Diet Therapy

Karen Malt, MSN, RN

Diets and Diet Modifications

 Nutritional Screening must be done within 24 hours

of admission to an acute care facility. A health care
technician or a nurse may utilize a series of
questions, which rates a client’s potential nutritional
risk.
 Changes in weight, appetite, N/V, dysphagia,
and/or disease state are reviewed. If a client has
a positive screen in these areas, a client may be
deemed at risk nutritionally. Clients found to be
at risk must have a assessment done by a
registered dietician.
Diets and Diet Modifications
 The nutritional Screening by the RD may include;
 Height/ weight, BMI, weight history
 Laboratory values
 Food intake information
 Potential food/drug interactions
 Mastication/swallowing ability
 Client’s ability to feed him or herself
 Bowel and bladder function
 Evaluation for the presence of pressure ulcers
 Food allergies/intolerance
 Food preferences/ cultural and religious beliefs, presence of
severe burns, infection, body consumption, learning barriers
Diets and Diet Modifications

 Nutrient Delivery Decision Making Tree –

 See Lutz, Mazur, Litch (2015) page 240
Diets and Diet Modifications

 Calories - The energy needed to raise the

temperature of 1 kilogram of water through 1 °C,
equal to one thousand small calories and often used
to measure the energy value of foods.
 Calorie Restriction (CR), or caloric restriction, or
energy restriction, is a dietary regimen that reduces
calorie intake without incurring malnutrition or a
reduction in essential nutrients.
 Calorie Increase – A dietary regimen that increases
caloric intake.
Diets and Diet Modifications

http://
www.mc.vanderbilt.edu/documents/cqa/files/Modified%20Diets%20Handout
s.pdf
 Clear liquid diet: Strained orange juice or lemonade (no pulp), apple,
grape and cranberry juice, tea, black coffee, plain gelatin, popsicles,
clear broth.
 Full liquid diet: Coffee, tea, cream, milk, milkshakes, fruit and
vegetable juices, sodas, Cream of Wheat, Cream of Rice, Coco Wheats,
pureed soups, Gelatin (Jell-O), whipped topping, custard-style yogurt,
pudding.
Diet and Diet Modifications

 High Fiber diet - is a diet high in non-digestible parts of plants,

which is fiber. Fiber is found in fruits, vegetables, whole grains, and
legumes. Insoluble fiber increases stool bulk, increases transit time of
food in the bowel and decreases constipation and the risk of colon
cancer.

 Low Fiber Diet - A low-fiber diet restricts foods high in fiber

(vegetables, fruits, grains). As a result, the amount of undigested
material passing through your large intestine is limited and stool bulk is
lessened. A low-fiber diet may be recommended for a number of
conditions or situations.
Nutrient Delivery

 Enteral Nutrition – The delivery of formula (which includes breast

milk to infants) into a functioning GI tract through a tube.
 Continuous- The instillation of liquid nutrition without
interruption. Always recommended for formulas delivered
directly into the small intestine. One recommended rate is
30-50 mL/hour, increasing daily by 25 mL/hour to the rate
necessary to meet energy needs. Gives the client’s GI tract
a chance to adjust to the formula and helps to prevent
complications that an occur due to tube feedings. Flush
tube with 30mL of water every 4 hours and after GRV
checks and medication administration. Flush with as little
water as possible in infants and children. Sterile water
should be used in immunosuppressed clients. Allow no
more than a 4 hour hang time for each bag of formula.
Feeding pump is required.
Nutrient Delivery

 Intermittent – The gradual instillation of

liquid nourishment four to six times per day
over 30 – 40 minutes with or without a pump.
Clients tolerate intermittent feedings much
better than bolus feedings because these
feedings more closely mimic normal eating
behavior. The tube should be flushed after each
feeding to minimize bacterial growth and
prevent contamination. Many clients prefer
intermittent because their mobility is not
continually prohibited with a pump.
Nutrient Delivery

