Basic Clinical Nutrition Pranithi Hongsprabhas MD. Objective Etiology of PEM Types/ prevalence of malnutrition Consequences of malnutrition How to diagnose and assess nutritional status Effect of nutrition therapy Nutrition for specific diseases References Shils M, Olson JA, Shike M, Modern Nutrition in Health and Diseases. 2005 ASPEN manual of nutrition 2005 ESPEN guideline for EN 2006 ASPEN guideline 2009 Malnutrition State of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients caused measurable adverse effects on tissue/body form and function and clinical outcome Malnutrition Over nutrition obesity dietary induced dyslipidemia Under nutrition protein energy malnutrition specific nutrient deficiency Hospital Malnutrition Incidence Community setting (common in chronically ill; cancer, lungs etc.) Hospital setting: 30-60 % (10-25% are severe) Progression Get worse in hospital Effect on Health Diseases Prognosis Mortality Relationship Between Loss of Lean Mass and Degree of Mortality LBM (% loss of total) 10 Complications (related to LBM loss Associated mortality Impaired immunity, increased infection 10 20 Decreased healing, weakness, infection 30 30 To weak to sit, pressure sore, pneumonia, no healing Death usually from 50 40 100 Diseases and Conditions Predisposing to Malnutrition Hypermetabolic State Excessive activity Difficult eating Medication Cytokines Nutrient intake Nutrient utilization Anorexia Physiologic Demand Depression Nutrient Loss dementia Socioeconomic Malabsorption Diseases and Conditions Predisposing to Malnutrition Decreased intake Decreased absorption Increased losses Altered metabolism Increased requirement Hensrud DD. Nutrition screening and assessment. Med Clin North Am 1999;83:1525-47 Substrate Utilization in Starvation Glucose utilized (g/hora) I II IV III V Exogenous Glycogen Gluconeogenesis 40 30 20 10 LEGEND I II III Fuel for brain Glucose Glucose Glucose IV Glucose, ketones V Fatty acid Glucose Ruderman NB. Annu Rev Med 1975;26:248 Simple Starvation: Marasmic Wasting Response to total/partial cessation of energy intake Short term starvation (<72 hr) Prolonged starvation (>72 hr) RMR, DIT, activity gluconeogenesis from aa, lactate tissue utilization of ketone, FFA Nitrogen excretion in Starvation Nitrogen Excretion (g/day) 12 Normal Range 8 Partial Starvation 4 Total Starvation 0 10 20 Days Long CL et al. JPEN 1979;3:452-456 30 40 Marasmus: Simple starvation Decreased metabolic rate Weight loss mainly from fat and also LBM Normal albumin level Bone and skin appearance Metabolic Response to Stress: Trauma/Sepsis Flow Phase Energy Expenditure Ebb Phase Time Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55 Metabolic Response to Stress: Protein Catabolism Nitrogen Excretion (g/day) 28 24 20 16 12 8 4 0 10 20 30 Days Long CL, et al. JPEN 1979;3:452-456 40 Metabolic Response to Stress Fatty Deposits Endocrine Response Fatty Acids Liver & Muscle (glycogen) Muscle (amino acids) Glucose Amino Acids Stress Starvation Response to starvation and inflammation Days to weeks or months Depend on hormonal and cytokine control Cytokine response Catabolic (IL-1, IL-6, TNF-) increased RMR decreased LBM increased protein breakdown Vascular permeability Hormonal response Aldosterone/ADH salt/ water retention Epinephrine, glucagon, cortisol lipolysis gluconeogenesis severe protein catabolism Catabolic state cannot be reversed by nutrition alone: Nutritional Resistance Stress Starvation Kwashiorkor or hypoalbuminemic malnutrition Low albumin level/ edema Loss of body protein: functional change Chronic Stress Starvation Mild -moderate stress + starvation Develops in months Complication of Malnutrition Reduced renal function: GFR and concentrating ability inability to handle Na load, acid load polyuria Liver: fatty liver Cardiac function GI: intestinal barrier Altered drug Pk Perspect Crit Care 1989; 2:1 Malnutrition