university of kwazulu-natal dietetics & human nutrition examination: november/december...

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UNIVERSITY OF KWAZULU-NATAL

SCHOOL OF AGRICULTURAL, EARTH & ENVIRONMENTAL SCIENCES

DIETETICS & HUMAN NUTRITION

EXAMINATION: NOVEMBER/DECEMBER 2013

SUBJECT, COURSE & CODE: DIET THERAPY – SURGICAL DIET360 - P2

DURATION : 3 HOURS TOTAL MARKS : 100

External Examiner : Mrs C MacDougall

Internal Examiner : Ms C Biggs

NOTE: THIS PAPER CONSISTS OF 26 PAGES AND A 26 PAGE FORMULA

HANDOUT. PLEASE CHECK THAT YOU HAVE ALL OF THEM.

ANSWER TWO (2) OUT OF THREE (3) QUESTIONS

QUESTION 1

1. Mr Knockdown, a 30 year old black African male, has been transferred to your surgical ICU

suffering from multiple trauma after being run over by a truck. He was resuscitated

efficiently and did not experience circulatory shock or reperfusion injury and is currently

being ventilated with high concentrations of oxygen. The air conditioners in the ICU have

not been functioning properly and with the very hot weather he has been sweating

excessively. As there was no enteral access the referring hospital initiated CPN with feed

ITN 8801A.

Additional information at the time of transfer is tabulated below.

Body weight (kg) 52 Urea (mmol/l) 15

Height (m) 1.74 Creatinine (mmol/l) 100

TST (mm) 10 Sodium (mmol/l) 124

MUAC (cm) 23.0 Potassium (mmol/l) 4.5

MAMC (cm) 19.8 Chloride (mmol/l) 99

Heart rate (beats per minute) 100 Bicarbonate (mmol/l) 23

Temperature (⁰C) 39 Blood glucose (mmol/l) 15

Respiratory rate (breaths/min) 25 Albumin (g/dl) 18

White blood cell count (mm3) 13 000 (high)

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DIET 360 P2

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DIET 360 P2

1.1.1 Using anthropometry and relevant biochemistry assess his nutritional status. (8)

Calculation/reading Interpretation

BMI

(kg/m2)

IBW (kg)

TST (mm)

MUAC

(cm)

MAMC

(cm)

5



DIET 360 P2

Biochemistry

1.1.2 It was mentioned on the ward round that he has SIRS. From what you know about

this patient is there evidence of this? Elaborate and include a definition of SIRS.

(9)

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DIET 360 P2

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DIET 360 P2

1.1.3 Calculate his energy and macronutrient requirements – use 1.5 g protein per kg ABW.

(7)

BMR

Stress factor

Activity factor

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DIET 360 P2

Total energy

Total protein (g)

Protein % of

Total energy

Total nitrogen (g)

NPE (kJ)

NPE to N ratio

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DIET 360 P2

Total CHO (g)

Mg/kg/min

Total fat

Reasoning if necessary:

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DIET 360 P2

1.1.4 Interpret his abnormal (out of range) biochemical laboratory results and explain the

possible causes of each derangement. (8)

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DIET 360 P2

1.1.6 There is now some limited enteral access – the team has asked you whether giving one

litre of Intestamine enterally in addition to the CPN would benefit this patient as they feel

that he is at an increased risk of oxidative damage from ROS production. The team is

concerned about giving him too much calcium.

1.1.6.1 Discuss the possible reasons for this patient being at an increased risk for oxidative

damage. (4)

1.1.6.2 What is your opinion regarding their recommendation of Intestamine? Discuss and

include a description of the product. (4)

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DIET 360 P2

1.2 Liverish (7 year old white male) has been referred to you for the dietary treatment of fatty

liver disease. There is a family history of diabetes and hypertension. His current

biochemical results are found in the table below.

Blood glucose (mmol/l) 4.5

Albumin (g/l) 42

Triglycerides (mmol/l) 3

AST (u/l) 80

ALT (u/l) 100

Weight (kg) 35

Height (m) 1.15

Discuss the dietary approach that you would use. (6)

[50]

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DIET 360 P2

QUESTION 2

2.1 Mrs Reenil is a 46 year old female (black African) who has been admitted into hospital

with end stage renal failure. A clinical examination on admission reveals that her nails

are very pale and she scratches her skin constantly. There is no noticeable oedema. At

present she is nauseas but not vomiting. She does not smoke or drink as she had a stroke

15 years previously. There is a family history of hypertension.