 Bolus – The instillation of liquid nourishment in less

than 30 minutes four to six times per day. Giving a
volume of feeding solution by gravity via syringe over
approximately 15 minutes. A client is fed only 4 – 6 times
per day. Feedings given by this method are frequently
poorly tolerated, and clients complain of abdominal
discomfort, nausea, fullness, and cramping. Some clients
tolerate bolus feedings after a period of adjustment in
which the volume is slowly increased. Clients on bolus
feedings should not recline for 2 hours after a feeding.
Tubes should be irrigated after each feeding to prevent
contamination. The client with normal gastric function
can usually tolerate 500 mL of formula at each feeding.
Nutrient Delivery
 Parenteral Nutrition – Nutrients are delivered to the client through the
veins (Intravenously). PN is normally used in acute care settings.
Review circumstances for use on page 323 Lutz, Mazur, Litch 2015.
 Peripheral Parenteral Nutrition (PPN) – means to feed the client via
a vein away from the center of the body in a line terminating in a
peripheral site.
 Central Parenteral Nutrition (CPN) – the client is fed via a central
vein. Clients are also fed via a central line that has been inserted
peripherally and threaded into the subclavian or jugular veins. This is
called a peripherally inserted central catheter or a PICC line.
 NOTE: CPN, PPN, PICC can all be used to provide partial or total daily
nutritional requirements. Clients who should not be fed through the
GI tract are candidates for CPN, PPN, or PICC.
Nutrient Delivery
 Peripheral Parenteral Nutrition – (PPN) – routine in some health care
institutions. IV solutions usually containing water, dextrose,
electrolytes, and occasionally other nutrients, are used to maintain fluid,
electrolyte, and acid-base balance. IV solutions do contain kilocalories
(a unit of energy of 1,000 calories).
 Amino Acids and Fats can be supplied peripherally. To prevent
ketosis (when the body does not have enough glucose for energy, it
burns stored fats instead, this results in a build up of acids called
ketones within the body. Some people encourage ketosis by
following a diet called the ketogenic or low-carb diet), Intravenous
lipid emulsions should contribute no more than 60% of the total
kilocalories provided. Dextrose concentrations are limited to
approximately 10%, because peripheral veins cannot withstand
greater concentrations.
 Overall, Lipids, amino acids, dextrose, electrolytes, trace
elements, and vitamins are all incorporated into one container.
Nutrient Delivery
 CPN and PICC Lines –
 When nutrients are infused into a terminal central
vein, parenteral nutrition is often referred to as
CPN. The Superior Vena Cava, one of the largest
diameter veins in the human body, is commonly
used for CPN.
 NOTE: CPN can deliver greater nutrient loads
because the blood flow in the superior vena cava
rapidly dilutes these solutions. CPN solution
must be sterile, CPN requires close monitoring,
and the therapy is costly. The nurse and dietician
are typically responsible for educating the client
going home on parenteral nutrition.
Nutrient Delivery
 Careful administration of the central line solution is important. Most
institutions have a strict protocol that must be followed by all health
care team members. A protocol is a description of steps for
performing a procedure.
 CPN Protocols include the following;
 A SLOW START
 A strict schedule
 Close monitoring
 Instructions for increasing the volume
 Maintenance of a constant rate
 Instructions for a slow withdrawal.
Nutrient Delivery
 Oral Delivery –
 Most institutionalized clients are fed orally. This is the optimal way
to eat, not only to obtain the nutritional value of the food eaten, but
also to satisfy the psychological and physical pleasure of eating.
 The Menu-
 Selective – similar to a restaurant menu where the
client chooses the food they would enjoy eating.
 Non-Selective – one kind of meal is served and given
to all of the clients.
Nutrient Delivery

 Eating Environment –
 Pleasant Environment such as pleasant odors,
sounds, lighting, sights.
 How can we promote a pleasant eating
environment in a clients room? What factors can
contribute to an unpleasant eating environment?
Nutrient Delivery
 Assisted Feeding –
 Food should be offered in “bite size” portions and in
the order the client prefers. Clients should not be
rushed. Talking with clients during mealtime makes it
pleasant. Personnel are encouraged “sit” while
feeding the client because this indicates a willingness
to spend time with them and encourages relaxation.
 In a long-term care facility, a client’s ability to feed
himself or herself should be re-evaluated at regular
intervals. Safe food temperatures should be
determined along with the dietary staff.
Nutrient Delivery

