Healthy Eating Flashcards
how many deaths in the UK are due to non communicable diseases
88.8% of all deaths
half of the top risk factors for morbdity …
relate to diet
What is the leading cause of cancer
Obesity
What is a nutritional assessment
- This is the systematic process of collecting and interpreting information in order to make decisions about the nature and cause of nutrition related health issues that affect an individual
What is a nutritional screen
- e.g. MUST
- which is a brief risk assessment which can be carried out by any healthcare professional and which may lead to a nutritional assessment by a dietician
What is the ABCDE model outlined for performing a nutritional assessment
- A = antropometry (weight and % weight change, BMI, MUAC, skin fold thickness)
- B = biochemistry - FBC, U&Es, LFT, Ca, B12, Folate, CRP, HBA1C
- C= Clinical - Disease states or symptoms
- D = dietary = energy and fluid requirements doing a dietary assessment
- E = environment - social and physiological factors
What do you ask when taking a dietary history
- what is patients typical food and fluid intake
- is the patient eating 3 meals a day
- if they ware unwell are they eating smaller meals than they used to when they were feeling well
- are they having regular drinks
- are they having carbohydrate foods and protein foods at each meal time
- are they eating at least one portion of fruit or vegetable each day
- are they able to cook for themselves
- do they have access to essentials such as bread, milk and cheese on a daily basis
- are they taking any nutritional supplements
What are barriers to loosing wieght
- dont know how to cook
- cost
- motivation
- psychological
- pain
What are commerical determinants of disease
factors that influence health which stem from the profit motive
What is energy expenditure
Sum of
- BMR
- Thermic effect of food eaten
- occupational activities
- non occupational activities
How do you caudate BMR
- can be calculated by measure oxygen consumption and carbon dioxide production
- usually taken from standardised taels that only require knowledge of the subjects age, weight and sex
What is the physical activity ratio expressed as
- multiples of the BMR for occupational and non occupational activities of varying intensities
What is the total daily energy expenditure
BMR X [Time in bed + (time at work x PAR) + (Non-occupational time x PAR)
What is the estimations for the total daily energy expenditure in the UK
- 8100kJ/1940 kCal for a 55 year old female
- 10600kJ/ 2550kCal for a 55 year old male
what can cause energy requirements to increase
- growing period
- pregnancy and lactation
- infection and trauma - but in general increased BMR associated with inflammatory or traumatic conditions is counteracted by a decrease in physical activity so that total energy requirements are not increased
What are the energy demands in a basal state
- resting muscle 20% - can be more than 50 fold increase in demand during exercise
- abdominal viscera - 35-40%
- brain 20%
- heart 10%
Vitamin A
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = oily fish, liver, dairy
- site of absorption = small intestine
- deficiency syndrome = xerophthalmia
Vitamin B1(thiamine)
- dietary source
- site of absorption
- deficiency syndrome
- dietary source - fortified cereals, flour, bread, grain, nuts, wide range of animal and vegetable products
- site of absorption = small intestine
- deficiency syndrome = Beriberi, Wernicke’s encephalopathy
Vitamin B2 (Riboflavin)
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = dairy products, cereal grains, meat, fish, broccoli, spinach
- site of absorption = proximal small intestine
- deficiency syndrome = angular stomatitis, chellitis
Vitamin B3 ( Niacin)
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = meat and cereals
- site of absorption = jejunum
- deficiency syndrome = pellagra
Vitamin B6 (Pyridoxine)
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = meat and cereals
- site of absorption = small intestine
- deficiency syndrome = polyneuropathy
Vitamin B12 (Cobalamin)
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = meat, fortified cereals, eggs
- site of absorption = terminal ileum
- deficiency syndrome = macrocytic anaemia, neuropathy, glossitis
Vitamin C (ascorbic acid)
