What do you monitor for TPN daily, weekly and monthly?
Daily: I/O, blood glucose, electrolytes(calcium, magnesium, phosphate, renal function)
Weekly: LFT, TG, 24 hour urine(make sure not spilling protein)
Monthly: RBC, copper, zinc, folate
How do you calculate ideal body weight?
Males: 50kg +2.3kg for every in over 5 feet
Females: 45.5kg + 2.3kg for every in over 5 feet
What does glucagon do?
Increases: -rate of glycogenolysis & release of glucose from the liver -rate of gluconeogenesis -use of fatty acids in respiration intead of glucose
What are the final products of carb digestion?
-fructose, glucose, galactose
What is gluconeogenesis? What stimulates?
-synthesis of glucose form noncarbohydrate precursors (like amino acids) -stimulated by glucagon, epic, cortisol
Pts. with HTN, what is the recommendation to lower?
lose weight, decrease sodium intake, DASH Diet, increase physical activity, decrease ETOH
What are the lab test indicators of poor nutritional status?
Serum albumin < 3.4
Total cholesterol < 160
Very low LDL
How are proteins metabolism?
--broken down to AA in GI tract and absorbed into blood --most of AA in blood enter cells and for new proteins but few free AA exist in blood with plasma proteins -constant equilibrium between cell proteins and free AA and plasma proteins
What is glycogenesis?
Glycogen made by glucose in the liver-stored
What do you limit and what is the rationale behind the limits for patients with chronic kidney disease?
1. Sodium restriction (1500-2000mg/day) -- Na can build up and cause fluid retention and HTN
2. Protein restriction (.6-.8g/kg/day) --waste products are not processed properly: ammonia, urea, uric acid
3. Lower potassium intake (oranges, nectarines, rasins, bananas, etc) -- K levels increase and can lead to arrhythmias
4. Lower phosphate intake (asparagus, avacoado, potatoes, tomatoes, pumpkin, spinach) --Phos levels increase and can cause Ca to leach from bones and lead to osteoporosis and hypercalcemia
5. Add Ca, Vit D, and iron supplements
What do you emphasize with Type I DM?
Stress basic healthy guidlines with emphasis on:
weight loss, healthy exercise, carb counting
What does growth hormone do to proteins and glucose?
--increases synthesis of cellular proteins --decreases glucose release and uses fatty acids for energy
Discuss SFA, MUFA, PUFA, and TFA
saturated fats (SFA) = animal sources, solid at room temp (exception = coconut & palm oils)
unsaturated fats (PUFA and MUFA) are the best for you, found in plants and usually liquid at room temp
SFA raise blood cholesterol, while PUFA and MUFA lower it
trans fats TFA (hydrogenated unsaturated fats) are the worst = increase LDL and lower HDL
What are some complications and risks of TPN?
1. catheter infections
2. refeeding syndrome(abrupt decrease in K, Mg &/ phosphorus from pancreatic stimulation and insulin secretion)
3. Metabolic related complications (hyperglucemia, electrolyte abnormalities= Na, Ca, K, Mag, Phos)
4. Hepatic dysfunction
With Type II DM, what are the things you shoot for? (ABCs) and 5 things
BMI greater than or equal to 25:
1. Reccomend 30 min of physical activity 5 days per week
2. lose 5-10% of body weight
3.limit caloric intake and time meals to stabilize sugar
4. carb consistency (45-55% of daily calories divided up into meals)
5. of daily calories: saturated fat <7%. total cholesterol <200mg, protein 15-20%, 14g of fiber per 1000kcal, 1500mg daily sodium limit
6. TIME MEALS
What do glucocorticoids do to proteins?
--decrease proteins in tissue
For TPN, critically ill patients need how many calories per day?
18kcal/kg per day
then incrrease to a goal of 25-30kcal/kg per day over the course of a week
Discuss what occurs with fat metabolism. What can be broken down, how fats can be synthesized, when it is broken down, and what hormones are involved.
--FA and TG can be synthesized from carbs--stored in adipose tissue
--FA and glycerol can be used for E (FA and glycerol make triglycerides)
-carbs down = LACK OF INSULIN, reduces rate of glucose use and increase fat metabolism
-epi, norepi, corticotropin, glucocorticoids, GH = horomone sensitive TG lipase
-TH can cause rapid mobilzation of fat
for TNP, how many grams of protein do patients need a day?
(moderate, critical and burn)
mild-moderate illness: .8-1.2g/kg/day
critically ill: 1.2-1.5 g/kg/day
severe burns: 2g/kg/day
What weights do you use for TPN?
Use current body weight UNLESS patient is obese
Obese patients = use IDEAL body weight
What does testosterone do to protein?
--increases protein in the tissue
What does cortisol do?
increases blood AA, decreases muscle protein
What does insulin do to protein, fat, and blood sugar?
Protein: -promotes uptake of AA by muscle and other tissue -promotes protein synthesis -inhibits protein degredation Fat: -increase transport to adipose cells -promotes TG synthesis -inhibits lipolysis Blood sugar: -increases absorption of glucose into cells -stimulates glycogenesis -inhibits glycogenolysis -inhibits gluconeogenesis
After absorption from the intestine fructose and galactose are converted in the liver to? Stored as? By what process?
-glucose, glycogen, glycogenesis
What does GH do?
decreases blood AA and increases muscle protein
What is glycogenolysis? What stimulates?
-glycogen is broken down into glucose in the liver and skeletal muscle -glucagon, epi
What are cholesterol lowering foods? What diet do pts with HDL follow?
Limit cholesterol to less than 200mg/day
Basic healthy diet full of fiber, fruits, veggies, low saturated fat
Foods that lower HDL = oatmeal, fish, omega-3, high fiber foods, walnuts and other nuts, olive oil, foods with added plant sterol.
