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Medical Nutrition Therapy

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Nutrition Status
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a measurement of the degree to which the individual’s physiologic needs for nutrients are met o When in optimal nutritional status: nutrients consumed support daily needs, promotes growth and development, general health, protection from illness, supports physical activities of daily living o Affects nutrient intake and nutrient requirements
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Nutrient Imbalance
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o Deficiencies and excess occur when nutrient intake does not match the individual’s requirements for optimal nutrition status o The body will maintain homeostatic mechanisms within a certain range of intakes o The farther you move away from desired range – results in under and overnutrition
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Development Deficiency
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o Inadequate intake/Impaired absorption/increased nutrient losses → body sotre/tissue level depletion → biologic dysfunction → physiologic dysfunction → cellular dysfunction → clinical signs and symptoms → mortality o Components of nutrition assessment: dietary history and nutrient intake → biochemical/physiologic studies → clinical signs and symptoms → vital statistics
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Nutrition Screening
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o Purpose: to quickly identify individuals who are malnourished or at nutritional risk and to determine if a more detailed assessment is warranted o Usually completed by DTR, nurse, physician, etc o At risk pt’s referred to RD o Characteristics: • Simple/easy to complete • Routine data • Cost effective • Effective in identifying nutritional problems • Reliable/valid o Review pt diet, drug, medical Hx (look for increased risk) o Weight and height: any unintentional weight gain or loss o Lab data and clinical signs of malnutrition o Check tray for amount eaten
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Nutrition Care Process
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• A systematic problem solving method that dietetics professionals use to critically think and make decisions to address nutrition related problems and provide safe, effective, high quality nutrition care • Standardized process for individual care • Documentation format: ADIME o A = Assessment o D = Diagnosis (PES) o I = Intervention o M, E = Monitoring and Evaluation
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Assessment
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obtain, verify, interpret data, tells us whether a nutrition Dx/problem exists o Identification and naming
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Diagnosis
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nutrition and dietary state/condition that affects the pt o Health/lab finding o Medical dx/problem or symptom o Examples: excessive protein intake (affects uremic syndrome), excessive carbohydrate intake (can affect dumping syndrome after gastric surgery), food and nutrition-related knowledge deficit (can affect blood glc/diabetes,, lipids/CVD, drug levels) o Problem related to Etiology as evidenced by Signs and Symptoms
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Intervention
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activities to address the problem o Select, plan and implement appropriate actions to meet pt nutrition needs o Driven by diagnosis o Based on scientific evidence – may have multiple o Translate assessment data into strategies or activities to meet established objectives o May include: changing diet prescription, counseling pt, providing supplements, tube feeding → change plan as pt condition changes o What, where, when, how
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Monitoring
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determine progress toward clients goals and desired outcomes o Monitoring: review and measurement of status at schedules times
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Evaluation
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systematic comparison with previous status, goals, reference standard o What will success look like (desired outcomes), did your plan work, do you need to assess new factors or reassess, how will you know when the pt is ready to function independently
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Nutrition Indicators
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clearly defined markers, observed and measured, relevant to nutrition dx o These are “clustered” to determine the existence of a nutritional PROBLEM and allows the RD to determine he best nutritional dx at that time o Also used to determine monitoring and evaluation goals o Review collected assessment data → cluster data elements together to form dx → compare pertinent data to reference standards o Energy Intake: • Are you comparing to a goal or reference standard? • How does the patient intake compare to recommendation? • Ex: Based on pt’s 3 day food diary, the pt has a total energy intake of 2600 kcal/day. Current intake is 144% (2600/1800 X 100) of recommended intake of 1800 kcal. • Defines nutritional status using: medical, social, nutritional, medication hx, physical examination, anthro measurements, and lab data
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Examples of nutrition indicators
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• Medical & Social Histories: includes info such as current complaint, past illnesses and surgeries, disease history, etc. • Medication history: make not of any medication that cause food/drug interactions • Nutrition or diet history
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Methods of obtaining dietary info
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o At least 72 hours o Daily food record/food diary o Food frequency questionnaire o 24-hr recall
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Nutrient intake analysis
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-Allows actual observation of food in clinical setting -Doesn’t account for possible variation in portion size -Doesn’t reflect intake of free-living individual
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Daily Food Record/Diary
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-Provides daily record of food consumption -Can provide info on quantity of food, how food is prepared, and timing of meals and snacks -Depends on variable literacy skills of participants -Requires ability to measure or judge portion size -Actual food intake possibly influenced by recording process -Reliability of records
