Nutrition and Diet Therapy 8th Edition

Nutrition and Diet Therapy 8th Edition
by Ruth Roth and Carolynn Townsend 1

Nutrition and Diet Therapy PowerPoint Presentation
Written by Susan L. Robson, MSN, RNP-c

Objectives Name the six classes of nutrients and their primary functions Recognize common characteristics of well-nourished people Recognize symptoms of malnutrition Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 5

Nutrients Organic Contains carbon, hydrogen, oxygen Carbon is found in all living things Example: carbohydrates, fats, proteins, vitamins Inorganic In simplest form when ingested Function: regulate body processes Example: water, minerals Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 9

Fats (lipids) Provides energy Highest kilocalorie value Sources of fat: meats, milk, cream, butter, cheese, egg yolks, oils, nuts Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 11

Protein Builds and repairs body tissues Provides energy Only one of the six nutrients that contains nitrogen Sources of protein: meats, fish, poultry, eggs, milk, cheese, corn, grains, nuts, and seeds Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 12

Minerals Inorganic compounds Regulate body processes Examples: calcium, phosphorus, potassium, sodium, chloride, iron, magnesium, zinc Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 14

The Six Essential Nutrients and Their Functions
Organic Nutrients Function Carbohydrates Provide energy Fats Proteins Build & repair tissues Vitamins Regulate body processes Inorganic Nutrients Minerals Water Regulates body processes Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 16

Stop and Share A client is at home recovering from surgery. You ask the client what they have eaten over the past 24 hours. The client states the following: Breakfast: 2 doughnuts, orange juice Lunch: lettuce salad with oil & vinegar, soda Snack: pretzels, soda Dinner: spaghetti with tomato sauce, garlic bread; wine Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 17

Stop and Share Discuss the answers to the following questions: What nutrients are missing in the client’s diet? Why are these nutrients important for this client? Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 18 18

Stop and Share The client is missing protein and water in the diet. Protein is needed to build and repair body tissues after surgery. Water is needed to prevent dehydration. Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 19

Characteristics of Nutritional Status
Good Poor Alert expression Apathy Shiny hair Dull, lifeless hair Clear complexion Greasy, blemished complexion Good color Poor color Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 20

Good Poor Bright, clear eyes Dull, red-rimmed eyes Pink, firm gums and well-developed teeth Red, puffy, receding gums, and missing or cavity-prone teeth Firm abdomen Swollen abdomen Firm, well-developed muscles Underdeveloped, flabby muscles Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 21

Good Poor Well-developed bone structure Bowed legs, “pigeon breast” Normal weight for height Over- or underweight Erect posture Slumped posture Emotional stability Easily irritated, depressed, poor attention span Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 22

Good Poor Good stamina Easily fatigued Seldom ill Frequently ill Healthy appetite Excessive or poor appetite Healthy, normal sleep habits Insomnia at night, fatigued during the day Normal elimination Constipation or diarrhea Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 23

Stop and Share Divide into groups of 2. Assess your partner for signs of good nutrition. Identify common characteristics associated with good nutrition exhibited in your partner. Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 24 24

Stop and Share Firm flesh on well-developed bone structures Pink gums and well-developed teeth Normal weight for height Shiny hair Clear skin Clear eyes Erect posture Alert expressions Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 25

Malnutrition Overnutrition Excess energy or nutrient intake Undernutrition Deficient energy or nutrient intake Overnutrition is a larger problem in the United States than undernutrition. Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 26

Stop and Share Identify at least 5 signs of malnutrition present in this child. Courtesy of the Centers for Disease Control and Prevention, Public Health Image Library Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 27 27

Relation of Food to Health
Cumulative Excess nutrients over time Examples: atherosclerosis, obesity, hypertension, diabetes, gallbladder disease, some cancers Deficiencies Nutrients lacking for extended period Examples: iron deficiency, beriberi, scurvy, osteomalacia, osteoporosis, rickets, goiter Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 29 29

Deficiency Diseases Deficiency Disease Iron deficiency Iron-deficiency anemia Beriberi Night blindness Goiter Kwashiorkor Marasmus Nutrients Lacking Iron Thiamin Vitamin A Iodine Protein All nutrients Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 30

Deficiency Diseases Deficiency Disease Nutrients Lacking Osteomalacia Calcium, vitamin D, phosphorus, magnesium, and fluoride Osteoporosis Calcium and vitamin D Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 31

Deficiency Diseases Deficiency Disease Pellagra Rickets Scurvy Xerophthalmia (blindness) Nutrients Lacking Niacin Calcium and vitamin D Vitamin C Vitamin A Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 32

Nutritional Assessment
Anthropometric measurements Clinical examination Biochemical tests Dietary/social history Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 33

Anthropometric Measurements
Height Weight Head circumference (children) Upper arm measurement Skinfold Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 34

Clinical Examination Clinical Signs Possible Deficiencies Pallor, blue half circles beneath eyes Iron, copper, zinc, B12, B6, biotin Edema Protein Bumpy “gooseflesh” Vitamin A Lesions at corner of mouth Riboflavin Glossitis Folic acid Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 37

Clinical Examination Clinical Signs Possible Deficiencies Numerous “black and blue” spots and tiny, red “pin prick” hemorrhages under the skin Vitamin C Emaciation Carbohydrates, proteins; kcal Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 38

Clinical Examination Clinical Signs Possible Deficiencies Poorly shaped bones or teeth or delayed appearance of teeth in children Vitamin C Slow clotting time of blood Vitamin K Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 39

Clinical Examination Clinical Signs Possible Deficiencies Unusual nervousness, dermatitis, diarrhea in same patient Niacin Tetany Calcium, potassium, sodium Goiter Iodine Eczema Fat Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 40

Biochemical Tests Serum albumin level Measures main protein in blood Determines protein status Serum transferrin level Indicates iron-carrying protein in blood  indicates iron stores low  indicates body lacks protein Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 41

Biochemical Tests Blood urea nitrogen (BUN) may indicate renal failure, insufficient renal blood supply, or blockage of the urinary tract Serum creatinine indicates amount of creatinine in blood used to evaluate renal function Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 42

Biochemical Tests Creatinine excretion indicates amount of creatinine excreted in urine over a 24-hour period used in estimating body muscle mass muscle mass depleted, as in malnutrition; level will be low Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 43

Biochemical Tests Other tests Hemoglobin (Hgb) Hematocrit (Hct) Red blood cells (RBCs) White blood cells (WBCs) Lipid profile (high & low-density lipoprotein, serum triglycerides) Urinalysis Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 44

Dietary/Social History
Evaluation of food habits. 24-hour recall: Client interviewed by the dietitian and asked to give types, amounts, and preparation of all foods eaten in past 24 hours Food diary: written record of all food and drink ingested in a specified period Computer diet analysis to determine nutrient deficiencies or toxicities Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 45

Dietary/Social History
Consideration of financial resources to obtain needed food, and properly store and cook food Food-drug interactions that can lead to malnutrition Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 46

Conclusion Nutrition and health are directly related. Effects of poor nutrition are cumulative. There are six essential nutrients: carbohydrates, fats, proteins, minerals, vitamins, and water. Nutritional assessment is the best way to determine deficiencies that may result from lack of nutrients. Chapter 1 Copyright © 2003 Delmar Learning, a Thomson Learning company 47

Objectives Define a balanced diet List the U.S. government’s Dietary Guidelines for Americans and explain the reasons for each Identify the food groups and their placement on the Food Guide Pyramid Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 50

Objectives Describe information commonly found on food labels List some food customs of various cultural groups Describe the development of food customs Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 51

Stop and Share Divide into groups of 2. Answer the following question: How do you know you eat a balanced diet? Share your answer with your partner. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 53

Stop and Share Meal Planning Cumbersome and time-consuming if tables have to be followed for each meal Tables provide Dietary Reference Intakes (DRIs). Simple system Dietary Guidelines for Americans developed by USDA and DHHS Food Guide Pyramid developed by USDA Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 54

Dietary Guidelines for Americans
Aim for a healthy weight. Be physically active each day. Let the Pyramid guide your food choices. Choose a variety of grains daily, especially whole grains. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 55

Choose a variety of fruits and vegetables daily. Keep food safe to eat. Choose a diet that is low in saturated fat and cholesterol, and moderate in total fat. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 56

Choose beverages and foods to moderate your intake of sugars. Choose and prepare foods with less salt. If you drink alcoholic beverages, do so in moderation. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 57

Food Guide Pyramid Bread, cereal, rice, pasta Vegetable Fruit Milk, yogurt, cheese Meat, poultry, fish, dry beans, eggs, nuts Fats, oils, sweets Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 58

Food Guide Pyramid (Courtesy of the USDA and DHHS, 1992, The food guide pyramid: A guide to daily food choices. Leaflet no. 572, Washington, D.C.) Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 59

Mediterranean Diet Pyramid
Developed by World Health Organization (WHO) and Harvard’s School of Public Health Encourages monounsaturated fats Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 60

Food Labeling Mandatory labeling for nearly all processed foods started in May, 1994 as a result of the Nutrition Labeling and Education Act (NLEA). Primary objective is to ensure that labels on most foods provide consistent nutrition information. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 61

Food Labeling: Nutrition Facts Required
Total calories Calories from fat Total fat Saturated fat Cholesterol Sodium Total carbohydrates Dietary fiber Sugars Protein Vitamin A Vitamin C Calcium Iron Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 63

Food Customs Food habits may be based on nationality, culture, and religion. Foods available in a certain area may be favored for economic reasons. Economic status and social status contribute to food habits. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 65 65

Stop and Share Consider the following questions: How can a health care professional gain knowledge regarding a patient’s dietary preferences? Why is it important for a health care professional to understand food patterns unique to different cultures? Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 66

Stop and Share Talking with the patient and learning about his or her background will help the health care professional gain knowledge regarding food preferences. Plan nourishing meals consisting of foods that appeal to the patient. Adjustments in diet can be made gradually and effectively. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 67

Native American Approximately half of the edible plants commonly eaten in the United States today originated with the Native Americans. Corn, potatoes, squash, cranberries, pumpkins, beans, wild rice, and cocoa beans Wild fruits, game, and fish Foods were commonly prepared as soups, stews or were dried. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 68 68

U.S. Southern Popular foods: corn bread, biscuits, grits, rice, sweet potatoes, squash, watermelon, oranges, peaches, fried fish, lima beans, green beans cooked with pork, barbecued/ stewed meats and poultry Diet may be high in fat and carbohydrates; limited in protein, iron, calcium, and vitamins A and C. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 70

Mexican Popular foods: beans, rice, chili peppers, tomatoes, tortillas made of corn meal or flour Beans and corn make a complete protein. Milk, green and yellow vegetables, and vitamin C-rich foods would improve these diets. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 71 71

Puerto Rican Popular foods: rice, beans, peppers, plantains, tomatoes, bananas, pineapple, mangoes, papayas, chicken, beef, pork Lacking milk nutritionally Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 72 72

Italian Popular foods: pastas, tomato sauces, cheese, fish, meat, root vegetables Excellent sources of nutrients include: eggs, cheese, tomatoes, green vegetables, and fruits. Fat-free milk and low-fat meat would improve diet. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 73

Northern and Western European
Popular foods: beef, pork, cooked vegetables, breads, cakes, and dairy products Fewer green vegetable salads and greater use of dark breads, potatoes, and fish than U.S. Midwest; otherwise similar. Fresh vegetables and fruits would add vitamins, minerals, and fiber to these diets. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 74

Central European Popular foods: potatoes, grain (especially rye and buckwheat), pork, cooked cabbage, carrots, onions, and turnips Eggs and dairy products used abundantly. To improve diet, limit number of eggs, use fat-free or low-fat dairy products, and add fresh vegetables and fruits. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 75

Middle Eastern Popular foods: grains, wheat, rice, chickpeas in the form of hummus, lamb, yogurt, cabbage, grape leaves, eggplant, tomatoes, dates, olives, and figs Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 76

Middle Eastern May contain insufficient amounts of protein and calcium depending on the amounts of meat and calcium-rich foods eaten. Fresh fruits and vegetables should be added to increase vitamins, minerals, and fiber. Black, very sweet coffee is a popular beverage. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 77

Chinese Popular foods: rice, soybeans, eggs, pork, and tea Low-fat diet Soy sauce is high in salt–problematic for patients on low-salt diets. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 78

Japanese Popular foods: rice, soybean paste and curd, vegetables, fruits, fish Tempura style (fried) Soysauce (shoyu) and tea are common. Diet lacks milk. May be deficient in calcium and excessive in salt. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 79

Indian Popular foods: eggs, dairy products, rice, peas, beans, spices (curry) Diet may be vegetarian. Eating with fingers is acceptable. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 80

Thai, Vietnamese, Laotian, Cambodian
Popular foods: rice, curries, vegetables, fruit Fish and meats are used in small amounts. Diet may lack adequate protein and calcium. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 81

Jewish Dietary Laws Kosher–foods prepared following rules Qualified person slaughters animals. Meat not prepared with milk or milk products. Dishes used for meat and dairy kept separate. Dairy and meat not eaten together. Mouth rinsed between fish and meat. Observe days for fasting. No cooking on Sabbath. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 83

Roman Catholic and Eastern Orthodox
Meat not allowed Ash Wednesday and fridays during Lent Eastern Orthodox Includes Christians from the Middle East, Russia, and Greece Meat, poultry, fish, and dairy products restricted wednesdays, fridays, and during Lent and Advent Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 84

Seventh Day Adventist and Mormon
Lacto-ovo vegetarians: use milk products and eggs, but no meat, fish, or poultry Nuts, legumes and meat substitutes, tofu Coffee, tea, and alcohol considered harmful Mormon Coffee, tea and alcohol prohibited Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 85

Islamic and Hindu Islamic Adherents of Islam are called Muslims Pork and alcohol prohibited; other meat slaughtered by specific laws During the month of Ramadan, Muslims do not eat or drink during daylight hours Hindu All life sacred; animals and eggs not eaten Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 86

Vegetarians Lacto-ovo: use dairy products and eggs, but no meat, poultry, or fish Lacto: use dairy products but no meat, poultry, or eggs Vegans: avoid all animal foods Diets should be carefully planned to include essential amino acids. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 87

Zen-Macrobiotic Diets
Developed from Zen Buddhism System of 10 diet plans Gradually give up foods as follows: desserts, salads, fruits, animal foods, soups, and ultimately vegetables, until only cereals–usually brown rice–are consumed. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 88

Conclusion Tools can be used to help patients plan a healthy diet. Individual food customs must be respected. A registered dietitian can help plan diets. Gradual corrections in dietary habits are easier to make and more effective when the reasons for the food habits are understood. Chapter 2 Copyright © 2003 Delmar Learning, a Thomson Learning company 89

Objectives Describe the processes of digestion, absorption, and metabolism Name the organs in the digestive system and describe their functions Name the enzymes or digestive juices secreted by each organ and gland in the digestive system Calculate your basal metabolic rate (BMR) Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 92

Digestion The breakdown of food in the body in preparation for absorption. Mechanical digestion: food is broken up by teeth and moved along GI tract by peristalsis. Chemical digestion: carbohydrates, proteins, and fats are broken down into nutrients tissues can absorb and use. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 93

Digestion Chemical changes occur through hydrolysis (the addition of water and breaking down of food molecules). Enzymes act on food substances, causing them to break down into simple compounds. An enzyme can act as a catalyst, which speeds up the chemical reactions without itself being changed in the process. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 94

Absorption The passage of nutrients into the blood or lymphatic system. Nutrients must be in their simplest form Carbohydrates: simple sugars Proteins: amino acids Fats: fatty acids and glycerol Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 95

Absorption Most absorption occurs in the small intestine; some occurs in the large intestine. Water is absorbed in the stomach, small intestine, and large intestine. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 96

Mouth Digestion begins here Enzyme (salivary amylase) acts on starch Starch is a complex carbohydrate Teeth break up food; food mixes with saliva “Bolus” formed Length of time food is in mouth is brief Small amounts of carbohydrates changed Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 98

Esophagus Food travels through this muscular tube Connects mouth to stomach Peristalsis and gravity act to move bolus Cardiac sphincter opens at lower end of esophagus to allow passage of bolus into stomach Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 99

Stop and Share What symptom results when the cardiac sphincter does not close properly? What is the name of the condition? What prevents this condition from occurring? Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 100

Stop and Share Indigestion or heartburn occurs as a result of stomach acid flowing back into the esophagus. This is called gastroesophageal reflux. The proper closing of the cardiac sphincter prevents the acidic content of the stomach from flowing back into the esophagus. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 101

Stomach Temporary storage of food Mixing of food with gastric juices Regulation of a slow, controlled emptying of food into the intestine Secretion of the intrinsic factor for vitamin B12 Destruction of most bacteria inadvertently consumed Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 102

Stomach Hydrochloric acid prepares the gastric area for enzyme action Pepsin breaks down proteins In children, rennin breaks down milk proteins Lipase acts on emulsified fats Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 103

Stop and Share You are preparing a teaching plan for the nursing staff working on a GI floor. You plan to review anatomy and physiology of the stomach. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 104

Stop and Share Complete the following objectives to prepare for your class: Identify the 3 parts of the stomach Define chyme Identify the condition that results from lack of the intrinsic factor in the stomach Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 105

Stop and Share Fundus: upper portion of the stomach Body of the stomach: middle area Pylorus: end of stomach near small intestines Chyme: semiliquid mass of food and gastric juices Pernicious anemia: lack of intrinsic factor Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 106

Small Intestine Hormones released Secretin causes pancreas to release sodium bicarbonate to neutralize acidity of chyme Cholecystokinin triggers gallbladder to release bile Bile Emulsifies fat after it is secreted into small intestine Produced in liver; stored in gallbladder Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 107

Small Intestine Enzymes are found in the pancreatic juice that is secreted into small intestine. Pancreatic proteases (trypsin, chymotrypsin, carboxypeptidases): split proteins Pancreatic amylase: converts starches (polysaccharides) to simple sugars Pancreatic lipase: reduces fats to fatty acids and glycerol Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 108

Small Intestine Produces enzymes Prepares foods for absorption Lactase, maltase, sucrase convert lactose, maltose, sucrose to simple sugars Peptidases reduce proteins to amino acids Twenty-two feet long Villi, hairlike projections, increase surface area for maximum absorption Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 109

Stop and Share The small intestine is divided into three sections. The duodenum is the first section of the small intestine. The jejunum is the middle section and the ileum is the last section. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 112

Large Intestine Colon walls secrete mucus to protect against acidic digestive juices in chyme. Major tasks of the large intestine: Absorb water Synthesize some B vitamins and vitamin K Collect food residue Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 113

Stop and Share You are providing pre-op teaching to a patient who is going to have intestinal surgery. The patient asks you to explain the structure of the large intestine. How do you respond? Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 114

Stop and Share The cecum (blind pocket), colon and rectum make up the large intestine. Contents travel through: Ascending colon Transverse colon Descending colon Sigmoid colon Rectum Anal canal Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 115

Metabolism The use of food by the body after digestion Results in energy Occurs after digestion and absorption; nutrients are carried by the blood to the cells of the body Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 117

Metabolism Oxidation Nutrients combine with oxygen Carbohydrates reduce to carbon dioxide and water Protein to carbon dioxide, water, and nitrogen Also known as aerobic metabolism Energy is released as nutrients are oxidized. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 118

Metabolism Anaerobic metabolism reduces fats without the use of oxygen. The complete oxidation of carbohydrates, proteins, and fats is commonly called the Krebs cycle. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 119

Metabolism Anabolism is the process of using energy from oxidation to create new compounds. Catabolism is the breakdown of compounds during metabolism. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 120

Stop and Share What condition is associated with too much thyroid hormone? What condition is associated with too little thyroid hormone? Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 122

Stop and Share Hyperthyroidism: metabolism speeds up and the body metabolizes its food too quickly, weight is lost. Hypothyroidism: metabolism slows down and the body metabolizes its food too slowly; patient tends to become sluggish and accumulate fat. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 123

Energy Needed for involuntary and voluntary activity Involuntary activity: maintenance of body tissue, temperature, growth Voluntary activity: walking, swimming, eating, reading, typing Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 124

Energy The unit used to measure the energy value of foods is the kilocalorie. kcal: amount of heat needed to raise the temperature of 1 kilogram of water 1 degree Celsius. kcal is commonly called calorie. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 126

Energy 1 gram of carbohydrate yields 4 kcal 1 gram of protein yields 4 kcal 1 gram of fat yields 9 kcal 1 gram of alcohol yields 7 kcal Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 127

Basal Metabolic Rate (BMR)
The rate at which energy is needed for body maintenance. The energy necessary to carry on all involuntary vital processes while the body is at rest. Also known as resting energy expenditure (REE). Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 130

Basal Metabolic Rate (BMR)
Factors that affect BMR: lean body mass, body size, sex, age, heredity, physical condition, and climate. BMR is greater in men than women. BMR increases during growth and fever. BMR decreases with age and during starvation. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 131

Calculating BMR Harris-Benedict equation Used by dietitians for persons over age 18 Uses height, weight, and age Female BMR 655 + (9.6 × weight in kg) + (1.8 × height in cm) – (4.7 × age) Male BMR 66 + (13.7 × weight in kg) + (5 × height in cm) – (6.8 × age) Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 132

Calculating BMR Another method used to estimate BMR Convert body weight from pounds to kilograms Multiply kilograms by 24 (hours per day) Multiply the answer obtained by 0.9 for a woman and by 1.0 for a man Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 133

Stop and Share 110 pound woman: BMR 1,080 kcal 110 pounds  2.2 (pounds per kg) = 50 kg 50 kg × 24 hours in a day = 1,200 kcal 1,200 kcal × 0.9 =1,080 kcal Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 135