Currently she is receiving haemodialysis 3 times per week. Her current medications

include Calcitriol (vitamin D3), Pregamal (iron and folic acid supplement),

Erythropoietin and Titralac.

On admission:

GFR (ml/min) 2

Albumin (g/l) 20

Hb (g/dl) 8.9

Iron (umol/l) 6.9

Urea (mmol/l) 20.0

Creatinine (mmol/) 1487

Sodium (mmol/l) 140

Potassium (mmol/l) 4.3

Chloride (mmol/l) 100

Bicarbonate (mmol/l) 26

Calcium (mmol/l) 1.5

Phosphate (mmol/l) 3.22

PTH High

2.2.1 Interpret her abnormal (out of range) biochemical laboratory results. Discuss in detail the

causes and where possible link them to her physical symptoms. (15)

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DIET 360 P2

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DIET 360 P2

2.1.2 Are the medications that her doctor prescribed appropriate? Elaborate in detail. (8)

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DIET 360 P2

2.1.3 You calculated her renal prescription as follows: protein 67g, energy 8400kJ,

carbohydrate 277g and the remainder as fat with the usual ranges for Na, K and

phosphate. Her current food intake is summarized in the exchanges which follow. Do

you need to adjust her intake/exchanges or can she continue on her current intake? If you

feel you can improve her intake then support this with minor changes to the exchanges

please. (2)

Group

Number

of

exchanges

Energy

(kJ)

Protein

(g)

Fat

(g)

CHO

(g)

PO4

(mg)

Na

(mg)

K

(mg)

Meat & meat substitutes

Meat - high P, low Na 2 700 14 10 0 240 110 180

Meat - high P, high Na 2 700 14 10 0 240 860 180

Meat - low P, low Na 0 0 0 0 0 0 0 0

Meat - low P, high Na 0 0 0 0 0 0 0 0

Legumes low Na 1 350 7 5 15 120 55 245

Legumes high Na 0 0 0 0 0 0 0

Milk 0 0 0 0 0 0 0

low kJ, fat, CHO 1 325 4 5 10 110 65 185

high kJ, fat, CHO 1 835 4 10 20 110 65 185

Starch 0 0 0 0 0 0 0

Starch low K, low kJ, low fat 7 2450 14 0 140 280 490 350

Starch low K, high kJ, high fat 1 835 2 10 20 40 70 50

Starch high K, low kJ, low fat 1 350 2 0 20 40 70 245

Starch high K, high kJ, high fat 1 835 2 10 20 40 70 245

Vegetables 0 0 0 0 0 0 0

Vegetables low K 1 90 1 0 2 20 20 75

Vegetables moderate K 1 90 1 0 2 20 20 150

Vegetables high K 0 0 0 0 0 0 0

Fruit 0 0 0 0 0 0 0

Fruit low K 0 0 0 0 0 0 0 0

Fruit moderate K 1 250 0.5 0 10 15 5 170

Fruit high K 1 250 0.5 0 10 15 5 240

Beverages 0 0 0 0 0 0 0

Beverages low kJ 0 0 0 0 0 0 0 0

Beverages high kJ 0 0 0 0 0 0 0 0

Sugar 1 155 0 0 10 0 0 10

Fat 1 160 0 5 0 0 45 0

Totals 0 8375 66 65 279 1290 1950 2510

Percent of total 14% 30% 56%

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DIET 360 P2

2.2 Bill Wrath underwent a gastrectomy (Bilroth 2) to surgically remove a very large gastric

ulcer. Post surgery, he was initially fed a semi elemental feed via a jejunostomy tube.

Subsequently he has successfully tolerated ice, water, clear and full fluids such as milk. It

is day 5 post surgery and he is ready to begin eating solid food – he does not need a puree

diet. Using the exchanges that follow please plan an appropriate diet remembering that he

loves pizza (thin base), tuna, haddock, beef stew with lots of vegetables, eggs, custard

(UltraMel or made from custard powder), chocolate, plain butter milk cake and pineapples.

You may use your renal exchanges to do this. MEAL PLANS CAN BE FILLED IN

USING PENCIL.

Food Exchange

Meat/legumes 10

Milk 2

Starch 10

Vegetables 2

Fruit 3

Fat 6

Sugar 0

Beverages As many as you decide

Briefly write down the type of diet that you are about to plan.

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DIET 360 P2

Exchange Code Number Meal plan

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DIET 360 P2

Exchange Code Number Meal plan

[50]

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DIET 360 P2

QUESTION 3

3.1 KC is a 10 year old black African male who is suffering from end stage chronic liver

cirrhosis with cholestasis (no jaundice) as a consequence of eating lots of mouldy

peanuts.

