NutritionInterventionPlanning 151312023

Physician theassessment
Medical Diagnosis through
theymade
Nurses is Applicationfor orderandfollow
any up
y E
Dietation
n interviewwiththepatient is NutritionAssessment is NutritionDiagnosisnoRecommendationfor Intervention akamedicalnutritional management
s
signsand
Reassessment
toensuretheappropriatenessofourdietaryplan dependingon
symptoms g the follow
gigglers up
Wemonitorand
Evaluateindicator
PES formate
Problemrelated
toetiologyas
evidenced
bysignsandsymptoms
Whyis itneeded

toberelatedtotheProblem
Etiologyneeds

berelatedtotheEtiologyandthe
Signssymptomsneedsto
Problem

Example

Obesityrelated tohighenergyas bytheBMIof35

evidenced

Sarah to
gtateng

High intakerelated lack

e nergy to ofknowledge orlackofPhysicalActivities asevidencedbythetotalenergyconsumedbythepatientthatwasobtainedfromtheinterview
orsedentarylifestyle orbehavior 124hrrecallofthedietaryintake

NutritionDiagnosis
is adynamicprocess changeswithreasons Excessiveintake
ofenergy sbetterenergyintake thisprocesscanbechanged
DiabetesMediant
MedicalDiagnosis
is aprocessthatcanNotbechangedhe NoDiabetes thisprocessdoesn'toccur

Differencebetween Assessment
andScreening
Assessment
isgeneralis aprocessfordefiningthenatureof
thatproblem determining a diagnosis anddevelopingspecifictreatment foraddressingtheproblem
recommendations

ordiagnosis
c omes
Screening asanumbrellaundernutritionalAssessmentasasystemisaprocessforevaluatingthepossiblepresenceofaparticularproblem outcomeis asimpleyesno
TIentification
ofhighlyrisk individuals
topreventmalnutrition

Whydidwe thePESstatement
formulate

toknowtheetiology todoan intervention Assessment

isactualintakesandneedsnpointsouttheprobleminthe
end

Diagnosisdomain
Nutrition
oratiistiliirt the
formate PES d
identity
1IntakeEnergybalancenutrients intakefluid
intake
to
or
eggs
fosters
2ClinicalFunctional biochemicalandweight
gg

PEStoidentifyanddescribeaspefignutritionproblemthatcanberesolvedorimprovedthroughtreatmentnutritioninterventionbyafoodandnutritionprofessional
theassessment
from

bytheexaminerlookingpale bythepatient feelsdicey

Documented
Signs Symptoms Complained
 of
Examples NutritionDiagnosisStatements PESPE

isgottenfromtheinterviewdietary
information evaluation
this evidence
sign
1 Excessivecaloric
tofrequent oflargeportionsofhighfatmeal etiology as byaveragedailyintakeofcaloriesexceeding
intake Problem related c onsumption evidenced

a mount
recommended
by500kcaland12poundweightgainduringthepast18months signs
evidence
sign

2Inadequateenergyintakerelatedto decreasedappetitesecondarytochronic obstructivepulmonarydiseaseasevidencedbyconsuminglessthan75 ofestimatedenergyneedsfor

1monthand unintential
weightlossof6 in 1month

Lecture 71312023

NutritionDiagnosisexample MedicalDiagnosisexample

atointake
inconsistent Émi Diabetes

toimproveyourPESstatement
How

Original

InconsistentCAOintakerelated
topoordietchoicesas byAlf
evidenced
All isn'ta ofCito
measure

isalab for
notameasure
value altointake
Improved

InconsistentCAOintakerelated
topoordietchoicesas by
evidenced
of180 moreCHOthan
consumption recommended

NutritionIntervention

Should beconsistentwithyourPESstatement

Basics
of Assessment

1IncreasedDemandsvsgrowthhyper metabolism

5causesof Malnutrition
2Increasedlossesisvomiting Diarrhea

3InadequateIntake povertypsychologicaldisorders disabilityelderlyAnorexia

Reasons

UInadequateUtilization
v
5Inadequate Absorption absorptionproblems
Obesity 1213
2023

Obesityisthe intake
e nergy the
exceeds
e nergyoutput
expenditure
the
excess isstoredinfat
energy of tissue
cells adipose

It a
developsw hen person's fatcellsincrease innumbersizeorboth

does
When excess fatinthebodyhappens
When
energy is thantheout
intake more

IDuringperiodsofgrowthinlate childhood

2Duringperiodsofexcessintakeincreaseinnumber
3whenfatcellshavereachedtheremaxsize
I 2 3 4 4Shrinkageoffatcellshowevernottheirnumber

Isitreversable
Yeswecandecreasesizeoffatcellsbutnotthenumber

88
888 0888 888
Never
Obese Obese lost
weight

TheAACEAdvanced workforaNewDiagnosisofObesity
Fram

Diagnosis Anthropometric Component Clinical Component

Overweight
Im
BMI2529.9kg Noobese
BMI 30kg1m Noobesityrelatedcomplication
iii
Obesity

stage
Obesity t BMI325kg1ms ofoneormoremildtomoderateobesityrelated
Presence complications

stages
obesity BMI asagim presence
tomoderateobesityrelated complications

Thebestwaytomeasureobesity over fat

weightusOver

Measurement
ofobesitybasedonBMIhasbeen questioned

Ithascriticallimitationsasit underestimates
adiposity bodyfatlevelsinthe population

might
misclassify whoisshortandmuscularasoverweightobese
someone

might
misclassify fluidretentionas
someonewith overweight

mightmisclassifysomeonewithexcessbody fatasnormal abdominal

obesity waistcircumference
take

fatpercentage
Body

Excessive
fatpercentageisassociatedwithmetabolicandhealthrisksofobesity
body

Whendiagnosisofo besityweneed tomeasuremultipleofindicators 1 ofIBW 121Waist

Percentage ceramference
3BMI14PercentageofBodyfat
Males
20 25 orhigher
Female

25324dg
 measurepercentageof
Howto fat
f
SkinoldnessCal
liborisused
Genderweight
2
3Bodydensity
4Equipments Bio
electrical method
Impidiancy Im
bodyDesa Not
accurate

Types ofObesity
s hapemale
Android Apple

Excesssubcutaneoustruncalabdominal fatassociatedwithhighriskofATNCVDandType2DM

Gynoid Pear Female

shape
femoral
Excessgluten fatdonotalterglucosemetabolism

Itcanbe general localized

or It is anddiffers
geneticallydetermined
bygender
Obesity 1432023

WaistHip

Waistcircumference

isanindicatorofabdominalfatasausefulpredictorofcardiometabolicdisease
From
itweknow
Type ofobesity
ofcardiometabolicdiseases is becauseresearchesshowedthatthereissomeassociationbetweenwaistcircumferenceandtheriskofchronicdiseasesincludingdiabetes
risk
andotherdiseasesbutmainlyitiscardiometabolicdiseases
cardiovasculard iseases

reference
Normal
lotopfoint uindicathighercardio metabolic
risk
Females 80cm
Male 294an

Cardio
m etabolic
risk
Female 788cm

Male 102am

thatagynoidmorpho
Note typelow
waist
hipratioFemale 0.8 Male of
20.9 thesecut pointsconstitute aprotectiveprofileagainstcardiometabolicrisk

Waistcircumferenceisanindicator of
1Riskofcardiometabolicdiseases
2typeofobesitydistributionoffat
 ofobesity ObesFacts2019124066
Causes

IFADdiet

waist cycling
gain

YoYo weightlossthenweightgain

of
Institution Health
National
for6monthsthenwtmaintenance
isweightloss 6months cyclekeepsongoing
bodygoesthroughasetfinttheory

Causes
ofobesity
1HeredityGenetics
Hormones and Neurotransmitters dopamine
toboost
How
your rate
metabolic

Resting
EnergyExpenditure
metabolic
1PhysicalActivities
Distribution
ofbodyfat
Sizeandnumberoffat
cells

Allofwhicharegenetically determinedalthoughmutationinthesegenesincreasestheriskofobesityotherfactorsmustbepresentforobesitytooccur

Ideas
Thoughts Effect
ourbehavior Outcomes

Overeating is Obesity

Ghrelin stomach

I
Leptin Insulin Pan
crease
a
Adiposetissue

Hormonescontrol thefoodintake
Intake Expenditure
1Leptin Obgene

leptin'sAction

ofBodyfat
Gain ofBodyFat
loss
I I
Bloodleptin
Increase

y I
Hypothalamusresponds Hypothalamusresponds

decrease
the
a ppetite the
increase a ppetite

melanocortins
neuropeptide
Y
I
infoodintake Increase food
intake
Decrease
in
Increase Decrease
inenergyexpenditure inenergyexpenditure
I
Decrease balance Positive balance
energy energy

2padreno
receptor
gene
located
intheadiposetissue
the
regulate rateand
restingmetabolic fatoxidationhowevernotallreportsprovided asignificantassociationbetweenthesemutationsandobesity

Thermogenesis

itis thatthermiceffectof
believed food defected obeseindividualsbut
is in thisdefectcausesobesityorresultsfromobesityisnot
wether clear

Resting
metabolic
ratedecreasewithbothageandenergyrestriction
foodintakeshiftstheresting
Restoring
metabolic linelevel
ratetowardthebase

Factors
regulating intake
energy and
weight
gain To theTotalenergyexpenditure
calculate

1 Thermogenesis 1Baselenergyexpenditure
2RestingMetabolicRate 2Physicalactivity
3Energy expenditure
inPhysicalActivities 3 Thermogenesis

19
Obesity 312023

CasescenariovsBiochemicaldatahormoneproblem
or thatregulatetherestingmetabolicrateandthefeedingactivity
neurotransmitters

i complications
pffeogyEggs

i iiii
lasersworkasindividualizedcases makepathophysiologyand the
know the
reasons from reasonsandcomplications weknowthe planDiet
intervention
plan
 Factors andweightgain
intake
regulatingenergy

1Brain neurotransmitters

epinephrinecortisol stress
h ormones Dopamine andNorepinephrineRegulatetheactivityoffeedingbehavior
released stressa
during
function
isfightorflight CorticotropinReleasing CRF
Factor

Potent
of
agentabnormalloss appetite food
anorexic for
food
Decreases intake thefeedingresponsestimulated
andweakens
by Yand
neuropeptide

Norepinephrine

Released exercise
during

Elevated starvation
during

They theactivity
regulate offeedingbehavior

awe
ISerotonin Ia
Neuropeptide
Y Endorphinsobese

y I I
CHO
increase Petite
P onsweetsand
Cravings

13 If
2 13 fatfoods
appetite
increasestarvation
high

Hormones

Insulin

Impaired
activity Impaired thermogenesis

Obese resistance
p eople insulin glucosedisposaland
defective depressedthermogenesis

neGot
hormones

Glucagon likepeptideI GLP1

exampleofaguthormone
involve
in ofinsulinreleasefromthepan
stimulation
in
crease toenteral
response intake
nutrient

inhibitsglucagonsecretion

Peptide
YYPyu
bytheLcellsofthedistalgutIleumcolon
Produced

GLP1causesdelayed gastricemptying
inhibits
GImotility
Bothhormones arethoughttoreducefoodintakeby satiety
promoting

ofGlp1andpyxlevelsthis
Promotes
is toresultinreduced food asaresultofimpairedsatiety
i ntake
understood postprandiall evels increased
Obesity

