruli
c.ii. Best overall measure of kidney function in health and disease
c.iii. A decrease in GFR precedes the onset of kidney failure
c.iii.1.
persistently reduced GFR is a specific diagnostic criterion for chronic
Kidney disease
c.iv. Estimated with equations using serum creatinine in combination with age, sex,
weight, or race
c.iv.1.
more muscle mass greater GFR
c.v. GFR < 15 indicates ESKD
2. Describe the pathophysiology, the major causes, the major nutrients that affect, and the treatment
of the renal diseases discussed in class (Nephrotic and Nephritic Syndrome, AKI, Kidney Stones,
CKD, ESKD)
Disease
Acute
Nephritic
Syndrome

Pathophysiology
Major Causes
Inflammation of
- Streptococcus
capillary loops of
Infect.
glomerulus with rapid (postinfectious)
onset/progressive
- IgA Nephropathy
destruction of glomeruli (Bergers disease)
if chronic.
- Systemic Lupus
Hematuria develops.
erythematosus
(blood in urine)
(SLE)
Can be fatal if dialysis
is not started quickly
(only 50% have
symptoms )

Symptoms:
- Hematuria (dark,
tea colored or
cloudy)
- Decreased urine
volume
- Swelling
(periorbital, later to
legs and feet
- Join and muscle
pain
- Malaise
- Headache
- Blurred vision
Chronic
Slow progressive
Nephritic destruction of glomeruli
syndrome Normal kidney fxn

Major Nutrients
- Restrict Protein
- Restrict K+ with uremia or
hyperkalemia.
- Mild Na+ restriction and
Fluid Restriction if they have
HTN.

Treatment
Immediate Dialysis if
severe
Less severe:
medication and diet

Sodium restriction
Potassium restriction
Protein restriction

Control hypertension
and renal failure
requires dialysis or

Nephrotic
Syndrome
(chronic
glomerulo
nephritis)

Acute
Kidney
Injury

Kidney
Stones
(nephrolit
hiasis)

Often asymptomatic
transplant
except for proteinuria
and hematuria
Loss of Glomerular
Primary causes:
- Replace Albumin and
Need to control
Barrier to Protein. >3g/ Glomerulonephriti other proteins
osmotic pressure
day of protein in the
s
- Supply dietary protein to
with protein loss in
urine (25x normal)
- Minimal Change maintain a positive Nitrogen the urine.
Disease (Nil), most balance and produce an
common in
increase in plasma albumin
children
concentration and
Secondary causes: disappearance of edema
- Diabetes
-slight protein restriction (.8- Lupus
1.0 gm/kg/day) should be
- Amyloidosis
from sources of HBV
- Increase Energy intake
(35kcal/kg/day)
- Na+ Restriction. (23gm/day with edema)
- Lower
Cholesterol/saturated fats
in diet
- K+ usually NOT restricted
Sudden reduction in
- Prerenal (Blood -nutritional care is
GFR, leading to a
loss, lose Na and complicated and delicate due - Enteral or
decreased excretion of fluid, heart failure, to metabolic acidosis, fluid
Parenteral Nutrition
metabolic waste
shock, liver
and electrolyte abnormalities, and Dialysis
products. (trauma,
failure, and burns and metabolic responses to - Use continuous
blood loss)
60-70%)
stress
renal replacement
- Intrinsic (25- Protein to cover
therapy (CRRT) or
Symptoms:
40%could be toxic hypercatabolism and use of hemodialysis)
- Edema
substances,
protein as a preferred fuel
- Do not want to
- Cola-colored urine allergic rxns,
source during stress
exacerbate
- Oliguria, anuria
prolonged lack of response, and protein losses metabolic
blood supply to
with CRRT/HD
derangements
- Later: fatigue,
- 0.8 g/kg without dialysis
decreased mental kidney)
- Postrenal (5-15 - 1.2-1.3 with dialysis
concentration,
- 1.5-2.5 with CRRT.
anorexia, nausea, % obstruction to
urinary
collecting
Energy
coverage (not
pruritis, tachycardia
system:
enlarged
greatly
affected
by AKI itself
- With obstruction
prostate, stones, but the AKI itself but the
crampy pain in
flanks, severe pelvic tumors, fibrosis). underlying pathology leading
- Prerenal is the
to critical illness plays
pain
most common
biggest role in determining
energy expenditure)
- Use indirect calorimetry or
25-35 kcals/kg for energy
expenditure. (calories may
come from the dialysate
solution: dextrose; must take
into account)
Form In renal pelvis
causing extreme pain
in ureter contraction.
May lead to obstruction
or infection.
Crystallization of urine
components: Calcium,
Uric Acid, Cystine, or
struvite.

