Nutrition and Diet Therapy

["276 PART III NUTRITION AND DIET THERAPY FOR ADULTS Minocha, A., & Adamec, C. (2004). The Encyclopedia of Sardesai, V. M. (2003). Introduction to Clinical Nutrition the Digestive System and Digestive Disorders. New (2nd ed.). New York: Marcel Dekker. York: Facts On File. Shils, M. E., & Shike, M. (Eds.). (2006). Modern Mistkovitz, P., & Betancourt, M. (2005). The Doctor\u2019s Nutrition in Health and Disease (10th ed.). Philadel- Guide to Gastrointestinal Health Preventing and phia: Lippincott, Williams and Wilkins. Treating Acid Reflux, Ulcers, Irritable Bowel Syndrome, Diverticulitis, Celiac Disease, Colon Temple, N. J., Wilson, T., & Jacobs, D. R. (2006). Nutrition Cancer, Pancreatitis, Cirrhosis, Hernias and More. Health: Strategies for Disease Prevention (2nd ed.). Hoboken, NJ: Wiley. Totowa, NJ: Humana Press. Paajanen, L. (2005). Cow milk is not responsible for most Thomas, B., & Bishop, J. (Eds.). (2007). Manual of gastrointestinal immune-like syndromes\u2014evidence Dietetic Practice (4th ed.). Ames, IA: Blackwell. from a population-based study. American Journal of Clinical Nutrition 82: 1327\u20131335. Webster-Gandy, J., Madden, A., & Holdworth, M. (Eds.). (2006). Oxford Handbook of Nutrition and Dietetics. Payne-James, J., & Wicks, C. (2003). Key Facts in Clinical Oxford, England: Oxford University Press. Nutrition (2nd ed.). London: Greenwich Medical Media. Yamada, T., Hasler, W. L., Inadomi, J. M., Anderson, M. A., & Brown, R. S., Jr. (2005). Handbook of Gastroenter- ology (2nd ed.). Lippincott, Williams and Wilkins.","OUTLINE 18C H A P T E R Objectives Diet Therapy for Glossary Diabetes Mellitus Background Information ACTIVITY 1: Diet Therapy and Time for completion Diabetes Mellitus Activities: 11\u20442 hours Treatment and Diet Therapy Optional examination: 1\u20442 hour Basic Nutrition Requirements Caloric Requirements Nutrient Distribution Food Exchange Lists Caring for a Diabetic Child Insulin Preparations, Oral Hypoglycemic Agents (OHAs or Diabetic Pills), and New Drug Therapy Nursing Implications Progress Check on Activity 1 References OBJECTIVES Upon completion of this chapter, the student should be able to do the following: 1. Explain the use of the exchange system in dietary control. 2. Identify the exchange groups and their subcategories. 3. List the carbohydrate, protein, fat, and energy values of each list of foods in the exchange groups. 4. Plan an appropriate menu for a person with a clinical condition that re- quires a calculated diet. 5. Describe the use of the calculated diet in controlling diabetes mellitus. 6. Describe the use of the calculated diet in controlling weight. 7. Describe the nursing implications appropriate to the disorders. GLOSSARY Atherosclerosis: formation of plaques containing cholesterol and other liquid material within the lumina of the arteries. Endogenous: produced within the body. 277","278 PART III NUTRITION AND DIET THERAPY FOR ADULTS Gestational diabetes: A high blood glucose level that de- However, we will provide examples of foods selected from velops during pregnancy. Usually there is a return to the 2007 edition. Also for ease of use, we exclude the normal following childbirth, but these women may complete listing of nutrient data for each selected food in develop NIDDM later in life. Appendix F. The instructors will provide an explanation for the extent of coverage of the food exchange lists in Glycemic index: A measurement of how fast starches and this chapter. Also, the Web sites of the two professional sugars metabolize in the blood stream. It indicates organizations are making available the complete 2007 how quickly specific foods affect blood sugar levels food exchange lists. based on a scale of 1 to 100. Glycemic control refers to the use of these specific foods to help control blood As explained in Chapter 1, the exchange lists remain sugar levels. The application of this concept is still the definitive tool used to plan diet therapy for persons being debated and, therefore, will not be included in with diabetes, and may be modified to meet specific this chapter. needs. High biological value: refers to complete proteins that The caloric value of a diet can be regulated by the supply abundant amounts of essential amino acids for number of servings allowed per day from each group. synthesis of new tissues. Obviously, the number of servings will depend on how many calories are prescribed in the diet plan, which de- Hyperglycemia: condition that occurs when the glucose pends on age, gender, and activity level, and if that indi- in the blood exceeds the normal range (the normal vidual needs to lose or gain weight. range for blood sugar levels is 70 to 120 mg\/ml). Consistent with the 3rd edition (2001) of the NCEP Hypoglycemia: condition that occurs when the glucose guidelines as discussed in Chapter 1, the diet should con- in the blood falls below normal range. tain not more than 25%\u201335% of total calories from fat. Of this amount, not more than 7% should come from Hypoglycemic agent: a drug sometimes used by diabet- saturated fat. Review Chapter 16 for particulars on the ics not receiving insulin to assist in lowering blood NCEP guidelines. sugar levels. It is not a hormone. Product labels provide valuable information regarding IDDM: insulin-dependent diabetes mellitus. the types of fats in products, although the percent of Insulin: hormone produced in the beta cells of the pan- trans fats does not appear on labels at present. creas that controls blood glucose levels. It is the only Because of the incidence of atherosclerosis in patients hormone that lowers blood sugar. with non-insulin-dependent diabetes mellitus (NIDDM), Ketoacidosis: formation and accumulation of ketone bod- the kind of fats used is an important factor in diet ies in body tissues and fluids. management. NIDDM: Non-insulin-dependent diabetes mellitus. Polydipsia: excessive thirst. Control of the diet is still depending on the monitor- Polyphagia: excessive hunger. ing of the total amount of carbohydrate and the type of Polyunsaturated: a fat that has two or more double bonds fats used. For clients who need to limit their sodium in- into which hydrogen can be added. take, foods in each list that contain 400 mg or more of Polyuria: excessive urination. sodium are marked with a symbol (a salt shaker). Triglycerides: the type of fat that is the body\u2019s main form of stored energy. The use of food exchange groups will not be new to the student who has studied the information on normal nu- BACKGROUND INFORMATION trition in Part I. Only a brief review of the principles is provided here. As explained above, Appendix F lists se- In 2007, the American Dietetic and Diabetes Associations lected foods from the 2007 edition of the food exchange updated its 2003 food exchange lists for diabetic patients. lists. These food groups are useful because they do the However, the principles and basic guidelines remain the following: same in the new revision with the following differences: 1. Permit nutrients to be counted in foods. 1. There is a large increase in the number of entries for 2. Facilitate meal planning by balancing the meal with food items. choices from each group. 2. The nutritional contributions of each food are pro- 3. Enable a patient to comply with diet instructions with vided for: gm\/serving, protein, fat, carbohydrate, sat- urated fatty acids, trans fats, polyunsaturated fats, minimal effort because of their easy application. cholesterol, sodium, fiber, and sugars. 4. Allow a certain flexibility and variety, and reduce diet 3. The source of data for each food is identified when monotony. available, e.g., U.S. Department of Agriculture, food 5. Emphasize foods containing more fiber and foods low labels, and so on. The new list contains a large number of foods and is in sodium. 6. Ensure a reduced intake of saturated fats and choles- impractical to reproduce completely in Appendix F. terol by a systematic procedure. 7. Enable a patient to raise or lower caloric content as needed.","CHAPTER 18 DIET THERAPY FOR DIABETES MELLITUS 279 8. Teach food selection in a practical way. blood, producing hyperglycemia. The sources of blood 9. Regulate the intake of carbohydrate, protein, and fat, glucose are: and permit the calculation of a diet for the over- 1. Carbohydrate (CHO): 100% of digestible CHO con- weight, underweight, or diabetic patient. verted to glucose. The exchange groups and their assigned values are 2. Protein: 58% converted to glucose. listed in Table 18-1. 3. Fat: 10% converted to glucose. 4. Glycogen (the liver\u2019s emergency supply of carbohy- The student should remember the caloric values for the three major nutrients: carbohydrate: 1 g \u03ed 4 calories; drate): converted to glucose when other sources are protein: 1 g \u03ed 4 calories; fat: 1 g \u03ed 9 calories. While al- used up. Muscle tissue also contains glycogen that cohol is not a nutrient, it does furnish 7 calories per gram may be used in emergencies. and is a factor to be considered in weight control. Because body fat contains some water, a pound of body Blood glucose is controlled by two hormones from fat equals 3500 calories. Diet calculations are based on the beta cells of the pancreas: insulin, which lowers blood calories per kilogram (kg) of body weight. The conversion sugar, and glucagon, which raises it. A third hormone, 1 kg \u03ed 2.2 lb is important. somatostatin, regulates the secretions of these two hormones. ACTIVITY 1: TREATMENT AND DIET THERAPY Diet Therapy and Diabetes Mellitus Although the cornerstone of treatment for diabetes mel- litus is diet therapy, there are some differences in the Diabetes mellitus is characterized by an inability to me- way that the therapy is applied, depending upon the type tabolize carbohydrate due to a deficiency of insulin or a of diabetes present. deficiency of receptor sites. The metabolism of protein and fat is also affected. The general classification of diabetes is based upon two major types: type I, insulin-dependent diabetes mel- Glucose is the form of carbohydrate that is carried litus (IDDM); and type II, non-insulin-dependent dia- in the blood; all carbohydrate breaks down to glucose. betes mellitus (NIDDM). Eighty-five to ninety percent of Without glucose, the cells have no energy source and the diabetic population is non-insulin dependent; the have to use muscle protein and tissue fat as an alter- other 10 to 15 percent is insulin-dependent. The follow- nate. Without insulin, glucose cannot go from the ing discussion illustrates some of the similarities and dif- blood into the cells. This glucose accumulates in the ferences between these types of diabetes. TABLE 18-1 Outline of the American Diabetes Association Food Exchange Lists Food Group Number Nutrient Food Lists CHO (g) Protein (g) Fat (g) Kcal \u2013 80 1. Carbohydrates Starch 15 3 \u2013 60 Fruit 15 \u2013 0\u20131 90 5 120 Milk: 8 150 Skim 12 8 Low fat 12 8 Whole 12 8 Other CHO Vegetable 15* 52 \u2013 25 2. Meat and meat Very lean \u2013 7 0\u20131 35 3 55 substitutes Lean \u20137 5 75 8 100 Medium fat \u2013 7 5 45 High fat \u2013 7 5 45 5 45 3. Fat Monounsaturated \u2013 \u2013 Polyunsaturated \u2013 \u2013 Saturated \u2013 \u2013 *Or 1 starch, or 1 fruit, or 1 milk. Some will also count as 1 or more fat(s).","280 PART III NUTRITION AND DIET THERAPY FOR ADULTS Type I\u2014IDDM Nutrient Balance This is the most severe form of diabetes, occurring most In the most widely used diabetic diet plans, daily carbo- often in childhood or young adulthood. It may, or may hydrate intake provides 50%\u201355% of the daily caloric re- not, be an inherited trait. Recent research indicates that quirement. Protein of high biological value is emphasized the islet cells of the pancreas may have been damaged, ei- for diabetic diets, especially for children and adolescents. ther by a disease (such as rubella) or by certain chemi- Protein provides 15%\u201320% of the daily caloric intake. cals that were toxic, which led to the onset of the disease. Emphasis is placed on using polyunsaturated fats and The classic symptoms of IDDM are polydipsia, polypha- limiting cholesterol in the remaining 30% of calories gia, and polyuria, accompanied by rapid weight loss and permitted for dietary fat. often ketoacidosis. An example will serve to illustrate the concept of nu- IDDM has a rapid onset, is very unstable, and causes trient balance: Mr. X is placed on a 1500 calorie per day metabolic imbalances that are difficult to control. For diabetic diet. The nutrient balance is 50% carbohydrate, these reasons the diet is very carefully planned and coor- 20% protein, and 30% fat. What is the number of grams dinated with the insulin and exercise regime. Failure to of each nutrient used in the daily diet plan? time and regulate the meals with these factors will result in great fluctuations in blood glucose, ranging from acute 1. Carbohydrate hypoglycemia to extreme hyperglycemia. Diet therapy is 1500 calories \u03eb .50 \u03ed 750 calories discussed at length later in this chapter. 750 calories\/(4 calories\/g) \u03ed 187 g carbohydrate, rounded to 190 g Type II\u2014NIDDM 2. Protein NIDDM has a much stronger genetic link than does 1500 calories \u03eb .20 \u03ed 300 calories IDDM. The majority of these clients are older adults be- 300 calories\/(4 calories\/g) \u03ed 75 g protein cause the onset is slow, and they are usually obese. Some endogenous insulin is still produced, making it unneces- 3. Fat sary for them to take insulin, except in unusual situa- 1500 calories \u03eb .30 \u03ed 450 calories tions (such as surgery or other stressors). 450 calories\/(9 calories\/g) \u03ed 50 g fat Obesity, physical inactivity, and hypertension are The diet prescription will be 190 g carbohydrate, 75 g strong risk factors for the onset of NIDDM. The symp- protein, and 50 g fat. The amount of food from each of the toms are similar to those of IDDM, except there is no exchange lists will be chosen to satisfy these nutrient weight loss and very rarely ketoacidosis. NIDDM is a requirements. milder form of diabetes and is most often controlled with weight loss and an exercise program. Occasionally an Alcohol usage is determined by the attending physi- oral hypoglycemic drug will be necessary. cian. Because alcohol contains 7 calories per gram and no nutrients, it is usually substituted for fats in the diet. A Persons with NIDDM have a high incidence of ather- chart showing the caloric content of individual servings osclerosis, making it advisable to counsel them on the of alcohol (one glass of wine or one glass of beer, for ex- need for reduced fat intake as well as reduced calories. ample) helps those diabetics who drink. As we have advanced in our knowledge of treatments CALORIC REQUIREMENTS for diabetes, diabetic persons are living longer. They have increased risks of developing major complications such Daily caloric need includes basal metabolism, activity as kidney disease, vascular disease, nerve impairment, rate, and physiological stress (such as a growth spurt or and diseases of the retina of the eye. In fact, as much as pregnancy). If the patient is overweight, the caloric range 20% of the diabetic population becomes blind. Fluctu- is usually 1200 to 1500 calories per day. If the patient is ations of blood glucose from uncontrolled diabetes are thin, young (growing), and male, it may be as high as thought to be one important factor in the onset of these 4000 calories per day. conditions, making it even more imperative to manage and monitor the diet carefully. Tables 18-2A and 18-2B contain food plans at four caloric levels, using the exchange system. They also meet BASIC NUTRITION REQUIREMENTS the nutrient balance concept, as previously discussed, of approximately 50% carbohydrate, 20% protein, and Basic nutrition requirements will be determined by sev- 30% fat. Complex carbohydrates containing good eral factors. Some of the guidelines used are physical as- amounts of fiber are emphasized when menu planning sessment, health and diet histories, and laboratory is done, as well as the use of lean protein foods and very reports. These factors, combined with the psychological little animal fat. There are many ways to calculate daily aspects of the client, will help the physician or healthcare caloric need for an adult diabetic patient. The methods specialist determine the diet prescription. include the three categories discussed in the following sections.","CHAPTER 18 DIET THERAPY FOR DIABETES MELLITUS 281 TABLE 18-2A Meal Plans at Four Caloric Levels Using the Exchange System Food Group Daily Food Distribution (total\/day) 1000 kcal 1200 kcal 1500 kcal 1800 kcal Carbohydrates group* 4 56 9 Starch\/bread list 3 34 4 Vegetable list 3 34 4 Fruit list 2 22 2 Milk list (skim) 3 45 6 Meat and meat substitute group Meat (lean) 1 12 2 1 12 2 Fat 0 11 1 Polyunsaturated Monounsaturated Saturated *Foods from the \u201cOther Carbohydrates\u201d list may be substituted for any foods in the carbohydrate group, as long as they do not exceed the total carbohydrate for the day and\/or result in a diet that does not meet the criteria for nutritional adequacy (balance). TABLE 18-2B Meal Plans for Four Caloric Levels Using the Exchange System Food Group Menu Pattern (Number of Exchanges Each Meal) (total\/day) 1000 kcal 1200 kcal 1500 kcal 1800 kcal Breakfast 1 12 2 Carbohydrates: 1 11 1 1\u20442 1\u20442 1\u20442 1\u20442 Starch\/bread 0 01 1 Fruit 1 11 1 Milk Meat or meat substitute 1 22 3 Fat 1 12 2 Lunch 1 11 1 Carbohydrates: 1\u20442 1\u20442 1\u20442 1\u20442 Starch\/bread 1 22 2 Vegetable 1 12 2 Fruit Milk 1 11 3 Meat 2 22 2 Fat 1 11 1 Dinner 1\u20442 1\u20442 1\u20442 1\u20442 Carbohydrates: 2 12 2 Starch\/bread 0 12 2 Vegetable Fruit 1 11 1 Milk 1\u20442 1\u20442 1\u20442 1\u20442 Meat 0 01 1 Fat 0 00 1 Snacks* Carbohydrate Starch\/bread Milk Fruit Meat *Can be used afternoon or evening (HS).","282 PART III NUTRITION AND DIET THERAPY FOR ADULTS Tables or Charts Method Female 11\u201315 years: average, 35 kcal\/kg body weight Most healthcare providers such as medical clinics, weight 16\u2013up years: average, 30 kcal\/kg body weight loss centers, diabetic centers, and others use standard tables or charts that provide your daily caloric needs ac- However, of all methods mentioned previously, tables cording to the standard variables such as race, age, sex, and charts are used by most clinics and healthcare providers. height, and physical activity. After the patient\u2019s daily caloric need is determined, Ideal Weights and Basal Energy Needs Method the physician (or dietitian) will prescribe the percentage of these calories from carbohydrate, protein, and fat, re- For nearly four decades, health professionals have been spectively. Then the permitted grams of these three nu- using three fundamental assumptions based on available trients can be calculated. medical observation as a base of calculating daily caloric needs: NUTRIENT DISTRIBUTION 1. A table or chart has been developed to show the When the daily amounts of protein, carbohydrate, and \u201cideal\u201d or \u201cdesirable\u201d weight of a man or a woman. fat have been determined, they are converted into food servings and spread throughout the day into three meals 2. A person\u2019s basal energy needs are generally figured and from one to three snacks, depending on the need for at 1 kcal\/kg body weight\/hr. insulin injection, oral drugs, activity, or a combination of these. Large amounts of food, especially carbohydrates, 3. Three levels of caloric expenditure have been devel- should be avoided at any one time. A balance of meals oped for three levels of physical activity. throughout the day provides better control. The diabetic person should have regular meal hours to avoid fluctu- An example is described below for calculating the daily ations in blood glucose. caloric need of an adult patient: FOOD EXCHANGE LISTS Patient\u2019s desirable \u03ed DW kg weight (DW) \u03ed DW kg \u03eb 20\u201325 kcal\/kg The exchange system of dietary control is widely used to \u03ed DW kg \u03eb 30 kcal\/kg manage the diet of a diabetic patient. This system permits Caloric need for \u03ed DW kg \u03eb 35 kcal\/kg flexibility in planning and preparation and allows measur- sedentary patient ing instead of weighing. It also offers a variety of food choices. However, the student will recognize, after study- Caloric need for patient ing the exchange lists, that it is not a suitable guide for with light activity planning meals for some ethnic groups or in all clinical sit- uations. People from diverse cultural backgrounds may Caloric need for patient need nutrition counseling. Many times the illiterate or with strenuous activity confused client will not understand the exchanges as writ- ten. Some clients have vision and\/or hearing impairments. Special considerations are made for other groups: child- At such a time, students may wish to research the partic- hood, adolescence, elderly, with adjustment made if the ular foods needed in order to individualize the diet or to person is overweight or underweight. As a result of new simplify it. The dietitian in a nearby healthcare facility can scientific studies, this method is not as popular as it once be an excellent source for additional information, and can was. assist in designing appropriate diet instructions. Individualized Method The exchange system provides equivalent food value for each food within a list; for example: Scientifically, the most sophisticated method of calcu- lating daily caloric needs uses many equations that cover Starch list: B vitamins, iron, protein, and carbohydrate several variables: race, age, sex, height, body mass index, and physical activity. This method is used mainly by large Meat list: iron, zinc, B12, protein, and varying fat medical and research centers and applies to all age contents groups. Milk list: carbohydrate, protein, varying fat contents, However, for children and adolescents, the following folacin and other vitamins from the B complex, vita- individualized method is applicable and used frequently mins A and D, and minerals (for children, common estimates are based on age and sex): Vegetable list: vitamins A, E, C, and K; B complex; fiber; protein; and carbohydrate Up to 1 year: 120 kcal\/kg of body weight 1\u201310 years: 100\u201380 kcal\/kg (declines as age increases) Fruit list: vitamins, minerals, carbohydrate, and fiber Adolescence: (Refer to Appendix F for the exchange lists.) Male 11\u201315 years: average, 65 kcal\/kg body weight 6\u201320 years: average, 50 kcal\/kg (high activity) 40 kcal\/kg (light activity) 30 kcal\/kg (sedentary)","CHAPTER 18 DIET THERAPY FOR DIABETES MELLITUS 283 CARING FOR A DIABETIC CHILD tion that the patient has been prescribed should be emphasized. Caring for a diabetic child requires many special consid- erations, some of which are listed below: The RN should: 1. Disease characteristics: 1. Reinforce the pharmacist\u2019s teaching and help patients a. The patient may be normal or underweight. to understand the medication used to help control b. Disease onset is abrupt and increases in severity their diabetes. Interpret and explain these tables to during growth periods. the patient if no pharmacist is available. c. Pancreatic cells cannot make insulin, and a dia- betic child is insulin dependent. 