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = fresh vegetables, citrus fruits, strawberries, spinach, tomatoes
- site of absorption = proximal ileum
- deficiency syndrome = scurvy
Vitamin D (Cholecalciferol)
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = oily fish, fortified breakfast cereals, margarine, eggs, milk
- site of absorption = jejunum as free vitamin
- deficiency syndrome = rickets, osteomalacia
Vitamin E (alpha - tocopherol)
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = plant oils, animal fats, nuts, seeds, vegetables
- site of absorption = small intestines
- deficiency syndrome = haemolysis, neurological deficits
Vitamin K
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = leafy green vegetables, liver, cheese, certain fruits
- site of absorption = small intestine
- deficiency syndrome = bleeding disorders
Folic acid
- dietary source
- site of absorption
- deficiency syndrome
- dietary source = animal and vegetable products
- site of absorption = jejunum
- deficiency syndrome = macrocytic anaemia
When should patients be screened for malnutrition in the hospital
All patients should be screened for malnutrition on admission and the findings linked to a care plan under supervision of MDT
Who is nutritional support necessary to provide for
- all severely malnourished patients on admission to hospital
- moderately malnourished patients who because of their physical illness are not expected to eat for more than 5 days
- normally nourished patients expected not to eat for more than 5 days or expected to eat less than half their intake for 8-10 days
What is refeeding syndrome
- shifts of water and electrolytes occur during parenteral and enteral feeding and this can be life threatening
Describe the mechanisms of action of refeeding syndrome
- Carbohydrate intake stimulates insulin release, which leads to cellular uptake of phosphate, potassium and magnesium
- Complications include hypophosphotaemia, hypokalaemia, hypomagnesaemia, fluid overload (because of sodium retention)
- Can result in arrhythmias, respiratory insufficiency, and is associated with increased mortality
what should patients receive if they have eaten little or nothing for 5 days
- if they have eaten little or nothing for 5 days they should initially receive no more than 50% of their energy requirements
What should patients at high risk of refeeding syndrome be given
- they should be given high potency vitamins daily for 10 days (Pabrinex) and oral and enteral thiamine 50mg 4 times daily for 10 days, along with multivitamins
Why are so many hospital patients malnourished
- Increased nutritional requirements – eg sepsis, burns, surgery
- Increased nutritional losses – eg malabsorption, output from stoma
- Decreased intake – eg dysphagia, nausea, sedation, coma
- Effect of treatment – eg nausea, diarrhoea
- Enforced starvation – eg prolonged periods of NBM
- Missing meals – eg due to investigations
- Difficulty with feeding – eg loss dentures, no one available to assist
- Unappetising food
What are the two ways in which enteral nutrition can be given
- by mouth
- by fine-bore nasogastric tube
- by percutaneous endoscopic gastrostomy (PEG) tube
- by needle catheter jejunostomy
how does the procedure of a nasogastric tube work
- Insert fine-bore tube intranasally with a wire stylet
- Confirm the position of the tube in the stomach by aspiration of gastric contents and check pH
- Check by X-ray if aspiration is unsuccessful or pH <5.5 is not definitive
What is the major problems of a nasogastric tube
- up to 60% of NG tubes fall out of place
What are the complications of a nasogastric tube
- regurgitation and aspiration into bronchus
- blockage of NG tube
- GI side effects - most commonly diarrhoea
- metabolic complications - hyperglycaemia, hypokalaemia, as well as low levels of magnesium, calcium and phosphate
Who is a PEG tube useful for
- useful for patients who need enteral nutrition for a prolonged period (e.g. >30 days) such as those with swallowing problems
How is a PEG tube placed into the stomach
- catheter is placed percutaneously into the stomach under endoscopic control
How does needle catheter jejunostomy work
- fine catheter is inserted into the jejunum at laparotomy and brought out through the abdominal wall
What makes up a standard enteric diet
- Nitrogen 10-14g/day as whole protein
- Carbohydrate as glucose polymers (49-53% of total energy)