Calcium stones:
- Hypercalciuria
- Dietary Ca
intake,
supplements
- Increased
intestinal
absorption
- Decreased renal
tubular

- Limit Oxalate food intake

- Do not take supplements of
Calcium (just DRI)
- Limit animal protein
(increases uric acid, Ca and,
oxalate in urine, mild
restriction (.8g/kg) )
- Restrict Na+ (increases
amount of Ca in urine 20002500 mg restriction)

- Prevention or
Shockwave
lithotripsy.
- Drink lots of fluid
- Avoid grapefruit
juice or soft drinks
- Coffee and tea are
fine (regular tea has
a lot of oxalate but

reabsorption
- Lots of fluids (water, 2-3 can drink it with
- Low serum
L) (goal is to produce 2- 2.5L milk)
phosphorus (renal of urine daily)
- Increase citrate and
leak)
-Intake of 250 ml with meals Magnesium.
oxalate stones: and snacks at bedtime and
- Hyperoxaluria:
during the night
-if hyperoxaluria,
(dietary intake ,
-at least half of fluid intake
-lower dietary
Seen in Crohns
should be water
oxalate and eat with
- irritable bowel, - Citrate (forms complex
calcium
gastric bypass due with calcium leaving less to (dont restrict
to fat
bind with oxalate, 4 oz real
calcium)
malabsorption or lemon juice diluted with
-Avoid calcium
a genetic defect.) water daily)
supplements
uric acid stones: - Mg (inhibits formation of
-gout
Ca-oxalate crystals) Good
-uric acid stones:
-malignant cancer sources include dairy
alkalinize urine pH,
-GI diseases with products, dark green veggies, dilute the urine,
diarrhea
apples
alkaline Ash diet
-Ash diet for uric acid
(milk, nuts, veggies,
crystals milk, nuts, veggies, no cranberries,
no cranberries, plums, and
plums, and prunes)
prunes)
and medications
Chronic
Kidney
Disease

Kidney Damage for >3 - Diabetes

months, with or without - HTN
decreased kidney
- Family History
function.
- AA, Pacific
Islander, Native
Or
Americans, and
Hispanics.
Decreased kidney
function measured by
GFR < 60 for > 3
months, with or without
kidney damage.

End-Stage BUN >100

Kidney
Creatinine 10-12
Disease
GFR <15.
Uremia: malaise,

Very individualized diet

Stage 1: Treat co(standard or renal diet morbid conditions to
is 70 gm protein, 2 gm
slow progression.
sodium 2 gm potassium
Maintain normal
but order should be
Protein.
individualized based on
labs, BP ,edema, stage of Stage 3 and 4:
CKD)
Decrease in many
Stages 1 and 2: only to
nutrients. (See in
control co-morbid conditions previous column)
(diabetes, HTN,
hyperlipidemia)
Dialysis and
Protein: .8 g/kg with > 50% eventual transplant
HBV (high biological values)
Stages 3 and 4:
- Protein restriction (GFR
<25) to 0.6-.75g/kg w/ >50%
HBV (more benefit in more
advanced disease)
- Increase energy intake (3035 kcal/kg if >60 yrs; 35
kcal/kg if <60 yrs)
- Decrease Na+ based on
labs, edema, BP (no added
salt or exact restrictions)
- K+ based on labs
- decrease Phosphorus with
binders (8-12 mg/kg/day)
- Ca2+ based on labs
- Monitor urine output (if
normal, unrestricted fluid)
- May restrict fluid if on
dialysis.
- Chronic DM
For dialysis:
Kidney Transplant,
- Hypertension
- Maintain adequate energy Dialysis (both
intake
Hemodialysis and
Glomerulonephriti
- Increase the amount of Peritoneal)
s
protein

weakness, N and V,
- Many other
muscle cramps, itching, diseases as well.
metallic taste in mouth,
confusion, stupor,
anorexia, edema,
anemia, bleeding
(gums, nose, GI tract)