 Assisting the Disabled Client –

 A disabled client may need total or only partial assistance through the meal.
 Partial assistance – opening cartons, cutting meat, etc.
 Visually impaired clients may need assistance in knowing where the food
is on the tray.
 A large napkin or clothing protector may be worn by a client who is slow,
or messy. Offer hot beverages in small amounts to avoid an accident.
 Disabled clients may handle “finger food” better.
 Some clients tolerate liquids that are thicker versus thinner.
 Watch for s/s of dysphagia, notify the Licensed Speech Pathologist to
evaluate swallowing/gag reflex. The Occupational Therapist has skill in
assisting clients with assistive devices for feeding.
Nutrient Delivery
 Supplemental Feedings – Many clients are unable to consume a
sufficient amount of calories due to disease/condition.
 The first step is to offer additional nutrition at or between
meals. All supplements must adhere to the client’s diet order.
Many clients accept liquid supplementation rather than solid
foods.
 Liquid Supplements Include:
 Milk
 Milk Shakes
 Instant Breakfast Drinks
 Commercially prepared beverages
Nutrient Delivery
 Supplemental Feedings (continued) –
 Many commercially prepared liquid formulas are available.
 Four types of supplements are used for oral and/or enteral
feedings.
 Modular Supplements – A nutritional supplement
that contains a limited number of nutrients, usually
only one.
 Standard or Polymeric Formulas – An oral or
enteral feeding that contains all of the essential
nutrients in a specific volume.
 Essential and Semielemental Formulas – Formula
that contains either totally or partially hydrolyzed
(broken down into its component amino acids)
nutrients.
Food and Drug Interactions
 The most commonly prescribed anticoagulant, “Warfarin,”
is given to prevent blood clot formation in clients with that
history, other clotting disorders, and those with mechanical
devices in the cardiovascular system.
 Warfarin works by competing with vitamin K at its binding
sites, thus inhibiting vitamin K clotting Factors or prolonging
clotting time and thus “thinning blood.” Eating foods high
in Vitamin K while taking warfarin decreases or may even
negate the desired effect of the drug. Clients should avoid
large quantities of foods with Vitamin K.
 Foods to avoid, see table 15-4 page 340 Lutz, Mazur, Litch
(2017).
 Foods High in Vitamin K; Kale, Spinach, Collards, Swiss
chard, Parsley, Broccoli, Cabbage, Endive, Romaine,
Asparagus.
Food and Drug Interactions
 Grapefruit Juice –
 Accidental discovery 1989, enhanced the absorption of felodipine
(Anti-hypertensive).
 Major effect is through the inhibition of CYP3A4 (important
enzyme) mainly found in the intestine and the liver. It oxidizes
small molecules, such as drugs and toxins, so that it can be
removed from the body.
 Oral bioavailability of affected drugs is increased dramatically, in
some cases as much as fivefold, sufficient to cause drug toxicity
and increased side effects, and/or treatment failure.
 The interaction occurs with the first glass of grapefruit juice
consumed, increases with severity with continued consumption of
juice consumed, and also continues for 3 – 5 days after cessation
of juice until the intestine can manufacture more of the enzyme.
 Review Drugs Affected by the consumption of Grapefruit Juice
page 263 Lutz, Mazur, Litch 2015.
Food and Drug Interaction
 Cranberry Juice – A similar mechanism but a
different enzyme is proposed to explain an
interaction between the anticoagulant
“warfarin” and cranberry juice. Warfarin is
metabolized by the cytochrome P450
enzymeCYP2C9 and cranberry juice contains
flavonoids known to inhibit P450 enzymes.
 Review Case Studies on page 263 Lutz,
Mazur, Litch (2017).
Food and Drug Interactions
 Monoamine Oxidase Inhibitors (MAO’s) – useful in treating
depression.
 Some foods contain tyramine, a metabolic product in the
conversion of the amino acid tyrosine to epinephrine. When a
client taking MAO’s consumes foods or beverages high in
tyramine, the drug prevents the normal breakdown of tyramine.
The oversupply of tyramine leads to excessive epinephrine,
producing high blood pressure. Sometimes the blood pressure is
so high it could lead to intracranial hemorrhage.
 Tyramine rich foods; Avocados, bananas, eggplant,
raspberries, sauerkraut, sour cream, aged cheese, yogurt,
canned meats, sausage, anchovies, ale, beer, chocolate.
Food and Drug Interactions
 Protein intake and its effect on Levodopa.
 Levodopa is given for Parkinson’s Disease. The amino acids in
dietary proteins may compete with the drug for transport
across the blood-brain barrier. Low protein diets with protein
intake shifted to the evening have proved helpful in stabilizing
drug effects. In addition, low protein products designed for
chronic renal failure are safe, well tolerated and tasty, and
useful in clients adhering to low protein diets.
Food and Drug Interaction

 A common Anti-Diabetic agent known as

“Metformin” is a known pharmacological cause of
Vitamin B12 deficiency, but the responsible
mechanisms are not established.
 Long-term treatment with metformin can potentially
lead to neuropathy, which is also a complication of
diabetes.
 Annual monitoring of vitamin B12 is recommended.
Food and Drug Interaction

