Nutrition - Conditions

Vitamin deficiencies

Fat soluble vitamins may be deficient in diseases of malabsorption such as Celiac disease (sprue), cystic fibrosis, chronic pancreatitis, inflammatory bowel disease or short bowel from multiple bowel resections. Water-soluble vitamin deficiencies are uncommon, but may be seen in wasting states (cancer, HIV, etc.), or after gastric bypass surgery during rapid weight loss and non-compliance with vitamin intake. Vitamin and mineral deficiencies may cause the following signs or symptoms:

Vitamin A = difficulty seeing at night, xerophthalmia (corneal erosions and scarring), dry skin Vitamin B1 = double vision (nystagmus, ophthalmoplegia), impaired gait, confusion, memory loss Vitamin B2 = anemia, dermatitis, sore throat-mouth-tongue Vitamin B3 = vomiting, hyperpigmented rash, diarrhea, disorientation-delusions-dementia Vitamin B12 = anemia, abnormal gait and balance, impaired memory and irritability, dementia Vitamin C = scurvy (poor wound healing, bleeding gums, petechiae, arthralgias, hyperkeratosis) Vitamin D = osteomalacia or rickets (in children), bone loss, muscle weakness or spasm Vitamin E = abnormal gait and balance, muscle weakness, neurologic abnormalities Vitamin K = poor blood clotting, skin bruising

Not Enough Fiber

Fiber refers to carbohydrates that cannot be completely digested. Fiber is present in all edible plants to include fruits, vegetables, grains and legumes. However, not all fiber is the same. One way to categorize fiber is by its source of origin. For example, fiber from grains is referred to as cereal fiber. Another way to categorize fiber is by how easily it dissolves in water. Soluble fiber partially dissolves in water whereas insoluble fiber does not dissolve in water. These differences are important in understanding fiber's effect on the risk of developing certain diseases.

Soluble Fiber Insoluble Fiber

Nuts and seeds
Dried peas

Whole grains
Whole wheat breads
Brown rice
Whole-grain breakfast cereals
Wheat bran

Fiber adds bulk to the diet and creates a sense of satiety (feeling “full” faster) and helps to control body weight. Fiber also aides in digestion and helps prevent constipation. Current recommendations suggest that adults should consume 21-38 grams of dietary fiber daily, depending on age and gender. Children aged 1 and older should consume at least 19 grams of fiber daily. The average American adult eats only 15 grams of dietary fiber a day. The following ideas may help to increase dietary fiber:

  • Eat at least 4 to 5 cups of fruits and vegetables each day. Fruits that are high in fiber include apples, oranges, berries, pears, figs and prunes. Vegetables that are high in fiber include broccoli, cauliflower, brussel sprouts, green peas, carrots and beans
  • Replace white bread with whole-grain breads and cereals. Eat brown rice instead of white rice. Eat more bran muffins, oatmeal, multiple-grain cereals (cooked or dry), brown rice, 100% whole-wheat bread and popcorn.
  • Check labels on food packages for the amounts of dietary fiber, as some foods/brands may have less fiber than you think.

Fiber may cause abdominal bloating, cramping or flatus (gas). These symptoms can be prevented by making small changes in dietary fiber intake over a period of time. Start with one of the changes listed above, then wait several days to a week before making another. Drink more fluid (nine 8 ounce glasses daily for women, and twelve 8 ounce glasses daily for men) as liquids help to digest fiber.

Too Much Salt (Sodium)

About 11% of the sodium in an average American diet comes from adding salt (or sodium-containing condiments) to foods while cooking or eating. However, 77% of sodium consumed comes from eating prepared or processed foods that contain salt. The kidneys regulate the amount of sodium in the body. If the kidneys cannot eliminate excess sodium, it accumulates in the blood, attracts and holds water, and increases blood volume and blood pressure, which increases the work on the heart. Certain diseases such as congestive heart failure, cirrhosis of the liver and chronic kidney disease can cause sodium retention in the body. Individuals older than 50 years of age, African-Americans, or those with a health condition such as hypertension, chronic kidney disease or diabetes may be more sensitive to the blood pressure effects of sodium. The National Academy of Sciences' Institute of Medicine has published recommendations for daily sodium intake between 1500 and 2400 milligrams (mg) daily for healthy adults. The following may also help to control sodium intake:

  • Eat more fresh foods and fewer processed foods. Most fresh fruits and vegetables are naturally low in sodium. Fresh meat is lower in sodium than luncheon meat, bacon, hot dogs, sausage and ham.
  • Read labels. Remove salt from recipes whenever possible. Leave out the salt in many recipes, including casseroles, stews and other main dishes. (Baked goods are an exception, as leaving out salt may affect the quality and taste of the food.)
  • Limit the use of condiments high in salt content. Salad dressings, sauces, dips, ketchup, mustard and relish all contain sodium.
  • Use herbs, spices and other flavorings to enhance foods. Use salt substitutes wisely. Some salt substitutes contain a mixture of sodium and other compounds, and using too much salt substitute may not reduce sodium intake. In addition, many salt substitutes contain potassium that may be harmful if one has kidney problems, heart failure or is taking medication that retains potassium.

