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NUTRITION AND NUTRITIONAL STATUS IN ILLNESS
ILLNESS
Altered food intake
Altered digestion
Altered metabolism
Altered excretion
MALNUTRITION
CHRONIC LUNG DISEASE (e.g. cystic fibrosis)
Nutritional-related problems
● Increased energy needs (↑work of breathing, infections, fever)● Increased nutrient losses (maldigestion & malabsorption of
protein/fat)● Decreased food intake (infections, other illnesses, breathing, cramps)● Impaired feeding skills●Outcomes of malnutrition:- Growth retardation (FTT, delayed puberty)- Malabsorption (steattorrhoea)- Poor immune status (recurrent infections)- Increased lung disease- More rapid progression of disease- Increased morbidity
CHRONIC LUNG DISEASEDietary treatment
Goals:● Improve growth, development, resistance to infection● Reduce excessive losses from maldigestion/malabsorption● Prevent progressive pulmonary disease/complications (glucose
intolerance, intestinal obstruction)
Strategies:● Increase intake of energy and protein- Supplement breast fed baby with high energy formula- Regular and enjoyable mealtimes- Larger food portions- Extra snacks- Select food with high nutrient density- Fortify foods/beverages
CHRONIC LUNG DISEASEDietary treatment (cont)
- MCT oil- Ω-3 fatty acids- Nocturnal feeds- Regular re-evaluation of intake● Replace enzymes- Insufficient replacement → poor tolerance of starch & fat● Monitor - Tolerance of lactose, fats, gas forming foods, food consistency- Hydration status- Micronutrient status● Provide adequate micronutrients- Vitamins A, D, E, K- Zinc- Iron- Calcium
CANCERNutritional-related problems
● Altered energy expenditure- Alterations in REE → cachexia/weight gain- Tumor growth- Infections● Digestion and absorption of nutrients affected● Changes in CHO, fat, protein metabolism- Glucose intolerance- Body fat depletion, ↓ HDL, ↑ VLDL- Protein depletion, ↓ muscle mass, ↑ muscle breakdown, ↓ rates of
synthesis● Decreased intake- Alterations in taste and smell- Position of tumor- Side-effects of cancer treatment
CANCERNutritional-related problems
● Symptoms with a nutritional impact- Nausea and vomiting- Bowel changes (diarrhoea/constipation)- Dysphagia, dry mouth, chewing/swallowing difficulties, abdominal
gas- Anorexia/early satiety- Pain, fatigue
CANCERDietary treatment
Goals:● Prevent/reverse nutrient deficiencies● Sustain and promote normal growth and development● Minimise nutrition-related side-effects● Maximise quality of life
Strategies:● Increase energy and protein intake- Small frequent meals- Energy dense foods● Decide on route of feeding- Oral, enteral, parenteral● Individual food preferences/aversions
CANCERDietary treatment
● Prevent further weight loss
● Control glucose intolerance- Complex carbohydrate, limit simple sugars- Regular meals
● Provide adequate micronutrients
- Vitamin B6, pantothenic acid, folic acid, Vitamins A, E, C, β-carotene
CANCERDietary treatment
● Treat side-effects of chemo-/radiation therapy- Loss of appetite/early satiety: High protein, high energy
supplementsLimit high fat foodsAvoid liquids with meals
- Nausea and vomiting: Frequent, small mealsNo strong odoursCool/room temperature foods
- Sore mouth/throat: Increase fluid intakeDecrease fibre and roughageSelect soft, moist food, add gravy/sauces
- Abdominal gas: Decrease fibre/roughageLimit high fat foodsExclude gasforming foods
HEART (e.g. Heart failure)
Nutritional-related problems● Stunted growth- Increased needs- Catabolic● Increased energy expenditure – rapid breathing● Decreased intake of food- Difficulty in breathing- Quickly tired● Insufficient/excessive weight gain (oedema)- Fluid retention/↓ circulation● Iron deficiency
HEARTDietary treatment
Goals:● Promote growth and development● Reduce/eliminate oedema● Avoid distention of diaphragm● Correct nutrient deficits
Strategies:● Increase energy, protein and fat intake- HBV protein sources- ↓ CHO and ↑ fat content to reduce RQ- Energy dense meals (1T fat → 135 kcal/1T sugar → 60 kcal)- Food with soft texture reduces chewing
HEARTDietary treatment (cont)
● Restrict fluid and salt intake with fluid retention- Monitor input/output- Sodium restricted diet (↓ dietary sources of Na+) - 1t salt → 2400 mg Na+
250 mL milk → 120 mg Na+ 1 slice bread → 150 mg Na+