- Slightly lower Na+ for

hemodialysis but highly
individualized
-fluid intake is highly
individualized depending on
edema, urine, BP
- Monitor K+ intake (watch out
for salt substitutes) (oliguric
or anuric patient should have
stricter response)
- Monitor Ca2+ and PO4
carefully to minimize effects
of PTH release and bone
resorption
- Restrict phosphorus
- Give synthetic form EPO and
supplement with iron
- Supplement water-soluble
Vit. & Fe
For Transplantation:
Acute phase: (6-8 wks after
transplant or during acute
rejection)
Protein: 1.3 to 1.5 gm/kg BW
Energy: 30 to 35 kcal/kg BW
Sodium: 2000 mg restriction
Calcium + phosphorus: 1200
mg may need supplements
Vitamins/minerals: use DRI
Chronic Phase
Protein= 1.0 gm/kg
Energy= Maintain an
appropriate weight for height
Sodium= individualized
depending on BP and fluid
retention
Vitamin/minerals: use DRI
may need extra vit D

3. Identify the byproducts of protein breakdown that accumulate in blood due to kidney dysfunction
and describe uremia and its signs/symptoms
a. Byproducts of Protein Breakdown
a.i. Blood urea nitrogen (BUN)
a.i.1.
nitrogenous waste product of protein metabolism
a.i.2.
will increase with kidney dysfunction
a.ii. Creatinine
a.ii.1.
waste product generated from muscle metabolism
a.ii.2.
creatinine clearance approximates GFR (more useful than just looking
at the amount of creatinine)
a.iii. Urea, uric acid, ammonia
b. Uremia
b.i. Malaise, weakness, nausea and vomiting, muscle cramps, itching, metallic taste in
mouth, confusion, stupor, anorexia, edema, anemia, bleeding, and many more
b.ii. All caused by the extremely low GFR that is causing blood nitrogenous waste to build
up
4. Outline the main dietary nutrients that need to be monitored in CKD patients and major food
sources of those nutrients (do not need to know the exact values of the recommendations)
a. Energy
a.i. Maintain adequate intake to spare protein for tissue synthesis (bc it is restricted)
a.ii. Prevent protein catabolism for energy and to achieve and maintain optimal
nutritional status
a.iii. Difficult due to poor appetite and GI symptoms.
a.iv. High in fats and sugars (problem for DM and CVD patients)
b. Protein
b.i. Will Increase Glomerular Pressure and accelerate kidney function loss
b.ii. Need adequate protein, however, to spare catabolic processes.
b.iii. Restriction more beneficial in advanced stages
c. Sodium
c.i. No added salt diet:
c.i.1.
Limit high-sodium smoked, cured, dried meats and cheeses,
condiments, salted snacks, and canned and dried soups
c.i.2.
No table and salt and limit salt in cooking
c.ii. 3000 mg
c.ii.1.
+ fast food and highly processed foods, salad dressings, regular
canned foods, pickled veggies, lunch meat
c.iii. 2000 mg: need to limit milk and milk products
c.iv. 1000mg : Breads only 2 servings per day
d. Potassium
d.i. Limit based on lab values
d.ii. May result in hyperkalemia: weakness, muscle cramps, tiredness, irregular
heartbeat, and cardiac arrest
d.iii. Should spread intake throughout day
d.iv. Oligouric and anuric patients should have stricter restrictions
d.v. Low values can be caused by diuretics, vomiting, diarrhea, laxative abuse and high
values can be caused by infection, GI issues, tissue trauma, acidosis, ace inhibitors,
catabolism
d.vi. Found in Fruits and Vegetables, dairy products, whole wheat, granola, bran, meats
(moderate), chocolate, nuts and seeds, peanut butter, molasses, salt substitutes
and low-sodium foods, higher in dried foods
e. Phosphorus
e.i. Hyperphosphatemia can cause itching, weak and brittle bones, calcium deposits in
blood vessels and organs including the heart and lungs
e.ii. May need phosphate binders in dialysis patients
e.iii.

f.

