B. Nutritional Deficiency States Cancer AIDS Renal failure COPD Heart failure.

B

Nutritional Deficiency StatesCancerAIDSRenal failureCOPDHeart failure

Impact of MalnutritionSusceptibility to infectionWeakness and fatigueImpaired wound healingImpaired growth and development in

childrenEdemaAnemia

Nutritional ProductsLiquid enteral productsIV fluidsPancreatic enzymesVitaminsminerals

Nutritional ProductsLiquid enteral products--Variety of

preparations for nutritional supplementation and for those with special conditions

Enteral feedings are preferable to TPN due to maintaining GI integrity, less risk for infection and less expensive

IV fluids used for hydration, specially prepared intravenous products to meet all nutritional needs

Nutritional ProductsPancreatic enzymes—amylase, protease,

lipase are required for absorption of CHO, protein, and fat

Pancrelipase used as replacement therapy in deficiency states incl. cystic fibrosis, chronic pancreatitis, pancreatectomy, and pancreatic obstruction

Vitamins—insufficient dietary intake to meet requirements

Dietary Reference IntakesRDA—recommended dietary allowance is the

amount estimated to meet the needs of approximately 98% of healthy children and adults in a specific age and gender group

Tolerable Upper Intake Level—UL. Maximum intake considered unlikely to pose a health risk in almost all healthy persons in a specified age group

With vitamins—D =50mg; E =1000mg; pyridoxine =100mg

With minerals—UL should not be exceeded due to toxicity

VitaminsA—vision, growth, bone development, skin

and mucous membranesE—antioxidant in destruction of certain fats,

may increase absorption, storage and duse of vitamin A

K—essential for normal clottingD—instrumental in bone health

VitaminsFat soluble==A, D, E, KWater soluble==B complex and CSupplements exert same physiologic effects

as fr. foodsNo Rx neededShould not exceed recommended amounts of

Vit. D, E, folic acid and vitamin ALarge doses of all minerals are toxicAntioxidants—may affect free radicals,

inconclusive studies regarding outcomes

VitaminsCyanocobalamin—B12—needed by all body cells incl.

RBCs, nerves, metabolism of CHO, proteins and fats. Pernicious anemia.

Folic acid—metabolism of all body cells, normal RBCs and growth. Megaloblastic anemias, neural tube defects . Grains, fresh green vegetables.

Niacin—B3—coenzyme in many metabolic processes; fat synthesis; tissue respiration. Grains, legumes. Pellagra (skin, mucous membranes, asthenia, psychosis)

Pyridoxine—B6—needed for conversion of tryptophan to niacin; helps release glycogen from liver and muscle tissue; helps maintain cellular immunity; functions in metabolism of CNS

VitaminsRiboflavin—B2—role in production of RBCs,

corticosteroids and gluconeogenesis. Milk products, leafy green vegetables and dry yeast. Dermatoses, glossitis, cheilitis.

Thiamine—B1—coenzyme in CHO metabolism, essential for energy production. Affects brain utilization of glucose. Dry yeast, wheat germ, nuts, legumes, vegetables. Beriberi (neurologic, cerebral and CV abnormalities).

VitaminsVitamin C—needed for formation of skin,

bone, teeth, cartilage, wound healing, metabolism of iron and folic acid, resistance to infection. Found in fruits and vegetables. Scurvy-bleeding of gums,joints, skin; anemia, loosening of teeth

Mineral--Electrolytes22 minerals necessary for human nutritionCalcium and phosphorus in bone developmentSodium (fluid balance), potassium (acid-base),

magnesium(nerve conduction), chlorine (fluid and lyte balance, acid base balance) and sulfur (component of proteins, insulin, B vitamins, some amino acids)

Trace elements: chromium, cobalt, copper, fluoride, iodine, iron, selenium and zinc—human nutrition

Manganese, molybdenum, nickel, silicon, tin and vanadium –normal growth and function of connective tissue

Minerals cont.Chromium—affects glucose utilizationCobalt—component of B12Copper—component of enzymes, RBCsFluoride—bones and teethIodine—thyroidIron—enzymes, component of hemoglobinSelenium—function of myocardium and other

musclesZinc—enzymes, necessary for cell growth, for

use of vitamin A

Electrolyte—mineral imbalances

Deficiencies usually related to inadequate intake or unusual losses (vomiting, diarrhea, gastric suction, laxative abuse)

Most excesses r/t excessive intake or impaired renal excretion

Cation-ExchangeKayexalate (sodium polystyrene sulfate) to

treat hyperkalemia. Orally or rectally, combines with potassium in the colon.

