Medical Nutrition Therapy I PDF Lecture Notes, August 2024

9/1/24 MEDICAL NUTRITION THERAPY I 15th Food, Nutrition and Dietetics Review Course Zarah G. Sales, MS, RND, RD, LD/N...

9/1/24 MEDICAL NUTRITION THERAPY I 15th Food, Nutrition and Dietetics Review Course Zarah G. Sales, MS, RND, RD, LD/N August 27, 2024 Prepared for the 15th FNDRC (not for public distribution) 1 Topics Covered v Basic Concepts in MNT v MNT for Food Allergies and Food Intolerances, Fever and Infections, Gastrointestinal Disorders, Liver, Pancreas and Gallbladder Diseases, Oncologic Conditions, Critical Care v Nutrient-Drug Interaction v Weight Management Prepared for the 15th FNDRC (not for public distribution) 2 1  9/1/24 Definitions and Basic Concepts Cells. Cells are the basic structural and functional unit of all life. Tissues. Tissues are groups of cells that share a common structure and function and work together. There are four types of human tissues: connective, which connects tissues; epithelial, which lines and protects organs; muscle, which contracts for movement and support; and nerve, which responds and reacts to signals in the environment. Organs. Organs are a group of tissues arranged in a specific manner to support a common physiological function. Organ systems. Organ systems are two or more organs that support a specific physiological function. Creative Commons, Nutrition and the Human Body Prepared for the 15th FNDRC (not for public distribution) 3 Prepared for the 15th FNDRC (not for public distribution) 4 2  9/1/24 Definitions and Basic Concepts Total Energy Expenditure Ø Basal Energy Expenditure (BEE) or Basal Metabolic Rate (BMR) Ø Thermic Effect of Food (TEE) – 10% of TEE Ø Activity Thermogenesis – most variable component of TEE Prepared for the 15th FNDRC (not for public distribution) 5 Definitions and Basic Concepts Indirect Calorimetry Ø gold standard for measuring energy expenditure Ø measures an individuals oxygen consumption and carbon dioxide production over a period of time Prepared for the 15th FNDRC (not for public distribution) 6 3  9/1/24 Definitions and Basic Concepts Estimating Energy Requirements Ø use of indirect calorimetry is not always practical or possible Ø other methods of estimating energy requirements: - predictive equations - simplistic weight-based equations Prepared for the 15th FNDRC (not for public distribution) 7 Hospital Setting Prepared for the 15th FNDRC (not for public distribution) 8 4  9/1/24 Dietitian vs. Nutritionist Dietitian v studies food, nutrition, and dietetics through an accredited university and approved curriculum, then completes a rigorous internship and passes a licensure exam v holds a valid certificate of registration and a valid professional identification card, which is renewed every 3 years and issued by PRC pursuant to RA 10862 (DOH AO 2019-0033) Nutritionist v studies nutrition via self-study or through formal education but does not meet the requirements to use the title RND Prepared for the 15th FNDRC (not for public distribution) 9 Dietetics in the Philippines v RA 10862 (2016) - repealing for the purpose PD 1286, appropriating funds therefore and for other related purposes the b) examination, registration and licensing of nutritionist- dietitians; (c) the standardization, supervision, control, and regulation of the practice of nutrition and dietetics; (d) the development of professional competence of nutritionist- dietitians through continuing professional development/education Prepared for the 15th FNDRC (not for public distribution) 10 5  9/1/24 Scope of Practice in Nutrition Dietetics a. Providing medical nutrition therapy through the application of the Nutrition Care Process for purposes of disease prevention, treatment, and management; b. Optimizing the health and well-being of patients/clients through the delivery of quality products, programs, and services; c. Promoting nutritional health and well-being of individuals, groups, communities and populations; d. Setting standards, guidelines and policies that create and encourage an environment that supports nutritional health; e. Managing food and nutrition systems, including programs, projects, and services; f. Facilitating and conducting food, nutrition and related research across a variety of practice settings; and, g. Educating and training others about food and nutrition in a variety of practice settings. Prepared for the 15th FNDRC (not for public distribution) 11 Definitions and Basic Concepts Therapeutic Diet v A diet modified or adopted from the normal diet to suit specific disease conditions; one designed to treat or cure disease, or to support medical management of a disease. Prepared for the 15th FNDRC (not for public distribution) 12 6  9/1/24 Definitions and Basic Concepts Common Reasons Therapeutics Diets are Ordered 1. To maintain/restore/correct nutritional status 2. To balance amounts of carbohydrates, fat and protein for control of a particular disease e.g. diabetes, kidney failure, etc. 3. To decrease/increase the amount of a micronutrient e.g. low Na diet 4. To exclude foods due to allergies or food intolerance 5. To provide texture modifications due to problems with chewing and/or swallowing Prepared for the 15th FNDRC (not for public distribution) 13 Definitions and Basic Concepts Principles of Dietary Modifications Liberalization Simplification Individualization Prepared for the 15th FNDRC (not for public distribution) 14 7  9/1/24 Diagnosing Malnutrition in Hospitalized Patients (ASPEN Malnutrition Criteria): SEVERE 5 Things Practitioners Need to Know About Malnutrition. Thick-It. https://thickit.com/blog/2022/09/29/5-things-practitioners-need-to-know-about-malnutrition/ Prepared for the 15th FNDRC (not for public distribution) 15 Diagnosing Malnutrition in Hospitalized Patients (ASPEN Malnutrition Criteria): MODERATE 5 Things Practitioners Need to Know About Malnutrition. Thick-It. https://thickit.com/blog/2022/09/29/5-things-practitioners-need-to-know-about-malnutrition/ Prepared for the 15th FNDRC (not for public distribution) 16 8  9/1/24 Nutrition Focused Physical Exam (NFPE) Iowa Academy of Nutrition and Dietetics. Registered Dietitians Leading the Way on Malnutrition Diagnosis and Nutrition Focused Physical Exams. 