Special topics in nutrition

Special Topics in NutritionKristopher R. Maday, MS, PA-C, CNSC

Surgical Physician Assistant ProgramDepartment of Nutritional Sciences

University of Alabama at Birmingham

Topics to Be DiscussedMedical Nutrition Therapy (MNT)

management for:Diabetes MellitusKidney DiseaseLiver DiseasePancreatitisCritical Illness

Medical Nutrition TherapyTherapeutic approach to treating medical

conditions and their associated symptoms using highly individualized, tailored diets devised and monitored by medical nutrition specialists and/or registered dieticians

Often implemented before, or concurrently with, pharmacotherapy

Can delay, halt, and even reverse the progression of certain diseases

Diabetes MellitusAmerican Association of Clinical

Endocrinologists (AACE)2011 Guidelines for initiation of MNT

Any patient with “pre-diabetes” should be started on lifestyle modifications Fasting plasma glucose of 100-125 mg/dL 2-hour post-prandial OGTT glucose of 140-199

mg/dL Hemoglobin A1C of 5.5-6.4%

Endocrine Practice. 2011;17(supplement 2)

Diabetes MellitusGoals of Medical Nutrition Therapy

Attain and maintain optimal metabolic outcomes Blood glucose levels within normal range

2011 - AACE Guidelines Hgb A1C < 6.5%

Lipid and lipoprotein profile that reduces macrovascular complications 2004 - NCEP ATP-III Guidelines

LDL < 100 mg/dL HDL > 40 mg/dL

Blood pressure levels that reduce risk of vascular complications 2003 - JNC 7

Systolic < 130 mmHg Diastolic < 80 mmHg

Prevent, or at least slow, the rate of development of chronic complications

Aid in weight loss 5-7% weight reduction

Clinical Diabetes. 2002;20(2)

Diabetes MellitusEnergy Balance

One of the most important aspects of nutritional management in diabetes is weight loss Decreased insulin resistance, improved measures in glycemia

and dyslipidemias, and reduction in blood pressuresGoal is for a reduction of 5-7% of starting weightBalance between reduction of caloric intake and energy

expenditures 500-1000 kcal deficit per day for healthy weight loss 150 minutes per week of moderate exercise

Pharmacotherapy reserved for patients with BMI > 27.0Bariatric surgery reserved for patients with BMI > 35

Clinical Diabetes. 2002;20(2)

Diabetes MellitusCarbohydrates

45-55% of daily calories 150-300g per day

Not all are created equal Sugars

Glucose, fructose, sucrose, lactose Starches

Amylose, amylopectin, resistant starch Fiber

14g per 1000kcalTotal amount of carbohydrates is more important than the

source or type Carbohydrate counting

Low glycemic index carbohydrates may help with glucose control

Diabetes MellitusCarbohydrate Counting

Determine total daily allowance of carbohydrates

Divide equally into meals and snacks

“Net” Carbs Total carbohydrates from

label or weighing If fiber > 5g, substract ½

of amount of fiber Substract ½ sugar

alcoholsWisconsin Diabetes Essential Care Guidelines, 2011 Diabetes Care. 2003;26(8)

Diabetes MellitusLipids

Diabetes Mellitus = Cardiovascular Disease Primary goal is to limit saturated fat and

cholesterol <7% of daily calories for fat and < 200 mg/day for

cholesterol Animal meats, butter, cream, cheese, hydrogenated

oils, lardSodium

Dietary Approaches to Stop Hypertension (DASH) Diet Limit sodium to 2400mg/day and gradually lower to

a goal of 1500mg/day

Chronic Kidney DiseaseMedical Nutritional Therapy is difficult

20-70% of dialysis patients suffer from primary protein-calorie malnutrition Anorexia from uremia, dysguesia, unpalatable diets,

concurrent illnesses, act of dialysis50% of new ESRD patients are caused by

diabetes Kidney is a major site of insulin degradation

As renal function declines, insulin levels riseManagement changes throughout the spectrum

of the disease processKidney Disease Outcomes Quality Initiative, 2000

Chronic Kidney DiseaseProtein is most important factor in nutritional

managementLimiting vs Replacing

Medical Nutritional Therapy GoalsMaintain, improve, and, if possible, restore

normal body composition of somatic proteins and visceral proteins

Prevent or ameliorate uremic toxicity and other metabolic disturbances

A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

Chronic Kidney Disease2000 – Kidney Disease Outcomes Quality

Initiative (KDOQI) GuidelinesStaging

1-5 based on progressively decreasing GFR Dialysis initiated in stage 4

3 main nutritional stratifications for renal diseaseNo dialysisIntermittant (maintenance) dialysisContinuous dialysis

Kidney Disease Outcomes Quality Initiative, 2000

Chronic Kidney DiseaseNo dialysis

Stage 1-3Energy expenditure is similar to equal age

healthy patients 35 kcal/kg/day

Limit protein intake to 0.6-0.75 g/kg/d Decreases nitrogenous wastes and inorganic

compounds Reduces incidence of hyperphosphatemia, uremia,

hyperkalemia, metabolic acidosis


Chronic Kidney DiseaseIntermittent (maintenance) hemodialysis

Stage 4-5Energy expenditure of 35 g/kg/d has been

shown to maintain both neutral nitrogen balance and unchanging body composition

Increased protein requirements due to removal of amino acids, proteins, and macronutrients 1.2 g/kg/day