The taste for salt is acquired, so it's also reversible. Decreasing salt intake gradually allows the taste buds to adjust to a lower salt diet.

Pregnant with Diabetes

It is estimated that 8% of all pregnancies are complicated by diabetes. Approximately, 60% of these cases represent gestational diabetes (GDM), 30% type 2 diabetes and 10% type 1 diabetes. The estimated total number of pregnant women per year in the United States who have diabetes is up to 400,000 per year. Early diagnosis and maintenance of normoglycemia (normal blood sugar) during pregnancy dramatically reduces the risk of congenital birth defects, large for birth infants (macrosomia), birth related trauma and a host of other possible complications.

For these reasons, all pregnant patients should be tested for diabetes. Once the screening tests are completed, patients can then be educated in a proper balanced meal plan. The following guidelines are recommended for diabetes screening during pregnancy.

  • Positive family history (parents, siblings, and children)
  • Previous gestational diabetes
  • Previous premature infant or unexplained stillbirth
  • Prior large for birth ( ≥ infant with congenital anomaly
  • Prior infant >/ = 4000 grams or ≥ 9 lbs)
  • Poor reproductive history (infertility) or recurrent spontaneous abortions.
  • Overweight (BMI > 25) or obese (BMI > 30)
  • Elevated blood pressure or hypertension
  • Glucosuria

If the GCT test results are abnormal, (> 130 mg/dl) initiate the GDM diet and Home Glucose Monitoring (HGM) immediately. Home Glucose Monitoring (HGM) and Diet can help manage glucose levels during antepartum, the time of pregnancy between conception and onset of labor. HGM is performed by checking a finger stick blood glucose at morning fasting, (before breakfast), before (AC) and one hour post (PC) every meal. Glucose goals for HGM are as follows:

Fasting and AC = 90 mg/dl PC glucose, 1-hour after the first bite of meal, ≤ 120 mg/dl

The goals of nutrition therapy during GDM to promote fetal well-being are to achieve normoglycemia, prevent ketosis and provide adequate weigh gain. Seek counsel from a registered dietician or use the Nutrition Jump Start teaching tool. You will then be able to identify the food that should be avoided and those that can be eaten to satiety.

Also, keep in mind the following calorie and BMI ratios:

  • 30 Kcal/kg of present pregnancy body weight if the women’s pregnancy BMI is 19 to 24
  • 24 Kcal/kg if her BMI is 24-29
  • 18 Kcal/kg if her BMI is greater than 30
  • 40 Kcal/kg if her BMI is less than 12

Patients should eat three daily meals with calorie distribution as 30% protein, 40% fat. Snacking should be de-emphasized and used only to abate hunger. Snacks are advised if unexpected low blood sugars occur during daily administration of insulin, but planned daily snacking should never be used to compensate for poor insulin placed on consistency of diet, exercise, and monitoring of glucose to achieve blood glucose control and appropriate weight gain during pregnancy.

For women with, “Low-Risk Diet Controlled GDM,” defined as meeting the home glucose monitoring (HGM) goals outlined above, the following is recommended:

  • Diabetes diet and home glucose monitoring throughout pregnancy.
  • Doctor office visits in high-risk clinic 2 weeks until 34 weeks gestation; then weekly.
  • Begin antepartum surveillance at 39-40 weeks with biweekly nonstress testing of the fetus.
  • Consider delivery by 40 weeks gestation or sooner for macrosomia (estimated Birth Weight > 4000 grams) or other maternal or fetal indications.

If the patient is at “high risk GDM” during antepartum when HGM goals are not met, Insulin Requiring GDM/Type 1 or Type 2 Diabetes, the following insulin therapy should be initiated:

Gestational Age: 6 – 12 weeks 0.7 U/kg day 12 – 28 weeks 0.8 U/kg day 28 – 36 weeks 0.9 U/kg day 36 – 40 weeks 1.0 U/kg day

Insulin should be prescribed such that 50% of the total daily dose is the basal insulin dosage and 50% is meal-related insulin dosage. The insulin analogs aspart and lispro have clinical trials that prove they are safe in pregnancy. To date there are not clinical trials in pregnancy for the long acting insulin detemir and glargine. The basal insulin needs to be given either with a continuous infusion pump or as three doses of NPH spaced 8 hours apart.

High risk patients should also schedule weekly visits with their obstetrician, ensure co-management occurs with their endocrinologist, and schedule early ultrasound scans to establish dates. The upper level ultrasound scan should be conducted at 20-22 weeks gestation with fetal echocardiogram, growth scan at 4 weeks and scans for EFW as indicated. Antepartum surveillance should begin at 34 weeks and include biweekly NSTS and weekly AFIs. Earlier testing will be indicated by associated maternal and fetal conditions. Delivery should occur no later than 40 weeks. An earlier delivery should be considered if pulmonary maternity is established or maternal or fetal indications are present. If induction or scheduled Caesarian Caeserian Section is needed, patients should take bedtime insulin the night before admission, fast in the morning, and do not take insulin the morning of admission.