2021. https://www.eatrightiowa.org/post/registered-dietitians-leading-the-way-on-malnutrition-diagnosis-and- nutrition-focused-physical-exams-1 Prepared for the 15th FNDRC (not for public distribution) 17 Nutrition Focused Physical Exam (NFPE) Iowa Academy of Nutrition and Dietetics. Registered Dietitians Leading the Way on Malnutrition Diagnosis and Nutrition Focused Physical Exams. 2021. https://www.eatrightiowa.org/post/registered-dietitians-leading-the- way-on-malnutrition-diagnosis-and-nutrition-focused-physical-exams-1 Prepared for the 15th FNDRC (not for public distribution) 18 9  9/1/24 Prepared for the 15th FNDRC (not for public distribution) 19 Food Allergies and Food Intolerances Prepared for the 15th FNDRC (not for public distribution) 21 10  9/1/24 Adverse Food Reactions encompass both food allergy and food intolerance Prepared for the 15th FNDRC (not for public distribution) 22 Adverse Food Reactions encompass both food allergy and food intolerance Prepared for the 15th FNDRC (not for public distribution) 23 11  9/1/24 Common Food Allergens - cow’s milk, egg, wheat, soy, fish, shellfish, tree nuts, peanut, sesame THE BIG NINE (Food Allergen Labeling and Consumer Protection Act of 2004) Prepared for the 15th FNDRC (not for public distribution) 24 DIAGNOSIS 1. Oral Food Challenge double-blind placebo-controlled 2. Skin Tests 3. RAST (Radioallergosorbent Extract Test) 4. ELISA (Enzyme-Linked Immunosorbent Assay) Prepared for the 15th FNDRC (not for public distribution) 25 12  9/1/24 SYMPTOMS OF FOOD ALLERGY v Dermatologic: hives, eczema v Gastrointestinal: nausea; vomiting; oral allergy syndrome (swelling of lips, tongue, throat); abdominal cramps and pain; bloating; gas formation; fecal blood loss, malabsorption v Respiratory: sneezing, nasal congestion and inflammation of tissues of the respiratory system, irregular breathing, and asthma v Systemic: pallor, irritability, headaches, low blood pressure, and cardiac arrhythmias Prepared for the 15th FNDRC (not for public distribution) 26 SYMPTOMS OF FOOD ALLERGY v Anaphylactic shock - involves the GIT, the skin, the respiratory tract, and the cardiovascular system Prepared for the 15th FNDRC (not for public distribution) 27 13  9/1/24 MEDICAL MANAGEMENT Anti-histamine Epinephrine Prepared for the 15th FNDRC (not for public distribution) 28 Dietary Management v Elimination Diet ü usual offending food such as protein rich foods are eliminated v Desensitization Diet ü the food causing the allergy is given gradually in increasing amounts over a period of 10 – 12 months. Prepared for the 15th FNDRC (not for public distribution) 29 14  9/1/24 Prepared for the 15th FNDRC (not for public distribution) 30 CELIAC DISEASE Ø diagnosed through: q assessment of family history of celiac disease q blood test for IgA ( anti-tissue transglutaminase and anti-endomysial) and tissue biopsy Prepared for the 15th FNDRC (not for public distribution) 31 15  9/1/24 Dietary Management Diet Rationale Restrict rye, oats, wheat and barley Rich in gluten Low fat Prevent steatorrhea Medium-chain triglyceride For better fat absorption Vitamin and mineral supplementation To replace losses High calorie To compensate weight loss Prepared for the 15th FNDRC (not for public distribution) 32 Prepared for the 15th FNDRC (not for public distribution) 34 16  9/1/24 Dietitian’s Role v Educating patients/parents/guardians on how to avoid allergens and manage food allergy, especially if accidental exposure occurs. v Support patients/parents. Prepared for the 15th FNDRC (not for public distribution) 35 Food Intolerance adverse reaction to a food caused by toxic, pharmacologic, metabolic, or idiosyncratic reactions to the food or chemical substances in the food Prepared for the 15th FNDRC (not for public distribution) 36 17  9/1/24 Lactose Intolerance v syndrome of diarrhea, abdominal pain, flatulence and bloating after intake of lactose containing foods v lactase deficiency v lactose act osmotically and attract fecal water and bacterial fermentation Prepared for the 15th FNDRC (not for public distribution) 37 Lactose Intolerance v Diet management: ü reduce lactose intake (i.e. dairy and dairy products) ü yogurt and cheese may be tolerated ü supplement vitamin D and Ca Prepared for the 15th FNDRC (not for public distribution) 38 18  9/1/24 MNT for Fevers and Infections Prepared for the 15th FNDRC (not for public distribution) 39 Infection Infection – is the result of successful invasion, establishment, and growth of pathogenic microorganisms in a host (localized). Sepsis – a term used to denote when infection has spread from one part of the body to other via circulatory system. Prepared for the 15th FNDRC (not for public distribution) 40 19  9/1/24 Fever (Pyrexia) is as rise in body temperature above normal (37.5 0C) v Low grade fever – consistently elevated temperature above 37.10C but below 38.20C v High grade fever is temperature higher than 38.20C v Hyperpyrexia/hyperthermia is a very high fever, more than 400C Prepared for the 15th FNDRC (not for public distribution) 41 Metabolic Changes ↑ metabolic ↓ glycogen stores and adipose rate tissues protein body fluids and catabolism electrolytes decreased loss of body gastrointestinal motility water Prepared for the 15th FNDRC (not for public distribution) 42 20  9/1/24 Interaction between malnutrition