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Nutrition 101: When, What, How to Feed

Nutrition 101: When, What, How to Feed. A Case-based Approach to Gastroenterology. Kimberly Carter, MS, PA-C Division of Gastroenterology University of Pennsylvania Kimberly.Carter2@uphs.upenn.edu. Nutrition: Why should we care….

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Nutrition 101: When, What, How to Feed

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  1. Nutrition 101: When, What, How to Feed A Case-based Approach to Gastroenterology Kimberly Carter, MS, PA-C Division of Gastroenterology University of Pennsylvania Kimberly.Carter2@uphs.upenn.edu

  2. Nutrition: Why should we care….

  3. Nutrition is an essential component of healthcare and is apart of most of what we do as GI specialists.

  4. Objective • Discuss the impact of gastrointestinal disease on nutrition status. • Outline key elements of a nutrition assessment. • Appraise various nutrition therapies as it pertains to dietary modifications and nutrition requirements. • Discuss the appropriateness of nutrition support.

  5. Nutrition in GI Disease: Nutritional Status

  6. Nutritional Assessment • Food and Nutrition related history • Medical, Surgical, and Social history • Anthropometric measurements • Nutrition focused physical exam findings • Biochemical data Bueche J, Charney P, Pavlinac J, et al. Nutrition Care Process and Model Part I: The 2008 Update. Journal of the American Dietetic Association. 2008;108(7)1113-1117.

  7. Food and Nutrition Related History • Dietary intake: 24 hour recall • Use of dietary supplements • Eating difficulties : poor dentition, taste disturbances, dysphagia • Gastrointestinal complaints: Nausea, vomiting, abdominal pain, diarrhea, constipation

  8. Medical History • Critical illness or chronic disease • Pancreatic insufficiency • IBD • Celiac disease Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.

  9. Surgical History • Major abdominal surgery, trauma • Previous GI surgery • Fistula, ostomy, mesenteric ischemia, short bowel syndrome Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.

  10. Social History • Living environment • Caregiver • Functional status • Alcohol or substance abuse • Mental health Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.

  11. Anthropometric Measurements • Height • Weight • Usual Body Weight (UBW) • Weight loss • 10 lbs. weight loss over 6 months is noteworthy • >10% of UBW • BMI • <18.5 underweight

  12. Nutrition focused PE findings • Loss of muscle mass and subcutaneous fat • Edema and ascites • Hair, skin, nails, perioral exam Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5): S29-S33.

  13. Physical Signs Phillips, SM. Jensen, C. Micronutrient deficiencies associated with malnutrition in children. In: UpToDate, Motil, KJ (Ed), UpToDate, Waltham, MA. (Accessed on April 30, 2014).

  14. Poor nutrient intake and excessive losses may contribute to malnutrition.

  15. Case Study # 1 • 76-year-old male with lung cancer is referred by his oncologist for anorexia and weight loss in setting of dysphagia and odynophagia. Endorses 30 lbs weight loss over the past 3 months. • Medications: Megace • Medical/Surgical history: HTN • Family history: unremarkable • Social History: Lives alone and able to perform ADL. Active community member. Strong family support. Fixed income. • ROS: fatigue, taste disturbances and weakness

  16. Case Study # 1 • Physical Exam: • Afebrile, 61 inches, 104 lbs. BMI 20 • Cachectic man with temporal, chest and deltoid wasting • Edentulous • Otherwise normal exam • Data: • PET/CT suggestive of extrinsic compression on the distal esophagus • EGD with evidence of esophagitis • Serology: Albumin 2.3, Prealbumin 15.6

  17. Assessment: Is this patient malnourished?

  18. Nutrition in GI Disease: Nutrition Support

  19. Nutrition Intervention • Oral nutrition supplements • Enteral Nutrition • Parenteral Nutrition

  20. Nutrition Support

  21. Enteral Nutrition Support • Functioning GI tract • Short vs. Long Term • NG/NJ vs. PEG/PEJ • Gastric: Bolus feedings • Jejunal: Continuous feedings • Disease Specific Formulas

  22. Parenteral Nutrition Support • Non-functioning GI tract • Central or PICC • EN vs. PN (Complications)

  23. Nutrition Support • Multi-disciplinary team • Refeeding Syndrome

  24. Case Study # 2 • 50-year-old male with ulcerative colitis and mesenteric ischemia s/p total abdominal colectomy with end ileostomy and small bowel resection on chronic TPN referred for nutrition evaluation.

