Therapy Notes

STM 4201 Therapeutic Nutrition
Course introduction
Lecture 1: Introduction to Nutrition
Care Process
Course Introduction
• From a basic nutrition (food and nutrients;
sources, functions, deficiencies and excesses),
developmental (nutrition throughout the life
cycle), to applied (nutrition and health;
community nutrition) up to nutrition as a
therapeutic tools for a disease’s management.
STM 4201-Course Introduction and NCP

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Course Objectives
• At the end of this course, student will be able
to:
– 1. Understand how individual’s nutritional
assessment is carried out and to associate it with
health’s condition;
– 2. Understand appropriate nutritional program
and diet for disease management;
– 3. Modify normal diet to therapeutic diet

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Learning Outcomes
• LO1 Discuss how nutritional assessment is carried out in
relation to nutritional problem. [PLO1 – C3, A3]
• LO2 Evaluate the link between nutritional assessment

and health’s outcomes [PLO3 – C6, A3]
• LO3 Explain appropriate nutritional and dietary plan for

disease management. [PLO3 – C6, A3]
• LO4 Evaluate how to modify normal to therapeutic diet.

[PLO7 – C6, P3]

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Therapeutic Nutrition
• Another term for medical nutrition therapy (MNT).
• The use of specific nutritional interventions to treat

an illness, injury or condition.
• Includes setting goals for the pt's treatment and

developing a specialized nutrition prescription that
includes pt education and self-management training.
• Becoming an increasingly important component of

integrated health-care systems.

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Purpose(s) of MNT
• To identify pts at risk for major nutrition-related health
problems and recommend dietary adjustments.
– 8/ 10 leading causes of death in the world including CHD,

stroke, DM, and some cancers are related to food and alcohol
consumption patterns.
• Others who benefit from MNT: the obese, elderly, and

infants of LBW.

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Purpose(s) of MNT
• To treat disorders: anorexia and bulimia nervosa, CF,
IBS, hyperlipidemia, lactose indigestion, gastric ulcers,
sprue and FTT.
• Adequate nutrition is essential to reduce morbidity and

mortality and other acute or chronic conditions.
• Helps to reduce health-care costs and minimizing the

need for surgery or lengthy hospital stays.

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MNT: Description
• MNT is used in a variety of treatment settings,
includes a comprehensive review of the pt's
medical history and dietary assessment with
laboratory values and anthropometric measures.
MNT: Intake assessment

• assessment of the pt's current and past diet
history.
• clinical evaluations, biochemical tests, and dietary
information.

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MNT: Intake assessment (cont)
• An initial evaluation may include an
assessment of:
– psychosocial data,
– sociological data,
• General understanding of nutrition,
learning style, together with readiness to modify
or change behavior.
– current exercise and activity level

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MNT: Dietary modification
• Specialized diets in
MNT may include:
– supplemental nutrition
for pts cannot obtain
adequate nutrients
through food intake
alone
– enteral nutrition
– parenteral nutrition

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MNT: Patient education
• A critical dimension of MNT, in
that pt compliance is essential
to the success of any preventive
or therapeutic nutritional
program.
• Includes: task, guideline, and

meal planning exercises.
• Education, motivation, and

counseling contribute to
effective patient participation.

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MNT: Preparation
• Nonmedical issues that must be considered.
• Example: pt's usual food choices, food likes
and dislikes, cultural values, and pt's ability to
implement the dietary changes. The attitudes
of other family members often influence the
patient's compliance.

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MNT: Results
• Results of MNT have been impressive enough in terms of
cost-effectiveness.
• On the individual level, the effectiveness of MNT

depends on the commitment of all members of the
health-care team, especially on the pt.
• Prioritized goals are critical when developing the

nutrition treatment plan, (+) ongoing assessment by the
pt and health care team members.

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Health care team roles
• Only a dietitian has sufficient training and knowledge to

accurately assess the nutritional adequacy of a pt's diet.
– to monitor pt receiving enteral, parenteral, and specialized
oral therapies in conjunction with other health care team
members.
• Physicians should learn the indications for special diets in

order to facilitate referrals to dietitians and to reinforce pt
compliance.

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STM4201 Lecture 2- Nutrition Care
Process: Screening
1/28/2021 STM4202- NCP:Screening

Nutrition Screening (NS)
• Purpose: To quickly identify individuals who are
malnourished or at nutritional risk and,
to determine if a more detailed assessment is
warranted.
• Usually completed by DTR, nurse, physician, or

other qualified health care professional.
• At-risk patients referred to dietitian.

Characteristics of NS
• Simple and easy to complete
• Routine data
• Cost effective
• Effective in identifying nutritional
problems
• Reliable and valid

Nutrition Screening Tools
• Acute-care hospital or residential setting
• Perinatal service
• Pediatric practice
• Malnutrition Screening Tool (MST)
• Nutrition Screening Initiative (NSI)
Cornerways

The Hawthorns Care Centre
Nutrition Questionnaire

Nutrition Care Process: Screening
• The Joint Commission (TJC) requires that nutritional
risk be identified within 24 hrs in all hospitalized pts.
• TJC also requires nutrition screening in accredited
ambulatory facilities.
• Standards of Care protocols determine process;
evidence-based guidelines.
• Use simple techniques, available info.
• May be done by other than RD.
• Usually simple form with targeted info.

Commonly Used Criteria for Nutrition Risk
Screening-Acute Care
• Diagnosis • Problems with chewing
• Wt or swallowing
• Wt change • Diarrhea
• Need for diet • Constipation
modification or • Food dislikes or
education intolerance
• Laboratory values
Institute of Medicine, 1999

Food and Nutrient Intake Risk Factors
• Intake > or < than required
• Swallowing difficulties
• GIT disturbances, bowel irregularity
• Impaired cognitive function or depression
• Unusual food habits (pica)
• Misuse of supplements
• Restricted diet
• Inability/unwillingness to consume food
• ↑ or ↓ in activities of daily living

Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th edition, p. 386
Psychological/Social Risk Factors
• Language barriers
• Low literacy
• Cultural or religious factors
• Emotional disturbances associated with
feeding difficulties (e.g., depression)
• Limited resources for food preparation or obtaining
food/supplies
• Alcohol/drug addiction
• Limited/low income
• Lack of ability to communicate needs
• Limited use or understanding of community resources

Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12 th edition, p. 386
Physical Risk Factors
• Extreme age (>80 years, premature infants, very young children)
• Pregnancy: adolescent, closely spaced, or three or more
pregnancies
• Alterations in anthropometric measurements, marked o’wt/
u’wt for age, ht, both; depressed somatic fat and muscle stores
NOTE: recent unintentional wt loss is more predictive of morbidity/mortality
than wt/ht status

Physical Risk Factors (cont)
• Chronic renal/cardiac disease, diabetes, ulcers,
cancer, AIDS, GI complications, hypermetabolic
stress, immobility, osteoporosis, neurological
impairments, visual impairments

Abnormal Laboratory Values
• Visceral proteins (albumin, prealbumin,
transferrin)
• Lipid profile (cholesterol, HDL, LDL,
triglycerides)
• Hemoglobin, hematocrit, other blood tests
• BUN, creatinine, electrolytes
• Fasting and PP blood glucose levels, HbA1c
Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th edition, p. 386
Prevalence of Nutrition Risk in Acute Care
• The prevalence of nutrition risk will vary depending
on the population screened and the criteria used for
screening.
• In published studies, prevalence of malnutrition in
hospitalized pts ranged from 12% - > 50%.
• There is little published data regarding nutrition
screening for other purposes.

Adult-Geriatric Inpatient Screening Criteria
1. Pregnant or lactating mother admitted to unit other than
ante-partum or mother-baby.
2. Sig unintentional wt loss 4.5 kg in past 1-2 mths.
3. Pt desires education on a therapeutic diet.
4. Pt unable to take oral or other feedings ≥5 days prior to
admission.
5. Pt on enteral or parenteral feedings.
6. Geriatric pt admitted for surgical procedure.
7. Pt with skin breakdown (decubitus ulcer).

Infant-Child-Adolescent
Inpatient Screening Criteria
1. Recent wt loss.
2. On special diet and needs education.
3. On tube/parenteral feedings.
4. Diabetic.
5. Receives ↑ cal feeds/concentrated formula.
6. Food allergy.
7. FTT.
8. Feeding problems/intolerance.
9. Teen who is pregnant or lactating.
10. Child being breast fed.

Issues in Nutrition Screening
• Most nutrition screening is done by staff other than
nutrition professionals.
• Identified at-risk pts are referred to nutrition

professionals less than half the time.
• Much of the research that exists validates more

comprehensive nutrition screening tools.

Issues in Nutrition Screening
• Little research has been done to validate or
evaluate nutrition screening as it currently
exists in most acute care institutions.
• There is no “gold standard” of nutritional

status that can be used as a benchmark.

BRIANNA HEEGER
NUTRITION
K E I KO K A M I YA
GALIA KESHESHIAN CARE PROCESS
E VG E N I YA N O Z D R I N A (NCP)
•  A systematic problem- •  A standardized model
solving method that intended to guide
food and nutrition Registered Dietitians
professionals use to and Registered
think critically and Dietetic Technicians,
make decisions that in providing high
address practice- quality nutrition care.
related problems.
WHAT IS THE NUTRITION CARE

PROCESS AND MODEL
•  Developed by the Academy of Nutrition and Dietetics
(AND)
•  Improve the consistency •  Provide structure and

terminology for research
and quality of
individualized patient/client studies and data
collection.
care and the predictability
of the patient/client •  Provide a standardized
outcomes. language.
WHY WAS THE NCP DEVELOPED

1.  Assessment: nutritional health status
2.  Diagnosis: interpret data
3.  Intervention: develop a plan of action
4.  Monitor/Evaluate: monitor the effectiveness of the
plan
NUTRITION CARE PROCESS: ADIM

AND NUTRITION CARE PROCESS AND MODEL
•  Initiates the data collection process that is
continued throughout the NCP and forms the
foundation for reassessment and reanalysis of
the data in Nutrition Monitoring and Evaluation
(Step 4).
STEP 1: NUTRITION ASSESSMENT

For individuals:
•  Patient/client through interview
•  Observation and measurements
•  Medical records
•  Referring health care provider
For population groups:
•  Data from surveys
•  Administrative data sets
•  Epidemiological or research studies
Nutrition Care Process Snapshot NCP step 1: Assessment www.eatright.org
HOW DO FOOD AND NUTRITION

PROFESSIONALS DETERMINE WHERE TO
OBTAIN NUTRITION ASSESSMENT DATA?
Food and nutrition-related history:
•  Food intake, nutrition and health awareness and
management, physical activity and exercise, and food
availability.
Biochemical data, medical tests and procedures

•  Include laboratory data (e.g., electrolytes, glucose, lipid
panel, and gastric emptying time).
Anthropometric measurements
•  Include height, weight, body mass index (BMI), growth
rate, and rate of weight change.
CATEGORIES OF NUTRITION
ASSESSMENT DATA
Nutrition-focused physical findings
•  Include oral health, general physical appearance, muscle
and subcutaneous fat wasting
Client history
•  Include medication and supplement history, social
history, medical/health history, and personal history.

…CATEGORIES OF NUTRITION
ASSESSMENT DATA
•  Determining appropriate data to collect
•  Determining the need for additional information
•  Selecting assessment tools and procedures that
match the situation
•  Applying assessment tools in valid and reliable ways
•  Distinguishing relevant from irrelevant data
•  Distinguishing important from unimportant data
•  Validating the data
NUTRITION ASSESSMENT: CRITICAL

THINKING
•  Identification and labeling of a nutrition problem that the
RD is responsible for treating independently.
•  Standardized terminology for nutrition diagnosis has
been developed to facilitate this step.
•  It is suggested that the RD use a PES Statement to
communicate the nutrition diagnosis (problem, etiology,
and signs/symptoms).
Examples:
•  “inadequate energy intake”, “overweight/obesity”, “food
and nutrition related knowledge deficit”, and “limited
access to food or water”
STEP 2. NUTRITION DIAGNOSIS

WHAT IS NUTRITION DIAGNOSIS?
•  Critical step between nutrition assessment and
nutrition intervention.
•  Identification of an existing nutrition problem, by
using the data collected in the nutrition assessment
that the RD is responsible for treating.
•  Creates a standardized nutrition diagnosis language
to describe nutrition problems consistently.
•  Different from a medical diagnosis.

STEP 2. NUTRITION DIAGNOSIS

PURPOSE
Medical Diagnosis Nutritional Diagnosis
Diabetes Excessive CHO intake r/t visits to Coldstone

Creamery as evidenced by diet hx and high hs
blood glucose
Trauma and closed head Increased energy needs r/t multiple trauma as
injury evidenced by results of indirect calorimetry
Liver failure Altered gastrointestinal function r/t cirrhosis of the

liver as evidenced by steatorrhea and growth
failure
NUTRITIONAL VS. MEDICAL DIAGNOSIS

Medical Diagnosis Nutritional Diagnosis
Obesity Excessive energy intake r/t lack of access to

healthy food choices (restaurant eating) as
evidenced by diet history and BMI of 35.
Dependence mechanical Excessive energy intake r/t high volume PN as

ventilation evidenced by RQ >1
Anorexia nervosa Undesirable food choices r/t history of anorexia

nervosa and self-limiting behavior as evidenced by
diet history and weight loss of 5 lb
NUTRITIONAL VS. MEDICAL DIAGNOSIS

•  Nutrition diagnosis is documented by writing a PES
statement.
•  The format for the PES statement is:
“Nutrition problem label related to ___________ as
evidenced by _____________.”
Example:
•  Inadequate fiber intake (NI-5.8.5) related to lack of
nutritional knowledge about desirable quantities of
fiber as evidenced by patient’s intake of fiber that is
insufficient when compared to the RDA.
NUTRITION DIAGNOSIS COMPONENTS

PES statement should be:
•  Clear and concise
•  Specific to the patient
•  Limited to a single problem
•  Accurately related to one etiology
•  Based on signs and symptoms from the
assessment data

PES statement components:
(P) Problem or Nutrition Diagnosis Label: Describes
alterations in the patient’s nutritional status.
(E) Etiology: Cause/Contributing risk factors linked to

the nutrition diagnosis label by the words “related to.”
(S) Signs/Symptoms: Data used to determine that the

patient has the nutrition diagnosis specified. Linked to
the etiology by the words “as evidenced by.”

(P) 1. Can the RD resolve or improve the nutrition diagnosis?
2. Consider the Intake Domain as the preferred problem type
(E) 1. Is the etiology listed the “root cause”?
2. Will RD intervention resolve or improve the problem by addressing the
etiology?
3. Can RD intervention at least lessen the symptoms?
(S) 1. Will measuring the signs and symptoms tell you if the problem is
resolved or improved?
2. Are the signs and symptoms specific enough?
PES Overall
Does nutrition assessment data support the nutrition diagnosis, etiology, and
signs and symptoms?
EVALUATING PES STATEMENT

• Intake
• Clinical
• Behavioral
NUTRITION DIAGNOSIS HAS THREE

GENARAL DOMAINS
Intake (NI)
•  Excessive or Inadequate intake compared to requirements
(actual or estimated)
Composed of five categories:

1.  Energy balance
2.  Oral or nutrition support intake
3.  Fluid intake
4.  Bioactive substance
5.  Nutrient

GENARAL DOMAINS
Clinical
•  Medical or physical conditions that are abnormal
Composed of three categories:
1.  Functional
2.  Biochemical
3.  Weight

GENERAL DOMAINS
Behavioral
•  Environmental related to knowledge, attitudes, beliefs,
physical environment, access to food, or food safety
Composed of three categories:

1.  Knowledge and beliefs
2.  Physical activity and function
3.  Food safety and access

GENERAL DOMAINS
•  Focuses on the issue at hand taking a detailed course of
action and utilizing resources.
•  Final goal is to modify an individual, a specific group, or
a community’s nutrition behavior.
Steps of Nutrition Intervention

1.  Selecting
2.  Planning
3.  Implementing
STEP 3: NUTRITION INTERVENTION

•  The nutrition intervention chosen is based by the
nutrition diagnosis and uses:
1.  team involvement
2.  science based principles
3.  additional research, if available.
•  The key element is that the RD improves the issue

by creating a rational plan with the help of the
whole family including the individual
STEP 3: NUTRITION INTERVENTION

•  Food and/or Nutrient Delivery
•  Nutrition Education
•  Nutrition Counseling
•  Coordination of Nutrition Care
NUTRITION INTERVENTION
STRATEGIES
•  Prioritize nutrition diagnoses
•  Consult AND’s EBNPG
•  Determine patient-focused expected outcomes
•  Confer with family members/caregivers
•  Define nutrition plan and strategies
•  Define time and frequency of care

PLANNING THE NUTRITION

INTERVENTION
•  Communicate the nutrition care plan
•  Help carry out the plan
IMPLEMENTING THE NUTRITION

INTERVENTION
The plan of action will be based on the patient's
diagnosis:
1.  Select the appropriate strategy based on the

problem
2.  Discuss the intervention to the patient (include
family)
3.  Explain the plan (i.e.nutrition education)
4.  Schedule of care (program duration follow-ups)
5.  Additional materials, documentations, financial/food
resources
STEPS OF NUTRITION INTERVENTION

•  An on-going course of action
•  Accurate, timely, and applicable records
•  Scrutiny of patient’s file should include:
1.  Date and time
2.  Goals and outcomes
3.  Plan’s adjustments
4.  Patient’s receptiveness
5.  Resources and referrals
6.  Follow-ups (observe progress) and frequency
7.  Discharge (if applicable)
DOCUMENTATION OF NUTRITION
INTERVENTIONS
•  Critical step that defines the outcomes specific
to nutrition care.
•  Overlapping between nutrition assessment,
monitoring and evaluation terminology (except
client history).
•  Generating a standardization of evaluating the
effectiveness of nutrition intervention.
STEP 4:NUTRITION MONITORING AND

EVALUATION
Purpose
•  To determine whether progress made is related to the
patient’s nutrition intervention goals and/or desired
outcomes.
•  To provide evidence if the intervention is/has been
effective in changing the behavior or status of the patient.
•  To evaluate nutrition care outcomes.
•  To create a standardized language for nutrition
intervention.
NUTRITION MONITORING AND

EVALUATION
RELATIONSHIP BETWEEN MONITORING
& INTERVENTION AND NCP
Monitoring provides findings that the nutrition
intervention has impacted the patient’s status
positively or negatively
Measuring outcomes by using data from the nutrition
care indicators*
Evaluate patient outcomes by comparing current findings
with previous status/behavior and patient’s
nutritional intervention goals
http://adaeal.com/ncp/NCP14/
MONITORING AND EVALUATION

COMPONENTS
•  Nutrition related behavioral and environmental outcomes
•  Food and nutrient intake outcomes
•  Nutrition related physical signs and symptoms
•  Nutrition related patient/client centered outcomes
NUTRITION OUTCOME CATEGORIES OF

MONITORING AND EVALUATION
•  Determine proper indicator/measures
•  Determine suitable data for comparison
•  Determine the process of the clients relating to expected
outcomes
•  Determine why the patient outcomes are different from the
expected outcomes
•  Determine issues that assist or hamper improvement
•  Determine how long a patient needs to be under nutrition
care
NUTRITION MONITORING AND

EVALUATION
Patient outcomes
• Improved nutrition intakes Cost outcomes
• Changes in physical signs • Decreased cost to health
and symptoms care system
• Increases patients quality of • Length of hospital stay
life • Outpatient visits
Health & disease outcomes • Procedures
• Prevention or maintenance • Medication and equipment
of health used
• Changes in knowledge
http://adaeal.com/ncp/NCP14
• Changes in severity,
duration of disease
HEALTH CARE OUTCOMES

Nutrition Assessment
•  Medical hx: 72 y.o. female admitted with decompensated
CHF; heart failure team consulted; has been admitted with
same dx 2x in past month; meds: Lasix and Toprol; current
diet order: 2 grams sodium; has lost 5 pounds in 24 hours
since admission; Output > input by 2 liters
•  Nutrition history: has been told to weigh herself daily but has
no scale at home. Does not add salt to foods at the table.
Noticed swollen face and extremities on day prior to
admission. Day before admission ate canned soup for lunch
and 3 slices of pizza for dinner; does not restrict fluids; has
never received nutrition counseling
NCP EXAMPLE #1: ACUTE CARE

Nutrition Diagnosis
•  Excessive sodium intake r/t frequent use of canned
soups and restaurant foods as evidenced by diet history.
•  Knowledge deficit r/t no previous nutrition education as
evidenced by frequent use of high sodium convenience
foods and inability to name high sodium foods.
•  Excess fluid intake r/t dietary indiscretions as evidenced
by diet hx and current fluid status.
•  Self-monitoring deficit r/t lack of access to scale as
evidenced by patient self report.

