NUTRITIONAL ASPECTS
and
CLINICAL MANAGEMENT
of
CHRONIC DISORDERS
and
DISEASES
CRC SERIES IN
MODERN NUTRITION
Edited by Ira Wolinsky and James F. Hickson, Jr.
Published Titles
Manganese in Health and Disease, Dorothy J. Klimis-Tavantzis
Nutrition and AIDS: Effects and Treatments, Ronald R. Watson
Nutrition Care for HIV-Positive Persons: A Manual for Individuals and Their Caregivers,
Saroj M. Bahl and James F. Hickson, Jr.
Calcium and Phosphorus in Health and Disease, John J.B. Anderson and
Sanford C. Garner
Edited by Ira Wolinsky
Published Titles
Practical Handbook of Nutrition in Clinical Practice, Donald F. Kirby
and Stanley J. Dudrick
Handbook of Dairy Foods and Nutrition, Gregory D. Miller, Judith K. Jarvis,
and Lois D. McBean
Advanced Nutrition: Macronutrients, Carolyn D. Berdanier
Childhood Nutrition, Fima Lifschitz
Nutrition and Health: Topics and Controversies, Felix Bronner
Nutrition and Cancer Prevention, Ronald R. Watson and Siraj I. Mufti
Nutritional Concerns of Women, Ira Wolinsky and Dorothy J. Klimis-Tavantzis
Nutrients and Gene Expression: Clinical Aspects, Carolyn D. Berdanier
Antioxidants and Disease Prevention, Harinda S. Garewal

Nutrient– Gene Interactions in Health and Disease, Naïma Moustaïd-Moussa
and Carolyn D. Berdanier
Micronutrients and HIV Infection, Henrik Friis
Tryptophan: Biochemicals and Health Implications, Herschel Sidransky
Nutritional Aspects and Clinical Management of Chronic Disorders and Diseases,
Felix Bronner
Forthcoming Titles
Handbook of Nutraceuticals and Nutritional Supplements and Pharmaceuticals,
Robert E. C. Wildman
Insulin and Oligofructose: Functional Food Ingredients, Marcel B. Roberfroid

0945_ FM_fm* Page 4 Thursday, June 20, 2002 11:13 AM
CRC PRESS
Boca Raton London New York Washington, D.C.
NUTRITIONAL ASPECTS
and
CLINICAL MANAGEMENT
of
CHRONIC DISORDERS
and
DISEASES
Edited by
Felix Bronner

This book contains information obtained from authentic and highly regarded sources. Reprinted material
is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable
efforts have been made to publish reliable data and information, but the authors and the publisher cannot
assume responsibility for the validity of all materials or for the consequences of their use.
Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, microfilming, and recording, or by any information storage or

p. cm — (CRC series in modern nutrition)
Includes bibliographical references and index.
ISBN 0-8493-0945-X
1. Diet therapy. 2. Cookery for the sick. 3. Diet in disease. 4. Chronic
diseases—Nutritional aspects. I. Bronner, Felix. II. Modern nutrition (Boca Raton, Fla.)
[DNLM: 1. Chronic Disease—therapy. 2. Diet Therapy. 3. Nutrition. WT 500 N976 2002]
RM216 .N886 2002
616

′

.044—dc21 2002023353
CIP

0945_ FM_fm* Page 6 Thursday, June 20, 2002 11:13 AM

Preface

Nutritional counseling and management are becoming important in health care,
particularly in the management of a number of chronic conditions and diseases. The
publication of this book is timely, because it aims to help physicians and their staffs
identify conditions and diseases that can be treated effectively with nutritional
intervention, and provides specifics on appropriate counseling and management.
The first of the 13 chapters discusses nutritional support for children, with
emphasis on premature infants, cystic fibrosis, and bronchopulmonary dysplasia. As
in all subsequent chapters, the authors, Valentine, Griffin, and Abrams, emphasize
the need for good general nutrition to ensure that an individual attains full genetic
potential. Malnutrition may be the result of inadequate nutrient intake — a possibility
that even in wealthy societies cannot be neglected — or may be due to illness or a
condition that magnifies the need for one or several nutrients. Diagnosis and assess-


