Post on 02-Jun-2018
8/10/2019 Nutritional Care Algorithmnou
1/50
Assoc p rof. Crist ian Seraf inceanu
Institutul de Diabet, Nutriie iBoli metaboliceN. PaulescuBucharest
8/10/2019 Nutritional Care Algorithmnou
2/50
Diet and physical activity are linked to more deathseach year than any single factor other than cigarettesmoking.
As health care providers, we can do more for our
patients by helping them eat healthy and exercise
regularly than any other intervention.
B Brenner, 2007
8/10/2019 Nutritional Care Algorithmnou
3/50
Nutritional care algorithm (nutritional medicaltherapy) for renal patients
1 nutritional screening
2 nutritional antecedents
3. nutritional behavior
4. clinical examination
5. biologic parameters
Identification of therapeutic goals:
1. Reasonable
2. Negotiable
3. Adjustable
acceptable
for own
lifestyle
Periodic evaluation:1. results monitoring -
- redefining goals
1. solving current problems
Nutritional medical intervention:
1. Diet
2. Nutritional supplements
8/10/2019 Nutritional Care Algorithmnou
4/50
1. Significant antecedents:
Physiologic
Pathologic
Therapeutic
Known nutritional problems or deficits
Chronic use of drugs with nutritional effects(i.e. chimiotherapy)
Psycho-social antecedents: Alcohol or drug abuse
Smoking
Financial and social status
Marital status
1. Specific signs and symptoms for nutritional deficiencies2. Subjective global assessment:
Evaluation of muscular waste
Evaluation of subcutaneous tissue
Presence of oedemas
Dialysis related items
8/10/2019 Nutritional Care Algorithmnou
5/50
Basal (level I): detection ofnutritional risk factors
-body mass index
-eating habits
-living environment
-functional status
Complete (level II): forpatients at nutritional risk
-history of weight changes (6mo)
-mid-arm circumference
-triceps skinfold
-mid-arm muscle area
-serum albumin
-total plasma cholesterol-clinical features
-drug prescriptions
-mental/cognitive status
8/10/2019 Nutritional Care Algorithmnou
6/50
Present
8/10/2019 Nutritional Care Algorithmnou
7/50
Eating habits (topics)
-not have to eat enough (each day)
-usually eats alone-poor appetite-special (restrictive) diets-does not eat vegetables, fruit or milk at least once
daily
-difficulties in chewing or swallowing-more than two alcoholic drinks per day (one forwomen)
-has pain in mouth , teeth or gums
8/10/2019 Nutritional Care Algorithmnou
8/50
8/10/2019 Nutritional Care Algorithmnou
9/50
Functional status - needs assistance(usually or always) with:
-bathing
-dressing
-toileting (grooming)
-eating (preparing food)-walking (traveling)
-shopping (for food)
8/10/2019 Nutritional Care Algorithmnou
10/50
5114.232.8Males 60-70y
55.81331.9Males 30-40y
35.414.531.7Females 60-70y
32.424.228.6Females 30-40y
Mid-armmuscle area(MAMA)
Tricepsskinfold(TS)
Mid-armcircumference(MAC)
Targetpopulation
8/10/2019 Nutritional Care Algorithmnou
11/50
Clinical features and mental/cognitive status:
-evident problems with mouth, teeth, gums
-difficulties with chewing
-angular stomatitis
-glossitis
-skin lesions (dry, loose, wounds, etc.)
-history of bone fractures
-clinical evidence of mental status impairment
-depressive illness (Geriatric Depression Scale, etc.)