Nutrition Intervention
•  Excessive sodium intake: Patient will attend Senior
Feeding site that provides low sodium meals; Patient will
implement survival skills low sodium diet principles and
attend heart failure diet program in heart failure clinic.
•  Self-monitoring deficit: Patient will obtain free home
scale from CHF case manager; will limit fluids to 2 liters/
day per instructions in Heart Failure Clinic if adherence
to low sodium diet does not achieve appropriate fluid
balance.

Monitoring and Evaluation
•  Patient will weigh himself daily and keep log; report to
heart failure case manager if weight ↑ 2 lb in 24 hours
•  Patient will bring 3 day diet record to heart failure clinic
for review by dietitian
•  Heart failure case manager will track hospital
readmissions over 12 months

•  JW is a 70 yr. old white man admitted for cardiac bypass
surgery. The nutrition risk reveals that he has lost weight
without trying and has been eating poorly for several weeks
before admission, leading to referral to the RD for nutrition
assessment.
•  Caloric intake: 1,200kcal/day (less than energy requirements
as stated in the recommended dietary allowances). Meals:
irregular throughout the day; drinks coffee frequently. History
of hypertension, thyroid dysfunction, asthma, prostate surgery.
JW lives alone in his own home. He lost his wife 3 months ago,
and for the past 6 months he rarely sits down to a cooked
meal.
NCP EXAMPLE #2
Nutrition Diagnosis
•  Involuntary weight loss related to missing meals as
evidenced by loss of 15 lbs over 3 months.
•  Inadequate oral food and beverage intake
NCP EXAMPLE #2
•  Diagnosis 1: Involuntary weight loss
• During the hospitalization JW will maintain his current
weight, following discharge he will begin to slowly gain
weight up to a target weight of 145lb.
•  JW will modify his diet to include adequate calories and
protein through the use of nutrient-dense foods to prevent
further weight loss and eventually promote weight gain.
NCP EXAMPLE #2
•  Diagnosis 2: Inadequate oral food and beverage intake
• While in the hospital JW will include nutrient-dense foods in
his diet, especially when his appetite is limited.
• Following discharge JW will attend a local senior center for
lunch on a daily basis to help improve his socialization and
caloric intake.
NCP EXAMPLE #2
Monitoring and Evaluation
•  Monitoring will include weekly weight measurements and
nutrient intake analyses while he is in the hospital and
biweekly weight measurements at the senior center or clinic
when he is back at home.
•  If nutrition status is not improving, such as JW’s weight
records and goals not being met, JW needs to be
reassessed and develop new goals and create plans for new
interventions.
NCP EXAMPLE #2
American Dietetic Association. Frequently Asked Questions Regarding the Nutrition Care
Process and Model (2008). Retrieved November 2, 2009 from www.eatright.org
Bueche, J., Charney, P., Pavlinac, J., Skipper, A., Thompson, E., & Myers, E. (2008). Nutrition
care process and model part I: The 2008 update. Journal of the American Dietetics
Association, 113-117. Retrieved November 13, 2010 from http://www.eatright.org/
HealthProfessionals/content.aspx.?id=7077&terms=NCP
Calhoun, J., Goukasian, C., Siritiranukul, j., & Young, R. Nutrition Care Process. November
2010. Retrieved November 2012
Leidys, L., Louisa, B., & Noura, A., & Star, E. Nutrition Care Process. November 2010.
Retrieved November 2012.
REFERENCES
Mahan, L.K., & Escott-Stump, S. (2008). Krause’s Food & Nutrition Therapy (12th ed.).
Philadelphia: Saunders.
Nutrition Care Process: Diagnosis, Intervention, Evaluation, and Monitoring. Retrieved from
www3.uakron.edu.
Nutrition Care Process Step 4: Nutrition monitoring and evaluation. On-line, International
Dietetics & Nutrition Terminology Reference Manual - Third Edition Retrieved November
13, 2010 from http://www.adancp.com/topic.cfm?ncp_toc_id=1124
Nutrition Diagnosis Snapshot (2009). In Pocket guide for International dietetics & nutrition
terminology (IDNT) reference manual (pp. 137-141). Chicago, IL: ADA
Nutrition Diagnosis Snapshot (2010). In Pocket guide for International dietetics & nutrition
terminology (IDNT) reference manual, ed. 3rd. (pp. 313- 314). Chicago, IL: ADA
REFERENCES
THANK YOU!
NOVEMBER 21, 2012
Documentation of Nutrition Care
Nutritional Care Record
• Written documentation of the nutritional
care process, including the interventions
and activities used to meet the nutritional
objectives
• “If it’s not documented, it didn’t happen.”
• Written as part of the Medical record
Nutrition Care Documentation
1. Quality assurance
2. Communication
1. Health care team
2. Verifies care given
3. Peer review
4. State audits
Documentation Styles
• ADIME (assessment, diagnosis, intervention,
monitoring and evaluation)
• DAP (diagnosis, assessment, plan)
• DAR (data, action, response)
• PIE (problem, intervention, evaluation)
• PES (problem, etiology, symptoms)
• IER (intervention, evaluation, revision)
• HOAP (history, observation, assessment, plan)
• SAP (screen, assess, plan)
• SOAPIER (subjective, objective,
analysis/assessment, plan, intervention, evaluation,
revisions)
• SOAP (subjective, objective, assessment, plan)
SOAP Notes
S: Subjective
• Info provided by patient, family, or other
• Pertinent socioeconomic, cultural info
• Level of physical activity
• Significant nutritional history: usual eating
pattern, cooking, dining out
• Work schedule
SOAP Notes—cont’d
O: Objective
• Factual, reproducible observations
• Diagnosis
• Height, age, weight—and weight gain/loss
patterns
• Lab data
• Clinical data (nausea, diarrhea)
• Diet order
• Medications
• Estimation of nutritional needs
A: Assessment
• Nutrition diagnosis
• Interpretation of patient’s status based on
subjective and objective info
• Evaluation of nutritional history
• Assessment of laboratory data and
medications
• Assessment of diet order
• Assessment of patient’s comprehension and
motivation
P: Plan
• Diagnostic studies needed
• Further workup, data needed
• Medical nutrition therapy goals
• Education plans
• Recommendations for nutritional care
SOAP EXAMPLE
• S: Patient works night shift, eats two meals a day, before
and after his shift; fried foods, burgers, ice cream, beers
in restaurants. Does not add salt to foods. Activity: Plays
golf 1x month.
• O: 34 y.o. male s/p MI with history of htn, DM2,
hyperlipidemia.
• Ht: 5 ft. 10 in; wt: 250 lb; BMI 36, Obesity II
• A: Excessive sodium intake (NI-5.10.2) related to
frequent use of vending foods as evidenced by diet
history. Pt could benefit from increased activity and
gradual wt loss as recovery allows
• P: Provided basic education (E-1) on 3-4 gram sodium
diet and wt management guidelines
• Patient will return to outpatient nutrition clinic for
lifestyle intervention and counseling (C-2.1).
Pros and Cons of SOAP Charting
PROS CONS
• Common use by nutrition • Tends to encourage
care professionals and lengthy chart notes
other disciplines • One study suggests
• Taught in most dietetics physicians are less likely
education programs to respond to this format
• Easy to learn and utilize than others*
• Downplays evaluation
• Emphasizes legitimacy of
objective over subjective
data
*Skipper A, Young M, Rotman N, Nagl H. Physicians’ implementation of dietitians’
recommendations: a study of the effectiveness of dietitians. J Am Diet Assoc 1994;94:45-49.
ADIME
Developed to facilitate the NCP
• A – Assessment
• D – Diagnosis
• I – Intervention
• M – Monitoring
• E - Evaluation
Assessment (A)
• All data pertinent to clinical decision
making, including diet history, medical
history, medications, physical assessment,
lab values, current diet order, estimated
nutritional needs
• Should include relevant data only
Diagnosis
• Should include PES statement for nutrition
diagnosis
• Patients may have more than one diagnosis,
but try to choose the one or two most
pertinent, or the ones you mean to address
Intervention
• What do you recommend or plan to do to
address the nutrition diagnoses?
• Recommend change in food-nutrient
delivery (supplement, change in diet,
nutrition support, vitamin-mineral
supplement) (NI)
• Nutrition education (E)
• Nutrition counseling (C)
• Coordination of nutrition care (RC)
Monitoring and Evaluation (ME)
• What will you monitor to determine if the
nutrition intervention was successful?
• Generally based on the signs and symptoms
• Weight
• Intake
• Lab values
• Clinical symptoms
Example of ADIME
• A - 34 y.o. male s/p MI with history of htn, DM2,
hyperlipidemia; ht: 5 ft. 10 in; wt: 250 lb; BMI 36,
obesity II. Patient works night shift, eats two
meals a day, before and after his shift--fried foods,
burgers, ice cream, beers in restaurants.. Does not
add salt to foods. Activity: Plays golf 1x month.
• D - Excessive energy intake (NI-1.5); excessive
sodium intake (NI-5.10.2) related to frequent use
of restaurant foods as evidenced by diet history.
Example of ADIME
• I – Provided basic education (E-1) on 3-4 gram
sodium diet and wt. management guidelines
(nutrition education); pt to return to outpatient
nutrition clinic for lifestyle intervention (C-2.1)
• ME – Evaluate weight (S-1.1.4), blood pressure
(S-3.1.7), diet history at outpatient visit sodium
intake (FI-6.2); energy intake (FI1.1.1); fat intake
(FI-5.1.1) Re-check lipids in 3 months (S-2.6)
Narrative Note
• Brief summary of progress, data, action in
a paragraph format
• Frequently used to document brief
interventions or follow-ups to initial
assessments
• Nutrition professionals may use for same
purpose or to document food preference
interviews, response to a patient question or
complaint, re-screening of low risk pts
Brief Narrative Note Example
34 y.o. male s/p MI with history of htn, DM2,
hyperlipidemia. Ht: 5 ft. 10 in; wt: 250 lb
Patient works night shift, eats two meals a day,
before and after his shift, fried foods, burgers,
ice cream, beers in restaurants. Does not add salt
to foods.
Nutrition diagnosis: Excessive energy intake
(NI-1.5) related to high intake of fat and
restaurant foods aeb BMI and diet history.
Response (Evaluation) Pt was able to list high
sodium foods and appropriate diet changes (BE-
2.2.1)
Electronic Medical Record
• Many health care institutions are
implementing electronic medical records
(Aultman and Mercy Medical Center)
• All disciplines can access the patient chart
concurrently
• Entries are more legible, making errors less
likely
• Data can be organized to support clinical
decision making
Revision
STM 3202 (Pemakanan Sepanjang Hayat)
Malaysian Dietary Guidelines

(MGD 2010)
Plan a sample menu based on calorie value
MALAYSIAN
DIETARY
GUIDELINES
(MDG 2010)
Hands-on
MDG, 2010
Key
Message 1:
Eat a variety of
foods within your
recommended
intake
1800 kcal/day
5 servings
2 servings
3 servings
1 servings
1 servings
1/2 servings
2 servings
Based on
2000 kcal/day
Based on
1500 kcal/day
Figure 3: Sample menu
1. Calculate the number of servings
according to each food groups below:
2. Estimate the total calorie for one-day-

menu listed in Fig 3.
3. Identify your own daily calorie
requirement and plan a complete one-
day-menu according to Malaysian Food
Pyramid recommendations.
How to plan your/ clients’ menu using
exchange system?
Siti
Female, 23 years old
A college student.
Hands-on Weight 50kg; Height 158cm
STEP 1: Calculate your energy requirement – (i) Quick method

STEP 1: Calculate your energy requirement – (ii) TEE (total energy expenditure)
Total Energy Expenditure = Resting Energy Expenditure/ Basal Metabolic Rate +

Physical Activity + Thermic Effect of Food Lab STM 3203
Pemakanan &
(TEE = REE/BMR + PA + TEF) Kesihatan
STEP 2: Identify protein requirement
@ 10-20% of TEI
RNI for Malaysia, 2017

STEP 3: Determine the % of energy distribution
RNI for Malaysia, 2017
STEP 4: Complete the Food distribution table
STEP 5: Plan your menu
Meals Menu
Breakfast
Morning Tea
Lunch
Afternoon
snack
Dinner
Supper
Based on
1500 kcal/day
STM4201 Lecture 5:
Hospital diets and Dietary Guidelines
1/29/2021 1
Hospital diets: Diet modifications
- Therapeutic diets are based on normal diet.
- The purpose is to supply the required nutrients in the form
that the body can handle.
- Therefore, to prepare & evaluate the diets, knowledge of
nutrient composition is necessary.
- Changes involved:
1) consistency: liquid diet, soft diet
2) energy value: wt reduction diet, ↑ cal diet
3) type of food/ nutrient consumed: sodium/
lactose-restricted diet, low/high-fiber/potassium diet.
4) elimination of specific food: allergy diet,
gluten/lactose-free diet.
1/29/2021 STM 4201 Standard hospital diet 2
& SOAP
Changes involved (cont)..
5) adjustment in level, ratio, or balance of protein, fat and CHO
E.g.- diet for diabetic, ketogenic-, renal- and chol-lowering diet
6) rearrangement of the number and frequency of meals

E.g.- diet for diabetic, post-gastrectomy diet
7) change in the route of delivery of nutrients (enteral or parenteral

nutrition)

& SOAP
1) Standard hospital diet
Based on the foundation of an adequate
diet pattern.
- as realistic as possible and yet ensure
fulfilled the nutritional needs of the pts.
- providing foods that the pt is willing and
able to eat, fit in with any required dietary
restrictions.

& SOAP
& SOAP
Regular diet
- Diet that has no restriction, “house diet”.
- Used when the pt’s medical condition warranted no
limitations.
- Basic, adequate, general diet of:
• 1600 to 2200 kcal
• 60- 80 g protein
• 60- 70 g fat
• 200- 300 g CHO
Follow the dietary recommendation

& SOAP
& SOAP
& SOAP
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& SOAP
Liquid diet
- For pt with condition require nourishment that is easily
digested and consumed, or that has minimal residue.
- Often prescribed for a brief period for pts:
• undergoing diagnostic procedure
• in preparation for surgery
• immediately after surgery
• with chewing or swallowing difficulties
- 2 types: clear liquid diet and full liquid diet

& SOAP
Clear liquid diet “transparent liquid food’
- Occasionally used as preparation for endoscopic or
colonscopic evaluation and in acute GI disturbances.
- Offers fluids and some electrolytes and a small amt of E.
• tea, broth, honey, carbonated beverages, clear fruit
juice and gelatin.
• DOES not include milk and fruit juices that contain
pulp.
- Not sufficient to replace electrolytes loss in vomitus or
diarrheal fluids
• 500 to 600 kcal
• 5-10 g prot
• 120-130 g CHO
• minimal fat
• small amount of Na and K.
- Inadequate in calorie and all essential nutrients

& SOAP
Full liquid diet
- Foods that are liquid or semi liquid at room or body temperature.
• Ice-cream, gelatin, yogurt without nuts or fruit and strained cooked
cereals such as cream of wheat, strained cream soups, pudding,
and custard. Condiments such as butter, margarine, cream, oil, salt
and spices can also be included.
- Used for pt who are unable to chew, swallow or digest solid foods.
- A transition between a clear liquid diet and a regular diet
- Can be adequate for maintenance requirements, except for fiber

• 1000 to 1500 kcal
• 45 to 50 g protein
• 50 to 65 g fat
• 150 to 170 g CHO
•1100 kcal, 40 g protein, 30 g fat, 170 g CHO
- The diet can be increased in protein and calorie value equal to a
regular diet. 14
Soft diet
- Used as a transition between a liquid and regular
diet.
- Moderately ↓ in cellulose, connective tissue and residue.
- Normally prescribed for post-operative pts or those with
GI problems.
- Suitable for pts with poor dentition.
- Most useful when the selection of food is guided by the
pt’s tolerance.
- 1800 to 2000 kcal, but will vary based on menu
selection, pt preference and other restrictions.

& SOAP
& SOAP
& SOAP
& SOAP
& SOAP
& SOAP
Low-Purine Diet
What Is Purine?
Purine is a compound found mostly in
foods that come from animals. It is very
high in organ meats, anchovies, mackerel,
and sardines.
Indication: Gout, hyperuricemia
The body processes purine into uric acid.

Too much uric acid can make gout worse.
Eating a low-purine diet means less uric
acid and less health problems from gout.

& SOAP
& SOAP
& SOAP
& SOAP
& SOAP
Dietary Guidance:
Translating the Message to the Public
Malaysian Dietary Guidelines 2010
• Eat variety of foods within your recommended intake.
• Maintain body weight in a healthy range
• Be physically active everyday.
• Eat adequate amount of rice, other cereal products and tubers.
• Eat plenty of fruits and vegetables everyday.
• Consume moderate amount of fish, meat, poultry, egg, legumes and nuts.
• Consume adequate of milk and milk products.
• Limit intake of foods high in fats and minimize fats and oils in food
preparation.
• Choose and prepare foods with less salt and sauces.
• Consume foods and beverages low in sugar.
• Drink plenty of water daily.
• Practise exclusive breastfeeding from birth until 6 mths and continue to
breastfeed until 2 y of age.
• Consume safe and clean foods and beverages.
• Make effective use of nutrition information on food labels.
& SOAP
Key message 1: Eat variety of foods within your
recommended intake.
• Choose daily food intake from a combination of foods
based on Malaysian Food Pyramid
• Choose daily food intake according to the serving size
recommended
– Supplements are not necessary

for most individuals, but may be
needed to meet specific
requirements (convalescence,
pregnant and lactating,
elderly)

& SOAP
Key message2: Maintain body weight in a
healthy range
• Maintain a body weight in a healthy range by balancing
calorie intake with physical activity
• Weigh regularly, at least once a week
• If adult, prevent gradual wt gain over time
• If overweight, aim for a slow and steady wt loss
• If underweight, increase energy intake as recommended

& SOAP
Key message 3: Be Physically active everyday
• Be active everyday in as many ways as you can
• Accumulate at least 30 minutes of moderate intensity
physical activity on at least 5 to 6 days a week, preferably
daily
• Participate in activities that increase flexibility, strength and
endurance of the muscles, as frequent as 2 - 3(x) a week
• Limit physical inactivity and sedentary habits
1/29/2021 29
Key message 4: Eat adequate amount of rice,
other cereal products (preferably whole grain) and
tubers
• Consume at least 4 servings of cereal foods daily
• Choose at least half of your grain products from whole grains
• Choose cereal products that are high in fibre, low in fat, sugar
and salt
1/29/2021 30
Key message 5: Eat plenty of fruits and
vegetables everyday
• Eat a variety of fruits everyday
• Eat a variety of vegetables everyday
• Eat at least 5 servings of fruits and vegetables
everyday
1/29/2021 31
Key message 6: Consume moderate amounts of
fish, poultry, egg, legumes and nuts
• Consume fish more frequently, if possible everyday
• Consume meat, poultry and egg moderately
• Practise healthier cooking methods for fish, meat poultry
and egg dishes
• Choose meat and poultry that are low in fat and cholesterol
• Consume legumes daily
• Include nuts and seeds weekly diet

& SOAP
Key message 7: Consume adequate amounts of
milk and milk products
• Consume milk and milk products everyday
• Replaced sweetened condensed milk and sweetened
condensed filled milk with unsweetened liquid or
powdered milk

& SOAP
Key message 8: Limit intake of foods high in fats
and minimise fats and oils in food preparations
• Limit the intake of SFA <10%
•  intake of unsat fats: MUFAs and
PUFAs
• Limit intake of high cholesterol foods

• Limit foods containing TFA
• Minimise the use of fat in food

preparation, keep total daily fat
intake between 20-30%
• When eating out, choose low fat

foods.

& SOAP
Compare between snack food vs staple

& SOAP
Key message 9: Choose and prepare foods with
less salt and sauces
• Limit salt intake to 1 tsp/D
• Reduce consumption of highly salted
foods and condiments
1/29/2021 36
Key message 10: Consume foods and beverages
low in sugar
• Eat foods low in sugar
• Drink beverages low in sugar

& SOAP
Key message 11: Drink plenty of water daily
• Drink 6-8 glasses of plain water daily
• Maintain fluid intake from other food sources
• Avoid alcoholic beverages
Vs.

