Nutritional Therapy

1. Nutritional Therapy Brenda McLoud BSN, RN, CGRN

2. OBJECTIVES • Outline the basic principles of good nutrition, nutritional assessment and nutritional. • Name three diseases or diagnosis and special diet for these.

3. Basic Principles • Nutritional status = balance between nutrient intake and energy expenditures. • Affected by • Internal factors • Age • Physical condition • External factors • Quantity of food • Quality of food

4. Patients with GI Disorders • Factors that interfere with food consumption • Factors that increase tissue destruction • Factors that interfere with patient’s ability to absorb nutrients • Factors that interfere with nutrient utilization or storage • Factors that increase nutrient excretion or loss • Factors that increase nutritional requirements

5. Six general classes of essential nutrients • Carbohydrates • Lipids • Proteins • Vitamins • Minerals • Water

6. Carbohydrates (CHO) • Class of energy-yielding nutrients • Contains Carbon, Hydrogen & Oxygen • Classified as • Simple • Mono and disaccharides • Complex • Polysaccharides • Glycogen • Fiber

7. Carbohydrates (CHO) • Food sources • Grains • Vegetables • Fruits • Milk & dairy products • Syrups and sugars • Recommended 45-60% of total daily calories is CHO

8. Digestion of CHO’s • In the mouth • Starches + α-amylase (salivary glands) = disaccharides • Hydrolyzes starches in the stomach • In the duodenum • Add pancreatic amylase = hydrolyzes remaining starches • In the jejunum • Disaccharides split into monosaccharides by brush border enzymes for absorption by enterocytes • Any condition compromising the duodenum or jejunum inhibits CHO absorption

9. End product of CHO catabolism = glucose • Glucose is a monosaccharide • Chief source of energy • Glucose is taken up by all cells of the body & used for immediate energy • Excess glucose converted to glycogen • Stored in liver & muscles • Liver glycogen converted to glucose for systemic distribution • Muscle glycogen used by the muscle itself • Excess dietary CHO converted to triglycerides for storage in adipose tissue

10. Lipids • Lipids = triglycerides, sterols & phospholipids • Serve as • Sources of energy • Thermal insulator • Precursor for steroid hormones • Structural components of cell membranes • Carriers of essential nutrients • Liver can produce most fatty acids • Cannot synthesize Omega-3 (linolenic) or Omega-6 (linoleic) fatty acids. These are considered essential and must be consumed through diet.

11. Lipids • Primary sources • Oils • Fats • Dairy products • Egg yolks • Meats • Fish oils • Nuts & seeds • Recommended total fat intake 20-35% daily calories

12. Digestion of Lipids • In the stomach • Gastric lipase begins hydrolysis • Short Chain Triglycerides (SCT) • Broken down by gastric & pancreatic lipase • Long Chain Triglycerides (LCT) • Emulsified by bile salts

13. Fat Malabsorption • Diseases • Crohn’s disease • Chronic pancreatitis • Cystic fibrosis • Fat enzyme deficiencies • Small bowel resections

14. Proteins (PRO) • Essential components of all living cells • Composed of building blocks called amino acids • Proteins are needed • Body structure • Hormone production • Enzymes • Fluid & electrolyte balance • Transport molecules • Energy

15. Proteins (PRO) • Chief Dietary Sources • Meats • Dairy products • Nuts • Seeds and legumes • Proteins can be used to build new tissue or catabolized for energy • Recommended level of daily proteins = 0.8 grams/kg of body weight • Nitrogen balance = method of measuring protein turnover in the body.

16. Nitrogen Balance • Neutral • Protein synthesis is equal to protein degradation • Healthy adult • Positive • Protein synthesis exceeds protein degradation • This normal state is to be expected in children, pregnant women and people recovering from an injury who are building new tissue. • Negative • Protein breakdown exceeds protein synthesis • occurs during physical or emotional stress, starvation (very low calorie diet), and diets lacking essential amino acids

17. Digestion of Proteins • In the stomach • Pepsin + Hydrochloric Acid (HCL) = amino acids & polypeptides • In the duodenum & jejunum • Pancreatic enzymes + polypeptides = basic peptides + amino acids • In lower jejunum & ileum • Remaining peptides hydrolyzed into amino acids and absorbed

18. Reduced Protein Absorption • Disorders that reduce gastric HCL secretion Or impair the production of proteolytic enzymes • Duodenal or jejunal inflammation • Infection • Gastric or intestinal resection

19. Vitamins • Group of organic compounds, work with enzymes, co-factors and other substances = essential for normal metabolism, growth & development and regulation of cell function • Fat-soluble • Vitamins A, D, E, and K • Absorbed with dietary fats & stored in the body • Water-soluble • All other vitamins (including all B vitamins & VitaminC) • Excreted in the urine & not stored in the body

