clinical nutrition prof. albert flynn university college cork
TRANSCRIPT
Nutrition activities in hospitals
• Basic care
• Diagnosis
• Therapy
• Teaching/education (students, staff, patients)
• Research
Basic care
• Who is responsible for feeding patients?
• Is food intake monitored?
• Is body weight monitored?
• Does dietician see every patient?
Diagnosis (Nutritional status)
Anthropometry:• height, weight, skinfold, weight
history
Clinical• evidence of nutritional status
– hair, skin, nails, eyes, perioral, oral, glands
– heart, liver, muscles, bones, neurological etc.
Diagnosis (Nutritional status)
Biochemical• Serum Albumin• Haemoglobin• Ferritin• Haematocrit• Folate• Phosphate• Calcium• Sodium
Dietary assessment• recall of food intake - diet history
Nutrition therapy• Doctor: recommends diet
• Dietician: diet formulation and menu plan, patient counselling
• Doctor - dietician interaction
• in-patient vs out-patient
• Need for community dieticians!
Does malnutrition occur in the hospitalised patient?
• malnutrition may be a cause and/or an effect of illness
• malnutrition may be present on admission
• malnutrition may occur during hospital stay
Does malnutrition occur in the hospitalised patient?
Weinsier et al. (1979) Am. J. Clin. Nutr. 32, 418. Hospital malnutrition. A prospective evaluation of general medical patients during the course of hospitalization.
• randomly selected group of patients (n 134)
• nutritional status assessed at entry & after ≥2 weeks
Does malnutrition occur in the hospitalised patient?
On admission 48% of patients had a high likelihood of malnutrition, which correlated with
- a longer hospital stay (20 vs 12 d for patients with a low likelihood of malnutrition)
- increased mortality rate (13 vs 4%)
Does malnutrition occur in the hospitalised patient?
Likelihood of malnutrition increased with hospitalization in 69% of patients
index % affected reduced arm circumference 79reduced weight 74reduced haematocrit 64reduced albumin 47
• Nutritional status worse at discharge than at admission• causes? Can it be avoided?
Undesirable practices identified (Weinsier1979)
• failure to record Ht, Wt, Wt. history
• failure to record diet history, food intake
• incomplete use of biochemical tests
• prolonged use of glucose/saline I.V. feeds
• withdrawing meals - diagnostic tests
• failure to recognise increased nutrient needs
• poor doctor-dietician interaction
• failure to monitor effects of medication/therapy on
appetite/food intake
• lack of nutrition awareness/education in doctors
Early nutrition assessment pays off
•Kruizenga HM. et al. 2005 Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. Nov;82(5):1082-9.
• 588 patients in mixed surgical-medical wards given either routine care (including whatever nutritional element may have been provided) or • were screened on admission using the Short Nutritional Assessment Questionnaire and those who were found to be malnourished were given protein-energy supplements (600 kcal and 12 gm protein/day)
Early nutrition assessment pays off
• Results: Recognition of malnutrition increased from 50% to 80% in the intervention group
• Malnourished patients spent less time in hospital in intervention than in the control group (11.5 vs 14.1 days, p<0.05)
• estimated additional cost for nutritional screening and treatment of €76 for each hospital day saved
Nutritional treatment of disease
• Dietary modification– qualitative– quantitative
– communication– behaviour modification– motivation– patient education
Nutritional treatment of disease
• Under-nutrition - protein, energy, vitamins, minerals
• Over-nutrition (obesity) - energy restriction
• digestive disorders
– cystic fibrosis
– colitis
– coeliac disease
• Metabolic disorders - diabetes mellitus
• diseases of liver, kidney, cardiovascular
• injury, surgery, convalescence
• enteral/parenteral nutrition
Therapeutic diets - cystic fibrosis
1. antimicrobials2. physiotherapy3. diet
• high energy (120-150% RDA)• no fat restriction• supplement with energy drinks• pancreatic enzyme replacement • supplement with vitamins (A, D, E)
• Growth failure• overnight nasogastric feeding
Diabetes mellitusEuropean Association for the Study of Diabetes [EASD] 1999
Overall aims: • to help optimize glycaemic control and reduce risk factors for cardiovascular disease and nephropathy
Diabetes mellitus
• those overweight
– reduce weight [BMI 18.5-25 kg/m2 for adults] and prevent wt. gain
• moderate physical activity at least 20-30 minutes most days
– improves glucose tolerance, blood lipid profile, weight control and maintains muscle mass
Diabetes mellitus• Saturated and trans-fatty acids under 8-10% of total energy
– Replace with polyunsaturated fat
• Total fat intake should not exceed 35% energy intake
• adequate intake of n-3 fatty acids
– oily fish and plant oils (e.g. rapeseed oil, soyabean oil)
• Protein intake 10-20% total energy
– In nephropathy - protein intake lower (0.8g/kg body weight/day)
Diabetes mellitus
• Carbohydrate + monounsaturated fatty acids to provide 60-70% of energy intake. • Carbohydrate-containing foods rich in dietary fibre or with low glycaemic index
– vegetables, fruits and cereals
• Moderate intakes of sucrose <10% E
• Insulin-treated patients
– timing and dose of insulin to match with the amount and time of carbohydrate-containing food intake
– to avoid both hypoglycaemia and excessive postprandial hyperglycaemia
Diabetes mellitus
• 5 or more servings of vegetables & fruit
• restrict salt intake to < 6g/day.
• alcohol
– intakes of up to 15g for women and 30g for men are acceptable
– for those on insulin alcohol with a meal including carbohydrate-containing foods - risk of hypoglycaemia
• compliance with dietary recommendations??
Effect of Phytosterols on Plasma Cholesterol
• Phytosterols containing foods (e.g. fat spreads) consumed in typical dietary amounts lower LDL cholesterol by 10-15%
• sterols have additive effects with statins
Phytosterols and Plasma Cholesterol - mechanism
• inhibit cholesterol absorption
• cholesterol forms crystals and is excreted in faeces
• also reduces cholesterol reabsorption from biliary cholesterol
• while liver increases cholesterol synthesis and LDL receptors in response to this, it is not sufficient to counteract the reduction in cholesterol absorption so blood cholesterol falls