Nutrition

1
Nutrition

• For the Hospitalized Patient

2
What is Important?

• Making Sure that the patient eats
• Making Sure that the patient eats the Right Foods

3
Objectives of this Talk

• What is Malnutrition?
• Why is this Important in the hospitalized
  patient?
• Specific Diets
• Other added information

4
Malnutrition

• WHO (World Health Organization) definition
• Cellular imbalance between the supply of
  nutrients and energy AND the bodys demand for
  them to ensure growth, maintenance and specific
  functions

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Why Is This Important in the Hospitalized Patient?

• Disease-related malnutrition is a major health
  care problem and results in a reduced ability to
  prevent, fight, and recover from disease.
• Malnutrition is associated with postoperative
  complications, increased length of hospital stay,
  and even death.

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To Whom Should We Pay Attention?

• 40 percent of older people are malnourished when
  they are admitted to hospital
• Nutritional status of 60 percent of all older
  patients will deteriorate further while they are
  in hospital
• Decreased Food Intake Represents an Independent
  Risk Factor for Hospital Mortality

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One Study in Australia

• 58 percent of the patients, who were aged 65 or
  over, had problems eating.
• Just under a third (31 percent) left more than
  two-thirds of their meal
• Only 15 percent had eaten their whole meal.
• More than half of the patients they studied (55
  percent) had problems opening food.
• About a third found it difficult to use cutlery
  (36 percent).

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More Results

• More than a fifth (23 percent) were too far away
  from their food.
• Interruptions were also frequent.
• One in five patients (19 percent) had a doctor's
  visit during mealtimes
• more than half (51 percent) had mealtimes
  interrupted by other staff, mostly nurses (92
  percent).

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What Happens in the Starving, Stressed Patient?

• Stress/Trauma activates the sympathetic nervous
  system (flight or flight)
• Utilization of carbohydrates are inhibited and
  hyperglycemia often occurs
• Insulin secretion declines
• Blood levels of glycogen, growth factor,
  catecholamines, thyroid hormones, ACTH, ADH all
  increase
• Lipolysis is activated, gluconeogenesis and
  proteolysis is acclerated, large amounts of
  protein are consumed to provide the energy needed

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How To Evaluate ThisNutritional Assessment

• Clinical History
• Exam and Body Composition Analysis
• Indirect Calorimetry
• Anthropomorphic Measurements
• Functional Studies of Muscle Function
• Biochemical Measurements

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What is Easy and Effective?

• History
• At admission or during stay 10 weight loss or
  more suggests protein malnutrition
• NPO or Clears gt 5-7 days
• Use one of the simple questionnaires
• The Short Nutritional Assessment Questionnaire
  (SNAQ)
• The Subjective Global Assessment
• DETERMINE

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The Short Nutritional Assessment Questionnaire
(SNAQ)

• Question Score
• Did you lose weight unintentionally?    
• gt6 kg in the past 6 mo 3    
• gt3 kg in the past month 2
• Did you experience a decreased appetite over the
  past month? 1
• Did you use supplemental drinks or tube feeding
  over
• the past month? 1
• Scoring
• Well nourished 0 or 1 points
• Moderately Malnourished 2 points
• Severely Malnourished 3 points

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Results of One Study for SNAQ

• Recognition of malnutrition improved from 50 to
  80 with the use of the SNAQ malnutrition
  screening tool during admission to the hospital.
• The standardized nutritional care protocol added
  600 kcal and 12 g protein to the daily intake of
  malnourished patients.
• Early screening and treatment of malnourished
  patients reduced the length of hospital stay in
  malnourished patients with low handgrip strength
  (ie, frail patients).
• To shorten the mean length of hospital stay by 1
  d for all malnourished patients, a mean
  investment of 76 (US91) in nutritional
  screening and treatment was needed.

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Subjective Global Assessment

• Strengths
• Combines self report, clinical assessment and
  simple bedside evaluation for dysphagia. 
• Identifies patients who may benefit from
  nutritional counseling or home delivered meals
• Includes evaluation of activities of daily
  living, depression, poor oral health,
  polypharmacy or status of underlying chronic
  conditions.
• Limitations
• A significant proportion of the instrument
  requires patient or proxy report and depends on
  the history being available and correct.