and infection Malnutrition Reduced Food Intake Impaired Digestion and Absorption Lowered Increased Nutrient Losses Resistance to Pathogens Increased Nutritional Requirement Infectious Disease Prepared for the 15th FNDRC (not for public distribution) 43 Goals of Dietary Management 1. To meet the increased nutritional needs, particularly for energy, protein, and fluids; 2. To maintain nutritional status or correct nutritional deficiencies that may have occurred 3. To modify the consistency of the diet according to body’s tolerance. Prepared for the 15th FNDRC (not for public distribution) 44 21  9/1/24 MNT for Fevers & Infections Diet Rationale High Kcal due to 13% increase of BMR per 0C or 7% increase per 0F High Protein due to 10% increase of BMR per 0C or 5.5% increase per 0F High Carbohydrate To spare protein High Fluids To replenish losses Progressive diet from clear to Gradual adjustment to peristaltic changes normal Vitamin and mineral supplements To replenish losses; to augment increased caloric requirement Prepared for the 15th FNDRC (not for public distribution) 45 Pulmonary Tuberculosis v caused by Mycobacterium tuberculosis v passed by droplets from a cough or sneeze by an infected person v signs and symptoms: coughing that lasts 3 or more weeks, coughing up blood, fever, night sweats, loss of appetite, chest pain, chills, unintentional weight loss Prepared for the 15th FNDRC (not for public distribution) 46 22  9/1/24 Pulmonary Tuberculosis DIET RATIONALE High kcal, high protein Due to presence of fever and infection; to restore plasma protein and promote wound healing à 35-40 kcal/kgIBW, 1.2-1.5 g/kgIBW PRO Vitamin B6 Displaced by isoniazid (common treatment) à supplement with 25 mg/day) Iron If iron studies show IDA A multivitamin with Increased requirements are impossible to meet mineral supplement with diet alone Krause, 2016 Prepared for the 15th FNDRC (not for public distribution) 47 HIV/AIDS Acquired immune deficiency syndrome (AIDS) is caused by the human immunodeficiency virus (HIV). Prepared for the 15th FNDRC (not for public distribution) 48 23  9/1/24 Human Immunodeficiency Virus (HIV) Prepared for the 15th FNDRC (not for public distribution) 49 Human Immunodeficiency Virus (HIV) Prepared for the 15th FNDRC (not for public distribution) 50 24  9/1/24 HIV/AIDS: MNT Energy v Establish if patient needs to gain, maintain, or lose weight v Individuals with well-controlled HIV are encouraged to follow the same principles of healthy eating and fluid intake recommended for the general population (Krause, 2016) Prepared for the 15th FNDRC (not for public distribution) 51 HIV/AIDS: MNT Protein v Follow the same principles of healthy eating and fluid intake recommended for the general population v Increase for opportunistic infections Micronutrients v Supplemental but not megadoses of vitamins and minerals Prepared for the 15th FNDRC (not for public distribution) 52 25  9/1/24 HIV/AIDS: MNT Nutrition support and oral nutrition supplements supplements v For underweight HIV-positive individuals Prepared for the 15th FNDRC (not for public distribution) 53 Oral Nutrition Supplements (ONS) v Between meals v Added to foods v Added into liquids v Enhances otherwise poor intake v May be needed by children or teens to support growth Prepared for the 15th FNDRC (not for public distribution) 54 26  9/1/24 Coronavirus disease 2019 (COVID-19) v Causative agent: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) v Characteristics: symptoms may appear 2-14 days after exposure to the virus: cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, new loss of taste or smell Prepared for the 15th FNDRC (not for public distribution) 55 Coronavirus disease 2019 (COVID-19) v Prevention tips: avoiding close contact with sick individuals, frequent washing of hands with soap and water, not touching the eyes, nose of mouth with unwashed hands, and practicing good respiratory hygiene v Dietary Management: Appendix C. DOH Memo 2020-0165 Interim Guidelines for Registered Nutritionist- Dietitians in Hospitals on the Nutritional and Dietary Management of Suspected, Probable, and Confirmed COVID-19 Patients, and on the Provision of Healthy Diet to Hospital Workforce Prepared for the 15th FNDRC (not for public distribution) 56 27  9/1/24 DOH Memo 2020-0165 Diet recommendations for COVID-19 patients shall include low carbohydrate diet, high protein diet, and neutropenic or low bacteria diet. The hospital RNDs shall provide food items that are rich in nutrients and minerals such as vitamin C, vitamin A and beta- carotene, vitamin D, B-vitamins, folate, zinc, protein, fat, with emphasis on bioflavonoids, probiotics, prebiotics, and resveratrol. Prepared for the 15th FNDRC (not for public distribution) 57 MNT for GI Disorders (time check!) GI Tract Prepared for the 15th FNDRC (not for public distribution) 58 28  9/1/24 Dental Caries Dietary Management ü Oral hygiene ü Avoid cariogenic foods ü Fluoride to stabilize enamel and lessen formation of caries ü Phosphate to cleanse and mineralize ü Protein Prepared for the 15th FNDRC (not for public distribution) 59 Periodontitis v refers to the inflammation of the supporting structure of the teeth (gingival and periodontal ligaments) with a resultant loss of alveolar bone Prepared for the 15th FNDRC (not for public distribution) 60 29  9/1/24 Periodontitis Dietary Management ü Supplement of Ca, vitamin A, protein, folic acid, and iron ü Softer consistency of food ü Oral hygiene Prepared for the 15th FNDRC (not for public distribution) 61 Tonsillitis v refers to the inflammation of the tonsils Dietary Management ü Moist, soft textured foods ü Avoid acid foods or sticky foods ü Avoid thermally irritating foods Prepared for the 15th FNDRC (not for public distribution) 62 30  9/1/24 Diseases