 Folic Acid and its effect on Aspirin

 Plasma proteins bind with nutrients as well as drugs.
 When there are insufficient binding sites on the plasma
proteins for all the drug or nutrients the access amount
accumulates in the blood stream as free small particles. The
kidney then excretes the folic acid in the urine.
 Aspirin displaces folic acid from its plasma protein. Increased
consumption of foods high in folic acid is recommended with
long-term use of aspirin therapy.
Food and Drug Interaction
 Sodium, Fluids, and Lithium
 Both sodium intake and increased fluid intake affect the mood
stabilizer Lithium.
 Lithium is used to treat bipolar disorder.
 The drug is absorbed, distributed, and excreted with sodium and
may result in the following situations;
 Decreased sodium intake with decreased fluid intake may lead
to lithium retention manifested by slurred speech, decreased
coordination, drowsiness, and muscle weakness or twitching.
 Increased sodium intake and increased fluid intake increase
the excretion of lithium, thus worsening signs and symptoms
of mania.
 NOTE: Use of loop diuretics (Bumex, Lasix) or angiotensin-
converting enzyme (ACE)(Zestril, Prinivil) Inhibitors
significantly increases the risk of hospitalization for Lithium
toxicity in the elderly.
Food and Drug Interaction

 Some drugs must be taken on an empty

stomach. A strict protocol is used for the drug alendronate
(Fosamox); a bone reabsorption inhibitor given for osteoporosis.
 Alendronate must be taken first thing in the morning
with plain water 30 minutes before any other meds,
food or beverages. Any intake other than the water,
significantly reduces its absorption.
 The person must remain in an upright position to
facilitate passage through the pylorus and minimize
risk of esophageal irritation.
Food and Drug Interaction
 Drugs taken with food.
 Food increases absorption or bioavailability of several drugs of
several classes.
 Example: Lovastatin; take with food increases its absorption.

 Certain Drugs need Fatty Foods for Absorption.

 Griseofulvin, an antifungal agent given to treat athlete’s
foot, is best absorbed when taken with a meal high in fat
content.
Food and Drug Interactions
 Tetracycline, an anti-infective agent, combines with Calcium, iron,
magnesium, and zinc to form insoluble compounds. The drug and the
nutrient thus bound are both less available for absorption.
 For this reason, Tetracycline should be administered 1 hour before or 3
hours after:
 Taking iron supplements
 Eating iron containing foods (red meat, egg yolks).
 Consuming milk, other dairy products, or calcium fortified juices.
 Taking antacids or multivitamins containing magnesium, aluminum,
calcium, or zinc.
 Tetracycline should be taken without food or milk to avoid a high risk
of treatment failure.
 Even a small amount of milk in tea or coffee can affect
bioavailability.
Weight Management

 Obesity – Excessive amount of fat on the body; for women, a fat

content greater than 30%; for men, a fat content greater than 25%.
 According to the CDC (2012), the annual health care cost of obesity
is approximately $147 billion dollars. Approximately, one-half of
these costs were paid for by Medicare and Medicaid. These costs
do not include the indirect costs such as absenteeism from work
and decreased productivity.
 The prevalence of obesity in the United States has had a starling
increase since the 1970’s.
 Many experts are concerned about the prevalence of obesity
among children in the United States.
Weight Management
 Percentage of Body Fat – The percentage of body fat is associated
with health risk.
 Fat Percentage; Females = 18% - 22%
 Fat Percentage; Males = 15% - 19%
 Body Mass Index (BMI) – The National Institutes of Health (NIH)
recommends and encourages all health care professional to use BMI to
classify clients as underweight, normal weight, over weight, and obese in
clinical settings.
 Underweight - <18.5
 Normal 18.5 – 24.9
 Overweight 25 – 29.9
 Obese class 1 >30
 Severely obese class 2 >35
 Morbidly obese class 3 >40
 Super obese >50
Weight Management

 Consequences of Obesity
 Susceptibility to medical problems
 Psychological ramifications
 Many clients find it difficult to break the cycle of behaviors
that contribute to obesity.
 Health care providers can educate overweight and obese
clients about the need for weight loss and encourage these
clients to lose weight.
Weight Management

 Achieving Weight Loss;

