Dumping Syndrome Diet

Description

The diet is modified to prevent the rapid introduction of a hyperosmolar solution into the proximal jejunum (“dumping”).  Several nutrition strategies may be employed, including altered macronutrient composition, size and timing of meals and avoidance of certain food constituents.  The diet limits beverages and liquids at meals, limits the intake of simple carbohydrates, and is high in protein and moderate in fat.

Indications

The dumping syndrome is a complication that may result from:

• the reduced storage capacity of the stomach following gastrectomy 
• any procedure that interferes with the pyloric sphincter or compromises the reservoir function of the stomach

    The “dumping syndrome” occurs in response to the presence of undigested food in the jejunum.  When this occurs, plasma fluids shift into the intestine area to equalize osmotic pressure, causing a drop in blood volume.  Symptoms vary among individuals and may consist of the following: abdominal bloating, nausea, cramps, diarrhea, weakness, diaphoresis and tachycardia.  In most cases, symptoms appear within 15 to 30 minutes after a meal.  The secretion of gastrointestinal hormones has also been implicated in causing hypotension and palpitations.  Some postgastrectomy patients experience “late postprandial dumping syndrome” characterized by hypoglycemia 1 to 2 hours after a meal.

Contraindications

If patient has malabsorption of fat, do not increase fat intake with the dumping syndrome diet.

Nutritional Adequacy

The diet can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in the Statement on Nutritional Adequacy .  The adequacy of the diet depends on the extent of the surgery and the individual’s food tolerance.  After gastric surgery some patients experience malabsorption, which may be specific for macro- or micronutrients.  Vitamin and mineral supplementation may be necessary, depending on the extent of surgery and whether the dumping syndrome symptoms persist .   

How to Order the Diet

Order as “Dumping Syndrome Diet.”  One or more features of the diet may be individually ordered, eg, Sugar in Moderation Diet, 120 cc fluid ½ to 1 hour before or after meals, 5 to 6 small meals, Lactose-Controlled Diet, Low-Fiber Diet, or other strategies listed under Planning the Diet.

Planning the Diet

1. Simple carbohydrate (lactose, sucrose, and dextrose) consumption is kept to a minimum to prevent the formation of a hypertonic solution and the subsequent osmotic symptoms, as well as to prevent late hypoglycemia.  Complex carbohydrates may be included.
2. Taking liquids with meals is thought to hasten gastrointestinal transit.  Consume adequate amounts of liquid throughout the day in small amounts at a time .  Carbonated beverages and milk are not recommended in the initial stages of the diet. 
3. Smaller, more frequent feedings (5 to 6 per day) are recommended to accommodate the reduced storage capacity of the stomach and to provide adequate nourishment. 
4. Lactose, especially in milk or ice cream, may be poorly tolerated due to rapid transit time, so should be avoided.  Cheese and yogurt are better tolerated.  A Lactose-Controlled Diet may be beneficial. 
5. Proteins and fats are increased as necessary to meet energy requirements.  An increased fat intake also delays gastric emptying.  A moderate fat intake (30% to 40% of kcal) and high protein intake (20% of kcal) are recommended .
6. Lie down and avoiding activity for an hour after meals may lessen symptoms. 
7. If  adequate caloric intake cannot be provided due to steatorrhea, use medium chain triglyceride products. 
8. Pectin may be utilized in the diet regimen to slow gastric emptying time .

Sugar in Diet Moderation

Description

The diet restricts foods high in added sugar and fat.  “Added sugar” is defined as that added to sweeten food at the table or added by the manufacturer, and is chiefly sucrose or corn syrup.

Indications

This is a less restricted diet for people trying to lose weight.  It is also used in conjunction with the “Dumping Syndrome Diet.”  (See Dumping Syndrome Diet in )  This diet is not meant for people with type 1 diabetes or type 2 diabetes.

How to Order the Diet

Order as “Sugar in Moderation Diet.”

Planning the Diet

Exclude the following foods.

FOOD GROUP	FOODS EXCLUDED
Beverages and Milk	Regular carbonated beverages; fruit ades; sugar-sweetened soft drinks; sugar-sweetened iced tea; chocolate milk; milkshake; eggnog; sweetened yogurt; cocoa (sweetened)
Breads and Crackers	Sweet rolls or breads; doughnuts
Cereals and Grains	Sugar-coated cereals; granola-type cereals; presweetened cooked cereals
Meat, Fish, Poultry, Cheese, Eggs, Legumes	Glazed meats
Vegetables and Potatoes	Candied or glazed vegetables; sweet pickled vegetables
Fruits and Juices	Sweetened fruits or juices; candied or glazed fruits
Desserts	Cakes, pies, cookies, pastries, sherbets, puddings, gelatin desserts (regularly sweetened), ice cream
Sugar and Sweets	Candy, chewing gum, sugar, honey, jam, jelly, marmalade, syrup, molasses
Miscellaneous	Sweet relishes