Resist
in
AnadipocytespecifichormoneisFat
cells

AnimportantlinkbetweenObesityInsulinresistanceanddiabetes
thatplaysaroleinvarietyof
Evidenced
processes has
b iological overlapping

malignancy asthma

2Nonalcoholicfattyliver
disease
DTI 5Inflammatoryboweldisease
6ChronickidneydiseaseDT2
 Ghrelin

secreted stomach
in
slowdownmetabolism
reduced
fatoxidation
effects food
various on intakeacting toincreaseappetiteand influencing
chewing time
food
i ntake

to andinfluencing chewingtime
a ppetite
acting increase

taste
preferences andfoodperception

increasing gastrointestinal motility

secretion
decreasinginsulin

InNonobese Ghrelinlevels
arehighestpriortoamealanddroprapidlyuponinitiationofeating
individuals

associatedwith levels
is
Obesity
reducedghrelin remains
u nproven

linked
Dietary loss
inducedweight to secretion
increasedghrelin hasbeenproposed
which tocontributeto
Poor termsuccessrates
long ofdietaryweightlossprogramsby promotingincreasedfood
consumption

A eatin
dip
on
bytheadiposetissuethat
Adipocytokinesecreted modulates
regulation
glucose andfattyacidcatabolism
levelsare
i nversely BMI
correlatedwith

typeadiabetes
4playsarolein E
metabolicd isorders AEitosderosis

aftergastric
levelsdrop bypasssurgery forupto6months

Causes
ofobesity
1Sleepshortenedsleepsaltersthe endocrine
of
regulation hunger andappetite
Recurrent
can
deprivation
sleep theamountcompositionanddistribution
m odify offoodintakeandmay totheobesityepidemic
contribute

2Stress
is
Cortisol released i nsulin
stimulates release
inappetiteoccurs
Increase

blootsefelsinthefight flightresponse
maintain
or

3CircadianRhythms
4Environment
food
Overeating toxic
environment

1Activeovereatingconsumptionofexcessiveportionsizesthatareacceptedasnorm
2Passiveovereating ofenergydensediet
consumption

Weight
cycling

SetPoint
Theory

itisbe personhas aset

thatevery
lived point

Fatstorageinnonobeseadultsappearstobe
Theory inamannerthatpreservesaspecificbodyweight
regulated

Studies
onlytemporarilyandthatRMRlowersresultinginaregion lostweight
Bodyweightcandisplaced of
 YoYoeffect
repeated
of loss
cycle weight andweight
gain

gain occurmorerapidlywith
Weight often loss
repeatedcycles weight
of
the and
bodybecomesmoreefficient making in
storing fat

Obesity1211312023

Complications

with
Associated

sexttimontimbalance
isHormonedependenttumors
Reproductive
Complications fertility

Dislipidemia

Is
cardiovascular
Diseases

Obesity
Increased
filefattyacidsisMetabolicsyndrome Hypertension

d y
l
en
Mechanical
stress sleepapneaisoxygenat
offwhileasleepforsecondsalackofoxygensupplytotissuesandcellsaroundthebody
I Osteoarthritis

lowbackpain

Complication

1 death
Premature
3Diabetes 5Breathingproblems 7 Reproductive Complications

2HeartDiseases 4Cancer 6Arthritis 8GallbladderDiseases

Management
ofObesity

A team
medical

amultidisciplinaryteam
work
they inanetworksystem
Whatisthe
tool of teammembers MedicalRecords
between
communication

areinthisteam
Who
medicals pecialist
Obesity

2Dieticianornutritionist
istinphysicalactivity offatishighitisbadtoweightlift
weight

4PsychiatricPsychologist

Goals
Guidelines
of treatment

Avoidstigmatization
Fatshamming
Management
ofthe psychological aspects
ofobesityimproving
self olfife
imageandquality
esteembody

loss
weight of510 issufficienttoobtainsubstantialhealthbenefitsfromdecreasing
wmfl.tt that
ess hasarelationwithobesity
Intervention

Goalsobjective

Planactiontoacheivethe
goalobjective

Reducingwaist
circumference
ismoreimportantthanweightloss
because
fatandtheassociatedcardio
v isceral
decrease risks
metabolic

abdominal
obesity
is
associated
of
withincreasedrisk chronicd iseases

TopreventweightregainYo
Yobydifferentapproachesarebehaviouralor pharmaceutical treatments
orbariatricsurgery

Consequences
of stigmatization
inpatientswithobesity
1Increasedriskofdepression 5Exercise avoidance
2Lowselfesteem 6Weightgain
3Poorbodyimage 7 Avoidanceofmedicalconsultation
4Increasedriskofeatingdisorderssbingeeating 8Suicide

Obesity1261312023

Modifications
Dietary

lossprograms
Weight

1Restrictedenergydiets
ruleisrestrictiononenergyintakeandphysicalactivitiesCut
basic down
energy tousethereservedenergyinthebody
of
mostprescribedmethod weightreductionbecause ofits efficiency

awell restricted
balanced diet
energy
Estimated
energy requirements 1800
1800 kcal
divide
energy
by
5055 CHO
1520 Protein
230 Fat Fatalcoholisrestricted
andMineralsupplementation
Vitamin
Whybecauseof
theextremeenergy ofdietaryintake
restriction

Caloric
d ecrease
of5001000kcaldayusuallymeetsthisgoal
Recommended
loss
weight 0.5 1161week 1lba0.5kg
NIHCriteria
NIHTreatment
BMI2735 0.51lbweek
BMI35 1 2lbweek
Continued
for6months re evaluated
monthly

d
10lossofBodyweighttotal
d
Weight for6months
maintenance

1
weightloss
Further
is
considered
2ExchangeSystemdiet beadequateamount
1800 can
1200 ofintake
forDiabetics
Origionalydesigned 2800 inadequateamountofintake
beusedforhealthypeople
Can

3FormulaDiet
Fit by
supplied pharmaceuticalandfood companies
processing

id kcal
Prov 900
as
distributed normalenergydistribution however
isNotnormal
itself
energy
Though
m intake
energy 50CHO

30 Fat
ProblemsDisadvantages

1 onaspecificproducts
Dependence

2Failuretomodifyeatinghabits
3Boredom
4Inadequateamountofenergy
begivenasareplacementofamealmajor
can dietis proteinpowder

4 Commercial
Program

Offerabalanceddietbutisassociatedwithmedicalproblemsdue totherapidweightloss
8001000kcal
Provide

Insufficient
to
data supportthe termeffectiveness
long

No behaviormodification
isgobacktothewaytheyusedtoeatandweight

5FADDietsand Practices

lead to overanextendedperiod
nutritionaldeficiency

lowCHOandhighFatdiets
Increasedketones
p roduction

Limitedappetitesuppression

FAD
Other diets

3Daydietisinstantweightloss
Cabbage diet
soup
diet
Grapefruit burns
says fathoweveritcaninteractwith medications

6ExtremeEnergy Restriction

200800kcal
Provide

Extreme restriction
energy

1Fasting
50 ofweightlostisfluidleadingtohypotension
ofuricacidGout
Accumulation

formation
Gallstone

2VerylowCalorieDietsUCD
loss20kg112weeks
Rapidweight

fast PM kgofIBWnoAto
S F1.5gl
Protein modified
sparing

33
diets
70gofProtein3045gofCHOsmallamountoffat
formulated
Commercially liquid

Newcastle dietmedicallysupervisedreversestype2diabetes
 Dietisonlyundertakenfora
short oftimefewweeks Usedasamealreplacement
period

isn'trecommendedbecause
Exercise
ofthe of tosupportit
insufficienta mount caloriesconsumed

Obesity 2832023

Management

Approaches thatareusedinthemanagementofobesity whatisthe

d ietarymanagementto forobesitymanagement
approach

1Dietaryrestriction is Restrictedenergydiet
2BehaviormodificationPhysicalActivities
3NutritionEducation lackof knowledge
iffaileda PharmaceuticalManagement

Behaviormodification

of bymanipulationof thattriggerthebehaviororbehavioritselfandconsequences
changes behavior attitudefactors

induce
515 weightloss
help
improve selfaffirmation and qualityoflife
lodging eggesteen

Genetically
determined
fat
distribution

Adi
Physical

Shorttermincreaseinenergyexpenditure

p
Improves
bodycomposition
Appetitecontrol

Stressreduction

Appetite Psychological wellbeing

Highself
esteem

triggerscertianneurotransmittersand
mgdyhgm.ge

support
Psychological
bingeeatingepisodes

When
t hese
a pproaches fail
1 isaddedto
medication
theprogram Pharmaceutical
approach

2Surgicalapproach

BariatricSurgeryProcedures

1Sleevegastrectomy607t5oremoved M alabsortive
absorption
reducing
surgeries

2Gaisericbypassnew stomach small

made
is large these
intestine connected
to
connect

3 bandingBaloon
Gastric

JawwiringILLEGAL
Liposuction
ima
 Surgerymay beanoptionforadultswhohave

Adults Teens

BMI340 BMI 35 withserious

ligathopygblems

BMI735withserious h 2 or sleepapnea
iq
diabetes severe
epgybtems Type

2
Typediabetesheart or apnea
disease sleep

I is tsese.o
p.ie
i gas sandingsurgery

Advantages
ofBariaticSurgery
1Improveeliminatetype2diabetes
2Improvelipidprofile
Karma
4Increasetestosteronelevels
inmen morbidobesity

E
5Improveeliminate bloodpressure
high

AH
1mostarelinkedtomalabsorption
2Macro
nutrientdeficiency

3 Micronutrientdeficiency

4Boneloss
5lowbloodglucoselevels hypoglycemia

6 Peripheralneuropathy
ofnervedamagetofeetlegsorhandscausingpainnumbnessandtingling
form

7 Dehydration

syndrome
Dumping

after
Common gastric surgery

itsagroupof symptomsthat from

result
may partofthe
having stomachremoved
orfromother the
involving
surgery
s tomach

of
Causes dumping
syndrome

itcanbemoredifficulttoregulate offoodwhichdumpstooquicklyintothesmall
movement intestine

eating foods
certain make likelywhich
more
syndrome
dumping absorb
rapidly from
water the
b ody

symptoms
may
after
happen dairyproducts
eating and fatsfried
certain food

Earlydumpingphase
happen
3060minaftermeal
small
intestines
stretches

water
pulled
of
out thebloodstream thesmallintestine diarrheal
vomiting

fromsmallintestine into
hormonesreleased bloodstreamaffect
blood pressure fainting

symptoms last
about hour
an
of
feeling fullness eating
justasmallamount diarrhearapidheartbeat
severe
Abdominal
l
pain
cramping orlightheaded
Sweatingflushing ness
Nauseavomiting
Obesity 214
2023

