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									Pink-Extra Credit                Blue-Nutrition Care Manual
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                                         Department of Nutrition
                                         School of Public Health
                                University of North Carolina at Chapel Hill

                             NUTRITION 640: Medical Nutrition Therapy
                                         SPRING 2009

I.     Course Description
       A lecture and skills course where students practice skills (such as calculating caloric intake and
       modifying intake, calculating diabetic diets, calculating sodium content of intakes, etc.) under the
       supervision of a registered dietitian. Nutrition 600, 610, 630 and 650 or equivalents required as a
       prerequisite or as a co-requisite.

II.    Instructor
               Amanda S. Holliday MS, RD, LDN
               Office: 241 Rosenau
               Office Hours: By Appointment
               Telephone: 966-7214

III.   Textbooks
           Mahan, K. and Escott-Stump, S. Krause’s Food, Nutrition and Diet Therapy, 12 Edition

           Pronsky, Zaneta M. Food-Medication Interactions. 15 Edition, 2008.

           Course pack at medical bookstore

       Other resources:
           ADA web site: for Position Papers link (along left side of home page) and
             other menu items of interest (explore and learn more about the profession)
           Blackboard for many of the readings, case studies, assignments and study guides
           Nutrition Care Manual (, username:
   , password: nutr64009)
           2nd floor study room
             - A physiology text and a medical dictionary

IV.    Foundation Knowledge covered in this course:
       1. the pathophysiology related to nutrition care;
       2. the macronutrient, fluid and electrolyte needs of individuals with a variety of disease states;
       3. laboratory parameters relating to various disease states;
       4. translate nutrition needs for common conditions into menus for individuals;
       5. document nutrition needs and suggested therapies in appropriate medical format;
       7. complementary and alternative nutrition and herbal therapies;
       6. some of the ethical issues related to nutrition care
       7. evolving methods of assessing health status
       8. assessment and treatment of nutritional health risks
       9. medical nutrition therapy
       10. strategies to assess need for adaptive feeding techniques and equipment

       By the end of this course students will have demonstrated the ability to:
       1. screen individuals for nutritional risk
       2. collect pertinent information for comprehensive nutrition assessments
       3. interpret medical terminology
       4. interpret laboratory parameters relating to nutrition
       5. calculate and interpret nutrient composition of foods
       6. calculate and/or define diets for health conditions
       7. calculate enteral and parenteral nutrition formulations
       8. translate nutrition needs into food choices and menus
       9. counsel individuals on nutrition
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V.    Learning Experiences
      1. Students will independently complete assignments covering varying aspects of the disorders
         under discussion.
      2. Study Guides are provided that will help the student organize information around various
         disease states. Completion of the study guides is optional for Nutrition 640 but will be required
         for the MPH students during Nutrition 710.
      3. In the assigned groups, students will work on the case study and lead a discussion of about
         20 minutes on the case.
      4. Each student who plans to become a registered dietitian in the near future would benefit from
         developing a Pocket Brain/Cheat Book to be used during supervised practice experiences.
         This is a collection of material you feel will help you get through your day. Throughout the
         semester suggestions will be made about what to put in your pocket brain but it is really up to
         the individual. Pocket brains can be used during the completion of the open book
         portions of exams in this class.

VI.   Grading
      Evaluation of student performance in this course will be based on the following:
              Learning experiences             30%
              Exams (3)                        70%
              Exams in this class are both closed book and open book. The open book exams will be
              practical work similar to homework assignments. Any reference that you have can be

      Grading Scale:
      Undergraduates:                                 Graduates:
         97-100          A+                                       93-100          H
           93-96         A                                          75-92         P
           90-92         A-                                         70-74         L
           87-89         B+                                      Below 70         F
           83-86         B
           80-82         B-
           77-79         C+
           73-76         C
           70-72         C-
        Below 70         D
        Below 60         F

      Honor System: The Honor Code is in effect in this class and all others at the University. I am
      committed to treating Honor Code violations seriously and urge all students to become familiar
      with its terms set out at If you have questions, it is your responsibility to
      ask me about the Code’s application.

      All exams and assignments must be submitted with the following signed statement:
      On my honor, no unauthorized assistance has been received or given in the completion of this
                                    Signature: ___________________________________

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VII.   Course Schedule

M      1/12   Introduction to the course
              A review of the medical record and an introduction to medical terminology
              Text: Krause, Chapter 17 and Appendix 1: General Abbreviations
              On Blackboard:
                      Position Paper: Role of the RD and DTR in Health Promotion and Disease Prevention
                      Position Paper: Integration of medical nutrition therapy and pharmacotherapy
                      NCP and MNT (side by side)
                      Public Policy News: The impact of HIPAA electronic transmissions and health
                            information privacy standards, JADA, 101(5), May 2001
                      Mp3 Download for ipod: Basic Word Structure (follow with Chabner Ch.1)
              Study Guide: General Medical Abbreviations
              Study Guide: Medical Terminology
              Assignment #1: Medical Terminology (due 1/14)

W      1/14   Routine Hospital Diets and Nutritional Supplements
              Text: Krause, Chapter 17 and Appendices 32-37
              Blackboard: Gelber, S. The Healing Potential of Hospital Food. Medscape General Medicine
                      7(3): 1-3, July 2005.
              ADA Nutrition Care Manual: Dysphagia (all)
              Assignment #1 due

F      1/16   Estimating Intakes
              On Blackboard: Position Paper: Fat Replacers
                      Position Paper: Use of nutritive and non-nutritive sweeteners
                      Position Paper: Weight Management
                      Zeman Chapter 6
              Exchange Lists for Weight Management (from Nutrition 630)

M      1/19   Martin Luther King Holiday – no class

W      1/21   Estimating Needs
              Text: Krause, Chapter 14
              On Blackboard:
                      Boullata, et. al, Accurate Determination of Energy Needs in Hospitalized Patients, JADA
                          107 (3): 393-401, 2007
                      Support Line article by Fish: Using equations to estimate caloric requirements in obese
                              people 26 (6): 20-22, 2004

F      1/23   Estimating Needs (con’t)
              Review assessment materials from Nutrition 630 or Krause, Chapters 13-14; Appendix 29.

M      1/26   Fluids and Electrolytes
              Text: Krause, Chapter 4
              On Blackboard: Simmons and Assell Acid-Base Basics, Support Line, 23(1), pg. 6-11, 2001
              Study Guide: Acid Base Balance

W      1/28   Pulmonary Disease
              Text: Krause, Chapter 35 – skip Cystic Fibrosis;
              Blackboard: Malone, A.M. Acute Respiratory Distress Syndrome: Pathophysiology,
                      Treatment and Nutrition Intervention, Support Line 20(6): 8-15, December 1998.
              Web site: click on A Physician’s
                      Guide to Nutrition in Chronic Disease Management (scroll to p. 6 – Chronic Obstructive
                      Pulmonary Disease)
                      Mrs. Holliday Presents: COPD Case #24: Stella Bernhardt
              Study Guide: Pulmonary Disease
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F     1/30   Enteral Nutrition
             Text: Krause, Chapter 20, pp. 506-516
             On Blackboard: Hearing, S.D. Refeeding syndrome is underdiagnosed and undertreated, but
                               treatable. British Medical Journal 328: 908-909, April 17, 2004.
                               Seder, C and Janczyk R. The Routine Bridling of Nasojejunal Tubes is a Safe
             and Effective Method of Reducing Dislodgement in the Intensive Care Unit. Nutrition in Clinical
             Practice 2008; 23; 651-654.

M      2/2   Enteral Practical work: Calculating Tube Feeding Requirements
             On Blackboard:
                     American Gastroenterological Association Medical Position Statement: Guidelines for
                              the Use of Enteral Nutrition. (Note: this is old but still comes up as one of the
                              best articles on the topic)
                     Duncan, H.D. and Silk, D.B.A. Tube Feeding Associated Diarrhea. The Oley Foundation
                     Parrish, Enteral Nutrition: The Art and Science. Nutrition in Clinical Practice 2003

W      2/4   The Upper GI Track
             Text: Krause, Chapter 26
             On Blackboard:
                     Beyer, P. L. Gastrointestinal disorders: Role of nutrition and the dietetics practitioner.
                             JADA 98(3): 272-277, 1998.
                     Nilsson et al. Lifestyle related risk factors in the aetilogy of gastroesophageal reflux Gut
                     2004; 53: 1730-1735
                     Flook. GERD: A fresh look at a common problem in primary care. The Journal of
                     Family Practice, 2007, 56(10A), pgs31a-34a.

             Study Guide: GI Diseases
             Assignment #2 Due: Pulmonary Disease/Enteral Feeding

F      2/6   Malabsorption Problems
             Texts: Krause, Chapter 27, pp. 681-689 and Chapter 38, pp. 909-919
             On Blackboard:
                     Grant, J. P., et. al. Malabsorption Associated with Surgical Procedures and Its
                             Treatment. Nutrition in Clinical Practice 11(2): 43-52, 1996.
                     Wooldridge, N. H. Nutrition Management of Cystic Fibrosis. Nutrition Focus 17(5): 1-9,
                             September/October 2002.
                     Gordon, et al. Nutrient Status of Adults with Cystic Fibrosis, JADA 107(12): 2114-2119,
                     Thompson, T. Questionable foods and the gluten-free diet: Survey of current
                             recommendations. JADA 100(4): 463-465, 2000.
                      See and Murray. Gluten-Free Diet: The Medical and Nutrition Management of Celiac
                             Disease. Nutrition in Clinical Practice 21:1-15, 2006.

M      2/9   The Lower GI Track
             Texts: Krause, Chapter 27; Appendix 41
             On Blackboard:
                      Matarese, et al. Short Bowel Syndrome: Clinical Guidelines for Nutrition Management.
             Nutrition in Clinical Practice 20: 493-502, 2005.
                      Wong, K. The Role of Fiber in Diarrhea Management. Support Line 20(6): 16-20,
                                December 1998.
                      Position Paper: Health Implications of Dietary Fiber. JADA 102(7): 993-1000, 2002
                      Case #14: Turn in for 5 points extra credit by 2/8
             Group 6: Stroke Case #18 due

W     2/11   TEST #1 Part A-Closed Book (1/12 through and including 2/9)
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F     2/13   TEST #1 Part B-Open Book

M     2/16   Nutrition in Rehabilitation Settings
             Group 6: Parkinson’s Disease Case #18 presentation
             Text: Krause, Chapter 41 and Appendix 35;
             On Blackboard:
                      Brody, R., Touger-Becker, R., vonHagen, S. and O’Sullivan-Maillet, J. Role of
                              registered dietitians in dysphagia screening. JADA 100(9): 1029-1037, 2000.
                      Palmer, J.B., Drennan, J.C. and Baba, M. Evaluation and Treatment of Swallowing
                              Impairments, American Family Physician 61(8): 2453-2462, April 2000.
                      Cook, A et al. Nutrition Considerations in Traumatic Brain Injury. Nutrition in Clinical
             Practice 23(6): 608-620, December 2008
             Study Guide: Rehabilitation

W    2/18    Critical Care and Pressure Ulcers
             Text: Krause, Chapter 39
             On Blackboard:
                      Fleishman, A. Adult Wound Care: Management of Pressure Ulcers. Today’s
                              Dietitian 7(1): 38-41.
                      Forrette, T.L. Indirect Calorimetry: Principles and Applications for Managing
                              Critically Ill Patients. Medscape General Medicine 7(4): 1-12, November 2005.
                      ADA Position Paper: Liberalization of the diet prescription improves quality of life for
                              older adults in long term care.

F     2/20   Parenteral Nutrition
             Text: Krause, Chapter 20, pp. 516-530

M     2/23   Parenteral Nutrition Practical work

W     2/25   Parenteral Nutrition Practice
             Case Studies - Estimating Intakes and Parenteral needs
             Group 1: Liver Disease Case #20 due

F     2/27   Liver Disease
             Text: Krause, Chapter 28, pp. 707-731
             On Blackboard:
                     Lieber, C.S. Relationships between nutrition, alcohol use and liver disease. Alcohol
                              Research and Health 27(3): 220-231, September 29, 2004.
                     Support Line article by Ariyan, W. Nutrition Management of Liver Disease. Support
             Line 26(6): 3-9, 2004.
             Study Guide: Liver and Gallbladder Disease
             Assignment #3 Due: Parenteral Nutrition

M      3/2   Liver and Gallbladder Disease (con’t)
             Group 1: Liver and Gallbladder Disease Case Study #20 presentation
             On Blackboard:
                     Gurk-Turner, C. Management of the Metabolic Complications of Liver Disease: An
                              Overview of Commonly Used Pharmacological Agents. Support Line 19(4): 17-
                              19, 1997.
             Group 2: Oncology Case Study #31 due

W      3/4   Exam 2A - Closed Book (2/16 through and including 3/2)

F      3/6   Exam 2B - Open Book (comprehensive)

             March 8-10 North Carolina Dietetic Association Meeting
             Durham, NC
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M      3/9   Spring Break

W     3/11   Spring Break

F     3/13   Spring Break

M     3/16   The Role of the Dietitian on the transplant team
             Text: Krause, Chapter 34 pgs. 895-896
             On Blackboard: Hasse, The Benefits of Nutrition Therapy in the Liver Transplant Patient
                              National Kidney Foundation, Nutrition and (kidney) transplantation

W     3/18   Cancer and HIV/AIDS
             Group 2: Oncology Case Study #31 presentation
             Text: Krause, Chapters 37 and 38
             On Blackboard:
                     Position of the ADA and Dietitians of Canada: Nutrition Intervention in the care of
                             persons with human immunodeficiency virus infection. JADA 104(9): 1425-1441,
                             September 2004.

F     3/20   Practical work related to cancer
             Texts: Krause, Chapter 18
             On Blackboard:
                     Spaulding-Albright, N. A review of some herbal and related products commonly used in
                              cancer patients. JADA 97(10) Supplement 2: S208-S215, 1997.
                     Position Paper: Functional Foods. Reaffirmed June 15, 2001.
             Group 3: Cardiovascular Disease Case Study #7 due

M     3/23   HTN/Congestive Heart Disease
             Text: Krause, Chapter 32 and 33
             On Blackboard:
                    Ayala, C., Croft, J.B. Wattigney, W.A. ad Mensah, G. A. Trends in Hypertension-
                            Related Death in the US: 1980-1998. J Clin Hypertension 6(12): 675-681, 2004.
                    Appel, L.J. Lifestyle Modification: Is It Achievable and Durable? The Argument For (Part
                            1) J Clin Hypertension 6(10):578-581, 2004.
                    Pickering, T.G. Lifestyle Modification: Is It Achievable and Durable? The Argument
                            Against (Part 2) J Clin Hypertension 6(10):581-584, 2004.
                    Kokkinos, P., Panagootakos, D.B. and Polychronopoulous, E. Dietary influences on
                            blood pressure: The effects of the Mediterranean diet on the prevalence of
                            hypertension. J Clin Hypertension 7(3):165-170, 2005.
             Web site:
                    Your Guide To Lowering Your Blood Pressure With DASH; NIH Publication #06-4082
W     3/25   Cardiovascular Disease
             Group 3: Cardiovascular Disease Case Study #7 presentation
             Text: Krause, Chapter 32
             On Blackboard:
                    Barclay, L. Waist-to-Hip Ratio vs BMI may be more accurate predictor of CV Risk.
                            Medscape Medical News, November 7, 2005.
                    Third Report of the National Cholesterol Education Panel Expert Program on
                            Detection, Evaluation and Treatment of High Blood Cholesterol in Adults:
                            Executive Summary, May 2001.
             Group 4: Diabetes Mellitus Case Study #27 due
             Study Guide: Cardiology
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F     3/27   Practical work related to heart disease
             On Blackboard:
             Case #6

M     3/30   Type I Diabetes
             Group 4: Diabetes Mellitus Case Study #27 presentation
             Text: Krause, Chapter 33
             Assignment #4: Nelms, Case #23 (due 4/15)
             Study Guide: Diabetes

W      4/1   Practical Work in Diabetes
             On Blackboard: Evidence Based Nutrition Principles and Recommendations for the Treatment
                     and Prevention of Diabetes and Related Complications, Diabetes Care 26:S51-S61,

F      4/3   Type II Diabetes and Gestational Diabetes
             On Blackboard:
                     Position Statement American Diabetes Association: Gestational Diabetes Mellitus.
                             Diabetes Care 27: S88-90, 2004.
                     Position Statement American Diabetes Association: Type 2 Diabetes in Children and
                             Adolescents. Diabetes Care 23(3): 381-389, 2000.
                     Javanovic, L. Current Management of Gestational Diabetes Mellitus. Nutrition & the
                     MD 24(12):1-8, 1998.

