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Clinical Nutrition Management For Nursing
Clinical Nutrition Management For Nursing
MANAGEMENT
FOR
NURSING
REGULAR DIET (FULL OR GENERAL HOSPITAL DIET) – ADULT
Description
The diet includes a wide variety of foods to meet nutritional requirements and individual
preferences of healthy adults. It is used to promote health and reduce the risks of developing
major, chronic, or nutrition-related disease.
Indications
The diet is served when specific dietary modifications are not required.
Nutritional Adequacy
The diet uses the 1800 - 2,000 kilocalorie level as the standard reference level for adults.
Specific calorie levels may need to be adjusted based on age, gender and physical activity.
Recommended healthy eating pattern:
Daily sodium intake to less than 2,300 mg and further reduce intake to 1,500 mg among
person who are 51 and older or have hypertension diabetes, or chronic kidney disease.
At the same time, consume foods with more potassium, dietary fiber, calcium and
vitamin D.
Increase daily intake of fruits and vegetables, whole grains, and nonfat or low-fat milk
and milk products.
Consume less than 10 percent of calories from saturated fatty acids by replacing with
monounsaturated and polyunsaturated fatty acids. Oils should replace solid fats when
possible.
Keep trans fat as low as possible.
Reduce the intake of calories from solid fats and added sugars.
Limit consumption of foods that contain refined grains, especially refined grain foods
that contain solid fats, added sugars, and sodium.
If you drink alcoholic beverages, do so in moderation, for only adults of legal age.
Keep food safe to eat.
HIGH-PROTEIN, HIGH-CALORIE DIET
Description
Additional foods and supplements are added to meals or between meals to increase protein
and energy intake.
Indications
A high-protein, high-calorie diet is served when protein and energy requirements are increased
by stress, protein loss (protein losing enteropathy, nephrotic syndrome), and catabolism. This
diet may be indicated in patients with:
protein-energy malnutrition
failure to thrive
cancer
burns
cystic fibrosis
human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)
chronic gastrointestinal diseases
This diet may also be indicated in preparation for surgery. An increase in energy is required to
promote the efficient utilization of proteins for anabolism.
Nutritional Adequacy
This diet is based on the regular diet supplemented with additional servings of high protein
foods such as milk and eggs. Commercial oral nutritional supplements may also be used to
provide added protein, calories and nutrients. This diet should provide at least 1.2 to 1.5 grams
of protein per kilogram of ideal body weight as compared to a regular diet which should
provide 0.8 grams of protein per kilogram body weight. It should provide approximately 3,500-
4,000 calories daily. Providing adequate energy and protein can minimize loss of lean tissue.
However, after approximately 700 calories are consumed, maximum protein sparing is
achieved. In some instances, six small feedings may be better accepted than three large meals.
MECHANICAL SOFT (DENTAL SOFT) DIET
Description
The diet is a modification of the Regular Diet for the edentulous resident who has difficulty
chewing or swallowing, or for the resident who has undergone temporomandibular joint (TMJ)
surgery. For the greatest variety of foods, all foods that are easily masticated are included in
the diet.
Indications
The Mechanical Soft Diet is indicated for the resident who has difficulty chewing or swallowing.
Planning the Diet
The Mechanical Soft diet consists of foods which are soft in texture and moist to minimize the
amount of chewing necessary for the ingestion of food and ease of swallowing. This diet is
based on the regular diet and includes foods which are chopped, ground, or pureed according
to the individual patient’s needs. Tough meats, nuts and seeds, raw fruits and vegetables, citrus
fruits and juices are omitted when the diet is ordered for oral surgery or lesions.
PUREED DIET
Description
The diet is soft in texture and mechanically nonirritating. Select foods are allowed in their
natural state provided they do not require additional mastication (i.e. cottage cheese,
scrambled eggs, etc.).
Indications
The Pureed Diet is used for patients who have problems chewing and swallowing and patients
who have esophageal inflammation or varices.