& SOAP
Key message 12: Practise exclusive
breastfeeding from birth until 6 mths and continue
to breastfeed until 2 years of age
• Prepare for breastfeeding during pregnancy
• Initiate breastfeeding within 1 hr of birth
• Breastfeed frequently and on demand
• Give only breast milk to baby below 6 mths with no
additional fluid or food
• Continue to give babies breast milk even if the baby is not
with the mother
• Introduce complementary foods to baby beginning at 6
mths of age
• Lactating mothers should get plenty of rest, adequate food
and drink to maintain health
• Husband and family members should provide full support
to lactating mothers 39
Key message 13: Consume safe and clean foods
and beverages
• Choose safe and clean foods and beverages
• Store foods appropriately
• Prepare foods hygienically
• Cook foods thoroughly
• Hold foods appropriately
• When eating out, choose safe and clean premises
1/29/2021 40
Key message 14: Make effective use of nutrition
information on food labels
• Use Nutrition Information
panel (NIP) as a guide in
making food choices
• Make use of nutrition claims
wisely
• Educate children on the use
of NIP

& SOAP
It’s All About You
Make healthy choices that fit your lifestyle
so you can do the things you want to do.
BE REALISTIC BE SENSIBLE
Make small changes overtime in Enjoy all foods, just don’t over do
what you eat and the level of activity it
you do. After all, small changes
work better than giant leaps
BE ADVENTUROUS BE ACTIVE
Expand your tastes to enjoy Walk the dog,
a variety of foods don’t just watch the dog walk
BE FLEXIBLE
Balance what you eat and the physical activity
you do over several days. No need to worry about
just one meal or one day
& SOAP
Upper Gastrointestinal
Disorders
Upper GI Anatomy
Nausea & Vomiting
Pathophysiology
• What health problems occur with

prolonged vomiting?
• Vomiting with abdominal pain: GI

disorder or obstruction
• Vomiting without abdominal pain:
medications, foodborne illness,
pregnancy,motion sickness,
neurological disease, etc
Treatment
• Find and correct the underlying cause

• Restore hydration
• Take medication with food
• May need suppressive medication
• What may be necessary in cases of
intractable vomiting?
Dietary interventions
• Small meals
• Beverages between meals
• Dry, starchy foods or cold/room
temperature foods may be better
tolerated
• Fatty, spicy, strong-smelling, or hot
foods may be less tolerated
Gastroesophageal Reflux
Disease - GERD
Pathophysiology
GERD occurs when acidic gastric juices

back flow into the esophagus through
an incompetent lower esophageal
sphincter (LES).
Symptoms of Gastroesophageal Reflux
Disease (GERD)
✓ Hearburn – most common GI complaint

✓ Reflux of small amounts of stomach acid into
the mouth
✓ pain may radiate to the neck and throat
With GERD – gastric reflux causes sometimes,

tissue damage.
Causes of GERD
✓Weakening or inappropriate relaxation of

lower esophageal sphincter
✓Associated with pregnancy due to the
elevation of progesterone which
esophageal sphincter
✓ Associated with hiatal hernia
(a condition in which the upper portion
of the stomach protrudes above the
diaphragm )
Consequences of GERD
✓Reflux esophagitis
(inflammation in the esophagus related
to the reflux of acidic stomach contents).
✓Esophageal ulcers
✓Scarring of ulcerated tissue
✓increased risk of cancer

Treatment of GERD - lifestyle
modifications
✓Avoid large meals to avoid increased

gastric pressure
✓Limit foods that weaken chocolate- high
fat foods- peppermint)
✓Avoid smoking and alcohol
✓lower esophageal sphincter pressure or
increase gastric acid secretion
( caffeine- garlic- onion-
modifications (cont’)
✓ Avoid eating bedtime snacks or lying down
immediately after meals Remain upright for
45 to 60 minutes after eating
✓ Consume meals 2-3 hours before bedtime
✓ Prop pillows under the head and upper torso
during sleeping
modifications (cont’)
✓Avoid wearing tight clothing that

increases pressure in the stomach
✓Lose weight if needed because weight
loss decreases intra-abdominal
pressure
✓Avoid use of non-steroidal anti
inflammatory drugs (NSAIDS)
• During times of esophagitis, avoid items that
may irritate the esophagus such as carbonated
beverages, citrus fruits and juices, spicy foods,
tomato products, and any other individual
intolerances.
• People who avoid citrus juices and tomato
products because of their acidity should be
encouraged to eat other sources of vitamin C.
Treatment of GERD
✓Drugs that suppresses acid secretion by

inhibiting receptors on acid-producing
cells.
✓Antacids
✓Surgery
Hiatal Hernia
Hiatal Hernia
• Part of stomach protrudes through

diaphragm into thoracic cavity
✓Prevents food from moving normally
along digestive tract
• Heartburn and food regurgitation into
mouth can occur
(continues)
Medical nutrition therapy
of Hiatal Hernia
✓Small, frequent meals of well-balanced
diet
✓Avoid irritants to esophagus
✓Avoid foods that relax lower esophageal
sphincter
✓Weight loss recommended if necessary
✓Avoid lying down two to three hours
after eating
Gastritis
Inflammation of the stomach mucosa
✓Acute cases
• Caused by irritating substances or treatments that
damage the gastric mucosa (alcohol, chemotherapy,
ingestion of toxins or corrosive materials)
✓Chronic cases
• Caused by long-term infections: Helicobacter pylori
• Autoimmune disease
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
Complications
Disrupted gastric secretory functions
• Hypochlorhydria or achlorhydria can

impair absorption of nonheme iron and
vitamin B12
• Pernicious anemia (reduces intrinsic
factor) results in macrocytic anemia of
vitamin B12 deficiency
Dietary interventions
✓Avoid irritating foods and beverages

✓Iron and vitamin B12 supplements
Gastric Surgery
– Partial gastrectomy
• Only part of the stomach is removed
• Remaining portion is connected to the
duodenum or jejunum
– Total gastrectomy
• Entire stomach removed
• Esophagus connected directly to the small
intestine
Post Gastrectomy Diet
✓Ice chips allowed 24-48 hours after

surgery. Some tolerate warm water
better than ice chips or cold water
✓Clear liquids such as broth, bouillon,
unsweetened gelatin, diluted
unsweetened fruit juice
✓Initiate post gastrectomy diet (clear
liquids pureed diet soft diet) and gradually
progress to normal diet as tolerated
✓Monitor iron, B12, and folic acid status
Post-surgical complications
Malabsorption, steatorrhea
Post-surgical complications affecting

nutrition:
• Fat soluble vitamins, calcium
• Folate, B12 (loss of intrinsic factor)
• Iron – better absorbed with acid
➢ Supplement may help
Conditions Affecting the
Stomach
1) Dyspepsia
Symptoms dyspepsia
Indigestion in the upper abdominal area

Symptoms may include :
o Stomach pain
o Heartburn
o Fullness
o Nausea
o Bloating
Causes of dyspepsia
✓Medical conditions : peptic ulcers,

GERD, motility disorders,
malabsorptive disorders,
gallbladder disease, abdominal
tumors, diabetes mellitus, renal
disease, thyroid disease, heart failure
✓Medications
✓Dietary supplements
Dyspepsia
• Potential food intolerances

✓Overeating
✓Specific foods – spicy
✓Coffee including decaffeinated
✓High-fat foods
✓Advised to consume small meals, well-
cooked foods - not overly seasoned, in a
relaxed atmosphere
Dyspepsia
• If the problem is organic in origin,

treatment of the underlying cause will
be the normal procedure.
Dyspepsia
• Bloating and stomach gas

✓Chewing gum
✓Smoking
✓Rapid eating, drinking carbonated
beverages
Omitting these practices generally helps

to correct the problem.
2) Peptic Ulcer
Peptic Ulcer
Erosion of the mucosal

layer of the stomach
(gastric ulcer) or
duodenum (duodenal
ulcer) caused by an
excess secretion of, or
decreased mucosal
resistance to,
hydrochloric acid.
Primary cause
• Helicobacter pylori infection is the

primary factor of the disease and was
found in 60% of Gastric ulcers
patients and in 80% of Duodenal
ulcers patients
• Another major factors is the use of
certain drugs like aspirin which can
damage mucosal tissue
• Emotional stress
Effects of emotional stress:
Has effects on physiological processes
• Rapid stomach emptying which increase the
acid load in the duodenum)
• Hormonal changes that impair wound
healing
• Increased acid and pepsin secretions
✓Has behavioral changes

• Use of alcohol
• Tobacco use
• NSAID use
Other causes
• genetic predisposition
• abnormally high secretion of
hydrochloric acid by the stomach
Signs and symptoms of Peptic
Ulcer
• Peptic ulcer symptoms vary.

• Ulcer pain may be experienced as a :
✓Hunger pain
✓Burning pain in stomach region
✓Sometimes aggravated by food
– causes loss of appetite and
weight loss
Complications of Peptic Ulcer
✓ GI bleeding
(black stool- vomit that
resembles coffee ground)
✓ Perforations of the stomach
or duodenum leading directly
into the peritoneal cavity
✓ Gastric outlet obstruction
due to inflammation
Drug therapy for Peptic Ulcer
1. Drugs that suppresses acid secretion by
inhibiting receptors on acid-producing
cells
2. Antacids
3. Coating agents
4. Antibiotics to eradicate H.pylori
Dietary considerations for peptic
ulcer
✓ Individualized to personal tolerances

✓ Avoid foods that increase acid secretion or
irritate the GI lining – alcohol, coffee, caffeine,
spicy foods, carbonated beverages, chocolate.
✓ Avoid large meals that cause stomach
distension
✓ Avoid lying down two to three hours after
eating
✓ No smoking ( it delay the healing)
✓ Good chewing of food.
ulcer (cont’)
• Sufficient low-fat protein should be

provided but not in excess because of
its ability to stimulate gastric acid
secretion.
• It is recommended that clients receive
no less than 0.8 gram of protein per
kilogram of body weight.
• However, if there has been blood loss,
protein may be increased to 1 or 1.5
grams per kilogram of body weight.
ulcer (cont’)
• Although fat inhibits gastric secretions,

because of the danger of atherosclerosis,
the amount of fat in the diet should not be
excessive.
• Carbohydrates have little effect on
gastric acid secretion.
• Vitamin and mineral supplements,
especially iron if there has been
hemorrhage, may be prescribed.
ulcer (cont’)
• Although fat inhibits gastric secretions,

because of the danger of atherosclerosis,
the amount of fat in the diet should not be
excessive.
• Carbohydrates have little effect on
gastric acid secretion.
• Vitamin and mineral supplements,
especially iron if there has been
hemorrhage, may be prescribed.
STM4201 Lecture 8: MNT for Lower
Gastrointestinal Tract Disorders
Normal Function of Lower GI Tract
 Digestion
 Absorption
 Excretion
 Digestion
 Begins in mouth & stomach
 Continues in duodenum & jejunum
 Secretions:
 Liver
 Pancreas
 Small intestine
1/30/2021 STM4201- MNT for Lower GIT 2

Normal Function
of Lower GI
 Absorption
 Most nutrients absorbed in
jejunum
 Small amounts of nutrients
absorbed in ileum
 Bile salts & B12 absorbed in
terminal ileum
 Residual water absorbed in colon
Sites of nutrients absorption

STM4201- MNT for Lower GIT 3
Principles of Nutritional Care
Intestinal disorders & symptoms:
 Motility
 Secretion
 Absorption
 Excretion
Dietary modifications:
 To alleviate symptoms
 Correct nutritional deficiencies
 Address primary problem
 Must be individualized

Common Intestinal Problems
 Intestinal gas or flatulence
 Constipation
 Diarrhea
 Steatorrhea
Photo courtesy http://www.drnatura.com/

Intestinal gas and flatulence
 Include N2, O2, CO2, H2, and CH4
  ‘volume’ or frequency of passage of gas (flatulence)
 Abdominal distention/ cramping pain
associated with gas accumulation
 Factors contribute to the amount of gas:

 Inactivity
  GI motility
 Aerophagia (swallowing air)
 Dietary components
 GI disorders

MNT for intestinal gas and flatulence
 Inactivity, dysmotility or partial obstruction may
contribute to the inability to move normal amounts of gas
produced
 Movement/ exercise may help
 Reduce CHO foods that are likely to malabsorbed &

fermented
 Legumes, soluble fiber, resistant starch, simple sugar
 In legumes- not only fiber but also starchyose and raffinose
(partially digested in the small intestine)
 Excessive CHO intake- fraction of undigested/ unabsorbed

residue for bacterial action in colon
 Alternative: use of ginger????

Constipation
 Hard stools, straining with defecation, infrequent bowel movements
 Normal frequency ranges from one stool every 3 days to 3 x/d
 5% - > 25% of the population, depending on how defined
 <3x/wk or <1x/wk (severe)
Causes- systemic
 Side effect of medication
 Metabolic endocrine abnormalities
 Lack of exercise, chronic use of laxative
 Ignoring the urge to defecate
 Vascular disease of the large bowel
 Systemic neuromuscular disease
 Poor diet, low in fiber, inadequate fluid intake, milk intake
 Pregnancy, anxiety, travel
1/30/2021 8
Causes of Constipation - Gastrointestinal
 Diseases of the upper GIT
 Celiac Disease
 Duodenal ulcer
 Diseases of the large bowel resulting in:
 Failure of propulsion along the colon
 Failure of passage though anorectal
structures
 Irritable bowel syndrome (IBS)
 Hemorrhoids
 Laxative abuse
1/30/2021
Copyright STM4201-
© 2000 by W. B. Saunders Company. All rightsMNT for Lower GIT
reserved. 9
Diagnostic Tests Constipation
Begins with a physical exam including a digital rectal
exam. Other tests:
 Thyroid tests
 Barium enema x-ray: colonic contrast study
 Sigmoidoscopy
 Colonoscopy
 Colorectal transit study
 Anorectal manometry tests
 Evacuation proctography

Treatment of Constipation
 Encourage physical activity as possible
 Bowel training: encourage pt to respond to urge to
defecate
 Change drug regimen if possible if it is contributory
 Use laxatives and stool softeners judiciously
 Use stool bulking agents such as psyllium and
pectin

Food History / Recall / Frequency
A complete food history and 24-hour recall should be
completed. Specific areas of concern should include:
 Number of daily servings from grains, fruits, vegetables,
nuts, and legumes
 Caffeine intake
 Fluid intake
 Evaluation of exercise and activity patterns

To quickly estimate fiber intake from a food
record
 (X) number of servings of fruits and vegetables by
1.5 g
 (X) number of servings of whole grains by 2.5 g
 (X) number of servings of refined grains by 1.0 g
 (+) specific fiber amounts for nuts, legumes, seeds,
and high-fiber cereals
 Total = estimated fiber intake
(Marlett 1997)

MNT for Constipation
 Depends on cause
 Use high fiber or high residue diet as appropriate
 If caused by medication, may be refractory to diet treatment

Nutrition Intervention for Constipation
 Eat adequate insoluble fiber
 gradually increase to 25-38 g
 Major sources of insoluble fiber include cellulose, psyllium,
inulin, and oligosaccharides.
 found in the skins of fruits, vegetables, wheat and rice bran &
whole wheat.
 ↑ fluid intake to 64 oz/d.

 Participate in daily physical activity.
 Use bulk-forming agents such as Psyllium.
 Avoid stool retention and initiate bowel retraining program
ADA Nutrition Care Manual nutritioncaremanual.org

Fiber, roughage, and residue
 Fiber or roughage
 From plant foods
 Not digestible by human enzymes
 Residue
 Fecal contents, including bacteria and the net
remains after ingestion of food, secretions into the GI
tract, and absorption
High-fibers Diet
 Most Americans/ people = 10 – 15 g/day
 Recommended = 25 g/day 0r 14 g/1000 kcal
 More than 50g/day = no added benefit,
may cause problems

High-Fiber Diet
 ↑ consumption of whole-grain breads, cereals,
flours, other whole-grain products
 ↑ consumption of vegetables, especially legumes,

and fruits, edible skins, seeds, hulls
 Consume high-fiber cereals, granolas, legumes to

increase fiber to 25 g/day
 ↑ consumption of water to at least 2 L (eight 8 oz

cups)

High-Fiber Diets: cautions
 Gastric obstruction, fecal impaction may occur
when insufficient fluid consumed
 With GI strictures, motility problems, increase

fiber slowly (~1 mo.)
 Unpleasant side effects

 Increased flatulence
 Borborygmus
 Cramps, diarrhea

Diarrhea
 Frequent evacuation of liquid stools
 Accompanied by loss of fluid and electrolytes
 Occurs when there is excessively rapid transit of intestinal
contents through the small intestine, ↓ absorption of fluids, ↑
secretion of fluids into the GI tract
 Etiology
 Inflammatory disease
 Infections
 Medications
 Overconsumption of sugars
 Insufficient or damaged mucosal absorptive surface
 Malnutrition
 Should identify and treat the underlying problem

Diagnostics in Diarrhea
Stool cultures:
 Fecal fat: qualitative and quantitative to rule
out fat malabsorption
 Occult blood
 Ova and paracytes
 Bacterial contamination
 Osmolality and electrolyte composition

Diarrhea Diagnostics
Intestinal Structure and Function
 Sigmoidoscopy
 Colonoscopy
Evaluation of hydration status and electrolyte
balance:
 Serum electrolytes, serum osmolality
 Urinalysis
 Physical examination
 Current wt, usual wt, % wt change

Diarrhea Nutritional Care Adults
Restore normal fluid, electrolyte, and acid-base
balance.
 Use oral rehydration solutions
 Coconut water, honey- find scientific articles
 WHO std for ORS:
 1/3-2/3 tsp salt,
 3/4 tsp sodium bicarbonate,
 1/3 tsp potassium chloride,
 1-1/3 Tbsp. sugar,
 1 liter bottled or sterile water.

Nutritional Intervention Diarrhea
 ↓ GI motility
 Avoid clear liquids and other foods high in simple
carbohydrates and sugar alcohols
 Avoid caffeine-containing products

 Avoid alcoholic beverages
 Avoid high-fiber and gas-producing foods such as

nuts, beans, corn, broccoli, cauliflower, or cabbage

Nutrition Intervention Diarrhea
 Stimulate the GIT by slow introduction of solid
food without exacerbation of symptoms
 Low-residue, low-fat, lactose-free nutrition therapy
should guide initial food selections
 If no evidence of lactose intolerance, then these

foods should be added back to the meal plan
(Steffen 2004).

Diarrhea Treatment for Adults
Repopulate GIT with microorganisms
 Prebiotics in modest amounts including pectin, oligosaccharides,
inulin, oats, banana flakes, onion, honey
 Probiotics, cultured foods and supplements that are sources of
beneficial gut flora
Low- or Minimum Residue Diet

 Foods completely digested, well absorbed
 Foods that do not increase GI secretions
 Used in:
 Maldigestion
 Malabsorption
 Diarrhea
 Temporarily after some surgeries, e.g. hemorrhoidectomy

Foods to Limit in a Low- or Minimum Residue Diet
 Lactose (in lactose malabsorbers)
 Fiber >20 g/day
 Resistant starches
 Raffinose, stachyose in legumes
 Sorbitol, mannitol, xylitol >10g/day

 Caffeine
 Alcohol, esp. wine, beer

Restricted-Fiber Diets
 Uses:
 When  fecal output is necessary
 When GIT is restricted or obstructed
 When  fecal residue is desired
 Restricts fruits, vegetables, coarse grains
 <10 g fiber/d
 Phytobezoars
 Obstructions in stomach resulting from ingestion of
plant foods
 Common in edentulous pts, poor dentition, with
dentures
 Potato skins, oranges, grapefruit

MNT for Infants and Children
 Acute diarrhea most dangerous in infants and
children
 Aggressive replacement of fluid/ electrolytes
 WHO/AAP recommend 2% glucose (20g/L) 45-90

mEq sodium, 20 mEq/L potassium, citrate base
 Newer solutions contain less glucose and less salt,
available without prescription

MNT for Infants and Children
 Continue liquid or semisolid diet during bouts of
acute diarrhea for children 9 to 20 months
 Intestine absorbs up to 60% of food even during

diarrhea
 Early refeeding helpful; gut rest harmful
 Clear liquid diet is inappropriate

Nutrition Intervention Diarrhea in Children
 Thicken consistency of the stool
 Banana flakes, apple powder, or other pectin sources

can be added to infant formula
 If the infant has begun solid foods, use of strained

bananas, applesauce, and rice cereal are the best
initial food choices
 AAP no longer recommends the BRAT diet

(bananas, rice, applesauce, and toast) for diarrhea
in children
Steatorrhea
 Excessive fat in the stool
 A consequence of disease, surgical resection of

organs involved in digestion & absorption of lipid
 Normally, 94-98% of ingested fat is absorbed
 In steatorrhea, ≥ 20% fat in the stool

Causes of steatorrhea
 Inadequate bile secretion secondary to liver disease or
billiary obstruction
 Blind loop syndrome

 part of the intestine becomes bypassed (op, IBD)
 digested food slows or stops moving through the intestines.
 Pancreatic insufficiency
 Inadequate reabsorption of bile salt
 ↓ fat re-esterification & formation and transport of
chylomicrons

Treatment
 The underlying cause of malabsorption must be
determined and treated
 Risk of vitamin deficiencies, Ca, Zn, Mg
 MCT- easier absorption in the absence of bile acid

 66% of coconut oil- MCT
 The oil is best used when incorporated into food

Diseases of Small Intestine
 Celiac disease
 Brush border enzyme deficiencies
 Inflammatory Bowel Disease (IBD): Crohn’s disease

and Ulcerative colitis
 Short Bowel Syndrome (SBS)

Celiac Disease
 Also called Gluten-Sensitive Enteropathy and Non-tropical
Sprue
 Caused by inappropriate autoimmune reaction to gliadin
(found in gluten)
 Much more common than formerly believed (prevalence 1
in 133 persons in the US)
 Frequently goes undiagnosed

Celiac Disease
 Results in damage to villi of intestinal mucosa – atrophy,
flattening
 Potential or actual malabsorption of all nutrients
 May be accompanied by dermatitis herpetiformis, anemia,

bone loss, muscle weakness, polyneuropathy, follicular
hyperkeratosis
 Increased risk of Type 1 diabetes, lymphomas and other

malignancies

Celiac Disease Symptoms
 Early presentation: diarrhea,
steatorrhea, malodorous stools,
abdominal bloating, poor weight
gain
 Later presentation: other

autoimmune disorders, failure to
maintain weight, fatigue,
consequences of nutrient
malabsorption
 Often misdiagnosed as irritable

bowel disease or other disorders

Normal human duodenal mucosa and peroral small bowel biopsy
specimen from a patient with gluten enteropathy.