Chelating Agents (metal antagonists)

Exjade (deferasirox) oral iron chelator for those who require frequent blood transfusions. Untreated iron accumulation from the transfusions can lead to heart failure and liver failure. 2007 warning of renal failure, neutropenia, thrombocytopenia.

Desferal (deferoxamine) parenteral to remove excess iron from storage sites. Combines with iron and is excreted by kidneys. Hemachromatosis, hemosiderosis due to hemolytic anemias.

ChelatorsCuprimine (penicillamine) chelataes copper,

zinc, mercury and lead which form soluble complexes and are excreted in urine. Use in Wilson’s Disease; cystinuria (AA) metabolic disorder resulting in calculi; to lead poisoning and RA

Chemet (succimer) for binding with lead in children.

Iron preparationsOral ferrous salts include sulfate, gluconate

and fumarateAdverse effects include nausea, discolored

stools, constipationContraindicated in hemosiderosis,

hemochromatosis, multiple blood transfusions, anemias not iron deficiency in nature, PUD, inflammatory intestinal disorders

Iron dextran—IV. Anaphylaxis.

MagnesiumMagnesium oxide or hydroxide for mild

hypomagnesemiaMagnesium sulfate parenterally for

pronounced Mg++ Deficiency, convulsions associated with

pregnancy and prevention of low magnesium in TPN

Contraindicated in renal impairment or in comatose

PotassiumHypokalemiaCan be secondary to dietary problems,

diuretics, those receiving only IV fluidsContraindicated in renal failure and in those

on potassium sparing diuretics and spironolactone

IV must be diluted well, infused slowly (often at 10 mEq/hour) to prevent cardiotoxicity. Monitor EKG.

ZincZinc sulfate and gluconate are OTCComponent of multivitaminsMetabolized in liver and excreted in feces

Enteral feedingsMaintain GI tract and immune system

functioningNG, OGJejunostomyPercutaneous endoscopic gastrostomyNasointestinal tubesFor feedings into stomach—intermittent feedingsFor feedings into jejunum or duodenum,

continuous feedingPotential complication is aspiration

Enteral FeedingsPulmocareAmin-Aid for those in renal failureNepro for those on dialysisSuplena—lower in protein and some

electrolytes for renal patients not on dialysisHepatic Aid II—protein restricted in liver

failureFluid restrictin as in 1.5kcal/mL

Parenteral SupportCentral or peripheral administrationCan give 5-10% peripherallyFat emulsions can be given peripherally or

centrally; no filterVitamins, sometimes insulinAminosyn-RFHepatAmine—special form. of amino acidsCautious use of lipids r/t hypertriglyceridemiaLarge doses Vit. C can cause stonesMonitor fluid and electrolytesMonitor blood sugars

Parenteral SupportIn liver failure—need Vit. A, B6, folic,

riboflavin, B12, pantothenic acid and thiamine

Niacin is contraindicatedExtreme caution with iron dextran

Drugs to aid Weight Management

Overweight ==BMI of 25 to 29.9kg/sq. meterObesity==BMI of 30 or moreDesired BMI is 18.5 to 24.9 kg/sq. meterWaist size >35 inches in women and >40

inches for men is another risk factor

ObesityMore common in women, minority groups

and poor peopleAssociated with serious health risksCancer of breast, colon, endometrialCentral obesity greatly contributes to breast

cancer (androstenedione to estradiol)Cardiovascular disorders—hypertension,

insulin resistance, hyperlipidemia, central adiposity

ObesityDiabetes mellitus—impaired glucose

tolerance, insulin resistance. Hyperinsulinemia, impaired lipid metabolism, hypertension

ObesityOsteoarthritisSleep apneaNASHIncreased complications of pregnancyInfertility in menGestational diabetesMetabolic syndrome—HDL (40,50), BP

