L-29 COM 5855: Blood & Lymph Disorders - Nutritional Care

• Lecture 29 involves, nutritional care in blood and lymph disorders
• It will be discussed within COM 5855 Hematopoietic and Lymphoreticular system
• It took place March 20, 2024, 8:10 - 9:00 am

Learning Objectives

• Recall common nutrients involved in the maintenance of healthy blood systems
• Identify complications of nutrient deficiencies in select blood disorders including HIV and Sickle Cell Anemia
• Describe common nutritional challenges in the care of cancer patients
• Compare alternative methods of nutrition support

Lecture Overview

• Case profile
• Nutrition and hematology review includes
  • Nutrition for healthy blood and lymph
  • Evaluating malnutrition
• Nutrition-related anemias includes risk, factors, and treatment
• Special conditions include
  • Sickle Cell Anemia
  • HIV and AIDS
  • Cancer

Meet Seth Case Study

• Seth is a 65-year-old male, retired banker, is married, and lives with his wife
• Seth is 70" tall and weighs 189lbs with a BMI of 27.2 kg/m²
• Seth's usual body weight (UBW) was 210lbs 6 months ago, and 202lbs 1 month ago
• Seth was newly diagnosed with colon cancer and his treatment plan includes surgery for resection, referral to an oncologist for radiation, and chemotherapy
• PMH includes hypertension and pre-diabetes
• Medications include metoprolol, pravastatin, daily multivitamin, and mineral tablet
• Clinical findings include BP 130/85, temp 99°, pulse 80 bpm, fatigue, central adiposity, intact skin, no edema, no wounds, evident loss of upper arm muscle mass, dry oral mucosa, intact dentition, and a normal tongue

Nutrition and Hematology Review

• A balanced diet involves water, fruits, whole grains, vegetables, fat, protein and dairy

Nutrition and Hematology

• Proper concentrations of water and electrolytes are needed
• Macronutrients provide energy supply in RBC formation and in RBC metabolism, with absence of mitochondria equalling anaerobic glycolysis or 2 ATP per glucose molecule
• Amino acid availability for protein synthesis is important for Hb and carrier proteins, and maintaining fluid balance through hydrostatic pressure
• Lipids are important for cellular membranes and essential fatty acids
• Micronutrients are often involved in formation and function of blood components

Common Micronutrient Deficiencies that affect Chronic Disease States

• Widespread deficiencies: Vitamin D, Vitamin E, Vitamin K, Calcium, Iron, Magnesium, and Potassium
• Moderate deficiencies: Vitamin B6, Folate, Vitamin C, Vitamin A, Phosphorus, and Zinc
• Mild deficiencies: Thiamin/Vitamin B1, Riboflavin/Vitamin B2, Niacin/Vitamin B3, Vitamin B12, Copper, and Selenium

Micronutrients in Blood and Lymph Systems

• Vitamin A (900 REAs for males and 700 RAEs for females)
  • Important for immune function, vision, reproduction, cell growth and differentiation and normal maintenance of the heart, lungs, kidneys, and other organs
  • Sources include the liver, fish oils, milk, eggs, leafy green vegetables, broccoli, orange and yellow vegetables, tomato products and fruits
  • Deficiency can lead to microcytic anemia and is possible in developing areas
• Vitamin B6 (1.3mg for both males and females)
  • Coenzyme form for various functions including protein metabolism and hemoglobin formation
  • Included in fish, beef liver, organ meets, potatoes, starchy vegetables and fruit (other than citrus)
  • Deficiency can lead to hypochromic microcytic, sideroblastic anemia as well as dermatitis, depression, confusion or weakened immune function
• Vitamin B9/Folate(400 mcg for both males and females, 600 mcg for pregnancy)
  • Coenzyme role in the synthesis of nucleic acids(DNA/RNA) and metabolism of amino acids and converts homocysteine to methionine
  • Included in vegetables(dark greens), fruits, nuts, beans, eggs, seafood, meat and poultry
  • Deficiency causes megaloblastic anemia in particular and poor diet, alcoholism or malabsorptive disorder
• Vitamin B12/Cobalamin(2.4 mcg for both males and females, 2.6 mcg for pregnancy)
  • Required for RBC formation, neurological function, and DNA synthesis as well as a co factor for methoinine synthase and catalyzing homocystein to methoinine
  • Included in fish, meat, poultry eggs, milk, yeast, fortified cereal
  • Deficiency fatigue and weightloss, constipation, neurological changes numbness/tingling with megaloblastic anemia
• Vitamin C/Ascorbic acid (90 mg male, 75 mg female, 85 mg for pregnancy, +35 mg and smokers)
  • Biosynthesis of collagen, Carnititine and neurotransmitters as well as role in immune function and absorption of nonheme iron
  • Includes citrus fruits, tomatoes, juices, potatoes, broccoli, kiwifruit, strawberries, Brussel sprout, and cantaloupe
  • Deficiency results in scurvy, from inadequate intake leading to malaise, inflammation, anaemia(iron deficiency)
• Vitamin D (600 IU for both males and females)
  • Promotes calcium absorption, modulates cell growth, neuromuscular/immune function as well as inflammation reduction
  • Found in fatty fish, beef liver, cheese, egg yolks and some mushrooms
  • Deficiency can cause skeletal anomalies or increased auto immunity as well as infections
• Iron
  • Essential role in the structure of hemoglobin, myoglobin, and oxygen transport
  • sources are lean meat and seafood and to a lesser extent beans, vegetables, and grains
  • Iron deficiency can result in a mild deficiency of serum ferritin concentrations and potentially IDA with reduced hemocrit and hemoglobin levels and subsequent microcytic/hypochromic anemia.
• Vitamin K (120 mcg for males and 90 mcg for females)
  • Acts as coenzyme for carboxylase, an enzyme synthesising protein in hemostasis and bone metabolism
  • Leafy greens, plant oils such as olive oil, and seeds for bacteria synthesis
  • Deficiency rare in adults and injected in infants
• Copper (900mcg for male and female)
  • Cofactor for enzymes involved in production, iron metabolism, brain development and immune function
  • Including shellfish, seeds and nuts, organ meats wheat bran cereal whole grains and chocolate
  • Deficiency can include micro/macrocytic anemia, connective tissue disorder, infection, hypercholesterolemia and osteoporosis

