Manual of Clinical Nutrition Management

458 Pages·2013·5.17 MB·English

M a n u a l o f
Clinical Nutrition
Management
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MANUAL OF CLINICAL NUTRITION MANAGEMENT

Table of Contents

I. Normal Nutrition and Modified Diets
A. Normal Nutrition .........................................................................................................................
Statement on Nutritional Adequacy .................................................................................................................................. A-1
Estimated Energy Requirement (EER): Male and Females Under 30 Years of Age ..................................... A-2
Estimated Energy Requirement (EER): Men And Women 30 Years of Age .................................................... A-2
Estimated Calorie Requirements (Kcal): Each Gender and Age Group at Three Levels of Physical
Activity ....................................................................................................................................................................................... A-3
Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Macronutrients .................. A-4
Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Vitamins ................................ A-5
Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Elements ............................... A-6
Dietary Reference Intakes (DRIs): Estimated Average Requirements .............................................................. A-7
Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Vitamins ................................................ A-8
Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Elements ................................................ A-9
Food Fortification and Dietary Supplements ............................................................................................................. A-10
Regular Diet – Adult .............................................................................................................................................................. A-11
High-Protein, High-Calorie Diet ....................................................................................................................................... A-13
Nutrition Management During Pregnancy and Lactation .................................................................................... A-14
Nutrition and The Older Adult .......................................................................................................................................... A-22
Mechanical Soft (Dental Soft) Diet .................................................................................................................................. A-28
Pureed Diet ................................................................................................................................................................................ A-30
Nutrition Management of Fluid Intake and Hydration .......................................................................................... A-32
Vegetarian Diets ...................................................................................................................................................................... A-36
Kosher Guidelines .................................................................................................................................................................. A-40
B. Transitional Diets .......................................................................................................................
Clear Liquid Diet ........................................................................................................................................................................ B-1
Full Liquid Diet ........................................................................................................................................................................... B-3
Full Liquid Blenderized Diet ................................................................................................................................................. B-4
Nutrition Management of Dysphagia ................................................................................................................................ B-6
Dumping Syndrome Diet ..................................................................................................................................................... B-15
Nutrition Management in Bariatric Surgery ............................................................................................................... B-17
Specialized Nutrition Support Therapy ........................................................................................................................ B-33
Enteral Nutrition Support Therapy for Adults .......................................................................................................... B-35
Parenteral Nutrition Support for Adults ...................................................................................................................... B-50
C. Modification of Carbohydrate and Fat .................................................................................
Medical Nutrition Therapy for Diabetes Mellitus........................................................................................................ C-1
Medical Nutrition Therapy for Gestational Diabetes ..................................................................................... C-15
Dietary Management With the Exchange System ........................................................................................... C-21
Sugar in Moderation Diet .................................................................................................................................................... C-35
Calorie-Controlled Diet for Weight Management ..................................................................................................... C-36
Medical Nutrition Therapy for Disorders of Lipid Metabolism ......................................................................... C-40
Fat-Controlled Diet ................................................................................................................................................................ C-55
Medium-Chain Triglycerides (Mct) ................................................................................................................................ C-57
D. Modification of Fiber ..................................................................................................................
Fiber-Restricted Diets............................................................................................................................................................. D-1
High-Fiber Diet .......................................................................................................................................................................... D-4
Dietary Fiber Content of Foods................................................................................................................................ D-11
Gastrointestinal Soft Diet .................................................................................................................................................... D-14
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E. Pediatric Diets ................................................................................................................................
Nutrition Management of the Full-Term Infant ........................................................................................................... E-1
Infant Formula Comparison Chart ............................................................................................................................ E-4
Nutrition Management of the Toddler and Preschool Child .................................................................................. E-7
Nutrition Management of the School-Aged Child ........................................................................................................ E-9
Nutrition Management of the Adolescent .................................................................................................................... E-12
Ketogenic Diet .......................................................................................................................................................................... E-14
F. Modification of Minerals .............................................................................................................
Sodium-Controlled Diet .......................................................................................................................................................... F-1
No Added Salt Diet (4,000-Mg Sodium Diet) ........................................................................................................ F-4
Food Guide — 3,000-Mg Sodium Diet ..................................................................................................................... F-5
2,000 Mg And 1,500 Mg Sodium Restricted Diet Patterns ............................................................................. F-6
Food Guide — 1,000-Mg Sodium Diet ..................................................................................................................... F-8
Nutrition Management of Potassium Intake .............................................................................................................. F-10
Potassium Content of Common Foods...................................................................................................................F-11
Nutrition Management of Phosphorus Intake ........................................................................................................... F-12
Phosphorous Content of Common Foods .............................................................................................................F-13
Nutrition Management of Calcium Intake ................................................................................................................... F-14
Calcium Content of Common Foods .......................................................................................................................F-15
G. Modification of Protein ...............................................................................................................
Protein-Controlled Diet for Acute and Refractory Hepatic Encephalopathy .................................................. G-1