of the Esophagus v Esophageal obstruction refers to the stricture of the esophagus caused by fibrotic tissues, increased pressure of herniation from adjacent organs, and abnormal growth of tissues. Prepared for the 15th FNDRC (not for public distribution) 63 Esophageal Obstruction DIETARY MGT RATIONALE Liquid diets To facilitate swallowing Tube feeding when To provide nutrition when oral necessary nutrition is inadequate or impossible Prepared for the 15th FNDRC (not for public distribution) 64 31  9/1/24 Dysphagia Dys = difficulty, painful, abnormal Phag(o) = pertaining to eating, engulfing, ingesting Complication: choking and/or aspiration into the lung Prepared for the 15th FNDRC (not for public distribution) 65 Nutrition Intervention *Consult speech therapist for a full evaluation. *The clinician has the responsibility to make recommendations for foods or drinks for a particular patient based on their comprehensive clinical assessment. Prepared for the 15th FNDRC (not for public distribution) 66 32  9/1/24 Gastroesophageal Reflux Disease (GERD) A condition in which partially- digested food in the stomach backs up into the esophagus; also a term for conditions commonly called acid indigestion, heartburn and reflux esophagitis. Prepared for the 15th FNDRC (not for public distribution) 68 GERD Dietary Management: v SFF and avoid high fat meals v Remain in upright position for 2 hours after meals v Losing weight, if overweight to help relieve pressure on the diaphragm v No alcohol, spices, chocolates, caffeine, nicotine to prevent high secretion of acid and decrease of LES pressure v Avoid food with high acid pH to avoid irritation v Avoid tight fitting clothes Prepared for the 15th FNDRC (not for public distribution) 69 33  9/1/24 Disorders of the Stomach Gastritis - is an acute or chronic inflammation of the mucous membrane of the stomach resulting in tissue damage and erosion. Prepared for the 15th FNDRC (not for public distribution) 70 What is the nutritional management for gastritis? Dietary Management v NPO for 24 hours to allow stomach to rest v Clear liquids to full liquid to soft as per patient’s tolerance v Folate and Vit. B12 supplementation if chronic Prepared for the 15th FNDRC (not for public distribution) 71 34  9/1/24 What is the nutritional management for gastritis? Dietary Management v Omit foods which can cause discomfort e.g. fried, fatty, processed v No alcohol, spices, caffeine to prevent irritation v Small frequent meals to prevent increase in acid production v Refrain from eating large meals before bed time Prepared for the 15th FNDRC (not for public distribution) 72 Disorders of the Stomach Peptic ulcer disease (PUD) - a chronic sore or crater extending through the protective mucous membrane lining and penetrating the underlying muscular tissue of the gut. Prepared for the 15th FNDRC (not for public distribution) 73 35  9/1/24 Clear Liquid Diet strained fruit juices, fat- free clear broth and bouillon, flavored and unflavored gelatin, popsicles, fruit ices (made without milk), sugar, honey, hard candy, coffee, tea, carbonated beverages, fruit beverage drinks Prepared for the 15th FNDRC (not for public distribution) 74 Full Liquid Diet Prepared for the 15th FNDRC (not for public distribution) 75 36  9/1/24 Soft Diet/Low Residue Prepared for the 15th FNDRC (not for public distribution) 76 True or False? Spicy foods cause ulcer. FALSE. But they can make ulcers worse. Prepared for the 15th FNDRC (not for public distribution) 77 37  9/1/24 Peptic Ulcer Disease Medical therapy -Antacids Counteract or neutralize acidity Magnesium-/aluminum-containing compounds Example: Maalox, Mylanta -Antibiotics Used to control H. pylori infestation Prepared for the 15th FNDRC (not for public distribution) 78 Dietary Management v Parenteral feedings of dextrose and amino acids when ulcer is bleeding v Transitional diet to regular diets as condition improves v Bland diet, SFF v Avoid tobacco products v Decrease alcohol, spices, coffee and caffeine containing food/beverages Prepared for the 15th FNDRC (not for public distribution) 79 38  9/1/24 Disorders of the Intestines Constipation- means having infrequent and difficult passage of small amounts of hard, dry stools. Causes: Poor diet, lack of exercise, immobility/prolonged bed rest, poor bowel habits, laxative abuse, pregnancy, loss of body salts, specific disease (lupus, stroke, Parkinsonism), nerve damage Prepared for the 15th FNDRC (not for public distribution) 80 Constipation Classifications: Atonic constipation- “lazy bowel”; rectum is full of feces but the urge to defecate is lacking. Stools are usually large and hard. Common in elderly. Spastic constipation- caused by overstimulation of the intestinal nerve endings which results in irregular contractions of the bowel. Stools are usually dry, hard, and small. Obstructive constipation- an obstruction or closure hinders the passage of intestinal residue. Adhesions, cancer or tumor may cause it. Prepared for the 15th FNDRC (not for public distribution) 81 39  9/1/24 Dietary Management Diet Rationale Atonic Constipation High fiber (20-35g) and fluids to promote motility, increase in bulk, and soften stool Spastic Constipation Low fiber, agar-agar to form stools Bland diet to prevent irritation Obstructive Constipation Low residue related to the size of obstruction Liquid diet if obstruction is extensive Parenteral feeding to meet the nutritional requirements Fiber-free as post-operative diet, to avoid discomfort Prepared for the 15th FNDRC (not for public distribution) 82 What should you increase along with a high fiber diet? TOTAL FLUIDS / WATER Prepared for the 15th FNDRC (not for public distribution) 83 40  9/1/24 Probiotics and Prebiotics PROBIOTICS - good bacteria which help in digestion and