Late
phasedumping
syndrome

a bout
happen
1 3hoursaftereating
duetoarapidriseandfallinbloodsugar
levels

the ofthisrapidswinginbloodsugarmaybeworsewheneatingsweetsothersimpleCHO
c ause

Symptoms

Fatigueweakness of
loss mental
concentration confusion

Flushingsweating ofhunger
Feelings

Shakinessd izziness fainting Rapidheartbeat

BariatricDietmajor
surgery

12weekPreOpDiet
diet decrease
purposes
the ofliver decreasestheriskofconsumption
size
proteinconsumption
Increasing leanmeat
CHOconsumption Avoidbreadspastacereals
Decreasing rice
Elimination
ofsugarsCandy desserts
juicessodas
Fluids Optimumhydrationlevel

2 2Dayspriortosurgery
dearliquiddiet
Strict starting dayspriortosurgery
two
broth
sugarfree JellO water
Oneproteinshakeeachday

3Week1 4postOpdiet
diet
purposes
TohelppreventpostOp complications

Week 1
little
have
Patients
toeat
d esire

existentafter
hormone
Hunger ghrelin isalmostnon surgery

I Partofthe thatproduces
stomach
of
majority g hrelinisremovedduring
surgery
Clearliquidsonly

food
Freeliquid
Sugar items

Tater BrothJell Decaf

O s
tea coffeesugarfree
drinks

d
Carbonated sweetbeverages caffeine
beverages
very sugar

me
Fullliquid
diet
withprotein
Proteinpowder with
mixed
asugarfreenon clear
carbonated liquid

freepuddingandnonfaticecream
Sugar
softnoodles
with
Soup
thincreamed
Very soups
Diluted
sugaraddedjuice
no
Thinned apple
sauce
 Week3

Softpureedfoods

60gofproteinperday
Provide

Eating
slowly
foods
new
Introducing one by
one
Avoid

Sugar
likepastariceandbread
foods
Starchy
Fibrousvegetables likecelerybroccoliasparagusraw
leafygreens

aWeek4 5
foods
Introducing

Avoid
Astolerated
foods
SodasFried

Fibrous
vegetables

s
drinkscandy Dessert
Sugary
other
Pastasand
highCHOPicea
milkandother
Whole foods u
milkdairy
whole
may forthepatienttolactoseintolerance n abdominal discomfort
lead

Nuts

226inBook
DietprogressionafterGastricBypassTable

Recommendations

3smallmealseverydayand 12snacks
Hydration
throughoutthedayislatephasesymptomsmay
show

Nofluids30minutesbeforeeachmeal
Avoidsnacking sodasandalcohol

dailyvitamins
recommended
Providing

protein
Adequate

Physicalactivity Astolerated

Treatment
Syndrome
Dumping

to
Foods avoids

and
Sugar other
as sweetdrinkscakescookies pastries sweetenedbreads
sweets such candy

solids
Eating the
anddrinkingliquidsduring meal
same 30minutesbeforeandafterthemeals
Foods toeat
Fibersupplements

Sugarreplacements
ComplexCHO

4 of or sugarfree
Morethan cups water other decaffeinated noncarbonated
beverages
toprevent dehydration

PharmaceuticalManagement

itcanaugment the
dietphysical therapyastreatmentfor
activityandbehavior with
patients

BMI330
BMI327withsignificantrisk
factors diseases
 ofaction Howdoesthese
Mechanism medication
work
appetite centralnervous
Decrease system CNS
Reduce
a bsorption
offatiswhenthis lipaseinhibitors
happens
are
given
Increase expenditure
energy

iscategorizedas
Medication

1CNSactingagents 2NonCNSactingagent
medications
bytheFDA
medicationsApproved

a gents
holaminergic 1Sibutramine Meridia
2Serotoninergicagents it BPandheartrate
increases

3Combinationofboth notappropriateforpatientswitha historyofcardiovascular

Sideeffects disorders

1Drymouth
2Headache 2Orli
stat orXenical
3Insomnia thebody'sabsorptionofsomefat
blocks andbeta
vitamins
soluble

4Constipation carotene

take daily
should
patient
a thatcontainsDEKAand
multivitamin

betacarotene

liposuction

fatbymeansofa1.2cmincisionthroughwhichatube
asitisafatremovalprocedureof
most
successful
areperformedonyoungerpersonwithonly
operations small
amounts
offattobe removed

itsa cosmetic
surgery
becauseusually
onlyapproximately 5lboffatareremovedatatime
thissurgerytechniquemayleadtodeathsevereinfectionscellulitisandhemorrhage

Behavior
Purging

the
ridding of for
body foodand caloriesconsumedinorder toloseweightorpreventweightgain
such
actions
as
vomitingexcessiveexercisefasting

of
aredifferentfrombulimianervosaisbecauseindividualsdoNotconsumealargeamount foodbeforetheypurge
they
Diabetes
M ellitus
4142023

Types of Diabetes

Type1Diabetes
Type2Diabetes
Gestational
Diabetes

Diabetesmellitus

describes
agroupofmetabolicdisorderscharacterizedbyelevatedbloodglucoseandalteredenergymetabolism
isanumbrellaforagroupofconditionsmetabolicdisordersthatare
Needs chronic Diabetes bloodglucoselevelandaltersenergy
be m ellitus
by
characterized elevated metabolism

these from
changes

defectiveinsulinsecretion

defectiveinsulinaction

combination
ofboth
becaused of
absolute
fordiminishedtissue toinsulinthatultimatelyresultsin
d eficiency
can by arelative
either insulin and responsiveness
hyperglycemia

Insulin

isahormoneproducedbybetacellsofthepancreasthatenablesmanycellstotakeupglucosefromthebloodandstoreenergyfuels
Glucosepresent Insulinutilize
by to
theglucose cells helpthebody
cells toutilize
glucose

Entregulatoryhormones thatopposeinsulinaction
GlucagonEpinephrineCortisol andgrowthhormones stress
hormone

Howdoesitoccur

Aseriesof e ncymesthatactivateasetofglucosetransporterproteinsGuru
I
a
a is the onglucosefromthebloodstreamintomuscleliverand cells
Pass fat
És
Insulin key
a o.s
o woman
g
j
channel
goose

rest
sous
xxxx
go.gg ooooo dowse
channel
gotta glucose
open
the
enters
cell
a so
a utilization
process
happen

Classification
Etiologic

Oldtimesdiabetestypeswherecalledinsulindependentand Non
Insulindependent

then this
theydiscoveredthat makesconfusion
n aming

whybothare insulin
g iving

itwasbasedonthe treatment

soitwaschangedtoType1andType2 based
ontherootcauseofthecondition
Gitwas based
onthe rather
e tiology the
than treatment

Asystembasedondiseaseorigin
TypeIDM
Type2DM
Other types
specific

1geneticdisorders hyperglycemia
3Hormonalimbalances 5Certaininfections
ofthepancreas
2diseaseswith 4Drugsorchemicals 6Immunesystemdisorders
sickness
to
leading
pancreas diabetes
 Type1DM Juvenilediabetes d iabetes
Childhood

1Immunemediated
autoimmune
mediateddestruction
ofthe cells
pancreatic

the
when body
ly
mistaking destroys
itsowncells
2Idiopathic
form
unusual
of phenotypictype 1diabeteswithastronghereditary andnoevidenceofautoimmunity
component

environment
genotype

3Latent a utoimmunediabetes
of adulthood

adult
onset
slowly eventual
progressive insulin but
requirement respond
may tooralagentinitially
test
Positive result of GAD andorisletcellantibodies
cygg.gg fgylase

Type2DM
Twometabolicdefectsoccur

1Insulinresistance M J
MDPhD Am
ScottGrundy

diminishedperipheralt issue
to
sensitivity insulin car
Coll did2012,59635
43
2 Deficient s ecretion
insulin

delayedorinadequateinsulinrelease

Elevatedglucose
in intermediate
are
range
caused
primarily
adeficiencyininsulinsecretedbybetacells
1 alossofbetacells
2impairmentofbetacellfunction
butless
Similar in secretioncharacterizedasPrediabetes
defects especially insulin
severe

thedifferencebetween
Whatis

TypeI DM TypeIDM
1 5 ofallcases 19095 ofthecases
2Absoluteinsulin deficiencycaused

with
by lesssensitivity
autoimmunemediated respond

of cells
destruction pancreatic
3 with
Associated
o besityphysical

3Beginsin and
childhood adolescence
and
inactivity i nsulin
resistance

oratanyage 4Thechronicdemandforinsulin
4 Diagnosedafterthedestruction graduallyexhausts
pcells
ofpcellswhereinsulin of flaters
production insulin

m asthe
d iseaseprogresses

5Noinsulinproduced nohyper insulinemia

5Hyper
insulinemia hyperglycemia

Type2DiabetesProposed Pathogenesis

Environment
Obesity Peripheraltissueinsulinresistance
g lucoseutilization
Inadequate

Bcell Type2Diabetes
Hyperglycemia exhaustion

Deranged
secretion
insulin

defects defect
pcell
GeneticPredisposition Multiple
genetic Primary
Pre
diabetes

a in bloodglucoselevels
describes condition which
arehigherthannormal However not bediagnosedwithtype2diabetes
highenoughto

approximately
1 in 3peoplewithpre onto
willgo
diabetes
typeadiabetes
develop

is
Prevention sustained
lifestyle
c hanges

1healthyeating
2increasedactivity
3reducingweight
research hasshownthatsomelong
term tothebodyespeciallytheheartandcirculatorysystemmayalreadybeoccurringduringpre
damage diabetes

Impairedfasting
g lucose IFG

I GandIGTPre
F
T
diabetesrepresent states
intermediate
of abnormalglucose thatexistbetweennormalglucosehomeostasis
regulation anddiabetes
level
fasting changed of110125mg
ldlto ADA2003
effigy
Impairedglucosetolerance IGT used tobecalledGGT
Inabilitytomaintainbloodglucoselevelwithout excessiveinsulinproduction Hyper
insulinemia

some
p eople thisdisorder
with havefastingg lucoselevelsslightly
may thannormal
h igher

Others have
may
levels
n ormal
tohighlevels
butafterglucoseloadingtheirbloodlevelsrises

InsulinResistance

useiteffectively
isaconditioninwhichthebodyproducesinsulinbutdoesnot

When haveinsulinresistanceglucosebuilds
p eople
upintheblood ofbeing
instead absorbed
bythecells
leading
toType2diabetesorPre
diabetes

Causes

major
contributors
areexcessweightandphysicalinactivity
ethnicity

certaindiseases PCOS metabolic

changes

and
tormones steroid use sportathletescoaches
somemedications

Older
age
p roblems sleep
sleep apnea

cigarette
s moking

risk
High
individuals
of diabetes

Family
history

Obesity
Overweight

pattern
eating
Unhealthy

Physical
inactivity

Increasing
age 45y
Bp
High
Ethnicity

Impairedglucosetolerance IGT
History of diabetes
g estational

Poor
nutrition
during
p regnancy
GestationalDiabetes
9142023

Most
commonmedicalcomplication
of
p regnancy

É areathighrisk
toidentifythosewho 25 oafgeandnormalbodyweight
Tj
years

NofirstdegreerelativeswithDM Geneticpredisposition

Pglucosebloodlevelinmother extra to
g lucose baby causes
baby toputonextraweight

Womenwho diagnosed
are withGDM 30 50 willrecurrentinfuturepregnancy
Upto50 ofwomenwithGDMwilldeveloptype2DM uwhyHowlackofPhysicalhealth Healthyeating andincreasing
weight
74foldincrease
Diagnosis

