Diet and Weight Control PDF

**DIET AND WEIGHT CONTROL** One needs to understand some commonly used terms before discussing weight control. The term normal weight can mean average, desired, or standard. Normal weight is that which is appropriate for the maintenance of good health for a particular individual at a particular tim...

**DIET AND WEIGHT CONTROL** One needs to understand some commonly used terms before discussing weight control. The term normal weight can mean average, desired, or standard. Normal weight is that which is appropriate for the maintenance of good health for a particular individual at a particular time. The following is a simple method of determining one's ideal body weight. It is known as the "rule of thumb" method 1. Males assume 106 pounds for the first 5 feet (60 inches) and add 6 pounds for each inch over 60. 2\. Females assume 100 pounds for the first 5 feet (60 inches) and add 5 pounds for each inch over 60. 3\. Large-boned individuals of both sexes increase the first sum by 10%. 4\. Small-boned individuals of both sexes decrease the first sum by 10%. This method is quick, but one must remember that it is only an estimate. Overweight can be defined as weight 10% to 20% above average. Obesity can be defined as excessive body fat, with weight 20% above average. Underweight is weight 10% to 15% below average. The medical standard used to define obesity is the body mass index (BMI). It is used to determine whether a person is at health risk from excess weight. The BMI is obtained by dividing weight in kilograms by height in meters squared. Fewer health risks are associated with a BMI range of 19 to 25 than with BMI above or below that range. A BMI between 25 and 30 indicates overweight, whereas a BMI over 30 indicates obesity. Table 16-1 presents a range of BMIs using English units, so one needn't do the metric conversion. The distribution of fat is another indicator of possible health problems. Fat in the abdominal cavity (visceral fat) has been shown to be associated with a greater risk for hypertension; coronary heart disease; type 2 diabetes; and certain types of cancer than has fat in the thigh, buttocks, and hip area. A pear-shaped body has a lower risk for disease than does the apple-shaped body. A waist-to-hip ratio also can give an indication of risk. This is determined by dividing the waist measurement by the hip measurement. A ratio greater than 1.0 in men and 0.8 in women indicates risk for the same diseases as given above. There also appears to be an increased risk of metabolic complications for men with a waist circumference of 40 inches and women with a waist circumference of 35 inches, according to the American Heart Association. Body weight is composed of fluids, organs, fat, muscle, and bones, so large variation exists among people. In addition to height, one needs to consider age, physical condition, heredity, gender, and general frame size (small, medium, or large) in determining desired weight. For example, a 6-foot 2-inch man with a 44-inch chest, 36-inch-long arms, and 8.5-inch wrists will weigh more than a 6-foot 2-inch man with a 40-inch chest, 35-inch-long arms, and 7.5-inch wrists because he has more body tissue. Table 16-2 gives lists of acceptable weights according to age, sex, and height for adults that reflect realistic weight goals. Some people can weigh more than is indicated on Table 16-2 and still be in good physical condition. Professional football players, because of the amount of lean muscle mass they develop, are examples. However, when they retire and reduce their physical activity, that same muscle can change to fat. If their weights remain the same, they then will be considered overfat because the proportion of fat will have become too high. Some can weigh what Table 16-2 indicates they should weigh and yet be overfat because too great a percentage of the weight is made up of fat. Body fat is measured with a caliper. Using a caliper correctly requires practice and skill. Because the fat under the skin on the stomach and on the upper arm is representative of the percentage of overall body fat, it is usually measured when knowledge of the percentage of body fat is required. If it is more than 1.5 inches, one is considered overweight. If it is under.5 inch, one is considered underweight (Figure 16-1). A moderate amount of fat is a necessary component of the body. It protects organs from injury and acts as insulation. The final determination of desirable weight depends on common sense. **OVERWEIGHT AND OBESITY** Obesity and overweight have become epidemic. Sixty-four percent of Americans are overweight or obese. Data from the National Center for Health Statistics show that 73% of adults 20 years old and older are overweight or obese. The percentage of overweight children and teens has tripled in the last 25 years and currently is 40.8%. Overweight puts extra strain on the heart, lungs, muscles, bones, and joints, and it increases the susceptibility to diabetes mellitus and hypertension. It increases surgical risks, shortens the life span, causes psychosocial problems, and is associated with heart disease and some forms of cancer. **Causes** There is no one cause for excess weight, but poor diet and inactivity appear to be leading factors. Genetic, physiological, metabolic, biochemical, and psychological factors can also contribute to it. Energy imbalance is a significant cause of overweight. People eat more than they need. Excess weight can accumulate during and after middle age because people reduce their level of activity and metabolism slows with age. Consequently, weight accumulates unless calorie intake is reduced. Hypothyroidism is a possible, but rare, cause of obesity. In this condition, the basal metabolic rate (BMR) is low, thereby reducing the number of calories needed for energy. Unless corrected with medication, this condition can result in excess weight. There are two popular theories about weight loss: the fat cell theory and the set-point theory. According to the fat cell theory, obesity develops when the size of fat cells increases. When their size decreases, as during a reducing diet, the individual is driven to eat in order for the fat cells to regain their former size. Therefore, it is difficult to lose weight and keep it off.According to the set-point theory, everyone has a set point or natural weight at which the body is so comfortable that it does not allow for deviation. This is said to be the reason why some people cannot lose weight below a "set point" or why, if they do, they quickly regain to that "set point." The only way to lower a set point is through exercising three to five times a week. **Healthy Weight** Not everyone fits the USDA weight table shown in Table 16-2 or the "healthy weight target," which is a BMI of 18.5 to 25. For anyone with a BMI of 25 or higher, a more realistic approach would be a reduction of one or two BMI points to reduce health problems and disease risks. After this loss has been maintained for 6 months, further lowering of the BMI needs to be attempted. A "healthy weight" may be the weight at which one is eating nutritiously, is exercising, has no health problems, and is free from disease. **DIETARY TREATMENT OF OVERWEIGHT AND OBESITY** Obviously, if a significant cause of overweight is overeating, the solution is to reduce portion size and caloric intake. This is seldom easy. To accomplish it, one must undertake a weight reduction (low-calorie) diet. For the diet to be effective, one must have a genuine desire to lose weight. The simplest and, therefore, perhaps the best weight reduction diet is a normal diet based on MyPyramid but with the calorie content controlled. Exchange lists provide another excellent method to healthfully control the calorie value of the diet. These lists were originally developed by the American Diabetes Association and the American Dietetic Association for use with diabetic patients. Counting fat grams is sometimes used to lower calorie intake. Each gram of fat contains 9 calories, so the reduction of only a few grams of fat per day may result in weight loss. However, for optimal absorption of fat-soluble vitamins, one requires that at least 10% of daily caloric intake come from fats, and 20% to 35% is the recommended amount for adults. Therefore, in diets limiting fats to 30% of total calories, one must consume 3 grams of fat per 90 calories; in those limiting fats to 20% of total calories, one must consume 2 grams of fat per 90 calories; and in those limiting fats to 10% of total calories, one needs 1 gram of fat per 90 calories. See Table 16-3 to calculate individual fat-gram allowances. A reduction of 3,500 calories will result in a weight loss of 1 pound. Physicians frequently recommend that no more than 1 or 2 pounds of weight be lost in 1 week. To accomplish this, one must reduce one's weekly calories (or expend more through exercising) by 3,500 to 7,000, or daily intake by 500 to 1,000. Diets should not be reduced below 1,200 calories a day or the dieter will not receive the necessary nutrients. The diet should consist of 10% to 20% protein, 45% to 65% carbohydrate, and 20% to 35% or less of fat. In other words, normal proportions of nutrients but in reduced amounts. The number of meals and snacks each day should be determined by the dieter's needs and desires, but the total number of calories must not be exceeded. There is no magic way of losing weight and maintaining the reduced weight, but there is a key to it. That key is changing eating habits. In fact, unless eating habits are truly changed, it is likely that the lost weight will be regained. The cost of slimness is eating less than one might prefer and exercising most days of the week for 90 minutes. **Food Selection** The dieter must learn to "eat smart." Daily calorie counting is not necessary if one learns the calorie and fat-gram values of favorite foods and considers them before indulging. Some foods are good choices on weight loss diets because of their lowcalorie and low-fat-gram values, and some foods should be used in moderation because of their high-calorie and high-fat-gram values (Table 16-4). The lowcalorie, low-fat-gram foods should be used during weight loss and thereafter. Substitutions of foods with very low calorie contents, preferably nutrient dense, should be made for those with high-calorie contents whenever possible. The following are examples: - Fat-free milk for whole milk - Evaporated fat-free milk for evaporated milk - Yogurt or low-fat sour cream for regular sour cream - Lemon juice and herbs for heavy salad dressings - Fat-free salad dressings for regular salad dressings - Fruit for rich appetizers or desserts - Consommé or bouillon instead of cream soups - Water-packed canned foods rather than those packed in oil or syrup There are many low-calorie, fat-free, low-fat, sugar-free, and dietetic foods on the market. A food that is said to be fat-free or sugar-free is not caloriefree. The food label must be read to determine if the product can fit into a healthy eating plan for weight reduction. Diet soda can act as a diuretic and can make one hungry, and it should be used in moderation. Ice water with lemon or lime slices makes a pleasant calorie-free drink and helps prevent dehydration. Some foods that can be eaten with relative disregard for caloric content (provided they are served without additional calorie-rich ingredients) are listed in Table 16-5. **Cooking Methods** Broiling, grilling, baking, roasting, poaching, or boiling are the preferred methods because no additional fat is added, unlike frying. Skimming fat from the tops of soups and meat dishes will reduce their fat content, as will trimming fat from meats before cooking. The addition of extra butter or margarine to foods should be avoided and should be replaced with fat-free seasonings such as fruit juice, vinegar, and herbs and spices. **Exercise** Exercise, particularly aerobic exercise, is an excellent adjunct to any weight loss program. Aerobic exercise uses energy from the body's fat reserves as it increases the amount of oxygen the body takes in. Examples are dancing, jogging, bicycling, skiing, rowing, and power walking. Such exercise helps tone the muscles, burns calories, increases the BMR so food is burned faster, lowers the set point, and is fun for the participant. Any exercise program must begin slowly and increase over time to avoid physical injuries. Exercise alone can only rarely replace the actual diet, however. The dieter should be made aware of the number of calories burned by specific exercises so as to avoid overeating after the workout. General daily guidelines for exercise are 30 minutes to prevent chronic diseases, 60 to 90 minutes to prevent weight gain, and over 90 minutes to maintain weight loss. Children should exercise or be active 60 minutes every day. Behavior Modification for Weight Loss Behavior modification means change in habits. The fundamental behavior modifications for a weight loss program are the development of a new and healthy eating plan and an exercise program that can be used over the long term. These are both major lifestyle changes, and one may need to participate in a support group or undergo psychological counseling in order to successfully adapt to these changes. It is important that one learn the difference between hunger and appetite. Hunger is the physiological need for food that is felt 4 to 6 hours after eating a full meal. Appetite is a learned psychological reaction to food caused by pleasant memories of eating it. For example, after eating a full meal, one is unlikely to be hungry. Yet when dessert is served, appetite causes one to want to eat it. One must learn to listen to one's body and recognize the difference between hunger and appetite. Additional behavior modifications are given below. 