absorption, enhancing immune system and regulating hormone balance, thus, protecting us from food-borne illnesses and from developing allergies. PREBIOTICS - are foods and nutrients that these probiotics like to eat. Prepared for the 15th FNDRC (not for public distribution) 84 What item would you not recommend to a client experiencing diarrhea? A. Caffeine B. Sports drink C. Prebiotics D. Probiotics Prepared for the 15th FNDRC (not for public distribution) 86 41  9/1/24 What item would you not recommend to a client experiencing diarrhea? A. Caffeine B. Sports drink C. Prebiotics D. Probiotics Prepared for the 15th FNDRC (not for public distribution) 87 MNT for Liver Diseases Prepared for the 15th FNDRC (not for public distribution) 89 42  9/1/24 Hepatitis v inflammation of the liver with necrosis of the liver cells, typically is defined clinically as elevated activity of serum aminotransferases alanine (ALT) and aspartate (AST). v Causes: heavy alcohol use, toxins, some medications, and some certain medical conditions, viral (Hepa A, B, C, D, E) Prepared for the 15th FNDRC (not for public distribution) 90 Hepatitis Diet Rationale IVF to replenish losses High kcal (30-35kcal/kBW) to meet energy demands for tissue building, to compensate losses due to fever and debilitation, renew strength High CHON (1-2g/kBW) for liver cell regeneration Adequate CHO (300-400g/day) to spare protein Low fat, MCT in presence of steatorrhea Prepared for the 15th FNDRC (not for public distribution) 91 43  9/1/24 Hepatitis Diet Rationale ADEK supplementation due to poor storage Fe supplementation inability to store iron Vit. B-complex energy metabolism supplementation Low sodium in case of ascites SFF, progressive diets according to tolerance Prepared for the 15th FNDRC (not for public distribution) 92 Liver Cirrhosis Prepared for the 15th FNDRC (not for public distribution) 93 44  9/1/24 Liver Cirrhosis v Alcoholism and hepatitis C are the common causes but may also result from biliary stenosis, hepatitis B-D, obesity with NAFLD, autoimmune hepatitis, prolonged exposure to chemicals, and inherited diseases such as glycogen storage disease, cystic fibrosis, hemochromatosis, Wilson disease, or galactosemia Prepared for the 15th FNDRC (not for public distribution) 94 Liver Cirrhosis Diet Rationale High kcal to meet energy demands (25 – 35 kcal/kgBW) Low CHON* to prevent nitrogen retention (0.8g/kgBW) Low fat**, MCT in presence of steatorrhea Low Na (2-4g), fluid to prevent water retention restriction Low fiber to prevent irritation (esoph varices) * higher in uncomplicated cirrhosis ** 30% or higher if needs additional calories Prepared for the 15th FNDRC (not for public distribution) 95 45  9/1/24 Liver Cirrhosis Diet Rationale Liquid diet to prevent irritation of the esophageal varices Fe supplementation inability to store iron Vit. B-complex supplementation energy metabolism Vitamin and mineral to replenish losses, faster supplementation wound healing SFF, progressive diets according to tolerance Prepared for the 15th FNDRC (not for public distribution) 96 Nutrition Management in Liver Diseases v SFF to increase energy intake v Sodium restriction when there is fluid retention v Fluid restriction if there is hyponatremia v CHO-controlled if there is hyperglycemia v Vitamin and mineral supplements v Oral liquid supplements or EN (tube feeding) for improved nutrient intakes Prepared for the 15th FNDRC (not for public distribution) 97 46  9/1/24 Diseases of the Gallbladder Prepared for the 15th FNDRC (not for public distribution) 98 Diseases of the Gallbladder Cholecystitis - inflammation of the gallbladder Cholelithiasis - presence or formation of gallstones in the gallbladder or bile ducts Choledocholithiasis- occurrence of stone in the biliary tree (cystic duct, hepatic duct, common bile duct) Cholangitis- inflammation of the bile ducts Prepared for the 15th FNDRC (not for public distribution) 99 47  9/1/24 Medical and Surgical Management Cholecystectomy – surgical removal of the gallbladder, especially if the stones are numerous, large or calcified. Prepared for the 15th FNDRC (not for public distribution) 100 Dietary Management: Post-op Diet Rationale Progression diets for better tolerance Low fat to alleviate the pain Low calorie for obese to prevent cholesterol and bile excretion High fiber, adequate fluid intake Prepared for the 15th FNDRC (not for public distribution) 101 48  9/1/24 Diseases of the Pancreas Prepared for the 15th FNDRC (not for public distribution) 102 Pancreatitis vinflammation of the pancreas vcharacterized by nausea, vomiting, steatorrhea, edema, hypotension, oliguria, dyspnea, cellular exudate, fat necrosis with hemorrhage vmay be acute or chronic Prepared for the 15th FNDRC (not for public distribution) 103 49  9/1/24 Dietary Management for Acute Pancreatitis v put pancreas at rest : NPO v hydration via IV v liquid diets in a few days v small frequent feedings v low fat diet in cases of bile obstruction v easily digested foods Prepared for the 15th FNDRC (not for public distribution) 104 Chronic Pancreatitis v recurrent attacks of epigastric pain v painful with meals v at-risk to PEM v aim of MNT is to prevent further pancreatic damage, decrease attacks of inflammation, alleviate pain, prevent steatorrhea and arrest malnutrition Prepared for the 15th FNDRC (not for public distribution) 105 50  9/1/24 Dietary Management for Chronic Pancreatitis v TF if oral diet is inadequate v pancreatic enzyme supplementation v low fat diet v use MCT oil v supplement fat soluble vitamins and B12 Prepared for the 15th FNDRC (not for public distribution) 106 Cystic Fibrosis v a life-limiting autosomal recessive inherited disease characterized by abnormality in the glands that produce sweat and mucus = thick mucus and frequent pulmonary