Stop and Share 170 pound man: BMR 1,854 kcal 170 pounds  2.2 (pounds per kg) = kg 77.27 kg × 24 hours in a day = 1,854 kcal 1,854 kcal × 1.0 =1,854 kcal Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 136

Conclusion Food is broken down through the processes of mechanical and chemical digestion into nutrients that can be absorbed. Enzymes act to break down nutrients. Absorption occurs mostly in the small intestines. Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 137

Conclusion During metabolism, carbohydrates and proteins are combined with oxygen in a process called oxidation. Energy released during oxidation is measured by the kcal. A person’s energy requirement can be measured in part by estimating the basal metabolic rate (BMR). Chapter 3 Copyright © 2003 Delmar Learning, a Thomson Learning company 138

Objectives Identify the functions of carbohydrates Name the primary sources of carbohydrates Describe the classification of carbohydrates Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 141

Facts Primary source of energy for the body. Least expensive and most abundant of the energy nutrients. Named for the chemical elements they are composed of—carbon, hydrogen, and oxygen. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 142

Providing Energy Each gram of carbohydrate provides 4 kcal. A body needs a constant energy supply. A half day’s supply of carbohydrates is stored in the liver and muscles for use as needed. Stored form is called glycogen. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 144

Protein-Sparing Action
The primary function of proteins is to build and repair tissues. When enough carbohydrates (at least g/day) are ingested, protein is spared. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 145

Normal Fat Metabolism Without an adequate supply of carbohydrates, fat is metabolized to meet energy requirements. Ketones are produced as a byproduct of fat metabolism. Ketosis may result. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 146

Stop and Share With a partner role-play the following: A patient asks the nurse about starting a high-protein, low-carbohydrate diet. How should the nurse respond? Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 147

Stop and Share Carbohydrates are necessary for energy. Lack of adequate carbohydrate intake may result in ketosis (a condition in which acids, called ketones, accumulate in the blood). Protein is best used for building and repairing body tissues. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 148

Providing Fiber Dietary fiber is found in grains, vegetables, and fruits. Recommended intake is g/day. Fiber lowers blood glucose levels; may prevent some colon cancers; and helps prevent constipation, hemorrhoids, and diverticular disease by softening stool. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 149

Food Sources Principal sources of carbohydrates are plant foods: Cereal grains Vegetables Fruits Nuts Sugars The only substantial animal source is milk. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 150

Monosaccharides Simplest form of carbohydrates Absorbed directly into bloodstream from the small intestine Glucose, fructose, galactose Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 152

Monosaccharides Glucose Also called dextrose All other forms are converted to glucose for eventual metabolism Berries, grapes, sweet corn, corn syrup Central nervous system, red blood cells and brain use only glucose as fuel Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 153

Monosaccharides Fructose Also called levulose or fruit sugar Ripe fruits, honey, soft drinks Sweetest of all the monosaccharides Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 154

Disaccharides Pairs of monosaccharides Must be changed to simple sugars by hydrolysis before absorption Sucrose, maltose, and lactose Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 156

Disaccharides Sucrose Composed of glucose and fructose Form of carbohydrate present in granulated, powdered, and brown sugar, and in molasses One of the sweetest and least expensive sugars Sources: sugar cane, sugar beets, maple syrup, candy, jams and jellies Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 157

Disaccharides Maltose Intermediary product in the hydrolysis of starch Also created during the fermentation process that produces alcohol Found in some infant formulas, malt beverage products, and beer Less sweet than glucose or sucrose Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 158

Disaccharides Lactose Sugar found in milk Distinct from other sugars in that it is not found in plants Helps body absorb calcium Less sweet than monosaccharides or other disaccharides Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 159

Stop and Share Your patient complains of bloating, abdominal cramps, and diarrhea after drinking milk or consuming a milk-based food such as processed cheese. What is the likely cause of these symptoms? What causes this condition? What recommendations can be made? Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 160

Stop and Share Lactose intolerance is the likely cause. Caused by insufficient lactase, the enzyme required for digestion of lactose. Low-lactose milk products can be used instead of regular milk. Lactase-containing products are also available. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 161

Polysaccharides Complex carbohydrates Compounds of many monosaccharides Important polysaccharides in nutrition: Starch Glycogen Fiber Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 162

Polysaccharides Starch Found in grains and vegetables Storage form of glucose in plants Supplies energy over a longer period of time because it takes the body longer to digest polysaccharides than monosaccharides or disaccharides Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 163

Polysaccharides Glycogen Sometimes called animal starch because it is the storage form of glucose in the body Hormone glucagon helps liver convert glycogen to glucose as needed Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 164

Polysaccharides Fiber It is indigestible because it cannot be broken down be digestive enzymes Insoluble: does not readily dissolve in water (cellulose, hemicellulose, lignins) Soluble: dissolves in water (gums, pectins, some hemicellulose, mucilages) Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 165

Polysaccharides: Sources
Starch Cereals, grains, potatoes, corn, beans, yams Dextrins Starch hydrolysis Glycogen Glucose stored in liver and muscles Cellulose Wheat bran, whole-grain cereals, fruits, green and leafy vegetables Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 166

Digestion and Absorption: Monosaccharides
Simple sugars absorbed directly into bloodstream Carried to the liver; fructose and galactose changed to glucose Glucose carried to cells Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 167

Digestion and Absorption: Disaccharides
Enzymes sucrase, maltase, lactase convert sucrose, maltose, lactose to simple sugars. Simple sugars absorbed directly into bloodstream Carried to the liver; fructose and galactose changed to glucose Glucose carried to cells Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 168

Digestion and Absorption: Polysaccharides
More complex; digestibility varies Cellulose wall broken down, starch changed to intermediate product dextrin, then maltose, and finally glucose Starch digestion begins in mouth where the enzyme salivary amylase begins to change starch to dextrin Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 169

Metabolism Islets of Langerhans in pancreas secrete insulin Insulin is the hormone that controls glucose metabolism Impaired or absent insulin secretion results in high blood glucose level (hyperglycemia) Low blood glucose level (hypoglycemia) Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 170

Dietary Requirements Food and Nutrition Board of the National Research Council recommends: Half of one’s energy requirement should come from carbohydrates Complex carbohydrates preferred Weight loss and fatigue can result from a diet deficient in carbohydrates Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 171

Stop and Share Solve the following problem: A patient’s total energy requirement is 2,000 kcal a day. How many grams of carbohydrate does this patient need per day? Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 172

Stop and Share If a patient’s total energy requirement is 2,000 kcal/day; ½ of these should be from carbohydrates. 2,000  2 = 1,000 kcal To figure out how many grams are needed, divide 1,000 by 4 (4 calories per gram of carbohydrate). 1,000 kcal  4 kcal/g = 250 grams Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 173

Conclusion Carbohydrates provide energy. They should be the major source of energy. These nutrients spare protein, maintain normal fat metabolism, and provide fiber. Excessive carbohydrate intake may lead to obesity, dental caries, and digestive disturbances. Chapter 4 Copyright © 2003 Delmar Learning, a Thomson Learning company 174

Objectives State the functions of fats in the body Identify sources of dietary fats Explain common classifications of fats Describe disease conditions with which excessive use of fats is associated Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 177

Facts Fats belong to a group of organic compounds called lipids. Greasy substances that are insoluble in water. Each gram of fat contains 9 kcal. Composed of carbon, hydrogen, and oxygen; lower proportion of oxygen than carbohydrates. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 178

Functions Provide energy Carry fat-soluble vitamins Supply essential fatty acids Protect and support organs and bones Insulate from cold Provide satiety to meals Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 179

Food Sources Animal Fatty meats Lard Butter Cheese Cream; whole milk Egg yolk Plant Vegetable oils Nuts Chocolate Avocados Olives Margarine Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 180

Visible and Invisible Fats
Fats in foods that are purchased and used as fats, such as butter or margarine, lard, cooking oils Invisible fats Fats that are not immediately noticeable such as those in egg yolk, cheese, cream, and salad dressings Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 181

Stop and Share You are the nurse teaching a class about nutrition. A client asks about ways to decrease the amount of fat in the diet. What are some suggestions you can give? Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 182

Stop and Share Beware of hidden fats! Decrease the amount of fatty meats (bacon, sausage, luncheon meats) and use lean meats instead. Use low-fat or skim milk. Use egg whites instead of yolks when possible. (Egg white contains no fat; it is almost entirely protein and water.) Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 183

Classification Triglycerides Most lipids in the body (95%) are triglycerides Composed of three fatty acids attached to a framework of glycerol Phospholipids Sterols Cholesterol Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 184

Fatty Acids Fatty acids are organic compounds of carbon atoms to which hydrogen atoms are attached. They may be classified in two ways. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 185

Fatty Acid Classification
May be classified by the body’s need for them Essential Nonessential May be classified by degree of saturation with hydrogen atoms Saturated Unsaturated Monounsaturated Polyunsaturated Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 186

Non-essential Fatty Acids
Can be synthesized by the body Arachidonic fatty acid, previously thought to be essential, can be synthesized in the body from linoleic fatty acid. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 188

Saturated Fats Each of its carbon atoms carries all the hydrogen atoms possible. In general, animal foods contain more saturated fatty acids than unsaturated. Usually solid at room temperature. Examples: Meat, poultry, egg yolks, whole milk, whole milk cheeses, cream, ice cream, butter, chocolate, coconut, palm oil Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 189

Monounsaturated Fats Fewer hydrogen atoms attached to one place among the carbon atoms of its fatty acids than saturated fats. Lowers low-density lipoprotein (LDL or “bad cholesterol”). Examples: Olive oil, canola oil, avocados, cashew nuts Recommended: 15% of total daily kcal Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 190

Polyunsaturated Fats Fewer hydrogen atoms attached to two or more places among the carbon atoms of its fatty acids than saturated fats. Examples: Cooking oils made from sunflower, safflower, sesame seeds or from corn or soybeans, soft margarines whose major ingredient is liquid vegetable oil, and fish Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 191

Polyunsaturated Fats Foods containing high proportions of polyunsaturated fats are usually soft or oily. Omega-3 fatty acids (found in fish) lower the risk of heart disease. Omega-6 (linoleic acid) has a cholesterol- lowering effect. Recommended: 10% of total daily kcal Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 192

Hydrogenated Fats Polyunsaturated vegetable oils to which hydrogen has been added commercially to make them solid at room temperature. This process, called hydrogenation, turns polyunsaturated vegetable oils into saturated fats. Margarine is made in this way. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 193

Trans-Fatty Acids (TFAs)
Produced when hydrogen atoms are added to monounsaturated or polyunsaturated fats to produce a semi-solid product like margarine and shortening. TFAs raise low-density lipoproteins (LDL) and total cholesterol. Major source: baked goods and restaurant foods Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 194

Phospholipid Found in both plant and animal foods, and is synthesized in the liver. Natural emulsifier that helps transport fat in the bloodstream. Example: Lecithin Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 195

Cholesterol Cholesterol is a sterol Fatlike substance Exists in animal foods and body cells Does not exist in plant foods Essential for the synthesis of bile, sex hormones, cortisone, and vitamin D Needed by every cell in the body Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 196

Stop and Share Your client has been diagnosed with a high cholesterol level greater than 200 mg/dl. Answer the following questions: What risks are associated with a high cholesterol level? What can be done to lower a high cholesterol level? Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 197

Stop and Share High cholesterol leads to atherosclerosis, a cardiovascular disease in which plaque (fatty deposits containing cholesterol and other substances) forms on the inside of artery walls. This can lead to heart attacks and strokes. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 198

Stop and Share Reduce the amount of total fat, saturated fats, and cholesterol. Increase monounsaturated fats in the diet, lose weight and exercise. Increase consumption of soluble dietary fiber. Medication may be prescribed in some cases. Daily cholesterol intake should not exceed 300 mg. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 199

Digestion and Absorption
95% of ingested fats are digested Complex process Chemical digestion of fats occurs mainly in the small intestine No digestion of fats occurs in the mouth Slight digestion in stomach where gastric lipase acts on emulsified fats such as those found in cream and egg yolk. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 200

Digestion in the small intestine Bile emulsifies the fats The enzyme pancreatic lipase reduces the fats to fatty acids and glycerol The body subsequently absorbs through the villi of the small intestine Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 201

Lipoproteins In the initial stages of fat absorption, bile joins with the products of fat digestion to carry fat. Later, protein combines with the final products of fat digestion to form special carriers called lipoproteins. Lipoproteins carry the fat in the blood to the body cells. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 203

Lipoproteins Classified according to mobility and density Types Chylomicrons Very-low-density lipoproteins (VLDLs) Low-density lipoproteins (LDLs) High-density lipoproteins (HDLs) Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 204

Very-low-density Lipoproteins (VLDLs)
Made by the liver to transport lipids throughout the body. Composed of 55-65% triglycerides. Carry triglycerides and other lipids to all cells. As the VLDL lose triglycerides, they pick up cholesterol from other lipoproteins in the blood and they then become LDL. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 206

Low-density Lipoproteins (LDLs)
Composed of 45% cholesterol with few triglycerides. Carry most of the blood cholesterol from the liver to the cells. Elevated blood levels greater than 130 mg/dl of LDL are thought to be contributing factors in atherosclerosis. “Bad cholesterol” Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 207

High-density Lipoproteins (HDLs)
Carry cholesterol from the cells to the liver for eventual excretion. Levels of HDL greater than 35 mg/dl are thought to reduce the risk of heart disease. Exercise, maintaining a desirable weight, and giving up smoking are all ways to increase one’s HDL. “Good cholesterol” Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 208

Metabolism and Elimination
The liver controls fat metabolism. The metabolism of fats occurs in the cells. Fatty acids are broken down to carbon dioxide and water, releasing energy. Portion of fat not needed for immediate use stored as adipose tissue. Carbon dioxide and water are waste products removed from the body by the circulatory, respiratory, and excretory systems. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 209

Stop and Share Your client asks you about a new dietary supplement that advertisers claim provides essential nutrients and lowers cholesterol “naturally”. How do you advise your client? Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 210

Stop and Share Any new dietary “supplement” for which a nutrition claim is made should be carefully evaluated. If the item is not included in the RDA or DRI, it is safe to assume that medical research has not determined that it is essential. Ingestion of dietary supplements of unknown value could, ironically, be damaging to one’s health. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 211

Fat Alternatives Olestra: Made from carbohydrates and fat FDA approved for use in snack food Government requires that food labels indicate olestra “inhibits absorption of some vitamins and other nutrients” Contains no calories; can cause cramps and diarrhea Simplesse: Made from egg white or milk protein Oatrim: Carbohydrate-based; derived from oat fiber Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 212

Dietary Requirements The Food and Nutrition Board’s Committee on Diet and Health recommends that people reduce their fat intake to 30% of total kcal. American Heart Association’s newest recommendation is to consume </=7% of saturated fats, 8-10% polyunsaturated fats and 15% monounsaturated fats. At present, 36% of kcal in U.S. diets is derived from fats. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 213

Conclusion Fats provide energy, carry essential fatty acids and fat-soluble vitamins, protect organs and bones, insulate from cold, and provide satiety to meals. Composed of carbon, hydrogen, and oxygen and are found in both animal and plant foods. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 214

Conclusion Each gram of fats provides 9 kcal. Digestion occurs primarily in small intestines. An excess of fat in the diet can result in obesity and possible heart disease or cancer. Chapter 5 Copyright © 2003 Delmar Learning, a Thomson Learning company 215

Objectives State one or more functions of each of the thirteen vitamins discussed Identify at least two food sources of each of the vitamins discussed Identify some symptoms of, or diseases caused by, deficiencies of the vitamins discussed Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 218

Facts Organic (carbon-containing) compounds that are essential in small amounts for body processes. Do not provide energy. Enable the body to use the energy provided by fats, carbohydrates, and proteins. Megadoses can be toxic. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 219

Vitamin types (13) Fat soluble (4): A, D, E, K Water soluble (9): Vitamin C Vitamin B complex which includes: thiamin (B1), riboflavin (B2), niacin, vitamin B6, folate, vitamin B12 (cobalamin), pantothenic acid, biotin Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 220

Requirements Vitamin allowances given by weight in milligrams (mg) or micrograms (mcg or g) Dietary reference intake (replacing recommended dietary allowance) UL–tolerable upper limits–maximum level of daily intake unlikely to cause adverse effects Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 221

Vitamin Deficiency People prone to vitamin deficiency Alcoholics Poor and incapacitated elderly Clients with serious diseases that affect appetite Mentally retarded Children receiving inadequate care Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 222

Deficiency of Fat-soluble Vitamins
Chronic malabsorption diseases Cystic fibrosis Celiac disease Crohn’s disease Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 223

Stop and Share Match the following terms with the correct definition. 1. Avitaminosis a. Concentrated form of vitamins 2. Hypervitaminosis b. Without vitamins 3. Vitamin supplement c. Condition caused by ingestion of excess vitamins Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 224

Avoiding Vitamin Loss Buy fresh, unbruised vegetables and fruits and use them raw when possible. Prepare fresh vegetables and fruits just before serving. Heat canned vegetables quickly and in their own liquid. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 226

Avoiding Vitamin Loss Follow package directions when cooking frozen vegetables or fruit. Steam, or use as little water as possible. Cover pan and cook for a short period of time. Save cooking liquid for soups, stews, and gravy. Store in a cool, dark place. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 227

Functions of Vitamin A Antioxidant; protects cells from destruction by oxygen. Maintains healthy eyes and skin, normal growth and reproduction, and a healthy immune system. Helps prevent infection. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 230

Sources of Vitamin A Preformed vitamin A (retinol) Carotenoids (provitamin A or beta-carotene) Fat-containing animal foods: liver, butter, cream, whole milk, cheeses Green leafy vegetables & fruits, carrots, sweet potatoes, squash, spinach, broccoli, mango, cantaloupe, pumpkin Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 231

Vitamin A Requirements
Commonly listed as retinol equivalents (RE) A retinol equivalent is 1 g retinol or 6 g beta-carotene Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 232

Stop and Share Excess Birth defects, hair loss, dry skin, headaches, nausea, dryness of mucous membranes, liver damage, and bone and joint pain Deficit Night blindness; dry, rough skin; increased susceptibility to infections; and blindness or xerophthalmia Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 234

Vitamin D Prohormone–converted to a hormone in the body. D2 (ergocalcifenol) is formed in plants. D3 (cholecalciferol) is formed in humans from cholesterol in the skin. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 235

Sources of Vitamin D Sunlight Milk, fish liver oils, egg yolk, butter, fortified margarine Most milk in the U.S. has 10 g of vitamin D concentrate added per quart. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 236

Vitamin D Requirements
Newborns through 51 years 5.0 g (200 IU) 51-70 years 10.0 g (400 IU) 70+ years 15.0 g (600 IU) Pregnant and lactating women Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 237

Stop and Share Excess Deposits of calcium and phosphorus in soft tissues, kidney and heart damage, and bone fragility Deficit Poor bone and tooth formation, rickets which causes malformed bones and pain in infants Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 239

Functions of Vitamin E Antioxidant Prevention of hemolytic anemia among premature infants Enhance immune system Retard spoilage of commercial foods Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 242

Sources of Vitamin E Vegetable oils: corn, soybean, safflower, and cottonseed, and products made from them such as margarine Wheat germ, nuts, green leafy vegetables Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 243

Vitamin E Requirements
Given as -TE (alpha-tocopherol equivalents) 1 mg of -TE = 1 IU Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 244

Stop and Share Your client asks you if it is possible to take too much vitamin E. How would you advise the client? What signs and/or symptoms can result from too little vitamin E? Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 245

Stop and Share Excess Relatively nontoxic, fat- soluble vitamin. Excess stored in adipose tissue. Avoid long-term megadoses. Deficit Serious neurological defects can occur from malabsorption. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 246

Vitamin K Made up of several compounds essential to blood clotting. Vitamin K1 (phylloquinone) Vitamin K2 (menaquinone) Synthetic Vitamin K (menadione) Vitamin K is destroyed by light alkalis. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 247

Functions of Vitamin K Formation of prothrombin; clotting of blood Candidates likely to receive Vitamin K Newborns immediately after birth Clients who suffer from faulty fat absorption After extensive antibiotic therapy Antidote for an overdose of anticoagulant Clients being treated for hemorrhage Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 248

Sources of Vitamin K Green leafy vegetables such as broccoli, cabbage, spinach, and kale. Dairy products such as eggs, meats, fruits, and cereals. Bacteria in small intestine synthesizes some vitamin K but must be supplemented by dietary sources. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 249

Vitamin K Requirements
Measured in micrograms. 0-6 months 2 g/day 6-12 months 2.5 g/day Men 120 g/day Women (same during pregnancy or lactation) 90 g/day Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 250

Stop and Share Excess Anemia can result from excessive amounts of synthetic vitamin K Deficit Defective blood coagulation, which increases clotting time and makes client prone to hemorrhage Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 252

Water-soluble Vitamins
Vitamin B complex Vitamin C Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 253

Vitamin B Complex: Thiamin
Thiamin B1 Essential for nerve and muscle action, and metabolism of carbohydrates and some amino acids. Sources include unrefined and enriched cereals, yeast, wheat germ, lean pork, organ meats, and legumes. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 254

Vitamin B Complex: Thiamin
Average adult female requires 1.1 mg/day. Average adult male requires 1.2 mg/day. Deficiency symptoms include loss of appetite, fatigue, nervous irritability, and constipation. Beriberi is a disease caused by extreme deficiency of vitamin B1. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 255

Vitamin B Complex: Riboflavin
Riboflavin B2 Necessary for: the metabolism of carbohydrates, protein, and fats; tissue maintenance (especially the skin around the mouth); and healthy eyes. Sources include milk, meats, poultry, fish, enriched breads, cereals, broccoli, spinach, and asparagus. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 256