20. Minerals • Inorganic nutrients which serve • To regulate enzyme metabolism • Maintain nerve & muscle integrity • Facilitate membrane transfer of essential compounds • Major minerals • Calcium, chloride, sodium, magnesium, potassium, sulfur, and phosphorus • Trace minerals (trace elements) • Chromium, cobalt, copper, fluorine, iodine, iron, manganese and zinc. • Essential mineral nutrients found in the body in small amounts (less than 0.005% of body weight)

21. Water • Acts as • Intracellular & extracellular solvent • Provides medium for transportation of nutrients and metabolic body wastes • Lubricates tissues • Helps maintain body temperature

22. Nutritional Assessment • Health & dietary history • Physical assessment • Record of growth patterns and velocity of growth • Diagnostic studies

23. Patients with nutritional deficits • Oral in take is preferred means of administering special diets • Enteral tube feedings used when patient is unable or unwilling to use the oral route • Patients with dysphagia, altered CNS function, severe anorexia 2˚ to primary underlying illness • Parenteral feeding (IV nutrition) • Provided through Central or Peripheral Venous Access • Patients without functional GI tract or those requiring prolonged bowel rest

24. Special Oral Diets • High Fiber Diet • Low Fiber Diet • Gluten Free Diet • Low Lactose Diet • Low Protein Diet • Low Fat Diet • 2 Gram Sodium Diet

25. High Fiber Diet • Soluble Fiber can dissolve in water • Sources – oat, bran, barley, nuts & flax seed • Food sources • Whole grain breads & cereals, fresh fruits & vegetables • Recommended for • Constipation & diverticulosis • Associated with decreased risk of colon & breast cancer

26. Low Fiber Diet • Recommended for • Active IBD, diverticulitis & acute phases of UC & Crohn’s Disease • Used as transitional diet after intestinal surgeries including colostomy & ileostomy procedures • Nutritional implications • May provide inadequate amount of many vitamins & minerals • May require supplementation

27. Gluten Free Diet • Gluten is a PRO found in wheat, oats, rye & barley • Used for treatment of Celiac Sprue • For review of Celiac Sprue (p. 154-155) • Patients must avoid obvious sources • Less obvious sources: wheat used as an extender in processed foods & beverages • Foods with modified food starch • Hydrolyzed vegetable PRO & malt

28. Gluten Free Diet • Appropriate substitutes • Rice, soybean, corn, buckwheat, potato & tapioca flours • A lifelong adherence to a gluten free diet is a big commitment. May be social liability esp. for children & teenagers • May develop secondary lactase deficiency – milk & dairy products should be limited initially • Supplements may be required to sustain growth & development in younger children

29. Low Lactose Diet • Patients with lactose intolerance • Symptoms • Hx of abdominal pain, diarrhea, bloating & flatulence after lactose ingestion • May occur with or without active disease • Patients with short-bowel syndrome, dumping syndrome or IBS • Ingredients to look for • Ingredients containing milk solids, lactose, milk sugar, galactose, or skim milk powder

30. Low Lactose Diet • Lactase tablets prior to consumption of lactose containing foods may prove helpful • Calcium sources • Calcium supplements, dark leafy veggies, sardines, salmon, fruit juices, soy & rice milk fortified with calcium

31. Low Protein Diet • Patients with • End-stage liver disease • Acute encephalopathy • Chronic renal failure • Dietary Restrictions • See Slide 15 for list of high PRO foods • Sources of high biological value PRO (animal products) = maximized PRO intake • Vitamin & Mineral Supplementation

32. Low Fat Diet • Controls symptoms of GI disease such as steatorrhea or diarrhea • May be used with acute gastroenteritis or pancreatitis • Major sources of dietary fat • Processed foods, baked foods, fried foods & whole fat dairy products • Avoiding • most whole or 2% dairy products, most desserts, cheeses, nuts, olives, high fat meats, mayonnaise, salad dressings, cream sauces or gravies

33. Low Fat Diet • May be helpful to facilitate the instruction of a Registered Dietician • Supplements of fat soluble vitamins A, D, E, & K may be necessary

34. 2 Gm Sodium Diet • Indications • Patients with ascitis & edema caused by severe liver disease • Patients should not add salt to food or to food preparation • High sodium foods to avoid • Most frozen meals, smoked meats, cheese, commercial mixes, commercially prepared desserts or soups & sodium containing seasonings

35. 4R GI Restoration • Remove • Replace • Reinoculate • Regenerate

36. Probiotics, Prebiotics & Fructo-oligosaccharides • Probiotics are viable organisms that improve intestinal microbial balance. • L. Acidophilus • Bifidobacterium infanitis is the first flora to colonize the intestines of newborns • Prebiotics are nondigestible food ingredients that may benefit the host by selectively stimulating growth of bacteria in the colon • Fructo-oligosaccharides (FOS) act to stimulate growth of bifidobacterium in the large intestine.

