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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 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 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 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 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 38 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 39 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. 40 Phosphorus Phosphorus restriction is recommended as soon as an elevated blood level is seen Some experts think 800-1000mg of phosphorus daily is adequate 41 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. 42 That was the early stages of CKD Any questions? 43 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 44 Types of treatment Peritoneal dialysis Hemodialysis Transplant 45 Peritoneal Dialysis Removes wastes and fluid Catheter in the abdomen Several exchanges daily 46 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 47 Medical Nutrition Therapy Calories Protein Fluids Sodium Potassium Phosphorus Calcium Vitamins 48 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 49 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 51 Sodium Helps regulate body fluid volume and balance Limiting sodium helps to prevent: Excessive thirst Fluid retention Elevated blood pressure 52 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 53 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 54 Fluid Allowance 1.0 to 1.5 liters per day Includes all foods liquid at room temperature 55 Potassium Mineral required for muscle contraction and nerve function Goal: Maintain levels between 3.5 and 5.5 mEq/L 56 Potassium Symptoms of elevated potassium or hyperkalemia are: Muscle weakness Numbness and tingling of extremities Decreasing pulse rate Cardiac arrest 57 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 58 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 59 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 60 Calcium Mineral needed for: healthy bones muscle contraction & relaxation proper nerve functioning Goal: Maintain level between 8.5 – 9.5 mg/dl 61 Calcium Allowance 2000 mg Sources to limit: Dairy products (milk, cheese, yogurt, ice cream) Fortified foods Medications 62 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