EXAM 3 REVIEW

Fast Facts on Diabetes

  • Diabetes
    • Total: 37.3 million people have diabetes (11.3% of the US population)
    • Diagnosed: 28.7 million people, including 28.5 million adults
    • Undiagnosed: 8.5 million people (23%)
    • Diabetes mellitus refers to metabolic disorders characterized by elevated blood glucose concentrations and disordered insulin metabolism
    • People with diabetes may be unable to produce insulin
    • Normally, after food is ingested, pancreatic insulin secretions rise, and the insulin enables muscle and adipose cells to take up glucose from the blood
    • Insulin is also secreted between meals in smaller amounts to restrain the glucose-raising actions of glucagon (a pancreatic hormone that promotes glucose production in the liver and the breakdown of liver glycogen)
    • In diabetes, insulin secretion may be inadequate, cells normally respond to insulin may be resistant to its effects, or abnormalities may be present
    • These impairments result in defective glucose uptake and utilization in muscle and adipose cells and unrestrained gluconeogenesis
    • The result is hyperglycemia, a marked elevation in blood glucose levels that can ultimately cause damage to blood vessels, nerves, and tissues
    • Normally: insulin also promotes triglyceride storage in adipose tissue and protein synthesis in muscle
    • In diabetes: impaired insulin action leads to degradation of lipids and protein, resulting in increased fatty acid and triglycerides in the blood and muscle changing.

Regulation of Blood Glucose

  • Insulin
    • Rise after meal
    • In response to rise in blood glucose
    • Secreted by beta cells in pancreas
    • Move glucose into cells
    • stimulate liver to store glucose in the form of glycogen
    • lower blood glucose level
  • Glucagon
    • Released between meal
    • In response to low blood glucose
    • Secreted by alpha celll in pancreas

Diabetes Mellitus (DM)

  • Caused by problem in the way the body synthesizes or uses insulin

Type 1 Diabetes (T1D)

  • Autoimmune destruction of pancreatic beta cells
    • environmental toxins or infections, genetic susceptibility
  • Onset of disease: childhood, adolescence
  • Deficiency or lack of insulin → Blood glucose accumulates in the blood (hyperglycemia)
  • Requires insulin replacement therapy

Type 2 Diabetes

  • Insulin Resistance
    • Cell’s reduced sensitivity to insulin
    • Insufficient insulin
    • Reduced glucose uptake by cells → hyperglycemia
  • Hyperinsulinemia
    • The pancreas increases secretion of insulin to compensate
    • Abnormally high level of insulin
  • Less production of insulin
    • High demand of insulin exhausts beta cells
  • Risk factor
    • Obesity, aging, physical inactivity
    • Family history and genetic inheritance
    • African Americans, Asian Americans, Hispanic Americans, Mexican Americans, Native Americans, and Pacific Islanders
  • Onset of disease: adulthood (>40 years old)
    • Children at risk: overweight or obese or have a family history of diabetes
  • Recommended treatment regimen: Diet and Excercise
    • Insulin injections are not always useful. Most people with type 2 diabetes do not take insulin
    • may need diabetes pills or insulin shots

Diagnosis of Diabetes Mellitus

  • Fasting Blood GLucose (FPG) --- after 8 to 10 hour fast

  • Random Blood Glucose

  • Postprandial Blood Glucose

  • Oral glucose tolerance test (OGTT)

    • Ingest a 75-gram glucose load → Plasma glucose measured at one or more time intervals

  • HbA1C (A1C; Glycated hemoglobin)

    • Measured glycemic control during the preceding 2 to 3 months

  • Overt symptoms --help to confirm diagnosis

  • Testing should be done twice, at different times

  • Diabetes

    • Random plasma glucose: > or equal to 200 mg/dL

Prediabetes

  • Blood glucose level between normal and diabetic
  • Risk of developing diabetes and cardiovascular diseases

Symptoms of Diabetes Mellitus

  • Symptoms are usually related to hyperglycemia (uncontrolled diabetes)
  • Flycosuria: Presence of glucose in ___
  • Weight loss: The body lose excess calories (glucose)
  • Polyuria: Excessive urine production, frequent urination
  • Polydipsia: Increased ____
  • Dehydration: dry mouth
  • Polyphagia: Increased ___
  • Potential consequences: blurred vision, increased infections, constant fatigue,

Complications of Diabetes Mellitus

  • Untreated diabetes may result potentially life threatening conditions including acute and chronic complications
  • Acute complications: diabetic ketoacidosis, hypoglycemia
  • People with T1D do not have enough insulin
  • When glucose is not available for energy, __ is broken down to synthesize ketone bodies for alternative fuel source in the liver. → ketosis (elevated levels of ketone bodies (acetoacetic acid, beta-hydrocybutyric acid, acetone) in the blood or urine)
  • Eventually, abnormally high levels of ketone bodies build up → diabetic ketoacidosis (DKA)
    • a serious complication of diabetes; life-threatening

Acute Complication: Diabetic Ketoacidosis (DKA)

  • A severe lack of insulin results in increased degradation of fat in the body, leading to diabetic ketoacidosis
  • Blood glucose > 250 mg/dL (> 1000 mg/dL in severe cases)
  • Ketosis: abnormal increase in ketone body concentrations
  • Acetone breath: Fruity odor on breath
  • Ketoacidosis: Acidic ketone bodies and rapid or deep breathing
  • Often the earliest sign of type 1 diabetes
  • Result from inappropriate diabetes management, illness, infection, psychological stress
  • Rare in Type 2 diabetes
    • DUring illness, infection, trauma, surgery
  • Treatment
    • Insulin therapy to correct hyperglycemia
    • IV fluid electrolyte replacement