weight reduction is recommended, sometimes facilitated by the need to avoid certain
foods or food constituents. An example is peptic ulcer disease, where strong gastric
stimulants should be avoided, even though antibiotics now constitute the principal
treatment, whereas for a long time previously, diet therapy played a major role.
Another example is Wilson’s Disease, where penicillamine treatment reduces the
body copper content and where copper-rich foods, e.g., beef liver, roasted cashew
nuts, and chocolate chips, should be avoided.
Diabetes mellitus is a condition that illustrates the complexity of medical and
nutritional management. Preuss and Bagchi, in Chapter 4, point out that glu-
cose–insulin perturbations, a category that includes but is broader than diabetes
mellitus, have increased in incidence, probably because of changes in lifestyle
brought about by industrialization, urbanization, and increased longevity. One con-
sequence of changes in lifestyle is the increase in obesity, which appears to exac-
erbate disturbances of insulin homeostasis. A primary goal of therapy is the return
to normal metabolism of the three major nutrient groups — carbohydrates, lipids,
and proteins — and the avoidance of later complications such as vascular disease
and insufficiency that may eventuate the need for amputation. To achieve that requires
intervention and the often substantial modification of social and cultural habits. This
represents a major challenge to the physician, as well to the patient, and the chapter
discusses these challenges as well as less classical approaches, such as the use of
botanical supplements.
Chapter 5 by Utermohlen discusses endocrine control of metabolism, with
emphasis on thyroid and glucocorticoid disease and, in Part 2, deals with diseases
of carbohydrate intolerance, specifically galactosemia and lactose intolerance. Sup-
pression of the excess hormone secretion in thyroiditis or Graves’ disease or thy-
roxine replacement in hypothyroidism needs to be accompanied by management of
the nutritional consequences of each condition, e.g., severe nutritional depletion of
persons with hypermetabolism due to thyrotoxicosis, or the difficulty of maintaining
a normal body weight for the hypothyroid patient. Special tables list the nutritional

diseases and their use to treat such diseases is perhaps less well known and is the
subject of Chapter 8 by Trevithick and Mitton. In addition to dealing with specific
eye diseases — cataracts, macular degeneration, retinopathy, retinitis pigmentosa,
glaucoma, and keratoconus — the authors describe the rod visual cycle and give a
lesson in genetics and oxidation stress. They also devote attention to the various
herbal nutritional supplements that have been proposed, some of which may be
harmful. Their reference list is particularly extensive for a field that may be unfamiliar.
Patients with cancer frequently suffer from protein-calorie malnutrition, with
weight loss the most common manifestation. Yet, as discussed by Mason and Choi,
in Chapter 9, evaluating this kind of malnutrition quantitatively is difficult, because
it depends entirely on the assessment tool employed. Still, physicians need to be
aware that malnutrition of a degree that worsens clinical outcome is common among
cancer patients. The chapter deals with the mechanisms of body weight loss in
cancer, the effects of the various major nutrients on cancer wasting, discusses the
efficacy of nutritional support, and provides specifics on how to accomplish this in
a variety of cancers, as well as in patients on chemotherapy or radiation therapy.
Targeted nutrient therapy, i.e., the administration of specific nutrients in more than
the usual quantities, e.g., omega-3 polyunsaturated fatty acids, or certain amino
acids, is critically discussed, as is the advisability of aggressive nutritional support,
either prophylactically or concurrent with treatment. Because many cancer patients
tend to seek and use “alternative” treatments, physicians and their staffs must try to
know this in order to better manage the patient’s treatment.
Smith and Souba deal in considerable detail with the nutritional aspects of trauma
and postsurgical care in Chapter 10. They analyze stress and the stress response in
relation to surgical stress, the determinants of the host response to stress, and the
role of cytokines as mediators of the stress response. Whereas most patients under-
going elective surgery are reasonably well nourished, there are specific endocrine
and neuroendocrine responses to surgery that have nutritional consequences and
need to be taken into account. In trauma patients, responses and consequences tend
to be more dramatic, and the increased metabolic demands following injury can

and the remainder of the chapter deals with approaches to be taken in mood and
psychotic disorders. Patients receiving monoamine oxidase inhibitors need to be on
a tyramine-restricted diet, which is described and discussed in detail.
For more than 3000 years, alcoholic beverages have been desirable drinks, yet
excessive drinking, leading to drunkenness and ultimately alcoholism, has been
known just as long. In the last chapter, Navder and Lieber discuss alcoholic bever-
ages, their place and effect on nutrition and nutritional status, the process of intox-
ication, and alcoholic liver disease. Potential treatment with polyunsaturated phos-
phatidylcholine, s-adenosylmethionine, or silymarin is discussed, and the effects of
alcoholism on the brain and other tissues besides the liver are described, as are drug
interactions. The authors thus deal with the correction of medical and nutritional
problems of alcoholism; more direct approaches, focusing on medication-induced
prevention, are emerging and when combined with the correction of nutritional
deficiencies, may, in the words of the authors, alleviate the suffering of the alcoholic
and reduce the public health impact of alcoholism.
In developing this book I was aware that most readers will read some, but not
all chapters. Repetition of nutritional principles and of applications therefore seemed
desirable. I thank the authors for their effort, patience, and willingness to accept
editorial suggestions, and CRC Press for bringing this project to fruition.