Vitamin B Complex: Riboflavin
Average adult female requires 1.1 mg/day. Average adult male requires 1.3 mg/day. Deficiency can result in cheilosis (a condition characterized by sores on the lips and cracks at the corners of the mouth); glossitis (inflammation of the tongue); dermatitis; and eye strain in the form of itching, burning, and eye fatigue. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 257

Vitamin B Complex: Niacin
Generic name for nicotinic acid and nicotinamide. A coenzyme in energy metabolism. Sources include meats, poultry, fish, peanuts, legumes. Milk and eggs are sources of tryptophan (precursor). Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 258

Measured in niacin equivalents (NE). 1 NE = 1 mg of niacin or 60 mg of tryptophan (an amino acid that is a precursor of niacin). Average adult female requires 14 mg/NE. Average adult male requires 16 mg/NE. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 259

Excessive amounts of niacin may cause flushing due to vascular dilation, GI problems, itching, and liver damage. May be used as a cholesterol-lowering agent under close supervision of a physician due to adverse side effects, which include liver damage and peptic ulcers. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 260

Deficiency symptoms include weakness, anorexia, indigestion, anxiety, and irritability. Pellagra is an extreme deficiency causing sores on the skin, diarrhea, anxiety, confusion, irritability, poor memory, dizziness, and untimely death. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 261

Vitamin B Complex: B6 Pyridoxine, pyridoxal, pyridoxamine Essential for protein metabolism and absorption, and aids in release of glucose from glycogen. Serves as catalyst in conversion of tryptophan to niacin; helps synthesize neurotransmitters such as serotonin and dopamine. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 262

Vitamin B Complex: B6 Sources include poultry, fish, liver, kidney, potatoes, bananas, spinach, and unrefined whole grains (oats and wheat). Deficiency symptoms include irritability, depression, and dermatitis. Deficiency in infants can cause various neurological symptoms and abdominal problems. Toxicity is rare; may cause temporary neurological problems. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 263

Vitamin B Complex: B6 Measured in milligrams. Average adult female requires mg/day. Average adult male requires mg/day. Need increases as protein increases. Oral contraceptives interfere with metabolism of vitamin B6 and can result in a deficiency. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 264

Vitamin B Complex: Folate
Folate, folacin, and folic acid are chemically similar compounds, and names are used interchangeably. Needed for DNA synthesis, protein metabolism, formation of hemoglobin. Sources include cereals fortified with folate, green leafy vegetables, legumes, sunflower seeds, fruits such as orange juice and strawberries. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 265

Measured in micrograms. Average adult female requires 400 g/day. Average adult male requires 400 g/day. Increased need during pregnancy and growth. 600 g/day required one month before conception through first six weeks of pregnancy. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 266

Deficiency linked to neural tube defects in fetus such as spina bifida (spinal cord or spinal fluid bulge through the back) and anencephaly (absence of the brain). Other signs include inflammation of mouth and tongue, poor growth, depression and mental confusion, problems with nerve functions, megaloblastic anemia. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 267

Excess can mask vitamin B12 deficiency and inactivates phenytoin, an anticonvulsant drug used by epileptics. FDA limits amount in over-the-counter supplements to: 100 g for infants 300 g for children 400 g for adults Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 268

Vitamin B Complex: B12 Cobalamin–contains mineral cobalt. Stored in body three to five years. Involved in folate metabolism, maintenance of the myelin sheath, and healthy red blood cells. To be absorbed, must bind with intrinsic factor in stomach. Pernicious anemia may result from loss of intrinsic factor. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 269

Vitamin B Complex: B12 Sources include animal foods, especially organ meats, lean meat, seafood, eggs, dairy products. Average adult requires 2.4 g/day. Increased need during pregnancy and lactation. Amount absorbed will depend on current need. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 270

Vitamin B Complex: B12 Deficiency is rare and may be due to congenital problems of absorption or years of a vegetarian diet with no animal foods. Symptoms inclued megaloblastic anemia, pernicious anemia (if intrinsic factor absent), anorexia, glossitis, sore mouth, tongue, pallor, depression, dizziness, weight loss, neurological system damage. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 271

Vitamin B Complex: Pantothenic Acid
Involved in metabolism of carbohydrates, fats, proteins. Essential for synthesis of neurotransmitter acetylcholine and steroid hormones. Sources include meats, poultry, fish, eggs, whole grain cereals, and legumes. Thought to be synthesized by the body. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 272

Vitamin B Complex: Pantothenic Acid
Food and Nutrition Board has provided an estimated intake of 5 mg a day for normal adults. Toxicity from excess not confirmed. Natural deficiencies unknown. Signs include weakness, fatigue, burning sensation in feet (deficiencies produced experimentally). Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 273

Vitamin B Complex: Biotin
Coenzyme in synthesis of fatty acids and amino acids. Sources include liver, egg yolk, soy flour, cereals, yeast. Synthesized in intestine by microorganisms, amount available for absorption unknown. Food and Nutrition Board suggests adequate intake of 30 g for adults. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 274

Vitamin B Complex: Biotin
Toxicity from excess unknown. Deficiency symptoms include nausea, anorexia, depression, pallor, dermatitis, increase in serum cholesterol. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 275

Vitamin C Ascorbic acid Has antioxidant properties and protects food from oxidation. Role in formation of collagen. Aids in absorption of nonheme iron. May be involved with formation or functioning of norepinephrine, some amino acids, folate, leukocytes, the immune system, allergic reactions. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 276

Vitamin C Sources include citrus fruits, melon, strawberries, tomatoes, potatoes, red and green peppers, cabbage, broccoli. Average female adult requires 75 mg/day. Average male adult requires 90 mg/day. Stress and cigarette smoking increase need. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 277

Stop and Share What disease results from a deficiency in vitamin C? What are the associated signs and/or symptoms? What results from excess? Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 278

Stop and Share Scurvy: disease characterized by gingivitis, easy bruising, pinpoint hemorrhages of the skin, poor wound healing, sore joints and muscles, weight loss. Extreme cases result in death. Found in sailors who lived without fresh fruits and vegetables. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 279

Stop and Share Deficiency of Vitamin C: bleeding gums, loose teeth, tendency to bruise easily, poor wound healing, scurvy. Excess: diarrhea, nausea, cramps, excessive absorption of food iron, rebound scurvy (when megadoses are stopped abruptly) and possibly oxalate kidney stones. Generally considered nontoxic. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 280

Vitamin Supplementation
Balanced diet provides nutritional needs of healthy people. No amount of vitamins will build muscles. Vitamins do not provide energy; they help to release the energy provided by nutrients. Heart disease, cancer and the common cold cannot be cured by vitamin supplements. Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 281

Conclusion Organic compounds that regulate body functions and promote growth. Each vitamin has a specific function. Well-balanced diet provides sufficient vitamins to fulfill body requirements. Fat-soluble vitamins: A, D, E, K Water-soluble vitamins: B complex, C Chapter 7 Copyright © 2003 Delmar Learning, a Thomson Learning company 282

Objectives List at least two food sources of given minerals List one or more functions of given minerals Describe the recommended method of avoiding mineral deficiencies Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 285

Facts Human body made up of specific chemical elements. Oxygen, carbon, hydrogen, and nitrogen make up 96% of body weight. Remaining elements, minerals, represent 4% of body weight. Minerals are essential for good health. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 286

Facts Inorganic elements are necessary to build tissues, regulate body fluids, and assist in various body functions. Found in all body tissues. Cannot provide energy by themselves. Contribute to production of energy within the body. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 287

Facts Enriched foods are foods to which nutrients, usually B vitamins and iron, have been added to improve their nutritional value. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 288

Classification Major minerals Required in amounts greater than 100 mg a day Trace minerals Needed in amounts smaller than 100 mg a day Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 289

Electrolytes Ions Electrically charged atoms resulting from chemical reactions Positively charged called cations Negatively charged called anions Must be balanced within body These ions are known as electrolytes Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 290

Electrolytes Maintain the body’s fluid balance, contribute to electrical balance, assist in transmission of nerve impulses and contraction of muscles, help regulate the body’s acid-base balance. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 291

Toxicity Toxicity occurs when concentrated forms of minerals are taken regularly over time. Excessive amount of one mineral may lead to deficiency of another mineral. Hair loss and changes in blood, hormones, bones, muscles, blood vessels, and nearly all tissues may result. Concentrated minerals only if prescribed. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 294

Calcium: Functions In combination with phosphorus, gives strength and hardness to bones and teeth. Bones provide storage for calcium. Needed for normal nerve and muscle action, blood clotting, heart function, and cell metabolism. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 297

Calcium: Regulation Hormonal system regulates delivery of calcium to cells. Every cell needs calcium and normal blood calcium levels are maintained even if intake is poor. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 298

Calcium: Regulation Parathyroid glands release a hormone telling the kidneys to retrieve calcium before it is excreted when blood calcium levels drop. This hormone, works with calcitriol causing increased release of calcium from bones by stimulating activity of osteoclasts. Both actions increase blood calcium levels. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 299

Calcium: Regulation Bones become increasingly fragile as calcium is withdrawn from them. Osteoporosis may result from years of low calcium intake. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 300

Calcium: Regulation Osteoblasts increase bone mass if blood calcium level is high until one is age years old. Bone mass will remain stable in women until menopause with adequate consumption of calcium, phosphorus, and vitamin D. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 301

Calcium: Sources Milk and milk products Dark green, leafy vegetables When vegetables contain oxalic acid, as spinach and Swiss chard do, the calcium remains unavailable because the oxalic acid binds it and prevents it from being absorbed Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 302

Calcium: Sources Fiber When the intake of fiber exceeds 35g a day, calcium will also bind with phytates (phosphorus compounds found in some high-fiber cereal), which also limits its absorption Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 303

Calcium: Sources Enhances absorption of calcium Vitamin D Calcium-to-phosphorus ratio that includes no more phosphorus than calcium Presence of lactose Retards absorption Lack of weight-bearing exercise Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 304

Calcium: Requirements
0-6 months mg 6-12 months mg 1-3 years mg 4-8 years mg 9-18 years 1,300 mg 19-50 years 1,000 mg years 1,200 mg Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 305

Calcium: Requirements
Pregnant women 14-18 years 1,300 mg 19-50 years 1,000 mg Lactating women same as nonlactating women of same age Source: Dietary Reference Intakes, Food and Nutrition Board, National Academy of Sciences-Institute of Medicine, 1997 Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 306

Calcium: Supplements Calcium carbonate, form found in calcium- based antacid tablets, has highest concentration of bioavailable calcium. Appear to be absorbed most efficiently when consumed in doses of 500 mg. Check for USP-approved products, which are unlikely to contain lead. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 307

Calcium: Deficiency Rickets results in poorly formed bone structure and causes bowed legs, “pigeon breast”, enlarged wrists or ankles, and stunted growth. “Adult rickets” (osteomalacia) causes bones to become soft. Tetany, characterized by involuntary muscle movement, results from insufficient calcium in blood. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 309

Phosphorus (P) Constituent of all body cells. Necessary for the formation of strong, rigid bones and teeth; metabolism of carbohydrates, fats, and proteins; proper acid-base balance; and effective action of several B vitamins. Stored in bones, absorption is increased in the presence of vitamin D. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 311

Phosphorus: Requirements
Adequate Intake 0-6 months 100 mg 6-12 months 275 mg Estimated Average Requirements 1-3 years mg 4-8 years mg 9-18 years ,055 mg Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 313

Phosphorus: Requirements
years 580 mg Pregnant and lactating women Same as for nonpregnant and nonlactating women Source: Dietary Reference Intakes, Food and Nutrition Board, National Academy of Sciences-Institute of Medicine, 1997 Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 314

Phosphorus: Deficiency
Deficiency is rare. Excessive use of antacids affect absorption. Symptoms of deficiency include bone demineralization (loss of minerals), fatigue, and anorexia. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 315

Potassium (K) Found primarily in intracellular fluid. Essential for fluid balance and osmosis. Maintains fluid level within the cell. Necessary for transmitting nerve impulses and muscle contractions. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 316

Potassium: Sources Fruits–especially melons, oranges, bananas, peaches Vegetables–mushrooms, brussel sprouts, potatoes, tomatoes, winter squash, lima beans, carrots Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 317

Potassium: Deficiency
Hypokalemia Caused by diarrhea, vomiting, diabetic acidosis, severe malnutrition, or excessive use of laxatives or diuretics Symptoms of deficiency include nausea, anorexia, fatigue, muscle weakness, heart abnormalities Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 318

Sodium Primary function is the control of fluid balance in the body. Maintains acid-base balance. Participates in the transmission of nerve impulses essential for normal muscle function. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 320

Sodium: Sources Table salt contains 40% sodium. One teaspoon of table salt contains 2,000 mg of sodium. Naturally available in animal foods. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 321

Sodium: Requirements 0-5 months 120 mg 6-11 months 200 mg 1 year mg 2-5 years mg 6-9 years mg 10-18 years 500 mg > 18 years mg Recommended Dietary Allowances: 10th Edition. Copyright 1989 by the National Academy of Sciences. Courtesy of the National Academy Press, Washington, D.C. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 322

Sodium: Deficiency Caused by severe vomiting, diarrhea, and heavy perspiration. Can upset the acid-base balance. Tetany due to alkalosis may develop. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 323

Sodium: Excess May cause edema and resulting hypertension. Associated with hypertension and congestive heart failure. Treatment includes sodium-restricted diets; 3-4g (no-added salt, or NAS) or 1-2g sodium-restricted diet. Diets below 1g rarely prescribed. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 324

Chloride (Cl) Essential for maintenance of fluid, electrolyte, and acid-base balance. Found in hydrochloric acid, cerebrospinal fluid, and muscle and nerve tissue. Helps blood carry carbon dioxide to the lungs and is necessary during immune responses when white blood cells attack foreign cells. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 325

Chloride Found almost exclusively in table salt or in foods containing sodium chloride. Estimated minimum requirement for normal adults is 750 mg a day. Deficiency is rare. Can occur with severe vomiting, diarrhea, excessive use of diuretics, and alkalosis. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 326

Magnesium (Mg) Vital to both hard and soft body tissues. Essential for metabolism. Regulates nerve and muscle function. Plays a role in the blood-clotting process. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 327

Magnesium: Sources Found primarily in plant foods. Green leafy vegetables, legumes, nuts, whole grains, some fruits (avocados and bananas) Milk in sufficient quantities Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 328

Magnesium: Requirements
Adequate Intake 0-6 months mg 6-12 months mg Boys and girls years 80 mg 4-8 years mg 9-13 years mg Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 329

Pregnant women years mg 19-30 years mg 31-50 years mg Lactating women years mg 19-30 years mg 31-50 years mg Dietary Reference Intakes, Food and Nutrition Board, National Academy of Sciences-Institute of Medicine, 2001. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 331

Magnesium: Deficiency
Deficiency among people on normal diets is unknown. Experimentally induced symptoms include nausea, mental, emotional, muscular disorders. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 332

Sulfur (S) Necessary to all body tissue and is found in all body cells. Contributes to the characteristic odor of burning hair and tissue. Necessary for metabolism. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 333

Sulfur Component of some amino acids. Found in protein-rich foods. Neither the amount of sulfur required by the human body nor its deficiency is known. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 334

Iron (Fe) Delivers oxygen to body tissues. Component of hemoglobin. Component of myoglobin, a protein compound in muscles that provides oxygen to cells. Utilized by enzymes that are involved in making amino acids, hormones, and neurotransmitters. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 336

Iron: Sources Meat, poultry, and fish are the best sources of iron. Animal flesh contains heme iron, which is absorbed more than twice as efficiently as nonheme iron. Nonheme iron is found in whole grain cereals, enriched grain products, vegetables, fruit, eggs, meat, fish, and poultry. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 337

Factors that Affect Iron Absorption
Increase Acid in the stomach Heme iron High body demand for red blood cells (blood loss, pregnancy) Decrease Phytic acid (in fiber) Oxalic acid Polyphenols in tea and coffee Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 338

Factors that Affect Iron Absorption
Increase Low body stores of iron Meat protein factor (MPF) Vitamin C Decrease Full body stores of iron Excess of other minerals (Zn, Mn, Ca) Some antacids Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 339

Iron: Requirements Men lose approximately 1 mg/day. Women lose approximately 1.5 mg/day. RDA for men is 10 mg, and for women age eleven through childbearing is 15 mg. RDA doubled during pregnancy; difficult to meet by diet alone. Iron supplement commonly prescribed during pregnancy. Heavy need during infancy and teens. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 340

Iron: Deficiency Caused by insufficient intake, malabsorption, lack of stomach acid, or excessive blood loss. Most common nutrient deficiency worldwide is iron-deficiency anemia. Symptoms include fatigue, weakness, irritability, shortness of breath, pale skin, and spoon-shaped fingernails. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 341

Iron: Excess Hemochromatosis is a condition due to an inborn error of metabolism and causes excessive absorption of iron. Untreated, can damage liver, spleen, heart. To control buildup of iron, patients with this condition must give blood on a regular basis. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 342

Iodine (I) Component of thyroid hormones, thyroxine (T4) and triiodothyronine (T3). Necessary for the normal functioning of thyroid gland, which determines rate of metabolism. Sources include iodized salt, seafood, and some plant foods grown in soil bordering the sea. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 343

Iodine RDA for adults is 150 g a day. Additional amounts needed during pregnancy and lactation. Lack of iodine results in decrease in thyroxine and triiodothyronine. Gland grows, forming a lump on the neck called a goiter. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 344

Iodine Myxedema is a condition of hypothyroidism in adults. Cretinism is low thyroid in a child; retards physical and mental development. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 345

Zinc (Zn) Cofactor for more than 300 enzymes. Essential for growth, wound healing, taste acuity, glucose tolerance, and mobilization of vitamin A within the body. Sources include meat, fish, eggs, dairy products, wheat germ, and legumes. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 346

Zinc RDA for normal adult males is 11 mg. RDA for normal adult females is 8 mg. Increased requirements during pregnancy and lactation. Symptoms of deficiency include decreased appetite, taste acuity, delayed growth, dwarfism, hypogonadism, poor wound healing, anemia, acnelike rash, impaired immune response. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 347

Selenium (Se) Constituent of most body tissues. Concentrated in liver, kidneys, and heart. Component of an enzyme that acts as an antioxidant, thereby protecting cells against oxidation and sparing vitamin E. Sources include seafood, kidney, liver, muscle meats. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 348

Selenium (Se) RDA for adult male is 70 g. RDA for adult female is 55 g. Selenium supplements appear to be effective in treating Keshan disease High doses are toxic causing vomiting, loss of hair and nails, and skin lesions. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 349

Copper (Cu) Found in all tissues; heaviest concentration in the liver, kidneys, muscles, and brain. Helps in formation of hemoglobin; aids in transport of iron to bone marrow for the formation of red blood cells; and participates in energy production. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 350

Copper (Cu) Sources include organ meats, shellfish, legumes, nuts, cocoa, whole grain cereals, and human milk. No RDA; NRC’s estimated safe intake for adults is mg/day. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 351

Copper (Cu) Deficiency is rare. People with malabsorption conditions and gross protein deficiency such as premature infants; clients on long-term parenteral nutrition programs lacking copper; and people taking excess zinc supplements are candidates for deficiency. Anemia, bone demineralization, and impaired growth may result. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 352

Copper (Cu) Excess is highly toxic. Single dose of mg can cause vomiting. Wilson’s disease is an inherited condition causing damage to liver cells and neurons. Detected early, copper-binding agents may be used to bind copper in bloodstream and increase excretion. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 353

Manganese (Mn) Constituent of several enzymes involved in metabolism. Important in bone formation. Sources include whole grains, tea, vegetables, and fruits. Adequate intake is 2.3 mg for men and 1.8 mg for women. No deficiency/toxicity from ingestion known. Inhalation linked to neurological problems. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 354

Fluoride (F) Increases resistance to dental caries, and may strengthen teeth and bones. Sources include fluoridated water, fish and tea. Commercially prepared foods with fluoridated water. Deficiency can result in increased tooth decay. Excess can cause discoloration or mottling of children’s teeth. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 355

Fluoride: Requirements
0-6 months .01 mg 6-12 months 0.5 mg 1-3 years mg 4-8 years mg 9-13 years mg Boys years 3.1 mg Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 356

Fluoride: Requirements
Girls years 3.0 mg Males 19+ years 4.0 mg Females 19+ years 3.0 mg Pregnant and lactating women Same as nonpregnant and nonlactating women of same age Dietary Reference Intakes, Food and Nutrition Board, National Academy of Sciences-Institute of Medicine, 1997. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 357

Chromium (Cr) Associated with glucose and lipid metabolism. Levels decrease with age except in lungs, where chromium accumulates. Sources include meat, mushrooms, nuts, yeast, organ meats, and wheat germ. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 358

Chromium (Cr) Safe and adequate daily intake for men is 35 μg and women 25 μg Deficiency related to disturbances in glucose metabolism. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 359

Molybdenum (Mo) Constituent of enzymes, and thought to play a role in metabolism. Sources include milk, liver, legumes, and cereals. Safe and adequate daily intake for adults is 45 g. No deficiencies noted. Excess inhibits copper absorption. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 360

Conclusion Megadoses of minerals are dangerous. Minerals are necessary to promote growth and regulate body processes. Originate in soil and water and ingested via food and drink. Deficiencies can result in anemia, rickets, and goiter. Excess can be toxic resulting in hair loss and changes in nearly all body tissues. Chapter 8 Copyright © 2003 Delmar Learning, a Thomson Learning company 361

Objectives Describe the functions of water in the body Explain fluid balance and its maintenance Name causes and consequences of water depletion Give causes and consequences of positive fluid balance Describe the acid-base balance of the human body Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 364

Facts Humans can live about 8 weeks without food. One can live only a few days without water. Water is in all body cells. 50-60% body weight of normal adults. Percentage is highest in newborns; decreases with age. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 365