Acute Complication: Hyperosmolar Hyperglycemic Syndrome

  • Usually seen in Type 2 diabetes
    • infection, illness, drug treatment that impairs insulin
    • Usually -- do not develop significant ketosis
  • Hyperglycemia increases in osmolarity
    • Hyperosmolar blood plasma
  • Substantial loss of fluid and electrolyte/Dehydration
    • Neurological delayment

Acute Complication: Hypoglycemia

  • Most frequent in Type 1 diabetes
    • may occur in Type 2 diabetes
  • Predisposing factors
    • Excessive dosage of insulin or antidiabetic drugs
    • Prolonged exercise
    • Skipped or delayed meals, inadequate food intake
    • Consumption of alcohol without food
  • Symptom
    • Dizziness, shakiness, sweating, heart palpitation
    • faint, seizures, coma
  • Treatment
    • Ingestion of foods that contain glucose

Chronic Complications

  • Prolonged exposure to high glucose concentration alters cellular structure and inhibits function
    • Affected tissue: Blood vessels, nervous system, lens of the eye, kidney
  • Contributing factor
    • High level of advanced glycation end productions (AGEs)
    • Combines with proteins, producing high level of this reactive compound

Macrovacular Complications

  • Endothelial cells lining blood vessels accumulate AGEs
    • Cause blood vessels thicker and weaker
    • → Accelerate the development of atherosclerosis in coronary arteris (cardiovascular disease) and arteries in limbs
  • Peripheral vascular disease
    • Impaired blood circulation in limbs
    • Increased risk of foot ulcers
  • Development of foot ulcers (diabetic foot)
    • Lead to ___ (tissue death)
    • amputation

Microvascular Complications

  • Diabetic retinopathy
    • Weakened capillaries in retina leak fluid, blood and lipids
    • Cause local edema or hemorrhaging
    • Damage and scarring with retinal tissue
    • Formation of new blood vessel (fragile, easily bleeding) → Release blood and protein that obscure vision → Cloudly lens, blurry vision
    • Leading cause of blindness
  • Diabetic nephropathy
    • Damaged capillaries in kidneys
    • Inadequate filtration of the blood → High blood pressure
    • Lose protein ___in urine
    • Kidney failure
    • end stage renal failure (ESRD)
      • The kidneys lose filtering ability
      • The accumulation of nitrogenous wastes in blood
    • requires dialysis (artificial filtration of blood)

Diabetic Neuropathy

  • Nerve damage from diabetes
    • Excess blood glucose and decreased blood flow can injure capillaries that nourish nerves (esp. in legs)
  • Peripheral (sensorimotor) neuropathy
    • Tingling, burning pain, weakness in feet and hands
    • Numbness (Loss of sensation)
    • “I can’t feel my feet when I’m walking.”
    • Cuts may go unnoticed. -- Contribute to the development of foot ulcers
    • Economic neuropathy
    • constipation, gastroparesis, sexual dysfunction, bladder dysfunction

Monitoring: Chronic Complications

  • Intensive diabetes management can help slow the progression of complications
  • Individuals with diabetes should be routinely monitored for signs of long-term complications

Treatment

  • Objective

Evaluation: Diabetes Treatment

Treatment

  • Objective
    • \     
    1. To maintain blood glucose levels within a desirable range
    • Type 1: Require insulin therapy
    • Type 2: Initially- nutrition therapy and exercise
      • Eventually- antidiabetic medication, insulin
    • Balancing act involving meal planning, proper timing of medications and physical exercise
    • \     
    1. To maintain healthy blood lipid concentrations
    • To control blood pressure
    • To manage weight

Evaluation: Diabetes Treatment

  • Self-monitoring of blood glucose (SMBG)

    • Using glucose meter

  • Continuous glucose monitoring system

    • measure tissue glucose levels using tiny sensory placed under the skin

  • __

    • Measure long-term glycemic control during the preceding 2 week period

  • Used during pregnancy

  • Ketone testing

    • check for the development of ketoacidosis

  • Nutrition Therapy

    • Nutrient Recommendation
    • Meal planning strategies
    • Improve blood glucose levels
    • Slow progression of complications
    • Physical activities
    • Insulin Therapy
    • Antidiabetic Drugs

  • Carbohydrate

    • should be consistent at meals and snacks
    • Low-carbohydrate dietes are NOT recommended
    • should be spaced through the day in several meals and snacks
    • select foods with low glycemic index
    • Fiber rich foods
    • Follow DRI: Female 25 g/d, Male: 38 g/d
    • legumes, wholel-grain cereals, fruits and vegetables
    • Minimally processed foods
    • For people with diabetes, including sweets in the diet requires careful planning

  • Sugars

    • Key to sweets: small portion and save them for special occasions so as to focus healthful foods
    • Optimize foods and beverages with added sugars
    • Sugar alcohols
    • Artificial sweeteners

  • Fat

    • People with diabetes are at high risk of developing CVD guidelines for dietary fat follow the suggestion for high CVD risk group
    • Saturated fat: <%7 of total calories
    • Cholesterol: <200 mg/day
    • Trans fat: Minimized intake
    • Omega fatty acids
    • Two or more servings of fish a week recommended

  • Protein

    • RDA for adults: 0.8 g/kg
    • Higher protein intakes discouraged
    • may be detrimental to kidney function

  • Alcohol

    • Limit alcohol intake to 1 drink a day

  • Micronutrient

    • the same as for the general population
    • Not recommended vitamins and mineral (V/M) supplementation unless nutrient deficiencies develop
    • ?mineral?
    • INconsistent results and insufficient evidence
      • Suggested that it may improve glycemic control in people with Type 2 diabetes
      • NOT recommended for Type 2 diabetes

