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TUTORIALS
SUBJECT
Changing Eating Behaviour
Nutrition Support - Assessing fluid and electrolyte
needs
Diet and Diabetes
Diet and Gastro-Intestinal Disease
Diet and Cardiovascular Disease
Respiratory Disease
Food Intolerance and Food Allergy
Nutrition and Renal Disease
Nutrition and Liver Disease
Nutrition in Bone Marrow Transplantation
Nutrition in the Treatment of Cancer
KEY DIETITIAN
Lisa Sinfield
Melanie Baker
Sayjal Amin
Clare Tilley or Angela Hall
Ellen Wilford & Balraj Sidhu
Sonal Patel
Kristian Bravin or Cathy Steele
Jenny McMahon
Clare Tilley
Clare Blakeman
Catherine Hanlon /Sue Kavanagh
NOTE:
Tutorials will not be held during your placement. A workshop format can be arranged.
If you would like this to happen ask your Lead Trainer - Dietetic Manager to organise.
Alternatively you can work through the exercises (where stated) and arrange for
feedback with the lead dietitian.
TUTORIAL: CHANGING EATING BEHAVIOUR
Aim: To provide an overview of patient centred approaches
Learning Outcomes
The student will be able to:
1. Define the qualities of a “Helping Relationship”
2. Describe the core conditions of a person centred approach
3. Describe ways in which an interview can be initiated to make the patient feel at ease
4. Discuss possible expectations/agendas of patients
5. Identify different models of behaviour change
6. Practice listening skills
7. Describe how interview styles can enhance dietetic practice
Exercise
Pre-tutorial reading
1. Counselling skills for dieticians – Judy Gable (each dept has a copy).
2. Handout: The Process of Change.
Further Reading
1. Counselling Skills for Dietitians by Judy Gable. Publisher: Blackwell Science. ISBN No
0-632-04261-3
2. Changing Eating and Exercise Behaviour by Paula Hunt and Melvyn Hillsdon. Publisher:
Blackwell Science. ISBN 0-632-03927-2
3. Motivational Interviewing by William R Miller and Stephen Rollnick. Publisher: Guilford.
ISBN 0089862-469-X
C PLACEMENT TUTORIAL
ASSESSING FLUID AND ELECTROLYTE NEEDS
AIMS
To assess the l, fluid and electrolyte needs for an individual referred for nutritional
support.
TUTORIAL
1. To complete the tutorial questions (following the fluid and electrolyte
powerpoint presentation).
2. List the parameters you need to assess during the dietetic treatment of (1) a
newly referred patient requiring an enteral feed and (2) a review of a patient
who has been receiving enteral feeds for 3 days. Include some information
about your rationale and where/who you need to liaise with to obtain this
information.
3. A reflective piece on the differences in monitoring a community fed home
enteral nutrition patient and a patient who is acutely unwell (ie on critical care
or acute medical/surgical ward) receiving enteral feeds.
INTERPRETING FLUID AND ELECTROLYTE NEEDS - Questions
1. What are the potential sources of fluid intake and fluid loss in hospital patients
Fluid intake
Fluid Losses
2. What type of IV fluids are given and what do they contain?
Name
Energy
Electrolytes
3. What are the potential causes of a low or high sodium concentration?
Low [Na]
High [Na]
4. What are the causes of a high / low K level?
Low [K]
High [K]
CASE STUDY
Mr X, 47 year old male, who had a anterior resection and ileostomy formed 4 days
ago. He weighed 70kg on the day of operation.
5. What is the patient’s estimated requirements baseline requirement for fluid
and sodium ?
6. How do you assess fluid and electrolyte intake/output from fluid balance
charts?
(Use fluid balance chart and table to estimate)
INPUT
Oral
FLUID
Sodium
FLUID
Sodium
IV - fluids
IV medications
Total
OUTPUT
Urine
Insensible losses
Stoma
Total
TOTAL
24 hour Fluid Balance Chart for Mr X
Time
IN (ml)
Oral
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
24.00
TOTAL
100
150
100
50
100
IV
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
125
100ml paracetamol
100 ml paracetamol
OUT (ml)
Urine
35
40
40
50
35
60
50
35
30
60
70
80
60
65
55
50
40
60
50
60
70
65
60
50
Stoma
800
400
600
Prescribed 2000ml 5% Dextrose and 1000ml 0.9% Saline per day
CASE STUDY 2
83 year old at home on PEG feeds, due to a CVA 10 months previously
Ad to hospital with pain, vomiting, 56kg on admission
On ad
Na 134
K 5.0
Urea 27.8
Creat 195
day 4
138
4.5
10.6
112
Comment on her biochemistry on day 1 and 4.
On day 4, her vomiting has settled. She is on IV antibiotics for a chest infection. Her
temp is normal. Her normal regimen is 1000ml Energy Multifibre /day with small
amounts of soft diet and thickened fluids. What advice would you give regarding
additional fluid?
CASE STUDY
Mr B, male 72 years, weight loss and diarrhoea, 68 kg
Relevant past medical history: CVA,C Diff PEG fed
Relevant treatment including drugs etc. CVA meds, codeine phosphate,
metronidazole,
The patient has been maintained on 1500ml Nutrison Standard, with approximately
500ml additional fluid / day.
FLUID BALANCE
IN
FEED 1500ml, Water flushes with medication, 500ml
OUT
Urine output, 1200ml/day
Bowels – x 5 (type 7) stool
BIOCHEMISTRY
Na
K
Urea
Creat
132mmol/litre
3.3
9.4
110
He is not receiving any IV fluids and is NBM
Review this patient – who you make any changes to his regimen?
TUTORIAL: ADULT DIABETES
The student should have had the opportunity to attend a diabetes clinic prior to the
tutorial. He/she should be familiar with the way that a diabetes clinic runs and the
role of the different members that work within the diabetes team.
AIMS
1. For the student to have a holistic understanding of diabetes and its
management, and the importance of achieving and maintaining good diabetes
control.
2. For the student to understand the role of the dietitian within diabetes
management, and the relevance of diet as part of treatment.
3. To understand the relationship between diet and lifestyle, drugs and insulin in
the management of diabetes.
LEARNING OUTCOMES
The student will be able to:1. Define diabetes in one simple statement.
2. List 7 symptoms of diabetes.
3. Give 4 major differing characteristics of each type of diabetes.
4. State the range of blood glucose in a person without diabetes.
5. State target levels of blood glucose for people with diabetes (consider
individual characteristics / circumstances).
6. State 2 key reasons why someone with diabetes should try to aim for these
targets
7. State the W.H.O. diagnostic criteria for diabetes and impaired glucose
tolerance.
8. State 3 different ways of monitoring diabetes control.
9. List 5 complications of diabetes.
10. Discuss the different oral hypoglycaemic drugs used for diabetes and the
dietary implications involved.
11. Discuss physiological insulin profile in someone without diabetes.
12. Briefly discuss the action of short, intermediate and pre-mixed insulin and
their relevance to diet.
13. Define a ‘hypo’ and give examples of why a hypo can occur.
14. Explain basic dietary principles of the diet for diabetes.
15. Discuss the effects of body weight and shape on diabetes management.
16. Discuss the effects of exercise and sickness on diabetes control.
EXERCISES
The student should have worked through the learning outcomes prior to the tutorial,
and preferably looked through one of the references below in order to gain a good
baseline knowledge and facilitate discussion. (Ask one of the diabetes specialist
dietitians for a copy).
Case studies will be used in the tutorial to review practical management.
References
1. Connor H, et al. The implementation of diabetes nutritional advice for people
with diabetes. Diabetic Medicine (2003): 20:786-807.
2. Evidence Based Nutrition Principles and Recommendations for the
Treatment and the Prevention of Diabetes and Related Complications.
Diabetes Care Volume 25. 148-198 2002.
3. Technical Review – Recommendations foe the nutritional management of
patients with Diabetes Mellitus.
Eur.J.Clin.Nutr. 52,467-481 (1998)
4. Recommendations for the nutritional management of patients with Diabetes
Mellitus.
Eur.J.Clin.Nutr. 54, 353-355 (2000)
Further Reading – Leicestershire Nutrition and Dietetic Service Diabetes Folder (1
copy held at each base).
INSULIN
Insulin is available in many forms. The type and brand of insulin used and popular
regimes will vary from hospital to hospital and region to region.
Below are some of the more common regimes and insulins you will come across.
Insulin Preparations
-
Rapid/short acting (soluble)
Intermediate/long acting (isophane)
Premixed
Insulin Regimes
 Basal bolus regime (4 x day or qds)
Rapid or short acting insulin 3xday i.e. before meals, and intermediate or long
acting insulin at bedtime (or twice per day).
Despite the number of injections, this regime offers the greatest flexibility of
dose and timing. It is best suited to people with Type 1 diabetes with irregular
or unpredictable meal times or for those who wish to adjust their insulin to
food on a frequent basis.
 Twice daily (bd)


