Case-3-5 Malnutrition Associated With Chronic Disease – Medical Nutrition Therapy: A Case-Study Approach : Book Guide

This Document Contains Cases 3 to 5 Case 3 – Malnutrition Associated with Chronic Disease I. Understanding the Disease and Pathophysiology 1. Outline the metabolic changes that occur during starvation/inadequate nutritional intake (not related to disease) that could result in weight loss. • inadequate nutrient supply • decrease in basal metabolic rate to conserve energy (decreased thyroid function leads to decreased BMR) • liver glycogen stores used up in first 12-24 hours (glycogenolysis) • energy from fat storage (lipolysis) provides >90% of kcal (ketones as primary energy source) • energy from protein/lean mass provides <10% of kcal for gluconeogenesis to provide glucose for obligate users (brain) • increased need for alanine and glutamine (from muscle) to stimulate gluconeogenesis • protein losses significant during first 7-10 days (1-2 kg lean body mass lost over first 7 days; skeletal muscle catabolized, muscle synthesis decreased) • organ function changes in GI tract result in loss of mass, decreases in villi, decreased enzyme secretion, impaired motility, and bacterial overgrowth, which lead to maldigestion and malabsorption • decreased protein synthesis in liver • muscle function decreases; breakdown of intercostal muscles can lead to decreased respiratory function; breakdown of cardiac muscle can lead to hypotension, bradycardia, and decreased cardiac output • immune function decreases to spare protein • decreased growth 2. Read the consensus statement of the Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition. Explain the differences between malnutrition associated with chronic disease and malnutrition associated with acute illness and inflammation. Malnutrition associated with chronic disease - this includes chronic diseases or conditions that have sustained mild to moderate inflammation (organ failure, pancreatic cancer, rheumatoid arthritis, diabetes mellitus, metabolic syndrome, chronic kidney disease, etc.) • Loss in lean body mass is gradual and can eventually reach significant depletion over time (several months). With nutritional intervention, lean body mass loss is slowed or potentially reversed. • Positive response to nutrition intervention also requires successful medical treatment of underlying disease. Malnutrition associated with acute illness and inflammation - this includes acute diseases or injury states with acute and severe inflammatory responses (major infection, burns, trauma, or closed head injury) • Significant depletion of lean body mass occurs over a short period of time (<1 month) without nutritional intervention. There are persistent signs of inflammation. With nutritional intervention, lean body mass loss is slowed, but still occurs if inflammation persists. • Priority of nutrition intervention is to provide nutrients to support organ system function and preserve immune function while acute medical treatment is provided. 3. Find the current definitions of malnutrition in the United States using the current ICD 10 codes. List all of them and describe the criteria for one of the diagnoses. ICD-10 Diagnosis Code E40 - Kwashiorkor • "Severe malnutrition with nutritional oedema with dyspigmentation of skin and hair." ICD-10 Diagnosis Code E41 - Nutritional marasmus • "Severe malnutrition with marasmus." (energy depletion/ reduced fat stores out of proportion with lean body mass loss) ICD-10 Diagnosis Code E42 - Marasmic kwashiorkor • "Severe protein-energy malnutrition" ○ Intermediate form ○ Signs of kwashiorkor and marasmus ICD-10 Diagnosis Code E43 - Unspecified severe protein-energy malnutrition • "Severe loss of weight [wasting] in children or adults, or lack of weight gain in children leading to an observed weight that is at least 3 standard deviations below the mean value for the reference population (or a similar loss expressed through other statistical approaches). When only one measurement is available, there is a high probability of severe wasting when the observed weight is 3 or more standard deviations below the mean of the reference population." ICD-10 Diagnosis Code E44 - Protein-energy malnutrition of moderate and mild degree • Weight loss in adults/children (or the lack of weight gain in children) that is 1 to 3 standard deviations from the reference population. ICD-10 Diagnosis Code E45 - Retarded development following protein energy malnutrition • Short stature, stunting, or physical retardation related to malnutrition ICD-10 Diagnosis Code E46 - Unspecified protein-energy malnutrition • Malnutrition or protein-energy imbalance that is not specified otherwise. 