Facts Two basic compartments Intracellular fluid (ICF): within cells; 65% of total body fluid. Extracellular fluid (ECF): outside cells; 35% of total body fluid. Divided into intravascular fluid (in blood stream) and interstitial fluid (between cells) Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 366

Body Fluid Compartments

Functions Major component of blood plasma. Solvent for nutrients and waste products. Necessary for hydrolysis of nutrients. Essential for metabolism. Lubricant in joints and digestion. Cools the body through perspiration. Provides some mineral elements. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 368

Sources Drinking water is the best source. Beverages are second-best source. Other sources include fruits, vegetables, soups, milk, and gelatin desserts. Energy metabolism produces water. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 369

Estimated Daily Fluid Intake for an Adult
Ingested liquids 1,500 ml Water in foods ml Water from oxidation ml Total 2,400 ml Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 370

Fluid and Electrolyte Balance
Electrolytes are measured in milliequivalents (mEq/L). Sensible (noticeable) water loss is water lost through urine. Insensible (unnoticeable) water loss is in feces, perspiration, and respiration. Waste products of metabolism excreted in the form of urine (500 ml of water each day). Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 371

Solute: substance dissolved in a solution. Osmosis: water flows from the side with the lesser amount of solute to the side with the greater solute concentration. Sodium, chloride, and potassium maintain the balance between intracellular and extracellular fluids. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 372

Potassium is the principal electrolyte in intracellular fluid. Sodium is the principal electrolyte in extracellular fluid. Osmolality measures particles in a solution. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 373

When electrolytes in extracellular fluid are increased, ICF moves to the ECF to equalize the concentration of electrolytes on both sides of the membrane. Reduces the amount of water in the cells. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 375

Hypothalamus stimulates pituitary gland to excrete ADH (antidiuretic hormone). ADH causes kidneys to reabsorb water. Thirst causes healthy person to drink fluids. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 376

When sodium in ECF is reduced, water flows from ECF into cells, causing cellular edema. Adrenal glands secrete aldosterone, which triggers kidneys to increase the amount of sodium reabsorbed. When the missing sodium is replaced in the ECF, excess water moves back to the ECF and edema is relieved. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 377

Amount of water use varies, depending on age, size, activity, environmental temperature, and physical condition. Average adult requirement is 1 ml for every kcal in food consumed. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 378

Stop and Share 1 ml × 1,800 kcal = 1,800 cc 1,800 cc  240 oz = 7.5 glasses of water It is recommended that adults drink eight 8-ounce glasses of fluid a day. Youth, fever, diarrhea, unusual perspiration, and hyperthyroidism increase the requirement. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 380

Dehydration Amount of water in the body is inadequate. Caused by inadequate intake or abnormal loss. Loss can occur from severe diarrhea, vomiting, hemorrhage, burns, diabetes mellitus, excessive perspiration, excessive urination, or the use of certain medications such as diuretics. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 381

Dehydration Symptoms of dehydration include low blood pressure, thirst, dry skin, fever, and mental disorientation. As water is lost, electrolytes are also lost. Treatment involves replacement of electrolytes and fluids. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 382

Dehydration 10% loss can cause serious problems. Blood volume and nutrient absorption are reduced, and kidney function is upset. 20% loss can cause circulatory failure and death. Infants are at high risk for dehydration when fever, vomiting, and diarrhea occur. Treatment involves IV fluids. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 383

Dehydration Thirst sensation lags behind the body’s need for water, especially in the elderly, children, athletes, and the ill. Feeling thirsty is not a reliable indicator of when the body needs water. Fluids should be drunk throughout the day to prevent dehydration. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 384

Dehydration Failure to replace water lost through perspiration could lead to one of the four stages of heat illness: Heat fatigue Heat cramp Heat exhaustion Heat stroke Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 385

Signs of Dehydration Health history reveals inadequate intake of fluids Decrease in urine output Weight loss Eyes appear sunken Tongue has increased furrows and fissures Oral mucous membranes are dry Decreased skin turgor Changes in neurological status Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 386

Excess Water Accumulation
Positive water balance–more water taken in than excreted; edema results. Hypothyroidism, congestive heart failure, hypoproteinemia, some infections, some cancers, and some renal conditions can cause water retention because sodium is not being excreted normally. Fluids and sodium may then be restricted. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 387

Acid-base Balance Regulation of hydrogen ions Acid gives off hydrogen ions Base picks up hydrogen ions Acidic substances–pH 1 to 7 Alkaline substances–pH 7 to 14 pH 7 is considered neutral Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 388

Acid-base Balance Blood plasma–pH 7.35 to 7.45 Intracellular fluid–pH 6.8 Kidneys maintain acid-base balance What a person eats affects the acidity not of the body but of the urine. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 389

Buffer Systems Regulate hydrogen ion content in body fluids Mixture of a weak acid and a strong base Normal buffer system–ratio of base to acid 20:1 Carbonic acid and sodium bicarbonate forms the body’s main buffer system. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 390

Buffer Systems Carbonic acid moves easily to buffer a strong alkali, and sodium bicarbonate moves easily to buffer a strong acid. Amounts are easily adjusted by the lungs and kidneys to suit needs. End products of metabolism are carbon dioxide and water, and together they can form carbonic acid. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 391

Buffer Systems The medulla oblongata in the brain causes the breathing rate to increase if the amount of carbon dioxide is more concentrated than it should be. This increases the rate at which the body rids itself of carbon dioxide. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 392

Buffer Systems Excess sodium bicarbonate is excreted via the kidneys. The kidneys can excrete urine from pH 4.5 to pH 8. The pH of average urine is 6. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 393

Acidosis and Alkalosis
Renal failure, uncontrolled diabetes mellitus, starvation, or severe diarrhea can cause acidosis. Alkalosis can occur when the body has suffered a loss of hydrochloric acid from severe vomiting or has ingested too much alkali, such as too many antacid tablets. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 394

Stop and Share A client is unhappy with her low sodium, fluid restricted diet. How can the health care professional best help the client? Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 395

Stop and Share Discuss realistic ways of planning menus for her and with her. Base menus on good nutrition, the client’s normal habits and desires. Review former diet with the client. Point out high-salt and high-liquid foods and present alternative foods in a positive manner. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 396

Conclusion Water is a component of all tissues. Solvent for nutrients and body wastes. Provides transport for both. Essential for hydrolysis, lubrication, and maintenance of normal temperature. Best sources are water, beverages, fruits, vegetables, soups, and water-based desserts. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 397

Conclusion Dehydration may result from lack of water. Positive water balance is an excess accumulation of water in the body. Acid-base balance is the regulation of hydrogen ions in the body. Healthy people have intricate maintenance systems for fluid, electrolytes, and acid- base balance. Chapter 9 Copyright © 2003 Delmar Learning, a Thomson Learning company 398

Objectives Identify diseases caused by contaminated food, their signs, and the means by which they are spread List signs of food contamination State precautions for protecting food from contamination Describe allergies and elimination diets and their uses Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 401

Food-related Illnesses
Pathogens are disease-causing agents. Pathogens or certain chemicals can contaminate food. Bacteria, viruses, molds, worms, and protozoa are pathogens that can contaminate food. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 402

Chemicals may be a natural component of specific foods, intentionally added during production or processing, or accidentally added through carelessness or pollution. Food poisoning is a general term for foodborne illness. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 403

When food poisoning develops as a result of a pathogen’s infecting someone, it is a foodborne infection. When it is caused by toxins produced by the pathogen, it is called food intoxication. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 404

Symptoms of food poisoning include vomiting, diarrhea, headache, and abdominal cramps. Many never know they are suffering from food poisoning and assume they have the flu. Young children, elderly or immunocompromised may become very ill and even die. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 405

Bacteria that Cause Foodborne Illness
Campylobacter jejuni Clostridium botulinum Clostridium perfringens Cyclospora cayentanensis Escherichia coli (E. coli 0157:H7) Listeria monocytogenes Salmonella Shigella Staphylococcus aureas Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 406

Campylobacter Jejuni One of the most prevalent causes of diarrhea. Found in intestinal tracts of pigs, sheep, chickens, turkeys, dogs, and cats. Onset is 2 to 5 days. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 407

Campylobacter Jejuni Symptoms include diarrhea, fever, headache, muscle and abdominal pain, and nausea. Transmitted via unpasteurized milk, contaminated water, and raw or undercooked meat, poultry and shellfish. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 408

Clostridium Botulinum
Botulism Found in soil and water, on plants, and in the intestinal tracts of animals and fish. Can be produced in sealed containers such as cans, jars, and vacuum-packaged foods. The rarest but most deadly of all food poisonings. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 409

Clostridium Botulinum
Onset is 4 to 36 hours after eating. Symptoms include double vision, speech difficulties, inability to swallow, and respiratory paralysis. Fatality rate in the US is about 65%. Great care must be taken to prevent botulism when canning foods at home. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 410

Clostridium Perfringens
The “cafeteria” or “buffet” germ Transmitted by eating heavily contaminated food. Symptoms include nausea, diarrhea, and inflammation of the stomach and intestine. Onset is 6 to 24 hours. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 411

Cyclospora Cayentanensis
A parasite that causes gastroenteritis. Transmitted by poor hygiene and contaminated water. Symptoms include watery diarrhea, abdominal cramps, decreased appetite, and low-grade fever. Onset is one week. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 412

Escherichia Coli Escherichia coli, commonly called “E. coli,” is a group of bacteria that can cause illness in humans. E. coli 0157:H7 is a very infectious strain of this group. Found in intestines of some mammals, raw milk, and contaminated water. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 413

Escherichia Coli Transmitted through contaminated water, unpasteurized milk or apple juice, raw or rare ground beef products, unwashed fruits or vegetables, and directly from person to person. Onset is 3 to 9 days. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 414

Escherichia Coli Symptoms include severe abdominal cramps, diarrhea that may be watery or bloody, and nausea. Complications: hemorrhagic colitis, hemolytic uremic syndrome in children Control by careful choice and cooking of food. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 415

Listeria Monocytogenes
Bacteria often found in human and animal intestines, and in milk, leafy vegetables, and soil. Transmitted by unpasteurized dairy foods; leafy, raw vegetables; and processed meats. Onset is 12 hours to 8 weeks after ingestion. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 416

Listeria Monocytogenes
Symptoms include fatigue, fever, chills, headache, backache, abdominal pain, and diarrhea. To prevent infection, meats and poultry should be thoroughly cooked and salad greens carefully washed. Make sure dairy products are pasteurized. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 417

Salmonellosis Salmonella Found in raw meats, poultry, fish, milk, and eggs. Transmitted by eating contaminated food or by contact with a carrier. Symptoms include headache, vomiting, diarrhea, abdominal cramps, and fever. Onset is 6 to 48 hours. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 418

Shigella Typically transmitted by an infected food handler with poor hand washing. Cold foods are common carriers. Onset is 1 to 7 days. Symptoms include diarrhea, fever, chills, headache, nausea, and abdominal cramps. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 419

Staphylococcus Aureus
Found on human skin. Transmitted by carriers and by eating foods that contain the toxin these bacteria create. Onset is 30 minutes to 8 hours. Symptoms include vomiting, diarrhea, and abdominal cramps. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 420

Stop and Share You are teaching a class about preventing food poisoning. What food preparation safety guidelines will you discuss? Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 421

Stop and Share All meats and poultry should be cooked thoroughly. Ground beef, veal, and lamb should be cooked to 160 degrees fahrenheit, and ground poultry to at least 165 degrees fahrenheit. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 422

Stop and Share Fruits and vegetables should be carefully washed, and unpasteurized milk, other dairy products, vegetable and fruit juices should be avoided. People with compromised immune systems should be especially vigilant. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 423

Stop and Share Thaw poultry and meats in the refrigerator or microwave and cook immediately. Avoid cross-contamination of raw and cooked foods by carefully cleaning utensils and counter surfaces that were in contact with raw food. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 424

Other Substances that Cause Food Poisoning
Mold Trichinella spiralis Protozoa Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 426

Mold A type of fungus. May cause respiratory problems. Can cause cancer. Symptoms include abdominal pain, vomiting, and diarrhea. Onset is 1 day to several months after ingestion. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 427

Trichinella spiralis A parasitic worm that causes trichinosis. Transmitted by eating inadequately cooked pork from infected pigs. Onset is 24 hours. Symptoms include abdominal pain, vomiting, fever, chills, and muscle pain. Cook all pork to an internal temperature of at least 170 degrees Fahrenheit. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 428

Protozoa (Dysentery) Introduced to food by carriers or contaminated water. Symptoms include severe diarrhea that can occur intermittently. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 429

Prevention of Foodborne Illnesses
Cleanliness of kitchen and equipment. Proper hand washing. Wear gloves if cooking with any hand wound. Cover and store foods to prevent microbes or animals from reaching it. Cook foods to appropriate temperatures. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 430

Prevention of Foodborne Illnesses
Limit standing time at temperatures between 40 and 140 degrees Fahrenheit. Prevent known carriers from preparing foods. Select only packages and jars that were sealed by the manufacturer. Avoid bulging cans, foods that look or smell odd, and foods showing signs of mold. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 431

Miscellaneous Food Poisoning
Ingestion of plants or animals that contain poison (mushrooms, rhubarb leaves, fish from polluted water) Cleaning agents Insecticides Drugs Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 432

Types of Allergic Reactions
Hay fever Urticaria Edema Headache Dermatitis Nausea Dizziness Asthma Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 434

Treatment of Allergies
Removal of allergen Food diary Laboratory tests Elimination diet Patient education Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 435

Elimination Diet A limited diet in which only certain foods are allowed in an attempt to pinpoint the food allergen causing the reaction. Additional foods are introduced slowly until an allergic reaction occurs. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 436

Common Food Allergens Milk Strawberries Chocolate Wheat Tomatoes Soybeans Corn Legumes Pork Eggs Tree Nuts Fish Citrus fruit Peanuts Shellfish Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 437

Teaching Considerations
Avoid microbial contamination of food supplies at home. Read food labels. Ask about ingredients of foods in a restaurant and at another person’s home. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 438

Conclusion Human ignorance or carelessness is usually the cause of food infection or poisoning. There are many safety factors related to food handling that can prevent contamination of food. Most common food allergens are milk, chocolate, eggs, tomatoes, fish, citrus fruit, legumes, strawberries, and wheat. Chapter 10 Copyright © 2003 Delmar Learning, a Thomson Learning company 439

Objectives Identify nutritional needs during pregnancy and lactation Describe nutritional needs of pregnant adolescents Modify the normal diet to meet the needs of pregnant and lactating women Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 442

Weight Gain During Pregnancy
Average weight gain is 25 to 35 pounds. Average weight gain during the first trimester is 2-4 pounds. The second and third trimester average one pound per week. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 443

Weight Gain During Pregnancy
Generally, no additional kcal are required during the first trimester. An additional 300 kcal is needed during the second and third trimesters. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 444

Prepregnancy Nutritional Needs
Research has shown that adequate prepregnancy nutrition is critical for the prevention of neural tube defects such as spina bifida. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 445

Nutritional Needs During Pregnancy
The protein requirement is increased by 20% for the pregnant woman over age 25 (25% for pregnant adolescent). No need to increase vitamin A. No increase in Vitamin D requirement for age 24 and younger; doubles for age 25 and older. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 446

Vitamin E requirement increases for all ages (from 8 to 10 g). Vitamin K requirement remains the same for women 25 and older (65 g), but dramatically increases for girls (from 45 g to 65 g). Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 447

Requirements for all the water-soluble vitamins are increased. Requirements for vitamins B and C are increased. Requirements for calcium, iron, zinc, iodine, and selenium are all increased. Iron supplements are commonly prescribed. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 448

Fulfillment of Nutritional Needs During Pregnancy
Base diet on the Food Guide Pyramid. Drink additional milk each day. Fat-free milk is best because it provides the needed nutrients without the fat and cholesterol. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 449

Fulfillment of Nutritional Needs During Pregnancy
Vitamin supplements may be prescribed. No unprescribed nutrient supplements should be taken because they may be harmful to the fetus. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 450

Concerns During Pregnancy
Nausea Constipation Heartburn Excessive weight gain Pregnancy-induced hypertension Pica Anemia Alcohol, caffeine, drugs, and tobacco Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 451

Nausea “Morning sickness” occurs most commonly in first trimester. Suggestions: Eat dry crackers or dry toast before rising Small, frequent meals Avoid food with offensive odors Avoid liquids at mealtime Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 452

Hyperemesis Gravidarum
Occurs when the nausea becomes so severe that it is life-threatening. This may require hospitalization and parenteral nutrition. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 453

Heartburn Caused by pressure on the mother’s stomach as the fetus develops. Eat small, frequent meals. Avoid spicy or greasy foods. Avoid liquids with meals. Wait at least one hour after eating to lay down and two hours before exercising. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 455

Excessive Weight Gain Reevaluate diet and eliminate food that does not fit within the Food Guide Pyramid. Drink fat-free milk. Eat clean, crisp, raw vegetables as a snack. Eat fruits and custards made with fat-free milk as desserts. Broil, bake, or boil instead of frying. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 456

Pregnancy-induced Hypertension
Formerly called “preeclampsia” or “toxemia.” Characterized by high blood pressure, presence of protein in the urine, and edema. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 457

Pregnancy-induced Hypertension
If condition persists, it may result in convulsions, coma, and death of the mother. There is a higher incidence of this disorder among mothers with inadequate diets. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 458

Pica Pica is the craving for nonfood substances such as starch, clay (soil), or ice. Soil binds with minerals making it impossible for the body to absorb them. If these substances take the place of nutrient rich foods in the diet, there can be multiple nutritional deficiencies. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 459

Anemia Anemia is a condition caused by an insufficiency of red blood cells, hemoglobin, or blood volume. Often the client with anemia feels weak and tired, has a poor appetite, and appears pale. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 460

Anemia Iron deficiency anemia is the most common form of anemia. Folate deficiency may lead to megaloblastic anemia, another form of anemia. Supplements may be prescribed. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 461

Alcohol, Caffeine, Drugs, and Tobacco
Fetal alcohol syndrome (FAS) is characterized by a growth deficiency, central nervous system dysfunction, and microcephaly (small head). Caffeine has been shown to cause birth defects in rats, but no data exists for humans. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 462

Illegal drugs can cause the infant to be born addicted. Drugs derived from vitamin A can cause fetal malformations and spontaneous abortions. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 463

Tobacco smoking is associated with low birth weights, sudden infant death syndrome (SIDS), fetal death, spontaneous abortions, and complications at birth. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 464

Diet for the Pregnant Woman with Diabetes
Nutrient requirements of the pregnant woman with diabetes are the same as for the nondiabetic pregnant woman. Dietitian should plan the diet depending on the type and number of insulin injections required. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 465

Diet for the Pregnant Woman with Diabetes
Gestational diabetics may require insulin during pregnancy. Oral hypoglycemic agents may be harmful to the fetus and should not be used. Artificial sweeteners have been found to be safe during pregnancy. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 466

Pregnancy During Adolescence
Nutritional, physical, psychological, social, and economic demands on pregnant adolescents are tremendous. High risk for pregnancy-induced hypertension and premature delivery. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 467

Pregnancy During Adolescence
Inadequate nutrition of the mother is related to both mental and physical birth defects. Much counseling and emotional support is needed. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 468

Lactation 2 to 3 weeks to establish a feeding routine. Recommended that no supplemental feedings be given during this time. Human milk is formulated to meet the nutrient needs of infants for the first 6 months of life. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 470

Lactation Does not supply iron, vitamin D, or flouride. Kcal requirements during breastfeeding increase. The Food and Nutrition Board suggests an increase of 500 kcal a day. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 471

Benefits of Breastfeeding for the Infant
Nutritional benefits: contains just the right amount of lactose, water, fatty acids, and amino acids. No babies are allergic to their mother’s milk. Human milk contains at least 100 ingredients not found in formula. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 472

Lower incidence of ear infections, diarrhea, allergies, and hospital admissions. Breast-fed babies receive antibodies from breast milk. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 473

Benefits of Breastfeeding for the Mother
Ability to quickly lose the pounds gained during pregnancy. Stimulates uterus to contract back to its original size. Breastfeeding is economical. Provides opportunity for resting. Milk is always at the right temperature and is readily available. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 475

Nutrient Requirements during Lactation
Most nutrient requirements are increased. Depends on age of the mother. Protein is the most important because it is secreted in the milk each day. Important to include fruits and vegetables rich in vitamin C. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 476

Nutrient Requirements during Lactation
Extra fat-free milk is beneficial. Increase fluid intake to replace loss. Check with obstetrician before using any medication or nutrient supplement. Caffeine may make infant irritable. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 477

Considerations for the Health Care Professional
Articles in newspapers and magazines may be inaccurate. Reeducation may be necessary. Teaching of pregnant teenagers presents the biggest challenge. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 478

Conclusion A pregnant woman is most likely to remain healthy and bear a healthy infant if she follows a well-balanced diet. Anemia and PIH are two conditions that can be caused by inadequate nutrition. Caloric and most nutrient requirements increase for pregnant and lactating women. Chapter 11 Copyright © 2003 Delmar Learning, a Thomson Learning company 479

Objectives State the effect inadequate nutrition has on an infant Identify the ingredients used in infant formulas Describe when and how foods are introduced into the baby’s diet Describe inborn errors of metabolism and their dietary treatment Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 482 482

Nutritional Requirements of the Infant
During the first year, the normal child needs about 100 kcal per kilogram of body weight each day. Infants up to 6 months of age should have 2.2 g of protein per kg of weight each day; age 6-12 months should have 1.56 g of protein per kg of weight each day. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 483 483