2. Teach patients to use insulin or diabetic pills properly d. As the patient grows older, the requirement for in- according to their prescription. sulin increases. 3. Coordinate meal and snack times with the prescribed 2. Dietary treatment goals: medication. a. To permit normal growth and activity b. To control the disease Insulin Preparations c. To permit a normal school and social life with min- imal restriction in freedom of movement and food There are more than 20 types of insulin products avail- choices able in four basic forms, each with a different time of d. To correspond with the action of insulin treatment. onset and duration of action. The decision as to which in- To achieve the above goals, the diet must recog- sulin to choose is based on an individual\u2019s lifestyle, a nize the child\u2019s food preferences and differ little physician\u2019s preference and experience, and the person\u2019s from that of the patient\u2019s peers. Also, the child blood sugar level. Among the criteria considered in must be provided adequate food to permit normal choosing insulin are: development and activities. \u2022 How soon it starts working (onset) 3. Diet prescription and meal planning \u2022 When it works the hardest (peak time) a. 75\u201390 kcal\/kg of the child\u2019s ideal weight. \u2022 How long it lasts in the body (duration) b. 3.3 to 2.2 g of protein per kg body weight, with decreasing amount for increasing age. Since 1982, most of the newly approved insulin prepa- c. 50% of total calories from complex carbohydrate, rations have been produced by inserting portions of DNA 20% from protein, and 30% from fat. (\u201crecombinant DNA\u201d) into special lab-cultivated bacteria d. Three meals and three snacks daily usually, with or yeast. This process allows the bacteria or yeast cells to other meal patterns determined by patient\u2019s clin- produce complete human insulin. Recombinant human ical condition, amount of insulin needed, daily ac- insulin has, for the most part, replaced animal-derived in- tivities, and other factors. sulin, such as pork and beef insulin. More recently, insulin e. Meal plan coordinated with activities\u2014sweets and products called \u201cinsulin analogs\u201d have been produced so extra fluids for strenuous and prolonged activities, that the structure differs slightly from human insulin (by eating a prescribed snack just before an exercise. one or two amino acids) to change onset and peak of ac- tion. Table 18-3 lists some of the more common insulin 4. Patient compliance and education preparations available today. Onset, peak, and duration of a. A young diabetic will accept a diet if it is not too action are approximate for each insulin product, as there different from that of his or her peers, and if it per- may be variability depending on each individual, the injec- mits the child freedom in school and play. tion site, and the individual\u2019s exercise program. b. The patient should learn how to use the exchange lists for fast foods, which is included in the pa- Insulin Delivery Devices tient\u2019s booklets for meal planning. This permits the child to eat fast foods with his or her friends All insulin delivery devices inject insulin through the without deviating from the dietary prescription. skin and into the fatty tissue below. Most people inject the insulin with a syringe that delivers insulin just under the INSULIN PREPARATIONS, ORAL skin. Others use insulin pens, jet injectors, or insulin HYPOGLYCEMIC AGENTS (OHAS OR pumps. Several new approaches for taking insulin are DIABETES PILLS), AND NEW DRUG THERAPY under development. Diet therapy must be coordinated with the patient\u2019s Syringes use of insulin or oral agent as prescribed by the attend- ing physician. A pharmacist can help to interpret Tables Syringes are hypodermic needles attached to hollow bar- 18-3 and 18-4 for the patient, and the specific medica- rels that people with diabetes use to inject insulin. Insulin syringes are small with very sharp points. Most have a special coating to help the needles enter the skin as pain-","284 PART III NUTRITION AND DIET THERAPY FOR ADULTS Table 18-3 Insulin Preparations Type of Insulin Examples Onset of Action Peak of Action Duration of Action 15 minutes 30\u201390 minutes 3\u20135 hours Rapid-acting Humalog (lispro) Eli Lilly 15 minutes 40\u201350 minutes 3\u20135 hours Short-acting NovoLog (aspart) (Regular) Novo Nordisk 30\u201360 minutes 50\u2013120 minutes 5\u20138 hours Humulin R Intermediate-acting Eli Lilly 1\u20133 hours 8 hours 20 hours (NPH) Novolin R Novo Nordisk 1\u20132.5 hours 7\u201315 hours 18\u201324 hours Intermediate- and Humulin N short-acting Eli Lilly The onset, peak, and duration of action of these mixtures would reflect a mixtures Humulin L composit of the intermediate and short- or rapid-acting components, Eli Lilly with one peak of action. Long-acting Humulin 50\/50 4\u20138 hours 8\u201312 hours 36 hours Humulin 1 hour none 24 hours 70\/30 Humalog Mix 75\/25 Humalog Mix 50\/50 Eli Lilly Novolin 70\/30 Novolog Mix 70\/30 Novo Nordisk Ultralente Eli Lilly Lantus (glargine) Aventis Source: U.S. Food and Drug Administration lessly as possible. Insulin syringes come in several dif- Insulin Pumps ferent sizes to match insulin strength and dosage. Insulin pumps are small pumping devices worn outside Insulin Pens of your body. They connect by flexible tubing to a catheter that is located under the skin of your abdomen. The fol- Insulin pens look like pens with cartridges, but the car- lowing recommendations are for a diabetic who likes to tridges are filled with insulin rather than ink. They can use this device: be used instead of needles for giving insulin injections. Some pens use replaceable cartridges of insulin; other \u2022 Program the pump to dispense the necessary amount models are totally disposable after the prefilled cartridge of insulin. is empty. A fine, short needle, like the needle on an in- sulin syringe, is on the tip of the pen. Users turn a dial \u2022 Usually, set the pump to give a steady small dose of in- to select the desired dose of insulin and press a plunger sulin, but you can give an additional amount in a short on the end to deliver the insulin just under the skin. time if needed, such as after a meal. Jet Injectors \u2022 If adjusted properly, these pumps allow close control of your insulin levels without multiple injections. Insulin jet injectors may be an option for people who do not want to use needles. These devices use high-pressure \u2022 Do not use this type of pump during physical activi- air to send a find spray of insulin through the skin. Jet in- ties that may damage the pump or disrupt the pump\u2019s jectors have no needles. connection to the body. \u2022 You still need to monitor your blood glucose levels regularly if you use this type of device.","CHAPTER 18 DIET THERAPY FOR DIABETES MELLITUS 285 Oral Hypoglycemic Agents nant human insulin for the treatment of adult patients (OHAs or Diabetic Pills) with type 1 and type 2 diabetes. It is the first new insulin delivery option introduced since the discovery of insulin Insulin is produced by the beta cells in the islets of in the 1920s. This is a new, potential alternative for many Langerhans in the pancreas. When glucose enters the of the more than 5 million Americans who take insulin blood, the pancreas should automatically produce the injections. right amount of insulin to move glucose into the cells. People with type 2 diabetes either produce too little in- NURSING IMPLICATIONS sulin, produce it too late to match the rise in blood glu- cose, or do not respond correctly to the insulin that is Since diabetes is a lifelong disease, the client needs to produced. Then glucose builds up in the blood, over- learn to take responsibility for self-care. To promote this flows into the urine, and passes out of the body. This outcome requires extensive education. means that the body loses its main source of energy even though the blood contains large amounts of glucose. Congress passed legislation allowing medical nutrition therapy (MNT) services to be compensated by insurance Diabetes pills work in one of three ways. They ei- companies after the cost-effectiveness of such therapy was ther stimulate the pancreas to release more insulin, demonstrated. The registered dietitian (RD) is designated increase the body\u2019s sensitivity to the insulin that is al- to be the primary teacher, but the nurse has a major role ready present, or slow the breakdown of foods (espe- in the teaching process. In fact, diabetes education centers cially starches) into glucose. employ many RNs as well as RDs for teaching classes that help patients understand and control their disease There are six categories of diabetes pills: sulfonyl- (Certified Diabetes Educators). Nurses are part of a teach- ureas, meglitinides, nateglinides, biguanide thiazol- ing team; therefore, they must be able to teach as well as idinediones, and alpha-glucose inhibitors. These are reinforce the information that all diabetic clients need. shown in Table 18-4. The topics covered should include the following: New Drug Therapy 1. Explanation of the disease and why the diet will help the client control it In 2006, the FDA approved the first ever inhaled in- sulin, Exubera, an inhaled powder form of recombi- 2. Principles of managing the diet: Table 18-4 Oral Antidiabetes Medications Category Sulfonylurea Action Generic Name Brand Name Manufacturer Diabinese Pfizer Stimulates beta cells to Chlorpropamide Glucotrol Pfizer release more insulin Glipizide DiaBeta\/Micronase\/ Aventis, Pharmacia Glyburide Glynase and Upjohn Amaryl Aventis Meglitinide Works with similar ac- Glimepride Prandin Novo Nordisk Nateglinide tion to sulfonylureas Repaglinide Biguanide Starlix Novartis Works with similar ac- Nateglinide Thiazolidinedione tion to sulfonylureas Glucophage Bristol Myers Squibb (Glitazone) Metformin Glucophage XR Bristol Myers Squibb Sensitizes the body to Metformin (long Alpha-Glucose the insulin already Glucovance Bristol Myers Squibb Inhibitor present lasting) Metformin with Avandia GlaxoSmithKline Helps insulin work Actos Takeda Pharmaceuticals better in muscle and glyburide fat; lowers insulin Rosiglitazone Precose Bayer resistance Pioglitazone Glyset Pharmacia and Upjohn Slows or blocks the Acarbose breakdown of Miglitol starches and certain sugars; action slows the rise in blood sugar levels follow- ing a meal Source: U.S. Food and Drug Administration","286 PART III NUTRITION AND DIET THERAPY FOR ADULTS a. Basic nutrition needs Patient Education b. Meal planning following the individual prescription c. Menu planning that allows variety in the diet A diabetic person may become ill from causes such as d. Purchase and preparation practices appropriate to infection, trauma, and so on. Patients with a short- term illness should follow the guidelines indicated in the diet therapy Exhibit 18-1. e. Adjustments for illness or unusual activity, espe- The patient is the most important member of the cially strenuous exercise healthcare team. His or her participation and cooperation f. Diabetic foods must be gained. \u2022 Diabetic foods are different from dietetic foods. Who to Teach and How The first group is either sugar-free or reduced in sugar content. The second refers to foods re- 1. Teaching one patient instead of a group of patients is duced in sugar, sodium, protein, or some other more useful to the patient, although it is more costly nutrients. in time and money. \u2022 Diabetic foods are recommended for some but 2. If group education is used, patients should be sorted not all patients. Regular foods suitable for every- by their type of diabetes (e.g., young and insulin- one are usually recommended, with only a few dependent diabetics, obese patients using OHAs, and exceptions. patients who are maintaining by diet alone). This sort- ing reduces confusion in the teaching process. If fea- g. A relative or caretaker who can assist with meal plan- sible, the use of both individualized and group ning should be present during patient education. education is ideal. h. The patient should be provided with as much in- 3. The benefits and limitations of using paraprofession- formation as possible. Some examples include: als to teach the patient should be considered. \u2022 Food exchange lists \u2022 Diet plans, written or in picture form 4. The patient\u2019s history should be studied, especially the \u2022 Scheduled meal times and frequency type of diet instructions he or she has previously re- \u2022 List of recommended cookbooks ceived. This ensures that the patient will not receive \u2022 Audio cassettes (if client is vision impaired) contradictory information during an education ses- The patient\u2019s level of reading and comprehension sion. Any information presented that seems to conflict must be considered, as well as any physical limita- with previous instructions should be explained to a tions. Diabetic patients required to restrict sodium patient\u2019s satisfaction. intake must be taught basic knowledge of the sodium content of foods. 5. At least one close relative or the patient\u2019s caretaker should be familiar with the information presented to i. Some over-the-counter, prescription, or illicit the patient and should be present for the teaching drugs interfere with glucose test results. For exam- sessions. ple, experience has confirmed that prolonged ex- Some teaching aids and counseling services for di- cess vitamin C intake can lead to a false urinary abetic persons include: glucose test. Local, city, and county diabetic programs and sup- 3. How to monitor blood and urine, why it is needed, port groups and how to keep good records Private and public diabetic (clinical) centers 4. How to inject insulin: dosage, type, site rotation, and why timing of meals to insulin schedule is important Professional sources of materials include drug com- panies, American Dietetic Association, American 5. How to recognize symptoms of hypoglycemia or hy- Diabetes Association, state health agencies, diabetes perglycemia and what to do about them educators 6. Why an exercise program is adjunct to diet therapy Food models, films, and slides 7. Complications of uncontrolled diabetes, especially Ethnic teaching materials atherosclerosis, which is 25% higher in the diabetic population than in the nondiabetic population Demonstration kitchens and demonstration food por- 8. Special dietary measures to prevent or delay onset of tion sizes atherosclerosis: reduced fat intake, increased fiber intake Recipes and cookbooks 9. Dietary teaching begins with diagnosis or hospital ad- mission, and not after discharge. Evaluation and follow-up teaching by the nurse or a clinical nutrition specialist should be scheduled. Since any comprehensive and successful diabetes management program must always include patient education, some special guidelines to assist in teach- ing follow.","CHAPTER 18 DIET THERAPY FOR DIABETES MELLITUS 287 EXHIBIT 18-1 Sick Day Guidelines 1. Never omit the daily dosage of insulin, even if you feel 12 g carbohydrate: 1 c milk; 1 c chocolate milk; too ill to eat your normal diet. You must consume some 15 g carbohydrate: 1 c tomato soup; nourishment. 1 c buttermilk; 1 c soy milk a. If feasible, take fluids hourly. Keep a record. Use small 1 frozen juice bar; amounts. Clear soups and broths will replace fluids 1\u20442 c plain ice cream; lost in vomiting and in diarrhea. 1\u20442 c regular gelatin (any flavor) b. Liquids and carbohydrates are more easily tolerated during illness than proteins and fats. Determine the 4. If you are still unable to eat after four or five liquid meals, amount of carbohydrate you are allowed per meal and call your physician for advice and take the following try to consume items listed below until you reach your precautions: carbohydrate allowance. a. Stay warm in bed. If possible, have a relative or friend nearby in case of an insulin reaction. 2. Check your diet plan. Food containing carbohydrates are b. Test your urine for glucose (sugar) and acetone fruits, milk, breads, and vegetables. Table 18-1 shows the (ketone) every six hours or so. If blood glucose is over amount of carbohydrate per exchange (serving) in each 250 mg\/dl a test for ketones should be done every list. Multiply the carbohydrate amount by the number of 4 hours. Have the results available when you call your exchanges allowed in each food group. An example for physician. Even though you are now eating less (as a breakfast is result of nausea and vomiting) than you usually do, your urine will show sugar and possible acetone. You will al- 1 fruit \u03ed 15 g carbohydrate ways need your normal insulin dose. Again, do not omit 1 milk \u03ed 12 g carbohydrate your daily insulin dose. Sometimes you may even need 2 bread \u03ed 30 g carbohydrate extra insulin. This may be in the form of regular insulin. 1 meat \u03ed 0 g carbohydrate 1 fat \u03ed 0 g carbohydrate 5. Call your physician if you are ill for more than 48 to 72 TOTAL \u03ed 57 g carbohydrate hours or if vomiting or diarrhea persists for more than a few hours. It is better to call sooner than to put yourself 3. Fluids easily tolerated are listed below along with their in jeopardy. carbohydrate equivalents: 6. Be prepared. Keep the following or similar items on hand: 15 g carbohydrate: 3\u20444 c ginger ale; 1\u20443 c grape juice; paregoric, Maalox, Tylenol, milk of magnesia, glucagon, 1\u20442 c orange juice; usual insulin, and refrigerated regular insulin. Take pre- 1\u20442 c apple or pineapple juice scribed item(s) with physician\u2019s consent. PROGRESS CHECK ON ACTIVITY 1 MULTIPLE CHOICE With the use of the exchange lists in Appendix F, com- Circle the letter of the correct answer. plete the following: 2. Which of the following foods is not a member of 1. Fill out Exercise 18-1 for a calculated diet for dia- any of the meat exchange groups? betes mellitus. a. 1\u20442 c pinto beans b. soy milk, 1 c Exercise 18-1 Complete the chart by filling in the information for each column. Diet Disease or Foods Foods Foods Nursing Calculated Condition Allowed Limited Forbidden Implications Diabetes Mellitus","288 PART III NUTRITION AND DIET THERAPY FOR ADULTS c. peanut butter, 1 tbsp c. fats. d. 1 hot dog d. all of the above. 3. Which of the following statements correctly de- 10. If 50% of the total calories in a 1500 calorie dia- scribes the action of insulin? betic diet is from carbohydrates, how many grams of carbohydrate will the diet contain? (Round to a. Insulin controls the entry of glucose into the nearest whole number.) cell. a. 50 b. Insulin regulates the conversion of glucose to b. 150 glycogen. c. 190 d. 210 c. Insulin decreases the conversion of glucose to fat for storage as adipose fat tissue. 11. Emphasis is placed on using polyunsaturated fats and limiting foods high in cholesterol in the diet d. Insulin allows fat to be converted to glucose as of the diabetic. The reason for this is: needed to return the blood glucose levels to normal. a. to aid in the prevention of cardiovascular diseases. 4. The caloric value of a diabetic diet should be: b. to aid in the digestive process. a. increased above normal requirements to meet c. to prevent skin breakdown. the increased metabolic demand. d. to control blood sugar. b. decreased below normal requirements to pre- 12. The daily intake of foods for the diabetic is spaced vent glucose formation. at regular intervals throughout the day. The rea- son for this is: c. the individual\u2019s normal energy requirement to maintain ideal weight. a. to prevent hunger pangs. b. to avoid symptoms of hypoglycemia or hyper- d. contributed mainly by fat to spare carbohydrate. glycemia. 5. In the exchange system of diet control, an ounce c. to modify eating habits. of canned tuna may be exchanged for all except: d. to prevent obesity. a. the same amount of lean meat. 13. Sally, an 8-year-old diabetic, is ready to go home b. 1\u20444 c 4% cottage cheese. from the hospital. Sally\u2019s mother should know c. 1\u20442 c tofu, light. that: d. one egg. a. all of her food must be measured. 6. The exchange system of diet control is based on b. she needs a snack before she exercises. principles of: c. she should always carry hard candy with her. d. all of the above. a. equivalent food values. b. flexible food choices. TRUE\/FALSE c. nutritional balance. d. all of the above. Circle T for True and F for False. 