4. Current ICD definitions of malnutrition use biochemical markers as a component of the diagnostic criteria. Explain the effect of inflammation on visceral proteins and how that may impact the clinician’s ability to diagnose malnutrition. What laboratory values may confirm the presence of inflammation? The body down-regulates albumin synthesis so that needed positive acute-phase proteins for the immune system (antibodies, complement, cytokines, C-reactive protein), clotting (fibrinogen), and wound healing can be made. Production of cytokines such as IL-1, IL-6, and tumor necrosis factor (TNF) is increased, which alters hormone secretion to favor a catabolic state, increasing muscle catabolism, gluconeogenesis, and lipolysis. These cytokines also inhibit protein synthesis (albumin, prealbumin, transferrin, retinol-binding protein) and muscle repair. Extracellular fluid is expanded (due to edema), causing biochemical tests to be diluted and results to appear low. Resting energy expenditure is elevated/increased and protein requirements are increased, making energy and protein needs difficult to accurately determine. If the cause of metabolic stress is severe or prolonged, nutrition intervention alone will not prevent muscle protein loss in inflammation if nutritional intake is inadequate. Therefore, measurement of albumin/ prealbumin is not an accurate measure for diagnosis of malnutrition when inflammation is present. II. Understanding the Nutrition Therapy 5. Mr. Campbell was ordered a mechanical soft diet when he was admitted to the hospital. Describe how his meals will be modified with this diet order. • This diet consists of foods that are mechanically altered by blending, chopping, grinding, or mashing so that they are easy to chew and swallow. • Use gravies, sauces, vegetable/ fruit juice, milk, half & half, broth, or water from cooking to moisten foods when mechanically altering and serving. • Casseroles or salads are served moist and without large chunks of meat or vegetables. • Soups are served with small pieces of easy to chew and swallow meats and vegetables. • Vegetables are cooked tender enough to be easily mashed with a fork. • Bread products are mixed with sauce, gravy, or syrup until the bread product begins to dissolve into a slurry. • Sticky and chewy foods such as peanut butter and caramel are not served. • Nuts; seeds; overly dry foods; and tough, fibrous, or stringy foods are avoided. 6. What is the Ensure Complete supplement that was ordered? Determine additional options for Mr. Campbell that would be appropriate for a high-calorie, high-protein beverage supplement. Ensure Complete is a 1.5 kcal/mL high-calorie, high-protein beverage supplement. It contains 350 kcal, 11 g fat, 51 g carbohydrate, and 13 g protein per 8-oz serving. It is a good source of 24 essential vitamins and minerals (948 mL/ 1422 kcal needed to meet 100% of RDIs). Additionally, it provides prebiotics and 610-650 mg of Alpha linoleic acid (ALA) per 8 oz. Ensure Complete is kosher, halal, and gluten free. It is okay to use in patients who are lactose intolerant but contraindicated in patients with galactosemia. Additional option examples: Whole milk milkshake (can add peanut butter, dry skim milk powder, etc. to increase protein and calories), Resource 2.0 (2.0 kcal/mL, 21 g protein/ 8 fl oz supplement), Resource Shake (2.0 kcal/mL, 15 g protein/ 8 fl oz supplement), Carnation Instant Breakfast (260 kcal/ 14 g protein per bottle, or use mix) III. Nutrition Assessment 7. Assess Mr. Campbell’s height and weight. Calculate his BMI and % usual body weight. Height: 6'3" (190.5 cm), weight: 156# (70.9 kg), UBW: 220# BMI = 70.9 kg / 1.905 m2 = 19.5 kg/m2 (BMI 18.5-24.9 considered normal weight; however, his BMI has decreased from 27.5 to 19.5 in 1-2 years, which is a significant decrease, and he is nearing underweight BMI status) % UBW = 156# / 220#  100 = 70.9% UBW (severe unintended weight loss in 1-2 years) 