Protein-Based Exchanges .............................................................................................................................................. G-5
Medical Nutrition Therapy for Chronic Kidney Disease .......................................................................................... G-7
Meal Patterns Using Healthy Food Guide ............................................................................................................ G-27
Simplified Renal Diet ............................................................................................................................................................. G-28
H. Diets for Sensitivity/Miscellaneous Intolerances .............................................................
Gluten-Free Diet ........................................................................................................................................................................ H-1
Food Guide – Gluten-Free Diet ....................................................................................................................................H-6
Tyramine-Restricted Diet ................................................................................................................................................... H-10
Lactose-Controlled Diet ....................................................................................................................................................... H-12
Nutrition Management of Food Hypersensitivities ................................................................................................. H-16
II. NUTRITION ASSESSMENT/INTERVENTION
Body Weight Evaluation and Indicators of Nutrition-Related Problems ........................................................ II-1
Stature Determination ............................................................................................................................................................ II-5
Body Mass Index (BMI) .......................................................................................................................................................... II-6
Determining Ideal Body Weight (IBW) Based on Height to Weight: The Hamwi Method...................... II-7
Standard Body Weight (SBW) Determination Based On NHANES II ................................................................. II-8
Determination of Frame Size ............................................................................................................................................... II-9
Estimation of Ideal Body Weight and Body Mass Index for Amputees .......................................................... II-10
Estimation of Energy Expenditures ................................................................................................................................ II-12
Estimation of Protein Requirements ............................................................................................................................. II-17
Laboratory Indices of Nutritional Status ..................................................................................................................... II-18
Classification of Some Anemias ........................................................................................................................................ II-20
Diagnostic Criteria for Diabetes Mellitus ..................................................................................................................... II-21
Major Nutrients: Functions and Sources ...................................................................................................................... II-23
Physical Signs of Nutritional Deficiencies ................................................................................................................... II-26
Food and Medication Interactions .................................................................................................................................. II-27
Herb and Medication Interactions .................................................................................................................................. II-34
III. CLINICAL NUTRITION MANAGEMENT
Introduction ............................................................................................................................................................................... III-1
Anticoagulant Therapy .......................................................................................................................................................... III-3
Burns ............................................................................................................................................................................................. III-6
Cancer ........................................................................................................................................................................................ III-10
Chronic Obstructive Pulmonary Disease ................................................................................................................... III-16
Corticosteroid Therapy ...................................................................................................................................................... III-20
Monitoring in Diabetes Mellitus ..................................................................................................................................... III-21
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Diabetes Mellitus: Considerations for Exercise .............................................................................................. III-23
Diabetes Mellitus: Considerations for Acute Illness ..................................................................................... III-25
Diabetes Mellitus: Gastrointestinal Complications ....................................................................................... III-27
Diabetes Mellitus: Oral Glucose-Lowering Medications and Insulin .................................................... III-29
Diabetes Mellitus: Fat Replacers and Nutritive/Nonnutritive Sweeteners ....................................... III-32
Dysphagia ................................................................................................................................................................................. III-35
Relationship of Dysphagia to the Normal Swallow ...................................................................................... III-37
Enteral Nutrition: Management of Complications ................................................................................................. III-38
Gastroesophageal Reflux Disease (GERD) ................................................................................................................. III-40
Heart Failure ........................................................................................................................................................................... III-42
HIV Infection and AIDS....................................................................................................................................................... III-46
Hypertension .......................................................................................................................................................................... III-62
Hypertriglyceridemia ......................................................................................................................................................... III-70
Hypoglycemia ......................................................................................................................................................................... III-72
Inborn Errors of Metabolism ........................................................................................................................................... III-74
Iron Deficiency Anemia ...................................................................................................................................................... III-77
Nephrotic Syndrome ........................................................................................................................................................... III-79
Obesity and Weight Management ................................................................................................................................. III-81
Pancreatitis.............................................................................................................................................................................. III-89
Parenteral Nutrition (PN): Metabolic Complications ........................................................................................... III-94
Calculating Total Parenteral Nutrition ........................................................................................................................ III-99
Peptic Ulcer .......................................................................................................................................................................... III-103
Pneumonia ............................................................................................................................................................................ III-104
Pressure Ulcers ................................................................................................................................................................... III-106
Management of Acute Kidney Injury and Chronic Kidney Disease (Stage V) ......................................... III-110
Nutrition Care Outcomes and Interventions In CKD (Stage V) Renal Replacement Therapy III-116
Wilson’s Disease ................................................................................................................................................................. III-119
IV. APPENDIX
Caffeine and Theobromine Content of Selected Foods and Beverages ........................................................... IV-1
Metric/English Conversions of Weight and Measures ............................................................................................ IV-2
Milligram/Milliequivalent Conversions ........................................................................................................................ IV-2
Salicylate Content of Selected Foods ............................................................................................................................... IV-3