Evaluating Nutritional Risk

• Use validated screening tools
• Greater than 10% unexplained weight loss or less than 85% ideal body weight
• Socioeconomic concerns and restrictive eating patterns
• Ensure adequate energy for a healthy weight
• Increased macronutrient requirements with activity and or anabolism
• Consider Altered micronutrient needs
  • Life cycle demands
  • Impaired metabolism or genetic impact
  • Medication and medical treatments
  • Immunity-building capacity

Diagnosing Malnutrition using ICD-10 codes

• E43 which is unspecified severe proteincalorie malnutrition
• E44.0 which is moderate proteincalorie malnutrition
• Acute from illness/injury with severe inflammation
• Chronic with mild to moderate chronic inflammation
• Social/environmental circumstances: without inflammation
• Characterized by two of the following
  • Weight loss
  • Insufficient energy intake
  • Loss of subcutaneous fat
  • Loss of muscle mass
  • Localized fluid accumulation
  • Diminished functional status through testing

Optimizing Nutrition Status

• What to ask
• what to examine
• what to address

Quick Scan of Dietary History for Seth Case Study

• Seth follows low-sodium, reduced saturated fat diet
• Before surgery, intake was decreased due to fatigue and poor appetite
• Post-radiation, Seth eats about 50% of his usual daily diet
• Due to pain when eating, Seth uses a soft-solid or full-liquid diet as needed (no fortified supplement)

Anemias

• Includes Microcytic, Normocytic and Macrocytic origins

Microcytic Anemia: Iron Deficiency

• High Risk Factors:
  • Vegetarian meal plan without vitamin/mineral supplementation
  • Low-energy diets/skipping meals
  • Chronic kidney disease
  • High intake of dietary fiber, coffee, or tea
  • Endurance athletes
  • Women with heavy menstrual periods
  • Women who are pregnant or lactating
  • Recent blood loss with surgery ulcers hemorrhoid
  • Medications that decrease absorption or utilization
• Consider lifestyle factors related to nutrition

Factors Affecting Bioavailability of Dietary Iron:

• Rate of absorption depends on the individual’s iron status, with lower iron stores leading to greater absorption rates averaging 20-30% in iron deficiency
• Type of iron in the diet influences absorption where heme iron > non-heme iron, Heme is commonly found in meats, and non-heme in eggs and grains
• between 3% and 8%, depending on the presence of dietary-enhancing factors such as ascorbic acid
• absorption can be inhibited by components such as carbonates, oxalates, phosphates and phytates as well as tea and coffee reducing absorption through insolubles and tannin
• Possible sign of early iron deficiency is reduced immunocompetence, such as phagocytic activity being reduced

Iron Deficiency: Nutritional Care

• Maximize absorption and prevent anemia by improving food choices to increase dietary intake
• To do so Include a source of vitamin C at every meal, include heme containing meat, fish, and avoid drinking tea/coffee
• For childbearing women consume foods high in heme-iron as well as vitamin C.
• Treatment will address underlying cause, goal is to replete iron
• Proper nutrition can prevent deficiency

Macrocytic Anemias: B12 Deficiency

• Includes impaired DNA synthesis where bone marrow is delayed
• Caused by pernicious anemia, malabsorption pancreatic sufficiency gastrectomy intake or Diphyllobothrium latum
• High homocysteine and methylmalonic acid
• Clinical attributes dementia reversible by B12 role in fatty acid pathways
• Shilling test differentiates malabsorption
• Intrinsic factor absorption