Felix Bronner

Farmington, Connecticut
March 2002

0945_ FM_fm* Page 10 Thursday, June 20, 2002 11:13 AM

The Editor

Felix Bronner, Ph.D.,


The American Journal of Physiology

,

The Journal of Nutrition

, and

The American
Journal of Clinical Nutrition

. Currently he is principal editor of the Bone Biology
domain of

TheScientific World Journal

. He was the founder and first chair of the
Gordon Research Conference on Bones and Teeth.

0945_ FM_fm* Page 11 Thursday, June 20, 2002 11:13 AM

0945_ FM_fm* Page 12 Thursday, June 20, 2002 11:13 AM

Contributors

Steven A. Abrams, MD

Children’s Nutrition Research Center
Baylor College of Medicine

Section of Neonatology
Baylor College of Medicine
Houston, TX

T. Alp Ikizler, MD

Vanderbilt University Medical Center
Nashville, TN

Jane Morley Kotchen, MD, MPH

Medical College of Wisconsin
Milwaukee, WI

Theodore A. Kotchen, MD

Medical College of Wisconsin
Milwaukee, WI

Chin Lee, MD

Pritzker School of Medicine
University of Chicago
Chicago, IL

Charles S. Lieber, MD

Bronx VA Medical Center and Mt. Sinai
School of Medicine
Bronx, NY


0945_ FM_fm* Page 13 Thursday, June 20, 2002 11:13 AM

F. Karen Olson, RD, LD

Mayo Clinic
Rochester, MN

Harry G. Preuss, MD

Georgetown University Medical
Center
Washington, DC

Sarah S. Richter, BS

School of Medicine
University of California at Davis
Davis, CA

J. Stanley Smith, Jr., MD

Penn State College of Medicine
M.S. Hershey Medical Center
Hershey, PA

Wiley W. Souba, MD, ScD, MBA

Penn State College of Medicine
M.S. Hershey Medical Center


0945_ FM_fm* Page 14 Thursday, June 20, 2002 11:13 AM

Contents

Chapter 1

Nutritional Support in Children 1

Christina J. Valentine, Ian J. Griffin, and Steven A. Abrams

Chapter 2

Nutrition and Cardiovascular Health 23

Theodore A. Kotchen and Jane Morley Kotchen

Chapter 3

Nutritional Support in Chronic Diseases of the Gastrointestinal Tract
and the Liver 45

Khursheed P. Navder and Charles S. Lieber

Chapter 4

Nutritional Therapy of Impaired Glucose Tolerance and Diabetes Mellitus 69

Harry G. Preuss and Debasis Bagchi


0945_ FM_fm* Page 15 Thursday, June 20, 2002 11:13 AM

Chapter 10

Nutritional Aspects of Trauma and Postsurgical Care 225

J. Stanley Smith and Wiley W. Souba

Chapter 11

Nutritional Management of Immunocompromised Patients: Emphasis
on HIV and AIDS Patients 267

Sarah S. Richter, Suzanne S. Teuber, and M. Eric Gershwin

Chapter 12

Food Intake Management in Patients with Psychiatric Disorders 291

Alexander R. Lucas, Diane L. Olson, and F. Karen Olson

Chapter 13

Nutrition and Alcoholism 307

Khursheed P. Navder and Charles S. Lieber

Index

321

Bronchopulmonary Dysplasia 14
Anthropometric Assessments of Growth in Infants with BPD 14
Relationship between Energy Metabolism, BPD, and Growth 15
Nutritional Management of Infants with Bronchopulmonary Dysplasia 15
Conclusion 16
Acknowledgments 16
References 16

INTRODUCTION

The care of children is increasingly driven by modern technology. With the use of
artificial surfactants and new ventilatory methods, the survival of the majority of
infants born at greater than 700 grams birth weight and a substantial portion of those
500 to 700 g at birth can be ensured. This achievement, however, has made it
necessary for nutritional support for premature infants and for the many children
with acute and chronic illnesses to constitute an integral part of clinical management.
1

0945_C01_fm.book Page 1 Tuesday, June 18, 2002 8:29 AM

2

Nutritional Aspects and Clinical Management of Chronic Disorders and Diseases

Complete nutritional support includes nutritional assessment, management, and
surveillance strategies. The goal of this integrated approach is to avoid malnutrition
and its resulting adverse effects on growth,

110


Clinically, physical signs can reflect nutrient deficiencies
but are late indicators of nutritional status