135/85 or higher, serum glucose >110, central adiposity

ObesityDecreased physical activitySedentary jobs and recreational activitiesLarge portion sizesFast foodsFast paceDepressionMedications can cause obesitychildren

Medications affecting weightAntihistamines such as loratadine and

diphenhydramine increase appetiteBeta blockers decrease BMR, increase fatigue

and decrease exericise toleranceStatins SteroidsPPIs may increase appetiteHormonal contraceptives—fluid and sodium

retentinMood stabilizing medication—lithium with

expected wt. gain up to 22#

Medications and weight gainAntiepileptics—phenytoin, valproic acid,

carbamazepine, gabapentin, lamotrigine. Slow metabolism and increases appetite.

Antidiabetic drugs—insulin, sulfonylureas, glitazones.

Antidepressants—SSRIs and TCAs. Antipsychotics-Zyprexa and Clozaril cause

gain in 40%. Risperdal less and Seroquel even less. Can even affect glucose tolerance.

Drugs for treating obesityReserve for those with BMIs of 30 kg per sq.

meter or greaterSensible dietPhysical activityBehavioral modification

Drugs for weight reductionSide effects—phenylpropanolamine,

fenfluramine, ephedraCurrent meds-Adipex, Didrex, MeridiaAffect dopamine and norepinephrine in brain

Adipex--phentermineMost frequently prescribed adrenergic

anorexiantSchedule IVShort term use< 3 monthsContraindicated in hypertension, CV disease

or drug abuseCaution in anxiety or agitationAdverse effects: nervousness, dry mouth,

constipation, tachycardia and hypertension

Meridia--sibutramineSchedule IVInhibits reuptake of serotonin and

norepinephrineCauses increased satiety, decreased food

intake and faster metabolismMay be used for longer period of timeCautious use in glaucoma, impaired hepatic

function and a history of drug abuseContraindicated in CV disorders hypertensionCommon SE: HA, insomnia, htn, tachy, anxiety

Xenical—Alli (orlistat)Decreases absorption of dietary fat (binds to

gastric and pancreatic lipases making them unavailable to break down fat)

Blocks 30% of fat ingestedImproves cholesterol levelsSide effects include oily spotting, fatty stools,

fecal incontinence and increased defecationPrevents absorption of fat-soluble vitamins

A,D, E, K

HerbalsFew studies to validate efficacyGlucomannan—”feel full”, laxative effect, can

cause hypoglycemiaGuarana—found in energy drinks, caffeine;

contraindicated in those with CV problems, worsens GERD

Laxative and diuretic herbs—aloe, rhubarb root, Super Dieter’s Tea

Weight loss programsAtkinsSouth BeachWeight watchersJenny Craig

Serotonin syndromeNeuroleptic syndromeMalignant hyperthermia

Neuroleptic Malignant Syndrome

Rare but potentially fatal reaction that can occur hours to months after initial drug use

S/S develop 24-72hCharacterized by fever, muscle rigidity,

agitation, confusion, tachycardia, delirium, respiratory failure and acute renal failure

Associated with antipsychotic meds such as Haldol, Geodon, Abilify, Seroquel, Thorazine

Treatment: stop antipsychotic, give dantrolene (muscle relaxant) and amantadine or bromocriptine (dopamine stimulators)

Malignant HyperthermiaA severe form of pyrexia that occurs during the

use of muscle relaxants and general inhalation anesthesia in persons with an inherited autosomal dominant trait.

Characterized by skeletal muscle rigidity, fever, hypercarbia, metabolic acidosis, and cyanosis.

Fatal in 70% of patients.Treat with Dantrium (dantrolene)—IV during

acute episodeMust watch liver functionsIncompatible with saline and D5W

Serotonin SyndromePotentially serious drug-related condition seen

in patients taking two or more drugs that increase CNS serotonin levels; the most common combinations involve MAO inhibitors, SSRIs , SNRIs and TCAs. Also can be caused by demerol, dextromethophan, and Zofran

Presents with muscle rigidity, tremors,fever, nausea, rapid heart rate, agitation and seizures.

Stop drugs, supportive care