- Inclusion of K+ rich foods● Avoid abdominal distention- Small frequent meals- Use bland low roughage foods● Ensure adequate intakes of food sources of vitamins E, B6, B12,
folic acid, riboflavin, thiamine, iron
GASTRO-INTESTINAL TRACTNutritional-related problems
● Medical conditions can affect functions in any part of the GIT – intake of food, digestion, absorption of nutrients and excretion of waste products
● Malnutrition affects digestion and absorption of nutrients- Villi atrophy → ↓ absorptive area- Enzyme deficiencies (lactase, sucrase, maltase)● Intolerances- Lactose- Gluten
GASTRO-INTESTINAL TRACTNutritional-related problems (cont)
● Food-induced symptoms- Carbohydrate-induced symptoms
Hypertonicity:Bloating (Gastric surgery)Diarrhoea (Antrectomy)
Poor absorption: Gas (Malabsorption)Bloating (Coeliac disease)Diarrhoea (SBS)Abdominal pain (Dietary fibre)
- Fat-induced symptomsDyspepsia (GERD)Bloating, early satiety (Gastric surgery)
GASTRO-INTESTINAL TRACTNutritional-related problems (cont)
● Symptoms with a nutritional impact
- Diarrhoea - ↑ nutrient loses- Nausea and vomiting - ↓ intake, ↑ losses- Pain, bloating – avoiding important foods, ↓ intake
GASTRO-INTESTINAL TRACTDietary treatment
Goals● Correct malnutrition/nutritional deficits● Provide sufficient nutrients for growth and development● Monitor GI function (intolerances, malabsorption)● Replace losses
Strategies● Provide sufficient energy & protein- Small frequent meals- Energy dense foods
GASTRO-INTESTINAL TRACTDietary treatment
● Replace losses- ORT- Soluble fibre (apples, bananas, carrots)- Potassium- MCT - Vitamins and minerals● Adjust consistency of foods / preparation methods● Withheld foods leading to problem/discomfort (depends on disease
condition)● Add foods to relieve problem- Soluble fibre (apples, banana, carrots)- Insoluble fibre (whole wheat, bran)
LiverNutritional-related problems
● Inadequate intake- Anorexia, nausea & vomiting (liver disease)- Early satiety (ascites, enlarged liver / spleen)- Restricted / unpalatable diets (low in fat / protein / salt)
● Impaired nutrient digestion and absorption- Steatorrhoea (bile salt deficiency)- Essential fatty acid deficiency- All nutrients (malnutrition related villous atrophy)
● Increased nutritional requirements- Hypermetabolism- Accelerated protein breakdown- Insufficient protein synthesis
LiverNutritional-related problems
● Altered nutrient metabolism - Carbohydrate: glycogenesis, glycogenolysis, gluconeogenesis (low
glygogen stores, fasting hypoglycaemia)- Protein: transamination & oxidative deamination (synthesis of serum
protein – low albumin levels, poor blood clotting)- Fat: energy production & synthesis of lipoproteins (fatigue,
catabolic)● Vitamin & mineral deficiencies - Storage of fat soluble vitamins, Vit B12, Zn, Fe, Cu, Mg- Transport of Vit A, Fe, Zn, Cu- Conversion of carotene, folate, Vit D ● Increased ammonia levels & risk of hepatic coma
LIVERDietary treatment
Goals● Correct malnutrition/nutritional deficits● Promote growth and development● Support residual liver function● Prevent fat stasis & steatorrhoea, bone disease, anaemia, coma ● Provide supportive treatment for complications
Strategies● Provide sufficient energy - Small frequent meals- Energy dense foods● Provide sufficient protein- HBV protein- ↑ BCAA and ↓ AAA- Vegetable protein ↓ methionine & ammoniagenic AA and ↑ fibre- Casein vs meat protein
LIVERDietary treatment (cont)
● Steatorrhoea- Modify fat intake- MCT vs LCT- monitor Ca++ & vit D● Ascites- Restrict fluid & salt intake● Renal insufficiency- Alter fluid, Na+, K+, PO4 intake● Adjust consistency of foods (oesophagaeal varices)● Withheld foods leading to problem / discomfort (depends on disease
condition)
TYPE 1DIABETES MELLITUSNutritional-related problems
● Under-/overweight- Energy not utilised- Obesity & insulin administration- Physical activity / exercise● Hyperglycaemia- Poor balance between amount of CHO / timing of eating & insulin
regimen● Hypoglycaemia- Brain development- Illness / infection & food intake / absorption● Dehydration (polyuria)● Long-term complications- Macrovascular- Microvascular
TYPE 1DIABETES MELLITUSDietary treatment
Goals● Provide appropriate energy and nutrients for optimal growth and