Celiac Disease Diagnosis
 Positive family history
 Pattern of symptoms
 Serologic tests: antiendomysial antibodies (AEAs),

immunoglobulin A (IgA), antigliadin antibodies (AgG-
AGA) or IgA tissue transglutaminase
 Gold standard is intestinal mucosal biopsy
 Evaluation should be done before gluten-containing

foods are withdrawn

Celiac Disease: Diet IS the Therapy
 Electrolyte and fluid replacement (acute phase)
 Vitamin and mineral supplementation as needed (calcium, vitamin

D, vitamin K, iron, folate, B12, A & E)
 Delete gluten sources from diet (wheat- gliadin, rye- secalin, barley-
hardein, oats- avenin)
 Substitute with corn, potato, rice, soybean, tapioca, and arrowroot
 Pts should see a dietitian who is familiar with this disease and its
treatment
Celiac Disease
 Read labels carefully for problem ingredients
 Even trace amounts of gliadin are problematic
 Common problem additives include fillers,
thickeners, seasonings, sauces, gravies, coatings,
vegetable protein

Tropical Sprue
 Cause unknown; possible infectious process

 Celiac disease: Non-tropical Sprue
 Imitates celiac disease
 Results in atrophy and inflammation of villi
 Sx: diarrhea, anorexia, abdominal distention
 Rx: tetracycline, folate 5 mg/d, B12 IM

Intestinal Brush Border Enzyme Deficiencies
 Deficiency of brush border disaccharidases
 Disaccharides not hydrolyzed at mucosal cell membrane
 May occur as
 Rare congenital defects
 Lack of sucrase, isomaltase, lactase in newborns
 Secondary to diseases that damage intestinal epithelium

 Crohn’s disease, celiac disease
 Genetic form
 Lactase deficiency

Lactase “Deficiency”
 70% of adults worldwide are lactase deficient, especially
Africans, South Americans, and Asians
 Maintenance of lactase into adulthood is probably the
result of a genetic mutation
 Diagnosed based on history of GI intolerance to dairy
products

Lactose Intolerance Diagnostics
Lactose breath hydrogen test

 Baseline breath hydrogen concentration is measured.
 Patient consumes 25 to 50 grams lactose.
 Breath hydrogen concentration is re-measured in 3 to 8
hours.
 An increase >20 ppm suggests lactose malabsorption (90%
sensitivity).

Lactase Deficiency Diagnostics
Lactose tolerance test:
 After 8-hour fast, baseline serum glucose is measured.
 Pt consumes 50-100 g of lactose
 Serum blood glucose levels are measured at 30, 60, and

90 min after lactose ingestion
 No increase in blood glucose levels suggests lactose

malabsorption (Pagana 2004).

MNT for Lactose Intolerance
 Most lactase deficient individuals can tolerate small
amounts of lactose (6-12 g) without symptoms, particularly
with meals or as cultured products (yogurt or cheese)
 Can use lactase enzyme or lactase treated foods, e.g. Lactaid

milk
 Distinct from milk protein allergy; allergy requires milk free

diet

MNT Strategies for Lactose Intolerance
 Start with small amounts of lactose containing foods (¼
cup of milk or ½ oz of cheese)
 Start with foods lower in lactose content
 Only include 1 dairy food a day and gradually increase the
amount as the days go by*
 Only eat 1 lactose-containing food/meal
 Drink milk or eat dairy foods with a meal or a snack, but
not alone
 Space lactose-containing foods several hours apart
 If drinking milk, heating the milk may improve tolerance
*A good strategy is to add in the equivalent of a maximum of

2-5 grams of lactose at a time.

MNT Strategies for Lactose Intolerance
 Try lactose-free or lactose-reduced milk
 Use lactase enzyme drops if pt drinking milk, but
must be added at least 24 hours before drinking the milk or
take lactase tablets before eating dairy foods
 Aged cheeses are naturally lower in lactose than a

processed cheese
 Yogurt, which contains bacteria that break down
the lactose may be easier to digest
 Buttermilk may also be easier to tolerate as it is a

fermented dairy food
Inflammatory Bowel Disease
 Crohn’s Disease and Ulcerative Colitis
 Autoimmune diseases of unknown origin
 Genetic component and environmental factors
 Onset usually between 15 to 30 years of age

Inflammatory Bowel Diseases (IBD)
Clinical features
 Food intolerances
 Diarrhea, fever
 Wt loss
 Malnutrition
 Growth failure
 Extraintestinal
manifestations
 Arthritic,
dermatologic,
hepatic

Crohn’s Disease
 May involve any part of GI
 Typically involves small & large
intestine in segmental manner with
skipped areas
 Affects all layers of mucosa
 Inflammation, ulceration, abcesses,
fistulas

Crohn’s Disease
 Fibrosis, submucosal thickening, scarring result in
narrowed segments, strictures, partial or complete
obstruction
 Multiple surgeries common with major resection

of intestine
 Malabsorption of fluids, nutrients
 May need parenteral nutrition to maintain adequate
nutrient intake, hydration

Ulcerative Colitis
 Involves only colon, extends from rectum
 Continuous disease, no skipped areas
 Inflamed mucosa, small ulcers, but not through
mucosa
 Strictures, significant narrowing not usual
 Rectal bleeding, bloody diarrhea common
 Often, colon removed

Important differences between Ulcerative Colitis and Crohn's Disease

Inflammatory Bowel Disease
Crohn’s Disease Ulcerative Colitis

 Involves any part of the  Involves the colon,
GI tract extends from rectum
 Segmental  Continuous
 Involves all layers of  Involves mucosa and
mucosa submucosa
 Steatorrhea frequent  Steatorrhea absent
 Strictures and fistulas  Strictures and fistulas
common rare
 Slowly progressive  Remissions and
 Malignancy rare relapses
 Malignancy common
IBD Diagnostics
Tests for initial diagnosis:

 Colonoscopy
 Lower gastrointestinal (GI) series with barium
enema
 ASCA (antisacchromyces antibodies) (Dubinsky
2003)
 ANCA (antineutrophil cytoplasmic antibodies)
(Dubinsky 2003)
 Biopsy
Tests for diagnosis, exacerbation, and
response to therapy
 C-reactive protein
 Erythrocyte sedimentation rate (ESR)
 Lactoferrin
 White blood count and differential
 Stool assessment for presence of leukocytes

IBD Medical Management
 To induce and maintain remission
 To maintain nutritional status
 During acute stages:
 Corticosteroids
 Anti-inflammatory agents
 Immunosuppressive agents
 Antibiotics

IBD Nutritional Management (acute)
 Low-residue, low-fiber liquid diet
 “Bowel rest” with parenteral nutrition
 Enteral nutrition may have better success at
inducing remission
 Diet tailored to individual:
 Minimal residue for reducing diarrhea
 Limited fiber to prevent obstruction
 Small, frequent feedings
 Supplements , MCT with fat malabsorption

Vitamin Needs in IBD
Use DRI baseline recommendations. The patient may
need higher levels of the following:
 Vitamin B-12
 Folate
 Thiamin
 Riboflavin
 Niacin
 Vitamin C
 Vitamin E
 Vitamin D
 Vitamin K

Food and Symptom Diary
FOOD AND SYMPTOM DIARY
FOOD AMOUNT ACTIVITIES SYMPTOMS

TIME
The American Dietetic Association Nutrition Care Manual online 5-05

IBD Nutritional Management (chronic)
 High protein, high calorie diet with oral
supplements
 Monitor vitamin-mineral status of iron, calcium,
selenium, folate, thiamin, riboflavin, pyridoxine,
vitamin B12, zinc, magnesium, vitamins A, D, E
 High fiber diet as tolerated
 Avoid unnecessary restrictions

Nutrition Prescription During Remission
 Maximize energy and protein intake and
replenishment of nutrient stores while tailoring
for patient's current gastrointestinal function.
 Avoid foods high in oxalate: persons with Crohn’s at

greater risk for oxalate stones due to fat
malabsorption/loss of calcium
 Increase antioxidant intake

 Use of probiotics and prebiotics
ADA Nutrition Care Manual online accessed 4-27-05

Short-bowel syndrome (SBS)
 Consequence of significant resections of small
intestine
 Jejunal resections
 Ileal resections
 40 – 50% small bowel resected
 Crohn’s, radiation enteritis, mesenteric infarct,
malignant disease, volvulus
 Peds: congenital anomalies, volvulus,
necrotizing enterocolitis

SBS Complications
 Malabsorption of micronutrients, macronutrients
 Fluid, electrolyte imbalances
 Wt loss
 Growth failure in children
 Gastric hypersecretion
 Kidney stones, gallstones

SBS: Predictors of Malabsorption,
Complications, Need for PN
 Length of remaining small intestine
 Loss of ileum, especially distal one third
 Loss of ileocecal valve
 Loss of colon
 Disease in remaining segments(s) of
gastrointestinal tract
 Radiation enteritis
 Coexisting malnutrition
 Older age surgery

Jejunal Resection
 Most digestion, absorption in first
100 cm of small intestine
 After period of adaptation, ileum
can perform functions of jejunum
 With loss of jejunum, less digestive
and absorptive surface

Ileal Resections
 May produce major nutritional,
medical problems with 100 cm+
resections
 Distal ileum:
 Site for absorption of vit B12/intrinsic
factor complex, bile salts, fluid
 Impaired bile salt absorption results in
malabsorption of fats, fat-sol vits,
minerals
 Increased absorption of oxalates =
renal stones

Ileal Resection
 In immediate post-op period, replace fluid losses

and sodium, magnesium, potassium via IV and
make pt NPO to control diarrhea
 Use medications to control gastric hypersecretion
 Slow GI transit with opioids and anticholinergics

such as Lomotil

Ileal Resection
 Transition to oral feedings using carbohydrate-

electrolyte feeds (oral rehydration fluids)
containing glucose, sodium chloride, sodium citrate
 Replace specific mineral and vitamin deficiencies

such as zinc, potassium, magnesium, vitamins A,
B12, D, E, K

Small Bowel Surgery – Nutritional Care
 Initially may require TPN
 2 general principles for resuming enteral
nutrition:
 Start enteral feedings early
 Increase feeding concentration, volume gradually

Small Bowel Surgery – Nutritional Care
 Small frequent mini-meals (6 – 10)
 Transition to more normal foods, meals may take
weeks to months
 Some pts never tolerate normal concentrations or
volumes of food
 Maximal adaptation of GI tract may take up to 1 yr
after surgery

Ileostomy or Colostomy
 Surgical creation of an opening from the body

surface to the intestinal tract = “stoma”
 Permits defecation from intact portion of
intestine
 “ileostomy” = removal of entire colon, rectum,
anus with stoma into ileum
 “colostomy” = removal of rectum, anus with
stoma into colon

Ileostomy or Colostomy
 Sometimes temporary
 Output from stoma
depends on location
 Ileostomy output will
be liquid
 Colostomy output more
solid, more odorous

Colostomy Illustration

Ileostomy or Colostomy – Nutritional Care
 Increase water, salt with ileostomies

 Pt w/ normal, well-functioning ileostomy usually
does not become nutritionally depleted
 W/ resection of terminal ileum need B12 supplement

Avoid practices that may contribute to swallowed
air and gas formation such as the following:
 Chewing gum
 Use of drinking straws
 Carbonated beverages
 Smoking
 Chewing tobacco
 Eating quickly

Add foods that may decrease odor, such as the following:
 Buttermilk
 Parsley
 Yogurt
 Kefir
 Cranberry juice

 May restrict fruits & vegetables so may need vitamin C

 May need to avoid very fibrous vegetables, chew well
 Individual tolerances
 For high output ileostomy may need to follow
dumping recommendations; use soluble fiber; monitor
fat soluble vitamins

Rectal Surgery
 Low residue to allow wound repair, prevent infection
 Chemically defined diets may be used to reduce stool
volume and frequency
Lower GI Disorders Summary
 Food intolerances should be dealt individually
 Patients should be encouraged to follow the least
restrictive diet
 Patients should be re-evaluated frequently and the diet
advanced as appropriate

Diseases of Large Intestine
 Irritable Bowel Syndrome

 Diverticular Disease
 Colon Cancer and Polyps

Irritable Bowel Syndrome (IBS)
 Not a disease – syndrome
 Abdominal pain, bloating, abnormal bowel
movements
 Alternating diarrhea, constipation
 Abdominal pain, relieved by defecation
 Bloating w/ feeling of excess flatulence
 Feeling of incomplete evacuation
 Rectal pain, mucus in the stool

IBS: Incidence in U.S.
 Occurs in individual between 30-50 y
 20% of women
 ~10 – 15% of men
 20 – 40% of visits to gastroenterologists
 30% asymptomatic
 One of the most common reason patients first
seek medical care
 Increased absenteeism, decreased productivity

IBS: Etiology
 Increased visceral sensitivity and motility in
response to GI and environmental stimuli
 React more to:
 Intestinal distention
 Dietary indiscretions
 Psychosocial factors
 Life stressors
 May have psych/social component (history of
physical or sexual abuse)

IBS and stress: review

IBS: Diagnosis
 Symptoms for 3 months or longer
 Positive family history
 Rule out other medical/surgical conditions
 Problem factors other than stress and diet:
 Excess use of laxatives, OTC meds
 Antibiotics
 Caffeine
 Previous GI illness
 Lack of regular sleep, rest patterns
 Inadequate fluid intake

IBS: Nutritional Care
 ID individual food intolerances
 Keep food record, include symptoms, time they occur in
relation to meals
 Avoid offending foods, substances
 Milk, milk products (lactose) only in presence of lactase
deficiency
 Fatty foods
 Gas-forming foods, beverages
 Caffeine, alcohol
 Foods w/  fructose or sorbitol

IBS: Nutritional Care
 Eat small frequent meals at relaxed pace, regular
times
 Gradually add dietary fiber to diet
 20 – 30 g
 Fiber supplements may help (psyllium)
 Fluids: 2 – 3 qts w/ fiber supp.
 Regular physical activity to reduce stress

Effectiveness of acupuncture to treat
irritable bowel syndrome: a meta-analysis

Diverticulosis
 Sac-like herniations or
outpouches of the
colon wall
 Caused by long-term
increased colonic
pressures
 Believed to result from
low fiber diet,
constipation

Diverticulitis
 Caused when bacteria or
other irritants are
trapped in diverticular
pouches
 Inflammation
 Abscess formation
 Acute perforation
 Acute bleeding
 Obstruction
 Sepsis

Diverticulitis: MNT for acute disease
 Use elemental diet if patient is acutely ill.
Progress to clear liquids
 Initiate soft diet with no excess spices or fiber.
Avoid nuts, seeds, popcorn, fibrous vegetables
 Ensure adequate intake of protein and iron
 Progress to normal fiber intake as inflammation
decreases
 Low fat diet may also be beneficial (?)- high fat
diet is believed to increase smooth muscle
contraction

Diverticulosis: MNT for chronic disease
 High fiber diet (increase gradually)
 Supplement with psyllium, methylcellulose may
be helpful
 2 – 3 qt water daily with high fiber intake
 Low fat diet may be helpful
 ? Avoid seeds, nuts, skins of plants

Colon Cancer
 Second most common cancer in adults
 Second most common cause of death
 Factors that increase risk:
 Family history
 Occurrence of IBD – Crohn’s, ulcerative colitis
 Polyps
 Diet
 Overweight
 Tobacco
 Stress
 Do not exercise regularly

Colon Cancer/Polyps: dietary risk factors
 Increased meat intake, esp. red meats
 Increased fat intake
 Low intakes of vegetables, high fiber grains,
carotenoids
 Low intakes of vitamins D, E, folate
 Low intakes of calcium, zinc, selenium
 Some food preparation methods (chargrilling)
 Other factors: family history, overweight, alcohol,
tobacco, stress, do not exercise in a regular basis

Colon Cancer/Polyps: possible dietary
protective factors
 Omega-3 fatty acids –fish oils, flaxseed, etc
 Wheat bran
 Legumes
 Some phytochemicals (plants)
 Butyric acid – dairy fats, bacterial fermentation of
fiber in colon
 Calcium

STM 4201 Lecture 9: MNT in Diabetes
1/30/2021 STM 4201 MNT for Diabetes 1

Types of DM
◼ Type 1(5-10%)
◼ Type 2 (90-95%)
◼ Gestational
◼ “Other Specific Types” from
– specific genetic syndromes
– surgery
– drugs
– Malnutrition (old term)
– infections
– other illnesses
◼ Impaired glucose tolerance (pre-diabetes)
MNT
Medical Nutrition Therapy

• The use of specific nutrition
interventions to treat an illness,
injury or condition.

Sources
CPG TYPE II DM , 2015 MNT TYPE II DM , 2013

Nutritional Assessment





MNT Type 2 DM
CPG TYPE 2 DM (2015)

Estimating Energy Requirements
for Type 2 Adults : Calories
Weight status Overweight Normal weight Underweight

Sedentary 30 kcal/kg 35 kcal/kg
Moderate activity 20-25 kcal/kg 35 kcal/kg 40 kcal/kg
Marked activity 40 kcal/kg 45 kcal/kg
Weight for calculation: use current body weight for all

except in obese (BMI 27.5) & underweight (BMI < 18.5)
calculate based on acceptable weight i.e. BMI 22
MNT TYPE 2 DM 1st Ed (2005)

Carbohydrate

Carbohydrate and Diabetes
• The amount of carbohydrate at a meal
affects the blood glucose more
than the type
– Sugar and starch have similar effects on
blood glucose
=
CHO counting
• Carb counting
helps people
with diabetes
plan their
meals and
snacks
• 1 serving of
food with
CHO = 15
grams of
CHO.
MNT TYPE 2 DM
2nd Ed (2013)

Glycemic Load (GL)
◼ = (amount of CHO x GI value) /100

◼ Total amaunt of available CHO is more
important than the source and type
(low/high GI)
◼ The higher the GL, higher elevation of
blood glucose
Glycemic Index (GI)
◼ Measures how quickly or slowly the
body metabolizes the CHO in foods into
glucose in comparison to reference
food.
◼ Although the use of GI has additional

benefit to glycaemic control when use
together with carbohydrate counting, it
should not be used in isolation. ISPAD, 2014
Protein
Normal renal function
◼ 15-20% energy
◼ Include lean meat, fish, chicken/poultry
without skin and soy protein
Impaired renal function

◼ Eg.diabetic nephropathy/ diabetic kidney
disease
◼ Protein restriction of 0.8-1.0g/kg body
weight / day
43
Cardio protective nutrition
◼ Limit total fat (25-35% energy)

◼ Saturated fat <7% energy
◼ Minimal trans fat <1% energy
◼ Dietary cholesterol <200 mg/day
◼ Sodium intake <2400 mg

Cardio protective nutrition cont’
◼ Plant sterols and stanols (2-3 g/day) –

may further lower total cholesterol by 4-11% and LDL by 7-15%.

