Nutrition
For the Hospitalized Patient
What is Important?
• Making Sure that the patient
eats
• Making Sure that the patient
eats the Right Foods
Objectives of this Talk
• What is Malnutrition?
• Why is this Important in the
hospitalized patient?
• Specific Diets
• Other added information
Malnutrition
WHO (World Health
Organization) definition:
Cellular imbalance between the
supply of nutrients and energy AND
the body’s demand for them to ensure
growth, maintenance and specific
functions
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.
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
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).
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).
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
How To Evaluate This
Nutritional Assessment
•
•
•
•
•
•
Clinical History
Exam and Body Composition Analysis
Indirect Calorimetry
Anthropomorphic Measurements
Functional Studies of Muscle Function
Biochemical Measurements
What is Easy and Effective?
• History
– At admission or during stay: 10% weight loss
or more suggests protein malnutrition
– NPO or Clears > 5-7 days
– Use one of the simple questionnaires:
• The Short Nutritional Assessment
Questionnaire (SNAQ)
• The Subjective Global Assessment
• DETERMINE
The Short Nutritional Assessment
Questionnaire (SNAQ)
Question
Did you lose weight unintentionally?
>6 kg in the past 6 mo
>3 kg in the past month
Did you experience a decreased appetite over the past month?
Did you use supplemental drinks or tube feeding over
the past month?
Scoring:
Well nourished: 0 or 1 points
Moderately Malnourished: 2 points
Severely Malnourished ≥3 points
Score
3
2
1
1
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 (US$91) in
nutritional screening and treatment was needed.
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.
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.
What to Look For?
Objective Findings/Exam
• Weight/Ideal body weight (<85% predicted)
– (IBW See Metropolitan Life Insurance Company
Charts)
– BMI <18 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
What to Test?
• Immune Function – lymphocyte <1800, skin testing, anergy
• Prealbumin
– T1/2 = 2 days
– Falsely elevated with RF, Hodgkin’s 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.
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 skin+stool 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 retinol:RBP (a molar ratio <0.8 suggests deficiency)
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
What Does a Hospitalized Patient
Need?
BMR x Activity Factor x Stress Factor
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 )
Quick Reference for Requirements
Without Stress or Activity
• Calories
1600
• Total Fat (g)
53
• Saturated Fat (g)
18
• Total
• Carbohydrate (g)
240
• Dietary Fiber (g)
20
• Protein (g)
46
1800 2000 2500 2800
59
65
73
80
19
20
24
25
270
300
330
375
23
48
25
50
25
55
30
65
Harris Benedict Formula
To Determine Total Daily Calorie
Needs = BMR x Activity
• If you are sedentary (little or no exercise) : CalorieCalculation = 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
What is Activity in the Hospitalized
Patient?
Patient Activity
Ambulatory
Activity Factor
1.25
Bedridden
1.15
Ventilator Support
1.10
Stresses of The ILL Patient
Patient Status
Stress Factor
Elective Operation/Minor Surgery
Non-Stressed, On Vent
CHF
Fever
Peritonitis
Long Bone Fracture
Mild to Moderate Infection
Multiple Trauma/Major Surgery
Stressed/Vent Dependent
Sepsis
Liver Failure/Cancer
Burns
1-1.2
1-1.2
1-1.2
1.1-1.2
1.13
1.05-1.25
1.2-1.4
1.3-1.55
1.4-1.6
1.5-1.75
1.5
1.25-2
Quick and Dirty
Energy Requirements kcal/kg/day
• Unstressed = 25
• Stressed = 35
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)
Don’t 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
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
• BMI<19
• Poor nutritional status (the current oral intake meets
<50% of energy needs)
• >7 days NPO
• Albumin <3 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
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
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.
Foods High in Vitamin K
•
•
•
•
•
•
•
•
•
Asparagus
Broccoli
Brussels Sprouts
Dandelion greens
Endive
Lettuce (iceberg, bibb, Boston and green leaf)
Parsley
Sauerkraut
Scallions
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"!
Vitamin D
•
•
•
•
1- 70 years old = 600 IU/day
> 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)
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)
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)
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.
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
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
Guideline for Nutritional
Interventions
• See Handout