question

Resting Energy Expenditure

answer

Also expressed as RMR and BMR, it is the energy required to maintain all body functions. A significant amount of energy is used to maintain metabolic activities. It is 60-75% of TEE.

question

Thermic Effect of Food

answer

The energy spent on the digestion, absorption and metabolism of food. It is 5-10% of TEE. This component is largely ignored in sick people.

question

What components are used to compute TEE?

answer

REE, Thermic effect of food, physical activity (15-30%), and illness or injury

question

What factors increase REE

answer

LBM, hormones (thyroid), pregnancy/lactation, environment/cold exposure, drugs/stimulants, stress, temperature/fever.

question

Direct Calorimetry

answer

Heat production parallels energy expenditure

question

Indirect Calorimetry

answer

Oxygen consumption parallels energy expenditure, clinical measure of TEE

question

Doubly labeled water

answer

Ingest water labelled with isotopes of oxygen and hydrogen; measures O2 and H disappearance from the body; Easier in free-living; Research studies as a measure of TEE.

question

Mifflin-St. Jeor Equation

answer

Energy expenditure estimation used more commonly for healthy and non-stressed individuals. Would need to multiply by a stress factor if used for sick individuals.

question

Sources of fluids in PN/EN pt

answer

Maintenance IV fluids; medications given via IV drip, Water flushes given with crushed medications; water flushes to keep tubes patent; water contained in EN or PN

question

Sources of fluid loss in pt

answer

chest tubes, percutaneous drains (biliary/pancreatic), wound drainage, ostomies/stool/urine, NG tube suction, excessive drooling, fistulas, increased insensible losses (burns, tracheostomies, fever, kinder beds)

question

Clinical or physical signs of nutritional deficiency

answer

Dehydration, edema, muscle wasting, decreased subcutaneous fat, clinical symptoms of vitamin/mineral deficiencies

question

When can you use Albumin, Pre-albumin, and transferrin to assess protein status?

answer

In stable patients, with good renal function. If pt is stress/inflammed the levels will not reflect protein status. TYN and UUN do not account for wound losses.

question

General Characteristics of EN

answer

Fed into GI track; Fed enterally; mimics the composition of normal diet in liquid form (polymeric, hydrolyzed)

question

General Characteristics of PN

answer

Fed outside GI tract; fed parenterally (intravenous, large or small veins, central or peripheral); concentrated monomeric formulas: glucose, free amino acids, lipids)

question

Oral Liquid Supplements

answer

Used when nutritional needs are not met by standard diet alone, often used to supplement a normal diet, commercially available, lactose and gluten free, high protein, high calorie nutrient dense foods and liquids.

question

Indications for EN support

answer

Cancer of the head and neck; radical surgery to the upper GI tract neck, oral pharynx, or upper respiratory track; esophageal cancer; dysphagia; gastroparesis; gastric outlet obstruction; mild malabsorptive disease (Crohn's disease, SBS, pancreatitis); inability to meet nutrient needs by intake alone (as with burn, trauma, sepsis and chemo pts); depressed mental status; neurological impairment; paralysis; P.O. intake less than cooler and protein needs (often d/t cancer and anorexia); correction of malnutrition d/t chronic disease.

question

Indications for EN support in children

answer

Congenital abnormalities of the mouth, esophagus, stomach or intestines; malabsorption as with cystic fibrosis, Crohn's, fat malabsorption; sucking and swallowing disorders (premature); brain injury; developmental delay; neuromuscular disorders; cerebral palsy; failure to thrive.

question

Indications and notes for NGT (nasogastric)

answer

Inadequate oral intake; high needs; Intubated/sedated; relatively functional GI tract; normally used short term

question

Indications and notes for nasoduodenal or nasojejunal

answer

Functional lower GI tract (proximal injury/surgery); inadequate gastric motility (high residuals); esophageal reflux. These routes require continuous drip feeding d/t bypassing gastric emptying

question

Indications and notes for gastrostomy

answer

Esophageal injury or obstruction; inability to swallow; anticipate EN needed for > 4 weeks. Long term usage. Caution: GERD and intractable vomiting

question

Indications and notes for Jejunostomy

answer

Obstruction/surgery proximal to jejunum; UGI stricture or fistula; inadequate gastric motility. Use long term transpyloric continuous drip

question

Continuous Drip EN

answer

Used in ICU settings; better tolerated in sick in-patient; less N, D, cramping, and bloating; may reduce risk of aspiration pneumonia; generally requires infusion pump (intestine); can by cycled in homecare puts with good tolerance to EN.