Dietary fiber
20-30 g/day as recommended by

MDG 2010
◼ High fiber diet
◼ ↓ Total cholesterol 2-3%
◼ ↓ LDL cholesterol up to 7%
◼ Improve glycemic control

Vitamins & minerals

Alcohol
Limited to 2 drinks: men; 1 drinks :women
1 drink
Should be taken with
= 15 g alcohol meals to prevent hypoglycemia
-alcohol blocks gluconeogenesis
= 360 ml beer & increase effects of insulin
= 150 ml wine
= 45 ml hard liquor / distilled spirits

Non-Caloric Sweeteners
◼ Saccharin (Sweet’N Low®)
◼ Aspartame (NutraSweet®)
◼ Acesulfame potassium,
acesulfame-K (Sweet One®)
◼ Sucralose (SPLENDA®)
“STAGES” OF TYPE 2 DIABETES
LIFESTYLE
MONOTHERAPY
100
%
COMBINATION
THERAPY
b-CELL

FUNCTION  REQUIRE
  INSULIN
UKPDS: “HOMA”
ANALYSIS IGT PP DM DM DM
BS “1” “2” “3”
-10 -5 0 5 10
YEARS FROM DIAGNOSIS
Source

Insulin Therapy in Type 2 DM
Insulin type
◼ Conventional – recombinant human insulin
◼ Analogue – structurally modified insulin
◼ Further divided:

Insulin regimen for Type II DM

The Diabetes Meal Plan
◼ The meal plan should be

based on
– pt’s current eating habits
– diabetes medications, if any
– current wt status
– collaborative goals (e.g.,
does the pt desire to lose
wt?)
1/30/2021 61
Macronutrients Based On:
◼ Pt’s current eating

habits (CHO, fat,
protein)
◼ Lipid levels and

glycemic control
◼ Pt goals

Meal Plan
◼ Estimate current energy, carbohydrate,
protein, and fat intake
◼ Evaluate current meal pattern and schedule
◼ Adjust meal plan to promote treatment

goals (energy, fat, carbohydrate
distribution)
◼ Evaluate based on standard meal planning

standards (e.g. Food Guide Pyramid)
Meal Plan: Oral Medications
◼ May do well with smaller, more frequent

meals and snacks, especially if taking an
insulin secretagogue (OHA)
◼ Snack servings should be taken from the
meal plan
◼ Sulfonylureas: promote increased insulin release by
the pancreas and help reduce insulin resistance, can
induce hypoglycemia
◼ Insulin sensitizers: biguanides- metformin (glucophage)
◼ Thiazolidinediones: muscle sensitivity to insulin
◼ -glucosidase inhibitor: slow the process of CHO digestion

Meal Plan: Insulin
◼ Can start with the meal plan and devise an

insulin regimen
◼ Many pts require a bedtime snack to prevent
night-time hypoglycemia
◼ Pts who use morning intermediate-acting

insulin (NPH) may require afternoon snack
◼ Pts on rapid-acting insulin do not need a

snack
Meal Planning: Carbohydrate
Counting
◼ Focus on CHO as major driver of post-prandial
blood glucose.
◼ Can be used for intensive management or for
basic meal planning.
◼ Must still address energy needs and
composition of overall diet.
◼ Allows increased flexibility.
◼ 1 carbohydrate serving = 15 g

Physical Activity

Effect of Physical Activity on Blood
Glucose
◼ Depends on:
– blood glucose level before exercise
– diabetes medication
– when and how much patient ate last
– physical fitness
– Type, duration and intensity of activity
◼ Blood glucose checks before and after exercise
are the key

Exercise and Type 1 diabetes
◼ Improves physical ◼ It has no direct

fitness effect on glucose
◼ Increases self control
confidence ◼ Proper timing of
◼ Improves CV exercise & insulin
function & CHD risk ◼ Avoid strenuous
profile exercise before bed
time

Exercise and Type 2 diabetes
◼ Improves physical Improves glucose

fitness & reduces control:
fat %. ▪ Improving insulin
sensitivity.
◼ Improves CV ▪ Increasing Glu T4
function & CHD risk (glucose transporters).
▪ Muscle cells become
profile more sensitive to insulin
◼ Increases self ▪ Keep the liver from
producing too much
confidence glucose
▪ Build more muscle
▪ Lose wt and keep it off
How physical activity can influence
insulin sensitivity?
◼ 1) enhancing both GLUT4-dependent and hypoxia-

dependent glucose transport in skeletal muscle;
◼ 2) increasing skeletal muscle vascularization,

mitochondrial neobiogenesis, and eventually tissue
mass;
◼ 3) repartitioning intracellular fat, thereby improving its

utilization;
◼ 4) fat mass loss.

Carbohydrate Snacks for Physical
Activity
Intensity Time Carbohydrate

(minutes)
Mild Less than 30 May not be
needed
Moderate 30-60 15 grams
High Over 60 30-50 grams

Exercising With Diabetes
Complications
◼ If pts have diabetes complications:

– An exercise stress test is recommended
– Don’t consider diabetes as barrier to exercise
◼ Most moderate lifestyle activities are safe
◼ Some activities may need to be modified

Exercising With Heart Disease
Caution: Choose:
◼ Very strenuous ◼ Moderate activity
activity such as walking,
◼ Heavy lifting or swimming, biking,
straining gardening
◼ Exercise in extreme ◼ Moderate lifting,
cold or heat stretching

Exercising with Hypertension
(high blood pressure)
Caution Choose
◼ Very strenuous ◼ Moderate activity
activity like:
◼ Heavy lifting or – walking
straining – weight lifting
with light weights
– stretching
Make sure blood pressure is in control first

Exercising with Retinopathy
(eye disease)
Caution Choose
◼ Strenuous exercise ◼ Moderate, low-impact
◼ Heavy lifting and activities:
straining – walking
◼ High-impact aerobics, – cycling
jogging – water exercise
◼ Bending your head ◼ Moderate daily chores
below your waist – toe that don’t require
touching lifting or bending your
head below your waist
Exercising with Nephropathy
(kidney disease)
Caution Choose
◼ Strenuous ◼ Light to moderate
activity activity like walking,
light housework,
gardening, water
exercise
Exercise is known to temporarily increase
**
protein excretion
Exercising with Neuropathy
(nerve disease)
Caution Choose
◼ Weight-bearing, high ◼ Low impact, moderate
impact, strenuous, or activities:
prolonged exercise: – biking
– jogging/running – swimming
– step exercise – chair exercises
– jumping – stretching
– light to moderate
– exercise in heat/cold daily activities
Check feet after exercise 78
Exercise Safely
◼ Check blood glucose before and after exercise

◼ Don’t exercise if blood glucose is too high or
too low
◼ Carry carbohydrate to treat low blood glucose
if pts are at risk

Exercise Safely
◼ Stop exercising if feel pain, lightheaded, or

short of breath
◼ Avoid strenuous activity in extremely hot,
humid, or cold weather
◼ Wear proper shoes for the activity to reduce
the risk of injury

Exercise Safely
◼ Wear diabetes identification

◼ Include warm-up and cool-down sessions
◼ Drink plenty of fluid

Hypoglycemia
Hypoglycemia

Hypoglycemia

Self-Monitoring
Blood Glucose (SMBG)

Diabetes in Children
◼ 75% of Type 1 diabetes occurs before 18 years
◼ Peak onset is 6 -11 years
◼ Balance between allowing for normal growth and

development, and need for glycemic control
◼ Need meal plan that fits child’s lifestyle and

promotes optimal compliance
Management Goals in
Children
◼ Support normal growth and development
◼ Control blood glucose
◼ Prevent acute and chronic complications
◼ Achieve optimal nutritional status
Gestational Diabetes
◼ Nutrition management similar to Type 1 and
Type 2.
◼ Diet tends to be slightly lower in CHO and

higher in protein and fat (30-35%)
◼ Requires individualized approach

STM 4201 Lecture 10
Medical Nutrition Therapy for
Cardiovascular Disease
Elsevier items and derived items © 2008, 2004 by Saunders, an imprint of Elsevier Inc.
Cardiovascular Disease (CVD)
The leading cause of death in the world.
Includes deaths from coronary heart disease
(CHD) and stroke.
1/3 of deaths occur before age 65.
Risk reduction; major breakthroughs in prevention
and treatment.
Cardiovascular Disease (cont)
In Malaysia, CHD deaths reached 22,701 (22.2%).
Malaysia total deaths by cause:
– 1. CHD
– 2. Stroke (11.7%)
– 3. Influenza & pneumonia (9.2%)
– 4. Road traffic accidents (7.9%)
– 5. HIV/AIDS (5.5%)
– 6. TB (4%)
– 7. Lung cancers (3.2%)
– 8. DM (3.1%)
– 9. Lung disease (2.8%)
– 10. Kidney disease (2.5%)
Coronary Heart Disease/ Coronary Artery Disease
Disease involving the network of blood vessels
surrounding and serving the heart.
Manifested in clinical end points of myocardial
infarction (MI) and sudden death.
Cardiovascular Risk Factors
Markers in Blood
Lipoprotein profile
Low-density–lipoprotein cholesterol
Total triglycerides
High-density–lipoprotein cholesterol
Inflammatory Markers
Fibrinogen
C-Reactive protein
Lifestyle Risk Factors
Tobacco
Physical inactivity
Poor diet
Stress
Excessive alcohol consumption
Related Diseases/ Syndrome
Hypertension
Diabetes
Obesity
Metabolic syndrome
Highlights of the Framingham Study:
Most Significant Milestones
1960 Smoking  the risk of heart disease
1961 Cholesterol level, BP and electrocardiogram
abnormalities  risk of HD
1967 Physical activity found to reduce risk, obesity  risk
of HD
1970 High BP  risk of stroke
1976 Menopause  risk
1978 Psychosocial factors found to affect HD
1988 High [HDL-c] to reduce risk of death
1996 Progression from HTN to heart failure described
2006 Beginning of the genetic research study
Major Disease Processes Contributing to CHD
Atherosclerosis- chronic (long-term

development)
Thrombosis- acute (late and brief event)
Natural Progression of Atherosclerosis
(From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)

Structure of Plaque
Pathophysiologic Steps in Development of CHD/ MI
Phase 1 Fatty streaks (atherogenesis)
Phase 2 Atheroma (or plaque) formation
Phase 3 Complicated lesions with
rupture (nonocclusive
thrombosis)
Phase 4 Complicated lesions with
rupture and occlusive
thrombosis
Phase 5 Fibrosis (occlusive) lesions
Much more than simple accumulation of lipids within the artery wall; it is
a complex inflammatory response to tissue damage
Blood Lipids and Lipoproteins
Total cholesterol: amount in all lipoprotein
fractions
Total triglyceride: hypertriglyceridemia
Chylomicrons: transport dietary fat and
cholesterol from small intestine to liver and
periphery
VLDL: transport endogenous triglyceride and
cholesterol
LDL: major cholesterol transport lipoprotein
HDL: reverse cholesterol transport
Genetic Hyperlipidemias
Familial hypercholesterolemia
Polygenic familial hypercholesterolemia
Familial combined hyperlipidemia
Familial dysbetalipoproteinemia
Hyperlipidemias
Elevated blood TG and/or chol
Lipoproteins found in blood
Chylomicrons = postprandial dietary fat, transport
of dietary TG
VLDL= lipid being transported from liver to
peripheral tissue, transport of endogenous TG
LDL= transport of cholesterol, major cholesterol
transport lipoprotein
HDL= reverse transport of cholesterol, tissues to
liver
Type of hyperlipidemia depends upon portion of
particles present
Prevention of CHD and Stroke
Alerting risk factors toward healthy patient

profile
Lipid targets—NCEP ATP III- focus on LDL
Therapeutic lifestyle changes
Prevention begins in children ages 2+
Assessing Risk
Counting risk factors and using algorithms
Very high risk, high risk, moderate risk, low
risk
Imaging tools
National Screening for Heart Attack
Prevention and Education (SHAPE)
Program
Blood Markers for CHD
Lipoprotein profile
– Total cholesterol >200 mg/dl (5.2 mmol/L)
– LDL cholesterol >130 mg/dl (3.4 mmol/L)
– HDL cholesterol <40 mg/dl (1.04 mmol/L)
– Triglycerides >150 mg/dl (1.7 mmol/L)
Inflammatory markers
– Fibrinogen
– C-reactive protein
– Homocysteine
Lipoprotein Assessment
Includes measurement of fasting TC, LDL-c,
HDL-c, and TG level
Classification of serum TG
<150 (mg/dL)
Normal
or < 1.7 (mmol/L)
150-199
Borderline High
or 1.7-2.3
200-499
High
or 2.3-5.6
>500
Very High
Or > 5.5
Factors associated with elevated TG’s
O’wt, obesity Certain medications

Physical inactivity Cigarette smoking
High CHO intake Alcohol intake
(>60% of calories)
Genetics
Type II Diabetes,
kidney failure
LDL CHOLESTEROL
<100 mg/dL or < Optimal
2.6 mmol/L
100-129 or 2.6-3.4 Near optimal/above optimal
130-159 or 3.4-4.1 Borderline high
160-189 or High
4.1-4.9
190/4.9 Very high
TOTAL CHOLESTEROL
<200/5.2 Desirable
200-239/5.2- 6.2 Borderline high
240/6.2 High
HDL CHOLESTEROL
<40/ 1.04 Low
>60/Elsevier
1.6items and derived items © 2008,High (negates
2004 by Saunders, a risk
an imprint of Elsevier Inc. factor)
LDL and HDL-c
Laboratory Values Predict Risk of CHD
LDL-C >130 mg/dl or 3.4 mmol/L

HDL-C <35 mg/dl or 0.9 mmol/L
TC >200 mg/dl or 5.2 mmol/L
TG >150 mg/dl or 1.7 mmol/L
Formula: LDL-C = TC – HDL-C–(TG/5)
HDL-c Levels Predict Risk of CHD
Increased by: Exercise
Wt loss
Moderation of alcohol
Decreased by: Obesity

No exercise
Cigarettes
Androgenic steroids
B blockers
High TGs
Genetic factors
LDL-c Levels Predict Risk of CHD
Increased by:
Fat in diet
Obesity
Genetic
Infection- Chlamydia pneumonia, H.pylori
Diabetes-
insulin resistance
Hypothyroidism
Decreased by:
Estrogen
Level to
LDL Initiate Consider Drug
Risk Category
Goal Lifestyle Therapy
Changes
CHD or CHD <100

130 mg/dL or 3.4
Risk Equivalents mg/dL or 100 mg/dL
mmol/L
(10 yr risk >20%) 2.6 mmol/L
<130 10 yr risk>10%:
2+Risk factors mg/dL
>130 mg/dL
160 mg/dL
<160
190 mg/dL or 4.9
0-1 Risk factor mg/dL or 160 mg/Dl
mmol/L
4.1
Elsevier items and mmol/L
derived items © 2008, 2004 by Saunders, an imprint of Elsevier Inc.
What causes heart disease
Smoking
 chol
80% of coronary deaths in France
 BP
Diabetes
Lifestyle Risk Factors

Tobacco use
Physical inactivity
Poor diet
Stress
Alcohol consumption
Elsevier items
Thomas et al, and deriveddes
Archives items © 2008,du
Maladies 2004 by Saunders,
Coeur an imprint of
et des Vaisseaux, 100Elsevier
(2007):Inc.
57
Factors that are considered a “High
Risk” for CVD
Established heart disease
Chronic kidney disease/ failure
Diabetes
10-year risk Framingham global risk >20%
http://hp2010.nhlbihin.net/atpiii/calculator.asp
Factors that place someone “at risk” for
heart disease
One or more of the following risk factors:

– Cigarette smoking
– Poor diet
– Physical inactivity
– Obesity, especially central obesity
– Family history of premature heart disease (<55
years of male relative, <65 years in female)
Factors that place someone “at risk” for
heart disease (cont)
– High BP
– Dyslipidemia
– Evidence of coronary calcification
– Metabolic syndrome
– Poor exercise capacity on a treadmill test
Calculating
CHD risk for
men
Modifiable Risk Factors for CHD
Physical inactivity
Obesity
High LDL-c (>100 with CHD, >130 without CHD)
Low HDL-c (<40)
Diabetes
HTN (>140/90)
Smoking
(High Blood Homocysteine)
(C-reactive protein)
Physical Activity
 risk of developing NIDDM by 6% for each 500-kcal/wk
expended
 mortality in people with NIDDM;  morbidity and
mortality in o’wt individuals even if they remain o’wt
Unfit men who become fit may reduce CVD mortality by
52% compared to those who remain unfit.
Recommendation is for 30 minutes of moderate activity
most days
 HDL- and  LDL-c
 BP up to 10/8 mmHg in hypertensive pts
Weight Control
On average, ~ 1/2 to 1 mmHg decrease in BP for

each pound wt loss in obese hypertensive (up to
~20# loss)
Wt reduction can  HDL-c
Obesity is the major risk for NIDDM
High cholesterol/ fat
Decreasing SFA and increasing PUFA can lead to

– 14% in TC
– 44% in the risk of heart disease.
Increasing trans fatty acids can lead to a 28%

increase in the risk of heart disease.
Current status on cholesterol/ SFA and
blood cholesterol
Diet-heart hypothesis (eating chol & SFA raises blood
cholesterol) originated from studies more than half
a century ago.
– 75% cholesterol is produced in the body
– 25% cholesterol from diet can’t be absorbed by
the body
Based on systematic review (Gazziano & Djousse, 2009)
it was found that the relation between dietary
cholesterol and the risk of CHD is not clearly
understood.
Diet and Prevention of CVD: Lipid
hypothesis
The problem with “Lipid hypothesis”
The problem with “Lipid hypothesis”
There is no linear relation between cholesterol
levels and heart attack or stroke risk.
This has been known for decades- Framigham

Report 1970.
Despite a massive use of statin cholesterol

drugs over the past two decades, the incidence
of CVD hasn’t changed.
“Lipid hypothesis” of heart disease
First proposed by Russian researcher David Kritchevsky in
1954, later by Ancel Keys.
Rabbits fed with cholesterol had heart disease induced.
Feeding the rabbits vegetable oils lowered cholesterol

(temporarily), the supposedly cause of heart disease.
In effect, it meant: Cholesterol = heart disease.
This hypothesis is irrelevant today in the light of findings by

many researchers
Inverse associations of SFA intake with mortality from total stroke,
intraparenchymal hemorrhage and ischemic stroke. No associations
between SFA and mortality from subarachnoid hemorrhage and heart
disease.
Intake of SFA was not associated with an increased risk of CHD, stroke
or CVD. Thus no significant evidence to conclude that dietary SFA is
associated with an increased risk of CHD or CVD events.
LCD were associated with significant decreases in body wt, TG, fasting
glucose, BP, BMI,… and an increase in HDL-c.
High blood pressure
Effect on SBP of:

Less salt : 5 mm Hg
More fruit & vegs : 3 mm Hg
More fruit & vegs, less fat : 5 mm Hg
All together : 11 mm Hg
Stronger effect in subjects with HTN
Diseases and Syndromes
Related to CVD
Hypertension
Diabetes
Obesity (especially abdominal obesity)
Metabolic syndrome
Non-modifiable Risk Factors
Menopausal status
Age
Family history
Gender
DASH diet
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
Dairy products, such as cheese, do not exert the negative effects on blood
lipids as predicted solely by the content of saturated fat. Calcium and
other bioactive components may modify the effects on LDL-c and
triglycerides… The consumption of yogurt, and other dairy products, in
observational studies is associated with a reduced risk of weight gain and
obesity as well as of CVD..
There is abundant evidence that a reduction in dietary sodium and
increase in potassium intake decreases BP, incidence of HTN, and
morbidity and mortality from CVD. However, there is no credible
evidence that existing policies have been effective in achieving
population goals for dietary sodium and potassium intake
AHA 2006 Diet Recommendations for
CVD Risk Reduction
• Balance calorie intake and physical activity to achieve or maintain a
healthy body weight.
• Consume a diet rich in vegetables and fruits.
• Choose whole grain, high-fiber foods.
• Consume fish, especially oily fish, at least twice a week.
• Limit intake of saturated fat to <7% of energy, trans-fat to <1% of
energy, and cholesterol to <300 mg/day by:
– Choosing lean meats and vegetable alternatives.
– Selecting fat-free (skim), 1%-fat, and low-fat dairy products.
– Minimizing intake of partially hydrogenated fats.
• Minimize your intake of beverages and foods with added sugars.
• Choose and prepare foods with little or no salt.
• When consuming alcohol, do so in moderation.
• When eating food that is prepared outside of the home, follow the
AHA Diet and Lifestyle Recommendations.
Modified from Lichtenstein AH et al: Diet and lifestyle recommendations revision 2006: a scientific statement from
the American Heart Association Committee, Circulation 114:83, 2006.
Nutrient Composition of the TLC
Dietary Pattern
Nutrient Recommended Intake
Saturated fat* Less than 7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Total fat 25%-35% of total calories
Carbohydrate† 50% to 60% of total calories
Fiber 25-30 g/day
Protein Approximately 15% of total calories
Cholesterol Less than 200 mg/day
Total calories (energy) Balance energy intake and expenditure to maintain
‡ desirable body weight/prevent weight gain
From National Heart, Lung, and Blood Institute: Detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment
panel III), Final report, U.S. Department Of Health and Human Services, NIH Publication No. 02-5215, Bethesda, Md, September 2002.
*Trans-fatty acids are another low-density–lipoprotein raising fat that should be kept at a low intake.
†Carbohydrate should be derived predominantly from foods rich in complex carbohydrates, including grains, especially whole gr ains, fruits,
and vegetables.
‡Daily energy expenditure should include at least moderate physical activity (contributing approximately 200 kcal/day).
Therapeutic Lifestyle Changes
Nutrient Composition of TLC Diet
Nutrient Recommended Intake
Saturated fat < 7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Total fat 25–35% of total calories
Carbohydrate 50–60% of total calories
Fiber 20–30 grams per day
Protein Approximately 15% of total calories
Cholesterol Less than 200 mg/day
Total calories (energy) Balance energy intake and expenditure
to maintain desirable body weight/
prevent weight gain
Step I and II Diets
The AHA and NCEP have developed these
diets to treat  BP & hypercholesterolemia
Designed to lower LDL levels, while at the
same time promoting good nutrition.
The AHA no longer use these diets and
recommend the TLC (from ATP III) diet.
ATP III continues to recommend the Step I
diet for the general public.
Step I Step II
Total fat- 30% or 30% or less

less
7%
Sat fat- 7-10%
up to 10%
Poly - up to 10%
up to 15%
Mono Up to 15%
55% or more
Carb 55% or more
Approx 15%
Pro Approx 15%
< 200 mg
Chol. < 300mg
Steps in Therapeutic Lifestyle Changes
Therapeutic Lifestyle Changes
ATP III TLC dietary pattern
AHA recommendations
– SFA <7% kcal, total fat 25-35% kcal, low
trans-fatty acids
 physical activity and decrease energy

intake for wt loss
DASH pattern
Very–low-fat diets
Steps in Therapeutic Lifestyle Changes (TLC)
First Visit
Begin Therapeutic Lifestyle Changes

