final Flashcards
(150 cards)
1
Q
EN
A
- tube feeding
- pertaining to the intestine
- providing nutrition directly into the GI tract
2
Q
PN
A
- pertaining to beside the intestine
- IV nutrition
- PPN and CPN
- TPN is outdated term
3
Q
when is EN needed
A
- inability to eat/eat enough
- impaired digestion, absorption, metabolism
- gut works
4
Q
contraindications of EN
A
- illeus
- complete obstruction of small or large bowel
- severe diarrhea without response to medication
- intractable vomiting
- high output external fistual
- hypovolemic or septic shock
- very poor prognosis
5
Q
short term access routes
A
nasogastric, orogastric, nasoenteric (if patient is at risk for aspiration, esophageal reflux, or delayed gastric emptying
6
Q
long term access routes
A
PEG, PEJ (decrease risk of tube feeding related aspiration)
7
Q
prepyloric feeding
A
- delivering nutrition into the stomach
- standard method
- NG tube, PEG
8
Q
post pyloric feeding
A
- delivering nutrition past the pyloric valve, into the small intestine
- used when gastric emptying is impaired, high risk of aspiration, severe gastric reflux, intestinal surgery history
- ND tube, jejunostomy
9
Q
elemental/semi elemental EN formula
A
- broken down/hydrolyzed macronutrients
- used for patients with enzyme deficiency, malabsorption, or other conditions resulting in maldigestion
10
Q
continuous tube feeding
A
administered over 8-24 hours daily
using pump to control feeding rate
11
Q
intermittent tube feeding
A
administered several times daily, over 20-30 min
using pump to control flow rate, or by gravity drip
12
Q
bolus tube feeding
A
administration of 250-500 mL of formula several times daily, using syringe to inject feedings through the tube
13
Q
ASPEN initiation and advnacement of EN
A
initate at 10-40 mL/h
advance by 10-20 mL/h every 6-8 hours to gaol rate
14
Q
ASPEN goals for non critically and critically ill
A
non critically: meet 80% of needs by 24-48h after initation
critically ill: initate EN within 24-48 h of admission (hemodynamically stable). meet 80% of needs by 72h after initiation
15
Q
ASPEN gastric residuals for monitoring tube feeding requirement
A
recommends against routine monitoring of gastric residuals
avoid holds on EN when gastric residuals are <500mL without other signs of intolerance
16
Q
refeeding syndrome
A
- potentially fatal
- large risk for malnourished people who begin nutrition support
- when a patient begins nutrition support, serum P, K, and Mg, will be abnormally low
- prevented by low initation/advancement of EN. avoid fluid overlead
17
Q
free water flushes
A
- flushing the feeding tube to prevent clogs and provide additional fluid requirements
- min 30 mL every 4 hours for continuous feeding, or before/after intermittent feeding
18
Q
propofol/diprivan
A
- medication/sedative for mechanically ventilated critically ill
- provides 1.1 kcal/mL, goes towards lipids
- mL/h * 24 hours * 1.1 kcal/mL = kcal/d
19
Q
nasogastric
A
- short term
- nose to stomach
- used when ok to have nasal placement
20
Q
nasoenteric
A
- short term
- nose to small intestine
- preferred if patient is at risk for aspiration, esophageal reflux, or delayed gastric emptying
21
Q
PEG (percutaneous endoscopic gastrostomy)
A
- long term
- less expensive, easy to insert, allows for bolus feeds
22
Q
PEJ (percutaneous gastrojejunostomy)
A
- long term
- decrease risk of tube feeding related aspiration, feeding pump required
23
Q
peripheral parenteral nutrition (PPN)
A
- administration of large volume, dilute solutions of nutritents into a small peripheral vein in the arm or back of the head
- short term
- most often used while awaiting a central line placement
- risk of vein collapse
- osmolarity must be <900 mOsm/L
- inappropriate for fluid restricted patients
- difficult ot maintain peripheral vein access for more than a few days
24
Q
central parenteral nutrition (CPN)
A
PICC
inserted in the arm and threaded into subclavin vein to the vena cava
long term
25
when to start PN if malnourished, nourished, and when to delay
- malnourished: ASAP
- nourished: after 7d if unable to recieve 50%+ of estimated requirements by oral or EN
- delay in patients with severe metabolic instability until the patient's condition has improved
26
two in one solution
- includes dextrose and amino acids
- lipids are separate
- advantage: greater flexibility in the amounts of dextrose and amino acids. any precipate can be observed
- disadvantage: requires two administration sets
27
three in one solution
- total nutrient admixture (TNA)
- includes dextrose, amino acids, and lipids
- advantage: requires one administration set
- disadvantage: opaque, so can't see precipate. electrolytes and final concentration of amino acids are limited
28
carb in PN
dextrose, 3.4 kcal.g
29
glucose influsion rate. reccomended? max?
