Nutritional Care Algorithmnou

8/10/2019 Nutritional Care Algorithmnou

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Assoc p rof. Crist ian Seraf inceanu

Institutul de Diabet, Nutriie iBoli metaboliceN. PaulescuBucharest


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Diet and physical activity are linked to more deathseach year than any single factor other than cigarettesmoking.

As health care providers, we can do more for our

patients by helping them eat healthy and exercise

regularly than any other intervention.

B Brenner, 2007


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Nutritional care algorithm (nutritional medicaltherapy) for renal patients

1 nutritional screening

2 nutritional antecedents

3. nutritional behavior

4. clinical examination

5. biologic parameters

Identification of therapeutic goals:

1. Reasonable

2. Negotiable

3. Adjustable

acceptable

for own

lifestyle

Periodic evaluation:1. results monitoring -

- redefining goals

1. solving current problems

Nutritional medical intervention:

1. Diet

2. Nutritional supplements


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1. Significant antecedents:

Physiologic

Pathologic

Therapeutic

Known nutritional problems or deficits

Chronic use of drugs with nutritional effects(i.e. chimiotherapy)

Psycho-social antecedents: Alcohol or drug abuse

Smoking

Financial and social status

Marital status

1. Specific signs and symptoms for nutritional deficiencies2. Subjective global assessment:

Evaluation of muscular waste

Evaluation of subcutaneous tissue

Presence of oedemas

Dialysis related items


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Basal (level I): detection ofnutritional risk factors

-body mass index

-eating habits

-living environment

-functional status

Complete (level II): forpatients at nutritional risk

-history of weight changes (6mo)

-mid-arm circumference

-triceps skinfold

-mid-arm muscle area

-serum albumin

-total plasma cholesterol-clinical features

-drug prescriptions

-mental/cognitive status


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Present


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Eating habits (topics)

-not have to eat enough (each day)

-usually eats alone-poor appetite-special (restrictive) diets-does not eat vegetables, fruit or milk at least once

daily

-difficulties in chewing or swallowing-more than two alcoholic drinks per day (one forwomen)

-has pain in mouth , teeth or gums


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Functional status - needs assistance(usually or always) with:

-bathing

-dressing

-toileting (grooming)

-eating (preparing food)-walking (traveling)

-shopping (for food)


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5114.232.8Males 60-70y

55.81331.9Males 30-40y

35.414.531.7Females 60-70y

32.424.228.6Females 30-40y

Mid-armmuscle area(MAMA)

Tricepsskinfold(TS)

Mid-armcircumference(MAC)

Targetpopulation


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Clinical features and mental/cognitive status:

-evident problems with mouth, teeth, gums

-difficulties with chewing

-angular stomatitis

-glossitis

-skin lesions (dry, loose, wounds, etc.)

-history of bone fractures

-clinical evidence of mental status impairment

-depressive illness (Geriatric Depression Scale, etc.)


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Various nutrientsDrugs (antacids,

laxatives,

anticonvulsivants)

Inadequate

absorption

Energy, proteinPoverty, isolation

Dietary fibreHabitual

constipation

Protein, vitamin B12Avoidance of meat ,

eggs

Vitamin C, folates,

vitamins B

Avoidance of fruits,

vegetables

Protein, vitamins BAlcohol abuse

Inadequate intake

Suspecteddeficiency

History ofMechanism


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Inborn errors of

metabolism

Various

Drugs(anticonvulsivants,

antimetabolites,isoniazide)

Decreasedutilization

Gastro-intestinal surgery

Pernicious anemia Iron, vitamin, B12

Parasites

Liposolublevitamins

(A,D,E,K),energy, protein

Malabsorption (diarrhea,weight loss, steatorrhea)

Inadequateabsorption

SuspecteddeficiencyHistory ofMechanism


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IronBlood loss

Suspecteddeficiency

History ofMechanism

Protein, vitamins

(water soluble)Dialysis

ProteinNephroticsyndrome

Protein,electrolytes

Diarrhea

Energy, proteinUncontrolled

diabetes mellitus

ProteinCentesis (ascitic,

pleural)

Magnesium, zincAlcohol abuse

Increased losses


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Suspecteddeficiency

History ofMechanism

Vitamin C, folatesSmoking

EnergyInfection, hypoxia

Energy, protein,vitamin CSurgery, burns,trauma

Energy, variousnutrients

Physiologicdemands

(adolescence,pregnancy,lactation)

