Nutrition [completed] Flashcards
What are the current UK diet and nutrition recommendations?
- At least FIVE portions of fruit and vegetables a day (11+)
- Intake of red and processed meat should be no more than 70g a day (19+)
- At least ONE portion (140g) of oil fish per week (all)
- Free sugars should be no more than 5% of DAILY CALORIE INTAKE
- Saturated fat should be no more than 11% of DAILY CALORIC INTAKE
What are the BMI ranges?
> 18.5 = underweight
18-5 - 24.9 = healthy weight
24.9 - 29.9 = overweight
29.9 -39.9 = obese
40 = severely obese
How is BMI calculated
Weight (kg) /Height² (m)
What are the adult recommendations for exercise?
Aim to be physically active everyday
Do strengthening activities 2x a week
150 mins of moderate aerobic activity OR 75 mins of vigorous aerobic activity a week
What are some limitations of BMI
Does not consider % of fat, muscle or bone
Does not consider age, gender or muscle mass
- muscular adults classed as overweight or obese
- older adults classes as healthy but could mostly be due to fat as muscle wastage increases
- Pregnancy: women should calculate BMI with pre-pregnancy weight
What are some causes of obesity?
Poor diet and lifestyle choices:
- eating a lot of processed or fat foods
- drinking too much alcohol
- eating out a lot
- oversized portions
- drinking too many sugary drinks
- lack of physical exercise
- comfort eating
What are some non-lifestyle and diet related causes of obesity?
hypothyroidism
Cushing’s syndrome
certain medications such as steroids
How is obesity managed first line?
Calorie restricted duet and increase in physical activity
Aim is to reduce weight by 0.5-1kg per week
When may bariatric surgery be an option?
BMI over 40
BMI 35-40 and other significant disease such as diabetes or hypertension
OR
all appropriate non surgical measures (diet, exercise, orlistat) have been tried but non clinically beneficial weight loss
patient under care of a specialist centre
patient fit for anaesthesia and surgery
patients commits to long term follow up
What will the patient have to do before a consultant will allow for bariatric surgery?
Adjust measures such as diet and exercise
What are the three most common types of bariatric surgery?
Gastric band
Gastric bypass
Sleve gastrectomy
What is a gastric band
Band place around the stomach so patient feels full after eating less food. Least invasive
What is a gastric bypass?
Top part of stomach joined to small intestine - patient feels full quicker and cannot absorb as much calories
What is a sleeve gastrectomy?
Removal of some of the stomach so patient cannot eat as much per meal and feels full sooner
Why do patents often need supplements after bariatric surgery?
Less food passes through stomach –> less absorption of vital vitamins and minerals. May need lifelong supplementation but especially in immediate aftermath.
What are some food pregnant women should avoid?
Raw fish
unpasteurised milk/dairy products
liver - Vit A can be harmful to baby
undercooked meats
cold cured meats
raw or partially cooked duck quail or goose eggs
no more than 200mg of caffeine a day
ALCOHOL
What supplements should pregnant women take?
Folic acid for first 12 weeks to prevents neural defects - 400mcg daily
Pregnacare - low dose multivitamin
What is “eating for two”? Should pregant women do this?
No they should just eat a normal healthy balanced diet whilst avoiding certain food
What is malnutrition?
State of nutrition where deficiency or excess of energy, protein and other nutrients causes measurable adverse effects on tissue/ body form etc.
What is mild food insecurity?
Working about ability to obtain food
What is moderate food insecurity?
compromising quality and variety of food.
Reducing quantities and skipping meals
What is severe food insecurity?
experiencing hunger
What is the burden of malnutrition on the NHS?
Affects 3 million people in the UK
25-34% of patients admitted to NHS hospitals at risk of malnutrition
estimated cost of £19.6 billion due to medical AND social care
What is the MUST score?
Malnutrition Universal Screening Tool - completed for all hospital admissions and screens for malnutrition/risk of malnutrition.
What factors does MUST look at?