(mL solution * % dextrose * 1000) / kg / 1440 = mg/kg/min
recommended: 3-4 mg/kg/min
max: 5 mg/kg/min
30
when to stop PN and EN
stop PN when EN meets >60% of needs for >3d
stop EN when oral meets > 75% of needs for >3d
31
lipid concentrations
10% = 1.1 kcal/mL = 11 kcal/g PN lipid
20% = 2 kcal/mL = 10 kcal/g PN lipid
30% = 3 kcal/mL = 10 kcal/g PN lipid
32
max lipid dose, stress and non stress
stress: 1 g/kg/d or less
non stress: 2-2.5 g/kg/d
33
lipid dosage equation
g lipid / kg
34
proteins
4 kcal/g
35
dysgeusia and egeusia
alters sense of taste and complete loss of taste
foods with strong distinct flavors, hydration
36
dysphagia
diffiuclty swallowing
texture modifed died
37
GERD
chronic digestive disorder that occurs when stomach contents/acid regularly flow back up into the esophagus
- avoid trigger foods
38
nausea and vomitting
- bland easy to digest foods, smaller portions, clear liquids
- avoid fatty fried spicy sweet smelly processed
39
gastritis
inflammation of the stomach lining
avoid acidic spciy fatty fried sugary processed
40
peptic ulcer disease
- sore in the lining of the stomach or duodenum
- eating a balanced diet, avoid the usual, probiotics
41
bariatric surgery
manage obesity, reduces stomach size
- 3 servings of milk/dairy and meat
42
dumbing syndrome
- when food moves to quickly from the stomach into the small intestine
- smaller meals, eat slower, limit sugar, more protein, fiber, fat, limit fluids
43
gastropareies
- chronic condition that slows or stops the stomach from emptyig food into the small intstine
- smaller more frequent meals of foods that are easy to digest (soft) and nutrient dense
- avoid high fiber high fat
- drink liquids
44
systole and diastole
systolic bp: force exerted on the walls of blood vessels during contraction
diastolic bp: force exerted during relaxations
45
primary vs secondary hypertension definition
- primary: high bp with no identifiable underlying cause
- secondary: high bp caused by another medical conditions
46
normal vs elevated blood pressure
normal: <120/80 mmHg
elevated: 120-129/<80 mmHg
47
stage 1 v stage 2 hypertension blood pressure
1: 130-139/80-89 mmHg
2: >140/90 mmHg
48
diuretics commonly used for hypertension + nutritional implications
risk of hypokalemia: loop, thiazide
risk of hyperkalemia, avoid excessive K+: potassium sparing
49
DASH diet
- effective at reducing BP, even without weight loss
- flexible balanced meal
- Variety of fruits, vegetables, whole grain
- Low fat dairy
- Fish, poultry, beans, nuts
- Vegetable oils
- Limit foods high in sat fat
- Limit sugar sweetened beverages and added sugars
50
atherscleorosis risk factors
- additive effect in their predictive power
- family history
- over 65 and male
- smoking
- physical inactivity
- diabetes
- dyslipidemia
51
5 criteria for metabolic syndrome
- increased waist circumference
- triglycerides > 150 mg/dL
- HDL-C <40 for men or <50 for women
- BP > 130/85 mmHg
- insulin resistance: FGP > 100 mg/dL
need 3/5 for diagnosis
52
importance of identification of metabolic syndrome
- cluster of commonly co-occuring metabolic risk factors
- increases risk for heart disease, stroke, T2DM
- other conditions with similar presentation: PCOS, cushings
53
food-drug interaction with some types of statins
- many drugs are metabolized by CYP34a enzyme in the small intestine
- chemicals in grapefruit inhibit this enzyme, so higher levels or the drug
- or necessary transport proteins can be blocked, so too little drug reaches the body
54
TLC diet
- therapeutic lifestyle changes for CVD prevetion
- targets LSL, most heavily involved in the development of atherosclerosis
- weight management, increased PA
- sat fat < 7% kcal