infections v CF mainly affects the pancreas = secretions become thick and can clog the ducts of the pancreas = affects absorption of protein, fats, and vitamins A, D, E, K Prepared for the 15th FNDRC (not for public distribution) 107 51  9/1/24 Dietary Management for Cystic Fibrosis Energy: 1.2 – 1.5x REI for age; individualized based on weight gain and growth; high calorie oral supplements and enteral tube feedings often necessary Individualized. CHO should be monitored to achieve glycemic control (use of artificial sweeteners should be used sparingly due to lower kcal content) No restriction on type of fat. High fat necessary for weight maintenance; aim for 35-40% total calories Prepared for the 15th FNDRC (not for public distribution) 108 Dietary Management for Cystic Fibrosis Protein: approximately 1.5 – 2x the RNI for age; no reduction for nephropathy Liberal, high salt especially in warm conditions and/or when exercising Routine supplementation with CF-specific multivitamins or a multivitamin and additional fat-soluble ADEK vitamins A high calorie diet must be maintained for adequate weight gain. (In impaired glucose tolerance, aggressive use of insulin rather than diet restriction) Prepared for the 15th FNDRC (not for public distribution) 109 52  9/1/24 MNT for Surgical Conditions Prepared for the 15th FNDRC (not for public distribution) 110 MNT for Surgical Conditions Surgery is defined as a “planned anatomical alteration of the human organism designed to arrest, alleviate, or eradicate some pathologic process”. Prepared for the 15th FNDRC (not for public distribution) 111 53  9/1/24 Dietary Management of Specific Surgical Conditions Condition Diet Rationale Tonsillectomy and Cold liquid diet, NDCF To prevent bleeding Adenectomy Surgery in Mouth, Neck, Tube feeding Difficulty in chewing and Esophagus swallowing IV if surgery is extensive Cold liquid diet As per patient’s tolerance Bland soft diet Gastric surgery as Low in simple CHO To avoid *dumping Gastrectomy syndrome High protein Moderate fat SFF As per patient’s tolerance Prepared for the 15th FNDRC (not for public distribution) 112 Dumping Syndrome Rapid gastric emptying Complication of gastrectomy Side effects include feeling bloated or too full after eating, nausea, vomiting, abdominal cramps, diarrhea, flushing, dizziness, rapid heart rate Prepared for the 15th FNDRC (not for public distribution) 113 54  9/1/24 Dietary Management ü SFF – to reduce load on the intestine ü Limit fluids during meals ü Fewer simple sugars ü More complex CHO; more soluble fiber ü Low lactose (lactose may be poorly tolerated due to rapid transport) Prepared for the 15th FNDRC (not for public distribution) 114 Dietary Management of Specific Surgical Conditions Condition Diet Rationale Cholecystectomy Low fat, soft diet then to To adjust to the ability to emulsify normal diet fat Clear, liquid, low residue diet To prevent irritation, gradual to soft and low fiber introduction of food Ostomies Adequate calories, high to speed up recovery e.g. ileostomy, protein colostomy Adequate fluids (8- to replenish losses 10cups/days) use of MCT When steatorrhea is present Rectal surgery Clear liquid diet (first 24 To prevent irritation, until wound hours) then non-residue diet healing is initiated Low fiber diet to encourage defecation as soon as possible Prepared for the 15th FNDRC (not for public distribution) 115 55  9/1/24 MNT in Critical Care Critical care is the complex medical management of a seriously ill or injured person. (Krause, 2016) Prepared for the 15th FNDRC (not for public distribution) 116 2016 ASPEN Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Ø The target of these guidelines is intended to be the adult (≥18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical ICU (MICU) or surgical ICU (SICU). Ø Specific patient populations addressed by these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese. Prepared for the 15th FNDRC (not for public distribution) 117 56  9/1/24 2016 ASPEN Assess patients on admission to the intensive care unit (ICU) for nutrition risk and calculate both energy and Guidelines for the protein requirements to determine goals of nutrition Provision and therapy. Assessment of Nutrition Support Initiate enteral nutrition (EN) within 24−48 hours Therapy in the following the onset of critical illness and admission to Adult Critically Ill the ICU and increase to goals over the first week of ICU Patient stay. Take steps as needed to reduce risk of aspiration or Bundle Statements improve tolerance to gastric feeding (use prokinetic agent, continuous infusion, chlorhexidine mouthwash, elevate the head of bed, and divert level of feeding in the gastrointestinal tract). Prepared for the 15th FNDRC (not for public distribution) 118 2016 ASPEN Implement enteral feeding protocols Guidelines for the with institution-specific strategies to Provision and promote delivery of EN. Assessment of Nutrition Support Do not use gastric residual volumes as Therapy in the Adult Critically Ill part of routine care to monitor ICU Patient patients receiving EN. Bundle Statements Start parenteral nutrition early when EN is not feasible or sufficient in high-risk or poorly nourished patients. Prepared for the 15th FNDRC (not for public distribution) 119 57  9/1/24 What is the best method for determining energy needs in the critically ill adult patient? A3a. We suggest that indirect calorimetry (IC) be used to determine energy requirements, when available and in the absence of variables that affect the accuracy of measurement. [Quality of Evidence: Very Low] A3b. Based on expert consensus, in the absence of IC, we suggest that a published predictive equation or a simplistic weight-based equation (25–30 kcal/kg/d) be used to determine energy requirements. Prepared