1Hb
AICtest
Oralglucosetolerance
termdiabetes
long mga
Glucose
test moldy
for
use oftype2diabetesandprediabetes
diagnosis 6.5 3126 3200
2Fastingplasmaglucosetest impairedfastingglucosetest Pre
diabetes
5.76.4 100125 140199

96bra test
Normal about
5 99 139

Complications

1Acute Complications

Control
ittoavoidchronic
andAcidosis
ketosis

inthe of
a bsence insulinthe
counter theproductionof
regulatoryhormonesstimulates

Glucose

Ketoneb odiesaccumulate blood

and
in excreted
inthe
urine

lungs restore
theacid to
basebalanceleading acetone
breath

Dehydration fluidimbalance
and
thetissuesduetotheincreaseconcentration blood
waterisdrawnfrom of
inthebloodfluidsexcreteexcessglucoseandketosethroughthekidney leadingtodehydration
concentration
high
g lucose

with
garagesareexcretedalong Hed nbd
g lucose s
PolyuriaandPolydipsia
a
of
frequency

urination
mouthdehydration

Coma
thepolyuria
From
hyperosmolar hyperglycemia coma and
p olydipsia

above600mg
levels di severedehydrationwithnoketones
Diabeticcoma

areashighastheprevioustypebutacidosisissevere
levels

of
Hyperglycemiacomplication diabetes
of
Hypoglycemia inappropriatemanagement diabetes

will to
lead dosethan
insulin
high
recommended
skippeddelayed

1Electrolyteimbalance 3Dehydration medications

glucoselowering

2Acidbaseimbalance yComa excessivephysicalactivity

food
inadequate intakeskipped
delayedforgot
toeat
Symptoms
of hyperglycemia

1HungerandHeadache
2SweatingandShake
ness

3ConfusionandNervousness
4 Disorientation andslurred
speech

5Repeatedepisodesmay impaircognitivefunctions
permently

6Effectbrain inchildren orcognitive

development functions adults
in

Lecture1111412023

to to
lead chroniccomplication
exposure acutecomplicationwould
Long
Hyperglycemia acute
n isan short
termcomplications

exposure tohighlevelofglucoseintheblood altersglucosemetabolism

innoninsulindependentNIDcells
because
sugar
alcoholsaccumulate andproteinsareglycosylated Abate
int
high acellular
glucose to
leads rapidformation
of
alcohols
sugar celldistentionandtoxicity
causing
Fructose
tul
Solve blurrvisiondestintion ofthelegs

Indiabetic reflexthe
atomiccontroland forDiagnosis

g Tocheckhowthepatient
givestheestimatedarragedwse

managed hiscondition

termexposureto
long causesformationof
highglucoselevel tocelldegradation
lead
irreversiblelinkage

Hyperglycemiaalterstheformationofglycoproteinsinthekidneysleadingtodiabeticsclerosiscanbe bygoodglycemiccontrol
avoided reversed
or

with
Patient risk
high ofkidneyfailureare
andcontinousexposure
high toglucose causes of
levelformation g lycoproteins
high inthekidneyswhichleadtosclerosis

2Chronic Complications

Notreversible
toelevatedglucoselevel
Highexposure glycoproteins d amage celld igredation
celldistentionand
control
Glycemic protects fromthesesicknessesanddiseases
thepatient

A Cardiovascular disease
OD DT2
Diabeticpeople
have risk
high ofCVD
manyinteracting
factorsc ontribute
tothe of
acceleration atherosclerosis

RiskfactorsofCVD

1Diabetes
2Otherosdorosis
3 Hypertension
mayact synergistically with
other wallabnormalitycellulardis
factors arterol functionlipoprotein
abnormality

Metabolicsyndrome

when obesityabdominal
obesity insulin
Hypertension Dislipidemia resistance
ortype2diabetesactsynergistically

BMicroangiopathy
thecapillariesandsmallbloodvessels
hyperglycemia damaging

Nephropathy andRetinopathy
twoimportantproblemswefacewithdiabetics
Most
 foots
Diabetic

Management
ofDiabetes
1 fordiabetesshouldbeconsideredinalladultsespicallywhoareoverweightBMI25andpreviousgestationaldiabetes
Screening

2Morethant rkfadorfor type2diabetes

adf.gg

2PCOS
3gestationaldiabetics
4Physicalinactivity
5 Hypertension particularly
historyof cardiovascular
diseases

6PreDiabetics
7 Dislipidemia

8Membersofhighrisk individuals
populations

Tomanagediabetes
1SetGoalsobjectivesofTreatments
bloodglucosewithinnormal
maintaining
range topreventhyperglycemia

achewingoptimumblood levels protectthemfromcomplicationsofdiabetes excardiovasculardiseases

controllingblood
pressure
treatment
of complications

oralanti
diabetic
agent
2DrugTherapy Insulin t herapy

3Physicalactivities
4Education
5Dietary modification

MedicalN utritionalTherapyMNT

itisa cornerstone
ofdiabetes prevention andmanagement

Majorobjectivefor of
DMpatientsismaintainingbloodglucosewithinnormalrangeacheivingoptimumlipidprofilemaintainingbloodpressurepreventionortreatment bylifestyle
complication

modification
MajorObjectives of to
inMNT
individual

nutrition
n eeds

culturalPersonalpretences

tochange
willingness

of
maintainpleasure e ating
s
foodchoices
by
limiting indicated scientificevidence
when

Lecture 161412023

of
Management diabetes

1Medical management

agent
gang

31,199
PhysicalActivities

5Dietarymodification

Therapy
Drug
Type1 has
i nsulin
deficiency noinsulinso
or needinsulinto
patients controlb loodglucose order utilize
in energyto
Type2can their
control
sometimes blood glucoselevelw ithoutmedications
byusinga
combination
ofdietandphysicalactivity
Iffailedoralantidiabeticagentsare prescribed alone
in
w ithoutm edications cases

Wecandomanagementintype2for thedietarymodificationandphysicalactivities
g lucoselevelin HighAbate
Medication
doNOTreplacedietandPhysicalactivities

Insulin
Therapy

Type1
to
receiveintermediatetype meet and
n eeds
baseline regular to
and insulinanalogs processenergyafter
for meals

Type2
insulin
in oralantidiabeticdrugs
with
used combination
onlyasingleinjectionof isgivenatbedtime
intermediate

Intensivetherapy

multiple
dailyinjections are
givena of2ormoretypesofinsulin34timesdaily
mixture

Oralanti
diabetic
agents

stimulates thereleaseof frombeta

insulin cells
stimulates
insulin
release
foronlyshorttimefollowingmealstohelpminimizepostmeal hyperglycemia

peripheralinsulinresistance
lessening

thedigestion
block ofstarchesandslowthedigestionof disaccharides
 Metformin Glucophage

Decreases
hepatic
glucoseproduction Gluconeogenesis liver

Decreases
intestinal
absorption
of glucose intestines

andutilizationumuscle
insulin
Improves
by peripheralglucoseuptake
sensitivity increasing

the
into
Insulinissated p ortal inthebasalstate
system atarateof1Uh BasalInsulinNeeds
its
rate 510foldsafterfoodintake
increases

needs folds
Basal
insulin n 40Uday
Luth 1510

of
Types insulin

1Humaninsulin
absorbed
morerapidlyand
peak thananimal
earlier insulin

majoradvantage
fewerantibodies
produces beusedforintermittenttreatments
ncan
Typeandtimingof be
s hould individualizedbased
insulin
on
1bloodglucoselevel 2eatinghabits 3Exercisehabits 4Weight
Single of
dose insulin seldom
is effective foroptimalbloodglucosecontrol

2Insulinanalogs
arapidinteractinginsulinwhoseaminoacidcomplicationhasbeenmodifiedthatitworksfasterandhasashorterdurationof
action

whyisitused
1reduceaftermeal ascomparedtoregular
hypoglycemia

2Associatedwithlowerrisksof betweenmeals
hypoglycemia andduringthe
night

Diet
andphysicalactivity
aremajorinfluencingfactorsfor in typesofdiabetes
sensitivity both
i nsulin

Thigh
at0Highfiberdits High
i nsulin
increase sensitivity have effects
opposite

decreaserequirements

Regular s keletal
activityi ncreases
physical toinsulin
muscles ensitivity

Example

Training
p rogram 60milesweek thepersonrequiredonly200ofinsulindayWhilethenon p eriodinwhichhe
training required
50Uday

ofInsulin
Properties

Concentration

Onset 1Injection
d Peak Purity
2Externalpump
y
Source 1Speedofabsorption
2Peak
 p hase
Honeymoon

of
Temporarilyremission after
diabetes the
initialtreatmentwith
i nsulin

p
Some cells remain
may
after
thediagnosis of diabetesandregaintheir
function
temporarily

Lecture181412023

of
Types Insulin

1InsulinAnalogsHumaninsulin
2Intermediate
3RegularInsulinRapidActing
4LongActing

Remember

usuallydoesn'ttake
Patients than
more onesingledoze ofaninsulintype
Jwhy
atsteadyconditionsstoresinsulintocoverthebody'srequirement
thebody

Forglucosetoutilizeinthebodyitneedsinsulinsothecellswork
Weneedbaselneedstocover
fromtypesastheinter forlongacting
and
mediant

Bolusi nsulinshort
actingrapid
acting

taken the
after meal
 Management
of diabetes

arethemajorstrategiesapprochesproto
What to
callsplansProcedure makeamedicalnutritionaltherapyfor
thediabeticpatients
1 Macro
in
nutrientDistribution Diabetesmanagement

ControllingCHO
prevents
hyperhypoglycemia
function
protein
mayhelppreservekidney
Controlling

fathelpprevent
Controlling disease
cardiovascular

listismostcommonlyusedapproachmethod
Exchang

CHO
counting

tocarbratio
Insulin

2PhysicalActivities
3NutritionEducationandCounseling

Physical
Activity

individuals
becarefullyevaluatedtodeterminethetypeandamountofphysicalactivity
should

with
People
2benefitmorethanthosewithtypet
type

Mentionsanimations Dislipidemia

2 Improves Had anddecreasesbloodpressure

profile
lipids 1Cardiovasculardiseases Hypertension

gg
a
Type than
benefitsmore
type1withphysical doesn't
activitiesH oweverthis meanthat
thereisno fortype1
benefits

insulin be anhourbeforeactivitytoprevent
s hould taken which
hypoglycemicreactions occur after
severalhours

i nsulindosebeforeand
Reduce theactivity
after
by3050
Nocturnalhypoglycemia

earlyinthe
startactivity day
Reduce
i nsulin
it
dose started lateinthe
day
be
should avoided blood
if are 100mgdehypoglycemia or
levels
glucose l ldl hyperglycemia gluconeogenesis
300mg
fluid
provideadequate eatbeforeduringandafterexerciseespeciallyCHO
intake