- cholesterol < 200 mg/d
- 10-25 g soluble fiber/d
- 2 g plant stanols/sterols/d
55
heart disease
plaque builds up in an artery
56
angina
harder for blood to get through
57
heart attach
plaque cracks and a blood clot blocks the artery
58
cardiac arrest
when the heart balfunctions and suddenly stops beating. electrical prblm
59
peripheral artery disease
occlusion of blood flow in noncoronary arteries (lower extremities)
60
atrial fibrillation
irregular heart beat, which can disrupt the flow of blood thru the hearth
61
heart failure
impairement of the ventricles' capacity to eject blood from the heart or to fill with blood. decreased cardiac output
62
nutrition recommendation for myocardial infarcation
- low fat, low sodium diet with easily digestible foods, prioritizing small, frequent meals
- once stable, more comprehensive heart healthy diet
63
balloon angioplasty and stents
- special tubing with an attached deflated balloon is threaded up to the coronary arteries
- balloon is inflated to widen blocked areas where blood flow to the heart has been reduced/cut off
- often combined with implantation of a stent to help prop the artery open and decrease the chance of another blockage
64
atherectomy
similar to angioplasty except the catheter has a rotation shaver on its tip to cut away plaque from the artery
65
coronary artery bypass graft (CABG)
- treats blocked heart arteries by creating new passages for blood to flow to heart
- takes arteries or veins from other parts of the body and using them to reroute the blood around the clogged artery
66
warfarin drug-nutrient interaction and recommendations
- vitamin K is essential for blood clotting
- warfarin is an anticoagulant that inhibits the vitamin K cycle
- patient should have consistent intake of vitamin K
- sources: green leafy vegetables, brussels sprouts, broccoli, cauliflower, cabbage
67
ejection fraction
- measurement that indicates how well the heart pumps blood out the left ventricle with each beat
- healthy: 50 -70%
- heart failure: below 40%
68
cardiac cachexia
- severe PEM associated with long term HF
- fat and muscle wasting, hypoalbuminemia, edema, decreased immune function, decreased mobility, QOL
- risk of refeeding syndrome
69
other medications that might increase risk of hyperkalemia
ACE inhibitors, angiotensin II receptor blockers (lorsartan/cozaar, avoid grapefruit), aldosterone agonists
70
how does heart failure affect fluid recommendations
- goal is to decrease blood volume (preload) to maintain CO
- 1-2 L/d fluid restriction for patients with serum Na <130 mEq/L
- daily weights can help monitor fluid balance
- education of fluid restriction: what is considered fluids, volumes, controlling thirst
71
how does heart failure affect sodium requirements
- goal is to decrease blood volume (preload) to maintain CO
- sodium intake < 2000 mg/d
- 1500 or 1000 mg/d restrictions as needed
- ana, fatigue, SOB lead to poor oral intake that many patient consume much less than 2000 mg
- NaCl is 39% sodium
1 tsp NaCl = 2300 mg
72
insulin
- anabolic hormone that controls metabolic fates of carbs, protein, and lipid
- T1DM cannot produce it themselves
- T2DM might need it if lifestyle changes and other medication aren't enough
73
glucagon
- peptide hormone released from alpha cells when glucose levels fall
- stimulates breakdown of glycogen (glycogenolysis), production of glucose (gluconeogensis), lipolysis
74
T1DM definiation and cause
- inability of cells to use glucose for energy
- causes cells to starve
- results in hyperglycemia
- immune mediated T1DM results from a cell-mediated autoimmune destruction of B cells
- more than 50 different gene associations
75