Nutritional Requirements of the Infant
Iron-fortified cereal is usually started at about 6 months. A vitamin K supplement is routinely given shortly after birth. Infants should not be given an excess of vitamin A or D. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 484 484

Breastfeeding Provides infant with temporary immunity to many infectious diseases. It is economical, nutritionally adequate, and sterile. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 485 485

Breastfeeding Easily digested Breastfed infants grow more rapidly during the first few months of life than formula-fed babies and have fewer infections. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 486

Breastfeeding Breast should be offered every 2 hours in the first few weeks. The infant should nurse 10-15min on each breast. Growth spurts occur at about 10 days, 2 weeks, 6 weeks, and 3 months; infant may nurse more frequently. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 487 487

Breastfeeding Indications of adequate nutrition include: The infant has six or more wet diapers per day. The infant has normal growth. The infant has one or two mustard-colored bowel movements per day. The breast becomes soft during nursing. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 488 488

Bottle Feeding The infant should be cuddled and held in an upright position. He should be burped. Formulas are developed so that they are similar to human milk in nutrient and kcal values. Synthetic milk made from soybeans may be used for sensitive or allergic infants. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 489 489

Bottle Feeding Sterile water must be used to mix formula. Infants under one year should not be given cow’s milk. Consistent temperature should be used. Infants should not be put to bed with bottle. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 491 491

Stop and Share Share with a partner your own feelings regarding breast vs. bottle-feeding. Do you support a woman who decides to breastfeed? Do you support a woman who decides to bottle feed? Could your beliefs impact the care you give? Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 492

Supplementary Foods Limit diet to breast milk or formula until the age of 4 to 6 months. Cow’s milk should be avoided until after one year of age. Solid foods should not be introduced before 4 to 6 months of age and should be done gradually. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 493 493

Supplementary Foods The typical order of introduction begins with cereal, usually iron-fortified rice, then oat, wheat, and mixed cereals. Cooked and pureed vegetables follow, then cooked and pureed fruits, egg yolk, and finally, finely ground meats. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 494 494

Supplementary Foods Between 6 and 12 months, toast, zwieback, teething biscuits, custards, puddings, and ice cream can be added. Honey should never be given to an infant because it could be contaminated with Clostridium botulinum bacteria. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 495

Supplementary Foods When the infant learns to drink from a cup, juice can be introduced. Juice should never be given from a bottle because babies will fill up on it and not get enough calories from other sources. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 496

Supplementary Foods Pasteurized apple juice is usually given first. It is recommended that only 4 oz. of 100% juice products be given because they are nutrient-dense. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 497

Indications for Readiness for Solid Foods
Ability to pull food into the mouth rather than pushing the tongue and food out of the mouth. Willingness to participate in the process. Ability to sit up without support. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 498 498

Indications for Readiness for Solid Foods
Having head and neck control. The need for additional nutrients. Drinking more than 32 ounces of formula or nursing 8 to 10 times in 24 hours. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 499 499

Special Nutritional Needs
Premature infants Cystic Fibrosis Failure to thrive Metabolic Disorders Galactosemia Phenylketonuria Maple Syrup Urine Disease Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 500 500

Premature Infants An infant born before 37 weeks gestation. The sucking reflex is not developed until 34 weeks gestation. Infants born earlier will require total parenteral nutrition, tube feedings, or bolus feedings. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 501 501

Premature Infants Other concerns include: low birth weight, underdeveloped lungs, immature GI tracts, inadequate bone mineralization, and lack of fat reserves. Many special formulas are available. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 502 502

Cystic Fibrosis An inherited disease Decreased production of digestive enzymes Malabsorption of fat Recommendation: % of diet should be from fat Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 503 503

Cystic Fibrosis Digestive enzyme is taken in pill form. There is a water-soluble form of fat- soluble vitamins that can be administered if normal levels cannot be maintained with the use of fat-soluble vitamins. Nighttime tube feedings may be indicated. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 504 504

Failure to Thrive Determined by plotting the height and weight of the infant on the growth chart. May be caused by poverty, congenital abnormalities, AIDS, lack of bonding, child abuse, or neglect. The first six months are the most crucial for brain development. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 505 505

Galactosemia A condition in which there is a lack of the liver enzyme transferase. Transferase normally converts galactose to glucose. The amount of galactose in the blood becomes toxic. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 506 506

Galactosemia Diarrhea, vomiting, edema, and abnormal liver function Cataracts may develop, galactosuria occurs, and mental retardation develops. Diet therapy: exclusion of anything containing milk from any mammal; nutritional supplements of calcium, vitamin D, and riboflavin. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 507 507

Phenylketonuria (PKU)
Lack the liver enzyme phenylalanine hydroxylase, which is necessary for the metabolism of the amino acid phenylalanine. Infants are normal at birth, but if untreated become hyperactive, suffer seizures, and become mentally retarded between 6 to 18 months. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 508 508

Phenylketonuria (PKU)
Diet Therapy: commercial formula “Lofenalac”, regular blood tests, synthetic milk for older children, avoidance of phenylalanine. Hospitals routinely screen newborns for PKU. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 509 509

Maple Syrup Urine Disease (MSUD)
Congenital defect resulting in the inability to metabolize three amino acids: leucine, isoleucine, and valine. Named for the odor of the urine of clients with the condition. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 510 510

Maple Syrup Urine Disease (MSUD)
Hypoglycemia, apathy, and convulsions occur and if not treated promptly, will result in death. Diet therapy: extremely restricted amounts of the three amino acids; a special formula and low protein diet is used; diet therapy necessary throughout life. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 511 511

Women, Infants, and Children (WIC)
A federally funded program that provides monthly food packages of infant formula or milk, cereal, eggs, cheese, peanut butter, and juice for a mother who is breastfeeding. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 512 512

Conclusion Babies must have adequate diets so that their physical and mental development are not impaired. Breastfeeding is nature’s way of feeding an infant. Formula feeding is also acceptable. Some infants have special nutritional needs. Chapter 12 Copyright © 2003 Delmar Learning, a Thomson Learning company 513

Objectives Identify nutritional needs of children aged 1 to 12 and of adolescents State the effects of inadequate nutrition during the growing years Describe eating disorders that can occur during adolescence. Evaluate the nutritive value of the fast- food products available in the United States today. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 516 516

Nutrition in Children Children who have an inadequate supply of nutrients–especially of protein–and kcal during their early years may be shorter and less intellectually able than children who receive an adequate diet. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 517

Children Aged 1-12 Once developed, poor eating habits will be difficult to change. Poor eating habits can exacerbate emotional and physical problems such as irritability, depression, anxiety, fatigue, and illness. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 518 518

Children Aged 1-12 Children’s appetites vary. As the child ages, the growth rate slows. Children’s likes and dislikes change. New foods should be introduced gradually. Snacks should be nutrient dense. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 519

Children Aged 1-12 Fats should not be limited before the age of two years. Whole milk is recommended until the age of two, but lowfat or fat-free should be served from two on. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 520 520

Children Aged 1-12 Calorie needs will depend on rate of growth, activity level, body size, metabolism, and health. Snacks are needed every 3 to 4 hours. Forcing a child to eat can cause eating disorders. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 521

Children Aged 1-12 Choking is prevalent in young children. To prevent choking, do not give children under four years of age peanuts, grapes, hot dogs, raw carrots, hard candy, or thick peanut butter. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 522

Kcal and Nutrient Needs of Young Children
Nutrient needs increase because of increase in body size. Need 2 to 3 cups of milk or equivalent in terms of calcium per day. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 523 523

Kcal and Nutrient Needs of Young Children
Minimize sweets. Limit sweetened fruit juices. Drink 1 ml of water for each kcal of food. Introduce fiber slowly. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 524 524

Childhood Obesity 25% of children are considered obese today. 85% of obese children over the age of ten will become obese adults. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 525 525

Childhood Obesity Leads to many health and social problems increased severity of asthma increased blood pressure, heart rate, and cardiac output hip and knee problems social stigma Treatment Exercise Portion and snacking control Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 526 526

What Parents Can Do Provide only healthy, nourishing foods. Limit TV and computer time. Exercise yourself. Never tell a child “he is too fat”. Learn correct portions. It is more important how often and how much is eaten rather than what. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 527 527

What Parents Can Do Never provide food as comfort or reward. Eat only at the table and at designated times. Give water rather than juice. Eat slowly. Determine if child is really hungry or just bored. Change your own bad habits. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 528 528

Adolescence Period of rapid growth that causes major changes. Physical changes like acne occur. Acne is not caused by specific foods. Adolescents typically have enormous appetites. Kcal requirements increase. Often substitute low nutrient density foods. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 529 529

Adolescence Except for Vitamin D, nutrient needs increase dramatically at the onset of adolescence. Because of menstruation, girls have a greater need for iron than do boys. Adolescents may prefer to imitate their peers. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 530 530

Adolescence Foods that are popular often have low nutrient density such as potato chips, sodas, and candy. Eating habits can be seriously affected by busy schedules, part-time jobs, athletics, social activities, and the lack of an available adult to prepare nutritious food. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 531

Adolescent Problems Related to Nutrition
Anorexia Nervosa Bulimia Overweight Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 532 532

Anorexia Nervosa A psychological disorder that causes a client to so drastically reduce kcal that the reduction disrupts metabolism. An inordinate fear of being fat. Results in hair loss, low blood pressure, weakness, amenorrhea, brain damage, and even death. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 533 533

Treatment for Anorexia Nervosa
Development of a strong and trusting relationship between client and care provider. Client must accept that weight gain and a change in body contours are normal during adolescence. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 534 534

Treatment for Anorexia Nervosa
Diet therapy Individual and family counseling Close supervision Time and patience Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 535 535

Bulimia A syndrome in which the client alternately binges and purges by inducing vomiting and using laxatives and diuretics to get rid of ingested food. Bulimics are said to fear that they cannot stop eating. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 536 536

Bulimia A bulimic usually binges on high-kcal foods such as cookies, ice cream, pastries, and other “forbidden” foods. Binging occurs when client is alone. Bulimia is not usually life-threatening, but it can irritate the esophagus and cause electrolyte imbalances, malnutrition, dehydration, and dental caries. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 537

Overweight Contributing factors include heredity, overfeeding as an infant or child, psychological factors. Treatment Evaluation by physician Discuss plan with dietitian Teach teen to understand the nutrient and kcal content of fast foods Exercise Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 539 539

Stop and Share Being overweight is particularly difficult during the adolescent period. What makes being overweight during adolescence especially difficult? Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 540

Stop and Share Being overweight during adolescence is apt to diminish the individual’s self- esteem and can exclude her or him from the normal social life of the teen years, further diminishing self-esteem. It also makes the adolescent prone to being overweight as an adult. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 541

Fast Foods Nutrient charts are often available at restaurants. Fast food is excessively high in fat and sodium, as well as kcal. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 542 542

Fast Foods Contain limited amounts of vitamins and minerals and little fiber. Nevertheless, fast food is more nutritious than sodas, cakes, and candy. Should be used with discretion in a balanced diet. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 543 543

Alcohol and the Adolescent
Alcohol is a depressant. It causes sleepiness, loss of consciousness, and even death. Abuse (overuse) of alcohol is called alcoholism. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 544 544

Affects absorption and normal metabolism of glucose, fats, proteins, and vitamins. Lack of absorption of niacin and thiamin prohibit the cells from using glucose for energy. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 545 545

Alcohol causes kidneys to excrete larger than normal amounts of water, resulting in loss of minerals. Excessive, long-term drinking can lead to liver cirrhosis, high blood pressure, and damage to heart muscle. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 546 546

Marijuana Use continues to increase among teens. Makes one hungry, especially for sweets. Lungs absorb THC, a fat-soluble substance that is transported to various body tissues for storage. May lead to the use of other drugs. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 547 547

Cocaine Highly addictive and extremely harmful. Weight loss is very common; addicts substitute the drug for food. Form that can be smoked is called “crack”. Half of crimes against property in the United States are related to the use of crack cocaine. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 548 548

Tobacco Is addictive. Can influence appetite, nutritional status, and weight. Smokers need more vitamin C because smoking alters the metabolism. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 549 549

Tobacco Low intakes of vitamin C, vitamin A, betacarotene, folate, and fiber are common among smokers. Smoking increases the risk of lung cancer and heart disease. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 550 550

Other Addictive Drugs Amphetamines cause heart, breathing, and blood pressure rates to increase. Methamphetamine is the most potent form of amphetamine. Symptoms include dry mouth, difficulty swallowing, dilated pupils, depressed appetite; as the drug wears off fatigue and depression are common. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 551 551

Other Addictive Drugs Inhalants are physically and psychologically addictive. Risks include depression, apathy, nosebleeds, headaches, eye pain, chronic fatigue, heart failure, loss of muscle control, and death. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 552 552

Dental Caries Promoted by the use of sugar in the diet. Avoid sticky sugar foods unless teeth can be brushed or rinsed immediately. Addition of fluoride to drinking water reduces the number of dental caries. Fluoride toothpaste is also helpful. Excessive fluoride can be toxic. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 553 553

Nutrition for the Athlete
The athlete needs additional water, kcal, thiamin, riboflavin, niacin, sodium, potassium, iron, and protein. Plain water is the recommended liquid for rehydration. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 554 554

“Electrolyte drinks” are useful after an athletic event but not during one. The increase in kcal depends on the activity and its length. Increased vitamin B for energy metabolism. Protein needs are not increased by physical activity. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 555 555

Increased need for potassium and sodium, which can be met by salting food to taste, bananas, and orange juice. Iron rich foods eaten with vitamin C-rich foods should satisfy extra iron requirement. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 556 556

Glycogen Loading Carboloading Sometimes used for long activities. Begins six days before an event and involves a regimen of diet and exercise to maximize the amount of glycogen in the muscles. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 557 557

Glycogen Loading For three days, the athlete eats a diet consisting of only 10% carbohydrate and mostly protein and fat as she performs heavy exercise. This depletes the current store of glycogen. The next three days, the diet is 70% carbohydrate, and the exercise is very light. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 558 558

Glycogen Loading This practice may result in an abnormal heart rate and some weight gain. It is recommended that the athlete exercise heavily and eat carbohydrates as desired. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 559

Glycogen Loading During the week before the competition, exercise should be reduced. On the day before competition, the athlete should eat a high-carbohydrate diet and rest. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 560

Young children may have poor appetites and parents may have related anxiety. The health care professional can be most helpful by exhibiting patience and understanding and by listening to the client and parents. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 561 561

Working with adolescent clients with disordered eating can be challenging. Health care professionals working with these clients should consult with the client’s psychological counselor. Parents of clients with disordered eating must be included in counseling. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 562 562

Conclusion Nutritional needs vary as children grow and develop. Nutrient needs gradually increase. Anorexia nervosa, bulimia, and obesity are problems of weight control that can occur during adolescence. Alcohol and drug abuse can be serious problems in adolescence. Chapter 13 Copyright © 2003 Delmar Learning, a Thomson Learning company 563

Objectives Identify the nutritional needs of young adults and the middle-aged Explain sensible, long-range weight control for these people Adapt menus to meet their nutritional and kcal requirements Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 566 566

Adulthood Broadly divided into three periods: young, middle, and late adulthood. Young adulthood age range is from years. Middle period ranges from about years of age. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 567

Nutrient Requirements
Growth is usually complete by age 25. Nutrient requirements of healthy adults during these years change very little. The iron requirement for women is higher than men until after menopause. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 568 568

Protein requirement for adults is 0.8 g per kilogram of body weight. Current requirement for calcium for adults from is 1,000 mg. Vitamin D requirement is 5 g per day. Both calcium and vitamin D are essential for strong bones, and both are found in milk. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 569 569

Three glasses of milk per day fulfill the calcium and vitamin D requirements. Bone loss begins slowly, at about the age of 35 to 40. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 570 570

Stop and Share You are teaching a class about rheumatoid arthritis to a group of middle aged adults. A participant asks the following question: “What diet changes can I make to prevent rheumatoid arthritis?” How do you respond? Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 571

Stop and Share Researchers have determined that diet changes have no effect on rheumatoid arthritis. Maintain a healthy diet that includes adequate calcium and protein. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 572

Stop and Share A multiple vitamin containing vitamin D and a calcium supplement should be taken daily. Omega-3 fatty acids have been helpful in reducing inflammation. Discuss with a physician. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 573

Kcal Requirements Begins to diminish after the age of 25. Basal metabolic rates are reduced by 2 to 3% a decade. Determined primarily by activity and amount of lean muscle mass. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 574 574

Nutrition Related Concerns
Eating Habits Weight Control Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 575 575

Eating Habits Food selection is often made based on concerns about weight, cost of food, or time. These habits may lead to nutrient deficiencies. People today are concerned about nutrition. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 576 576

Eating Habits Selection of food, however, is often based on convenience and flavor rather than nutritional content of food. Consequently, many people ingest more fat, sugar, salt, and high-calorie foods and less fiber and other nutrients. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 577 577

Weight Control Weight control is one of the top concerns of adults in the United States today. Most people are interested in controlling their weight. Being overweight can introduce health problems. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 578 578

Weight Control Being overweight can lead to an increased incidence of diabetes mellitus and hypertension. Overweight people are poor risks for surgery, live shorter lives, and are prone to social and emotional problems. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 579 579

Weight Control Most common cause of being overweight is energy imbalance (more calories have been taken in than were needed for energy). An intake of 3,500 kcal more than the body needs for maintenance and activities will result in one extra pound. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 580 580

Weight Control Genetics and a hypothyroid condition can also contribute to overweight condition. The best solution is increased exercise combined with reduced kcal. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 581 581

The young and middle years of life are busy. Most people feel they have too many things to do and too little time to accomplish them. Families, jobs, and social obligations lead to more responsibilities. The health care professional can help the client have hope and alert others on the team to problems that need addressing. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 582

Conclusion Although kcal requirements diminish after age 25, most nutrient requirements do not. Food must be selected with increasing care as one ages to ensure that nutrient requirements are met without exceeding the kcal requirement. Overweight can cause health problems and a weight loss program should be undertaken. Chapter 14 Copyright © 2003 Delmar Learning, a Thomson Learning company 583

Objectives Explain the nutritional and kcal needs of people 65 and over Explain the development of given chronic diseases Identify physiological, economic, and psychosocial problems that can affect a senior citizen’s nutrition Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 586

Physiological Changes
Body’s functions slow with age, and its ability to replace worn cells is reduced. The metabolic rate slows. Bones become less dense. Lean muscle mass is reduced. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 587

Eyes don’t focus on nearby objects as they once did; some grow cloudy from cataracts. Poor dentition is common. Heart and kidneys become less efficient. Hearing, taste, and smell are less acute. Immune system may be compromised if poor nutrition has been chronic. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 588

Excessive weight, certain vitamin deficiencies and the type of diet being followed may influence some types of arthritis. Eating a healthy, well-balanced diet that includes the “5 a day” fruits and vegetables, along with grain products can beneficial to those with arthritis. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 589

Digestion is affected because secretion of hydrochloric acid and enzymes is diminished. There is a decrease in the intrinsic factor synthesis, which leads to a deficiency of vitamin B12. Tone of intestines reduced resulting in constipation or, in some cases, diarrhea. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 590

Psychosocial Changes Feelings do not decrease with age. Age does not diminish the psychosocial needs of the client. Psychosocial problems can increase as one grows older Problems feeling useful, appreciated and loved Loss of self-esteem Grief Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 591

Psychosocial Changes Economic changes include retirement that may result in decreased income. Loss of spouse with resulting loneliness and possible financial impact can occur. Problems like these can diminish a person’s appetite and ability to shop and cook. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 592

Sidestepping Potential Problems
Healthy eating habits throughout life, an exercise program suited to one’s age, and social activities that please can prevent or delay physical deterioration and psychological depression during the senior years. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 593

Food-drug interactions must be monitored closely in the elderly. Dairy products should not be consumed within two hours of taking the antibiotic tetracycline or it will not be absorbed. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 594

A person taking a blood clot-reducing drug such as coumadin or warfarin (often called blood thinners) needs to consume vitamin K-rich food in moderation as they counteract blood thinners. The antioxidant vitamins are not to be taken with blood clot-reducing medications because they tend to thin the blood. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 595

Nutritional Requirements
Follow a modified food guide pyramid for individuals 70 and older. Despite the physical changes the body undergoes after the age of 51 or so, only a few of the recommendations for people in that age category are less than those for younger people. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 596

Protein requirement remains at the average 50 g per day for women and 63 g for men. This is based on 0.8 g per kg of body weight. After age 65, it may be advisable to increase one’s daily protein intake to 1.0g per kg of body weight. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 597

Vitamin requirements do not change after the age of 51, except for a slight decrease in the RDAs for thiamin, riboflavin, and niacin because of decreased kcal intake. The need for iron is decreased after age 51 in women because of menopause. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 598

The kcal requirement decreases approximately 2 to 3% a decade because metabolism slows and activity is reduced. The Nutrition Screening Initiative checklist was developed to identify those at “no nutritional risk,” “moderate nutritional risk,” and “high nutritional risk.” Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 599

Food Habits of Senior Citizens
Established food habits may be especially difficult to change. The following may cause difficulties in food selection and preparation: Decreased income during retirement Physical disability Inadequate cooking facilities Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 600

Anorexia caused by grief, loneliness, boredom, or difficulty in chewing can decrease food consumption. Many senior citizens consume diets deficient in protein; vitamins C, D, B6, B12, and folate; and the minerals calcium, zinc, iron, and sometimes kcal. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 601

Variety and nutrient-dense foods should be encouraged. Water is important to help prevent constipation, to maintain urinary volume, and to prevent dehydration. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 602