What do epi, cortisol and GH do?
increase blood glucose and fatty acids
What are the nutritional goals of a patient with DM and the 5 key components to the nutrition prescription?
5 keys are:
1. caloric intake = calories in = calories used
2. WEIGHT LOSS = increase phys act + weight management
3. consistency with daily carb intake
4. nutritional content (make sure eating healthy, dense carbs for example)
5. Time meals and snacks
What are some guidlines of fats for adults? Which ones to limit, which ones are good?
25-35% energy should come from fat (higher for kids)
<10% should be sautrated!! because they raise LDL
PUFA and MUFA increase HDL!
KEEP TRANS FATS, and HYDROGENATED OILS LOW
<300mg cholesterol/day to decrease CVD
USE OILS NOT FATS
Name some examples of:
1. Saturated fats
4. Trans fatty acids
1. animal fat, milk, meat, eggs, butter, cheese, coconut and palm oil
2. olive oil
3. omega-6 veggie oils (soybean, corn, canola, sunflower), omega 3 (fish oils
4. margarine, snack chips, imitation cheese, processed foods
What are some etiologies for weight loss? Why have inadequate intake and excess requirements?
Etiologies = cancer
inadequate intake = depression, lack of funds, gi problems, chronic illness
excess requirements = increased metabolic demands (healing from surgery), thyroid abnormalities, excessive exercise
What do you use to evaluate weight loss? Labs and BMI?
BMI < 19
Labs: CBC - anemia, neutropenia
CMP = hypoalbunemia
Lipids -- decreased cholesterol and TG
Thyroid panel = if indicated
What are etiologies for weight gain? What would cause decreased metabolism? fluid retention?
Etiology = increased intake
Decreased metabolism = thyroid issue, age, menopause, sedentary lifestyle
fluid retention = heart failure, liver failure/cancer, ovarian cancer
What do you do to evaluate weight gain and what labs do you draw?
BMI is elevated
Labs: CBC = anemia (iron deficiency or anemia of chronic disease)
CMP --> look for elevated LFT, decreased albumin
TSH --> low
What are some causes of malnutrion in hospital patient?
What are some causes of malnutrition in a hospital patient?
(increased nutrient losses)
malabsorption (ex: c diff)
protein losing enteropathy (cancer--> fluid to leak out of tissues)
What are some causes of malnutrition in a hospital patient?
(increased nutrient requirements)
What are the three phases in response to critical illness and what are in each?
1. Ebb phase (vasoconstriction, increased co2 consumption, fever--> shutting down metabolism)
main goal is to keep organs from failing and shutting down
2. flow phase (last of acute illnes, marked by hypercatabolism, mediated by catecholamines, results in neg N balance and shift to utilizing fat as fuel source)
3. Anabolic phase (onset of recovery, normal VS, improved appetite and diruesis)
What are the etiologies of obesity?
3. medication side effects (anti-depressants, anti-epileptics, anti-psychotics, steriods, anti-diabetics, anti-hypertensives)
4. secondary to diseases (cushings, insulinoma, hypothyroid, growth hormone deficiency, hypothalamic damage)
What are the major co-morbidities associated with being overweight and obese?
1. Type II diabetes
2. HTN = hyperinsulinemia can increase symp activity, renal Na retention and possibily vascular tone (h2o follows Na)
3. Dyslipidemia = affects all lipid values, decreases HDL
4. Heart disease = CHD related to all three above, heart failure increases due to all above, atrial fib/flutter increase b/c of increased cardiac workload
5. Stroke = women--> ischemic, men --> hemorrhagic and ischemic
7. OBSTRUCTIVE sleep apnea = more tissue on neck and back of throat
8. Cancer = increased death rates
What are the BMI and waist circumferences for underweight-obese?
30-34.9 obese I
35-39.0 obese II
>40 obese III
Men & women < or = 102 cm, 40in or 88cm, 35 in = risk, but lower than would be if greater than
What are the caloric intakes to lose weight and what are some types of diets to try with an obese patient?
Usually try for 1200-1600 calories per day, DONT go lower than 1000
GOAL is lose 5% in 6months
balanced low-calorie/portion controlled
What are the order of things you woud try with treatment in an obese patient?
1. diet (100-1600 calories a day)
2. exercise (10-15 min per day)
3. Behavior modifications
4. Medications (if none of above are working)
5. Surgery if meds arent working
What are some idications that an obese patient is ready for surgery?
Pt has failed other non-surgical weight loss (honestly)
pt is well-informed and motivated to make lifestyle change
pt has acceptable risk for surgery
pt has BMI < 40 or <35 with co-morbidities
What are the contraindications for obese patient that would like surgery?
Pts with untreated depression or psychosis
pts currently using drugs or ETOH
pts with prohibitive surgical risks
pts unable/unwilling to coply with lifelong diet and nutritional requirements
Discuss Lap Band surgery. How it works and what pts it is good for.
Relatively few side effects
Able to increase or decrease amount of restriction
Good for younger women who want to have kids
Discuss sleeve gastrectomy. What surgery does, how weight is losst and complications (dumping syndrome).
Restrictive and perminant--> staple part of stomach therefore more directly in line with small intestine
Pts need to eat small portions
Patients can get dumping syndrome: carbs broken down really fast and absorbed fast = pt gets ill, flushed, dizzy
Discuss Roux-en-Y gastric bypass, what it does, who is canidate and complications.
Perminant restrictive and malabsorptive-- shows very good long term results--works very good for weight loss
Part of small intestine is bypassed, only have small stomach pouch
Problems: acid, base of stomach and small intestine not as acidic andb basic
Pts need to eat proteins, vitamins, B12, folate, iron and calicum
pts need to be compliant with blood checks
Good surgery because cannot overcome malabsorption