Theme Topic Pg Nutrition Using Biochemical Data to Assess Malnutrition 1 Support and Drugs and Interactions 2 Assessment Estimating Requirements 3 Food Fortification 4 Continuous Enteral Feeding 5 Bolus Enteral Feeding 6 Enteral Nutrition - Troubleshooting 7 Central Parenteral Nutrition (custom) 8 Peripheral Parenteral & Osmolarity Calcs 9 Managing Electrolytes 10 Refeeding Syndrome 11 Gastroenterology IBS and Coeliac Disease 12 Inflammatory Bowel Disease 13 Gastro-oesophageal Reflux and Gastroparesis 14 Pancreatitis and Liver Diseases 15 Diverticular, Malabsorption and Intestinal Failure 16 Renal Chronic Kidney Disease 17 Renal Replacement Therapies 18 Neuroscience Stroke Rehab 19 Parkinson’s Disease and Spinal Cord Injury 20 Oncology Cancer Treatments 21 Symptom Management 22 Cachexia 23 Diabetes and Diabetes and Insulin 24 Obesity Diabetes Drug Treatment and Observations 25 Obesity and Weight Loss 26 Paediatrics Autism and Food 27 Infant Feeding 28 Neonates and Growth 29 Cow’s Milk Allergy 30 Gut Problems and Deficiency 31 Miscellaneous Metabolic Disorders 32 Medical Critical and Intensive Care 33 Dietary Barriers Surgical 34 Swallowing and Dysphagia 35 The IDDSI Framework 36 Cultural and Religious Diets 37 Consulting Consultation Structures 38 Placement advice, conversions, and templates 39+ 1 Using Biochemical Data to Assess Malnutrition Basic Bloods Species Dietetic Relevance (use local ranges) Notes CRP Is the patient hypermetabolic? Urea or IL-1 can help ▪ Identify stress Level confirm a translation ▪ Helps identify cause of low Alb/Hb/Tf to protein breakdown Albumin Negative acute phase protein indicates invalid if CRP is high nutrition/hydration. Blood Urea High – dehydration, low – overhydration Also affected by AKI (where Creatinine is normal) and CKD. Will be high May indicate of high protein metabolism. in first 2 weeks of fast White Cell Similar interpretation to CRP – Count immunological stress Look for trends over time, and don’t rely on biochemical data in isolation. See also electrolytes (pg10). TLC, albumin, Hb, and RBP are unsuitable markers of nutrition. Species Deficiency Homeostasis Stressors Test Notes Sources Fe Anaemia GI absorption Blood loss, Ferritin toxicity risk Animal Poor growth exercise >12mcg Invalid if ↑CRP veg w/ Vit-C Zn Immune GI absorption Fistulas, ZnSo4 toxicity risk (Cu) Red meat, Skin rash Faecal loss diarrhoea /Serum Invalid if ↑CRP Flour Cu Neutropenia Lost in bile Biliary Caerulo- Zn-induced Greens, Myelopathy fistula plasmin Invalid if ↑CRP Fish Se Immune Nephrological Exercise, Plas-Se/ High Animal Arrhythmia smoking GTperox toxicity risk US-food I Dental caries Nephrological Pregnancy, TSH Def. with CF Milk, Hypothyroidism lactation Invalid if ↑CRP Seafood Species Deficiency Homeostasis Stressors Test Notes Sources Vitamin Dark Adaptation Poor. Good Unknown Liver Falls during APR Carrots, A Immune liver stores retinol (RBP) milk, eggs Vitamin Osteomalacia Poor. BP Critical 25OHDx High toxicity risk Sunlight, D Immune observed illness (supplements) fish, milk, Vitamin Beriberi Nephrological Critical ETK Rapid deficiency Cereals B1 Immune illness Alcoholism Vitamin Lesions on lips, Nephrological Critical Urinary Causes B3,6,9 Milk, eggs, B2 tongue, skin illness B2 deficiencies vegetables Vitamin Pellagra Nephrological Critical Serum Alcoholism Meat, fish, B3 Weakness illness B3 cereals Vitamin Pancytopenia (PN) Nephrological Unknown Serum ↑ Zn deficiency Green B9 High homocysteine B9 B2 & B12-induced vegetables Vitamin Megaloblastic-An Extensive liver Unknown Serum Gastrectomy or Milk, yeast B12 Weakness stores. 3-20yrs B12 reduced HCl NB: metabolic stress normally causes a general increase in micronutrient demands. Placement Pack University of Surrey Dietetics Society | December 2020 2 Common Drugs and Interactions Some Common Drugs Analgesics – Pain reduction: *Aspirin, Celecoxib, Co-codamol, Codeine, *Diclofenac, Dihydrocodeine, *Etoricoxib, Fentanyl, Gabapentin, *Ibuprofen, *Indomethacin, Ketamine, *Mefenamate, Morphine, *Naproxen, Nefopam, Oxycodone, Paracetamol, Tramadol. Antiarrhythmics – Adenosine, Amiodarone, Atenolol, Bisoprolol, Digoxin, Diltiazem. Antibiotics – Amoxicillin, Ceftazidime, Cefuroxime, Cephalexin, Ciprofloxacin, Clarithromycin, Clindamycin, Co-amoxiclav, Doxycycline, Flucloxacillin, Gentamycin, Levofloxacin, Meropenem, Nitrofurantoin, Piperacillin, Trimethoprim, Vancomycin. Anticoagulants – Apixaban, Enoxaparin, Funderparinex, Heparin, Rivaroxaban, Warfarin. Anticonvulsants – seizures: Carbamazepine., Clonazepam, Diazepam. Lorazepam, Gabapentin, Levetiracetam (Keppra), Phenytoin, Sodium valproate (Epilim). Antidepressants – Amitriptyline, Fluoxetine, Mirtazapine, Sertraline, Venlafaxine, Citalopram. Antiemetics – anti-nausea: Levomepromazine, Metoclopramide, Ondansetron, Prochlorperazine, Cyclizine. Antihypertensives – Amlodipine, Atenolol, Bisoprolol, Candesartan, Diltiazem, Doxazosin, Lisinopril, Losartan, Nifedipine, Ramipril. Antihyperglycemics – Glicazide, Insulin, Metformin. Bronchodilators – Ipratropium, Theophylline, Tiotropium, Salbutamol. Diuretics – AmilorideS, BendroflumethiazideW, BumetanideW, FurosemideW, IndapamideW, SpironolactoneS. Statins – Atorvastatin, Simvastatin, Pravastatin. Laxatives – Bisacodyl, Glycerine Suppositories, Microlax Enema, Movicol, Phosphate Enema, Senna, Sodium Docusate, Lactulose PPIs – Esomeprazole, Lansoprazole, Omeprazole, Ranitidine (H2 R-blocker), Peptac. Some Common Drug-Nutrient Interactions Drugs Interactions Drugs Interactions ACE-inhib. (-pril) ↓ Zn Levodopa ↓ amino acids ↓ Vit-B6 Antacids ↓ micronutrients esp. B12 Levothyroxine give IV, not EN. monitor TSH Antibiotics ↓ taste ↓ Vit-B, Divalent ions Metformin ↓ appetite Anticonvulsants ↓Vit-D Methotrexate ↓ folate (give 1 day after) Antipsychotics ↓ riboflavin Mirtazapine ↑ appetite Barbiturates ↓ ascorbate NSAIDs* ↓ appetite ↑ diarrhoea Benzodiazepines ↓ Ca Oestrogens ↓ pyridoxine, folate Captopril ↓ appetite↓ taste Orlistat ↓ fat ↓ fat-soluble vitamins Co-trimoxazole ↑ K esp. in TPN PPIs ↓ gastric acid ∴ ↓ Vit-B12 Ciprofloxacin Do not use with milk Phytosterols ↓ cholesterol Chlorpromazine ↑ nausea Phenytoin Do not give enterally Corticosteroids ↑ appetite Progesterone ↑ appetite Digoxin ↓ electrolytes Retrovirals Avoid with high-fat meals Diuretics (K-S) ↓ folate ↑ K SSRI’s ↓ appetite ↑ dry mouth ↓ Vit-B9 Diuretics (K-W) ↓ K ↓ Zn Serotonin ↓ nausea Gentamicin ↓ electrolytes Spironolactone ↓ appetite Hypoglycaemics ↓ Vit-B9 ↓ Vit-B12 Statins ↓ CoQ10 Insulin ↑ appetite Warfarin Limit Vit-K. rest EN 1hr - & + Isoniazid must supp. Vit-B6 Xenical ↓ fat ↓ fat-soluble vitamins Placement Pack University of Surrey Dietetics Society | December 2020 3 Estimating Energy/Protein Requirements Find body mass and BMI (kg/m2). Consider clinical condition (stress). Adjust mass for ascites/oedema. protein g/kg (nitrogen g/kg). NB: Very high protein diets may warrant Vit-B6 supplementation. Placement Pack University of Surrey Dietetics Society | December 2020 4 Food Fortification Patient food fortification tips: - Eat ‘little and often’ during the day e.g. 3-4 meals and snack in-between. - Indulge in the foods you fancy - opt for the full-fat versions. - Fry or roast foods instead of grilling or boiling them. - Consider ready meals or a delivery service as an alternative to cooking. - Stock basic food items in case you are unable to get to the shops. - Try the 1,2,3 approach: 1pt fortified milk, 2 snacks, 3 food boosters per day. Fortified Milk 4tbsp dried milk powder + 1 pint of whole milk. Mix the powder with a . small amount of milk to make a paste and then whisk in the rest. This adds 140kcal without affecting flavour or volume. Adapted from resources produced by Western Sussex Hospitals Dietitians. Placement Pack University of Surrey Dietetics Society | December 2020 5 Continuous Enteral & Fluid Restriction Continuous can be preferential as smaller amounts of may be better tolerated and feeding overnight allows more time to eat during the day. It may also be easier to meet micronutrient requirements than with bolus feeding. Placement Pack University of Surrey Dietetics Society | December 2020 6 Bolus Enteral Nutrition Placement Pack University of Surrey Dietetics Society | December 2020 7 Troubleshooting (Enteral Nutrition) A full nutritional assessment should be carried out at least monthly in the community and biweekly in an acute setting. In children and critical groups, weekly. Symptom Possible Cause Possible Solution Diarrhoea