Meal Planning Strategies: Basic Carbohydrate Counting

  • Type 1 Diabetes: must maintain a consistent carbohydrate intake to match the insulin regimen
  • Type 2 Diabetes: develop dietary patterns that suit lifestyle and medication schedules
  • \   
    1. Determine an appropriate energy intake
    • Daily energy expenditure: 200 cal/day
  • \   
    1. Determine daily carbohydrate allowance
    • CHO allowance 50% of total kcal
    • ****1 portion= 15 g of CHO
    • CHO portions/d
    • 50% of 1000 kcal= 1000 kcal of CHO
    • 1000 kcal CHO/ 4kcal/g CHO= 250 g CHO/d
    • 1 portion = 15 g CHO
    • (~17 CHO portions)
  • \   
    1. Distribute carbohydrates among meals and snacks: Distribute CHO in meals and snacks shown below
  • \   
    1. Select any CHO containing food from food groups in meal plan: Food selections containing ~15 g CHO are interchangeable
  • q portion = 15g CHO = 1 portion of starchy food, milk or fruit

Meal Planning Strategies: Exchange List System

  • Sorts foods according to their proportions of carbohydrates, fat, and protein
    • each item in food group

Regular Physical Activity

  • Central feature of diabetes management
  • Benefits
    • Improve insulin sensitivity, blood pressure, body weight, and cardiovascular functioning
  • at least 150 minutes of moderate-intensity of physical activity
    • or 75 minutes of vigorous aerobic activity each week
  • \
    • Resistance exercise at least 2-3 times weekly

Insulin Therapy

  • Necessary for individuals who cannot produce enough insulin to meet metabolic needs
  • Insulin Regiment for Type 1 diabetes
    • Best managed with intensive insulin therapy
    • Multiple daily injections of several types of insulin
    • Honeymoon period
    • After initiation of insulin therapy -- experience of a temporary remission of symptoms and a reduced need for insulting
      • Due to a temporary improvement in pancreatic function
      • During remission period, avoid insulin excess
    • Insulin Regimen for Type 2 diabetes
    • ~30% of those

Complication of Insulin Therapy

  • Hypoglycemia
    • Most common complication of insulin treatment
    • Result from intensive insulin therapy
    • Immediate treatment
    • Relieved with 15-20g of CHO in ~15 minutes
    • CHO = 4 glucose tablets, 4 tsp table sugar, 1 Tbsp honey, 1/2 c orange juice, 15 small jellybeans
    • For people with severe hypoglycemia risk
    • Glucagon injection
  • Fasting Hyperglycemia
    • Hyperglycemia in the early morning that develops after an overnight fast of at least 8 hours
  • Dawn Phenomenon
    • In diabetes, the body does not release more insulin to match the early-morning rise in blood sugar (3am-8am)
  • Rebound Hyperglycemia (Somogyl effect)
    • Rebounding high blood sugar as a result of nighttime hypoglycemia
    • take too much insulin before bed or skip nighttime snack → rapid drop of blood glucose level overnight → release glucagon, cortisol, and catechlonamine → morning hyperglycemia
  • Treatment
    • adjust the dosage or formulation of insulin administered

Pregnancy in Diabetes

  • Pregnancy increases insulin resistance and insulin need for woman with diabetes
  • ~7% of nondiabetic women develop gestational diabetes
  • Health risks for baby
    • Premature delivery, miscarriage, birth defects, macrosomia (abnormally large baby), hypoglycemia

Gesetational Diabetes (GD)

  • Higher risk of developing Type 2 diabetes
    • Their children are at risk of obesity and T2D
  • Risk for Baby:
    • macrosomia, hypoglycemia at birth, respiratory disease
  • Risk factor
    • Age > 25, Family history of diabetes, Obese (BMI > or equal to 30)

Nutrition Therapy: Pregnancy

  • Maintaining glycemic control at conception and during pregnancy is critical
    • To minimize risk of birth defects

Nutrition Therapy: gestational Diabetes

  • Carbohydrate
    • CHO intake should be spaced throughout the day
    • Restrict carbohydrates to 20-45% of total energy
    • May improve blood glucose level after meal

Prevention of Type 2 Diabetes

  • Weight management
    • Recommend sustained weight loss of 5-10% of body weight for overweight and obese people
    • Losing 7% of body weight (ex: 14 lb for 200 lb)
    • Prevent additional weight gain
  • Active lifestyle
    • At least 150 min of moderate physical activity a week
  • Dietary modifications
    • Increased intake of whole grains and dietary fiber
    • Decreased intake to avoid excessive energy

Syllabus - Class Schedule

  • Typos
    • In-class activity on Module 12
    • Exam Review
    • Exam 5:

Exam 3- Next Week

  • Exams 1 and 2 covered basic nutrition Stress Response, while Exams 3 and 4 cover advanced topics related to clinical nutrition
  • Before taking Exams 3 and 4, read the lecture and textbook at least twice
  • Chapters 11-15 (Modules 10-12)
  • Available from April 11 (Tuesday) to April 16 (Sunday)
  • Only one attempt

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Nutrition for Metabolic Stress and Cardiovascular Diseases