Planning the Diet
This diet is composed of regular foods that are blenderized or have a natural pudding like
texture, such as ice cream, jello, mashed potatoes and baby food. It may be used as either a
temporary or long-term diet.
short-term use when an acute illness or surgery causes an intolerance for foods (eg,
abdominal distention, nausea, vomiting, and diarrhea)
to temporarily restrict undigested material in the gastrointestinal tract or reintroduce
foods following a period with no oral intake when poor tolerance to food, aspiration, or
an anastomotic leak is anticipated
to prepare the bowel for surgery or a gastrointestinal procedure
to use as a transition from NPO to full or general liquid diet
Planning the Diet
This diet consists of foods that are clear and liquid or become liquid at room temperature. It
contains minimal residue and can be easily digested and absorbed. It includes the following
foods only: clear broth, gelatins, smooth fruit ices, popsicles, sugar, clear juices (apple,
cranberry and grape), fruit flavored drinks, coffee, tea or coffee substitute. Carbonated
beverages are optional. The diet should contain high protein, clear liquid oral nutritional
supplement if it is used longer than three (3) days.
FULL LIQUID DIET
Description
The Full Liquid Diet (General Liquid Diet) consists of foods that are liquid at body temperature,
including gels and frozen liquids. The diet provides nourishment that is easy to consume and
digest with very little stimulation to the gastrointestinal tract.
Indications
The Full Liquid Diet may be indicated following oral surgery or plastic surgery of the face or
neck area in the presence of chewing or swallowing dysfunction for acutely ill patients. The Full
Liquid Diet has been traditionally used as a postoperative transitional diet after administration
of clear liquid diet and before administration of soft diet. The diet is intended for short-term
use only; therefore, attempts are not usually made to increase the variety of foods offered to
provide for the total adequacy of nutrients.
Contraindications
Due to the liberal use of milk and foods made with milk, the diet is high in lactose. A temporary
lactose intolerance may occur in some patients following surgery. Symptoms of lactose
intolerance upon ingestion of a Full Liquid Diet may result, and the diet should be modified for
the patient.
NUTRITION MANAGEMENT OF DYSPHAGIA
Description
Dysphagia is not a disease, but a disruption in swallowing function. Although dysphagia can
occur at any age, it is particularly prevalent in older adults. Dysphagia may result from
neurological disorders, degenerative diseases, cancers, or post intubation trauma. The nutrition
management of dysphagia includes modifying the consistency and texture of foods and liquids
according to the patient’s tolerance, which is determined by a comprehensive medical,
swallowing, and nutrition evaluation by the healthcare team including the physician, speech-
language pathologist, and registered dietitian. Therapeutic goals for nutrition are customized
and often include diet modifications and swallowing retraining. An individualized meal plan will
generally include modifications in the texture and consistency of foods (eg, pureed or textured-
modified foods and thickened liquids) that optimize the quality of nutritional intake while
reducing the risk of aspiration or choking.
Indications
Dysphagia is an impairment in one or all stages of swallowing, resulting in the reduced ability to
obtain adequate nutrition by mouth and a possible reduction of safety during oral feeding.
Patients with dysphagia have difficulty moving food from the front to the back of the mouth,
channeling the food into the esophagus, or both processes. Dysphagia may be caused by weak
or uncoordinated muscles of the mouth and/or throat, motor and sensory defects impeding
chewing or swallowing, or both conditions. If dysphagia is suspected, a swallowing evaluation
should be performed by a qualified healthcare provider. This evaluation may include a bedside
evaluation, indirect or fiberoptic laryngoscopy, fiberoptic endoscopic evaluation of swallowing,
and a videofluoroscopic swallow study (VFSS), which is also known as a modified barium
swallow study. The VFSS is a definitive test in diagnosing the type of dysphagia.