for the 15th FNDRC (not for public distribution) 120 In adult obese ICU patients, what are the appropriate targets for energy and protein intake to achieve nitrogen equilibrium and meet metabolic requirements? If IC is unavailable, we suggest using the weight-based equation 11–14 kcal/kg actual body weight per day for patients with BMI in the range of 30–50 and 22–25 kcal/kg ideal body weight per day for patients with BMI >50. We suggest that protein should be provided in a range from 2.0 g/kg ideal body weight per day for patients with BMI of 30–40 up to 2.5 g/kg ideal body weight per day for patients with BMI ≥40. Prepared for the 15th FNDRC (not for public distribution) 121 58  9/1/24 Prepared for the 15th FNDRC (not for public distribution) 123 Burns Refer to tissue injury or destruction caused by excessive heat, caustics (acids or alkalis), friction, electricity or radiation Characterized by decrease blood volume, plasma protein loss, edema, damage to blood vessel walls, increased metabolic rate, weight losses, nitrogen and nutrient losses, hyperglycemia Prepared for the 15th FNDRC (not for public distribution) 124 59  9/1/24 Classification Prepared for the 15th FNDRC (not for public distribution) 125 “Rule of Nines” Adults (15 y.o and up) Children (15 y.o and below) Prepared for the 15th FNDRC (not for public distribution) 126 60  9/1/24 Prepared for the 15th FNDRC (not for public distribution) 127 Dietary Management Objective: to achieve nitrogen balance and minimize tissue losses Diet Rationale Fluid resuscitation/IVF To replace fluid losses Tube feeding (if necessary) within To meet energy needs when oral 12h of injury intake is impossible High kcal To spare protein High protein, HBV For wound healing 1.5 to 2 g/ KBW in adults 1.5 to 3 g/KBW in children Source: ESPEN Endorsed Recommendations Prepared for the 15th FNDRC (not for public distribution) 128 61  9/1/24 NUTRITION SUPPORT v delivery of formulated enteral or parenteral nutrients to appropriate patients for the purpose of maintaining or restoring optimal nutritional status and health. Prepared for the 15th FNDRC (not for public distribution) 129 Algorithm for Decisions Can the GIT be used? “Inability to use the GIT” Yes No “inadequate intake” Parenteral nutrition Oral Tube feed < 75% intake Short term Long term More than 3-4 weeks Peripheral PN Central PN No Yes A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric NGT Gastrostomy patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA. Nasoduodenal Jejunostomy or nasojejunal Prepared for the 15th FNDRC (not for public distribution) 130 62  9/1/24 Algorithm for Decisions Can the GIT be used? “Inability to use the GIT” Yes No “inadequate intake” Parenteral nutrition Oral Tube feed < 75% intake Short term Long term More than 3-4 weeks Peripheral PN Central PN No Yes A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric NGT Gastrostomy patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA. Nasoduodenal Jejunostomy or nasojejunal Prepared for the 15th FNDRC (not for public distribution) 131 Tube feeding access Prepared for the 15th FNDRC (not for public distribution) 132 63  9/1/24 Enteral Nutrition (EN) v Nutritional support via tube placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum) q often called tube feeding q Exhaust all oral diet methods first! Prepared for the 15th FNDRC (not for public distribution) 133 What are the indications of enteral feeding? v Impaired food ingestion: dysphagia, unconscious, fractured mandible, respiratory failure, inability to suck (premature infants) v Impaired digestion of whole (intact) foods: chronic pancreatitis, Crohn’s disease, short bowel syndrome v Cannot meet nutritional requirements: major burn, trauma, anorexia nervosa, severe wasting Prepared for the 15th FNDRC (not for public distribution) 134 64  9/1/24 Enteral formula categories TYPE/INDICATION FOR CHARACTERISTICS USE 1. Intact formulas - for patients with normal or (Polymeric formulas) minimally impaired digestion; intact protein; instituted at full strength; aka “meal replacement formula” Prepared for the 15th FNDRC (not for public distribution) 135 Enteral formula categories TYPE/INDICATION FOR CHARACTERISTICS USE 2. Hydrolyzed formulas - for patients with compromised GI (Predigested/Monomeric/ tract who require hydrolyzed Elemental formulas) nutrients for improved digestion Prepared for the 15th FNDRC (not for public distribution) 136 65  9/1/24 Enteral formula categories TYPE/INDICATION FOR CHARACTERISTICS USE 3. Modular formulas - Composed of single pre-digested nutrients (e.g. protein, CHO, or fat) Prepared for the 15th FNDRC (not for public distribution) 137 Enteral formula categories TYPE/INDICATION FOR CHARACTERISTICS USE 4. Specialty formulas - For patients who require different (Disease-specific) proportions of protein, amino acids, carbohydrate, fat and electrolytes (i.e. patients with liver, renal, pulmonary diseases, and diabetes) Prepared for the 15th FNDRC (not for public distribution) 138 66  9/1/24 Intact/Polymeric Formulas Php950 - 1010/400g = 7 servings Prepared for the 15th FNDRC (not for public distribution) 139 Hydrolyzed/Elemental Php2400/1 L ~1200kcal Php 620/237 mL ~284 kcal Php1550/400g ~1800kcal Prepared for the 15th FNDRC (not for public distribution) 140 67  9/1/24 Specialty Formula Php1240/900g Php1775/800g Php265/237 mL Prepared for the 15th FNDRC (not for public distribution) 141 Specialty Formula Php1050/380g ~5 servings Php1900/370g ~5 servings Prepared for the 15th FNDRC (not for public distribution) 142 68  9/1/24 Modular Formulas Php210/60 mL 80 kcal, 20g PRO Php1175/223g 1 serving = 25 kcal, 6 g PRO Prepared for the 15th FNDRC (not for public distribution) 143 Rate and Method of Delivery* *Determined by medical status, feeding