INDEX

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I. NORMAL NUTRITION AND MODIFIED DIETS
A. Normal Nutrition
Statement on Nutritional Adequacy ........................................................................................................... A-1
Estimated Energy Requirement (EER):Male and Females Under 30 Years of Age..................... A-2
Estimated Energy Requirement (EER): Men and Women 30 Years Of Age ................................... A-2
Estimated Calorie Requirements (Kcal): Each Gender and Age Group at Three Levels of
Physical Activity .......................................................................................................................................... A-3
Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Macronutrients A-4
Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Vitamins ............. A-5
Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Elements ............ A-6
Dietary Reference Intakes (DRIs): Estimated Average Requirements .......................................... A-7
Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Vitamins ............................. A-8
Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Elements ............................ A-9
Food Fortification and Dietary Supplements ....................................................................................... A-10
Regular Diet – Adult ....................................................................................................................................... A-11
Food Guide For Americans (1800-2000 Calorie Pattern) ............................................................... A-12
High-Protein, High-Calorie Diet ................................................................................................................ A-13
Nutrition Management During Pregnancy and Lactation ................................................................ A-14
Daily Food Group Guidelines ....................................................................................................................... A-14
Table A-1: Guidelines For Weight Gain After The First Trimester Of Pregnancy .................. A-14
Nutrition And The Older Adult .................................................................................................................. A-22
Table A-2: Contributors To Unintended Weight Loss and Malnutrition in Older Adults ... A-25
Mechanical Soft (Dental Soft) Diet ............................................................................................................ A-28
Food Guide – Mechanical Soft (Dental Soft) Diet ................................................................................. A-29
Pureed Diet ....................................................................................................................................................... A-30
Food Guide – Pureed Diet .............................................................................................................................. A-30
Nutrition Management Of Fluid Intake And Hydration .................................................................... A-32
Fluid Content Of The Regular Diet - Sample .......................................................................................... A-33
Vegetarian Diets .............................................................................................................................................. A-36
Kosher Guidelines .......................................................................................................................................... A-40
Food Guide – Kosher Diet .............................................................................................................................. A-41

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STATEMENT ON NUTRITIONAL ADEQUACY
The Dietary Reference Intakes (DRIs) of the Food and Nutrition Board of the Institute of Medicine, National
Academy of Sciences, are used as the standard for determining the nutritional adequacy of the regular and
modified diets outlined in this manual. DRIs reference values that are quantity estimates of nutrient intakes to
be used for planning and assessing diets for healthy people. The DRIs consist of four reference intakes:

 Recommended Daily Allowances (RDA), a reference to be used as a goal for the individual.
 Tolerable Upper Intake Level (UL), the intake level given to assist in advising individuals of what intake
levels may result in adverse effects if habitually exceeded.
 Estimated Average Requirement (EAR), the intake level which data indicates that the needs for 50% of
individuals consuming this intake will not be met.
 Adequate Intake (AI), a recommended intake value for a group or groups of healthy people based on fewer
data and substantially more judgment than used in establishing an EAR and subsequently the RDA.