14. T F The majority of adult-onset diabetics are un- 7. How much orange juice would substitute for the CHO in an uneaten slice of bread? derweight at the time the disease is discovered. a. 1\u20442 c 15. T F A diabetic diet is a combination of specific spe- b. 3\u20444 c cial foods that cannot be changed. c. 1 c d. 1\u20131\u20442 c 16. T F Diabetics should follow a low carbohydrate diet of about 50 g a day. 8. The diabetic diet is designed for long-term use and contains a balance of: 17. T F A medium-size fresh peach contains 10 g car- bohydrate and 40 calories. a. energy. b. nutrients. 18. T F Insulin preparations now available are pro- c. distribution. duced by recombinant DNA. d. all of the above. 19. T F Insulin analogs differ from regular insulin in 9. Sources of blood glucose include: their onset and peak action. a. carbohydrates. 20. T F Insulin is used to metabolize sugar in the b. proteins. body.","CHAPTER 18 DIET THERAPY FOR DIABETES MELLITUS 289 A diabetic patient in the hospital received insulin in Carbo- the morning and ate breakfast, but was nauseated at hydrate Protein Fat lunch and could not eat. Circle T for the appropriate (grams) (grams) (grams) nursing interventions for this situation and F for the inappropriate ones. Milk (2%), 2 exchanges Vegetables, 3 exchanges 21. T F Remove the lunch tray and tell the patient to Fruit, 3 exchanges let you know when he feels like eating. Lean meat, 6 exchanges Medium fat meat, 22. T F Relieve the nausea by appropriate means. 23. T F Remove the lunch tray, asking the meal pre- 2 exchanges Fat, 5 exchanges parers to substitute liquids of equal value for Bread, 6 exchanges the carbohydrate foods on the tray. 24. T F After you observe that the patient is better, offer him or her the liquids you ordered. MATCHING 33. Arrange the allowances in Question 32 into a day\u2019s menu: Match the foods in the left column with their nutrient Breakfast Lunch Dinner Snack values in the right column. 25. 1 slice bacon a. 12 g carbohydrate, 8 g 26. 2 tbsp peanut butter protein, 5 g fat 27. 1\u20442 c oatmeal b. 15 g carbohydrate, 3 g 28. 1\u20442 c beets protein MULTIPLE CHOICE 29. 1\u20442 c tofu c. 5 g carbohydrate, 2 g Circle the letter of the correct answer. protein 34. The caloric value of the diet in Question 32 is ap- proximately: d. 7 g protein, 5 g fat a. 1250 calories. e. 5 g fat b. 1500 calories c. 1600 calories. LISTING AND DESCRIPTION d. 1850 calories. 30. List five nursing implications for dietary care of a 35. An intake reduction of 1000 calories daily would diabetic patient. enable an obese person to lose weight at which of a. the following rates: b. c. a. 1 lb per week d. b. 2 lb per week e. c. 3 lb per week d. 4 lb per week 31. Describe 5 of the 10 essential factors that a diabetic patient must know to control his or her disease. 36. Which two of the following food portions have the a. lowest caloric values: b. c. a. 4 oz lean meat d. b. 1 granola bar e. c. 1 slice raisin bread d. 1 8-oz glass of whole milk FILL-IN SHORT ANSWERS 32. Calculate the carbohydrate, protein, and fat value of the following day\u2019s allowance: 37. People with type II diabetes usually have one of the following conditions: a. b. c.","290 PART III NUTRITION AND DIET THERAPY FOR ADULTS 38. The three criteria that should be considered in dren with type 1 diabetes. American Journal of choosing insulin are: Clinical Nutrition, 77: 83\u201390. Green Pastor, J. (2003). How effective is medical nutrition a. therapy in diabetes care? Journal of American Dietetic Association, 103: 827\u2013831. b. Hark, L., & Morrison, G. (Eds.). (2003). Medical Nutrition and Disease (3rd ed.). Malden, MA: Blackwell. c. Lewis, G., & Thomson, L. L. (2005). Optimizing Glycemic Control with Diabetes Technology and Diabetes 39. The four basic types of insulin products are: Medical Nutrition Therapy with Advanced Insulin Management. Chicago: American Dietetic Association. a. Mahan, L. K., & Escott-Stump, S. (Eds.). (2008). Krause\u2019s Food and Nutrition Therapy (12th ed.). Philadelphia: b. Elsevier Saunders. Mann, J. I. (2006). Nutrition recommendations for the c. treatment and prevention of type 2 diabetes and the metabolic syndrome: An evidenced-based review. d. Nutrition Reviews, 64: 422\u2013427. Mann, J., & Truswell, S. (Eds.). (2007). Essentials of 40. The three ways diabetes pills work in the body are: human nutrition (3rd ed.). New York: Oxford Univers- ity Press. a. Nasu, R. (2005). Effect of fruit, species and herbs on glu- cocidase activity and glycemic index. Food Science b. and Technology Research, 11: 77\u201381. Nuttall, F. Q. (2007). Dietary management of type 2 dia- c. betes: A personal odyssey. Journal of American College of Nutrition, 26(2): 83\u201394. REFERENCES Physicians Committee for Responsible Medicine. (2002). Healthy Eating for Life to Prevent and Treat Diabetes. American Diabetes Association. (2007). Food Exchange New York: John Wiley. Lists for Diabetes. Alexandria, VA: Author. Powers, M. (2003). American Dietetic Association Guide to Eating Right When You Have Diabetes. New York: American Dietetic Association. (2006). Nutrition Wiley & Sons. Diagnosis: A Critical Step in Nutrition Care Process. Reader, D. (2006). Impact of gestational diabetes mellitus Chicago: Author. nutrition practice guidelines implemented by regis- tered dieticians. Journal of American Dietetic American Dietetic Association. (2007). Food Exchange Association, 106: 1426\u20131433. Lists for Diabetes. Chicago: Author. Ross, T., Boucher, J. L., & O\u2019Connell, B. S. (Eds.). (2005). American Dietetic Association Guide to Diabetes Beham, E. (2006). Therapeutic Nutrition: A Guide to Medical Nutrition Therapy and Education. Chicago: Patient Education. Philadelphia: Lippincott, Williams American Dietetic Association. and Wilkins. Shils, M. E., & Shike, M. (Eds.). (2006). Modern Nutrition in Health and Disease (10th ed.). Philadelphia: Lippin- Bendich, A., & Deckelbaum, R. J. (Eds.). (2005). cott, Williams and Wilkins. Preventive Nutrition: The Comprehensive Guide for Tahbaz, F. (2006). An audit of diabetes control, dietary Health Professionals (3rd ed.). Totowa, NJ: Humana management, and quality of life in adults with type 1 Press. diabetes mellitus. Journal of Human Nutrition and Dietetics, 19(1): 1\u20133. Buchman, A. (2004). Practical Nutritional Support Thomas, A. M., & Gutierrez, Y. M. (2005). American Technique (2nd ed.). Thorofeue, NJ: SLACK. Dietetic Association Guide to Gestational Diabetes Mellitus. Chicago: American Dietetic Association. Caballero, B., Allen, L., & Prentice, A. (Eds.). (2005). Thomas, B., & Bishop, J. (Eds.). (2007). Manual of Encyclopedia of Human Nutrition (2nd ed.). Boston: Dietetic Practice (4th ed.). Ames, IA: Blackwell. Elsevier\/Academic Press. Coulston, A. M., Rock, C. L., & Monsen, E. L. (Eds.). (2001). Nutrition in the Prevention and Treatment of Disease. San Diego, CA: Academic Press. D\u2019Adamo, P. (2004). Diabetes: Fight It with Blood Type Diet. New York: Putman. Deen, D., & Hark, L. (2007). The Complete Guide to Nutrition in Primary Care. Malden, MA: Blackwell. Gibertson, H. R. (2003). Effect of low-glycemic-index di- etary advice on dietary quality and food choice in chil-","OUTLINE 19C H A P T E R Objectives Diet and Disorders of the Glossary Liver, Gallbladder, and Background Information Pancreas ACTIVITY 1: Diet Therapy for Time for completion Diseases of the Liver Diet Therapy for Hepatitis Activities: 1 hour Diet Therapy for Cirrhosis Optional examination: 1\u20442 hour Hepatic Encephalopathy OBJECTIVES (Coma) Cancer of the Liver Upon completion of this chapter, the student should be able to do the Liver Transplants following: Nursing Implications Progress Check on Activity 1 1. Describe the major functions of the normal liver. ACTIVITY 2: Diet Therapy for 2. Identify the appropriate diet therapy for treating liver diseases and state Diseases of the Gallbladder the rationale for its use in treating hepatitis, cirrhosis, hepatic coma and and Pancreas liver failure, and cancer. Major Disorders of the 3. Describe the diet therapy used for liver transplantation. Gallbladder 4. Evaluate nursing interventions to promote optimal nutrition in a patient Diet Therapy for Gallbladder with liver disease. Disease 5. Discuss the causes of gallbladder and pancreatic disorders, and describe Obesity, Dieting, and Gallstones how they affect food metabolism. Diet Therapy for Acute 6. Identify the sequence of physiological events in which bile assists in the Pancreatitis absorption and metabolism of foods. Diet Therapy for Chronic 7. Differentiate among cholecystitis, cholelithiasis, and cholecystectomy in Pancreatitis relation to their effects on the digestion and metabolism of foods. Nursing Implications for 8. Describe and give examples of the diet therapy used for gallbladder disease. Patients with Gallbladder 9. Identify the major causes of pancreatitis. Disorders Nursing Implications for 291 Patients with Pancreatitis Progress Check on Activity 2 References","292 PART III NUTRITION AND DIET THERAPY FOR ADULTS 10. Relate the association between pancreatitis and gall- Hepatitis C virus (HCV) is associated with chronic ac- bladder disease. tive hepatitis, liver cirrhosis, and liver cancer. Hepatitis D virus (HDV), previously called non-A, non- 11. Describe the diet therapy for pancreatitis and the B, is toxic to functional liver cells and may be related reasons for its use. to the onset of HAV and HBV. Hepatitis E virus (HEV), the newest of the discovered 12. Discuss appropriate nursing interventions for pa- viral liver diseases, has a mortality rate of 80%\u201390%. tients with gallbladder disease or pancreatitis. It may be due to toxic liver injury such as with carbon tetrachloride or acetaminophen overdose. Pregnant GLOSSARY women who contract HEV, usually in the third trimester, die of fulminant liver failure. Ascites: abnormal accumulation of serous fluid within Jaundice: yellowness of the skin, mucous membranes, the peritoneal cavity (the space between the abdomi- and excretions (jaundice is not a disease, but is a nal walls and the pelvic cavity). symptom of numerous disorders of the liver, gallblad- der, and blood; it occurs when pigment in the blood is Calculi (\u201cstones\u201d): an abnormal concretion, usually of destroyed). mineral salts, occurring in the body in hollow organs Marasmus: protein-calorie malnutrition, causing growth or passages. retardation and wasting of muscle. Pancreas: a large elongated gland located transversely be- Cholecystectomy: removal of the gallbladder by surgical hind the stomach between the spleen and duodenum. procedure. Portal (circulation): circulation of blood through layer vessels from the capillaries of one organ to those of an- Cholecystitis: inflammation of the gallbladder, acute or other (applies here especially to passage of blood from chronic. the GI tract and spleen through the portal vein to the liver). Cholecystokinin: a hormone secreted in the small intes- Psychotropic: capable of modifying mental activity; a tine that stimulates gallbladder contraction and se- drug that affects the mental state. cretion of pancreatic enzymes. BACKGROUND INFORMATION Cholelithiasis: calculi in the common bile duct. Cholesterol: a steroid alcohol found in animal fats, bile, Liver blood, brain tissue, whole milk, egg yolk, liver, kid- A normal liver regulates the proper digestion, metabo- neys, adrenal gland, and the myelin sheath of nerve lism, and absorption of food. The following is an outline fibers. of the liver\u2019s major functions: Edema: abnormal accumulation of fluid in the intercel- lular spaces of the body. 1. Storage\u2014The liver stores: Emulsify: to mix together two immiscible liquids. One is a. Approximately 1 lb of glycogen, the body\u2019s emer- dispersed into the other in small drops. gency energy supply; this supply lasts 12 to 36 Encephalopathy: any chronic degenerative disease of the hours when used as the only energy source. brain. b. More fat-soluble than water-soluble vitamins Esophageal varices: varicose veins in the esophagus that c. More iron than any other part of the body occur most often as a result of obstruction of the por- tal circulation. 2. Circulation\u2014The liver regulates: Fulminant: sudden, severe; occurring suddenly with a. Blood volume great intensity. b. Blood transfer from the portal to systemic circu- Gallbladder (GB): the pear-shaped organ located below lation the liver which serves as a storage place for bile. c. Fluid transfers Hepatic: pertaining to the liver. Hepatitis virus classification: 3. Metabolism\u2014The liver participates in: Hepatitis A virus (HAV), previously called infectious a. Carbohydrate metabolism by interconverting glu- hepatitis, is spread by the oral-fecal route from an in- cose and glycogen as needed; it also converts fected person through contaminated water and food. amino acids to glucose in the presence of excess Although it is a very serious disease it does not cause protein or low carbohydrate level chronic hepatitis or cirrhosis. A recent vaccine, better b. Fat metabolism by providing bile salts for emulsi- than gamma globulin, is now on the market. fying fat, cholesterol, and lipoproteins and by con- Hepatitis B virus (HBV), formerly called serum hep- verting excess amino acid and carbohydrate to fats atitis, is classified as a sexually transmitted disease c. Protein metabolism by forming plasma proteins, (STD) because it is spread via body fluids, semen, prothrombin, and urea saliva, tears, and by needle-sharing among drug users. It is a major factor in chronic liver disease and liver cancer. It can persist a lifetime in body fluids. Up to 75% of carriers are Asian.","CHAPTER 19 DIET AND DISORDERS OF THE LIVER, GALLBLADDER, AND PANCREAS 293 4. Detoxification\u2014The liver detoxifies all ingested: ACTIVITY 1: 1. Drugs 2. Poisons Diet Therapy for Diseases of the Liver From the functions of the liver listed, it should be ob- DIET THERAPY FOR HEPATITIS vious that a diseased liver adversely affects gastrointesti- nal function and the use of food. Viral hepatitis, inflammation of the liver, is a major world health problem, causing the illness and death of millions Gallbladder and Pancreas of people. Currently scientists have discovered five types of hepatitis. They are described in the glossary. Even The gallbladder (GB) is an accessory organ to the gas- though they are unrelated in function, the goal of med- trointestinal (GI) tract. The emulsification of fats by bile ical management and diet therapy for hepatitis of any salts from the GB is an important contribution to the type is to promote liver tissue healing. overall efficiency of GI functioning. Gallbladder disease is a common but potentially serious disorder. The most Medical management for hepatitis includes (a) opti- common disorder is cholelithiasis, or formation of gall- mum nutrition for healing, (b) complete bed rest to re- stones. It develops in 10%\u201320% of the Western world\u2019s duce inflammation and metabolism, and (c) alcohol and population. Nearly 80%\u201390% of gallstones are composed all other drugs are prohibited to avoid further liver dam- primarily of cholesterol. age. Diet therapy appropriate for hepatitis includes the following considerations: Some population groups are more susceptible to GB disease, such as older men and women, and especially 1. Protein: 1.2\u20131.5 g\/kg body weight per day women who have borne children. Others include Native 2. Carbohydrate: no carbohydrate restriction; however, Americans and individuals using oral contraceptives and drugs that lower blood cholesterol levels. Heredity ap- serum glucose should be monitored as hyper- and hy- pears to have a major influence in the development of poglycemia can result from liver dysfunction. gallstones. Diet plays a role, but a minor one. For exam- 3. Fat: 30% of calories, with restrictions only indicated ple, excess use of polyunsaturated fats can increase the in- with maldigestion due to reduced synthesis and secre- cidence of GB disease. tions of bile acids 4. Energy (Calories): 25\u201335 kcal\/kg body weight per day Other contributing factors include obesity and intes- 5. A multivitamin mineral supplement at 100% of the tinal diseases that involve the malabsorption of bile salts. RDAs\/DRIs may be necessary. Occasionally, the stress of pregnancy is responsible. 6. Fluids and sodium restriction may be necessary if Populations with a low intake of total fat appear to be edema or ascites is present. less vulnerable to cholelithiasis. 7. If adequate nutrition cannot be maintained by oral feedings, enteral feedings or TPN may be indicated. Medical management of GB disease includes tempo- rary use of drugs to dissolve the stones, and surgery if the Table 19-1 presents a sample menu for a high- patient is not undernourished or obese. An undernour- carbohydrate, high-protein, high-vitamin, and moderate- ished patient can be replenished, while an obese one can fat diet. Food may need to be liquid at first; concentrated lose weight. The actual surgery (cholecystectomy) has formulas can be used that contain a modified fat con- less nutritional implication than believed previously. The tent, as tolerated by the patient. procedure allows bile to enter the small intestine on a continuous basis. With time, the bile ducts may enlarge DIET THERAPY FOR CIRRHOSIS and store bile. Because of this adaptation, many clients resume a normal diet one to two months after surgery. Cirrhosis is the final stage of certain liver injuries, in- cluding alcoholism, untreated hepatitis, biliary obstruc- Because the pancreas is an important accessory organ tion, and drug and poison ingestion. Malnutrition, of the GI tract and a major producer of digestive enzymes, chronic active hepatitis, and excessive intake of vitamin any pancreatic disorder can seriously impair the body\u2019s A for a prolonged time also induce cirrhosis. In fact, cited ability to digest food. Reduced production of pancreatic cases of vitamin A overdose that produced cirrhosis, and enzymes may occur in cystic fibrosis, chronic pancreati- ultimately death, report doses ranging from 25,000 IU tis, pancreatic cancer, or protein-calorie malnutrition. to 100,000 IU taken continuously for two to six years. The pancreas may become inflamed and\/or obstructed The persons believed they were improving their health. by chronic alcohol abuse or GB disease. Food eaten dur- The liver is unable to generate new cells, which are re- ing these conditions becomes the source of excruciating placed with fibrous, nonfunctioning tissue. pain, and the client will avoid eating. Consequently, the person\u2019s nutritional status is very poor. Determining the Stages of Cirrhosis type of pancreatic disorder is of major importance when planning nutritional care for patients with pancreatitis. Cirrhosis has early and late stages. The early stages affect the digestive system and cause such symptoms as nausea,","294 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 19-1 Sample Menu for a Diet Containing Approximately 2500 kcal, 90 g of Protein, 300 g of Carbohydrate, and 100 g of Fat Breakfast Lunch Dinner Orange juice 1 c Grape juice, 1\u20442 c Lamb chop, 1 Eggs, scrambled Tuna salad, 1\u20442 c Carrots, cooked, 1 c Muffin, whole wheat, 2 Lettuce leaves, 4 Cole slaw, with mustard and vinegar, 1 c Margarine, 1 pat Tomato, 2 slices Potato, baked, 1 med Coffee, tea Bread, whole wheat, 2 slices Margarine, 1 tbsp Sugar Milk, skim, 1 c Milk, skim, 1 c Salt, pepper Coffee, tea Fresh peach Jelly Sugar Coffee, tea Sugar Salt, pepper Salt, pepper Snack Snack 8 oz low-fat yogurt 4 sugar cookies Apple juice, 1 c vomiting, distention, diarrhea, and anorexia. These symp- vitamin\/mineral supplements; electrolyte replacements; toms are managed by a dietary plan similar to that for hepatic aids; and parenteral feedings. hepatitis. The rationale also is the same: to support resid- ual liver function and prevent further cell destruction. If the cirrhosis is alcohol induced, deficiency of magne- Compliance with dietary and other medical recommen- sium and vitamin B complex is often present. Alcohol re- dations will delay development of the late stages of the duces vitamin absorption and increases mineral excretion. disease for years for some patients. HEPATIC ENCEPHALOPATHY (COMA) In the later stages of cirrhosis, the patient is severely malnourished. Edema, ascites, anemia, infections, in- Hepatic coma is caused by brain damage resulting from testinal bleeding, jaundice, and esophageal varices may the inability of a damaged liver to metabolize ammonia be present. Renal failure also may occur. The patient is compounds. Irritability, confusion, drowsiness, apathy, in critical condition. Primarily, a diet high in protein, and irrational behavior precede the coma. Other signs carbohydrate, vitamins, and calories, and moderate in are motor dysfunction and fecal breath odor. Ammonia is fat is preferred for advanced cirrhosis. However, other di- formed from protein in the intestines by bacterial action. etary changes are prescribed according to the patient\u2019s The protein may be ingested or derived from blood condition: (bleeding into the intestine). Treatment includes antibi- otics, psychotropic drugs, enemas to remove blood and 1. Protein\u2014If hepatic coma is not indicated, protein re- protein from the bowel, and diet therapy. Diet therapy mains at 75 to 100 g daily. If, however, the patient in impending hepatic coma is as follows: shows signs of impending coma, the physician should reduce protein intake to lessen the chance of coma. 1. Protein intake is limited to 0 to 50 g daily, depending on the blood ammonia level. Note that dietary protein 2. Sodium\u2014Edema and\/or ascites is counteracted by a is derived chiefly from milk and meats and is of high 500 to 1000 mg sodium (daily) diet. Fluid intake may biological value. It produces minimal ammonia be- be limited. Refer to Chapter 16 for sodium-restricted cause it is used optimally without waste; that is, it is diets. not metabolized for energy. Supplemental branched chain amino acids (leucine, 3. Texture\u2014Esophageal varices, if present, are managed isoleucine, and valine) can be used as a source of pro- by semisolid or liquid diets to avoid potential rupture tein for the heart, muscle, and brain, as well as for and hemorrhage. Tube feedings are not advised for energy. They are not dependent on the liver but are patients with this complication. These patients should metabolized by other body tissues. avoid coffee, tea, pepper, chili powder, and other irri- tating seasonings. 