Planning the Diet
Enteral feedings may be necessary to supplement oral intake until a sufficient quantity of food
can be consumed. If enteral nutrition for neurological dysphagia is anticipated to last for longer
than 4 weeks, a percutaneous endoscopic gastrostomy (PEG) tube is preferable to a nasogastric
tube. PEG tubes are associated with fewer treatment failures and improved nutritional status as
compared to nasogastric tubes, and they allow the patient to receive adequate nutrition while
oral intake is stabilized. In one study, more than half of the patients who received a PEG tube
due to poor tolerance of thickened food were eventually able to resume oral feedings. If a
patient can tolerate oral liquids, the medical food supplements should be in compliance with
the consistency prescribed for the patient. A record of food intake, including fluid intake and
enteral feedings, is necessary at all stages of dysphagia therapy. When oral intake approaches
the patient’s energy and protein requirements, the patient should begin to be weaned from the
enteral feedings.
The dietitian and the speech-language pathologist should work collaboratively and use the
results from both the medical evaluation and a swallowing study to choose appropriate foods
and beverages for the individual patient. The National Dysphagia Task Force found that the
Dysphagia Outcome and Severity Scale provided the best scale to determine the level at which
the National Dysphagia Diet (NDD) should be recommended.
The severity of dysphagia determines the level of the diet required. The food plan is divided
into multiple levels of solid food and liquid consistency to maximize the dysphagic patient’s
nutritional intake. Diet orders should include the National Dysphagia Diet levels and the desired
liquid consistency (eg, thin, nectar-like, honey-like, or spoon-thick). With each progression of
the diet, both the level of the diet and the liquid consistency need to be specified in the
nutrition prescription. The three NDD levels are:
NDD Level 1: Dysphagia Pureed: Foods are thick and smooth and have a moist pudding-
like consistency without pulp or small food particles. They cling together, are easy to
swallow, and require a minimum amount of manipulation in the mouth. Sticky foods or
foods that require a bolus formation or controlled manipulation of the mouth (eg,
melted cheese and peanut butter) are omitted. The diet provides no coarse textures (eg,
fibrous foods) to prevent irritation. Food and fluid intake should be monitored.
NDD Level 2: Dysphagia Mechanically Altered: Foods are moist, soft, and simple to
chew, and they easily form a cohesive bolus. The diet provides a transition from pureed
foods to easy-to-chew foods. Moistened ground meats (pieces should not exceed ¼-inch
cube), vegetables cooked to a soft mashable texture, soft-cooked or canned fruits, and
bananas are included. Some mixed textures are expected to be tolerated. More
frequent feedings may be beneficial. Food and fluid intake should be monitored.
NDD Level 3: Dysphagia Advanced: Foods are moist, soft, in bite-size pieces, and nearly
regular in texture. Hard, sticky, and crunchy foods are excluded.
How to Order the Diet
General considerations: Dietary considerations vary with each patient. The importance of
individual food consistencies cannot be overemphasized. For example, dysphagic patients with
an obstruction may be able to safely consume liquids, while other dysphagic patients may
aspirate liquids and require thickened liquids with a puree consistency. A recent study showed
that carbonated liquids are a dietary option for patients who experience penetration/aspiration
into their airways; thickened liquids are also safe for these patients. If a patient cannot tolerate
thin liquids, foods that become thin liquid at room temperature (70 deg. F) or body
temperature (98 deg. F), such as gelatin, ice cream, and sherbet, should also be avoided.
The following guidelines should be considered when planning the diet for a dysphagic patient:
One of the most important considerations of food texture is cohesiveness, or the ability to stay
together. Patients can often chew through foods but are unable to press the food into a bolus
unless it is naturally or artificially cohesive. For patients who cannot swallow a smooth pureed
food, a higher-texture food (more viscous) is desired to rehabilitate muscles. The larger surface
area provides stimulation to the nerve and muscle groups that assist the swallowing process.
Do not combine textures, such as dry cereal with milk or chunky vegetable soup in
broth, in the same bolus. Do not use fluids to wash down the bolus. It may be
appropriate to alternate liquid and solids. Present foods and fluids separately, checking
for complete swallows after each mouthful.