An AI is given when the RDA cannot be set. Both of these reference intakes are to be used as goals in
planning and assessing diets for healthy individuals (1,2). The DRIs do not cover special needs for nutrients
due to various disease conditions. DRIs are reference values appropriate for both assessing population
intakes and planning diets for healthy people (1,2).

When referring to energy, use Estimated Energy Intake (EER). EER is the average dietary energy intake
that is predicted to maintain energy balance in a healthy adult of a defined age, gender, weight, height and
level of physical activity, consistent with good health. For children, pregnant and lactating women, the EER
includes the needs associated with deposition of tissues or the secretion of milk at rates consistent with good
health (3).

The sample menus throughout this manual have been planned to provide the recommended DRIs for men,
31 to 50 years of age, unless indicated otherwise, and have been analyzed by a nutrient analysis software
program. For specific values, refer to the following tables of recommended DRIs from the Food and Nutrition
Board of the National Academy of Sciences. However, it is acknowledged that nutrient requirements vary
widely. The dietitian can establish an adequate intake on an individual basis.

Nutrient analysis of the menus is available from Webtrition and reflects available nutrient information.
Webtrition pulls nutrient information from either the USDA Standard Reference database (which includes 36
of the 41 RDA/DRI nutrients) or the manufactures information (manufactures are required only to provide 13
of the 41 RDA/DRI nutrients). Because of this, nutritional analysis data may be incomplete for some foods
and/or some nutrients that are listed in the DRI. The Menu Nutrient Analysis Report in Webtrition uses a (+)
to indicate a partial nutritional value and a (-) to indicate no nutritional value available.

The DRIs are provided in a series of reports (3-7). Full texts of reports are available at www.nap.edu.

References
1. Yates AA, Schlicker SA, Suitor CW. Dietary Reference Intakes: The new basis for recommendations for calcium and related nutrients,
B vitamins, and choline. J Am Diet Assoc. 1998;98:699-706.
2. Trumbo P, Yates A, Schlicker S, Poos M. Dietary Reference Intakes: Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine,
Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. J Am Diet Assoc. 2001;101(3):294-301.
3. Institute of Medicine’s Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids,
Cholesterol, Protein, and Amino Acids. (Macronutrients). Washington, DC: National Academy of Sciences, 2005: 107-180.
4. Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Food and Nutrition
Board, Washington, DC: National Academy Press;1997.
5. Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid,
Biotin, and Choline. Food and Nutrition Board, Washington, DC: National Academy Press;1998.
6. Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Cartotenoids. Food and Nutrition Board,
Washington, DC: National Academy Press;2000.
7. Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Molybdenum,
Nickel, Silicon, Vandium and Zinc. Food and Nutrition Board. Washington, DC: National Academy Press; 2001.

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ESTIMATED ENERGY REQUIREMENT (EER) FOR MALE AND FEMALES
UNDER 30 YEARS OF AGE
Body Mass Median Reference Reference
Age Sex Index (kg/m2)a Heightbcm(in) Weighta kg (lb) Kcal/day
2-6 mo M 62(24) 6(13) 570
F 62(24) 6(13) 520
7-12 mo M 71(28) 9(20) 743
F 71(28) 9(20) 676
1-3 y M 86(34) 12(27) 1046
F 86(34) 12(27) 992
4-8 y M 115(45) 20(44) 1,742
F 115(45) 20(44) 1,642
9-13 y M 17.2 144(57) 36(79) 2,279
F 17.4 144(57) 37(81) 2,071
14-18 y M 20.5 174(68) 61(134) 3,152
F 20.4 163(64) 54(119) 2,368
19-30 y M 22.5 177(70) 70(154) 3,607c
F 21.5 163(64) 57(126) 2,403c
aTaken from new data on male and female median body mass index and height-for-age data from the Centers for Disease
Control and Prevention National Center for Health Statistics Growth Charts (Kuczmarski, et al., 2000).
bCalculated from CDC/NCHS Growth Charts (Kuczmarski et al., 2000); median body mass index and median height for ages
4 through 19 years.
cSubtract 10 kcal/day for males and 7 kcal/day for females for each year of age above 19 years.

Adapted from: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino
Acids (Macronutrients). Washington, DC: National Academies Press, 2002.