EnergyFever,

hyperthyroidism

Increasedrequirements


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hyperpigmentation of

sunlight exposedareas

hair

nails

Skin

Organ/syste

m

lack of shine, easy

pluckable

spoon-shaped

Petechiae,

ecchymoses

pallor

dry, scaly

Abnormal finding

hypothyroidism,chemotherapy,

psoriasis

proteins, Zn, linoleic

acid

pulmonary or heartchronic disease

iron

Liver disease, aspirin

overdoseVit K, C

hemorrhage,pigmentation

disordersiron, vit B12

chemical burns,Addisons diseaseniacin or tryptophan

environmentalessential fats, vit.A

Non-nutritionalassociation

Nutritional deficiency


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Protein deficiency

Vit. C

Vit B2

Vit B2, B6, niacin

Vit A

Nutritionaldeficiency

Bilateral

enlargement

spongy, bleeding,receding

magenta, loss ofpapillae, swollen

bilateral (angular

stomatitis) orvertical cracks

(cheilosis)

dry, grayish, nightblindness

Abnormal findingNon-nutritional

associationOrgan/system

Tumors,

hyperparathyroidism

parotid glands

Drugs (dilantin),lymphoma,

thrombocytopenia,aging, poor dental

hygiene

gums

Crohndisease,

bacterial or fungalinfections

tongue

dentures problems,herpes, syphilis,

AIDSlips

Gauchers diseaseeyes


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Methods to assess protein and energy status

Protein stores Other methods Energy balance

visceral somatic

Salb

Sprealb

Stransf

Ret. bind. prot.IGF-1

Anthropometry

BIA

Nitrogen balance

Densitometry

Creat. Kinetics

Isotope studiesDEXA

NMR

others

SGA expenditure balance


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Immediate proteicintake marker

Anabolic growthfactor

2-6 h0.55-1.4UI/ml

Insulin-likegrowthfactor 1 (IGF1)

Proteic intakemarkerhypercatabolicstates

Pro-vitamin Atransporter

0.5 (12h)0.37Rhetynolbindingprotein(RBP)

Malnutrition (earlymarker); acutehypercatabolic states

Thyroidhormonestransporter

2-30.2-0.4Prealbumin

(transthyretin)

malnutrition (more

early) marker; negativeinflammation marker

plasma iron

carrier

8-92.6-4.3Transferrin

late malnutritionmarker

Coloid-osmoticpressure

18-2035-45Albumin

Nutritional

significance

Normal

function

Plasmatic

life (d)

Norma

l range(g/l)

Parameter


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____________ Diarrhea ___________ Anorexia__________ Nausea __________ Vomiting

__________ None

3. Gastrointestinal Symptoms (lasting >2 weeks)

__________ Starvation

__________ IV or hypocaloric liquids__________ Full liquid diet

__________ Suboptimal solid diet

Type: __________ Increased intake_________Change

Duration: __________ Weeks_________ No change

2. Dietary Intake (relative to normal)

_______no change ________decreaseChange in past weeks: _______increase

Percent weight loss in past 6 months _______________

Overall weight loss in past 6 months _______________

Current weight _______________

Weight 6 months ago _______________

Maximum body weight _______________

1. Weight Change


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__________ C = severely malnourished

__________ B = moderately (or suspected of being) malnourished

__________ A = well nourished

SUBJECTIVE GLOBAL ASSESSMENT RATING (select one)

__________ Ascites

__________ Ankle edema

__________ Muscle wasting (quadriceps, deltoids)

__________ Loss of subcutaneous fat (shoulders, triceps, chest, hands)

(For each trait specify: 0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe)

PHYSICAL EXAMINATION

____________ Bedridden

____________ Ambulatory

Type: ____________ Works suboptimally___________ Dysfunction

Duration: ____________ weeks___________ NO dysfunction

4. Functional Capacity

ROSPEN, Poiana Braov, 2004


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Dialysisduration**

Co-morbidities

Functionalstatus

Digestivesymptoms

Dietaryintake

changes/ 6mo

Weightchanges/6mo

Parameter

/score

43210

More than 48mo

24-48 mo, RRF12-24 mo, RRFLess than 12mo, no RRF

Less than 12mo, RRF

Multiple,severe

1 severemoderatemildNo

BedridingMinimal effortsdifficulty(toileting)

Usual effortsdifficulty(housekeeping)

Walkingdifficulty

Good/normal for age

AnorexiaFrequentdiarrhea/vomiting

Vomiting/other moderate

nauseano

starvationLiquid/hypocaloric diet

Moderateglobal

decrease

Suboptimalsolid food

no

15%10-15%5-10% 5%no


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Malnutrition:

-absent: 04-mild: 58

-moderate: 914

-severe: 15 -24


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1. Classifying nutritional deficits in weight - for - height:reference values (Torm B, Chen F, 1994)

Weight - for - height ratio = actual bodyweight/reference weight for height (RWH)

RWH = 50+0,75(H-150)+(Age-20)/4 Normal: 90-110%

Mild deficit: 80-89%

Moderate deficit: 70-79%

Severe deficit:


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2. Body mass index (BMI, Quetelet index)

3. Tricipital skinfold (TS)

4. Mid-arm circumference (MAC) 5.Mid-arm muscular area (MAMA)

(MAC - TS)2/12.56

All anthropometric measurements must be interpreted for age, sex, race


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Indication= patients with significant risk of malnutrition afternutritional history and physical examination (SGA).

Aim= to detect specific nutritional deficiencies beforeonset of

clinic or anthropometric manifestations.

Proteinstatus: central for the prevention, diagnosis and treatment ofmalnutrition:

Bi - compartmental pattern (of evaluation):

Metabolic active proteins (3050%)

Muscle (somatic) proteins (75%)

Visceral proteins (25%)

Metabolic inactive proteins (5070%):

Bones, joints

Iron status.

Calcium and phosphorus status.

Vitamins status.


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Nitrogen balance= ratio between the amount ofnitrogen consumed as proteins and the amountexcreted by the body.

The expected value for healthy adults is 1 the rate ofproteins synthesis (anabolism) equals the rate of proteindegradation (catabolism)

Formula: PRO(g)/6,25 = UUN(g)4(g), where:

PRO: protein ingestion/24h(g)

6,25: protein nitrogen index

UUN: urinary urea nitrogen/24h (g)

4(g): constant for nonurea nitrogen + nonurinarynitrogen (stool, sweat)

Disequilibrium of nitrogen balance need dietary and/ornon dietary correction (i.e.: increased losses in criticallyill patients).



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a. Somatic protein status Lean body mass assessment (muscle mass)can

be estimated by the 24h urinary creatinine excretion

comparing with a standard (expected) excretion

based on height Urinary creatinin excretion:

Is a constant on ideal weight:

23 mg/Kgc/day in men

18 mg/Kgc/day in women

Its variation is exclusively determined by height (see

standards in table)



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11411751831190

10761701739185

10011651642180

9501601467170

9001551386165

8511501325160

Urinarycreatinine /24h

(mg)

Height (cm)Urinary

creatinine /24h

(mg)

Height (cm)

FemalesMales


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1) Include questions about diet and exercise in all yourroutine patient histories.

2) Assess all patients height, weight and BMI.Measure waist circumference when appropriate.

3) Help patients understand the association betweentheir diet and exercise habits and their risk for

chronic diseases.

4) Begin to negotiate realistic lifestyle changes that canbe achieved and maintained over time.


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Increased total calories (andportion sizes)-energy density

Increased fast food consumption

Increased saturated fat and salt

intake

Low fruit and vegetable intake

Inadequate calcium intake


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USDA Food Guide Pyramid


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2001 ATP III Guidelines target LDL

Diabetes is a CHD risk equivalent

Metabolic syndrome should be treated withintensified lifestyle changes.

BMI >30 considered a major risk factor for CVD

Therapeutic Lifestyle Diet (TLC) developed Fat intake 25 - 35% of total calories

Limit saturated fat Increase monounsaturated fat


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Nutrient Recommended Intake

Saturated fat Less than 7% of total calories

Polyunsaturated fat Up to 10% of total caloriesMonounsaturated fat Up to 20% of total calories

Total fat 2535% of total calories

Carbohydrate 5060% of total calories

Fiber 2030 grams per day

Protein Approximately 15% of total calories

Cholesterol Less than 200 mg/day

Total calories (energy) Maintain healthy weight/prevent weight

Stanol esters 2 grams/day

Soy protein 25-40 grams/day

Soluble fiber 5-10 grams/day

Fish at least 2 times a week


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TransFatty Acids

Beef, PorkVeal,Lamb, Butter,

Cheese

HydrogenatedVegetable Oils

Saturated Fatty Acids

Corn, Safflower,Sunflower,Soybean

Omega-6Fatty Acids

Fish, Flaxseed,Soybean,Marine Vegetation

Omega-3Fatty Acids

PolyunsaturatedFatty Acids

Olive Oil,Canola Oil,

Nuts, Avocado

MonounsaturatedFatty Acids

Unsaturated Fatty Acids

Shortening

Margarine

Sources of Dietary Fat

More Atherogenic Less Atherogenic

Cocoa ButterCoconut Oil

Palm Oil

Source: ATP III Guidelines. NCEP 2001 Report


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According to the JNC VII 2003 Report, individuals

with a systolic BP of 120-139 mm Hg or a diastolicof 80-89 mm Hg should be considered asprehypertensive and require health promotinglifestyle modifications to prevent CVD.