Milk, whole grain, dried beans, peas and lentils, protein, nuts and seeds, chocolate
and caramels, soft drinks, beer, chocolate drinks, canned teas (found in so many
foods that is difficult to control just by diet)
e.iv. PROCESSED MEATS AND COLAS!!!!
Calcium

f.i. Monitor calcium & PTH to prevent bone resorption

g. Iron
g.i. Liver cant produce EPO, may need to supplement iron to treat anemia
h. Water-Soluble Vitamins
h.i. Lost during dialysis
h.ii. Need to supplement in both dialysis and non dialysis
i. Fluid
i.i. Teach patients how to deal with thirst, highly individualized

5. Describe the different methods of renal replacement therapy (transplant, HD and PD)
a. Transplant
a.i. Donors include living related and non related as well as cadaver
a.ii. High demand: could be on wait list for a while
a.iii. Rejection of foreign tissue is a major concern
a.iv. Management of nutrients based on immunosuppressive therapy metabolic effects
a.v. Acute Phase Management: Increase Protein, Increase Energy, Restrict Salt,
Increase Calcium, and use DRI for vitamins and minerals
a.vi. Chronic Phase Management: Elevate Protein, Maintain appropriate weight,
Individualize sodium intake, maintain Calcium regimen, use DRI for vitamins and
minerals
b. Hemodialysis
b.i. Electrolytes set to approximate physiologic levels so that solutes that are increased
or decreased in the blood are corrected
b.ii. 3 to 5 hours, three times per week
b.iii. Blood accessed through arteriovenous fistulas (anastomoses) or arteriovenous grafts
(need to wait for these to heal
b.iv. ADVANTAGES: Less chance of infection, do not have to take any pills, all done by a
medical staff, socialization, better if patient is older or has a disability, instant
improvement, easier on family, frequent contact with hospital staff
b.v. DISADAVANTAGES: set schedule, transportation, harder to travel, fatigue, needle
sticks, difficult for CVD patients due to hypotension
c. Peritoneal Dialysis
c.i. Catheter is surgically implanted into the abdomen and peritoneal cavity
c.ii. Exchanges done manually or using a cycler
c.iii. Hyperosmolar dialysate because of dextrose concentration
c.iv. Two Types
c.iv.1.
a. Continuous Ambulatory Peritoneal Dialysis (CAPD)
c.iv.1.a.
3-4 manual exchanges of 1-3 L each during the day, with dwell
times of 4 to 6 hours, plus one in the evening with a longer dwell time
c.iv.1.b.
exchanges take 30-40 minutes
c.iv.1.c.
more liberal dietary fluid, sodium and potassium
c.iv.1.d.
complications: peritonitis, hypotension, and weight gain
c.iv.1.e.
allows for more dextrose absorption (hyperglycemia) absorb
60% dextrose
c.iv.2.
Continuous Cycling Peritoneal Dialysis (CCPD) or Automated
Peritoneal Dialysis (APD)
c.iv.2.a.
cycler automatically control timing of exchanges and the
filling/draining of solution 3 to 5 times during the night
c.iv.3.
morning fill remains all day or one mid-afternoon exchange
c.iv.4.
absorb 40% dextrose
c.v. ADVANTAGES: done at home, more flexible schedule, increased interdependence, self
administration and monitoring, once per month clinic, more liberal diet, more
metabolically stable, easy travel, preserves residual renal fxn, no needles
c.vi. DISADVANTAGES: time commitment, patient is responsible for Tx, problem solving ,
must be committed, need a back up person, storage of supplies at home, dextrose
weight gain, full feeling, higher risk of infection, no baths or swimming, few nursing
homes allow

