PHAR 721 Nutrition, Vitamins, Complementary and Alternative Medicine Lecture 20

PHAR 721 Nutrition, Vitamins, Complementary and Alternative Medicine Dietary/Herbal Supplements: Endocrine Herbals Ladan Panahi, PharmD, BCPS [email protected] 1 ...

PHAR 721 Nutrition, Vitamins, Complementary and Alternative Medicine Dietary/Herbal Supplements: Endocrine Herbals Ladan Panahi, PharmD, BCPS [email protected] 1  What is it? Endogenous antioxidant and cofactor in glucose metabolism Small amounts exist in plant and animal sources with the greatest amounts in spinach and broccoli Alpha-Lipoic What is it used for? Acid (ALA) Peripheral neuropathy in diabetes Diabetes Mellitus Type 2 Initiates teas attila Also available Rx in Europe How does it work? as IV Acts on glucose transporters and stimulates glucose uptake Improved nerve conduction and blood flow, insulin sensitivity and oral glucose tolerance tests Antioxidant 2  What is the evidence for efficacy: Diabetes Mellitus Type 2 Alpha- In several neuropathy trials, reductions in glucose and hemoglobin A1C were not significant Small trials have documented clinically Lipoic Acid significant lowering of fasting blood glucose, insulin and hemoglobin A1C, primarily when alpha-lipoic acid was (ALA) added to standard antidiabetic medications Although a strong recommendation for glucose control cannot yet be made, alpha-lipoic acid’s safety profile supports use in individual patients Usual dose: 600 mg to 1800 mg/day Alpha-Lipoic Acid (ALA) mainlyfortype diabeticpt's What is the evidence for efficacy: diabetic neuropathy Three meta-analyses concluded that intravenous and oral supplementation is beneficial, with improvement in total symptom scores, neuropathy impairment scores, and short-term symptoms of pain and paresthesia 4-year study of 460 patients, alpha-lipoic acid was demonstrated to be more useful in preventing progression of neuropathy rather than being used as an acute treatment Alpha-lipoic acid may be considered a treatment option for diabetic neuropathy 4  What is the evidence for safety? Alpha- Adverse reactions rare and mild: headache, nausea, diarrhea, rash, and hypoglycemia Lipoic Acid N/V/D dose dependent Drug interactions: (ALA) Antacids and mineral containing supplements, Antihyperglycemics chelating activity ofALA 5 Alpha-Lipoic Acid Who may consider this product? Patients with diabetes type 2 (adjunct) or diabetic neuropathy (discuss with physician first) How should we counsel our patients? May take 3 to 5 weeks to see improvement in diabetic neuropathy Monitor blood glucose more frequently initially Take on an empty stomach food reduesbioavailability 30 by Separate from antacids by 2-3 hours 6  Cinnamon What is it? What is it used for? Cinnamon plant native Help lower blood to South Asia & glucose Indonesia, South America and West Indies Frequently used as a spice and aromatic 7  Types of Cinnamon Available Cinnamomum cassia or “ Cassia cinnamon” Most common type found in grocery stores Used to lower blood glucose Contains coumarin may worsen hepatic disorders Cinnamomum verum or “Ceylon cinnamon” True cinnamon Human trials found no effect on blood glucose or insulin Contains little to no coumarin 8  How does it work? Increase insulin sensitivity through increased insulin receptor autophosphorylation and increase Cinnamon cellular glucose uptake Inhibits inactivation of insulin clearance glu receptors by tyrosine phosphatase Whole cinnamon seems to delay gastric emptying, which could reduce postprandial glucose spikes bloodglucose after eating 9  Cinnamon What is the evidence for efficacy? – A 2019 review of 18 studies of cinnamon supplementation in people with diabetes suggested that cinnamon could reduce blood sugar but didn’t have a significant effect on hemoglobin A1C, which reflects blood sugar levels over a longer period of time. However, it’s unclear whether these findings are meaningful because 10 of the studies didn’t identify the type of cinnamon used, and 8 of the studies were judged to be of low quality for other reasons. – ADA Guidelines 2021: “There is no clear evidence that dietary supplementation with vitamins, minerals (such as chromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) can improve outcomes in people with diabetes who do not have underlying deficiencies, and they are not generally recommended for glycemic control.” Rationale: insufficient evidence  Cinnamon What is the evidence for safety? Case reports of contact dermatitis from cinnamon oil (topical) and pediatric poisoning from accidental ingestion Coumarin mainly concentrated in Cassia cinnamon is hepatotoxic in animal models and human case reports do not use in pt'sthat already has hepatic disorder Do not use cassia cinnamon in hepatic disease Potentiation of hypoglycemic reactions in patients on antihyperglycemic medications is theoretically possible but not noted in clinical trials Usual dose: 2-6 grams/day (ground cinnamon) **1/2 teaspoon = 1 gram** 0.5-1 gram/day (aqueous C. cassia extract; most effective form)  Who may or may not consider this product? Consider for adjunctive therapy in some Diabetic patients Cinnamon How should we counsel our patients? Not enough strong evidence to recommend as monotherapy in diabetes Do not use if have