Diet Therapies -

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Diet Therapies & Drug/Nutrient Interactions

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Traditional Hospital Diets

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• I have summarized very succinctly the salient features of numerous diets.

• Each diet has a small table that goes along with it.

• It is uniform throughout these sections so that you get used to thinking about diets in a uniform manner.

• Where possible, I have combined diets for disease states that have identical diet therapy.

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Diet Name: Clear LiquidBasis for Diet: this is nutritionally inadequate; use/d for a short period of time; leaves no residue after digestion. It is used with anorexia, N/V, acute diarrhea, post-operative progression, and transition between tube feeding and oral feeding.Comments: Offer every 1-2 hours, small servings, 6-10 teaspoons at a time.Tools for the Patient: this diet decreases thirst, regulates electrolytes and water homeostasis, stimulates peristalsis in post-op patients.Cautions: Do not use for more than a few days: it leads to weight loss, tissue wasting

and nutrient deficiencies.Foods Excluded:

Milk Fruits VeggiesAll Whole (clear juices

o.k.)All

Breads/Starches Meat FatsAll All except plain

flavored gelatinAll

Beverages Spices/Seasonings/PreservativesAll except coffee, tea, fat-free

broth, bouillion, sodasExclude meat soups, gravies, sauces, chili powder,

black pepper, mustard seed, and nutmeg as these all INCREASE HCl production in the stomach.

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Diet Name: Full LiquidBasis for Diet: Consists of foods that are liquid/liquefy at room or body temperature; for chewing, swallowing difficulties, jaw wiring, acute GI problems. Use after clear liquid in post-op progression.Comments: offer every 4 hours or as necessary.Cautions: This diet is generally iron deficient, high in lactose, hence may NOT work for those with lactose intolerance. It's high in fat; high in calcium, low in fiber: may constipate the patient.

Foods Excluded:Milk Fruits Veggies

All but non-fat dry milk

As per clear liquid All

Breads/Starches Meat FatsAll All All

Beverages Spices/Seasonings/PreservativesAs per clear liquid

dietAs per clear liquid diet

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Diet Name: BRAT dietBasis for Diet: NONE! This is NO LONGER USED! It is nutritionally dangerous!Comments: Foods that were included were Bananas, Rice, Applesauce and Toast/Tea --B...R...A...TTools for the Patient: Inform health care providers that this is no longer in use!Cautions: This diet is no longer in use!Foods Excluded: Doesn't matter! No longer in use!

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Diet Name: Soft Diet, aka, Dental Soft Diet/Mechanical Soft DietBasis for Diet: An adequate diet for ease of eating/digesting. A transition diet. Most useful when patient guides its application. May be used for those who have poorly fitting dentures or who have no teeth or after CVA (cerebrovascular accident -- stroke)Comments: Double check gingival mastication, i.e., can they "gum" some of their food, too?Cautions: Low in cellulose/residue


None All but soft, raw, canned and

frozen, dried fruits

All but diced, soft or chopped

Breads/Starches Meat FatsAll but soft rolls, breads, biscuits

All but minced or ground

All except chopped nuts

Beverages Spices/Seasonings/Preservativesnone None

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Diet Name: Soft-Fiber RestrictedBasis for Diet: for reducing fecal output as in GI blockage or irritable bowel syndrome; use in between full-liquid and normal diet in therapeutic progression. It's nutritionally o.k. without harsh fiber or excessive richness.


All except milk, cottage cheese, cream cheese, cheddar and Swiss cheese

Membranes (around oranges, grapefruits); skins (around apricots,

apples, pears)

Skins and fried

Breads/Starches Meat FatsHi-fiber foods CHEWY meats Fried eggs, all

except cream, margarine,

vegetable oils, fats for cooking, gravy,

cream saucesBeverages Spices/Seasonings/Preservatives

None Use in moderation

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Diet Name: Low ResidueBasis for Diet: used in acute irritable bowel syndrome, diverticulitis, before or after bowel surgery; provides a minimum of fiber (fiber is in the diet)/residue (residue is after digestion); used for chronic diarrhea brought about by anxiety; food poisoning, malabsorption processes, laxative abuses, cancer of the GI system and AIDS-related infections.Comments: May wish to use anti-diarrheals as necessaryCautions: Lacking in calcium, iron, and vitamins. Use only for a few days.

Foods Excluded:Milk Fruits VeggiesAll All All

Breads/Starches Meat FatsAll but white

bread, macaroni, noodles

All but tender All

Beverages Spices/Seasonings/PreservativesAll but clear

soups, tea, coffeeSee clear liquids diet

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Diet Name: General Diet/Diet-As-ToleratedBasis for Diet: For routine maintenance; to promote general health; not greater than 30% of calories from fat; 12.5% (more or less) protein and the rest complex carbohydrates.Comments: See section on exchange system; modify as necessary for patient's "comfort"


None None NoneBreads/Starches Meat Fats

None None NoneBeverages Spices/Seasonings/Preservatives

None None

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Diet Name: PureedBasis for Diet: See General diet -- same diet, just pureed for patients who have difficulty chewing and swallowing, e.g., post-CVAComments: Be creative and colorful to create an

aesthetically pleasing plate; spices and seasonings may even help a little bit; an ounce of red wine at supper time seems to stimulate appetite in those who are post-CVA, on cancer chemotherapy, have AIDS-related dietary suppression. Δ9-THC, the active ingredient in marijuana seems to help, as well, and may be a useful alternative to Marinol (the FDA-approved form of Δ9-THC taken orally) when inhaled if the patient is having difficulty keeping foods, liquids, oral medicines "down".

Foods Excluded: See General Diet

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Diet Name: Sodium RestrictedBasis for Diet: to relieve fluid load on kidneys; to reduce pulmonary edema; to assist with sodium depleting diuretics. To manage sodium-sensitive hypertension; congestive heart failure (there is a move on now to change this to simply heart failure as not everyone develops congestion); liver dysfunction; any other disease that promotes fluid retention; steroid therapy for anti-inflammationComments: Most of our sodium intake is from foods in the meat, grain and milk food groupsTools for the Patient: For this diet to work -- as with most of the diets in these 2 sections -- the best approach is to communicate clearly with and work with the patient. Remember the patient is paying you, not the other way around.There are at least three levels of sodium restriction. These levels and their allowed intakes of sodium are following:

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Mild 1 Moderate 2 Severe 3

2-3 g Na/day 1-1.5 g Na/day 0.5-0.7 g Na/day

In the "Spices/Seasonings" box, below, are the restrictions for each level of sodium restriction by superscript.


All but skimmed None See belowBreads/Starches Meat Fats

See below Reduce animal foods and increase

plant foods

Reduce anyway

Beverages Spices/Seasonings/PreservativesAnything with sodium -- including

softened water (that contains sodium ions)

Baking powder, baking soda, pickles, MSG, sodium acetate, sodium benzoate, salt

1,2,3 No salt at the table1,2,3 No salty foods

2 No processed foods with sodium chloride2 FOUR exchanges of bread per day allowed

3 All of the above PLUS low-sodium breads3 NO beets, spinach, chard, kale, celery

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Diet Name: Fat Modified DietBasis for Diet: To prevent cardiovascular disease. There

are 2 fat-modifying programs: Step 1 and Step 2 diets. They are summarized in the table below:

Step 1 Step 2Generally recognized diet for

everyone. With borderline high cholesterol, follow a

healthy diet and retest after 1 year -- if no changes

with/following this diet, go to Step 2

Further reduce for this part

Not more than 30% of kcal from fat (< 10% of kcal from

saturated; < 10% of kcal from polyunsaturated; 10-15% of kcal from mono-unsaturated; < 300 mg cholesterol/day);

50-60% of kcal from complex carbohydrates; 10-20% of

kcal from protein

Not more than 30% of kcal from fat (< 7% of kcal from

saturated; <10% of kcal from polyunsaturated; 10-15%

mono-unsaturated; < 200 mg cholesterol/day); 50-60% of

kcal from complex carbohydrates; 10-20% of

kcal from protein

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Tools for the Patient: Exercise helps, begin with assistance, i.e., MD, DO, RN, trainer; Do NOT attempt to lose too much weight too rapidly: gallstones will precipitate due to the decreased solubility of the cholesterol salts in the gall bladder.Foods Excluded: The table is for Step 1 diets. For Step 2, further reduce as described

above.Milk Fruits Veggies

All natural cheeses, whole milk None Those prepared in fats/sauces

Breads/Starches Meat FatsCommercial baked goods,

sweetsFatty cuts of meat, skins Chocolate, butter, bacon,

fat, yolk-dressings like mayonnaise

Beverages Spices/Seasonings/PreservativesNO alcohol in excess:1 bread exchange =

30 mL gin, whiskey, rum, vodka75 mL dry wine

150 mL beerThese promote reduced LDL's

and elevated HDL's (for a healthy heart)

As necessary for patient's comfort

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Therapeutic Diets

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• This next section consists of abbreviated diets for therapeutic purposes, as opposed to traditional hospital diets for those who need to lower their fat intake or who need to regulate their water and electrolyte intake and balance.