8. After reading the physician’s history and physical, identify any signs or symptoms that support the diagnosis of malnutrition using the proposed definitions of malnutrition by AND/ASPEN malnutrition guidelines. • feelings of weakness, lack of energy • decreased temperature • cachectic appearance, appears older than years • noted temporal wasting • dry mucous membranes with petechiae (nose), dry mucous membranes (throat) • reduced strength on neurologic exam • decreased muscle tone in extremities, noted loss of lean mass in quadriceps and gastrocnemius, +1 pedal edema • dry skin with ecchymosis • shallow respirations (decreased muscle tone in diaphragm), increased respiratory rate 9. Evaluate Mr. Campbell’s initial nursing assessment. What important factors noted in his nutrition assessment may support the diagnosis of malnutrition? • abdominal appearance: flat • palpation of abdomen: soft • dry skin • tenting skin turgor • skin condition: ecchymosis, dry, tearing • mucous membranes: dry, petechiae 10. What is a Braden score? Assess Mr. Campbell’s score. How does this relate to his nutritional status? A Braden score is an assessment of a patient's risk of developing pressure ulcers. The Braden score looks at 6 criteria: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Mr. Campbell's Braden score is 17. This indicates that he is currently at mild risk of developing pressure ulcers. Nutrition relates to the Braden score because it is one of the 6 criteria involved. Poor nutrition can lead to poor wound healing, poor skin turgor, decreased mobility/ activity, and decreased sensory perception and increases the risk of the patient developing a pressure ulcer. Poor nutrition also makes it more difficult for pressure ulcers to heal. 11. Identify any signs (including laboratory values) or symptoms from the physician’s history and physical and from the nursing assessment that are consistent with dehydration. • dry skin • tenting skin turgor • skin condition: ecchymosis, dry, tears, tenting • mucous membranes: dry, petechiae • +1 pedal edema • diminished bilateral pulses • cloudy, amber urine 12. Determine Mr. Campbell’s energy and protein requirements. Explain the rationale for the method you used to calculate these requirements. For the critically ill, mechanically ventilated patient, the Penn State equation would be most appropriate. Since Mr. Campbell is not mechanically ventilated, it is best to use a 25-35 kcal/kg American Chest Physician’s nomogram. 25-35 kcal/kg: (25  70.9 kg) to (35  70.9 kg) = 1773-2482 kcal per day (approx. 1800-2400 kcal/day) The Harris-Benedict with or without stress factors, Ireton-Jones, Fick, or Mifflin-St Jeor equations are NOT recommended for use with non-obese critically ill patients. Estimated protein requirements in non-obese critically ill: 1.2-1.75 g/kg/day: (1.2  70.9) to (1.75  70.9) = 85-124 g protein per day 13. Determine Mr. Campbell’s fluid requirements. Compare this with the information on the intake/output report. Fluid requirements are recommended to be 1.0-1.5 mL/kcal of intake for adults. For Mr. Campbell’s EER of 1800-2400 kcal/day, this would be 1800-2400 mL/day (1.0 mL/kcal) or 2700-3600 mL/day (1.5 mL/kcal). If he increases his protein intake he may need the higher amount of fluid to handle the higher renal solute load. The intake/output record indicates his fluid requirement to be 2000-2500 mL (approx 1.0 mL/kcal). This is a good range to start with; intake can then be compared with output and adjusted as necessary. Using the patient’s intake from 9/22-9/23, he took in 2520 mL that day but only had ~1440 mL output. This can be expected due to his likely dehydrated state and should be monitored to match his output. Fluid intake may need to be decreased if this trend continues. 