Emphasize reduction in SFA and cholesterol
Initiate moderate physical activity
Consider referral to a dietitian (MNT)
Return visit in about 6 weeks
Other risk factors????
Steps in Therapeutic Lifestyle Changes (TLC) (continued)
Second Visit
Evaluate LDL response

Intensify LDL-lowering therapy (if goal not achieved)
– Reinforce reduction in saturated fat and cholesterol
– Consider plant stanols/ sterols
– Increase viscous (soluble) fiber
– Consider referral for MNT
Return visit in about 6 weeks
PA/ wt management????
Steps in Therapeutic Lifestyle Changes (TLC) (continued)
Third Visit
Evaluate LDL response

Continue lifestyle therapy (if LDL goal is achieved)
Consider LDL-lowering drug (if LDL goal not achieved)
Initiate management of metabolic syndrome
(if necessary)
– Intensify wt management and physical activity
Consider referral to a dietitian
Dietary Factors
Fat
Saturated fatty acids
Monounsaturated fatty acids
– Trans fatty acids
Polyunsaturated fatty acids
Omega-3 fatty acids
Amount of dietary fat
Dietary cholesterol
The quality of dietary oils and fats has been widely recognised to be
linked to the pathogenesis of CVD. Prolonged consumption of the
repeatedly heated oil has been shown to increase BP and TC, cause
vascular inflammation as well as vascular changes which predispose to
atherosclerosis..
In general, treatment with EPA+DHA appears to lower patient
triglycerides more effectively, but in those patients with very high
triglyceride levels, use of EPA+DHA also raised low-density lipoprotein
cholesterol levels, whereas EPA alone did not. Both formulations, at
doses that do not lower triglycerides, have been shown to reduce CVD
events in some, but not all, studies.
While the majority of former studies showed a benefit of n-3 FA acid
intake, recent clinical trials using n-3 supplements on top of established
medication and prudent nutrition did not confirm these findings…..The
most recent meta-analyses observed clear benefits of fish consumption,
but not of n-3 capsules intake.
Dietary Factors–cont’d
Fiber
Antioxidants
Soy protein
Stanols and sterols
Weight loss
Effect of diet on CV deaths
Salt (-3 g/day) 1: 16%

Fish (4x/week) 2: 14%
Fruit (+1 portion/day) 3: 7%
Vegetables (+1 portion/day) 3: 4%
Fat (replace SFA by PUFA) 4: 12%
Overall: 53%
Theoretical5:
1 Law et al, British Medical Journal. 302 (1991):819
75%
2 Whelton et al, American Journal of Cardiology 93 (2004):1119
3 Dauchet et al. Journal of Nutrition 136 (2006):2588
4 Hu et al, Journal of the American Medical Association. 288 (2002):2569
5 Franco et al. British Medical Journal. 329 (2004):1447
2006 AHA Diet and Lifestyle Goals for
CVD Risk Reduction
Consume an overall healthy diet
Aim for a healthy body wt
Aim for recommended levels for LDL, HDL,
and TG
Aim for a normal BP
Aim for a normal blood glucose level
Be physically active
Avoid use of and exposure to tobacco products
Primary Prevention with Lipoprotein Analysis
(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No. 93-3095. Bethesda,
MD: National Heart, Lung, and Blood Institute, 1993.)
Primary Prevention in Adults without Evidence of CHD:
Initial Classification Based on TC and HDL-c
(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No. 93-3095. Bethesda,
MD: National Heart, Lung, and Blood Institute, 1993.) HDL = high-density lipoprotein.
2007 Lifestyle guidelines for prevention of
CVD in Women
Do not smoke
Physical activity
– A minimum of 30 minutes of moderate intensity
activity (brisk walking) on most, preferably all
days of the week
– For wt loss or maintenance: 60-90 minutes of
moderate intensity activity on most, preferably
all days of the week
2007 Lifestyle guidelines for prevention of
CVD in Women (cont)
Consume a diet rich in:
– Fruits and vegetables
– Whole grains
– High fiber foods
Consume fish, especially fatty fish at least
2x/wk (source of n-3 fatty acids)
Women with heart disease, MAY want to
consider n-3 supplementation of 850-1000
mg/day
Consider screening women with CHD for
depression and treat when appropriate
2007 Guidelines for prevention of CVD
in Women
Limit SFA to <7% of calories (15-20 g/day)
Limit cholesterol intake to < 200 mg/day
Reduce sodium intake to < 2300 mg/day
Achieve and maintain an appropriate wt
through healthy behavior changes (physical
activity, calorie intake, and formal behavior
programs if indicated)
Manage diabetes, blood lipids and high BP
aggressively
Saturated Fat
Serving Total Fat Saturated

Food size (g) Fat (g)
Prime Rib 3 oz 28 12
Sirloin Steak 3 oz 12 5
Ground beef,reg 3 oz 16 6
Ground beef, lean 3 oz 6 3
Milk, whole 1 cup 8 5
Milk, 1% 1 cup 2.5 2
Cheddar cheese 1 oz 9.5 6
Mozzarella 1 oz 4.5 3
Plant sources of n-3 fatty acids
Canola oil
Flaxseed and flaxseed oil
Walnuts
Soybean oil, tofu
n-6
The human body is inefficient at
converting ALA into EPA and DHA, and n-6
what is converted, is highly variable and n-3

inconsistent due to several n-3
bioconversion factors.
n-3
Inflammatory eicosanoid precursors
Pro- and anti-inflammatory action of n-
3 PUFAs
Possible mechanism…
Ineffective or potentially harmful
interventions
Hormone therapy to prevent or treat CVD
Use of anti-oxidant supplements (Vit E, C,
beta carotene) to prevent or treat CVD
Folic acid
Routine use of aspirin (in healthy women
under 65 years of age)
Treatment with HT in post-menopausal women for either primary or
secondary prevention of CVD events is not effective, and causes an
increase in the risk of stroke, and venous thromboembolic events. Short-
term HT treatment should be at the lowest effective dose, and used with
caution in women with predisposing risk factors for CVD events.
Results from large randomized controlled trials did not support long-
term use of single antioxidant supplements for CVD prevention due
to their null or even adverse effects on major cardiovascular events or
cancer. Diet quality indexes that consider overall diet quality rather than
single nutrients have been drawing increasing attention. Cohort studies
and intervention studies that focused on diet patterns such as high total
antioxidant capacity have documented protective effects on CVD risk.
Limited evidence supports any benefit from vitamin and mineral
supplementation for the prevention of cancer or CVD. Two trials found a
small, borderline-significant benefit from multivitamin supplements on
cancer in men only and no effect on CVD.
The efficacy of aspirin for secondary prevention of cardiovascular
disease is well established, but the clinical benefit of aspirin for
primary prevention of CVD is less clear. The primary literature
suggests that aspirin may provide a reduction in CVD events, but the
absolute benefit is small and accompanied by an increase in bleeding.
Clinical identification of Metabolic Syndrome (any
3 of the following)
Risk Factor Defining level
Abdominal Obesity Waist Circumference
Men >102 cm(>40”)
Women >88 cm (>35”)
Triglycerides 150 mg/dL
HDL Cholesterol
Men <40 mg/dL
Women
<50 mg/dL
Blood Pressure 130/ 85 mmHg
Fasting Glucose 110mg/dL
Quantity of Soluble Fiber Needed Daily to
Produce Lipid-Lowering Effect
Pectin: 6 - 40 g
Gums: 8 - 36 g
Dried beans or legumes: 100 - 150 g
Dry oat bran: 25 - 100 g
Oatmeal: 57 - 140 g
Psyllium: 10 - 30 g
General Goals for Treatment
of Hyperlipidemias
Achieve IBW.
Decrease simple sugars and alcohol.
Decrease total fat, especially chol and SFA.
Increase complex CHO and fiber.
Pharmacologic Management
Diet is still important to minimize need for drugs
After a 6-month trial on each diet, drugs are
added to the treatment.
Types
– Bile acid sequestrants (e.g., cholestyramine)
– Nicotinic acid
– HMG CoA reductase inhibitors (statins) (e.g.,
lovastatin, pravastatin)
– Fibric acid derivatives (e.g. clofibrate,
gemfibrozil)
– Probucol
Medical Intervention
Percutaneous coronary intervention (PCI)
Coronary artery bypass graft (CABG)
MI- Coronary Infarction, Coronary Thrombosis,
or Heart Attack
Some part of coronary circulation blocked
Ischemia leads to muscle destruction
Diagnosis: ECG; blood levels of enzymes
such as LDH and CPK
Myocardial Infarction (MI)
Post-infarction nutrition
1. 1st 24 hrs: no caffeine, liquid diet
(nausea and choking are common)
2. Small frequent meals; soft or liquid diet
3. Na+ restriction if BP and fluid status indicate
4. Consistent diet information
5. Drugs that cause nausea- digitalis, morphine
Summary/ Focal Points
Lifestyle changes, MNT at the cornerstone, are pivotal to
maintaining cardiovascular health.
In the past the focus has been on lipid lowering; however,
more research is uncovering the role of diet in inflammation
and endothelial dysfunction, which are involved in
atherogenesis.
LDL-c levels are the primary target for medical nutrition
therapy.
The AHA, TLCs, and DASH dietary patterns are
recommended in both the primary and secondary prevention
of CVD.
Lecture 11 STM 4201
Medical Nutrition Therapy for Renal
Disorders
.
Video
◼ https://www.youtube.com/watch?v=E1myFSlpy-A
(1st Video - CKD)
◼ https://www.youtube.com/watch?v=LtdWg4ygm_E
&t=223s
(2nd Video – Diabetic Nephropathy)
◼ https://www.youtube.com/watch?v=mi34xCfmLhw
(3rd Video – Failing Kidney Tx Options)
Group Discussion
◼ Form a group of 3 members
◼ Assign to each member (1 person – 1 video)
◼ Discuss the topic with 3 persons who were
assigned with similar video.
◼ Return to your earlier group and explain
your topic to your group members.
◼ Summarize the 3 topics in a mind map
(1 group – 1 mind map)
◼ Post your group’s mind map in e-learning
(CKD Forum)
Functions of the Kidney
 Excretory
 Acid-base balance
 Endocrine
 Fluid and electrolyte balance
2/1/2021
. STM4201 MNT for renal disorders 4
The Most Common Kidney Diseases
 Glomerulonephritis
 Glomerulosclerosis
 Nephrotic syndrome
 Diabetic Nephropathy
 Acute Renal Failure
 Chronic Renal Failure
 End-Stage Renal
2/1/2021
Primary Renal Disease
2/1/2021
 Glomerulonephritis- Inflammation or damage of
glomeruli / membrane tissue; nephritic syndrome.
 Causes of damage other than infections: acute interstitial
nephritis, associated with use of creatine supplement.
– Signs: HTN, edema, changes in urine color, nausea, vomiting and
headaches.
ANCA: anti-neutrophil
cytoplastic antibody
2/1/2021
 Nephrotic Syndrome- A set of symptoms including
proteinuria, edema and hyperlipidemia.
 Glomerulosclerosis- Nephrosclerosis (the scarring or

hardening of the tiny blood vessels within the kidney) due
to toxic substances, medications and painkillers.
 Diabetic Nephropathy- Related to sclerosis (scarring),

major factor in the development of ESRD.
2/1/2021
 Acute Renal Failure - Sudden kidney failure caused by
blood loss, drugs or poisons.
– If the kidneys are not seriously damaged, acute renal failure may
be reversed.
 Chronic Renal Failure - Gradual loss of kidney function

is called Chronic Renal Failure or Chronic Renal Disease.
 End-Stage Renal Disease - The condition of total or

nearly total and permanent kidney failure.
2/1/2021
Hematological Indicators
 i) Hemoglobin: ↓ due to lack of erythropoietin (EPO),
produced by the kidney; pts receive synthetic EPO tx
(Epogen)
– May have anemia of chronic disease
 ii) Ferritin : may be indicator of iron overload; ↑ ferritin may
mean EPO resistance (deficient production of erythropoietin)
2/1/2021
Glomerular Filtration Rate (GFR)
 Best index of kidney function
 Used to establish stage of CKD
 GFR is the amount of filtrate formed per minute based on
total surface area available for filtration (number of
functioning glomeruli)
 Can be determined using injected isotope (inulin)
measurement in urine
 Can be calculated from serum creatinine using standard
equations
2/1/2021
Medical Nutrition Therapy (MNT)
for Chronic Kidney Disease
(CKD)
*NKF-KDOQI define CKD as either

kidney damage or a decreased GFR of
less than 60 mL/min/1.73 m2 for at
least 3 months
*National Kidney Foundation Kidney Disease Outcomes Quality Initiative
2/1/2021 MNT for CKD

Chronic Kidney Disease (CKD)
◼ Definition: An irreversible loss of renal function for at
least three months
◼ Diagnosis: Based on – i) GFR, ii) pathological
changes (kidney damage) and iii) presence of the
abnormality such as
a. Persistent microalbuminuria
b. Persistent proteinuria
c. Persistent haematuria
d. Radiological evidence of structural abnormalities of the kidneys
e. Biopsy proven glomerulonephritis
(CPG MOH: Management of CKD in Adults, 2011)

Stage of CKD (NKF-KDOQI* Classification)
2/1/2021 *National Kidney Foundation Kidney Disease Outcomes Quality Initiative

Prevalence of CKD
◼ Pts diagnosed with CKD in Malaysia - no. of pts
with CKD receiving dialysis increased from 15,087
in 2006 to 37,183 in 2015
(23rd Malaysian Dialysis & Transplant Registry, 2015).
◼ Protein-energy
malnutrition is a
common complication of
CKD (Kopple et al, 2000)

Protein–energy malnutrition
◼ Defined as insufficient energy or
protein supply to meet the body’s
metabolic demands as a result of
either:
 an inadequate dietary intake of protein
 intake of poor quality dietary protein
 increased demands due to disease, or
 increased nutrient losses.
Protein-energy malnutrition in CKD

Factors Contributing to
Wasting in CKD pts

Factors Contributing to
Wasting in CKD pts

Nutritional status of CKD pts
◼ In 2015, 62% of HD pt and almost 89% of PD pt had
serum albumin < 40 g/dl. Nutritional markers such as
↓serum albumin and ↓ BMI have been identified as
independent factors for death in Malaysian dialysis pt.
(23rd Malaysian Dialysis & Transplant Registry)
◼ Appropriate medical nutrition therapy (MNT) provided by
a dietitian can help reduce the burden of nutrition -
related problems as MNT has an important role slowing
in the progression of CKD while maintaining optimal
nutrition (Levey et al. 1996) In addition, MNT reduces the
risk for CKD in individuals with diabetes and
hypertension (Delahanty et al. 1998)
Modifiable Risk Factors for
Progression of CKD
◼ Control of blood pressure
◼ Control of HbA1c
◼ Control of proteinuria or albuminuria
◼ Cessation of smoking, ↓ in dyslipidemia and

↑ in PA promote organ blood flow and
potentially reduce CKD damage.

Objectives of Nutrition
Management
Depend on stage of CKD:
A. Early Chronic Kidney Disease

(Stage 1&2)
B. Pre-Dialysis (Stage 3&4)

C. Haemodialysis (HD) and
Continuous Ambulatory
Peritoneal Dialysis (CAPD)
(Stage 5)

Management
A. Early Chronic Kidney Disease
(Stage 1&2)
◼ Treatment of co-morbid conditions such
as DM, HTN, and other chronic diseases
to slow the progression of renal failure
◼ Reduce the risk for CVD such as
hyperlipidaemia
◼ Providing regular nutritional counseling
based on an individualized plan of care in
order to promote good quality of life

Management
B. Pre-Dialysis (Stage 3&4)
◼ To delay the progression of kidney failure
◼ Maintain good nutritional status in preventing malnutrition by:
i) giving adequate protein and energy
ii) ensuring sufficient nutrients such as Ca, Fe, and other
vitamins and mineral
◼ Minimize electrolyte and mineral disturbances such as PO4,
K+, Ca, Na+ and fluids to manage co-morbidities (anemia,
bone disease, HTN)
◼ Encourage physical activity according to patient’s condition
and ability.
◼ Providing regular nutritional counseling based on
individualized
2/1/2021
plan of care in order to promote good QOL
MNT for CKD
Management
C. Haemodialysis (HD) and Continuous Ambulatory
Peritoneal Dialysis (CAPD) (Stage 5)
◼ Maintain or improve nutritional status in order to prevent
malnutrition by:
i) giving adequate protein and energy
ii) ensuring sufficient nutrients such as Ca, Fe, and other
vitamins and mineral
◼ Minimize electrolyte and mineral disturbances such as PO4,
K+, Ca, Na+ and fluids.
◼ Control fluids intake
◼ Prevent and manage co-morbidities such as CVD, anemia,
bone disease and DM
◼ Encourage physical activity according to patient’s condition and
ability.
◼ Providing regular nutritional counseling based on individualized
plan of care in order to promote
2/1/2021 MNT forgood
CKD QOL
The Need for Nutrition
Assessment
◼ GFR of less than 60ml/min is associated in laboratory
parameters of serum albumin, hemoglobin, serum
bicarbonate, decreases in body weight and dietary intake
of protein and energy (Kopple et al. 1989; Ikizler et al. 1995)
◼ There were positive correlation between mortality and age
of pts, serum cholesterol, diastolic blood pressure while
BMI, serum albumin, serum phosphate and haemoglobin
concentration were negatively correlated with mortality (23rd
Malaysian Dialysis & Transplant Registry)
◼ CAPD patients are more prone to protein malnutrition

compared to HD patients (23rd Malaysian Dialysis & Transplant Registry)
The Need for Nutrition
Assessment
23rd Malaysian Dialysis & Transplant Registry

◼ Therefore, all CKD patients should
undergo nutrition assessment to
evaluate protein calorie malnutrition
followed with appropriate intervention.

Nutrition Assessment and
Monitoring
◼ Anthropometric Assessment : Height,
Weight; post-dialysis (HD)/post drainage
(CAPD), body composition (bioimpedance,
BIA), triceps skinfold or mid-arm
circumference (MAC), SGA
◼ Biochemical Assessment : Serum albumin, Na+, Ca,
PO4, creatinine / urea, microalbumin, serum lipids, FBS /
HbA1c, Hb, BP.
◼ Dietary Assessment : Nutrient intake & meal plan,
food/supplement intake, eating out, smoking/alcohol,
recipe modification & food preparation, food label,
physical activity/functional status Activity of Daily Living
Nutrition Prescription
A. Calories
◼ Stage 1-4, Hemodialysis, CAPD and Peritonitis :
➢ 35 Kcal/kg body weight if < 60 years of age
➢ 30 – 35 Kcal/kg if > 60 years of age
(Includes calories from dialysate due to glucose absorption)
◼ Adequate energy intake is important to maintain neutral
nitrogen balance, to promote higher serum albumin
concentrations and more normal anthropometric
parameters and to improve protein utilization (Kopple et
al 1986)
◼ Approximately 60 – 70% of dialysis fluids glucose may
be absorbed during a 6 hr dwell (Bannister DK et al 1987)
◼ Caution: Monitor weight gain in CAPD patients.
A. Calories
◼ Energy expenditure of patients undergoing maintenance HD
is similar to that normal, healthy individuals (K/DOQI 2000)
◼ Acutely ill maintenance dialysis patients are generally
inactive physically and their energy needs will be diminished
by the extent to which their physical activity has been
decreased. Thus energy intakes of 30 – 35 kcal/kg BW are
recommended (K/DOQI 2000)
◼ The recommended total daily energy intake, including both
diet and energy intake derived from the glucose absorbed
from peritoneal dialysate should be 35kcal/kg/d (K/DOQI
2000)
B. Protein (Stage 1&2)
➢ 0.8 g/kg BW
◼ The requirement for protein is
unchanged in well control DM, but in hyperglycemic

individuals, protein synthesis is decreased and protein
breakdown increased, leading to a negative nitrogen
balance. This suggests that during periods of
hyperglycemia or weight loss, somewhat higher protein
intakes are required to achieve nitrogen balance, but
whether this alone will correct the abnormality is
unknown (Dikow et al 2002)
B. Protein (Stage 3&4; Pre-dialysis)
➢ 0.6 g/kg BW, if severe malnourish, use 0.75 g/kg
BW (K/DOQI 2000) at least 50% HBV protein
◼ Low protein will maintain nutritional status (Kopple et al
1973, Walser 1993, Tom et al 1995, Kopple et al 1997,
Fleischmann et al 1998) particularly if they receive higher
energy intake (ie. 35 kcal/kg/d)
◼ Low protein diet reduces the generation of nitrogenous
waste and inorganic ions which causes many of the
clinical and metabolic disturbances characteristic of
uremic individuals (K/DOQI 2000)

B. Protein (Stage 3&4; Pre-dialysis)

◼ HBV has an amino acid composition that is similar to
human protein, is likely to be animal protein and tends
to be utilized more efficiently by human to conserve
body proteins individuals (K/DOQI 2000)
◼ Caution: if patient is planning to undergo dialysis, a
higher protein intake may be warranted and ensure
energy intake is adequate.