• This section is by no means exhaustive. • This section has been alphabetized for

ease of searching, as you need.

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Diet Name: Acid AshBasis for Diet: HAS NO MERITComments: End products of foods in this diet are supposed to be acidic. This includes foods like cranberries, plums, prunes, meat, bread, poultry, fish, eggs, cheese, legumes, cereal foods, corn, almonds, chestnuts and coconut.

Cautions: THIS DIET HAS NO MERITFoods Excluded:

Milk Fruits VeggiesCONTROVERSIAL -- NO EVIDENCE FOR MERIT

Breads/Starches Meat FatsCONTROVERSIAL -- NO EVIDENCE FOR MERIT

Beverages Spices/Seasonings/PreservativesCONTROVERSIAL -- NO EVIDENCE FOR MERIT

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Diet Name: Acute GlomerulonephritisBasis for Diet: To replace albumin and other proteins lost in the urine; provide positive nitrogen balance; assist kidneys, reduce BUN and creatinine levels; lower BP; reduce edemaComments: Regulate protein with uremic patients -- reduce by 4-fold if necessary; lower sodium levels with edemaTools for the Patient: Increase intake of Vitamin D, calcium and iron levels as needed to keep up with losses

Foods Excluded:

Milk Fruits Veggiesprn prn prn

Breads/Starches Meat Fatsprn prn prn

Beverages Spices/Seasonings/Preservativesprn; with oliguria, restrict to

500-700 mL qdprn; and for sodium regulation

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Diet Name: Acute Myocardial InfarctionBasis for Diet: To promote healing/recovery; to decrease constipation; to regulate weight; see also congestive heart failure (now called heart failure as not everyone gets congested)Comments: Reduce the incidence of arrhythmias by serving food at body temperatureTools for the Patient: Encourage stress management; d/c EtOH; utilize small frequent feedingsCautions: Supplement calcium, magnesium and potassium

Foods Excluded:

Milk Fruits Veggiesprn Increase apple juice prn

Breads/Starches Meat FatsIncrease oat bran use Increase fish use Increase olive oil use

Beverages Spices/Seasonings/PreservativesCaffeine prn NO salt if patient has heart failure; R/O sodium-insensitive

hypertension

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Diet Name: AIDS/HIV infection, GenericBasis for Diet: To promote healing; reduce weight loss; see also herpes viruses' diets. To stop weight loss; regulate temperature; treat diarrhea and N/V; correct electrolyte imbalancesComments: breast-feeding women who are HIV positive probably ought to switch over to formula for their babiesTools for the Patient: small, frequent feedings; limit simple carbohydrates; teach about role of nutrition in immunityCautions: Hand washing for EVERYONE -- reduces passage of microbes that may be fatal to the patient with AIDS

Foods Excluded:

Milk Fruits Veggiesprn prn (with sore mouth, reduce

acidic juices)prn

Breads/Starches Meat Fatsprn Increase fish use

(ω-3 fatty acids)prn

Beverages Spices/Seasonings/Preservativesprn prn

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Diet Name: AlcoholismBasis for Diet: Reducing GI inflammation to increase absorption of vitamins; high energy diet at 35-45 kcal/kg IDEAL BODY WEIGHT (about 150-175% of BMR); protein sparing (which is why high carbohydrates are needed); help the liver "heal"; prevent hypoglycemia; return water and electrolytes to normalComments: protein at 2-g/kg-body weight will spare muscle catabolism; increase potassium; make meals appetizingTools for the Patient: Provide support, counseling services, AACautions: play NO GAMES with these patients: they are MASTERS!

Foods Excluded:

Milk Fruits Veggiesprn prn; increase B complex and

Vitamin Cprn

Breads/Starches Meat Fatsprn prn prn; not more than 30%,

anyway, unless the patient is hyperlipidemic, then may

wish to reduceBeverages Spices/Seasonings/Preservatives

Alcoholic beverages prn

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Diet Name: Alkaline ash -- catabolites are cationsBasis for Diet: this diet has NO MERITComments: The end products are supposed to be alkaline; found from foods such as milk, fruit, veggies, peanuts, walnuts, Brazil nuts.

Foods Excluded:

Milk Fruits VeggiesCONTROVERSIAL -- NO EVIDENCE FOR MERIT

Breads/Starches Meat FatsCONTROVERSIAL -- NO EVIDENCE FOR MERIT

Beverages Spices/Seasonings/PreservativesCONTROVERSIAL -- NO EVIDENCE FOR MERIT

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Diet Name: Angina pectorisBasis for Diet: to correct malnutrition; to decrease constipation; small frequent feedings; see also acute myocardial infarctionComments: Teach stress management, exercise helps, weight control helpsTools for the Patient: regulate weight and weight loss; fluids ad-lib

Foods Excluded:

Milk Fruits Veggiesprn prn Restrict sodium containing

veggiesBreads/Starches Meat Fats

prn -- sodium restriction (below)

prn -- sodium restriction Restrict anyway to less than 30%

Beverages Spices/Seasonings/PreservativesNot more than 5 cups of coffee (or the equivalent)

qd

Restrict sodium intake

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Diet Name: Anorexia nervosa -- "Low Calorie Diet for" (indicates counselor's/nutritionist's "good" intentions)Basis for Diet: to get patient "back on track"; to correct weight loss to healthy body weight with 500-1000 gram gain per weekComments: increase protein to reduce edema; tube-feed if patient is less than 40% ideal body weight; SLOWLY increase food intake!Tools for the Patient: teach cognitive theory techniques to increase self-esteem; include family members, if possible -- it's not always.Cautions: Do NOT force feed unless absolutely necessary -- part of this illness is food rejection, rather, teach normal eating behavior/cues

Foods Excluded:

Milk Fruits VeggiesNone None None

Breads/Starches Meat FatsNone None None

Beverages Spices/Seasonings/PreservativesThose with caffeine "No added salt" will reduce fluid retention

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Diet Name: Bronchial asthmaBasis for Diet: to reduce mucous production and increase energy for breathingComments: encourage small, frequent feedings to reduce discomfort; fluids prn to decrease mucous; work with the patient and family to reduce and/or d/c (discontinue) incidences that trigger attacks. Patients with endogenous asthma may have abnormal tryptophan metabolism -- with dietary restrictions to 200-350 mg trp/day, symptoms improve (Unge, 1984; Burtis, p. 700).Tools for the Patient: take meds as per M.D.; in some cases, thiamin HCl can reduce mosquito bites that decrease allergic asthma; learn stress management; teach parent's to "deal with" children who manipulate with their asthma so that these kids do not learn how to be victims!