ESTIMATED ENERGY REQUIREMENT (EER)
a
FOR MEN AND WOMEN 30 YEARS OF AGE

Height PAL b Weight for BMI Weight for BMI EER, Men (kcal/day)c EER, Women (kcal/day)c
(m[in]) of 18.5 kg/m2 of 24.99 kg/m2 BMI of BMI of BMI of BMI of
(kg [lb]) (kg [lb]) 18.5 kg/m2 24.99 kg/m2 18.5 kg/m2 24.99 kg/m2
1.50 Sedentary 41.6 (92) 56.2 (124) 1,848 2,080 1,625 1,762
(59) Low active 2,009 2,267 1,803 1,956
Active 2,215 2,506 2,025 2,198
Very Active 2,554 2,898 2,291 2,489

1.65 Sedentary 50.4 (111) 68.0 (150) 2,068 2,349 1,816 1,982
(65) Low active 2,254 2,566 2,016 2,202
Active 2,490 2,842 2,267 2,477
Very Active 2,880 3,296 2,567 2,807

1.80 Sedentary 59.9 (132) 81.0 (178) 2,301 2,635 2,015 2,221
(71) Low active 2,513 2,884 2,239 2.459
Active 2,782 3,200 2,519 2,769
Very Active 3,225 3,720 2,855 3,141
aFor each year below 30, add 7 kcal/day for women and 10 kcal/day for men. For each year above 30, subtract 7 kcal/day for women
and 10kcal/day for men.
bPhysical activity level.
cDerive from the following regression equations based on doubly labeled water data:
Adult man: EER=661.8-9.53xAge (y)xPAx(15.91xWt [kg]+539.6xHt[m]
Adult woman EER=354.1 – 6.91xAge(y)xPAx(9.36xWt [kg] + 726xHt [m])
Where PA refers to coefficient for Physical Activity Levels (PAL)
PAL=total energy expenditure + basal energy expenditure.
PA=1.0 if PAL >1.0 < 1.4 (sedentary).
PA=1.12 if PAL > 1.4<1.6 (low active).
PA=1.27 if PAL > 1.6<1.9 (active).
PA=1.45 if PAL > 1.9 < 2.5 (very active).

Source: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002).
This report may be accessed via www.nap.edu.
Copyright 2002 by the National Academy of Sciences. All rights reserved.
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ESTIMATED CALORIE REQUIREMENTS (IN KILOCALORIES) FOR EACH
a
GENDER AND AGE GROUP AT THREE LEVELS OF PHYSICAL ACTIVITY
(1)
Estimated amounts of calories needed to maintain energy balance for various gender and age groups at three
different levels of physical activity. The estimates are rounded to the nearest 200 calories and were determined
using the Institute of Medicine equation.

Activity Level b
Gender Age (years) Sedentaryb Moderately Active Active
Child 2-3 1,000—1,200 c 1,000-1,400c 1,000-1,400c
Female d 4-8 1,200-1,400 1,400-1,600 1,400-1,800
9-13 1,400-1,600 1,600-2,000 1,800-2,200
14-18 1,800 2,000 2,400
19-30 1,800-2,000 2,000-2,200 2,400
31-50 1,800 2,000 2,200
51+ 1,600 1,800 2,000-2,200
Male 4-8 1,200-1,400 1,400-1,600 1,600-2,000
9-13 1,600-2,000 1,800-2,200 2,000-2,600
14-18 2,000-2,400 2,400-2,800 2,800-3,200
19-30 2,400-2,600 2,600-2,800 3,000
31-50 2,200-2,400 2,400-2,600 2,800-3,000
51+ 2,000-2,200 2,200-2,400 2,400-2,800

aBased on Estimated Energy Requirements (EER) equations, using reference heights (average) and reference weights (healthy) for each
age/gender group. For children and adolescents, reference height and weight vary. For adults, the reference man is 5 feet 10 inches tall
and weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126 pounds. EER equations are from the Institute of
Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington
(DC): The National Academies Press; 2002.
bSedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. Moderately active means a
lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light
physical activity associated with typical day-to-day life. Active means a lifestyle that includes physical activity equivalent to walking
more than 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life.
cThe calorie ranges shown are to accommodate needs of different ages within the group. For children and adolescents, more calories are
needed at older ages. For adults, fewer calories are needed at older ages.
dEstimates for females do not include women who are pregnant or breastfeeding.

Reference
Dietary Guidelines for Americans 2010. Available at:
http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf Accessed Jan 31, 2011.

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