underlying liver impairment 12 Introduction to Malnutrition and Nutrition Screening, Assessment, Diagnosis, and Intervention Ladan Panahi, PharmD, BCPS PHAR 721 Nutrition, Vitamins, Complementary and Alternative Medicine [email protected] 13  Learning Objectives Define nutritional screening and assessment Discuss the purpose of a nutrition screening program Discuss the purpose of a nutrition assessment program Determine when to screen and when to assess Identify who is at risk for malnutrition 14  “Fuel”-> provides bulk energy Nutrients needed in Macronutrients large quantities Carbohydrates, fat, and Is protein 15  Estimated amounts of calories needed to maintain calorie balance for various gender and age groups at three different levels of physical activity FYI: Average Adult women: 1,600 to 2,400 calories per Dietary day Calorie Intake Adult men: about 2,000 to 3,000 calories per day 16  Introduction to Malnutrition energy input energy output 17 Definitions Based on American Society for Parenteral and Enteral Nutrition(ASPEN) guidelines for nutrition c https://www.nutritioncare.org/guidelines_and_clinical_resourc es/Malnutrition_Solution_Center/ 18 Malnutrition Is this patient at risk for malnutrition? Energyinput Energyoutput Pt is malnourished  Prevalence of in-hospital malnutrition for pediatric and adult patients: 13% to 88% Prevalence of Up to 12% of the malnourished, hospital patients are severely Malnutrition malnourished 26% hospital readmission rate in malnourished elderly 20  Prevalence of Malnutrition Diagnosis in Hospital Settings Malnutrition is rarely diagnosed in hospitals. A 2018 Agency for Healthcare Research and Quality (AHRQ) analysis revealed: Only 8% of hospital visits had a malnutrition diagnosis. 25% to 54% of hospital patients are affected by malnutrition. https://www.nutritioncare.org/uploadedFiles/Documents/Malnutrition/MAW_2020/Why%20Nutrit ion%20is%20Important_Patient%20Over%20the%20Age%20of%2065.pdf 21  Definition of Malnutrition Nutrition imbalance “An acute, subacute or chronic state of nutrition, in which varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function.” 22  Starvation-associated Inadequate or poor-quality food intake Etiology of Disease-related Diseases that alter food intake or Malnutrition nutrient requirements, metabolism, or absorption Chronic or acute conditions Associated with inflammation. 23 Etiologic basis for malnutrition diagnosis. (Data from References1 and 2.) Citation: Chapter 164 Assessment of Nutrition Status and Nutrition Requirements, DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition; 2023. Available at: https://accesspharmacy.mhmedical.com/content.aspx?bookid=3097&sectionid=270780147 Accessed: October 08, 2023 Copyright © 2023 McGraw-Hill Education. All rights reserved  Increased mortality Increased morbidity Outcomes- Based Impact Decreased function of Malnutrition Decreased quality of life Higher healthcare costs Increased frequency and length of hospital stay 25 Steps to Target Malnutrition Once diagnosed with malnutrition: Creation of a nutrition care plan Implementation of the plan Patient monitoring Evaluation of the plan Evaluation of the care setting Reformulation of the plan or termination of therapy 26 Nutrition Screening The nutrition screening process identifies needs for further nutrition intervention or monitoring based on patient’s nutrition risk 27 Definitions Based on ASPEN 28 Definitions Based on ASPEN Continued 29  “A process to identify an individual who is malnourished or who is at Definition risk for malnutrition to determine if a detailed nutrition assessment is of indicated.” Nutrition Screening First step in nutrition care 30  Nutrition screening should be designed to quickly and reliably identify those who are at risk of Definition of nutrition-related poor outcomes Nutritional Screening Ideal nutrition screen is quick Continued , simple , and noninvasive and can be done by lay and healthcare providers in many settings 31  Screening for nutrition risk is suggested for hospitalized patients (E) ASPEN Nutrition Support Guideline Rationale: Nutrition risk, Recommendations identified by nutrition screening, is associated with: Longer length of hospital stay Complications Mortality 32 Joint Commission An independent U.S.-based organization that accredits over 22,000 healthcare programs and organizations, symbolizing quality and performance excellence. Aims to improve public healthcare by evaluating organizations and inspiring them to provide safe, high-quality care. Develops healthcare standards with experts and conducts on-site surveys to ensure compliance, awarding the Gold Seal of Approval™ to qualifying institutions. 