NUTRITION MODULE 1-5, Study notes of Nutrition

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NUTRITION

MODULE 1

Generalities

I. Definition of Terms A. Medical Nutrition Therapy

• refers to the use of specific nutrition services to treat an illness, injury or condition.
• Consists of two phases: o Nutrition assessment ▪ The evaluation of nutritional status through measurements of food and nutrient intake and evaluation of nutrition – related indicators such as anthropometric measurements, physical findings and laboratory test. o Nutrition therapy ▪ Interventions used in the treatment of a disorder or illness and includes diet therapy, nutrition counseling and / or the use of specialized therapies such as supplementation with nutritional or medical foods and nutritional support through enteral or parenteral methods. B. Dietetics
• The combined science and art of regulating the planning, preparing and serving meals to individuals or groups under various conditions of health and disease according to the principles of nutrition and management, with due consideration for economic, social, cultural and psychological factors. C. Diet Therapy
• Is the branch of dietetics that is concerned with the use of food for the therapeutic purposes. II. Goals in the Therapeutic Modification of the Diet
• Maintain / restore good nutriture
• Afford rest to the diseased organ / system
• Correct nutritional deficiencies if present
• To bring about changes on body weight whenever necessary
• Adjust food intake to: o Digestive capacity of the gastrointestinal tract (GIT) o Ability to metabolize nutrients o Prevent / treat manifestations of the disease o Eliminate offending food substances III. Considerations in the modification of the Regular Diet
• Normal requirement and allowance for the patient based on the recommended nutrient intake (RNI)
• Pathophysiology of the disease
• Duration of the disease
• Previous nutriture of the patient
• Socioeconomic, religious and other factors
• Tolerance to food
• Dietary factor/s to be altered IV. Principles of Dietary Management

1. Individualization – patient’s actual food intake, preferences, habits, economic status, religious practices must be considered.
2. Simplification – modified diet should vary from his usual normal food intake as little as possible
3. Liberalization – should supply the essential nutrients as generously as the disease process would allow. V. General Diets

Lacto - vegetarian Plant foods Dairy products bu t NO eggs Ovo – vegetarian Plant foods Allows use of eggs Diet may be low on calcium Pesco – vegetarian Plant foods Dairy products but NO eggs Allows fish in the diet Semi – vegetarian Plant foods Moderate use of dairy products ( low fat and infertile eggs) Main dish of legumes or meat analogues of textured vegetable protein (VTP) is substituted for meat fish and poultry Liberal amount of fruit and vegetables Allows chicken and fish in the diet but NO red meats Total Vegetarian (Vegan) Does not allow all foods of animal origin Zen Macrobiotic Diet – extreme type which consists of ten stages; very inadequate and prolonged use ay result to multiple nutritional deficiencies. VI. Diet for Pregnancy and Lactation a. Designed to meet the increased needs due to normal physiologic changes in pregnancy and lactation b. Emphasis on foods high in calcium i. Dried and fresh anchovy ii. Dried fish iii. Shellfish iv. Crustaceans v. Milk, cheese, ice cream vi. Soybeans vii. Leafy vegetables c. Food rich in iron are prescribed i. Liver ii. Egg yolk iii. Shellfish iv. Leafy vegetables (except bitter gourd leaves) v. Soybeans, banana flower d. Iron Supplementation is highly recommended e. Adolescent pregnant girls require a diet higher in calories, proteins, vitamins and minerals to meet both the needs of the developing fetus and their own growth. VII. Diet for the Elderly a. Lower in energy than the full or regular diet since energy requirements are reduced in the elderly