On assessment you discover that he has moderate ascites. He suffers from muscle

cramps (which annoy him immensely) and falls over things at night as he does not see

them in his way. His food tastes funny and he gets full very quickly. Over the next 6

months he is being worked up for a liver transplant using the kasei procedure.

Current medication includes lactulose, cholestyramine, an aminoglycoside diuretic and

pancreatic enzymes.

Additional information:

Weight (kg) 30.0

Height (m) 1.25

MUAC (cm) 12.5

TST (mm) 6

Blood glucose (mmol/l) 2.1 to 2.9

Sodium (mmol/l) 142




Ammonia Not raised

3.1.1 Nutritionally assess KC using anthropometry only. (11)

Reading eg Z score etc Interpretation

Calculate estimated

weight

Estimated weight for

age

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DIET 360 P2

% expected weight for

age

Estimated weight age

Height for age 1.25 m

% Expected height for

age

Height age

TST 6 mm

MAC 12.5 cm

MAMC

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DIET 360 P2

3.1.2 Interpret his abnormal (out of range) biochemical laboratory results and explain the

possible causes of each derangement in detail. (5)

3.1.3 Based on the little that you know about his symptoms do you think that he might benefit

from supplementation with specific vitamins and minerals? Discuss in detail how any

possible deficiencies that you have identified could be related to the liver cirrhosis. (9)

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DIET 360 P2

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DIET 360 P2

3.1.4 Discuss whether each medication is appropriate for KC and include the reason for its use.

(5)

3.1.5 His mother is very puzzled as you have prescribed corn flour as part of his treatment.

She wants to know if she can give him stew and use the corn flour as a thickener when

cooking his meals. Discuss with her why you feel it is necessary as well as when and

how it should be given. (4)

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DIET 360 P2

3.1.6 A new BCAA supplement is available on the local market. Discuss briefly whether

BCAA may be of benefit in the treatment of liver disease in general and then whether you

think KC in particular would benefit. (6)

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DIET 360 P2

4.1 The hypermetabolic response in both trauma and burns is very important in the early

stages of the injury. Fill in the summary diagram below to demonstrate the

hypermetabolic response in burns. (10)

[50]

27

UNIVERSITY OF KWAZULU-NATAL

SCHOOL OF AGRICULTURAL, EARTH & ENVIRONMENTAL SCIENCES



SUBJECT, COURSE & CODE: DIET THERAPY – SURGICAL DIET360 - P2

DURATION : 3 HOURS TOTAL MARKS : 100

External Examiner : Mrs. C MacDougall

Internal Examiner : Ms C Biggs

NOTE: THIS PAPER CONSISTS OF 39 PAGES AND A 27 PAGE FORMULA

HANDOUT PLEASE CHECK THAT YOU HAVE ALL OF THEM

DO TWO (2) OUT OF THREE (3) QUESTIONS

STUDENT NUMBER:___________________________________________________________

QUESTION 1

Mr Knockdown, a 30 year old black African male, has been transferred to your surgical ICU

suffering from multiple trauma after being run over by a truck. He was resuscitated efficiently

and did not experience circulatory shock or reperfusion injury and is currently being ventilated

with high concentrations of oxygen. The air conditioners in the ICU have not been functioning

properly and with the very hot weather he has been sweating excessively. As there was no

enteral access the referring hospital initiated CPN with feed ITN 8801A.

Additional information at the time of transfer is tabulated below.

Body weight (kg) 52 Urea (mmol/l) 15

Height (m) 1.74 Creatinine (mmol/l) 100

TST (mm) 10 Sodium (mmol/l) 124

MUAC (cm) 23.0 Potassium (mmol/l) 4.5

MAMC (cm) 19.8 Chloride (mmol/l) 99

Heart rate (beats per minute) 100 Bicarbonate (mmol/l) 23

Temperature (⁰C) 39 Blood glucose (mmol/l) 15

Respiratory rate (breaths/min) 25 Albumin (g/dl) 18

White blood cell count (mm3) 13 000 (high)

29

Body weight (kg) 52

Height (m) 1.74

TST (mm) 10

MUAC (cm) 23.0

MAMC (cm) 19.8

Heart rate (beats per minute) 100 High

Temperature (⁰C) 39 High

Respiratory rate (breaths/min) 25 High

White blood cell count (mm3) 13 000 (high) High

Urea (mmol/l) 15 High

Creatinine (mmol/l) 100 Normal

Sodium (mmol/l) 124 Low

Potassium (mmol/l) 4.5 Normal

Chloride (mmol/l) 99 Normal

Bicarbonate (mmol/l) 23 Normal

Blood glucose (mmol/l) 15 High

Albumin (g/dl) 18 Severely depleted

1.1.2 Using anthropometry and relevant biochemistry assess his nutritional status. (8)

Biochemistry

BMI (kgm2) 17.2 Mild malnutrition (golden and golden)