Foods Excluded:

Milk Fruits VeggiesCommonly due to its ability to be allergenic

None (increase vitamins A, C, B6 and zinc-containing fruits)

prn

Breads/Starches Meat Fatsprn Eggs, seafood, fish, again,

due to allergenic abilityprn

Beverages Spices/Seasonings/Preservativesprn Sulfites, again, due to allergenic ability

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Diet Name: BulimiaBasis for Diet: correct imbalances from bingeing and purging; see also anorexia nervosaComments: Include family if possible -- may be the root of the problem, proceed cautiouslyTools for the Patient: teach life-stress management; support/therapy groups; assertiveness training useful; teach ramifications of electrolyte imbalances; remind the patient that there is "no such thing as a bad food"

Foods Excluded:



Beverages Spices/Seasonings/PreservativesSee anorexia See anorexia

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Diet Name: Cancer, GenericBasis for Diet: overcome the effects of chemotherapy; prevent weight loss (increases longevity/success of therapy); prevent infection; support therapyComments: Adenoma: a neoplasm (new growth) of glandular epithelium; Sarcoma: a neoplasm arising from connective tissue, e.g., muscle, bone; Epithelioma: a neoplasm originating in the epidermis or mucous membrane. This diet is a high protein diet; feed the patient prn patient's desires; force feed ONLY if the tumor is treatable; socialize prn to eat.Tools for the Patient: serve foods at room temperature (decreases temperature sensitivity in mouth without teeth); watch for changes in taste, sore mouth, edema, constipation.Cautions: avoid unscientific therapies (laetrile, mushrooms); watch electrolytes and water balance

Foods Excluded:

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Breads/Starches Meat Fatsprn; reduce to decrease incidence of caries from

thick saliva

prn prn

Beverages Spices/Seasonings/Preservativesprn; sodas (may use "flat" sodas that won't

increase N/V

prn; use ad lib to stimulate appetite; if the patient can't keep food down, marijuana may be useful -- it may be useful after/during

chemo.

Yes, Marinol is available as an oral medicinal. The key is ORAL -- if your patient is unable to keep anything down, Marinol is worthless, too. You have to put aside your

own feelings about grass and think of the benefit to the patient. REMEMBER: the first maxim of medicine is DO NO HARM! To withhold treatment as a result of your

own personal feelings takes away the patient's right to the best medical and/or nursing care, possible, as well as to making informed choices/consent throughout

his/her care. To withhold a treatment from the patient because of your own personal feelings that may be of benefit to the patient is simply cruel. Ultimately, anyone in

health care will be judged by their compassion, their willingness to relieve pain and suffering and their commitment to seeing that their patient -- if terminal -- dies with

dignity and without pain and with respect.

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Diet Name: Cerebral aneurysmBasis for Diet: to reduce fluids to reduce cerebral edema; to treat constipation to reduce straining (and intracranial pressure, simultaneously); to lower blood pressure; see also cerebrovascular accident diet.Comments: Restrict sodium and cholesterol prnTools for the Patient: prune juice and bran reduces constipation; teach independence as diet progresses; may need to puree of blenderize foods for ease of chewing/swallowing

Foods Excluded:

Milk Fruits Veggiesprn per above prn per above prn per above

Breads/Starches Meat Fatsprn per above prn per above prn per above

Beverages Spices/Seasonings/Preservativesprn; caffeine prn; sodium restrictions

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Diet Name: Cerebrovascular accident (CVA; aka stroke)Basis for Diet: See also soft diet; weight management to regulate blood pressure, lipids and decrease work effortComments: encourage small bites with slow chewingTools for the Patient: teach independenceCautions: Do everything reasonably possible to avoid choking and/or aspiration

Foods Excluded:

Milk Fruits Veggiesprn Tart juices, bananas Crisply cooked

Breads/Starches Meat FatsMashed potatoes, soft

breadsStringy, unboned fish, sticky

peanut butterprn with weight reduction

Beverages Spices/Seasonings/PreservativesNO straws, use with care:

may aspirate -- thicken with gel; excessively sweet

juices

prn

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Diet Name: Chronic Fatigue Syndrome (may be caused by Epstein-Barr Virus; EBV)Basis for Diet: See also HIV and HSV diets; to prevent malnutritionTools for the Patient: support groups; encourage exercise prn

Foods Excluded:




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Diet Name: Chronic glomerulonephritisBasis for Diet: See also acute glomerulonephritis; to lower blood pressure, reduce incidence of UTI; decrease proteinuria; reduce edemaComments: reduce protein when kidneys are no longer able to excrete catabolic products; fluid retention is BETTER regulated through sodium ion regulation than through water regulation; patients will feel thirsty even though they are edematous (this water is unavailable to them, remember)

Foods Excluded:



Beverages Spices/Seasonings/PreservativesSodium-containing Sodium restricted with edema

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Diet Name: Chronic Obstructive Pulmonary Disease (COPD)Basis for Diet: See also bronchial asthma; to correct malnutrition to decrease infection risk; promote weight loss to reduce the effort of breathing; to correct dehydration to liquefy mucous; to treat constipation to reduce work load on the heartTools for the Patient: chicken soup is better than water at clearing the airway

Foods Excluded:

Milk Fruits Veggiesprn to reduce mucous prn (see asthma) Limit to reduce edema

Breads/Starches Meat FatsLimit to reduce edema Limit to reduce edema Reduce to less than 30%,

anyway, but use wisely to increase kcal for energy to

breatheBeverages Spices/Seasonings/Preservatives

prn with theophylline Ad lib

Emphysema – Alveoli and Clubbed Fingers

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Old Terminology

Pink Puffer Blue Bloater/Blower

Thin, no edema, no CHF Heavy, CHF common

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Diet Name: Congestive Heart Failure (there is a move on to lose the "Congestive" as not everyone develops congestion)Basis for Diet: See also COPD; this is where the heart fails as a pump; reduce edema; small frequent feedings; weight regulation; correct malnutritionComments: at first, severe sodium restriction that may be lessened as edema is reduced if possibleTools for the Patient: With heartburn and gas, exclude breads/starches, fruits and veggies that are high in roughageCautions: double check potassium frequently -- loop diuretics are potassium wasting, use Slo-K, K-Lyte types of potassium replacements; bananas do not provide enough potassium to combat the loss of potassium from diuretics; avoid EtOH

Foods Excluded:

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Milk Fruits Veggiesprn prn -- see above prn -- see above

Breads/Starches Meat Fatsprn -- see above stringy Reduce anyway to less than

30%Beverages Spices/Seasonings/Preservatives

Caffeine at first, then allow 4-5 cups of coffee a day if

desired

Use prn in place of table salt

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Diet Name: ConstipationBasis for Diet: to teach the large bowel to function; to reduce discomfort; to return the patient to "normal" bowel habits (a daily bowel movement (BM) is NOT for everyone!)Tools for the Patient: liberal water intake; avoid abusing laxatives as they may cause megacolonCautions: avoid Dulcolax with dairy products: it dissolves in the stomach, then causes N/V

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Two Kinds of Constipation & Food Excluded

Atonic Constipation1 Spastic constipation2

Lazy bowel Due to obstruction; nerves, anxiety, etc.

Milk Fruits VeggiesLimit None1; all in pain phase2; then

increase prune juice, dried, raw fruits

None1; all in pain phase2, then increase raw

Breads/Starches Meat FatsNone1; bran2 and whole

grains2Limit Nuts2

Beverages Spices/Seasonings/PreservativesSodas prn

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Diet Name: Cor pulmonale (right ventricular hypertrophy with failure)Basis for Diet: See COPD; sodium restricted, MI and CHF dietsComments: typically seen in smokers due to the lung parenchyma turning "brittle" and "hard", hence, right heart works harder, enlarges, fails and develops into cor

Foods Excluded:

Milk Fruits VeggiesSee COPD, Sodium-

restricted, MI and CHF dietsSee COPD, Sodium-restricted,

MI and CHF dietsSee COPD, Sodium-

restricted, MI and CHF dietsBreads/Starches Meat Fats

See COPD, Sodium-restricted, MI and CHF diets



Beverages Spices/Seasonings/PreservativesSee COPD, Sodium-

restricted, MI and CHF dietsSee COPD, Sodium-restricted, MI and CHF diets

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Diet Name: Cystic FibrosisBasis for Diet: to meet increased energy needs; get patient to ideal body weight (IBW); make certain patient is obtaining enough protein in diet for age; may need to greatly increase kcal needs due to respiratory distress syndrome; replace lytes from vomiting/diarrhea; provide essential fatty acids to reduce eczemaComments: May need extra pancreatic enzymes; double vitamins A, D and E and iron intake; increase sodium intake (due to increased sweat loss); soft foods reduce chewing fatigue; increase fish in diet for increased ω-3 fatty acidsCautions: replace zinc and potassium lost prn