Malabsorption Change to a hydrolysed feed. High feed osmolarity Use less dense formula or increase gradually. Intolerance of bolus feeds Smaller more frequent boli or use continuous feeding. High infusion rate Slow infusion rate (35-50ml/hr) and increase as tolerated. Drugs (antibiotics, Review drug prescriptions laxatives) Nausea/vomiting High infusion rate Slow infusion rate (35-50ml/hr) and increase as tolerated or trial continuous. Slow gastric emptying Consider prokinetics or jejunal feeding, or reduce fibre. Psychological factors Address behavioural issues, recommend referral to a psychologist if appropriate. Medicines are given at the Allow time between giving same time as feeds medicines and feeds. Constipation Gastric motility Trial fibre increase. Drugs Review drug prescriptions. Regurgitation or Gastro-oesophageal reflux Correct position, anti-reflux aspiration drugs, feed thickener, continuous infusion, post-pyloric feeding. High infusion rate Slow infusion rate (35-50ml/hr) and increase as tolerated. Intolerance of bolus feeds Smaller more frequent boli or use continuous feeding. Abdominal pain Fibre feed (critical/intensive Possible gut ischaemia which Leucocytosis, care) can cause sepsis. Remove from tachycardia, fever. fibre feed and report to MDT. Adapted from PENG pocket guide to clinical nutrition (3rd Ed) Placement Pack University of Surrey Dietetics Society | December 2020 8 Parenteral Nutrition, Custom Formulae Non-custom PN may be calculated similarly as shown for EN. However, custom formulae (separate bags) allow a feed to be more specific to protein targets. Remember to monitor and subtract any other intakes from targets (oral, IV). -- SmofKabiven bags are now popular as the mixed lipid profile shows benefits. 10kcal/g lipid is based on a high-MCT formula. 3.4kcal/g is standard for dextrose. To calculate TPN using custom bags: Writing the regimen (trusts will differ in layout preferences) PN volume (ml)________ Bag type__________ Infusion rate (ml/hr) ____________ Amino Acids (g) or as energy (kcal) or as volume (L)__________ Dextrose (g) or as energy (kcal) or as volume (L)___________ Lipids (g) or as energy (kcal) or as volume (L)___________ Total energy (kcal)_________ Micronutrients? Y/N Total fluids (L)_________ Placement Pack University of Surrey Dietetics Society | December 2020 9 Peripheral PN & Osmolarity Peripheral feeding is usually short-term. Dilute solutions with greater lipid content may be used to avoid the infiltration of feed into extravascular tissues. Two factors govern infiltration risk: osmolarity and rate of infusion. A higher energy target would normally mean increasing either feed density or infusion rate. In PPN, both opportunities are very limited. Therefore, it may not be possible to meet targets. Feeds must not exceed 900mOsm/L and no more than 2L/24hr may be infused. Calculating Osmolarity: Species Factor Dextrose (g) x5 = ___ mOsm/L Amino Acids (g) x 10 Lipids (g) x1.5 Add electrolytes from solution (1mmol/L of any compound =1mOsm/L). Example: 20mmol/L NaCl + 5mmol/L KCl + 20mmol/L K3PO4 = 45mOsm/L (The sum of electrolytes, vitamins, and minerals may be displayed on the PN datasheet. If data is unavailable, 350mOsm/L can be used as an estimate.) Placement Pack University of Surrey Dietetics Society | December 2020 10 Electrolyte Management Species K+ PO43- Ca2+ Mg2+ Serum Range 3.5-5.0 mmol/L 0.7-1.5mmol/L 2.15-2.55mmol/L 0.7-1.0mmol/L Homeostasis Colonic (short Nephrological, Hormonal, very good. Nephrological term) & intestinal, bone Rarely disturbed. nephrological Effects of a Nausea, GI Confusion, Tetany, seizure, Common in ICU hypo issues, respiratory weakness, ataxia hyporeflexia Tetany, seizure, failure arrhythmia, hypo K Cause of a -Refeeding -Refeeding -Resp. alkalosis -Refeeding hypo -Insulin admin -Diab. KA -Vit-D deficiency -Diab. KA -Diarrhoea -Insulin admin -Blood transfusion -Malabsorption -Laxative abuse -Alcoholism -Mg depletion -Alcoholism -K-wasting meds -Renal Repl. -Renal problems -GI loss, fistulas -Mg depletion -malabsorption -PPIs. -Renal loss, meds Interventions -Oral suppl. (KCl) -Oral (K-) IV in preference as % -IV in preference as to a hypo -IV suppl. (KCl) -IV suppl. GI absorption is low GI toxicity can occur. -Review meds -Review meds at high doses. 0.5-2mEq/kg 10-15mEq/day Effects of a ECG changes, Anorexia, nausea, Nausea, vomiting, Nausea, flushing, hyper respiratory failure calcification ileus, hypotension, depression, confusion, coma weakness Cause of a -Renal clearance -Renal clearance -Hyperparathyroidism -Renal clearance hyper -Haemolysis -Cell lysis -Malignancy -Dehydration (bleeds, injuries) (tumour, injuries) (osteolytic) -Trauma/stress -K-sparing meds -Excess sources -Vit-D toxicity (rare) -High intake Interventions -Removal of K -Removal of PO43- -Loop diuretics -Reduce sources to a hyper from IVs - PO43- binders -Calcitonin -Review antacids -Review meds (CaCO3) -Remove excess -Loop diuretics? -Exchange resins -Consider renal Ca/Vit-D -Renal Repl. (GI reabsorption) formula -IV-Ca Low serum albumin can generate a misleading total Ca score. To correct for low albumin (<40g/L). Use the equation: Na+ (133 - 146 mmol/L) Placement Pack University of Surrey Dietetics Society | December 2020 11 Refeeding Syndrome (RFS) Refeeding syndrome occurs when patients are fed for the first time after a prolonged period. In this situation, the respiratory substrate shifts from predominantly fat (in starvation) to predominantly carbohydrate (fed state). Those at risk are commonly post-surgical patients or those suffering from restrictive eating disorders. The sudden increase in central metabolism causes electrolytes (K+, PO43-, Mg2+) and thiamine to enter respiring tissues from the blood following a sudden increase in cellular utilisation. These shifts leave blood values dangerously low and risk cardiac and respiratory failure, coma, and death. It is important to identify those at risk and intervene safely and continuously monitor those most at risk (particularly biochemistry and cardiac rhythm). Identifying risk (Illustrative only, check local guidance) Risk parameter: / Risk level: MEDIUM HIGH EXTREME RISK RISK RISK Very little or no nutritional intake for some days >5 days >10 days >15 days Underweight body mass index <18.5kg/m2 <16kg/m2 <14kg/m2 Unintentional weight loss in last 3 months >5% >10% >15% Low levels of K+, PO43-, and Mg2+ before feeding X X If severe Chronic vomiting, diarrhoea, severe malabsorption Use judgement Safe Intervention Procedure Placement Pack University of Surrey Dietetics Society | December 2020 12 Irritable Bowel Syndrome Recurrent abdominal pain and changes in stool output associated with specific foods. It is caused by hypersensitivity to visceral distension, particularly in the colon. Common triggers: high-fat foods, spices, caffeine, and alcohol. Eliminate Lactose intolerance and Coeliac Disease. Coeliac Disease GI inflammation and a high immune response to gluten. Similar symptoms to IBS may be present before diagnosis. Low Fe, B9, B12 are common due to malabsorption. Characterised by dysfunctional intestinal villi. A small intestine biopsy image, where villi are visibly atrophic due to Coeliac Disease. Most patients respond well to a gluten-free diet. If unresponsive, consider re- diagnosis or trailing the FODMAP diet. Gluten-containing foods show wheat, barley, rye, spelt, or oats* as ingredients. *Oats are gluten-free but are often contaminated with wheat during processing. Educate the patient on label-reading and ensure they consider food batter, couscous, pasta, muesli, sauces, and beers. Placement Pack University of Surrey Dietetics Society | December 2020 13 Inflammatory Bowel Disease IBD is a set of complex disorders where parts of the GI tract are inflamed and damaged by T-cell overstimulation and cytokine release. Mucous production and gut permeability become compromised and malabsorption may follow with the loss of gastric and pancreatic secretions. Diseases include: Ulcerative colitis - Localised within the colon and affects the mucosa only. Crohn’s disease - Usually ileum/colon (can be anywhere). Can perforate all tunics. Symptoms of dietetic concern are diarrhoea, blood loss from the GI tract, pain, cramps, bloating, fistulas, mouth ulcers, and anaemia (linked to blood losses). These change during fluctuation between inactivity (remission) and activity (relapse). Nutritional Consequences IBD causes hypermetabolism so estimate requirements accordingly. This, alongside