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DETERMINE

• Strengths
• Quick and easy to administer 10 item
  questionnaire to patient or proxy. 
• The checklist identifies patients who may benefit
  from nutritional counseling or home delivered
  meals
• Evaluates activities of daily living,
  depression, poor oral health, polypharmacy or
  status of underlying chronic conditions
• Limitations
• The instrument is dependent on the patient or
  proxy having the information and being
  forthright.

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What to Look For?Objective Findings/Exam

• Weight/Ideal body weight (lt85 predicted)
• (IBW See Metropolitan Life Insurance Company
  Charts)
• BMI lt18 kg/m2
• Anthropometrics weight to height assessment
  difficult since there are fluid shifts or
  accumulations and inaccurate wts
• Physical Exam temporal wasting, thenar atrophy,
  
• GI tract functioning i.e. previous surgery

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What to Test?

• Immune Function lymphocyte lt1800, skin testing,
  anergy
• Prealbumin
• T1/2 2 days
• Falsely elevated with RF, Hodgkins Disease,
  Steroids
• Falsely low with acute catabolic stress, hepatic
  disease, stress, infection, surgery
• Albumin
• T1/2 21 days so does not reflect acute changes
• Falsely elevated with dehydration
• Falsely low with edema, hepatic disease, anemia,
  malabsorption, diarrhea, burns, volume overload,
  ESRD
• Transferrin
• T1/2 7 days
• Fat Soluble Vitamins
• A, E, and 25-hydroxyvitamin D can be measured
  directly.
• Prothrombin time is used as a proxy to measure
  vitamin K.

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More Tests

• U24 hr for Urea nitrogen (cannot be used with RF)
• Nitrogen balance used to measure degree of
  catabolism
• Nitrogen Balance Intake Output
• Protein Intake/6.25 (Urine urea nitrogen 4)
  the 4 is to account for the skinstool loses
• Goal is to have at least 3 to 4 grams positive
  for growth and repair
• Serum carotene
• correlated with vitamin A status
• can be used as a surrogate marker of
  malabsorption and nutritional status
• Retinol Binding Protein (RBP) - used to determine
  visceral protein mass in nutritional studies
  related to health.
• measurement of serum retinol levels (levels less
  than 20 micrograms/dL suggest deficiency) or
• the ratio of retinolRBP (a molar ratio lt0.8
  suggests deficiency)

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Requirements in General

• Figure out Calories needed then what percentages
  based on nutrients
• Nutrients
• 3 major sources for the Fuel/Calories
• Amino Acids/Protein 15
• Non Stressed Protein 0.8 to 1 gm/kg/day or 150
  mg of nitrogen/kg/day
• Stressed 1.7g/kg/day or 200 -250 mg N/kg/day
• Fat 25-50
• CHO 35-65
• Plasma Electrolytes
• Vitamins and Micronutrients
• Fat Soluble Vitamins are more likely than Water
  Soluble to be low if malnourished

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What Does a Hospitalized Patient Need?

• BMR x Activity Factor x Stress Factor

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Basic Metabolic Rate (BMR)The Minimum

• Women
• BMR 655 ( 4.35 x weight in pounds ) ( 4.7 x
  height in inches ) - ( 4.7 x age in years )
• Men
• BMR 66 ( 6.23 x weight in pounds ) ( 12.7 x
  height in inches ) - ( 6.8 x age in year ) 
• Women
• BMR 655 ( 9.6 x weight in kilos ) ( 1.8 x
  height in cm ) - ( 4.7 x age in years )
• Men
• BMR 66 ( 13.7 x weight in kilos ) ( 5 x
  height in cm ) - ( 6.8 x age in years )

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Quick Reference for Requirements Without Stress
or Activity

• Calories 1600 1800 2000 2500 2800
• Total Fat (g) 53 59 65 73 80
• Saturated Fat (g)
• 18 19 20 24 25
• Total
• Carbohydrate (g)
• 240 270 300 330 375
• Dietary Fiber (g)
• 20 23 25 25 30
• Protein (g) 46 48 50 55 65

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Harris Benedict FormulaTo Determine Total Daily
Calorie Needs BMR x Activity

• If you are sedentary (little or no exercise)
  Calorie-Calculation BMR x 1.2
• If you are lightly active (light exercise/sports
  1-3 days/week) Calorie-Calculation BMR x
  1.375
• If you are moderatetely active (moderate
  exercise/sports 3-5 days/week)
  Calorie-Calculation BMR x 1.55
• If you are very active (hard exercise/sports 6-7
  days a week) Calorie-Calculation BMR x 1.725
• If you are extra active (very hard
  exercise/sports physical job or 2x training)
  Calorie-Calculation BMR x 1.9

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What is Activity in the Hospitalized Patient?