8/10/2019 Nutritional Care Algorithmnou
12/50
Various nutrientsDrugs (antacids,
laxatives,
anticonvulsivants)
Inadequate
absorption
Energy, proteinPoverty, isolation
Dietary fibreHabitual
constipation
Protein, vitamin B12Avoidance of meat ,
eggs
Vitamin C, folates,
vitamins B
Avoidance of fruits,
vegetables
Protein, vitamins BAlcohol abuse
Inadequate intake
Suspecteddeficiency
History ofMechanism
8/10/2019 Nutritional Care Algorithmnou
13/50
Inborn errors of
metabolism
Various
Drugs(anticonvulsivants,
antimetabolites,isoniazide)
Decreasedutilization
Gastro-intestinal surgery
Pernicious anemia Iron, vitamin, B12
Parasites
Liposolublevitamins
(A,D,E,K),energy, protein
Malabsorption (diarrhea,weight loss, steatorrhea)
Inadequateabsorption
SuspecteddeficiencyHistory ofMechanism
8/10/2019 Nutritional Care Algorithmnou
14/50
IronBlood loss
Suspecteddeficiency
History ofMechanism
Protein, vitamins
(water soluble)Dialysis
ProteinNephroticsyndrome
Protein,electrolytes
Diarrhea
Energy, proteinUncontrolled
diabetes mellitus
ProteinCentesis (ascitic,
pleural)
Magnesium, zincAlcohol abuse
Increased losses
8/10/2019 Nutritional Care Algorithmnou
15/50
Suspecteddeficiency
History ofMechanism
Vitamin C, folatesSmoking
EnergyInfection, hypoxia
Energy, protein,vitamin CSurgery, burns,trauma
Energy, variousnutrients
Physiologicdemands
(adolescence,pregnancy,lactation)
EnergyFever,
hyperthyroidism
Increasedrequirements
8/10/2019 Nutritional Care Algorithmnou
16/50
hyperpigmentation of
sunlight exposedareas
hair
nails
Skin
Organ/syste
m
lack of shine, easy
pluckable
spoon-shaped
Petechiae,
ecchymoses
pallor
dry, scaly
Abnormal finding
hypothyroidism,chemotherapy,
psoriasis
proteins, Zn, linoleic
acid
pulmonary or heartchronic disease
iron
Liver disease, aspirin
overdoseVit K, C
hemorrhage,pigmentation
disordersiron, vit B12
chemical burns,Addisons diseaseniacin or tryptophan
environmentalessential fats, vit.A
Non-nutritionalassociation
Nutritional deficiency
8/10/2019 Nutritional Care Algorithmnou
17/50
Protein deficiency
Vit. C
Vit B2
Vit B2, B6, niacin
Vit A
Nutritionaldeficiency
Bilateral
enlargement
spongy, bleeding,receding
magenta, loss ofpapillae, swollen
bilateral (angular
stomatitis) orvertical cracks
(cheilosis)
dry, grayish, nightblindness
Abnormal findingNon-nutritional
associationOrgan/system
Tumors,
hyperparathyroidism
parotid glands
Drugs (dilantin),lymphoma,
thrombocytopenia,aging, poor dental
hygiene
gums
Crohndisease,
bacterial or fungalinfections
tongue
dentures problems,herpes, syphilis,
AIDSlips
Gauchers diseaseeyes
8/10/2019 Nutritional Care Algorithmnou
18/50
Methods to assess protein and energy status
Protein stores Other methods Energy balance
visceral somatic
Salb
Sprealb
Stransf
Ret. bind. prot.IGF-1
Anthropometry
BIA
Nitrogen balance
Densitometry
Creat. Kinetics
Isotope studiesDEXA
NMR
others
SGA expenditure balance
8/10/2019 Nutritional Care Algorithmnou
19/50
Immediate proteicintake marker
Anabolic growthfactor
2-6 h0.55-1.4UI/ml
Insulin-likegrowthfactor 1 (IGF1)
Proteic intakemarkerhypercatabolicstates
Pro-vitamin Atransporter
0.5 (12h)0.37Rhetynolbindingprotein(RBP)
Malnutrition (earlymarker); acutehypercatabolic states
Thyroidhormonestransporter
2-30.2-0.4Prealbumin
(transthyretin)
malnutrition (more
early) marker; negativeinflammation marker
plasma iron
carrier
8-92.6-4.3Transferrin
late malnutritionmarker
Coloid-osmoticpressure
18-2035-45Albumin
Nutritional
significance
Normal
function
Plasmatic
life (d)
Norma
l range(g/l)
Parameter
8/10/2019 Nutritional Care Algorithmnou
20/50
____________ Diarrhea ___________ Anorexia__________ Nausea __________ Vomiting
__________ None
3. Gastrointestinal Symptoms (lasting >2 weeks)