route and volume, and nutritional goals 1. Bolus v 300 to 400 ml rapid delivery via syringe several times daily Prepared for the 15th FNDRC (not for public distribution) 144 69  9/1/24 Rate and Method of Delivery 2. Intermittent ─ v 300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe Prepared for the 15th FNDRC (not for public distribution) 145 Rate and Method of Delivery 3. Continuous—via gravity drip or infusion pump Prepared for the 15th FNDRC (not for public distribution) 146 70  9/1/24 Ready-to-hang (RTH) enteral feeding Php4400/1 L Prepared for the 15th FNDRC (not for public distribution) 147 Rate and Method of Delivery 4. Cyclic v via pump usually at night Prepared for the 15th FNDRC (not for public distribution) 148 71  9/1/24 COMPLICATION SUGGESTIONS FOR RESOLVING PROBLEMS Diarrhea Assess the following: § administration of enteral formula(room temperature) § volume of bolus feedings, drip rate of the drip feedings and number of ccs per hour for pump administration § handling techniques § osmolality of the feeding § lactose intolerance. Consider a fiber-containing formula to increase bulk of the stool. Aspiration Head of the bed should be elevated to 30-45 degrees. Tube placement must also be checked. Prepared for the 15th FNDRC (not for public distribution) 151 COMPLICATION SUGGESTIONS FOR RESOLVING PROBLEMS Clogged tubes Flush tubes with 50-150 cc of water before and after administration of formula or addition of medications. Avoid use of juice, carbonated beverages, or sugary fluids to flush the tube. Avoid use of crushed medications. Liquid medications may contain sorbitol, which may clog the tube. Constipation Provide adequate fluids. Assess needs for fiber containing formula Prepared for the 15th FNDRC (not for public distribution) 152 72  9/1/24 COMPLICATION SUGGESTIONS FOR RESOLVING PROBLEMS Abdominal Assess the ff: volume of formula administered within a short distention period of time possibility of lactose intolerance Nausea/ Consider holding feeding for 12 hours until excessive vomiting passes Vomiting Check residual and tube placement A change in formula may be necessary. Refer to physician Prepared for the 15th FNDRC (not for public distribution) 153 SUGGESTIONS FOR RESOLVING COMPLICATION PROBLEMS Contamination Closed systems are ideal for avoiding potential contamination. They can hang for up to 24-48 of formula hours. Avoid addition of liquids/formulas/medications in a bag that has been hanging for a long period of time. If open systems are used, formula should not hang more than 4-8 hours. Clean poles and surrounding areas often. Discard unused formula Use sanitary techniques for mixing and administering formula. Prepared for the 15th FNDRC (not for public distribution) 154 73  9/1/24 When should parenteral nutrition begin in the critically ill patient at high nutrition risk? G2. Based on expert consensus, in the patient determined to be at high nutrition risk (eg, NRS 2002 ≥5 or NUTRIC score ≥5) or severely malnourished, when EN is not feasible, we suggest initiating exclusive PN as soon as possible following ICU admission. Prepared for the 15th FNDRC (not for public distribution) 155 Algorithm for Decisions Can the GIT be used? “Inability to use the GIT” Yes No “inadequate intake” Parenteral nutrition Oral Tube feed < 75% intake Short term Long term More than 3-4 weeks Peripheral PN Central PN No Yes A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric NGT Gastrostomy patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA. Nasoduodenal Jejunostomy or nasojejunal Prepared for the 15th FNDRC (not for public distribution) 156 74  9/1/24 Routes of Parenteral Nutrition Central access —both long- and short-term placement Peripheral or PPN —New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis 10% to 15 % weight loss Nutritional needs not met; patient refuses food Prepared for the 15th FNDRC (not for public distribution) 159 Contraindications for Parenteral Nutrition GI tract works “IF THE GUT WORKS, USE IT!” Terminally ill Only needed briefly ( 200 Morbid Obesity 150 - 200 Severe Obesity % DBW = ABW 100 120 - 149 Obese DBW 110 - 119 Overweight 90 - 109 Normal Weight 80 - 89 Mild Underweight 70 - 79 Moderate Underweight < 70 Severe Underweight Prepared for the 15th FNDRC (not for public distribution) 200 95  9/1/24 Diagnosis of Overweight/Obesity and Underweight A. Indirect Methods 2. Use of BMI (Adult) Formula: BMI = Wt (kg) Ht (m2) Prepared for the 15th FNDRC (not for public distribution) 202 Diagnosis of Overweight/Obesity and Underweight A. Indirect Methods 2. Use of BMI (Adult) BMI Range Class/Category BMI Range (Asia- (WHO) Pacific 25.0 Prepared for the 15th FNDRC (not for public distribution) 203 96  9/1/24 Dietary Management (Adult) Calorie adjustment for weight gain/loss: ± 500 kcal/day = 1 lb wt gain/loss week ± 1000 kcal/day = 2 lbs wt gain loss/week Prepared for the 15th FNDRC (not for public distribution) 204 Dietary Management: Overweight/Obesity (Adult) Determine Calorie Prescription: 1. Calculate TER on the basis of DBW 2. Calculate TER using ABW and deduct 500 – 1000 kcal/day 3. Allow 20– 25 kcal/kg DBW/day v Use ‘trial diet’ and observe outcome Prepared for the 15th FNDRC (not for public distribution) 205 97  9/1/24 Dietary Management: Overweight/Obesity (Adult) v Total Calories – individualized v Calorie distribution Fat – use lower limit (20% of TER) Protein and CHO – the rest of TER v Food selection: emphasize bulky low calorie foods to provide satiety without increasing calories v Vitamin and mineral supplements: imperative for diets -3 z-score for children 0-59 months (or for children 6-59 months, MUAC 115 mm). v Severe Acute Malnutrition (SAM) is identified by severe wasting WFH < -3 z-score for children 0-59 months (or for children 6-59 months, MUAC