Ideal body

weight

56.0 ie 18.5 lower end of BMI

TST On 50th

normal fat stores

MUAC Below the 5th Just above 22 cm – below would be

mildly malnourished so thin arms

MAMC 19.8 Below the 5th low muscle stores

Albumin is severely depleted – could

reflect nutritional status as mildly

malnourished but more likely a result of

trauma and the acute phase response

So mild malnutrition as low BMI with

low muscle mass but normal fat stores

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1.1.2 It was mentioned on the ward round that he has SIRS. From what you know about

this patient is there evidence of this? Elaborate including a definition of SIRS. (9)

The most common points left out here was the fact that he was a high risk as he had experienced

multiple trauma and was in the surgical ICU

Definition

Systemic Inflammatory Response Syndrome - This is an excessive inflammation from the

activation of the innate immune system and the proinflammatory cascade (Clifford 2004)

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with the increased formation of humoral mediators (catecholamines, glucocorticoids),

proinflammatory cytokines (TNF, IL-1, IL-6) and chemokines (C5a, LTB4, PAF) which shifts

the T-helper cells to the Th1-type

Diagnosis/symptoms of SIRS is 2 or more of the following

Temperature >38⁰C or <36⁰C his temp is 39⁰C

Heart rate of >90 beats per minute – his heart rate is 100

Respiratory rate of >20 breathes per minute his is 25

White blood cell count >12 000/mm3 – his is 13 000

High risk is surgical ICU and multiple trauma

So yes he has SIRS

1.1.3 Calculate his energy and macronutrient requirements – use 1.5 g protein per kg ABW.

This was poorly done as most used the stress factor for multiple trauma and not the SIRS – I was

surprised because I did go over this in class and in a practical session plus a similar question was

in their last practical on schofield calculations – fat and CHO will vary according to each

students preference. There should have been 8 marks allocated not 7. Full marks given for NPE

and max ox rate only if the result was explained ie above the recc NPE of 420 therefore

sufficient NPE supplied to protect protein.

(7)

Answer

Ventilated so an activity factor of -15%

SIRS as opposed to multiple trauma therefore 50% stress factor not 40%

Basal Metabolic Rate: 6158 kJ

Metabolic rate adjustment 50 % 3079 kJ

Activity factor -15 % -924 kJ

Total Energy 8313 kJ

Protein g/kg BW Protein

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(g)

1.5 78

% TE NPE:gN

16 560

CHO

% of Tot E Total CHO (g)

54 264

mg/kg/min

3.5

Fat

% of Tot E Total Fat (g)

30 66

1.1.4 Interpret his abnormal (out of range) biochemical laboratory results explaining the possible

causes of each derangements. (8)

Most did not look at the CPN regimes he was on to determine if he was being overfed.

White blood cell count (mm3) 13 000

Urea (mmol/l) 15

Creatinine (mmol/l) 100

Blood glucose (mmol/l) 15

Sodium (mmol/l) 124

High WBC indicates infection

High urea but normal creatinine so not acute kidney injury likely to be from overfeeding

protein as the feed they are on gives 22.4 g N instead of 12.5 g nitrogen – also massive

breakdown from the skeletal muscle and release of protein – release of catabolic hormones -

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High blood sugar levels – can be from overfeeding cho but the amount being given does not

exceed the maximal oxidative rate – usually insulin resistance from release of catabolic

hormones Accelerated (increased glucagon levels) Results in hyperglycaemia to maintain a

supply of glucose during hypotension and poor organ perfusion (GIT is also an organ)

Low sodium possibly from dehydration as has been excessive sweating

1.1.5 There is now limited enteral access – the team has asked you whether giving one litre

of Intestamine enterally in addition to the CPN would benefit this patient as they feel

that he at an increased risk of oxidative damage from ROS production. The team is

concerned about giving him too much calcium.

I am surprised as to how badly this question was answered. They had 2 practical sessions on

feeds including Intestamine and it was gone over in a practical and in class.