development● Achieve and maintain ideal body weight● Attain & maintain optimal metabolic outcomes on an individual basis- Blood glucose- Lipids● Prevent hypo- and / or hyperglycaemia● Reduce risk of long-term micro- and macrovascular complications● Improve health through food choices & physical activity● Address individual needs- Personal / cultural preferences- Lifestyle- Willingness to change
TYPE 1DIABETES MELLITUSDietary treatment
Strategies● Determine food & meal plan then integrate insulin regimen into
usual eating habits & physical activity schedule● Issues regarding CHO- Carbohydrate sources (fruits, grains, starchy vegetables, milk,
sugars)- Consistency in timing (distribution) & amount (portion sizes)- Glycaemic Index vs Glycaemic Load- Sweeteners- Blood glucose monitoring- Adjustments for exercise● Issues regarding protein - Requirements- Plant vs animal protein
TYPE 1DIABETES MELLITUSDietary treatment
● Issues regarding dietary fat- Saturated & trans fats- Unsaturated fats
● Other dietary components- Salt- Vitamins & dietary antioxidants- Non-starch polysaccharides (fibre)
● Diabetic products
CHRONIC RENAL DISEASENutritional-related problems
● Growth retardation- Restrictive diets- Poor food intake (uraemia → ↓ appetite)- Increased losses (↑ permeability of basement membrane →
proteinuria)● Oedema- ↓ Excretion- ↓ Protein intake → ↓ albumin● Hyperkalemia● Hypertension● Renal bone disease- ↑ PO4 → Ca++ resorption from bones & ↑ Ca++ absorption from GIT- secondary hyperthyroidism & renal osteodystrophy- ↓ Activation of vit D● Anaemia
RENAL Dietary treatment
Goals● Provide adequate energy● Regulate protein intake● Manage fluid balance & electrolytes● Regulate Ca++ & PO4 intakes● Provide adequate micronutrient & iron intakes
Strategies● High energy, low protein foods (CHO, PUFA/MUFA)● Control protein intake - Optimal growth- HBV 65 – 70% total protein intake- Blood urea- PO4 content
RENAL Dietary treatment
● Reduce Na+ intake if hypertensive- ‘No added salt’/salt restriction- Fresh foods● K+ modified diet if hyperkalaemia occurs● Fluid restriction individualised if necessary● Limit dietary PO4 without compromising protein intake● Supplement Ca++
● Provide foods rich in iron, folic acid, vit C & B12
- Haem iron vs non-haem iron- Components affecting absorption (phytates, polyphenols, Ca++)● Modify dietary fats for prevention of cardiovascular disease
DIALYSISNutritional-related problems
● ↑ Protein losses
● Electrolyte changes (K+)
● Fluid retention
● ↑ Glucose intake (PD)
● Steroid treatment- ↑ Appetite- Weight gain
DIALYSIS Dietary treatment
Strategies● Monitor weight gain between dialysis sessions● Monitor changes in urea / creatinine● Monitor changes in electrolytes● Monitor fluid intake & output
HIV and AIDSNutritional-related problems
● Underweight- Increased energy expenditure- Malabsorption- Altered macronutrient metabolism● Loss of lean body mass- ↓ Dietary intake- Preferential loss of body protein- Opportunistic infections● Growth faltering● Gastrointestinal complications- Food intolerance, malabsorption, constipation, diarrhoea● Lipodystrophy syndrome- Insulin resistance- Impaired glucose tolerance- Dyslipidaemia
HIV and AIDSDietary treatment
Goals● Provide optimal nutrition● Support regeneration of immune system● Maintain growth, development & activity● Help adherence to medication● Preserve lean body mass● Prevent overweight & obesity● Encourage cardioprotective diet● Encourage healthy eating● Provide advice on food safety & hygiene
Strategies● Increase energy & protein intake- Adjust energy intake for mobility, infection, weight loss,
malabsorption- Energy & nutrient dense meals & snacks (full cream milk, cheese,
PUFA / MUFA, ω-3 fats, sugar, jam)- HBV protein
HIV and AIDSDietary treatment
● Optimise food intake- Delayed weaning: Appropriate milk intake for age- Neuro-developmental delay: Modify food consistency, finger foods,
daily routine- Eating difficulties: Soft non-acidic foods, avoid spicy food & drink,
straws to bypass lesions, suck ice lollies- Growth faltering: Space drinks & snacks away from meals, avoid
excessive fluid intake● Food intolerance- Lactose-free● Constipation / diarrhoea● HAART: Interactions between drug & food, nutritional side effects● Lipodystrophy syndrome- Impaired glucose tolerance: CHO distribution- ↑ Total cholestrol: ↓ SFA, ↑ PUFA / MUFA, ω-3 fatty acids- ↑ TG: ↓ Refined CHO, ω-3 fatty acids, fruit & vegetables● Hygienic storage, preparation, serving of food