Food Fads and the Elderly
Senior citizens may spend money on unnecessary vitamins, minerals, and special honey, molasses, bread, milk, and other foods that food faddists may promote as important. The money could be better spent on foods from the Food Guide Pyramid. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 603

Stop and Share Some older people are consciously or unconsciously searching for eternal life, if not youth. Food faddists may pick this segment of the population to profit from their ignorance. Some older people with chronic disease may hope that products will bring them relief. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 605

Osteoporosis Condition in which the amount of calcium in bones is reduced, making them porous. Bone density scan can be done with a special X-ray to determine if one has osteoporosis. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 606

Osteoporosis Sedentary life coupled with a diet deficient in calcium, vitamin D, and fluoride, and estrogen loss contribute to the condition. Estrogen replacement therapy (ERT), 1,500 mg of calcium, and exercise are possible preventative measures. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 607

Osteoporosis Another possible cause of osteoporosis may be a diet containing excessive amounts of phosphorus, which can speed bone loss. Sodas and processed foods contain phosphorus, and their consumption is increasing as milk consumption is decreasing in the United States. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 608

Arthritis Disease that causes the joints to become painful and stiff. Regular use of aspirin or anti- inflammatory drugs may help relieve the pain, but have side effects such as bleeding in the stomach lining. There is no cure for arthritis. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 609

Cancer Diets consistently high in fat, or low in fiber and vitamin A may contribute to cancer. Research about the role of nutrition in cancer development continues. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 610

Diabetes Mellitus Chronic disease that develops when the body does not produce sufficient amounts of insulin or does not use it effectively for normal carbohydrate metabolism. Diet is very important in the treatment of diabetes mellitus. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 611

Hypertension High blood pressure can lead to strokes. It is associated with diets high in salt or possibly low in calcium. Most Americans ingest from 2 to 6 times the amount of salt needed each day. The earlier a person reduces salt intake, the better that person’s chances of avoiding hypertension. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 612

Heart Disease Heart attack and stroke are the major causes of death in the United States. Arteries become blocked (occluded), thereby preventing the normal passage of blood. Atherosclerosis: plaque, a fatty substance containing cholesterol, accumulates in the walls of the artery. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 613

Effects of Nutrition Cumulative over many years. Effects of a lifetime of poor eating habits cannot be cured overnight. Prevention should begin in childhood. Nutrition can be used to help stabilize the condition of a client who has a chronic disease. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 614

Diets for Senior Citizens
Plan around the Food Guide Pyramid. When special health problems exist, the normal diet should be adapted to meet individual needs. Federal government provides states with funds to serve senior citizens hot meals at noon in senior centers. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 615

Diets for Senior Citizens
The federal government also provides transportation for those who are otherwise unable to reach the senior center for the meal. Meals-on-Wheels project provides food for homebound individuals. Participating people pay according to ability. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 616

Each client is an individual with individual needs. It is important to remember that these clients have feelings worth addressing. The incapacitation that can accompany old age is a terrible indignity, and these clients deserve special care. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 617

Conclusion The elderly segment of the population continues to increase. The nutritional needs of this group is a growing concern. Many of the chronic diseases of the elderly could be delayed or avoided by maintaining good nutrition throughout life. Chapter 15 Copyright © 2003 Delmar Learning, a Thomson Learning company 618

Objectives Discuss the causes and dangers of overweight Discuss the causes and dangers of underweight Identify foods suitable for high-kcal diets and those suitable for low-kcal diets Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 621

“Rule of Thumb” Method for determining desired weight. Males assume 106 pounds for the first 5 feet (60 inches) and add 6 pounds for each inch over 60. Females assume 100 pounds for the first 5 feet (60 inches) and add 5 pounds for each inch over 60. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 622

“Rule of Thumb” Large-boned individuals of both sexes increase the first sum by 10%. Small-boned individuals of both sexes decrease the first sum by 10%. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 623

BMI Body Mass Index Medical standard used to define obesity. Used to determine whether a person is at health risk from excess weight. Obtained by dividing weight in kilograms by height in meters squared. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 625

BMI Fewer health risks are associated with a BMI range of 19 to 25 than with a BMI above or below that range. A BMI greater than 25 indicates obesity and health risks. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 626

Fat Distribution Fat in the abdominal cavity is associated with a greater risk for hypertension, diabetes, coronary heart disease, type 2 diabetes, and certain types of cancer than fat in the thigh, buttocks, and hip area. Pear-shaped body has a lower risk for disease than does apple-shaped body. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 627

Overweight and Obesity
Overweight is a serious health hazard. It increases susceptibility to diabetes mellitus and hypertension. No one cause for obesity. Energy imbalance is a significant cause. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 628

Theories of Weight Loss
Fat cell theory: obesity develops when the size of fat cells increase. Set point theory: everyone has a set point or natural weight at which the body is so comfortable that it does not allow for deviation. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 629

Healthy Weight Not everyone can match the “healthy weight target”, which is a BMI of 19 to 25. A “healthy weight” may be the weight at which one is eating nutritiously, is exercising, has no health problems, and is free from disease. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 630

Dietary Treatment for Obesity
Reduce one’s food intake Weight-reduction (low-kcal) diet Base on the Food Guide Pyramid Use exchange lists to control kcal value Counting fat grams is another method Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 631

Dietary Treatment for Obesity
Reduction of 3,500 kcal results in weight loss of one pound. No more than 1 to 2 pounds lost in a week. Do not reduce below 1,200 kcal per day. Diet should consist of 15 to 20% protein, 45 to 55% carbohydrate, 30% or less fat. Key is changing eating habits. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 632

Food Selection Substitution foods: Fat-free milk for evaporated milk Evaporated fat-free milk for evaporated milk Yogurt or low-fat sour cream for regular sour cream Lemon juice and herbs for heavy salad dressings Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 633

Food Selection Substitution foods: Fat-free salad dressings for regular salad dressings Fruit for rich appetizers or desserts Bouillon instead of cream soups Water-packed canned foods rather than those packed in oil or syrup Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 634

Low-kcal Foods Black coffee Plain tea Cantaloupe Strawberries Lettuce Bean sprouts Cabbage Mushrooms Asparagus Tomatoes Zucchini Cauliflower Broccoli Celery Cucumbers Spinach Red/green peppers Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 635

Cooking Methods Broiling, grilling, baking, roasting, poaching, boiling Trim fat from meat before cooking Skim fat from the tops of soups and meat dishes Avoid addition of extra butter or margarine Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 636

Exercise Excellent adjunct to any weight-loss program Lowers set point Dancing, jogging, bicycling, skiing, rowing, power walking Such exercise helps tone muscles, burns kcal, increases the BMR so food is burned faster, and is fun for the participant. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 637

Stop and Share Your client would like to use behavior modification for weight loss. What recommendations could you give your client? Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 638

Stop and Share Weigh regularly, but not daily. Don’t wait too long between meals. Join a support group and go to meetings during and after the weight loss. Eat slowly. Use a small plate. Use low-kcal garnishes. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 639

Stop and Share Eat whole, fresh foods and avoid processed foods. Treat yourself with something besides food. Anticipate problems (banquets and holidays) and “undereat” slightly before and after. “Save” some kcal for snacks and treats. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 640

Stop and Share If something goes wrong, don’t punish yourself by eating. If no weight loss for 1 week, realize it may be from exercising (production of lean muscle) or water retention. If binging occurs, don’t punish yourself. Go for a walk, movie, or museum. Call a friend. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 641

Stop and Share Adapt family meals to suit your needs. Don’t make a production of your diet. Avoid the heavy-kcal items. Limit yourself to a spoonful of something too rich for a weight-loss diet. Substitute something you like that is low in kcal. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 642

Stop and Share Take small portions. Eat vegetables and bread without butter or margarine. Include daily exercise. Park further from work and walk. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 643

Crash Diet Intended to cause a very rapid rate of weight reduction. Results in an initial rapid weight loss. Weight loss caused by a loss of body water and lean muscle mass rather than body fat. Plateau period follows in which weight does not decrease. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 644

Yo-Yo Effect Disillusionment occurs and may lead to “eating binge”. This can result in regaining weight. Causes dieter to try another weight-loss diet, creating a yo-yo effect. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 645

Popular Reducing Diets
Severely limit the foods allowed, providing a danger of nutrient deficiencies over time. May provide too much cholesterol and fat. May contain an excess of protein which puts too great a demand on the kidneys and may be life threatening if sufficient potassium is not provided for the heart. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 646

Surgical Treatment of Obesity
May be used when obesity becomes morbid (damaging to health) Two types Gastric bypass Stomach banding Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 647

Gastric Bypass Most of the stomach is stapled off, creating a pouch in the upper part. The pouch is attached directly to the jejunum. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 648

Stomach Banding Stomach is also stapled but to a slightly lesser degree than in gastric bypass. Food moves to the duodenum, but the outlet from the upper stomach is somewhat restricted. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 649

Gastric Bypass and Stomach Banding

Surgery for Obesity Common complications include diarrhea, electrolyte and fluid imbalances, liver problems, kidney stones, and bone disease. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 651

Pharmaceutical Treatment of Obesity
Miracles are still in short supply. Amphetamines (pep pills) depress appetite. Effectiveness reduced within a short time. Causes nervousness and insomnia. Can become habit-forming. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 652

Over-the-Counter Diet Pills
Intended to reduce appetite, not thought to be effective. Contain caffeine, artificial sweeteners, and phenylpropanolamine, which can damage blood vessels and should be avoided. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 653

Diuretics and Laxatives
Do not cause a reduction of body fat, only water. An excess can result in fluid and electrolyte imbalance. Laxatives can become habit-forming. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 654

Sibutramine (Meridia)
Suppresses appetite. Used in conjunction with a reduced calorie diet. Indicated for those with a BMI of at least 30. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 655

Orlistat (Xenical) Blocks one-third of the fat in food from being digested. Reduced calorie diet with no more than 30% fat should be followed. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 656

Underweight Treated by a high-kcal diet or high-kcal diet combined with psychological counseling. It can be as difficult for an underweight person to gain weight as it is for an overweight person to lose it. Diet should be based on the Food Guide Pyramid. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 657

Underweight 3,500 kcal added to normal weekly intake to gain 1 pound per week. An extra 500 kcal taken in each day. Easily digested food is recommended. Avoid fried and bulky foods. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 658

Conclusion The health care professional must support and encourage the client regarding weight control. Excessive weight endangers health and should be lost using a restricted-kcal diet based on the Food Guide Pyramid. Excess weight is caused by energy imbalance. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 659

Conclusion Underweight is also dangerous to health, and psychological counseling as well as a high-kcal diet may be required for proper treatment. Behavior modification must be an essential component of any weight-loss or weight- gain regimen. Chapter 16 Copyright © 2003 Delmar Learning, a Thomson Learning company 660

Objectives Describe diabetes mellitus and identify the types Describe the symptoms of diabetes mellitus Explain the relationship of insulin to diabetes mellitus Discuss appropriate nutritional management of diabetes mellitus Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 663

Diabetes mellitus Glucose is the primary source of energy for the body. Glucose is transported by the blood, and its entry into the cells is controlled by insulin. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 664

Insulin Secreted by the beta cells of the islets of Langerhans in the pancreas gland. When there is inadequate production of insulin or the body is unable to use the insulin it produces, glucose cannot enter the cells and it accumulates in the blood, creating hyperglycemia. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 665

Symptoms Polyuria: excessive urination Polydipsia: excessive thirst Polyphagia: excessive appetite Loss of weight, weakness, fatigue Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 666

Complications Ketones: substances to which fatty acids are broken down in the liver. Ketoacidosis: condition in which acids from ketones accumulate. May lead to diabetic coma which can result in death if the client is not treated quickly with fluids and insulin. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 667

Complications Atherosclerosis is a major cause of death in diabetics. Retinopathy is the leading cause of blindness in the United States. Kidney disease resulting in dialysis. Nerve damage (neuropathy) is not uncommon. Infections, especially of the urinary tract are frequent problems. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 668

Etiology The cause of diabetes is unconfirmed although it is believed that it may be hereditary. Environmental factors may also play a role in the development of diabetes. Viruses or obesity may precipitate the disease. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 669

Classification Type 1: insulin-dependent diabetes mellitus Type 2: non-insulin-dependent diabetes mellitus Gestational diabetes: diabetes in pregnancy Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 670

Type 1 Formerly juvenile-onset diabetes mellitus. Occurs between the ages of 1 and 40. 10 to 20% of all diabetes cases. Secrete little, if any, insulin. Clients become insulin dependent requiring both insulin injections and a carefully controlled diet. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 671

Type 2 Previously called adult-onset diabetes. Usually occurs after age 40, new evidence suggests screening at age 25. Obesity epidemic has increased prevalence among young adults. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 672

Type 2 Treatment: diet, exercise, oral glucose- lowering medication (may or may not need insulin). Goals of medical nutrition therapy include maintaining healthy glucose, blood pressure and lipid levels; weight reduction. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 673

Gestational Diabetes Occurs between sixteenth and twenty- eighth week of pregnancy. Insulin required if not responsive to diet and exercise. Usually, gestational diabetes disappears after the infant is born. Diabetes can develop 5 to 10 years after the pregnancy. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 674

Treatment Goals: Control blood glucose levels Provide optimal nourishment for the client Prevent symptoms and thus delay complications Normal blood glucose levels are 70 to110 mg/dl. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 675

Treatment Regimes Diet alone Diet combined with glucose-lowering medication Diet combined with insulin Exercise combined to any of the above Regularly monitor blood glucose levels in addition to any of the above Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 676

Nutritional Management
Client’s kcal needs will depend on age, activities, lean muscle mass, size and REE. Recommended: Carbohydrates 50 to 60% of the kcal 40 to 50% from complex carbohydrates 10 to 20% from simple sugars Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 677

Nutritional Management
It is the total amount of carbohydrates eaten that affects blood sugar levels rather than the type. Fats should be limited to 30% of total kcal. Proteins provide from 15 to 20% of total kcal. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 678

Carbohydrate Counting
Newest method for teaching a diabetic client how to control blood sugar with food. The starch/breads, milk, and fruits have all been put under the heading of “carbohydrates.” Exchange lists are utilized in carbohydrate counting as well as traditional meal planning. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 679

Diets Based on Exchange Lists
Most commonly used method of diet therapy is based on exchange lists. These lists were developed by the American Diabetes Association in conjunction with the American Dietetic Association. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 680

Foods within each list contain approximately equal amounts of kcal, carbohydrates, protein, fats. One food on a particular list can be substituted for any other food on that particular list and still provide the client with the prescribed types and amounts of nutrients and kcal. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 681

The amounts of nutrients and kcal on one list are not the same as those on any other list. The diet is given in terms of exchanges rather than as particular foods. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 682

Stop and Share Use the exchange lists in your text starting on page 323 to identify the number of each exchange in the following meal. Turkey sandwich made with 4 oz extra lean turkey ham and 1 Tbsp reduced- calorie mayonnaise on reduced-calorie bread, 1.5 oz of pretzels, and iced tea. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 683

Stop and Share Two slices reduced calorie bread: 1 starch exchange Turkey ham: 4 meat exchanges Mayonnaise: 1 fat exchange Pretzels: 2 starch exchanges Iced tea: Free (Total: 3 starch, 4 meat, 1 fat exchange) Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 684

Fiber High fiber intake appears to reduce the amount of insulin needed because it lowers blood glucose. It also appears to lower the blood cholesterol and triglyceride levels. High fiber may mean 25-35g of dietary fiber a day. Increase water when increasing fiber. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 685

Alternative Sweeteners
Saccharin has been shown to produce bladder cancer in rats when used in large quantities. Approved by FDA: Aspartame–made from amino acids; does not require insulin for metabolism. Sucralose–sweetener made from sugar molecule. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 686

Dietetic Foods Use of diabetic foods is generally a waste of money and can be misleading to the client. Often the containers of foods will contain the same ingredients as containers of foods prepared for the general public. These foods will contain carbohydrates, fats, and proteins that must be calculated in the total day’s diet. Read the label! Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 687

Alcohol Not recommended for diabetic clients. Limited use sometimes allowed if approved by physician. Some diabetic clients who use hypoglycemic agents cannot tolerate alcohol. Include in diet plan if used. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 688

Exercise Type 2: exercise helps improve weight control, glucose levels, and the cardiovscular system. Type 1: exercise can complicate glucose control. If done, should be on regular basis, and considered carefully as meals are planned to avoid hypoglycemia. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 689

Insulin Therapy Clients with type 1 diabetes must have injections of insulin everyday to control blood glucose levels. Must be injected because it is a protein and would be digested if swallowed. Human insulin most common and preferred; made synthetically. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 690

Insulin Therapy Beef or pork insulin available. Not as commonly used because antibodies in them make them less pure than human. Insulin classified by action: very rapid-, rapid-, intermediate- and long-acting. Intermediate types work within 2 to 8 hours and are effective 24 to 28 hours. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 691

Insulin Therapy Shorter and longer-acting insulin may be given together and more than one injection a day may be required. Insulin pumps are now available and can deliver short-acting continuous dose and pre-meal boluses. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 692

Insulin Reactions Insulin reaction, or hypoglycemic episode, can result from too much insulin. Symptoms include headache, blurred vision, tremors, confusion, poor coordination, eventual unconsciousness. Brain damage, coma, or death may result. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 694

Treatment for Insulin Reactions
Conscious clients may be treated by giving them a glucose tablet, a sugar cube, or a beverage containing sugar followed by a complex carbohydrate. Unconscious clients require intravenous treatment with dextrose and water. Diabetic clients should carry identification. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 695

Considerations for Health Care Professional
If diet is followed, medication is taken, and time is allowed for sufficient exercise and rest, one can live a near- normal life. Emphasize importance of eating all of the prescribed food. Meals should be eaten at regular times, and clients should read labels. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 696

Conclusion The diabetic diet is used in treating diabetes mellitus, a metabolic disease caused by the improper functioning of the pancreas. Serious complications, including death, can occur if condition is left untreated. Treatment includes diet, medication, and exercise. Chapter 17 Copyright © 2003 Delmar Learning, a Thomson Learning company 697

Objectives Identify factors that contribute to heart disease Explain why cholesterol and saturated fats are limited in some cardiovascular conditions Identify foods to avoid or limit in a cholesterol-controlled diet Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 700

Objectives Explain why sodium is limited in some cardiovascular conditions Identify foods that are limited or prohibited in sodium-controlled diets Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 701

Cardiovascular Disease
Affects heart and blood vessels. Leading cause of death and permanent disability in the United States. Can be acute (sudden) or chronic. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 702

Acute: myocardial infarction (MI, heart attack) Chronic: develops over time, loss of heart function Heart may or may not maintain circulation. Heart may beat faster and enlarge to compensate. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 703

Congestive heart failure occurs when the heart cannot maintain blood circulation to all body tissues. The heart muscle (myocardium), the valves, the lining (endocardium), the outer covering (pericardium), or the blood vessels may be affected by heart disease. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 704

Arteriosclerosis and Atherosclerosis
Arteriosclerosis: arteries become thick and hard making the passage of blood difficult and sometimes impossible. Atherosclerosis: affects inner lining of arteries where deposits of cholesterol, fats, and other substances accumulate over time, thickening and weakening artery walls. Deposits are called plaque. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 705

Atherosclerosis Plaque may cause a reduced blood flow beyond the obstruction; ischemia occurs. Ischemia may cause pain. Angina pectoris: Chest pain; may radiate down left arm. If lumen of vessel narrows completely in a coronary artery, a heart attack occurs. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 706

Atherosclerosis Coronary artery bypass graft (CABG): procedure to bypass circulation around a clogged artery. Cerebrovascular accident (CVA): blood flow to brain is blocked or blood vessel bursts (stroke). Peripheral vascular disease: vessels in extremities affected. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 708

Risk Factors Contributory factors: Obesity Diabetes mellitus Male sex Heredity Personality type (ability to handle stress) Age (risk increases with age) Sedentary lifestyle Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 710

Hyperlipidemia: Medical Nutritional Therapy
Primary treatment for hyperlipidemia. Involves reducing the quantity and types of fats and often kcal in the diet. American Heart Association guidelines: blood cholesterol 200 mg/dl or less is desirable 200 to 239 mg/dl is borderline high 240 mg/dl and greater is high Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 711

Hyperlipidemia: Medical Nutritional Therapy
American Heart Association recommendations for prevention: Adult diets contain less than 200 mg of cholesterol per day No more than 30% of kcal from fat; maximum of 7% from saturated fats, 8% from polyunsaturated fats, 15% from monounsaturated fats Proteins 12 to 20% of kcal, and carbohydrates 50 to 55% of kcal Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 712

Stop and Share Your client has been given a very low fat diet to follow. The client expresses to you that it is almost impossible to follow this diet. What recommendations would you suggest? Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 713

Stop and Share A diet very low in fat will seem unusual and highly unpalatable. It takes 2 to 3 months to adjust to a low-fat diet. Change should be made gradually if physician allows. Provide client with information about the fat content of foods and methods to prepare it. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 714

Stop and Share Encourage client to select whole, fresh foods and to prepare them without addition of fat. Lean meat should be selected and all visible fat removed. Use fat-free milk and fat-free skim cheeses. Gradually introduce grams of fiber. Discuss challenges with a dietitian and the M.D. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 715

Cholesterol-lowering Agents
If appropriate blood lipid levels cannot be attained within 3 to 6 months by use of fat-restricted diet alone, the physician can prescribe a cholesterol-lowering drug. Example: simvastatin (Zocor) Client teaching: Zocor interacts with grapefruit and its juice; total avoidance is necessary. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 716

Myocardial Infarction
Caused by blockage of a coronary artery supplying blood to heart. Heart tissue beyond blockage dies. Causes: atherosclerosis, hypertension, abnormal blood clotting, infection such as that caused by rheumatic fever (damages heart valves). Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 717