 Diet Therapy
 Physical Activity
 Behavior Therapy
 Pharmacotherapy
 Weight Loss Surgery
 Combined Therapy
Eating Disorders
 Anorexia Nervosa – a medical condition that results from imposed-
starvation. Appears at a rate of 80-85% in young women at age 12-25 and is 10-
20 times more likely in females than men. This can be life-threatening.
 Symptoms include:
 Recent unplanned weight of 5% or more
 Amenorrhea
 Constipation/Laxative abuse
 Excessive hair loss
 Abnormal Sleep Pattern
 Preoccupation with food
 Body Image Disturbance
 Misconception about physical status
 Intake of only 500-800 calories per day
 Slow eating
 Increased physical activity
 Social Isolation
 Intense fear of becoming obese
 Poor muscle tone
Eating Disorders
 Bulimia – more common than anorexia nervosa, especially
during adolescence and young adulthood. The mean age for
females at diagnosis was 23 years. The condition is rare in
males.
 Bulimics binge and purge.
 Binging – consumption of as much as 5,000 – 20,000
kilocalories per day.
 Purging – intentional clearing of food out of the GI System
by vomiting, enemas, laxatives, and diuretics. Bulimics are
more apt to maintain a normal body weight by restricting
food and dieting before binging episodes. Athletes such as
ballerinas, and gymnasts can tend to be bulimic.
Eating Disorders
 Binge-Eating Disorder;
 Recognized as a distinct eating disorder in the Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition.
 Binge eaters eat large amounts of high fat food, and high sugar
foods in short periods of time.
 Binge eaters do not follow a binge with a purge.
 Affects more females than males.
 These clients may be overweight or obese.
 Often associate eating with periods of stress, and anxiety.
 Eat until uncomfortable full.
 Binge eating can contribute to the mal affects of obesity.
Diet in Diabetes Mellitus and
Hypoglycemia
 Macronutrient Distribution – There is NO ONE
optimal mix of carbohydrate, protein, and fat that
must be followed by every diabetic. It should be
individualized depending on factors such as lifestyle,
preference, and other co-morbidities.
 Low-fat, low carbohydrate, and the Mediterranean
Diet have all been effective eight loss diets in
research studies.
 Monitoring Carbohydrate intake through counting,
choices, or experienced based estimates are
recommended for achieving glycemic control.
Diet in Diabetes Mellitus and
Hypoglycemia
 General Guidelines that pertain to carbohydrates include the following:
 Carbohydrates from fruits, vegetables, whole grains, legumes, and
low fat milk is encouraged.
 Monitoring Carbohydrate (CHO) consumption by CHO counting,
exchanges, or experienced based estimation remains a good
strategy.
 The use of the glycemic index of food.
 Sucrose containing foods can be substituted for other CHO in the
meal plan, if added to the meal plan, covered with insulin or other
glucose lowering medications.
 People with diabetes are encouraged to consume a variety of fiber
containing foods.
 Sugar alcohols and nonnutritive sweeteners are safe when consumed
within the daily levels established by the U.S. Food and Drug
Administration.
Diet in Diabetes Mellitus and
Hypoglycemia
 Exchange Lists –
 Are used to teach clients portion sizes, food
composition, and meal plan distribution.
 Many find this method of meal planning too
complex to learn and difficult to implement.
 Use of exchange lists are often taught in outpatient
settings.
Diet in Diabetes Mellitus and
Hypoglycemia
 MY-plate for Diabetes
 See Figure 17-5 for details.
 Half of the dinner plate should be filled with non-starchy
vegetables such as spinach, carrots, lettuce, greens,
cabbage, green beans, broccoli, cauliflower, tomatoes,
cucumber, beets, mushrooms, onions, and peppers.
 The second half of the plate should be divided in two.
 ¼ = starchy foods, whole grain bread, rice, pasta,
tortillas, cooked beans, peas, corn, potatoes, low fat
crackers, snack chips, pretzels, fat free pop corn.
 ¼ = Low fat proteins such as poultry without the skin,
fish, seafood, lean cuts of beef and pork, tofu, eggs, or
low fat cheese.
Diet in Cardiovascular Disease
 Sodium Controlled Diet – Individual’s with hypertension or
heart failure may need to control their sodium intake. The
preference for salty foods is learned and culturally transferred.
 Unseen contributions to sodium intake may come from
beverages, over the counter medications, and even drinking
water. Some clients elect to use bottled water, distilled water, or
demineralized water for drinking and cooking to consume
preferred sodium-containing foods. Some clients prefer a daily
allotment of salt in a shaker to be used as desired. Table 18-13
page 321 Lutz, Mazur, Litch (2017) list the sodium content of
beverages.
 Salt substitutes are available, but may contain potassium,
which are unsuitable for clients with kidney disease or those
taking ACE inhibitors. Clients should consult their doctor before
taking a salt substitute.
Diet in Cardiovascular Disease

 Reducing Saturated Fat – About 2/3 of saturated fat

in the U.S. diet comes from animal fats. Using non-fat
or low-fat dairy products is an especially important
strategy because milk fat contains more cholesterol
raising fatty acids than meat fat does.
 Cooking methods also affects the fat content in meat.
 Methods to decrease fat content of meat includes
warm water rinsing cooked meat.
Diet in Cardiovascular Disease

