Lecture 44

1. Objectives
a. Identify common foods that are high in cholesterol, saturated, monounsaturated, polyunsaturated, Ω-3
fatty acids, complex carbohydrates, soluble and insoluble dietary fiber, sodium, calcium and potassium.
i. Cholesterol
1. LVVLLV – BBKKLL
ii. Omega 3 FA
1. Flax seeds, Walnuts, Sardines, Salmon, Soybeans, Tofu, Shrimp, Brussels, Cauli, Winter
iii. Fiber Content
1. Legumes, Grains, Psyllium Seeds, Fruits, and Vegetables
b. Identify common foods that are high in sodium, calcium and potassium.
i. Biscuits and pancakes are high in Na+ while Mulitgrain Oatmeal and Nuts are low in Na+
c. Identify effects of the above food components and alcohol on plasma lipids and cardiovascular health.
i. For Sure Bad
1. Na+ >2400mg and more than 1 drink for women or 2 drinks for men
2. K+ <2400mg or Ca2+ <1000mg
ii. Maybe Bad
1. Low Magnesium (needed in order to inhibit vascular smooth muscle contraction)
2. Low antioxidants/phytochemical
3. High total fat and saturated fats (Omega 3s and PUFA may be helpful)
d. Identify the effects of altering dietary folate, B6, B12 or methionine on homocysteine levels and
cardiovascular disease risk.
i. If you are lacking in Folate, B6, and B12 then you will not convert Homocysteine to Methionine
e. Recall principles of the controversies regarding the vascular benefit of adding antioxidant vitamins and
foods to the diet, including USPSTF recommendation grades.
i. Don’t need to add antioxidant Vitamin Supplements for CVD risk reduction
ii. It is better to eat the AHA diets, balance energy intake and output, and have good lipid levels
iii. Fruits and veggies, Fish, Fiber
iv. Na+ less than 1,500mg
v. Goals
1.  LDL and  TG and  HDL,
f. Relate how plant sterols and stanols influence cholesterol absorption and LDL levels.
i. Stanols/sterols will decrease intestinal cholesterol absorption and lower LDL levels
ii. Fish oil also decreases your TG levels
g. Select features of the DASH diet and the Therapeutic Lifestyle Change plans that are comparable or
contrasting when advising patients for cardiovascular disease prevention and therapy.
i. DASH Diet combines dietary recommendations – Na+, K+, Ca2+, Mg2+, and fat type
1. More effective than addressing individual components
2. Good for people who have HTN, DM, CKD, Blacks, and 51 years or older
h. Select common comorbidities and drug treatments influencing dietary recommendations for
cardiovascular patients (warfarin, vitamin K containing foods).
i.
i. Recognize how weight loss, physical activity, alcohol and sodium in the diet affect LDL and HDL levels,
insulin resistance, abdominal obesity, glucose intolerance, hypertriglyceridemia and the risk of
diabetes and hypertension.
i. HDL is lowered with
1. Obesity, inflammation, inactivity, cigarettes, and high TGs
ii. HDL is raised with
1. Exercise, moderate alcohol consumption, estrogen, and loss of body fat
 j. Identify key components of the Therapeutic Lifestyle Change (TLC) diet recommendation of the
National Cholesterol Education Program (NCEP).
i. Start off with lifestyle therapies (eat better, physical activity, consider RD referral)
ii. 6 weeks later evaluate LDL response, if not better intensify treatment, consider plant sterols,
increased fiber intake, reduce high saturated fats, cholesterol, and trans fats
iii. 6 weeks later evaluate LDL response, now maybe consider Statin, treat metabolic syndrome
k. Compare the TLC diet with diets advocating extremely low or high fat intakes and the expected effects
on levels of the major classes of lipoproteins.
i. Total fat should be 25-35% of calories
l. Metabolic Syndrome?