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Food Frequency
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-Easily standardized -Can be beneficial when considered in combo w/ usual intake -Provides overall picture of intake -Requires literacy skills -Doesn’t provide meal pattern data -Requires knowledgeable portion sizes
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24 Hr recall
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-Quick and easy -Requires memory -Requires knowledge of portion sizes -May not represent usual intake -Requires interviewing skills
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Anthropometrics
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o Children growth charts – CDC & WHO • Length and height differ from adults o Weight: ideal weight for height, actual body weight, % weight loss/gain, BMI • Meausure weight at admission, current and usual, determine percent change over time (weight pattern), determine percent above or below usual or ideal bw o ALWAYS MEASURE o Infant <2 yrs old are measured by length NOT HEIGHT
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Calculating BMI
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• Weight (kg) / height (m) squared • Weight (lb) / height (in) squared X 703 • Categories: • Underweight: < 18.5 kg/m2 • Normal weight: 18.5-24.9 kg/m2 • Overweight: 25-29.9 kg/m2 • Obese: <30 kg/m2
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Calculating IBW
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• HAMWI Formula: • M = 106 # (per 5 ft) + 6 # (per in) • W = 100# (per 5 ft) + 5 # (per in) Add 10% for large frame Less 10% for small frame Ex: 5’11 = 106 +66 = 172 (10% of that is 17 lbs added for large frame)
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% Ideal and Usual Body Weight
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• %IBW = current wt/IBW X 100 • %UBW = current wt/UBW x 100 • % weight change = (Usual wt – current wt)/usual wt X 100 • Minimum wt for survival is 48-55% UBW • Mild: 80-90% • Moderate: 70-80% • Severe: <70%
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Highest percent usage of Body’s energy
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LIVER
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Body Composition
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o Subcutaneous fat (skin-fold thickness) o Circumference measurements • Waist – hypertension, CVD correlation > 40 in for men, >35 in for women • Waist-to-hip Ratio – detect fat deposition in HIV patients, and detect CVD risk better than BMI. Ratio of 1.0 for men, 0.8 for women at risk • Midarm • Head • Calf
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Classifying Malnutrition
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• BW • Body fat • Somatic and visceral protein stores • VIT D levels • Lab values
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Specimen Types
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o Whole blood, serum, plasma, blood cells, RBC’s, WBC’s, blood spots, other tissues, urine, feces, saliva, nails, hair, sweat
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Static Assays
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measures ACTUAL levels of nutrients, specific for nutrient of interest, limitation: dietary intake influence level
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Functional Assays
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measure physiologic ACTIVITY, can be sensitive for a nutrient at its functional site, but not always
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Assessment of Protein-Calorie Malnutrition
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o Hormonal and cell-mediated response to stress o Negative acute-phase respondents • Albumin, PAB, transferrin – DECREASE • Indicate inflammation and protein-calorie malnutrition o Positive acute-phase respondents • CRP, ferritin – INCREASE o NITROGEN BALANCE
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Hepatic Transport Proteins
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• ALBUMIN – *Prime indicator, 18-21 days • TRANSFERRIN – iron to bone marrow for hemoglobin • PREALBUMIN – indicates if interventions are working
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Microcytic Anemia
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iron deficiency in RBCs
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Macrocytic Anemia
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folate of Vit B12 deficiency
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Megaloblastic Anemia
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folate deficiency
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Pernicious Anemia
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vit B12 deficiency
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Schilling Test
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B12 absorption problems – radioactive
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Normocytic Anemia
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chronic and inflammatory diseases
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Lab tests for iron deficiency anemia
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• Hematocrit/packed cell volume • Hemoglobin • Ferritin – effects of inflammation • Serum transferring response test – not affected by inflammation
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Inflammation
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o Hs-CRP o Homocysteine o Indices of oxidative stress: • Antioxidant status, phytochemicals, enzymes • Markers: Free oxygen radical test o Lab test results used to predict the risk of nutritional anemias are not useful to assessing pt with an inflammatory response
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Albumin and Malnutrition
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• Normal Reference ranges: 3.7 – 4.7 g/dL • Mild Depletion: 2.8 – 3.4 g/dL • Moderate Depletion: 2.1 – 2.7 g/dL • Severe Depletion: <2.1 g/dL • Major plasma protein • Albumin acts like tiny sponges to hold onto water, thus promoting normal oncotic pressure and hydration o Levels strongly influenced by hydration status, level drops with edema and increases with dehydrateion o Not an acute sensor of nutritional status in critically ill individuals or of early malnutrition o Major carrier of non-soluble substances: lipids, hormones, Rx, bilirubin, metals
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Marasmus