1.1.6.1 Do you think that he is at an increased risk for oxidative damage? Discuss.

(4)

Yes as there is increased ROS production from:

Tissue damage and inflammation (trauma , ischemia, infection)

Increase in BMR

Catecholamines released during trauma and critical illness

Being ventilated with high concentrations of oxygen to obtain sufficient arterial oxygenation

1.1.7.1 Would you agree with their recommendation of Intestamine?

Discuss including a description of the product. (4)

The amount is incorrect ie not to give more than 500 ml

Would agree with the principle though as it contains a mix of glutamine, selenium, zinc,

betacarotene, vitamin C and E and antioxidant cocktails have been shown to reduce mortality

and days on the ventilator, less infections. but there is no calcium in intestamine so that is not

a problem

1.2 Liverish (7 year old white male) has been referred to you for the dietary treatment of fatty

liver disease. There is a family history of diabetes and hypertension.

Blood glucose (mmol/l) 4.5

Albumin (g/l) 42

Triglycerides (mmol/l) 3

AST (U/l) 80

ALT (u/l) 100

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Weight (kg) 35

Height (m) 1.15

Blood glucose (mmol/l) 4.5 Normal

Albumin (g/l) 42 Normal

Triglycerides (mmol/l) 3 High

AST (U/l) 80 High

ALT (u/l) 100 High

Weight (kg) 35

Height (m) 1.15

Discuss the dietary approach you would take. (6)

First need to establish that the child is very overweight for actual height as BMI is

35/1.32 = 26.5 which is way above the plus 3 z score ie weighs too much for his height

so this needs to be treated so need a controlled weight loss as to rapid a weight loss will

exacerbate this problem by releasing lots of fat – Rapid weight loss might enhance the

disease progression (Angulo 2002 citing Franzese et al 1997) by leading to portal

inflammation and fibrosis (Angulo & Lindor 2001). A loss of ½ kg per week in

children (Angulo 2002 citing Franzese et al 1997) Weight loss needs to be maintained.

As the TG levels are high these need to be decreased by reducing the use of refined CHO

decreasing SUFA and cholesterol and increase PUFA and fibre and antioxidants.

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QUESTION 2

Mrs Reenil is a 46 year old female (black African) who has been admitted into hospital with end

stage renal failure. A clinical examination on admission reveals that her nails are very pale and

she scratches her skin constantly. There is no noticeable oedema. At present she is nauseas but

not vomiting. She does not smoke or drink as she had a stroke 15 years previously. There is a

family history of hypertension.

Currently she is receiving haemodialysis 3 times per week. Her current medications include

vitamin D3 (Calcitriol), Pregamal (iron and folic acid supplement), Erythropoietin and Titralac.

On admission:

GFR (ml/min) 2

Albumin (g/l) 20

Hb (g/dl) 8.9

Iron (umol/l) 6.9

Urea (mmol/l) 20.0

Creatinine (mmol/) 1487

Sodium (mmol/l) 140




Calcium (mmol/l) 1.5

Phosphate (mmol/l) 3.22

PTH High

2.2.1 Interpret her abnormal (out of range) biochemical laboratory results. Discuss in detail the

causes and where possible link them to her physical symptoms. (15)

GFR (ml/min) 2

Albumin (g/l) 22 moderately depleted

Hb (g/dl) 8.9 Low

Iron (umol/l) 6.9 Low

Urea (mmol/l) 20.0 High

Creatinine (mmol/) 1487 High

Calcium (mmol/l) 1.5 Low

Phosphate (mmol/l) 3.22 High

PTH high High

Albumin is moderately depleted as a result of stress ie the kidney is involved with the

manufacture of albumin so this is not an appropriate nutritional indicator as in this case

it probably reflects stress rather than chronic malnutrition

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Urea is very high and this in combination with a high creatinine confirms the diagnosis of

renal failure.The kidney is unable to clear the urea and creatinine which are the

breakdown products of protein. This contributes to the nausea.

The calcium levels are low which can be expected in decompensated end stage renal

disease as the rise in phosphate levels bind with calcium causing the calcium levels to

drop however the albumin levels are also low and calcium binds to albumin so as this is

not a corrected calcium the levels may not actually be low so interpret with caution.

Phosphate levels are very high – expected in renal disease as the kidney can no longer

excrete phosphate – this causes calcium and phosphate to bind which in turn lowers

calcium levels which stimulates the release of PTH which explains the raised levels of

PTH. The raised levels of phosphate also are the cause of the itchy skin.

Her haemoglobin and serum iron levels are low ie she is anaemic – this correlates to the

pale nails – expect this in renal failure as there is a def of EPO which manufactures rbc

which in turn carries iron. There is also a low protein diet ½ , blood loss from

haemodialysis, ½GI bleeding, ½ frequent blood sampling, ½her high levels of

uremia destroy red blood cells, ½ she is nauseas so eating less ½ and decreased iron

absorption ½ – she is not on salicylates so no mark for this.