A premixed or free mixed injection before breakfast and before evening meal.
(To free mix, a patient mixes together their own combination of short and
longer acting insulin in a syringe).
This regime is best for people with more predictable mealtimes and who are
unlikely to self adjust insulin. Used for people with both Type 1 and Type 2
diabetes.
Intermediate or long acting insulin once (often at bedtime) or twice daily in
combination with short acting insulin if required or with OHA’s.
This regime is suitable for people with Type 2 diabetes transferring to insulin.
Sometimes those with newly diagnosed Type 1 diabetes commence twice
daily intermediate action insulin, and quick acting insulin is added at
mealtimes as required.
Insulin pumps. Pump usage is becoming more common in the UK.
Leicestershire has a pump programme, although currently only a small
number of people with Type 1 diabetes use a pump locally. Insulin pumps
are worn permanently and provide a continuous infusion of quick acting
insulin. The wearers then give themselves a bolus of insulin at mealtimes,
the amount given being determined by the CHO content of the meal.
Any combination of insulin types and number of injections can be used to suit the
individual patients' lifestyle and requirements for insulin. So, although the above are
common, other regimes should not be considered unusual.
INSULIN
Rapid Acting (insulin analogues) Onset 15 mins, Peak Action 0.5-2.5 hrs, Duration
3-5 hrs
(can be taken immediately before eating)
Humalog
Novorapid
(insulin lispro)
(insulin aspart)
Short acting Onset 30 mins, Peak Action 1-3 hrs, Duration 6-8 hrs
(taken 20-30 mins before eating)
Actrapid
Humulin S
Intermediate acting Onset around 1-2 hrs, Peak Action 4-6 hrs, Duration 18-24 hrs
(taken before bed or 20-30 mins before eating, depending on regime)
Insulatard
Humulin I
Long acting (analogue) insulin. Onset approximately 2 hours, no peak, duration 1724 hours, individual variation.
Glargine (Lantus)
Detemir (Levemir)
Pre-mixed Onset 30 mins, Duration 18-24 hrs
(analogue mixtures taken immediately before eating, others 20-30 mins before
eating)
Humalog mix 25 (25% rapid acting(analogue) insulin)
Humalog mix 50 (50% rapid acting(analogue) insulin)
Novomix 30
(30% rapid acting (analogue)insulin)
Human Mixtard 30ge - 30/70 mixture(30% short acting/70% intermediate acting)
This is the most common mixture used
(Also available as Mixtard 10, 20, 40 and 50)
Humulin M3 - 30/70 mixture
(Also available as M2 and M5)
All the above insulins are human sequence insulin. Animal insulin is still available
and continues to be used by many people who have always been on animal insulin. It
will usually be pork insulin as beef insulin is now rare.
There are many other types of insulin available; the ones listed above are probably
the most commonly used.
Insulin is available in either cartridges, for use in insulin pens, in vials for use with
syringes, or as pre-filled disposable pens.
For more information on available insulin and formats see an up to date BNF.
ORAL HYPOGLYCAEMIC AGENTS (OHA’S)
There have been significant developments in the type and amount of OHA’s available
to treat Type 2 diabetes in the last few years. OHA’s might be broadly split into two
main categories - insulin secretagogues, i.e. those which increase the insulin
production from the pancreas, and insulin sensitizers, which improve the body’s use
of insulin or reduce insulin resistance.
While older agents such as metformin and gliclazide are still effective and popular,
the newer agents offer some benefits such as reduced risk of hypos and shorter
duration of action. From a dietary perspective, this helps us to individualize our
advice more and particularly helps when trying to facilitate weight loss.
INSULIN SECRETAGOGUES
Sulphonylureas
Generic name
Gliclazide
Glimepiride
(Glibenclamide
(Tolbutamide
(Glipizide
Brand name
Diamicron
Amaryl
much less common now)
but may be seen in primary care)
and/or in pts diagnosed for many years)
Prandial Glucose Regulators
Repaglinide
Nateglinide
Novonorm
Starlix
Insulin sensitizers
Biguanide
Metformin
Glucophage
Thiazolodinediones (‘Glitazones’)
Rosiglitazone
Pioglitazone
Avandia
Actos
Others
Alpha-glucosidase Inhibitor
Acarbose
Glucobay
TUTORIAL : DIET AND GASTRO INTESTINAL DISEASE
AIMS
1.
2.
To revise the anatomy and physiology of the GI tract.
To increase knowledge about common GI tract disorders and to justify the
type of nutritional support or dietary treatment used.
LEARNING OUTCOMES
At the end of the tutorial, the student will be able to:


State the major absorptive roles of the various parts of the GI tract.
Clarify the significance of losing the ileocaecal valve and terminal ileum.
Describe dietary advice which should be given to patients with various GI
disorders.
EXERCISES
(To be prepared prior to the tutorial and discussed at the tutorial).
1.
Summarise the dietary advice which should be given to patients with the
following:
hiatus hernia, diverticular disease, constipation, irritable bowel syndrome,
oesophagectomy, oesophageal stents and short bowel syndrome.
2.
Describe both short and long term nutritional problems that may be
experienced by a patient who has had a total gastrectomy. Discuss possible
solutions.
3.
A case study is given on the day which summarises the diet history and
symptoms of a newly diagnosed Coeliac; explain which items of food would
need to be excluded. The patient also has a poor appetite and iron deficiency
anaemia, what additional advice would you give?
4.
Be able to identify three differences between Crohn’s Disease and Ulcerative
Colitis.
5.
Another case study is given on the day about a patient with Crohn’s Disease.
From the information given, calculate energy and protein requirements.
Consider different ways that these nutritional requirements could be met,
stating reasons for products chosen. Explain the blood results.
An endoscopy shows that the most inflamed part of the bowel is the ileum
and an ileostomy is performed. What dietary advice would you give? How
does this advice differ from that given to a patient with a colostomy?
REFERENCES