 

Pengaruh Penyimpanan dan Metode Pengolahan Batang Tebu (Saccharum Officanarum L) terhadap Mutu Gizi Minuman Sari Tebu

Sari tebu adalah salah satu minuman yang didapat dari ekstraksi tanaman tebu. Tebu selain digunakan untuk bahan dasar pembuatan gula juga dapat diolah menjadi minuman fungsional yang bermanfaat bagi kesehatan, maka penelitian tentang profil zat gizi sari tebu sangat diperlukan untuk mendukung pemanfaatan minuman sari tebu sebagai minuman fungsional kesehatan.

Tujuan penelitian untuk mengetahui adanya pengaruh penyimpanan dan metode pengolahan batang tebu terhadap profil gizi dan mutu organoleptik sari tebu. Hasil dari penelitian ini diharapkan dapat mendukung sari tebu sebagai minuman fungsional kesehatan untuk masyarakat.

Jenis penelitian ini adalah eksperimen dengan perlakuan penyimpanan dan metode pengolahan batang tebu dengan menggunakan 3 replikasi. Penelitian dilakukan di laboratorium Teknologi Pangan Jurusan Gizi Poltekkes Kemenkes Malang pada bulan Maret 2010.

Hasil analisis kadar glukosa dan fruktosa menunjukkan bahwa kadar glukosa dan fruktosa tertinggi terjadi pada perlakuan batang tebu fresh dan tidak dikupas sebelum digiling yaitu sebesar 2,653 % dan 2,621%. Hasil analisis kadar kalium menunjukkan bahwa kadar kalium tertinggi tertinggi terjadi pada perlakuan batang tebu yang disimpan selama satu minggu dan tidak dikupas sebelum digiling yaitu 127,340 mg/100 ml sari tebu. Analisis mutu organoleptik menunjukkan bahwa panelis cenderung menyukai warna, aroma dan rasa dari produk sari tebu yang telah dikupas sebelum digiling.

Berdasarkan penelitian ini dapat diketahui bahwa sari tebu akan mengalami penurunan kadar glukosa dan fruktosa pada kelompok perlakuan disimpan selama satu minggu dan dikupas sebelum digiling, namun pada kadar kalium justru akan meningkat setelah batang tebu disimpan selama satu minggu dan tidak dikupas sebelum digiling. saran dari penelitian ini adalah adanya penelitian lanjutan tentang cara memperpanjang daya simpan sari tebu, serta mutu gizi dan mutu organoleptik.

Kata kunci : Sari Tebu, Glukosa, Fruktosa, Kalium.

Diets for Vegetarian

Description

A Vegetarian Diet is a variation of the Regular Diet in which certain or all foods of animal origin are excluded.  A wide spectrum of dietary practices are considered vegetarian.

Ovolactovegetarian: Milk and milk products as well as eggs are the only animal products included.

Lactovegetarian:  Milk and milk products are the only foods of animal origin included.

Ovovegetarian:  Eggs are the only animal product included.

Total vegetarian (vegan):  The diet consists of foods of plant origin only.

Indications

Vegetarian diets are adapted for a variety of health, ecological, economical, philosophical, and ethical reasons .  Many epidemiologic data suggest a positive relationship between vegetarian lifestyles and risk reduction for several chronic degenerative diseases such as obesity, coronary artery disease, hypertension, diabetes mellitus, and some types of cancer.  However, this relationship likely is due to lifestyle factors in addition to diet .

               

Nutritional Adequacy

Vegetarian diets are healthful and nutritionally adequate when appropriately planned .  The diet can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in the Statement on Nutritional Adequacy in Section IA.  Nutrients that are often of concern are vitamins B₁₂ and D, calcium, iron, zinc, and linolenic acid.  All vegan children should have a reliable source of vitamin B₁₂, and if sun exposure is limited, vitamin D supplements or fortified foods should be emphasized .  Pregnant and lactating vegans should receive, respectively, supplements of 2 mg and 2.6 mg of vitamin B₁₂ daily, and if sun exposure is limited, should have their diet supplemented with 10 mg of vitamin D .

I am vegetarian, are you?

How to Order the Diet

Order as “Regular Diet – Vegetarian.”  The patient’s particular dietary constraints will be considered.

Planning the Diet

A Vegetarian Diet can be made adequate by careful planning and by giving attention to the following guidelines:

·         Keep to a minimum the intake of foods with low-nutrient density, such as sweets and fatty foods.

·         Choose a variety of foods, including fruits, vegetables, whole grains, legumes, nuts, seeds, and, if desired, dairy products and eggs.