After the attack, the client is in shock. Fluid shift occurs, and client may be thirsty. Client should be NPO (nothing by mouth). IV fluids may be given. After several hours, client may begin to eat. Liquid diet usually recommended first 24 hours. Then, a low-cholesterol, low-sodium diet. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 718

Foods should not be extremely hot or cold. Food that is easy to chew and digest prescribed. Percentage of energy nutrients will be based on particular needs of the client. Sodium limited to prevent fluid overload. Restriction on caffeine the first few days after an MI. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 719

Congestive Heart Failure
Injury to the heart muscle occurs from atherosclerosis, high BP, rheumatic fever. When damage is extreme and the heart cannot provide adequate circulation, the amount of oxygen taken in is insufficient for body needs. Shortness of breath is common and chest pain can occur on exertion. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 720

Tissues retain fluid that would normally be carried off by the blood. Sodium builds up, and more fluid is retained, resulting in edema. Heart beats faster and enlarges to compensate. Death can occur in severe cases. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 721

Body tissues do not receive sufficient amounts of nutrients. Edema may mask the problems of malnutrition and underweight. Fluid restriction may be ordered. Diuretics aid in the excretion of water and sodium, and a sodium-restricted diet typically prescribed. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 722

Diuretics can cause excessive loss of potassium. Blood potassium levels should be carefully watched to prevent hypokalemia which can upset the heartbeat. Fruits, especially oranges, bananas, and prunes are excellent sources of potassium. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 723

Hypertension Chronically high blood pressure. Essential, or primary hypertension: 90% of cases; cause is unknown. Secondary hypertension: 10% of cases; caused by another condition. Causes of secondary hypertension include kidney disease, problems of the adrenal glands, use of oral contraceptives. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 724

Hypertension Blood pressure commonly measured is that of the artery in the upper arm. Sphygmomanometer is used to measure it. Systolic pressure: top number taken as the heart contracts. Diastolic pressure: taken when the heart is resting. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 725

Hypertension Measured in millimeters of mercury (mm Hg). Hypertension can be diagnosed when, on several occasions, the systolic pressure is 140 mm Hg or more and the diastolic pressure is 90 mm Hg or more. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 726

Hypertension Contributes to heart attack, stroke, heart failure, and kidney failure. “Silent disease” because sufferers can be asymptomatic. Frequency increases with age and is more prevalent among African Americans. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 727

Hypertension Heredity and obesity are predisposing factors in hypertension. Smoking and stress also contribute to hypertension. Weight loss usually lowers blood pressure and, consequently, clients are often placed on weight-reduction diets. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 728

Hypertension Sodium and fluid collect in body tissue, causing edema, extra pressure is placed on the blood vessels. Sodium-restricted diet, often accompanied by diuretics, can be prescribed to alleviate this condition. Increasing fruits and vegetables to 6 to 10 servings per day helps to lower blood pressure. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 729

Dietary Treatment Weight loss Sodium-restricted diet Diuretics When diuretics are prescribed together with a sodium-restricted diet, the client may lose potassium via the urine and, thus, be advised to increase the amount of potassium-rich foods in the diet. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 730

Sodium-Restricted Diets
Regular diet in which the amount of sodium is limited. Used to alleviate edema and hypertension. Food and Nutrition Board recommends daily intake of sodium be limited to no more than 2,400 mg (2.4 g). Board itself set a safe minimum at 500 mg/day for adults. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 731

Impossible to have a diet totally free of sodium. Meats, fish, poultry, dairy products, and eggs all contain substantial amounts of sodium naturally. Cereals, vegetables, fruits, and fats contain small amounts of sodium naturally. Water contains varying amounts of sodium. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 732

Many products contain sodium; check labels. Some over-the-counter medicines contain sodium. Physician’s permission should be obtained before using any medication or salt substitute. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 733

Adjustment to Sodium Restriction
Most people are accustomed to salt in their food and transition to sodium-restricted diet may be difficult. It will help the client if the reduction in sodium can be gradual. Remind the client of the numerous herbs, spices, and flavorings allowed. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 734

Most of the cardiac clients will be told they must reduce the fats, sodium, and sometimes, the amount of kcal in their diets. Help the cardiac client want to learn how to help himself or herself via nutrition. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 735

Conclusion Cardiovascular disease represents the leading cause of death in the United States. May be acute, as in myocardial infarction, or chronic, as in hypertension and atherosclerosis. Hypertension may be a symptom of another disease. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 736

Conclusion Cholesterol is associated with atherosclerosis and a low-cholesterol diet or a fat-restricted diet might be prescribed. The health care professional can encourage the client to maintain a healthy weight, exercise, limit salt and fat intake, and avoid smoking to reduce the risk of heart disease. Chapter 18 Copyright © 2003 Delmar Learning, a Thomson Learning company 737

Objectives Describe, in general terms, the work of the kidneys. Explain why protein is restricted for renal clients. Explain why sodium and water are sometimes restricted for renal clients. Explain why potassium and phosphorus are sometimes restricted for renal clients. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 740

Kidneys Kidneys excrete wastes, maintain volume and composition of body fluids, and secrete certain hormones. They filter the blood, cleanse it of waste products, and recycle other, usable, substances so that the necessary constituents of body fluids are constantly available. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 741

Kidneys One million working parts called nephrons. Glomerulus is the filtering unit. The kidneys maintain both the composition and the volume of body fluids. They maintain fluid balance, acid-base balance and electrolyte balance. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 742

Kidneys Waste materials sent via 2 tubes called ureters from the kidneys to the urinary bladder. 1.5 liters of urine excreted per day. Waste materials include end products of protein metabolism (urea, uric acid, creatinine, ammonia, and sulfates), excess water and nutrients, dead renal cells, and toxic substances. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 743

Kidneys Oliguria: urinary output less than 500 ml/day. Kidneys unable to adequately eliminate waste products–can result in renal failure. Kidneys indirectly stimulate the bone marrow to produce red blood cells. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 744

Types of Renal Disorders
Initially caused by infection, degenerative changes, diabetes mellitus, cardiovascular disorders, cysts, renal stones, trauma. When severe, renal failure may result. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 745

Acute Renal Failure Acute renal failure occurs suddenly and may last a few days to a few weeks. Caused by another medical problem such as a serious burn, a crushing injury, or cardiac arrest. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 746

Chronic Renal Failure Develops slowly, number of functioning nephrons constantly diminishing. Uremia is a condition in which protein wastes that should normally have been excreted are instead circulating in the blood. Symptoms include nausea, headache, coma, convulsions. Severe renal failure will result in death unless dialysis used. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 747

Nephritis Inflammatory diseases of the kidneys. Caused by infection, degenerative processes, or vascular disease. Glomerulonephritis is a nephritis affecting the capillaries in the glomeruli. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 748

Nephrosclerosis Hardening of renal arteries. Caused by arteriosclerosis and hypertension. Usually occurs in older people, sometimes develops in young diabetic clients. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 749

Polycystic Kidney Disease
Relatively rare, hereditary disease. Cysts form and press on the kidneys. Kidneys enlarge and lose function. Although people with this condition have normal kidney function for many years, renal failure may develop near the age of 50. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 750

Nephrolithiasis Stones develop in the kidneys. Stones classified according to their composition–calcium oxalate, uric acid, cystine, calcium phosphate, and magnesium ammonium phosphate (known as struvite). Associated with metabolic disturbances and immobilization of the client. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 751

Dietary Treatment of Renal Disease
Extremely complicated. Intended to reduce the amount of excretory work demanded of the kidneys while helping them maintain fluid, acid-base, and electrolyte balance. Clients with chronic renal failure may have protein, sodium, potassium and phosphorus restricted. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 752

Sufficient calories necessary: 25 to 50 kcal per kilogram of body weight. Energy requirements should be fulfilled by carbohydrates and fat. Protein increases the amount of nitrogen waste the kidneys must handle. Diet may limit protein to 40 grams based on glomerular filtration rate and weight. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 753

Sodium may be limited if the client tends to retain it. Fluids are typically restricted for renal clients. Calcium supplements may be prescribed. Vitamin D may be added and phosphorus limited, to prevent osteomalacia. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 754

Potassium may be restricted in some clients because hyperkalemia tends to occur in end stage renal disease (ESRD). Excess potassium can cause cardiac arrest. Renal clients often have an increased need for vitamins B, C, and D, and supplements are often given. Iron is commonly prescribed. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 755

Dialysis Done be either hemodialysis or peritoneal dialysis. Hemodialysis requires permanent access to the bloodstream through a fistula. Hemodialysis is done 3 times a week for 3- 5 hours at a time. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 756

Dialysis Peritoneal dialysis makes use of the peritoneal cavity. Less efficient than hemodialysis. Treatments usually last about 10 to 12 hours a day, 3 times a week. Complications include peritonitis, hypotension, weight gain. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 757

Diet During Dialysis Dialysis clients may need additional protein. Amount must be carefully controlled. A client on hemodialysis requires 1.0 to 1.2g of protein per kilogram of body weight to make up for losses during dialysis. A client on peritoneal dialysis requires 1.2 to 1.5g protein per kilogram body weight. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 758

Diet During Dialysis 75% of this protein should be high biological value (HBV) protein, found in eggs, meat, fish, poultry, milk, and cheese. Potassium is usually restricted. A typical renal diet could be written as “80-3-3” which means 80g protein, 3g sodium, and 3g potassium daily. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 759

Diet During Dialysis Healthy people ingest from 2,000 to 6,000 mg of potassium per day. Daily intake allowed clients in renal failure is 3,000 to 4,000 mg. End stage renal disease clients intake allowed is 1,500 to 2,500 mg per day. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 760

Diet After Kidney Transplant
Need for extra protein or for the restriction of protein. Carbohydrates and sodium may be restricted. Additional calcium and phosphorus may be necessary if there was substantial bone loss before the transplant. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 761

Stop and Share A client with renal disease is on a potassium restriction of 3,000 mg. What recommendations would you give the client? Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 762

Stop and Share Regulate intake by making careful choices. Milk is normally restricted to ½ cup a day because it is high in potassium. Suggest use of potassium content charts to select low potassium foods. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 763

Stop and Share Low potassium (< 150 mg/serving) fruits include: Applesauce Berries Figs Fruit cocktail Grapes Lemon, lime Nectors Mandarin oranges Peaches Pears Plums Rhubarb Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 764

Dietary Treatment of Renal Stones
Treatment varies based on type of stone. Clients should drink lots of fluid. Eat a well-balanced diet. Once stones have been analyzed, specific diet modifications may be indicated. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 765

Calcium Oxalate Stones
A diet low in calcium can reduce the risk of calcium oxalate renal stones. In fact, higher dietary calcium intake may decrease the incidence of renal stones for most people. Reduce level of oxalate, which is found in beets, wheat bran, chocolate, tea, rhubarb, strawberries, spinach. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 766

Uric Acid Stones Purine-rich foods restricted. Purines are the end products of nucleoprotein metabolism. Found in meats, fish, poultry, organ meats, anchovies, sardines, meat extracts, broths. Usually associated with gout, GI diseases that cause diarrhea, and malignant disease. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 767

Cystine Stones Cystine is an amino acid. Cystine stones may form when the cystine concentration in the urine becomes excessive because of a hereditary metabolic disorder. Increase fluids and recommend an alkaline-ash diet. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 768

Struvite Stones Composed of magnesium ammonium phosphate. Sometimes called infection stones because they develop following urinary tract infections caused by certain microorganisms. Low phosphorus diet is often prescribed. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 769

Client with renal disease has a lifelong challenge. Develop a trusting relationship with the client. Help motivate clients to learn how to manage their nutritional requirements and help the dietitian assist them. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 770

Conclusion Kidneys rid the body of wastes, maintain fluid, electrolyte, and acid-base balance, and secrete hormones. Entire body is affected by kidney disease. Diet therapy extremely complex. Untreated severe kidney disease can result in death unless client receives dialysis or kidney transplant. Chapter 19 Copyright © 2003 Delmar Learning, a Thomson Learning company 771

Objectives Explain the uses of diet therapy in the gastrointestinal disturbances discussed here Identify the foods allowed and disallowed in the therapeutic diets discussed Adapt normal diets to meet the requirements of clients with these conditions Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 774

GI Tract Digestion and absorption of food occurs in the gastrointestinal tract. Primary organs include mouth, esophagus, stomach, small and large intestine. Liver, gallbladder, and pancreas are accessory organs. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 775

Dyspepsia Indigestion, discomfort in the digestive tract, can be physical or psychological in origin. “Heartburn”, bloating, pain, regurgitation. Psychological stress treatment includes: Finding relief from underlying stress Allowing sufficient time to relax and enjoy meals learning to improve eating habits Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 776

Esophagitis Irritating effect of acidic gastric reflux on mucosa of esophagus. Heartburn, regurgitation, and dysphagia. Chronic, or reflux esophagitis is caused by recurrent gastroesophageal reflux (GER) Causes include hiatal hernia, reduced lower esophogeal sphincter pressure, abdominal pressure, or recurrent vomiting. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 777

Hiatal Hernia A part of the stomach protrudes through the diaphragm into the thoracic cavity. The hernia prevents the food from moving normally along the digestive tract. Food moves back into the esophagus, creating a burning sensation (heartburn), and sometimes food will be regurgitated into the mouth. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 778

Nutrition Therapy for Hiatal Hernia
Small, frequent meals; well-balanced diet. Avoid irritants such as carbonated beverages, citrus fruits and juices, tomato products, spicy foods, coffee, pepper, and some herbs. Avoid foods that relax sphincter such as alcohol, garlic, onion, oil or peppermint and spearmint, chocolate, cream sauces, gravies, margarine, butter, and oil. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 780

Nutrition Therapy for Hiatal Hernia
If client is obese, weight loss may be recommended. Avoid lying down 2 to 3 hours after eating. When lying down, sleep with head and upper torso elevated. Surgery may become necessary. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 781

Peptic Ulcers Erosion of the mucous membrane. May occur in the stomach (gastric ulcer) or the duodenum (duodenal ulcer); cause unclear. Factors that predispose: genetics, high secretion of hydrochloric acid, stress, excessive use of aspirin or ibuprofen, smoking, Helicobacter Pylori bacteria. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 782

Peptic Ulcers Symptoms include gastric pain (burning relieved with food or antacids), hemorrhage (usually requires surgery). Treatment: drugs such as antibiotics and cimetidine to kill bacteria and inhibit acid secretion respectively. Antacids neutralize excess acid. Rest and counseling. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 783

Peptic Ulcers Sufficient low-fat protein should be provided. No less than 0.8g of protein per kilogram of body weight recommended. Avoid caffeine containing beverages, alcohol, aspirin, smoking. Well-balanced diet of three meals a day. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 784

Diverticulosis/Diverticulitis
Diverticulosis is an intestinal disorder characterized by little pockets in sides of the large intestine where food gets trapped. Diverticulitis can result from bacteria breeding in these pockets. Cause is diet lacking sufficient fiber. Diet treatment includes clear liquid diet, then low-residue progressing to high fiber over several weeks. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 786

Residue-controlled Diets
Residue is the solid part of feces. Residue is made up of all the undigested and unabsorbed parts of food (including fiber), connective tissue in animal foods, dead cells, and intestinal bacteria and their products. Most of this residue is composed of fiber. Diets can be adjusted to increase or decrease fiber and residue. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 788

The High-fiber Diet 30g or more of dietary fiber is believed to help prevent diverticulosis, constipation, hemorrhoids, and colon cancer. A high-fiber diet is often 25 to 35g. Coarse and whole grain breads and cereals, bran, all fruits, vegetables (especially raw), and legumes. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 789

Low-residue Diet 5 to 10g of fiber a day is intended to reduce the normal work of the intestines by restricting the amount of dietary fiber and reducing food residue. Low-fiber or residue-restricted diets may be used in cases of severe diarrhea, diverticulitis, ulcerative colitis, and intestinal blockage and in preparation for and immediately after intestinal surgery. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 790

Stop and Share A client with severe diarrhea has been placed on a low-residue diet. What kinds of foods would you recommend for the client? Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 791

Stop and Share Milk, buttermilk (limit to 2 cups/day) Cottage cheese and some mild cheeses Butter and margarine Eggs, except fried Tender chicken, fish, sweetbreads, ground beef, and ground lamb Soup broth Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 792

Stop and Share Cooked, mild-flavored vegetables without coarse fibers Refined breads and cereals, white crackers, macaroni, spaghetti, and noodles. Custard, sherbet, vanilla ice cream. Coffee, tea, cocoa, carbonated beverage. Salt, sugar, small amount of spices as permitted. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 793

Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) is a chronic condition causing inflammation in the GI tract. Two examples include ulcerative colitis and Crohn’s disease. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 794

Treatment of Inflammatory Bowel Disease
Anti-inflammatory drugs Medical nutrition therapy Low-residue diet 100g of protein, additional kcal, vitamins, and minerals Severe cases may require total parenteral nutrition (TPN) Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 798

Ileostomy or Colostomy
Clients with inflammatory bowel disease may require a surgical opening, a stoma, from the body surface to the intestine for the purpose of defecation. Ileostomy: from ileum to abdomen surface. Colostomy: from colon to abdomen surface. May be temporary or permanent. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 799

Ileostomy or Colostomy
Clients with ileostomies have a greater than normal need for salt and water because of excess losses. A vitamin C supplement is recommended, and, in some cases, a B12 supplement may be needed. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 800

Celiac Disease Nontopical sprue or gluten sensitivity Characterized by malabsorption of virtually all nutrients. Thought to be hereditary. Symptoms include diarrhea, weight loss, and malnutrition. Stools are foul-smelling, light-colored, and bulky. Cause unknown. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 801

Celiac Disease Elimination of gluten from diet gives relief. A gluten-controlled diet is used to treat celiac disease. Gluten is a protein found in barley, oats, rye, and wheat. Difficult to avoid these products. Rice and corn may be used. Read labels. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 802

Cirrhosis Liver disease may be acute or chronic. Cirrhosis is a general term referring to all types of liver disease characterized by cell loss. Alcohol abuse is the most common cause of cirrhosis. Other causes include congenital defects, infections, or other toxic chemicals. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 803

Cirrhosis Liver does regenerate, however, the replacement during cirrhosis does not match the loss. Complications include hypertension, anemia, hemorrhage in the esophagus. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 804

Cirrhosis Dietary treatment of cirrhosis provides at least 25 to 35 kcal or more, and 0.8 to 1.0g of protein per kilogram of weight each day. Supplements of vitamins and minerals are usually needed. In advanced cirrhosis, 50 to 60% of the kcal should be from carbohydrates. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 805

Cirrhosis Sometimes cirrhosis causes ascites. Sodium and fluids may be restricted. If there is bleeding in the esophagus, fiber can be restricted to prevent irritation of the tissue. Smaller feedings will be better accepted than larger ones. No alcohol is allowed. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 806

Hepatitis Inflammation of the liver. Caused by viruses or toxic agents such as drugs and alcohol. Hepatitis A virus (HAV) contracted through contaminated drinking water, food, and sewage via a fecal-oral route. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 807

Hepatitis Hepatitis B virus (HBV) and hepatitis C virus (HCV) are transmitted through blood, blood products, semen, and saliva. Hepatitis B and C can lead to chronic active hepatitis (CAH), which is diagnosed by liver biopsy. Chronic active hepatitis can lead to liver failure and end stage liver disease (ESLD). Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 808

Hepatitis Symptoms may include nausea, headache, fever, fatigue, tender and enlarged liver, anorexia, and jaundice (yellow cast of the skin and eyes). Weight loss can be pronounced. Treatment involves bed rest, plenty of fluids, diet therapy. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 809

Diet Therapy for Hepatitis
Diet should provide 35 to 40 kcal per kilogram of body weight. Most kcal should be provided by carbohydrates; moderate amounts of fat; and if the necrosis has not been severe, up to 70 to 80grams of protein for cell regeneration. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 810

Diet Therapy for Hepatitis
If the necrosis has been severe and the proteins cannot be properly metabolized, they must be limited to prevent the accumulation of ammonia in the blood. Clients may prefer frequent, small meals rather than three large ones. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 811

Cholecystitis and Cholelithiasis
Being female, obesity, total parenteral nutrition (TPN), very-low-calorie diets for rapid weight loss, the use of estrogen, and various diseases of the small intestine are frequently associated. Cholecystitis: Inflammation of gallbladder Cholelithiasis: Gallstones Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 812

Inhibit the flow of bile and cause pain. Symptoms include pain, which can be severe, indigestion, and vomiting (particularly after the ingestion of fatty foods). Treatment may include medication to dissolve the stones and diet therapy. Surgery may be indicated. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 813

Diet therapy includes abstinence during acute phase. Followed by clear liquid diet and, gradually, a regular but fat-restricted diet. Fats allowed range from 40 to 45 grams a day. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 814

Pancreatitis Inflammation of the pancreas. May be caused by infections, surgery, alcoholism, biliary tract (includes bile ducts and gallbladder) disease, or certain drugs. May be acute or chronic. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 815

Pancreatitis Symptoms include abdominal pain, nausea and steatorrhea (abnormal amounts of fat in the feces). Malabsorption (particularly of fat-soluble vitamins) and weight loss. If islets of Langerhans are destroyed, diabetes mellitus may result. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 816

Pancreatitis During acute pancreatitis, the client is nourished strictly parenterally. Later, when the client can tolerate oral feedings, a liquid diet consisting mainly of carbohydrates is given because, of these 3 nutrients, carbohydrates have the least stimulatory effect on pancreatic secretions. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 817

