Optimizing Optimizing Nutrition TherapyNutrition Therapy

Prevalence of Malnutrition

• Increased complications• Prolonged length of stay• Higher hospital costs• Increased mortality

Malnutrition occurs frequently in hospitalized patients. It is associated with:

Nutritional Screening and Assessment

• Screening identifies and classifies patients at risk for malnutrition

• Assessment – evaluates nutritional status – biochemical parameters – anthropometric measurements – Subjective Global Assessment (SGA)

Early Detection of Malnutrition

Patients at risk:

History of chronic diseases

Psychiatric disorders

Gastrointestinal diseases Chronic renal insufficiency

Impaired immune function

CancerDiabetesElderlyChronic renal failureCOPD

Normal Energy Metabolism and Nutritional Needs

• Nutrients are necessary to sustain life• The utilization of nutrients depends on availability

(fasting) and the inflammatory response (stress)• Energy requirements vary according to clinical condition • Caloric distribution varies according to metabolic status

Metabolic Response to Starvation and Trauma: Nutritional Requirements

• The metabolic response to starvation is an adaptive mechanism

• Nutritional needs increase in trauma

Nutritional Requirements

• Energy– Harris-Benedict Equation x stress factor– “Rule of thumb”: 25 – 30 kcal/kg BW– Indirect calorimetry

• Protein– Stable patients: 0.8 – 1.0 g/kg BW– Stressed patients: 1.2 – 2.0 g/kg BW

Nutritional Requirements

• Lipids – Stable patient: 25% – 30% of calories – Stressed patient: 20% – 35% of calories

• Carbohydrates – Stable patient: 50% – 65% of calories

• Diabetes mellitus, hyperglycemia, COPD, hypercapnia, may benefit from

– carbohydrates (about 30% of calories)– lipids (about 50% of calories)

Nutritional Requirements

• Vitamins and Minerals – Stable patient: 100% daily recommended intake – Stressed patient: 100% daily recommended intake,

(COPD, cancer, antioxidants critical care)

– Hepatic patient: BCAA, B Vitamins, folate Na, Cu, Fe, Mn

– Renal failure: Na, K, CI, PO4,Vitamin A

– HIV/AIDS: antioxidants,Vitamins B6, B12

Early Intervention as Part of Initial Care

Enteral Nutrition• Oral supplements• Tube feeding

Parenteral Nutrition• Total• Peripheral

“If the gut works, use it!”

Parenteral Nutrition

• Supplies partial or total nutrition through venous access• Supplies practically all essential nutrients• Metabolic monitoring and changes in solution components

are needed to maintain metabolic balance

Benefits of Enteral Nutrition Therapy

• Maintains GI tract structure and function• Enhances intestinal immune function• Reduces bacterial translocation• Decreases risk of sepsis• Fewer complications than with parenteral

nutrition• Lower costs

Improved Patient Outcomes

• Improved wound healing• Decreased risk of complications

– Nosocomial infection• Decreased length of stay• Decreased healthcare costs

Barriers to Nutritional Intervention

• Lack of physician awareness

• Limited physician knowledge of nutrition therapy

• Minimal support from administration

Lack of Physician Awareness

• Physicians consider this the responsibility of other

professionals

• Nutritional assessment not included by physician as part of the initial history and physical

• Only considered important when severe malnutrition is evident

• Nutritional evaluation could be included in patient history and physical exam with minimal effort

Lack of Administrator’s Awareness

Administrator’s lack the knowledge of the positive impact that nutrition therapy can have on patient care and in reducing hospital costs.

Goals of the TNT Program

Improve patient care Give physicians the knowledge to prevent and manage

nutrition-related problems. Teach them how to do this early, safely and efficiently.

TNT Program: Next Steps

• Screening – Establish a nutritional screening and assessment program

• Standards – Develop guidelines and standards of care for

nutrition therapy• Intervention

– Promote early nutrition therapy

TNT Program: Next Steps

• Education – Raise awareness and increase knowledge of

healthcare team members on importance of nutrition therapy

• Research – Collect data on the incidence of malnutrition and

positive clinical outcomes of nutritional intervention

CONGRATULATIONS!

TNT was sponsored by Abbott Laboratories