- Fat as triglycerides (30-35% of total energy)
- Other: trace elements, electrolytes, vitamins
What are the different ways in which you can do parenteral nutrition
- peripheral parental nutrition
- central venous catheter parenteral nutrition
what is peripheral parenteral nutrition
- specially formulated mixtures for peripheral use available: these have a low osmalitiy <800mOsm/L and contain lipid emulsions
where can peripheral parenteral nutrition be placed
- peripheral cannula
- peripherally inserted central catheter
Where can a peripheral cannula be inserted
- 20cm can be inserted into a mid-arm vein - can be left for up to 5 days
Where can peripherally inserted central catheter be inserted
- 60cm - can be placed into an antecubital fossa that has its distal end lying in a central vein
What are the benefits of a peripherally inserted central catheter
- less risk of thrombophlebitis
- hyperosmolar solutions can be given
- can be used for up to 1 month
What is the most appropriate way to give parental nutrition
- central venous catheter parenteral nutrition
How does central venous catheter parenteral nutrition work
- Silicone catheter is placed into a central vein, usually adopting an infraclavicular approach to the subclavian vein
- Skin-entry site should be dressed carefully and not disturbed unless there is a suggestion of catheter-related sepsis
What does a central venous catheter for parenteral nutrition contain
Administered via 3L bags over 24h – contains 2250kCal
- 14g nitrogen 1L
- 50% glucose 0.5L
- 20% glucose 0.5L
- 10% lipids 0.5L, fractionated soya oil 100g/L, soya oil 50g, medium-chain triglycerides 50g/L
- Other: trace elements, electrolytes, water-soluble and fat-soluble vitamins, heparin and insulin if required
What are the complications for central venous catheter parenteral nutrition
- catheter related sepsis
- central vein thrombosis
- pneumothorax
- embolism
Describe catheter related sepsis causes and when it should be suspected
- Organisms (mainly Staph) enter along the side of the catheter leading to septicaemia
- Prevented by ensuring careful and sterile placement of the catheter, not removing the dressing, and not giving other substances via the central catheter
- Should be suspected if patient develops fever and leucocytosis
What is the treatment of catheter related sepsis
- removal of the central catheter
- systemic antibiotics
How do you monitor parenteral nutrition
Blood tests
- daily = plasma electrolytes and glucose
- twice weekly = FBC, LFT, Calcium, phosphate
- Weekly = magnesium, zinc, triglycerides
Nutritional status
- weekly weight and skin fold thickness
Nitrogen balance assessment
- complete collections of urine (grams of protein required = urinary nitrogen x 6.25)
What can protein calorie malnutrition lead to
- muscle function
- delayed hypersensitivity
- wound healing
- gondal dysfunction
What groups are at risk of under nutrition in the UK
- elderly - particularly if they are living in a care home or in a hospital
- those that live alone
- drugs and alcohol
- people with chronic conditions such as diabetes, kidney disease and chronic lung disease
- people with progressive illnesses such as cancer
What vitamin deficiencies do vegans have
- Vitamin B12
- Vitamin D
- Zinc
- iron
- omega 3
- calcium
What is anorexia nervosa
- This is an eating disorder
- patients try to keep their weight down as low as possible by either not eating enough food or exercising too much or both
How do you diagnose anorexia nervosa
DSM5 or ICD10
What is the DSM 5 criteria for anorexia nervosa
Must meet all of the current DSM criteria to be diagnosed with anorexia nervosa
- Restriction of food intake leading to weight loss or a failure to gain weight resulting in a ‘significant low body weight’ of what would be expected for someones age, sex and height
- fear of becoming fat or gain weight
- have a distorted view of themselves and of their condition
How do you assess someone you suspect of having an eating disorder
SCOFF questionnaire - two or more positive answers to the following questions are suggestive of anorexia or bulimia
- do you ever make yourself sick because you feel uncomfortably full
- do you worry that you have lost control over how much you eat
- have you recently lost more than 1 stone in a 3 month period