question

Bolus EN

answer

Gastric feeding (cannot be used post-pyloric); appropriate for long-term feedings; allows mobility for pt; allows mealtime feedings that mimics normal eating patterns; usually 50-500cc/feeding

question

Intermittent EN

answer

Given "drip" method; gravity garage or pump; feeding bag; may give same volume as bolus but over a longer time period; can be given nocturnally at increased rate to allow daytime mobility; used to transition to oral feedings; used for intestine feedings to increase mobility.

question

Indications for use of standard EN formula

answer

normal GI function with mild/moderate stress

question

Indications for use of high protein, high Kcal EN formula

answer

hypermetabolic, volume restrictions, high protein

question

Indications for use of elemental/partially hydrolyzed EN formula

answer

Malabsorption, bowel rest, pancreatitis

question

What does low residue mean?

answer

Only a small amount of the EN is getting to the colon.

question

Complications of EN

answer

Diarrhea, Constipation, Bloating, Nausea/vomiting, high residuals, aspiration, naso-pharyngeal irritation, clogged tube, hyperglycemia, hypoglycemia, dehydration, hypokalemia, hypophosphatemia

question

Complications of overfeeding on EN

answer

hyperglycemia, lipogenesis, fluid and fat gain vs LBM, immunosuppression (XS lipid and linoleic acid), excess CO2 production, increased minute ventilation.

question

Complications of underfeeding on EN

answer

loss of lean tissue, skin breakdown, poor wound healing, immundysfunction. Intake is often <75% of order

question

What is the most serious life-threatening complication of enteral therapy?

answer

Aspiration/Pneumonia

question

Benefits of EN

answer

Stimulates immune barrier function at GI; attenuates bacterial translocation; physiologic presentation of nutrients; maintains gut mucosal integrity; attenuates hypermetabolic response; simplifies fluid/electrolyte management; more "complete" nutrition that PN; provides iron, fiber, glutamine, phytochemicals that are not found in PN; less infectious complications; stimulates return of bowel function; less expensive.

question

MNT for flatulence

answer

Low fructose diet, reduce gas forming foods, increase physical activity

question

Causes of flatulence

answer

Swallowed air, distention, cramping, high fiber (raffinose), high fructose diets.

question

Constipation is defined as

answer

low stool caliber, hard stool, no BM for 3 days

question

Causes of constipation (systemic etiology)

answer

Side effect of medication (narcotics, NSAIDs); metabolic endocrine abnormalities, such as hypothyroidism, uremia (renal failure), hypercalcemia, systemic neuromuscular disease (ALS), spina bifida, Parkinson's disease, lack of exercise, bedridden hospitalized or LTC (any sedentary lifestyle); ignoring the urge to defecate; vascular disease of the large bowel; poor diet low in fiber; pregnancy

question

Causes of constipation (gastrointestinal etiology)

answer

cancer; diseases of the upper GIT; Diseases of the large bowl resulting in failure of propulsion along the colon (colonic inertia) and/or failure of passage through anorectal structures (outlet obstruction); IBS; anal fissures or hemorrhoids; laxative abuse; stimulants; patients of opioids.

question

Constipation: Nutrition-related contributing factors

answer

Low intake of fruits, vegetables and whole grains; consumption of the typical refined American diet; decreased fluid intake, water; increased consumption of caffeinated beverages; dairy products (milk and hard cheese); laxative abuse (senna, castor, phenylphthalenin)

question

Laxatives

answer

senna, castor, phenylphthalein

question

Constipation MNT

answer

High (non-soluble) fiber diet; increase intake of whole grain cereals; increase intake of f&v (raw or cooked w/ skins and hull), and legumes; increase water to 8 cups of water per day; OTC fiber supplements of fermentable fibers (psyllium, methylcellulose)

question

Types of diarrhea

answer

Osmotic, secretory, exudative, medication induced, malabsorptive

question

Osmotic diarrhea is caused by

answer

overconsumption of sugars (fructose, lactose intolerance)