2. The diet provides 1500 to 2000 calories per day, mainly derived from carbohydrates and fat. This re- For a patient with poor appetite, other measures are duces tissue breakdown and ammonia formation. used to provide adequate nutrients and calories. These in- clude oral formulas high in nutrients and calories;","CHAPTER 19 DIET AND DISORDERS OF THE LIVER, GALLBLADDER, AND PANCREAS 295 3. Vitamins are given intravenously; vitamin K is espe- 2. 30\u201335 calories per kg weight, taking into considera- cially needed to reduce bleeding. tion fever, infection, or other complications 4. Fluid output is balanced by equal intake. Urine voided 3. Assuming renal function is normal, a diet offering and other fluid lost are recorded. 1.2\u20132 g of protein per kg per day is recommended. Protein requirements are increased due to: 5. TPN or enteral nutrition are also standard forms of \u2022 Immunosuppressive medications can result in diet therapy for liver failure. muscle or fat breakdown. \u2022 Wound healing status. CANCER OF THE LIVER 4. Food preferences and selections can pose a prob- The diet for a patient with liver cancer is high in carbo- lem. Extensive assistance from caregivers is essen- hydrate, protein, fluid, vitamins, and calories and mod- tial. Advises on food variety such as type, taste, erate in fat. Alternate intervals of feeding (other than texture are important. Small and frequent meals three meals a day) are indicated for all cancer patients, are encouraged. but especially when the liver is involved and the utiliza- tion of nutrients is compromised. The diet will be indi- 5. Most patients cannot achieve the recommended nu- vidualized to fit the patient\u2019s tolerance. For instance, trients intake without dietary supplements, though when cancer patients develop an aversion to meat, meat some do not welcome such products or procedures. substitutes are offered to satisfy the high protein need. 6. Enteral or tube feedings may be necessary to supply The type of protein-calorie malnutrition that devel- recommended intakes of calories, protein, and other ops during advanced liver disease and hepatic cancer is nutrients in order to assist the patient to reach an ac- severe and is accompanied by the many complications ceptable improvement in the overall health and oral common to marasmus. The malnourishment only adds consumption. to other clinical problems, making the restoration and maintenance of optimum nutrition difficult. At all times, the patient is monitored closely for clin- ical improvement in the following: All liver disorders present a challenge to the nurse to provide adequate nutrition for the patient. \u2022 Healing of wounds \u2022 Infection LIVER TRANSPLANTS \u2022 Physical activity \u2022 Adjustment to all aspects of nutrition intervention Liver transplantation for patients with end-stage liver disease is now a standard operation, and survival rate is One can determine when to start an oral diet by using acceptable within the current medical care system. the following guides: Persons considered candidates for transplantation in- \u2022 An intact digestive system is confirmed. clude those with progressive, irreversible liver disease \u2022 All tubes are removed from the digestive system. whose chances for survival are less than 10% without a \u2022 Ability to chew and swallow. transplant and for whom conventional treatment has failed. Diagnosis in adult candidates for transplantation Most liver recipients will be able to start oral intake include biliary cirrhosis, chronic active hepatitis, and within the first 1\u20132 days after transplantation. However, fulminant liver failure with encephalopathy. Common initial feedings should be in small amounts to observe diagnosis in child candidates are biliary atresia or inborn patient response. errors of metabolism. Patients with alcoholic cirrhosis, hepatic malignancies, or advanced lung and kidney dis- Initial feedings follow standard postsurgical hospital ease are not considered candidates because their chances dietary management: clear fluids to a regular diet as rap- of survival are poor. idly as tolerated. Other considerations such as use of sup- plements, restriction of a nutrient (sodium, fats, or In general, nutrition therapy for a post liver trans- carbohydrate) should be individualized by the care team plant patient has the following objectives: and the attending dietitian. \u2022 Hasten wound healing. The issue of food safety, especially the occurrence of \u2022 Reduce or prevent infection. pathogens in the food, must be closely monitored. All \u2022 Increase metabolism to preserve lean body mass. standard hospital routine practices of excluding mi- \u2022 Normalize hydration. crobial contamination must be implemented. Any pa- \u2022 Supply adequate energy to permit physical therapy. tient with a liver transplant is a good candidate for infection. Major nutrition support after transplant includes the following: However, as time progresses, accumulated experience will allow hospital dietitians to implement more appro- 1. Determine appropriate weight for diet calculation. The priate nutrition interventions for the patient after the weight measure can be achieved with proper procedure. transplant.","296 PART III NUTRITION AND DIET THERAPY FOR ADULTS NURSING IMPLICATIONS Diet Therapy for Transplantation Responsibilities of the nurse in treating cirrhosis are as Candidates need aggressive nutritional support such as follows: is necessary in all major surgery. Thorough nutritional assessment before the surgery is necessary. Patients gen- Dietary Plans erally have poor nutritional status and may require en- teral or parenteral nutrition before surgery for optimal 1. The dietary plan for each patient should be individu- postoperative results. These patients are given antibi- alized according to clinical conditions, appetite, and otics before and after surgery to reduce bacterial devel- so on. For example, a patient with advanced cirrho- opment. A low-bacteria diet is also recommended before sis may be very hungry in the morning, and a large and after surgery. breakfast should be provided. The essentials of food-handling precautions for trans- 2. Many patients with ascites prefer frequent, small plantation are as follows: meals to large ones, which can cause discomfort by raising portal pressure. 1. Avoid all fermented dairy products such as yogurts and cheeses. 3. Any meal planning must consider gastrointestinal disorders such as diarrhea, nausea, vomiting, and 2. Do not eat vegetables, including salads and garnishes, anorexia. Such conditions interfere, both physically and fruits that are not peeled. and psychologically, with eating. 3. Defrost frozen foods in the refrigerator or microwave. 4. Low-sodium milk is more acceptable if flavoring such 4. Do not use foods kept at room temperature or kept as honey or vanilla is added. heated for long periods of time. 5. Patients do not like most oral nutrition formulas with 5. Serve and eat foods quickly following preparation. medium-chain triglycerides (MCT) added. Experience 6. Cover and freeze leftovers immediately. confirms better acceptance by some patients when 7. Use refrigerated leftovers within two days. the beverage is served chilled. 8. Keep the preparation and serving area very clean. 9. Be sure that sanitary techniques are maintained 6. Work with the dietitian to devise ways to encourage optimal intake. throughout, and that food handlers are vigilant about personal habits and dress. Patient Monitoring PROGRESS CHECK ON ACTIVITY 1 1. A careful record of food intake is useful. FILL-IN 2. Be alert to signs of impending coma. 3. Always balance fluid intake and output. Use a separate sheet of paper for your answers. Teamwork 1. Fill in the sheet marked Exercise 19-1 for a high- carbohydrate, protein, and vitamin diet with mod- 1. Teamwork is mandatory. The team includes the nurse, erate fat. physician, dietitian, patient, and family members. 2. Plan a breakfast menu for a diet that is high in 2. Conferences and strategy sessions with members of calories, carbohydrate, protein, and vitamins, and the team ensure that the patient will be encouraged moderate in fat. to eat. 3. Alter this breakfast menu to meet the needs of a Alcoholism and Drugs client who daily requires 40 g protein and 2 g sodium. 1. The nurse should refrain from judging the patient\u2019s drinking habits. 4. Mrs. J. is admitted to the hospital with a diagnosis of infectious hepatitis and is placed in isolation. 2. The patient should be provided with assistance, in- Her diet prescription is 350 g carbohydrate, 100 g cluding such therapy as Alcoholics Anonymous meet- protein, and 100 g easily digested fat. She will re- ings and rehabilitation centers. ceive a therapeutic dose vitamin supplement. Answer the following questions about her diet: 3. The patient should be given intense education on the disease and its complications and treatment. a. What is the caloric value of her diet? 4. No alcoholic beverage is permitted in the hospital. b. Why were the extra calories ordered? Abstinence at home is strongly encouraged. 5. The patient should comply with specific usage for any prescription drugs and avoid all others.","CHAPTER 19 DIET AND DISORDERS OF THE LIVER, GALLBLADDER, AND PANCREAS 297 Exercise 19-1 A practice on the dietary management of selected disorders and nursing implications Complete the chart by filling in the appropriate information for each column. Diet Disease or Foods Foods Foods Nursing Condition Allowed Limited Forbidden Implications High- Hepatitis carbohydrate, protein, and Early vitamin; cirrhosis moderate fat Cancer Marasmus Uncomplicate Postoperative convalescence c. Compare the ordered protein intake with the i. What precautions with the eating utensils will RDAs\/DRIs for an adult nonpregnant woman. the nurse observe with this patient? (See Chapter 9.) j. What other diseases require the diet prescribed d. Why is the extra protein needed? for hepatitis? e. What is the role of the extra carbohydrate? 5. List the nine guidelines used to instruct patients, f. What is the rationale for the extra vitamins? caregivers, and dietary and nursing personnel re- garding appropriate food-handling practices be- g. Which foods should be avoided? fore and after a liver transplant. a. h. If Mrs. J. develops ascites, what additional re- b. strictions should be placed on her diet? c. d. e. f. g. h. i.","298 PART III NUTRITION AND DIET THERAPY FOR ADULTS ACTIVITY 2: weight, if he or she is obese, which many are. In these cases, supportive therapy is largely dietary. Diet Therapy for Diseases of the Gallbladder and Pancreas Two recent advances in the removal of gallstones that do not require surgery are being used for selected pa- The normal function of the gallbladder is to concentrate tients. One, called litholysis, involves the use of either and store the bile derived from the liver. The liver pro- oral doses or direct installation into the gallbladder of duces 600 to 800 milliliters of bile per day, and the gall- certain bile acids that dissolve the stones. The second bladder concentrates and stores 40 to 70 milliliters. When method, a process called lithotripsy, uses either ultra- fat enters the duodenum, it stimulates the secretion of a sonic waves or laser beams to mechanically break the hormone, cholecystokinin, which is carried by the blood stones into tiny fragments that can then be eliminated. to the gallbladder. This hormone directs the gallbladder to contract, so that bile is released into the common duct These methods, and new ones still being developed, and then travels to the duodenum. The function of bile are being used successfully for many patients. However, is to emulsify fats so that they can be broken down or di- not all patients are candidates for these procedures. gested by fat-splitting enzymes, the lipases. Any inter- Those who have other medical problems, such as people ference with the flow of bile impairs fat digestion. with chronic liver disease or women who are pregnant, are excluded. Additionally, these procedures work only Because gallstones may enter the common bile duct when the stone size is small. Surgery will still be the and block the flow of the pancreatic juice and enzymes, choice of treatment for many patients. pancreatitis is a common complication of gallbladder dis- ease. Pancreatitis is a severe disorder, since the enzymes Regardless of the type of treatment, a low-fat, high- in the immobile juice can cause the pancreas to digest it- fiber diet is recommended, with caloric reduction, prior self. Acute pain and tenderness result, and in critical to surgery or treatment, if weight loss is needed and the cases the pancreas may hemorrhage. The treatment of cholecystectomy is not an emergency. Table 19-2 pro- choice is to inhibit the secretion of the enzymes and to vides a guide for choosing suitable foods, and Table 19-3 treat for shock and renal shutdown. In this case, diet lists a sample menu using these foods although the therapy is useful only after the crisis has subsided. caloric content will require further reduction if weight loss is an objective. Another causative factor for pancreatitis, especially a chronic condition, is alcoholism. Irrespective of the cause DIET THERAPY FOR GALLBLADDER DISEASE of pancreatitis, dietary treatment and nursing implica- tions are the same. Dietary fat is reduced to diminish gallbladder contrac- tion, which is responsible for pain and associated symp- MAJOR DISORDERS OF THE GALLBLADDER toms. Fat modification involves only its quantity, approximately 40 to 50 g intake per day. Protein provides The two major disorders of the gallbladder are chole- only 10%\u201312% of the daily calories, since most protein cystitis and cholelithiasis. Cholecystitis usually results foods also contain fats. The remainder of the day\u2019s calo- from a low-grade chronic infection. The major compo- ries should be derived from carbohydrates. nent of bile is cholesterol. When the gallbladder mucosa becomes inflamed or infected, the cholesterol may pre- If weight loss is indicated, calories will be reduced ac- cipitate, forming gallstones of almost pure cholesterol cordingly. Use of both the weight-reduction diets dis- crystals. Cholelithiasis is an end result of cholecystitis, cussed in other chapters and the food exchange system but a high-fat intake over a long period of time also pre- is recommended. Caloric intake should not be less than disposes to gallstone formation. The body will produce 1200 calories per day. These diets are used only before more cholesterol to make more bile to assist in the me- surgery; otherwise, a patient can be placed on these diets tabolism of fat. after he or she has completely recovered from surgery. Another consideration is to provide such patients with vi- Treatments and Therapy tamin K to reduce bleeding. Cholecystectomy is the surgical removal of the gallblad- Restriction of foods that can cause abdominal discom- der. When a person with cholecystitis or cholelithiasis fort, such as gas, is individualized and not implemented eats a meal, especially if fat content is high, the gallblad- randomly. der contracts in response to cholecystokinin stimulation. This causes severe pain, fullness, distention, nausea, and Because the body manufactures its own cholesterol vomiting. Surgery is usually the treatment of choice. in amounts several times more than is present in the However, surgery may be postponed for two reasons: daily diet, restricting dietary cholesterol to reduce gall- until the inflammation subsides, or until the patient loses stone formation has been questioned. Since cholesterol is manufactured from fat in the diet, lowering total fat in- take may prove more effective. In addition to a comprehensive diet therapy for pa- tients with gallbladder disorder, some suggestions will","CHAPTER 19 DIET AND DISORDERS OF THE LIVER, GALLBLADDER, AND PANCREAS 299 TABLE 19-2 Permitted and Prohibited Foods in a Fat-Restricted Diet Food Group Foods Permitted Foods Prohibited Milk and milk products Skim milk (fortified with vitamins A and Whole milk and all products made from it; Breads and equivalents D): fluid, dry powder, and evaporated; low-fat and 2-percent milk and all prod- yogurt and buttermilk made from skim ucts made from them; heavy cream, Meats and equivalents milk (fortified with vitamins A and D). half-and-half, sour cream; cream Cheese and eggs sauces, nondairy cream substitutes. Beverages Enriched or whole-grain bread; plain buns Fruits and vegetables and rolls; crackers; graham crackers, Biscuits, dumplings, corn bread, waffles, Soups matzo, melba toast; other varieties not pancakes, nut breads, doughnuts, spicy Fats specifically excluded; all cereals that are snack crackers, sweet rolls, popovers, Sweets tolerated by the patient; potatoes except French toast, corn chips, muffins, all those specifically excluded; rice (brown items made with a large quantity of fat; or white); spaghetti, noodles, macaroni; cereals with nuts and 100 percent bran barley; grits; wild rice; flours (all may be omitted if not well tolerated; varieties). fried potatoes, creamed potatoes, potato chips, hash-browned potatoes and po- Limited to 4 to 6 oz daily; all lean fresh tato salad, scalloped potatoes; fried rice, meat, fish, or poultry (no skin) with fat egg noodles, casseroles prepared with trimmed; shellfish, salmon, and tuna cream or cheese sauce; chow mein noo- canned in water; foods may be pan- dles, bread stuffing; Yorkshire pudding; broiled, broiled, baked, roasted, boiled, Spanish rice; fritters; spaghetti with stewed, or simmered; soybeans, peas, strongly seasoned sauce. and meat analogues if tolerated. Fried, creamed, breaded, or sauteed items; Any variety not specifically prohibited sausage, bacon, frankfurters, ham, (2 oz cheese equivalent to 3 oz meat); luncheon meats, meats with gravy, 1 egg yolk a day, any style, with no fat many processed and canned meats; any used in cooking; egg whites may be used seafood packed in oil; nuts, peanut as desired; 1 egg yolk equals 1 oz meat. butter, pork and beans. Most nonalcoholic beverages except those Any cheese made from whole milk, includ- specifically excluded. ing cream cheese; any egg that is creamed, deviled, or fried. All varieties not excluded and tolerated by the patient. All beverages containing chocolate, cream, or whole milk; for example, milk Broth, bouillon, or consomm\u00e9 with no fat; shakes and eggnog, alcoholic beverages fat-free soup stocks; all homemade soups if not permitted by doctor. or cream soups made with allowed in- gredients; soups made with skim milk, Avocado and any not tolerated by the pa- clear soups with permitted vegetables tient; fried and creamed vegetables, veg- and meats with fat skimmed off; pack- etables with cream sauces or fat added; aged dehydrated soup varieties. any variety not tolerated. Limited to 2 to 3 tsp per day; all fats and Most commercial soups; any soup made oils (e.g., margarine, butter, shortening, with cream, fat, or whole milk. lard); heavy cream (1 tbsp \u03ed 1 tsp fat); sour cream or light cream (2 tbsp \u03ed 1 All fats exceeding the 2- to 3-tsp limit, tsp fat); cream substitute (4 tsp \u03ed 1 tsp including bacon drippings. fat); salad dressing (1 tbsp \u03ed 1 tsp fat); low-calorie dressing in small amounts Any candies or sweets made with nuts, not counted in fat allowances. coconut, chocolate, cream, whole milk, margarine, butter. Plain sweets, honey, syrup, sugar, mo- lasses, jams, jellies, plain sugar candies, (continues) chewing gum, hard candy, marshmal- lows, gum drops, jelly beans, sour balls, preserves, marmalade, tutti-frutti.","300 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 19-2 (continued) Food Group Foods Permitted Foods Prohibited Any products made with whole milk, Desserts Sherbet, Jell-O, water ice, fruit-flavored Miscellaneous Popsicles and ices; rice, bread, corn- cream, chocolate, butter, margarine, starch, tapioca puddings; plain gelatin, nuts, egg yolks. gelatin with fruit added; fruit whips, puddings and custards made with skim Any sauces made with fat, oil, cream, or milk and egg whites; cookies made with milk; olives, pickles, garlic, chili sauce, skim milk or egg whites; arrowroot chutney, horseradish, relish, cookies, vanilla wafers, angelfood cake, Worcestershire sauce. sponge cake. All herbs and spices tolerated and not specifically excluded; artificial sweet- ener, baking soda, baking powder. TABLE 19-3 Sample Menu Supplying 40\u201345 g of Fat, with 80\u201390 g of Protein, 260\u2013280 g of Carbohydrate, and 1700\u20132000 kcal Breakfast Lunch Dinner Orange juice, 1\u20442 c Beef broth and noodles, 1\u20442 c Tomato juice, 1\u20442 c Oatmeal, cooked, 1\u20442 c Chicken, broiled, 2 oz Beef, lean, broiled, 3 oz Egg, poached, 1 Saltines, 4 Potato, baked, small, 1 Raisin toast, 1 slice Margarine, 1 tsp Green beans, 1\u20442 c Jam, 2 tsp Green salad with lemon juice, 1\u20442 c Roll, hard, small, 1 Margarine, 1 tsp Orange, 1 Butter, 1 tsp Milk, skim, 1 c Cola, 8 oz Gelatin or fruit cocktail, 1\u20442 c Sugar, 2 tsp Sugar, 2 tsp Milk, skim, 1 c Coffee or tea Coffee or tea Sugar, 2 tsp Salt, pepper Salt, pepper Coffee or tea Salt, pepper help to relieve certain symptoms of these patients. Table those with a BMI of 24 to 25. Risk may increase sevenfold 19-4 summarizes the information. in women with a BMI greater than 45 compared to those with a BMI less than 24. OBESITY, DIETING, AND GALLSTONES Researchers have found that people who are obese Obesity is a strong risk factor for gallstones, especially may produce high levels of cholesterol. This leads to the among women. People who are obese are more likely to production of bile containing more cholesterol than it have gallstones than people who are at a healthy weight. can dissolve. When this happens, gallstones can form. Body mass index (BMI) can be used to measure obesity in People who are obese may also have large gallbladders adults. BMI is calculated from this equation: that do not empty normally or completely. Some studies have shown that men and women who carry fat around BMI \u03ed Weight (kg) (M) their midsections may be at a greater risk for developing Height (M) \u03eb Height gallstones than those who carry fat around their hips and thighs. The table in Appendix A calculates BMI for you. A BMI of 18.5 to 24.9 refers to a healthy weight, a BMI of 25 to Weight-loss dieting increases the risk of developing 29.9 refers to overweight, and a BMI of 30 or higher refers gallstones. People who lose a large amount of weight to obese. Also see Chapter 7. quickly are at greater risk than those who lose weight more slowly. Rapid weight loss may also cause silent gall- As BMI increases, the risk for developing gallstones stones to become symptomatic. Studies have shown that also rises. Studies have shown that risk may triple in people who lose more than 3 lb per week may have a women who have a BMI greater than 32 compared to greater risk of developing gallstones than those who lose weight at slower rates.","CHAPTER 19 DIET AND DISORDERS OF THE LIVER, GALLBLADDER, AND PANCREAS 301 TABLE 19-4 Dietary Intervention to Relieve Some Symptoms from Gallbladder Diseases GI problems Bloating Some suggestions of nutrition intervention and counseling to relieve symptoms Diarrhea 1. Eat slow and chew thoroughly. Gas 2. Reduce intake foods with lactose. Take with food commercial preparation capable of digesting lactose. Pain 3. Avoid foods with high contents of fats and\/or fiber. 