Thomas, B (2001). Manual of Dietetic Practice. Blackwell Scientific
Publications.
Holt, A (1998). Protocol For the Use of Elemental Diets in Crohn’s Disease.
SHS.
The Coeliac Handbook. The Coeliac Society, High Wycombe.



Nightingale, JMD (1995). The Short-bowel Syndrome. European Journal of
Gastroenterology and Hepatology 7; 514-520.
LNDS Diet Sheets.
LNDS Dietary Management of Irritable Bowel Syndrome
TUTORIAL : DIET AND GASTRO INTESTINAL DISEASE
AIMS
1.
2.
To revise the anatomy and physiology of the GI tract.
To increase knowledge about common GI tract disorders and to justify the
type of nutritional support or dietary treatment used.
LEARNING OUTCOMES
At the end of the tutorial, the student will be able to:


State the major absorptive roles of the various parts of the GI tract.
Clarify the significance of losing the ileocaecal valve and terminal ileum.
Describe dietary advice which should be given to patients with various GI
disorders.
EXERCISES
(To be prepared prior to the tutorial and discussed at the tutorial).
2.
Summarise the dietary advice which should be given to patients with the
following:
hiatus hernia, diverticular disease, constipation, irritable bowel syndrome,
oesophagectomy, oesophageal stents and short bowel syndrome.
2.
Describe both short and long term nutritional problems that may be
experienced by a patient who has had a total gastrectomy. Discuss possible
solutions.
3.
A case study is given on the day which summarises the diet history and
symptoms of a newly diagnosed Coeliac; explain which items of food would
need to be excluded. The patient also has a poor appetite and iron deficiency
anaemia, what additional advice would you give?
4.
Be able to identify three differences between Crohn’s Disease and Ulcerative
Colitis.
5.
Another case study is given on the day about a patient with Crohn’s Disease.
From the information given, calculate energy and protein requirements.
Consider different ways that these nutritional requirements could be met,
stating reasons for products chosen. Explain the blood results.
An endoscopy shows that the most inflamed part of the bowel is the ileum
and an ileostomy is performed. What dietary advice would you give? How
does this advice differ from that given to a patient with a colostomy?
REFERENCES

Thomas, B (2001). Manual of Dietetic Practice. Blackwell Scientific
Publications.