1\. Weigh regularly (for example, once a week), but do not weigh yourself daily. 2\. Don't wait too long between meals. 3\. Join a support group and go to meetings during and after the weight loss. 4\. Eat slowly. 5\. Use a small plate and fill it two-thirds with fruits, vegetables, and whole-grain products and just one-third with meat products. 6\. Use low-calorie garnishes. 7\. Eat whole, fresh foods that are low-calorie and nutrient-dense. Avoid processed foods. 8\. Treat yourself with something other than food. 9\. Anticipate problems (e.g., banquets and holidays). "Undereat" slightly before and after. 10\. "Save" some calories for snacks and treats. 11\. If something goes wrong, don't punish yourself by eating. 12\. If there is no weight loss for 1 week, realize that lean muscle mass is being produced from exercising or there may be retention of water. 13\. If a binge does occur, don't punish yourself by continuing to binge. Stop it! Go for a walk, to a movie, to a museum. Call a friend. 14\. Adapt family meals to suit your needs. Don't make a production of your diet. Avoid the heavy-calorie items. Limit yourself to a spoonful of something too rich for a weight loss diet. Substitute something you like that is low in calories. 15\. Take small portions. 16\. Eat vegetables and bread without butter or margarine. 17\. Include daily exercise. Park further from work and walk. Patience and encouragement are needed throughout the adoption of a healthful diet and exercise regime. Temptation is everywhere, and the dieter should be forewarned. Just one piece of chocolate cake could set the diet back for half a day (400--500 calories) and lower resistance to future temptation. Breaking the diet one day will make it seem easy to break it a second day and so on. Fresh vegetables and drinks of water may be used to harmlessly prevent or soothe the hunger pains that are bound to appear. The human body needs at least eight glasses of water each day, and water can give one a feeling of being full. A short walk or a few minutes of exercise may help to turn the dieter's thoughts from food. **Fad Diets** Many of the countless fad diets regularly published in magazines and books are crash diets. This means they are intended to cause a very rapid rate of weight reduction. Often fad diets require the purchase of expensive foods. Others are part of a weight loss plan including exercise with special equipment. Expensive food items and equipment can add to the burden of dieting. A crash diet usually does result in an initial rapid weight loss. However, the weight loss is caused by a loss of body water and lean muscle mass rather than body fat. Sudden weight loss of this type is followed by a plateau period; that is, a period in which weight does not decrease. Disillusionment is apt to occur during this period and may cause the dieter to go on an eating binge. This can result in regaining the weight that was lost and sometimes more. This weight gain in turn causes the dieter to try another weight loss diet, creating a yo-yo effect. Some popular reducing diets severely limit the foods allowed, providing a real danger of nutrient deficiencies over time, and their restricted nature makes them boring. Some provide too much cholesterol and fat, contributing to atherosclerosis. Some contain an excess of protein, which puts too great a demand on the kidneys. Rapid weight loss can cause the formation of gallstones that could result in the need for surgery. These diets ultimately fail because they defeat the dual purpose of the dieter, which is to lose weight and prevent its returning. Both can be accomplished only if eating habits are changed, and crash diets do not do this. **Surgical Treatment of Obesity** When obesity becomes morbid (damaging to health) and dieting and exercising are not working, surgery could be indicated. Two of the surgical procedures used are the gastric bypass and stomach banding. Both procedures reduce the size of the stomach. In gastric bypass, most of the stomach is stapled off, creating a pouch in the upper part. The pouch is attached directly to the jejunum so that the food eaten bypasses most of the stomach. In stomach banding, the stomach is also stapled but to a slightly lesser degree than in gastric bypass. The food moves to the duodenum, but the outlet from the upper stomach is somewhat restricted. In both procedures the reduced stomach capacity limits the amount of food that can be eaten, and fewer nutrients are absorbed. Consequently, weight is lost. These procedures are done only on morbidly obese clients who meet certain strict criteria. A psychological evaluation will also be given to determine if the client is ready to change his or her lifestyle and adhere to healthier eating and an exercise routine. If not, the surgery will not be a success. Also, extensive nutrition counseling with a dietitian will take place before and after the surgery. Some obese people may feel that this surgery would be a quick fix, but it is not. There can be complications such as bleeding; infections; gastritis; gallstones; and iron, vitamin B12, and calcium deficiencies. Another common complication is "dumping syndrome," which can cause nausea and vomiting, diarrhea, bloating, and dizziness. Dumping occurs when foods quickly pass into the intestines without absorption of any nutrients. This happens after partial stomach removal or small intestine removal, where food (chyme) dumps directly into the large intestine. **Pharmaceutical Treatment of Obesity** The use of any weight loss medication, whether by prescription or over the counter, should be considered very carefully. Miracles are still in short supply. Amphetamines (pep pills) have been prescribed for the treatment of obesity because they depress the appetite. However, it has been learned that their effectiveness is reduced within a relatively short time. The dosage must be regularly increased, they cause nervousness and insomnia, and they can become habit forming. Consequently, they are rarely prescribed now. Over-the-counter diet pills are available. They are intended to reduce appetite but are not thought to be effective. In addition to caffeine and artificial sweeteners, they contain phenylpropanolamine, which can damage blood vessels and should be avoided. Some people believe that diuretics and laxatives promote weight loss. They do, but only of water. They do not cause a reduction of body fat, which is what the dieter is seeking. An excess of either could be dangerous because of possible upsets in fluid and electrolyte balance. In addition, laxatives can become habit-forming. They should not be used on any frequent or regular basis without the supervision of a physician. Although there is no magic pill to help those with excess weight reduce, the wish for one remains, and pharmaceutical companies continue the search. Two medications that have recently been approved by the Food and Drug Administration (FDA) are sibutramine (Meridia) and orlistat (Xenical). Sibutramine helps to suppress the appetite and is used in conjunction with a reduced-calorie diet. It is indicated for those with a BMI of at least 30. Orlistat works in the digestive system where it blocks about one-third of the fat in food from being digested. It is recommended that a reduced-calorie diet with no more than 30% from fat be followed when taking orlistat. **UNDERWEIGHT** **Dangers** Underweight can cause complications in pregnancy and cause various nutritional deficiencies. It may lower one's resistance to infections and, if carried to the extreme, can cause death. **Causes** Underweight can be caused by inadequate consumption of nutritious food because of depression, disease, anorexia nervosa, bulimia, or poverty, or it can be genetically determined. It also can be caused by excessive activity, the tissue wasting of certain diseases, poor absorption of nutrients, infection, or hyperthyroidism. For further discussion of anorexia nervosa and bulimia. **Treatment** Underweight is treated by a high-calorie diet or by a high-calorie diet combined with psychological counseling if the condition is psychological in origin as, for example, in depression or anorexia nervosa. In many cases, a high-calorie diet will be met with resistance. It can be as difficult for an underweight person to gain weight as it is for an overweight person to lose it. The diet should be based on MyPyramid so that it can be easily adapted from the regular, family menus or to a soft-textured diet. The total number of calories prescribed per day will vary from person to person, depending on the person's activity, age, size, gender, and physical condition. If the individual is to gain 1 pound a week, 3,500 calories in addition to the individual's basic normal weekly calorie requirement are prescribed. This means an extra 500 calories must be taken in each day. If a weight gain of 2 pounds per week is required, an additional 7,000 calories each week, or an additional 1,000 calories per day, are necessary. This diet cannot be immediately accepted at full-calorie value. Time will be needed to gradually increase the daily calorie value. In this diet, there is an increased intake of foods rich in carbohydrates, some fats, and protein. Vitamins and minerals are supplied in adequate amounts. If there are deficiencies of some vitamins and minerals, supplements are prescribed. Nearly all nutritious foods are allowed in the high-calorie diet, but easily digested foods (carbohydrates) are recommended. Because an excess of fat can be distasteful and spoil the appetite, fatty foods must be used with discretion. Fried foods are not recommended. Bulky foods should be used sparingly. Bulk takes up stomach space that could be better used for more concentrated, high-calorie foods. See Table 16-6 for high-calorie and high-protein shakes and spread that could be used to increase caloric intake. Persons requiring this diet frequently have poor appetites, so meals need to be especially appetizing. Favorite foods should be served, and portions of all foods should be small to avoid discouraging the clients. Many of the extra calories needed may be gotten as snacks between meals, unless these snacks reduce the client's appetite for meals and consequently reduce daily calorie total. Some clients do better if the number of meals is reduced, thereby increasing the appetite for each meal served. When the causes of underweight are psychological, therapy is required before the diet is begun, and the dietitian and therapist may well need to consult one another before and during treatment. Foods to be avoided in a high calorie diet are foods the client dislikes, fatty foods, and bulky, low-calorie foods. **CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL** Even for the most determined clients, a successful weight loss program will be charged with anxiety. There will be days of disappointment. It will take a long time to reach the ultimate goal. The health care professional will need to supply psychological