Stress Response

  • What can cause metabolic stress (changes in blood pressure, glucose/protein/fat metabolism) to the body?
  • Metabolic stress can lead to
    • hypometabolism or hypermetabolism?
    • loss or gain of muscle tissue?
    • Increase or decrease of nutritional needs?
  • The body’s nonspecific response to a variety of stressors, such as infection, fractures, surgery, burns and wounds
  • Metabolic Stress
    • Disruption in body’s internal chemical environment
    • Result from uncontrolled infections or extensive tissue damage
  • During stress
    • What is the priority during the stress?
    • __ production
    • for metabolic processes that support immediate survival
    • Heart rate and breathing rate ___
      • to deliver oxygen and nutrients to cells more quickly and
    • Blood pressure __
    • Energy is diverted from processes that are not life sustaining
      • growth, reproduction and long term immunity
      • If stress continues for a long period, interferences with these processes begins
      • possibly resulting in growth retardation and illness../
  • The stress response is mediated by several hormones, which are released into the blood soon after the onset of injury
  • Catecholamines
    • fight-or flight hormones
    • stimulate heart muscle, raise blood pressure, and increase metabolic rate → Hypermetabolism
  • (Epinephrine
    • promotes glucagon secretion from the pancreas
    • prompt the release of _ from _
  • Cortisol (stress hormone)
    • enhances muscle protein degradation, acid levels in the blood → make amino acids available for conversion to __
  • Energy nutrients are mobilized from storage and released into blood
  • All of these hormones have similar effects on glucose and fat metabolism causing
    • the breakdown of into
    • the production of _ from amino acids
    • the breakdown of triglycerides in _ in adipose tissue
  • Thus the combined effects of these hormones contribute to hyperglycemia
  • (from adrenal gland) and (from hypothalamus)
  • help to maintain blood volume by stimulating the kidneys to reabsorb more sodium and water

In Prolonged Stress

  • Excess Cortisol
    • breakdown of __ → muscle wasting
    • __ wound healing
    • (Activate or suppress?) immune responses
    • increasing susceptibility to infection
    • leads to insulin resistance, contributing to___
  • Excess Cortisol causes the depletion of protein in muscle, bone, connective tissue, and the skin
    • Inhibits protein synthesis → muscle wasting
    • breakdown of muscle mass and loss of strength
    • impairs wound healing
    • suppresses immune responses
    • increasing susceptibility to infection
    • Insulin resistance → hyperglycemia

Main Nutritional Goals: Metabolic Stress

  • Metabolic changes during stress
  • (hyper or hypo?) metabolism
  • (negative or positive?) nitrogen balance
  • → __
    • may impair organ function and delay recovery
  • Insulin resistance → _ glucose
    • increases the risk of infections that can lead to complications and higher mortality
    • The principal goals of nutrition therapy
  • Metabolic changes during stress
    • hypermetaholism
    • negative nitrogen balance
    • insulin resistance
    • hyperglycemia
    • hypermetabolism and negative nitrogen balance can lead to wasting, which can impair organ function and delay recovery
    • Hyperglycemia increases the risk of infection that can lead to complications and higher mortality

Estimating Energy Needs for Acute Stress

  • Step 1. Estimate the RMR using indirect calorimetry or a predictive equation
  • Step 2. Multiply the estimated RMR by an appropriate stress factor for acute illness
  • **note that patients with acute illnesses are usually bedridden and do not require additional energy for activity
  • Use the below Mifflin-St.Jeor equation to calculate an appropriate energy intake for a 35 year old male patient with acute pancreatitis
  • 1 ft= 12 in 1 kg=2.2lb 1 in=2.54 cmt
  • Men (10 x wt in kg) + (6.25 x ht in cnt) - (5 x age in years) + 5
  • Women: (10 x wt in kg) + (6.25 x ht in cm) - (5 x age in years) = 161
  • Examples of Stress Factors
    • Intensive care: 1.0 to 1.1
    • Minor surgery 1.2
    • Acute kidney injury 1.3
    • Burns (>20% of body surface)
    • Acute pancreatitis
  • Stress factor -- Acute pancreatitis 1.4 to 1.8
  • * patients with acute illnesses are usually bedridden and don’t require additional energy

Protein Requirements in Acute Stress

  • For critically ill patients
    • (0.8 protein/kg/d > 0.8 g of protein)
  • N balance is difficult to achieve during acute stress because hormonal changes encourage the degradation of body protein
  • __ required during critical illness also contributes substantially to muscle breakdown
  • 2 amino acids supplementation
    • Promote wound healing, engance immunity
    • Control
  • For non obese critically ill patients
    • 1.2 - 2 g kg/day
  • For obese critically ill patients
    • 2.0-2.5 /kg ideal body weight.d
  • Despite high intakes, N balance is difficult to achieve during acute stress because hormonal changes encourage the degradtion of body proteins
  • The bed rest required during critical illness also contributes substantially to muscle breakdown
  • dlutamineand arginine supplementation

Carbohydrate and Fat Intakes in Acute Stress

  • Carbohydrate
    • Main source of energy
    • 50-60% of calories
  • Fat
  • * *In patients with severe hyperglycemia -- up to 50% of calories
  • may suppress immune function
  • increases the risk of infections and hypertriglyceridemia

Micronutrient Needs in Acute Stress

  • INcreased needs, but unknown specific requirements
  • Antioxidants
    • Vitamimn , Vitamin , S ,
    • counter oxidative stress
    • immunity and wound healing
  • Nutrients believed to promote healing or benefit function- 2 amino acids, _ fatty acids, antioxidants

Review- Metabolic Stress

  • Metabolic stress
  • Hormonal Responses
  • Metabolic changes during stress
    • Hypermetabolism, negative nitrogen balance, insulin resistance, hyperglycemia → increased risk of infection, muscle wasting, impaired wound healing
  • Major objectives of nutrition therapy during stress
    • Preserve lean tissue, mainly immune function, promote healing, high protein diet

Cardiovascular Disease (CVD)

  • A group of disorders involving the heart and blood vessels
    • Coronary heart disease )CHD)
    • The most common form of CVD
    • Caused by ( ) (Hardening of arteries) ( ) in coronary artery
      • Restricts blood flow in coronary arteries
      • Thickening of walls
      • ? (crystallized fatty substance buildup) ( ) forms in the artery