Symptom-associated appetite suppression and malabsorption, makes protein-energy malnutrition very common. Micronutrient deficiencies are also prevalent, B-vitamins notably so. Consider in conjunction with absorption sites as shown on page 1. Medical Interventions Often, the medical intervention includes providing immunomodulating immunosuppressants such as methotrexate which suppress systemic activity, or biologic immunosuppressants which act specifically on overactive helper T cells to reduce inflammation. These include Stelara, Entivyo, Humira, and Infliximab. This intervention may replace exclusive enteral nutrition with a hydrolysed formula (for adults), which shows benefits for less clear reasons. This is still recommended by ESPEN and others but is not favoured by NICE except in children. Dietetic Interventions Alongside drug therapies, the purpose of dietetic intervention is to: (1) manage symptoms (2) reduce malnutrition (3) extend remission periods. Whilst hydrolysed (elemental) enteral nutrition is still a valuable option in reducing malnutrition, healing the mucosa and inducing remission, the focus is shifting to the use of specific dietary components to manage symptoms long-term. An elimination diet may be useful to identify dietary triggers, which may be high-fibre, low-fibre, or specific foods such as dairy, wheat or soya. A potentially useful diet is ‘low fat, fibre limited exclusion’ (LOFFLEX). 50g fat and 10g fibre are permitted each day in a 2-4-week trial. This results in a diet high in white bread, rice, lean meat, skinless vegetables, and most fruits. High fibre diets, including vegan diets, may help to maintain remission and reduce lesions of the intestinal mucosa, associated with the resultant short-chain fatty acids. However, this will not be suitable for all patients and is contraindicated in those with strictures, where a low fibre diet and a mashed diet is required. Placement Pack University of Surrey Dietetics Society | December 2020 14 Gastro-oesophageal Reflux Disease (GORD) Characterised by inappropriate relaxation of the lower oesophageal sphincter, causing pre- chyme to reflux into the oesophagus, causing ‘heartburn’ and damaging the oesophageal mucosa, causing erosive oesophagitis. GORD is common, present in 10% of older people. Reflux is triggered by gastric distension in those with GORD. advice is normally to eat smaller meals (‘little and often’), to eat slowly to avoid excess air intake, and to leave at least four hours after a meal before lying down. GORD is correlated with energy intake and is more prevalent in obesity. Fruit juice, alcohol, coffee, and carbonated drinks are often avoided by GORD patients as they may exacerbate reflux risk. Calcium supplementation may increase reflux through proton pump stimulation, this diminishes when CaCO3 is used as a gastric acid neutraliser. Gastroparesis Gastroparesis describes delayed gastric emptying without mechanical obstruction, due to dysfunction of the Cajal (pacemaker) cells of the stomach or of the vagus nerve. It is common in diabetes (diabetic neuropathy) but may also be idiopathic or neurological (pg20). In those with gastroparesis, more than 60% of food remains in the stomach after 2 hours. Patients present with chronic nausea and vomiting, malnutrition, and postprandial fullness. Dietetic intervention should manipulate food volume, content, and consistency to ease gastric emptying. It is often useful to use prokinetics, and possibly implantable pacemakers as a medical treatment alongside this. Placement Pack University of Surrey Dietetics Society | December 2020 15 Pancreatitis Adapted from text from Advanced Nutrition and Dietetics in Gastroenterology (BDA, 2015) Liver Diseases Western diet variables and central adiposity are associated with many types of liver disease. Other diseases have viral or genetic origins. Early-stage liver disease does not normally warrant any specialist dietetic input, but the metabolic changes of end- stage liver disease, Cirrhosis, present additional and unique challenges. Infections Hepatitis A, B, C, D, E Metabolic NAFLD, steatohepatitis Toxic Alcohol-related liver disease, Vascular Budd-Chiari syndrome drug overdose Cholestatic Primary biliary cirrhosis, primary Other Cystic -fibrosis-related liver sclerosing cholangitis disease, autoimmune hepatitis, cryptogenic liver disease Cirrhosis of hepatic tissue is synonymous with an inability to store and release glycogen normally. Gluconeogenesis from amino acids compensates for this loss. Regular snacks, including 50g CHO before bed, can avoid further protein catabolism. In cholestatic disease, malabsorption of fats and vitamins causes steatorrhea and calcium malabsorption. IV supplementation of micronutrients may be indicated. Jaundice (secondary to cirrhosis) can cause taste changes and appetite suppression, and further malnutrition – consider alternative ONS. Removing dietary alcohol can the most valuable change in both alcohol-induced cirrhosis and other causes – the decrease in acetaldehyde stimulates collagen synthesis and thus decreases further fibrosis of hepatic parenchyma. Placement Pack University of Surrey Dietetics Society | December 2020 16 Diverticular Disease & Diverticulitis Diverticula are herniations usually of the sigmoid colon, through the circular muscle. They are thought to be linked to high colonic luminal pressure, commonly due to a very low-fibre and very high meat diet. This slows stool output and increases water resorption, causing high pressure at the sigmoid and lower descending colon. When a diverticulum starts showing symptoms, it is classed as diverticular disease. If it becomes inflamed/ infected, this is diverticulitis. Malabsorption Malabsorption has various causes and it is said causes which must be addressed. It may be described as either a digestive or absorptive failure, and either specific (one nutrient/system) or general (multiple primary effects). General Malabsorption Selective Malabsorption Digestive Loss of pancreatic function e.g. lactose intolerance, micronutrients for Failure Pancreatectomy, chronic those on PPIs, inborn errors (e.g. pancreatitis, cystic fibrosis. acrodermatitis enteropathica). Absorptive Small bowel resection, coeliac Bile acid malabsorption, steatorrhoea, Failure disease, and allergies which Inflammatory Bowel Disease, fructose causes intestinal inflammation (GLUT5) malabsorption. These diverse conditions have in common a spectrum of symptoms: painful bloating, flatulence, and stool changes – caused by unabsorbed nutrients passing to the colon and undergoing microbial fermentation. The condition of steatorrhoea (pale stools) is caused specifically by failure of fat absorption, caused by conditions limiting fat absorption, or drugs such as Orlistat. Intestinal Failure Acute - Type 1 <28 days, self-limiting (ileus – short term PN). Acute - Type 2 > 28 days, trauma, fistula, sepsis, after GI resections. (TPN). Chronic – Type 3 irreversible, large resections, (requires home TPN). Small bowel losses and actions: >100cm jejunum + colon = possible oral / EN with or without supplements 50-100cm jejunum + colon = possible oral / EN with supplements <50cm jejunum + colon = TPN only Placement Pack University of Surrey Dietetics Society | December 2020 17 Chronic Kidney Disease Chronic Kidney Disease (CKD) is characterised by stages of worsening nephrological function. A Glomerular filtration rate (GFR) of <60ml/min signifies a kidney disorder (CKD if for >90 days). Serum creatinine levels increase during such kidney disorders. Tracking creatinine is a useful marker for kidney function and may be extrapolated to estimate GFR (eGFR). Be aware that creatinine is also effected by muscle mass (pg1), sex, and ethnicity. Nutritional Problems in Chronic Kidney Disease Protein-Energy Wasting (PEW), seen in CKD patients, describes a combination of inflammation, metabolic acidosis, regulatory changes, and nutrient losses. This can cause significant protein loss. Death rates are 4x higher for such malnourished patients. . In stages 4-5, uraemia (high blood urine) causes nausea and taste changes, exacerbating protein-energy wasting. From stage 4, hyperphosphataemia can lead to hyperparathyroidism and soft tissue calcification. . Chronic Kidney Disease-Mineral Bone Disorder (CKD-MBD) As GFR decreases, serum phosphate increases, decreasing vitamin D synthesis and thus calcium absorption and serum calcium levels. Addressing these electrolyte abnormalities requires greater parathyroid hormone (PTH) and cause bone loss. Limiting dietary phosphorus (without compromising protein intake) is key to slow this development and improving bone mineral outcomes. Commonly, phosphate binders (Ca-acetate) and Vitamin D supplementation are also indicated. Dietary K may not need to be reduced except in chronic hyperkalaemia. Placement Pack University of Surrey Dietetics Society | December 2020 18 Renal Replacement Therapies Haemodialysis (HD): The main mode of dialysis. Excess water and urea are pass through a synthetic membrane and are removed in the dialysate, and electrolyte and acid-base balance is restored. Of potential dietetic concern, glucose, amino acids, and micronutrients may also be removed. HD patients are likely to need dietary electrolyte restrictions and may experience moderate fatigue on dialysis days. Peritoneal Dialysis (PD): A sterile solution is infused into the peritoneum, which then acts as the dialysis membrane. After a set time, the fluid is removed and replaced. PD patients usually require fewer dietary restrictions than HD patients. Protein requirement for HD/PD patients (in the absence of other disease) ≈ 1.15g/kg. No deviation from traditional energy formulae is required. Consider B-complex & vitamin C supplementation for dialysis patients even if deficiency is subclinical. Kidney Transplantation: Pre-transplant objectives: Treat obesity, hypertension, PEW, and ensure adequate nutrition to improve outcome potential. . Short term post-transplant objectives: Prevent acute rejection, minimise infection (food and interpersonal hygiene). Nutritional monitoring. A successful kidney transplant allows previous dietary restrictions to be relaxed. Long term post-transplant objectives: preserve renal function, provide adequate (but not excessive) protein at 0.8g/kg/day, and reduce CVD risk. Dietary Restriction Advice: Detailed patient resources from Oxford University Hospitals have been made available at www.ouh.nhs.uk/services/departments/renal/leaflets.aspx including Low potassium, low phosphate, low sodium, and overall meal ideas. Placement Pack University of Surrey Dietetics Society | December 2020 19 Stroke Rehab A ‘stroke’ occurs when blood supply to part of your brain is cut off. There are 2 main types of stroke . Ischaemic: resulting from a blocked blood vessel in the brain. Haemorrhagic resulting from bleeding in or around the brain. People who are obese, diabetic, and have hypercholesterolaemia are more at risk of a stroke due to associated arteriosclerosis. Hypertension is a biomarker for this. Following a stroke, patients may have limited cognitive and emotional functioning, communication difficulties, vision problems, and/or dysphagia. Dietetics Hydration and Oedema Physical Assessments Stroke patients are at risk of dehydration and overhydration. It is often useful to combine biochemical variables of overhydration (low urea, sodium, albumin) with a physical assessment, checking for oedema. Strokes often lead to oedema in the affected side of the body (opposite side to event) This does not indicate overhydration. Check the other arm/leg for indications of global oedema. Following a stroke, dysphagia, physical and psychosocial issues and increased energy requirements due to metabolic stress can lead to malnutrition. Many patients will require PEG feeding, but you have to assess this individually rather than liberally as some patients improve after a couple of weeks on an NGT. Stroke rehabilitation patients often have difficulty self-feeding and should be provided with physical help (hand-feeding), verbal encouragement, and equipment to encourage safe feeding. Red trays and cups are often used in clinical settings to identify patients requiring assistance with eating and drinking. Placement Pack University of Surrey Dietetics Society | December 2020 20 Parkinson’s Disease Parkinson’s Disease (PD) is a progressive neurological condition where dopamine is lost, impacting control and ultimately inhibiting movement and other functions. Dietetic input is usually required in the context of gastrointestinal problems secondary to PD, such as loss of senses, dysphagia, and delayed gastric emptying. Bone weakening is also common in those with PD, alongside depleted reserves of vitamin D and K. PD can slow the movement of the colon, causing constipation. High fibre menu options (or fibre-containing enteral feeds) may be advisable. Levodopa-Protein Interaction (co-beneldopa, co-careldopa, Sinemet, Madopar) One of the most important medications used to treat PD is levodopa. It acts as a prohormone of dopamine, improving stiffness and slowness of movement. However, levodopa must compete with dietary amino acids for enterocyte absorption. Because of this, it must be taken 60 minutes before protein-containing food. This would also translate into a break in enteral nutrition (but not parenteral). A protein redistribution diet is also worth exploring as a secondary option, where most of the daily protein is taken in the evening outside of important Levodopa-taking times. This is usually only indicated in cases of delayed GI motility. Eating a very low protein snack (such as crackers) with a dose may help to reduce sickness and other side effects. Spinal Cord Injury Spinal cord injuries (SCI) are described by the site of damage. It’s important to consider this as it will impact some of the functional factors affecting nutrition and food intake. Bowel management is difficult in patients with spinal cord injuries. Transit times are reduced and overuse of fibre containing feeds can often increase transit times rather than reducing them. Obesity is more prevalent in those with spinal cord injuries than with other patients. Predictive equations have shown to over‐estimate energy requirements by approximately 10% following spinal cord injury. An adjusted Body Mass Index (BMI) of 22 kg/m2 and 25 kg/m2 to classify overweight and obesity respectively should be used. Weight loss rate should be 0.5 to 1 kg per week for the first 6 months and should aim to achieve an initial weight loss goal of up to 10% from initial body weight. Pressure sores are more likely in SCI patients. Adequate protein and fluid intakes have shown to be key in SCI centre audits. Placement Pack University of Surrey Dietetics Society | December 2020 21 Cancer Treatment Cancer is a consequence of genetic mutations which result in the production and growth of abnormal cells. It may be inherited or can be a result of lifestyle and environmental factors. The primary (original) tumour may spread via blood or lymph to other tissues to cause secondary tumours (metastases). The TNM staging system is widely used in hospitals for cancer reporting as it indicates the stage, size and if the tumour has spread: . T to the size of and extent of the main tumour (ranges from 1-4) N refers to the number of nearby lymph nodes that have cancer. M refers to whether the tumour has metastasized. . Radiotherapy . Radiotherapy (RT) uses high energy ionising radiation, usually with curative intent. RT can be given externally or internally (brachytherapy, radioisotope therapy). Treatment length can vary from one single fraction (individual radiation treatment) to 6-7 weeks of five fractions per week. . Common side effects include taste changes, swallowing difficulties, dry mouth, sore mouth and throat, mucositis (painful inflammation and ulceration of the GI tract, including the mouth), nausea and/or vomiting, diarrhoea. . Symptoms can vary depending on the site of RT: head and neck area will affect the ability to eat and swallow, pelvic area results in abdomen cramps and diarrhoea. As RT treatment progresses, there is an increased risk of morbidity and quality of life. . Chemotherapy: . Chemotherapy involves using cytotoxic drugs to destroy cells. These disrupt the way cancer cells grow and divide, but they also affect normal healthy cells. Chemotherapy can be given as oral tablets, a bolus, continuous intravenous infusion, intramuscular/subcutaneous/ intrathecal injections or as a combination. Combinations of cytotoxic drugs are often used toxicity can continue to build up to 1- 2 weeks post-chemotherapy treatment. . Common side effects include loss of appetite, anorexia, a sore mouth, taste changes, mucositis, constipation, diarrhoea, nausea and/or vomiting. Note: Cytotoxic drug-nutrient interaction: Methotrexate and vitamin B9 – Folic acid supplementation advised (BNF) to prevent methotrexate-induced adverse effects. Placement Pack University of Surrey