B. Protein (HD patients)
➢ 1.2 g/kg BW, if severe malnourish and acute illness

(if increase intensity in dialysis, use 1.3 g/kg BW
with at least 50% HBV protein (Acchiardo et al 1990)
◼ Studies show that protein intake less than 1.2 g/kg/d
are associated with lower serum albumin levels and
higher morbidity in HD patients.
◼ Protein intakes greater than 1.2 or 1.3 g/kg/d may also
benefit the catabolic, acutely ill HD patients.
B. Protein (CAPD Patients)
➢ 1.2 – 1.3 g/kg BW, if acute illness use 1.3 g/kg BW

with at least 50% HBV protein (Shilling et al 1985)
◼ Hypoalbuminemia is more to occur when the protein
intake is less than 1.3 g/kg/d and significantly
associated with an increased incidence of peritonitis
and more prolonged hospital stay.

C. Carbohydrate (Stage 1 – 5)
◼ 50 – 60% of energy intake; but for DM patients, follow
diabetic diet guidelines. Fiber 20 – 30 g per day.
◼ CHO should be utilized to make up the balance of the
required energy intake
◼ Complex CHO is recommended & dietary fiber for good
glycemic control in diabetic patients (Beto 1995)
◼ Incorporating low protein CHO food sources and
simple sugars can assist in meeting energy
requirements of pt on low protein diet.
D. Fats (Stage 1 – 5)
◼ 25 – 35% of total kcal; emphasize reduced SFA less
than 7% total kcal, PUFA up to 10% of total kcal, MUFA
up to 20% of total kcal, cholesterol < 200 mg/day.
◼ Encourage daily regular physical activity whenever
possible. If dietary intervention is inadequate, drug
therapy should be started after 3 months (K/DOQI 2003)
◼ Patients are considered at highest risk for CVD (K/DOQI
2003)

D. Fats
◼ In non-diabetic pre-dialysis pt, hypertryglyceridaemia can
be reduced by both increasing the dietary PUFA:SFA
ratio and reducing the CHO content of the diet.
◼ Pt with other coronary risk factors (smoking, HTN,
obesity and lack of exercise) should be encourage to
modify their behavior + modified lipid diet
◼ Management of lipid abnormalities by dietary CHO and
fat restriction alone has been reported to be effective in
dialysis pt. However, additional dietary restriction is
difficult to achieve in the already fluid and protein
restricted pt, and the limited of diet is counterbalanced by
the risk of malnutrition in these pts.
E. Sodium (Stage 1&2)
◼ Low sodium intake (less than 2.4 g/d) (K/DOQI 2003)

◼ Strict control of BP can delay renal progression and
control CVD
◼ Other lifestyle modifications recommended: wt control, ↓
intake of SFA & Chol., glycemic control, limit alcohol,
exercise and stop smoking.

E. Sodium (Stage 3&4)
◼ Low sodium intake (less than 2.4 g/d) (K/DOQI 2003)

*Gradual reduction is recommended to max. tolerance
and acceptance
◼ Na+ excretion is inadequate in advanced renal failure
◼ ↑Na+ intake → ↑extra cellular volume and Na+
imbalance
◼ ↑Na+ intake limits the efficacy of anti-hypertensive
medication (Mailloux et al, 1998)

E. Sodium (Stage 5)
◼ HD : 2 – 3 g Na+ per day (ADA 2002)
◼ CAPD : 2 – 4 g Na+ per day (ADA 2002)
◼ ↑Na+ intake → ↑ thirst and complicate

fluid control
◼ Should be individualized based on BP
and wt (ADA 2002)
◼ No added salt diet is recommended.

F. Fluids (Stage 1 – 4)
◼ Generally no restriction. Keep fluid balance to maintain
hydration status (ADA 2002)
◼ Capacity to handle water is limited → must monitor fluid
intake to avoid overload or dehydration
◼ Fluid retention → require individualized advice
◼ Must take into consideration environmental temperature

and activity level of the pt.
◼ Aware all signs of fluid overload and dehydration

F. Fluids (HD Patients)
◼ 750 to 1000 ml/day
◼ Fluid balance affected by:

 Fluid intake
 Fluid removal from dialysis
 Na+ intake
◼ ↑ interdialytic wt gain among pts on HD results in ↑
mortality risk (Kimmel et al)
◼ Maintain fluid gain between HD to less than 3% - 5% dry
wt (ADA 2002) or 2 to 3kg

F. Fluids (CAPD Patients)
◼ up to 1500 ml/day
◼ Fluid balance affected by:
 Fluid intake
 Ultrafiltration capacity of peritoneal membrance
 Na+ intake
◼ Ultrafiltration normally can remove 2.0 – 2.5 kg fluid per
day
◼ ↑ ultrafiltration through the use of hypertonic exchanges
can treat fluid overload. But hypertonic solution may risk
in
 ↑risk of obesity
 Hypertriglyceridemia
 Damage to peritoneal membrane (EDTNA/ERCA 2002)
G. Potassium
◼ Stage 1-4 : no restriction unless blood potassium level is
elevated
◼ HD : 2 – 3g adjust to serum levels (8-17 mg/kg body wt)
◼ CAPD : 3 – 4g adjust to serum levels (8-17 mg/kg body wt)
◼ K+ levels may be depressed or elevated
◼ Hyperkalemia → cardiac arrhythmias / cardiac arrest
◼ Consider non-dietary causes of hyperkalemia (Bansal

1992)
 Loss of residual renal function, acidosis, catabolism, inadequate
dialysis, dialysate K concentration too high, drug induced.
H. Phosphate
◼ Stage 1-2 : no restriction unless indicated
◼ Stage 3-5 : 800 – 1000 mg/d (adjust for dietary protein needs)
◼ HyperPO4 and the associated conditions begin to appear
as GFR declines <60 ml/min → elevated parathyroid
hormone (sign of bone disease)
◼ Require early detection and treatment to prevent bone
disease of chronic hyperparathyroidism, and to minimize
the increased risk for CVD (Slatopolsky E, Block et al, 1998;
Ammann K et al, 1999; Block GA et al 2000 )
◼ In pre-dialysis pt, prescriptions of low protein intake has
been shown to be effective to prevent or correct
hyperPO4. (MDRD, 1994) MNT for CKD
H. Phosphate
◼ A limited removal of PO4 occurs with dialysis
◼ The appropriate dose of PO4 binder should be ideally

based on PO4 content meals and snacks. It should be
taken with meals. The type of PO4 binder usually used
are calcium carbonate and calcium acetate.

I. Calcium
◼ Stage 1&2 : should meet RDI
◼ Stage 3 - 5 : total calcium provided by calcium-based

phosphate binder should not exceed 1500 mg/d
◼ Calcium from diet + PO4 binder should not exceed 2000
mg/d (K/DOQI 2003)
J. Iron
◼ Stage 1 - 5 : should meet RDI. Achieve with
supplementation of 200mg elemental iron (K/DOQI 2003)

K. Water Soluble Vitamins
◼ Stage 1 – 5 : supplement to meet recommended daily
intake requirements
◼ For Vitamin C; supplement up to 60 – 100 mg/d
L. Fat Soluble Vitamins

◼ Stage 1 – 5 : Intake should meet recommended daily
requirements.
◼ For CAPD pt, may be given active Vitamin D therapy by
physician.

Special Topics
A. Vegetarian Diets
◼ Indian-styled vegetarians – various dhals and legumes
incorporated into gravies, stews and snacks, milk and
milk product eg yoghurt
◼ Chinese-styled vegetarians – tofu, textured vegetable
proteins (meat analogues) and soy milk.
◼ Caution: may not protein adequacy, may also face
problems of controlling K+, PO4 and Na+

Special Topics
Guidelines for Planning Vegetarian Renal Diets:
◼ Should consume a wide variety of plant foods such as
cereal, legumes, nuts and seeds, fruits and vegetables.
◼ Some vege consume milk and eggs → considered.
◼ Consider that cereal foods will contribute a substantial

amount of protein in the vegetarian diet.

Special Topics
B. Nutrition Support in CKD:
◼ Moderate protein and electrolyte levels plus added fiber
products may be given. Too high protein can risk of
dehydration, hypernatremia, and azotemia.
◼ Concentrate formulas to minimize fluid overload. Monitor
fluid status.
◼ PO4 binders may need to be withheld if refeeding
syndrome occurs (fatal shifts in fluids and electrolytes that may occur
in malnourished patients receiving artificial refeeding).
◼ Chose appropriate formulas.

Special Topics
C. Use of herbal supplements:
Herb Use Comments/effects
Ginseng Multiple, stress, Can create anxiety, increased BP,
memory, hypoglycemia, decreased anti-coagulant
strength activity, insomnia, headache, asthma attacks.
Do not use in CKD.
Garlic Cardiac/reduce Side effects, bad breath, gastritis, impaired
lipid levels blood clotting, can effect insulin & OHA.
Gingko Memory, Headache, anxiety, restlessness, diarrhea,
biloba concentration anorexia
Ref : McCann (2002)

Special Topics
D. Diabetics with kidney failure:
◼ Ensure protein and energy intake is adequate to prevent
malnutrition
◼ Total CHO intake should be monitored and use of simple
sugars should be limited to improve glycemic control
◼ Ensuring adequate fiber intake may be beneficial to
improve glycemic control and prevent constipation.
However, PO4 and K+ intake should be monitored
especially with the use of whole grain products, beans
and legumes.

Enteral Formula
➢ Calorically dense – 2 Kcal/ml
➢ Low in Protein (7.1 g / serving), sodium,
potassium, and phosphorus.
➢ Each can provides at least 25% of recommended
levels of vitamins / minerals for pre-dialysis
patients.
➢ Prescribed for pts who lost weight, thus need

more calories, but restricted protein (pre-dialysis).
Enteral Formula
➢ Calorically dense – 2 Kcal/ml
➢ High in Protein (16.6 g / serving), Low in
potassium, phosphorus & sodium.
➢ Each can provides at least 25% of
recommended levels of vitamins / minerals for
dialysis patients.
➢ Ideal for people on dialysis

Summary
Macronutrient, Fluid & Electrolyte Recommendations by stage of CKD
Early CKD Pre-dialysis HD PD

Energy (kcal/kg/day)
Protein (g/kg/day)
Phosphate (mg/day)
Calcium (mg/day)
Potassium (mg/day)
Sodium (mg/day)
Fluid (ml/day)
Medical Nutrition Therapy
For Cancer 1
New Cancer Cases Diagnosed
in Malaysia (2007-2011)
• New cases =103,507
• Caused 13.56% death (2015)
• 3rd most common cause of
death
4
The Most Common Cancer In Malaysia
4
Gender Differences in Sites of Cancer
Introduction
Cancer
• Abnormal cell division
and reproduction that
can spread throughout
the body
• Three stages of
carcinogenesis:
i) Initiation (initial stage)
ii)Promotion (initiated cells
are activated)
iii)Progression, i.e
metastasis
Nutrition & carcinogenesis
Carcinogen
• Physical, chemical or viral agents that
induces cancer
• Diet contain both:
I. Inhibitor – antioxidant (vitamin C,
vitamin A and the carotenoids, vitamin
E, selenium, zinc) & phytochemicals
II. Enhancer of carcinogenesis - saturated
fat in red meat, alcohol, smoked,
grilled & preserved foods.
Fat
Red meat, dietary fat and milk intake should be minimised as they
appear to increase the risk of prostate cancer. Fruit and vegetables and
polyphenols may be preventive in prostate cancer, but further studies are
needed to draw more solid conclusions and to clarify their role in
patients with an established diagnosis of prostate cancer. Selenium and
vitamin supplements cannot be advocated for the prevention of prostate
cancer and indeed higher doses may be associated with a worse
prognosis. There is no specific evidence regarding benefits of probiotics
or prebiotics in prostate cancer.
Metabolic
Obesity syndrome
↑ circulating levels
of insulin-like growth
factor-1 (IGF-1)
Age Hyperglycemia
IGF-1
• Secretion ↑ when insulin level ↑
• Stimulate the growth of cancer cells.
MNT for
Cancer Prevention
Chemoprevention
• Defined as the use of drugs, vitamins, or other
agents to reduce the risk of, or delay the
development or recurrence of cancer (NIH, NCI, 2015).
• Coffee and Tea: contains various antioxidant and
phenolic compounds - have anticancer properties.
• Fruits and Vegetables: contains anticarcinogenic
agents - antioxidants such as vitamins C and E,
selenium, and phytochemicals.
• Soy and Phytoestrogens: contains phytoestrogens
and isoflavones - modest amounts of soy protect
against breast cancer (ACS, 2012)
Cancer Prevention Recommendations
MNT for
Cancer Treatment
Nutritional Issues in Cancer Care
Depletion of nutrient stores, anorexia, weight loss and poor nutritional
status are found in many individuals at the time of diagnosis (Goldman
et al. 2006).
Malnutrition in cancer patients can have a significant adverse effect impact on

clinical, cost and patient centred outcomes such as complications (infections),
treatment response, treatment interuptions, unplanned admission, length of
stay and quality of life (Schattner & Shike 2006; COSA 2011).
The prevalence of malnutrition in cancer patients ranges from 8-84%

depending on tumour site, stage and treatment (Maarten von
Meyenfeldt 2005, Brown et al. 2008).
Considering the implications of malnutrition, it is important to initiate early

intervention to help prevent or reverse malnutrition and to improve prognosis
of cancer patients.
9
Impediments to Adequate Nutrition
1. Tumor-Induced Effects on Nutrition Status
• Tumor-induced pathophysiological changes alter
the macronutrient metabolic pathways leading to
increased protein catabolism, muscle protein
degradation and elevated lipid oxidation.
• The type or stage of cancer may affect energy
metabolism
2. Treatment-Induced Effects on Nutrition Status
• Side effects of cancer treatments vary among
patients, depending on the type, length, and
dose of treatments and the type of cancer being
treated.
Cancer Treatment and
Nutritional Implications
Chemotherapy
– Anemia, fatigue, nausea, vomiting,
loss of appetite, mucositis, changes
in taste and small, xerostomia,
dysphagia, diarrhea, constipation
Immunotherapy
– Fatigue, chills, fever, flu-like
symptoms, decreased food intake
Radiation therapy
– Fatigue, loss of appetite, skin
changes, and site-specific effects
Cancer Treatment and Nutritional Implications–cont’d
Hematopoietic stem cell transplantation
– Nausea, vomiting, anorexia, dysgeusia, stomatitis, oral
and esophageal mucositis, fatigue, and diarrhea
– Dietary precautions with neutropenia
– Graft versus host disease (GVHD): immunologic
reaction of allogeneic donor cells (graft) reacting
against the pt (host) tissue
– Sinusoidal obstructive syndrome (SOS): occlusion of
small hepatic venules caused by hepatotoxins &
radiation therapy/ chemo
Surgery
– Fatigue, pain, loss of appetite
Basic principles of nutrition
in cancer patients
1. Malnutrition (protein-calorie malnutrition)
2. Significant weight loss
3. Anorexia
4. Cachexia
• Progressive wasting syndrome evidenced by
weakness and a marked and progressive loss
of body weight, fat, and muscle
5. Sarcopenia (severe muscle depletion)
Cancer Cachexia
Progressive wt loss
Anorexia
Generalized wasting and weakness
Immunosuppression
Altered BMR
Abnormalities in fluid and energy
metabolism
Mediated via cytokines, including
TNF-a and TNF-b, cachectin, IL-1,
IL-6, and IFN-a
https://www.youtube.com/watch?v=sqWTt4k3PAI
BMI nutritional status by diagnoses.*Others included multiple myeloma, sarcoma, leukemia,
thymoma, meningioma, plasmocytoma, melanoma, cancer of the bladder, kidney, or pancreas, or
occult primary tumor metastases.
Mariana Ramos Chaves et al. The Oncologist 2010;15:523-

530
©2010 by AlphaMed Press

PG-SGA nutritional status (A, B, or C) by diagnoses.*Others included multiple myeloma,
sarcoma, leukemia, thymoma, meningioma, plasmocytoma, melanoma, cancer of the bladder,
kidney, or pancreas, or occult primary tumor metastases.
Mariana Ramos Chaves et al. The Oncologist 2010;15:523-

530
©2010 by AlphaMed Press

Objectives of Nutrition Management
i)For individual who is at pre-cancer treatment
or pre-surgery
• To maintain or prevent declining (or further
decline) in nutritional status and improve overall
nutritional status and its associated outcomes in
adults at risk of or with malnutrition
ii)For individual who is ongoing radiotherapy
or/and systemic therapy
• To minimise a further decline in nutritional
status, maintain quality of life (QoL) and
For adequate symptom management.
11
Nutrition Screening
and NCP Flowchart
14
MST
SGA &
PGSGA
15
Adapted from: The American Society for Parenteral and Enteral Nutrition (ASPEN) 2011
Nutrition Screening
16
Evidence Statement of Nutrition Screening
Evidence Statement Grade References
MST is an effective and validated B DAA, 2006
screening tool for identifying risk of COSA, 2011
malnutrition in cancer patients
Malnutrition screening should be B COSA, 2011
undertaken in all patients at diagnosis to
identify those at nutritional risk and
should be repeated at intervals through
each stage of treatment (e.g. surgery,
radiotherapy / chemotherapy and post
treatment). If identified at high risk, do
refer to the dietitian for early intervention.
All HNC patients receiving radiation A
therapy should be referred to dietitian for COSA, 2011
nutrition support intervention
17
Malnutrition Screening Tool (MST)
1. Have you lost weight recently without trying?
If no (0)
If unsure( 2)
If yes, how much weight (kg) have you lost?
0.5–5.0 ( 1)
>5.0–10.0 (2)
>10.0–15.0 (3)
>15.0 (4)
2. Have you been eating poorly because of a decreased appetite?
No ( 0)
Yes (1)
If score 0 or 1 not at risk of
malnutrition
≥ 2 at risk of malnutrition
Ferguson M, Bauer J, Banks M, Capra S. 1999. Development
of a valid and reliable malnutrition screening tool for adult
acute hospital patients. Nutrition. 15: 458–464. 18
19
Nutrition Assessment Criteria
(i) Tools/ Instruments
- The Scored Patient Generated–Subjective Global Assessment
(PG-SGA) - gold standard (Leuenberger et al., 2010)
- Subjective Global Assessment (SGA)
(ii) Assessment Parameters

- Medical history
- Anthropometric data
- Biochemical assessment
- Clinical assessment
- Dietary Information
- Functional status and QoL
• The use of combination method (Tools and

Assessment Parameters) is best suggested for
nutritional assessment (Davies, 2005)
20
21
22
Nutrition Prescription:
Energy Requirement
Factors to be considered to ensure that adequate energy:
• individual’s diagnosis, presence of other diseases,
• intent of treatment (e.g., curative, control, or palliation),
• anticancer therapies (e.g., surgery, chemotherapy, biotherapy, or radiation therapy)
• presence of fever or infection, and other metabolic complications such as refeeding syndrome
23
Protein Requirement
Table 4: Estimating Daily Protein Needs in Cancer Patients
29
FLUID &
MACRONUTRIENT
REQUIREMENT
27
Table 5: Estimating Fluid
Needs in Cancer Patients
Age (years) Fluid Requirement, ml/kg
16-30, active 40
31-55 35
56-75 30
76 or older 25
These recommendations are just for maintenance needs. Fluid
requirement in fluid overload or dehydration patients need to
be adjusted.
Source: ADA, 2000
30
Algorithm of Nutrition
Support for Cancer Patients
31
32
Ref: ESPEN, 2006; FESEO, 2008
and Recommendation
35
Diet and Counseling
Recommendation Grade References
• Intensive dietary counselling and ONS are able to A ESPEN, 2006;

increase dietary intake and to prevent therapy- FESEO, 2008;
associated weight loss and interruption of radiation DAA, 2008
therapy in patients undergoing radiotherapy of
gastrointestinal or head and neck areas
• Dietitian should be part of the multidisciplinary team A DAA, 2008
and frequent dietitian contact has been shown to COSA, 2011
improve patients’ nutrition outcomes and quality of life
• At low nutritional risk patients (MST = 0-1) C Bauer, 2007;