Atherosclerosis Development

  • Minimal, chronic injuries damage the inner artery wall
    • Sheer stress of blood pressure
  • Elicit inflammatory response
    • Attract monocytes/macrophages
  • LDL slip under the thin layer of endothelial cells in artery wall
    • Become oxidized LDL by local enzyme from immune cells
    • Macrophages engulf oxidized LDL → Foam cells
  • Fatty streaks
    • Layers of foam cells develop into fatty deposits within artery walls
  • Plaques
    • Fatty streaks accumulates lipids (cholesterol), calcium, smooth muscle cells, and cellular debris
    • Form crystallized, hard structure
  • Hardened plaque buildup
    • Narrow lumen

Consequences:Atherosclerosis

  • Ischemia
    • the deficiency of blood and oxygen within the tissue served by an obstructed artery
  • Thrombosis
    • Plaque ruptures → blood clot enlarges over time on plaque surface → obstructed blood flow
  • (Embolism
    • A portion of a clot can break free and travel → if it lodges into a narrowed artery → obstructed blood flow to the surrounding tissue
  • Atherosclerosis can affect almost every organ in the body
    • Heart attack and stroke

Coronary Heart Disease (CHD)

  • Impaired blood flow through coronary arteries

    • heart attack, or even sudden death
    • Most heart attacks occur with __%blocage

  • Symptoms

  • ( ) (chest pain), pain in left shoulders, left arm, neck, back or jaw

  • shortness of breath, weakness or fatigue, nausea, vomiting, abdominal discovery

  • 1/3 of patients who had heart attacks had no chest pain

    • Women are more likely than men to have a heart attack that is not accompanied by chest pain

  • Non-modifiable risk factors for CHD?

  • Modifiable risk factors for CHD?

  • Advancing age

    • Men (> 45 yr), Women (>55 y)

  • Gender

    • Women vs. Men
    • Women typically develop CHD ~10 years later than men do
    • Lifetime risk of developing CHD
      • 49% for men, 32% for women

CHD Risk Assessment

  • Because heart disease develops over many years, prevention should begin well before symptoms appear
  • Family and personal medical history
  • Blood lipid profile
    • Total cholesterol, LDL cholesterol, HDL cholesterol, Triglycerides (VLDL(
    • (Low or high?) HDL is highly predictive of CHD risk)
  • Blood pressure
  • Body weight
    • Overweight and obessity, esp. abdominal obesity
    • Waist circumference: Men
    • Cigarette smoking
    • The presence of diabetes

Therapeutic Lifestyle Changes Program (TLC)

  • Much of the treatment focuses on lowering ___
    • After a person’s level of risk has been identified
    • 3-part program to CHD risk reduction
    • By National Heart Lung and Blood Institute
    • 3 main components
    • dietary strategies
      • Cholesterol

TLC Diet Reduction of Cholesterol

  • Saturated fat

    • Strongest effect to raise blood __ levels
    • foods rich in sat, fat
    • < ( ) % saturated fat of total calories
    • \     
    1. Replace saturated fat with MUFA, PUFA
    • To lower LDL level
    • \     
    1. Replace saturated fat with carbohydrates
    • lower LDL, but may lower ( ) and raise ( )
    • To minimize A level- Limit
    • Include fiber rich foods

  • Dietary cholesterol

    • Limit cholesterol to < __ mg per day
    • Food sources? Can find cholesterol in plant sources

  • Soluble fibers

    • Source: oats, barely, beans and fruit
    • reduce LDL cholesterol levels by inhibiting rfeabsorption in small intestine and reduce cholesterol synthesis in the liver

  • Plant sterols or plant stanols

    • interfere with cholesterol
    • Fortified food

  • Lowering Blood Pressure

  • Reduction of Trisglycerides (TG)

  • Fish and Omega 3 Fatty Acids

    • EPA and DHA
    • reduce inflammation, blood clotting and TG
    • 2 or more servings per week with emphasis of fatty fish
    • Fish oil supplements
    • lowering TG levels
    • Side effect: ( )
    • Land-based OMega 2 FA
    • flaxseed oil

Reduction of TG

  • Alcohol
    • Only Low or moderate consumption lower CHD risk
    • <1 drink/day for women and <2 drinks for men
      • Light to moderate consumption of alcohol has favorable effects on overall CHD risk
    • High alcohol intakes can elevate __ and TG levels

TLC Lifestyle Changes

  • Smoking cessation
    • Smoking promotes atherosclerosis
    • Inhibits vasodilation, promotes blood clotting, decrease oxygen

TLC Weight Management

  • Weight reduction
    • Obesity (exp. abdominal obesity) is associated with metabolic abnormalities
    • hypertension, elevated blood TG, low HDL, insulin resistance
    • Weight loss can improve CHD risk factors
    • The goal of a typical weight reduction

Topics Covered so Far

  • CVD
    • Development of CVD CIA atherosclerosis
    • Consequences of atherosclerosis
  • Coronary heart disease
    • Risk factors
    • Assessment
    • TLC for reducing CVD risks

Hypertriglyceridemia

  • Elevated blood triglycerides (TG) increases CHD risk
  • Dietary and lifestyle changes
    • restrict ( ) intake
    • Limit the intake of ( )
    • foods made with white flour and added sugars
    • Control body weight/physical activity
  • Severe hypertriglyceridemia

Drug Therapies: CHD Prevention

  • If fails to improve CHD risk with lifestyle changes alone
  • Statin
    • Reduce cholesterol synthesis in the liver
  • Bile acid sequestrants
    • Bind bile acids in SI, reducing cholesterol absorption
  • Fibrates
    • Modulate production of proteins that regulate lipoprotein synthesis and breakdown
  • (? vitamin)
    • Reduce LDL production

Diet and Drug Interaction

  • Anticoagulants (warfarin)
    • Require consistent vitamin ( ) intake to maintain effectiveness
    • Not recommended -- supplementation of vitamin E, fish oils, garlic, and gingko
  • Statins