 The DASH diet is a dietary pattern promoted by the

U.S.-based National Heart, Lung, and Blood Institute to
prevent and control hypertension. The DASH diet is rich
in fruits, vegetables, whole grains, and low-fat dairy
foods; includes meat, fish, poultry, nuts, and beans;
and is limited in sugar-sweetened foods and beverages,
red meat, and added fats. In addition to its effect on
blood pressure, it is designed to be a well-balanced
approach to eating for the general public. DASH is
recommended by the United States Department of
Agriculture as one of its ideal eating plans for all
Americans.
Diet in Cardiovascular Disease

 Foods containing Omega 3 fatty acids –

 Sources of Omega 3 Fatty Acids: Seafood is
the largest source of omega-3 fatty acids
which includes fish such as tuna, salmon
and halibut, and other sea foods including
algae and krill. Walnuts, soy foods,
pumpkin seeds and canola (rapeseed) oil
are other sources of omega-3 fats.
Diet in Renal Disease
 Clients with renal disease need additional calories.
 In the absence of diabetes, clients on high kilocalorie diets
are usually given all the simple carbohydrates and
monounsaturated and polyunsaturated fats they will eat.
Trans-fats are minimized.
 Inadequate non-protein kilocalories, however, will
encourage tissue breakdown and aggravate uremia.
 Clients with renal disease need 35-40 kcal/kg per day. An
adequate intake of kilocalories is crucial to the success of
the dietary treatment.
 In addition, persons with diabetes, need good control of
blood sugar levels. Clients must learn how to best
distribute the sugars throughout the day for optimal blood
glucose control.
Diet in Renal Disease
 In renal clients, a primary goal of nutritional therapy is controlling
nitrogen intake. Control may mean increasing or decreasing dietary
protein as the client’s medial condition and treatment approach
changes.
 The kind of protein fed to the client may make a difference.
 50% of the dietary protein should be of high biological value
(Eggs, Meat, Dairy)
 A vegetarian diet has also been proven to be beneficial to the
renal client. This diet may be high in potassium and phosphorus.
The client’s goal is to eat the right combination of plant proteins
while keeping potassium and phosphorus under control.
 Protein restrictions are effective only if the client is consuming
enough calories.
 Clients receiving dialysis need increased protein because dialysis
results in loss of 1 – 2 grams of amino acids per hour of dialysis.
Diet in Renal Disease

 The desired amount of sodium in renal clients

depends on individual circumstances.
 Dietary levels of sodium are based on blood
pressure and fluid balance and also on
comorbidities such as heart failure.
 The sodium intake of renal clients must be
restricted to prevent sodium retention with
consequent generalized edema.
Diet in Renal Disease

 Dietary potassium must be monitored in renal clients.

 Hypokalemia – low blood potassium level; must be
avoided because it could introduce cardiac
arrhythmias and eventually cardiac arrest.
 See Box 19-1 High Potassium Foods and 19-2 Low
Potassium Foods.
 The recommended intake of potassium is 2.0 – 3.0
grams per day for most clients. If a clients potassium
level is elevated (5.0 – 6.5 mEq/L), dietary potassium
intake should be minimized to less than 2.4 grams per
day.
Diet in Renal Disease
 Phosphorus, Vitamin D, and Calcium – are normally
balanced. In clients with kidney disease, vitamin D cannot be
activated, a situation leading to low serum calcium level. At the
same time the kidneys cannot excrete phosphorus, a situation
leading to an elevated serum phosphorus level.
 When Serum calcium level drops, calcium is released from the
bones because of the increased secretion of Parathyroid
Hormone (PTH). PTH is secreted to correct the calcium
imbalance. This chain of events may lead to renal
osteodystrophy (faulty bone formation) and vascular calcification
(leads to high incidence of cardiovascular disease), which are
complications of chronic renal disease.
 Treatment for hypocalcemia is and secondary
hyperparathyroidism is activated Vitamin D. When phosphorus
levels are high, dietary restrictions must by followed; See Box 19-
3 Lutz, Mazur, Litch (2017) page 342
Diet in Renal Disease

 Fluid – Pre-dialysis and dialysis clients must restrict

fluid consumption because the kidneys can no longer
excrete the excess fluid.
 Clients on dialysis must restrict fluid to 500-1000 mL
plus 24 hour urinary output.
 This fluid restriction allows for a fluid gain of 2 to 2 ½
kilograms between dialysis treatments.
Diet in Renal Disease

 Clients with renal disease often have hyperlipidemia.