T2DM definition and cause
- body produced insulin, but tissues are insulin resistant
- polygenic
76
T1DM clinical manifestations
- lipolysis
- fatty acids transformed to ketones
- pH decreases: metabolic acidosis/ketoacidosis, Kussmaul respirations
- K, Na, Mg, P lost
- hypovolemia: causes weight loss, can lead to hypovolemic shock
77
T2DM clinical manifestions
- insidious onset
- increased thirst, hunger
- frequent urination, infections
- unintended weight loss
- fatigue, blurred vision
- slow healing sores
78
how is DM diagnosed
A1C > 6.5%
FPG > 126 mg/dL
2-h PG > 200 mg/dL
with symtoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose > 200 mg/dL
79
hemoglobin A1C vs plasma glucose
A1C: % glycated hemoglobin, 3 month avg picture of blood glucose levels
plasma glucose: current blood sugar level at a specific point in time
80
normal, prediabetes, and diabetes A1C percentages
normal: below 5.7%
prediabetes: 5.7 - 6.4%
diabetes: 6.5% or higher
81
acute complications of DM management
- side effects and complications of insulin therapy: hypoglycemia
- dawn phenomenon
- diabetes ketoacidosis (DKA)
- hyperglycemic hyperosmolar syndrome (HHS)
82
long term complications of DM treatment
- macrovascular and microvascular complication
- cardiovascular, cerebrovascular, and pheripheral artery diseases
- retinopathy, nephropathy, neuropathy
83
how many g of carb = 1 carb choice
15 g
84
dawn phenomennon
- result of hormones controlling circadian rhythms
- hyperglycemia occurs between 5 am and 9 am
85
somogyi effect
- low blood glucose overnight (nocturnal hypoglycemia) followed by dramatic increase in the morning (hyperglycemia)
- eg. took insulin at night but did not have evening snack with enough carb
86
diabetes ketoacidosis (DKA)
- form of life threatening, severe hyperglycemia
- most common in T1DM
87
hyperglycemic hyperosmolar syndrome (HHS)
- develops more gradually than DKA, so more easily overlooked
- more common in T2DM
88
What is the specialty certification available for working with people with diabetes?
certified diabetes care and education specialist (CDCES)
89
whe
90
Why is it important for a dietitian to ask a patient who has DM whether they are taking insulin? How might this information change the nutrition education given?
- carb choices are timed with insulin regimen, prevent blood sugar spikes and crashes
- insulin affects how the body processes carbs
91
rapid and short acting insulin
lispro, aspart, glulisine, regular
92
intermediate and long acting insulins
NPH, determir, giargine
93
onset, peak and duration of insulins
onset: how quickly the insulin starts to lower blood sugar after injection
peak: time when the insulin is at its max effectiveness
duration: how long the insulin continues to work before its effects wear off
94
15-15 rule
- for hypoglycemia, FPG < 70 mg/dL
- symptoms: shakiness, dizziness, sweating, hunger, fast heartbeat, confusion, irritability
- 15 g fast acting carb, recheck blood sugar in 15 min
- if still under 70 mg/dL, repeat
- once over, eat meal or snack
95
hypoglycemia and hyperglycemia symptoms
hypo: shakiness, loss of consciousness, sweating, hunger, irritability, heartbeat
hyper: thirst, urination, fatigue, light headed
96
insulin carb ratio
15 g carb = 1 carb choice = 1 unit insulin
matching insulin with meals
97
blood glucose may increase if
- eats more
- less active
- stress
- too little insulin
- ill/infection
- other meds
- expired and not stored insulin
98
blood glucose may decrease if
- eats less
- more active
- too much insulin
- alc, in the absence of food
99
Explain the differences between ischemic strokes, hemorrhagic strokes, transient ischemic attacks, and aneurysms.