33  Joint Commission Standards The Joint Commission mandated a 24 hour nutrition screen for inpatients upon admission when applicable for the patient's condition (criteria defined by the organization) Inpatient: periodic rescreening should occur at regular intervals determined by the institution and the patient population, usually every 3 to 7 days Outpatient: Nutrition screening may be performed for outpatient at their first visit , to pinpoint individuals needing comprehensive nutrition assessment and care. RELEVANCE: cost-effective way to help decrease complications and length of hospital stay 34 https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/provision-of-care-treatment- and-services-pc/000001652/ Nutritional Screening Tools 35  Examples of Nutritional Screening Tools Mini-Nutritional Assessment–Short Form (MNA- SF)  Geriatric patients Malnutrition Screening Tool (MST) 36  ASPEN Guidelines: Based on expert consensus, we suggest a determination of nutrition risk (eg, More Nutritional nutritional risk screening [NRS 2002] Screening Tools: or NUTRIC score ) be performed on all patients Nutritional admitted to the intensive care unit Screening Tools in (ICU) Critically Ill Critical care patients, critically ill, and ICU patients are all synonymous terms https://aspenjournals.onlinelibrary.w iley.com/doi/full/10.1177/01486071 15621863 organfailure ICU ventilated 9 lungs vasoconstrictors CV 37 NRS 2002 38 NRS 2002 Continued 39  NUTRIC SCORE do havenot to memorise 40 NUTRIC SCORE CONTINUED 41  Van Bokhorst-de Objective: assess the validity and van der Schueren predictive validity of nutrition screening tools for the general hospital population et al. Review on Identified 83 studies (32 screening tools) Authors’ Conclusion: “none of the tools Nutritional performed consistently well to establish Screening Tools the patients’ nutrition status” Many of the screening tools have 2 common queries: (1) unintentional recent weight loss and (2) inadequate food intake in the last 1 or 2 weeks Correia MITD. Nutrition Screening vs Nutrition Assessment: What's the Difference? Nutr Clin Pract. 2018 Feb;33(1):62-72. doi: 10.1177/0884533617719669. Epub 2017 Dec 14. PMID: 28727954. 42  Diagnostic criteria vary Concerns Poor specificity and sensitivity with Screening Interobserver reliability Tools Fail to appreciate the role of the inflammatory response on acute phase proteins that are used as indicators of nutrition status 43  If patient is ‘nutritionally-at-risk’, the next step would Typically within 48 be to do a nutritional assessment to 72 hrs The Next Step If patient is not ‘nutritionally-at-risk’, re-screen the patient Typically every 3 to during specified regular intervals 7 days to prevent determined by the institution policy or hospital- acquired when nutritional/clinical malnutrition status changes 44  Nutritional Assessment A comprehensive nutrition assessment is required to formulate a nutrition care plan for an individual found to be nutritionally at- risk for nutrition-related poor outcomes 45  “A comprehensive approach to assist in Definition: diagnosing nutrition problems that uses Nutrition a combination of the following: medical, nutrition, and medication histories; Assessment physical examination; anthropometric measurements; and laboratory data.” 46  Nutrition assessment is a comprehensive approach to identifying nutrition-related problems. It uses a combination of medical, nutrition, Nutrition medication, and client histories; nutrition- focused physical examination (NFPE); Assessment anthropometric measurements; and biomedical data/medical diagnostic tests Continued and procedures. Nutrition assessment is the next step after identifying nutritional risk through screening. Nutrition assessment findings are then applied to a diagnostic framework to derive the malnutrition diagnosis. 47  Nutrition assessment is suggested for all patients who are identified to be at nutrition risk by nutrition screening (E) ASPEN Nutrition Support Guideline Recommendations Continued Rationale: Malnourished patients have: More infectious Longer hospital and noninfectious Greater mortality length of stay complications 48  Difference between nutritional screening and assessment Nutrition screening is distinct from nutrition assessment. It is a systematic method designed to quickly and consistently identify individuals with pre-existing malnutrition or those at risk for malnutrition. 49 Summary: Screening vs. Assessment Citation: Correia MITD. Nutrition Screening vs Nutrition Assessment: What's the Difference? Nutr Clin Pract. 2018 Feb;33(1):62-72. doi: 10.1177/0884533617719669. Epub 2017 Dec 14. PMID: 28727954. 50  Malnutrition QI leads to better patient and healthcare outcomes. Malnutrition Quality CMS Reporting: Hospitals must report performance on the Improvement Global Malnutrition Composite Score (GMCS) to the Centers for Medicare & Medicaid Services (CMS) to receive full Medicare (QI) payment. The first nutrition-focused quality measure endorsed by the National Quality Forum and addresses malnutrition in hospitalized patients, a widespread but underdiagnosed issue. Starting in 2024, hospitals can report on GMCS to fulfill CMS requirements and potentially secure full Medicare payment. 51  Global Malnutrition Composite Score Figure adapted from: https://malnutritionquality.org/wp-content/uploads/GMCS-for-IQR-Introduction.pdf Data will then be publicly available on https://www.medicare.gov/care-compare/ 52 Knowledge Check What is the main purpose of the Global Malnutrition Composite Score (GMCS) in hospital quality reporting? A. To reduce hospital costs. B. To monitor malnutrition risk in outpatients. C. To track hospital performance in addressing malnutrition using a standardized process. D. To assess patient satisfaction with hospital meals. 53 Questions? 54