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Introduction to Clinical Nutrition

Introduction to Clinical Nutrition. NFSC 370 D. Bellis McCafferty. Illness. Example : Cancer. Altered Digestion and Absorption. Altered Nutrient Excretion. Altered Food Intake. Altered Metabolism.

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Introduction to Clinical Nutrition

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  1. Introduction to Clinical Nutrition NFSC 370 D. Bellis McCafferty

  2. Illness Example : Cancer Altered Digestion and Absorption Altered Nutrient Excretion Altered Food Intake Altered Metabolism Examples: Loss of appetite, altered food likes/dislikes, difficulty chewing and swallowing, reduced saliva secretion Examples: radiation enteritis, surgical resection of GI tract, diarrhea Example: increased energy needs due to altered energy use in cancer Examples: fecal loss of fat-soluble vitamins and calcium in clients with cancers that affect enzyme secretion or bile salt production Malnutrition

  3. Clinical Nutrition(Medical Nutrition Therapy) Purpose • To achieve or maintain good nutritional status. American Dietetic Association • Professional organization representing Registered Dietitians (RD) and Dietetic Technicians (DTR)

  4. Patient Care: Team Approach(Interdisciplinary) • Physician • Registered Dietitian • Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistant • Pharmacist • Speech Therapist • Occupational Therapist • Social Worker

  5. The Nutrition Care Process • Identifying and meeting a person’s nutrient and nutrition education needs. Five steps: 1.AssessAssessment of nutritional status 2.AnalyzeAnalyze assessment data to determine nutrient requirements 3.DevelopDevelop a nutrition care plan to meet patient’s nutrient and education needs. 4.Implement: Implement care plan 5.Evaluate: Evaluate effectiveness of care plan: ongoing follow-up, reassessment, and modification of care plan.

  6. THE PATIENT SHOULD BE AN ACTIVE PARTICIPANT IN THE CARE PROCESS!

  7. Assessing Nutritional Status • Historical Information • Physical Examination • Anthropometric Data • Laboratory Analyses

  8. Historical Information • Health History (medical history) - current and past health status • diseases/ risk factors for disease • appetite/food intake • conditions affecting digestion, absorption, utilization, & excretion of nutrients • emotional and mental health

  9. Historical Information • Drug History • prescription & OTC meds • illicit drugs • nutrient supplements, HERBS and other “alternative” or homeopathic substances • multiple meds (who’s at risk?) Meds can alter intake, absorption, metabolism, etc. Foods can alter absorption, metabolism, & excretion of meds.

  10. Historical Information • Socioeconomic History - factors that affect one’s ability to purchase, prepare, & store food, as well as factors that affect food choices themselves. • Food availability (know local crops/produce) • occupation/income/education level • ethnicity/religious affiliations • kitchen facilities • transportation • personal mobility (ability to ambulate) • number of people in the household

  11. Historical Information • Diet History—analyzing eating habits, food intake, lifestyle, so that you can set individualized, attainable goals. • Amount of food taken in • Adequacy of intake – omission of foods/food groups • Frequency of eating out • IV fluids • Appetite • Restrictive/fad diets • Variety of foods • Supplements (overlaps)

  12. Historical Information • Tools for taking a diet hx: • 24 hour recall • Usual intake – can find trends, such as breakfast/snacks • Food Frequency Questionnaire/Checklist • Food Records • Observing food intake • Analysis of Food Intake Data • INDIVIDUAL NEEDS FOR NUTRIENTS VARIES

  13. Assessing Nutritional Status • Historical Information • Physical Examination • Anthropometric Data • Laboratory Analyses

  14. Physical Examination: “A picture is worth a thousand words.” • weight status • mobility • confusion • signs of nutrient deficiencies/malnutrition • esp. hair, skin, GI tract including mouth and tongue • Fluid Balance (dehydration/fluid retention)

  15. Physical Examination: “A picture is worth a thousand words.” • Limitations of Physical Findings • Depends on assessor! • Many physical signs are nonspecific: ie. cracked lips from sun/windburn vs. from malnutrition, dehydration…