Amount
ofCHO depends
typedurationindividualresponsesand
onthe blood test
g lucose

Regularadjustmentsafter
the of
are
initiation treatment needed

andPregnancy
Diabetes

risk
high of spontaneous abortions

riskof
increased hypertension

birth from
defects
to
exposure highblood andketones
glucose

blood
high can
g lucose lead
resultinmacrosomiawhich in the
p roblems delivering baby

GestationalD iabetes

Provideindividualizeddiets with
along insulin
t herapy necessary if
CHOis distributed
intosmallmealsnacksto maintainblood
in
l evels pregnant
glucose donotrequireinsulin
who
limiting at
CHO breakfasthelpmaintainmorningblood l evels
g lucose

to fuel growingfetus
snack preventnocturnal hypoglycemiaandketosisandprovide
bedtime
to

ofinsulin
Calculation
TDITotalDaily
Insulin

Type1
TDI wt
flag0.10.3U
1kgstartlow
 Type2

1 Underweight advance
ageDialysis
TDIwtf
lag0.301kg
2 Normal
weight

TDIwtkg0.4Ukg
3Overweight
TDIw1kgO.SU
t kg
4Obesesteroidusehighinsulinresistance
TDIwekg0.601kg

tocarbratio
Insulin

person
every to
responddifferently insulin

Iunitoffastactinginsulincancover15gofCHO for Adults

some

Younitoffastactinginsulinmightcover15gofCito forYoungchildren
to
needs knowthe
exchange list
Type2 patients someinsulinnaturally
produce
usually soaTDIdosecannotbecalculatedreliably

500Rule of
Users Huma
logandNovo
log

gof by1unitofinsulin
CHOcovered
Ig
Example

Amantakes40UdayofHumalogHiscarbtoinsulinratiois 1unitinsulinforevery12.5gofCHO
50g 12.5gof970 by1unitofinsulin
covered

450rule users ofRegularInsulin

45 gofUtothatis by1unitofinsulin
covered

Example

dayofRegularinsulinHerinsulintocarbratiois 1unit
Awomentakes30Ul ofinsulinforevery15gofCHO
4,501 15g ofCHO by1unitofinsulin covered

CorrectionFactor
CF
Ishowmanypointthebloodsugarwilldropwithoneunitofinsulin
Correction blood
FactorDose Current sugarTargetblood
sugar
Factor
Correction

CorrectionFactor
is 1unitofinsulinshouldlowertheindividual's bloodglucoselevelby35mg 4
di12mmol
jiffy
Example

CBG
199 d d
Carb60 CF17,81 35 10g 1insulinunits
100
TBG 60g insulinunits
ICR 1 10 Correctionfactordose

ofinsulin
TDD50units ng
gyp n

Example
d d d
Whatisherinsulincarbratio
Carb60 CFMY 42.5 10g 1insulinunits
60g insulinunits

Ii hisoping Correctionfactordose

3
by 6
120 5.4units units
insulin units

Type2DM CAOdistributionismorecontrolled

20
Breakfast

AM snack 10

Lunch
30
PM snack10
Dinner 20

BTsnack
10

Mealplanning
strategies

CHOcounting

aneffectivemethodofallowingdiabeticpatentstoobtainneedednutritionwhileattainingthedesiredbloodglucoselevel
Patient this
using diet should
plan Howitworks whatpatientneeds todo
d it doseandkeeprecords
2Understandtheportionsize 2MonitorthetimeandamountofCHOintakeateachmeal
3Controltheirintakeofenergy 3Monitorthetimeandamountofinsulinorantidiabeticdrugs
4LearntoeatconsistentamountsofUtoatregulartimes 4Physicalactivity
steamtomamamama

SimplecalculationfromexchangelisttoknowInsulinCarbratio
2Toastbread 30g
1 of
slice cheese
chedder
nOg if 15gofcarb is1insulinHowmuchgof1110 Howmuchinsulinunitsistaken
3 of
slices tomato n Og
1mediumapple 15g 57g
insulinunits

Iapofmilk is12g
57guCHOcounting Insulinunits3.8 4units
Lecture
7152023

S ystem
Digestive

aseriesoforgansjoinedinalongtwistingtubefromthemouthtotheanus
Mucosa

ismoisttissuethatlinestheGItube
inthemouthstomachandsmallintestinesmucosacontainstinyglandsthatproducejuicesthat
areinvolvedindigestion
liver
andpancreas
produce
digestive
juices that theintestinethroughsmall
reach tubes

of
Parts other
playmajorroleinthedigestivesystem
ansyg.gs
Nerves

Functions
of tract
gastrointestinal

1Fooddigestionandabsorption
2Gutisoneofcorediseasefightingsystemsofthebody
3Sendingmessagestootherpartsofthebody
4Fluidbalance

Parts
ofthesmall intestine

to
connected stomach
directly

35m long
Consist
of Duodenum
Jejunum and
Ileum

Enzymes areproducedby
1Salivaryglands mouth
2Pancreas
3Intestinalcells
areproducedbythecellsinfluencingbileandpancreaticjuicesproduction
Hormones

Cellsabsorb
sugars acids vitaminssaltsandwater
Aminoacidsfatty

thebloodstreamandcarried
Theyenter tootherpartsofthebody

oftheColon
Parts

11.5mlong
Consist
ofCecumColon RectumandAnus
Partlydigestedfoodsmoves intocolon
t hroughcecum

andelectrolytesareremoved
Watersomenutrients

stool
Remaining
isstoredinrectumandleavesthroughan
us
 and
Nutrition
GItractDisorder

Aproperdietandnormally functioning
GItractareimportantfor
1Deliveryofnutrients
2 ofnormalGImotility
Promotion

3 of Prevention
and
nutrientd eficiencies malnutrition

4Repairofdamaged intestinal
epithelium

5 ofnormalluminal
Restoration bacterialpopulations

6 ofnormalimmune
Maintenance functions frompathogens
tolerance

protection
frompathogens

Diseases
ofSmallIntestine
1Celiacdisease
2Inflammatoryboweldisease IBD Crohn'sdiseaseandUlcerativecolitis

3Infections
4Intestinalcancer
5Intestinal obstruction

6Irritablebowelsyndrome IBS
7 Ulcers issuchaspepticulcer

Diseases
oflargeIntestine
1 Colorectal
cancer

2Colonicpolyps
colitis is ulcersofthe
3 Ulcerative
andrectum
colon

4Diverticulitisisinflammationinfectionofpouchesinthecolon
5IrritablebowelsyndromeLIBS isnotalife diseasethreatening

Constipation

infrequent difficultb owelm ovements

or
itis asymptombutnotadisease
accompanied
by
abdominaldiscomfort headaches backachesandproduction
ofgases Flatuence
it's exposureorchronicexposurefor
long thissymptomcanleadtochronicdiseases

Improp
aredietImbalanceddietInadequatedietcancausechronic constipationwhichlead
toobstructionin intestines
Severconstipation

FecalImpaction A compacted
mass offecalmaterialinthecolonrectum

Theintestinemay Infection
ofthe
andInflammation liningtheabdominal
membrane

andcause cavitycaused leakageof

infectious
organismsthrougha
rupture
by
Peritonitis perforation
inanabdominal organ

Causes
of contipation

1Fluidand i mbalances
electrolyte

2Hormonal i mbalances

3Chroniclaxativeabuse
 4Lackofphysicalactivity
5Useofsomemedications
6Useofantacids
7Useofanti hypertensives

8PregnancyandAging
of blowfiberandfluidintake
Growth fetus

Hormonal
changes Decrease
physicalactivity

Decrease
GImotilitydrugs
Guidelines
forHighFiber
diets

increasefiber
intakegradual
y
intake
increasefluidity
toatleast21perday
calculatefiber
intake forclientperday 12g u 1000kcal Highfiber
weneedto exceedthata mount

DiverticulaDisease
r oftheColon
Diverticulosis

in sidesoftheintestines pocketsarecalled Diverticula

p ocketsforming the
little

SignandSymptoms
cramps

bloating
constipation

Diverticulitis

Inflammation
ofthe diverticula

andSymptoms
Signs
Abdominal
pain
Episodes
ofdiarrheaand constipation

flatus
fever

bleeding

MedicalN utritional
Therapy

1Give Antibiotics Medical

2Clearliquiddiet isfollowedbyalowresiduedietisallowstheboweltorestandheal
3Highfiberdietwillbeinitiated
4Thebulk bythehighfiberdietwill benefitsofhighfiberdietafterleavingthepatienttohealandrest
provided

stoolvolume
increase

the
reduce p ressure inthecolon
thetimethefood
shorten timeto
isintheintestinegivingbacterialess grow

Diarrhea

notadiseasebutit'sasymptomofmany
it's oracomplicationoftreatmentsor
clinical
conditions medications

characterized
bypassageoffrequentbowelmovement
canbeacute or chronic
in
lastingfor2weeks
 Chronicdiarrhea

butchallengingclinicalscenario
common

defined
asadecreaseinstoolconsistencyfor 4
than weeks
more
intothreebasiccategories
Divided

1Watery
2Fatty malabsorption

3Inflammatory
MedicalN utrition
Therapy

Objectives

Identifyandtreatthe
primaryunderlyingproblem
Managefluidandelectrolytereplacement

Incasesofseverediarrhea fluidandelectrolyte
Restoring isfirstpriority
Electrolytelossesespecially KandNatshouldbecorrectedearlyusingoralglucoseelectrolytesolutionswithaddedKt
ofNatandglucose
OralRehydrationSolution ORSworkbecausetheycontainconcentrations

NutritionTherapy

diet
Restrictive

astheBRAT
such diet arenutrientpoorandthereisnoevidencethatthey
arenecessaryduringacutediarrhealillness
withinsolublefiber
Avoidfoods
whole
of
wheatbreadskin fruits
and and
vegetablesnuts corn peas
Avoidcaffeine fat
andlactose high foods forming
gas
foodsand
friedhighly foods
seasoned

Rawvegetables
salad
greenstomatocarrots

Fruits

pineappleorange grapefruit

salttofoods
Add

torestoresodium
lecture1415
2023

UlcerDisease
Peptic

Chronicdisease

by
Characterized

1 that
Factors the
damages acidpepsin
m ucosa Chlorid andulcerogenicdrugs

itsprotection mucosalbarrierprostaglandinsandmucosalsecretion
2Factorsfor
Resulting
inalesionoftheliningoftheupperdigestivetract

Clinical
manifestations

Epigastricdiscomfort

severeandcontinuousheartburnpain
Burning

Pain
h appens 13hoursaftereating
s
nausea vomiting

discomfort
inGItract lossofappetite
flatulence

loss
significant ofbodyweight

thatthepepticulceroccur
Areas

1Upperstomach ulcer
Esophageal

2Gastriculcer
3Duodenalulcer

andRiskfactors
Causes

1 Hpyloriinfection
isabacteria
majorcause ofpepticulcer
responsible
for
most
cases ofchronic inflammation
ofthegastricmucosaandpepticulcergastriccancerandatrophicgastritis
2Genetics Ethnicity I
3Age13060mayoccuratanyage ofthemucous
withdeterioration
inflammation
chronic

