Clinical Nutrition for Pharmacists

Question 1

how can you improve your diet to reduce the risk of Cardiovascular disease?

Answer 1

1) Increase omega 3 fatty acid intake
2) Reduce saturated fat intake
3) Antioxidant supplementation

Question 2

how do you calculate BMI?

Answer 2

BMI (kg/m2) = WEIGHT (kg)/ (HEIGHT)2 (m2)

Question 3

outline the BMI ranges for normal, overweight, obese class I,III,III

Answer 3

1) normal range: 18.5-24.9- average
2) overweight 25-29.9- increased risk of co-morbidities
3) obese class I: 30-34.9- moderate
4) obese class II: 35-39.9- severe
5) obese class III: >40 vere severe risk of co-morbidities

Question 4

Define: Malnutrition

Answer 4

a state of nutrition in which a deficiency or excess of energy, protein and other nutrients causes measurable adverse effects on tissue / body form (body shape, size and composition, function and clinical outcome.

Question 5

when does malnutrition occur and how many people in the world suffer from it ?

Answer 5

1) Occurs when diet is insufficient to meet the demands of the body
2) Around 3 million people in the UK are malnourished or at risk of malnutrition
3) This relates to an estimated cost of £13 billion due to medical and social care required

Question 6

what is a MUST score?

Answer 6

1) Malnutrition Universal Screening Tool
2) Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training. (NICE)
3) Completed for all hospital admissions

Question 7

what are the 5 steps to acquiring a MUST score?

Answer 7

1) Height and weight for BMI
2) Note unplanned weight loss and score
3) Establish acute disease score
4) Add scores from steps 1-3 for complete score
5) Use management guidelines or local policies to create action plan

Question 8

what BMI do malnourished patients have ?

Answer 8

1) Malnourished patients i.e. - BMI of less than 18.5 kg/m2
2) unintentional weight loss greater than 10% within the last 3–6 months
3) a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.

Question 9

when are patients at risk of malnutrition?

Answer 9

1) eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for 5 days or longer
2) a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism

Question 10

outline the total energy, protein and fluid intake For people who are not severely ill/malnourished

Answer 10

1) 25–35 kcal/kg/day total energy
2) 0.8–1.5 g protein kg/day
3) 30–35 ml fluid/kg - account for losses and intake
adequate electrolytes, minerals, micronutrients and fibre if appropriate.

Question 11

what are the 3 phases to Starvation

Answer 11

1) Glycogenolytic: Glycogen stores in liver and muscle used up in 24 hours. Fall in blood glucose. Increase in glucagon.
2) Gluconeogeneic: Fall in insulin. Protein breakdown (lean tissue) releases amino acids for glucose production.
3) Ketogenic: Lipolysis releases free fatty acids and glycerol from adipose tissue.
- Glycerol converted to glucose by liver and kidneys.
- Free fatty acids converted to ketones by liver.
- Also depletion of intracellular electrolyte stores.

Question 12

what is Refeeding Syndrome?

Answer 12

1) Caused when a person in a state of prolonged starvation is given nutrition
2) Serious complication
3) When person starts to eat - sudden shift in energy source and insulin secretion
4) Glycogen, fat and protein synthesis for which phosphate, magnesium and thiamine are required
Increased absorption of potassium and magnesium into cells
5) This leads to a decrease in serum levels of K, Po4, Mg

Question 13

what are the symptoms of refeeding syndrome?

Answer 13

1) rhabdomyolysis
2) respiratory failure
cardiac failure
3) hypotension
4) arrhythmias
5) seizures
6) coma
7) sudden death

Question 14

Outline how you would prevent refeeding syndrome and which patients are at high risk?