6. Describe the pathophysiology of renal osteodystrophy and what nutrients are involved
a. Pathophysiology
a.i. Renal Failure decreases GFR
a.ii. Retention of Phosphate, diet restricted, vitamin D activation drops
a.iii. Serum calcium concentrations decrease
a.iv. Increased PTH in an effort to increase serum calcium
a.v. Bone resorption
a.vi. Osteitis fibrosa
b. Osteomalacia: Soft Bones due to hypomineralization
c. Soft-tissue Calcification: from rise in calcium-phosphate ion product
d. Osteitis Fibrosa: retention of phosphate by abnormal kidneys results in
hyperphosphatemia, which causes hypocalcelmia resulting in secondary
hyperparathyroidism
e. Vitamin D activation decreases
e.i. Kidneys cannot activate vitamin D anymore
e.ii. Reabsorption of calcium decreased
f. Diet is restricted which also leads to low calcium intake
Lecture 8: Gastrointestinal Diseases Reinhard
1. List all possible nutrient deficiencies which may arise from atrophic gastritis or chronic use of proton
pump inhibitors
a. Deficiencies
a.i. Iron
a.ii. B-12 Deficiency
a.iii. Folic Acid
a.iv. Zinc
a.v. Calcium
a.vi. Magnesium
2. Select
a.
b.
c.
d.
e.
f.
g.
h.

the most likely causes of peptic ulcer disease in the absence of helicobacter pylori infection
NSAIDs
Other prescription medications
Alcohol abuse (chronic gastritis, cancer)
Smoking, nicotine
Stress/shock
Surgery/trauma
Genetics
Toothpicks

3. State the nutritional problems arising in most patients after gastrectomy

a. Dumping Syndrome: caused by rapid emptying of undigested food into the jejunum;
affects ~50% of all gastric surgical patients; may have early and late phases
a.i. Early Phase: within 20-90 minutes of eating
a.i.1.
GI: abdominal pain, distension, nausea and vomiting, diarrhea
a.i.2.
Vasomotor symptoms: flushing , palpitations, sweating ,dizziness,
and hypotension
a.ii. Late Phase: 2 to 3 hours later, similar symptoms recur due to hypoglycemia (not
everyone experiences this)
b. Hypoglycemia
c. Functional lactose intolerance (have enough enzyme, but not adequate time for it to be
released and work properly)
d. Iron deficiency (reduced conversion to Fe2+)
e. B12 deficiency ( if total gastrectomy)
f. Post-Gastrectomy Diet
f.i. High protein, moderate fat, and lower carb diet (to control hypoglycemia)
f.ii. Avoid concentrated sweets (hyperosmotic load to the intestines)

f.iii.
f.iv.
f.v.
f.vi.
f.vii.
f.viii.

Smaller, more frequent meals

45 min delay after eating for liquid intake
Lie down after eating
Avoid Hypertonic liquids
Fe deficiency is common
B12 supplements because gastric acid reduced

4. Identify the dietary constituents that must be avoided for patients with celiac disease
a. Malabsorption from damage to absorptive surfaces and enzymes that are produced in
mucosal cells of the duodenum and jejunum
b. Avoid gluten
b.i. WORB
b.ii. wheat, oat, rye and barley
b.ii.1.
oats may be acceptable for some, but should be limited to cup of dry
oats or less/day
c. Increase the protein content to 1 to 2 g/kg of body weight
d. Increase Vitamin supplements
e. Reduce Lactose Intake
f. Reduce fiber intake in flare-up, but slowly increase
5. Outline the nutritional problems (some are symptoms) of celiac disease
a. Nutrient malabsorption
b. Diarrhea/steatorrhea
c. Weight loss
d. Fe2+ anemia
e. Edema/low albumin
f. Bone disease (Ca, P, Mg and vitamin D deficiencies)
g. GI symptoms can be delayed up to 8 years