Dietetics Society | December 2020 22 Symptom Management Dry Mouth Frequent sips of fluids throughout the day. (Xerostomia) Try sucking ice cubes or ice lollies. Keep foods moist by adding sauces & gravies. Ask GP to prescribe mouthwashes, lozenges, artificial saliva sprays. Taste Changes If a food is unacceptable, try again after 1-2 weeks as taste may have changed. Use seasonings, spices and herbs to flavour foods. Carbonated drinks may be easier than other fluids Mucositis Effective pain control at appropriate times to avoid compromising food intake. Appropriate mouthcare (brushing with a soft toothbrush at least twice per day, rinse with warm water during the day). Eat soft, moist foods by adding sauces, gravy, custard etc. Mash or liquidise foods. Avoid dry or rough-textured food e.g. toast, crisps, raw veg (Broccoli, cabbage, spinach, cauliflower, Brussels sprouts, peas, beans, sweetcorn, onion and radish are commonly reported hardest to swallow). Avoid very hot, spicy, or salty foods and acidic/ tart beverages. Coughing or Have foods with sauces and gravies. swallowing Finely chop meat and vegetables, make casserole and stews difficulties Cut crusts off bread Liquidise foods if easier to manage Some home delivery companies offer a soft-food range. ONS Tiredness Use convenience meals – ready meals, canned food, frozen pre-prepared meals, food delivery service. Support from family, friends, neighbours with cooking and shopping if possible. If pt doesn’t want to eat, suggest nourishing drinks/soup options and fortify these. Constipation Gradually increase fibre intake (if appropriate). Aim to have 8-10 cups of fluid per day. Gentle exercise such as walking if possible. Laxatives may need to be considered if a symptom is severe. Diarrhoea Reduce amount of dietary fibre until symptoms settle. *Note – Dietary Avoid fatty and spicy foods, alcohol change won’t help Drink 8-10 cups of fluid per day to prevent risk of dehydration. if side effect of RT. Nausea and/or Avoid spicy, greasy, fried, strong-smelling foods. vomiting Cold or room temperature foods may be easier to tolerate. Sip cold or chilled fluids, ice-lollies or ice cubes. Replace electrolytes lost from vomiting with energy drinks, fruit juice and salty drinks e.g. Bovril. Eat in a well-ventilated room, Get some fresh air before eating. Placement Pack University of Surrey Dietetics Society | December 2020 23 Cancer Cachexia Cancer cachexia describes an altered metabolic state seen in 50-80% of cancer patients. It is characterised by an ongoing loss of skeletal muscle mass despite conventional nutritional support. The main features include weight loss, anorexia, asthenia and anaemia. Cancer tumour growth leads to loss of muscle due to tumour- related inflammation. Amino acids are diverted from skeletal muscle maintenance and towards synthesis acute-phase proteins such as CRP. Also, increased anaerobic respiration and gluconeogenesis cause an increase in energy-inefficient lactate cycling (Cori Cycle). Alongside skeletal muscle loss, cachexia may also cause anorexia and stimulate other catabolic pathways, such as glucose metabolism and lipid mobilisation. Although conventional nutrition support cannot treat or reverse cachexia, nor improve patient outcomes, it still indicated if the cachexia is compounded by malnutrition. This is common as a result of anorexia and depression. Several drug treatments may be used, such as prokinetics and corticosteroids that induce gastric emptying increase appetite respectively, encouraging greater food intake. Increasing protein intake to up to 2g/kg/day may subdue some aspects of the pathology, but more evidence is needed to roll out this recommendation to all patients. Supplementing n-3 fatty acids is also a possible intervention, as this may increase anti-inflammatory activity and decrease the effects of cachexia. Whilst this is safe, success is varied and as with protein, wide-scale recommendations are currently tentative. Placement Pack University of Surrey Dietetics Society | December 2020 24 Diabetes and Insulin Absorption of carbohydrate-containing food leads to an increase in blood glucose and consequently insulin production, allowing glucose to be absorbed into cells and returning blood glucose to a baseline of 3.5-5.1mmol/l. In diabetes, however, less or no insulin is produced (type 1 diabetes) or insulin is ineffective due to insulin resistance and beta-cell insufficiency (type 2 diabetes) leading to hyperglycaemia. Blood tests can indicate impaired glucose tolerance (pre-diabetes) or diabetes. Pre-diabetes Diabetes Fasting blood glucose ≥6.1 mmol/l ≥7.0 mmol/l Random blood glucose ≥7.9 mmol/l ≥11.1 mmol/l GGT 2 hour value ≥7.9 mmol/l ≥11.1 mmol/l HbA1C ≥ 42 mmol/mol (≥6.0) ≥48mmol/mol (≥6.5%) Poorly managed diabetes can lead to long term complications throughout the body, including retinopathy, CVD, nephropathy, neuropathy, and strokes. Acute complications include hypoglycaemia, diabetic ketoacidosis and hyperosmolar non-ketonic coma (HONK). Type 1 Diabetes Type 1 diabetes is an autoimmune condition resulting in insufficient insulin production due to the destruction of pancreatic β-cells. The cause of T1DM is unknown but is a combination of genetic and environmental triggers. It tends to be young-onset but may be diagnosed later. Treatment of T1DM involves injecting exogenous insulin at strategic time points, concerning carbohydrate intake. Carbohydrate counting education is an important part of intervention. Carbohydrate/Insulin ratios change and are patient-specific. • Offering structured education to optimise glycaemic control (e.g. DAFNE) • Annual screening of HbA1C, lipids, blood pressure and BMI • Annual screening of retina function, microalbuminuria, and sensation in feet • Insulin medication and advice on avoiding and treating hypoglycaemia Type Names Usage Rapid-acting Fiasp Before eating Quick-acting Humalog, Novorapid, Before eating Mixed insulin Novomix 30, Humalog 25 Twice daily before eating Intermediate-acting Humulin I, Insulatard Twice daily Long-acting Lantus, Levemir Twice daily Very long-acting Tresiba, Toujeo Once-daily Type 2 Diabetes Type 2 diabetes is relative insulin deficiency and tends to be diagnosed later in life. It accounts for 90% of diabetes cases. Risk factors for T2DM include older age, genetics, central obesity, smoking and a poor diet (high fat, high GI, low fibre, excess alcohol). Treatment of T2DM should include education on regulating carbohydrate intake. Generally, patients should aim for around 30-40g CHO per meal (120g/day) and combine this with protein and fibre sources, which help delay gastric emptying. Teach what 30-40g CHO looks like. (eg. 5-6 egg-size potatoes, 2sl bread, or 2x Weetabix) Placement Pack University of Surrey Dietetics Society | December 2020 25 Diabetes Drug Treatment and Observations Correcting Hypoglycaemia (when BG <4mmol/L) 1. 15-20g fast acting carbohydrate (4 jelly babies, 60ml glucojuice, 50ml glucogel, 3 heaped teaspoons sugar, 150ml cola) 2. Wait 5-10 minutes, if still below 4mmol/L, repeat step 1. 3. Follow up with slow-release carbohydrate (1sl bread, small banana) or your next meal if due. This prevents another hypo. The Dawn Effect Overnight, the body releases hormones such as growth hormone, cortisol and glucagon leading to glucose release. Alongside insufficient or ineffective insulin, this leads to elevated morning blood glucose. This may be prevented by avoiding carbohydrates at night, changing medications, and using an overnight insulin pump. Alcohol Following consumption of alcohol, the liver prioritises metabolising the alcohol over releasing glucose and gluconeogenesis which can lead to delayed hypoglycaemia. Strategies to avoid hypoglycaemia induced by alcohol Include eating carbohydrates before/ during alcohol consumption and before bed, carrying around hypoglycaemia treatments e.g. glucose gels, or considering reducing insulin medication dosages. Hypoglycaemia symptoms can be mistaken for just being heavily intoxicated. It is recommended that the patient’s friend are aware, and they carry a medical ID card explaining their condition. Placement Pack University of Surrey Dietetics Society | December 2020 26 Obesity and Weight Loss (Adults) Obesity is defined by a BMI >30kg/m2 (severe >50kg/m2). Obesity is usually multicausal. Associated eating patterns are bound to socioeconomic and health factors. Obesity increases the risk of type 2 diabetes, CVD, certain cancers, and bone diseases. Obesity may also present