support and nutritional advice when disappointing results create the need for emotional support. It is essential that the health care professional see the problems, support the client, and then effectively lead her or him back to the diet. The key words for the health care professional are support and encouragement. **DIET AND DIABETES MELLITUS** Diabetes mellitus is the name for a group of serious and chronic (longstanding) disorders affecting the metabolism of carbohydrates. These disorders are characterized by hyperglycemia (abnormally large amounts of glucose in the blood). According to the American Diabetes Association, 23.6 million people in the United States have diabetes. An estimated 17.9 million people have been diagnosed with the disease with 5.7 million going undiagnosed. There are approximately 57 million people with pre-diabetes. There were 1.6 million new cases of diabetes in people 20 years old and older diagnosed in 2007 (American Diabetes Association \[ADA\]). It is a major cause of death; blindness; heart and kidney disease; amputations of toes, feet, and legs; and infections. Hundreds of years ago, a Greek physician named it diabetes, which means "to flow through," because of the large amounts of urine generated by victims. Later, the Latin word mellitus, which means "honeyed," was added because of the amount of glucose in the urine. Diabetes insipidus is a different disorder. It also generates large amounts of urine, but it is "insipid," not sweet. This is a rare condition, caused by a damaged pituitary gland. It is not discussed in this chapter. The body needs a constant supply of energy, and glucose is its primary source. Carbohydrates provide most of the glucose, but about 10% of fats and up to nearly 60% of proteins can be converted to glucose if necessary. The distribution of glucose must be carefully managed for the maintenance of good health. Glucose is transported by the blood, and its entry into the cells is controlled by hormones. The primary hormone is insulin. Insulin is secreted by the beta cells of the islets of Langerhans in the pancreas. When there is inadequate production of insulin or the body is unable to use the insulin it produces, glucose cannot enter the cells and it accumulates in the blood, creating hyperglycemia. This condition can cause serious complications. Another hormone, glucagon, which is secreted by the alpha cells of the islets of Langerhans, helps release energy when needed by converting glycogen to glucose. Somatostatin is a hormone produced by the delta cells of the islets of Langerhans and the hypothalamus. All actions of this hormone are inhibitory. It inhibits the release of insulin and glucagons. The amount of glucose in the blood normally rises after a meal. The pancreas reacts by providing insulin. As the insulin circulates in the blood, it binds to special insulin receptors on cell surfaces. This binding causes the cells to accept the glucose. The resulting reduced amount of glucose in the blood in turn signals the pancreas to stop sending insulin. **ETIOLOGY** The etiology (cause) of diabetes is not confirmed. Although it appears that diabetes may be genetic, environmental factors also may contribute to its occurrence. For example, viruses or obesity may precipitate the disease in people who have a genetic predisposition. The World Health Organization indicates that the prevalence of the disease is increasing worldwide, especially in areas showing improvement in living standards. **SYMPTOMS** The abnormal concentration of glucose in the blood of diabetic clients draws water from the cells to the blood. When hyperglycemia exceeds the renal threshold, the glucose is excreted in the urine (glycosuria). With the loss of the cellular fluid, the client experiences polyuria (excessive urination), and polydipsia (excessive thirst) typically results. The inability to metabolize glucose causes the body to break down its own tissue for protein and fat. This response causes polyphagia (excessive appetite), but at the same time a loss of weight, weakness, and fatigue occur. The body's use of protein from its own tissue causes it to excrete nitrogen. Because the untreated diabetic client cannot use carbohydrates for energy, excessive amounts of fats are broken down, and consequently the liver produces ketones from the fatty acids. In healthy people, ketones are subsequently broken down to carbon dioxide and water, yielding energy. In diabetic clients, fats break down faster than the body can handle them. Ketones collect in the blood (ketonemia) and must be excreted in the urine (ketonuria). Ketones are acids that lower blood pH, causing acidosis. Acidosis can lead to diabetic coma, which can result in death if the client is not treated quickly with fluids and insulin. In addition to the symptoms previously mentioned, diabetic clients suffer from diseases of the vascular system. Atherosclerosis (a condition in which there is a heavy buildup of fatty substances inside artery walls, reducing blood flow) is a major cause of death among diabetic clients. Damage to the small blood vessels can cause retinal degeneration. Retinopathy is the leading cause of blindness in the United States. Nerve damage (neuropathy) is not uncommon, and infections, particularly of the urinary tract, are frequent problems. **CLASSIFICATION** The types of diabetes are prediabetes, type 1, type 2, and gestational. Prediabetes means that the cells in the body are not using insulin properly. The diagnosis is made by a fasting blood glucose, which is more than 110 but less than 126 mg/dl. One's lifestyle will determine when prediabetes will advance to type 2. Type 1 diabetes develops when the body's immune system destroys the pancreatic beta cells. These are the only cells in the body that make the hormone insulin that regulates blood glucose. Type 1 diabetes is usually diagnosed in children and young adults. It can account for 5% to 10% of all cases of newly diagnosed diabetes. Some risk factors include genetics, autoimmune status, and environmental factors. Type 2 diabetes was previously called adult-onset diabetes because it usually occurred in adults over the age of 40. Type 2 is associated with obesity, and obesity has become an epidemic, which has drastically increased the incidence of type 2 diabetes among adolescents and young adults. A family history of diabetes, prior history of gestational diabetes, impaired glucose tolerance, older age, physical inactivity, and race and ethnicity can predispose one to type 2 diabetes. African Americans, Hispanic and Latino Americans, Native Americans, some Asian Americans, and Native Hawaiians and other Pacific Islanders are at particularly high risk for type 2 diabetes. It is not uncommon for the client to have no symptoms of diabetes and to be totally ignorant of his or her condition until it is discovered accidentally during a routine urine or blood test or after a heart attack or stroke. In type 2 diabetes, hypertension may be present as part of the metabolic syndrome (i.e., obesity, hyperglycemia, and dyslipidemia) that is accompanied by high rates of cardiovascular disease. The American Diabetes Association recommends that blood pressure be controlled at \>130/80 mm Hg for diabetics. Type 2 diabetes can usually be controlled by diet and exercise, or by diet, exercise, and an oral diabetes medication. Table 17-1 shows six types of oral glucose-lowering medications in order from newest and most frequently used to oldest and least frequently used. The goals of medical nutrition therapy for clients with type 2 diabetes include maintaining healthy glucose, blood pressure, and lipid levels. Also, because approximately 80% of type 2 clients are overweight, these clients may be placed on weight reduction diets after their blood glucose levels are within acceptable range. Thus, monitoring their weight loss also becomes part of their therapy. Exenatide (Byetta) injection is the first in a new class of drugs for the treatment of type 2 diabetes. The drugs are called incretin mimetics. When food is eaten, incretin hormones are released from cells located in the small intestine. In the pancreas, incretins will act on the beta cells to increase glucosedependent insulin secretions to ensure an appropriate insulin response after a meal. This medication is used in conjunction with the nonsulfonylurea metformin to help clients lower their HgbA1c to less than 7%. HgbA1c is a blood test to determine how well blood glucose has been controlled for the last 3 months. The American Diabetes Association prefers the outcome be less than 6%. Gestational diabetes can occur between the sixteenth and twenty-eighth week of pregnancy. If it is not responsive to diet and exercise, insulin injection therapy will be used. It is recommended that a dietitian or a diabetic educator be consulted to plan an adequate diet that will control blood sugar for mother and baby. Concentrated sugars should be avoided. Weight gain should continue, but not in excessive amounts. Usually, gestational diabetes disappears after the infant is born. However, diabetes can develop 5 to 10 years after the pregnancy. Secondary diabetes occurs infrequently and is caused by certain drugs or by a disease of the pancreas. **TREATMENT** The treatment of diabetes is intended to do the following: 1\. Control blood glucose levels 2\. Provide optimal nourishment for the client 3\. Prevent symptoms and thus delay the complications of the disease Treatment is typically begun when blood tests indicate hyperglycemia or when other previously discussed symptoms occur. Normal blood glucose levels (called fasting blood sugar, FBS) are from about 70 to 100 mg/dl. Treatment can be by diet alone or by a diet combined with insulin or an oral glucose-lowering medication plus regulated exercise and the regular monitoring of the client's blood glucose levels. The physician and dietitian can provide essential testing, information, and counseling and can help the client delay potential damage. The ultimate responsibility, however, rests with the client. When a person with diabetes uses nicotine, eats carelessly, forgets insulin, ignores symptoms, and neglects appropriate blood tests, he or she increases the risk of developing permanent tissue damage. **NUTRITIONAL MANAGEMENT** The dietitian will need to know the client's diet history, food likes and dislikes, and lifestyle at the onset. The client's calorie needs will depend on age, activities, lean muscle mass, size, and REE. It is recommended that carbohydrates provide 50% to 60% of the calories. Approximately 40% to 50% should be from complex carbohydrates (starches). The remaining 10% to 20% of carbohydrates could be from simple sugar. Research provides no evidence that carbohydrates from simple sugars are digested and absorbed more rapidly than are complex carbohydrates, and they do not appear to affect blood sugar control. It is the total amount of carbohydrates eaten that affects blood sugar levels rather than the type. Being able to substitute foods containing sucrose for other carbohydrates increases flexibility in meal planning for the diabetic. Fats should be limited to 30% of total calories, and proteins should provide from 15% to 20% of total calories. Lean proteins are advisable because they contain limited amounts of fats. Regardless of the percentages of energy nutrients prescribed, the foods ultimately eaten should provide sufficient vitamins and minerals as well as energy nutrients. The client with type 1 diabetes needs a nutritional plan that balances calories and nutrient needs with insulin therapy and exercise. It is important that meals and snacks be composed of similar nutrients and calories and eaten at regular times each day. Small meals plus two or three snacks may be more helpful in maintaining steady blood glucose levels for these clients than three large meals each day. The client with type 1 diabetes should anticipate the possibility of missing meals occasionally and carry a few crackers and some cheese or peanut butter to prevent hypoglycemia, which can occur in such a circumstance. The client with type 2 diabetes may be overweight. The nutritional goal for this client is not only to keep blood glucose levels in the normal range but to lose weight as well. Exercise can help attain both goals. **Carbohydrate Counting** Carbohydrate counting is the newest method for teaching a diabetic client how to