• Patient Activity Activity Factor
• Ambulatory 1.25
• Bedridden 1.15
• Ventilator Support 1.10

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Stresses of The ILL Patient

• Patient Status Stress Factor
• Elective Operation/Minor Surgery 1-1.2
• Non-Stressed, On Vent 1-1.2
• CHF 1-1.2
• Fever 1.1-1.2
• Peritonitis 1.13
• Long Bone Fracture 1.05-1.25
• Mild to Moderate Infection 1.2-1.4
• Multiple Trauma/Major Surgery 1.3-1.55
• Stressed/Vent Dependent 1.4-1.6
• Sepsis 1.5-1.75
• Liver Failure/Cancer 1.5
• Burns 1.25-2

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Quick and Dirty

• Energy Requirements kcal/kg/day
• Unstressed 25
• Stressed 35

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Protein Requirements g/kg/day

• Mild stress 0.8-1
• Moderate stress 1-1.2
• Severe stress 1.2-2
• ARF 1-1.5
• ESRD 0.5-0.6 (if not on Hemodialysis)
• Hemodialysis 1.1-1.5
• Liver Failure 0.5 (with encephalopathy)

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Dont Forget Hydration

• Baseline 30-35 ml/kg/24 hr
• Add 2-2.5 ml/kg/day of fluid for each degree of
  temperature
• Account for excess fluid losses

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When to Ask For Help

• Apon Admission if Enteral Dependent, Parenteral
  Dependent, Documented Malnutrition, Failure to
  Thrive, New Diagnosis of Diabetes/Renal Failure,
  Severe/Complicated Wounds
• BMIlt19
• Poor nutritional status (the current oral intake
  meets lt50 of energy needs)
• gt7 days NPO
• Albumin lt3 measured in the absence of an
  inflammatory state
• Severe Weight Changes Usual BW-Current BW x
  100/ Usual BW Weight Change
• 1 week 1-2, 1 mo 5 or greater, 3 mo 7.5 or
  greater, 6 mo 10 or greater

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Diets

• Diabetic 1500-1800 or 1900-2500 cal
• Controls CHO, Limits Na, Fat, Chol
• Renal
• Controls K, Protein, Phosphorous (HD 800 mg/d,
  Peritoneal Dialysis 1200mg/d)
• Common Modifier fluid restriction
• Sodium
• Cardiac 4g Na HTN and CVD
• Caridac 2g Na CHF, Fluid restrict?
• Regular Diet with 4g Na HD patients with good
  K, Phos
• Liver 2 g Na Cirrhotic with Ascites
• Differences Cardiac restricts Fat, Chol,
  Caffeine Liver does not restrict Fat, Protein
• Dysphagia Two Part Order
• Texture Pureed (1), 2, Mechanical Soft or
  Regular
• Liquid Level Thin, Nectar-thick, Honey-thick,
  Spoon-thick
• Enteral Feeding whole different lecture for
  indications, how, types, costs

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Sodium

• Amount of Sodium in Salt
• ¼ teaspoon salt 600 milligrams of sodium
• ½ teaspoon salt 1,200 milligrams of sodium
• ¾ teaspoon salt 1,800 milligrams of sodium
• 1 teaspoon salt 2,300 milligrams of sodium
• 1 teaspoon baking soda 1,000 milligrams of sodium
• Many non-prescription drugs such as antacids,
  laxatives, aspirin,
• cough medicines and mouthwash have sodium. Ask
  your doctor or
• pharmacist for more information.
• Water softening equipment can add large amounts
  of sodium to water.

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Foods High in Vitamin K

• Asparagus
• Broccoli
• Brussels Sprouts
• Dandelion greens
• Endive
• Lettuce (iceberg, bibb, Boston and green leaf)
• Parsley
• Sauerkraut
• Scallions

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Calcium

• Calcium Citrate
• recommended form of calcium supplements because
  it is best absorbed by the body.
• Calcium Citrate does not require the presence of
  stomach acid to dissolve.
• Limit your supplement to no more than 500 mg at
  one time to increase absorption.
• All calcium supplements should include Vitamin D,
• Goal is 1500 mg of calcium from food and
  supplements.
• Do not take calcium supplements around the same
  time as prenatal or iron supplements.
• The daily value of Calcium on food labels
• There is an easy way to figure out how many
  milligrams (mg) of calcium is in food items. All
  you have to do is remove the from the Daily
  Value for calcium and add a "0"!