  16. Assessing Nutritional Status • Historical Information • Physical Examination • Anthropometric Data • Laboratory Analyses

  17. Anthropometric Data - physical measurement of the body anthropos = human metric = measure • Indirect assessment of body composition and development • Used in Nutrition Assessment: • Measures using height and weight • Measures of body composition (fat vs. lean tissue) • Functional Measures

  18. Anthropometric Data Measures Using Height and Weight BMI Body Mass Index wt (kg) ht (cm)2 or wt (lb) X 705 ht (inches) 2

  19. Anthropometric Data Measures Using Height and Weight • 18.5-24.9 • 25+ • 30+ • Pros: • many studies have identified the health risks associated with a wide range of BMIs • easy to look up on chart • screening tool

  20. Anthropometric Data Measures Using Height and Weight • Cons: BMI can misclassify up to one out of four people. • Does not account for fat distribution • Doesn’t account for LBM - may misclassify frail/sedentary or very muscular people Met Life Insurance weight-for- height tables • Weights based on lowest mortality

  21. Example: Height & Weight Table For Women Feet Inches SmallFrame MediumFrame LargeFrame 5' 1" 106-118 115-129 125-140 5' 2" 108-121 118-132 128-143 5' 3" 111-124 121-135 131-147 5' 4" 114-127 124-138 134-151 5' 5" 117-130 127-141 137-155 5' 6" 120-133 130-144 140-159 5' 7" 123-136 133-147 143-163 5' 8" 126-139 136-150 146-167 5' 9" 129-142 139-153 155-176 Weights at ages 25-59 based on lowest mortality. Weight in pounds according to frame (in indoor clothing weighing 3 lbs.; shoes with 1" heels)

  22. Anthropometric Data Measures Using Height and Weight Assessing “Ideal Body Weight” Hamwi Equation: • Females: 100# for first 5’ of height, plus 5# per inch over five feet • Males: 106# for first 5’ of height, plus 6# per inch over five feet • +/- 10% to calculate a range (for those under 5’ tall, subtract 2 lb. per inch under 5’) ** Amputations, immobility:

  23. 7% Whole arm 6.5% 43% Below elbow 3% Hand 1% Whole leg 18.5% Above knee 13% Below knee 6% Foot 1.8%

  24. Interpretation %IBW Actual (present) weight X 100 = %IBW IBW • example: 5’6” woman weighs 160#. What is her % IBW? • 160  130 = 123%

  25. Interpreting % IBW  200% IBW = morbidly obese (or 100# over IBW)  120 % (130%) = obese 110 - 120 = overweight 90 - 109 = normal 80 - 89 = mildly compromised nutrition status (mild malnutrition) 70-79 = moderate < 70% = severe

  26. Anthropometric Data Measures Using Height and Weight • Assessing “Usual Body Weight” Actual (present) weight X 100 = % UBW UBW • example: 110# female lost 10# over past month • 110/120 x 100 = 91.6% UBW, or loss of about 8%

  27. Interpreting % UBW 85-90% mild 75-84% moderate <75% severe OR wt. change (unintentional weight loss) mild moderate severe 1 week 1-2% >2 1 month 5 >5 3 months 7.5 >7.5 6 months 10 10-15 >15

  28. Anthropometric Data Measures of Body Composition (fat vs. lean tissue) Body Fat Measurements • fatfold (skinfold) • waist-to-hip ratios • hydrodensitometry (hydrostatic weighing) • bioelectrical impedance

  29. Anthropometric Data Measures of Body Composition Midarm muscle circumference – indirectly measures protein status by estimating arm muscle mass. • Midarm circumference and triceps fatfold • plug into an equation: mmc (cm) = mc (cm) - [.314 x triceps fatfold (mm)]

  30. Anthropometric Data Functional Measures of Nutrition Status Hand Grip Strength • Dynamometer • Not appropriate w/arthritis/muscular disorders

  31. Interpreting Measurements • Requires caution • Interpreting Measurements • Sometimes difficult to measure 2’ mobility problems, injury, loose, hanging skin • Hydration/dehydration affects weight, fatfolds, and MAMC • Standards used are controversial