control blood sugar with food. The starch and bread category, milk, and fruits have all been put under the heading of "carbohydrates." This means that these three food groups can be interchanged within one meal. One would still have the same number of servings of carbohydrates, but it would not be the typical number of starches or fruits and milk that one usually eats. For example, one is to have four carbohydrates for breakfast (2 breads, 1 fruit, and 1 milk). If there is no milk available, a bread or fruit must be eaten in place of the milk. The exchange lists are utilized in carbohydrate counting as well as in traditional meal planning. Protein, approximately 3 to 4 ounces, is eaten for lunch and dinner. One or two fat exchanges are recommended for each meal. Two carbohydrates should be eaten for an evening snack. These are only beginning guidelines. A dietitian or diabetic educator can help tailor this to the individual client. **Diets Based on Exchange Lists** The method of diet therapy most commonly used for diabetic clients is that based on exchange lists. These lists were developed by the American Diabetes Association in conjunction with the American Dietetic Association and are summarized in Table 17-2 and included completely in Table 17-3. Under this plan, foods are categorized by type and included in the lists in Table 17-3. The foods within each list contain approximately equal amounts of calories, carbohydrates, protein, and fats. This means that any one food on a particular list can be substituted for any other food on that particular list and still provide the client with the prescribed types and amounts of nutrients and calories. The amounts of nutrients and calories on one list are not the same as those on any other list. Each list includes serving size by volume or weight and the calorie value of each food item, in addition to the grams of carbohydrates, and, when appropriate, proteins and fats. The number of calories needed will determine the number of items prescribed from any particular list. These lists also can be used to control calorie content of diets and are thus appropriate for low-calorie diets. The total energy requirements for adult diabetic clients who are not overweight will be the same as for nondiabetic individuals. When clients are overweight, a reduction in calories will be built into the diet plans, typically allowing for a weight loss of 1 pound a week. The diet is given in terms of exchanges rather than as particular foods. For example, the menu pattern for breakfast may include 1 fruit exchange, 1 meat exchange, 2 bread exchanges, and 2 fat exchanges. The client may choose the desired foods from the exchange lists for each meal but must adhere to the specific exchange lists named and the specific number of exchanges on each list. Vegetables (nonstarchy) are relatively free and can be eaten in amounts up to 11 ⁄2 cups cooked or 3 cups raw. If more than this amount is eaten at one meal, count the additional amount as one more carbohydrate. Snacks are built into the plan. In this way, the client has variety in a simple yet controlled way. When there are changes in one's physical condition, such as pregnancy or lactation, or in one's lifestyle, the diet will need to be modified. A change in job or in working hours can affect nutrient and calorie requirements. When such changes occur, the client should be advised to consult her or his physician or dietitian so that calorie and insulin needs can be promptly adjusted. **SPECIAL CONSIDERATIONS FOR THE DIABETIC CLIENT** **Fiber** The therapeutic value of fiber in the diabetic diet has become increasingly evident. High-fiber intake appears to reduce the amount of insulin needed because it lowers blood glucose. It also appears to lower the blood cholesterol and triglyceride levels. High-fiber may mean 25 to 35 grams of dietary fiber a day. Such high amounts can be difficult to include. High-fiber foods should be increased very gradually, as an abrupt increase can create intestinal gas and discomfort. When increasing fiber in the diet one must also increase intake of water. An increased fiber intake can affect mineral absorption. **Alternative Sweeteners** Sucralose is the newest sweetener to gain approval by the FDA. Sucralose is made from a sugar molecule that has been altered in such a way that the body will not absorb it. Aspartame is the generic name for a sweetener composed of two amino acids: phenylalanine and aspartic acid. The FDA removed the sweetener saccharine from its list of products that could cause cancer. Research indicates that all these sweeteners are safe. All have been approved by the FDA, and their use has been endorsed by the American Diabetes Association. **Dietetic Foods** The use of diabetic or dietetic foods is generally a waste of money and can be misleading to the client. Often the containers of foods will contain the same ingredients as containers of foods prepared for the general public, but the cost is typically higher for the dietetic foods. There is potential danger for diabetic clients who use these foods if they do not read the labels on the food containers and assume that because they are labeled "dietetic," they can be used with abandon. In reality, their use should be in specified amounts only, as these foods will contain carbohydrates, fats, and proteins that must be calculated in the total day's diet. It is advisable for the diabetic client to use foods prepared for the general public but to avoid those packed in syrup or oil. The important thing is for the diabetic client to read the label on all food containers purchased. **Alcohol** Although alcohol is not recommended for diabetic clients, its limited use is sometimes allowed if approved by the physician. However, some diabetic clients who use hypoglycemic agents cannot tolerate alcohol. When used, alcohol must be included in the diet plan. **Exercise** Exercise helps the body use glucose by increasing insulin receptor sites and stimulating the creation of glucagon. It lowers cholesterol and blood pressure and reduces stress and body fat as it tones the muscles. For clients with type 2 diabetes, exercise helps improve weight control, glucose levels, and the cardiovascular system. However, for clients with type 1 diabetes, exercise can complicate glucose control. As it lowers glucose levels, hypoglycemia can develop. Exercise must be carefully discussed with the client's physician. If done, it should be on a regular basis, and it must be considered carefully as the meal plans are developed so that sufficient calories and insulin are prescribed. **Insulin Therapy** Clients with type 1 diabetes must have injections of insulin every day to control their blood glucose levels. This insulin is called exogenous insulin because it is produced outside the body. Endogenous insulin is produced by the body. Exogenous insulin is a protein. It must be injected because, if swallowed, it would be digested and would not reach the bloodstream as the complete hormone. After insulin treatment is begun, it is usually necessary for the client to continue it throughout life. Human insulin is the most common insulin given to clients. This insulin does not come from humans but is made synthetically by a chemical process in a laboratory. Human insulin is preferred because it is very similar to insulin made by the pancreas. Animal insulin comes from cows or pigs and is called beef or pork insulin. These insulins are rarely used because they contain antibodies that make them less pure than human insulin. Various types of insulin are available. They differ in the length of time required before they are effective and in the length of time they continue to act. This latter category is called insulin action. Consequently, they are classified as very rapid-, rapid-, intermediate-, and long-acting. Those most commonly used are intermediate-acting types that work within 2 to 8 hours and are effective for 24 to 28 hours. For type 1 diabetes, insulin is often given in two or more injections daily and may contain more than one type of insulin. Injections are given at prescribed times. More insulin-dependent diabetic clients are using insulin-pump therapy for better blood glucose control. Pumps deliver insulin two ways: the basal rate and a premeal bolus. The basal rate is a small amount of short-acting insulin delivered continuously throughout the day. This insulin keeps blood glucose in check between meals and during the night. Premeal boluses of short-acting insulin are designed to cover the food eaten during a meal. This allows more flexibility as to when meals are eaten. Insulin pumps are not for everyone. An endocrinologist and diabetes educator can determine the best candidates for pump therapy. **Insulin Reactions** When clients do not eat the prescribed diet but continue to take the prescribed insulin, hypoglycemia can result. This is called an insulin reaction, or hypo-glycemic episode, and may lead to coma and death. Symptoms include headache, blurred vision, tremors, confusion, poor coordination, and eventual unconsciousness. Insulin reaction is dangerous because if frequent or prolonged, brain damage can occur. (The brain must have sufficient amounts of glucose in order to function.) The physician should be consulted if an insulin reaction occurs or seems imminent. Conscious clients may be treated by giving them a glucose tablet, a sugar cube, or a beverage containing sugar followed by a complex carbohydrate. If the client is unconscious, intravenous treatment of dextrose and water is given. It is advisable for the diabetic client to carry identification explaining the condition so that people do not think he or she is drunk when, in reality, the person is experiencing an insulin reaction. **CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL** It is important to point out to the diabetic client that one can live a near-normal life if the diet is followed, medication is taken as prescribed, and time is allowed for sufficient exercise and rest. The importance of eating all of the prescribed food must be emphasized. It is important for meals to be eaten at regular times so that the insulin--glucose balance can be maintained. It is imperative that the client learn to read carefully all labels on commercially prepared foods. Adjustments must be made in shopping, cooking, and eating habits so that the diet plan can be followed. Family meals can be simply adapted for the diabetic diet. The diabetic client soon learns which exchange lists are to be included at each meal and at snack times and the foods within each exchange list. (See Table 17-3 for the exchange lists, Table 17-4 for free foods, and Table 17-5 for seasonings that can be used.) **DIET AND CARDIOVASCULAR DISEASE** Cardiovascular disease (CVD) affects the heart and blood vessels. It is the leading cause of death and permanent disability in the United States today. The grief and economic distress it causes are staggering. Organizations, especially the American Heart Association, are promoting programs designed to alert people to the risk factors for cardiovascular disease and thereby reduce its frequency. A group of risk factors have been identified and are known as the metabolic syndrome, previously known as syndrome X. These risk factors apply to children as well as adults. - Abdominal obesity - High blood lipids such as high triglycerides, low HDL, and high LDL - High blood pressure - Insulin resistance - Elevated highly sensitive C-reactive protein in the blood Those diagnosed with metabolic syndrome are at increased risk of coronary heart disease, stroke, peripheral vascular disease, and type 2 diabetes. Cardiovascular disease can be acute (sudden) or chronic. Myocardial infarction, or MI, is an example of the acute form. Chronic heart disease develops over time and causes the loss of heart function. If the heart can maintain blood circulation, the disease is classified as compensated heart disease. Compensation usually requires that the heart beat unusually fast. Consequently, the heart enlarges. If the heart cannot maintain circulation, the condition is classified as decompensated heart disease, and congestive heart failure (CHF) occurs. The heart muscle (myocardium), the valves, the lining (endocardium), the outer covering (pericardium), or the blood vessels may be affected by heart disease. **ATHEROSCLEROSIS** Arteriosclerosis is the general