Heart Attack: Treatment

  • Limited blood supply to hear muscle → death of heart tissue
  • Immediate treatment
    • Drug therapies
    • thrombolytic, anticoagulants, aspirin, painkillers
    • No foods except sips of water or clear liquids
  • Once able to eat
    • Heart healthy food

Stroke

  • Ischemic strokes (87%)
    • obstruction of blood flow to brain tissue
    • blood clot within an artery narrowed by atherosclerosis
    • Hemorrhagic strokes (13%)
    • bleeding within the brain
      • Ruptured blood vessel
    • Transient ischemicattacks (TIAs)
    • sudden, short-lived strokes
    • warning sign that a more severe stroke may follow
    • Short term neurological symptoms
      • confusion, slurred speech, numbness, paralysis, difficulty speaking

Stroke: Treatment

  • Drug Therapy
    • Antiplatelet drugs (aspirin) or anticoagulants (warfarin)
    • Thrombolytic drugs for ischemic stroke
    • to restore blood flow and percent brain damage
  • Consequence (according to the injured brain area)
    • Impaired body movements, senses and speech
    • one side of the body may be weakened or paralyzed
  • Nutrition Care
    • Goal
    • Maintain nutrition status/health despite disabilities by stroke
    • Determine the nature of self-feeding difficulty
    • Coordination problems
      • Use of utensils
    • Dietary adjustment for proper food intake
    • Diet to improve blood lipid levels and BP

Hypertension (HTN)

  • Primary risk factor for atherosclerosis and CVD
    • Damaging effect on arteries; Force the heart to work harder and weaken heart muscle
    • Risk of cardiac arrhythmias, heart failure, sudden death
    • primary cause of stroke and kidney failure
  • Risk factors
    • Increased age
    • Genetic factors
    • Family history
    • Obesity
    • Salt sensitivity
    • BP increases
    • Alcohol consumption

Dietary Approaches to Stop Hypertension (DASH) Eating Plan

  • Emphasis on fruit/vegetable

Hypertension: Treatment

  • usually require two or more medications
    • Using a combination of drugs with different modes of action can reduce the doses of each drug needed

Heart Failure

  • = congestive heart failure
  • Chronic, progressive condition in which the heart muscle is unable to pump enough blood through the heart to meet the body’s needs for blood and oxygen
  • Consequence: inadequate blood delivery and fluid buildup in veins and tissues
    • To accommodate the extra workload → heart enlarges or pumps faster → may weaken enough to fail completely
  • Cause:
    • chronic disorders that create extra work for heart muscle
    • Develop mainly in older adults

Heart Failure: Consequences

  • Affects food intake and physical activity level
    • Abdominal bloating, liver enlargement

Heart Failure: Treatment

  • Debilitating symptoms, complex treatments and an uncertain outcome
  • Goal:
    • Slow the disease progression

Heart Failure: Nutrition Therapy

  • ( ) Restriction
    • To prevent fluid accumulation
  • Fluid restriction
    • For patients with persistent fluid retention
    • 2 liters per day or less
  • Adequate fiber intake
    • To reduce constipation ( due to diuretic use and reduced physical activity)
  • Small frequency meals
    • For individuals with abdominal or chest pain

Nutrition for Kidney Disease and Cancer

Outline
  • Renal Nutrition
    • Functions of the Kidneys
    • Chronic Kidney Disease
    • Evaluation
    • Consequences
    • Nutrition Therapies
  • Cancer Nutrition
    • Cancer development
    • Causes of cancer
    • Environmental
    • Nutrition factors
  • Metabolism
  • Treatment
  • Nutrition Therapy
Q
  • What are the roles of the kidneys?
Functions of Kidneys: Regulations of Fluid Balance
  • Kidneys are central to the regulation of blood volume and blood pressure
    • The functional unit of the kidneys is the nephron
  • Kidneys reabsorb needed substances and water and excrete wastes with some water in the urine
  • Blood Filtration
    • Retain blood cells and most plasma proteins in the blood
    • regulate the extracellular fluid volume, electrolyte concentrations, and acid-base balance
    • excrete metabolic waste products
    • (Urea, creatinine, various drugs, toxicants
  • Blood pressure regulation
    • Renin catalyzes the formation of anglotensin I from angiotensinogen
    • angiotensin I is converted to angiotensin II
    • Angiotensin II-- a potent vasoconstrictor → raise BP
      • stimulate the release of aldosterone → reabsorb sodium and water → increase plasma volume and BP
  • Hormone production
    • Erythropoietin
    • stimulate the production of red blood cells in the bone marrow
    • Conversion of vitamin D to active form calcitriol
    • Help to regulate calcium balance and bone formation
Chronic Kidney Disease (CKD)
  • CKD affects ~13% of the U.D population
  • gradual, irreversible loss of kidney function that results from long-term disease or injury
    • typically progresses over many years without causing symptoms
  • Causes
    • ( ) and ( )
    • The most common causes of CKD
    • cause 45% and 27% of cases, respectively
    • Polycystic kidney disease, Infection, IPA
CKD Assessment
  • Two key makers
    • Glomerular Filtration Rate (GFR)
    • the rate at which the kidneys form filtrate
    • considered the best index of overall kidney function
  • If kidneys are not working well, ( ) is excreted in the urine
    • Urine ( )
    • increased excretion of this and marker of kidney damage
    • UACR
  • Other lab measure
  • If kidneys are not working well, ( ) will stay in the blood
    • BUN ( )
    • Serum electrolyters
    • urinaryalysis
Consequences of CKD
  • From the early stages to the advanced stages
    • the functional nephrons
  • Fluid and electrolyte imbalances
    • The declined GFR, the levels of fluid and electrolytes are altered
    • Hyperkalemia (increase in serum _ ), hyperphosphatemia (increase in serum ( ) )
  • (Fluid Retention (Edema
  • → Increased secretion of aldosterone to prevent increases in serum potassium
  • → contributes to the development of hypertension
  • Renal osteodystrophy ( ) PTH and Calcium?
    • Increased secretion of parathyroid hormone (PTH) to prevent elevations in serum phosphate
  • Metabolic acidosis: Excrete excess H+
Uremic Syndrome
  • Clinical syndrome marked by elevated concentrations of ( ) in the blood and associated with F/E and hormone imbalances and metabolic abnormalities
    • May develop during the later stage of CKD
  • Hormonal imbalances
    • unable to produce (erythyopoietin → anemia
    • Reduced production of vitamin D → contributes to renal osteodysthropy
  • Altered heart function (hyperkalemia, hypocalcemia)
    • F/E imbalances result in HTN, increased risk of stroke and heart attack
  • Neuromuscular disturbances ( DUe to toxic waste in brain)
    • malaise, irritability, muscle cramping/tremor, restless leg syndrome, confusion, mental impairments, seizures
  • Skin → Uremic: hyperpigmentation pruritus ( )
  • tiny yellow-white crystals in urea deposit