105

(Table 1.1). Subtle nutrient deficiencies
can be identified earlier with the use of tools such as 24-hour dietary recalls or 3-
to 5-day food diaries, which are then compared with the U.S. recommended dietary
intakes (RDA). These intakes for most nutrients have been updated recently but a
single revised RDA is not yet available.
Indirect calorimetry is a more sophisticated method to measure caloric require-
ments,

20

but it is technically difficult and not yet widely used clinically in children.
Body composition is routinely evaluated with the aid of measurements of weight,
length (or height for children over 2 years of age), and head circumference and is
plotted for age using the new Centers for Disease Control (CDC) growth charts
(http//www.cdc.gov/growthcharts). Generally, percentiles of normative values are
between the 5th and 95th percentile. Body stores of protein and calories are indi-
rectly measured using anthropometric measures such as mid-arm circumference and
triceps skinfold, respectively.

37

Mid-arm circumference is measured by relaxing the
arm and measuring the arm circumference midway between the olecranon and the
tip of the acromion.


13

Additional methods, such
as hydrodensitometry, total body potassium, total body water, neutron activation,
photon and x-ray absorptiometry, bioelectrical impedance, and total body electrical
conductivity, can be used to estimate the proportion of lean and fat tissue but have
limited clinical use in hospitalized children.

2

Effective management and surveillance begins after classification of nutritional
status is obtained. Waterlow

110

has established a triad approach to the determination
of the level of malnutrition by dividing subjects into three groups: 1) normal;

0945_C01_fm.book Page 2 Tuesday, June 18, 2002 8:29 AM

Nutritional Support in Children

3

TABLE 1.1
Clinical Signs Associated with Nutritional Deficiencies

Nutritional Deficiency Clinical Signs

Skeletal & Muscle Systems

Riboflavin Magenta tongue
Folate, niacin, riboflavin, iron, vitamin B

12

Atrophic filiform papillae
Niacin, folate, riboflavin, iron, vitamin B

12,

Pyridoxine Glossitis
Teeth
Fluorine Caries
Gums
Vitamin C Swollen, bleeding
Glands
Iodine Thyroid enlarged
From Suskind RM and Varma RN. Assessment of nutritional status of children.

Pediatr. Rev

. 5:195–202,
1984. With permission.

0945_C01_fm.book Page 3 Tuesday, June 18, 2002 8:29 AM

4

Nutritional Aspects and Clinical Management of Chronic Disorders and Diseases



Triceps Skinfold Percentiles (mm

2

)
Age
Group
5 25 50 95 5 25 50 95

Males

Females

1–1.9 6 8 10 16 6 8 10 16
2–2.9 6 8 10 15 6 9 10 16
3–3.9 6 8 10 15 7 9 11 15
4–4.9 6 8 914 7 81016
5–5.9 6 8 915 6 81018
6–6.9 5 7 816 6 81016
7–7.9 5 7 917 6 91118
8–8.9 5 7 816 6 91224
9–9.9 6 7 10 18 8 10 13 22
10–10.9 6 8 10 21 7 10 12 27
11–11.9 6 8 11 24 7 10 13 28
12–12.9 6 8 11 28 8 11 14 27
13–13.9 5 7 10 26 8 12 15 30
14–14.9 4 7 9 24 9 13 16 28
15–15.9 4 6 8 24 8 12 17 32
16–16.9 4 6 8 22 10 15 18 31

(defined as “very low birth weight,” VLBW). These infants have missed much or

TABLE 1.3
Percentiles of Upper Arm Circumference (mm) for Whites of the
United States Health and Nutrition Examination Survey I of 1971 to 1974

Age
Group
5 25 50 95 5 25 50 95

Male

Female

1–1.9 142 150 159 183 138 148 156 177
2–2.9 141 153 162 185 142 152 160 184
3–3.9 150 160 167 190 143 158 167 189
4–4.9 149 162 171 192 149 160 169 191
5–5.9 153 167 175 204 153 165 175 211
6–6.9 155 167 179 228 156 170 176 211
7–7.9 162 177 187 230 164 174 183 231
8–8.9 162 177 190 245 168 183 195 261
9–9.9 175 187 200 257 178 194 211 260
10–10.9 181 196 210 274 174 193 210 265
11–11.9 186 202 223 280 185 208 224 303
12–12.9 193 214 232 303 194 216 237 294
13–13.9 194 228 247 301 202 223 243 338
14–14.9 220 237 253 322 214 237 252 322
15–15.9 222 244 264 320 208 239 254 322
16–16.9 244 262 278 343 218 241 258 334

monal,

9

motor,

14

and digestive

71

functions, so standard approaches to feeding may
be inappropriate. Consequently, VLBW infants are susceptible to malnutrition that
may lead to poor growth,

47

chronic lung disease,

99

rickets,

101

and cholestasis.