__________ Starvation
__________ IV or hypocaloric liquids__________ Full liquid diet
__________ Suboptimal solid diet
Type: __________ Increased intake_________Change
Duration: __________ Weeks_________ No change
2. Dietary Intake (relative to normal)
_______no change ________decreaseChange in past weeks: _______increase
Percent weight loss in past 6 months _______________
Overall weight loss in past 6 months _______________
Current weight _______________
Weight 6 months ago _______________
Maximum body weight _______________
1. Weight Change
8/10/2019 Nutritional Care Algorithmnou
21/50
__________ C = severely malnourished
__________ B = moderately (or suspected of being) malnourished
__________ A = well nourished
SUBJECTIVE GLOBAL ASSESSMENT RATING (select one)
__________ Ascites
__________ Ankle edema
__________ Muscle wasting (quadriceps, deltoids)
__________ Loss of subcutaneous fat (shoulders, triceps, chest, hands)
(For each trait specify: 0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe)
PHYSICAL EXAMINATION
____________ Bedridden
____________ Ambulatory
Type: ____________ Works suboptimally___________ Dysfunction
Duration: ____________ weeks___________ NO dysfunction
4. Functional Capacity
ROSPEN, Poiana Braov, 2004
8/10/2019 Nutritional Care Algorithmnou
22/50
Dialysisduration**
Co-morbidities
Functionalstatus
Digestivesymptoms
Dietaryintake
changes/ 6mo
Weightchanges/6mo
Parameter
/score
43210
More than 48mo
24-48 mo, RRF12-24 mo, RRFLess than 12mo, no RRF
Less than 12mo, RRF
Multiple,severe
1 severemoderatemildNo
BedridingMinimal effortsdifficulty(toileting)
Usual effortsdifficulty(housekeeping)
Walkingdifficulty
Good/normal for age
AnorexiaFrequentdiarrhea/vomiting
Vomiting/other moderate
nauseano
starvationLiquid/hypocaloric diet
Moderateglobal
decrease
Suboptimalsolid food
no
15%10-15%5-10% 5%no
8/10/2019 Nutritional Care Algorithmnou
23/50
Malnutrition:
-absent: 04-mild: 58
-moderate: 914
-severe: 15 -24
8/10/2019 Nutritional Care Algorithmnou
24/50
1. Classifying nutritional deficits in weight - for - height:reference values (Torm B, Chen F, 1994)
Weight - for - height ratio = actual bodyweight/reference weight for height (RWH)
RWH = 50+0,75(H-150)+(Age-20)/4 Normal: 90-110%
Mild deficit: 80-89%
Moderate deficit: 70-79%
Severe deficit:
8/10/2019 Nutritional Care Algorithmnou
25/50
2. Body mass index (BMI, Quetelet index)
3. Tricipital skinfold (TS)
4. Mid-arm circumference (MAC) 5.Mid-arm muscular area (MAMA)
(MAC - TS)2/12.56
All anthropometric measurements must be interpreted for age, sex, race
8/10/2019 Nutritional Care Algorithmnou
26/50
Indication= patients with significant risk of malnutrition afternutritional history and physical examination (SGA).
Aim= to detect specific nutritional deficiencies beforeonset of
clinic or anthropometric manifestations.
Proteinstatus: central for the prevention, diagnosis and treatment ofmalnutrition:
Bi - compartmental pattern (of evaluation):
Metabolic active proteins (3050%)
Muscle (somatic) proteins (75%)
Visceral proteins (25%)
Metabolic inactive proteins (5070%):
Bones, joints
Iron status.
Calcium and phosphorus status.
Vitamins status.
8/10/2019 Nutritional Care Algorithmnou
27/50
Nitrogen balance= ratio between the amount ofnitrogen consumed as proteins and the amountexcreted by the body.
The expected value for healthy adults is 1 the rate ofproteins synthesis (anabolism) equals the rate of proteindegradation (catabolism)
Formula: PRO(g)/6,25 = UUN(g)4(g), where:
PRO: protein ingestion/24h(g)
6,25: protein nitrogen index
UUN: urinary urea nitrogen/24h (g)
4(g): constant for nonurea nitrogen + nonurinarynitrogen (stool, sweat)
Disequilibrium of nitrogen balance need dietary and/ornon dietary correction (i.e.: increased losses in criticallyill patients).
