Jacqueline Vitug, RND

Review of Sources and Values

Outline

Objectives

Definition of Terms

Food Sources

Case Study

Objectives

To review food sources of sodium,

potassium, and phosphorus;

To integrate learned information

on actual practice

Sodium is the most plentiful electrolyte in

the extracellular fluid with a concentration

ranging from 135 to 145 mEq/L.

Hyponatremia refers to a serum sodium

level that is below normal (135 mEq/L).

Dilutional VS Depletional Hyponatremia

Metheny, 2011

s o d i u m

Severe hyponatremia is

associated with high rates of

morbidity and mortality, but its

treatment can also result in

morbidity.

Koda-Kimble and Young, 2012

s o d i u m

Salt

FNRI: 5g salt = 2000 mg Na

NDAP/NIH: 6g salt = 2400 mg Na

AHA/AND/CDC/FDA: 5.8g salt = 2300 mg Na

s o d i u m

equivalent of 1 tsp

40% sodium

considered a gentle oral challenge

(Yeates, 2004)

Patient EA is currently being fed with Formula

NDB 1200 kcal per day via NGT. He was

assessed to be hyponatremic and the

Attending Physician ordered to adjust the

feeding’s sodium content to 4 grams per day.

s o d i u m

Case Patient

How much salt should be added to the feeding?

Patient EA is currently being fed with Formula NDB 1200 kcal

per day via NGT. He was assessed to be hyponatremic and

the Attending Physician ordered to adjust the feeding’s sodium content to 4 grams per day.

s o d i u m

Na Requirement 4000 mg

Formula NDB, 1200 kcal - 1044 mg

2956 mg

÷ 2400 mg (per 1 tsp)

1.23 tsp

~ 1 ¼ tsp

Case Patient

How much salt should be added to the feeding?

Potassium is the major intracellular cation

with normal concentration levels at roughly

between 3.6 and 5 mmol/L.

Hypokalemia refers to a serum potassium

level that is below 3.6 mmol/L.

p o t a s s i u m

Cohn, 2000

p o t a s s i u m

Banana, raw

358 mg K / 100 g

~ 143 mg K / 1 exchange

Bananas are commonly used for

increasing potassium intake.

p o t a s s i u m

Other Fruits rich in potassium

All values per 100g. USDA

09037 Avocado 485 mg

09148 Kiwi fruit, green 312 mg

09181 Melons 267 mg

09206 Orange juice 200 mg

09226 Papaya 182 mg

09316 Strawberries 153 mg

09273 Pineapple juice, unsweetened 130 mg

09412 Pears 101 mg

09016 Apple juice, unsweetened 101 mg

09004 Apple, raw, no skin 90 mg

Patient EA’s attending physician ordered for

adjustment of feeding to 6g potassium per day.

His feeding was also revised to 1600 kcal 45 g

protein per day at 1.5 kcal/mL dilution.

p o t a s s i u m

Case Patient

What considerations should be made in increasing

the total potassium content of the feeding?

Patient EA’s attending physician ordered for

adjustment of feeding to 6g potassium per day.

His feeding was also revised to 1600 kcal 45 g

protein per day at 1.5 kcal/mL dilution.

p o t a s s i u m

Consider

Low protein

maximize protein-rich foods that are high

in potassium

Case Patient

p o t a s s i u m

Protein-rich sources of potassium

All food items (except whey) are cooked; values per 100g. USDA

13496 Beef, lean 308 mg

05014 Chicken, meat 180 mg

01129 Egg, chicken, whole, hard-boiled 126 mg

Egg, chicken, white 135 mg

10042 Pork, loin 356 mg

15212 Salmon, pink 439 mg

15052 Tanigue (Spanish mackerel) 554 mg

05306 Turkey, ground 294 mg

14058 Whey powder isolate 872 mg

p o t a s s i u m

Starchy Foods rich in potassium

All values per 100g. USDA

Beans, Potatoes & other rootcrops

Baked: 300 to 600 mg

Boiled: less than 300 mg

Rice, brown, cooked, 79 mg

Rice, white, cooked, 29 mg

Bread, white, 126 mg

Bread, wheat, 177 mg

Patient EA’s attending physician ordered for

adjustment of feeding to 6g potassium per day.

His feeding was also revised to 1600 kcal 45 g

protein per day at 1.5 kcal/mL dilution.

p o t a s s i u m

Consider

Dilution

vegetable juices yield higher potassium

without adding bulk

Case Patient

p o t a s s i u m

Leafy Vegetables rich in potassium

All values per 100g. USDA

RAW COOKED

Arugula 369 mg --

Broccoli 316 mg 293 mg

Camote tops 508 mg 312 mg

Chinese Cabbage 371 mg 252 mg

Lemongrass 723 mg --

Parsley 554 mg --

Spinach 558 mg 466 mg

Phosphorus is an essential mineral that is

required by every cell for optimal function.

Normal serum phosphorus concentration is

2.5–4.5 mg/dL (0.80–1.45 mmol/l).

Hypophosphatemia refers to a serum

phosphorus level that is below 2.5 mg/dL.

Knochel, 2006 Amanzadeh, 2006

p h o s p h o r u s

Patient MAN developed hypophosphatemia on his

4th week of confinement. He is on conventional

feeding at 1600 kcal 80g protein per day and his

attending physician ordered to increase phosphorus

in feeding to at least 1200 mg per day. Skimmed

milk flushing was also started at 50 mL every 4 hours.

p h o s p h o r u s

What considerations should be made in increasing

the total phosphorus content of the feeding?

