Clinical Nutrition

Prof. Albert FlynnUniversity 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: 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