Malnutrition

  • Protein-energy wasting (PEM)
    • Losses of muscle mass and energy reserves
    • Contributing factors
    • The metabolic derangements in CKD
      • lead to breakdown of body proteins and ( ) nitrogen balance
    • Poor eating
    • Due to dietary restrictions, anorexia, depression
    • Nutrient losses
    • Bleeding abnormally
    • may be a consequence of dialysis

Treatment of CKD

  • The goals of treatment
    • To slow disease progression
    • prevent or alleviate complications
Drug Therapy for CKD
  • Antihypertensive drugs
    • Treatment of hypertension is critical for preventing disease progression and reducing CVD risk
  • Erythropoeietin (epoetin; EPO)
    • To treat ( ); by injection or IV administration
  • Phosphate binders
    • to reduce serum phosphate levels; (taken with food)
  • Sodium bicarbonate
    • to reverse adisols
  • cholesterol-lowering medications
Dialysis
  • replaces kidney function by removing excess fluid and waste from the blood
  • Hemodialysis (HD)
    • the blood is circulated through a dialyzer (artificial kidney), where it is bathed by a dialysate, a solution that selectively removes fluid and wastes
  • Peritoneal dialysis (PD)
    • the dialysate is infused into a person’s peritoneal cavity, and the blood is filtered by the peritoneum
  • After several hours, the dialysate is drained, removing fluid and wastes

Nutrition Therapy: Energy

  • The patient’s diet strongly influences disease progression, the development of complications, and serum levels of nitrogenous wastes and electrolytes
  • Consume enough energy
    • Due to malnutrition
    • Individuals at risk of PEM should consume foods with high energy density
    • may require oral supplements or tube feeding
  • Peritoneal dialysis
    • Most dialysates contain glucose ( in the form of __ )
    • ~64% of this glucose is absorbed
    • Weight gain is sometimes a problem when PD continues for a long period
  • Moderate protein restriction
    • to slow disease progression and reduce N wastes
    • Protein req higher in non-dialysis or during dialysis
  • Non-dialysis
    • 0.6 to 0.8 g/kg/day with at least 50% of protein from high quality protein sources
    • to meet enough protein needs and prevent wasting
    • to ensure adequate intake of EAA-- consume high-quality protein sources such as (eggs, milk products, meat, poultry, fish, soybeans
    • During Dialysis
    • ( ) g/kg/d

Nutrition Therapy: Lipids

  • To control elevated blood lipids and reduce CVD risk
  • to limit their intakes of ( ) fats and ( ) fats and refined sugars and alcohol
  • often encouraged to consume high-fat foods to improve their energy intakes
    • the foods should provide mostly ( ) fats

Nutrition Therapy: Fluids and Sodium (Na)

  • Most people with kidney disease tend to retain sodium and may benefit from mild sodium restriction
    • Na restriction if congestive heart failure, edema, HTN
  • Amounts are based on urine output
    • \     > or equal to 1 L fluid output -- 2-4g Na and 2 L fluid
    • < or equal to 1 L fluid output -- 2 g Na and 1-1.5 Lfluid
  • Fluids are not restricted until urine output decreases
  • Patients on fluid-restricted diets
    • flavored gelatin, soups

Nutrition Therapy: Potassium (K)

  • K restrictions to prevent hyperkalemia
  • HD -- Restriction is necessary to prevent hyperkalemia
    • Between dialysis treatments, K levels rise
  • PD -- can consume K more freely
    • PD can remove too much K from blood
  • K-rich food sources
    • (All fresh foods
    • dried beans, fish, milk/milk products, nut butters, wheat bran, molasses, nuts
    • salt substitutes and low sodium products
    • potassium chloride
    • Salt substitutes and low sodium products
    • Potassium chloride

Nutrition Therapy: Phosphorus

  • Phosphorus restriction
    • Why? hyperphosphatemia contributes to hyperparathyroidism
    • Consequence of hyperparathyroidism?
  • Food sources
    • milk, milk products, liver, chocolate
  • Phosphate binder
    • to control phosphorus level
  • Foods high in phosphorus: barley, dried peas and beans, bran (oat, wheat), fish, buckwheat groats, milk products, bulgur, nuts and seeds, canned iced tea, organ meats, canned lemonade, peanut butter, coconut, soybeans, tofu, cornmeal, couscous,

Nutrition Therapy: Vitamins and Minerals

  • dialysis -- lose (?- water or fat_- soluble vitamins) and some trace minerals into the dialysate
    • folic acid and vitamin B6 may be deficient because of poor intake and loss through dialysis
  • Vitamin D supplementation
    • for patients with suspected deficiency
  • mineral? deficiency is common in hemodialysis patients
  • may be due to inadequate dietary intakes, impaired iron absorption, and blood losses

