dru ledder ms rd. nutrition therapy for cardiovascular disorders more than ½ the people who die in...
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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 cholesterolElevated triglyceridesObesityHypertensionGenerally poor eating habits and sedentary
lifestyle
Lipid CriteriaTotal Cholesterol<200 mg/dL – Desirable200-239 mg/dL: Borderline High>240 mg/dL: High
LDL Cholesterol – “Lousy” Cholesterol - want these numbers Low
<100 mg/dL: optimal100-129 mg/dL: Near optimal/above optimal130-159 mg/dL: Borderline high160-189 mg/dL: High<190 mg/dL: Very high
Lipid CriteriaHDL Cholesterol – “Happy” Cholesterol - want these
numbers High<40 mg/dL: Low>60 mg/dL: High
Triglycerides<150 mg/dL: Normal150-199 mg/dL: Borderline high200-499 mg/dL: High>500 mg/dL: Very high
Nutrition Therapy for Cholesterol & Lipid DisordersTherapeutic Lifestyle Changes (TLC)Saturated Fat - <7% of total caloriesPolyunsaturated Fat – up to 10% of total caloriesMonounsaturated Fat – Up to 20% of total
caloriesTotal Fat: 25 – 35% of total caloriesCarbohydrate: 50 – 60% of total caloriesFiber: 20 – 30 grams/dayProtein: 15% of total caloriesCholesterol: Less than 200 mg/dayTotal Calories: Balance energy intake and
expenditure to maintain desirable body weight/prevent weight gain
Hypertension CriteriaNormal: <120/80
Pre-hypertension: 120/80 – 139/89
High blood pressureStage 1: 140/90 – 159/99Stage 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 fatFocuses on fruits, vegetables, and fat-free or low-fat
milk and milk productsIs rich in whole grains, fish, poultry, beans, seeds, and
nutsContains fewer sweets, added sugars and sugary
beverages, and red meats than the typical American diet
DASH GuidelinesTotal fat - 27% of caloriesSaturated fat - 6% of caloriesProtein - 18% of caloriesCarbohydrate - 55% of caloriesCholesterol - 150 mgSodium - 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 mgCalcium - 1,250 mgMagnesium - 500 mgFiber - 30 g
Fat & Sodium Explorerhttp://www.americanheart.org/
fatsandsodiumexplorer/explorer.html
Class Activity
Nutrition Therapy for DiabetesData 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 peopleUndiagnosed: 5.7 million peoplePre-diabetes: 57 million peopleNew Cases: 1.6 million new cases of diabetes are
diagnosed in people aged 20 years and older each year.
Types of DiabetesType 1 – Insulin dependent
Type 2 – Insulin Resistance
Gestational Diabetes
Pre Diabetes
Age: >60 yearsEthnicity: African-Americans, Native
Americans, Pacific Islanders, Asian Americans
Genetics and family historyObesityHistory of gestational diabetesImpaired glucose metabolism: prediabetesPhysical inactivity
Diabetes – Risk Factors
Diagnosing Diabetes
Body weight, height, BMIWaist circumference
Men >40 inches and women >35 inches shown increase in insulin resistance
Blood pressureLab work
Hemoglobin A1CFasting glucoseUrinary glucoseBUN & creatineLipid profile
Diabetes – Nutrition Assessment
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 energyEspecially with insulin resistance can often result in
low blood sugar after meals of primarily CHOLow blood sugars result in craving sweets &
starchesHeadaches – 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 changeWeight lossAdditional factors for other health concerns
SodiumFatsCalcium/Magnesium/PotassiumFluids/Fiber
Diabetes – Nutrition Recommendations
Survival Skills
3 meals per day and 2-3 snacks each dayReading a food label, to find CHO contentLimit 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 GuidelinesCarbohydrates - 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 Planning3 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)
SnacksWomen/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 (1-2 servings carbohydrate)/add protein or veggies
Diabetes Meal Planning - Sample Meal Plan
1800 calories/180 g CHOBreakfast 500 calories/45 g CHO or 3 CHO choiceLunch 500 calories/45 g CHO or 3 CHO choicePM Snack 100 calories/30 g CHO or 2 CHO choiceSupper 500 calories/45 g CHO or 3 CHO choiceHS Snack 200 calories/15 g CHO or 1 CHO choice
Diabetes Risk Test
http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/
Class Activity
LiverA 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 HepatitisProtein: 1.2 – 1.5 grams/kg body weight/dayCarbohydrate: no restriction – monitor glucose
and adjust as necessaryFat: 30% of calories – restrictions only with
maldigestion due to reduced synthesis and secretions of bile acids
Calories: 25 – 35 kcal/kg body weight/dayMultivitamin supplement at 100% RDAs/DRIsFluid and sodium restriction if edema or ascites
presentIf adequate nutrition cannot be maintained by oral
feeding, enteral feedings or TPN may be indicated
Nutrition Therapy for CirrhosisCirrhosis 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 CirrhosisProtein: 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 limitedTexture
Esophageal varices present – semisolid or liquid diet to avoid potential rupture
Tube feedings not advisedAvoid coffee, tea, pepper, chili powder, or any other