2.2.2 Are the medications that her doctor prescribed appropriate? Elaborate in detail. (8)

Vitamin D3 (Calcitriol)

Vitamin D3 is appropriate as Vitamin D is inactivated by high levels of urea which

reduce the biologic action of calcitriol and phosphate (reduce renal enzyme (1- -

hydoxylase) which converts vitamin D to its active form and the kidney stimulates the

conversion of vitamin D to its active form.

Pregamal

Pregamal as an iron supplement is appropriate because she has been started on EPO and

the additional iron is needed to manufacture the newly created red blood cells.

40

Folic acid is appropriate as renal patients are often deficient in folate and folic acid is

essential in the formation of red blood cells so appropriate with the EPO.

Erythropoietin

EPO – is appropriate as in end stage renal failure the kidney can no longer manufacture

this and this results in the anemia which needs correcting

Titralac

Titralac is both a calcium supplement and a phosphate binder – necessary as it is taken

with meals and snacks – the calcium binds with the phosphate in the GIT and reduces the

absorption of phosphate – very necessary in this case because of the high phosphate

levels however usually the levels of phosphate are lowered first before a phosphate

binder is used.

2.1.3 You calculated her renal prescription as follows: protein 67g, energy 8400kJ,

carbohydrate 277g and the remainder as fat with the usual ranges for Na, K and phosphate. Her

current food intake is summarized in the exchanges which follow. Do you need to adjust her

intake/exchanges or can she continue on her current intake? If you feel you can improve her

intake then support this with minor changes to the exchanges please. (2)

Group

Number

of

exchanges

Energy

(kJ)

Protein

(g)

Fat

(g)

CHO

(g)

PO4

(mg)

Na

(mg)

K

(mg)


Meat - high P, low Na 2 700 14 10 0 240 110 180


Meat - low P, low Na 0 0 0 0 0 0 0 0

Meat - low P, high Na 0 0 0 0 0 0 0 0

Legumes low Na 1 350 7 5 15 120 55 245


0 0 0 0 0 0 0

Milk 0 0 0 0 0 0 0

low kJ, fat, CHO 1 325 4 5 10 110 65 185

high kJ, fat, CHO 1 835 4 10 20 110 65 185

0 0 0 0 0 0 0

Starch 0 0 0 0 0 0 0

Starch low K, low kJ, low

fat 7 2450 14 0 140 280 490 350

Starch low K, high kJ, high

fat 1 835 2 10 20 40 70 50

Starch high K, low kJ, low

fat 1 350 2 0 20 40 70 245

41

Starch high K, high kJ, high

fat 1 835 2 10 20 40 70 245

0 0 0 0 0 0 0


Vegetables low K 1 90 1 0 2 20 20 75



0 0 0 0 0 0 0

Fruit 0 0 0 0 0 0 0

Fruit low K 0 0 0 0 0 0 0 0

Fruit moderate K 1 250 0.5 0 10 15 5 170

Fruit high K 1 250 0.5 0 10 15 5 240

0 0 0 0 0 0 0

Beverages 0 0 0 0 0 0 0

Beverages low kJ 0 0 0 0 0 0 0 0

Beverages high kJ 0 0 0 0 0 0 0 0

Sugar 1 155 0 0 10 0 0 10

Fat 1 160 0 5 0 0 45 0

Totals 0 8375 66 65 279 1290 1950 2510

Percent of total 14% 30% 56%

Group

Number

of

exchanges

Energy

(kJ)

Protein

(g)

Fat

(g)

CHO

(g)

PO4

(mg)

Na

(mg)

K

(mg)