question

Secretory diarrhea is caused by

answer

bacteria, viruses, toxins

question

Exudative diarrhea is caused by

answer

HFD, mucus, fluid, electrolytes, blood, plasma proteins, Crohn's, UC, radiation

question

What medications can cause diarrhea

answer

antibiotics (AAD)

question

Malabsorptive diarrhea is caused by

answer

decreased absorptive surface (celiac) or low bile or pancreatic enzymes (steatorrhea)

question

What electrolytes are lost with excess fluid loss

answer

sodium and potassium

question

What is the leading cause of nosocomial diarrhea

answer

Clostridium difficile

question

Clostridium difficile

answer

leading cause of nosocomial diarrhea; opportunistic proliferation of pathogenic organisms associated with antibiotic therapy and chronic use of PPIs; spore forming and spread via tube feedings from pt to pt. Causes colitis, secretory diarrhea, colon dilation (magacolon), peritonitis, can be fatal; diagnosed by still sample, tx w/ antibiotics

question

Diarrhea MNT

answer

Oral fluids/electrolytes (carbonated beverages, sports drinks-potassium, soups, vegetable juice, isotonic liquids); avoid-sugar alcohol, fructose, lactose; w/ servere acute vomiting use IV hydration; with chronic diarrhea check zinc status; do not need to with hold food.

question

BRAT Diet

answer

not evidence based to treat diarrhea, high CHO and fructose, bananas, rice, applesauce and toast.

question

Tropical spruce

answer

Infectious diarrhea d/t bacterial overgrowth d/t mucosa atrophied/inflamed d/t decreased absorption. Can result in multiple vitamin and mineral deficiencies (low HCl and IF)-folic acid, B12

question

Irritable bowel syndrome nutrion-related presenting features

answer

Alternating diarrhea and constipation, dyspepsia, bloating, distention, incomplete evacuation, mucus in stool, discomfort after eating. R/o lactose intolerance or other GI dx. IBS is a diagnosis of exclusion

question

IBS-MNT

answer

Soluble fiber (normalize transit time), eliminate offending foods, low FODMAP (?), individualized to pt d/t variability in food tolerances. Probiotics (bifidobacterium infantis)

question

What is not allowed on a low FODMAP diet

answer

fructose, lactose, oligosaccharides (fructans or galactans), polyols.

question

Small Intestine Bacterial Overgrowth (SIBO)

answer

Bacterial overgrowth from stasis in the intestine, obstruction, radiation enteritis, fistula, IBD, IBS, or removal of ileocecal valve, surgical repair. Bacterial will cause a loss of bile salt function resulting in steatorrhea, bacteria use B12 resulting in def.

question

SIBO Tx

answer

antibiotics for bacterial overgrowth, probiotics and probiotics to regain normal cultures. Limit refined CHO *increase whole grains, veggies and oligosaccharides. May use MCT, Low FODMAP, B12 supplement

question

Common tests for malabsorption

answer

Direct stool examination; fecal fat test; C-xylose absorption test; breath test; pancreatic exocrine deficiency; schilling test (B12 malabsorption, protein losing enteropathy); Intestinal biopsy looking for celiac, eosinophilic enteritis, giardiasis, Crohn's disease.

question

Primary lactose intolerance

answer

deficiency in lactase brought on by gradual decline in lactase production

question

Secondary lactose intolerance

answer

intestinal infection or destruction of mucosal cells, intractable diarrhea, Crohn's and gluten sensitive enteropathy

question

Tests used to diagnose lactose intolerance

answer

Breath Hydrogen test or lactose tolerance test

question

Lactose intolerance MNT

answer

decrease consumption of lactose containing foods/milk; lactase enzyme replacements and treated milk products added to diet; calcium and vitamin D supplements; Identify hidden sources of lactose (milk solids, whey, casein)

question

Nutritional concerns with steatorrhea

answer

loss of energy/wt loss; loss of fat soluble vitamins; loss of ca and mg; increased absorption of oxylate (urolithiasis)

question

MNT for steatorrhea

answer

low fat diet; MCT supplements; water forms of fat soluble vitamins

question

Etiologies of celiac disease

answer

genes (familial or HLA class II), immune (antigliadin Ab), gliadin intolerance, damaged mucosa (decrease absorptive surface)

question

Gold standard for diagnosis of celiac disease

answer

endoscopic tissue biopsy

question

MNT for celiac disease

answer

Gluten free diet

question

Dermatitis Herpetiformis

answer

Red, raised, small or large blisters that burn and itch intensely, not unique to celiac disease.