irritating seasoningsPatients with poor appetite
Oral nutritional supplements, vitamin/mineral supplements, electrolyte replacements, parenteral feedings
Gallbladder & PancreasGallbladder function is to concentrate and
store bile from the liverWhen 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 dietAdequate amounts of carbohydrates & fiber
Acute cholecystitisLow fat dietDecrease gas forming veggies
Fat soluble vitamins may need to be replacedCholecystectomy
Fat intake limited for several monthsIntroduce fats gradually
Nutrition Therapy for Acute Pancreatitis
Goal is to prevent the secretion of pancreatic enzymes
Start NPO using TPN feedingsAs healing progresses, the diet can progress
Clear liquid with amino acids, predigested fatsBland diet in 6 small feedingsNo stimulants
Nutrition Therapy for Chronic Pancreatitis
Low fat dietVitamin and mineral supplementation –
especially fat soluble vitamins (A, D, E, K), and B complex
Tube feedings or TPN may be necessaryNo alchohol
Kidney Disease2 kidneysEach the size of your fistOne on each side of your spineWeight 4-6 ounces eachNephron - the basic functioning unit of the
kidney1 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 balanceProduce some of the body’s hormones to
control anemia, blood pressure, and bonehealth
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Diet with CKD – Early StagesProtein: 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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PhosphorusPhosphorus restriction is recommended as
soon as an elevated blood level is seenSome experts think 800-1000mg of
phosphorus daily is adequate
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PotassiumIf 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 5A treatment for Stage 5 kidney diseaseBlood 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 toreplace kidney function
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Types of treatmentPeritoneal dialysisHemodialysis Transplant
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Peritoneal DialysisRemoves wastes and fluidCatheter in the abdomenSeveral exchanges daily
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HemodialysisBlood circulates through a filter (dialyzer) to
remove wastes and fluidA machine controls speed and safety factorsHemodialysis can be done in-center or at
home, night or dayTraditional: At a dialysis facility3 treatments/week - 3 to 4 hours each
treatment
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Medical Nutrition Therapy
CaloriesProteinFluidsSodiumPotassium
PhosphorusCalciumVitamins
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CaloriesCalorie 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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ProteinEssential 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 day50% to 60% high biological valueIncreased needs in catabolic statesAdequate calories for protein sparing
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SodiumHelps regulate body fluid volume and balance
Limiting sodium helps to prevent:Excessive thirstFluid retention Elevated blood pressure
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Sodium Allowance2.0 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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FluidsFluidsFluid accumulates in the body between dialysis
treatments Interdialytic weight gain3 to 5% of EDW
Excess fluid can cause: EdemaShortness of breathHypertensionCongestive heart failure
Fluid accumulates in the body between dialysis treatments Interdialytic weight gain3 to 5% of EDW
Excess fluid can cause: EdemaShortness of breathHypertensionCongestive heart failure
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Fluid AllowanceFluid Allowance
1.0 to 1.5 liters per day
Includes all foods liquid at room temperature
1.0 to 1.5 liters per day
Includes all foods liquid at room temperature
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PotassiumMineral 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 weaknessNumbness and tingling of extremitiesDecreasing pulse rateCardiac 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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PhosphorusMineral widely available in many foods
85-90% found in bones & teeth
Vital to energy production and storageGoal:
Maintain levels between 3.5 and 5.5 mg/dl
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Phosphorus Allowance 800 – 1000 mg
½ cup milk ~100 mg1 ounce cheese 100 – 290 mg½ beans (pinto, lima) = 125 mg3 ounces meat = 195 mg1 ounce nuts = 120 mg 2 tablespoons peanut butter = 120 mg
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CalciumMineral needed for:
healthy bonesmuscle contraction & relaxationproper 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
Hg g/dl 14 – 18 11 – 12
Iron Saturation % >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
Intact PTH pg/ml <100 150 - 300
ReferencesStanfield, 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.pdf
Erin Hetrick, MS, RD, LDN – Kaplan University Professor & Renal Dietitian