 Significant hypertriglyceridemia is commonly present in clients
with a history of renal disease.
 Treatment of elevated triglycerides;
 Modified fat diet
 Modification of carbohydrates
 Increase exercise
 Avoid saturated fats and trans fats
 Simple sugars and alcohol should be limited.
Diet in Renal Disease
 Anemias in clients with renal disease may be due to:
 A lack of kidney’s production of erythropoietin
 A decreased oral iron intake
 Blood loss
 Epoetin alfa may be used to increase red blood cell
production and correct anemia.
 Iron deficiency anemia may be diagnosed by examining
the ferritin level of the blood. A lab value less than 12 mcg
per liter suggests iron deficiency.
 Absorption of iron is enhanced when iron supplements are
taken on an empty stomach or with vitamin C.
Diet in Renal Disease
 Vitamin and Mineral supplementation of
water soluble vitamins is recommended
for the renal client.
 Vitamin and Mineral supplementation of
fat soluble vitamins is avoided due to
potential for toxicity.
Diet in Renal Disease
 Stones composed of uric acid form when the urine is
persistently acidic.
 Animal protein is rich in purines, which may increase
uric acid in the urine.
 Meat consumption should be limited to 6 ounces per
day.
 Purines are sometimes complications of “gout.” A
hereditary metabolic disease that is a form of arthritis.
A symptom of gout is inflammation of a joint.
 A purine restricted diet is commonly prescribed for
gout. See Table 19-6 page 345 for purines in foods.
Diet in Digestive Diseases
 Peptic Ulcer Disease – common illness that affects
more than 6 million people in the United States yearly.
 Form when the mucosa is insufficiently resistant to
stomach acids. If just the superficial cells are
involved, the lesion is an erosion. If the muscular
layer is involved, the person has an ulcer. H Pylori
has been associated with chronic gastritis, peptic
ulcer, and gastric cancer.
 NSAID’s account for 50% of peptic ulcers. Stress,
although not the main causative factor, may
contribute to the development of peptic ulcer
disease.
Diet in Digestive Diseases
 Disorders of the Stomach –
 Gastritis – Inflammation of the stomach, can be chronic or acute. Worldwide,
the most common cause of gastritis is Helicobacter pylori.
 Dietary Treatment for Gastritis
 Foods to Avoid
 Foods that cause pain
 Foods that cause gas, especially vegetables in the cabbage
family (broccoli, cauliflower, Brussel sprouts).
 Gastric irritants such as caffeine and alcohol
 NSAID’s such as aspirin, ibuprofen, and naproxen
 Strong spices, including nutmeg, pepper, garlic, and chili powder
 Foods Allowed
 Eat at regular intervals
 Eat in a relaxed manner
 Chew food, especially fibrous food, slowly and thoroughly
Diet in Digestive Diseases
 Dumping Syndrome – A complication of a surgical
procedure that removes, disrupts, or bypasses the
pyloric sphincter. The pyloric sphincter normally only
allows a small amount of food in the small intestine at
a time. After the pyloric sphincter is surgically
removed , concentrated liquid is suddenly “dumped”
into the intestine. This syndrome is most commonly
associated complete or partial gastrectomy.
 Diet for Dumping Syndrome – See Table 20-4, page
358 Lutz, Mazur, Litch (2017)
Diet in Digestive Diseases
 The Low FODMAP diet is often recommended as a way to
relieve chronic digestive complaints such as bloating, abdominal
pain, gas, excessive burping, diarrhea and constipation. These
symptoms are common in people with Irritable Bowel
Syndrome (IBS).
 The Most Common S/S of IBS include:
 Cramping
 Bloating
 Abdominal Pain, Gas
 Constipation or Diarrhea
 Mucus in Stools
https://livinghappywithibs.com/2013/04/21/foodmap-food-list
/
Diet in Digestive Diseases
 Inflammatory Bowel Diseases –
 In the individual with IBD, the immune system mistakes food, bacteria and
other materials in the bowel as foreign substances and it attacks the cells of
the intestine.
 The two most common IBD’s are Crohn Disease and Ulcerative Colitis.
 The concept of “Bowel Rest” has been abandoned, and IBD patients are now
advised to eat a diet as unrestricted as possible.
 There is a genetic correlation for both of these diseases.
 The two share similarities, but also have major differences. See Table 20-
8 page 475 Lutz, Mazur, Litch (2017)
 Specific actions to achieve those goals include the following;
 Avoid foods that worsen symptoms Take vitamin/mineral
Supplements
 Take small, frequent meals Eliminate dairy foods if
lactose intolerant
 Drink adequate fluids Limit excess fat
 Avoid caffeine, Alcohol Reduce
Carbohydrates/high fiber
Diet in Digestive Diseases
 Colostomy – A part of the large intestine is resected, and a
stoma is created in the abdominal wall. Has both a physical and
psychological impact on the client.
 Colectomy – Surgical removal of a part or all of the colon.
 Dietary Guidelines for the Ostomy Client
 A soft or general diet is usually served to ostomy clients
after recovery from surgery with restrictions based on
tolerance. Stringy, high fiber foods are initially avoided
until tolerance has been demonstrated.
 Stringy, High fiber foods; Celery, corn, cabbage,
coleslaw, peas, sauerkraut, spinach. Coconut, dried
fruit, membranes on citrus fruit, popcorn, nuts, seeds,
and skin on fruits.
Diet in Digestive Diseases
 Diverticulum Disease-
 A diverticulum is an outpouching of intestinal membrane
through a weakness in the intestine’s muscular layer, chiefly
in the colon.
 Dietary factors that may increase risk of diverticular disease
include:
 Red meat intake
 Obesity
 Alcohol
 Dietary fiber deficiency
 Diverticulosis – The presence of diverticulum
 Diverticulitis- The diverticula become inflamed
Disease of the Liver
 Cirrhosis of the Liver- the liver becomes scarred and ineffective at
regeneration. The most common causes of cirrhosis are alcoholism and
chronic hepatitis. The only treatment for end stage liver is liver
transplant.
 Dietary Treatment of Cirrhosis
 Avoid alcohol
 Ingestion of 4 – 6 meals per day
 Late evening snack to avoid fasting and catabolism