Use smooth gravies on all ground meat.
Rice and cottage cheese are difficult for some dysphagic patients to swallow. Use rice in
casseroles with a soup base, and include only pureed small-curd cottage cheese in the
diet. Milk does not cause mucous formation. However, milk can aggravate thickening of
mucus in some people, which can reduce their ability to manage secretions. Blended
yogurt or lactose-free supplements may be used if milk is not tolerated.
Liquids: Patients who have dysphagia frequently have difficulty drinking thin liquids, which are
not easily channeled to the back of the mouth. Fluid intake is often limited in patients with
dysphagia, leading to an increased risk of dehydration. Adequate hydration can be ensured by
the introduction of thickened liquids followed by the progression to thinner liquids as
swallowing proficiency is gained. While there is some fluid content in many foods, especially
pureed foods, the use of thickened liquids may be necessary to assure adequate hydration.
Viscosity Borders and Ranges for Thickened Liquids
The NDD Task Force has suggested the following viscosity borders and ranges:
intractable vomiting
severe diarrhea
high-output enterocutaneous fistula (greater than 500 mL/day) and distal to site of
feeding tube tip placement
conditions warranting total bowel rest, such as severe acute necrotizing pancreatitis
(unless jejunal enteral feeding can be provided beyond the ligament of Treitz)
severe inflammatory bowel disease
upper gastrointestinal hemorrhage (caused by esophageal varices, portal hypertension,
or cirrhosis)
short-bowel syndrome (less than 100 cm of small bowel remaining)
intestinal obstruction (depending on location)
a prognosis that does not warrant aggressive nutrition support
Orogastric: The feeding tube is inserted through the mouth, with the tip resting in the
stomach.
Nasogastric: The feeding tube is inserted through the nose, with the tip resting in the
stomach.
Nasoduodenal: The feeding tube is inserted through the nose, with the tip resting in the
duodenum.
Nasojejunal: The feeding tube is inserted through the nose, with the tip resting in the
jejunum.
Esophagostomy: The feeding tube is inserted through a surgical opening in the neck and
passed through the esophagus, with the tip resting in the stomach.
Gastrostomy: The feeding tube is inserted through the abdominal wall into the stomach
via percutaneous endoscopic guidance or surgical placement (surgical “open”
gastrostomy).
Jejunostomy: The feeding tube is inserted through the abdominal wall into the jejunum
via percutaneous endoscopic guidance or surgical placement (surgical “open”
jejunostomy).
Enteral Feeding Administration
Continuous feeding/delivery: Continuous feedings require that the enteral formula be
administered at a controlled rate with a pump over a 24-hour period. The pump should deliver
the controlled rate within 10% accuracy and be calibrated periodically to ensure accuracy.
Continuous feedings are indicated for unstable critically ill patients, patients unable to tolerate
high-volume feedings, patients with malabsorption, and patients at increased risk for
aspiration. Feedings may be initiated at full strength in the stomach or at an isotonic strength in
the small bowel at a rate of 10 to 30 mL/hour. Then, the rate may be gradually increased as
tolerated in increments of 10 to 25 mL/hour every 4 to 8 hours to the goal rate. Strength and
volume should not be increased simultaneously.
Intermittent or cyclic feeding/delivery: Intermittent or cyclic feedings are administered over an
8- to 20-hour period by using a pump to control the rate of delivery. This method of tube
feeding is most beneficial for patients who are progressing from complete tube feeding support
to oral feedings as discontinuation of feedings during the day may help to stimulate the
appetite. Intermittent or cyclic feeding is also beneficial for ambulatory home-care patients
who are unable to tolerate bolus feedings because it allows freedom from the pump and
equipment. Since this method of delivery usually requires a higher infusion rate, monitoring for
formula and delivery tolerance is necessary. Formula and delivery intolerance can be avoided
by a gradual transitioning of the patient from continuous feeding to an intermittent feeding
schedule.