BMI
Weight loss
Acute disease
Puts people as low, medium or high risk
What is the criteria for people who ARE MALNOURISHED and nutritional support should be considered:
Malnourished
- BMI less than 18.5
OR
- unintentional weight loss over 10% within the last 2-6 months
OR BMI less than 20 AND unintentional weight loss over 5% in the last 3-6 months
What is the criteria for people who are AT RISK OF MALNUTRITION and nutritional support should be considered:
- people who have eaten little or nothing for over 5 days and are likely to eat little or nothing for the next 5 days
- people with poor absorptive capacity/high nutrient loss/increased nutritional needs from causes such as catabolism.
What are the principles of nutritional support based on?
energy protein or fluid
In patients who are not severely ill/injured or at risk of refeeding syndrome what should a nutritional prescription provide?
25-35 kcal/kg/day total energy (including protein)
0.8 - 1.5g protein (0.13-0.24g of nitrogen)/kg/day
30-35ml fluid/g whilst allowing for loss and added fluid from IV
- adequate electrolytes, minerals and micronutrients (and fibre)
Patients who have eaten little or nothing for more than 5 days should have nutrition support introduced at…
no more than 50% of requirements for the first 2 days
Then increase feed rates to meet full needs if no refeeding issues
What types of nutritional support is available in adults
Oral
Enteral
Parenteral
Who should receive oral nutrition
Patients who are malnourished or at risk of malnutrition who can swallow safely
When should oral nutrition support be stopped?
When the patient is established on adequate oral intake from food
What different oral nutrition products are available?
Juice
Milkshakes
High energy powders
Soups
Semi-solid/dysphagia ranges
High proteins
Shots (low vol, high conc.)
Why is dysphagia an issue with less viscous liquids?
Swallow reflex may not move fast enough and liquid can go into lungs. patient can aspirate.
What should be considered before prescribing oral nutrition?
- Patient preference
- Suitability - halal, kosher, gluten free
- Consistency - dysphagia may require thickeners but they taste bad and gritty : yoghurt or pudding may be better
- Flavour variety - avoids taste fatigue
- Age: specific products for people over 65 who may be at risk of vit D deficiency
- Fluid requirements and electrolyte balance : short gut may not tolerate hyperosmolar products as Cana increase stoma loss leading to dehydration as more water flushed into stoma
Should oral nutrition supplements be prescribed without being monitored?
No
When may oral nutrition supplements be stopped?
- dietary intake is meeting requirements
- weight has reached target
- bmi in healthy range
- medical condition has changed (e.g. can swallow solid food again)
- taste fatigue
What is enteral nutrition?
Feeding directly into the GI tract with a tube so bypasses upper GI.
What are the types of enteral nutrition tubes?
Nasogastric: throat to stomach
Nasojejunal: nose to small bowel
Jejunostomy: outside body to small bowel
Gastrostomy: outside body into stomach
What should people be switched to enteral nutrition?
When they can no longer swallow safely or adequately BUT still have a functional accessible GI tract
Why is a functional accessible GI tract needed for enteral nutrition?
Absorptive capacity GI tract still needed
Which enteral nutrition types are indicated for shorter periods of time?
Nasogastric and nasojejunal (2-4 weeks)
When should enteral feeding be stopped?
When patient is established on adequate oral intake
What would you not monitor for in enteral nutrition?
taste fatigue
What is parenteral nutrition?
Administering nutrition directly into the bloodstream by infusion
When can parenteral nutrition be be considered?
- Inadequate or unsafe oral or enteral nutritional intake
NON FUNCTIONAL, INACCESSIBLE OR PERFORATED GI TRACT
What is the role of the nutrition support team in parenteral nutrition?
- select appropriate regimen
- stability and compatibilty of regimen
- review
- Education for patient, junior doctors and nurses
- Pharmacy aseptic services if need to make up at hospital
Why is stability and compatibility of regimen important in parenteral nutrition?
Usually commercial available product is a big 2.5L bag with all constituents
Patients can have different requirements based on deficiencies
May have to give some seperate - e.g. potassium drip
What percentage of estimated needs is used in TPN for the first 24-48 hours?