Pancreatitis As recovery progresses, small, frequent feedings of carbohydrates and protein with little fat or fiber are given. Vitamin supplements may be given. Alcohol is forbidden in all cases. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 818

Conclusion A wide variety of therapeutic diets are used for clients with GI disturbances. Peptic ulcers: drugs, avoidance of alcohol and caffeine. Diverticulosis: high-fiber diet. Diverticulitis: gradual progression from clear liquid to high-fiber diet. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 819

Conclusion Ulcerative colitis: low-residue diet combined with high protein and high kcal. Cirrhosis: substantial, balanced diet, with occasional restrictions of fat, protein, salt, or fluids. Hepatitis: full, well-balanced diet, although protein may be restricted. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 820

Conclusion Cholescystitis and cholelithiasis: fat- restricted diet and, in cases of overweight, a kcal-restricted diet as well. Pancreatitis: TPN to individualized diet as tolerated. Chapter 20 Copyright © 2003 Delmar Learning, a Thomson Learning company 821

Section 3 Medical Nutrition Therapy

Chapter 21 Diet and Cancer

Objectives Discuss how nutrition can be related to the development or the prevention of cancer State the effects of cancer on the nutritional status of the host Describe nutritional problems resulting from the medical treatment of cancer Describe nutritional therapy for cancer clients Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 824

Cancer Cancer is the second leading cause of death in the United States. It is a disease characterized by abnormal cell growth and can occur in any organ. Cancerous tumors are malignant, affecting the structure and consequently the function of organs. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 825

Cancer The mortality rate for cancer clients is high, but cancer does not always cause death. Oncology is the study of cancer. An Oncologist is a physician who specializes in cancer. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 826

Causes of Cancer Precise etiology of cancer unknown. Heredity, viruses, environmental carcinogens, and possibly emotional stress may contribute to its development. Cancer is not inherited, but some families appear to have a genetic predisposition for it. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 827

Causes of Cancer Environmental carcinogens include radiation (x-rays, sun, nuclear wastes), certain chemicals (ingested in food, water or touched by skin) and certain substances that are breathed in (tobacco smoke and asbestos). Carcinogens cause cancer after repeated exposure. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 828

Causes of Cancer Viruses linked to cancer: Epstein Barr, hepatitis B, and herpes simplex II. Epstein Barr: nasopharyngeal cancer, T-cell lymphoma, Hodgkin’s disease and gastric carcinoma Hepatitis B: liver cancer Herpes Simplex II: cervical and uterine cancer Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 829

Classifications of Cancer
Majority of all cancers fall under these headings: carcinomas, sarcomas, lymphomas, and leukemias. Skin cancer is becoming more prevalent. There are three types of skin cancer: basal cell, squamous cell, and melanoma. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 830

Relationships of Food and Cancer
Both good and bad relationships between food and cancer exist. Carcinogens include nitrates in cured and smoked foods such as bacon and ham. Regular ingestion associated with stomach and esophagus cancer. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 831

High-fat diets associated with uterine, breast, prostate, and colon cancers. Excessive caloric intake associated with gallbladder and endometrial cancer. Smoking and drinking alcohol associated with lung, mouth, pharynx, and esophagus cancer. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 832

Diets high in fiber help protect against colorectal cancer. Diets rich in vitamin C may protect against stomach and esophagus cancer. Diets high in vitamin A may protect against lung, bladder, and larynx cancer. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 833

Flavonoids, phenols, and indoles are phytochemicals. These are substances that occur naturally in plant foods and are thought to be anticarcinogenic. Eat five or more servings of fruits and vegetables each day. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 834

Legumes such as soybeans, dried beans, and lentils contain vitamins, minerals, protein, and fiber and may protect against cancer. High intakes of soy foods are associated with a decreased risk of breast and colon cancer. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 835

An immune system that has been damaged—possibly through malnutrition—may be a contributing factor in the development of cancer. Excessive protein and fat intake, however, may be a factor in the development of cancer of the colon. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 836

The Effects of Cancer Unexplained weight loss, weakness, anorexia. Loss of muscle tissue and hypoalbuminemia. Sense of taste and of smell becomes abnormal. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 837

The Effects of Cancer Satiated earlier than normal. Abnormal insulin production with hyperglycemia. Hypercalcemia, renal stones, impaired kidney function Cachexia: severe malnutrition and body wasting. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 838

Treatment of Cancer Surgical removal, radiation, chemotherapy, or a combination of these methods used to treat cancer. Side effects of these treatments can affect nutrition. These include xerostomia (dry mouth) and dysphagia (difficulty in swallowing). Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 839

Treatment of Cancer Tooth decay and loss of teeth sometimes occurs. Radiation and chemotherapy may depress appetite. Anorexia (loss of appetite), nausea, vomiting, and diarrhea can lead to fluid and electrolyte imbalances. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 840

Nutritional Care Kcal needs of the cancer client are greater than before the illness. Clients on high-protein and high-kcal diets tolerate the side effects of therapy and higher doses of drugs better than those who cannot eat normally. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 841

Nutritional Care Clients can form aversions to food making anorexia worse. To help with aversions: Hold chemotherapy 2 to 3 hours before and after meals Include favorite foods served attractively in familiar ways Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 842

Nutritional Care If chewing is a problem, use a soft diet. For diarrhea, use a low-residue diet. High-protein, high-kcal diets and plenty of fluids recommended for clients undergoing radiation or chemotherapy. 45 to 50 kcal per kg of body weight per day. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 843

Nutritional Care Carbohydrates and fat will be needed to provide energy and spare protein for tissue building and the immune system. 1.0 to 1.2g of protein per kg of body weight a day. Malnourished clients may need from 1.3 to 2.0g of protein per kg of body weight a day. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 844

Nutritional Care Vitamins and minerals are essential. During chemotherapy and radiation therapy the recommendation is to eliminate vitamin A and vitamin E in supplemental form and in the diet. Intake of these vitamins may prevent cancer cells from self-destructing and work against cancer therapy. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 845

Nutritional Care Encourage food that will increase appetite. Foods brought from home Cold foods may be more appealing than hot foods Milk, cheese, eggs, and fish may be more appealing than meat (can taste bitter) Add sugar if foods are not sweet tasting Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 846

Nutritional Care Salad dressings, gravies, sauces, and syrups appropriately served on foods can be helpful for dry mouth. Several small meals may be better tolerated than three large meals. Use drugs to control nausea and pain. Nutritional supplements may be needed. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 847

Stop and Share A client with cancer may feel that comments to encourage eating are depressing reminders of the cancer and the situation. How can the health care professional be helpful to the client? Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 848

Stop and Share At appropriate time, explain why it is important that the client eat. Encourage the client to eat foods the client enjoys. Recommend the client avoid eating at the time of day nausea is likely to occur. Refrain from food that gives off odors that contribute to nausea. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 849

Conclusion Cancer is a disease characterized by abnormal cell growth. Energy needs increase because of the hypermetabolic state and the tumor’s need for energy nutrients. Surgery, radiation, and chemotherapy can cause side effects that affect nutrition. Chapter 21 Copyright © 2003 Delmar Learning, a Thomson Learning company 850

Objectives Describe the body’s reactions to stress and relate them to nutrition Explain the special dietary needs of surgical and burn clients Discuss enteral and parenteral nutrition Explain the special dietary needs of clients with fever and infection Explain the special dietary needs of AIDS clients Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 853

Homeostasis Homeostasis is a state of physical balance; a stable condition. Normally, the body operates in a state of homeostasis. When the body experiences the trauma of surgery, severe burns, or infections, this balance is upset. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 854

Homeostasis During its response to physical stress, the body signals the endocrine system, which activates a self-protective, hypermetabolic response. Surgery, burns, and infections can create stress. Nutrition plays an important role in the lives of clients undergoing this stress. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 855

Nutritional Care of Surgery Clients
Surgery stresses the client. If the surgery is elective, nutritional status should be evaluated before surgery. Extra protein, carbohydrates, vitamins, and minerals may be needed. In cases of overweight, improved nutritional status includes weight reduction before surgery whenever possible. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 856

Nutritional Care of Surgery Clients
Clients will usually be NPO (nothing by mouth) after midnight the night before surgery. This ensures that the stomach contains no food, which could be regurgitated and then aspirated during surgery. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 857

Nutritional Care After Surgery
In most cases, intravenous solutions are given first 24 hours after surgery. Solutions contain water, 5 to 10% dextrose, electrolytes, vitamins, and medications as needed. Maximum kcal supplied by solutions is 400 to 500 kcal per 24-hour period. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 858

Estimated daily kcal requirement for adults after surgery is 35 to 45 kcal per kilogram of body weight. A high-protein diet of 80 to 100g a day may be recommended. Extra minerals and vitamins are needed. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 859

Stop and Share Your client weighs 192 pounds and has just had major surgery. How many kcal will the client require in a 24-hour period? Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 860

Stop and Share First, calculate the client’s weight in kilograms. 192 lbs  2.2 kg/lb = kg Next, multiply the client’s weight in kg by the number of kg/lb (35, then 45) to get range. 87kg x 35kcal/kg = 3045 87kg x 45kcal/kg = 3915 Client needs between 3,045-3,915 kcal/day Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 861

When peristalsis returns, ice chips may be given and, if they are tolerated, a clear liquid diet can follow. Normally in postoperative cases, clients proceed from the clear-liquid diet to the regular diet. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 862

The average client will be able to take food within 1 to 4 days after surgery. Sometimes following gastric surgery, dumping syndrome occurs within 15 to 30 minutes after eating. Characterized by dizziness, weakness, cramps, vomiting, and diarrhea. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 863

Dumping Syndrome Caused by food moving too quickly from the stomach into the small intestine. To prevent dumping syndrome, the diet should be high in protein and fat, and carbohydrates should be restricted. Gradually reintroduce complex carbohydrates. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 864

Dumping Syndrome Fluids should be limited to 4 ounces at meals. Divide total daily food intake and serve as several small meals in an attempt to avoid overloading the stomach. Some clients do not tolerate milk well after gastric surgery. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 865

Tube Feeding Enteral nutrition includes the forms of feeding that bring nutrients directly into the digestive tract. Tube feedings may be necessary in clients due to unconsciousness, surgery, stroke, severe malnutrition, or extensive burns. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 866

Tube Feeding Nasogastric tube (NG) inserted through the nose and into the stomach or small intestine. Used for periods of 6 weeks or less. Gastrostomy (opening into the stomach) or jejunostomy (opening into the jejunum) may be done surgically if feeding is needed for longer than 6 weeks. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 867

Tube Feeding Numerous commercial formulas available for tube feeding. Polymeric formulas (1-2 kcal/ml) contain intact proteins, carbohydrates, and fats that require digestion. Used for clients that can digest and absorb nutrients normally. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 868

Tube Feeding Elemental, or hydrolyzed formulas (1.0 kcal/ml) contain the products of digestion of proteins, carbohydrates, and fats, and are lactose-free. Used for clients who have limited ability to digest or absorb nutrients. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 869

Tube Feeding Modular formulas ( kcal/ml) can be used as supplements to other formulas or for developing customized formulas for certain clients. Not nutritionally complete by themselves. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 870

Tube Feeding Methods of administration: Continuous: On-going over 16- to 24-hour period Intermittent: At night, with food eaten during the day Bolus: Given over a 15-minute period Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 871

Problems Associated with Tube Feeding
The osmolality of a liquid substance means the number of particles per kilogram of solution. When a formula with high osmolality reaches the intestine, the body may draw fluid from the blood to dilute the formula. Weakness, diarrhea can occur. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 872

Problems Associated with Tube Feeding
Aspiration can occur (some of the formula enters the lung), causing the client to develop pneumonia. Tube may become clogged, or client may pull the tube out. Placement of tube should be checked with an X-ray to decrease possibility of aspiration. Keep head of bed elevated. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 873

Parenteral Nutrition The provision of nutrients intravenously. Used if the gastrointestinal tract is not functional or if normal feeding is not adequate for the client’s needs. Total parenteral nutrition (TPN) or hyperalimentation is when parenteral nutrition is used to provide total nutrition. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 874

Parenteral Nutrition Peripheral vein used for nutrient solutions needed for two weeks or less. Central vein used for TPN needed for an extended period of time. High blood flow facilitates quick dilution of highly concentrated TPN reducing risk of phlebitis and thrombosis. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 875

Complications of Parenteral Nutrition
Infection at site of catheter can cause infection of blood called sepsis. Bacterial or fungal infections can develop in the solution if unrefrigerated for over 24 hours. Abnormal electrolyte levels, phlebitis, or blood clots can occur. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 876

Loss of skin surface leads to enormous losses of fluids, electrolytes, and proteins in cases of serious burns. Fluids and electrolytes are replaced by intravenous therapy immediately to prevent shock. Glucose is not included in these fluids for the first 2 to 3 days after the burn, to reduce the risk of hyperglycemia. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 877

Enormous increase in energy is needed for the healing process to occur. Protein needs can be as high as 1.5 to 3.0 or more grams per kilogram of weight, and fat intake, 15 to 20% of nonprotein calories. A high-protein, high-kcal diet is used. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 878

Nutrition Therapy for Burn Clients
There is an increased need for vitamin C and zinc for healing. Vitamin B is needed for the metabolism of the extra nutrients. The badly burned client needs sufficient fluids to help kidneys hold the unusual load of wastes in solution and to replace those lost. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 879

Nutritional Care of Fevers and Infections
Fever is a hypermetabolic state in which each degree of fever on the Fahrenheit scale raises the basal metabolic rate (BMR) 7%. If extra kcal are not provided during fever, the body first uses its supply of glycogen, then its stored fat, and finally its own muscle tissue for energy. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 880

Protein intake should be increased because of infections (sepsis). Minerals are needed to help build and repair body tissue and to maintain acid- base, electrolyte, and fluid balance. Extra kcal are needed for the increased metabolic rate. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 881

Extra vitamins are also necessary for the increased metabolic rate and to help fight the infection causing the fever. Extra liquid is needed to replace that lost through perspiration and possibly vomiting and diarrhea, which can accompany infection. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 882

Nutritional Care of the AIDS Client
HIV invades the T cells, which are white blood cells that protect the body from infections. When the T cells cannot function normally, the body has no resistance to opportunistic infections. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 883

Opportunistic infections are caused by other microorganisms that are present but do not affect people with healthy immune systems. HIV infection ultimately leads to acquired immune deficiency syndrome (AIDS), which is incurable and fatal. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 884

Persons diagnosed as being HIV-positive should have a baseline nutrition and diet assessment by a registered dietitian. Unhealthful eating habits can be corrected at an early stage of the disease, and future nutritional needs explained. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 885

AIDS clients experience serious protein- energy malnutrition (PEM) and thus, body wasting. This may be referred to as HIV wasting syndrome, which results in hypoalbuminemia and weight loss. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 886

When possible, medications should be given after meals to reduce the chance of nausea. Sores in the mouth or esophagus can make eating painful, and soft foods may be better tolerated than others. Taste can be affected. Avoid spicy, highly acidic, extremely hot or cold foods. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 887

Additional sugar and flavoring may increase the acceptability of liquid supplements. Because of the nausea and diarrhea, sufficient fluids are essential. Tube feeding may be necessary if client has difficulty swallowing or simply cannot eat. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 888

Causes of Nutrient Loss in AIDS
Anorexia Cancer Diarrhea Increased metabolism due to fever Certain medications Malabsorption caused by cancer or diarrhea Protein energy malnutrition Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 889

Causes of Anorexia in AIDS
Medications: Cause nausea, vomiting Oral infections: Diminish saliva, alter taste, cause mouth pain Altered taste: Changes or exaggerates flavors Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 890

Causes of Anorexia in AIDS
Fever, pain: Depresses appetite Depression: Depresses appetite Dysphagia: Makes swallowing difficult Dementia: May cause client to forget to eat Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 891

Stop and Share Give medications after meals. Offer soft food. Avoid spicy, acidic, and extremely hot or cold foods. Serve frequent, small meals. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 893

Stop and Share Add sugar and flavorings to liquid supplements. Take advantage of the “good” days and offer any food the client tolerates. Talk with the client to help ease concerns about finances, family, and friends. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 894

Conclusion Surgery, burns, fevers, and infections are traumas that cause the body to respond hypermetabolically. This response creates the need for additional nutrients at the same time that the injury causes a loss of nutrients. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 895

Conclusion Care must be taken to provide extra fluid, proteins, kcal, vitamins, minerals, and carbohydrates as needed in these situations. When surgery is elective, nutritional status should be improved before surgery. When food cannot be taken orally, enteral or parenteral nutrition should be used. Chapter 22 Copyright © 2003 Delmar Learning, a Thomson Learning company 896

Objectives Describe how illness and surgery can affect the nutrition of clients Identify and describe three or more nutrition-related health problems that are common among elderly clients needing long-term care Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 899

Objectives Demonstrate correct procedures for feeding a bedridden client Explain the importance of adapting the family’s meal to suit the client’s nutritional requirements Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 900

Nutritional Care Fever, nausea, fear, depression, chemotherapy, and radiation can destroy appetite. Vomiting, diarrhea, chemotherapy, radiation, and some medications can reduce or prevent absorption of nutrients. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 901

Protein Energy Malnutrition
When the increased needs for energy and protein are not met by food intake, the body must use its stores of glycogen and fat. Body breaks down its own tissues to provide protein for energy. Protein-energy malnutrition can be a problem among hospitalized clients. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 902

Protein Energy Malnutrition
PEM can delay wound healing, contribute to anemia, depress the immune system and increase susceptibility to infections. Symptoms of PEM include weight loss and dry, pale skin. Iatrogenic malnutrition is malnourishment as a result of hospitalization. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 903

Improving the Client’s Nutrition
Formal nutritional assessments should be made on a regular basis. All members of the health care team should be alert to signs of malnutrition every day. Listen to client’s concerns and watch reaction to food served. Include dietitian in plan of care. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 904

Feeding the Client In the home, the family menu should serve as the basis of the client’s meal whenever possible. Omit or add certain foods as necessary. Vary the method of preparation if needed. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 905

Serving the Meal When serving food at the bedside, tray should be lined with a pretty cloth or paper liner. Attractive dishes should be used. Food should be arranged attractively. Utensils arranged conveniently. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 906

Serving the Meal Serve water, as well as another beverage. Serve food at proper temperature. Give client the opportunity to use the bedpan and to wash before the meal is served. Client should be in a comfortable position. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 907

Serving the Meal Any unpleasant sights should be removed. Pleasant conversation during preparation can improve the client’s mood. Tray should be placed so that it is easy for the client to feed self. If client needs help, prepare items by opening containers and anticipating needs. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 908

Serving the Meal Client should be given sufficient time to eat. If meal is interrupted, warm food should be re-heated. Help client brush teeth after meal. Document intake per facility policy. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 909

Feeding the Client Sit near the side of the bed. Small amounts of food should be placed toward the back of the mouth with a slight pressure on the tongue with the spoon or fork. Clients should not be fed with a syringe. If paralyzed, food and straw should be placed on nonparalyzed side of the mouth. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 910

Feeding the Client Allow client to help self as much as possible. If client begins to choke, help her or him sit up straight. Do not give food or water while the client is choking . Client’s mouth should be wiped as needed. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 911

Feeding the Client A client diagnosed with dysphagia will require a specialized diet. Depending upon the swallowing abnormality, the client may need pureed foods with either thin or thickened liquids. A dysphagic client should not use straws. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 912

Feeding the Blind Client
Arrange the food as if the plate were the face of a clock. Use a pattern for preparing the meal, so the client knows where each item will be each time. People who are blind usually feel better when they can help themselves. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 913

Plate as a Face of a Clock

Physical Problems of the Institutionalized Elderly
Majority of people 85 and over have at least one chronic disease such as arthritis, osteoporosis, diabetes mellitus, cardiovascular disease, mental disorder. These conditions affect their attitudes, physical activities, appetites and, thus, nutritional status. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 915

PEM is a major problem for this population. Anemia can develop and contribute to fatigue, confusion and depression. Sufficient animal protein and vitamin C should be provided in the diet. Pressure ulcers (bedsores) can develop in bedridden clients. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 916

Healing of pressure ulcers requires treatment of the ulcer, relief of the pressure, a high-kcal diet with sufficient protein, vitamin C and zinc supplements. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 917

Constipation can be caused by inadequate fiber, fluid, or exercise. Other causes include medication; reduced peristalsis; or former abuse of laxatives. Treatment includes increasing fluid, fiber, and exercise. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 918

Diarrhea can be caused by lack of muscle tone in the colon. An increase of fiber in the diet combined with supplemental vitamins and minerals may be helpful. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 919

The sense of smell declines with age and the appetite diminishes. Xerostomia (dry mouth) can be caused by disease or medications. Drinking water, eating frequent small meals, and chewing sugar-free gums or candies may be helpful. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 920

Dysphagia (difficulty swallowing) can result from a stroke, closed head trauma, head or neck cancer, surgery, or Alzheimer’s and other diseases. Many dysphagia clients must have thickened liquids. Dysphagia clients should always be in an upright position when eating. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 921

Conclusion Illness and surgery can have devastating effects on client’s nutritional status. PEM can be a significant problem in hospitals. Bedridden client should be given the bedpan and allowed to wash hands before meal. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 922

Conclusion Client should be encouraged to feed self. However, help should be offered and needs anticipated. The client who is blind can eat more easily if food is arranged in a set pattern on the plate. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 923

Conclusion Provide pleasant conversation and atmosphere. Record type of diet, time of meal, client’s appetite, and type and amount of food eaten. Nutrition-related health problems in the elderly can sometimes be relieved with proper treatment. Chapter 23 Copyright © 2003 Delmar Learning, a Thomson Learning company 924

Nutrition and Diet Therapy 8th Edition

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