ROSPEN, Poiana Braov, 2004
8/10/2019 Nutritional Care Algorithmnou
28/50
a. Somatic protein status Lean body mass assessment (muscle mass)can
be estimated by the 24h urinary creatinine excretion
comparing with a standard (expected) excretion
based on height Urinary creatinin excretion:
Is a constant on ideal weight:
23 mg/Kgc/day in men
18 mg/Kgc/day in women
Its variation is exclusively determined by height (see
standards in table)
ROSPEN, Poiana Braov, 2004
8/10/2019 Nutritional Care Algorithmnou
29/50
11411751831190
10761701739185
10011651642180
9501601467170
9001551386165
8511501325160
Urinarycreatinine /24h
(mg)
Height (cm)Urinary
creatinine /24h
(mg)
Height (cm)
FemalesMales
8/10/2019 Nutritional Care Algorithmnou
30/50
1) Include questions about diet and exercise in all yourroutine patient histories.
2) Assess all patients height, weight and BMI.Measure waist circumference when appropriate.
3) Help patients understand the association betweentheir diet and exercise habits and their risk for
chronic diseases.
4) Begin to negotiate realistic lifestyle changes that canbe achieved and maintained over time.
8/10/2019 Nutritional Care Algorithmnou
31/50
Increased total calories (andportion sizes)-energy density
Increased fast food consumption
Increased saturated fat and salt
intake
Low fruit and vegetable intake
Inadequate calcium intake
8/10/2019 Nutritional Care Algorithmnou
32/50
USDA Food Guide Pyramid
8/10/2019 Nutritional Care Algorithmnou
33/50
8/10/2019 Nutritional Care Algorithmnou
34/50
2001 ATP III Guidelines target LDL
Diabetes is a CHD risk equivalent
Metabolic syndrome should be treated withintensified lifestyle changes.
BMI >30 considered a major risk factor for CVD
Therapeutic Lifestyle Diet (TLC) developed Fat intake 25 - 35% of total calories
Limit saturated fat Increase monounsaturated fat
8/10/2019 Nutritional Care Algorithmnou
35/50
Nutrient Recommended Intake
Saturated fat Less than 7% of total calories
Polyunsaturated fat Up to 10% of total caloriesMonounsaturated fat Up to 20% of total calories
Total fat 2535% of total calories
Carbohydrate 5060% of total calories
Fiber 2030 grams per day
Protein Approximately 15% of total calories
Cholesterol Less than 200 mg/day
Total calories (energy) Maintain healthy weight/prevent weight
Stanol esters 2 grams/day
Soy protein 25-40 grams/day
Soluble fiber 5-10 grams/day
Fish at least 2 times a week
8/10/2019 Nutritional Care Algorithmnou
36/50
TransFatty Acids
Beef, PorkVeal,Lamb, Butter,
Cheese
HydrogenatedVegetable Oils
Saturated Fatty Acids
Corn, Safflower,Sunflower,Soybean
Omega-6Fatty Acids
Fish, Flaxseed,Soybean,Marine Vegetation
Omega-3Fatty Acids
PolyunsaturatedFatty Acids
Olive Oil,Canola Oil,
Nuts, Avocado
MonounsaturatedFatty Acids
Unsaturated Fatty Acids
Shortening
Margarine
Sources of Dietary Fat
More Atherogenic Less Atherogenic
Cocoa ButterCoconut Oil
Palm Oil
Source: ATP III Guidelines. NCEP 2001 Report
8/10/2019 Nutritional Care Algorithmnou
37/50
According to the JNC VII 2003 Report, individuals
with a systolic BP of 120-139 mm Hg or a diastolicof 80-89 mm Hg should be considered asprehypertensive and require health promotinglifestyle modifications to prevent CVD.
Lifestyle issues: weight, diet, physical activity, alcohol and smoking
Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNC VII. JAMA. 2003;289:2560-2572.
8/10/2019 Nutritional Care Algorithmnou
38/50
459 adults enrolled with mean base-line BP of 131.3/84.7 mm Hg.