50%
What is the ideal way for PN to be given when first started?
Over the longest time possible
What line access is needed for PN?
central or peripheral
What is important about the line being used to give TPN?
It can ONLY be used for the TPN cannula. other medicines cannot be added on
What must be monitored during TPN?
Infection
Liver function
Fluid abnormalities (urine output)
Electrolytes (K, Na, Cr)
Refeeding syndrome
Blood glucose
Thrombosis
How can we balance intake of electrolytes?
Adjusting how much of the TPN bag is used based on kidney function
Why does blood glucose need to be controlled with PN?
When GI is functional not everything is absorbed. As we are bypassing the GI tract there is nothing to stop all of the glucose in the bag going in to the body
When should PN be stopped and how?
When the patient is established on adequate oral and/or enteral support.
To stop - titrate with oral intake and withdraw gradually
When may a person be on PN for their whole life?
High output stomas where nothing is retained in the GI tract.
Whar are the three phases to starvation?
glycogenolytic
gluconeogenic
ketogenic
What is the glycogenolytic phase of starvation?
Person starts getting hungry. glycogen stores in liver and muscle used up in 24 hours. decrease in blood glucose and increase in glucagon
What is the gluconeogenic phase of starvation?
Fall in insulin. Protein breakdown to release amino acids for glucose production
What is the ketogenic phase of starvation?
Lipolysis to release fatty acids and glycerol from adipose tissue. glycerol can be converted to glucose by liver and kidneys. Free fatty acids converted to ketones by liver
What is the aim of each phase in starvation?
Freeing up essential substrates for brain function and getting as much glucose as possible. Also depletes intracellular electrolyte stores.
What is refeeding syndrome?
A serious complication caused by giving a person parenteral or enteral nutrition after they have been in a state of prolonged starvation and their body has gotten used to their being no nutrition available
What happens in refeeding syndrome?
Person receives nutrition
1. Sudden shift in energy source and insulin secretion
2. synthesis of glycogen, fat and protein - phosphate, magnesium and thiamine required
3. more magnesium and potassium absorbed into the cells
4. decreases in serum potassium, phosphate and magnesium
What are the symptoms of refeeding syndrome?
Deranged electrolytes: Mg, K, PO4 and Ca (Sometimes)
Rhabdomyolysis
Respiratory failure
Cardiac failure
Hypotension
Arrythmias
Seizures
Coma
Sudden death
How is refeeding syndrome prevented?
Thorough nutritional assessment prior to feeding
First bag of TPN is over 48 hours (day 1 = 50% , day 2 = 50%)
Who is at a higher risk of refeeding syndrome?
ONE or more of:
BMI < 16
Unintentional weight loss > 15% in the last 3-6 months
little or no nutritional intake for >10 days
Low levels of potassium, phosphate, or magnesium before feeding
TWO or more of:
BMI < 18.5
Unintentional weight loss > 10% in the last 3-6 months
little or no nutritional intake for >5 days
History of alcohol misuse or drugs such as insulin, chemotherapy, antacids or diuretics
What is an example of a chemotherapy agent that can increase risk of refeeding?
Cisplatin as it is NEPHROTOXIC - can mess up electrolyte balances
How should patients at risk of refeeding syndrome be managed before feeding starts?
Oral THIAMINE 200mg-300mg daily
Vitamin B compound strong 1 or 2 tablets TDS (could contain RIBOFLAVIN, NICOTINAMIDE, PYRIDOXINE, THIAMINE)
OR IV VITAMIN B (pabrinex - contain THIAMINE AND ASCORBIC ACID)
How should patients at risk of refeeding treatment be managed during feeding?
Start at a maximum of 10kcal/kg/day
Increase levels slowly to meet or exceed full needs by 4-7 days
Restore circulatory volume and monitor clinical status and fluid balance closely
Supplement potassium, phosphate and magnesium unless pre-feeding plasma levels are high. Look at plasma levels and what is in TPN bag to help decide dose.
Why would pre-feeding plasma levels of potassium, phosphate and magnesium be high?
TO make sure levels don’t drop with nutritional support.