-Recommend a well balanced diet FESEO, 2008
-Recommend healthy traditional diet according to
needs, preferences and symptomatology
-Healthy, balanced, assorted, appetizing and
adequate amount of food and nutrients
38
Diet and Counseling
Recommendation Grade References
• At moderate nutritional risk patients (MST = 2) C Bauer, 2007

- Recommend high protein-energy diet
- Try 6 smaller meals/snacks per day
- Include 3-4 servings of energy and protein
rich foods or drinks daily
- Oral nutritional supplements 2-3 servings per

day
• At high nutritional risk patients (MST = 3-5) C Bauer, 2007
- Recommend high protein high energy diet
- Recommend high protein high energy
supplements 2-3 times per day
- Consider intensive nutrition support
39
Dietary Guidelines for Immunosuppressed
Patients – Neutropenic Diet
• The use and effectiveness of neutropenic diet is

not scientifically proven.
• Neutropenic diets are not standardized.
• Further research is needed to better evaluate
the benefit of neutropenic diet (Steven, 2011).
• Food safety education and high risk foods
restriction is needed when handling
immunosuppressed patients (ADA, 2006).
48
Nutrition Education
& Counselling
51
Nutrition Intervention Strategies for
Patients with Cancer
Complementary and Alternative Therapies
Whole medical systems
– Traditional Chinese Medicine, ayurvedic medicine, homeopathy,
naturopathy
Mind-body interventions
– Mindfulness, meditation
Biologically based therapies
– Botanicals, dietary supplements, vitamins, minerals
Manipulative and body-based methods
– Massage, yoga, reflexology, prayer
Energy therapies
– Veritable and measurable – sound, light, energy
– Putative such as biofields
Islamic medical approach
Physical Activity
& Cancer
53
…exercise after the diagnosis of breast cancer improves mortality,
morbidity, health related quality of life, fatigue, physical functioning,
muscle strength, and emotional wellbeing.
54
54
MNT for
Cancer Survivor
• Most eating-related side effects of cancer

treatments go away after treatment ends.
• Key recommendations:
➢ Maintain healthy weight
➢ Practice healthy eating & be physically
active
53
Nutrition Support:
Enteral and Parenteral Nutrition
Nutrition Support
 Definition: the provision of nutrients to pts
who cannot meet their nutritional requirements
by eating standard diets
 Goals:
➢Prevent or treat macro &micronutrient deficiencies
➢Provide doses of nutrients compatible with existing
metabolism
➢Avoid or manage complications related to the
technique of nutritional delivery
➢Improve pts’ outcomes
Enteral Nutrition (EN)
 Nutritional support via placement through

the nose, esophagus, stomach, or intestines
(duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
—Exhaust all oral diet methods first.
Parenteral Nutrition (PN)
 Provide nutrients directly into
bloodstream intravenously
 Indicated when patient require nutrition

support but unable/unwilling to take
it orally or enterally
Nutrition Support:
Enteral and Parenteral Nutrition
Long term
 To identify the pts with pre-existing
malnutrition or with risk for malnutrition
Conditions That Require Other
Nutrition Support
 Enteral  Parenteral
—Impaired ingestion —Gastrointestinal
—Inability to consume incompetency
adequate nutrition —Hypermetabolic
orally state with poor
—Impaired digestion, enteral tolerance or
absorption, metabolism accessibility
—Severe wasting or
depressed growth
Conditions That Often Require Nutritional Support
Conditions That Often Require Nutritional Support –
cont’d
EN vs. PN
For the best outcomes:
Use EN in preference to PN whenever possible

because of its established benefits:
➢ Maintains gut mucosal integrity

➢ Prevents pancreatic & biliary flow dysfunction
➢ Has fewer complications/ lower risk of infection
➢ Incurs lower costs
Route of Administration
Considerations in Enteral Nutrition
1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical requirements
5. Rate and method of delivery
6. Tolerance
Formula Selection
The suitability of a feeding formula should be evaluated
based on
Functional status of GI tract
Physical characteristics of formula (osmolality, fiber
content, caloric density, viscosity)
Macronutrient ratios
Digestion and absorption capability of patient
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte
needs or restriction
Cost effectiveness
Factors to Consider When Choosing an Enteral
Formula
Types of EN Formula
Contain whole proteins, complex CHO and long chain triglycerides
(nutrients are intact / have not been broken down)
Pre-digested formulas, nutrients are broken down to their simplest form

Types of EN Formula
/ specialized formula
Enteral Access: Clinical Considerations
 Duration of tube feeding

—Nasogastric or nasoenteric tube for short
term
—Gastrostomy and jejunostomy tubes for
long term
 Placement of tube
—Gastric
—Small bowel
Placement Site
 Access (medical status)
 Location (radiographic confirmation)
 Duration
 Tube measurements and durability
 Adequacy of GI functioning
Enteral Tube Placement
https://www.youtube.com/w
atch?v=yBzy3tHOps0
Administration: Feeding Rate
 Continuous method = slow rate of 50 to
150 ml/hr for 12 to 24 hours
 Intermittent method = 250 to 400 ml of

feeding given in 5 to 8 feedings per 24
hours
 Bolus method = may give 300 to 400 ml

several time a day
Advantages—Enteral Nutrition
 Provides nutrition when oral is not
possible or adequate
 Costs less than parenteral nutrition
 Preserves gut integrity
 Preserves immunologic function of gut
 Increased compliance with intake
Disadvantages—Enteral Nutrition
 GI, metabolic, and mechanical
complications—tube migration; increased
risk of bacterial contamination; tube
obstruction
 Costs more than oral diets
 Less “palatable/normal”
 Labor-intensive assessment, administration,
tube patency and site care, monitoring
Complications of Enteral Feeding
Microbiological hazards
• Touch contamination
• Formula manipulation
• Prolonged hang time
• Unsafe storage
• Reusing feeding sets
Gastrointestinal complications
• Diarrhea
• Constipation
• Nausea and vomiting
• Abdominal distention, bloating, cramping, gas
Diarrhea – factors UNRELATED to
tube feeding
Diarrhea – factors RELATED to
tube feeding
Consideration of Physical Properties
of Enteral Formulas
 Residue
 Viscosity
—Size of tube is important
 Osmolality (solute/solution): consider protein
source
—Intact (do not affect osmolality)—soy
isolates; sodium or calcium casein;
lactalbumin
—Hydrolyzed (more particles)—peptides or
free amino acids
Lower Osmolality
 Large (intact) proteins
 Large starch molecules
Higher Osmolality
 Hydrolyzed protein or amino acids
 Disaccharides
Complications of Enteral Feeding
Metabolic complications / Refeeding
syndrome
• Dehydration / overhydration
• Hyperglycemia
• Hyper/hyponatraemia
• Hyper/hypophosphataemia
• Hyper/hypokalaemia
• Hypercapnia (excessive CHO load; overfeeding)
Mechanical complications
• Aspiration pneumonia
• Nasal, esophageal and mucosal irritation and
erosion
• Irritation and leakage at stoma site
• Tube clogging
Refeeding
Syndrome • Neuro-muscular
dysfunction
https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC2440847/ • Cardiac
arrhythmia
 Rapid fluxes in insulin production due to the CHO load.

 Severe electrolyte & fluid shifts associated with metabolic
abnormalities in malnourished pts undergoing refeeding
(whether orally, enterally or parenterally).
 Occur due to the rapid shift of electrolytes (K+, PO4, Mg2+ )

from the extracellular to intracellular space, along with
sodium and water retention
Aspiration Pneumonia
Inhalation of stomach contents or
secretions of the oropharynx, leading
to lower respiratory tract infection.
Feeding tolerance
 Signs and symptoms:
—Hydration
—Weight change
—Esophageal reflux
—Lactose/gluten intolerances
—Respiratory distress
—Nausea, vomiting, diarrhea
—Constipation, cramps, abdominal distention
—Aspiration
—High gastric residual volume (GRV)
Assessment of feeding tolerance:
Gastric residual volume (GRV)
Assessment of feeding tolerance:
Diarrhea
How to Determine Energy and
Protein
kcal/ml x ml given = kcal
% protein x kcal = kcal as protein
kcal as protein x 1 g/4 kcal = g protein
Example: Patient drinks 200 ml of a 15.3%

protein product that has 1 kcal/ml
1 kcal/ml x 200 ml = 200 kcal

0.153 % protein x 200 kcal = 30.6 kcal
30.6 kcal x 1g protein/4 kcal = 7.65 g protein
Energy in Formulas
1 to 1.2 kcal/ml = usual concentration
2 kcal/ml = highest concentration
Protein
 From 4% to 26% of kcal is possible
 14% to 16% of kcal is usual
 18% to 26% of kcal—considered to be
high-protein solution
Recommended Water
 Healthy adult: 1 ml/kcal or 35 ml/kg
 Healthy infant: 1.5 ml/kcal or 150 ml/kg
 Elderly: consider 25 ml/kg with renal, liver,

or cardiac failure; or consider 35 ml/kg if
history of dehydration
Enteral Nutrition Monitoring
© 2004, 2002 Elsevier Inc. All rights reserved.

https://www.aci.health.nsw.gov.au/resources/nutrition/hen/
gastrostomy-tubes/robs-story-life-with-a-feeding-tube
Parenteral Nutrition
 Provide nutrients directly into
bloodstream intravenously
 Indicated when patient require nutrition

support but unable/unwilling to take
it orally or enterally
Routes of Parenteral Nutrition
 Central access (TPN)

—catheter placed in large,
high blood flow vein eg:
superior vena cava
 Peripheral access (PPN)

—catheter placed into small
vein in forearm/ hand
PICC = peripherally inserted central catheters

Advantages—Parenteral Nutrition
 Provides nutrients when less than
2 to 3 feet of small intestine remains
 Allows nutrition support when GI

intolerance prevents oral or enteral
support
Disadvantages- Parenteral Nutrition:
 Costly
 Long term risk of liver dysfunction,

kidney and bone disease, and nutrient
deficiencies
Indications for Total
Parenteral Nutrition
 GI non functioning
 NPO >5 days (NPO: nil per os)
 GI fistula
 Acute pancreatitis
 Short bowel syndrome
 Malnutrition with >10% to 15 % weight loss
 Nutritional needs not met; patient refuses
food
Complications - PN
 Overfeeding
 Acid-base abnormalities
 Refeeding Syndrome
Calculating Nutrient Needs
 Avoid excess kcal (> 40 kcal/kg)
 Adults
kcal/kg BW
Obese—use desired BMI range or an
adjusted factor
Adjusted Body Weight
Adjusted IBW for obesity
Female:
([actual weight – IBW] x 0.32) + IBW
Male:
([actual weight – IBW] x 0.38) + IBW
Protein Requirements
 1.2 to 1.5 g protein/kg IBW
mild or moderate stress
 2.5 g protein/kg IBW

burns or severe trauma
Carbohydrate Requirements
Max. 0.36 g/kg BW/hr
Lipid Requirements
 4% to 10% kcals given as lipid meets EFA
requirements
 Usual range 25% to 35% max. 60% of

kcal or 2.5 g fat/kg
Administration
 Start slowly
(1 L 1st day; 2 L 2nd day)
 Stop slowly
(reduce rate by half every 1 to 2 hrs)
Monitoring and Complications
 Infection
 Catheter care
Monitor
 Weight
(daily)
 Blood
Daily
Electrolytes (Na+, K+, Cl-)
Glucose
Acid-base status
Monitor—cont’d
 Blood
Twice/week
Ammonia
Weekly
Hgb
Triglycerides
Monitor—cont’d
 Other:
Oral intake (daily) if applicable

Urinary output (daily)
Activity, temperature, respiration (daily)
Document in Chart
 Type of feeding formula and tube
 Method (bolus, drip, pump)
 Rate
 Intake energy and protein
 Tolerance, complications, and
corrective actions
 Patient education
Outline:
 Definition
 Screening tools and indications
 Management steps
 Approach to patient with obesity
 Case
Oman
Why to stand against obesity ?
The greater the waist

circumference and BMI,
the greater the risk of
CVD, type 2 diabetes,
and all-cause mortality.
AHA/ACC/TOS 2013
NICE: Obesity: identification, assessment and management Clinical guideline (2014).

`

Screening ?
 (BMI)
 Waist circumference ( mainly if BMI < 35 )
 Combined Approach.
 Note: BMI is not accurate for muscular pt.
 There are different guidelines for the

timing of screening .
When to screen ? different guidelines
Nice 2014:
 Use Your Clinic Judgment
USPSTF
 Screen all ≥ 18 yrs for obesity.
AHA/TOS 2013:
 BMI at annual visits or more frequently. ( level E )

Managment
Patient centered Plan:
 State His weight loss goals
 Addressing barriers to change
 Developing strategies to maintain long-term lifestyle
changes.
Management :
 Behavioral Interventions
 Improving nutrition
 Increasing physical activity
 Maintenance !!
Management:
 Behavioral interventions and Diet should be initiated
in patients who are obese.
 Then initiate the exercise plan .
 You may think about the Medications and the surgical

interventions later on .
Behavioral Interventions :
The USPSTF recommends :
 Motivational interviewing
 1-2 sessions /months .
Behavioural interventions
 Self-monitoring of behaviour and progress
 Stimulus control
 Goal setting
 Slowing rate of eating
 Ensuring social support
 Problem solving Skills
 modifying thoughts
 Reinforcement of changes
 Relapse prevention Skills
 Strategies for dealing with weight regain.
Motivational Interviewing Techniques

Motivational Interviewing Techniques

Dietary Approaches :
Which Dietary Approaches Have Been Shown to Be Most
Effective for Weight Loss?
 Adherence to calorie reduction .
 Simple and realistic diet modifications have the highest

likelihood of success
 AAFP Recommendation :A deficit of at least 500 kcal per

day from the total daily calorie requirement can be
achieved with intake of 1,200 to 1,500 kcal for women and
1,500 to 1,800 kcal for men.
Diet
 Aim: Total energy intake ˂ energy expenditure
2013 AHA/ACC/TOS
Physical activity
The USPSTF recommends :
 150 to 300 min/week of moderate-intensity activity
or
 75 to 150 min/week of vigorous activity per week.
 Continue even if no weight loss!!
 Decrease inactivity.
 To prevent obesity: 45–60 min/day of moderate-
intensity activity particularly if they do not reduce
their energy intake.
 Obese who lost weight: 60–90 min/day of activity to

avoid regaining weight.
Activity as part of daily life
 Brisk walking
 Gardening
 Cycling
 Swimming
 Stair climbing
Pharmacotherapeutic options
 Only for patients who have not achieved weight loss
goals with diet and lifestyle changes.
 Extensive discussion of the risks and benefits with the

patient .
Surgical Intervention
 Bariatric surgery
AAFP :Bariatric surgery Indications:
After Failure of non surgical intervention
 BMI > = 40
 BMI 35 – 40 with co-mobidites (e.g. DM, HTN)
Adjustable gastric banding can be consider in also in

case of:
 BMI: 30 – 34.9 with recent onset DM – II.
 BMI: 30 – 34.9 with obesity-related comorbidities.
Case
Case
 A 52-year-old woman
 Backgound:
 Obesity wt 121 kg
 DM-II for last 9 years
 Depression
 HTN
 DLS
 OA
 PC:
 Fatigue, difficulty losing weight, and no motivation.
 Decrease in her energy level
 She denies polyuria, polydipsia, polyphagia, blurred
vision, or vaginal infections.
 Weight gain started 6 years back.
 After started on insulin.
 Pervious trials:
 Tries to cut down on her eating
 Hypoglycemia.
 Fearful of hypoglycemia that she often eats extra
snacks.
 Advised in her DM visit to:
 High BMI
 Advised: Weight loss and exercise
 Pain in her knees and ankles makes it difficult to do any
exercise.
 She is on:
 Insulin N: 45 - 35 U
 Insulin R: 10 U - 20 U.
 HbA1C: 8.9%
In the case
1. Multiple Co-morbdites
2. Diet > Hypoglycemia > taking more snakes
3. Arthritis > not able exercise
Points to Remember
 Use your clinical judgment to investigate co-
morbidities.
 Manage Comorbidities.
 Assess readiness: if not ready > give information about
obesity and f/u.
Adult
 Any underlying causes
 Eating behaviors
 Comorbidities (e.g.: DM-II, HTN, CVD , OA, DLS and
sleep apnea)
 Lipid profile, BP and HbA1c.
Back to our patient
 Agreed to follow a restricted-calorie diet and to
decrease her insulin to 30 U of NPH and 10 U of
regular insulin twice daily.
 As she had no contraindications to metformin
(Glucophage), she was also started on 500 mg orally
twice daily.
 She returned to clinic 3 months later, still on the same
dose of insulin.
 She was feeling a little less depressed.
 She continued to complain of fear of hypoglycemia in
the middle of the night and was overeating at night.
 Despite this she had lost 3 kg.
 Her blood glucose values were still elevated in a range
of 7-13 mmol before meals.
 She was reassured that further insulin reduction would
prevent hypoglycemia.
 Her insulin dosage was decreased to 25 U of NPH and
5 U of regular insulin twice daily and metformin was
increased to 500 mg three times daily.
 Two months later, she returned to the clinic with an
average blood glucose level of 8.6 mmol.
 Her weight was now 111 kg, and her HbA1c was 7.5%.
 She was feeling much more energetic, no longer felt
depressed, and was able to start a walking program.
Important Points :
 Those who loss their weight quickly are using usually
the diet that they can not continue with it for long
time , so they remained weight quickly .
 Reduce the weight over period of months .

 The main issue not to decrease the weight but how to
maintain the weight after reduction.
 Orlistat ??? Still not available

 Insluin Victoza for Metabolic syndrome x
References :
 NICE:
 Obesity: identification, assessment and management Clinical
guideline (2014).
 Obesity prevention (2006)
 AAFP:
 Update on office based strategies for the management of obesity.
 Diagnosis and management of obesity guideline 2013
 2013 AHA/ACC/TOS: ( American College of Cardiology/American Heart Association,

Task Force on Practice Guidelines and The Obesity Society )
 Guideline for the Management of Overweight and Obesity in
Adults .

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STM 4201 Therapeutic Nutrition

STM 4201-Course Introduction and NCP

STM 4201-Course Introduction and NCP

• LO2 Evaluate the link between nutritional assessment

• LO3 Explain appropriate nutritional and dietary plan for

• LO4 Evaluate how to modify normal to therapeutic diet.

STM 4201-Course Introduction and NCP

• The use of specific nutritional interventions to treat

• Includes setting goals for the pt's treatment and

• Becoming an increasingly important component of

STM 4201-Course Introduction and NCP

– 8/ 10 leading causes of death in the world including CHD,

• Others who benefit from MNT: the obese, elderly, and

STM 4201-Course Introduction and NCP

• Adequate nutrition is essential to reduce morbidity and

• Helps to reduce health-care costs and minimizing the

STM 4201-Course Introduction and NCP

MNT: Intake assessment

STM 4201-Course Introduction and NCP

STM 4201-Course Introduction and NCP

STM 4201-Course Introduction and NCP

• Includes: task, guideline, and

• Education, motivation, and

STM 4201-Course Introduction and NCP

STM 4201-Course Introduction and NCP

• On the individual level, the effectiveness of MNT

• Prioritized goals are critical when developing the

STM 4201-Course Introduction and NCP

• Only a dietitian has sufficient training and knowledge to

• Physicians should learn the indications for special diets in

STM 4201-Course Introduction and NCP

1/28/2021 STM4202- NCP:Screening

• Usually completed by DTR, nurse, physician, or

• At-risk patients referred to dietitian.

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

Institute of Medicine, 1999

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

1/28/2021 STM4202- NCP:Screening

• Identified at-risk pts are referred to nutrition

• Much of the research that exists validates more

1/28/2021 STM4202- NCP:Screening

• There is no “gold standard” of nutritional

1/28/2021 STM4202- NCP:Screening

WHAT IS THE NUTRITION CARE

• Improve the consistency • Provide structure and

WHY WAS THE NCP DEVELOPED

NUTRITION CARE PROCESS: ADIM

STEP 1: NUTRITION ASSESSMENT

HOW DO FOOD AND NUTRITION

Biochemical data, medical tests and procedures

NUTRITION ASSESSMENT: CRITICAL

STEP 2. NUTRITION DIAGNOSIS

STEP 2. NUTRITION DIAGNOSIS

Diabetes Excessive CHO intake r/t visits to Coldstone

•  Improve the consistency •  Provide structure and

•  The key element is that the RD improves the issue

1.  Select the appropriate strategy based on the