Cancer Development (Carcinogensis)

  • Initiation
    • Normal cells are initiated through genetic mutations that alter gene expression induce abnormal division in a single cell
  • Promotion
    • The proliferation of the abnormal cells results in the formation of a tumor (neoplasm)
  • Tumor development
    • The tumor can disrupt the functioning of the normal tissue
  • Metastasis
    • The cancerous tumor releases cells into thee bloodstream of lymphatic system
    • some tumor cells may metastasize spreading in regions in the body
    • angtogenesis

Causes of Cancers

  • No one single cause for cancer
  • Interaction of many factors together that produces cancer
  • Genetic mutation
    • Genetic inheritance
    • born with a genetic defect that alters DNA structure, function, or repair
    • Environmental factors

Nutrition-Related Factors that Influence Cancer Risk

  • Obesity: Esophagus, colon, rectum, pancreas, liver, gallbladder, kidney, breast (postmenopausal), ovary, endometrium, prostate
  • Red neat, processed meat
  • Salted and salt preserved meats: ?
  • Beta-carotene supplements: ?
  • High-calcium diets (>1500 mg daily)
  • Alcohol: mouth, pharynx, larynx, esophagus, colon, rectum, liver, breast
  • Low level of physical activity: colon, rectum, breast

Nutrition and Decreased Cancer Risk

  • Consuming fruits and vegetables may reduce the risks of some cancers
  • ( ) activity
    • Possible benefit has been attributed to nutrients and phytochemicals
    • may prevent or reduce oxidative reactions in cells that cause DNA damage
    • enhance immune responses that protect against cancer development
  • (Folate
    • functions in DNA synthesis and repair, thus inadequate intakes may allow DNA damage to accumulate
  • Dietary fiber
    • Fruits and vegetables contribute to dietary fiber
    • may help
  • Lycopene

Questions

  • which food preparation methods has been associated with increasing cancer risk?
  • Consumption of meat carcinogens linked to cancers of the colon, rectum, pancreas and kidney

Metabolic Changes in Cancer

  • Inflammatory and Catbolic state
    • Induced by cytokines from tumor cells and immune cells
    • Muscle wasting
    • Increased rate of protein turnover
    • (reduced or increased?) protein synthesis
    • Muscle contributes amino acids for gluconeogenesis depleting the body’s supply of protein
    • TG breakdown → increased serum fatty free
  • Inflammatory and catabolic state
    • induced by cytokines from tumor cells and immune cells
    • Muscle wasting
Q
  • What are the primary medical treatments for cancer

Chemotherapy

  • Reduced Nutrient Intake
    • Abdominal pain
    • Anorexia
    • Nausea and vomiting
    • Oral mucositis
    • Reduced taste sensation
  • Increased Nutrient Losses
    • Diarrhea
    • Gastrointestinal inflammation malabsorption
    • Comiting
  • Altered Metabolism
    • Anemia, neutropenia
    • D/E imbalances
    • due to vomiting, diarrhea, or malabsroption
    • Hyperglycemia
    • Negative nitrogen and micronutrient balance

Radiation Therapy

  • Reduced Nutrient Intake

Reduced Food Intake and Wasting

  • ( ) (loss of appetite) -- a major contributor to the weight loss
    • chronic nausea; early satiety; fatigue; pain
  • Mental stress
    • A cancer diagnosis can cause distress, anxiety and depression → reduce appetite
  • Gastrointestinal obstructions
    • A tumor may obstruct FI tract → N/V, early satiety
  • Chemotherpay and radiation treatments
    • N/V, dry mouth, altered taste perception, oral mucositis, esophagitis, dysphagia, abdominal pain
    • Dry mouth: try ice chips or sugar free gum

Nutrition Therapy for Cancer

  • The goals of nutrition therapy
    • maintain a healthy weight
    • preserve muscle tissue
    • prevent or correct nutrient deficiencies
    • provide a diet that patients can tolerate and enjoy
  • Malnutrition screening
    • when cancer is diagnosed and reassessed during the treatment and recovery periods

Protein and Energy

  • For patients at risk of weight loss and wasting, the focus of nutrition care is to ensure appropriate intakes of protein and energy
  • Protein
    • 1.0-1.5 protein kg/day
  • Adequate Energy

Low-microbial diets (neutropenic diets)

  • To minimize the risk of foodborne illness and infectious complications for patients with suppressed immunity or neutropenia
  • Consume
    • only well-cooked meat, eggs, pasteurized milk products, fell washed F/V
  • Foods to avoid
    • unpasteurized juices and milk products
    • nay moit fresh F/V or include only foods sterilized by cooking or canning
  • List of foods to avoid
    • Raw and undercooked meat, fish , shellfish, poultry, eggs, bacon
    • Deli meats unless heated until steaming
    • Pickled fish
    • Nonpasteurized milk and raw milk products
    • Fresh salad dressings containing raw eggs or the cheese (soft, blue0veined cheese_
    • Unwashed raw F/V juices
    • Raw honey
    • All miso products and tempeh

Enteral and Parenteral Nutrition Support

  • Tube feedings or parenteral nutrition
    • for patients who develop complications that interfere with food intake or have long-term or permanent GI impairment
  • Patients who undergo radiation therapy for head and neck cancers develop dysphagia or oral mucositis and may benefit from (Tube or IV?) feeding
  • Whenever possible, enteral nutrition is strongly preferred over parenteral nutrition
    • Why? to preserve ( ) and avoid ( )
    • Parenteral nutrition is reserved to patients who have inadequate GI function
    • GI Obstructions, prolonged N/V and radiation enteritis