Meat - high P, low Na 0 0 0 0 0 0 0 0


Meat - low P, low Na 2 700 14 10 0 130 110 180

Meat - low P, high Na 2 700 14 10 0 130 860 180

Legumes low Na 1 350 7 5 15 120 55 245


0 0 0 0 0 0 0

Milk 0 0 0 0 0 0 0

low kJ, fat, CHO 1 325 4 5 10 110 65 185

high kJ, fat, CHO 1 835 4 10 20 110 65 185

0 0 0 0 0 0 0

Starch 0 0 0 0 0 0 0

Starch low K, low kJ, low

fat 7 2450 14 0 140 280 490 350

Starch low K, high kJ, high

fat 1 835 2 10 20 40 70 50

42

Starch high K, low kJ, low

fat 1 350 2 0 20 40 70 245

Starch high K, high kJ, high

fat 1 835 2 10 20 40 70 245

0 0 0 0 0 0 0


Vegetables low K 1 90 1 0 2 20 20 75



0 0 0 0 0 0 0

Fruit 0 0 0 0 0 0 0

Fruit low K 0 0 0 0 0 0 0 0

Fruit moderate K 1 250 0.5 0 10 15 5 170

Fruit high K 1 250 0.5 0 10 15 5 240

0 0 0 0 0 0 0

Beverages 0 0 0 0 0 0 0

Beverages low Kj 0 0 0 0 0 0 0 0

Beverages high Kj 0 0 0 0 0 0 0 0

Sugar 1 155 0 0 10 0 0 10

Fat 1 160 0 5 0 0 45 0

Totals 0 8375 66 65 279 1070 1950 2510

So prescription great except for phosphate being too high so need to simply change the 4 high

phosphate meats to 4 low phosphate meats.

2.3 Bill Wrath underwent a gastrectomy (Bilroth 2) to surgically remove a very large gastric

ulcer. Post surgery, he was initially fed a semi elemental feed via a jejunostomy tube.

Subsequently he has successfully tolerated ice, water, both clear and full fluids such as

milk. It is day 5 post surgery and he is ready to begin eating solid food – he does not need a

puree diet. Using the exchanges that follow please plan an appropriate diet remembering

that he loves pizza (thin base), tuna, haddock, beef stew with lots of vegetables, eggs,

custard (UltraMel or made from custard powder), chocolate, plain butter milk cake and

pineapples. You may use your renal exchanges to do this.

Food Exchange

Meat/legumes 10

Milk 2

Starch 10

Vegetables 2

Fruit 3

Fat 6

Sugar 0


43

First briefly summarize the diet you are going to plan.

Mark sheet

Need to plan a light moderate fat no refined cho diet (no sugar, sweets, sugar containing cold

drinks or carbonated beverages) with small frequent feeds and separating liquids from solids.

Food Exchange Planned

Meat/legumes 10

Milk 2

Starch 10

Vegetables 2

Fruit 3

Fat 6

Sugar 0


Based on above table has the student planned the correct number of exchanges? Yes/No

Are the correct amounts and foods allocated to each exchange? Eg is 1 starch = 1 slice of bread

etc Yes/No

If no then write incorrect foods/amounts below.

Did they separate liquids from solids? Yes/No

Did they avoid sugar, refined carbohydrates and other sweet things?

Did they include foods not allowed on the light diet? Yes/No

Did they give small, frequent meals Yes/No

Did they include as many favorite foods as possible?

Pizza Not allowed on light diet

Tuna Tinned in water should have been included

Haddock Not allowed on light diet as smoked fish

Beef stew Allowed but needed to stipulate the vegetables for light

diet

Eggs Allowed but not fried

Custard Only allowed if sugar not used

Chocolate Not allowed on light diet

Plain butter milk cake Not allowed as a refined carbohydrate

Pineapples Not allowed on light diet

Breakfast

Snack

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Lunch

Snack

Supper

Final comment:

QUESTION 3

3.1 KC is a 10 year old black African male who is suffering from end stage chronic liver

cirrhosis with cholestasis (no jaundice) as a consequence of eating lots of mouldy peanuts.

On assessment you discover that he is moderately ascetic. He suffers from muscle cramps

(which annoy him immensely) and falls over things at night as he does not see them in his way.

His food tastes funny and he gets full very quickly. Over the next 6 months he is being worked

up for a liver transplant using the kasei procedure.

Current medication includes lactulose, cholestyramine, an aminoglycoside diuretic and

pancreatic enzymes.

Additional information:

Weight (kg) 30.0

Height (m) 1.25

MUAC (cm) 12.5

TST (mm) 6

Blood glucose (mmol/l) 2.1 to 2.9

Sodium (mmol/l) 142




Ammonia Not raised

3.1.7 Nutritionally assess KC using anthropometry only. (11)

How to calculate the weight of a child with ascites was done in a test in class and gone

over in class therefore this should have been done properly

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Reading eg Z score etc Interpretation

Calculate estimated

weight

Need to use BMI for age ie on the 0 Z score is 16.5 therefore 16.5 X

1.56 = 25.8 kg.