Related Complication Impaired immunity: CMI, chemotaxis, phagocytosis, complement Slow wound healing Muscle atrophy Compromised respiratory function: hypoxic ventilatory drive, impaired resp muscle, VC, MV LOS, treatment cost Mortality Risk of Malnutrition Hospital cost Cumulative mortality 26,359 Hospital Stay 50 (US D) Cost per Patient Mortality %status Nutritional 30,000 Ri sk of Mal nut r i t i on 18,896 PEM 40 25,000 Severe No Ri sk of non-PEM 20,000 30 Mal nut r i t i on 15,000 20 7,902 10,000 11,174 6,858 Mild 4,979 10 5,000 0 0 0 0 Normal 1 2 Pneumonia 3 4 5 Intestinal surgery 6 7 8 Complication 5 10 15 Months After Hospitalization 9 20 Reilly J et al. JPEN 1988 American Journal of Medicine (Cederholm T, Jägrén C, Hellström K. Outcome of Protein-Energy Malnutrition in Robinson et al. JPEN 1987 Elderly Medical Patients, 1995;98:67-74) Characteristic Differentiating of Marasmus and Marasmic kwashiorkor Marasmus Marasmic kwashiorkor Develops over mo-yr Develops over weeks Low intake Usually from low intake and Usually emaciated Edema not prominent Usually normal albumin Lower mortality than kwashiorkor stress Appear well nourished Edema is characteristic May be no wt loss Usually low serum protein Higher mortality How to Detect Patients at Risk? Nutritional screening Identify the characteristics associated with nutritional problems Identify patients at nutritional risk Nutritional assessment Collect and evaluate clinical conditions, diet, body composition and biochemical data, among others Classify patients by nutritional state: well-nourished or malnourished Nutritional Screening Involuntary increase or decrease in weight > 10% of usual weight over 6 months or > 5% of usual weight over 1 months Inadequate oral intake Barrocas et al. J Am Diet Assoc 1995: 95: 648 Nutrition Screening Tool Nutritional Risk Screening A) Body mass index 0 = greater than 20 1 = 18-20 2 = < 18 score B) Has the patient unintentional loss BW over the past 3 months 0 = no 1 = a little up to 3 kg 2 = a lot more than 3 kg score C) Food intake- has this decrease over the last month prior to admission 0 = no 2 = yes score D)Stress factor/ severity of illness 0 = non 1 = moderate 2 = severe score Screening If score 0-2 No action If score 3-4 Monitor + review in a week/ food record chart If score > 5 refer to dietitic advice University hospital Nottingham: A. Micklewright, S.P. Allison and Z. Stanga Total score Nutritional Assessment Clinical assessment Subjective Global Assessment Body composition Biochemical data Functional assessment Subjective Global Assessment History Wt change Changes in dietary intake Gastrointestinal symptoms Functional capacity Link between disease and nutritional requirement PE focused on nutritional aspects degree of fat loss muscle wasting edema/ ascites clinical signs of nutritional deficiency Detsky AS, et al. JPEN 1987; 11: 8-15. SGA SGA: Classification Well nourished Moderately malnourished or suspected malnutrition Severely malnourished Class A: no change in BW, normal intake, < 5 % wt loss, or > 5% wt loss but recent gain and improve appetite Class B: 5-10% wt loss without recent stabilization or gain, poor dietary intake and mild loss of subcutaneous tissue Class C: ongoing wt loss of > 10% with severe subcutaneous tissue loss and muscle wasting often with edema General: Muscle Wasting Hair Flaky paint dermatosis: protein deficiency Essential fatty acid deficiency syndromes (EFADs) Zinc deficiency Pellagra •dermatitis •dementia •diarrhea •death niacin deficiency Perifollicular Petechia: Vitamin C deficiency Vitamin K deficiency Nutritional Assessment Body Composition Parameter Weight and height BMI = weight/ height2 Triceps or subscapular thickness of skin fold Mid-arm muscle circumference and midarm muscle area Anthropometric Measurement Limitation Fluid: overhydration, dehydration Technique: reproducibility Do not