6. Identify components of diet for inflammatory bowel disease that is in remission

a. High Calories (if weight loss)
b. High Protein
b.i. increase to 1.5g/kg body weight or higher
c. Omega 3 Fatty Acids from foods or supplements
d. Vitamin and Mineral Supplements
d.i. A, D, E, K B6, B12, Iron, Zinc, Copper, Calcium, Potassium, Folate, and Magnesium
(low vit D linked to need for hospitalization, surgery)
e. If on corticosteroids: Increase potassium, but decrease Sodium
f. Requires small, but frequent meals
g. Exacerbating Factors
g.i. High sugar intake
g.ii. Low fruits and vegetables
g.iii. Lower fiber intake
7. Describe why medium chain triglycerides (MCT) are useful in treating various lower GI diseases
a. 6-10 carbon fatty acids hydrolyzed from longer fatty acids
b. Require NO emulsification and minimal digestion
c. Provide 8.3 kcal/gram, replace energy from malabsorbed normal triglycerides (9 kcal/gram)
d. Downside: do not get essential fatty acids from MCT
8. List the nutrients which may require supplementation after an ileostomy
a. Protein: but not because of malabsorption, but rather for weight loss
b. Fat
c. Water-Soluble Vitamins
c.i. B12
c.ii. Folic Acid
d. Fat Soluble Vitamins (ADEK)

e. Minerals: Ca, Mg, Zn, Mn, Se, Cr

f. Notes
f.i. Parenteral give at first, then enteral
f.ii. Gut Enhancers: SCFAs, Amino Acids, Growth Hormones, Pro/prebiotics
9. Distinguish between the two main types of nutrition support, enteral nutrition, and parenteral
nutrition
a. Enteral: feeding tube placed in the gastrointestinal tract (therefore, the tract needs to be
mostly intact and functional)
a.i. Preferred over parenteral if the patient is capable
a.ii. Lower cost
a.iii. Lower risk for complications (sepsis, puncturing vessels/lung)
a.iv. Physiological benefits:
a.iv.1.
Stimulate gallbladder emptying (lower risk for stone formation)
a.iv.2.
Avoids steatosis (fatty liver): increases release of enteroglucagon into
portal circulation
a.iv.3.
Maintains gut-associated lymphoid tissue (GALT); compromised GALT
reduces total immunity by 20%
a.iv.4.
Suppresses cytokine response
a.v. Tube entry can be nasal entry or ostomy (surgical) and can be delivered to the
esophagus, stomach, duodenum, or jejunum
b. Parenteral: bypasses the gut; nutrients delivered directly into the blood stream (GIT does
not need to be functional)
10. Describe the importance of osmolality with regard to enteral nutrition
a. Osmolality of Enteral Formulas:
a.i. 300-600mOs (up to 900 for hydrolyzed/elemental) compared to 280-320 mOS for
plasma
a.ii. Isotonic formula is close to osmolality of plasma (usually preferred)
a.iii. Hypertonic Formula:
a.iii.1.
May affect tolerance
a.iii.2.
Key issue for certain GI diseases
a.iii.3.
Less problematic for gastric feeding than intestinal
a.iii.4.
Excessive hyperosmolarity leads to diarrhea and intestinal discomfort
a.iii.5.
Broken down macro nutrients (proteins AA) results in increased
osmolality
a.iv. Osmolality less of a problem when tube ends at stomach (gastric feeding vs.
intestinal feeding)
11. Outline the advantages of enteral nutrition compared to parenteral nutrition
a. Enteral is always preferred over parenteral
b. Lower cost for methods and material and also nursing labor costs
c. Lower risk for complications such as sepsis, punctures of vessels and lungs
d. Stimulates the gallbladder emptying (lower risk for stone formation)
e. Avoids steatosis (fatty liver; release of enteroglucagon into portal circulation)
f. Maintains GALT (compromised, leads to 50% decrease in immunity)
g. Suppresses cytokine response
12. State the indications for the use of parenteral nutrition
a. Use either a peripheral or central vessel
b. Indications for Parenteral Nutrition:
b.i. <10% SI intact
b.ii. Severe malabsorption
b.iii. Pancreatitis, Crohns, ulcerative colitis
b.iv. GI obstruction
b.v. High nutrient needs
c. Peripheral Access Site: short term, 2000-2500 kcals (problems include: vein collapse,
embolism, and phlebitis)

d. Central Access Site: long term, >2500 kcals (problems include: lung/ heart/vessel
perforation, high expense, sepsis, and hyper/hypoglycemia)

e. PICC (peripherally inserted central catheter): catheter threaded through a peripheral

vessel to a central vein. Fewer risks/ complications. Need peripheral vein integrity