Holt, A (1998). Protocol For the Use of Elemental Diets in Crohn’s Disease.
SHS.

The Coeliac Handbook. The Coeliac Society, High Wycombe.



Nightingale, JMD (1995). The Short-bowel Syndrome. European Journal of
Gastroenterology and Hepatology 7; 514-520.
LNDS Diet Sheets.
LNDS Dietary Management of Irritable Bowel Syndrome
TUTORIAL: RESPIRATORY DISEASE
1. Name 4 common respiratory diseases.
2. List some common risk factors/causes for the respiratory diseases
named in question 1.
3. Define chronic obstructive pulmonary disease (COPD).
4. How can COPD impact on dietary intake and nutritional status
5. What are some of the consequences of malnutrition in COPD?
6. What impact can BMI have on mortality in COPD?
7. What is pulmonary rehabilitation? Consider why this benefits patients.
8. What is cystic fibrosis? List 2 organs (other than the lungs) that this
disease effects and the consequences this might have on nutrition.
References
 British lung foundation. www.lunguk.org.
 World health organisation. www.who.int





NICE. Chronic obstructive pulmonary disease (updated) (CG101) 2010.
COPD Education. www.copdeducation.org.uk The health foundation.
Landbo et al. Prognostic Value of Nutritional Status in Chronic Obstructive
Pulmonary Disease. AM J RESPIR CRIT CARE MED 1999;160:1856–1861.
Prescott et al. Prognostic value of weight change in chronic obstructive
pulmonary disease: results from the Copenhagen City Heart Study. Eur
Respir J 2002; 20: 539–544.
Cystic fibrosis trust. NUTRITIONAL MANAGEMENT OF CYSTIC FIBROSIS.
2002.
http://www.cftrust.org.uk/aboutcf/publications/consensusdoc/C_3500Nutrition
al_Management.pdf
TUTORIAL : FOOD INTOLERANCE AND FOOD ALLERGY
AIM
For the student to understand the dietary treatment of food intolerance and be able to
extract and use relevant information from the patient and medical investigations in
the formulation of appropriate dietary advice.
LEARNING OUTCOMES
1.
Outline the role of the dietitian in patients with food allergy/food intolerance
(investigative, advice, monitoring).
2.
List symptoms of food allergy and food intolerance.
3.
Describe the differences between cow’s milk protein and lactose intolerance
and the dietary treatment for each.
4.
Describe the merits and disadvantages of allergy testing.
5.
Be familiar with Leicestershire Nutrition and Dietetic Service diet sheets and
resources available for use with patients with food allergy/intolerance.
EXERCISES
1.
Pre-tutorial exercise at supermarket, finding out suitable products for various
dietary exclusions, e.g. milk free, low additive.
2.
In 2 groups, to examine a food diary of a case study patient with suspected
food intolerance and discuss:
- question to ask at interview
- relevant information from food diary/food and symptom diary
- what information might be given
TUTORIAL: DIET AND RENAL DISEASE
AIM
To increase the understanding of renal disease and the role of diet in its
management.
LEARNING OUTCOMES
The student will be able to:
1.
State five functions of the kidney
2.
State why the incidence of malnutrition in renal disease is high.
3.
Describe how to assess and monitor the nutritional state of patients with renal
disease.
4.
Explain the difference between Chronic Kidney Disease (CKD) and Acute
Kidney Injury (AKI).
5.
Discuss the effects of chronic renal failure on biochemical parameters.
6.
List the important dietary components that are manipulated in renal disease,
with examples of foods high in these components.
Session Plan
Students will be asked to go in pairs or small groups to see a given patient on
one of the renal wards. The students will then work together to complete a
dietetic card for the patient, looking up any medication
conditions/terminology/abbreviations they do not understand.
From the medical notes they will be able to see if there has been any dietetic
input into this patient, and they can take this into account when establishing a
continuing dietetic plan. On collection of all information about the patient,
including drug charts, nursing notes, nursing and medical staff or by talking
with the patient, they will return to their supervisor.
The patient visited can then be presented by the students to the supervisor
and the case discussed. The dietary management of the patient will be
discussed and students will be expected to have a basic knowledge of the
dietetic advice that may be provided to renal patients.
Attached charts should also be completed during the tutorial time. Estimated
time for tutorial – half a day.
References
Thomas B (2001) Manual of Dietetic Practice. Blackwell Scientific Publications.
Iphone/android applications
 National Kidney Foundation (Manage CVD Risk in Patients with Reduced
eGFR) –Definitions of chronic kidney disease, stages of kidney disease, risk
factors for chronic kidney disease.
 Kidney Diseases (Michael Quach) – mini dictionary of kidney disease,
diabetes and descriptions of dialysis.
TUTORIAL: NUTRITION AND LIVER DISEASE
AIM
To increase understanding of liver disease and the role of diet in its management.
LEARNING OUTCOMES
The student should be able to:
1.
2.
3.
4.
5.
6.
List the major functions of the liver
List 2 types of liver disease and 2 causes of each.
List 7 possible symptoms of liver disease.
Justify the aim of dietary modification in liver disease and discuss the
rationale for this
Calculate estimated energy and protein requirements for individuals with liver
disease
Devise appropriate enteral feeding regimens for patients with liver disease
EXERCISES
To be prepared prior to the tutorial and discussed at the tutorial.
List the major functions of the liver.
…………………………………………………………………………………………………
…………
…………………………………………………………………………………………………
…………
…………………………………………………………………………………………………
…………
…………………………………………………………………………………………………
…………
…………………………………………………………………………………………………
…………
…………………………………………………………………………………………………
…………
Name two types of liver disease and two causes for each.
Type of liver disease
Cause of liver disease
1.
1.
2.
1.
1.
2.
Give seven examples of symptoms of liver disease which may be seen.
1………………………………………………………………………………………
2………………………………………………………………………………………
3………………………………………………………………………………………
4………………………………………………………………………………………
5………………………………………………………………………………………
6………………………………………………………………………………………
7………………………………………………………………………………………
CASE STUDY A
Mrs A is a 40 year old lady admitted with anorexia, abdominal swelling, shortness of
breath and nausea. She has a history of Non-Alcoholic Steato Hepatitis (NASH).
Her weight is 57kg. Mrs A has mild oedema and moderate ascites. Her oral intake at
home consisted of cup a soup and ice cream.
Her blood results show:
 Alkaline phosphate (ALP)
 Serum Gamma Glutamyl Trans Peptidase (GL)
 Serum Albumin