term for vascular disease in which arteries harden (become thickened), making the passage of blood difficult and sometimes impossible. Atherosclerosis is the form of arteriosclerosis that most frequently occurs in developed countries. It is believed to begin in childhood and is considered one of the major causes of heart attack. Atherosclerosis affects the inner lining of arteries (the intima), where deposits of cholesterol, fats, and other substances accumulate over time, thickening and weakening artery walls. These deposits are called plaque. Plaque deposits gradually reduce the size of the lumen of the artery and, consequently, the amount of blood flow. The reduced blood flow causes an inadequate supply of nutrients and oxygen delivery to and waste removal from the tissues. This condition is called ischemia. The reduced oxygen supply causes pain. When the pain occurs in the chest and radiates down the left arm, it is called angina pectoris and should be considered a warning. When the lumen narrows so that a blood clot (thrombus) occurs in a coronary artery and blood flow is cut off, a heart attack occurs. The dead tissue that results is called an infarct. The heart muscle that should have received the blood is the myocardium. Thus, such an attack is commonly called an acute myocardial infarction (MI). Some clients who experience an MI will require surgery to bypass the clogged artery. The procedure is a coronary artery bypass graft (CABG), which is commonly referred to as bypass surgery. When blood flow to the brain is blocked in this way or blood vessels burst and blood flows into the brain, a stroke, or cerebrovascular accident (CVA), results. When it occurs in tissue some distance from the heart, it is called peripheral vascular disease (PVD). **Risk Factors** Hyperlipidemia, hypertension (high blood pressure), and smoking are major risk factors for the development of atherosclerosis. Other contributory factors are believed to include obesity, diabetes mellitus, male sex, heredity, personality type (ability to handle stress), age (risk increases with years), and sedentary lifestyle. Although some of these factors are beyond one's control, some factors are not.It is known that dietary cholesterol and triglycerides (fats in foods and in adipose tissue) contribute to hyperlipidemia. Foods containing saturated fats and trans fats increase serum cholesterol, whereas unsaturated fats tend to reduce it. Lipoproteins carry cholesterol and fats in the blood to body tissues. Low-density lipoprotein (LDL) carries most of the cholesterol to the cells, and elevated blood levels of LDL are believed to contribute to atherosclerosis. Highdensity lipoprotein (HDL) carries cholesterol from the tissues to the liver for eventual excretion. It is believed that low serum levels of HDL can contribute to atherosclerosis. Diet can alleviate hypertension (discussed later in this chapter), reduce obesity, and help control diabetes mellitus. A sedentary lifestyle can be changed. Exercise can help the client lose weight, lower blood pressure, and increase the HDL ("good") cholesterol level. Exercise must be done in consultation with the physician and be increased gradually. Also, one can stop smoking. In sum, a person can considerably reduce the risk of atherosclerosis and thus an MI, CVA, and PVD. **MEDICAL NUTRITION THERAPY FOR HYPERLIPIDEMIA** Medical nutrition therapy is the primary treatment for hyperlipidemia. It involves reducing the quantity and types of fats and often calories in the diet. When the amount of dietary fat is reduced, there is typically a corresponding reduction in the amount of cholesterol and saturated fat ingested and a loss of weight. In overweight persons, weight loss alone will help reduce serum cholesterol levels. The American Heart Association categorizes blood cholesterol levels of 200 mg/dl or less to be desirable, 200 to 239 mg/dl to be borderline high, and 240 mg/dl and greater to be high. In an effort to prevent heart disease, the American Heart Association has developed guidelines in which it is recommended that adult diets contain less than 200 mg of cholesterol per day and that fats provide no more than 20% to 35% of calories, with a maximum of 7% from saturated fats and trans fat, a maximum of 8% from polyunsaturated fats, and a maximum of 15% to 20% of monounsaturated fats. Carbohydrates should make up 50% to 55% of the calories and proteins from 12% to 20% of them. Currently, it is believed that nearly 40% of the calories in the average U.S. diet come from fats. A fat-restricted diet can be difficult for the client to accept. A diet very low in fat will seem unusual and highly unpalatable (unpleasant-tasting) to most clients. It takes approximately 2 or 3 months to adjust to a low-fat diet. If the physician will allow it, the change in the nutrient makeup of the diet should be made gradually (Table 18-1). Information about the fat content of foods and methods of preparation that minimize the amount of fat in the diet are essential to the client. The client must be taught to select whole, fresh foods and to prepare them without the addition of any fat. Only lean meat should be selected, and all visible fat must be removed. Fat-free milk and fat-free milk cheeses should be used instead of whole milk and natural cheeses. Desserts containing whole milk, eggs, and cream are to be avoided. In a fat-controlled diet, one must be particularly careful when using animal foods. Cholesterol is found only in animal tissue. Organ meats, egg yolks, and some shellfish are especially rich in cholesterol and should be used in limited quantities, if at all. Saturated fats are found in all animal foods and in coconut, chocolate, and palm oil. They tend to be solid at room temperature. Polyunsaturated fats are derived from plants and some fish and are usually soft or liquid at room temperature. Soft margarine containing mostly liquid vegetable oil is substituted for butter, and liquid vegetable oils are used in cooking. Studies indicate that water-soluble fiber, such as that found in oat bran, legumes, and fruits, bind with cholesterol-containing substances and prevent their reabsorption by the blood. It is thought that 20 to 25 grams of soluble fiber a day will effectively reduce serum cholesterol by as much as 15%. This is a large amount of fiber and must be introduced gradually to the diet along with increased fluids or the client will suffer from flatulence. Table 18-2 lists foods to limit on a low-cholesterol diet. Some clients will find the diabetic exchange lists useful for controlling the fat content of their diets. When fat-controlled diets are severely restricted, limiting calorie intake to 1,200, they may be deficient in fat-soluble vitamins. Consequently, a vitamin supplement may be needed. If appropriate blood lipid levels cannot be attained within 3 to 6 months by the use of a fat-restricted diet alone (see Table 18-3 for menus), the physician can prescribe a cholesterol-lowering drug such as atorvastatin (Lipitor) or simvastatin (Zocor). Food and/or drug interactions can occur with cholesterol-lowering drugs, as well as with other cardiac drugs. For example, Zocor and Lipitor interact with grapefruit and its juice; therefore total avoidance is necessary. **MYOCARDIAL INFARCTION** Myocardial infarction is caused by the blockage of a coronary artery supplying blood to the heart. The heart tissue denied blood because of this blockage dies (see Figure 18-2). Atherosclerosis is a primary cause, but hypertension, abnormal blood clotting, and infection such as that caused by rheumatic fever (which damages heart valves) are also contributory factors. After the attack, the client is in shock. This causes a fluid shift, and the client may feel thirsty. The client should be given nothing by mouth (NPO), however, until the physician evaluates the condition. If the client remains nauseated after the period of shock, IV infusions are given to prevent dehydration. After several hours, the client may begin to eat. A liquid diet may be recommended for the first 24 hours. Following that, a low-cholesterol-- low-sodium diet is usually given, with the client regulating the amount eaten. Foods should not be extremely hot or extremely cold. They should be easy to chew and digest and contain little roughage so that the work of the heart will be minimal. Both chewing and the increased activity of the gastrointestinal tract that follow ingestion of high-fiber foods cause extra work for the heart. The percentage of energy nutrients will be based on the particular needs of the client, but, in most cases, the types and amounts of fats will be limited. Sodium is usually limited to prevent fluid accumulation. Some physicians will order a restriction on the amount of caffeine for the first few days after an MI. The dual goal is to allow the heart to rest and its tissue to heal. **CONGESTIVE HEART FAILURE** Congestive heart failure (CHF) is an example of decompensation, or severe heart disease. Heart failure is caused by conditions that damage the heart muscle, including coronary artery disease (CAD), heart attack, cardiomyopathy, valve disease, heart defects present at birth, diabetes mellitus, and chronic renal disease. Heart failure can also occur if several diseases or conditions are present. In this situation, when damage is extreme and the heart cannot provide adequate circulation, the amount of oxygen taken in is insufficient for body needs. Shortness of breath is common, and chest pain can occur on exertion. Because of the reduced circulation, tissues retain fluid that would normally be carried off by the blood. Sodium builds up, and more fluid is retained, resulting in edema. In an attempt to compensate for this pumping deficit, the heart beats faster and enlarges. This adds to the heart's burden. In advanced cases when edema affects the lungs, death can occur. With the inadequate circulation, body tissues do not receive sufficient amounts of nutrients. This insufficiency can cause malnutrition and underweight, although the edema can mask these problems. In some cases a fluid restriction may be ordered. Diuretics to aid in the excretion of water and sodium and a sodium- restricted diet are typically prescribed. Because diuretics can cause an excessive loss of potassium, the client's blood potassium should be carefully monitored to prevent hypokalemia, which can upset the heartbeat. Fruits, especially oranges, bananas, and prunes, can be useful in such a situation because they are excellent sources of potassium and contain only negligible amounts of sodium (Table 18-4). When necessary, the physician will prescribe supplementary potassium. **HYPERTENSION** When blood pressure is chronically high, the condition is called hypertension (HTN). In 90% of hypertension cases, the cause is unknown, and the condition is called essential, or primary, hypertension. The other 10% of the cases are called secondary hypertension because the condition is caused by another problem. Some causes of secondary hypertension include kidney disease, problems of the adrenal glands, and use of oral contraceptives. The blood pressure commonly measured is that of the artery in the upper arm. This measurement is made with an instrument called the sphygmomanometer. The top number is the systolic pressure, taken as the heart contracts. The lower number is the diastolic pressure, taken when the heart is resting. The pressure is measured in millimeters of mercury (mm Hg). Hypertension can be diagnosed when, on several occasions, the systolic pressure is 140 mm Hg or more and the diastolic pressure is 90 mm Hg or more. The blood pressure categories are the following: - Normal---less than 120/less than 80 mm Hg - Prehypertension---120--139/80--88 mm Hg - Stage 1 hypertension---140--159/90--99 mm Hg - Stage 2 hypertension---160/100 mm Hg Hypertension contributes to heart attack, stroke, heart failure, and kidney failure. It is sometimes called the silent disease because sufferers can be asymptomatic (without symptoms). Its frequency increases with age, and it is more prevalent among African Americans than others. Heredity and obesity are predisposing factors in hypertension. Smoking and stress also contribute to hypertension. Weight loss usually lowers the blood pressure and, consequently, clients are often placed on weight reduction diets. Excessive use of ordinary table salt also is considered a contributory