1. If there is dehydration, standard clear liquids and\/or juices, may help to cover loss of fluid and electrolytes. 2. If stool is copious, no food by mouth. If indicated, medical management may be prescribed to compensate for fluid and electrolytes loss. 3. Depending on clinical observation, transition to a modified or regular diet may be prescribed with special consideration to fiber, lactose, fats, and spices. 1. Modify amount of fiber in the diet. 2. Eat and chew slowly with mouth closed. Do not give anything by mouth during the acute phase. When the acute attack has subsided, a clear liquid or fat-free broth may be tried. Tolerance to this regimen can be followed by a low-fat diet. Also, 1. Return to a normal diet when clinical responses so indicate. 2. Avoid or limit high fat or greasy foods including butter, whole milk, certain cheeses, doughnuts, and so on. A very low-calorie diet (VLCD) allows a person who is above 40. Experts estimate that one third of patients who obese to quickly lose a large amount of weight. VLCDs have bariatric surgery develop gallstones. The gallstones usually provide about 800 calories or less per day in food usually develop in the first few months after surgery and or liquid form, and are followed for 12 to 16 weeks under are symptomatic. the supervision of a healthcare provider. Studies have shown that 10%\u201325% of people on a VLCD developed You can take several measures to decrease the risk of gallstones. These gallstones were usually silent; they did developing gallstones during weight loss. Losing weight not produce any symptoms. About one third of the di- gradually, instead of losing a large amount of weight eters who developed gallstones, however, did have symp- quickly, lowers your risk. Experts recommend losing 1\u20132 toms, and some of these required gallbladder surgery. lb per week. You can also decrease the risk of gallstones associated with weight cycling by aiming for a modest Experts believe dieting may cause a shift in the bal- weight loss that you can maintain. Even a loss of 10% of ance of bile salts and cholesterol in the gallbladder. The body weight over a period of 6 months or more can im- cholesterol level is increased, and the amount of bile salts prove the health of an adult who is overweight or obese. is decreased. Following a diet too low in fat or going for long periods without eating (skipping breakfast, for ex- Your food choices can also affect your gallstone risk. ample), a common practice among dieters, may also de- Experts recommend including some fat in your diet to crease gallbladder contractions. If the gallbladder does stimulate gallbladder contracting and emptying. not contract often enough to empty out the bile, gall- However, no more than 30% of your total calories should stones may form. come from fat. Studies have also shown that diets high in fiber and calcium may reduce the risk of gallstone de- Weight cycling, or losing and regaining weight re- velopment. Finally, regular physical activity is related to peatedly, may increase the risk of developing gallstones. a lower risk for gallstones. People who weight cycle, especially with losses and gains of more than 10 pounds, have a higher risk for gallstones DIET THERAPY FOR ACUTE PANCREATITIS than people who lose weight and maintain their weight loss. In addition, the more weight a person loses and re- The aim of diet therapy is to prevent the secretion of pan- gains during a cycle, the greater the risk of developing creatic enzymes. Both food and alcohol stimulate pancre- gallstones. atic secretions. The clinical management procedures of acute pancreatitis are as follows: Why weight cycling is a risk factor for gallstones is unclear. The rise in cholesterol levels during the weight 1. Initial measures are lifesaving. These include IV or loss phase of a weight cycle may be responsible. TPN feedings, replacement of fluid and electrolytes, blood transfusions, and drugs for pain and inhibiting Gallstones are common among people who undergo gastric secretions. Nasogastric suction may also be gastrointestinal surgery to lose weight, also called used to remove gastric contents. Nothing is given by bariatric surgery. Gastrointestinal surgery to reduce the mouth. size of the stomach or bypass parts of the digestive sys- tem is a weight loss method for people who have a BMI","302 PART III NUTRITION AND DIET THERAPY FOR ADULTS 2. As healing progresses, the first oral diet usually con- 3. Pancreatic enzymes come in capsule and tablet form sists of clear liquid with amino acids, predigested fats, and should be swallowed whole. They should not be and other commercial preparations added gradually. given with hot food or liquids, to avoid breaking their The patient progresses to a bland diet given in six protective coating. They are taken only with meals. small feedings. No stimulants\u2014coffee, caffeine, tea, colas, alcohol\u2014are allowed. 4. The patient with pancreatitis has a poor appetite and may not eat well enough to repair damage done. The DIET THERAPY FOR CHRONIC PANCREATITIS patient may not enjoy the type of modifications re- quired. Extra support, encouragement, and counsel- The aim of diet therapy is to treat the malabsorption and ing are necessary. prevent malnutrition. Diet therapy for chronic pancreati- tis usually consists of a bland diet of soft or regular con- 5. Be able to supply sources of group support and coun- sistency in small meals at frequent intervals (six feedings), seling to patients whose disease is caused by alco- and contains no stimulant foods. Pancreatic enzymes are holism: The person who is alcohol dependent cannot given orally with food. Alcohol is strictly forbidden. usually abstain from alcohol without support. 1. Use a low-fat diet. PROGRESS CHECK ON ACTIVITY 2 2. Vitamin and mineral supplementation may be neces- FILL-IN sary, especially fat-soluble vitamins A, E, and K. B 1. Fill in the sheet marked Exercise 19-2 for a low- complex vitamins may also be replaced. fat diet. 3. Tube feedings or TPN may be necessary. 2. Alter the following day\u2019s menu to make it suitable for a patient on a low-fat diet (50 g). Calories are NURSING IMPLICATIONS FOR PATIENTS not restricted. Do not change more than is neces- WITH GALLBLADDER DISORDERS sary to meet the diet\u2019s restriction. Breakfast Responsibilities of nurses treating patients with gall- Orange juice bladder disorders include the following: Oatmeal with half-and-half and sugar 1. Evaluate the low-fat diet for adequacy of fat-soluble vi- tamins and substitute alternate sources of the vita- Fried egg mins, if necessary. Toast with butter and jelly 2. Provide instructions on correct methods of food preparation. Discourage use of fats and oils for sea- Coffee soning and frying foods. Lunch 3. Assess the patient\u2019s tolerance for foods that cause dis- Pork chop with dressing comfort and flatulence. Omit those from the diet. Buttered green beans 4. Assure nutritional adequacy of a diet with removal of foods not tolerated and substitution of alternate sources as needed. 5. Implement adequate patient education regarding tis- sue repair after a cholecystectomy. 6. Be alert to the correlation between obesity and gallstones. 7. Be alert to the correlation between dieting and gallstones. NURSING IMPLICATIONS FOR PATIENTS Corn on the cob WITH PANCREATITIS Roll Butter 1. The patient should be taught that no alcohol or caf- Milk and tea with sugar feine can be tolerated in his or her diet. Sources of caf- feine include coffee, tea, and cola beverages. 2. The patient can develop diabetes if the islet cells of the pancreas malfunction. Evaluate frequently for symp- toms. If diabetes develops, a calculated diet will be used.","CHAPTER 19 DIET AND DISORDERS OF THE LIVER, GALLBLADDER, AND PANCREAS 303 Dinner 7. T F People on a very low-calorie diet (VLCD) have Spaghetti with meat sauce a greater risk of developing gallstones. Tossed green salad\/Italian dressing 8. T F Weight cycling does not increase the risk of developing gallstones. French bread\/butter 9. T F Gallstone formation is correlated with obesity and dieting. Ice cream with fudge sauce REFERENCES Red wine American Dietetic Association. (2006). Nutrition Diagnosis: A Critical Step in Nutrition Care Process. Coffee Chicago: Author. 3. Write a 1-day menu for a patient who has chronic Beham, E. (2006). Therapeutic Nutrition: A Guide to pancreatitis and has lost 20 lb since the onset two Patient Education. Philadelphia: Lippincott, Williams months ago. and Wilkins. 4. Risk of gallstone formation can be reduced with: Bendich, A., & Deckelbaum, R. J. (Eds.). (2005). a. Preventive Nutrition: The Comprehensive Guide for b. Health Professionals (3rd ed.). Totowa, NJ: Humana c. Press. TRUE\/FALSE Charlton, M. (2006). Branched-chain amino acid en- Circle T for True and F for False riched supplements as therapy for liver disease. 5. T F People who are obese are more likely to have Journal of Nutrition, 136: 295s\u2013298s. gallstones than people who are at a healthy Deen, D., & Hark, L. (2007). The Complete Guide to weight regardless of where the fat is. Nutrition in Primary Care. Malden, MA: Blackwell. 6. T F Weight loss at any rate has no effect on gall- stone formation. DeMeo, M. T. (2001). Pancreatic Cancer and Sugar Diabetes. Nutrition Reviews, 59: 112\u2013118. Eastwood, M. (2003). Principles of Human Nutrition (2nd ed.). Malden, MA: Blackwell Science. Elliot, L., Molseed, L. L., & McCallum, P. (2006). The Chemical Guide to Oncology Nutrition (2nd ed.). Chicago: American Dietetic Association. Escott-Stump, S. (2002). Nutrition and Diagnosis- Related Care (5th ed.). Philadelphia: Lippincott, Williams and Wilkins. Exercise 19-2 A practice on the dietary management of gallbladder disease and nursing implications Complete the chart by filling in the columns with appropriate information. Diet Disease or Foods Foods Foods Nursing Low-fat diet Condition Allowed Limited Forbidden Implications Gallbladder disease","304 PART III NUTRITION AND DIET THERAPY FOR ADULTS Hark, L., & Morrison, G. (Eds.). (2003). Medical Nutrition Payne-James, J., & Wicks, C. (2003). Key Facts in Clinical and Disease (3rd ed.). Malden, MA: Blackwell. Nutrition (2nd ed.). London: Greenwich Medical Media. Ko, A. H. (2007). Pancreatic cancer and medical history in a population-based case-control study in the San Sardesai, V. M. (2003). Introduction to Clinical Nutrition Francisco Bay area. Cancer Causes & Control, 18: (2nd ed.). New York: Marcel Dekker. 809\u2013819. Schardt, D. (2004). Not everybody must get stones: How Lieber, C. S. (2000). Alcohol: Its metabolism and interac- to avoid gallbladder disease. Nutrition Action Health tion with nutrients. Annual Review of Nutrition, 20: Letter, 31: 8\u201310. 395\u2013430. Shils, M. E., & Shike, M. (Eds.). (2006). Modern Nutrition Lin, Y. (2006). Dietary habits and pancreatic cancer risk in Health and Disease (10th ed.). Philadelphia: in a cohort of middle-aged and elderly Japanese. Lippincott, Williams and Wilkins. Nutrition and Cancer, 56: 40\u201349. Thomas, B., & Bishop, J. (Eds.). (2007). Manual of Mahan, L. K., & Escott-Stump, S. (Eds.). (2008). Krause\u2019s Dietetic Practice (4th ed.). Ames, IA: Blackwell. Food and Nutrition Therapy (12th ed.). Philadelphia: Elsevier Saunders. Webster-Gandy, J., Madden, A., & Holdworth, M. (Eds.). (2006). Oxford Handbook of Nutrition and Dietetics. Mann, J., & Truswell, S. (Eds.). (2007). Essentials of Oxford, London: Oxford University Press. Human Nutrition (3rd ed.). New York: Oxford Univer- sity Press. Zivkovic, A. M. (2007). Comparative review of diets for metabolic syndrome: implications for nonalcoholic Marian, M. J., Williams-Muller, P., & Bower, J. (2007). fatty liver disease. American Journal of Clinical Integrating Therapeutic and Complementary Nutri- Nutrition, 86: 285\u2013300. tion. Boca Raton, FL: CRC Press. Mehta, K. (2002). Nonalcoholic fatty liver disease: Pathogenesis and the role of antioxidants. Nutrition Reviews, 60: 289\u2013293.","OUTLINE CHAPTER 20 Objectives Diet Therapy for Glossary Renal Disorders Background Information ACTIVITY 1: Kidney Function Time for completion and Diseases Activities: 1 hour Acute Nephrotic Syndrome Optional examination: 1\u20442 hour Nephrotic Syndrome Acute Renal Failure OBJECTIVES Chronic Renal Failure Progress Check on Background Upon completion of this chapter, the student should be able to do the following: Information and Activity 1 ACTIVITY 2: Kidney Disorders 1. Discuss the use of diet therapy in renal disorders. 2. Describe the therapeutic diets used in renal disorders and the rationale for and General Dietary Management their use. Description and General 3. List appropriate nursing interventions to promote adequate nutrition in Considerations Dietary Management a patient with renal disease. National Kidney Foundation Nursing Implications for GLOSSARY Activities 1 and 2 Progress Check on Activity 2 Albuminuria: albumin in the urine. ACTIVITY 3: Kidney Dialysis Antigen-antibody response: antigens are those substances that induce an im- Definitions and Descriptions Nursing Implications for mune response (the foreign invaders); they react with antibodies, which are Activity 3 the immune bodies that destroy the invaders. Patient Education and Azotemia: nitrogenous compounds in the blood. Counseling BUN: blood urea nitrogen. Major Resources CAPD: continuous ambulatory peritoneal dialysis: dialysis performed by the Teamwork patient in a continuous process. Progress Check on Activity 3 ACTIVITY 4: Diet Therapy for 305 Renal Calculi Causes of Kidney Stones Dietary Management Nursing Implications Progress Check on Activity 4 References","306 PART III NUTRITION AND DIET THERAPY FOR ADULTS CCPD: continuous cyclic peritoneal dialysis: dialysis by empties into collecting ducts. Urine enters via the ureter a machine that performs frequent exchanges of and leaves at the rate of 1000 to 1500 ml per day. The dialysate while the patient is sleeping. convoluted tubule, known as Henle\u2019s loop, filters blood that circulates through it. It excretes nitrogenous waste: CNS: central nervous system. ammonia, urea, uric acid, and creatinine, as well as toxic Collagen disease: a disease that attacks the connective substances ingested or formed from body metabolism. These substances are excreted in water that is not reab- tissue of the body, such as rheumatoid arthritis, lupus sorbed at the time. The glomerulus holds back in circu- erythematosus, or rheumatic fever. lation large molecules such as blood proteins. Another CRF: chronic renal failure. function of the kidney is the manufacture of erythropoi- Dialysis: the passing of molecules in a solution through etin, which stimulates the formation of red blood cells in a semipermeable membrane, passing from the side bone marrow. The kidney also converts inactive vitamin with the higher concentration of molecules to the side D to the active form the body uses and releases into the with the lower concentration (a method used in cases blood stream, but does not excrete, thus maintaining the of defective renal function to remove from the blood calcium to phosphorus ratio in the bone. those elements that are normally excreted). Diaphoresis: perspiration (sweating), especially profuse The kidney, along with the lungs, regulates the blood perspiration. pH by restoring neutrality. This is accomplished by se- Filtration: the process of eliminating certain particles creting hydrogen ions when there is too much acid, and from a solution. excreting bicarbonate when it is too alkaline. Electrolytes Glomerulus: a small cluster of capillaries encased in a and other substances such as amino acids, glucose, capsule in the kidney; a part of the nephron. sodium chloride, and vitamin C are either excreted or HD: hemodialysis: use of a machine (artificial kidney) reabsorbed, depending upon what the blood needs to outside of the body to remove waste products from maintain homeostasis. The kidney also helps regulate the patient\u2019s blood. blood pressure. Hematuria: blood in the urine. Hyperphosphatemia: high blood phosphate level. Each kidney contains over a million nephrons. Loss of Hypocalcemia: low blood calcium level. half of these, such as donation of a kidney or loss of one LBV: Low biological value (protein). in an accident, does not affect kidney function. Kidney Nephron: the basic unit of the kidney. Each nephron can function diminishes with age, and the elderly person may form urine by itself, and each kidney has approxi- have only a one-half to two-thirds filtration rate com- mately one million nephrons. Each glomerulus brings pared to a young adult. However, kidney function is still blood and waste products to the nephron, which filters adequate unless disease occurs. it continuously and produces urine, which carries the wastes to be eliminated. Excess sodium, potassium, Mechanisms of kidney function and the role of nutri- and chloride are also eliminated in urine, and blood is tion in maintaining them are discussed in the following reabsorbed. activities. Oliguria: diminished urine secretion in relation to fluid intake (less output than intake). ACTIVITY 1: Oxalate: a salt of oxalic acid. A poisonous acid found in various fruits, vegetables, and metabolism of ascor- Kidney Function and Diseases bic acid. It combines with calcium and is excreted in urine. High concentration may cause urinary calculi. Because the kidney is such a major factor in the mainte- Proteinuria: presence of proteins in the urine. nance of body homeostasis, there is little doubt that the Pyuria: presence of pus in the urine. consequences are extremely serious any time disease oc- Renal: pertaining to the kidney. curs and the kidneys fail. Renal disease can be caused by Renal calculi: formation of mineral stones, usually cal- damage to the kidneys themselves or by other diseases cium, in the renal tubules. such as diabetes, atherosclerosis, or hypertension. SOB: shortness of breath. Uremia: presence of urinary constituents in the blood. The most common terms used in describing kidney malfunctioning are hematuria, proteinuria, pyuria, al- BACKGROUND INFORMATION buminuria, oliguria, azotemia, and uremia. These condi- tions are dangerous to health. The kidney is an organ of excretion, conversion, secre- tion, reabsorption, manufacture, and regulation. Its In addition to excretory functions for maintenance structural and functional unit is the nephron. The of chemical homeostasis, balancing of body fluids, and nephron has a glomerulus attached to a long tube that maintenance of normal pH, the kidney controls blood pressure. Changes in sodium balance affect blood pres- sure as well as the rise in renin levels. Renin is a pro- teolytic enzyme secreted by the kidneys, which acts in blood plasma to form angiotensive II, a powerful","CHAPTER 20 DIET THERAPY FOR RENAL DISORDERS 307 vasoconstrictor. This further elevates blood pressure. of essential amino acids. Milk and eggs are the standard, Most patients with renal disease have hypertension. with meat, fish, and poultry following. The damaged kidney also decreases its production of NEPHROTIC SYNDROME erythropoietin, which is a critical determinant of ery- throid activity. This deficiency results in the severe ane- This disorder covers a group of symptoms resulting from mia present in chronic renal disease. kidney tissue damage and impaired nephron function. It may also occur because of other diseases such as diabetes The diseased kidneys will cease to produce the ac- or collagen disease, or from drug reactions, infections, or tive vitamin D hormone so necessary to maintain the chemical poisoning. Causes are unknown in some pa- calcium-phosphorus ratio in the bone. Serum phospho- tients. The symptoms are massive edema, proteinuria, rus levels rise as the kidneys are no longer able to ex- and body wasting. Dietary management covers the crete phosphorus. Hyperphosphaturia occurs and restoration of fluid and electrolyte balance, reversal of lowers serum calcium levels. Also, calcium is not ab- body wasting, and correction of hyperlipidemia, if present. sorbed from the gut because calcitrol is not present. Renal osteodystrophy is the result of these imbalances. ACUTE RENAL FAILURE Osteodystrophy is the condition whereby