Foods Excluded:

Milk Fruits VeggiesYes, due to lactose

intoleranceWatch during diarrhea prn

Breads/Starches Meat FatsNone None Gravy, fried foods, dressings,

pastries, peanut butter, creamed foods, chips,

excess butterBeverages Spices/Seasonings/Preservatives

Stay away from carbonated sodas

Use sparingly since many cause gas formation (bloating)

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Diet Name: Degenerative Bone/Joint DiseaseBasis for Diet: To promote bone healing/growth and healthy body weight;Comments: encourage weight loss for those over weight; increase calcium and protein (primarily for the elderly); double check for food allergies; increase vitamin C (ascorbic acid) intake, lysine and copper intakeTools for the Patient: increase fish oils; increase zinc and vitamin E intake; if patient requires joint replacement therapy, help prepare patient; stay away from fad dietsCautions: with steroidal anti-inflammatory drugs (SAID's), calcium and protein are depleted; sodium retention occurs with potassium loss; watch blood sugars as they will elevate

Foods Excluded:

Milk Fruits Veggiesprn (dry skim milk is low calories and cheap for

calcium)

prn prn

Breads/Starches Meat Fatsprn prn Not more than 30%, anyway

Beverages Spices/Seasonings/Preservativesprn; limit caffeine: chelator prn

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Diet Name: Depression (tyramine restricted with MAOI's -- monoamine oxidase inhibitors); two kinds of depression: EXOGENOUS: unrealistic reaction to life event or internal conflict; ENDOGENOUS: multiple factors cause intrapsychic conflict; MAJOR, requires anti-depressants and psychotherapy or BOTH (the best combination, BTW)Basis for Diet: See also Tyramine restricted diet; provide appropriate nutrition, e.g., ECT (electroconvulsive therapy) requires an increase in kcalTools for the Patient: Reduce/cease caffeine at night time; increase tryptophan with high protein, high carbohydrate diet (increases serotonin levels; Wurtman and Wurtman have theorized that dietary starch is hydrolyzed to glucose, glucose causes the beta cells in the pancreas to secrete insulin, insulin elevates CNS levels of tryptophan, tryptophan is the biological precursor to serotonin which regulates mood, creating a sense of well-being; their studies showed that when obese women, women who have PMS and people trying to quit smoking loaded up on carbohydrates, their moods were elevated, much like that seen in those who have seasonal affective disorder [SAD], as well)

Foods Excluded:

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Milk Fruits Veggiesprn Canned figs, ripe bananas Broad bean pods, ripe

avocadoBreads/Starches Meat Fats

prn Aged cheeses, smoked/pickled herring, chicken liver, sausage,

salami, pepperoni

Commercial gravies

Beverages Spices/Seasonings/PreservativesBeer, red wine, ale Fermented soy sauce, yeast concentrates

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Tyramine • Tyramine is a precursor to and has some activity similar to the

catecholamines. It can build up to dangerously high levels and lead to headaches, CVA and hypertension. Specific foods in three groups are as follow:

"Free foods" with ≤5 μg tyramine/g

food

"Moderate" foods with 5-20 μg

tyramine/g food

"Avoided" foods with > 20 μg tyramine/g food

Cottage cheese, ricotta, cream cheese, milk,

fresh/fresh frozen meat/poultry, fresh

fish/shellfish

Processed American cheese, Gouda, coffee, hot

chocolate, cola drinks (1-3 cups

per day)

Aged cheeses (cheddar, blue, Swiss, Parmesan, Mozzarella), ale, beer, sherry,

red/white wines, yogurt, canned meats, liver, pepperoni, bologna, Genoa salami, Chinese

pea pod, eggplant, mixed Chinese vegetables, figs, avocados, chocolate (European, not American), soy sauce, yeast concentrates

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Diet Name: DiarrheaFour Types of Diarrhea:

Functional diarrhea Organic diarrhea Osmotic diarrhea Secretory diarrheaDue to

irritation/stressDue to a lesion in the

bowelDue to gluten, fat,

lactoseDue to bacteria,

viruses, bile acids, laxatives, hormones:

WORST of the 4 kinds!

Basis for Diet: To regulate water and electrolyte balance; prevent dehydration; prevent weight loss; restore normal motility of the bowelComments: NO BRAT!!!!!!Tools for the Patient: Avoid temperature extremes: stimulates bowel activity; small frequent feedingsCautions: if due to Clostridium difficile, avoid opiates and kaolins as they will cause the bowel to "blow out" -- REALLY BAD THING!

Foods Excluded:

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Milk Fruits VeggiesTemporarily Omit apple juice prn


Beverages Spices/Seasonings/PreservativesAvoid sodas (increases osmotic pressure and decreases electrolytes

taken up)

prn

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Diet Name: Failure to thrive (ORGANIC: state of disease; INORGANIC: from another cause; emotional; may be due to decreased eating (neglect) or inadequacy)Basis for Diet: A general diet to promote healthy growth; primary malnutrition is from faulty feeding; secondary malnutrition is from disease that inhibits uptake of nutrients; double check RDA's; liberal water -- WITHOUT edemaTools for the Patient: teach caregiver appropriate dietary goals; use growth charts -- they go over GREAT with mothers who want the best for their kids and they are EASY; follow the KISS method (Keep It Stupid Simple); follow up at home or in the clinic regularly

Foods Excluded:



Beverages Spices/Seasonings/PreservativesNone None

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Diet Name: Fetal Alcohol Syndrome (see also Failure to Thrive diet)Basis for Diet: to promote "normal" growth and development; promote mentation within reasonComments: Be as positive with the client as possible; they need to learn healthy self-esteemTools for the Patient: teach caregiver about proper nutrition; follow growth/development with growth charts; improve (increase) intake and status of nutrition

Foods Excluded:




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Diet Name: Fever of Unknown Origin (FUO)Basis for Diet: See also Generic Infection diet; prevent dehydrationComments: every 1° F increase = a 7% increase in BMR (review q10 rule from CHEM 121 and/or CHEM 122); replace protein and carbohydrates prn fever; watch electrolytes and water balance; treat N/V

Foods Excluded:




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Diet Name: Folic Acid Deficiency AnemiaBasis for Diet: to bring red blood cells, white blood cells and platelets back to normal; to improve weight; to increase folate levels in the blood; to correct anemiaComments: teach appropriate nutrition; increase folate, protein, calcium, iron, vitamin C (increases folate and iron uptake) and vitamin B12 uptake; double check folate levels in pregnancyTools for the Patient: with sore mouth use small, frequent feedings with bland/liquid or soft foodsCautions: d/c EtOH

Foods Excluded:

Milk Fruits Veggiesprn prn (1 fresh fruit provides

sufficient folate, as do whole grains, fish, leafy greens, legumes, grapefruit, meat,

broccoli)

prn

Breads/Starches Meat Fatsprn prn prn; not more than 30%,

anywayBeverages Spices/Seasonings/Preservatives

prn prn sore mouth

53

Anemia – In General

General Symptoms of Anemia: weakness, palpitations, pallor, shortness of breath (SOB), extreme fatigue, headache and cardiomegaly.

54

Folic Acid Deficiency Anemia

• Lab results: macrocytic RBC's, reduced RBC production, reduced WBC, reduced platelets.

• Weakness and pallor.• Breakdown of mucous membranes which

lead to ulcers and infections, sore tongue, diarrhea, malabsorption.