4More inmales
prevalent
andglandsresulting
membrane
in 1Chlorhydria
5 Environmentalrisk
factors
2lossointrinsic
f factor
AAlcoholandSmoking
inhibitreduce
of
secretion mucusandbicarbonate acid
increasing
s ecretion

B Somemedications
steroidsand steroidalanti
aspirin non agent
inflammatory

of ulcer
Diagnosis peptic istestistheupperendoscopy

Nutritional Management

Medical
Therapy isGoalsof
Medicaltherapy

1Stress management
1Relievepain
2 Medications
isstop 2Promotehealingofulcer
3Nutritional management
to
Diet herapy 3Preventrecurrence
Goals
ofNutritionalManagement
1 Prevent secretion
hyper ofpeptricchloride ids thesoreandpaininthegastricandduodenalmucosa
reduce

2Restoreandmaintaingoodnutrition
Vitamin
3Supplynutrientsneededforhealing Protein
4Provideadiet consistent withindividualsrequirementsandlife
style

Dietary
Management

calories
is
distribution adjustedaccording
tothepatient'sneeds
sufficientcalories
tomaintainrecoverthenutritionalstatus
Forweightloss20 25kcalling
Formaintenance2530kcalkg
Forweightgain3035k calling
Protein
intake and
sudden s evere

1.2gl dayinacutestage 5 8week

lagbodyweightper
1.5gl stage with
dayinrecovery
lagbodyweightper Ctosupporthealingprocess
vitamin

CHO

to
adjusted patient'sneeds

NO disaccharidesconcentration
toavoid fermentation

To thehealingprocess
accelerate

1Line
essential

tomaintaintheimmunesystemfunctionasaresponsetooxidativestress
tohealwounds
phase11
Acute
mg
phase40mg
Recovery

2Selenium
reduceinfectioncomplicationsandimprovehealing
may
Acutephase55mg

phase400mg
Recovery

3VitaminA
used
asasupplement
4Iron
IronDeficiency
caused
by
bleeding

useof
antacids

growth ofHpylori
by
Prevented

mgofiron
dailyintakeof45
supplied
bytheingestionofmeats hemeiron
Concomitant
consumption
ofVitaminC ironabsorptionfromthediet
enhances

Recommended
dose ofVitaminC
Acutephase
75mg
phase500mg
Recovery
 5FolicacidandVitaminB

Chronic
useofantacidsaffectsthebioavailabilityofthesevitamins

VitaminBiz
synthesized
by
inthecolonbutnotabsorbed
microbiota
intestinal

causes
deficiency

celldivision
impaired

megaloblastica nemianeurologicdisorders

isfor2.4mgdayofvitaminBiz
Recommendation

Obtainedfrom and
animalfoodsmilkmeat
eggs

Lifestylemodifications

1 Coffee beavoided
decaffeinatedshould

acidproductionresultingin
Whyraisesgastric
mucosalirritations

2Omitalcoholtobaccopepperchilipowderandmustardseeds
3Supplynutrientsneededforhealing ProteinvitaminCLind
Lecture1615
2023

InflammatoryBowelD isease

Prevalence his
ofCri andViera
disease
tie colitis
IBDtypesthatcausechronicinflammationanddamageinthe
ve are gastrointestinal tract

IBDis otfhemostprevalentgastrointestinal disease

one
considered

arethegroupsthathashighrisk
What ofIBD
1Inpatients1530yearsofage
2Somelaterin adulthood

3RacialandEthnic differences
genetic

Whatarethe thetwodiseases
differencesbetween

Structural
changes

Crohn'sDisease

most theend
affects
commonly ofthesmallintestineileum
canaffect oftheGITfrommouthtoan
anypart us
may inpatches
appear

of GI whileleavingotherareasarecompletelynormal
affectsomeareas the tract

inflammation
may
throughthe
extend entirethickness
ofthebowelwall
MA
Alllayersoftheintestinalwallscan
beinvolved

toonlyCrohn'sdiseasespecific
leading complications

1Fistulaabnormalconnectionbetweentheintestineandotherorgans
2Abscesscollectionofpus
g wearea narrowingthat canlead d

Colitis
Ulcerative

limited
tothelargeintestinecolonandtherectum
inflammationoccurs
onlyinthe
innermost
oftheliningotfhe
layer intestine

intherectumandlowercolon
begins

spread
may to theentirecolon
c ontinuously involve

by
cured surgicalremoval
ofthecolon
 ClinicalFeatures

Inflammation
impairsthe ofaffectedGIorganstofunctionproperly
ability

diarrhea
Persistent
toopeningsinskinandaroundtheanalregionthat
Fistulas lead
n
Abdominal
pain stool
drain andinfectedmaterial
Rectalb leeding Abscess lead
tosymptomsofseverepainandfever
Fever Stricture
tointestinalblockagewithsymptomsoffillingupquicklyaftermealsnauseaandvomiting
islead
to
Urgency have
bowelm ovements

andfatigue
loss
weight

Othersymptoms
thanthe be
other tract
byIBD
intestinal
Organs can involved
1Eyesasredeyeorblurredvision
2Mouthnosoresinthemouth
3Jointsajointpainwithwithoutjointswellingandredness
4Skinisrashesskinulcersmostinvolvingthelowerlegs

Etiology CausesandRisk
Factors

suchasaninfectiondietorenvironmentalfactorsthatactivatestheimmune
aninitialtrigger system

thisleadsto andattackonnormalintestinal
i nflammation
uncontrolled cells

Smoking

todevelopCrohn'sdiseaseandhavemore
likely formthannon
aggressive smokers

less todevelopUlcerativecolitisandtendtohavealessseverecoursethannonsmokers
likely
Genetics

both
d iseases alsoexistinthe
can samefamily

oftheinflammationoftheintestinalmucosainIBD
Characteristics

1Episodesofabdominalpain
2Bloodystool
3Weightloss
4theinfluxof esndmacrophages
neutrophil
g
cells
immune

CytokinesProteolytic

freeradicals
enzymesand

1
Inflammationand

Ulceration

Five basic
major causes ofmalnutrition
1Inadequateintake
2Inadequateabsorption
3InadequateUtilization
4Increaseddemand
5Increasedlosses
 NutritionalProblems

v u r
diarrhea
Severe and
Nausea Malabsorption
causes
malabsorption's
andbleeding Abdominal
pain by
caused

andsurgicalremoval
and
Dehydration

iii
nutrientlosses
I Iftheillumisaffectedremoved acids
Amino acidssugars
fatty
and
Malnutrition
i andminerals
vitamins

Fatsolublevitaminsfattyacids am
and Bizwouldbeaffected
V itamin

Anemia

loss
Weight anemiaisdue diarrheaand
and to
bleeding

Poor
growthinchildrenisdue tomalnutritionassociatedwiththediseaseandmedications corticosteroids
bone
Decreased mineral
densityiscommon IBD
inchildren adolescentsandadultswith
i
Inadequate and
ntake a
of
bsorption calcium

88 Vitamin Ddeficiency
Useofmedication

nutrientdeficiency
Micro
Macro

Inadequateintake isProtein malnutrition

energy
Low Bizandfolate isAnemia
ironVitamin
lowvitaminDandvitamink is OsteomalaciaandOsteoporosis
lowvitaminE uPeripheralneuropathy
LowvitaminA nNightblindness
lowthiamineandBvitamins nBeriberistomatitisorglossitis

NutritionalAssessment

1Dietaryintake
2 evaluation
Anthropometric

3Biochemicalmeasurementofvitaminsandelementsisneeded

Nutrition
Intervention
arethemajorobjectivesMNI
what

1topromoteimmunityandhealing
2tocontrolsignsandsymptoms
3toprevent nutritionaldeficiencies

4topreventanemiaand osteoporosis

5maintainnormalgrowthforchildren

of IBD
Role dietand
Diseaseand
there positiveassociationbetween Crohn's
is intakeoffatPolyunsaturatedFattyAcidsOmega6fatty
high acidandmeat
andfiber
fruit
while intakesappear
tobeprotective
using
retrospective
dietaryhistoriesmake itdifficulttoclarifythestrengthofanyassociation
Nutrition
support

1Oralnutritional
supplements
ons
nutritionalrequirementsfor
welltoleratedtomeetthe
it's aremalnourishedoratriskofmalnutrition
withCrohn'sdiseasewho
p atients

giventoachieveoptimumenergy Upto600kcalday recommended

2Enteraltubefeedingfornutritionalsupport
ifwefailedwithnormalfoodandONS
patient still
is malnourished
orhigh ofbeing
risk malnutrition

3Parenteralnutrition
failure
intestinal

tryto if
withoralintake possiblewithparenteralnutrition
continue

To the
achieve best
nutritional
of
status amixture oralenteralandparenteralroutesused
together

4Preoperative nutrition
parenteral

formalnourishedpatientwhentheoral beused
Internalroutecannot

It isusedonlyin2cases
1Improvenutritionalstatuspriortobowelsurgery
2Improvepostoperativeoutcomes
Lecture
21152023

Diseases
oftheGallbladder

Chile
l ithiasis
of
formation g allstones calculi

Ch
oledochlithiasiswhenstones
o slipintothebileductsproducingobstructionpainandcramps
Cholecystitiswhen
passageobf ileintothe isinterrupted
duodenum

Gallstones
arecomposedofCholesterolbilirubinandcalciumsalts also
Bacteria
playaroleingallstone
formation

of
Formation g allstones

lowgradechronic changes the

Produce
in Absorptivecapabilities waterbile
Excess acid Cholesterol
may
Gallstones

infections gallbladderm ucosa areaffected be

may
absorbed out
precipitate

Prevalence

Infemalemorethanmales
Variable ethnic
by groups
Environmentalfactors
diseasecondition

Symptoms

of withgallstones
Majority patients areAsymptomatic
Symptomatic
g allstones

right quadrantabdominal
upper pain
nauseaand
vomiting

colic
paindecreaseoverseveralhoursbiliary
severe

pain fevernoprogresstocholecystitis
p resistent and
with
Onexamination thereispaintopalpationintherightupperquadrantMurphy'ssign

le
Cholithiasisand riskfactors CentralObesityInsulinresistanceanddiabetes
liverdiseaseshare
fatty

MNT

artsreasoner m
Promote Prevent

I
gallstonedevelopment gallbladdercontractions

1Consumptionoflargeamountsofanimalproteinandfat SFA

Fiji
1Highfiber
2Lackofdietaryfiber 2Lowfat
3Weightcycling 3Plantbaseddiet
ChronicCholecystitis termlow
islong offat
fatdietcontaining2530 calories
Lecture
2852023

Diseases ofGastrointestinaltract SmallIntestine

Celiacdisease
isageneticautoimmunedisorder
ga g autoimmunewhen
the
ly its cells
mistaking attack own
body