the bones be- come soft and calcium is deposited in the soft tissues. Acute renal failure includes an abrupt renal malfunction It is a common, complex, and usually inevitable out- because of infection, trauma, injury, chemical poison- come of renal disease. ing, severe allergic reaction, or pregnancy. The symp- toms are nausea, lethargy, and anorexia. Oliguria may Diseases of the kidney, whether acute or chronic, have be present at first, followed by diuresis. Azotemia may many causes. The origin of the disease and the portion of also be present. Acute renal failure is a life-threatening the nephron it affects will determine the symptoms and situation and requires immediate medical management. subsequent treatment. Depending upon the type, kidney disease may produce a nephrotic syndrome with signifi- Dietary management includes the restoration of fluid cant protein loss, decreased overall renal function, or a and electrolyte balance, elimination of azotemia, and im- combination of these. Objectives of nutritional care will plementation of nutritional rehabilitation. The dietary depend upon the abnormality to be treated. Causes, treatment is similar to that for acute glomerulonephri- symptoms, and dietary management of various disorders tis. Many patients need dialysis, especially if they are pro- are described in the following sections. gressing to chronic renal failure. ACUTE NEPHROTIC SYNDROME CHRONIC RENAL FAILURE An example of the acute nephrotic syndrome is glomeru- Chronic renal failure results from a slow destruction of lonephritis, caused by poststreptococcal infection, which kidney tubules and may be due to infection, hyperten- may occur in tonsil, pharynx, or skin. It is most com- sion, hereditary defect, or drugs. Dietary management mon in children and adolescents. Symptoms vary from involves the balancing of fluid and electrolytes, correction mild to severe: fever, discomfort, headache, slight edema, of metabolic acidosis, minimization of the toxic effect of decreased urine volume, mild hypertension, hematuria, uremia, and implementation of nutritional rehabilitation. proteinuria, and salt and water retention. Prognosis ranges from complete recovery to renal failure. PROGRESS CHECK ON BACKGROUND INFORMATION AND ACTIVITY 1 Dietary management of acute nephrotic syndrome is controversial. Some clinicians prefer restriction of pro- MULTIPLE CHOICE tein, fluid, and sodium intakes, while others do not. Circle the letter of the correct answer. Diet Modification 1. The functional unit of the kidney is the: Acute glomerulonephritis in children is not usually con- sidered crucial unless complications arise. They are gen- a. tubule. erally placed on bed rest with antibiotic drug therapy. b. glomerulus. The fluid intake will be adjusted to output, including c. nephron. losses from diarrhea and\/or vomiting. d. ureter. Diet therapy may be similar to the initial management 2. Approximately how many ml of water leave the of acute renal failure, that is, 25 g of protein (70%\u201380% body via the kidney per day? HBV) and 500 milligrams of sodium. Fluid permitted varies with the patient. HBV refers to the high biological a. 1000\u20131500 value of protein. Protein in a restricted diet such as this b. 2000\u20132500 must be from those foods furnishing the greatest amount","308 PART III NUTRITION AND DIET THERAPY FOR ADULTS c. 500\u20131000 Define: d. 3000 18. Renin 3. Neutrality is restored to the body by the kidney in which of these ways? 19. Osteodystrophy a. reabsorption of electrolytes 20. HBV protein b. secretion of hydrogen ions c. excretion of bicarbonate ACTIVITY 2: d. all of the above Kidney Disorders and General Dietary 4. The vitamin whose activity depends upon efficient Management kidney function is: DESCRIPTION AND GENERAL a. ascorbic acid. CONSIDERATIONS b. B12. c. D. As indicated in Activity 1, there are several types of kid- d. retinol. ney disorders. No matter what type it is, the kidney fails to function properly. A kidney disorder or renal failure 5. When a person loses one kidney through accident may be the result of diseases that involve the nephron, or donation, kidney function is altered by: such as untreated glomerulonephritis, insulin-dependent diabetes, infectious renal vascular disease, or congenital a. 1\u20444. abnormalities. The clinical symptoms result from the b. 1\u20442. loss of functioning nephrons and decreased renal blood c. 2\u20443. flow, as well as inability of the kidney to concentrate d. 0. urine, or to maintain acid-base and electrolyte balance. Dehydration or water toxicity may occur if the amount of 6. An elderly person\u2019s kidney function may be ingested fluid is not carefully controlled. altered by: Metabolic acidosis occurs in advanced stages because a. 0\u20131\u20444. of reduced excretion of phosphate sulfates and organic b. 1\u20444\u20131\u20442. acids from food metabolism. These substances increase c. 1\u20442\u20132\u20443. in body fluids, displacing the bicarbonates. d. 3\u20444\u20131. Sodium balance cannot be maintained by the failing FILL-IN kidney. Any increase in sodium intake will result in edema, as the sodium is not excreted. The kidney performs six major functions. Name them and give one example of each function. Nitrogen retention and anemia, as well as increasing hypertension, are all a direct result of advancing deteri- Function Example oration of the nephrons. Laboratory findings indicate azotemia and elevated BUN, serum creatinine, and uric 7. acid levels. 8. Depending on the clinical stage, renal failure in any form may lead to acute malnutrition with its myriad 9. symptoms. The health professional will observe weak- ness, lethargy, fatigue, SOB, oral and GI bleeding, diar- 10. rhea, vomiting, CNS involvement, ulceration in the mouth, fetid breath, and increased susceptibility to any 11. infection, as well as the aching and pain in bones and joints due to the osteodystrophy. 12. Name five of the most common terms used in kidney malfunctioning, and define the term. Term Definition 13. 14. 15. 16. 17.","CHAPTER 20 DIET THERAPY FOR RENAL DISORDERS 309 DIETARY MANAGEMENT urine output is the usual pattern for determining fluid intake. The dietary management is specific for each type of kid- ney disorder or renal failure and is usually individual- Individual needs vary. Each person\u2019s weight, blood pres- ized. However, there are many commonalities in diet sure, and urine output must be monitored to determine therapy, which are discussed in the next section. It pro- exact needs. Body weight and blood pressure will increase vides those general considerations in the dietary man- if the person is retaining sodium (and fluid). The person\u2019s agement of patients with renal failure. In practice, the weight and blood pressure will fall if sodium intake is too attending physician and a registered dietitian individual- low. Calcium carbonate supplements are sometimes or- ize the dietary strategies applicable to specific clinical dered by the doctor. Calcium should be supplemented to stage and patient conditions. 1200\u20131600 mg\/day. Calcium carbonate and calcium ac- etate are considered the appropriate supplements. The following are the general principles of dietary management in renal disease: Fat-soluble vitamins are not supplemented. Water- soluble vitamins may require supplementation due to 1. Achieve a balance between intake and output. deficiencies arising from anorexia, uremia, and altered 2. Alleviate symptoms. metabolism. Treatment with vitamin supplementation is 3. Maintain adequate nutrition. on an individual basis. 4. Retard progression of renal failure in order to post- NATIONAL KIDNEY FOUNDATIONS pone dialysis. The National Kidney Foundation (www.kidney.org) rec- Diet therapy is focused on controlling five nutrients: ommends the following nutritional intakes for two types protein, sodium, potassium, phosphorus, and fluids. of kidney patients, among others. Levels of each nutrient need to be individually adjusted according to progression of the illness, type of treatment Chronic Renal Insufficiency being used, and the patient\u2019s response to treatment. Using a patient with a glomerular filtration rate (GFR) of Generally the following dietary restrictions apply: 5\u201360 ml\/min as an example, the nutritional intakes are as follows: 1. Sodium: 1500\u20133000 mg 2. Potassium: generally no restriction from food sources. 1. Protein: The patient should receive 0.55\u20130.60 g\/kg\/day. At least 0.35 g should be derived from those with high Potassium chloride (salt substitutes) may not be used biological value (HBV). in renal patients. 3. Phosphorus restriction varies. Whenever protein is 2. Energy: The patient should receive at least 35 kcal\/ reduced in the diet, the dietary source of phosphorus kg\/day. falls. Further restriction is usually unwarranted un- less serum phosphorus is elevated. As renal disease 3. Phosphorous: The patient should be restricted to 10 progresses, and diet alone cannot control phosphorus, or less mg\/kg\/day. phosphate binders become necessary. Calcium-based phosphate binders are recommended and the use of Acute Renal Failure aluminum-based binders contraindicated because of the potential for aluminum toxicity. The following are recommendations for nutritional in- 4. Protein: 0.6 g\/kg body weight is the lowest recom- takes for a patient with acute renal failure: mended level plus 24-hour urinary protein loss. For patients at nutritional risk and those who cannot ad- 1. Protein: The patient is advised to take in 0.6\u20130.8 here to the diet, raising the protein allowance to gm\/kg body weight (ideal or standard). 0.7\u20130.8 g\/kg body weight may become necessary. Patients with IDDM are generally recommended to 2. Sodium: The patient is allowed 1\u20132 gm\/day depend- have 0.8 g\/kg body weight because insulin deficiency ing on blood pressure, fluid retention, and status of increases the rate of protein degradation. At least 75% diuretic phase. of protein should come from HBV protein; the use of eggs should be encouraged because of their high bi- 3. Potassium: The patient is allowed 2 gm\/day to replace ological quality: high protein foods should be distrib- loss from diuretic treatment. The serum phosphorus uted over 24 hours. level should be maintained at less than 5 mEq\/l. 5. Calories: adjusted for slow weight gain, maintenance of weight, or slow weight loss as necessary. Calories 4. Phosphorus: Intake is regulated so that an acceptable should be from carbohydrate and fat. level is maintained in the serum. 6. Fluid: intake to be calculated. Urine output is useful as a basis for estimating daily fluid needs. Five hun- 5. Calcium: Intake is regulated so that an acceptable dred ml for insensible water loss added to 24-hour level is maintained in the serum. 6. Fluid: Intake is regulated by output. The replacement for daily loss is accompanied by an addition of 500 ml.","310 PART III NUTRITION AND DIET THERAPY FOR ADULTS 7. Vitamins\/minerals: The daily intake is adjusted to re- They are then made available to hospitals, medical clin- flect patient metabolic status. Patients receiving total ics, community healthcare centers, and so on. These or- parenteral nutrition (TPN) are usually given higher ganizations in turn distribute them to the patients. doses of these two nutrients. At the same time, many bookstores sell books devoted 8. Fiber: Though an intake of 20\u201325 gm\/day is recom- entirely to dietary care for kidney patients. Most of them mended, the actual intake level will depend on the are written by health professionals. Many patients buy clinical status of the patient. such books to have more varieties of meal plans. Renal Exchange Lists At this age of computer technology, there are many types of software available to provide the same informa- Refer to Chapter 1 on the use of food exchange lists in tion. Using a home computer with such software, a pa- general. For the last 25 years, the National Kidney tient can type in his or her dietary prescription and be Foundation (NKF) has been the main organization that shown the appropriate meal plans. has gradually developed comprehensive food exchange lists to assist patients with kidney disorders who require NURSING IMPLICATIONS FOR ACTIVITIES a very structured dietary regimen. 1 AND 2 For most kidney patients, a diet prescription revolves Caloric Intake around five nutritional requirements: 1. Be aware that adequate caloric intake is an impor- \u2022 Calories tant health requirement for renal patients. \u2022 Protein \u2022 Sodium 2. Plan menus knowing that high caloric intake is diffi- \u2022 Potassium cult to accomplish if grains and starchy vegetables \u2022 Phosphorus are excluded or severely limited. Example: The attending medical team for a patient 3. Use caloric-dense items such as heavy cream, sweets, determines that a nondiabetic kidney patient daily in- and carbonated beverages to provide calories when takes should be: they are needed. \u2022 Calories: 2100 kcal The recommended 30% of total calories from fat with \u2022 Protein: 60 g only 10% from saturated fats may not be feasible for pa- \u2022 Sodium: 2 g tients with renal disease. It may be necessary to aban- \u2022 Potassium: 15 or less mg don fat restrictions in order to meet energy needs and supply enough calories to prevent protein from being To comply with this prescription, it will be transformed used for energy. Complex carbohydrates contain LBV pro- into a meal plan for breakfast, lunch, and dinner. The in- tein, which must be counted as part of the total protein formation is then provided to the patient. Obviously, the allowance, and so are limited. Saturated fat and choles- task becomes large when the patient must have a variety terol can be reduced if necessary by using more polyun- of meal plans to avoid eating the same food daily. saturated and monounsaturated types of fats. Currently, there are two ways to make such plans available. Fluid Over the last 25 years, the NKF has systematically de- veloped food exchange lists for kidney patients for the 1. Apportion the limited fluid intake equally throughout major food groups: milk, meat, starches, vegetables, the waking hours. fruits, and fats. Within each food group, the NKF deter- mines nutrients contributed by one serving of a food 2. Keep the patient\u2019s mouth clean and moist when flu- item. For example, each serving ( e.g., 1\u20442 c milk or 1\u20444 c ids are restricted. evaporated milk) within the milk group will contribute: 120 kcal, 4 g protein, 80 mg sodium, 185 mg of potas- 3. Compensate for diarrhea or diaphoresis by prescrib- sium and 11 mg of phosphorous. Thus the exchange lists ing additional fluid intake. for milk group will provide many foods, each serving of which contributes the same amount of nutrients. 4. Be aware that proper eating posture is needed for pa- tients with edema and ascites. For example, sitting Using similar approaches, the nutrients contributed by upright causes discomfort and anorexia for this group one serving of a food item in meat, starches, and so on are of patients. also determined. Finally, the NKF issues the food ex- change lists for all major food groups. Diet Compliance Using such exchange lists, dietitians and other health 1. Plan diets with the knowledge that patients dislike a professionals have developed many meal plans to comply diet with little bread, potato, and other low-biological with dietary prescriptions ordered by the health team. value protein foods. Such diets are unpalatable and","CHAPTER 20 DIET THERAPY FOR RENAL DISORDERS 311 will be further rejected by patients with nausea, vom- 8. iting, and anorexia. 9. 2. Realize that when a patient does not comply with a 10. diet, treatment is handicapped and prolonged. 11. 3. Through patient education, help the patient under- List the four general principles of dietary management in stand the problems and make an effort to comply with renal disease. the dietary prescription. 12. 13. PROGRESS CHECK ON ACTIVITY 2 14. 15. MULTIPLE CHOICE Circle the letter of the correct answer. 1. Chronic renal failure usually occurs over a long ACTIVITY 3: period of time from diseases that affect the nephron. Included are all except which of these Kidney Dialysis diseases? DEFINITIONS AND DESCRIPTIONS a. renal osteodystrophy b. congenital abnormalities Dialysis refers to the diffusion of dissolved particles c. untreated glomerulonephritis (solutes) from one side of the semipermeable membrane d. insulin-dependent diabetes to the other. Kidney dialysis was started in 1960 and has helped many uremic patients since then. Basically, two 2. Reduced secretion of phosphate, sulfates, and or- kinds of dialysis are used to treat the end stage of renal ganic acids from ingested foods results in: failure: hemodialysis and peritoneal dialysis. a. metabolic alkalosis. Hemodialysis, sometimes known as extracorporeal b. metabolic acidosis. dialysis, uses a machine (artificial kidney) outside the c. edema. body. Blood is drawn or pumped out of the body and d. ascites. made to circulate through a special machine equipped with a synthetic semipermeable membrane. The dialysate 3. Hypertension in renal failure is usually the in this case also contains glucose and electrolytes, which result of: resemble concentrations of blood plasma found in the body. Much nitrogenous waste from the patient\u2019s blood a. sodium retention. plasma diffuses into the dialysate. The cleansed blood is b. calcium excretion. returned to the patient\u2019s body and the used dialysate is re- c. metabolic acidosis. placed with fresh. The patient undergoes hemodialysis d. erythrocyte reduction. two to four times a week for three to six hours at a time in the hospital or at a dialysis center. Between dialysis 4. General dietary restrictions include which of treatments, nitrogenous waste products, potassium and these nutrients? sodium, and fluids accumulate, and dietary modifications are necessary to control them. Serum amino acids and a. calcium, phosphorus, vitamin D water-soluble vitamins are lost in the dialysate, and water- b. calcium, phosphorus, potassium soluble vitamin supplements are necessary. c. sodium, protein, water d. all of the above Peritoneal dialysis may be intermittent or continu- ous. With intermittent dialysis a catheter is placed in the 5. There is an increase in if a patient is abdominal cavity and one to two liters of dialysis fluid retaining sodium. introduced into the abdominal cavity and removed every hour. This process is repeated until the blood urea drops a. blood pressure and weight to normal levels. Loss of blood protein and amino acids b. fluid and acidosis are greater in peritoneal dialysis than in hemodialysis. c. calcium and appetite d. pulse and respiration With continuous ambulatory peritoneal dialysis (CAPD), the patient does his or her own dialysis, and the SHORT ANSWER process is continuous. The fluid (dialysate) is introduced into the peritoneal cavity and remains there for four to List six nursing implications for patients on a renal diet (two from each category of fluid, calorie, and compliance). 6. 7.","312 PART III NUTRITION AND DIET THERAPY FOR ADULTS six hours, allowing waste products to diffuse into the 1. Dietary potassium is controlled. The amount of potas- dialysate. The dialysate is then drained and replaced with sium a person can tolerate will depend on his or her fresh fluid. With CAPD, no dietary restriction of fluid, body size, amount of renal function remaining, and sodium, or potassium is necessary. However, calcium whether there is infection or protein catabolism. The supplements may be needed, and phosphorus is re- physician determines when restrictions are necessary stricted. No phosphate-binding antacids are used. The to keep K\u03e9 from rising above safe levels. A daily intake dialysate contains dextrose, which is absorbed by the of 1950\u20133100 mg per day is usually prescribed. body. Calorie control and an exercise program may be needed to prevent excess weight gain. In addition, the 2. Sodium and fluids are regulated to the individual. If extra dextrose can lead to elevated triglycerides and a the person gains excessive weight between dialysis lower level of high-density lipoproteins (HDLs), increas- treatment, they are reduced. No weight gain between ing the risk of coronary heart diseases. Protein and amino treatments indicates that both should be increased. acid losses are minimal and are easily replaced by diet. Continuous cyclic peritoneal dialysis (CCPD) uses a ma- 3. The majority of hemodialysis patients require cal- chine that performs frequent exchanges of dialysate while cium supplementation. the patient is sleeping. The dialysate is left in place dur- ing the day. 4. Water-soluble vitamins are supplemented; fat- soluble vitamins are not given routinely. Both CAPD and CCPD require that the patients and\/or their caregivers receive training in aseptic technique and 5. Diabetic patients on hemodialysis require an ex- dialysate exchange, as these treatments are carried out at change list different from the American Dietetic home. Association\u2019s exchange lists for meal planning. This is because of the need to control the sodium, potassium, NURSING IMPLICATIONS FOR ACTIVITY 3 and phosphorus content of the diet; the amount of these nutrients in each food choice must be calcu- Reluctant Patients lated as well as the usual amount of protein, carbohy- drate, and fat. The ADA publishes a guide: A Healthy Be aware that patients being transferred from hemodial- Food Guide, Diabetes and Kidney Disease, National ysis to CAPD are often reluctant to give up their restric- Renal Diet. This guide was compiled by the Renal tive diets. Explain clearly the possible effects of a Dietetic Practice Group of the American Dietetic restricted diet while on CAPD: Association and the National Kidney Foundation, Council on Renal Nutrition. The Kidney Foundation 1. Hypotension and dizziness from sodium depletion also publishes a brochure on dining out for renal pa- 2. Nausea, vomiting, irregular heartbeat, and muscle tients. See the References section for addresses. weakness from potassium depletion PATIENT EDUCATION AND COUNSELING 3. Dehydration due to rapid fluid removal 1. The nurse is an integral part of the multidisciplinary Dietary Regime health team. Education of the patient involves a full assessment of the individual\u2019s nutrition, medical, so- The following counseling plan is used with success at ciological, economic, and psychological status. many clinics as a guide for patients on peritoneal dialysis: 2. Recognize that this is a permanent adjustment for 1. High protein: 1.2\u20131.5 g\/kg body weight. the individual and his or her family, and it will disrupt 2. Limit phosphorus intake to 1200 mg\/day. their lifestyles. a. Nuts and legumes\u2014one serving\/week 3. As the disease progresses there will be progressively b. Dairy products\u20141\u20442 c daily more difficult restrictions. Some patients may adapt, c. Eggs\u2014no more than one others will not. 3. High potassium\u2014eat a wide variety of fruits and veg- etables daily. 