55

Diet Name: Gall Bladder Disease (ACUTE: cholecystitis is almost always due to stones --CHRONIC: due to bacteria, chemical irritants or stones; two forms of stones 1) cholesterol -- precipitates when levels of cholesterol are much greater than levels of bile acids and levels of phospholipids, 2) pigment stones)Basis for Diet: to reduce RUQ painComments: *Acute cholecystitis -- +Chronic cholecystitis (refer to above boxes with these superscripts)Cautions: when losing excess weight, do it slowly: if go too fast and do not drink enough water, cholesterol stones precipitate due to decreased solubility (i.e., exceeds the Ksp of cholesterol -- refer to CHEM 102 notes)

Foods Excluded:

Milk Fruits VeggiesFatty*; reduce+ Increase pectin-containing

fruits (binds cholesterol)Reduce use to decrease gas

formationBreads/Starches Meat Fats

prn Fatty*; reduce+ All*; reduce+

Beverages Spices/Seasonings/Preservativesprn; may wish to decrease

sodasprn; high spice

56

Diet Name: Generic InfectionBasis for Diet: protein sparing, high energy, rehydrate, support patient's defense mechanisms; treat anorexiaComments: increase Vitamin A, folate, Vitamin C, B complex and protein as below:

InfectionsMild Moderate Septic

Increase protein above RDA by: Up to 20% Up to 40% Up to 60%

Foods Excluded:Milk Fruits Veggiesprn prn prn

Breads/Starches Meat Fatsprn prn Not more than

30%, anywayBeverages Spices/Seasonings/Preservatives

prn prn

57

Diet Name: Gestational Hypertension (aka pre-eclampsia [primarily in grav 1 and older than 35 YOA])Basis for Diet: to reduce blood pressure to normal; reduce edema; correct protein calorie malnutritionComments: may need to increase vitamin C and B6; sodium controlled at 1-2 grams per day unless otherwise directedTools for the Patient: watch sudden weight gains (> 1 kg per week) that are not explained by dietCautions: watch sudden weight gains (> 1 kg per week) that are not explained by diet

Foods Excluded:

Milk Fruits Veggiesprn prn Watch the high sodium

veggiesBreads/Starches Meat Fats

See veggies See veggies Reduce to not more than 30%, anyway

Beverages Spices/Seasonings/PreservativesSee veggies prn; see veggies

58

Diet Name: GoutBasis for Diet: to increase the excretion of sodium urate crystals; moderate in protein (0.8 g/kg BW; increased carbohydrates, low fat to increase urate excretionComments: increase fluids to decrease stone formation (bicarbonate po helps, too); treat complications, e.g., CVA, hypertension, kidney diseaseTools for the Patient: EtOH may precipitate gout attacks as may stress; do NOT lose weight fast!: this precipitates, via ketonemia, acute gout attacks; stress management and exercise

Foods Excluded:


Breads/Starches Meat Fatsprn Anchovies, smoked meats,

sardines, liver, kidney, brain, heart, caviar, herring -- increase mackerel and salmon as the high

fats in these fish reduce the inflammatory response

Gravies; not more than 30%, anyway

Beverages Spices/Seasonings/Preservativesalcohol prn

59

Diet Name: Hemorrhoids/ectomy (1) Internal: are normal and are rarely painful; do bleed; 2) External: common, tender, painful, bluish localized varicose veins at anal margin; bleed)Basis for Diet: To reduce pain and irritation; soften bowel material; to ease bowel movements and reduce painComments: *low fiber with pain (see below); high fiber without pain; begin with progression diet: clear liquid to full liquid to low fiber/soft to full/regular diet with 20 g fiberTools for the Patient: OTC preparations with "caines" may exacerbate an allergic reaction. Preparation H may not work, but it won't hurt -- sometimes doing something IS better than doing nothingCautions: with recurrent bleeding, d/c aspirin, d/c or reduce NSAID's; double check iron, Vitamin K and the B vitamins

Foods Excluded:

Milk Fruits VeggiesNone* None* None*

Breads/Starches Meat FatsNone* None* Reduce to not more than


Increase to 8-10 glasses water per day

Highly seasoned foods (pepper?!) and relish

60

Diet Name: Herpes Simplex Virus (HSV) I and IIBasis for Diet: See also HIV/AIDS diet; other related herpes viruses' diets; decrease inflammation; prevent spreadTools for the Patient: stress management; milk is naturally high in LysCautions: if increase Lys in diet, it alters the Lys/Arg ratio which may elevate cholesterol levels

Foods Excluded:

Milk Fruits Veggiesprn prn sore mouth prn



61

Diet Name: Hiatal herniaBasis for Diet: to increase motility and empty the stomach into the duodenum and NOT the esophagus; to reduce GERD; get to IBWComments: Patient may be using H2 antagonists, dopaminergics, prokinetics, proton pump inhibitors, and antacidsTools for the Patient: leave PM and hs (night time) snacks alone; if eat, sit UP for 2 hours before you go to bed; small frequent feedings; stay away from water bedsCautions: excessive calcium from Tums causes low magnesium and phosphorus blood levels; only 33% of the dose of calcium is absorbed from Tums -- nevertheless, Tums may cause a nasty hypercalcemia when taken in large doses; Tums is not a good source of calcium -- too alkaline (review CHEM 142 or BIOL 224 notes)

Foods Excluded:

Milk Fruits Veggiesprn acid production Citrus juices Tomatoes/saucesBreads/Starches Meat Fats

prn acid production Restrict (one of the three biggest stimulators of HCl

secretion)_

Limit fried foods, creamed sauces, gravy, pastries, nuts,

potato chips, butterBeverages Spices/Seasonings/Preservatives

Coffee (caffeinated/ decaffeinated)

Chocolate, peppermint, onions, garlic, spearmint, alcohol -- d/c smoking; otherwise, prn

Hypertension – DASH Diet

Dietary Approaches to Stop Hypertension (DASH)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESNational Institutes of Health

National Heart, Lung, and Blood InstituteNIH Publication No. 06-4082

Originally Printed 1998Revised April 2006

The DASH eating plan follows heart healthy guidelines to limit saturated fat and cholesterol. It focuses on increasing intake of foods rich in nutrients that are expected to lower blood pressure, mainly minerals (like potassium, calcium, and magnesium), protein, and fiber. It includes nutrient-rich foods so that it meets other nutrient requirements as recommended by the Institute of Medicine.

63

64

Daily Nutrient Goals Used inthe DASH Studies

(for a 2,100 Calorie Eating Plan)Total fat 27% of calories Sodium 2,300 mg*

Saturated fat 6% of calories Potassium 4,700 mg

Protein 18% of calories Calcium 1,250 mg

Carbohydrate 55% of calories Magnesium 500 mg

Cholesterol 150 mg Fiber 30 g

* 1,500 mg sodium was a lower goal tested and found to be even better forlowering blood pressure. It was particularly effective for middle-aged and older

individuals, African Americans, and those who already had high blood pressure.

65

DASH: Food Groups and Examples, Non-Inclusive, within Food Groups

Grains Vegetables Fruits Fat-free or low-fat milk and

milkproducts

Lean meats, poultry, and fish

Sweets and

added sugars

per week

Nuts, seeds,

and legumes

Fats and oils

1 slice bread

1 oz dry cereal1/2 cup cooked

rice, pasta, or

cereal

1 cup raw leafy

vegetable1/2 cup cut-up raw or cooked

vegetable1/2 cup

vegetable juice

1 medium fruit

1/4 cup dried fruit 1/2 cup fresh,

frozen, or canned

fruit 1/2 cup

fruit juice

1 cup milk or yogurt

1.5 oz cheese

1 oz cooked meats,

poultry, or fish

1 egg

1 Tbsp sugar1 Tbsp jelly or

jam1/2 cup sorbet, gelatin1 cup

lemonade

1/3 cup or 1.5 oz nuts

2 Tbsp peanut butter

2 Tbsp or 1/2 oz seeds

1/2 cup cooked legumes

(dry beans

and peas)

1 tsp soft margarine

1 tsp vegetable oil

1 Tbsp mayonnaise

2 Tbsp salad

dressing

• Exercise is required with DASH

• Portion control, as well, is required

• Not an endorsement –one possible alternative: Chefmate Digital Nutritional Scale –battery operated and easy to use

66

67

DASH: Number of Daily Servings forOther Calorie Levels

Servings per Day

Food Groups 1600 kcal per day 2600 kcal per day 3100 kcal per day

Grains* 6 10–11 12–13

Vegetables 3–4 5–6 6Fruits 4 5–6 6

Fat-free or low-fat milk and milk

products2–3 3 3–4

Lean meats,poultry, and fish 3–6 6 6–9

Nuts, seeds, andlegumes 3/week 1 1

Fats and oils 2 3 4Sweets and

added sugars 0 ≤2 ≤2

* Whole grains are recommended for most grain servings as a good source of fiber and nutrients.