Estimated weight for

age

Below the 10th percentile

Underweight/very underweight ie

no WHO terminology as a

percentile not a z score

% expected weight for

age

25.8/32*100= 80.6 %

Normal nutrition according to the

welcome ie not below 80%

Estimated weight age 8 years

Height for age 1.25 m On minus 2 Z score

Stunted

% Expected height for

age

1.25/1.38*100= 90.6%

Mild malnutrition

Height age 7 years 6 months

TST 6 mm Below 5th

So low fat stores

MAC 12.5 cm Below 5th

So thin arms

MAMC About 10.5 Below 5th

So low muscle stores

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He is suffering from mild chronic malnutrition (stunted) with low fat and muscle stores.

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3.1.8 Interpret his abnormal (out of range) biochemical laboratory results explaining the

possible causes of each derangement in detail. (5)

Blood glucose (mmol/l) 2.1 to 2.9 Low

Sodium (mmol/l) 142 Normal

Potassium (mmol/l) 2.5 Low

Chloride (mmol/l) 103 Normal

Bicarbonate (mmol/l) 25 Normal

Ammonia Not raised normal

He is hypoglycaemic – would expect this in liver failure esp in children – often insufficient

storage of CHO because of because of spatial limitations (no space) and liver cell damage

This can eventually result in hypoglycaemia (also made worse by the decreasing capacity for

gluconeogenesis)

He is hypokalemic - probably from the aminoglycoside diuretic

3.1.9 Based on the little that you know about his symptoms do you think that he might benefit

from supplementation with specific vitamins and minerals? Discuss in detail how any

possible deficiencies that you identify can be related to the liver cirrhosis. (9)

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There are taste changes, muscle cramps and night blindness so……..

Deficiency most likely in chronic alcoholic liver disease and longstanding cholestasis. Might be

night blindness. therefore needs vitamin A supplementation Circulating concentrations of

retinol and carotenoids are decreased . Decreased hepatic synthesis and release of RBP ie

decreased release from hepatic stores. Decreased hepatic vitamin A and carotenoid stores,

increased urinary loss of RBP. Been implicated in abnormal taste perception but

controversial (Garrow, James and Ralph, 2000 pg 579)

Cholestryamine impairs absorption of fat soluble vitamins

Food tastes funny and muscle cramps so would supplement with mg and zinc supplementation

especially as zinc and vit A def often exist together

3.1.10 Discuss whether each medication is appropriate for KC and include the reason for its use.

(5)

Cholestyramine may be prescribed to promote gall bladder contractions and he has

cholestasis

Pancreatic enzyme supplementation - has cholestasis and as bile salts are necessary to

activate pancreatic lipase, pancreatic enzyme supplementation may be necessary in

cholestasis.

Lactulose - is a nonabsorbable disaccharide ie oligosaccharide which increases the

production of SCFA in the colon thus lowering colonic pH which in turn decreases the

number of ammonia producing bacteria and decreases the absorption of ammonia from

the GIT

aminoglycoside Diuretics – need to use this as persistent ascites ie in combo with a salt

restriction and perhaps a fluid restriction.

3.1.11 His mother is very puzzled as you have prescribed cornflour as part of his treatment. She

wants to know if she can give him stew and use the cornflour as a thickener when

cooking his meals. Discuss with her why you feel it is necessary as well as when and

how it should be given. (4)

Why necessary - Uncooked corn starch (raw cornflour) releases glucose slowly and results in a

smoother blood sugar curve when compared to glucose polymers which will help prevent low

blood sugar levels.

When it should be given - This effect may last approximately 4 to 9 hours if the cornflour is

given every 4 to 6 hours

How it should be given - can mix with drinks (fruit juice, milk etc) or cold foods.

50

The cornstarch has to be raw so cooking it as a stew thickener will defeat the purpose

3.1.12 A new BCAA supplement is available on the local market. Discuss briefly whether

BCAA may be of benefit in the treatment of liver disease in general and then whether you

think KC in particular would benefit. (6)

Most AA from both endogenous and exogenous protein are metabolised by the liver.

BCAA are the exception in that they are mainly broken down by skeletal muscle, heart and

kidney and are both an nb source of E to the muscle as well as being precursors of other

AA’s. So supplementation with BCAA might help prevent the protein energy

malnutrition by being able to give more protein without placing additional stress on the

liver

May be a role for BCAA in severe encephalopathy which this child is not in as the

ammonia levels are not raised

There was a large lack of compliance and high drop out rate due to the unacceptable taste

of the solution and this child has no appetite already ie food tastes funny and gets full

quickly

No RCT with BCAA in children in liver failure so don’t actually know

4.1 The hypermetabolic response in both trauma and burns is very important in the early

stages of the injury. Fill in the summary diagram below to demonstrate the hypermetabolic

response in burns. (10)

university of kwazulu-natal dietetics & human nutrition examination: november/december...

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