14. From the nutrition history, assess Mr. Campbell’s usual dietary intake. How does this compare to the requirements that you calculated for him? Can your evaluation of his dietary intake contribute to the evidence for diagnosing malnutrition? Estimated using USDA Super Tracker (http://www.choosemyplate.gov/supertracker-tools/supertracker.html): Breakfast: 1 boiled egg: 77 kcal, 6 g protein; coffee: 2 kcal; few bites toast: 57 kcal, 3 g protein Lunch: 1 cup chicken noodle soup: 63 kcal, 3 g protein; 1 cup low-fat (1%) milk: 102 kcal, 8 g protein Dinner: few bites ground meat: 104 kcal, 11 g protein; few bites mashed potatoes: 56 kcal, 1 g protein Snacks: 1 can Ensure Plus: 355 kcal, 13 g protein Total: 816 kcal, 45 g protein Estimated requirements: 1800-2400 kcal, 85-124 g protein. This is approximately 984-1584 kcal short of needs and 40-79 g protein short of needs. This represents a 34%-45% intake of energy needs for several months, which is consistent with severe chronic malnutrition in adults (20% unintentional weight loss. Unintended weight loss related to decreased ability to consume sufficient energy as evidenced by weight loss of >30% of UBW in 1-2 years. I: Gradually increase energy and protein intake through use of high-calorie, high-protein supplements, modulars, and patient’s favorite food preferences to goal of 1800-2400 kcal, 85-124 g protein per day. Encourage fluids between meals and snacks to avoid early satiety. ME: Monitor intake/output. Monitor daily weights, lab values, assess for potential for refeeding. Monitor patient acceptance of diet, supplements. Case 4 – Hypertension and Cardiovascular Disease I. Understanding the Disease and Pathophysiology 1. Define arterial blood pressure (BP) and explain how it is measured. • Blood pressure is the measure of resistance of blood flow against the walls of the arterial vessels and is measured using a stethoscope and sphygmomanometer. • The sphygmomanometer is inflated to a pressure greater than arterial pressure during systole, completely obstructing blood flow. • As pressure is released from the sphygmomanometer, blood pressure falls to the systolic pressure, resulting in the first sound heard through the stethoscope. • When this sound (a distinct beat) first disappears, this is the diastolic pressure. • Units of pressure are usually in millimeters of mercury (mmHg). 2. Discuss briefly the mechanisms that regulate arterial blood pressure including the sympathetic nervous system, the renin-angiotensin-aldosterone system (RAAS), and renal function? • The brain integrates information from sensors called baroreceptors that continually measure blood pressure. • Various hormones such as norepinephrine and epinephrine control resistance of the blood vessels. ○ Norephinephrine acts as a vasoconstrictor. When the diameter of blood vessels is decreased (either by norepinephrine or by a disease process such as atherosclerosis), blood pressure will increase. ○ Vasodilation will decrease blood pressure. • Other hormones including aldosterone and vasopressin (ADH) also assist in blood pressure control. ○ Aldosterone is released to increase sodium reabsorption and, with vasopressin, will increase water resorption and blood volume, leading to an increase in blood pressure. • Additionally, the kidneys respond to their own baroreceptors. ○ If blood pressure is low, renin is released, which in turn controls the levels of angiotensin II, which causes vasoconstriction and thus also increases blood pressure. • Proper renal function is necessary for the actions of RAAS and thus abnormalities in BP can be seen in conditions like chronic kidney disease and acute kidney injury. • All of these responses cause an overall increase in heart rate, stroke volume, and, ultimately, blood pressure. 3. What causes essential hypertension? What is the etiology? • Essential or primary hypertension has no known cause but there are multiple risk factors. • Risk factors include excessive sodium intake, low potassium intake, alcohol intake, lack of exercise, smoking, stress, and obesity • Generally, increased heart rate, increased stroke volume, and increased total peripheral resistance are each compensated for by decreasing values of the other two. • If compensation does not occur, hypertension can occur. 4. What are the common symptoms of essential hypertension? • Many people with hypertension do not experience any symptoms at all initially. • Others experience headaches—especially upon waking. These headaches may be accompanied by nausea and vomiting. • Long-term symptoms may include blurred vision, unsteady gait, nocturia, and edema. 