barriers that reduce quality of life. A target of 0.5-1.0kg/week weight loss for up to 10% of initial body weight. should usually be set, in agreement with the patient and multi-disciplinary team. Identify barriers and implement appropriate strategies using the following tool. Quantify the effect of each strategy and include this in the management plan. Bariatric Surgery Surgery (gastric sleeve, bypass) is used where lower tier treatments fail. Dietetics Pre-surgery – to strictly limit carbohydrate intake to 120g/day for up to 2 weeks. This decreases the size of the liver and makes the surgical site more accessible, preventing complications. This restrictive diet normally requires multivitamin supplementation. Post-surgery – Purreed diet for 2 weeks, soft for another 6 weeks, build up to normal after this. Taking micronutrient supplements is very important in this patient group due to malabsorption and low intake. Baricol is an all-in-one drug available privately. Other alternatives must be assessed individually, and normally include a multivitamin, a calcium + vitamin D supplement, ferrous fumarate, and dietary metal supplement with appropriate Cu:Zn ratio. Interventions should aim for 40-60% excess body weight loss (when compared to IBW). It is common for these patients to lose too much weight and require ONS. Placement Pack University of Surrey Dietetics Society | December 2020 27 Autism and Food . Autism Spectrum Disorders (ASD) are a category of neurobiological conditions associated with weakened social skills, hypersensitivity to different sensory or social stimuli, and difficulty coping with unspecific instruction. It is also associated with periods of intense, specific interests and repetitive behaviours. Autism is not associated with lower intelligence nor does it imply a deficit of emotions. Some people with autism experience eating problems. This is often linked to a sensitivity to certain textures, smells, and tastes, although it can be non-sensory. ▪ Hyper-selectivity (eating fewer than 20 foods) or food of certain temperatures. ▪ An aversion to trying new foods (food neophobia). ▪ An aversion to eat, or eat specific foods, in certain environments. In addition to correcting nutritional deficiencies (low ferritin, vitamins A and D), the following approaches should be trialled under dietetic supervision. Don’t underestimate the notion of environment, the cause is not always food-specific. Environmental changes can create issues with sensory processing and food aversion. Keeping a food-location-response diary can help monitor changes and spot patterns. Look out for different smells, different temperatures, bright environments, different people, loud background noises. Placement Pack University of Surrey Dietetics Society | December 2020 28 Infant feeding Until 6 months, sterile breastmilk or formula should be provided. After 6 months, complementary feeding should commence alongside breastfeeding. Breastfeeding has unequivocal health benefits for the mother and child and information should be given on feeding including breast and formula options. Support and guidance should be offered for mothers that are breastfeeding or struggling with breastfeeding. NICE guidelines recommend following the UNICEF baby friendly initiative as a minimum standard. Formula feeding There is a risk of infection or illness if milk is not prepared safely. All milk and apparatus must be sterile. Infant infections can be dangerous and require hospital admission. Evidence-based advice should be given for sterilising feeding equipment. Bottle feeding Tips – Breast or Formula • Offer feeds when the baby shows early signs of being hungry. • Don’t be forceful. • If the baby is upset, then try to calm them before starting a feed. • Hold baby close in a slightly upright position. • Look into the baby’s eyes and talk gently (this may help to calm them). • Gently rub the teat above the baby’s top lip, this will encourage them to open their mouth and poke their tongue out. • Allow just enough milk to cover the teat and pace the feed to meet baby’s needs, gently removing it if the baby appears to want a break. Complementary Feeding As previously stated babies around 6 months (and never younger than 4 months) should be started on solid food, these foods should be introduced with the addition of breastmilk or formula milk to ensure the diet is nutritionally adequate. When breast milk or formula is no longer given, the baby should be getting a wide range of nutrients from a variety of foods. Starting solid food earlier or later can be associated with poor infant outcomes. Healthy feeding Checklist 1. The baby… 2. The baby’s nappies… Has at least 8 feeds in 24hr At least 5 heavy, wet nappies in 24hr Is generally calm after feeding At least 2 dirty nappies in 24hr Takes deep, rhythmic sucks Stools are significant and yellow Swallows audibly 3. Breasts (if applicable) Generally feeds for 5-40 minutes Breasts and nipples are comfortable Has normal skin and is alert for feeds Nipples don’t change shape during feed Has not lost more than 10% weight Have other options and aids been tried? Placement Pack University of Surrey Dietetics Society | December 2020 29 Neonates and Growth Prematurity is defined as a birth more than 3 weeks early (37 weeks gestation). This presents some novel challenges that student dietitians must be aware of. Due to lower nutrient stores and more demanding growth needs, possibly combined with common conditions such as chronic lung disease, nutrient demands are likely greater in premature babies. However, problems such as poor suckling coordination and an immature GI tract present challenges in meeting said needs. A small trophic EN feed is recommended to stimulate GI-tract development. Average weight gain: Premature babies: Measuring and plotting: Activity 2 Answers Placement Pack University of Surrey Dietetics Society | December 2020 30 Cow’s Milk Allergy Cows Milk Allergy (CMA) in children is one of the most common food allergies and is usually present before one year of age. An allergy can be categorised into: 1) Immunoglobulin (Ig)E mediated food allergy, which produces immediate symptoms (usually within 2 hours of cow’s milk ingestion and can affect multiple organs and be severe and life-threatening - anaphylaxis) 2) Non-IgE-mediated food allergy reactions usually occur between 2 and 72 hours after cow’s milk ingestion (Mixed IgE and non-IgE are typically delayed) Assessment • Assessing symptoms concerning milk exposure, reproducibility of symptoms and any comorbid atopic conditions. • Examining for nutritional status or comorbid atopic conditions. • Arranging for a skin prick test and/or serum specific IgE allergy testing if there are suspected IgE- mediated allergy. Management • Paediatric dietitians should monitor growth and nutrition, and advise about hypoallergenic infant formulas, if appropriate. • A trial elimination diet of cow's milk from the mother's/infant's diet for 2–4 weeks • Following this, the at-home reintroduction of cow's milk is needed to confirm the diagnosis if there is a clear improvement in symptoms. • Advising a cow's milk-free diet until the child is 9–12 months old (non-IgE). • Advising guardians on food allergen avoidance and support/information sources. iMAP guidance notes that in exclusively breastfed infants, the likelihood of sufficient cow's milk protein passing into breast milk to trigger reactions is low, so complete cow's milk exclusion may not be needed. If the child has signs of current atopic eczema or there is any history at any time of immediate-onset symptoms, do not advise a home reintroduction and instead arrange a referral to an allergy specialist for testing and ongoing management. Milk ladder Tolerance to cow's milk protein should be assessed using a 'milk ladder' and monitoring for the return of symptoms. A milk ladder (see image) reintroduces baked milk products first as heating reduces allergenicity. Once tolerance is established, greater exposure of less processed milk should be gradually encouraged, ending in the reintroduction of fresh cow's milk. If symptoms return on reintroduction of cow's milk, a cow's milk-free diet should be continued, and the child should be re-evaluated after a further 6 to 12 months Placement Pack University of Surrey Dietetics Society | December 2020 31 Gut Problems and Deficiency Infantile Colic (excessive and unexplained crying) . Parents should be reassured and that this is normal, especially at 0-3 months, and encouraged