 Hepatitis – Inflammation of the Liver.

 Can result from viral infections, drugs, toxins. Acetaminophen
poisoning accounts for 50% of acute liver failure cases in the U.S.
The overdose can be deliberate or accidental.
 Nutritional Care – A high-calorie, high protein, moderate fat diet is
often prescribed for hepatitis clients.
Gallbladder Disease
 Gallbladder- a small, pouch-like organ whose
function is to store bile.
 Cholelithiasis – the presence of gallstones. About
15% of men and 30% of women have gallstones.
 The main signs of gallbladder disease is pain after
ingestion of fat caused by spasms of the
gallbladder. The pain is upper right quadrant and
often radiates to right shoulder.
 Dietary Modifications include, restriction of dietary
fat.
 Treatment is cholecystectomy or removal of the
gallbladder.
Diseases of the Pancreas
 Pancreatitis – Inflammation of the pancreas. Most cases are
alcohol related. Symptoms include; pain left upper quadrant, N/V,
Laboratory tests reveal elevated Amylase and lipase. Some
cases of pancreatitis can be hereditary.
 Treatment;
 NPO for 48 hours to avoid stimulating the pancreas
 Aggressive hydration with IV fluids
 Clear liquids after pain has been controlled and N/V cease
 Low fat, soft diet
 Soft to general diet over 3-4 days
Cystic Fibrosis
 Cystic Fibrosis – a Genetic Disease causing obstruction of
exocrine glands with thick mucus. CF affects multiple organs,
and is characterized by:
 Pulmonary dysfunction and infection
 Pancreatic impairment contributing to malnutrition
 Elevated sweat chloride
 Male infertility
 Treatment is supportive. Nutritional support provided in
the link below.
http://
www.nutritionmd.org/health_care_providers/respiratory/cysti
c_fibrosis_nutrition.html
Diet and Cancer
 Dietary habits linked to cancer
 See Box 21-1 page 377 Lutz, Mazur, Litch (2017).
 See Table 21-1 page 378 Lutz, Mazur, Litch (2017).
 Among promising areas of study are:
 Tomato or lycopene-containing foods and prostate
cancer.
 Cruciferous vegetables (Broccoli, cauliflower, Brussel
sprouts) for lung, prostate, and bladder.
 Allium Vegetables (garlic, onion, leeks, chives,
scallions) gastric cancer
 Folate-rich foods and vegetables (foods high in B9
vitamin, dark leafy vegetables) colon cancer
 Citrus fruits and lung cancer
Diet and Cancer
 The American Cancer Society advises clients to consume a diet that is high in
vegetables, fruits, and whole grains.
 Recommendations on nutrition and physical activity in those who are living with
advanced cancer are best based on individual nutrition needs and physical ability.
 During active cancer treatment the overall goal should be to:
 Prevent or resolve nutrient deficiencies
 Achieve or maintain a healthy weight
 Preserve lean body mass
 Minimize nutrition related side effects
 Maximize quality of life including an individualized exercise plan
 Common Nutritional Problems page 509 Lutz, Mazur, Litch (2017).
 Early satiety/anorexia
 Taste alterations
 Local effects in the mouth
 N/V and diarrhea
 Cachexia
 Altered immune response