Bolus formula delivery not requiring a pump: The syringe bolus-feeding method involves the
delivery of 240 to 480 mL of formula via a feeding tube over a 20- to 30-minute period, three to
six times a day, to meet estimated nutritional requirements. This method is usually restricted to
gastric feedings and may be contraindicated in patients who have a high risk of aspiration,
disorders of glucose metabolism, or fluid management issues.
Enteral Feeding Formula and Equipment Maintenance Guidelines
Formula:
Bring formula to room temperature before feeding, but do not allow the formula to
remain unrefrigerated for more than 12 hours.
The hang time for formula in an open system should be less than 8 hours or as specified
by the manufacturer. Formula from a closed system is provided in ready-to-hang,
prefilled containers and may hang for 24 to 48 hours per manufacturer’s guidelines.
Discard any formula remaining in the container after the hang time has expired.
Opened, unused formula should be kept refrigerated for no longer than the
manufacturer’s specifications (usually 24-48 hours).
Formula delivery guidelines:
Irrigate the tube every 4 hours with 20 to 30 mL of warm sterile water or saline to
ensure patency for continuous feeding. Also, irrigate the tube before and after each
intermittent feeding or medication administration.
To reduce bacterial contamination, flush water through the bag and tube every 8 hours
before adding new formula when an open system is in place.
Avoid putting food and beverages into the tube (eg, juice, milk, and soda).
Flush tube with purified sterile water or saline before and immediately after the
administration of medicines to avoid clogging the tube.
To reduce the risk of contamination and infection, the feeding bag should be properly
labeled, and tubing should be changed every 24 hours or as specified by the
manufacturer.
Refer to organization-specific interdisciplinary enteral nutrition monitoring protocol and
policy as needed.
Patient monitoring guidelines:
Medications via enteral feeding tubes: Feeding tubes should be irrigated with at least 15 mL of
warm purified or sterile water (or saline) before and immediately after the administration of
medications (52). Since crushed medications can clog tubes, liquid medications should be used
when possible. Many oral medicines formulated for slow release may be surrounded by an
enteric coating and should not be crushed and administered through the feeding tube. Multiple
types of medication should be administered separately (52). Temporary cessation of enteral
feeding may be indicated for 1 hour before and 1 hour after the administration of phenytoin
sodium (Dilantin), a commonly used anticonvulsant medication, because components of the
enteral formula, such as calcium, decrease the bioavailability of this drug.
PARENTERAL NUTRITION SUPPORT FOR ADULTS
Overview
Parenteral nutrition is the provision of nutrients intravenously. Since the 1960s, major advances
have been seen in the technique, delivery, and formulation of parenteral nutrition. The use of
guidelines for practice has improved nutritional markers and reduced the rates of complications
of patients receiving parenteral nutrition. The two primary types of parenteral nutrition are
central parenteral nutrition (CPN) and peripheral parenteral nutrition (PPN).
In CPN (or total parenteral nutrition), nutrients are provided through a large-diameter vein,
usually the superior vena cava, by access of the subclavian or internal jugular vein. The CPN
formulas are hyperosmolar (1,300 to 1,800 mOsm/L) and consist of dextrose (15% to 25%),
amino acids, and electrolytes to fully meet the patient’s nutritional needs. The nutrient and
fluid composition of CPN can be adjusted to meet the individual needs of patients who require
fluid restriction. When venous access for the delivery of nutrients is required for longer than 2
weeks, CPN is indicated because it can be maintained for prolonged periods.
