Clinical Nutrition Prof. Albert Flynn University College Cork

1. Clinical NutritionProf. Albert FlynnUniversity College Cork

2. Nutrition activities in hospitals • Basic care • Diagnosis • Therapy • Teaching/education (students, staff, patients) • Research

3. Basic care • Who is responsible for feeding patients? • Is food intake monitored? • Is body weight monitored? • Does dietician see every patient?

4. 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.

5. Diagnosis (Nutritional status) Biochemical • Serum Albumin • Haemoglobin • Ferritin • Haematocrit • Folate • Phosphate • Calcium • Sodium Dietary assessment • recall of food intake - diet history

6. 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!

7. 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

8. 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

9. 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%)

10. Does malnutrition occur in the hospitalised patient? Likelihood of malnutrition increased with hospitalization in 69% of patients index % affected reduced arm circumference 79 reduced weight 74 reduced haematocrit 64 reduced albumin 47 • Nutritional status worse at discharge than at admission • causes? Can it be avoided?

11. 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

12. 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)

13. 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

14. Nutritional treatment of disease • Dietary modification • qualitative • quantitative • communication • behaviour modification • motivation • patient education

15. 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

16. Therapeutic diets - cystic fibrosis 1. antimicrobials 2. physiotherapy 3. 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

17. Diabetes mellitus European Association for the Study of Diabetes [EASD] 1999 Overall aims: • to help optimize glycaemic control and reduce risk factors for cardiovascular disease and nephropathy

18. Diabetes mellitus • thoseoverweight • 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

19. 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)

20. 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

21. 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??

22. 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

23. 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