Dietetics Flashcards
Starvation refers to food deprivation. Malnutrition refers to the undernutrition and overnutrition as well as disorders of micronutrient balance. Define the following:
Undernutrition:
Sarcopenicobestiy:
Undernutrition is protein-energy malnutrition
Sarcopenicobesity: Muscle-little-obesity => muscle wasting in obese patients
What is the effect of muscle wasting on patient outcomes in the realm of dietetics.
Muscle wasting occurs due to malnutrition or obesity (sarcopenicobesity)
Muscle wasting makes it difficult to adhere to exercise regimens, only prolonging the malnutrition or obesity. Muscle wasting, in impairment of mobility also leads to increased pressure sores
1/3 of all patients admitted to hospital and 40-60% of residents in nursing homes suffer from malnutrition. What are the consequences of malnutrition? (7 for 5/5)
Increased morbidity via impaired wound healing, impaired immune response => more infections, muscle wasting => reduced mobility => increased pressure sores
Increased mortality
Increased healthcare needs and cost: Increased need => harder to appropriately allocate resources and times to patients, increased length of hospital stay, more GP visits, more readmissions
Through what processes can disease cause malnutrition (not mechanisms, just how you would categorize causes of malnutrition)?
1) Reduced ability to eat (dysphagia, dietary restrictions of disease or medication for disease)
2) Reduced ability to digest or absorb (CF!, Celiac, IBD, Gastroenteritis)
3) Increased energy needs (Cancer, infection, inflammation, autoimmune)
4) Increased nutrient loss (CKD, gastroenteritis)
What tool is used to screen for malnutrition? What is it based on? Explain in detail how it is used and how you would manage the patient based on the different results
MUST - Malnutrition Universal Screening Tool
Based on BMI, Weight loss in last 3-6 months, Effect of acute disease
0 = Low => Routine clinical care and repeat screening (every week in hospital)
1 = Medium => Observe and document intake and output charts
2+ = High => Treat: Dietitian referral or !Food first followed by food fortification and supplements
Who would be prescribed a high protein, high calorie diet
Cancer tx, wound healing, dialysis, CKD with major proteinuria
Give indications for Dietitian referral when completing your medical assessment
(include diseases if confident)
Same as causes of malnutrition
Poor nutritional intake e.g. Anorexia, dysphagia
Significant weight loss/ unintentional weight loss
Underlying illness impairing absorption (CF, Celiac - gluten free, IBD, pancreatitis)
Increased needs due to disease (Cancer, infl, infection)
Increased Elimination (CKD - Albumen, Dialysis, Cancer tx - High protein, high calorie)
Other: Enteral tube feeding, PTN, Low/high fibre diet (Diverticulitis, hernia etc…), weight loss for surgery, lipid-lowering diet…
What is included in a full nutritional assessment?
ABCD:
Anthropometry: Weight hx, BMY, Waist-hip ratio, skinfold, Mid-arm muscle circumference (MAMC), Hand grip
Biochemistry: Albumin, Cholesterol, U&Es, Vitamin Levels
Clinical Assessment: Acute illness, Past medical hx, meds, metabolism
Dietary Assessment: 24hr recall, food frequency, food diary, intake/output
How is albumin used in the realm of dietetics? Is it reliable? What is it affected by?
Albumin is a nutritional marker but only in patients with mild/ moderate disease. It is not reliable in sicker patients e.g. ICU or Post-op
It is affected by sepsis (Reduces albumin), infection, inflammation, fluid shift post-op, protein-losing states (Kidney injury), Hepatic dysfunction => reduced synthesis)
Within a 24 hour period, how much energy does a 80 kg patient require in hospital?
What is the general amount of calories an adult patient should receive?
20-35kcal/kg/24 hours according to NICE
=> 1700 - 2800 kcal/24 hours
General is 1300-2500kcal/24hrs
Beaumont is 1500-1600kcal & 50-60g of protein
What patients require nutritional support
Malnourished patients => 2+ score on MUST => BMI <18.5, Weight loss >10% in last 2-6 months OR BMI <20 + weight loss >5%
Patients at risk of malnutrition (Infection, cancer, reduced absorption, increased elimination, oral intake compromised >5 days)
What are the different Feeding routes for nutritional support?
Enteral feeding: Nasogastric, nasoduodenal, nasojejunal tubes, gastrostomy, jejunostomy
Intravenous alimentation: PPN (Peripheral parenteral nutrition), TPN (Total parenteral nutrition)
Where is PPN inserted?