factor in hypertension. Table salt consists of over 40% sodium plus chloride. Both are essential in maintaining fluid balance and thus blood pressure. When consumed in normal quantities by healthy people, they are beneficial. When the fluid balance is upset and sodium and fluid collect in body tissue, causing edema, extra pressure is placed on the blood vessels. A sodium- restricted diet, often accompanied by diuretics, can be prescribed to alleviate this condition. When the sodium content in the diet is reduced, the water and salts in the tissues flow back into the blood to be excreted by the kidneys. In this way, the edema is relieved. The amount of sodium restricted is determined by the physician on the basis of the client's condition. Previous research focused primarily on sodium as a primary factor in the development of hypertension, but as research continues, the effects of chloride also are receiving increasing scrutiny. In addition, the particular roles of calcium and magnesium in relation to hypertension are being studied. Knowing that sodium raises blood pressure and that potassium lowers blood pressure, the NIH (National Institutes of Health) created the DASH (Dietary Approaches to Stop Hypertension) eating plan. The DASH plan has been clinically shown to reduce high blood pressure while increasing the serving of fruits and vegetables to 8 to 12 servings per day, depending upon calorie intake. Many fruits and vegetables are high in potassium levels, which will lower blood pressure. The newest guideline for potassium intake is 4.7 grams, or 4,700 mg, per day to lower blood pressure. It is recommended that a physician be consulted if the DASH eating plan is undertaken and one is already on blood pressure--lowering medication. **DIETARY TREATMENT FOR HYPERTENSION** As indicated above, weight loss for the obese client with hypertension usually lowers blood pressure, and thus a calorie-restricted diet might be prescribed. A sodium-restricted diet frequently is prescribed for clients with hypertension. Certain ethnic groups, such as African Americans with new onset of HTN and those already diagnosed with HTN, should limit sodium intake to 1,500 mg/day. A discussion of this diet follows. When diuretics are prescribed together with a sodium-restricted diet, the client may lose potassium via the urine and, thus, be advised to increase the amount of potassium-rich foods in the diet (see Table 18-4) **Sodium-Restricted Diets** A sodium-restricted diet is a regular diet in which the amount of sodium is limited. Such a diet is used to alleviate edema and hypertension. Most people obtain far too much sodium from their diets. It is estimated that the average adult consumes 7 grams of sodium a day. A committee of the Food and Nutrition Board recommends that the daily intake of sodium be limited to no more than 2,300 mg (2.3 grams), and the Board itself set a safe minimum at 500 mg/day for adults (see Table 8-5). Sodium is found in food, water, and medicine. It is impossible to have a diet totally free of sodium. Meats, fish, poultry, dairy products, and eggs all contain substantial amounts of sodium naturally. Cereals, vegetables, fruits, and fats contain small amounts of sodium naturally. Water contains varying amounts of sodium. However, sodium often is added to foods during processing and cooking and at the table. The food label should indicate the addition of sodium to commercial food products. In some of these foods, the addition of sodium is obvious because one can taste it, as in prepared dinners, potato chips, and canned soups. In others, it is not. The following are examples of sodium-containing products frequently added to foods that the consumer may not notice. - Salt (sodium chloride)---used in cooking or at the table and in canning and processing. - Monosodium glutamate (called MSG and sold under several brand names)---a flavor enhancer used in home, restaurant, and hotel cooking and in many packaged, canned, and frozen foods. - Baking powder---used to leaven quick breads and cakes. - Baking soda (sodium bicarbonate)---used to leaven breads and cakes; sometimes added to vegetables in cooking or used as an "alkalizer" for indigestion. - Brine (table salt and water)---used in processing foods to inhibit growth of bacteria; in cleaning or blanching vegetables and fruits; in freezing and canning certain foods; and for flavor, as in corned beef, pickles, and sauerkraut. - Disodium phosphate---present in some quick-cooking cereals and processed cheeses. - Sodium alginate---used in many chocolate milks and ice creams for smooth texture. - Sodium benzoate---used as a preservative in many condiments such as relishes, sauces, and salad dressings. - Sodium hydroxide---used in food processing to soften and loosen skins of ripe olives, hominy, and certain fruits and vegetables. - Sodium propionate---used in pasteurized cheeses and in some breads and cakes to inhibit growth of mold. - Sodium sulfite---used to bleach certain fruits in which an artificial color is desired, such as maraschino cherries and glazed or crystallized fruit; also used as a preservative in some dried fruit, such as dried plums. Because the amount of sodium in tap water varies from one area to another, the local department of health or the American Heart Association affiliate should be consulted if this information is needed. Softened water always has additional sodium. If the sodium content of the water is high, the client may have to use bottled water. Some over-the-counter medicines contain sodium. A client on a sodiumrestricted diet should obtain the physician's permission before using any medication or salt substitute. Many salt substitutes contain potassium, which can affect the heartbeat. The amount of sodium allowed depends on the client's condition and is prescribed by the physician. In extraordinary cases of fluid retention, a diet with 1 gram a day can be ordered. A very low restriction limits sodium to 2 grams a day. A moderate restriction limits sodium to 3 to 4 grams a day. **Adjustment to Sodium Restriction** Sodium-restricted diets range from "different" to "tasteless" because most people are accustomed to salt in their food. It can be difficult for the client to understand the necessity for following such a diet, particularly if it must be followed for the remainder of his or her life. If the physician allows, it will help the client adjust if the sodium content of the diet can be reduced gradually. It is helpful, too, to remind the client of the numerous herbs, spices, and flavorings allowed on sodium-restricted diets (Table 18-5). Clients will also find it useful to practice ordering from a menu so as to learn to choose those foods lowest in sodium content. **CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL** Clients with heart conditions serious enough to require hospitalization can be frightened, depressed, or angry. Most will be told they must reduce the fats, sodium, and, sometimes, the amount of calories in their diets, which could make them feel overwhelmed. The health care professional will find various moods among these clients. Most will need nutritional advice. Some will want it. Some will be against the new diets. The most important thing the health care professional can do is help the cardiac client want to learn how to help himself or herself via nutrition. **DIET AND RENAL DISEASE** The kidneys are intricate and efficient processing systems that excrete wastes, maintain volume and composition of body fluids, and secrete certain hormones. To accomplish these tasks, they filter the blood, cleansing it of waste products, and recycle other, usable, substances so that the necessary constituents of body fluids are constantly available. Each kidney contains approximately 1 million working parts called nephrons. Each nephron contains a filtering unit, called a glomerulus, in which there is a cluster of specialized capillaries (tiny blood vessels connecting veins and arteries). Approximately 180 liters of ultrafiltrate is processed each day. As the filtrate passes through the nephrons, it is concentrated or diluted to meet the body's needs. In this way, the kidneys help maintain both the composition and the volume of body fluids and, consequently, they maintain fluid balance, acid-base balance, and electrolyte balance. The liquid waste is sent via two tubes called ureters from the kidneys to the urinary bladder, from which they are excreted in approximately 1.5 liters of urine per day. These waste materials include end products of protein metabolism (urea, uric acid, creatinine, ammonia, and sulfates), excess water and nutrients, dead renal cells, and toxic substances. When the urinary output is less than 500 ml/day, it is impossible for all the daily wastes to be eliminated. This condition is called oliguria. When the kidneys are unable to adequately eliminate nitrogenous waste (end products of protein metabolism), renal failure can result. The recycled materials are reabsorbed (taken back) by the blood. They include amino acids, glucose, minerals, vitamins, and water. The kidneys synthesize and secrete certain hormones as needed. For example, it is the kidneys that make the final conversion of vitamin D. Active vitamin D promotes the absorption of calcium and the metabolism of calcium and phosphorus. The kidneys indirectly stimulate bone marrow to reproduce red blood cells by producing the hormone erythropoietin. **RENAL DISEASES** **Etiology of Renal Disease** Kidney disorders can be initially caused by infection, degenerative changes, diabetes mellitus, high blood pressure cysts, renal stones, or trauma (surgery, burns, poisons). When these conditions are severe, renal failure may develop. It may be acute or chronic. Acute renal failure (ARF) occurs suddenly and may last a few days or a few weeks. It can be caused by another medical problem such as a serious burn, a crushing injury, or cardiac arrest. It can be expected in some of these situations, so preventive steps should be taken. **Classification of Renal Disease** Chronic kidney disease develops slowly, causing the number of functioning nephrons to diminish. When renal tissue has been destroyed to a point at which the kidneys are no longer able to filter the blood, excrete wastes, or recycle nutrients as needed, uremia occurs. Uremia is a condition in which protein wastes that should normally have been excreted are instead circulating in the blood. Symptoms include nausea, headache, convulsions, and coma. Severe renal failure can result in death unless dialysis is begun or a kidney transplant is performed. Nephritis is a general term referring to the inflammatory diseases of the kidneys. Nephritis can be caused by infection, degenerative processes, or vascular disease. Glomerulonephritis is an inflammation affecting the capillaries in the glomeruli. It may occur acutely in conjunction with another infection and be self-limiting, or it may lead to serious renal deterioration. Nephrosclerosis is the hardening of renal arteries. It is caused by arteriosclerosis and hypertension. Although it usually occurs in older people, it sometimes develops in young diabetic clients. Polycystic kidney disease is a relatively rare, hereditary disease. Cysts form and press on the kidneys. The kidneys enlarge and lose function. Although people with this condition have normal kidney function for many years, renal failure may develop near the age of 50. Nephrolithiasis is a condition in which stones develop in the kidneys. The size of the stones varies from that of a grain of sand to much larger. Some remain at their point of origin, and others move. Although the condition is sometimes asymptomatic, symptoms include hematuria (blood in the urine), infection, obstruction, and, if the stones move, intense pain. The stones are classified according to their composition---calcium oxalate, uric acid, cystine, calcium phosphate, and magnesium ammonium phosphate (known as struvite). They are associated with metabolic disturbances and immobilization of the client. **SPECIAL CONSIDERATIONS FOR CLIENTS WITH RENAL DISEASES** **Dietary Treatment of Renal Disease** Dietary treatment is intended to slow the buildup of waste in the bloodstream. Decreasing waste in the bloodstream will control symptoms of fluid retention, hyperkalemia, and nausea and vomiting. The goal is to reduce the amount of excretory work demanded of the kidneys while