ischemic: 80% of all strokes
hemorrhagic: higher mortality
transient ischemic attach (TIA): mini stroke
aneurism: can lead to hemorrhaging
100
major risk factors of strokes
- smoking
- BMI
- PA
- diet
- total cholesterol
- bp
- FPG
- risk doubles each decade after 55
- African Americans are 2x more likely than white
101
nutrition intervention for a patient who had a stoke
- difficulty chewing, problems swallowing, reduced ability to feed self, decreased oral intake
- swallowing assessment, texture modified diets
- consider EN
- consider other concurrent diagnoses such as DM or HTM
102
dementia + nutritional concerns
- AD is most common
- amyloid plaques and tangles in the brain
- GI side effects of medications
- self-feeding/meal prep difficulty
- inadequate intake
- dehydration
- weight loss
- dysphagia, chewing difficulty
- malnutrition
103
nutrition goals for dementia
- prevent malnutrition
- maximize nutritional intake
- minimize unintentional weight loss
- promote adequate hydration
- minimize confusion
- promote enjoyment and quality of life
104
nutritional interventions for dementia
- maximize intake when patient has appetite and is alert
- texture modification
- thickened liquids
- adaptive equipment
- finger foods
- extended meal times, meal assistance, encouragement, cues
- minimize environmental cues
- liquid supplements/fortified foods
- caregiver education
105
desirable BMI for dementia
- 22-27
106
classic symptoms of parkinson's
tremor at rest
rigidity
akinesia (loss of movement)
bradykinesia (slowness of movement)
postural instability
107
nutritional concerns of parkinson's
- drug nutrient interactions
- medication side effects (dry mouth, constipation, nausea, vomiting)
- inadequate intake
- dehydration
- self feeding problems
- chewing/swallowing problems
- choking/aspiration
- malnutrition
108
drug nutrient interactions for parkinson's
- dietary proteins may interfere with levels of L-drops. amino acids compete for the same transport protein
- possible pyridoxine (B6) interaction. may lead to metabolism of L-dopa before it reaches the brain
109
Amyotrophic lateral sclerosis (ALS)
- lou gehrig's disease
- progressive destruction of motor neurons that control voluntary movements leading the muscle atrophy
- no known cure
- poor prognosis: 3-5 years post diagnosis
110
Amyotrophic lateral sclerosis (ALS) nutritional concerns
- increased energy needs
- chewing/swallowing difficulties
- weight loss
- immobility
- early PEG placement may be beneficial to allow for early nutritional stabilization
111
nutrition related concerns of multiple sclerosis (MS)
- medication side effects (N/V, dry mouth)
- meal prep/self feeding issues
- dysphagia, modified consistency diets
- constipation/bladder dysfunction (neurogenic bladder)
- weight loss/malnutrition
- weight gain due to inactivity
- weakness
112
MNT for epilepsy
- ketogenic diet
- effective in 50% of pediatric pts who do not respond to AEDs
- mechanism of action is not fully understood
- strict adherence required
- multivitamin and mineral supplement
- encourage fluids
113
classic ketogenic diet
- initiation in hospital over 5 days, starting with 2-3 day fast
- 4:1 or 3:1 ratio of g fat to g protein + carb
- kcal: 75-90% of RDAs
114
modified Atkins diet
- very CHO restricted (15-20g/d)
- liberal fat and protein
115
low glycemic index diet
- selected CHO are restricted (40-60 g/d)
- low GI < 50
116
MCT diet
increased ketogenic potential of MCT, included at all meals and snacks
117
phenytoin
- antiepileptic drugs (AEDs)
- hold TF 2 hours before and after
- may need Ca, Vit D, and thiamin supplement
- supplements may interfere with drug absorption, take separated by 2h
118
PCOS definition, etiology
- most common hormonal reproduction problem in women of child bearing age
- ovary doesn't produce all of the hormones it needs for eggs to fully mature
- immature eggs may remain as cysts
- exact cause is unknown
119
PCOS symptoms
- can affect a women's menstrual cycle, fertility, hormones, insulin production, heart, blood vessels, body weight, body hair growth
- weight gain/obesity, esp around waist
- increased serum cholesterol, bp
- increased hair
- acne oily skin, dandruff
120
PCOS diagnosis
- no single test
- usually includes serum levels of hormones
- elevated cholesterol and TGs, elevated glucose
121
PCOS medical treatment and nutrition therapy
- no cure, based on symptoms
- medications includes drugs for birth control, diabetes, fertility, spironolactone
- weight management; even 10% wl can make menstruation more regular
- spacing CHO throughout the day to assist with BG abnormalities
122
thyroid hormones
- controls metabolic rate
- Thyroxine (T4) is a major hormone
- Triiodothyronine (T3) is a more active hormone
- hyposecretion: hypothyroidism
- hypersecretion: hyperthyroidism
123
hypothyroidism definition and etiology
- clinical state resulting from decreased production/secretion of thyroid hormones
- iron deficiency is the most frequent cause
- otherwise, from dysfunction of thyroid or pituitary gland, which produces TSH
124
hypothyroidism clinical manifestations
- reduces BMR
- intolerance of cold
- weight gain
- easily fatigue
- bradycardia
- pitting edema of lower extremities
- slow reflexes and movement
- increased levels of total cholesterol and LDL
- increased insulin resistance
- goiter: primary failure of thyroid or lack of iodine
125
medical treatment and nutrition intervention for hypothyroidism
- administration of exogenous thyroid hormone
- monitor for signs of overtreatment
- correct for iron deficiency
- assess drug-nutrient interactions
- Fe, Ca, Mg supplements should be taken at least 4 hours before/after levothroxine
126
hyperthyroidism definition and etiology
- excessive secretion of thyroid hormones T3 and T4
- most commonly caused by Grave's disease (autoimmune disease)
- antibody TSI mistakenly targets TSH receptors on thyroid cells
- organ specific autoimmune disease
127
hyperthyroidism clinical manifestations
- palpitations
- nervousness
- sweating
- hyperdefecation
- heat intolerance
- oligomenorrhea
- wl despite increased appetite
- drooping eyelids
- sinus tachycardia
- exopthalmos (buldging eyes)
128
hyperthyroidism medical treatment and nutrition therapy
- surgical removal of thyroid gland
- antithyroid drugs
- radioactive iodine therapy to destroy thyroid glandular tissue
- ensure adequate intake
- monitor for drug nutrient interactions
129
A pregnant woman undergoes an OGTT, and finds out she has elevated BG values. What type of diabetes is this? Why is it important for this to be part of a pregnancy check-up?