·         Choose whole or unrefined grain products whenever possible, instead of refined products.

·         If milk products are consumed, use lower fat versions.

·         Include a regular source of vitamin B₁₂, along with a source of vitamin D if sun exposure is limited.

Protein: Although vegetarian diets usually meet or exceed requirements for protein, they typically provide less protein than non-vegetarian diets.

    The body’s need for essential amino acids can be met by consumption of animal or plant sources of protein.  Although plant foods contain less of the essential amino acids than do equivalent quantities of animal foods, a plant-based diet can provide adequate amounts of amino acids when a varied diet is consumed on a daily basis.  A mixture of different proteins from unrefined grains, legumes, seeds, nuts, and vegetables will complement each other in their amino acid profiles so that deficits in one are made up by the others.

    Different types of protein that complement each other should be eaten over the course of the day.  However, since after absorption, amino acids from exogenous and endogenous sources combine in the body’s protein pool, it is not necessary that complementation of amino acid profiles be precise and present in the same meal .

    Vitamin B₁₂: A vegan should supplement his or her diet with vitamin B₁₂ by using a cobalamin  Although the requirement for vitamin B₁₂ is minute, vegetarians must include a reliable source of vitamin B₁₂ in their diets or be at risk of eventually developing a deficiency.  Supplements are advised for all older vegetarians because absorption of vitamin B₁₂ becomes less efficient as the body ages .  Also, breast-fed vegan infants should receive a source of vitamin B₁₂ if the mother’s diet is not supplemented . supplement or by selecting fortified foods such as fortified soy milk or breakfast cereals, to ensure an adequate intake of the active form of the nutrient.

    Calcium: Calcium intake of ovolactovegetarians is comparable or higher than that of nonvegetarians.  However, vegans’ intake of calcium is generally lower than that of either ovolactovegetarians or omnivores.  It should be noted that vegans may have lower calcium needs than nonvegetarians because diets that are low in total protein and have more alkaline have been shown to have a calcium-sparing effect.  If vegans do not meet calcium requirements from food, dietary supplements are recommended .

    Vitamin D: Reliance on sunlight alone, particularly in northern climates or in cultures where most of the body is concealed in clothing, may not provide all of the vitamin D needed.  A vitamin D supplement may be necessary for persons who do not ingest vitamin D-fortified milk products or cereals or do not obtain 5 to 15 minutes of exposure to sunlight daily (5), especially for dark-skinned individuals .             

    Energy: Vegan diets tend to be high in bulk, making it more challenging for them to meet energy needs, especially for infants, children, and adolescents.  Frequent meals, snacks, and eating foods higher in fat can help vegetarian children meet energy needs .

    Iron: The non-heme iron found in plant foods is more sensitive than heme iron to both inhibitors and enhancers of iron absorption .  Western vegetarians have a relatively high intake of iron from plant foods, such as dark-green leafy vegetables, iron-fortified cereals, and whole grains.  Although vegetarian diets are higher in total iron than nonvegetarian diets, iron stores are lower because iron from plant foods are poorly absorbed.  However, the frequency of anemia is not any higher in the vegetarian population than in the nonvegetarian population.  Vegetarians’ higher vitamin C intake may improve their iron absorption.

    Zinc: Vegetarians should strive to meet or exceed the DRI for zinc due to the low bioavailability of zinc from plant sources and because the effects of marginal zinc status are poorly understood.

    Linolenic Acid: Diets that do not include fish or eggs lack the long chain n-3 fatty acid docosasahexaenoic acid (DHA).  It is recommended that vegetarians include good sources of linolenic acid in their diets, such as walnuts, canola oil, and linseed oil.

Obesity and Management of Weight

Discussion

Approximately 35% of women and 31% of men age 20 years and older are overweight or obese.  One-fourth of children and adolescents ages 6 to 17 years is considered overweight or obese (1). The prevalence of overweight and obesity in the United States has increased substantially.  The increase in overweight Americans rose from 25.4% (second National Health and Nutrition Examination Survey [NHANES II]) in 1976 to 1980, to 33.3% (NHANES III) in 1988 to 1991.  In 1998, an estimated 97 million adults in the United States are considered overweight or obese — 55% of the population (3).  Obesity contributes to many adverse health outcomes, including type 2 diabetes; cardiovascular disease; hypertension; stroke; osteoarthritis; gallbladder disease; sleep apnea and respiratory problems; and endometrial, breast, prostrate, and colon cancers .  Obesity-related conditions are estimated to contribute to 300,000 deaths yearly, ranking second only to smoking as a cause of preventable death.  The total cost of obesity amounted to $99.2 billion in 1995, with $51.6 billion being direct medical costs.