b. Food selection guide for the regular diet may be followed with the following modifications: i. Avoid fried and fatty foods, gravies, cream sauces, salad dressings, rich desserts, excessive spices and seasonings, strong coffee or tea ii. Large and hard pieces of food may be chopped or ground or pureed iii. Certain foods like dried beans, cabbage, radish may be omitted if these cause gastrointestinal distress iv. Limit food with nutritive value v. Include liberal amounts of fruit and vegetables for dietary fiber vi. Increase fluid intake VIII. Diets Modified in Consistency a. Liquid Diets i. Clear Liquid Diet a. Also known as Non Residue Diet b. Made up of clear liquid foods which leave no residue in the GIT c. Intended to supply fluid and energy foods in a form that requires minimal digestion d. Used to relieve thirst, provide fluid for prevention of dehydration, minimize stimulation of GIT and serve as initial feeding after surgery or IV feeding. e. Nutritionally inadequate; should not be prescribed without supplementation for more than 2 days f. Include: plain tea, black coffee, fat free broth, ginger – ale, plain gelatin, glucose solution, fruit drinks ii. Full Liquid Diet a. Allows food that are liquid at room temperature or readily become liquid at body temperature b. Adequate in energy value and protein when carefully planned c. Needs prophylactic supplementation with vitamins and minerals especially Vitamin A and iron. d. Given in 6 or more feeding per day b. Soft Diet i. Follows regular diet but is modified in consistency and texture ii. For patients who are physically or psychologically unable to tolerate the regular diet iii. Allows food that are easy to digest (low cellulose content; no tough connective tissue) iv. Can be nutritionally adequate but needs to be supplemented with vitamins and minerals if diet is used for long periods v. This diet avoids the following foods: a. All raw, strongly flavored, high fiber vegetables b. Whole grain cereals and products, sticky rice, corn, corn meal or grits c. Meats with excessive fat and connective tissue, deep fried and highly spiced or cured meats, nuts and greasy food. vi. Modifications of the Soft Diet a. Mechanically soft diet

• Also called dental soft or geriatric soft diet
• Consists of food that require minimal chewing b. Soft Bland diet
• Similar to soft diet but additional restrictions on hot spices like chilies, mustard, pepper, caffeinated drinks and alcohol
• Food is given in small frequent feedings

iv. Low Protein Diet a. Provides about 30 grams of protein per day, 2/3 of which is high in biologic value b. Should provide sufficient calories for maximum utilization of limited dietary protein and to prevent or minimize tissue breakdown c. Low in vitamin B and iron v. Low Fat Diet a. Fat provide no more than 15% of total calories b. Higher calorie levels may be obtained by increasing the allowance for fruit, rice exchanges or sugar. c. Permit the use of egg in the diet with the rest of the meal exchanges selected from the low-fat meat group d. Absorption of fat soluble vitamins is impaired when fat intake is low, supplementation is needed. vi. Low Cholesterol Diet a. Dietary cholesterol kept at less than 300 mg/day b. Regulates both the amount and type of fat c. Provides 15% to 25% of total calories as fat d. Omit trans fatty acids e. Poly unsaturated fatty acid (PUFA) / Saturated fatty acid ration of 2-3 : 1 vii. Low Carbohydrate Diets a. Prefer complex carbohydrates b. Are higher in fat and protein than regular diet c. If higher calorie levels are desired, monosaturated fats like olive oil, peanut and sesame oils are used to provide extra calories viii. Low Potassium Diet a. Vitamins A and C are likely to be low and must be supplemented b. Indicated for hyperkalemia and Addison’s disease ix. Sodium Restricted Diet a. Limits the use of table salts and foods naturally high in sodium b. Levels of sodium restricted Diet 500 mg sodium diet All foods are prepared without salt Omit canned or processed food with salt Omit vegetables with high natural salt content 1000 mg sodium diet ¼ tsp salt may be added to food daily Omit canned or processed food with salt 2000 mg sodium diet Selected canned and frozen foods may be included For cardiac and hypertensive patients Prophylaxis for pregnant women 4000 mg sodium diet Regular diet with no added salt on the table and limited use of high sodium foods Also known as no added salt diet (NAS) Food plan for 2000 mg sodium diet + ¾ tsp salt For essential hypertension IX. Nutritional Support

a. Enteral Nutrition i. Refers to delivery of food and nutrients both orally and by tube directly into the GIT ii. Indications: a. Patient who has functioning GIT but unable to ingest enough nutrients orally or have very high nutrient requirements iii. Types of Enteral Formulation a. In ready to use liquid of powdered form or may be prepared from liquid and blenderized common foods b. May be:

• Nutritionally complete – can be used alone in a specified volume of formula
• Modular – to provide different forms of individual nutrients to supplement existing formulas
• Combined – to meet specific therapeutic needs c. Standard tube feeding
• Based largely on milk, sugar and soft cooked eggs
• Essentialy fiber free and is high in cholesterol, fat and sugar
• Contraindicated for patients with: o Hypercholesterolemia o Hypertryglyceridemia o Coronary artery disease d. Blenderized tube feeding
• Includes food normally included in soft diet which can be blenderized easily
• Individually planned to meet specific needs of patients such as low cholesterol, low fat, high fiber etc. b. Parenteral Nutrition i. a team effort designed for individuals who can neither accept nor assimilate nutrients given enterally ii. Types: a. Peripheral vein route b. Parenteral hyperalimentation / intravenous hyperalimentation c. Total parenteral nutrition (TPN)
• For patients needing more nutrients than normal and those requiring parenteral support longer than 5 – 7 days
• Hypercaloric solution is delivered through a silicone inserted into subclavian vein and running through the superior vena cava into the right atrium DIETARY CALCULATIONS I. Determination of Desirable Body Weight (DBW) a. Modified Tanhauser’s Method
• DBW (kg) = (height in cm – 100) – 10% ( height in cm) II. Body Mass Index (BMI) a. Used to identify lean, overweight or obese individuals b. BMI = weight in kg / height in meters^2 III. Determination of Nutritional Status (Nitriture) a. Defined as condition of the body as a result of consumption and assimilation of nutrients b. Nutriture = [ Actual body weight (ABW) – desirable body weight (DBW)] Desirable body weight (DBW)

NUTRITION

MODULE 2

• Diet and Nutrition Before and During

Pregnancy

• Infants and Preschool Children

• School Aged Children and Adolescents

I. PRE- AND PERICONCEPTIONAL NUTRITION N PREGNANCY

a. Why is preconceptional nutrition important?

• The fetus is most vulnerable to nutritional deficiencies in the FIRST TRIMESTER of pregnancy, before the woman realizes she is pregnant
• Evidence showed that poor nutrition has both immediate and long term consequences
• Barker hypothesis – proposes that fetal growth plays a major role in determining the risk of some dietary related noon – communicable disease ( cardiovascular disease and diabetes mellitus type 2 in adulthood)
• Preconception - 3 months before pregnancy
• Periconception – 2 – 3 months after pregnancy b. What dietary changes can the mother make to increase the likelihood on conceiving and giving birth to a healthy infant?
• Folic acid supplements and folic acid rich food o Protection against neural tube defect (NTD) ▪ Prevention of first occurrence of NTD : 400 mcg during preconception until 12 weeks of pregnancy ▪ Prevention of recurrence of NTD : 5000mcg during preconception until 12 weeks of pregnancy
• Eat a varied diet: o 5 portions of fruits and vegetables a day o eat a variety of different foods from all food groups o restrict foods containing too much saturated fat and sugar
• Achieve and maintain ideal weight at preconception (normal BMI) o Obesity (BMI > 30) can inhibit ovulation due to associated changes in insulin activity and its effect on hormones activity o Obesity at conception can influence the pregnancy, delivery and infants death o Underweight ( BMI < 18.5) at conception can increase the risk of pre – term delivery and of delivering low birth weight infant o Reduce alcohol consumption and ideally exclude alcohol o Avoid excessive intake of retinol / Vitamin A ( not beta carotene) o Smoking should be stopped as it can cause premature labor and low birth weight infants c. Dietary Guidelines during Pregnancy i. Caffei
• Beverages containing caffeine are advised in moderation (< 4 cups a day of these combined equivalent to < 300mg/day)
• Decaffeinated drinks or other drinks should be suggested
• Tea and coffee reduce intake of iron

INFANTS AND PRESCHOOL CHILDREN

I. Breastmilk versus bottle feeding a. Breastmilk is the best choice for infant feeding i. Composition is not homogenous ii. Colostrum is produced 1 – 3 days postpartum becoming mature milk after 3 weeks