B12 Deficiency: Nutritional Care

• A family history of the disease
• Surgical removal of stomach or intestine, Chron's
• Autoimmune diseases, including type 1 diabetes
• HIV and AIDS patients; older adults
• Strict vegetarian (vegan) diets
• Nutrition intervention: and attention to all B-Complex
• Injections may be needed for high risk
• Found through fish, meat, poultry, eggs, milk and fortified foods

Macrocytic Anemias: Folate Deficiency

• Is when there is malnutrition, malabsorption, or insufficient intake (increased demand like pregnancy or hemolytic anemia)
• medications such as methotrexate phenytoin, and trimethoprim
• Alcoholics are a high-risk group
• Biomarkers with elevated homocysteine and normal methylmalonic acid
• Clinical Exam: no neurologic symptoms are displayed

Folate Deficiency: Nutritional Care

• Easily treatable with dietary correction and supplementation
• Special considerations in alcoholism, childbearing years, children, malabsorptive disorders, and MTHFR polymorphism
• Folic acid is available through multivitamins and supplements containing B-complex vitamins, and supplements with folic acid
• The common dose is 680 to 1,360 mcg DFE (400 to 800 mcg folic acid), and child multi ranges from 340 to 680 (200 to 400 mcg folic acid)
• Folate is easily found in food such as vegetables, seafood, meat, spinach, liver, asparagus

Nutritional risk indicators in sickle cell disease (SCD)

• Degree of malnutrition present
• Increased energy and protein expenditure secondary to disease complications or other factors
• Presence of neurologic damage from a stroke resulting in impaired ability or desire to eat
• Presence of significant chronic pain which results in impaired intake

Malnutrition Classifications

• Mild is 81% to 90% of recommended weight
• Moderate is 70% to 80% of recommended weight
• Kwashiorkor is when edema is present
• Marasmus is when their weight is less than 70%
• SCD increases calories
  • pulmonary disease
  • Chronic inflammation/infection such as osteomyelitis
• Anemia requires additional energy
  • leads to increase of protein turnover which increases cardiac output

Sickle Cell Anemia

• Common vitamin deficiencies for serum A, E, D along with B6, and B2
• Nutrient such as zinc or magnesium have no known biomarkers

Sickle Cell Anemia: Nutritional Care

• There should be Increased energy expenditure when diagnosing
• Well balance is important along with smaller and frequent feeding
• Optimize fluid status, treat Health Issues, Micronutrient supplementation such as zinc, or folate.
• Enteral is a route towards treating inadequate diets

"Meet Seth" Case study – Part 1 s/p Colon resection

• 88% UBW with very poor appetite
• Post op post 1 day, positive bowel
• Start a softdiet which is low residue
• Monitor Gl effects
• High protein
• Consider glutamine

"Meet Seth" Case study – Part 2 s/p Radiation Therapy

• 80% UBW with very poor appetite
• Re-admitted to the hospital after 2 months of fatigue and diarrhoea from enteritis
• Consider Prominent clavice bone
• Promote high protein intakes manage gl
• Parenteral support when possible
• Consider glutamine

Nutrition in Cancer

• Disease ,Side effects and changes due to cancer can create need to assess food intake and supplements
• Consider the nutrition counseling can improve with quality of life with proper monitoring of cachexia

Medical Treatment

• Benefits include an appetite increase weight gain increase
• risk can include side effects like insomnia or adrenal insuffienices
• Lack of doses duration

Nutritional Care: Cancer

• Alter textures, eat soft non acidic meals, chew gum avoid sugars/salts with more frequent meals in less amounts
• Eat plant origns or 1/3 from aminal sources will increase weight
• Reduce red meats and be active and limit alcohol
• Oral route and encourage good nutrition while monitoring the timing
• Normal, Hypermetabolic or nutritional repletion may alter need for EE Immune formulas are beneficial when giving nutritional tube,

Low microbial diets

• Severely immunocompromised individuals can benfit through ingesting pathogen foods
• Patients should practice food safety with uncooked or pasteurized drinks
• Thoroughly cook eggs as well as wash vegetables

Session Summary Points:

• Nutrients affect blood and lymph formation; many have a direct impact
• Nutritional care intervention in treating selected disorders which are from insufficient intake
• Impairing the to consume amounts from nutrients
• Focus on approach to care within individual

Practice questions:

• What is a good suggestion in helping a cancer patient who is experiencing dysgeusia? (plastic)
• Which of the following has a major role in immunity and contributes to normochromic microcytic anemia when a dietary deficiency is present?(iron)
• What is a major predisposing factor to increased nutritional risk in sickle cell patients? (pain)