    Obesity is the result of a positive energy balance; energy intake exceeds energy expenditure.  Several lifestyle factors, including excessive energy intake, fat intake, and physical inactivity, are associated with the pathophysiology of obesity.  Growing evidence suggests a strong link between genetic factors and the pathogenesis of obesity.  Genes involved in energy regulation like leptin, a signal protein for satiety produced in the adipose tissue, and other hormones or peptides, such as neuropeptide Y, may have important implications for understanding the causes of obesity .  Ongoing research is required to determine the role of genetic factors in obesity treatment.

Adults (Age 18 years and Older)

The body mass index (BMI) is most frequently used to classify an adult’s degree of overweight or obesity.  A BMI is calculated by dividing weight in kilograms by height in meters squared.  BMI = weight (kg)/ height (m²).

    The BMI is correlated with body fatness.  Several studies have indicated the relationship between an elevated BMI and an increased incidence of morbidity and mortality.  According to the Dietary Guidelines, the cutoff for a healthy weight for both men and women is a BMI of 25 kg/m².  Studies have demonstrated that morbidity increases significantly above a BMI of 25.  A BMI of 25 to 29.9 kg/m² is considered overweight.  Obesity is defined as a BMI of 30 kg/m² or more (3). Guidelines established by the American Obesity Association suggest determining BMI-related health risk not only based on the BMI but also by evaluating the presence of comorbid conditions and/or other risk factors that place individuals at an increased health risk.  For more information on these guidelines, refer to the Weight Management Protocol Disease Management Decision Chart in Medical Nutrition Therapy Across the Continuum of Care: Supplement 1 . 

The presence of excess fat in the abdomen out of proportion to total body fat is an independent predictor of increased risk and morbidity.  Evidence from epidemiologic studies shows waist circumference to be a better marker of abdominal fat content than the waist-to-hip (WHR) ratio; waist circumference also is the most practical anthropometric measurement for assessing a patient’s abdominal fat content before and during weight-loss treatment (3).  However, these waist circumference measurements lose their incremental predictive power in patients with a BMI of 35 kg/m² or more because these patients will exceed the cutoff points. 

Children and Adolescents

In the United States one child in five is overweight, and the number of overweight children continues to grow.  Over the last two decades, this number has increased by more than 50%, and the number of “extremely” overweight children has nearly doubled (8).  The classification of overweight for children is determined by plotting the height and weight on growth charts.  The height and weight growth charts developed by the National Center for Health Statistics (NCHS) are most commonly used. The NCHS weight-for-height curve is appropriate for the prepubescent child.  The NCHS is a valid measure for overweight (greater than the 90th percentile) females younger than 10 years and males younger than 11.5 years (9).  However, it is not useful to assess weight for height in an adolescent.  Body mass index (BMI) percentiles are suggested to assess weight for height in adolescents.  For individuals 6 to 17 years of age, the third National Health and Nutrition Examination Survey (NHANES III) study defined overweight as a body mass index (BMI) exceeding the 95th percentile for BMI for those of the same age and sex.  The American Medical Association’s Guidelines for Adolescent Preventative Services recommend that if the BMI percentile is greater than 95, the child is overweight, and if the BMI percentile is 85 to 95, the child is at risk for overweight .

    Children with a body weight greater than the 85th percentile should be referred to a second-level screen to determine underlying causes.  The second-level screen includes family history, blood pressure, total cholesterol, in-depth diet history, and behavioral and environmental assessment.  An in-depth medical assessment is recommended for children at or above the 95th percentile (7,11).

    After the adolescent’s height and weight are measured, the BMI can be calculated, as described above.  Once the BMI is determined, use the appropriate chart below to determine whether the adolescent needs further evaluation or counseling regarding his or her weight. The BMI should not be calculated if the adolescent has disabilities that confound measurements of height or weight.

Like adults, children and adolescents who are obese have an increased risk for vascular disease.  Likewise, children and adolescents who are overweight have a higher incidence of high blood pressure and high cholesterol.  The risk for overweight children remaining overweight in adulthood is strongly correlated.  Weight gain among children and adolescents is attributed to a combination of poor dietary habits, family lifestyle, physical inactivity, ethnicity, socioeconomic status, and genetic makeup.  Obesity is more prevalent among girls and Hispanic, African American, and American Indian children (8).  Parenteral obesity of at least one parent more than doubles the risk of a child’s obesity in adulthood, whether or not the child is obese (12).

Early intervention is recommended.  The goal of treatment is not weight loss, but to slow the rate of weight gain so that children and adolescents grow into their adult weight.  Overweight children should not be put on restrictive diets.  Children and adolescents must receive adequate vitamins, minerals, protein, and energy to maintain healthy growth.  Governmental dietary guidelines currently recommend that children older than 2 years of age gradually begin to adopt a diet that, by age 5, contains no more than 30% of energy from fat.  A diet low in fat, saturated fat, and cholesterol (less than 300 mg/day) is encouraged for most school-age children and adolescents.