• The immunological factors are not only present in colostrum produced during the first few days of lactation, but continue throughout breastfeeding

II. BENEFITS OF BREASTFEEDING

a. For the mother i. Encourages bonding between mother and infant ii. Helps women lose extra weight gained during pregnancy iii. Breastfeeding stimulates uterine contractions that help return the uterus to normal size iv. Suppresses ovulation v. Breastmilk is free vi. Convenience b. For the infant i. Offers complete nutrition for the first six months ii. Decreased gastrointestinal infections III. CONTRAINDICATIONS FOR BREAST FEEDING a. The WHO recommends avoidance of all breastfeeding for the HIV positive mothers when replacement feeding is affordable, feasible and acceptable, sustainable and safe. i. In settings where this is difficult, exclusive breastfeeding for 6 months is recommended if HIV+ mothers are unable to provide adequate replacement feed b. Untreated TB c. Hepatitis C who have cracked or bleeding nipple d. Infants with galactosemia i. Lactose free infant formula should be used e. Phenylketonuria infants should alternate breastmilk with phenylalanine – free formula

VII. FALTERING GROWTH

• Weight faltering is defined as weight falling through percentile spaces, low weight for height or no catch up from low birth weight
• Growth faltering is defined as crossing down through length / height percentile as well as weight, a low height or a height less than expected from parental heights SCHOOL AGED CHILDREN AND ADOLESCENTS I. Why diet is important in childhood and adolescence i. Children need balanced diet to meet requirements for growth and development ii. Health related behavior and attitudes towards food are formed in childhood iii. The processes for some adult diseases may start early in life a. Growth and development i. Requires increase in energy, protein and several vitamins and minerals ii. If nutrition is insufficient, stunting of growth may result iii. Once growth spurt is over, nutrient requirements become those of adults a. Increase in muscle growth in boys b. Increase adipose fat in girls II. Nutritional problems of children and adolescents a. Obesity / overweight b. Iron deficiency anemia c. Constipation d. Underweight e. Vegetarianism f. Acne g. Dental health

I. Undernutrition a. Often referred to malnutrition b. Arises as a consequence of an inadequate intake of energy and macronutrients c. May also be associated with frank or subclinical micronutrient deficiencies d. Classification: i. Body Mass Index (BMI)

1. Most often used to identify risk of undernutrition in adults 2. It cannot be used in children where height may be stunted as a result of poor nutrition; in the very elderly where a true height may be difficult to measure or where unusual body morphology invalidates the ratio of weight to height ii. Mid – upper arm circumference (MUAC) 1. Can be used if BMI cannot be calculated due to the absence of an accurate height measurement or because true weight is obscure by fluid retention iii. Standard deviation score (z score) 1. Calculated from reference population data and used to determine risk of undernutrition in children 2. No values for heights are required and it is independent of age making it useful in field situations a. Z score = (patients weight – median weight for the population) / SD value for population iv. Malnourished patients are not always thin v. The consequence of failing to identify and treat undernutrition are potentially serious therefore caution should be used when interpreting results e. f. Treatment of Undernutrition

II. Metabolic response to injury a. Describes the biochemical and hormonal consequences of major injury, trauma, surgery with or without infection and the resulting nutritional changes that may have very significant clinical effects b. Overall effects: i. Loss of appetite → decrease nutrient intake ii. Perturbation of fat and carbohydrate metabolism with apparent inability to use these as metabolic substrates → increase circulating levels and deposition of lipid in adipose and vital organs iii. Lean tissue is broken down, may provide amino acids required during inflammatory response iv. Protein loss may be substantial and have clinical consequences. c. Effect of starvation i. Starvation may interfere with the metabolic response ii. III. Re – feeding syndrome (RS) a. Severe fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing re – feeding b. Pathophysiology: i. In starvation, decrease intake of energy and particularly carbohydrate → decrease insulin secretion and increase catabolism of fat and protein for energy → decrease intracellular electrolytes and especially decrease phosphate levels