5. Using the JNC 8 guidelines, how is the diagnosis of hypertension made? What blood pressure readings are used to identify normal BP, stage 1 hypertension, and stage 2 hypertension? • At least two measurements of blood pressure • Taken after patient has been seated quietly for at least 5 minutes in a chair with feet on the floor • Arm supported at heart level • Using an appropriately sized cuff • Diagnosis: ○ Normal: 160/>100 mmHg 6. List the risk factors for developing hypertension. What risk factors does Mrs. Moore currently have? Discuss the contribution of ethnicity to hypertension, especially for African Americans • Overweight or obesity • Smoking/second-hand smoke • Physical inactivity • Excessive salt consumption • Too little potassium and vitamin D • Low intakes of potassium, magnesium, and calcium • Excessive alcohol consumption • Stress • Race or ethnicity (African American, Hispanic) African Americans (43% for males and 45.7% for females), Filipinos, and South Asians have a higher prevalence of hypertension; Mexican American have lower reported rates • Genetics • Aging • Certain chronic diseases: diabetes, kidney disease, sleep apnea, hypercholesterolemia, atherosclerosis • Mrs. Moore risk factors include: ○ Family history ○ African American ancestry ○ Excessive salt consumption ○ Alcohol consumption (although not excessive) ○ Overweight ○ Smoker (quit 1 year ago) 7. What are the four major modes of treatment for hypertension? • Lifestyle modifications ○ Wt reduction ○ DASH eating plan ○ Physical activity ○ Moderation of alcohol consumption • Pharmacologic ○ ACEIs (angiotensin-converting enzyme inhibitors) ○ ARBs (angiotensin receptor blockers) ○ BBs (beta blockers) ○ CCBs (calcium channel blockers) ○ Thiazide-type diuretics • Smoking cessation • Wt. loss 8. Dr. Evans indicated in his note that he will “rule out metabolic syndrome.” What is metabolic syndrome? • Abdominal obesity (waist circumference: > 40" (102 cm) and > 35" (88 cm) in men and women, respectively) • Atherogenic dyslipidemia (↑ triglycerides [≥ 150 mg/dL], ↓ HDL-cholesterol [< 40 mg/dL and 100 mg/dL) • Proinflammatory state • Prothrombotic state 9. What factors found in the medical and social history are pertinent for determining Mrs. Moore's coronary heart disease (CHD) risk category? • Elevated cholesterol • HTN • Overweight/obesity • Increasing age • African American • Former smoker • Physical inactivity 10. How is hypertension related to other cardiovascular disorders? What are the possible complications of uncontrolled or untreated hypertension? • Increased blood pressure requires the heart to work harder; potentially leading to left ventricular hypertrophy and eventually heart failure • Elevated BP damage the blood vessel walls promoting atherosclerotic plaques • Elevated BP can dislodge blood clots and atherosclerotic plaques, which can block smaller arterioles or capillaries and result in an ischemic attack • May damage the small arterioles of the kidneys needed for proper blood filtration and urine excretion II. Understanding the Nutrition Therapy 11. Briefly describe the DASH eating plan and discuss the major nutrients that are components of this nutrition therapy. • Rich in potassium, magnesium, calcium, and fiber from ○ Fruits ○ Vegetables ○ Low-fat dairy products ○ Whole grains ○ Nuts • Reduced in saturated fat, cholesterol, and total fat by ○ Reduced red meats ○ Increased poultry and fish • Reduced in concentrated sugars and sugar-containing beverages • Adequate kcal for wt management 12. Using the 2015 Dietary Guidelines, describe why decreased sodium intake is targeted as a focus to improve the health of Americans. • In hypertensive patients, reduction of dietary sodium to recommended levels lowers blood pressure by approximately 3.5%. • From 63%-91% of women and 81%-97% of men consumed more than the UL for sodium • All age and sex groups consume far more than the UL for sodium • Concern for its relationship to hypertension risk 13. What do the current literature and the Evidence Analysis Library (EAL) indicate regarding the role of sodium intake in the control of hypertension? Is there a significant correlation between sodium intake and cardiovascular risk? Salt sensitivity (defined as ≥ 10% increase in mean arterial pressure with salt loading) occurs in ~ 50% of hypertensive patients. Target organ events are higher in salt sensitive patients. Sodium adversely affects endothelial cells and an increased Na/K ratio is also associated with increased CVD and CVA. Therefore, consumption of 150 mg/dL (220 mg/dL) ○ HDL < 40 mg/dL (30 mg/dL) ○ Blood pressure ≥ 130/≥85 mmHg (140/99) ○ Insulin resistance; FBG ≥ 100 mg/dL (136 mg/dL) 12. List the abnormal values that are found in his lipid profile? What are the long-term implications? What are the possible treatment options for these abnormalities? • Total cholesterol of 235 mg/dL and LDL-C of 160 mg/dL are increased. • Markers of coronary artery disease, HDL-C 30 mg/dL and apolipoprotein A, are low. • All of these lipid abnormalities are risk factors for coronary artery disease. • Treatment options include: ○ Lowering trans-and saturated-fat intake (lower LDL cholesterol) ○ TLC diet ○ Physical activity (may increase HDL-C) ○ Pharmacological intervention (ex: statins, bile acid sequestrants, nicotinic acid, and fibrates) ○ Soluble fiber (decrease total and LDL cholesterol) 13. Mr. Garcia was prescribed the following medications on discharge. What are the rationale and the food-medication interactions for this list of medications? Medication Rationale Possible Food-Medication Interactions Lopressor 50 mg daily Β-1-blocker; decreases heart rate and cardiac output; decreased workload of heart Take with food to increase bioavailability. Avoid natural licorice. Lisinopril 10 mg daily ACE inhibitor; vasodilation and reduction in BP due to inhibition of Angiotensin II production; reduced total peripheral resistance Take without regard to food. Low-Na, low-calorie diet may be recommended. Caution with K supplementation. Avoid alcohol. Nitro-Bid 9.0 mg twice daily Nitrate; vasodilation; reduced total peripheral resistance Take 1 hr. before or 2 hrs. after meals. NTG 0.4 mg sl prn chest pain Nitrate; vasodilation; reduced total peripheral resistance and hence reduction in cardiac workload/stress; eases pain from angina Take 1 hr. before or 2 hrs. after meals. ASA 81 mg daily NSAID; blockade of COX enzymes and inhibition of platelet aggregation; prevents future clots that may result in an MI Take with 8 oz. water or milk after meals or with food to reduce GI irritation. 14. You talk with Mr. Garcia and his wife. They are friendly and seem cooperative. They are both anxious to learn what they can do to prevent another heart attack. What are examples of questions that you ask them to assess how to best help them? • What is your normal pattern of eating? • What is your level of physical activity? • Who does most of the food shopping and cooking? • Have you ever been on a diet of any kind before? • Do you eat out, and if so, how often? • What are your serving sizes? • Do you snack often? • Do you drink alcohol, and if so, how much? • Are you taking any nutritional supplements? 15. Are there other issues besides diet that should be addressed to support successful lifestyle changes for Mr. Garcia? If yes, please list them. • Planning ahead will be helpful. • He should stop smoking. • Physical activity and preferably in a form that induces excitement or maintained interest • Referral to cardiac rehabilitation as an outpatient would provide an avenue for continued intervention. 16. From the information gathered within the assessment, list possible nutrition problems using the correct diagnostic terms. • Food-medication interaction • Food and nutrition-related knowledge deficit • Excessive mineral intake (sodium) • Inadequate fiber intake • Physical inactivity IV. Nutrition Diagnosis 17. Select two of the identified nutrition problems and complete the PES statement for each. • Inadequate bioactive substance intake of plant stanols/sterols and soluble fiber related to food and nutrition-related knowledge deficit as evidenced by lack of foods containing these • Food-medication interaction related to lopressor, lisinopril, and aspirin as evidenced by need to avoid licorice, take medications with food, and avoid excess sodium • Food and nutrition-related knowledge deficit as evidenced by patient’s wife only associating dietary changes with use of “corn oil and avoiding frying foods” and inquiring about the use of supplements • Excessive mineral intake (sodium) related to food- and nutrition-related knowledge deficit as evidenced by consumption of high-sodium foods (tomato soup) and lack of previous nutrition therapy. V. Nutrition Intervention 18. For each of the PES statements you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). • Inadequate