gestational diabetes
if left untreated, poses risk
130
primary goal of DM treatment
maintain blood sugar levels to normal
131
Describe the consistent carbohydrate diet. Is this the same as a low carb diet?
Eating a consistent amount of carbs throughout the day, to keep blood sugar levels stable
Not restricting carb intake
132
NCP steps
1. Nutrition assessment
2. Nutrition diagnosis
3. Nutrition intervention
4. Nutrition monitoring and evaluation
133
nutrition screening
"On ramp" to the NCP
Anyone who is trained can quickly identify those who may benefit from nutrition care (NCP)
Identifies level of nutrition risk
High risk = complete nutrition assessment by RD
JCAHO requires must be done 24H
134
EBP components
- best available scientific research
- clinical expertise of the practitioner
- patient values and preferences
135
methods to obtain height on a patient who cannot stand
half arm span x2
knee height w equation
136
calorie count
best for assessing actual food intake in an inpatient setting
food weight before/after or % consumed visually estimated
3 day calorie count
137
When are actual(current) body weight (ADW), usual body weight (UBW), and ideal body weight (IBW) used?
ABW: most situations, most calculations
UBW: when a person has experienced significant weight fluctuations
IBW: to use with certain protein recommendations validated using IBW
138
% UBW and %wl
% UBW = CBW/UBW
% weight loss = (UBW - CBW)/UBW
139
adjusted bw for amputations
segment proportion that represents the missing limb is added to the actual body weight
CBW/(1-proportion) x 100
140
somatic protein status
muscle stores
creatinine height index (CHI)
nitrogen balance
141
visceral protein status
(nonskeletal muscle stores)
albumin
transferrin
transthyretin aka prealbumin
retinol binding protein
c reactive protein
not reliable indicators of nutritional protein status or malnutrition
142
how is metabolism affected by stress
everything ramps up
inflammation
increase metabolic rate, energy needs, body temp, blood glucose
primary fuel: protein -> gluconeogensis
143
how is metabolism affected by starvation
everything slows down
no inflammation
decrease metabolic rate, energy needs, body temp, blood glucose
- preservation of lean mass, protein stores
- major fuel source: fat -> ketones
144
nutrition diagnosis domains
intake*, clinical, behavioral/environmental
145
PES statement relations
- etiology causes problem
- signs and symptoms provide evidence for etiology and for the problem
- intervention directed at improving signs and symptoms and aimed at addressing etiology
146
first thing you do in the planning stage of nutrition intervention
prioritize nutrition diagnosis
147
nutrition education
Instruction or training intended to lead to nutrition-related knowledge
Group classes, individual instruction, written instruction, or via phone or electronic communication
Outpatient setting is more conducive to education
In acute-care setting, more content-focused
Quickly useable content and straight forward instructions
148
nutrition counseling
Supportive process, characterized by a collaborative counselor–client relationship
Establishes goal setting and individualized action plans
149
muscle loss sites
temple, quads, patellar, calves, clavicle, pectoral, deltoid, dorsal hand
150
fat loss sites
obrital, cheek, triceps, biceps, thoracic, lumbar, ribs