reflect variation in bone size, skin compressibility Creatinine Height Index Correlates with lean body mass CHI = actual 24-hr Cr excretion expected Cr excretion estimated 18-20 kg muscle produce 1 g Cr expected Cr excretion female male interpretation > 80 % 60-80% < 60% 18 mg/kg 23 mg/kg 0-mild depletion moderate depletion severe depletion Creatinine Height Index/ Excretion Factors affecting CHI reliability renal insufficiency rhabdomyolysis bed rest catabolic state incomplete collection Laboratory Assessment: Visceral Protein Reserve Hepatic secretory protein Protein MW T 1/2 Normal range Albumin 65,000 18-20 d 3.5-5.5 g/dl TFN 76,000 7-10 d 1.6-3.6 g/l 12-24 hr 160-350 mg/l 2-4 hr 0.10-0.40 mg/l Prealbumin 54,980 RBP 21,000 Nutritional Assessment: Biochemical Parameters Serum albumin Total lymphocyte count Serum transferrin Serum prealbumin TIBC Serum cholesterol At risk level < 3.5 g/dl < 1500 cell/mm3 < 140 mg/dl <17 mg/dl <250 mg/dl <150 mg/dl Heymsfield SB, et al. In: Modern Nutrition in Health and Disease. Phiadelphia, PA: Lea& Febiger; 1994: 812-41. Nutrition Support Nutritional Support:Indication NPO > 10-14 day PEM or at nutritional risk Inadequate oral intake Maldigestion, malabsorption Nutrient loss fistula, dialysis, drainage Hypercatabolic state: sepsis, burn, multiple trauma Perioperative severely malnorished Nutrition Aim/ Goal Improve nutritional depletion malnourished/ low catabolism Minimized nutritional related complication Maintain nutritional status/ prevent malnutrition malabsorption unable to eat critically illness moderate hypercatabolic state Improve clinical outcome perioperative nutrition nutrition in BMT trauma Estimated Energy Requirement 1. Requirement = BEE x AF x SF Harris Benedict Equation BEE m = 66+13.7 wt+5 ht-6.3 age f = 655+9.6wt+17ht-4.7age Activity factor = 1.2 (low), 1.3 ( moderate ) , 1.5 ( high ) Stress factor = mild 1-1.1, moderate 1.2-1.4, severe 1.5-2 2. Kcal/kg 25-30 kcal/kg/d Protein Requirement Population Rates(g/kg/d) normal/unstress .8 postoperative* 1.1-1.5 septic 1.2-1.5 multiple trauma 1.8 burned 1.5-4.0 Nitrogen Balance N balance = N output - N intake N output = UUN+UNUN+ misc = UUN +(2-4) (g) N intake = Protein intake(g) 6.25 Fat Requirement Essential fatty acid linoleic: 4% of total calorie linolenic: 0.2-0.4% of total calorie Source of energy : 9kcal/1g 20-35% Mineral Requirement Mineral Requirement Na /Cl 2-3 K 2-3 Mg 0.125-0.2 (meq/kg/d) Ca 60 (meq/d) PO4 60 (meq/d) (meq/kg/d) (meq/kg/d) Vitamin Requirement/ Trace Element Requirement According to RDA Key Vitamins and Minerals Vitamin A Wound healing and tissue repair Vitamin C Collagen synthesis, wound healing B Vitamins Metabolism, carbohydrate utilization Pyridoxine Essential for protein synthesis Zinc Wound healing, immune function, protein synthesis Vitamin E Antioxidant Folic Acid, Iron, B12 Required for synthesis and replacement of red blood cells How is Nutritional Support Prescribed? Average nutritional prescription should include 25-35 kcal/kg/day total energy, 0.8-1.5 g protein (0.13-0.24 g nitrogen)/kg/day, 30-35 ml fluid/kg, electrolytes, minerals, micronutrients, and fiber Contraindication of Nutrition Support Unstable hemodynamics Severe fluid, electrolyte, acid- base disorder (esp. PN) Uncontrolled infection Enteral Nutrition: Contraindication Unstable condition: hemodynamics Intestinal obstruction Massive GI bleeding Intestinal ischemia Severe malabsorption, inflammation, severe ileus Contraindication of Nutrition Support Unstable hemodynamics Severe fluid imbalance: overload or dehydration Severe electrolyte, acid- base disorder Uncontrolled sepsis EN PN Gut obstruction End stage malignancy: EOL determined Massive GI bleeding Intestinal ischemia Severe malabsorption, inflammation Nutritional Support For A Patient At Risk Of Malnourishment ทานมี แนวทางให้โภชนบาบัดใดไดบ ? ่ ้ าง ้ ผูป ้ ่ วยกินเองได้ ผูป ้ ่ วยกินเองไดน ้ ้ อย ผูป ้ ่ GI ่ แต ้ ้ อยมากหรือกินเองไมได ้ ่ วยกินเองไดน function ยังปกติ ผูป ้ ่ วยที่ GI function ผิดปกติบางส่วน ผูป ้ ่ วยที่ GI tract failure Nutrition Support Oral diet Soft Regular For specific disease Diabetic diet High protein diet Renal diet Low sodium diet Low fat diet Oral supplement Artificial Nutrition Support Enteral tube feeding Naso/Orogastric gastrostomy Enteric: nasojejunostomy, jejunostomy Parenteral nutrition PPN TPN Common Complications: ETF Mechanical Irritation or infection Tube displacement Aspiration Tube clogging Gastrointestinal Nausea Vomiting Abdominal distention Diarrhea Constipation Metabolic Dehydration Hyperglycemia Elevated serum electrolytes Low serum electrolytes Mizock BA. J Crit Illness 1993;8:1116-1127, American Gastroenterological Association. Gastroenterol 1995;108:1280-1301, ottlieb K, Iber F. J Crit Illness 1991;6:817-824 Monitoring of EN Assessment of GI tolerance Abdominal discomfort (fullness, cramping, pain) Nausea and vomiting Abdominal distention Bowel sound Stool pattern Diarrhea constipation Monitoring of EN Aspiration precaution Tube feeding residual: Gastric residual volume (GRV) Head lift ≥ 30o Aspiration detection Clinical signs and symptoms CXR Hydration status Assessment of hydration status Physical exam I/O Determine fluid requirement 30-35 ml/kg/d Extra fluid Assessment of nutrition intake Caloric count Parenteral Nutrition (PN) PPN, TPN Indication GI tract failure Inadequate EN Contraindication Unstable condition Uncontrolled serious condition Terminal stage conditions (EOL determined) Complication of PN Line sepsis: CRI Metabolic derangement/ re-feeding syndrome Fluid/ electrolyte/ acid-base imbalance Overfeeding syndrome Liver complication Infectious Complication ‘Catheter related infection’ (CRI) Tunnel site infection Hub contamination Infusate contamination Seeding of other site of infection Guideline for prevention of intravascular device-related infection.Infectious control and hospital epidemiology 1996;17(7):438-473 Refeeding Syndrome (Nutrition Recovery Syndrome) Metabolic complication occurs when nutritional support given to severely malnourished Electrolyte abnormalities Hypo K+, Mg2+, PO43- from intracellular shift Weakness Respiratory failure arrhythmia Na/fluid retention from Insulin/Glucagon ratio (antinatriuresis) Refeeding edema, Fluid overload Metabolic thiamin demand Substrate shift: from FA to glu VCO2/O2 and work of breathing Risk For Refeeding Syndrome ≥1 BMI <16 Unintentional weight loss >15% in 3-6 months ≥ 10 days with little or no nutritional intake Low Mg2+, K+, or PO43- before feeding ≥2 BMI <18.5 Unintentional weight loss >15% in 3-6 months ≥ 5 days with little or no nutritional intake Alcohol misuse, chronic diuretic, antacid, insulin use, or chemotherapy How To Prevent and Management of Refeeding Syndrome In high risk patients Start 10 kcal/kg/d, gradually within a week Before/during of 1st 10 d of feeding oral thiamin 200-300 mg/day +1-2 vitamin B co strong tablets 3 times/d or IV vitamin B +balanced multivitamin and mineral supplement each day monitor and supplement oral, enteral, or intravenous K, PO43- and Mg intake. K+ PO43Mg2+ 2-4 mmol/kg/day 0.3-0.6 mmol/kg/d 0.2 mmol/kg/d IV or 0.4 mmol/kg/d oral Metabolic Complication to Overfeeding Hyperglycemia Hypertriglyceridemia Hypercapnia Fatty liver Hypophosphatemia, hypomagnesemia, hypokalemia Barton RG. Nutr Clin Pract 1994;9:127-139 Hepatobiliary Complication Adults Steatosis Steatohepatitis Cholestasis Biliary sludge Cholelithiasis Acalculous cholecystitis Fibrosis Micronodular cirrhosis Nutrition Monitoring For nutrition response Monitoring of complication Monitoring • Vital signs, body weight • Fluid intake and output • Electrolytes, glucose, BUN/Cr, Ca, P, Mg • 24-hour total urinary urea nitrogen • Estimated nutrient intake (all administration routes) • Liver enzymes