question

Ulcerative colitis

answer

is a mucosal disease of the large intestine, including the rectum

question

Crohn's disease

answer

may involve any part of the GIT; most in distal ileum and colon; segments of inflamed bowel.

question

Ulcerative Colitis nutrition-related presenting features

answer

Chronic diarrhea, frequent watery stools; up at night; bloody diarrhea; fever; anorexia; wt loss; low hgb, hct, albumin, and potassium; elevated ESR and CRP

question

Ulcerative Colitis - MNT

answer

oral fluids and electrolytes; low fiber, low residue (acute phases); may add soluble bulking agent to prevent constipation and diarrhea; monitor zn levels w/ chronic persistent diarrhea; monitor Hgb, HCT, f/u with Fe studies indicated with anemia, etiology is GI bleed depletes iron.

question

Crohn's Disease - MNT

answer

Crohn's disease can lead to severe malnutrition. May require complete bowel rest (PN or EN hydrolyzed/elemental, low fat formulas); nutrition must be individualized and monitored (electrolytes, fluid status, wt, growth in children, anemia, fat soluble vitamins, pre-albumin, CRP-inflammation, zinc). Tropic feeds. Similar to UC, low fiber; low residue. High protein, high calorie; may benefit from MCT, vitamin and mineral supplementation, lactose restriction prn.

question

Fistula

answer

Abnormal opening between organs. Caused by birth defects, trauma, inflammatory disease, malignant disease, enterocutaneous post surgery

question

Fistula MNT

answer

Restore fluid and electrolyte balance, PN may be necessary and depends on location of the fistula, enteral nutrition may be possible using predigested formulas, oral diets

question

Short bowel syndrome

answer

Loss of 70-75% of the small bowel (100-120 cm of small bowel w/o colon or 50 cm of small bowel with colon). Results in wt loss, diarrhea, decreased transit time, malabsorption, dehydration, loss of electrolytes, hypokalemia; steatorrhea; B12 def; loss of fat soluble vitamins; fatty acid mineral soaps with ca, zn, and mg.

question

SBS MNT

answer

1) PN, 2) slow introduction of EN, focus on glutamine, nucleotides, SCFAs first (tropic feeds); MCT for fat soluble vitamins; evaluate narcotics. Eventually the remaining bowel will increase its absorptive surface.

question

MNT for Ileostomy or Colostomy

answer

Nutrition needs very; avoid gas and odor forming foods; fluid and electrolyte needs; B12 supplement

question

Diverticulosis nutrition-related issues

answer

High refined carbohydrate, high fat low fiber "western" diet contributes to disease

question

Diverticulosis MNT

answer

High fiber, low fat. Special focus on soluble fibers

question

Soluble fiber supplements

answer

metamucil, fibercon, citrucel, psyllium

question

Colorectal Cancer Nutrition-related contributing factors

answer

High fat, low fiber, refined "western" diet; low ca and FA intake; high alcohol (beer) intake; high meat intake; obesity; tobacco.

question

Colorectal cancer nutrition-related protective factors

answer

whole grain, FA, ca, vit D, multivitamin, PA and NSAIDs

question

Screening for GI disease: What is the most important indicator

answer

unintentional wt loss

question

Screening for GI disease: "flags" in diet hx

answer

Changes in appetite; N, V, & D; chewing/swallowing problems; food intolerances; supplements; pre and probiotics; typical intake/ability to take fluids

question

Screening for GI disease: "flags" in lab values

answer

Vit B12, FA, Ferritin, vitamin D

question

Achalasia

answer

Failure of esophageal neurons, in ability to relax the LES, MNT- Liquids not tolerated

question

Odynophagia

answer

Painful swallowing, as with the canker sores as a result of oral and esophageal cancers. MNT-liquids better tolerated than solids

question

Nutrition-related presenting characteristics for dysphagia

answer

Pt c/o food sticking in throat; aspiration pneumonia; wt loss; PEM

question

Dysphagia MNT

answer

Modify texture and consistency of pets diets per recommendations of swallow study. Avoid acidic foods and alcohol to help with symptoms. Correct nutritional deficiencies, prevent further wt loss, utilize high protein, high calorie food choices, oral supplements and EN