Adequate exercise also is encouraged.  The US Surgeon General’s Report on Physical Activity and Health recommends 30 minutes a day of moderate to vigorous physical activity for children and adults

Adults

Weight management is defined as the adoption of healthful and sustainable eating and exercise behaviors indicated for a reduced risk for disease and for improved feelings of energy and well-being (17).  A nonrestrictive approach to eating based on internal regulation of food (hunger and satiety), exercise, and healthful eating habits should be emphasized.  The probability of long-term maintenance of weight loss and goals is increased in persons who exercise regularly, use social support to maintain eating and exercise habits, view their eating and exercise regimens as a permanent lifestyle, and do not allow lapses to deter them from their lifestyle (3,6). The recommended minimum energy level is 1200 kcal/day for women and 1400 to 1500 kcal/day for men (3,18).  Recent evidence suggest moderation in total energy is the key variable in promoting weight loss (18).

Energy: Energy requirements should be based on individual needs to promote gradual weight loss.  Consideration of a realistic energy goal is important for successful patient compliance with a weight-management program.  It is recommended that the rate of weight loss be 0.5 to 1.5 lb/week.  The recommended minimum energy level is 1200 kcal/day for women and 1500 kcal/day for men .

Protein: To preserve lean body mass, intake should be 0.8 to 1.2 g of dietary protein per kilogram of body weight .

Fat: Fat should be 20% to 30% of total energy.  Limit saturated fats to less than 6% to 8% of fat calories. Findings of the U.S. Department of Agriculture have found that diets low to moderate in fat (15% to 30%) tend be lower in total energy and highest in diet quality when compared to low carbohydrate diets (< 0%) .

Carbohydrates: Carbohydrates should make up 50% to 60% of total energy.  Selecting sources high in fiber is recommended, for example, fruits, vegetables, whole grain breads, cereals, and legumes.  Consumption of 20 to 35 g of fiber daily has been demonstrated to reduce energy density of food consumed and promote satiety by delaying gastric emptying (20). Findings of the U.S. Department of Agriculture have found that diets high in carbohydrate (>55%) and low to moderate in fat (15% to 30%) tend be lower in total energy and highest in diet quality when compared to low carbohydrate diets (<30%) .

Exercise: The US Surgeon General’s Report on Physical Activity and Health recommends 30 minutes of moderate to vigorous physical activity per day for children and adults (16).  Increased physical activity should be a key component of a weight-loss program (3,17).  A combination of weight resistance or strength training and aerobic exercise is recommended to preserve lean body mass and promote the loss of adipose tissue. 

Behavior modification: Behavior modification is an integral component of weight loss and weight management and should be combined with a healthy eating plan to achieve optimal outcomes (17).  Behavior modification is based on the premise that eating is a conditioned response.   A goal of behavior modification is to help the patient realize and eliminate the associations that control eating behavior.

Very-low-calorie diets (VLCD): These specialized feeding regimens provide less than 800 kcal/day and are recommended only to patients who are at a very high health risk related to obesity.  Criteria for these regimens are a BMI greater than or equal to 30 with no comorbidities or risk factors, or a BMI greater than or equal to 27 with comorbidities or other risk factors (1).   Individuals on a VLCD should be under the supervision of a physician.  The typical treatment duration is 4 to 6 months.  Patients provided less than 800 kcal/day are at risk for protein, vitamin, and mineral deficiencies.

High-quality protein (0.8 to 1.5 g/kg of ideal body weight [IBW] per day) and a minimum of 50 g of carbohydrate should be provided.  Depending on the formulation and regimen used, vitamin and mineral supplementation may be needed (1).  People with a history of gallbladder disease, cardiac abnormality, cancer, renal or liver disease, type 1 diabetes, or HIV should use these regimens with caution.  Studies have shown that weight loss as much as 20 kg over 12 to 16 weeks have provided significant improvements in diabetes, hypertension, and cardiovascular conditions when using VLCD regimens (1).  However, weight is gradually regained after treatment, and the long-term outcome of VLCD has demonstrated that most individuals regain all the weight they lost within 5 years of stopping the diet .

Pharmacotherapy: The pharmacologic agents currently available for obesity intervention are designed to contribute to energy deficit through a variety of mechanisms (21).  Fenfluramine (Pondimin) and dexfenfluramine (trade name Redux) have been voluntarily withdrawn from the market because of reports of their association with valvular heart disease.  They are serotoninergic agents and act primarily by increasing serotonin levels in the brain, leading to a decrease in appetite. 

