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Dru Ledder MS RD
Nutrition Therapy for
Cardiovascular Disorders
 More than ½ the people who die in the US die from
heart and blood vessel disease
 75% of all hospitalized patients show symptoms of
heart problems
Nutritional Risk Factors in Heart
Disease
 Elevated cholesterol
 Elevated triglycerides
 Obesity
 Hypertension
 Generally poor eating habits and sedentary lifestyle
Lipid Criteria
Total Cholesterol
 <200 mg/dL – Desirable
 200-239 mg/dL: Borderline High
 >240 mg/dL: High
LDL Cholesterol – “Lousy” Cholesterol  - want these numbers
Low
 <100 mg/dL: optimal
 100-129 mg/dL: Near optimal/above optimal
 130-159 mg/dL: Borderline high
 160-189 mg/dL: High
 <190 mg/dL: Very high
Lipid Criteria
HDL Cholesterol – “Happy” Cholesterol  - want these numbers
High
 <40 mg/dL: Low
 >60 mg/dL: High
Triglycerides
 <150 mg/dL: Normal
 150-199 mg/dL: Borderline high
 200-499 mg/dL: High
 >500 mg/dL: Very high
Nutrition Therapy for Cholesterol
& Lipid Disorders
Therapeutic Lifestyle Changes (TLC)
 Saturated Fat - <7% of total calories
 Polyunsaturated Fat – up to 10% of total calories
 Monounsaturated Fat – Up to 20% of total calories
 Total Fat: 25 – 35% of total calories
 Carbohydrate: 50 – 60% of total calories
 Fiber: 20 – 30 grams/day
 Protein: 15% of total calories
 Cholesterol: Less than 200 mg/day
 Total Calories: Balance energy intake and expenditure
to maintain desirable body weight/prevent weight gain
Hypertension Criteria
 Normal: <120/80
 Pre-hypertension: 120/80 – 139/89
 High blood pressure
 Stage 1: 140/90 – 159/99
 Stage 2: >160/100
Nutrition Therapy for Hypertension
Dietary Approaches to Stop Hypertension (DASH) flexible and balanced eating plan that has been shown to
lower high blood pressure
 Research shows that the DASH eating plan lowers blood
pressure. The plan:
 Is low in saturated fat, cholesterol, and total fat
 Focuses on fruits, vegetables, and fat-free or low-fat milk and
milk products
 Is rich in whole grains, fish, poultry, beans, seeds, and nuts
 Contains fewer sweets, added sugars and sugary beverages,
and red meats than the typical American diet
DASH Guidelines
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Total fat - 27% of calories
Saturated fat - 6% of calories
Protein - 18% of calories
Carbohydrate - 55% of calories
Cholesterol - 150 mg
Sodium - 2,300 mg* (1,500 mg of sodium was a lower goal
tested and found to be even better for lowering blood
pressure)
Potassium - 4,700 mg
Calcium - 1,250 mg
Magnesium - 500 mg
Fiber - 30 g
Class Activity
 Fat & Sodium Explorer
 http://www.americanheart.org/fatsandsodiumexplore
r/explorer.html
QUESTIONS???
Nutrition Therapy for Diabetes
Data from the 2007 National Diabetes Fact Sheet (the
most recent year for which data is available)
 Total: 23.6 million children and adults in the United
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States—7.8% of the population—have diabetes.
Diagnosed: 17.9 million people
Undiagnosed: 5.7 million people
Pre-diabetes: 57 million people
New Cases: 1.6 million new cases of diabetes are
diagnosed in people aged 20 years and older each year.
Types of Diabetes
 Type 1 – Insulin dependent
 Type 2 – Insulin Resistance
 Gestational Diabetes
 Pre Diabetes
Diabetes – Risk Factors
 Age: >60 years
 Ethnicity: African-Americans, Native Americans,
Pacific Islanders, Asian Americans
 Genetics and family history
 Obesity
 History of gestational diabetes
 Impaired glucose metabolism: prediabetes
 Physical inactivity
Diagnosing Diabetes
Diabetes – Nutrition Assessment
 Body weight, height, BMI
 Waist circumference
 Men >40 inches and women >35 inches shown increase
in insulin resistance
 Blood pressure
 Lab work
 Hemoglobin A1C
 Fasting glucose
 Urinary glucose
 BUN & creatine
 Lipid profile
Diabetes – Nutrition
Recommendations
How the body uses CHO
 Carbohydrate foods (grains, starches, fruit, sweets) break
down to GLUCOSE
 Protein foods (meats, nuts, beans) break down to AMINO
ACIDS
 Fat foods (oils, butter, margarine, avocado, bacon) break
down to FATTY ACIDS.