3 week control diet run-in period
Subjects randomized to 3 groups for 8 weeks Control diet
Diet rich in fruits (5 servings/d) and vegetables (3 servings/d)
Combination diet: fruits/veggies, low fat dairy (2 servings/d),low saturated fat (
8/10/2019 Nutritional Care Algorithmnou
39/50
412 adults enrolled with mean BP of 135/86 mm Hg. Mean BMI=30
90 day trial. Subjects randomized to 2 groups:
Control diet
DASH diet: fruits (5 servings/d), vegetables (3 servings/d),low fat dairy (2 servings/d), low saturated fat.
Each group spent 30 days on each 1150, 2300, and 3450 mg Na/day
DASH and low sodium resulted in a 7.1 mm Hg in systolic pressurein patients with normal blood pressure.
11.5 mm Hg
in systolic pressure in those with HTN.
Effects of reduced sodium seen in both patients with normal and highblood pressure regardless of race or gender.
Source: Sachs FM,et.al. NEJM 344:3-10, 2001.
8/10/2019 Nutritional Care Algorithmnou
40/50
Do you taste your food before you add salt?
How often do you eat salty foods, such as chips, pretzels,salted nuts, canned and smoked foods?
Do you read labels for sodium content?
How many servings of fruits and vegetables do you eat everyday?
How often do you eat or drink dairy products? What kind?
How often do you eat out? What kinds of restaurants
8/10/2019 Nutritional Care Algorithmnou
41/50
2-4 mm HgLimit alcohol to no morethan2 drinks/d for men and
1 drinks/day for women.
Moderate alcohol consumption
4-9 mm HgEngage in regular aerobicactivity such as walking
Increase physical activity
2-8 mm HgReduce sodium to no morethan 2.4 g/day sodium or 6g/day NaCl
Dietary sodium reduction
8-14 mm HgConsume diets rich in fruits,vegetables, low fat dairy
Adapt DASH eating plan
5-20 mm Hg for each10 kg weight loss
Maintain normal bodyweight (BMI 18.5-24.9)
Weight Reduction
Approximate Systolic
Blood PressureReduction
RecommendationsModification
2.
8/10/2019 Nutritional Care Algorithmnou
42/50
USDA Food Guide Pyramid
DASH PYRAMID
8/10/2019 Nutritional Care Algorithmnou
43/50
DASH PYRAMID
8/10/2019 Nutritional Care Algorithmnou
44/50
Achieve normal or near-normal blood glucose levels
Achieve optimal lipid levels Appropriate calorie recommendations
Maintain reasonable weight for adults
Growth and development for children and teens
Improve health through optimal nutrition and physical activity
Prevent, delay, or treat nutrition-related complications
Individualized based on usual lifestyle habits and
need/willingness to change
Source: American Diabetes Association. Nutritional Recommendations and Principles forPeople with Diabetes Mellitus. (Position Statement). Diabetes Care. 1998;21(Suppl 1):S32-35.
8/10/2019 Nutritional Care Algorithmnou
45/50
Diabetes Prevention Program (DPP) Research Group
27 Centers following patients from 1996 to 1999
Recruited 3234 people over 2.8 years >25 years old
Fasting glucose 95 - 125 mg/dL
140 - 199 mg/dL 2 hours post 75 oral glucose load
BMI >24
Source: Diabetes Prevention Program II. NEJM. 2002:346;393-403
8/10/2019 Nutritional Care Algorithmnou
46/50
Year
8/10/2019 Nutritional Care Algorithmnou
47/50
Incidence of type 2 diabetes
was reduced by 58% with
lifestyle intervention and by
31% with Metformin, as
compared to placebo.
Lifestyle intervention group
significantly better outcome
compared to medication or
placebo groups.
8/10/2019 Nutritional Care Algorithmnou
48/50
6.6
6.8
7.0
7.2
7.4
7.67.8
8.0
8.2
8.4
Initial 6 Week 3 Month 6 Month
No Education
1 RD visit3 RD visits
Source: Franz et al., J Am Diet Assoc 95:1009-17, 1995
HgbA1C
8/10/2019 Nutritional Care Algorithmnou
49/50
In diabetics, there is a strong correlation betweenmetabolic syndrome and CVD.
Metabolic syndrome patients with type 2 diabetes havea higher prevalence of microalbuminuria ormacroalbuminuria.
Patients with metabolic syndrome have a small LDLparticle size pattern and preclinical atherosclerosis.
8/10/2019 Nutritional Care Algorithmnou
50/50