Cathecholaminergic drugs, such as phentermine and phentermine resin (Adipex-p, Fastin, and others), which frequently are prescribed with fenfluramine and dexfenfluramine, have a different mechanism of action and still remain available.  They decrease appetite and food intake by increasing the availability of norepinephrine in the brain.  Merida, a centrally acting agent, is classified as a selective serotonin and norepinephrine reuptake inhibitor; it does not stimulate release of neurotransmitters.  Merida seems to reduce body weight by modifying intake through increased satiety, and animal data suggest that it may also raise energy expenditure by stimulating thermogenesis (22).  Xenical, a pancreatic lipase inhibitor, is the first obesity medication that acts nonsystemically.  Patients should take this medication with meals, as it takes effect within 2 hours of ingestion.  Patients receiving Xenical should follow a moderately low-fat diet (less than 30% fat of total energy), with fat distributed evenly at each meal.  Side effects may include gas, oily leakage, and diarrhea.

Criteria for pharmacotherapy include a BMI of 30 or more with no comorbid conditions, or BMI of 27 or more with comorbid conditions and/or a very high health risk (3).  Complications include dry mouth, nausea, headache, and insomnia (1,3,17,21), increased blood pressure, and increased heart rate.   Patients who should avoid this regimen for weight loss are those with unstable cardiovascular disease, are under 18 years of age, are pregnant or lactating, or are receiving monoamine oxidase inhibitors (MAOIs), antidepressants, or migraine medications.  Medical nutrition therapy, exercise, and behavior modification should be provided in adjunct to pharmacotherapy .  Studies demonstrate that individuals receiving anorexiant medications lose on average 0.5 lb/week (1).  Weight loss plateaus by 6 months, and weight regain occurs after medication therapy stops.  A limited number of studies have evaluated the safety and efficacy of anorexiant medications for more than 2 years.  The physician must continually assess drug therapy for efficacy and safety.

Surgery: Weight loss surgery is one option for weight reduction in a limited number of patients with severe obesity: those with a BMI greater than or equal to 40 or a BMI of 35 or more with comorbid conditions (3).  Roux-en-Y gastric bypass and vertical banded gastroplasty are the most commonly performed and widely accepted surgical procedures for weight loss (3,17).  The primary benefit of surgical therapy is durable weight loss and maintenance of weight loss (1).  The average weight loss associated with gastric reduction surgery is 40% to 75% of excess body weight, which correlates to approximately 30% to 40% of initial weight (1).  Most weight loss occurs in the first 6 months and continues for up to 18 to 24 months.  The initial 6 months is marked by the most rapid weight reduction and improvements in comorbid conditions.  Prospective studies show that the average weight 10 years after surgery is approximately 55% of excess body weight, with a weight regain of 10% to 15% of the initial weight lost (23).  Criteria for surgical intervention for weight loss includes a BMI of 40 or more with no comorbid conditions or health risk, or a BMI greater than or equal to 35 with comorbid conditions or health risks (1,3) or a body weight 100 lb over IBW.  A preoperative behavior change program is highly recommended.  Complications include those associated with any surgery, gallstones, nutritional deficiencies requiring supplementation, and the dumping syndrome.  Refer to Gastric Reduction Surgery for Obesity earlier in this section.

Body Mass Index

Body Mass Index(BMI) can be used to indicate if you are overweight, obese, underweight or normal. It will, however, overestimate fatness in people who are muscular or athletic. It is not a good index for adolescents or children. Because of these problems with BMI, this calculator shows extra statistics to help inform and judge your paitent's body compared to others of the same height and age, including these weight and height charts.

Women tend to believe they look their best at values between 20 to 22 and men are usually satisfied with a BMI of 23 to 25. If BMI  is between 17 to 22, life expectancy is longer than average.

if BMI is between 23 and 25, patients are not considered overweight by most people. But if BMI is 26 or more, that's not good.

If you like this software please click download on left side

Ketogenic Diet

Description

The ketogenic diet is designed to establish and maintain ketosis. The diet is very high in fat and severely restricted in carbohydrates. This is done by calculating the diet to provide 3 to 4 grams of fat for each 1 gram of protein and carbohydrate combined, thus converting the fuel burned by the body from carbohydrate to fat.  A physician prescribes the ratio of 3:1 or 4:1 as appropriate for each individual patient.  The diet is calculated to meet the specific needs of each individual for calories and protein, and provides little to no carbohydrate depending on protein requirements.  Even with the high fat content of the diet, weight is usually maintained with very little gain.  This is possible because calories are calculated to meet only 75% of the individual’s Dietary Reference Intake (DRI) for energy.  The foundation of the diet is either heavy whipping cream or MCT oil.  The diet using whipping cream is described below.