Chronic Kidney DiseaseContinuous hemodialysis

2 types Peritoneal

Energy requirement is 35 kcal/kg/d Protein requirement is 1.3 g/kg/d

CRRT Energy requirement is 35 kcal/kg/d Protein requirement is 1.5-2.5 g/kg/d


Chronic Kidney Disease Diet recommendations

Fluid restrictionElectrolyte restriction

Sodium, potassium, phosphorus, magnesiumDetermine protein needsProvide adequate calories to meet demand

Chronic Liver Disease Protein-calorie malnutrition is very prevalent in the

cirrhotic populationPro-inflammatory cytokines suppress appetiteEarly satiety from gastric compression due to ascitesDysguesia and nausea from toxic metabolitesAccelerated starvation

Fat is preferred fuel source, so protein is broken down for gluconeogenesis and other biochemical pathways

Malabsorption Bile salt deficiency and protein losing enteropathy

Protein loss from paracentesisPoor diet


Chronic Liver Disease Goals of Medical Nutrition Therapy

Prevent protein-calorie malnutrition by slowing or stopping catabolism

Attain optimal glucose controlCorrect and prevent vitamin and mineral

deficienciesImprove hepatic function and promote

regeneration by: Reversal of encephalopathy Reduction of ascites and edema Correction of electrolyte abnormalities

Prepare for transplantation if necessary A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

Chronic Liver DiseaseEnergy requirements

25-35 kcal/kg/d 120% if patient is cachectic

Add 10% if patient has ascitesProtein requirements

0.5-0.7 g/kg/d and increase to 1.5g/kg/d if tolerated Ideally, protein should be high in branched chain amino

acids and low in aromatic amino acidsFluid restrictions

1000-1500 ml/dayLimit sodium to 2ooomg/dayFat soluble vitamin replacement


PancreatitisMild disease can be managed with pancreatic rest,

IVF, and analgesia with a rapid return to PO intake20% of pancreatitis cases are severe

Mean length of stay in hospital is 1 monthUp to 30% mortality

Factors contributing to malnutritionIncreased energy requirement due to physiologic stressReduced PO intake due to abdominal pain, nausea,

paralytic ileusIncreased nutrient loss from malabsorptionPoor diet and physiologic reserve


PancreatitisMainstay of treatment was NPO, NGT, and TPN

Pancreatic rest vs Bowel rest 30-50% incidence of infection with severe pancreatitis Increased incidence of bacterial translocation with bowel rest

Factors that effect pancreatic stimulationNeural

Vagus nerveChemical

Protein, lipid, carbohydrate, gastric acidMechanical

Distention of the gastric wall and duodenumHormonal

Gastrin, secretin, VIP, CCKMcClave SA . J Parenter Enteral Nutr. 2006;30(2)

PancreatitisKey points in management

Identify the severity of pancreatitis APACHE II or Ranson criteria

<9 or <2 will likely not need nutritional supportDuration of ileus

Enteral nutrition is tolerated by > 50% of patients if ileus is <5 days in duration

Obtaining enteral access Must be placed at or below the Ligament of Treitz

Traditionally used fluoroscopy or endoscopy Newer beside modalities available

Using a peptide-based or elemental tube feed will decrease the physiologic stress to breakdown the formula


Enteral vs Parenteral Nutrition in Acute Pancreatitis

McClave SA. J Parenter Enteral Nutr. 2006;30(2)

Critical IllnessMalnutrition incidence as high as 40% in ICU

Actual vs Perceived Benefits of providing adequate nutrition

during critical illnessSupports anabolism and prevent catabolism

Maintain a positive nitrogen balanceMaintain immune systemDecrease LOS, decreased ventilator days, and

decreased overall mortality

Woo. Nutr Clin Pract. 2010;25(2)

Critical IllnessMetabolic Response to Critical Illness

Hypermetabolism Increased energy demands Protein catabolism exceeds rate of protein synthesis

Increased proteolysis for amino acids used in gluconeogenesis

Hyperglycemia Insulin resistance from stress and increased

gluconeogenesis from counter regulatory hormonesReduction in energy stores

Increased lipolysis for glycerol and free fatty acidsA.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

Long CL. J Parenter Enteral Nutr. 1979;3(6)

Critical IllnessGoals of Medical Nutrition Therapy

Provide adequate calories to prevent catabolism Over- and underfeeding can have adverse effects Calculations

25-30 kcal/kg/d Harris Benedict with appropriate stress factors Ireton-Jones

Measurements Indirect Calorimetry

Provide enough protein to keep in positive nitrogen balance 1.5 g/kg/d for most

2 g/kg/d for severe stress, trauma, burns 24hr urine urea nitrogen collection for direct measurement

Early initiation of nutrition (within 48 hours)Enteral > Parenteral route A.S.P.E.N. Nutritional Support Practice Manual.

2nd ed.

Recap of Medical Nutrition TherapyDiabetes Mellitus

Carb counting, weight loss, lipid reductionChronic Kidney Disease

Decrease protein early, increase protein lateFluid and electrolyte restriction

Chronic Liver DiseasePrevent PCM my providing adequate calories

and low aromatic proteins high in BCAA

Recap of Medical Nutrition TherapyPancreatitis

Enteral=Good, TPN=BadMust be trans-jejunalElemental formula better

Critical IllnessProvide adequate energy to meet physiologic

demandsProvide adequate protein to maintain positive

nitrogen balanceEarly initiation of enteral nutrition better than

TPN

Questions

Kristopher R. Maday, MS, PA-C, CNSCAssistant ProfessorUniversity of Alabama at BirminghamSurgical Physician Assistant Program1530 3rd Ave South, SHPB 466Birmingham, AL 35294-1212Telephone: [email protected]

Special topics in nutrition

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