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Vitamin D

• 1- 70 years old 600 IU/day
• gt 70 years old 800 IU/day
• Upper safe limit is 4000 IU/day
• Sources
• Sunlight 15-30 minutes/day
• Foods codliver oil, salmon canned, tuna fish
  canned, shrimp cooked, fortified
  milk/yogurt/orange juice
• Medicines that interfere with Vit D
• Antacids with magnesium, corticosteroids, weight
  loss drugs (xenical, orlistat, alli), cholesterol
  reducing drugs (chlosteramine, questran,
  locholest), seizure medications
  (phenytoin/dilantin, phenobarbitol), thiazide
  diuretics (HCTZ)

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Potassium

• Foods Very High in Potassium (more than 400 mg
  per serving)
• Fruits Dried prunes (¼ cup), dried apricots (¼
  cup), prune juice, orange juice, grapefruit
  juice, papaya, banana, honeydew melon, cantaloupe
• Vegetables Tomato paste, tomato puree, beet
  greens, lima beans, squash, iceberg lettuce,
  sweet potato, kidney beans, Chinese cabbage,
  tomatoes, French fries (1 small order), parsnips,
  frozen spinach, pumpkin, mushrooms, white
  potatoes (1 potato), Brussels sprouts, broccoli,
  cucumber
• Other Yogurt, salmon (½ fillet), barley,
  molasses (1 Tablespoon), cream of tartar (1
  teaspoon), tuna (3 ounces), eggnog, skim milk,
  trail mix with chocolate chips, low sodium baking
  powder (1 teaspoon)

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Potassium

• Foods High in Potassium (more than 200 mg per
  serving)
• Fruits Peaches, pears, watermelon, mandarin
  oranges, mango (1 medium mango), apple juice,
  blackberries, nectarine (1 nectarine), red or
  green grapes, strawberries, dried figs (2 figs),
  raisins (¼ cup), kiwi (1 medium), raspberries,
  boysenberries
• Vegetables Asparagus, sweet corn, carrots,
  summer squash, celery, cauliflower, turnip
  greens, red/green peppers, beets, onions, black
  eyed peas, spinach, zucchini
• Other Peanut butter (2 Tablespoons), 1 milk,
  raisin bran cereal, low-fat buttermilk, plain
  potato chips, soy milk, part skim ricotta cheese,
  seasoned dried bread crumbs, vanilla ice cream (½
  cup), sunflower seeds (¼ cup), ground beef 85/15
  (3 ounces), pumpkin seeds (1½ cups), roasted
  turkey (3 ounces), white rice, egg substitute (¼
  cup), almonds (24 nuts)

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Iron

• Iron tablets may be taken 3 times a day, in
  between meals.
• Avoid taking iron with a phosphate binder
  (Calcium carbonate, Tums, Phos- Ex, Phos-Lo,
  Cal-Carb, Calcium acetate)
• Large amounts of Calcium bind with iron and make
  iron less available for absorption by the body.
• If a calcium binder is taken with meals, wait at
  least one hour after a meal before taking iron.
• Avoid taking iron with coffee or tea (wait at
  least one hour), as well as with
• Foods high in vitamin C will increase absorption
  of iron in your body.

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Phosphorous

• High in Phosphorous
• Liver
• Sunflower seeds
• Wheat germ
• Pumpkin seeds
• Moderate Phosphorous
• Milk, Dairy Products
• Chocolate
• Legumes
• Nuts and Seeds
• Meats
• Whole grains
• Bran Cereals
• Muffins

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Magnesium

• Adults need between 320mg-420 mg/day
• Good Sources
• Nuts almonds, cashews, peanut butter
• Legumes and Seeds blk eyed peas, garbanzo
  beans, kidney beans, lima beans, navy beans,
  sesame seeds ground as tahini, soybeans,
  sunflower seeds
• Whole Grains
• Dark Green Vegetables beet greens, broccoli,
  spinach
• Other vegetables artichokes, avocados
• Dried fruit - figs
• Soy Products - tofu
• Chocolate
• Meats
• Seafood crabs, lobster, shrimp
• Dairy Products
• Other oatmeal, potato baked with skin on, wheat
  bran, wheat germ

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Guideline for Nutritional Interventions

• See Handout