Indications

The diet serves as an adjunct to anti-convulsant medications in controlling intractable seizures.  It is used in cases of resistance to medications or drug toxicity (1,2).  Sustained ketosis appears to be important in modifying the convulsive threshold (1,3).  The diet seems to be most effective in children 18 months to 10 years of age (4), although it can be used with older children and adults with varying degrees of success.  The diet is administered to those who have myoclonic absence (drop) and atonic seizures, which are difficult to control with medications.  It may also benefit children with generalized tonic-clonic (grand mal) seizures and seizures of the Lennox-Gestault Syndrome.  The ketogenic diet can be used for all types of seizures, especially if medication therapy is not effective (5).

    The diet requires a trial period of 2 to 3 months during which effectiveness is assessed and the diet is adjusted to maintain strong ketosis.  Once it is determined that the diet is effective on controlling seizure activity, a commitment of 1 to 2 years is required after which weaning is done gradually.  Because of the extreme dietary regimens involved in this diet, the Johns Hopkins Pediatric Epilepsy Center recommends use of the ketogenic diet for those individuals who have more than 2 seizures a week despite treatment with at least 2 different anticonvulsant medications (6).

Nutritional Adequacy

The ketogenic diet is inadequate in vitamin B-complex vitamins, folate, iron, calcium, and zinc.  The diet must be supplemented with vitamins, iron and calcium in forms that are sugar-free.

How to Order the Diet

Order as “Ketogenic Diet.”  A nutrition consult by a registered dietitian must accompany the diet order, as the diet has to be precisely calculated.  All medications must be carbohydrate free, as well as toothpaste.  The diet must be initiated in a hospitalized setting under close supervision.

Planning the Diet

A gram scale and a copy of the Epilepsy Diet Treatment book (6) are paramount in administering this diet effectively

Fat Controlled Diet

Description

Omitting and/or limiting fat-containing foods restricts the total amount of fat in the diet.  The type of fat is not considered.

Indications

A fat-controlled diet is indicated for individuals who are unable to properly digest, metabolize, and absorb fat.  Common diseases of the hepatobiliary tract, pancreas, intestinal mucosa, and lymphatic system impair fat digestion, metabolism, and absorption (1-5).  A low fat-diet may also be useful in the treatment of patients with gastroesophageal reflux (4,6).

Contraindications

In pancreatic insufficiency, enzyme preparations remain the primary treatment for steatorrhea.  As normal a diet as possible is encouraged to increase the likelihood that a nutritionally adequate diet will be consumed (5,7,8).  The diet should restrict fat only to the individual’s tolerance level.

    The treatment of choice for gallstones at the present time, where indicated, is surgery.  There is no reason in the postoperative period to restrict or modify fat intake in any way.   

Nutritional Adequacy

The Fat-Controlled Diet can be planned to meet the Dietary Reference Intakes (DRIs) for all nutrients as outlined in the Statement on Nutritional Adequacy in Section IA.  Vitamin E intake will be lower than in a regular diet.  However, the requirement for vitamin E is proportional to the intake of polyunsaturated fatty acids, which will also be reduced in a Fat-Controlled Diet.

High Calorie High Protein Diet

Description

Additional foods and supplements are added to meals or between meals to increase protein and energy intake.

Indications

A high-protein, high-calorie diet is served when protein and energy requirements are increased by stress, protein loss (protein losing enteropathy, nephrotic syndrome), and catabolism.  This diet may be indicated in patients with:

·         protein-energy malnutrition

·         failure to thrive                            

·         cancer

·         burns

·         cystic fibrosis

·         human immunodeficiency virus  (HIV)/acquired immunodeficiency syndrome (AIDS) 

·         chronic gastrointestinal diseases

    This diet may also be indicated in preparation for surgery.  An increase in energy is required to promote the efficient utilization of proteins for anabolism.

Nutritional Adequacy

The diet can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in Statement on Nutritional Adequacy in Section IA.

How to Order the Diet

Order as “High-Protein, High-Calorie Diet.”  The dietitian determines a target level of protein and energy to meet individual needs based on guidelines as stated in Estimation of Protein Requirements in Section II.

Planning the Diet

The diet is planned as a Regular Diet with addition of between-meal supplements that increase energy intake by at least 500 kcal and protein intake by 25 g for adults.  Examples of high-protein, high-energy supplements are milk shakes, eggnogs, puddings, custards, and commercial supplements.

    For children, the diet generally should provide 120% to 150% of the Dietary Reference Intakes (DRIs) for energy and protein.  The actual amounts of energy and protein provided will depend on the child’s or adolescent’s age, height, weight, medical status, and nutrition goals. 

The Older Adult and Nutrition

Aging is a process that occurs throughout life.  Its impact, however, is often ignored until adulthood.  Progressive changes in body composition, sensory perception, functional status and physiologic functioning occur at all ages.  The rate of change is strongly influenced by the genetic background and life experiences of the individual .