37. Other oligosaccharides • Inulins, isomalto-oligosaccharides, lactilol, lactosucrose, lactulose, pyrodextrins, soy oligosaccharides, transgalacto-oligosaccharides and xylo-oligosaccharides

38. Enteral Nutrition • Administration of prescribed diet by means of a flexible tube inserted into the stomach or small bowel, either transnasally, surgically or endoscopically • Indications • Maintenance of nutritional status in patients with a functioning GI tract that cannot ingest food & nutrients to meet energy requirements • Anorexia, malabsorption syndromes, chronic malnutrition, infants with failure to thrive, major burns, severe trauma, hepatic or renal failure, CVA or esophageal tumor

39. Enteral Nutrition • Contraindications • Patients with hemodynamic instability, intestinal fistulas, bowel obstruction or sever motility dysfunction • Enteral nutritional support is preferred over parenteral nutrition (PN) for patients with functional GI tract but oral feeding is not possible. • Compared to PN, Enteral nutrition is safer, less expensive, reduces risks of catheter related infections & helps maintain gut integrity.

40. Potential complications • GI complications • Nausea, vomiting or cramping • Constipation • Abdominal distention • Diarrhea • Dumping syndrome • Malabsorption/maldigestion • Mechanical complication • Tube placement • Presence of feeding tubes • Tube obstruction/clogging • Aspiration

41. Potential complications • Metabolic complications • Fluid & electrolyte imbalances • Trace elements, vitamin & mineral deficiencies • Excessive carbon dioxide production • Refeeding syndrome

42. Nursing Care • Frequent monitoring • Gastric residuals every 4 hours • Daily weight to detect fluid shifts • Daily I & O • Consistency, volume & frequency of BM’s • S & S of intolerance • Abdominal distention, vomiting, nausea, diarrhea, constipation • Daily Electrolyte levels, BUN, Creatinine • Inspection of tube site for placement, patency, infection

43. Parenteral Nutrition (PN) • IV infusion of nutrients; protein (amino acids), CHO (dextrose), fat (lipid), and additives (vitamins, minerals, electrolytes, trace elements). • Delivered through central or peripheral veins. • Indications • Patients who are moderately to severely malnourished • Patients with negative nitrogen balance and not expected to meet nutritional requirements short term

44. Indications & Contraindications • Central Parenteral Nutrition = Total Parenteral Nutrition (TPN) • Risks of complications may outweigh potential benefits of therapy • PN may be ordered for • Patients with GI disorders • Pre-op prep for malnourished patients • Patients with post-op surgical complications • Post-op care of neonates • Infants with intractable diarrhea

45. Potential Complications of TPN • Infection & sepsis complications • Catheter contamination during insertion • Long-term indwelling catheter • Catheter seeding from blood-borne or distant infection • Contaminated solution

46. Potential Complications of TPN • Metabolic Complications • Dehydration; hypovolemia • Bone demineralization • Hyperglycemia, rebound hypoglycemia • Hyperosmolar, hyperglycemic, nonketotic coma • Azotemia • Electrolyte disturbances • Deficiencies of essential fatty acids, trace elements, vitamins & minerals • Altered acid-base balance • Elevated liver enzymes • Fluid overload

47. Potential Complications of TPN • Mechanical complications • Catheter misplacement • Hemothorax (blood in the chest) • Pneumothorax (air or gas in the chest) • Hydrothorax (fluid in the chest) • Hemomediastinum (blood in mediastinal spaces) • Subcutaneous emphysema • Hematoma • Arterial puncture • Myocardial perforation

48. Potential Complications of TPN • Mechanical Complications (cont) • Catheter embolism • Cardiac dysrhythmia • Air embolism • Endocarditis • Nerve damage at the insertion site • Laceration of lymphatic duct, Chylothorax, Lymphatic fistula • thrombosis

49. Nursing Care • Daily weights • Accurate I & O’s • Blood glucose monitoring • Daily labs to adjust electrolytes • Prevention of infection • Maintenance of prescribed rate of flow • Ongoing patient assessment • Provision of patient/family education and support

50. Review • Excess glucose is stored in the liver and in the muscles in the form of: • A. Adipose tissue. • B. Glycogen • C. Disaccharides • D. Triglycerides