In PPN, a peripheral vein provides venous access. This form of parenteral nutrition is similar to
CPN except that lower formula concentrations must be used because the peripheral vein can
only tolerate solutions that are less than 900 mOsm/L. Compared with CPN formulas, PPN
formulas have lower concentrations of dextrose (5% to 10%) and amino acids (3%). Because
higher concentrations cannot be infused into the peripheral vein, PPN requires larger fluid
volumes to provide energy and protein doses comparable to the doses provided by CPN. The
larger fluid volume poses a challenge for patients who require fluid restriction. The maximum
volume of PPN that is usually tolerated is 3 L/day (125 mL/hour). Repletion of nutrient stores is
not a goal of PPN, and it should not be used in severely malnourished patients. The use of PPN
is indicated only for mildly to moderately malnourished patients who are unable to ingest
adequate energy orally or enterally, or for patients in whom CPN is not feasible. Typically, PPN
is used for short periods (5 days to 2 weeks) because of limited tolerance and the vulnerability
of peripheral veins (eg, risk of peripheral venous thrombophlebitis).
Indications
Guidelines for the implementation of parenteral nutrition have been developed by the
American Society for Parenteral and Enteral Nutrition (ASPEN). Parenteral nutrition is indicated
for patients who are unable to receive adequate nutrients via the enteral route (eg, patients
who have a nonfunctional or severely compromised gastrointestinal tract). The indications for
parenteral nutrition include:
HIGH-FIBER DIET
Description
Dietary fiber is beneficial for health maintenance and disease prevention and is a key nutrition
intervention strategy for several chronic diseases including cardiovascular disease, diabetes
mellitus, and also effective in weight management, and bowel-related diseases. A high-fiber
diet emphasizes the consumption of dietary fiber from foods of plant origin, particularly
minimally processed fruits, vegetables, legumes, and whole-grain and high-fiber grain products.
A plant-based diet may also provide other nonnutritive components such as antioxidants and
phytoestrogens that have implications as health benefits. Dietary fiber intake in the United
States continues to be at less than the recommended levels, with an average daily intake of
only 15 g. Major sources of dietary fiber in the US food supply include grains and vegetables.
White flour and white potatoes provide the most fiber in the US diet, about 16% and 9%,
respectively, not because they are concentrated fiber sources, but because they are the most
widely consumed. Legumes only provide about 6% of fiber and fruits provide only 10% of fiber
in the overall US diet because of low food consumption. The Philippine Dietary Reference
Intakes recommends an intake of 20-25 g of fiber per day.
Indications
Promote food intake patterns consistent with the Pinggang Pinoy that encourages a
wide variety of plant foods to achieve fiber intakes goals. Emphasize fruits, vegetables,
and whole-grain breads and cereals.
Foods made with whole-grain flours are substituted for foods made with refined flours
and starches.
People who experience difficulty in chewing fruits and vegetables may increase fiber in
their diet by consuming one or more servings daily of a high-fiber cereal, such as bran;
substituting whole-wheat bread for white bread; and consuming soft or cooked fruits
and vegetables.
FAT-CONTROLLED DIET
(50 Grams)
Description
Omitting and/or limiting fat-containing foods restricts the total amount of fat in the diet. The
type of fat is not considered.
Indications
A fat-controlled diet is indicated for individuals who are unable to properly digest, metabolize,
and absorb fat. Common diseases of the hepatobiliary tract, pancreas, intestinal mucosa, and
lymphatic system impair fat digestion, metabolism, and absorption. A low fat-diet may also be
useful in the treatment of patients with gastroesophageal reflux.
Contraindications
In pancreatic insufficiency, enzyme preparations remain the primary treatment for steatorrhea.
As normal a diet as possible is encouraged to increase the likelihood that a nutritionally
adequate diet will be consumed. The diet should restrict fat only to the individual’s tolerance
level. The treatment of choice for gallstones at the present time, where indicated, is surgery.
There is no reason in the postoperative period to restrict or modify fat intake in any way.
Ordering the Diet
SODIUM-CONTROLLED DIET
Description
The Sodium-Controlled Diet limits sodium intake. Foods and condiments high in sodium are
eliminated or restricted at suggested levels to optimally manage blood pressure and underlying
medical conditions associated with hypertension or chronic organ damage.
The average dietary sodium intake is approximately 4,100 mg/day for American men and 2,775
mg/day for American women. The consumption of processed foods accounts for 75% of the
daily sodium intake. The minimum daily sodium requirement for healthy adults is 500 mg.