 CHO foods have greatest immediate influence of Blood
Sugar
Diabetes – Nutrition
Recommendations
Campfire illustration
 CHO foods like kindling. Hot fire but goes out. Can result
post meal burn out or lack of energy
 Especially with insulin resistance can often result in low
blood sugar after meals of primarily CHO
 Low blood sugars result in craving sweets & starches
 Headaches – usually resolved by eating
 Protein & Fat are like the big logs that burn slow and make
coals. Extends your energy.
 Strive for a meal that has a mix of CHO foods, lean protein,
healthy fats (ie. olive oil)
Diabetes – Nutrition
Recommendations
Individualized Meal Plan
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Calorie & CHO goal
Exercise recommendations
Coaching & support for behavior change
Weight loss
Additional factors for other health concerns
 Sodium
 Fats
 Calcium/Magnesium/Potassium
 Fluids/Fiber
Diabetes – Nutrition
Recommendations
Survival Skills
 3 meals per day and 2-3 snacks each day
 Reading a food label, to find CHO content
 Limit sugar in beverages, jello, candy, overt source of
glucose etc.
 Somewhat even distribution of CHO foods per meal
throughout the day to help normalize blood sugars
 Keep a food record for follow up visit and more
detailed instruction and recommendations
Joslin Diabetes Center Nutrition
Guidelines
 Carbohydrates - 40% of total caloric intake - total
should not be less than 130 gm/day
 Fiber - 20-35 gm
 Fat - 30-35 % of total caloric intake
 Saturated fat should be limited to < 10% of total caloric
intake or < 7% in individuals with LDL-Cholesterol > 100
mg/dl
 Polyunsaturated fat should comprise up to 10% of total
calories
 Monounsaturated fat up to 15-20% of total calories.
 Protein 20-30% of total caloric intake
Suggested Macronutrient Distribution
According to Clinical Guidelines
Diabetes Meal Planning
 3 meals, and snacks as needed – depending on
medications.
 Meals:
 Women/weight loss : 30-45 grams carbohydrate per
meal (2-3 servings of carbohydrate)
 Men/weight loss : 45 – 60 grams carbohydrate per meal
(3-4 servings of carbohydrate)
 Snacks
 Women/weight loss: 0-15 grams carbohydrate per snack
(0-1 servings carbohydrate)/ add protein or veggies
 Men/weight loss: 0-30 grams carbohydrate per snack (12 servings carbohydrate)/add protein or veggies
Diabetes Meal Planning - Sample
Meal Plan
 1800 calories/180 g CHO
 Breakfast 500 calories/45 g CHO
 Lunch
500 calories/45 g CHO
 PM Snack 100 calories/30 g CHO
 Supper
500 calories/45 g CHO
 HS Snack 200 calories/15 g CHO
or 3 CHO choice
or 3 CHO choice
or 2 CHO choice
or 3 CHO choice
or 1 CHO choice
Class Activity
Diabetes Risk Test
http://www.diabetes.org/diabetesbasics/prevention/diabetes-risk-test/
QUESTIONS???