Case Patient

p h o s p h o r u s

Phil FCT - J022

Milk, powder, non-fat, instant

860 mg P / 100 g (361 calories)

~ 189 mg / 22 g (80 calories)

USDA - 01151

Milk, fluid, non-fat, without added vit.A/D

239 mg P / 1 cup (80 calories)

Milk is a good source of phosphorus

Patient MAN developed hypophosphatemia on his 4th week of

confinement. He is on conventional feeding at 1600 kcal 80g

protein per day and his attending physician ordered to increase phosphorus in diet to at least 1200 mg per day.

Skimmed milk flushing was also started at 50 mL every 4 hours.

p h o s p h o r u s

Consider:

Calories & Protein

skimmed milk to be included in computation

50 mL skimmed q 4˚ = 300 mL / day

~ 1.2 NF Milk exchanges

~ 96 cals, 10g CHON

~ 239 mg Phosphorus

Case Patient

Patient MAN developed hypophosphatemia on his 4th week of

confinement. He is on conventional feeding at 1600 kcal 80g

protein per day and his attending physician ordered to increase phosphorus in diet to at least 1200 mg per day.

Skimmed milk flushing was also started at 50 mL every 4 hours.

p h o s p h o r u s

Consider:

Choice of Food

replace commonly used food items

with higher phosphorus content

Case Patient

p h o s p h o r u s

F016 Beef, lean meat, boiled 174 mg

F111 Chicken, white meat, boiled 154 mg

H004 Egg, chicken, whole, boiled 180 mg

H002 Egg, chicken, white 11 mg

F161 Pork, center loin 90 mg

*15212 Salmon, pink, cooked 313 mg

G072 Tanigue 236 mg

F208 Turkey, breast 185 mg

*14058 Whey powder isolate 581 mg

Protein-rich sources of phosphorus for EN

All values per 100g.

Philippine FCT, 1997. *USDA

p h o s p h o r u s

*20041 Rice, brown, cooked 77 mg

*20451 Rice, white, cooked 37 mg

A183 Rice Gruel 15 mg

*18069 Bread, white 98 mg

*18064 Bread, wheat 149 mg

A150 Oatmeal, quick-cooking, cooked 50 mg

Other Food Sources to be considered for EN

All values per 100g.

Philippine FCT, 1997. *USDA

p h o s p h o r u s

C038 Peanut, without skin, roasted 417 mg

C063 Soy bean curd, tofu 83 mg

C064 Soy bean curd, tokwa 119 mg

C043 Sesame Seed, dried, toasted 427 mg

Other Food Sources to be considered for EN

All values per 100g. Philippine FCT, 1997

Patient MAN developed hypophosphatemia on his 4th week of

confinement. He is on conventional feeding at 1600 kcal 80g

protein per day and his attending physician ordered to increase phosphorus in diet to at least 1200 mg per day.

Skimmed milk flushing was also started at 50 mL every 4 hours.

p h o s p h o r u s

Consider:

Tolerance to Dairy

Case Patient

If patient MAN is lactose intolerant, what would

you recommend as his dietary phosphorus

source?

p h o s p h o r u s

Soy Milk (USDA-43543) 267 mg

Coke, regular 41 mg

Diet Coke 18 mg

Coke Zero 36 mg

Pepsi, regular 35 mg

Diet Pepsi 27 mg

Pepsi Max 35 mg

Other Food Sources to be considered for EN

Values per 240 mL.

Summary

Mild to moderate electrolyte (Na, K,

P) requirements may be met orally

(enterally) with careful planning.

e n d

Academy of Nutrition and Dietetics. http://www.eatright.org/Public/content.aspx?id=6442452758

Amanzade J and Reilly RFJ. Nature Clinical Practice Nephrology (2006) 2, 136-148 http://www.nature.com/nrneph/journal/v2/n3/full/ncpneph0124.html

American Heart Association. http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Shaking-the-Salt-Habit_UCM_303241_Article.jsp

Center for Disease Control and Prevention. http://www.cdc.gov/salt/pdfs/Sodium_QandA.pdf

Cohn JN et al. New Guidelines for Potassium Replacement in Clinical Practice. Arch Intern Med. 2000;160:2429-2436 http://fm.mednet.ucla.edu/img/download/newguidelinesforpotassiumreplacement.pdf

Felsenfeld AJ and Levine BS. American Journal of Kidney Disease. 2012 Oct;60(4):655-61 http://www.ncbi.nlm.nih.gov/pubmed/22863286

Gropper SS and Smith JL. Advanced Nutrition and Human Metabolism, 6th ed. Wadsworth. 2013:438-439, 463

Knochel JP. Phosphorus. In: Shils ME, Shike M, Ross AC, Caballero B, Cousins RJ, eds. Modern Nutrition in Health and Disease. 10th ed. Baltimore: Lippincott Williams & Wilkins;2006:211-222

Koda-Kimble and Young's Applied Therapeutics: The Clinical Use of Drugs. 10th ed. Lippincott Williams & Wilkins. 2012: 199

r e f e r e n c e s

Metheny, NM. Fluid and Electrolyte Balance, 5th ed. Jones & Bartlett Publishers. 2011: 45-46,52,127

Nutritionist-Dietitians’ Association of the Philippines. http://www.ndap.org.ph/knowledge-updates/128

phyticacid.org

USDA National Nutrient Database for Standard Reference. Release 27.

US Food and Drug Administration. http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm315393.htm

US National Library of Medicine. National Institutes of Health http://www.nlm.nih.gov/medlineplus/dietarysodium.html

WHO. Promoting Good Nutrition and Health Module 3, page 16 http://www.wpro.who.int/philippines/publications/module3.pdf

Yeates, et al. CMAJ 2004;170(3):365-9 http://www.cmaj.ca/content/170/3/365.full.pdf

r e f e r e n c e s