- do you believe yourself to be fat when others say you are too thin
- would you say that food dominates your life
Take a history
- Symptoms of eating disorder
- complications of eating disorders
- co-morbidities and symptoms suggestive of an alternative cause
- mental health
How do you diagnose a patient with short bowel syndrome
- detailed patient history
- X ray, CT, MRI
- LAB test - FBC, LFTs, U&Es
How do you manage short bowel syndrome
- Replacement of vitamins and minerals depending on the extent and position of the bowel obstruction
- oral rehydration salts to promote adequate hydration in diarrhoea
- codeine phosphate to reduce intestinal motility and reduce diarrhoea
- colestryamine - for patient with an intact colon and less than 100cm of ileum resected - reduce diarrhoea
- Growth factors
- be aware when prescribing drugs via the oral route that they might not be able to get absorbed
What do you measure in Anthropometry
- BMI/Waist circumference
- weight history
- hand grip strength
- mid arm muscle circumference
- bioelectrical impedance
What do you measure in clinical
- nutritional requirements and stress factor
- sepsis/infection
- metabolic response
- nutrient losses- D&V, fistulas, surgical drains
- impaired ingestion, digestion or absorption
What do you measure in biochemistry
- U&Es
- serum proteins - albumin, pre-albumin, calcium, albumin, vitamin D, PTH, CRP, WCC, ESR
- haematological parameters - LFTs
what do you measure in dietary
- Assess intake - quality/quantity, diet history, 24 hour recall, FFQ, consider energy/protein intake, micronutrients and electrolytes, cultural/soical considerations
Name some types of patients who could experience malnutrition
- elderly
- sheltered housing
- low income
- IV drug users
Name some types of patients who could experience vitamin deficiencies
- elderly
- alcohol excess
- cultural/ethinic groups
- restricted diets e.g. veganism, coeliacs
- cystic fibrosis
Name the types of mineral deficiencies
- renal failure
- weight loss
- dietary restriction
Define osteoporosis
- Osteoporosis is defined as reduced bone mass and micro-architectural deterioration
- associated sub-optimal levels of calcium and vitamin D and accelerated by increased alcohol consumption
What are the signs of scurvy
- haemorrhages
- receding gums
- abnormal bone
- detine formation
When does Koilonychia present
- Spoon nails and presents with iron deficiency anaemia
What is dermatitis herpetitiformis linked to
- linked to coeliac disease
What factors effect protein requirements
Inadequate intake of protein
- anorexia or ageing
Reduced ability to use available protein
- insulin resistance, protein, anabolic resistance, high splanchnic extraction
- immobility
Greater need for protein
- inflammatory disease
- oxidative modification of proteins
What are colonic polyps
- these are small non-cancerous growth of cells which form on the inside lining of the colon or rectum
What are included in refeeding bloods
- potassium
- magnesium
- calcium
- phosphate
How do you manage refeeding syndrome
- IV phosphophates polyfusor (PPF) infusion
- 1 PPF infusion via a dedicated peripheral IV line in 24 hours
- measure serum phosphate, magnesium, sodium, potassium, calcium and creatinine at baseline and daily over 3 days
What is IBS
- This is a chronic functional disorder of the GI tract in the absence of organic disease
- defined as recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months with 2 or more of the following: improvement of defectation, onset associated with a chain in the frequency of stool, onset associated with a chance in form of stool
What are the types of IBS
- IBS with constipation
- IBS with diarrhoea
- Mixed IBS (diarrhoea and constipation)
What is the definition of FODMAPs
A collection of short chain carbohydrates and sugar alcohols found in foods naturally or as food additives
- FODMAPS include fructose, fructans, galacto-oligosaccharides, lactose and polyps
What is coeliac disease
- Coeliac disease is an autoimmune disease caused by sensitivity to the protein gluten
What conditions are linked to coeliac disease
- dermatitis herpetiformis
- type 1 diabetes
- autoimmune hepatitis
What antibodies do you test for in coeliac disease
- Tissue transglutaminase, Anti-endomysial
Name three histology changes in coeliac disease
- Villous atrophy
- crypt hyperplasia
- lymphocyte infiltration