Liver
 A normal liver regulates the proper digestion,
metabloism, and absoprtion of food
 Diseases of the liver can adversly affect gastrointestinal
function and the use of food
Nutrition Therapy for Hepatitis
 Viral hepatitis - inflammation of the liver
 The goal of nutrition management for hepatitis is to
promote liver tissue healing
Nutrition Therapy for Hepatitis
 Protein: 1.2 – 1.5 grams/kg body weight/day
 Carbohydrate: no restriction – monitor glucose and adjust
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as necessary
Fat: 30% of calories – restrictions only with maldigestion
due to reduced synthesis and secretions of bile acids
Calories: 25 – 35 kcal/kg body weight/day
Multivitamin supplement at 100% RDAs/DRIs
Fluid and sodium restriction if edema or ascites present
If adequate nutrition cannot be maintained by oral feeding,
enteral feedings or TPN may be indicated
Nutrition Therapy for Cirrhosis
 Cirrhosis is the final stage of certain liver injuries
(alcoholism, untreated hepatitis, bilary obstruction,
drug/poison ingestion)
 Malnutrition, chronic acute hepatitis, and excessive
intake of vitamin A can induce cirrhosis
Nutrition Therapy for Cirrhosis
 Protein: 75 – 100 grams/day (If hepatic coma is not
indicated)
 Sodium: Edema and/or ascites is counteracted 500 – 1000
mg sodium. Fluid intake may be limited
 Texture
 Esophageal varices present – semisolid or liquid diet to avoid
potential rupture
 Tube feedings not advised
 Avoid coffee, tea, pepper, chili powder, or any other irritating
seasonings
 Patients with poor appetite
 Oral nutritional supplements, vitamin/mineral supplements,
electrolyte replacements, parenteral feedings
QUESTIONS???
Gallbladder & Pancreas
 Gallbladder function is to concentrate and store bile
from the liver
 When fat enters the duodenum, it stimulates the
release of bile which helps emulsify fats so they can be
broken down
 When gallstones are present, they block the flow of
pancreatic juices and pancreatitis can occur
 Alcoholism can also cause pancreatitis
Nutrition Therapy for Cholecystitis
(inflammation of the gallbladder)
 Chronic cholecystitis
 Fat/calorie controlled diet
 Adequate amounts of carbohydrates & fiber
 Acute cholecystitis
 Low fat diet
 Decrease gas forming veggies
 Fat soluble vitamins may need to be replaced
 Cholecystectomy
 Fat intake limited for several months
 Introduce fats gradually
Nutrition Therapy for Acute
Pancreatitis
 Goal is to prevent the secretion of pancreatic enzymes
 Start NPO using TPN feedings
 As healing progresses, the diet can progress
 Clear liquid with amino acids, predigested fats
 Bland diet in 6 small feedings
 No stimulants
Nutrition Therapy for Chronic
Pancreatitis
 Low fat diet
 Vitamin and mineral supplementation – especially fat
soluble vitamins (A, D, E, K), and B complex
 Tube feedings or TPN may be necessary
 No alchohol
QUESTIONS???
Kidney Disease
 2 kidneys
 Each the size of your fist
 One on each side of your spine
 Weight 4-6 ounces each
 Nephron - the basic functioning unit of the kidney
 1 million per kidney
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What do they do?
 Remove waste products and extra fluid from
the blood by forming urine
 Keep blood chemicals in balance
 Produce some of the body’s hormones to
control anemia, blood pressure, and bone
health
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Diet with CKD – Early Stages
 Protein: To restrict or not to restrict?
 For persons in stages, 1, 2,3 – protein intake is often
limited to 12-15% of each day’s calorie intake or to .8
grams/kg body weight.
 Persons with Stage 4 CKD may be advised to reduce
protein to 10% of calorie intake each day, which is .6.75 grams protein/kg body weight.
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Phosphorus
 Phosphorus restriction is recommended as soon as an
elevated blood level is seen
 Some experts think 800-1000mg of phosphorus daily is
adequate
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Potassium
 If the level is high, a low potassium diet is prescribed.
Restricting such foods as avocados, dried fruits
(raisins, apricots, prunes), potatoes, oranges, bananas,
and salt substitutes is often needed.
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That was the early stages of CKD
Any questions?