Peripherally into any vein
Where is TPN inserted?
Centrally => subclavian via PICC line (peripherally inserted central catheter)
What type of tube feed is given to diabetic patients? (tube = enteral feeding not TPN)
Low carb
What type of tube feed is given to renal patients
Renal feed => high protein, high calorie diet
What are the kcal/ml and protein in g/100ml of the standard feed?
Polymeric 1kcal/ml and 4g/100ml of protein
What type of feed is given to those with impaired absorption or fistulae?
Semi-elemental which is composed of nutrients more readily absorbed by the gut
Eiscopentaenoic acid, gamma-linolenic acid, and antioxidant-enriched feeds are typically given to patients suffering from…
ARDS
severe Acute Liver failure
How would you provide nutritional support to a patient with SBS (short bowel syndrome)
SBS, short bowel syndrome = > Less SA to absorb. Enteral feeding not enough => needs to be supplemented with PN
Compared to Parenteral nutrition, enteral nutrition has superior metabolic handling of nutrients, less infectious complications and significant cost-savings. What are the contraindications to putting a patient on nasogastric feed? (5)
Gut ischemia
Prolonged ileus
High output fistula
Obstruction distal to feeding tube
Extensive reduction of absorptive surface (short bowel syndrome)
Intractable vomiting
What is/are the contraindication(s) to Parenteral nutrition
When the GIT is viable and Enteral nutrition is possible, it should always be performed. => TPN is only used when EN isnt viable
What is being monitored in a patient on TPN?
Fluid balance monitoring and glycemic control
4-hourly: Vitals
Daily: FBC, U&Es, !check refeeding syndrome (!!Potassium, phosphate, magneium, !!calcium)
2/week: Albumin, LFTs
Triglycerides after 1-2 days then weekly
What are the main complications of TPN? (5)
Insertion: infection, trauma, phlebitis
Hyper/hypoglycemia
Hypertriglyceridemia
Electrolyte disturbances
!!!Hepatic: Raised enzymes (LFTs), Cholestasis, steatosis
Metabolic bone disease (reduced calcium, phosphorus)
Over/underfeeding
Fluid status abnormalities
Define Refeeding Syndrome
How does it occur?
Life-threatening acute micronutrient deficiencies (potassium, phosphate, magnesium), fluid, and electrolyte imbalance disturbing organ function that may result from over-rapid or unbalanced nutrition support.
A starved patient has their body converting protein into glucose (muscle wasting). When a patient is fed after being starved, the body releases a large amount of insulin which stimulates ATPase pump (requires magnesium) which drives K+ into cells (=>reduced serum K+) and Na out. This causes phosphate to shift into cells and magnesium excreted renally
Carb load is observed when feeding as the body will convert everything to glucose. B1 (thiamine) is essential as a coenzyme for carb metabolism
How would you categorize a patient to be at risk of refeeding syndrome?
Any one of: BMI <16, >15% unintentional weight loss, very little/no intake for >10 days, low levels of K+. PO4 or Mg2+
Any 2 of: BMI <18.5, >10% unintentional weight loss, very little/no intake for > 5 days, history of alcohol abuse (thiamine), Hx of chemotherapy drugs, diuretics, antacids
What types of patients are at risk of refeeding syndrome?
Alcoholics
Eating disorders
mental illness
Chronic dieters
Elderly patients living alone (frail)
Patient with chronic GI disease affecting absorption.
What are the main minerals affected in refeeding syndrome?
What are the complications of refeeding syndrome?
Phosphate, potassium, and magnesium (all low)
Low phosphate => cardiac failure, arrhythmia, liver dysfunction => hemorrhage, Hemolytic anemia, lethargy, weakness, seizures, confusion, paralysis, rhabdomyolysis
Low Potassium => Cardiac arrest, arrhythmia, resp depression, paralysis, rhabdomyolysis, constipation, ileus, polyuria, polydipsia
Low magnesium => Tachycardia, arrhythmia, resp depression, ataxia, confusion, muscle tremors, weakness, tetany, abdominal pain, anorexia.
What is the prevention/treatment of refeeding syndrome when giving a patient nutritional support?
Choose lower kcal feed and 5-10kcal/kg/24hr for severe and 15-20 for mild/moderate
Give IV Pabrinex for 3-5 days or 100mg Thiamine TDS for 10 days
Supplement electrolytes and vitamins (multivitamin, B vitamins etc..)