68

Diet Name: HypoglycemiaBasis for Diet: to maintain/regulate blood glucose levelsComments: small, frequent feedings ("grazing"); for fasting-type, carry candy or fruit juices; for post-prandial-type, reduce concentrated sweets and carbohydrates to not more than 100 grams per dayTools for the Patient: AVOID dietetic foods: BIG SNAFUBAR!; exercise, Increase protein in diet

Foods Excluded:


Breads/Starches Meat Fatsprn prn Reduce to not more than


prn prn

69

Diet Name: HyponatremiaBasis for Diet: to correct electrolyte/water imbalanceComments: PRIMARY SALT DEPLETION: sodium loss is greater than water loss; reduced ECF (review BIOL 223/224 notes); use hyper/iso-tonic saline with salty broths. DILUTIONAL HYPONATREMIA: water retention is greater than sodium retention; use low sodium diet and diuretics prn; WATER INTOXICATION: restrict fluids

Foods Excluded:

Milk Fruits VeggiesPer type of hyponatremia above

Breads/Starches Meat FatsPer type of hyponatremia above

Beverages Spices/Seasonings/PreservativesPer type of hyponatremia above

70

Diet Name: Iron deficiency anemiaBasis for Diet: to correct iron levels and increase iron absorption; to increase blood iron and blood cell numbersComments: to increase iron absorption, increase hydrogen ion concentration; treat constipation; pica common (primarily with excessive life savers, ice, lettuce, celery, chips, chocolate), so this needs "correcting"Tools for the Patient: teach about difference in stool color from brown to green/black and that this is normal with therapy; take supplements with food; increase Vitamin C to increase iron uptake, too.

Foods Excluded:

Milk Fruits Veggiesprn With high fiber (binds iron) With oxalates

Breads/Starches Meat FatsWith phytates; with high

fiberprn Not more than 30%, anyway

Beverages Spices/Seasonings/Preservativesprn; tea, coffee (contain

tannins)prn; EDTA

Signs and symptoms (S/S) of iron deficiency anemia

71

Signs and symptoms (S/S) of iron deficiency anemia

• Brittle, flat with longitudinal ridges on finger nails. May be spoon shaped.

• Atrophy of taste buds on tongue, split lips at corners of mouth, sore mouth.

• GI S/S: no HCl production, gas, constipation, lack of appetite -- hepatosplenomegaly may be present.

• Numb-tingling hands and feet.• Lab results: microcytic, hypochromic RBC, low

hemoglobin, elevated RBC, reduced hematocrit (PCV), low ferrous ion levels, elevated iron binding protein (FeBP).

72

Diet Name: Kwashiorkor/MarasmusBasis for Diet: to increase protein to compensate for high carbohydrate, low protein diet that causes it; to prevent weight loss; prevent infections; promote wound healingComments: treat infections; check electrolytes and water balance; refrain from OVER feeding (use progressive diets)Tools for the Patient: Supplement minerals and vitaminsCautions: Watch for heart failure with/without edema; check phosphate, magnesium, potassium deficiencies (generally due to over feeding)

Foods Excluded:

73

Kwash and Maras• 1) Kwashiorkor: aka

protein deficiency. The name means a syndrome which develops in a child who is being weaned from the breast at about 1 YOA following the birth of the next baby.

• 2) Marasmus: aka protein CALORIE malnutrition. A state of chronic total under-nutrition that occurs mainly in children and has varying degrees of severity. This produces gradual wasting away of body tissue with general emaciation and starvation.

74

General Comparison Between The Signs of Kwashiorkor and MarasmusKwashiorkor Signs Marasmus

X Growth retardation XX**** Underweight X

X Apathy, behavior changes XX EdemaX Muscular wasting XX DepigmentationX DermatosisX HypoalbuminemiaX Fatty liverX Diarrhea XX Abnormal fat metabolismX Reduced vitamin A absorption

Hypothermia XGlucocorticoids X

****Masked by edema

75

Milk Fruits VeggiesAll at first; then "redevelop" lactose tolerance with skim

milk, slowly

prn prn



76

Diet Name: Maple Syrup Urine Disease (MSUD; review CHEM 220 notes)Basis for Diet: inborn error of metabolism; reduce branched chain amino acids (BCAA's) in diet; for thiamin responsive give 100 mg thiamin per day; control BCAA's for lifeCautions: make certain there is adequate calorie intake for protein sparing

Foods Excluded:

Milk Fruits Veggies(Milk contains 350 mg leu,

228 mg ileu and 245 mg val) use SMALL amounts only

None None

Breads/Starches Meat FatsThose with high levels of

BCAA'sThose with high levels of BCAA's; GELATIN may be used since it is

WAY low in BCAA's

None


77

Diet Name: Muscular DystrophyBasis for Diet: a general diet, modified prn; to promote health; high fiber to decrease constipationComments: encourage exercise to reduce obesity due to inactivityTools for the Patient: eat foods in such a manner that they are easy to chew and swallow (blenderize prn)

Foods Excluded:


Breads/Starches Meat Fatsprn prn (blender) prn; not more than 30%,

anywayBeverages Spices/Seasonings/Preservatives

prn prn

78

Diet Name:Nephro/UrolithiasisBasis for Diet: to minimize stone formation and increase hydration; to get rid of the stoneComments: increase fluids to AT LEAST 2 liters every 24 hours to dilute and increase solubility; determine stone composition (refer to your BIOL 224 notes); with uric acid stones, alkalinize urine with citrate or bicarbonate; B6 decreases oxalate by 50%Tools for the Patient: EXCESSIVE cranberry juice is needed to acidify the urinary tract so it is not very practical -- 2-3 grams qd Vitamin C does the same; double check calcium levels in drinking water, you may need to switch to deionized water instead of "softened water" if necessary

Foods Excluded:

Milk Fruits VeggiesWith calcium oxalate

stonesprn Oxalate containing

(asparagus, mushrooms, legumes, spinach)

Breads/Starches Meat Fatsprn; oatmeal Purine-rich foods, e.g.,

sardines, organ meats, wild game, anchovies, herring, meat

extracts, poultry

Not more than 30% anyway; meat broth, gravy

Beverages Spices/Seasonings/Preservativesprn; caffeine prn

79

Diet Name: Peptic Ulcer DiseaseBasis for Diet: R/O gall bladder disease; double check for Helicobacter pylori; reduce pain; promote healing/recovery; correct steatorrheaComments: may be low in iron; increasing fiber reduces symptomsTools for the Patient: stop smoking; small frequent feedings; learn to relax (stress reduction); learn stress management; do not skip meals due to increased acid production with/due to stressCautions: watch for B12 malabsorption

Foods Excluded:

Milk Fruits VeggiesAvoid (first milk proteins

buffer the acid, then secondly, the hydrogen ion concentration rises making

the situation worse)

Acidic juices prn

Breads/Starches Meat Fatsprn red Limit anyway to less than

30%Beverages Spices/Seasonings/Preservatives

caffeine The following exclusions ALONE make the "liberal bland diet": alcohol, black pepper, garlic, cloves, chili powder

80

Diet Name: Pernicious anemiaBasis for Diet: See also folate deficiency diet; to treat the anemia; to correct anorexiaComments: soft foods due to glossitis (beefy, red tongue); if vegetarian, use supplement

Tools for the Patient: lifelong injections are necessary -- po B12 does NOT work as intrinsic factor is not being secreted for B12 uptake (see milk category below for exception to this rule)Cautions: avoid fad diets

Foods Excluded:

Milk Fruits Veggiesprn; when taking Trinsicon (a supplement with iron,

vitamin C, folate and intrinsic factor)

prn prn

Breads/Starches Meat Fatsprn prn Not more than 30% anyway


81

Vitamin B12 Deficiency Anemia: Pernicious Anemia

• Anorexia, diarrhea, nausea, weight loss, vomiting, weakness, dyspnea, palpitations, lemon yellow tinge to skin, hepatosplenomegaly may occur, spinal cord degeneration may occur in some patients causing difficulty in walking, difficulty in sensing position and/or difficulty in sensing vibrations in legs.