Many leading health authorities suggest targeting less than 2,300 mg/day for healthy adults.
Indications
The Sodium-Controlled Diet is used in the treatment of conditions characterized by edema
(water retention), including the following:
Use reduced sodium or no-salt-added products. For example, choose low or reduced
sodium, or no-salt-added versions of foods and condiments.
Buy fresh, plain frozen or canned with “no-salt added” vegetables.
Use fresh poultry, fish and lean meat, rather than kosher, canned, smoked or processed
meats.
Choose ready-to-eat breakfast cereals that are lower in sodium.
Limit cured foods (bacon and ham), foods packed in brine (pickles, pickled vegetables,
olives and sauerkraut), and condiments (MSG, mustard, horseradish, catsup and
barbecue sauce). Limit even lower sodium versions of soy sauce and teriyaki sauce- treat
these condiments as you do table salt.
Use spices and herbs instead of salt. In cooking and at the table, flavor foods with herbs,
spices, lime, lemon, vinegar, or salt-free seasoning blends.
Cook rice, pasta, and hot cereals without salt. Cut back on instant or flavored rice, pasta,
and cereal mixes which usually have added salt.
Choose “convenience” foods that are lower in sodium. Cut back on frozen dinners,
mixed dishes such as packaged mixes, canned soups or broths and salad dressings –
these often have a lot of sodium.
Rinse & soak canned foods, such as beans to remove some sodium. Only use water
packed no salt added in tuna or salmon.
GLUTEN-FREE DIET
Description
The Gluten-Free Diet is the primary treatment for celiac disease, which is also called gluten-
sensitive enteropathy or celiac sprue. The only treatment for celiac disease is lifelong
adherence to a gluten-free meal pattern, including strict avoidance of prolamins, which are
proteins found in wheat, rye, barley, and tritical. Dermatitis herpetiformis is the term for the
skin manifestation of celiac disease. The Gluten-Free Diet also helps to control most cases of
dermatitis herpetiformis associated with gluten-sensitive enteropathy.
Indications
Celiac disease is an immune-mediated disease characterized by chronic inflammation of the
small intestine mucosa that results in malabsorption due to atrophy of the intestinal villa.
Although celiac disease was once thought to be a rare childhood disease, it is now recognized
as a fairly common multisystem disorder that occurs in one in 133 people. Individuals with
celiac disease have an immunologic reaction to proteins termed prolamins, which are found in
wheat, rye, and barley. When foods containing gluten are consumed by a person with celiac
disease, the digestive process fails and an immunologically reactive protein fragment remains.
The resulting villous atrophy and inflammation of the mucosa result in malabsorption. Although
the classic presentation of celiac disease is diarrhea, wasting, malabsorption, failure to grow,
bloating, and abdominal cramps, not all individuals with celiac disease have these symptoms.
Compliance with a gluten-free dietary pattern reduces the prevalence of diarrhea, constipation,
abdominal pain and bloating, nausea or vomiting, reduced gut motility, delayed gastric
emptying, and prolonged transit time. The following grains and plant foods can be included in a
gluten-free prescription:
Rice, corn, amaranth, quinoa, teff (or tef), millet, finger millet (ragi), sorghum, Indian
rice grass (Montina), arrowroot, buckwheat, flax, Job’s tears, sago, potato, soy, legumes,
tapioca, wild rice, cassava (manioc), yucca, and nuts
Nonmalt vinegars, including cider vinegar, wine vinegar, and distilled vinegar.
TYRAMINE-RESTRICTED DIET
Description
Foods containing tyramine and other vascoconstrictive amines are eliminated from the
Tyramine-Restricted Diet.