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starvation or Fasting o Weight is often </ = 80% of normal but albumin may be within reference range (inadequate intake of calories and protein) o Within 24 hours glycogen stores are depleted o Insulin levels drop o 75 grams of muscle protein are catabolized during the first 2-3 days of a fast o involuntary reduction of BMR o conservation of visceral protein stores
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Kwashiorkor
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Hypoalbuminemic Malnutrition o Inadequate intake of protein; energy intake may be marginal o Weight may be normal or excessive but protein stores (albumin) is low o Conservation of somatic prtoeins
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Body Protein Store
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o Approx 12 kg, enough to theoretically supply 2 weeks worth or energy needs o Total depletion of protein would have profound adverse effects, including depletion of visceral proteins, decreased immune response, impaired wound healing, impaired organ function and death o Somatic proteins = muscle proteins (75%) o Gut proteins o Visceral proteins = organ proteins (25%)
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Lab tests used to assess protein/nutritional status
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o Albumin (1/2 life of 12-21 days) o Retinol binding protein (1/2 life of 10-12 hours) o Prealbumin (1/2 life of 2-3 days) o Transferrin (1/2 life of 8-10 days) o Cholesterol
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Estimated Energy Requirement
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o For a fever, calculate 7% for every degree over 98.7 o Calculate REE using Mifflin for normal pt, and Harris-Ben for trauma pts o REE X activity factor X injury factor + fever factor = TEE o TEE – 500 for weight loss, + 500 for weight gain
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Fluid Needs
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o Weight in kg = fluid needs in mL (cc)/day
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Factors that increase fluid needs
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• Fever • Nasogastric tube • Fistula wound drains • Diarrhea • Vomiting • Hyperventilation/respirator • Excessive perspiration • Pressure ulcer
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Factors that decrease fluid needs
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• Congestive heart failure • Cardiac disease • Renal disease • Dilutional hypoatremia • Edema
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Serum Electrolytes
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Total parenteral nutrition or with renal conditions, chronic obstructive pulmonary disease, uncontrolled DM, endocrine disorders
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Glucose
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Indicates DM, insulin resistance Monitor levels with triglycerides for glucose intolerance
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Creatinine
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Increased with renal disease, decreased with PEM
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BUN or urea
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Increased in those with renal disease and excessive protein catabolism, decrease with liver failure and negative nitrogen balance
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Albumin Serum Enzymes
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Increased in those with malignant, muscle, bone, intestinal, liver diseases, acute inflammatory disease
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Bilirubin
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Increased with drugs, gallstones, bilary duct diseases, Hemolysis and decreased with anemias
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Total Calcium
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Hypercalcemia with endocrine disorders, malignancy, hypervitaminosis D
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Phosphorus
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Hypoparthyroidism and decreased intake, chronic antacid ingestion, renal failure
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Total Cholesterol
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Decreased with protein-calorie malnutrition, liver diseases and hyperthyroidism
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Triglycerides
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Increased with glucose intolerance, or those not fasting
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Nutrition Diagnosis Categories
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o Intake: actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support o Clinical: nutrition findings or problems identified as related to medical or physical conditions o Behavior-Environmental: nutrition findings or problems identified as related to knowledge, attitudes or beliefs, physical environment, or food supply and safety.
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PES
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o Problem: (diagnostic label) describes alterations /issue related to client’s nutrition – actual not potential o Etiology: cause or contribution risk factors o Signs or Symptoms: defining characteristics o Ex: P – excess energy intake, E – related to significant increase in weight S: as evidenced by 5 lb weight gain during the last 3 weeks due to consumption of 500 kcal/day more than the estimated needs.
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Nutrition Intervention May include:
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o Changing diet prescription o Counseling patient o Providing food or nutrition supplement o Initiating tube feeding o Providing resource information o What, where, when, how o Change plan if patient’s condition changes
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Iatrogenic Malnutrition
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protein-energy malnutrition related to long hospital stay or lack of food
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Phases of dying patients in Hospice
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o Denial o Anger o Bargaining o Depression o Acceptance
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Palliative Care
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encourages the alleviation of physical symptoms, anxiety and fear while attempting to maintain the patient’s ability to function independently – quality of life