Lifestyle issues: weight, diet, physical activity, alcohol and smoking

Source: The Seventh Report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure JNC VII. JAMA. 2003;289:2560-2572.


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459 adults enrolled with mean base-line BP of 131.3/84.7 mm Hg.

3 week control diet run-in period

Subjects randomized to 3 groups for 8 weeks Control diet

Diet rich in fruits (5 servings/d) and vegetables (3 servings/d)

Combination diet: fruits/veggies, low fat dairy (2 servings/d),low saturated fat (


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412 adults enrolled with mean BP of 135/86 mm Hg. Mean BMI=30

90 day trial. Subjects randomized to 2 groups:

Control diet

DASH diet: fruits (5 servings/d), vegetables (3 servings/d),low fat dairy (2 servings/d), low saturated fat.

Each group spent 30 days on each 1150, 2300, and 3450 mg Na/day

DASH and low sodium resulted in a 7.1 mm Hg in systolic pressurein patients with normal blood pressure.

11.5 mm Hg

in systolic pressure in those with HTN.

Effects of reduced sodium seen in both patients with normal and highblood pressure regardless of race or gender.

Source: Sachs FM,et.al. NEJM 344:3-10, 2001.


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Do you taste your food before you add salt?

How often do you eat salty foods, such as chips, pretzels,salted nuts, canned and smoked foods?

Do you read labels for sodium content?

How many servings of fruits and vegetables do you eat everyday?

How often do you eat or drink dairy products? What kind?

How often do you eat out? What kinds of restaurants


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2-4 mm HgLimit alcohol to no morethan2 drinks/d for men and

1 drinks/day for women.

Moderate alcohol consumption

4-9 mm HgEngage in regular aerobicactivity such as walking

Increase physical activity

2-8 mm HgReduce sodium to no morethan 2.4 g/day sodium or 6g/day NaCl

Dietary sodium reduction

8-14 mm HgConsume diets rich in fruits,vegetables, low fat dairy

Adapt DASH eating plan

5-20 mm Hg for each10 kg weight loss

Maintain normal bodyweight (BMI 18.5-24.9)

Weight Reduction

Approximate Systolic

Blood PressureReduction

RecommendationsModification

2.


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USDA Food Guide Pyramid

DASH PYRAMID


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DASH PYRAMID


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Achieve normal or near-normal blood glucose levels

Achieve optimal lipid levels Appropriate calorie recommendations

Maintain reasonable weight for adults

Growth and development for children and teens

Improve health through optimal nutrition and physical activity

Prevent, delay, or treat nutrition-related complications

Individualized based on usual lifestyle habits and

need/willingness to change

Source: American Diabetes Association. Nutritional Recommendations and Principles forPeople with Diabetes Mellitus. (Position Statement). Diabetes Care. 1998;21(Suppl 1):S32-35.


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Diabetes Prevention Program (DPP) Research Group

27 Centers following patients from 1996 to 1999

Recruited 3234 people over 2.8 years >25 years old

Fasting glucose 95 - 125 mg/dL

140 - 199 mg/dL 2 hours post 75 oral glucose load

BMI >24

Source: Diabetes Prevention Program II. NEJM. 2002:346;393-403


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Year


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Incidence of type 2 diabetes

was reduced by 58% with

lifestyle intervention and by

31% with Metformin, as

compared to placebo.

Lifestyle intervention group

significantly better outcome

compared to medication or

placebo groups.


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6.6

6.8

7.0

7.2

7.4

7.67.8

8.0

8.2

8.4

Initial 6 Week 3 Month 6 Month

No Education

1 RD visit3 RD visits

Source: Franz et al., J Am Diet Assoc 95:1009-17, 1995

HgbA1C


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In diabetics, there is a strong correlation betweenmetabolic syndrome and CVD.

Metabolic syndrome patients with type 2 diabetes havea higher prevalence of microalbuminuria ormacroalbuminuria.

Patients with metabolic syndrome have a small LDLparticle size pattern and preclinical atherosclerosis.


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Nutritional Care Algorithmnou