bioactive substance intake of plant stanols/sterols and soluble fiber related to food and nutrition-related knowledge deficit as evidenced by lack of foods containing these ○ Goal: Consume recommended 3 g/day of plant stanols and 10-25 g soluble fiber ○ Intervention: Nutrition education that includes the purpose of these recommendations; supported by the evidence presented by the Academy of Nutrition and Dietetics Evidence Library and the American Heart Association • Food-medication interaction related to lopressor, lisinopril, and aspirin as evidenced by need to avoid licorice, take medications with food, and avoid excess sodium ○ Goal: Follow instructions regarding timing of medications associated with meals and avoidance of certain foods such as sodium and licorice ○ Intervention: Nutrition education • Food and nutrition-related knowledge deficit as evidenced by patient’s wife only associating dietary changes with use of “corn oil and avoiding frying foods” and inquiring about the use of supplements ○ Goal: Ability to identify and utilize resources that include the complete list of recommendations associated with the ATP3 and TLC ○ Intervention: Nutrition counseling that includes goal setting and problem solving. Use of technology to access appropriate web sites such as the American Heart Association, Academy of Nutrition and Dietetics, and NIH’s NHLBI. • Excessive mineral intake (sodium) related to food- and nutrition-related knowledge deficit as evidenced by consumption of high-sodium foods (tomato soup) and lack of previous nutrition therapy. ○ Goal: Consume < 2400 mg/day of sodium as indicated by the TLC diet ○ Intervention: Nutrition education of low-sodium foods to incorporate into his diet, such as fruits, vegetables, whole-grains, and unprocessed meats. Suggest using Mrs. DASH to added flavor to recipes without adding salt. 19. Mr. Garcia and his wife ask about supplements. “My roommate here in the hospital told me I should be taking fish oil pills.” What does the research say about omega-3 fatty acid supplementation for this patient? • Eating fish and taking supplements are the most common ways to obtain fish oils. ○ Mackerel, tuna, salmon, sturgeon, mullet, bluefish, anchovy, sardines, herring, and trout are especially rich in omega-3 fatty acids (~1 gram of omega-3 fatty acids in about 3.5 ounces of fish). ○ Fish oil supplements are usually made from mackerel, herring, tuna, halibut, salmon, cod liver, whale blubber, or seal blubber. A small amount of vitamin E is often added to prevent spoilage. • Researchers believe fish oil may reduce triglycerides by 20-50%. ○ Lovanza, a fish oil supplement, has been approved by the FDA to lower triglyceride levels. ○ Lovanza is sold in 1-g capsules and contains EPA and 375 mg DHA. ○ 1-4 g/day are recommended for treatment of high triglyceride levels. ○ Mr. Garcia’s triglyceride levels are WNL. • Fish oil may be beneficial in protecting healthy persons from developing heart disease (6 g/d fish oil for first 6 months, then 3 g/d from then on). • Persons with heart disease may be able to lower their risk of dying from heart disease by taking fish oil capsules containing 0.3-6 g EPA + 0.6-3.7 g DHA. Mr. Garcia may benefit from this treatment dosage. • Obtaining large amounts of fish oils from some dietary sources, like shark, king mackerel, and farm-raised salmon, may be unsafe due to contamination with mercury and other industrial and environmental chemicals. Fish oil supplements do not contain these contaminants. VI. Nutrition Monitoring and Evaluation 20. What would you want to assess in three to four weeks when he and his wife return for additional counseling? (Hint: Your follow-up assessment should be based on signs and symptoms in your PES statements.) • Examine his diet record to determine whether he is following the prescribed diet (sodium, fiber, plant sterols/stanols, and other foundations of the TLC diet). • Where problems exist, provide additional information and strategies for intervention. • Monitor weight. • Monitor progress made toward cessation of smoking and increasing physical activity. • Evaluate level of motivation/interest in lifestyle changes (stage of change) Solution Manual for Medical Nutrition Therapy: A Case-Study Approach Marcia Nahikian Nelms 9781305628663, 9780534524104, 9781133593157