GlutenRelated
Disorders
g Allergic
L GlutenAtaxia

WheatAllergy

NotAutoimmune NotAllergic Glutensensitivity

Non
celiac s ensitivity commonly
gluten todescribepersonswithnonspecificsymptoms withouttheimmuneresponse
used ofCeliacDiseaseorthesignificant
intestinaldamage

Wheatallergy
isanimmunereactionof anyproteinin aretreatedbyavoidanceof
wheat Condition specific
dietarycomponents
d escribesindividualswho
i ntolerance
Gluten have symptomsand whomaymay nothaveceliacdisease

sensitivityORGlutenintolerance
Gluten

Twotermsusedtodescribesymptoms
1Nausea 2Abdominalcramps 3Diarrheaafteringestinggluten

WhatisGluten
found wheat
in
Peptidesgluten and
ingliadin aremoreresistanttocompletedigestionbyGIenzymesandmayreachthe
smallintestineintact

Celiac
Disease S ensitiveEnteropathy
Gluten

by
Characterized combination
of4factors
1Geneticsusceptibility
2Exposuretogluten
3Environmental trigger
4Autoimmuneresponse
Pathophysiology

1Immuneand inflammatory
response

2AtrophyandflatteningofvilliDamagetotheintestinalmucosa
3 normal
Compromised secretorydigestiveand absorptivefunctions

4Impairedmicroandmacronutrientabsorption
MedicalDiagnosis forCeliacdisease
frequentlymisdiagnosed as
IrritablebowelSyndrome
lactase deficiency
Gallbladderd isease

Other notnecessarilyinvolvingthe
disorders
GItract
Diagnosis
by
exclusion
ofallother relateddiseases
conditionsincluding gluten

Complication NutritionalP roblems

MalabsorptionoffatproteinandCHO useveremalnutritiondelayedgrowth underweight

FolateBizIrondeficiency isAnemia
K
Vitamin deficiencyisCoagulopathiesbleedingdisorders

InadequateCalciumabsorption nbonedisease

is
Lactoseintolerance common

NutritionalManagement

withsymptoms
People
ofglutensensitivityandgluten not
s hould
intolerance
be to a freedietbeforeconfirmingadiagnosisofCeliacDisease
generally advised follow gluten

I
Why
1 maymaskthe ofwhichaglutenfreedietisnotthe
medicalc ondition
u nderlying treatment

2difficultto celiacdiseaseafterfollowingaglutenfreedietformonthsyears
diagnose

3Glutenfreedietcanbe andrestrictive
expensive

How tomanageforceliacdisease
ugiveglutenfreedietdietisadequatewhenchosenaccordingtodailydietaryplan
be
should excluded
Foods Ch 620621
29pg

ofaglutenfreediet
Initiation improvesnutrient
absorption andmanypatientswhoeatwellbalancedgluten
free donotneednutritionalsupplementation
diets
Pancreatitis

1Acute Pancreatitis

Mostcommongastrointestinal forhospitalization
causes

withasubstantialmorbidityandmortality
associated

Most causeis
common

1Gallstones
2Alcohol

ofpancreatitisis any2of3
Medicaldiagnosis established with criteria

1Abdominalpain
2Serumamylaseandorlipasegreaterthan3timestheupperlimitofnormal
3 Characteristics
seenincross
findings sectionalabdominalimaging

Cornerstones
ofmedical management dude
in
1 Aggressive intravenoushydration

2Appropriatenutritional management

3Pain management

4 Surgeryisimportantaspectsin
Endoscopic
ofacutegallstonepancreatitis
management

of
EtiologyReasonsCauses acutepancreatitis

1BiliaryTractdisease
ismostcommoncauseofacutepancreatitis
p ancreatitis
gallstone

is by by
pancreatitis caused ductobstruction gallstone
induced
gallstone

2Alcohol
mostfrequent
second
of
cause acutepancreatitis

3Hyper ia
triglycerides

isararecauseofacutepancreatitis
to
due the of triglyceriderichlipoproteinsreleasinghighconcentrationoffreefattyacidswhichinjurethevascularendotheliumof
hydrolysis excessive

thepancreas
4Genetic
mutationshave
been with
associated
thedevelopment ofacutepancreatitis
SpecificCysticfibrosis
genegenotypesshown tobesignificantly withAcutepancreatitis
associated

5Drug
Rare
awidevarietyodfrugssulfonamidesdiuretics tetracycline azathioprine estrogenandsteroids
reactionsdirect
proposedmechanismsimmunologic effect
toxic toxicmetaboliteischemiaandthrombosis

6Infectious
bacterialfungaland
Viral parasitic

7Trauma
of
incidence pancreatic
injury
to
majorityisrelated direct
trauma

minority with
associated blunt
trauma

8 Hypercalcemia

elevatedCalciumlevel

Themechanismexposuretohypercalcemialeadstotoxicitydisruptionof signalingand
intracellular celldamage
 9Vascular
Pancreatic
ischemia
secondaryto hematologicaldiseaseischemiasecondary
toshock
10Pregnancy
11 Autoimmune
pancreatitis

12Malignancies
13Certaintypesofcancers

Nutrition

oral
Early to thegutmucosalbarrierand
feedinghelps protect reduce
willreducethediseaseprognosis
b acterialt ranslocation which return
in
nospecificofdietinthese
recommendations

Iforalfeedingfailedenteralfeedingis considered

2Chronicpancreatitis
longtermdisease
itisasyndromeinvolving
1Inflammation
2Fibrosis
3lossofacinar
MTwhihanmanifestin
1Abdominalpain
2Malnutrition
3ExocrineandEndocrine insufficiency

andRiskfactors
Etiology
Chroniccalcifying
p ancreatitis

1Alcohol
2Smoking
3Genetics
Chronicobstructivepancreatitis

1Stricture
aAcutepancreatitis
btrauma
2Tumermalignancies
Steroidresponsivepancreatitis

Autoimmunepancreatitis

Nutritionrelatedproblems

InChronic bothexocrineandendocrineinsufficiency
pancreatitis
may
develop
leadingtomalnutritionovertime
Maldigestion isdependsontheseverityof
theunderlyingdisease

of
Severity malnutrition

1Malabsorptionand ofnutrientscausesimpairednutritionalstatus
depletion

2Increasedmetabolicactivityduetotheseverityofthedisease
 ant intake
Persist alcohol
painafteramealandmatdigestionarethe
main ofweightlosswhichisassociatedwithmatdigestion
c auses offat
affect
Nutritionaldeficienciesnegatively
iftheyarenot
outcomes treated

Management

Treatmentshould
bemultidisciplinaryandthemainstayoftreatmentis
1Stopalcoholintake
2Paintreatment
3Dietarymodifications
4Pancreaticenzymesupplementation

Maingoalsfornutritionalinterventionsare

1ensuresufficientmacroandmicronutrientsintake
2decreasemaldigestion

3decreasemalabsorptionandotherriskfactors
4preventtreatmalnutrition
NutritionManagement

Adequate intakecalculatedbased
energy onREEand IF
Protein
diet of101.5glkgbodyweight
smallmeals
Frequent 48timesaday
forsteatorrheapersists mediumchaintriglyceridescanbeusedtoincreasefatabsorption
Ifweightgainisinsufficientand
Fatsolublevitamins REDA vitaminBizandothermicronutrientsshouldbesupplementedifserumlevelsindicatedeficiencies
lowfiberdiet
whybfibermay en
absorb
cymesanddelaythe of
absorption nutrients

adequatequantity of exogenouspancreatic is
enzymes necessary correct to
protein lipidmatdigestion
and

NutritionManagement

toachieveenergyendprotein requirements oralsupplementationmightbe

beneficial

Internalnutritionusedwhenpatents donotobtainsufficientcalorieintake
israrelyusedinpatientswithchronicpancreatitisandshouldonlybeusedincaseofGItractobstructionorasasupplementtoenternal
Parenteral
nutrition

nutrition
 3052023
Lecture

ofmetabolism
Inbornerrors

3majornutrientsthatarenotmetabolizedcorrectly
1Protein aminoacidsorganicacidsureacycle
2Carbohydrateglucosegalactosefructose
3Fatfattyacidstransportelectrontransportchain

Phenylketonuria

Dietaryprotein Oxidation Thyroxine

i
alanine
Is
Phenylalanine
hydroxylase
Phinyi Tyrosine Melanin
x
tissue
mean I Tetrahydrobiopterin Dihydrobiopterin
Catecholamines Protein
synthesis

Phenyl
pyruvate

lactate
Phenyl acetate
Phenyl

Dietarym anagement

anunderstandingofbothnormalnutritionalrequirementsandthebasic
biochemical defect
requires

principle
of
strategies managementare
reduction
Dietary of substrates
by ofitsdietarysources
restriction
or acids associated
p rotein amino
frequently theformationofthetoxic
with metabolites

For in cycledefectsgalactoselactoseingalactosemia
example phenylalanine PKU proteinrestriction urea
in
of
Replacement essentialnutrients thataredeficientasaresultof
the blockfor
metabolic examplecysteine HCV
in
Cofactortherapy Pharmacologicaldoseof to nonfunctionaleneymeactivity
specificvitamins induce

of
Enhancement excretion
orproductutilizationtoformnontoxicmetaboliteslikesodiumbenzoateinureacycledisorders
Dietary be
should started early possible protect
t herapy as
as to
thebrainfromthetoxiceffects ofthesubstrateanditsbyproduct
measurements
Frequent
ofplasmaaminoacidsandothermetabolitesisessentialformonitoring andcontrolofthe
deficiencies disorder

Symptoms ofPKU
1Mentalretardation
2Behavioralsocialproblems
3Seizurestremorsorjerking movements
inthearmsandlegs
4Hyperactivity
5Stuntedgrowth
6Skinrashes eczema
7 Smallheadsize microcephaly
8 Mustyodorinthechild'sbreathskinorurineiscausedfromtoomuchphenylalanineinthebody
9Fairskinandblueeyesiscausedby phenylalaninecannott ransform intomelanin

Maple urinedisease
syrup
isametabolicdisorderpasseddownthroughfamiliesinwhichthebodycannotbreakdowncertainpartsof
proteins
branded
condition smelllike
can maplesyrup acid
amino
 of
Symptoms maple urinedisease
syrup
1Avoidingfood vomiting
2Coma
3Feedingdifficulties
4Lethargyseizures
5Urinethatsmellslikemaplesyrup

Possiblecomplication

Coma
Death

Neurologicaldamage

Homocysteinuria

ofmethioninemetabolismleadingtoanabnormalaccumulationofhomocysteineanditsmetabolitesinbloodandurine
isadisorder

Cystathionine

beta
synthase

isa
deficiency
inherited
rare
disorder

Symptoms ofhomocystinuria Mainclinicalfeatures

1Increasebloodclotting 1Eye
2 Brittle
bones other
or skeletalabnormality 2Skeleton
logastricanemia
3Mega 3Centralnervoussystem
4Seizures 4Vascularsystem Thromboembolism

5 delay
developing andlearningdisability

Clinical
management
of Phenylketonuria

canalmostcompletelypreventcerebraldamage
treatment
Dietary inPKUpatientswhenstartedinfirstweeksoflife
atloweringblood
aims concentration
phenylalanine

Traditionaldietarytreatmentconsists
of
1 Restriction
oftheessentialaminoacid byreducingthenaturalproteinintake
Phenylalanine

2Supplementation ofallaminoacidsbut phenylalanine

3Restoration ofallotherdietary caused the

by severe
deficiencies restriction natural
in protein
 Special considerations: Dietary restrictions in maternal PKU

Protein and amino acid requirements

(Pregnancy)

1e trimester: + 1 g/day
2e trimester: + 9 g/day
3e trimester: + 31 g/day
breastfeeding woman

+ 19 g protein/day (up to 6 mos)

+ 12.5 g protein/day

source: WHO/FAO/UNU Expert Consultation 2007:

 Special considerations: Dietary restrictions in maternal PKU

• Weight assessment is important because weight

loss is associated with loss of phenylalanine
control.