4. Emotional support, psychological counseling, and in- 4. High fluid intake to prevent dehydration. formational support are needed to cope with all the 5. Limit or avoid sweets and fats. adjustments that must be made. 6. Control weight. Incorporate the extra calories from dialysate into total calories for the day. 5. Crises and personal loss are ever-present factors in 7. Encourage adequate consumption. CAPD patients are renal disease. often anorexic. MAJOR RESOURCES The dietary modifications for patients undergoing he- modialysis differ in several aspects from peritoneal dial- Apart from hundreds of private and government publica- ysis or CAPD. The differences are as follows: tions on nutrition, diet, and kidney disorders, two major professional organizations (American Dietetic Association [ADA] and the National Kidney Foundation [NKF]) have","CHAPTER 20 DIET THERAPY FOR RENAL DISORDERS 313 developed and distributed guideline documents that are is the most desirable. Qualified dietitians are trained to used by professionals and health facilities throughout monitor the nutrition status of dialysis and predialysis pa- this country. They are as follows: tients. The nurse is on the front line to provide clinical observations and to implement nutritional and dietary 1. A Clinical Guide to Nutrition Care in End-Stage intervention. Renal Disease (3rd edition in progress) PROGRESS CHECK ON ACTIVITY 3 2. Guidelines for Nutrition Care of Renal Patients, 3rd edition, 2001. FILL-IN Define or describe fully: 3. National Renal Diet: Professional Guide and the National Renal Diet Client Education Guides, 2002 1. Dialysis (update in progress for simplified version of National Renal Diet). Health professionals should consult these resources in patient care. TEAMWORK 2. Hemodialysis The dietary treatment of patients with kidney disorders 3. Peritoneal dialysis is best done by teamwork as confirmed by the latest clin- ical observations: 4. Dialysate 1. The low-protein diets used in renal disease study have 5. CAPD been found to be safe for periods of 2 to 3 years. Declines in protein and calorie intake are of concern 6. Name the four waste products from the patient\u2019s because of the potential adverse effects of protein calo- blood that are diffused into the dialysate: rie malnutrition. Some individuals exhibit low body a. weight and altered anthropometric and biochemical b. data. Continuous dietary surveillance is needed, and c. the diet of patients with end-stage renal disease must d. be carefully monitored during treatment. 7. Two reliable resources on renal disease informa- 2. Marked improvements in the administration of dialy- tion are: sis has not been matched by the protein and caloric a. therapy provided to dialysis patients. Intensive assess- b. ment and documentation of malnutrition and medical nutrition therapy is highly recommended if the out- 8. Three important guideline documents for health comes of dialysis patients are to be positively affected. professionals responsible for renal diseases are: a. 3. Malnutrition is an important risk factor for mortality b. among dialysis patients. Malnutrition is mild to mod- c. erate in approximately 33% of dialysis patients and severe in approximately 6%\u20138%. The underlying MULTIPLE CHOICE causes of malnutrition in this population include low Circle the letter of the correct answer. nutrient intake, underlying illnesses, and the dialysis procedure itself. 9. Which of these nutrients should be restricted in the diet of the person on CAPD? 4. The National Institutes of Health Consensus Develop- a. sodium ment Conference on Morbidity and Mortality of b. potassium Dialysis brought together experts from a number of disciplines including nephrology, pediatrics, and nu- trition to prepare a consensus statement on a num- ber of issues related to dialysis of renal patients. Among their findings, the consensus panel concluded that medical nutrition therapy is critical to the effec- tive treatment of patients with renal disease, and trained dietitians are best suited to provide such nu- tritional intervention. In each of these findings, the combined contribution from a nurse and a dietitian in the multidisciplinary team","314 PART III NUTRITION AND DIET THERAPY FOR ADULTS c. fluid These factors include the chemistry of the urine and\/or d. phosphorus the conditions of the urinary tract. 10. The amount of protein needed for a patient on Calcium Stones peritoneal dialysis is: By far the majority of kidney stones\u2014about 96%\u2014are a. 0.4\u2013.6 g\/kg body weight composed of calcium compounds. The calcium usually b. 1.0\u20131.2 g\/kg body weight combines with phosphates or oxalates. Excessive urinary c. 1.2\u20131.5 g\/kg body weight calcium may result from prolonged use of high-calcium d. 0.8 g\/kg body weight foods such as milk and dairy products, from alkali ther- apy for peptic ulcer, or from continued use of a hard 11. Effects of a severely restricted diet on a patient water supply. Also, excess vitamin D may cause increased with CAPD include all of these except: calcium absorption from the intestine, as well as in- creased calcium extraction from the bone. Prolonged im- a. hemorrhagic shock. mobilization such as occurs in body casting, long-term b. nausea and vomiting. illness, or disability may lead to withdrawal of calcium c. heart arrhythmias. from the bones and increased calcium in the urine. d. dehydration. Uric Acid Stones 12. Caloric control and exercise are necessary for CAPD patients because: Three percent of kidney stones are uric acid stones, while cystine stones average only 1% (cystine is an amino acid a. patients gain excess weight from being that accumulates in urine from a hereditary disorder). immobilized. Uric acid stones may come from rapid tissue breakdown (body wasting), prolonged use of high-protein and low- b. fluid is more easily excreted in this way. carbohydrate fad diets, and purine breakdown (purine is c. the dialysate contains absorbable dextrose. a body by-product). d. amino acids are converted to energy. Urinary Tract and Stone Formation MATCHING Stone formation is facilitated by the following: Match the food item on the left with its recommenda- tion on the right for a person on peritoneal dialysis. Write 1. Concentrated urine (examples include not drinking the appropriate letter in the space provided. enough fluid, excessive sweating) 13. eggs a. increase potassium 2. Favorable urine acidity (the lower the acidity of the 14. oranges\/bananas intake urine, the higher the calcium stone formation; high- 15. nuts and legumes acid urine favors uric acid stone formation) 16. water b. decrease phosphorus 17. milk intake 3. Vitamin A deficiency (the resulting changes in the urinary tract tissue favor stone formation) TRUE\/FALSE c. increase to prevent dehydration 4. Recurrent urinary tract infections d. limited to one DIETARY MANAGEMENT e. limited to 1\u20442-cup Using diet therapy to manage kidney stones is only part serving of the medical regimen. The overall dietary treatment is based on the type of stone. Dietary recommendations to Circle the letter of the correct answer. treat kidney stones are as follows: 18. T F Dietary treatment of patients with kidney dis- 1. Drink a lot of fluid. This will dilute the urine and flush orders is best done by teamwork of a nurse and out the stones in some patients. It is ineffective for a dietitian. other patients. 19. T F Low-protein diet can be used by renal disor- 2. Reduce intake of the components of the stones. For ders patients indefinitely without side effects. example, a calcium stone may be treated with a low- calcium diet. A stone containing primarily phospho- 20. T F Malnutrition is an important risk factor for rus may be treated with a low-phosphorus diet. The mortality among dialysis patients. same applies to stones with oxalic acid. When the stone component changes, these therapeutic diets ACTIVITY 4: Diet Therapy for Renal Calculi CAUSES OF KIDNEY STONES Although the basic cause of kidney stones is unknown, there are many direct and indirect contributing factors.","CHAPTER 20 DIET THERAPY FOR RENAL DISORDERS 315 TABLE 20-1 Daily Meal Planning for a 800-mg Calcium Diet Food Group Example Approximate Calcium Content (mg) Milk, cheese, eggs 2 c reduced-fat milk Breads and equivalents 3 slices bread 600 Cereals, flours 1 c Puffed rice 60 Meat, poultry, fish 3 oz chicken; 4 oz lamb; 11\u20442 oz shad, baked Vegetables 1\u20442 c beets, cooked; 1\u20442 c eggplant, cooked 7 Fruits 1\u20442 c applesauce; 2 med. nectarines; 1 med. apple 30 Fats 5\u20136 servings bacon fat, salad dressings, and others 30 Potatoes and equivalents 1\u20442 c noodles 20 Soup (broth of permitted meats or 1\u20442 c vegetable-beef 5 15 soups made with permitted ingredients) 2\u20134 servings Beverages 1 c flavored gelatin 5 Desserts No limit Miscellaneous (sugar, nondairy 10\u201320 5 creamer, sweets, etc.) 0 simultaneously change the pH (acidity or alkalinity) TABLE 20-2 Sample Menu for a 800-mg of the urine as indicated: Calcium Diet Stone Diet Urinary pH Breakfast Chemistry Modification acid ash Juice, cranberry, 1\u20442 c Calcium acid ash Farina, 1\u20444 c Low calcium acid ash Bread, 1 slice Phosphate (800 mg) Margarine, 2 tsp 1\u20442 c reduced-fat milk Oxalate Low phosphate Salt, pepper; sugar (1000 mg) Imitation cream, nondairy creamer, or coffee whitener Coffee or tea Low oxalate Lunch Stones composed of uric acid, cystine, and struvite Soup, tomato, made with milk, 1\u20442 c are unresponsive to diet modifications. Stones com- Chicken, boneless, canned, 3 oz posed of calcium oxalate and calcium phosphate are Mushrooms, canned, 1\u20442 c responsive to treatment and diet modification. Bread, 1 slice 3. Change the acidity or alkalinity of the urine by eating Butter or margarine, 2 tsp certain foods. Pears, canned, 1\u20442 c Salt, pepper; sugar To illustrate the use of a low-calcium diet, Tables Imitation cream, nondairy creamer, or coffee whitener 20-1 and 20-2 show a meal plan and menu, respec- Coffee or tea tively, for an 800-mg calcium diet. Table 20-3 classi- fies foods according to their acid-base reactions in Dinner the body. The acidity or alkalinity of the urine can be Fruit cocktail, canned, 1\u20442 c modified by consuming more of the appropriate type Veal roast, 3 oz of foods. Potato, baked, med. 1 Cauliflower, cooked, 1\u20442 c NURSING IMPLICATIONS Bread, 1 slice Butter or margarine, 2 tsp Calcium Intake 1 c reduced-fat milk Lemon ice, 1 c 1. Although milk can increase an acid urinary pH, it is Imitation cream, nondairy creamer, or coffee whitener high in calcium. Coffee or tea Salt, pepper; sugar 2. A low-calcium diet should include foods fortified with vitamin D, which promotes absorption of calcium. 3. Ascertain calcium content of drinking water. If nec- essary, use packaged beverages or distilled water for drinking and food preparation.","316 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 20-3 Classification of Foods According to Their Acid-Base Reactions in the Body Alkaline-Ash-Forming or Acid-Ash-Forming or Neutral Foods Alkaline-Urine-Producing Foods Acid-Urine-Producing Foods Milk and cream, all types Meat, poultry, fish, shellfish, cheese, eggs Butter, margarine, fats and oils Fruits except plums, prunes, Plums, prunes, cranberries (cooking), salad oil, lard Corn, lentils and cranberries Bread (especially whole-wheat bread not Cornstarch, arrowroot, tapioca Carbonated beverages Sugar, honey, syrup All vegetables except corn and lentils containing baking soda or powder) Nonchocolate candy Chestnuts, coconut, almonds Cereals, crackers Coffee, tea Molasses Rice, noodles, macaroni, spaghetti Baking soda and baking powder Peanuts, walnuts, peanut butter Pastries, cakes, and cookies not con- taining baking soda or powder Fats, bacon Fluid Intake 7. Egg and cheese omelet 8. Milk 1. Warn the patient about dehydration. Prescribe more 9. Carrots fluids if the patient perspires heavily or is losing fluid 10. Olives for other reasons. REFERENCES 2. Ascertain the reasons for withholding fluid, such as for scheduled medical tests. Check the validity of the American Dietetic Association. (2006). Nutrition Diag- official request. nosis: A Critical Step in Nutrition Care Process. Chicago: Author. 3. All concerned persons must ensure the patient re- ceives plenty of fluids during the day and the night. Axelsson, J. (2004). Truncal fat mass as a contributor to inflammation in end-stage renal disease. American PROGRESS CHECK ON ACTIVITY 4 Journal of Clinical Research, 80: 1222\u20131229. MULTIPLE CHOICE Beauvieux, M. C. (2007). New predictive equations im- prove monitoring of kidney function in patients with Circle the letter of the correct answer. diabetes. Diabetes Care, 30: 1988\u20131994. 1. The diet therapy indicated for a patient with cal- Beham, E. (2006). Therapeutic Nutrition: A Guide to cium phosphate kidney stones is: Patient Education. Philadelphia: Lippincott, Williams and Wilkins. a. low calcium and phosphorus, alkaline ash. b. high calcium and phosphorus, acid ash. Buchman, A. (2004). Practical Nutritional Support c. low calcium and phosphorus, acid ash. Technique (2nd ed.). Thorofeue, NJ: SLACK. d. high calcium and phosphorus, alkaline ash. Caglar, K. (2002). Approaches to the reversal of malnu- 2. In planning a diet for a patient with calcium phos- trition, inflammation, and atherosclerosis in end-stage phate kidney stones, which of the following foods renal disease. Nutrition Reviews, 60: 378\u2013387. could you use in unlimited amounts? Cheria, G. (2004). Role of L-arginine in the pathogene- a. fruits sis and treatment of renal disease. Journal of b. meat Nutrition, 134: 2801s\u20132806s. c. milk d. cheese Deen, D., & Hark, L. (2007). The Complete Guide to Nutrition in Primary Care. Malden, MA: Blackwell. MATCHING Eastwood, M. (2003). Principles of Human Nutrition (2nd Match the foods on the left to the type of restriction in an ed.). Malden, MA: Blackwell Science. acid-ash diet: Echols, M. S. (Ed.). (2006). Renal disease. Philadelphia: 3. Dried beans a. unrestricted Saunders. 4. Potato b. partially restricted 5. Cranberry relish c. not allowed Escott-Stump, S. (2002). Nutrition and Diagnosis- 6. Bananas Related Care (5th ed.). Philadelphia: Lippincott, Wil- liams and Wilkins. Hark, L., & Morrison, G. (Eds.). (2003). Medical Nutrition and Disease (3rd ed.). Malden, MA: Blackwell.","CHAPTER 20 DIET THERAPY FOR RENAL DISORDERS 317 Johansen, K. L. (2006). Association of body size with Sardesai, V. M. (2003). Introduction to Clinical Nutrition health status in patients beginning dialysis. American (2nd ed.). New York: Marcel Dekker. Journal of Clinical Nutrition, 83: 543\u2013549. Shils, M. E., & Shike, M. (Eds.). (2006). Modern Nutrition Mahan, L. K., & Escott-Stump, S. (Eds.). (2008). Krause\u2019s in Health and Disease (10th ed.). Philadelphia: Food and Nutrition Therapy (12th ed.). Philadelphia: Lippincott, Williams and Wilkins. Elsevier Saunders. Thomas, B., & Bishop, J. (Eds.). (2007). Manual of Di- Mann, J., & Truswell, S. (Eds.). (2007). Essentials of etetic Practice (4th ed.). Ames, IA: Blackwell. Human Nutrition (3rd ed.). New York: Oxford Univer- sity Press. Webster-Gandy, J., Madden, A., & Holdworth, M. (Eds.). (2006). Oxford Handbook of Nutrition and Dietetics. Payne-James, J., & Wicks, C. (2003). Key Facts in Clinical Oxford, London: Oxford University Press. Nutrition (2nd ed.). London: Greenwich Medical Media.","","OUTLINE CHAPTER 21 Objectives Nutrition and Diet Glossary Therapy for Cancer Background Information Patients and Patients Progress Check on Background with HIV Infection Information Time for completion ACTIVITY 1: Nutrition Therapy Activities: 1 hour in Cancer Optional examination: 1\u20442 hour The Body\u2019s Response to Cancer The Body\u2019s Response to Medical Therapy Planning Diet Therapy Nursing Implications Progress Check on Activity 1 ACTIVITY 2: Nutrition and HIV Infections Background Basic Role of Nutrition in HIV Infections General Guidelines for Nutrition Therapy in HIV Infections Nutrition in Terminal Illness Alternative Nutrition Therapies Special Nutritional Care for Children with AIDS Food Service and Sanitary Practices Nursing Implications Progress Check on Activity 2 References OBJECTIVES Upon completion of this chapter the student should be able to do the following: 1. Assess a client\u2019s nutritional status using physical examination, diet his- tory, and results of laboratory and clinical tests. 2. Identify factors that may alter nutrition. 3. Devise a plan for appropriate diet therapy based on client assessment, the stage of the disease, and its symptoms. 4. Identify the most common causes of malnutrition in patients with can- cer or AIDS. 5. Describe measures to enhance food intake and retention. 6. Identify dietary modifications to increase amounts of needed nutrients. 319","320 PART III NUTRITION AND DIET THERAPY FOR ADULTS 7. Describe methods for the following alterations: mod- Chemotherapy: treatment with anticancer drugs. ifying consistency, texture, and flavor suitable to the Dysgeusia: distortion of the sense of taste. patient\u2019s stage of illness and\/or treatment; increase Gliomas: primary intercranial tumors. the total amount of nutrients; modifications com- HIV (human immunodeficiency virus): the virus that repli- patible with the client\u2019s social, cultural, and ethnic beliefs. cates itself in the T cells and destroys the lymphocyte. Humoral immunity: specific acquired immunity in which 8. In conjunction with the oncology team (doctor, di- etitian, pharmacist), implement a nutrition care plan antibodies produced by B lymphocytes and plasma to promote optimal nutrition. cells predominate. Genetically programmed to recog- nize antigens and destroy them. 9. Provide nutrition instructions and council to pa- Hypogeusia: reduced taste. tient, family, and\/or significant others of patients Kwashiorkor: a severe protein deficiency disease. with cancer or AIDS. Leukemia: neoplasm of the blood cells. Lymphoma: cancer appearing in the lymph nodes, spleen, 10. Revise nutrition care plans as situations change. liver, and bones (Hodgkin\u2019s). Marasmus: a condition characterized by loss of body tis- Optional Objectives for Additional Study sue and strength owing to lack of sufficient caloric intake over a prolonged period. 1. Evaluate some unproven nutritional therapies often Metastasis: spread or transfer of cancer from one organ used by patients with cancer or HIV infections (refer or body part to another not directly connected to the to Chapter 12, Alternative Medicine). primary site. Opportunistic infections: infections caused by nondisease- 2. Review the essentials of food-handling precautions producing organisms when resistance has been de- used for all patients, but especially those with com- creased by surgery, illness, and other disorders. promised immune systems. Palliative care: care affording relief and comfort, but not cure, usually offered when the patient is terminally 3. Discuss foods and fluids that provide comfort dur- ill. ing the terminal phase of cancer or AIDS, and the Sarcoma: any malignant tumor of primary tissues other ethics of decisions sometimes described as \u201cheroic than those listed in carcinoma definition. measures.