• A wide variety of shapes and sizes of RBC's are present.

• No gastric HCl is produced, reducing intrinsic factor release from the stomach walls to zero.

82

Diet Name: Phenylketonuria (PKU)Basis for Diet: Inborn error of metabolism; to maintain very low phe levels; increase tyr in diet; maintain phe levels around 2-19 mg/dl; to reduce mental retardation and promote normal growth/developmentComments: teach about positive attitudes with this diet (yucky!); supplement with zinc, manganese and niacinCautions: establish daily requirements for phe (norm blood levels ≈ 3-7 mg/dl; often 15-30 in PKU); increase phe when febrile (decreased phe intake causes anorexia, fever [paradox], N/V, stunted growth)

Foods Excluded:

Milk Fruits VeggiesAll, except for minimal amounts -- use Lofenalac, Phenyl-free or

Maxamaid XP formulas

None Legumes

Breads/Starches Meat FatsBreads; use lots of sugars to

boost kcalAll plus peanut butter None

Beverages Spices/Seasonings/PreservativesThose with aspartame (Nutra

Sweet) or Equalprn

83

Diet Name: PyelonephritisBasis for Diet: preserve renal function; regulate blood pressure; acidify urine to decrease urinary bacterial growth (K-Phos Original, Vitamin C)Comments: fluids ad lib/prn -- *BELOW: increases the acidity of the urineCautions: restrict sodium intake with blood pressure regulation

Foods Excluded:

Milk Fruits Veggiesprn (increase cranberries, plums,

prunes)*(increase corn, lentils)*

Breads/Starches Meat Fats(increase bread/starch)* prn (increase peanuts, walnuts)*

Beverages Spices/Seasonings/Preservativescaffeine prn

84

Diet Name: Rheumatoid ArthritisBasis for Diet: autoimmune disorder; to reduce incidence of inflammationComments: restrict sodium as necessary; treat constipation; may need to puree foodsTools for the Patient: avoid quackery; increase protein and calcium; see also Degenerative Bone/Joint DietCautions: restrict sodium intake when necessary

Foods Excluded:


Breads/Starches Meat Fatsprn Herring, mackerel, salmon

(ω-3 fatty acids cause inflammatory reactions)

Not more than 30% anyway

Beverages Spices/Seasonings/Preservativesprn; caffeine prn

85

Diet Name: Shingles -- see also HSV dietsBasis for Diet: reduce fever (fluids ad lib/prn); treat unplanned weight loss and anorexiaComments: if use po or topical steroids, watch for secondary infections to be "masked"; also with topical steroids, use with extreme care as they also cause thinning of skin, delaying healing of the lesionsCautions: hand wash; watch for secondary infections; refrain from covering these lesions as they tend to multiply rapidly when sealed

Foods Excluded:




86

Diet Name: Surgery, GenericBasis for Diet: BEFORE surgery: prepare body reserves of nutrients for healing after surgery; restrict to clear liquid, then npo; support; high calorie/high protein diet UNLESS patient is obese; watch the obese patient: fat retains anesthetics, does not heal well and is hard to suture -- these patients may be hard to awaken after surgery and may spontaneously cease breathing because they have retained so much anesthetic.AFTER surgery: replace protein/glycogen; double check electrolytes and water balance; replace iron lost during surgery; increase zinc, vitamins A and K and arginine (speeds wound healing); prevent infectionComments: remember D5W is only 170 kcal/L; progress diet from npo to regular, graduallyTools for the Patient: up and about ASAP; 3-12 months post-op, control/regulate kcal (fat gain stage); eat and drink slowly

Foods Excluded:

Milk Fruits VeggiesPer MD Per MD Per MD

Breads/Starches Meat FatsPer MD Per MD Per MD

Beverages Spices/Seasonings/PreservativesPer MD Per MD

87

NOTE• Until recently, MD's were not heavily instructed

about nutrition. • You may have to help them figure out what the

patient's diet needs to be pre- AND post-operatively.

• Recently, medical schools have been adding nutrition to the curriculum for medical students.

• It is not, yet, at the depth of a one-semester course although it is improving.

• Rely on your nutritionists/dieticians and your own training to advocate for your patient.

88

Diet Name: Tyramine restricted diet -- see also Depression diet (exogenous depression: caused by an unrealistic reaction to a life event or internal conflict; endogenous depression: multiple factors cause intrapsychic conflict; MAJOR, requires anti-depressants and psychotherapy -- or BOTH which is the best combination)Basis for Diet: avoids MAOI for depression problems: hypertension, headache, palpitations, CVATools for the Patient: reduce/cease caffeine at night time; increase trp with high protein/carbohydrate diet to increase serotonin levels; avoid ANY high protein food that has been aged, pickled, fermented, smoked, stored for a long time, spoiled or contaminated

Foods Excluded:

Milk Fruits Veggies

Aged cheeses (blue, brick, Brie, Camembert, cheddar, Gorgonzola,

Mozzarella, Parmesan, Roquefort and unpasteurized cream or yogurt)

Canned figs, ripe bananas, raspberries

Broad bean pods, ripe avocado, sauerkraut

Breads/Starches Meat Fats

Yeast breads Aged meat, liver, dry sausage, smoked/pickled

herring, chicken liver, sausage, salami, pepperoni

Commercial gravies, chocolate, peanuts

Beverages Spices/Seasonings/Preservatives

Beer, red wine, ale, chianti, vermouth, white wine, port, distilled spirits

Fermented soy sauce, yeast concentrates/extracts

89

Interactions between Nutrients and Drugs:

A VERY Brief Introduction

90

Definitions

• Primary nutrient malabsorption means that the nutrient gets into the bowel, but it is not taken up across the bowel.

• Secondary nutrient malabsorptionmeans that the nutrient may or may not have crossed the bowel into the blood, and may not be utilized or may be over-utilized by the cells in the body.

91

Some Illustrative Drugs Causing Primary Nutrient Malabsorption

92

Drug Use Action Nutrients lostCholestyramine Bile-binding resin Binds bile salts and

nutrientsFat, Vitamins A, D, K,

B12 and ironColchicine Treats gout Enzyme damage;

reduces cell reproduction

Fat, B12, pro-vitamin A, lactose, sodium and

potassium ionsMethyl DOPA Antihypertensive ????? B12, folate, iron

Mineral oil Laxative Nutrients dissolve in oil and are excreted

Vitamins A, D and K

Neomycin Antibiotic Binds bile salts; reduces activity of pancreatic lipase

Fat, B12, nitrogen, lactose, sucrose, ionized sodium, potassium, iron,

calciumPASA Antitubercular Blocks reuptake of B12

in the bowelFat, folate, B12

Phenolphthalein (now supposed to be off the market)

Laxative Rapid intestinal transit Calcium and potassium ions and Vitamin D

KCl Potassium replacement therapy

Reduces ileal pH B12

93

Some Illustrative Drugs Causing Secondary Nutrient

Malabsorption

94

Drug Use ActionCimetidine Ulcers Reduces B12 absorption

Tricyclic antidepressants (e.g.,

Elavil)

Antidepressant Weight gain due to stimulated appetite

Phenobarbital Anticonvulsant Increases Vitamin D metabolism

Prednisone Allergies, COPD Reduces calcium ion transport; increases Na+

retentionMethotrexate DHFR inhibitor in leukemia Reduces folate levels

95

Some Illustrative Drugs Causing Vitamin Antagonism

Target vitamin Drug that antagonizes it

K Coumarins

Folate Methotrexate; trimethoprim

B6 Isoniazid; Levodopa

96

Effects of Oral Contraceptives on Nutrition

Nutrient effected Effect Clinical result

Vitamin A Impairs liver storage ?Vitamin B6 Alters trp metabolism

and B6 metabolismAbnormal protein metabolism; mood

alterations

Vitamin B12 Reduces B12 levels ?pernicious anemia?