helping them maintain fluid, acid-base, and electrolyte balance. Clients require sufficient protein to prevent malnutrition and muscle wasting. Too much, however, can contribute to uremia. Typically, the client with chronic renal failure will have protein and sodium, and possibly potassium and phosphorus, restricted. It is essential that renal clients receive sufficient calories---25 to 50 calories per kilogram of body weight---unless they are overweight. Energy requirements should be fulfilled by carbohydrates and fat. The fats must be unsaturated to prevent or check hyperlipidemia. If the energy requirement is not met by carbohydrates and fat, ingested protein or body tissue will be metabolized for energy. Either would increase the work of the kidneys because protein increases the amount of nitrogen waste the kidneys must handle. The diet may limit protein to as little as 40 grams for predialysis clients. The specific amount of protein allowed is calculated according to the client's glomerular filtration rate (GFR) and weight. Fluids and sodium may be limited to prevent edema, hypertension, and congestive heart failure. Calcium supplements may be prescribed. In addition, vitamin D may be added and phosphorus limited to prevent osteomalacia (softening of the bones due to excessive loss of calcium). Phosphorus appears to be retained in clients with kidney disorders, and a disproportionately high ratio of phosphorus to calcium tends to increase calcium loss from bones. Potassium may be restricted in some clients because hyperkalemia tends to occur in end-stage renal disease (ESRD). Excess potassium can cause cardiac arrest. Because of this danger, renal clients should not use salt substitutes or low-sodium milk because the sodium in these products is replaced with potassium. Potassium restriction can be especially difficult for a renal client, who probably must limit sodium intake. Potassium is particularly high in fruits---one of the few foods a client on a sodium-restricted diet may eat without concern. Renal clients often have an increased need for vitamins B, C, and D, and supplements are often given. Vitamin A should not be given because the blood level of vitamin A tends to be elevated in uremia. If a client is receiving antibiotics, a vitamin K supplement may be given. Otherwise, supplements of vitamins E and K are not necessary. Iron is commonly prescribed because anemia frequently develops in renal clients. It is sometimes necessary to increase the amount of simple carbohydrates and unsaturated fats to ensure sufficient calories. **Dialysis** Dialysis is done by either hemodialysis or peritoneal dialysis. The most common is hemodialysis. Hemodialysis requires permanent access to the bloodstream through a fistula. Fistulas are unusual openings between two organs. They are often created near the wrist and connect an artery and a vein. Hemodialysis is done three times a week for approximately 3 to 5 hours each visit. Peritoneal dialysis uses the peritoneal cavity as a semipermeable membrane and is less efficient than hemodialysis. Treatments usually last about 10 to 12 hours a day, three times a week (Figure 19-3). Some clients also use continuous ambulatory peritoneal dialysis (CAPD). The dialysis fluid is exchanged four or five times daily, making this a 24-hour treatment. Clients on CAPD have a more normal lifestyle than do clients on either hemodialysis or peritoneal dialysis. Some complications associated with CAPD include peritonitis, hypotension, and weight gain. **Diet during Dialysis** Dialysis clients may need additional protein, but the amount must be carefully controlled to prevent the accumulation of protein waste between treatments. A client on hemodialysis requires 1.0 to 1.2 grams of protein per kilogram of body weight to make up for losses during dialysis. A client on peritoneal dialysis will require 1.2 to 1.5 grams of protein per kilogram of body weight. The protein needs for clients on CAPD are 1.2 grams per kilogram of body weight. Seventy-five percent of this protein should be high biological value (HBV) protein, which is found in eggs, meat, fish, poultry, milk, and cheese. Potassium is usually restricted for dialysis clients. Healthy people ingest from 2,000 to 6,000 mg per day. The daily intake allowed clients in renal failure is 3,000 to 4,000 mg. End-stage renal disease further reduces intake allowed to 1,500 to 2,500 mg a day. The physician will prescribe the milligrams of potassium needed by the client. Table 19-1 lists low-, medium-, and high-potassium fruits and vegetables. Clients are taught to regulate their intake by making careful choices. Milk is normally restricted to 1 ⁄2 cup a day because it is high in potassium and high in methionine, an essential amino acid. A typical renal diet could be written as "80-3-3," which means 80 grams of protein, 3 grams of sodium, and 3 grams of potassium a day. There may be a phosphorus restriction also. And there is often a need for supplements of water-soluble vitamins, vitamin D, calcium, and iron. The ability of the kidney to handle sodium and water in ESRD must be assessed often. Usually, the diet contains 3 grams of sodium, which is the equivalent of a no-added-salt diet. Sodium and fluid needs may increase with perspiration, vomiting, fever, and diarrhea. The fluid content of foods, other than liquids, is not counted in fluid restriction. Clients on fluid restriction must be taught to measure their fluid intake and urine output, examine their ankles for edema, and weigh themselves regularly. **Diet after Kidney Transplant** After kidney transplant, there may be a need for extra protein or for the restriction of protein. Carbohydrates and sodium may be restricted. The appropriate amounts of these nutrients will depend largely on the medications given at that time. Additional calcium and phosphorus may be necessary if there was substantial bone loss before the transplant. There may be an increase in appetite after transplants. Fats and simple carbohydrates may be limited to prevent excessive weight gain. **Dietary Treatment of Renal Stones** Because the causes of renal stones have not been confirmed, treatment of them may vary. In general, however, large amounts of fluid---at least half of it water---are helpful in diluting the urine, as is a well-balanced diet. Once the stones have been analyzed, specific diet modifications may be indicated. **Calcium Oxalate Stones** About 80% of the renal stones formed contain calcium oxalate. Recent studies provide no support for the theory that a diet low in calcium can reduce the risk of calcium oxalate renal stones. In fact, higher dietary calcium intake may decrease the incidence of renal stones for most people. Dietary intake of excessive animal protein has been shown to be a risk factor for stone formation in some clients. Stones containing oxalate are thought to be partially caused by a diet especially rich in oxalate, which is found in beets, wheat bran, chocolate, tea, rhubarb, strawberries, and spinach. Evidence also indicates that deficiencies of pyridoxine, thiamine, and magnesium may contribute to the formation of oxalate renal stones. **Uric Acid Stones** When the stones contain uric acid, purine-rich foods are restricted (Table 19-2). Purines are the end products of nucleoprotein metabolism and are found in all meats, fish, and poultry. Organ meats, anchovies, sardines, meat extracts, and broths are especially rich sources of them. Uric acid stones are usually associated with gout, GI diseases that cause diarrhea, and malignant disease. **Cystine Stones** Cystine is an amino acid. Cystine stones may form when the cystine concentration in the urine becomes excessive because of a hereditary metabolic disorder. The usual practice is to increase fluids and recommend an alkaline-ash diet. **Struvite Stones** Struvite stones are composed of magnesium ammonium phosphate. They are sometimes called infection stones because they develop following urinary tract infections caused by certain microorganisms. A low-phosphorus diet is often prescribed. **CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL** The client with renal disease has a lifelong challenge. Anger and depression are common among these clients. These feelings complicate management of the disease if they contribute to the client's unwillingness to learn about his or her nutritional needs. These complications then add to the client's problems. The health care professional can be extremely helpful if he or she can develop a trusting relationship with the client. Such a relationship can be established by listening to the client's complaints, needs, and concerns and responding with sincere understanding and sympathy. This approach can help motivate clients to learn how to manage their nutritional requirements and help the dietitian assist them. **DIET AND GASTROINTESTINAL PROBLEMS** The gastrointestinal (GI) tract is where digestion and absorption of food occur. The primary organs include the mouth, esophagus, stomach, and small and large intestine. The liver, gallbladder, and pancreas are accessory organs that are also involved in these processes. Numerous disorders of the gastrointestinal system cause countless individuals distress and consequently affect the nation's economy because they keep so many people home from work. Some problems are physiologically caused; others can be psychological in origin. It is sometimes difficult to determine the cause or causes of a GI problem. Consequently, controversy exists in some cases about proper treatment. **DISORDERS OF THE PRIMARY ORGANS** **Dyspepsia** Dyspepsia, or indigestion, is a condition of discomfort in the digestive tract that can be physical or psychological in origin. Symptoms include heartburn, bloating, pain and, sometimes, regurgitation. If the cause is physical, it can be due to overeating or spicy foods, or it may be a symptom of another problem, such as appendicitis or a kidney, gallbladder, or colon disease or possibly cancer. If the problem is organic in origin, treatment of the underlying cause will be the normal procedure. Psychological stress can affect stomach secretions and trigger dyspepsia. Treatment should include counseling to help the client: - Find relief from the underlying stress - Allow sufficient time to relax and enjoy meals - Learn to improve eating habits **Esophagitis** Esophagitis is caused by the irritating effect of acidic gastric reflux on the mucosa of the esophagus. Heartburn, regurgitation, and dysphagia (difficulty swallowing) are common symptoms. Acute esophagitis is caused by ingesting an irritating agent, by intubation, or by an infection. Chronic, or reflux, esophagitis is caused by recurrent gastroesophageal reflux (GER). This can be caused by a hiatal hernia, reduced lower esophageal sphincter (LES) pressure, abdominal pressure, recurrent vomiting, alcohol use, overweight, or smoking. Cancer of the esophagus and silent aspiration may be life-threatening for those with gastroesophageal reflux disease (GERD). **Hiatal Hernia** Hiatal hernia is a condition in which a part of the stomach protrudes through the diaphragm into the thoracic cavity. The hernia prevents the food from moving normally along the digestive tract, although the food does mix somewhat with the gastric juices. Sometimes the food will move back into the esophagus, creating a burning sensation (heartburn), and sometimes food will be regurgitated into the mouth. This condition can be very uncomfortable. **Medical Nutrition Therapy** The symptoms can sometimes be alleviated by serving small, frequent meals (from a well-balanced diet) so that the amount of food in the stomach is never large. Avoid irritants to the esophagus such as carbonated beverages, citrus fruits and juices, tomato products, spicy foods, coffee, pepper, and some herbs. Some foods can cause the lower esophageal sphincter to relax, and these should be avoided. Examples are alcohol, garlic, onion, oil of peppermint and spearmint, chocolate, cream sauces, gravies, margarine, butter, and oil. If the client is obese, weight loss may be recommended to reduce pressure on the abdomen. It may also be helpful if clients avoid late-night dinners and lying down for 2 to 3 hours after eating. When they do lie down, they may be more comfortable sleeping with their heads and upper torso somewhat elevated and wearing loose-fitting clothing. If discomfort cannot