Indications
The Tyramine-Restricted Diet is indicated when patients are receiving monoamine oxidase
inhibitors (MAOIs) and the medication Zyvox (Linezolid), an oxazolidinone antibiotic possessing
weak, reversible monoamine oxidative inhibitor activity. MAOI’s treat anxiety and depression
by inhibiting the inactivation of neurotransmitters. Therapy with MAOIs is used to prevent the
catabolism of dietary tyramine, which normally is metabolized in the gastrointestinal tract. The
result is an increased concentration of tyramine in the body, causing the release of
norepinephrine and an elevation of mood. Increase amounts of tyramine, however, can cause
an excess amount of norepinephrine to be released, which may result in a hypertensive crisis.
This is characterized by severe headaches, palpitation, neck stiffness or soreness, nausea or
vomiting, sweating, fever, and visual disturbances.
Many foods normally contain small amounts of tyramine and other vasopressor amines. Large
amounts have been reported only in aged, fermented, pickled, smoked, or bacterially
contaminated products. When fresh foods are stored, especially meat, poultry, fish, and related
items such as pâté, gravy, and soup stock, fermentation occurs and the tyramine content of the
food increases. Since heat does not destroy tyramine, all foods should be fresh, fresh frozen, or
canned and should be handled, prepared, stored, and served in ways that maximize freshness.
Resynthesis of monoamine oxidase occurs slowly, and food interactions may occur up to 3
weeks after withdrawal of some MAOI medications. Prudent practice is to start the tyramine-
restricted diet when the medication therapy is begun and to continue the diet for 4 weeks after
the medication regimen is withdrawn.
CANCER
Discussion
A cancer patient’s nutritional status and well-being are greatly impacted by the type of cancer
and the treatment methods. In turn, nutritional status and overall health affect the patient’s
ability to tolerate treatment and achieve the desired clinical outcome. To optimize clinical
outcomes, patients who are diagnosed with cancer should receive early nutrition intervention
with a complete nutritional assessment and a plan of care. When patients with colorectal
cancer who are undergoing pelvic radiation receive individualized nutrition counseling, they
experience improvements in energy and protein intake, nutritional status, and quality of life
and reductions in symptoms of anorexia, nausea, vomiting, and diarrhea. Similar findings are
seen in patients who are receiving chemotherapy for esophageal cancer, head and neck cancer,
lung cancer, or acute leukemia. Patients who receive a pretreatment nutrition evaluation and
weekly visits during chemoradiation and chemotherapy experience reduced weight loss,
improved energy and protein intake, and improved quality of life; these patients may also have
fewer unplanned hospitalizations, shorter hospital stays, and improved tolerance to treatments
for a variety of cancers.
The use of enteral nutrition to increase the energy and protein intake of outpatients who are
undergoing intensive radiation therapy for stage III or IV head and neck cancer maintains
nutritional status and improves tolerance to therapy. Medical food supplements that are used
to improve the energy and protein intake of patients who are undergoing radiation therapy for
head and neck cancer are associated with fewer treatment interruptions and reduced mucosal
damage and may minimize weight loss.
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Discussion
GERD involves the symptomatic reflux of gastric contents- particularly acid, pepsin, and bile-
into the esophagus which results in damage to the esophageal mucosa and leads to esophagitis,
regurgitation, and heartburn. Heartburn is often elicited by lying flat or bending over. If the
reflux is severe enough, the same positions may evoke actual regurgitation of gastric fluid into
the mouth, causing choking, coughing, and possible pulmonary aspiration. Other symptoms
may include dysphagia, pain on swallowing and water brash (when the mouth suddenly fills
with a large amount of fluid secreted from the salivary glands).
Ordinarily the esophagus is protected from reflux of gastric contents by contraction of the
lower esophageal sphincter (LES). In persons with chronic esophageal reflux, the sphincter
pressure tends to be lower. Either increased intragastric pressure or decreased LES pressure
causes GERD.
Treatment is aimed at modifying the factors that promote gastroesophageal reflux and
irritation. Treatment requires a multifactorial approach and is aimed at nutrition and lifestyle
modifications, drug therapy, consisting of antacids and hydrogen antagonists and, rarely,
surgery.
Management goals are as follows: