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Dietetics 2 - Balanced diet | Malnutrition
Quiz by Keisha S Lewis
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Durata: 2 ore Obiettivi della lezione: ✅ Comprendere l’importanza del menù nella ristorazione ✅ Analizzare i criteri per la creazione di un menù bilanciato ✅ Studiare le tipologie di menù ✅ Saper progettare un menù in base al contesto e al target PRIMA PARTE: TEORIA (50 minuti) 1. L’importanza del menù nella ristorazione Il menù è la “vetrina” del ristorante: definisce l’identità del locale Influenza la scelta del cliente e il successo economico dell’attività Deve rispettare la filosofia del ristorante (tradizionale, gourmet, etnico, fast casual, fine dining…) 2. Le tipologie di menù 🔹 Menù fisso → prezzo stabilito, piatti predefiniti (es. menù turistico) 🔹 Menù à la carte → ampia scelta, prezzi diversi per ogni portata 🔹 Menù degustazione → percorso gastronomico consigliato dallo chef 🔹 Menù stagionale → basato su ingredienti disponibili in una stagione 🔹 Menù dietetico o speciale → per esigenze alimentari (vegetariano, vegano, senza glutine, ipocalorico) 3. Criteri per la creazione di un menù equilibrato ✔ Equilibrio nutrizionale → bilanciamento tra proteine, carboidrati e verdure ✔ Varietà di sapori, colori e consistenze → alternare piatti leggeri e strutturati ✔ Stagionalità e territorialità → ingredienti freschi e locali ✔ Fattibilità tecnica → piatti realizzabili con attrezzature e personale disponibili ✔ Food cost e profitto → costi delle materie prime e margine di guadagno SECONDA PARTE: ESERCITAZIONE PRATICA (50 minuti) Attività 1: Analisi di menù esistenti (20 min) 📌 Gli studenti analizzano diversi menù di ristoranti reali, valutando: Struttura (numero di portate) Bilanciamento dei piatti Prezzi e target di clientela 🔹 Domande guida: Il menù è vario ed equilibrato? I prezzi sono coerenti con la qualità e il tipo di locale? Il menù è chiaro e leggibile? Attività 2: Creazione di un menù (30 min) 📌 Divisi in gruppi, gli studenti progettano un menù per un ristorante a scelta tra: Trattoria tradizionale Ristorante gourmet Pizzeria con proposte innovative Street food di alta qualità 🔹 Consegna: 4 portate (antipasto, primo, secondo, dessert) Nome dei piatti e breve descrizione Prezzo indicativo Giustificazione delle scelte 🎤 Presentazione finale: ogni gruppo presenta il proprio menù alla classe e ne discute le scelte. CONCLUSIONE (20 minuti) Revisione delle attività svolte Domande e chiarimenti Riflessione sull’importanza della progettazione di un buon menùChapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we won’t talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined α and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic Drug Alpha1 Blockers (we’ve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an α1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic Drugs Alpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels → lowers peripheral resistance → Results in decreased BP So ….Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesn’t everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitors aka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patient’s chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-life Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers (ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia… Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTN Treatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)Filmic Techniques Based on the work of Brad Smilanich Mis-en-Scene: originally a French theatrical term arrangements of all the visual elements of the stage area in film – “the contents of the frame and the way those contents are organized” include: lighting, costume, décor, props, camera movement or distance . . . all photographic decisions etc. Proxemics: Spatial relationship among characters within the mis-en-scene Rule of Thirds: a compositional rule of thumb in painting, design, photography etc. suggests image divided into 9 equal parts with two vertical and two horizontal lines important elements of the mis-en-scene should be placed along these lines and their intersections some suggest aligning with intersections makes for more interesting pictures than just centreing the subject Proxemics Camera Distance: Quite literally, how far the camera is from the subject being filmed The Hand Camera Camera Distance: Quite literally, how far the camera is from the subject being filmed Extreme Close Up: Singles out one small portion of the body or object Used to intensify emotion, or show reaction Camera Distance: Close up Shot: Shows head of character or small significant object Used to show emotions Camera Distance: Medium Shot: shows figures from the waist up allows character to be seen within background Camera Distance: Long Shot: shows figures from feet up similar to the “stage” in live theatre orients audience to figures within a location or surrounding Camera Distance: Extreme Long Shot: Sometimes called an ‘establishing shot’ Panoramic view of an exterior location orients audience to a location Camera Distance: Camera Angle: Camera’s angle of view relative to the subject being photographed High Angle Shot: looks down on the subject often used to make the subject look small and insignificant (in combination with camera distance) puts the camera (audience) in ‘power’ position Camera Angle: Low Angle Shot: looks up at the subject often used to make the subject look large and powerful puts the camera (audience) in a ‘submissive’ position Camera Angle: Flat Angle Shot: camera on same plane as the subject