to reach out to friends/family for support. In some cases, splitting feeds into smaller, more regular feeds without changing overall food volume can help. . Medical treatment is available in the form of a 1 week trial of lactase drops or simethicone drops. Treatment should only be continued if improvement is seen. (NB. If lactase drops are beneficial, this does not indicate lactose intolerance.) . Vomiting . Vomiting acutely in small amounts is normal, but excessive vomiting can cause nutritional problems and be a symptom of underlying conditions. If vomiting is related to feeding times, smaller, more frequent feeds may be worth exploring. Bloody or bile-stained vomit should always be flagged to the relevant medical doctor. . Diarrhoea Defined as four or more watery stools per day, but any change in bowel movements is notable. The main aim is to prevent dehydration with fluids and ORS (Dioralyte). Iron deficiency This is the most common paediatric deficiency, especially in what were premature babies. It normally develops after 6 months, when Iron stores become scarce. It expresses as poor growth, tiredness, anorexia, breathlessness, and behavioural problems. Note those with restricted diets and delayed complementary feeding. Request blood ferritin & serum Iron if concerned. Note bioavailability (haem ≈ 30% / non-haem ≈ 10%) if estimating intake sufficiency. Provide BDA food factsheet (Iron) for food suggestions (can be mashed). Placement Pack University of Surrey Dietetics Society | December 2020 32 Metabolic Disorders Inborn metabolic errors can be linked to a genetic deficiency in a metabolic enzyme or a transporter protein. The result is a deficiency and/or toxic excess of a certain metabolite. Most metabolic disorders are autosomal recessive. . Phenylketonuria (PKU) (1 in 10,000) Caused by a deficiency in phenylalanine hydroxylase, which converts phenylalanine to tyrosine. This results in an inability to process phenylalanine, causing a toxic accumulation of phenylketone and making Tyrosine an essential amino acid. Under the exchange system, patients will be permitted a tolerable allotment of ‘exchanges’ per day. Many foods have very low phenylalanine and are not limited under this system (such as strawberries in the adjacent illustration). Planning meals based on this system should be discussed. Hartnup’s Disease (1 in 30,000) Caused by a genetic defect in the transporter for non-polar amino acids, particularly tryptophan. Patients with Hartnup’s disease are therefore poor at absorbing these amino acids and retaining them in the nephrons. Normally presents as secondary niacin deficiency. Placement Pack University of Surrey Dietetics Society | December 2020 33 Critical and Intensive Care . “a minor injury or infection leads to a localised inflammatory response, whereas a major injury or infection leads to a systemic inflammatory response” M, After an initial 24-48hr period, hypermetabolism, insulin resistance, and hyperglycaemia are usually seen for 2-3 weeks (major burns or unresolved sepsis may be longer). Skeletal muscle is rapidly depleted to facilitate gluconeogenesis and synthesis of acute-phase proteins. Glucose provision, even at maximum rates, will not preserve lean tissue, only reduce its loss. After this period, support should stimulate protein synthesis. . As anthropometric data is less valid and factors more complex, separate energy estimation equations exist. The most consistent is the Penn State equation: Overfeeding Syndromes in Critical Care . Overfeeding syndromes are the main driver of the increased infection tisk commonly associated with parenteral nutrition. PN itself does not inherently carry a higher risk. Excess protein can cause hyperuraemia, or (when the urea cycle is at maximum capacity, due to hypermetabolism and poor liver health) hyperammonaemia. Tube Feeding Syndrome This is where the feed provides insufficient water for its osmotic load. The water needed in patients with poor renal function is greater. Dense, high protein feeds are most likely to cause this, but it is avoidable with proper fluid maintainance. Excess lipid can cause hepatic encephalopathy and/or fatty liver when exceeding the capacity for oxidation and VLDL synthesis. Do not exceed 1.25g/kg/day. Excess carbohydrate may lead indirectly to the consequences of excess lipid. Moving to glucose as a metabolic fuel also has its own disadvantage of increasing the patient’s respiratory quotient (RQ), meaning more CO2 needs to be released. This makes it harder to wean patients from artificial ventilation. Early vs. late Parenteral Nutrition in Critical Care Late PN (5-8-day delay) may be advantageous in preventing complications associated with overfeeding and can help decrease dependence on PN, decreasing ITU stays. Note that late PN is contraindicated if the patient is: (1) malnourished at baseline, (2) receiving less than 50% energy and/or protein requirements enterally, or (3) is at very high hypoglycaemia risk. Note: in the NICU, the exact same concept applies, where ‘malnourished at baseline’ is equivalent to neonates who are preterm, VLBW, or ELBW. Late PN may benefit others. Placement Pack University of Surrey Dietetics Society | December 2020 34 Surgery Malnutrition and underfeeding are both risk factors for post-surgical complications. Therefore, nutritional screening is essential before and after surgery. Early oral or enteral feeding is particularly important for any surgical patient at nutritional risk, especially for those undergoing gastrointestinal surgery. The surgery itself leads to inflammation. This results in increased metabolic stress. As explained elsewhere in this pack, the resultant catabolism of glycogen, fat and protein causes muscle mass loss to aid healing and immune response. This loss of muscle is a short and long-term burden for functional recovery. Insulin resistance is common after most kinds of surgery as a response mechanism to starvation, caused by the inhibition of glucose oxidation. Preoperative carbohydrate treatment can be considered to reduce the impact of postoperative insulin resistance and length of stay in hospital. However, there is still no definite conclusion on this recommendation. For patients who cannot be fed orally or enterally, an intravenous administration of 200g glucose preoperatively is recommended. Dietetic Aim: Optimise nutritional status before surgery to optimise healing, recovery, and reduce risk of postoperative complications. • Mildly Malnourished - Short-term (7-10 days) nutrition support • Severely Malnourished– 7-14 days of nutrition support may be appropriate. • Infected/ Septic– focus on treating the infection. Surgery usually postponed. Preoperative Preparation: - Fasting from midnight is unnecessary in most patients. Patients with no risk of aspiration can drink clear fluids until 2 hours and solids are allowed until 6 hours before anaesthesia. Post – Surgery: - Nutritional intake (balanced hospital diet and/or ONS/ENS/TPN) should continue after surgery without interruption. It can be initiated, in most cases, immediately after surgery as early intake is beneficial, even after procedures such as cholecystectomy and colorectal resection. Monitor symptoms and increase intake carefully. - Adapt the oral intake according to the individual’s tolerance and type of surgery carried out with special caution to elderly patients. If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of caloric requirement) for more than seven days, a combination of enteral and parenteral nutrition is recommended. . Note: PN is only recommended for patients who cannot meet their energy needs orally/enterally withing 5-7 days. It should only be initiated if the duration of PN is anticipated to be >7 days. Placement Pack University of Surrey Dietetics Society | December 2020 35 Swallowing and Dysphagia Dysphagia describes the inability to chew or swallow normally or to transfer liquid or solid foods from the oral cavity to the stomach. It is mostly seen in patients with stroke, progressive neurological disorders, anoxic brain injury, some learning disabilities, cancers, or injuries affecting the head/neck. Dysphagia can stem from problems affecting different stages: • Preparatory Stage - food going to from plate to mouth. Saliva production. o Can be helped by hand-feeding, tray positioning, special cutlery. • Oral Stage (voluntary) – Chewing (mastication). • Pharyngeal stage (involuntary) – The movement of food from the mouth through the pharynx to the oesophagus. o