300 µ/L
240 µ/L
24 µ/L
How do you assess this patient?
What dietary modifications would you advise? What problems might you
have implementing the diet?
Mrs A has an Oesophago-gastro-duodenoscopy (OGD) which shows that she
has several varices. Mrs A’s intake remains very poor. What would you
advise?
As the patient’s ascites is resistant to diuretic treatment, the doctors request a
stricter sodium restriction of 40mmol. What would you do regarding this?
It has been decided that Mrs A is going to have a liver transplant assessment.
What advice would you give her for home?
CASE STUDY B
Mr B is a 54 year old gentleman presenting with jaundice, abdominal distension
(moderate ascites) and increasing confusion. He has a history of alcohol abuse,
consuming at least one bottle of vodka daily. During the first 24 hours of his
admission, Mr B becomes increasingly drowsy. By the time he is transferred to the
hepatology ward, Mr B is not easily responding to verbal or painful stimuli. Mr B is
diagnosed with alcoholic hepatitis on a background of chronic alcoholic liver disease.
He currently has grade 3 hepatic encephalopathy. Mr B cannot be weighed due to his
current condition.
The medical team request you assess Mr B for enteral feeding.
You visually estimate Mr B’s height as 6ft and BMI as 24kg/m².





What is Mr B’s weight likely to be? NB: Moderate ascites present
Calculate Mr B’s estimated nutritional requirements.
What type of enteral feeding tube do you feel is most appropriate for Mr B and
why?
Devise a feeding regimen for Mr B.
What other information would you have found useful when assessing Mr B
and devising the feeding regimen? Is there any way you could have obtained
this information?
Mr B gradually becomes less drowsy.
 Are there any other anthropometric assessments you would consider using to
determine Mr B’s nutritional status and nutritional needs? Justify your
response.
REFERENCES