Answer 14

1) Thorough nutritional assessment before feeding is started.
2) Recent weight change over time, nutrition, alcohol intake, and social and psychological problems
3) High risk of refeeding: patient has one or more of the following:
- BMI(kg/m2) 15% in the past 3-6 months
- Little or no nutritional intake for >10 days
- Low levels of potassium, phosphate, or magnesium before feeding
Or the patient has two or more of the following:
- Body mass index 10% in the past 3-6 months
- Little or no nutritional intake for >5 days
- History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics

Question 15

Outline the guidelines for the management of refeeding syndrome

Answer 15

1) patient at risk
2) check K+, Mg , Ca2+, phosphate
3) before feeding starts administer 200-300mg thiamine daily orally, vitamin B high potency 1-2 tablets 3 times daily and multivitamin or trace element supplement once daily
4) start feeding 0.0418mj/kg/day . slowly increase feeding over 4-7 days
5) rehydrate carefully and supplement correct levels of potassium, phosphate, calcium and magnesium
6) monitor potassium, phosphate, calcium and magnesium for the first 2 weeks and amend treatment as appropriate

Question 16

what is Parenteral Nutrition (PN) and when is it given?

Answer 16

1) Nutrition given intravenously in hospital or community
Is a ‘complete’ mixture of all nutrients
2) Indicated when inadequate or unsafe oral and/or enteral nutritional intake
3) Non-functional, inaccessible or perforated (leaking) gastrointestinal tract
4) Skilled healthcare professionals should ensure that the total nutrient intake accounts for: energy, protein, fluid, electrolyte, needs activity levels and the underlying clinical condition
5) NST review patients referred for PN usually specialist dietician, pharmacist and nurse
6) Selection of appropriate regimen for patient
7) Stability and compatibility of regimen
8) PN bags are compounded in the pharmacy Aseptic Services Unit

Question 17

why is Parenteral Nutrition a high risk form of providing nutrition?

Answer 17

1) infection
2) Liver abnormalities
3) Fluid abnormalities
4) Electrolyte abnormalities
5) Refeeding
6) Blood glucose control
7) Thrombosis

Question 18

Drug nutrient interactions can alter the pharmacokinetics of the drug. give examples where the absorption of a drug has been altered.

Answer 18

1) Magnesium or aluminium antacids with phosphate
2) Tetracyclines chelate with calcium, magnesium and iron
3) Quinolones - ciprofloxacin absorption reduces by 50% if given with enteral feed

Question 19

Drug nutrient interactions can alter the pharmacokinetics of the drug. give examples where the Metabolism of a drug has been altered.

Answer 19

1) Grapefruit juice – cytochrome P450 enzyme inhibitor therefore reduce metabolism of certain drugs hence increased plasma concentrations eg amiodarone, ciclosporin, simvastatin
2) Folate
3) Pyridoxine (vitamin B6)- can increase how quickly the body breaks down and gets rid of levodopa

Question 20

Drug nutrient interactions can alter the pharmacokinetics of the drug. give examples where the excretion of a drug has been altered.

Answer 20

1) Diuretics

2) Amphotericin

Question 21

why is the Physical interaction between drug and feed product important for enterally fed patients

Answer 21

1) Enteral feeding tubes can become blocked
2) Examples: phenytoin, digoxin carbamazepine
Antacids bind to proteins
3) Penicillins - feed can reduce absorption Never add drug to feed

Question 22

what advice would you give to diabetics ?

Answer 22

1) Dietary advice is key for diabetics
2) Reduce microvascular and macrovascular complications
3) Manage body weight
4) Treat and prevent dyslipidaemia
5) Treat and prevent hypertension
6) Prevent CHD
7) Prevent and manage diabetic nephropathy and neuropathy

Question 23

what is Coeliacs disease and outline the dietary advice you would provide to Coeliac patients

Answer 23

1) Intolerance to gluten
2) Ingestion of gluten leads to intestinal atrophy – malabsorption
3) Symptoms include: diarrhoea, weight los, abdominal distension, fatigue
4) Coeliacs MUST have gluten free diet:
- Avoidance of all foods with wheat, rye, barley, oats
- Rarely medicines can contain gluten
- Some gluten free products are prescribed under ACBS
- May need calcium and vitamin D supplementation

Question 24

explain the role of a pharmacist with regards to nutrition

Answer 24

1) Integral member of the Nutrition Support Team (NST) in hospitals
2) Review enterally and parenterally fed patients in community pharmacy and in hospitals
3) Prevent and manage risks of refeeding syndrome
4) Pharmacists must have knowledge of the principles of good nutrition
5) Provide dietary advice for all patients
6) Accessible to public - can influence dietary habits and poor nutrition
7) Advise on drug–nutrient interactions