question

EGD

answer

Esophagogastroduodenoscopy, used to evaluate GERD

question

GERD

answer

Backward flow of the stomach or duodenal contents into the esophagus, result of competency of the LES

question

Esophagitis

answer

Inflammation, ulceration, erosions, scarring of the esophagus. D/t reflux, ingestion of corrosive agent, infection, intubation, radiation, eosinophilic infiltration, NSAIDs,

question

Barrett's Esophagus

answer

Precancerous condition; risk factors: prolonged GERD, mae gender, >50 yo, family hx

question

Hiatal hernia

answer

out-pouching of a portion of the stomach into the chest through esophageal hiatus of the diaphragm

question

Hiatal Hernia MNT

answer

wt reduction and decreasing meal size. May require surgery

question

GERD/Hiatal hernia nutrition-related presenting characteristics

answer

S exacerbated by fried foods, spicy foods, large meals, over-eating, alcohol, caffeine, and dietary indiscretion. pt c/o heart burn after large meals; chronic GERD may cause dysphagia, dental erosions

question

MNT for GERD

answer

Prevent pain and chemical irritation of esophageal mucosa (avoid acidic foods, alcohol, spiced foods); Prevent reflux (avoid foods that lower LES pressure i.e. high fat, greasy, alcohol, carminatives, chocolate. Avoid eating 2-4 hrs before bed; raise head of bed; avoid PA immediately following meals; avoid wearing tight fitting clothing; avoid overeating. Reduce Acidity of Gastric Contents (proton pump inhibitors, H2 receptor antagonist, antacids)

question

Omeprazole/prilosec

answer

Proton pump inhibitors, decrease Mg.

question

H2 receptor Antagonists

answer

cimetidine (Tagamet); Ranitidine (Zantac)

question

Antacids

answer

Magnesium and Aluminum hydroxide, calcium carbonate, magnesium phosphate

question

Ingesting too many magnesium based antacids can

answer

cause diarrhea and deplete phosphorus.

question

MNT for cancers of the oral cavity, pharynx and esophagus

answer

Modify texture and consistency of pets diets per recommendations of swallow study. Avoid acidic foods and alcohol to help with symptoms. Correct nutritional deficiencies, prevent further wt loss, utilize high protein, high calorie food choices, oral supplements and EN; f/u with nutritional plan. Tx of cancer may cause nutritional issues (decreased saliva production, tooth decay, swallowing difficulties, tooth extractions).

question

Esophagectomy MNT

answer

individualized NTRI plan and f/u, nutritional support (TF), slow progression to oral feedings. Monitor dumping syndrome, nutrient malabsorption, recommend liquid multivitamins and B12

question

What is required for normal RBC synthesis

answer

Functional bone marrow, EPO, protein, iron, B12, FA, Vit C, B6

question

What lab measures RBC size

answer

MCV

question

What lab measures RBC production

answer

Reticulocytes

question

Anemia

answer

decrease in the oxygen-carrying capacity of blood d/t decreased hemoglobin

question

Which anemias are affected by alcohol consumption

answer

Folic acid, B12, GI bleeding, Immune suppression, liver disease, impaired biosynthetic processes

question

What medications can result in anemia

answer

NSAIDS, Steroids, antacids, H2 blockers, anticoagulants, myelosuppressive drugs, vitamin antagonists

question

Microcytic Anemias

answer

IDA, ACD, Thalassemia, Sideroblastic

question

Causes of macrocytic anemia

answer

B12 and FA deficiencies, pernicious anemia, liver disease, hypothyroidism, drugs (FA and B12 antagonists, antivirals)

question

Normocytic anemias

answer

ACD/AI, pregnancy, bleeding, renal failure, cirrhosis, CLL, CML

question

What medications can result in anemia

answer

NSAIDS, Steriods, antacids, H2 blockers

question

What anemia patients my responds well to EPO tx

answer

pt with renal disease, rheumatoid arthritis, HIV, multiple myeloma

question

What anemias should not be tx with iron?

answer

blood loss, ACD/AI, thalassemia, sideroblastic, lead toxicity, sickle cell (?)

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