\u201d Staging: determination of the extent of cancer by the use of exams and diagnostic tests. GLOSSARY Stomatitis: inflammation of the oral mucosa involving the lining of the inside of the cheeks, tongue, palate, Adenocarcinoma: a cancer that begins in cells that line floor of the mouth, and gums. the internal organs. T cells: specialized lymphocytes in the immune response that originate from stem cells in bone marrow and AIDS (acquired immunodeficiency syndrome): a deadly migrate when mature to the thymus gland. viral disease that destroys the body\u2019s immune system Teratoma: a cancer of mixed components. by invading the helper T lymphocytes. Xerostomia: dry mouth. ARC (AIDS-related complex): the opportunistic infec- BACKGROUND INFORMATION tions that begin in a host when the immune system is compromised. Cancer is a group of more than 100 different diseases. Cancer occurs when cells become abnormal and keep di- Asthena: lack of strength or energy, debilitation. viding without control or order. Most cancers are named B cells: specialized lymphocytes that produce im- for the type of cell or organ in which they begin (see Glossary). Screening for cancer includes physical exam- munoglobulins. They originate in the bone marrow ination, laboratory tests and procedures, and the use of cells and involve many cells in the body in the im- imaging modalities to look at internal organs. The most mune response. common detection and diagnostic tools are CT (or CAT) Cachexia: severe malnutrition and emaciation marked scans, MRI, ultrasonography, endoscopy, and biopsy. by anorexia, unintentional weight loss, loss of muscle Common tests include blood and urine tests, Pap smears, and fat stores, anemia, and immunoincompetence. mammograms, fecal occult blood, and others as needed. Candidiasis: infection with the fungus of the genus Following the results of the screening, a determination Candida, appearing as whitish lesions in moist areas is made of the size and extent of the cancer, and a treat- of the skin or inner mucous membranes. ment plan is developed. This process is called staging. Carcinogen: any substance that causes cancer. Carcinoma: a cancer that begins in the skin or in tissue that lines or covers internal organs. Arises from the surface, glandular, or parenchymal epithelium. Cellular immunity: specific acquired immunity in which T lymphocytes predominate. A cell-mediated response, they multiply rapidly, engulf, and digest antigens.","CHAPTER 21 NUTRITION AND DIET THERAPY FOR CANCER PATIENTS AND PATIENTS WITH HIV INFECTION 321 The nutritional status of the individual predicts toler- 7. T F Many studies indicate that more cancer pa- ance and response to therapy. Individuals who do not tients die of malnutrition than from the lose weight have significantly longer survival time than disease. those who do. Malnourished individuals are most sus- ceptible to infection and less likely to tolerate or derive 8. T F Loss of independence does not create a major optimal benefits from therapy. Malnutrition is also an trauma on nutritional status. important issue in the quality of life of individuals diag- nosed with cancer. Many studies indicate that more can- MULTIPLE CHOICE cer patients die of malnutrition than from the disease. Circle the letter of the correct answer. Cancer and HIV infections share many similarities in the effects of malnutrition on the disease prognosis, pro- 9. Screening for cancer includes: gression, response to therapy, and the quality of life. Death in the individual with HIV syndrome is correlated a. physical examination. with the degree of loss of lean body mass, and sustained b. laboratory tests and procedures. weight loss is a predictor of progression to AIDS. c. use of imagining modalities to look at internal Numerous studies indicate that malnutrition can pre- dict death from AIDS. organs. d. all of the above. There are myriad nutritional and metabolic changes characteristic of both cancer and AIDS. These changes 10. Common tests for cancer include: are directly related to the body\u2019s response to the disease, treatment methods, surgical procedures, and psycholog- a. blood and urine tests. ical and emotional responses of the individual. They will b. pap smears. be discussed in detail in Activity 1. c. mammograms. d. fecal occult blood. A number of emotional factors contribute to nutri- e. all of the above. tional status, such as depression, guilt, fear, denial, pain, conditioned aversions, and reaction to drugs. Loss of in- 11. The nutritional status of the cancer patient dependence creates a major trauma. predicts: Formidable challenges face care providers and care- a. tolerance and response to therapy. givers of individuals who have cancer or HIV infections b. susceptibility to infection. and AIDS. This chapter deals with the nutritional aspects c. quality of life of individuals. of care. d. all of the above. PROGRESS CHECK ON BACKGROUND INFORMATION 12. Cancer and HIV infections share many similarities in the effects of malnutrition on: TRUE\/FALSE a. the disease prognosis and progression. Circle T for True and F for False. b. response to therapy. c. the quality of life. 1. T F Marasmus is a condition characterized by loss d. loss of lean body mass and sustained weight of body tissue and strength due to lack of suf- ficient caloric intake over a prolonged period. loss. e. all of the above. 2. T F Kwashiorkor is a common, severe protein de- ficiency disease in the United States. ACTIVITY 1: 3. T F T cells are regular lymphocytes in the immune Nutrition Therapy in Cancer response that originate from stem cells in bone marrow and migrate when mature to the thy- Nutrition therapy for cancer patients is highly individ- mus gland. ualized, depending on the body\u2019s response to the dis- ease, the site of the cancer, the type of treatment, and the 4. T F B cells are specialized lymphocytes that pro- specific physical and psychological responses of the pa- duce immunogloblins. They originate in the tient. Myriad metabolic and nutritional changes are bone marrow cells and involve many cells in characteristic of nearly all cancer patients. These in- the body in the immune response. clude fatigue, asthenia, cachexia, anorexia, anemia, fluid and electrolyte imbalances, hypogeusia or dysgeusia, xe- 5. T F Palliative care affords relief and comfort, but not rostomia, dysphagia, esophagitis, malabsorption, stom- cure, offered usually to terminally ill patients. atitis, nausea and vomiting, fever, altered metabolic rate, negative nitrogen balance, and edema. Infection is not 6. T F Staging is a process to develop a treatment plan uncommon. based on the results of screening and determi- nation of the size and extent of the cancer.","322 PART III NUTRITION AND DIET THERAPY FOR ADULTS THE BODY \u2019S RESPONSE TO CANCER TABLE 21-1 Common Nutritional Problems Occurring in Cancer Patients with The specific type of cancer, and the disease process itself, Three Major Treatment Modes has profound effects on the entire body system and cause primary nutritional deficiencies. Some examples of the Radiation Therapy (effects depend upon site of body\u2019s responses to several types of cancer are given in irradiation) the following paragraphs. Head, neck, or esophagus Cancers occurring in the gastrointestinal tract or ad- 1. Anorexia jacent tissue cause difficulty in ingestion and use of nu- 2. Impaired taste acuity trients. Obstruction curtails intake, and malabsorption 3. Reduced food intake interferes with digestion of fats and fat-soluble vitamins, 4. Tooth decay and gum disease especially vitamin D, which in turn leads to decreased 5. Difficulty swallowing metabolism and absorption of calcium, causing osteo- 6. Decreased salivary secretions and taste sensations malacia. Abdominal tumors may cause fistulas to develop, 7. Sensitivity to texture and temperature of food leading to bypass of the small intestine and consequent 8. Inflamed oral mucosa malabsorption. Adenocarcinoma of the colon leads to se- vere electrolyte imbalance. General malabsorption also Abdomen contributes to fluid and electrolyte imbalance. Vomiting 1. Loss of intestinal villi and absorbing surfaces and diarrhea result in loss of water-soluble vitamins. 2. Vascular changes 3. Inflammation Intestinal malignancies contribute to hypokalemia. 4. Obstructions Cancer of the bone, or breast cancer with metastasis to 5. Strictures, fistulas the bone, also lead to hypokalemia. Cancer within the 6. Anorexia and nausea thyroid gland will result in hormonal imbalances. 7. Malabsorption Pancreatic cancer and resulting pancreatectomy lead to 8. Diarrhea the loss of digestive enzymes and diabetes mellitus. Chemotherapy Anorexia, the most common symptom, is related to 1. Interference with production of both white blood cells altered metabolism, type of treatment, or emotional dis- tress. Increased hemolysis, bleeding of lesions, fistulas, and red blood cells and malabsorption of nutrients needed for hemoglobin 2. Nausea, vomiting, stomatitis, anorexia, ulcers, and di- formation (iron, protein, folic acid, vitamin B12, and vi- tamin C) lead to severe anemia. arrhea; response of the GI system similar to those that occur in radiotherapy THE BODY \u2019S RESPONSE TO MEDICAL 3. Body fluid and electrolyte disturbances THERAPY 4. Hair follicle loss Current cancer therapy takes three major forms: sur- Surgical Therapy (effects site dependent) gery, radiotherapy, and chemotherapy. Sometimes they are used in combination. Nutrition support for these GI Tract modalities enhances chances of success of the treat- ments. See Table 21-1. 1. Impaired food ingestion Surgery 2. Malabsorption Surgical procedures pose special nutritional problems 3. Potential dumping syndrome depending on the site. For example, head and neck sur- gery or resections greatly affect intake, requiring differ- 4. Possible low blood glucose following gastric resection ent feeding methods, feeding intervals, and modifications in oral food preparation. 5. Insulin deficiency from resection of the pancreas (dia- betes mellitus) Nutrition goals for surgical procedures include the following: 6. Fluid and electrolyte imbalances 1. Provide optimal nutrition preoperatively and maxi- 7. Head and neck surgery or resection poses special feed- mum support postoperatively to facilitate the heal- ing problems: different feeding methods (enteral or ing process and overall body metabolism. parenteral) and feeding intervals, and modifications in oral food preparation. 2. Provide specific modifications of the nutrients ac- cording to the surgical site and organ function Radiotherapy involved. Radiation therapy significantly influences nutritional sta- tus, depending on the site and intensity of the treatment. 1. Radiation to the head and neck or esophagus affects oral mucosa, salivary secretions, taste sensation, and sensitivity to temperature and texture of food. The","CHAPTER 21 NUTRITION AND DIET THERAPY FOR CANCER PATIENTS AND PATIENTS WITH HIV INFECTION 323 nutrition plan will include the alterations necessary for all major nutrients, including fluids, are based on the to overcome these effects. demands of the disease and treatment. Individual needs 2. Radiation to the abdomen may produce loss of intes- may vary, but the general guidelines are the same. tinal villi and absorbing surfaces, vascular changes, ulcer formation, inflammation, obstructions, stric- 1. Energy: Increase total energy value to prevent exces- tures, and curtailment of food (from anorexia and sive weight loss and meet increased metabolic de- nausea). Many alterations and modifications in the mands. An adult in good nutritional status requires nutrition plan will be needed to provide aggressive less than 2000 kcalories per day for maintenance. A nutrition therapy to these patients. severely malnourished patient may require 3000 to 4000 kcalories. Carbohydrates should supply most of Chemotherapy the energy intake with fat restricted to about 30% of total calories. Chemotherapy has the same effect on normal cells as they do on cancer cells. This becomes most apparent in 2. Protein: Provide additional amino acids and nitrogen changes in the bone marrow, hair follicles, and GI tract. for healing and tissue regeneration. An adult in good nutritional status requires less than 80\u2013100 g for 1. Bone marrow effects include interference with pro- maintenance and anabolism. A malnourished patient duction of both white and red blood cells, producing will need more, depending on individual requirement anemia, infection, and bleeding. and treatment(s). 2. GI effects include nausea, vomiting, stomatitis, 3. Vitamins and minerals: Key vitamins and minerals anorexia, ulcers, and diarrhea. control energy, protein, and amino acid metabolism. Review Chapters 2 through 6 for specifics. Some char- 3. Hair follicle effects are body hair loss and alopecia. acteristics are given here. The B-complex vitamins are coenzymes in protein and energy metabolism. PLANNING DIET THERAPY Vitamins A and C are components of tissue structure. Vitamin C is also an antioxidant and functions in im- Table 21-2 summarizes the guidelines in planning diet mune and enzyme reactions. Vitamin A functions in therapy for cancer patients. The objectives of diet ther- cell differentiation and protective immunity. Vitamin apy are to do the following: D has a vital role in the metabolism of calcium and phosphorus in bone and blood serum. Vitamin E pro- 1. Meet the increased metabolic demands of the disease tects the integrity of cell walls. Many minerals have and prevent catabolism of the body tissues. structural and\/or enzymatic roles in metabolic and tissue building processes. 2. Alleviate symptoms of the disease and its treatment by adapting the food and feeding methods to the 4. Water is second only to oxygen as the most impor- individual. tant nutrient in the human body, and maintenance of the fluid and electrolyte balance is especially crucial The basis for planning care includes: in cancer. Review Chapter 6 for the functions and dis- tribution of body water. 1. Thorough personal nutrition assessment 2. Vigorous nutrition therapy to maintain good nutri- Many individuals with cancer or AIDS subscribe to unproven nutritional therapies, from personal beliefs tional status and support that it will help them take control of their disease, on 3. Revision of care plan as individual status changes the advice of family and friends, or information found on Web sites and other media. Herbal remedies, macro- Major eating problems, as discussed earlier, are: biotic diets, metabolic therapy, and thymus gland extracts are often encountered by the healthcare profes- 1. Appetite problems include anorexia caused by sys- sional when taking diet histories. Megavitamin and min- temic effects of cancer and treatment modalities, de- eral therapies (taking 10 times the RDAs\/DRIs) are pression, anxiety, and stress. These problems lead to among the most often used. Vitamins that are popular are cancer cachexia. A, C, B12, and thiamine, and the minerals iron, zinc, and selenium. 2. Mouth problems caused by stomatitis, sore mouth, dysgeusia, hypogeusia, low salivary production, and These therapies and others can be harmful, and more candidiasis often occur. details are described in Chapter 12 on alternative medicine. 3. Gastrointestinal problems, in the upper intestine, in- Special considerations in feeding a cancer patient in- clude nausea, vomiting, bloating, postgastectomy clude the following: dumping syndrome, and so on. In the lower intes- tine, diarrhea, constipation, lactose intolerance, and 1. Do not provide drinks during meal time if the patient so on occur. experiences nausea. Separate liquid from solid foods. Each of the following factors is related to tissue pro- tein synthesis and energy metabolism. Increased needs","324 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 21-2 General Guidelines for Nutrition Therapy There are no exact rules for diets for the cancer patient because each is highly individualized. The general guidelines in the following table will be helpful in planning optimal nutrition for a patient, based on the alterations that you find when you assess the needs of the individual. Alterations \u2022 Modify consistency as liquids may be difficult to swallow; soft foods are better tolerated. Liquids Pain, nausea, decreased taste sensations, diarrhea, fever, can be thickened to semisolid consistency. decreased appetite, anorexia \u2022 Wait one or two minutes between bites. Appropriate Interventions \u2022 Cool foods are better tolerated. \u2022 Avoid spicy, acidic, or irritating foods. \u2022 Small, frequent high-caloric, high-protein meals with snacks between meals and at bedtime. Alterations \u2022 Calorie-dense supplements that provide 100% of all Nausea, vomiting required nutrients. Appropriate Interventions \u2022 Milkshakes and custards are good snack foods. Avoid milk products if lactose deficiency or diarrhea is \u2022 Offer foods cold or room temperature and soft, salty present. foods as tolerated. \u2022 Increase foods with high liquid content, such as \u2022 No greasy, spicy, or rich foods. sauces, gravy, or broth if dry mouth is a problem. \u2022 Separate intake of liquids from solids by at least an \u2022 Use appetite stimulants, pain medications, or hour. antiemetics as needed. \u2022 Offer crackers or dry toast. \u2022 Offer high-protein, high-calorie milkshake \u2022 Provide an attractive environment. supplements. Alterations \u2022 Use antinausea medications before meals. Diminished taste, unpleasant taste in mouth, food Alteration aversions Constipation Appropriate Interventions Appropriate Interventions \u2022 Increase taste sensations: add spices, flavorings such as herbs, lemon, sugar, and wine. \u2022 Offer high-fiber foods, including fresh fruits and veg- etables. \u2022 Remove any foods to which client is adverse. Substitute foods of equal nutrient value. \u2022 Offer extra fluids. \u2022 Provide stool softeners when needed. \u2022 Frequent rinsing of mouth, brushing helps. \u2022 Fluids with meals and throughout the day. Alterations \u2022 Use temperature extremes (hot\/cold) to stimulate Diarrhea, malabsorption taste buds. \u2022 Foods served in attractive environment. Appropriate Interventions \u2022 Eliminate any unpleasant odors. \u2022 Plastic eating utensils may be substituted if client \u2022 Provide a low-residue diet and supplements. \u2022 Offer small frequent feedings at room temperature. has a metallic taste in mouth. \u2022 Avoid gas-forming, fatty, or high-lactose foods; citrus \u2022 Zinc deficiencies sometimes present; supplement fruits; alcohol; caffeine; and caffeine-containing may be necessary (doctor\u2019s order). beverages. \u2022 Use soy supplement formulas. Alterations \u2022 Provide foods high in sodium and potassium (ba- nanas, potatoes, bouillon, Gatorade, etc.). Stomatitis, esophagitis, sore mouth \u2022 Provide foods high in soluble fiber (applesauce, oat- meal, cream of wheat, others). Appropriate Interventions \u2022 Provide 8 c fluid if tolerated. \u2022 Administer antidiarrheal medications. \u2022 Offer frequent small meals and snacks with soft tex- \u2022 Provide multivitamin supplements. ture, bland, cool to cold. Alteration \u2022 Avoid acidic foods and juices, very hot or very cold foods, and spices. Fever \u2022 Avoid hard or irritating foods. Appropriate Interventions \u2022 Use chilled foods and fluids, cooled oral supplements. \u2022 Brush with a soft toothbrush 2\u20133 times daily. \u2022 Increase fluid volume. \u2022 Use topical analgesics before meals to decrease pain. \u2022 Use refrigerated foods. \u2022 Sprays, mouthwash, baking soda, or salt rinses used \u2022 When planning the diet, include the patient, his or to patient tolerance. her family members, caregivers, and others who may be able to help with selection of allowed foods. Alteration Remember to take into account cultural, ethnic, and religious beliefs. Dysphagia Appropriate Interventions \u2022 Offer small, frequent, high-protein, high-calorie meals, supplemented with calorie-dense high-protein puddings. Source: Adapted from Wilkes, G. M. (1999). Cancer and HIV nutrition (2nd ed.). Sudbury, MA: Jones and Bartlett Publishers.","CHAPTER 21 NUTRITION AND DIET THERAPY FOR CANCER PATIENTS AND PATIENTS WITH HIV INFECTION 325 2. If the patient has diarrhea, avoid the following: 10. Encouragement and support are very helpful. These a. Vitamin C supplements in high dosage have a positive effect on a patient\u2019s emotional status. b. Laxative teas They denote caring, comfort, and concern. Emphasize c. Foods containing sorbitol such as sugar-free candy eating to get well, and health and wellness instead of and gums illness. d. Dairy products rich in lactose e. Caffeine 11. Investigate the use of enteral and\/or parenteral meth- ods of feeding if they become necessary. Oral intake 3. If the patient has a decreased appetite, do not recom- is preferred but may not be feasible in some cases. mend large meals. 12. Client education, with the nurse either as the pri- 4. If the patient has oral thrush, avoid the following: mary teacher or as support teacher in a team effort, a. Salty, hot, and\/or spicy foods is effective in gaining desired goals. b. Acidic foods such as citrus fruits, tomato-based products, vinegar or vinegar-based foods 13. Frequent follow-up teaching is desirable. 5. If the patient has difficulty in swallowing, avoid foods PROGRESS CHECK ON ACTIVITY 1 that are difficult to swallow. Examples include sticky foods such as peanut butter. FILL-IN 6. If a patient is insulin resistant, avoid a low-fiber diet. 1. Individualized nutrition therapy for cancer pa- 7. If the patient experiences a change in taste sensation, tients is dependent on: a. do not use oral supplements in metallic cans. b. NURSING IMPLICATIONS c. The effectiveness of cancer treatments and patient\u2019s sub- sequent recovery depend in large part upon adequate nu- d. trition. Both are affected by nutrition intake and utilization. e. 1. Malnutrition in a cancer patient is not inevitable. 2. Name five nutritional changes characteristic of Most patients can be adequately nourished, if properly cancer patients: planned and executed nutrition therapy is provided. a. 2. Be aware that nutrition therapy must be proactive. b. Early assessment, intervention, and continuing preventive measures to prevent malnutrition are c. mandatory. d. 3. Nutrition therapy is designed for specific physical and psychological needs and is highly individualized, de- e. pending upon the response of each body system to the disease and treatment modality. 3. Nutrition goals for surgical procedures include: a. 4. Nutrition care plans are patient centered: patients need to have some control in planning during dis- b. ease stages and therapy effects. c. 5. Anticipate psychosocial situations that relate to ap- petite, various foods, drug effects, lifestyle, and be- 4. The basis for planning diet therapy for cancer pa- liefs of the client. tients includes: a. 6. Provide the patients with information regarding symptoms they are experiencing, actions of their drug b. regimes, and mouth care tips they can do themselves. c. 7. Make a thorough assessment of energy, protein, elec- trolyte, fluid, and micronutrient needs of the patient 5. Three major effects of chemotherapy on the body to use as a baseline for planning diet. are: 8. Nutritional assessment includes physical examina- a. tion, lab measurements (albumin, lymphocyte count, CBC, nitrogen balance, others), past medical history, b. present dietary intake (24-hour recall), and any other factors affecting intake. c. 9. Make revisions in the patient\u2019s diet as situations change."]