be controlled, surgery may be necessary. **Peptic Ulcers** An ulcer is an erosion of the mucous membrane. Peptic ulcers may occur in the stomach (gastric ulcer) or the duodenum (duodenal ulcer). The specific cause of ulcers is not clear, but some physicians believe that a number of factors including genetic predisposition, abnormally high secretion of hydrochloric acid by the stomach, stress, excessive use of aspirin or ibuprofen (analgesics), cigarette smoking, and, in some cases, a bacterium called Helicobacter pylori may contribute to their development. A classic symptom is gastric pain, which is sometimes described as burning, and in some cases, hemorrhage is also a symptom. The pain is typically relieved with food or antacids. A hemorrhage usually requires surgery. Ulcers are generally treated with drugs such as antibiotics and cimetidine. The antibiotics kill the bacteria, and cimetidine inhibits acid secretion in the stomach and thus helps to heal the ulcer. Antacids containing calcium carbonate can also be prescribed to neutralize any excess acid. Stress management may also be beneficial in the treatment of ulcers. Sufficient low-fat protein should be provided but not in excess because of its ability to stimulate gastric acid secretion. It is recommended that clients receive no less than 0.8 gram of protein per kilogram of body weight. However, if there has been blood loss, protein may be increased to 1 or 1.5 grams per kilogram of body weight. Vitamin and mineral supplements, especially iron if there has been hemorrhage, may be prescribed. Although fat inhibits gastric secretions, because of the danger of atherosclerosis, the amount of fat in the diet should not be excessive. Carbohydrates have little effect on gastric acid secretion. Spicy foods may be eaten as tolerated. Coffee, tea, or anything else that contains caffeine or that seems to cause indigestion in the client or stimulates gastric secretion should be avoided. Alcohol and aspirin irritate the mucous membrane of the stomach, and cigarette smoking decreases the secretion of the pancreas that buffers gastric acid in the duodenum. Currently, a well-balanced diet of three meals a day consisting of foods that do not irritate the client is generally recommended. **Diverticulosis/Diverticulitis** Diverticulosis is an intestinal disorder characterized by little pockets in the sides of the large intestine (colon). When fecal matter collects in these pockets instead of moving on through the colon, bacteria may breed, and inflammation and pain can result, causing diverticulitis. If a diverticulum ruptures, surgery may be needed. This condition is thought to be caused by a diet lacking sufficient fiber. A high-fiber diet is commonly recommended for clients with diverticulosis. Along with antibiotics, diet therapy for diverticulitis may begin with a clear liquid diet, followed by a low-residue diet that allows the bowel to rest and heal. Then a high-fiber diet will be a initiated. The bulk provided by the high-fiber diet increases stool volume, reduces the pressure in the colon, and shortens the time the food is in the intestine, giving bacteria less time to grow. **Inflammatory Bowel Disease** Inflammatory bowel diseases (IBDs) are chronic conditions causing inflammation in the gastrointestinal tract. The inflammation causes malabsorption that often leads to malnutrition. The acute phases of these diseases occur at irregular intervals and are followed by periods in which clients are relatively free of symptoms. Neither cause nor cure for these conditions is known. Two examples are ulcerative colitis and Crohn's disease (Table 20-1). Ulcerative colitis causes inflammation and ulceration of the colon, the rectum, or sometimes the entire large intestine. Crohn's disease is a chronic progressive disorder that can affect both the small and large intestines. The ulcers can penetrate the entire intestinal wall, and the chronic inflammation can thicken the intestinal wall, causing obstruction. Both conditions cause bloody diarrhea, cramps, fatigue, nausea, anorexia, malnutrition, and weight loss. Electrolytes, fluids, vitamins, and other minerals are lost in the diarrhea, and the bleeding can cause loss of iron and protein. Treatment may involve anti-inflammatory drugs plus medical nutrition therapy. Usually a low-residue diet is required to avoid irritating the inflamed area and to avoid the danger of obstruction. When tolerated, the diet should include about 100 grams of protein, additional calories, vitamins, and minerals. In severe cases, total parenteral nutrition (TPN) (a process in which nutrients are delivered directly into the superior vena cava; see Chapter 22) may be necessary for a period. As the client begins to regain health, the diet may be increasingly liberalized to suit the client's tastes while maintaining good nutrition. **Ileostomy or Colostomy** Clients with severe ulcerative colitis or Crohn's disease frequently require a surgical opening from the body surface to the intestine for the purpose of defecation. The opening that is created is called a stoma and is about the size of a nickel. An ileostomy (from the ileum to abdomen surface) is required when the entire colon, rectum, and anus must be removed. A colostomy (from the colon to abdomen surface) can provide entrance into the colon if the rectum and anus are removed. This can be a temporary or a permanent procedure. Clients with ileostomies have a greater-than-normal need for salt and water because of excess losses. A vitamin C supplement is recommended and, in some cases, a B12 supplement may be needed. Eating a well-balanced individualized diet will prevent a nutritional deficiency for clients with ileostomies and colostomies. **Celiac Disease** Celiac disease, also called nontropical sprue or gluten sensitivity, is a disorder characterized by malabsorption of virtually all nutrients. It is thought to be due to heredity. Symptoms include diarrhea, weight loss, and malnutrition. Stools are usually foul-smelling, light-colored, and bulky. The cause is unknown, but it has been found that the elimination of gluten from the diet gives relief. Untreated, it is life-threatening because of the severe malnutrition and weight loss it can cause. A gluten-controlled diet (Table 20-2) is used in the treatment of celiac disease. Gluten is a protein found in barley, oats, rye, and wheat. All products containing these grains are disallowed. Rice and corn may be used. A reduction in the fiber content is also frequently recommended. If the client is under weight, the diet should also be high in calories, carbohydrates, and protein (Table 20-3). Fat may be restricted until bowel function is normalized. Vitamin and mineral supplements may be prescribed. Lactose intolerance sometimes develops with celiac disease. It is not easy to avoid food products containing wheat. Breads, cereals, crackers, pasta products, desserts, gravies, white sauces, and beer contain wheat or other cereal grains with gluten. The client will have to learn to read food labels carefully and to avoid restaurant foods such as breaded meats or fish, meatloaf, creamed vegetables, and cream soups. **DISORDERS OF THE ACCESSORY ORGANS** **Cirrhosis** The liver is of major importance to, and plays many roles in, metabolism. Except for a few of the fatty acids, all nutrients that are absorbed in the intestines are transported to the liver. The liver dismantles some of these nutrients, stores others, and uses some to synthesize other substances. The liver determines where amino acids are needed and synthesizes some proteins, enzymes, and urea. It changes the simple sugars to glycogen, provides glucose to body cells, and synthesizes glucose from amino acids if needed. It converts fats to lipoproteins and synthesizes cholesterol. It stores iron, copper, zinc, and magnesium as well as the fat-soluble vitamins and B vitamins. The liver synthesizes bile and stores it in the gallbladder. It detoxifies many substances such as barbiturates and morphine. Liver disease may be acute or chronic. Early treatment can usually lead to recovery. Cirrhosis is a general term referring to all types of liver disease characterized by cell loss. Alcohol abuse is the most common cause of cirrhosis, but it can also be caused by congenital defects, infections, or other toxic chemicals. Although the liver does regenerate, the replacement during cirrhosis does not match the loss. In addition to the cell loss during cirrhosis, there is fatty infiltration and fibrosis. These developments prevent the liver from functioning normally. Blood flow through the liver is upset, and a form of hypertension, anemia, and hemorrhage in the esophagus can occur. The normal metabolic processes will also be disturbed to such a degree that, in severe cases, death may result. The dietary treatment of cirrhosis provides at least 25 to 35 calories or more and 0.8 to 1.0 gram of protein per kilogram of weight each day, depending on the client's condition. If hepatic coma appears imminent, the lower amount is advocated. Supplements of vitamins and minerals are usually needed. In advanced cirrhosis, 50% to 60% of the calories should be from carbohydrates. In some forms of cirrhosis, clients cannot tolerate fat well, so it is restricted. In another form, protein may not be well tolerated, so it is restricted to 35 to 40 grams a day. Sometimes cirrhosis causes ascites. In such a case, sodium and fluids may be restricted. If there is bleeding in the esophagus, fiber can be restricted to prevent irritation of the tissue. Smaller feedings will be better accepted than larger ones. No alcohol is allowed. **Hepatitis** Hepatitis is an inflammation of the liver. It is caused by viruses or toxic agents such as drugs and alcohol. Necrosis occurs, and the liver's normal metabolic activities are constricted. Hepatitis may be acute or chronic. Hepatitis A virus (HAV) is contracted through contaminated drinking water, food, and sewage via a fecal-oral route. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are transmitted through blood, blood products, semen, and saliva. Hepatitis B and C can lead to chronic active hepatitis (CAH), which is diagnosed by liver biopsy. Chronic active hepatitis can lead to liver failure and end-stage liver disease (ESLD). In mild cases, the cells can be replaced. In severe cases, the damage can be so extensive that the necrosis leads to liver failure and death. There can be bile stasis and decreased blood albumin levels. Clients experience nausea, headache, fever, fatigue, tender and enlarged liver, anorexia, and jaundice. Weight loss can be pronounced. Treatment is usually bed rest, plenty of fluids, and medical nutrition therapy. The diet should provide 35 to 40 calories per kilogram of body weight. Most of the calories should be provided by carbohydrates; there should be moderate amounts of fat and, if the necrosis has not been severe, up to 70 to 80 grams of protein for cell regeneration. If the necrosis has been severe and the proteins cannot be properly metabolized, they must be limited to prevent the accumulation of ammonia in the blood. Clients may prefer frequent, small meals rather than three large ones. Clients with liver disease require a great deal of encouragement because their anorexia and consequent feelings of general malaise can be severe. Their recovery takes patience, rest, and time. **Cholecystitis and Cholelithiasis** The dual function of the gallbladder is the concentration and storage of bile. After bile is formed in the liver, the gallbladder concentrates it to several times its original strength and stores it until needed. Fat in the duodenum triggers the gallbladder to contract and release bile into the common duct for the digestion of fat in the small intestine. If this flow is hindered, there may be pain. The precise etiology of gallbladder disease is unknown, but heredity factors may be involved. Women develop gallbladder disease more often than men do. Obesity, total parenteral nutrition (TPN), very low calorie diets for rapid weight loss, the use of estrogen, and various diseases of the small intestine are frequently associated with gallbladder disease. Cholecystitis (inflammation) and cholelithiasis (gallstones) may inhibit the flow of bile and cause pain. Cholecystitis can cause changes in the gallbladder tissue, which in turn can affect the cholesterol (a constituent of bile), causing it