i. Truncal obesity – 35 for women, 40 for men
ii. Triglycerides - >150
iii. LDL levels - <40 for men or <50 for women
iv. Blood Sugar - >100
v. Hypertension - >130/85
m. AHA/ACC Guidelines for Cardiovascular Risk
i. LDL, HDL, TG
ii. MUFA – 0.3, 0.3, 1.7
iii. PUFA – 0.7, 0.2, 2.3

Lecture 45
1. Malnutrition
a. Definitions
i. 5% in 1 month
ii. 10% in 6 months
iii. 15% in 1 year
b. Adverse Effects
i. Lung structure, function elasticity lost
ii. Decreased respiratory muscle mass
iii. Loss of lung immune defense
iv. Control of breathing
c. Other problems
i. Anemia decrease O2 capacity and increases WOB
ii. Ion loss makes muscle function poor
iii. Vitamin C decreases lung structure collagen
iv. Decreased surfactant levels increase WOB
v. Hypoporteinemia decrease colloid oncotic pressure resulting in pulmonary edema
d. Significant Weight Loss
i. 1 week = 1-2%
ii. 1 month = 5%
iii. 3 months = 7.5%
iv. 6 months = 10%
e. MNT for Malnutrition
i. Increase engery, protein, and nutrient intake
ii. Improves nutrional status
iii. Improved quality of life
iv. Weight gain
2. COPD
a. Ramifications
 i. Increased energy needs
ii. Altered fluid balance
iii. Decreased food intake, fatigue, anorexia
iv. Increased CO2
v. Difficulty chewing and swallowing due to dyspnea
vi. Impaired peristalsis – decreased O2 in the gut
b. MNT
i. Lean mass may decrease even with bodyweight stable as fluid retention may mask it
ii. Energy needs may be increased or decreased
iii. Nutritional supplementation promotes significant weight gain in COPD especially if malnour
iv. Macronutrients
1. Pushed up the amount of calories from fat (Normal 20-35) which will lower the RQ to .7
2. Protein is 1.2-1.7
3. Ensure – 230 calories, 150 fat caloreis
4. Pulmocare – 350 calories, 198 fat calories
v. Micronutrients
1. Get enough mag and calcium for muscle relaxation
2. Get enough Vit C for collagen formation, more if smoker, 90, 75, 85, 120
3. If on glucocorticoids watch for Ca2+, K+, and Vit D
vi. Mealtime
1. Adeuqate intake – small portions, favorites, social interaction
2. Aspiration – eat slow, chew well, sequence breathing/swallowing, sit upright
3. O2 at mealtime
3. Cystic Fibrosis
a. Ramifications
i. Maldigestion and Malabsorption
1. Thick mucous plugs block pancreatic enzyme secretion and bicarb secretion
2. Reduced resporption of bile acids
3. Excess mucous on GI tract reduced nutrient absorbtion
ii. Pulmonary infections increase energy needs
iii. Eventrually pancreatic endocrine involvement  diabetes type stuff
b. MNT
i. Individualize treatment
ii. Goals
1. Control maldigestion/absorbtion
2. Provide adequate energy for growth or maintanence of height and weight
3. Prevent nutrient deficiency (reduce risk of pulm infection)
iii. Pancreatic enzyme replacement therapy – enteric coated, given with meals
iv. Energy needs
1. May be increased depending on pulm involvement (1.2 to 1.5 times normal)
v. Macronutrients
1. Lower end or protein and carbs, increased fat (EFA and Omega 3)
vi. Micros
1. Na+ loss needs to be replaced
2. Water soluble vitamins if using the pancreatic nutrient replacement
3. Fat soluble as well – A, K, D
4. Asthma
a. Asthma can consume, but with increased CO2 retention and less O2 in can cause less fat burning
b. Magnesium, Antioxidants, Omega 3 or 6 – POSSIBLE, not yet
 c. Milk is ok, if avoided can have nutrient deficiencies
d. Drug Interactions
i. Bronchodilaotrs – dry mouth, NVD
ii. Anti-inflammatories – Na+ retention
iii. Corticosteroids – Hyperglycemia, Na+ retention, Hypokalemia
e. Whole foods, optimal energy balance, correct any diagnosed defiecnyc/excess
5. ARDS
a. Decreased CO2 clearance – affects macros
b. Hypercatabolic/metabolic – energy needs
c. Loss of lean body mass
d. Confounding lab results – fluid retention complicates mass, O2 is needed for metabolism
e. Energy Needs
i. Harris Benedict Equation
ii. Mifflin St. Jeor  1.2-1.4 times higher than Harris Benedict
iii. Indirect Calorimetry –
iv. Normal is 0.8g/kg, increased to 1.5-2 in ARF
v. Carbs need more O2 and eliminates same CO2
f. Micronutrients
i. Balnce and ADI
ii. Salt and water relationship, Calcium, K+, and Mag2+
g. Feeding Strategies
i. Same first three –
ii. Special formularies can be helpful but are very expensive
iii. Next would be enteral or parenteral feeding