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Clinical Nutrition Prof. Albert Flynn University College Cork 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: • Dietician: diet formulation and menu plan, patient counselling recommends diet • 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 reduced arm circumference reduced weight reduced haematocrit reduced albumin % affected 79 74 64 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 costeffectiveness 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. antimicrobials 2. physiotherapy 3. 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 mellitus European 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 6070% 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 carbohydratecontaining 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