09.04 Nutrition (Diet) in Disease

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Hi guys. I'm so excited today to talk to you about nutrition and disease. In this lesson, we are going to discuss a few diseases that have a very big impact on nutrition.

The key diseases that have a nutrition impact play a large role in the absorption, digestion, storage, metabolism or excretion of nutrients in the body. For example, the pancreas produces an enzyme that helps break down food before digestion, and the pancreas produces a hormone that helps with glucose transport into the cells of the body. In this lesson, I will really focus on how the disease relates to nutrition, but for a deeper look, we have great lessons for each.
So, I'd like to get started with one of our most vital organs, the heart. The heart is a pump, and its main purpose is to pump blood to circulate nutrients throughout the body. Our heart connects to vessels which are like flexible pipes that traverse or travel throughout the body. Unfortunately, those vessels can be damaged with poor diet, which requires the heart to work harder, which can lead to damage of the heart over time.

So, let's discuss some cardiac disorders and their nutritional relevance. Hypertension is an elevated blood pressure that can lead to stroke, myocardial infarction and coronary heart disease. For hypertension, research has found the DASH diet to be the most effective. The DASH diet recommends a low sodium, less than 2,400 milligrams per day, and high calcium, magnesium, potassium, protein, and fiber. To do this, you can increase fruit and vegetables and whole grains. Check out the reference for this lesson for more on the Dash Diet.

Heart failure, due to salt and water retention commonly seen, the diet focus is low in sodium and possibly a fluid restriction.

For myocardial infarction and coronary heart disease, the diet is the same. We want to do low sodium, low fat and cholesterol, and a focus on decreasing the saturated and trans fats in the diet and increasing the mono-unsaturated fats. We also went to increase fiber and omega three fatty acids. The goal here is to decrease any atherosclerosis in the vessels.

Lifestyle changes for all of the above include smoking cessation, limiting alcohol intake, maintaining a healthy weight, increased physical activity, and then of course keeping the blood pressure and blood cholesterol within normal limits. You may also want to limit caffeine which can increase the heart rate.

The next disease I would like to discuss is diabetes. Insulin acts as the key and the cell as a lock to allow glucose into a cell. In diabetes, you either have too little of the key, like in type one diabetes, or a malfunctioning lock or both, like in type two diabetes. Elevated blood sugars can lead to damage of the vessel walls, which is the main reason for the vision and kidney damage seen in diabetes. It also explains why heart disease is the leading cause of death for patients with diabetes.

So first, I want to discuss the diet. It's incredibly important for patients with diabetes. Patients with type two, in particular, who change their diet and maintain a healthy weight can sometimes manage blood sugars with lifestyle changes alone. In all cases of diabetes, you want to limit carbohydrate intake, spreading the carbohydrate out throughout the day, and maintaining a healthy weight. For patients on insulin, the timing of carbohydrate becomes very important.

Lifestyle changes include increasing physical activity and maintaining a healthy body weight. Also, smoking cessation and limiting alcohol intake.

An essential skill for patients with diabetes is blood sugar management, which requires testing and monitoring. A fasting and a two hour postprandial, which is two hours after a meal are the most common times to check blood sugars. It's very important to know how to test and when to test and what those numbers should be.

Here, I want to go into a little more detail about insulin and food. The first chart here is insulin peak times for different insulins. And the second chart shows how blood sugars respond to a high carbohydrate meal.

About 15 minutes after you eat a meal containing carbohydrates, the blood sugar starts to rise. They will reach their peak about one hour in, about one hour postprandial, and should return back to normal about three hours after a meal.

The insulin that most closely matches the peak in blood sugars are the rapid acting insulins. Regular insulin is a little slower. So, in an ideal setting, it would be given a little before the start of a meal. However, if you give rapid acting or fast acting insulin and then your patient gets nauseous or is made NPO or nothing by mouth, they don't eat, that can cause a problem. So in practice, insulin is usually given after the start of a meal.

Different insulins act in different ways. The reason that you need to learn the peak times of different insulins is so that you can make sure a patient's insulin is peaking at the right time to handle a load of carbohydrate from the meal. If the food happens too soon, the blood sugars will spike too high and then possibly drop too low when the insulin finally kicks in.

Now, I would like to move on to gastrointestinal disorders. Nutrients enter the body through the GI tract. Any malfunction along any part will impact nutrition in some way. Movements in the GI tract propel food from one end to the other. Chemicals help to break down food to allow for absorption. The mouth and stomach use movement and chemicals to break down food. The small intestines absorb most nutrients. The large intestines allow for reabsorption of water.

So, we'll start here with oral. Dysphasia, which is a swallowing disorder, requires alterations in food consistency and possibly even nutrition support. So, interventions, patients should be positioned in high Fowler's, and proper oral care is very important. We encourage small bites, extra chewing, and also it might be good to look for medications that might cause a dry mouth, which would worsen the dysphasia.

Esophageal and gastric typically require one of three interventions. So, those three are increased gastric emptying, delayed gastric emptying, or avoiding stomach irritation.

So, we'll start with the first one. To increase gastric emptying, you want to do for patients that have gastro-paresis or gastroesophageal reflux disease. We want to keep their head up after a meal so they don't experience reflux and the stomach can empty. We also want them to eat small, frequent meals so the stomach doesn't get too full. Things like high fiber or fat would also delay gastric emptying. So, we want to avoid those and make sure that they're drinking plenty of fluids while they eat. Avoid caffeine, smoking and alcohol.

For a delay in gastric emptying, a condition where you would want to really focus on this is one called dumping syndrome. Almost the opposite, we want you to lay down after meals to delay gastric emptying, eat small frequent meals and avoid liquids during meals and an hour before and after. Limiting high sugar meals and adding fat and protein with each meal can help prevent hypoglycemia that's often seen in dumping syndrome.

