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