10


small for gestational age (SGA), or large for gestational age (LGA). Appropriate for
gestational (AGA) infants are in the 10th to 95th percentile of weight for their
gestational age; small for gestational age infants (SGA) are below the 10th percentile;
and large for gestational age (LGA) are above the 90th percentile. The risk of growth
failure is increased in SGA infants, and they often have greater nutrient requirements
than AGA infants.

78

Large for gestational age infants (LGA) also have health risks
such as hypoglycemia, requiring greater glucose intakes initially.

48

In addition,
difficulty in labor and delivery, as evidenced by a low Apgar score at 5 minutes of
age, has been associated with a higher incidence of necrotizing enterocolitis. The
clinical diagnosis, maternal and perinatal history, human milk availability, and med-
ications often influence feeding plans and should be noted.
The usual goal of nutrition support for premature infants is to attempt to achieve
intrauterine nutrient accretion rates.

5

Defining these rates is not always simple,
because good recent data for normal

in utero

accretion of most nutrients are not


It must be empha-
sized that these should be used as guidelines and not standards because of differences
in birth weights, illness patterns, feeding practices, and the management styles of
the clinical settings in which they were developed. Optimal nutrition should then

0945_C01_fm.book Page 6 Tuesday, June 18, 2002 8:29 AM

Nutritional Support in Children

7

provide nutrients of proper quantity and quality to avoid catabolism and provide
accretion without adding a toxic overload to such an immature infant.

N

UTRIENT

N

EEDS
AND

M

ANAGEMENT


intra-
ventricular hemorrhages,

36

or necrotizing enterocolitis.

12

Recommended intravenous
volumes include initially 60 to 80 ml/kg/day on day one, advancing to 150 ml/kg/day
by day five. Fluid losses can increase significantly in very immature infants, those
receiving phototherapy, and those nursed under radiant warmers.

50

Electrolytes
needed include sodium, 2 to 4 meq/kg/day, and potassium, 1 to 2 meq/kg/day, to
maintain normal serum electrolytes and urine output. Electrolyte supplementation
must be guided by frequent monitoring of the serum electrolyte concentrations. If
the infant has additional fluid and electrolyte losses, as for example in the case of
intra-abdominal infections or losses from chest tubes or ostomies, then frequent
monitoring is needed to ensure appropriate fluid and electrolyte replacement.

Parenteral Nutrition

Energy Needs

An energy source should be started rapidly because of the infant’s limited glycogen

8

Nutritional Aspects and Clinical Management of Chronic Disorders and Diseases

Lipids

A lipid source is needed to avoid essential fatty acid deficiency

33

because stores of
linoleic acid (C18:2w6) are low in premature compared to term infants.

33

A minimum
of 0.5 to 1 g/kg/day of lipid is needed to avoid essential fatty acid deficiency.

3

A
continuous 24-hour infusion

54

of 20% Intralipid

®

(KabiVitrum) intravenous emulsion


and it has been speculated that long-term
parenteral nutrition without carnitine may limit efficient fatty acid oxidation.

58

Carnitine can, if desired, be given as an intravenous supplement of 10mg/kg/day, if
no source of enteral milk is given for prolonged periods.

Protein

Protein can be begun on the first day of life at 1 to 2 g/kg/day and should be advanced
to at least 3g/kg/day as soon as feasible to promote positive nitrogen balance.

85

Cystathionase activity is minimal in the liver of infants,

103

as are cystathionine

γ

-lyase
and cysteinesulfinic acid decarboxylase.

114

Cysteine and taurine, therefore, become

Vitamins and Minerals

Vitamins in parenteral nutrition mixtures are provided in the United States using
MVI-Pediatric (Armour) at a dose of 40% of the 5 ml vial if the infant weighs less
than 2kg (38) and at 100% if the infant weighs more than 2kg.
Preterm infants are born with low reserves of vitamin A.

93

Parenteral nutrition
sources are low in vitamin A and a substantial amount, up to 50 to 75%, is lost in
the intravenous tubing.

94

Several investigators have reported that infants with chronic
lung disease have lower plasma vitamin A levels than healthy premature infants,

93,109

and some clinical trials have suggested that supplementation with parenteral vitamin
A may decrease the incidence of bronchopulmonary dysplasia in at-risk infants.
Delivery of vitamin A can be markedly enhanced by the direct addition of
multivitamins

39

or of a retinyl palmitate source directly in the lipid infusion.

111