Avoid stomach irritation is the last one. This will need to do with conditions like gastritis or peptic ulcer disease where you want to avoid frequent meals and snacking, which stimulate gastric secretions, avoid NSAIDs, aspirin, caffeine, cigarettes, alcohol and spicy foods because all of these things can irritate the stomach.

Now, we will discuss the intestines. Inflammatory bowel disease includes Crohn's and ulcerative colitis. The interventions focus on limiting residue in the intestines by decreasing fiber. And then we want to increase calories and protein because absorption may be poor. Also avoid nicotine and foods that can aggravate diarrhea.

For diverticulitis and diverticulosis, during an episode of diverticulitis, a patient is typically put on a clear liquid diet that is advanced as tolerated to a low fiber diet. Once the body has had some time to heal, patients to transition to a high fiber diet to help prevent recurrence of diverticulitis.

Ileostomies and colostomies. The diet is centered around symptom management. For interventions, we focus around fluids and electrolytes since they are reabsorbed in the colon, increased calories and protein to promote healing, and emotional support due to altered body image. Some common symptoms of the diet that we can help with: Number one, gas. You can limit eggs, carbonation, any foods from the cabbage group. For constipation, you can limit and nuts and seeds. And then for odors, limiting things like onions, garlic, eggs, cabbage and fish can help with that.

Now, some of our related organs. We will start with the liver. The liver has a huge role in nutrition. It synthesizes or builds proteins and metabolize fats and carbohydrates and proteins, and it stores carbohydrates, vitamins and minerals. Interventions: You want to make sure the patient has adequate protein to prevent muscle breakdown, no caffeine, nicotine or alcohol. Possibly might need a vitamin or mineral replacement, and encourage calorie intake because malnutrition is common for liver patients. The abdominal distension causes early satiety, which means you get full quickly. Patients may also experience nausea, abdominal pain, and loss of appetite. Liver disease, associated with alcoholism, can lead to a deficiency of thiamine. So, supplementation may be necessary.

The pancreas produces enzymes that break down our food. So with inflammation, we can't break down our food appropriately. Intervention is to limit pancreatic stimulation which occurs with any intake. So, a diet order of NPO or nothing by mouth and an NG two that suctions is typical. And then usually after a couple of days, they'll trial a clear liquid diet and monitor for tolerance. If a patient is pain free, then they may progress as tolerated to a full liquid, and then to a low fat.

For cholecystitis, we recommend a low fat diet if the gallbladder is removed, but you can typically progress to a normal diet again over time.

Now, let's discuss some common GI side effects patients might experience from diseases or medications and what we can do for them nutritionally. First nausea. Diet, strong odors, seasonings and smells can worsen nausea. So, serving foods at room temperature and offering a bland, low fat, high carbohydrate diet can help. Also good oral care and elevating the head of the bed are important.

For constipation, a diet high in fiber, plenty of fluids and activity can help keep the bowels moving. Increase fiber slowly and avoid chronic laxative use if possible because it can make their bodies stop working naturally.

For diarrhea, a diet in soluble fiber can help add bulk to the stool. Diarrhea can lead to dehydration and loss of electrolytes, so we need to replete. So, for the intervention, small frequent meals, room temperature foods, avoid spicy foods, reducing fat, reducing soluble fiber which are in whole wheat and whole grains, and increase the soluble fibers which you can find in apples, pears, and oatmeal.

And last thing on this slide, anorexia, which is a loss of appetite. It can be caused by a disease or medications. So the diet, we want to encourage high calorie, high protein foods and supplementation if needed. Check for medications that may be the cause. Appetite stimulants like Megase may be used, and then help to assess and manage depression or anxiety. Another recommendation would be small frequent meals, and then monitor for changes in bowel habits. And then, of course, provide these people with good oral care.

Now, I get to talk about my favorite organ, the kidneys. So the first step in the process of the kidneys is called filtration where the blood cells, platelets, proteins, they're all pulled out in the kidneys to return to the blood or to the body. The next step is called reabsorption. In this step, fluid, electrolytes, glucose, things like bicarb, these are all pulled out and also returned to the body.

So, the blood goes into the kidneys, and in the first two steps, the body is pulling out what it wants to keep and returning those things to the circulation. In this next step, secretion, the body secretes waste products into the tubules to get rid of them. Some examples are hydrogen ions to maintain blood pH, potassium, urea, creatinine and drugs.

And then our last step here, excretion. At the end of this process is a waste product called urine which will leave the kidneys, travel to the bladder for eventual excretion.

So, let's discuss the diet for kidneys, which can be a bit overwhelming. There are two main types of diet that you need to understand for your renal patient. However, know that it is not cut and dry and depends a lot on the actual patient labs.

In chronic kidney disease, stage one and two, the main focus is really going to be here, limiting protein and limiting salt. Later stages of chronic kidney disease, you may start looking here, to limiting fluid, if you notice water retention, potentially limiting potassium and phosphorus if the lab values are abnormal, because the kidneys are not filtering them out like they should.

However, on a dialysis diet, fluids also need to be monitored. We will track weight gain between dialysis treatments and limit fluid if weight gain is significant. A big change here is protein actually needs to be increased now. Some protein from the blood is lost during the dialysis process, and protein needs are higher than normal. We're going to continue again to watch potassium and phosphorous and limit if needed.

The three main takeaways from this lesson: First diseases that have the largest impact on nutrition have a big role in how nutrients are processed throughout the body. Because of these close relationships, lifestyle modifications and diet modifications can have a big impact on the management of these diseases.
I'm so glad that you hung in there with me on this lesson. I love nutrition, and I'm so glad to share this with you. Now, go out and be your best self today, and as always, happy nursing.
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