• The total weight gain for pregnancy is normally

11-16 kg by 40 weeks’ gestation.

• If weight gain is below these recommendations,

then a 10% increase in energy intake is
prescribed. This is achieved by use of ‘free foods’,
and energy supplements.
 Phe Levels
• PHENYLALANINE
• Premature: 98-213 nmol/mL
• 0-31 days: 38-137 nmol/mL
• 1-24 months: 31-75 nmol/mL
ofphenylalanineinblood
Whatisthetarget

• 2-18 years: 26-91 nmol/mL

• > or =19 years: 35-85 nmol/mL

• Conversion Formulas:
• Result in mg/dL x 60.6=result in nmol/mL

• TYROSINE
• Premature: 147-420 nmol/mL
• 0-31 days: 55-147 nmol/mL
• 1-24 months: 22-108 nmol/mL
• 2-18 years: 24-115 nmol/mL
• > or =19 years: 34-112 nmol/mL

• Conversion Formulas:
• Result in mg/dL x 55.6=result in nmol/mL
• Result in nmol/mL x 0.0181=result in mg/dL
 Low Phenylalanine Food Pattern?
What is Not Included:
• Foods that contain large amounts of phe must be
eliminated from a low phe diet. These foods are high
protein foods, such as milk, dairy products, meat, fish,
chicken, eggs, beans, and nuts. These foods cause high
blood phe levels for people with PKU.
• This target is an easy way to visualize the foods allowed
on the diet for PKU. The phenylalanine-free formula,
such as Phenyl-Free*, is the center of the target diet. As
the foods get further away from the bull's-eye, they are
higher in phenylalanine. The foods outside the target are
not included in the low-phenylalanine meal plan.
 Dietary Management
Inherited Disorder Phenylketonuria (PKU)

Enzyme Activity Affected Phenylalanine Hydroxylase

Basic Principle of Dietary Life-long diet 2.25-3 gm protein

Management per day. Modified to contain
phenylalanine 25-70 mg/kg/d.

Result of Treatment To decrease the accumulation of

phenylalanine in the blood.
To provide adequate protein for
normal growth rate and
intellectual development.
 Dietary Management
Inherited Disorder Homocystinuria B6 non-
responsive
Enzyme Activity Affected MTHFR = 5,10-methylene-THF
reductase; betaine-Hcy S-
methyltransferase; CBS =
cystathionine β-synthase;
MS=Methionine synthase

Basic Principle of Dietary Life-long diet 2-3 gm protein per

Management day. Modified to contain
Methionine 15-50 mg/kg/d.
the
replace e Cysteine 200-300 mg/kg/d.
deficiency

Result of Treatment To maintain normal plasma

levels of methionine, cysteine
and homocysteine.
To promote normal growth rate .
To maintain normal nutritionalSta
 maplesyrup

Nutrition management urine disease

• The goal of therapy is to maintain

plasma leucine concentrations of
100–200 μmol/L for infants and
children <5 years and 100–300 μmol/L
for those over 5 years of age.
• Nutrition management includes use of
medical foods devoid of branched-
chain amino acids, dietary leucine
restriction, supplemental valine and
isoleucine, and provision of adequate
energy, protein, vitamins, and
 Dietary Management
Inherited Disorder Maple syrup urine disease
(MSUD)
Enzyme Activity Affected Branched-chain keto acid
dehydrogenase enzyme complex

Basic Principle of Dietary Life-long diet 2.25-3 gm protein

Management per day. Modified to contain:
Isoleucine 30-80 mg/kg/d.
Leucine 40-100 mg/kg/d.
Valine 30-95 mg/kg/d.

Result of Treatment To prevent accumulation of

Branchedchain
BCAA’s and their a-keto
dervatives in the body fluids to
aminoacid
prevent neurotoxicity.
To provide adequate protein for
 Urea Cycle Disorders
(UCD)
• Urea cycle disorders (UCDs) result
from inherited deficiencies in any
one of the six enzymes or two
transporters of the urea cycle
pathway.
• (CPS1, OTC, ASS1, ASL, ARG1, NAGS,
ORNT1, or citrin).
 Enzyme Activity Affected
• Five catalytic enzymes:
– Carbamoylphosphate synthetase I (CPS1)
– Ornithine transcarbamylase (OTC)
– Argininosuccinic acid synthetase (ASS1)
– Argininosuccinic acid lyase (ASL)
– Arginase (ARG1)
• One cofactor-producing enzyme: N-acetyl
glutamate synthetase (NAGS)
• Two amino acid transporters:
– Ornithine translocase (ORNT1; ornithine/citrulline
carrier; solute carrier family 25, member 15)
– Citrin (aspartate/glutamate carrier; solute carrier
family 25, member 13)
 Symptoms
• Infants with a UCD appear normal at birth
but rapidly develop:
• cerebral edema and the related signs of:
– lethargy,
– anorexia,
– hyper- or hypoventilation,
– hypothermia,
– Seizures: (About 50% of neonates with severe
hyperammonemia)
– neurologic posturing, and coma.
 Symptoms

• Abnormal posturing and encephalopathy

are often related to the degree of central
nervous system swelling and pressure on
the brain stem.
• Hyperventilation secondary to the effect
of hyperammonemia on the brain stem,
results in respiratory alkalosis.
 Symptoms
• In most the hyperammonemic episode is
marked by:
– loss of appetite,
– vomiting, lethargy, and behavioral
abnormalities.
• Sleep disorders,
• delusions, hallucinations,
• psychosis may occur. (‫)ذﻫﺎن‬
• Hypoventilation and respiratory arrest
follow as pressure increases on the
brain stem.
 Galactosemia
• Infants with this metabolic condition
are not able to metabolize a certain
type of sugar (galactose) found
primarily in breast milk, cow’s milk,
and dairy products.
• When galactose can not be broken
down and digested, it builds up in the
tissues and blood in large amounts. Its
byproducts also build up in large
amounts.
Symptoms
The initial signs
include:
Refusal to eat
Spitting up or vomiting
Yellowing of the skin
(jaundice)
Lethargy
Cataracts
Learning disabilities
Neurological impairments
Ovarian failure
 Dietary Management
Inherited Disorder Galactosemia

Enzyme Activity Affected Galactose 1 Phosphate Uridyl

Transferase
Galactokinase
Galactose 4 Epimerase

Basic Principle of Dietary Life-long diet carbohydrate

Management controlled.
Restrict free galactose and
lactose from diet.

Result of Treatment To prevent hypoglycemia

To prevent liver and kidney
dysfunction.
To maitain blood and urine free
of galactose.
Lecture 61612023

liverDiseases

1HepatitisA
anacuteliverdiseasecausedbyhepatitisAvirus lastingfromfew
weeksto months
several

to
notlead chronicinfection
does

Transmission

of
Ingestion fecal
matterfrom
to
contact
closeperson person

Ingestion of food
contaminated
ordrinks

2HepatitisB
aliver B
c aused hepatitis virus
disease
by
ranges weeks to
inseverityfromamildillnesslastingafew long
serious canleadtoliver
that
termillness disease
cancer
Transmission

with
Contact bloodsemenand
infectious other
body from
fluids having withaninfectedperson
sex
contaminatedneedles
sharing
infected
m other
tohernewborn

3HepatitisC
thehepatitisCvirus
aliverdiseasecausedby
infections ometimes
results canleadtocirrhosisof
inanacuteillnessbutmostoftenbecomesachronicconditionthat the
liver livercancer
and
Transmission

withthe
contact blood
ofaninfectedpersonprimarilythroughsharing toinjectdrugs
n eedles
contaminated

4LiverCirrhosis
of byadisease
cause death
12thleading

affectmen thanwomen
slightlymore

inwhichthe
condition due
slowlydeterioratesandmalfunctions
liver tochronicinjury
Scartissuereplacehealthy
liver
tissueblocking the flowof blood theliver
t hrough

impairstheliver'sability
Scarring to
infections
Control

bacteriaand
Remove from
toxins theblood
what the oftheliver
4 anddrugs
functions process
nutrientsh ormones
are
make thatregulateblooddotting
p roteins

bile
produce tohelpabsorbfatsinduding andfat
cholesterol vitamins
soluble

Causes
oflivercirrhosis
1Heavyalcoholconsumption
2 ChronichepatitisC
3Obesity

Nonalcoholic liverdisease
fatty
Accumulation
offatdropletsinthehepatocytessteatosis isFibrosisCirrhosisCarcinoma
Causes
ofNAF
LD
1Drugs
2Inbornerrorsof metabolism

3Acquiredmetabolicdisorders
4commonlyassociatedwithobesitydiabetesmellitus dyslipidemiaandinsulinresistance
5Autoimmunehepatitis
damageand
bythebody'simmunesystemattackinglivercellsandcausing
thisiscaused inflammation cirrhosis
eventually

factors
genetic makepeoplemore toautoimmunedisease
dispored

autoimmune
hepatitis aremoreforfemales
p ercentage

6BiliarycirrhosisaDiseasesthatdamagedestroybileduct
7InheriteddiseasesCysticfibrosis Wilsondiseasegalactosemiaandglycogen
hemochromatosis
storagediseases

8Drugstoxinsandinfections

Symptoms

stagesof
nosymptomsinearly thedisease
disease
progress

1Weaknessandfatigue
2Lossofappetite
3Nauseaandvomiting
4Weightloss
5Abdominalpainandbloatingwhenfluidaccumulatesintheabdomen
6itching

Signs of malnutrition

1lossofmusclemass
2Lossofsubcutaneousadiposetissue
3Increaseintissuewater

Complications

1Edemaandascites
2Bruisingand easily lackofproteinsneededforblooddotting
bleeding

3Portal hypertension

andgastropathyiswhen
varices
Esophageal portal occurs
hypertension
itmaycause blood
enlarged
intheesophagusstomach
vessels

Splenomegaly

4Jaundice
5Gallstones
6Sensitivityto medications

7Hepatic oftoxinsintheblood
encephalopathy accumulation

c hanges
personality

intellectual
impairment

depressedlevel
of consciousness

8InsulinresistanceandType2diabetes
9Livercancer
10Otherproblems
hepatorenaland
hepato
pulmonarysyndromes
 ofnutrition
Goals are
intervention

Preventingmalnutrition

function
Improvingliver
states
catabolic hepaticencephalopathy
Avoiding u maytrigger