Folate Reduces RBC numbers; increase folate binding protein

Megaloblastic anemia

97

Summary of The Additive Effects of A Drug with A Nutrient or

Nutrient-like Product Drug + Alcohol or food = Effect

Chlorpropamide (oral hypoglycemic)

+ Alcohol = Shortness of breath (SOB), headache, flushing

ADH inhibitors (disulfiram,

metronidazole)

+ Alcohol, alcohol-containing foods

= Belly and chest pain, flushing, headache, N/V

Tolinase, Orinase (oral hypoglycemics)

+ Alcohol, sugar, sweets = Confusion, weakness, irrational behavior, unconsciousness

MAOI's (anti-depressants)

+ Cheese, red wine, chicken liver

= CVA, hypertensive crises, headache

Isoniazid (anti-TB) + Yeast (foods high in tyramine)

= N/V, restlessness

98

Summary of The Food Effect on Drug Absorption

• This list is not inclusive: always look up the medication you are either giving or taking to learn the effects of nutrients on its bioavailability.

Food Effect on Drug Absorption

Absorption reduced by food Absorption delayed by food

Amoxicillin, ampicillin, aspirin, isoniazid, l-DOPA, Pen-G [V-K],

phenobarbital, tetracycline

Tylenol, aspirin, cephalexin, digoxin, furosemide, sulfanilamide,

sulfasoxazole

99

Nutrient/Drug Interactions

Exhaustive; Not All-inclusive, however

100

Drug Name Class/Indication CommentAtarax Antihistamine/

anxiolyticPotentiates CNS depression with EtOH

Ativan Benzodiazepine anxiolytic

Potentiates CNS depression with EtOH

Librium Benzodiazepine anxiolytic


Serax Benzodiazepine anxiolytic


Xanax Benzodiazepine anxiolytic


Haldol Butyrophenone antipsychotic


Moban Dihydrolindolone antipsychotic

Potentiates CNS depression with EtOH; tablets contain calcium that may interfere with

tetracycline/phenytoin absorptionThorazine Aliphatic phenothiazine

antipsychotic; retractable hiccups, too


101

Drug Name Class/Indication CommentAnafranil Tricyclic

antidepressant for obsessive compulsive

disorder


Desyrel Triazolopyridine Potentiates CNS depression with EtOHElavil Tricyclic

antidepressant (endogenous sort --see Depression diet)


Lithobid Lithium salt for bipolar manic depressive

disorder

Potentiates toxicity of indomethacin, xanthine and caffeine (SIDEBAR: caffeine is a trimethyl xanthine. 3

cups of coffee contain approximately 425 mg of caffeine and increase the FEV [see BIOL 224 notes]

by 20%. The 425-mg of caffeine are equivalent to 200 mg of aminophylline (dimethylxanthine similar to

theophylline). Caffeine is metabolized, partially, to theophylline.)

Nordil MAOI for refractory depression

AVOID: cheeses, salami, chocolate (European moresothan American) wine, pickled herring, chicken livers,

yeast extract, broad beans, yogurt

102

Drug Name Class/Indication CommentParnate MAOI for

refractory depression

AVOID: EtOH and trp

Paxil Selective serotonin reuptake

inhibitor (SSRI)

AVOID: EtOH and trp

Prozac SSRI AVOID: EtOH and trp (increased CNS stimulation with trp)

Mebard Barbiturate anticonvulsant

Antagonizes vitamins D and K and oral contraceptives (SIDEBAR: penicillins,

tetracyclines, cephalosporins and griseofulvin inhibit the effects of oral

contraceptives. If you do NOT want to get pregnant when on one of these kinds of

drugs, utilize barrier contraception.)Mesantoin Hydantoin

anticonvulsantAVOID: EtOH, calcium-containing antacids reduce absorption; reduces vitamins D and

K levels, too.

103

Drug Name Class/Indication CommentAccutane Retinoic acid

derivativeAVOID: Vitamin A and EtOH

Achromycin V Tetracycline antibiotic

Antacids, iron, zinc, calcium, magnesium, dairy products, urinary alkalinizers and food decrease absorption -- ALSO: inhibits oral contraceptive

activityRetin A Retinoic acid

derivativeAVOID: spices, lime

(?mechanism not clear, but is a fact)Orinase Oral hypoglycemic AVOID: EtOH (disulfiram-like reaction); antagonized

by niacinTolinase Oral hypoglycemic AVOID: EtOH (disulfiram-like reaction); antagonized

by niacin; potentiated, also, by salicylatesBentyl GI tract

anticholinergicConcomitant antacids inhibit absorption

Cytotec Prostaglandin E analog

AVOID: magnesium-containing antacids

Maalox caplets Antacid Reduces tetracycline absorption; absorption blocked by rhubarb, spinach, bran

104

Drug Name Class/Indication CommentFuroxone Antimicrobial AVOID: tyramine-containing foodsAzulfidine Salicylate-

sulfonamideDecreases folate absorption given concomitantly

Dramamine Antihistamine May potentiate ototoxicity of antibiotics (especially aminoglycosides)

Cotazym Pancreatic enzymes May antagonize ironCefobid Cephalosporins AVOID: EtOH for AT LEAST 72 hours after the

last doseCipro Quinolone AVOID: concomitant antacids, iron and zincFlagyl Nitroimidazole AVOID: EtOH during and AT LEAST 24 hours

after useNoroxin Quinolone AVOID: concomitant antacids and minerals;

potentiates caffeineFulvicin P/G Griseofulvin Potentiates EtOH; reduces oral contraceptive

activity

105

Drug Name Class/Indication CommentDepen Chelator in

rheumatoid arthritisAntagonized by mineral supplements

Didrome Calcium regulator AVOID: calcium, iron, magnesium and aluminum within 2 hours of dose

Phoslo Phosphate regulator AVOID: calcium supplements and antacids; may inhibit tetracycline absorption

Matulane Procarbazine (adjunct in Hodgkin's

disease)

Disulfiram reaction with EtOH; AVOID: tyramine-containing foods

Allbee with C Vitamin supplement Iron blocks tetracycline uptakeMaterna Pre-post-natal

supplementIron and calcium reduce calcium absorption across the bowel -- oxymoron: why give tetracycline to a pregnant or nursing woman?!?!?!?! Ya don't! It doesn't allow the enamel to develop adequately on their kid's/fetus' teeth and they turn a mottled brown color and require dental work later on.

106

Drug Name Class/Indication CommentRocaltrol Calcitriol Hypermagnesemia with magnesium-containing

antacids; reduced absorption with cholestyramine or mineral oil

Stuart Prenatal Supplement Iron, calcium blocks tetracycline absorption --SO!? See Materna, above

Oral contraceptives

Oral contraceptive Antacids and antibiotics may inhibit absorption

Axotal Barbiturate and analgesic (primarily

for tension headache)

With EtOH or NSAID's cause increased risk of GI bleed

Antabuse EtOH deterrent EtOH reaction with tonics, foods, after-shaves, back rubs, lab experiments where EtOH or

another alcohol is present

107

Drug Name Class/Indication CommentHabitrol Smoking cessation

aidQuitting smoking increases caffeine metabolism -- there's nothing worse than a nervous, wired,

newly quit smoker!Asbron-G Xanthine and

expectorant (asthma, bronchitis, COPD)

AVOID: other xanthines, e.g., caffeine, theobromine

Macrobid or Macrodantin

Antibiotic AVOID: magnesium trisilicate

K-Phos Original Urinary acidifier Hyperkalemia may occur with potassium supplements

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