  32. Summing Up • Anthropometric measures provide valuable information regarding body wt. and composition • Do not reflect nutrition status alone • Accuracy requires on the skill of the assessor • Caution interpreting results

  33. Assessing Nutritional Status • Historical Information • Physical Examination • Anthropometric Data • Laboratory Analyses

  34. Laboratory Analyses • Help determine what’s happening on the inside of the body • Automated measurements of several blood components from a single blood sample • serum - • plasma -

  35. Laboratory Analyses Interpreting Biochemical Tests • Many can be skewed with fluid retention or dehydration. • Over-hydration can cause _____ numbers • Dehydration can cause ______ numbers • These are clues that anthropometrics are probably skewed as well.

  36. Overhydrated = diluted blood Dehydrated = concentrated blood Normal hydration 1 dl blood 10 mg/dl 5 mg/dl 20 mg/dl

  37. Laboratory Analyses:Biochemical Tests Of Protein Status • Somatic proteins - physical work • Serum/visceral proteins (circulating proteins & proteins found in the liver, kidneys, pancreas, and heart) maintain fluid balance synthesize enzymes and hormones mount immune response heal wounds • Therefore, protein status is an indicator of immune response.

  38. Laboratory Analyses:Biochemical Tests Of Protein Status • Synthesized in the liver • May reflect liver function • Measurements skewed if liver diseased • Remember, when kcals are inadequate, protein is used to make glucose.

  39. Laboratory Analyses:Biochemical Tests Of Protein Status Serum Albumin: • >50% total serum protein • Helps maintain fluid and lyte balance • Transports many nutrients, hormones, drugs, etc. • Used as indicator of protein status (visc. protein stores) • Half life ___________ 3.5-5.0 = adequate 2.8-3.4 = mildly depleted 2.1- 2.7 = moderately depleted <2.1 = severely depleted visceral protein stores

  40. Laboratory Analyses:Biochemical Tests Of Protein Status Problems with albumin: • not very sensitive, long half life •  levels reflect prolonged depletion, but • normal levels may not reflect short term changes in nutritional status. • Levels  : • Remember, number affected by plasma volume, so  in over-hydration and  in dehydration.

  41. Laboratory Analyses:Biochemical Tests Of Protein Status Serum Transferrin = (TIBC x 0.76) + 18 • Shorter half-life ____________ • Transports iron: • If Fe deficiency present, doesn’t accurately reflect protein status • Transferrin levels RISE with Fe deficiency! Inverse relationship •  levels may indicate __________________ •  levels may indicate __________________

  42. Laboratory Analyses:Biochemical Tests Of Protein Status • Levels  : • Levels  : Normal: >200 mg/dl Mild 150-200 mg/dl Moderate 100-149 mg/dl Severe <100 mg/dl

  43. Laboratory Analyses:Biochemical Tests Of Protein Status Prealbumin (thyroxine-binding prealbuin or transthyretin TTHY) • Being used more: some facilities using in place of albumin • Half life: ______________ • Sensitive indicator of protein status • Good indicator of pt. response to MNT •  $$ to run than albumin

  44. Laboratory Analyses:Biochemical Tests Of Protein Status Prealbumin • Levels  : • Levels  : Normal: 15-40 mg/dl Mild: 10-15 mg/dl Moderate: 5-10 mg/dl Severe: <5 mg/dl

  45. Laboratory Analyses:Biochemical Tests Of Protein Status Nitrogen Balance Studies (usually only used in severe metabolic stress) 1. Track the patient’s UUN (Urinary Urea Nitrogen) 2. 24 hour record of protein intake 3. Plug into nitrogen balance equation: N balance (g) = protein intake - (UUN + 4) 6.25

  46. Remember how this works? Amino Acids C-C-N C-C-N Urea (BUN) N-C-N Excreted via kidneys (UUN)

  47. N balance (g) = protein intake - (UUN + 4) 6.25 • “4” represents non-urea N+ lost in feces, urine, skin, and respiration • every 6.25 grams of protein contains 1 gram of nitrogen 0 or - = + = • Goal for repletion :

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