Practical Guide to Nutrition in Liver Disease, Liver Interest Group of British
Dietetic Association, 1994. Published by Madden & Wicks.
Thomas B, Bishop J. (2007) Manual of Dietetic Practice, Blackwell Scientific
Publications.
ESPEN Guidelines for Nutrition in Liver Disease and Transplantation. Clinical
Nutrition 1997: 16: 43.55.
Plauth, M., Cabré, E., Riggio, O., Assis-Camilo, M., Pirlich, M., Kondrup J.,
(2006) ESPEN Guidelines on Enteral Nutrition: Liver Disease, Clinical
Nutrition, 25: 285-294
Liver section of PENG Pocket Guide to Clinical Nutrition
TUTORIAL : NUTRITION IN BONE MARROW TRANSPLANTATION
AIMS
1.
2.
3.
4.
To gain an understanding of the role of bone marrow transplantation as
a treatment.
To have an appreciation of the role of the dietitian in the care of these
patients.
To be aware of the nutritional problems encountered by these patients.
To have an appreciation of the methods used to monitor the nutritional
status of these patients.
LEARNING OUTCOMES
The student will be able to:1.
List 3 conditions that require a bone marrow transplant.
2.
Provide a simple definition for each of the above conditions.
3.
Identify at least 5 possible symptoms affecting a patient’s nutritional
status arising from their conditioning treatment (chemo-radio therapy).
4.
List:
5.
Name the most common types of marrow transplants.
6.
List 4 complications associated with a BMT.
7.
State 2 advantages and 2 disadvantages in relation to the use of clean
diets for these patients.
8.
Identify at least 7 nutritional assessment techniques that can be used
for the pre-transplant patient.
4 types of antiemetics
3 types of antidiarrhoeals
2 types of antifungal medication.
REFERENCES
1.
2.
Manual of Dietetic Practice, Ed. B Thomas (2001).
LNDS Clinical Guidelines for the Dietary Management of Bone Marrow
Recipients. Produced by Sarah Cooper (1998).
TUTORIAL : NUTRITION IN THE TREATMENT OF CANCER
AIMS
1. To be aware of the role of diet in the prevention of cancer.
2. To be aware of the nutritional problems encountered by cancer
patients.
3. To have an appreciation of the role of the dietitian in the care of
cancer patients.
4. To gain an understanding of the term cancer cachexia and its effect on
patient care.
LEARNING OUTCOMES
1. Identify at least 4 risk factors and 3 protective factors for the
development of cancer.
2. Describe how the following 4 different cancers and the treatment of
these may affect nutritional status
a. Lung
b. Colorectal
c. Breast
d. Oesophageal
3. Describe chemotherapy and list 5 common side effects from this
treatment
4. Describe radiotherapy and list 5 common side effects from this
treatment
5. What suggestions would you make to help alleviate the following
symptoms and help maximise nutritional intake
a. sore mouth
b. nausea/vomiting
c. constipation
d. taste changes
6. What is the significance of TNM staging and briefly describe how this
information is used.
7. Describe the term cancer cachexia
EXERCISE 1
Mrs X is a 66 year old lady.
She has metastatic non small cell lung cancer (T4 N1 M1) and she is no
longer receiving active treatment.
Her current weight is 46kg, 6 weeks ago her weight was 54kg, her height is
1.60m. She is cachetic and breathless.
She has been referred for nutritional support. What would be the aim of your
dietetic input and what advice might you give?
EXERCISE 2
Mr Y is a 54 year old gentleman.
He has squamous call carcinoma of the larynx (T2 N0 M0). He is in the third
week of a four week course of radiotherapy to the larynx. He reports painful
dysphagia.
His weight is currently 76kg down by 2kg over the last week, his height is
1.79m.
He reports his typical daily diet was:Breastfast
3 x Toast with margarine
Lunch
pickle
2 x Crusty bread rolls with ham and mustard / cheese and
Packet of crisps
Evening meal
Lamb chops, chips and mixed vegetables
Apple
Supper
2 x Packet of crisps
2 whiskeys
Due to his painful dysphagia he is no longer able to manage the above.
Calculate this patient’s BMI and nutritional requirements and suggest ways of
modifying the above diet to prevent further weight loss.
REFERENCES
1.
2.
3.
4.
5.
6.
Food, Nutrition and the Prevention of Cancer; a Global Perspective
(2007). Publisher - World Cancer Research Fund (WCRF).
Nutritional Aspects of the Development of Cancer. C.O.M.A. Report
(1998). DoH.
Manual of Dietetic Practice, Section 4. Ed. B Thomas (2007).
LNDS website
Cancer Research UK website
Macmillan website