feels most ‘normal’ to an audience Camera Angle: Canted Shot: frame is unbalanced in relation to the subject may indicate a symbolic unbalance in the character Camera Angle: Camera Movement literally the camera moving with or around or to follow the subjects in the mis-en-scene or frame Camera Movement: Tilting Movement camera moves up or down on a horizontal axis similar to head nodding movement may be used to show subjects relation to surroundings Camera Movement: Panning Movement camera moves side to side on a vertical axis similar to head shaking movement may be used to establish setting Camera Movement: Dolly Movement camera mounted on a vehicle that moves along with the subject (camera moves, not pivots) follows the subject to signify something important Camera Movement: Crane Shot camera mounted on a crane or boom permits camera to move in & out, up & down, backward & forward often used for high aerial establishing shots Misc. Shots: Hand Held: camera carried to seem jerky, giving ‘realistic feel’ Push In: camera moves up to a character’s face to indicate an epiphany (realization) Spiral: camera circles subject for effect End for ELA 20-2 and 10-1 Shot Transitions/Editing: artificial editing done to string together multiple shots to create a narrative scene or sequence a cut is the change from one shot to another usually separated in to ‘soft’ and ‘hard’ cuts Jump Cut: an instantaneous change from one shot to another this can be very natural or may disorient the audience, depending on how it is used Transitions/Editing Swish Pan: A pan where the speed of the camera is so fast that images are blurry used often to connect events in different settings that are connected by time Transitions/Editing Dissolve: transition where one shot gradually dissapears while another shot gradually appears often used to suggest change of setting or long time passage i.e. flashbacks Transitions/Editing Fade In/Out: transition where the shot gradually overexposes to white or underexposes to black often used to suggest a lengthy passage of time or change in location Transitions/Editing Wipe: transition where one shot is gradually eliminated as another shot moves onto the screen can be vertically or horizontally often suggests movement of the camera to another location Transitions/Editing Iris In/Out: transition where one shot gradually appears as an expanding circle in the middle of an old image suggests . . .??? Transitions/Editing Shot-Reverse Shot: one character is shown looking (often off-screen) at another character, and then the other character is shown looking "back" at the first character. Since the characters are shown facing in opposite directions, the viewer unconciously assumes that they are looking at each other. Transitions/Editing Two-Shot: Face-up shot of two people. Often used in interviews, or when two presenters are hosting a show. A "One-Shot" could be a mid-shot of either of these subjects. A "Three-Shot", unsurprisingly, contains three people. Transitions/Editing Shot Transitions/Editing: Sound: used to reflect or enhance what is shown visually on the screen can include dialogue, music, sound effects, voiceover etc. Diegetic Sound: sound that has a source in the world of the story dialogue spoken by characters, sound made by objects, or music coming from a source grounded in the story of the film Non-diegetic Sound: sound that has a source outside the world of the story usually part of the score or the soundtrack Parallel Sound: sound that complements the image shown i.e. romantic music during a love scene Counterpoint Sound: sound that contradicts the ‘feeling’ of the image a happy song played while images of graphic violence are portrayed Voiceover: voice of a non-visible narrator laid over the scene often provides some comment about the narrative of the film Sound Bridge: used to ‘soften’ the transition between one scene and another takes sound from the next shot and overlays it on the current shot 2-3 seconds earlier than we see the image Examples of Diegetic/Non-Diegetic: In the first clip, the non-diegetic music changes to diegetic music when the main character moves inside of the convenience store. In the second clip, the “duhn duhn duuuuh” which often is non-diegetic becomes diegetic because it is the band in the passing bus playing that music! End for ELA 20-1 Lighting: Can be used by a director to: Control the mood of a scene guide a viewer’s eye to a specific place in mis-en-scene Emphasize and de-emphasize elements in frame Add texture and color Make people look beautiful, ugly, sinister, or angelic Standard 3-Point Lighting: uses three lights called the key light, fill light and back light forms the basis of most lighting. once you understand three point lighting you are well on the way to understanding all lighting. Key Light: main light usually the strongest and has the most influence on the look of the scene. it is placed to one side of the camera/subject so that side is well lit and other side has shadow. Fill Light: secondary light is placed on the opposite side of the key light used to fill the shadows created by key softer and less bright than key Back Light: placed behind the subject ; lights it from the rear. provides definition and subtle highlights around the subject's outlines. Separates subject from background provides a three-dimensional look. Standard 3-Point Lighting: http://www.zvork.fr/vls/ Try using this simulator to play with lighting with those 3 points.Dietetics Part 1Nutrición clínica : Restricciones dietéticas, alergias y nutrición culturalDiuretics110.31.b.17.C Topic: Reading/Vocabulary Development