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Treatment for Stage 5
 A treatment for Stage 5 kidney disease
 Blood is cleaned through filtration
 a natural filter inside the body (peritoneal dialysis)
 an artificial filter outside of the body (hemodialysis)
 Dialysis must be done on a regular basis to
replace kidney function
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Types of treatment
 Peritoneal dialysis
 Hemodialysis
 Transplant
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Peritoneal Dialysis
 Removes wastes and fluid
 Catheter in the abdomen
 Several exchanges daily
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Hemodialysis
 Blood circulates through a filter (dialyzer) to remove
wastes and fluid
 A machine controls speed and safety factors
 Hemodialysis can be done in-center or at home, night
or day
 Traditional: At a dialysis facility
 3 treatments/week - 3 to 4 hours each treatment
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Medical Nutrition Therapy
Calories
 Protein
 Fluids
 Sodium
 Potassium
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Phosphorus
 Calcium
 Vitamins
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Calories
 Calorie requirements: 30 to 40 kcal/kg of actual
or Adjusted BW/day
 Adjusted to maintain, decrease, or increase
actual body weight as desired
 Individualized for carbohydrate, fat and
cholesterol recommendations
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Protein
 Essential for growth, maintenance, preventing
infection, and anemia
 Important for wound healing and repair
Protein Requirements
 1.2 to 1.5 gm/kg Adjusted Body Weight per day
 50% to 60% high biological value
 Increased needs in catabolic states
 Adequate calories for protein sparing
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Sodium
 Helps regulate body fluid volume and balance
 Limiting sodium helps to prevent:
 Excessive thirst
 Fluid retention
 Elevated blood pressure
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Sodium Allowance
 2.0 to 3.0 gm (2000 to 3000 mg)/day
 May be higher for patients with residual renal function
and those on peritoneal dialysis
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Fluids
 Fluid accumulates in the body between dialysis
treatments
 Interdialytic weight gain
 3 to 5% of EDW
 Excess fluid can cause:
 Edema
 Shortness of breath
 Hypertension
 Congestive heart failure
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Fluid Allowance
 1.0 to 1.5 liters per day
 Includes all foods liquid at room temperature
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Potassium
 Mineral required for muscle
contraction and nerve function
 Goal:
 Maintain levels between 3.5 and 5.5 mEq/L
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Potassium
 Symptoms of elevated potassium or
hyperkalemia are:
 Muscle weakness
 Numbness and tingling of extremities
 Decreasing pulse rate
 Cardiac arrest
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Potassium Allowance
 2.0 to 3.0 gm (2000 to 3000 mg) per day
 Based on lab values
 Allowed more if residual renal function or on
peritoneal dialysis
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Phosphorus
 Mineral widely available in many foods
 85-90% found in bones & teeth
 Vital to energy production and storage
 Goal:
 Maintain levels between 3.5 and 5.5 mg/dl
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Phosphorus Allowance
800 – 1000 mg
 ½ cup milk ~100 mg
 1 ounce cheese 100 – 290 mg
 ½ beans (pinto, lima) = 125 mg
 3 ounces meat = 195 mg
 1 ounce nuts = 120 mg
 2 tablespoons peanut butter = 120 mg
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Calcium
 Mineral needed for:
 healthy bones
 muscle contraction & relaxation
 proper nerve functioning
 Goal:
 Maintain level between 8.5 – 9.5 mg/dl
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Calcium Allowance
 2000 mg
 Sources to limit:
 Dairy products (milk, cheese, yogurt, ice cream)
 Fortified foods
 Medications
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Nutrition and Renal-Related
Laboratory Measures
Healthy
Stage 5 CKD
BUN mg/dl
<25
50 – 100
Creatinine mg/dl
<1.6
10 – 18
Albumin g/dl
>4.0
≥4.0
14 – 18
11 – 12
>25
25 – 50
Ferritin ng/ml
12 – 300
100 – 500
Potassium mEq/l
3.5 – 5.0
3.5 – 5.5
Corrected Calcium mg/dl
8.5 – 10.5
8.4 – 9.5
Phosphorus mg/dl
2.5 – 4.5
3.5 – 5.5
<100
150 - 300
Hg g/dl
Iron Saturation %
Intact PTH pg/ml
QUESTIONS???
References
 Stanfield, P. & Hui, Y.H. (2010). Nutrition and Diet
Therapy, Self-Instructional Approaches.
Massachusetts: Jones and Bartlett Publishers.
 Escott-Stump, S. (1997). Nutrition and Diagnosis
Related Care. Lipincott Williams & Wilkins.
 NHLBI DASH Eating Plan -
http://www.nhlbi.nih.gov/health/dci/Diseases/dash/dash_
what.html
 Joslin Dietary Guidelines http://www.joslin.org/docs/Nutrition_Guideline_Graded.p
df
 Erin Hetrick, MS, RD, LDN – Kaplan University Professor &
Renal Dietitian