The muscles of the mouth or throat may be dysfunctional, so boli and liquids can be aspirated (drawn into the lungs). Warning signs of dysphagia: Coughing/dribbling/choking during or after eating and/or drink, difficulty chewing, pocketing food in the cheeks, fluid leaking from the nose after swallowing, frequent chest infections, gurgling voice after eating and drinking. MDT approach is essential for dysphagia management: • Assessment– identified by nursing/medical, referral to SALT and RD. • Determine a safe feeding route, consistency, and nutrition. • Educate the patient, carer and care team on barriers & encouragement. • Monitor progress and intake closely. Dysphagia may improve or worsen. International Dysphagia Diet Standardisation Initiative (IDDSI) The IDDSI framework is the global standard used to describe texture modified foods and thickened drinks for individuals. It consists of 8 levels and can be used for all ages. See page 36. Placement Pack University of Surrey Dietetics Society | December 2020 36 The IDDSI Framework Level 5 minced and moist - Meat, fish, fruit and vegetables must be finely chopped to 4mm lump size. - Cereal must be served thick with small soft 4mm lumps. No separated milk. - Rice requires a sauce to moisten it. It should not be stick/gluey. Level 6 soft & bite-sized - Meat and fish cooked tender enough so pieces are no bigger than 1.5cm2 - Fruit should be soft, chopped, and vegetables steamed or boiled to 1.5cm2 - Rice requires a sauce to moisten it. It should not be stick/gluey Level 7 regular – easy to chew - Everyday foods that are easy to chew and swallow - Do not use foods that are hard, tough, chewy, fibrous, or stringy. How to test a food is suitable for its IDDSI level Foods and fluids must pass the fork and spoon test Level 3 – Drips slowly in dollops through the prongs of a fork. Level 4 – A small amount may flow through prongs, it does not dollop or drip continuously through fork prongs. Sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or flicked. Food and thickened fluid must pass the fork and spoon test Level 5 – Lump size is about 4mm which just about fits between the prongs of a fork. Sample falls off spoon fairly easily if the spoon is tilted or flicked. Minced and moist foods must pass the fork and spoon test Level 6 – Lump size must be no bigger than 1.5cm x 1.5cm in size. To ensure food is soft enough, press down the fork until the food is completely squashed. When the fork is lifted, the food should not regain its shape. Level 7 (easy to chew) – Food must be able to break apart easily with the side of a fork or spoon. Also, press down the fork until the food is completely squashed. When the fork is lifted, the food should not regain its shape. What to avoid for IDDSI levels 3-6 Mixed thin and thick textures Soup with pieces of food/nuts, cereal and milk Hard or dry food Nuts, raw veg, dry cereal, dry bread Tough or fibrous foods Steak, pineapple Chewy Cheese, marshmallows, chewing gum, dried fruit, Crispy Cornflakes, crisps, crackling Sharp or spiky Crisps Crumbly bits Crumple, dry biscuits Pips, seeds Pumpkin seeds, white of the orange Foods with skin or shells Peas, grapes, skin-on fish, sausage skin Husks Shredded wheat, bran Placement Pack University of Surrey Dietetics Society | December 2020 37 Cultural and Religious Diets Considering patients’ personal food choices, culture, and religious traditions is important for encouraging adherence and acceptability. In addition to changes to certain products, many regions of the world do not share the UK’s meal format. Religious food differences Geographical food differences Traditional foods of a region are strongly linked to physical variables in that region and food traditions are often carried forward even when geographical factors cease to carry as much importance (through the globalisation of the food supply). Simple examples are that temperate climates will usually yield higher plant diets, coastal areas will be higher in fish, and more remote, less fertile areas will rely more heavily on dried and preserved food. Examples of differences for the largest foreign-born populations in the UK: East Asia • Very little milk consumption, replaced with tofu, soya milk, fish. • Dried and salted protein-rich foods are more popular. • Rice often forms the basis of most meals. South Asia • Flatbreads (high phytate) are more common. • Legumes and Lentils (dried) are used regularly. • Rice and curry dishes are often central, as is seafood in places like Sri Lanka. Poland • Meats, often higher fats such as pork. • Preserved vegetables. • Oily fish, especially herring. Placement Pack University of Surrey Dietetics Society | December 2020 38 Consultation Structures Before the consultation, it’s important to study details of past medical history, weight history, treatments, diagnosis, and any other available information. You can use the consultation to fill in the missing information. If you have reliable data, you can roughly estimate requirements beforehand. Starting the consultation Introduce yourself, be friendly. Ask how they’d like to be addressed, Ask the patient to describe the problem. E.g. “Could you tell me why you’re here today?”. This helps ensure your information is correct and helps you understand their perspectives. As they’re responding, use active listening techniques. Ask permission to take notes. Ensure they understand the role of the session and understand their condition. You should also briefly explain how food may interact with the condition. Data collection & intervention Explain your plan for the session to the patient and ask if that sounds good. As you’re collecting information, try to extract other information and make conversation so it doesn’t feel as clinical to the patient. Once you’ve collected enough information, summarise it to the patient and ask her if you’ve understood it right. Identify dietetic diagnosis and then negotiate the dietetic plan – work with the patient and ensure they’re comfortable and optimistic. Help the patient understand how they can implement it. Ending the consultation Summarise the session (“what we’ve talked about today is…”) and then review the treatment plan briefly. Agree on next steps (e.g. a follow-up appointment). Future consultations Introduce the session by reviewing what you did last time, what you found, and what you talked about. Ask how they’ve been getting on: new symptoms, biochemical or clinical changes, diet history. Placement Pack University of Surrey Dietetics Society | December 2020 39 Placement advice and visual aids 1. At the beginning of placement, it can be useful to find out the following pieces of information: • Contact/ ‘bleep’ numbers of dietitians, relevant offices etc. • Oral nutrition supplements and enteral feeds available. (When you know the list of supplements and feeds available, it can be useful to have a booklet with the nutritional content of these feeds as this will save you some time when making appropriate plans for patients) • Learn your trust’s refeeding policy – trusts can differ in their policy and may differ to the illustrative one provided in this pack. • Their dietetic referral pathway/criteria – (the majority of trusts use MUST but it can be useful to know what types of patients are an immediate priority in that department. • Waiting list capacity – useful to know this for clinics when arranging follow- up appointments. (A lot of trusts have capacity for 2-3 months). • Enteral regimen sheets and information for bed-end folders/ medical notes. 2. Keep a list of medical abbreviations, treatments and drugs you learn throughout placement. You can continue to build on this throughout your career. 3. Introduce yourself to other staff at the beginning of placement. These MDT relationships will be useful throughout placement e.g. if you need to discuss IDDSI upgrades with SALT or handing over to nurses, etc. 4. Keep a diary/use your portfolio to document the challenges or difficulties faced during placement, whether it is a difficult patient or a time constraint. A question about dealing with the challenges or difficulties is often asked in Band 5 job interviews and it can be hard to think of these on the spot. 5. Take the initiative to seek as many extra opportunities as possible during placement. Supervisors will notice this but it will also add to your placement experience. Placement Pack University of Surrey Dietetics Society | December 2020
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