M      4/6   Managing Type I Diabetes in Children and Adolescents
             Guest Speaker: Gwen Murphy, PhD, RD, LDN
                            Coordinator, Duke Diabetes Camp
             Course Pack: Brink, S. J. How to apply the experiences from the Diabetes Control and
                            Complications Trial to children and adolescents? Annals of Medicine 29: 425-
                            438, 1997.
                    Gregory, P. Nutrition management of a collegiate football player with insulin
                            dependent diabetes: Guidelines and a case study. JADA 94(7): 775-777,
                            1994. (Getting old but illustrates a point)

W      4/8   Catch up as needed OR
             Medical Ethics and Patients’ Rights
             On Blackboard:
                     Barclay, L. FDA Approves Implantable Chip Used to Access Medical Records.
                             Medscape Medical News, October 25, 2004.
                     Position Paper: Ethical and legal issues in nutrition, hydration and feeding.
                     Standards of Professional Practice for Dietetics Professionals.
                     Code of Ethics for the Profession of Dietetics

F     4/10   Spring Holiday-no class

M     4/13   Problems in Pediatrics – Infant Formulas, Failure to Thrive and Childhood Obesity
             Guest Speaker: Gwen Murphy, PhD, RD, LDN
                            Pediatric Dietitian, Duke University Medical Center
                            Pederson, A.L. Tube Feeding Update. Nutrition Focus, 17(6): 1-8, Nov/Dec

W     4/15   Selected Developmental Disabilities – Clefts and Cerebral Palsy
             On Blackboard: Krick, J. Nutritional Implications in Children with Cerebral Palsy. Nutrition
                            Focus 18(3): 1-7, 2003.
             Web sites:; Link to Feeding Issues
                            Epilepsy Foundation site on General information about the ketogenic diet
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             Assignment #4 due: Nelms Case #23

F     4/17   Renal Disease - Pre-dialysis
             Text: Krause, Chapter 36
             Case #32
             Group 5: Renal Disease Case Study #26 due

M     4/20   Renal Disease - Peritoneal Dialysis
             On Blackboard:
                    Beto, J. A. Which Diet for Which Renal Failure: Making Sense of the Options. JADA
                             95(8): 898-903, 1995.
                    Support Line article by Richards, M. Nutrition management of the patient with acute
                             renal failure. Support Line 26(6): 10-19, 2004.

W     4/22   Renal Disease – Hemodialysis
             Group 5: Renal Disease Case Study #26 presentation
             Text: Krause, Chapter 36
             On Blackboard:
                     Rubin, H.R., Patient Ratings of Dialysis Care with Peritoneal Dialysis vs
                             Hemodialysis. JAMA 291(6): 697-703, February 11, 2004.
                     Charney, David I. Medical Treatment in Renal Disease: Basic Concepts in Dialysis.
                             Support Line 20(1): 3-7, 1998.

F     4/24   Osteodystrophy and other Musculoskeletal Disorders
             On Blackboard: Renal Osteodystrophy
                      Cunningham, E. What nutritional factors affect the risk of gout? JADA 104(11): 1737,
                             November 2004.
             Nutrition Care Manual: Purine Restricted Diet

M     4/27   Practical work related to kidney disease
             Case #33
             Assignment #5 due
             Course Evaluations

M     5/04   Final Exam at 8:00 A.M.
             Closed book from 3/16 through 4/27
             Open book is comprehensive
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                                         Department of Nutrition
                                         School of Public Health
                                University of North Carolina at Chapel Hill

                              NUTRITION 640: Medical Nutrition Therapy
                                          SPRING 2007

Case Studies: There is a lot of material covered in the case studies so I will work with each group to
identify which questions in the case study to focus on. Some of it will be didactic and some of it will be
practical hands on. Please have your Case Study to me 1-2 days prior to your presentation so I can review
it and make changes if necessary. Please let me know your thoughts and concerns as the semester goes
on and don’t wait until the course is finished.

Bennie                    Group 5: Renal Disease, Case #26: Enez Joaquin
Boden                            Material due: April 17, 2009
Bryan                            Presentation: April 22, 2009

Cox                       Group 3: Cardiovascular Disease, Case #7: James Klosterman
Gold                             Material due: March 20, 2009
Grubb                            Presentation: March 25, 2009

Loftis                    Group 1: Liver Disease, Case #20: Teresa Wilcox
Marsh                            Material due: February 25, 2009
Medders                          Presentation: March 2, 2009

Mosberg                   Group 2: Oncology, Case # 31: Denise Mitchell
O’brien                          Material due: March 2, 2009
Paxton                           Presentation: March 18, 2009

Salucci                   Group 4: Diabetes, Case #22: Susan Cheng
Simmons                          Material due: March 25, 2009
Um                               Presentation: March 30, 2009

Witnov                    Group 6: Stroke, Case #18: Ruth Noland
Wyatt                            Material Due: February 9, 2009
Yarbrough                        Presentation: February 16, 2009

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