    Older adults display wide individual variations in aging processes and thus in nutritional needs and concerns.  Maximizing and maintaining adult potential becomes the major health care objective.  The nutritional care goal is to provide education and support to achieve this objective as decreases in metabolic needs, declining activity levels, illness, infirmity, economic hardship, loss of social support systems, and other variables mandate adjustments in food intake.

    Each older adult should be viewed as a unique individual.  Chronological age and functional capacity do not directly correlate.  Diversity increases with age .  Provision of quality nutritional care requires the regular, systematic, longitudinal assessment of each older individual as well as a nutritional care plan based on specific needs identified.  The least restrictive regimen possible should be implemented.

Dietary Considerations for the Older Adult

The DRIs divide the adult population older than 50 years into 2 life-stage groups: 51 through 70 years and older than 70 years .  DRIs for calcium and related nutrients (phosphorus, magnesium, vitamin D, and fluoride), and for folate and B vitamins (thiamin, riboflavin, niacin, vitamins B₆ and B₁₂, panthothenic acid, biotin, and choline) have been established .  

    Taste and smell dysfunction tends to begin at around 60 years of age and becomes more severe in persons over 70.  Two thirds of persons over 75 years of age are edentulous.  More sweet flavorings or salty foods may be required to satisfy the appetite of elderly individuals.

Energy and Nutrient Considerations

Basal metabolic rate (BMR) decreases 2% with each decade of life; lean body mass declines 6% with each decade and is usually replaced with fat.  As BMR decreases with advancing age and physical activity is reduced, energy needs decrease.  The current DRIs suggest an average gradual reduction of kilocalories after the age of 19 years by deducting 10 kcal/day for males, and 7 kcal/day for females for each year of age above 19 years.  For a 51 year old male, this would equate to a 320 kilocalorie reduction from the baseline DRI .  Refer to Section IA for Dietary Reference Intake Values for Energy by Active Individuals .   Meeting the nutritional needs of the older adult is challenging because although caloric needs decrease, protein, vitamins and minerals remain the same or increase.  The average daily calorie intake for persons over 51 years of age is 2400 calories for men and 2000 calories for women .  Health problems arise when the caloric intake is less than 1500 kcal per day .

    The 2002 DRIs to recommend that the RDA for protein should be 0.8 g/kg daily for adults of all ages.  However, other studies recommend protein be increased to 1.0 to 1.25 g/kg daily  or 12% to 14% of total energy intake for the elderly.

    Metabolic and physical changes that affect the status of vitamin B₆, B₁₂, and folic acid may alter behavior and general health, whereas adequate intake of these nutrients prevents some decline in cognitive function associated with aging .  Deficiencies of these nutrients, along with inadequate intake of vitamin C and riboflavin, may result in poor memory .  Immune function affected by nutritional status may be improved by an increased intake or supplementation of protein, vitamins B₆ and E, and zinc .  It is recommended that persons 51 years of age and older consume foods fortified with vitamin B₁₂ or take a supplement containing vitamin B₁₂, as 10% to 30% of older adults have protein-bound vitamin B₁₂ malabsorption .

    Vitamin D levels may be reduced in the elderly even with adequate exposure to the sunlight, and deficiency may be exacerbated by homebound status, use of sun block, poor dietary intake, decreased capabilities to synthesize cholecalciferol in the skin, and decreased number of gastrointestinal receptors .  Decreased capacity to absorb calcium is also observed because of reduced estrogen levels, low circulating 25 (OH)D, partial intestinal resistance to 1,25(OH)D, and impaired renal conversion of 25(OH)D to 1,25(OH)2D .  Supplementation of 1.0 to 1.7 g calcium along with vitamin D (400 IU) is shown to reduce the incidence of age-related hip fractures and decrease the rate of age-related bone loss .

    Dehydration is a major problem for the elderly.  Water intake needs are the same for the young and the old, but the elderly are prone to inadequate water intake.  Frequently, diseases will reduce the ability to recognize thirst, create an inability to express thirst, or decrease access to water.  Even healthy elderly persons appear to have reduced thirst in response to fluid deprivation.  Fear of incontinence and difficulty making trips to the toilet, due to arthritic pain or other immobility, may also interfere with adequate fluid consumption.  The elderly should be encouraged to ingest about 2 L of fluid per day or 30 cc/kg body weight.

Contributors to Poor Nutritional Status in the Elderly

A variety of factors may contribute to poor nutritional status as individuals age . Table A-4 lists some of the factors frequently identified as potential causes of malnutrition.  These must be kept in mind when evaluating nutritional status and when developing a care plan to prevent, delay, or correct problems identified.  For some conditions, cure is not possible but ameliorative or palliative nutritional interventions are often indicated .  Improvement in the quality of life will frequently ensue.