  25. Prognosis of Short Gut Syndrome (SGS) • Presence of residual underlying disease • Length of remaining small intestine • Presence or absence of colon in continuity O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10

  26. Clinical Consequences SGS Table 1. Jejunal resection of 50-60% is usually well tolerated. Greater than 30% ileal resection is poorly tolerated. Severe malabsorption occurs with residual small bowel < 60 cm. Deficiencies include fluid and electrolytes (mild to moderate cases)/plus nutrient absorption (severe cases). Severe fluid and electrolyte loss is associated with end jejunostomy. Magnesium, calcium, and zinc deficiencies are common. O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10

  27. Bowel Adaptation SGS • Gastric hypersecretion • Increased pancreaticobiliary secretions • Mucosal hyperplasia • Increased mucosal blood flow • Improved segmental absorption O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10

  28. Short Gut Syndrome Medical Nutrition Therapy (MNT) Table 2. General Management Strategies for SBS Fluids Avoid drinking water without food Spread fluid intake throughout the day Sip liquids Restrict hypotonic fluids Drink oral rehydration solution containing salt and carbohydrates Diet Eat small, frequent meals balanced in nutrient content Add salt to the diet (only for patient with colon in continuity) Increase quantity of food intake Follow a high complex-carbohydrate diet (patients with a colon) Avoid osmoticallyactive sweeteners, which might cause diarrhea O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10

  29. Short Gut Syndrome MNT • Hypomotility agents • Rotating antibiotics • Enzyme replacement

  30. Short Gut Syndrome Shortgutsupport.com

  31. Nutrition in GI Disease: Nutritional Therapy

  32. Case Study # 3 • 29-year-old female with history of RYGB referred for evaluation of iron deficiency anemia in the absence of overt GI blood loss. • Celiac and H Pylori serology negative • Endoscopic evaluation unremarkable • Micronutrient deficiencies: Calcium, Zinc, Vitamin D, B12

  33. Nutrition and RYGB Malabsorption • Many patients stop supplements after bariatric surgery • Look for other micronutrient deficiencies • Often subtle deficiencies are asymptomatic

  34. Nutrition and Malabsorption • Hypoalbuminemia • Steatorrhea • Fe deficiency anemia • B 12 deficiency • Thiamine deficiency

  35. Nutritional Therapy • 60-120 grams of protein daily • Long-term vitamin/mineral supplementation • Periodic clinical and biochemical monitoring Heber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95(11):4823-4843.

  36. Biochemical Monitoring • 6, 12, 18, 24 months then annually • Fe, B12, Folate, Calcium, Vitamin D, Albumin, pre-albumin • Optional • Vitamin A, Zinc, B1 Heber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95 (11):4823-4843.

  37. Dietary modifications • Consume small frequent meals • Avoid ingestion of liquids within 30 min of solid food • Avoid simple sugars • Increase intake of fiber and complex carbohydrates • Increase protein intake Heber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95(11):4823-4843.

  38. Case Study # 4 • 26-year-old male with ileocolonicCrohn’s disease presents with fatigue, low energy and weight loss. • Iron, B 12 and Vitamin D deficiency

  39. Nutrition and IBD • Nutrient deficiencies • Hypoalbuminemia • Fe • B12 • Vitamin D • Folic acid • Calcium • Magnesium

  40. Nutritional Therapy • Vitamin/Mineral Repletion • Elimination Diet • Lactose Free • Low Residue • Probiotic

  41. Case Study # 5 • 23-year-old female with history of Type I DM presents with bloating, flatulence, and diarrhea in the setting of anemia • Positive celiac serology with duodenal biopsy c/w villous atrophy

  42. Nutrition and Celiac Disease • Micronutrient deficiencies • Pancreatic insufficiency

  43. Gluten-free diet • Eliminates wheat, rye, and barley • Rice, corn, millet, potato, buckwheat, and soybeans are safe • Common gluten free foods • fresh fish, meats, milk, cheese, fruits, vegetables • Gluten-free substitutes are often expensive and may be difficult to access

  44. Management of Celiac Disease • Milito T, Muri M, Oakes J, et al. Celiac disease: Early diagnosis leads to the best possible outcome. Journal of the American Academy of Physician Assistants. 2012;25(11):43-47.

  45. Nutrition in GI Disease: Nutritional Therapy

  46. Nutrition and IBS • Multifactorial: visceral hypersensitivity, gut flora, diet

  47. Nutritional Therapy • Lactose Free diet • Probiotics • Fiber Supplements (Psyllium) • FODMAP Diet

  48. FODMAP • Fermentable OligoDiMonosaccharides and Polyols • Poor absorption • Osmotic effect • Bacterial fermentation Simren M. Diet as a Therapy for irritable bowel syndrome: progress at last. Gastroenterology. 2014;146(1):10-12.

  49. Absorption of FODMAPs • Presence or absence of enzymes • Small intestinal transit time • Dose of carbohydrate • Presence of underlying mucosal disease • Food Composition Simren M. Diet as a Therapy for irritable bowel syndrome: progress at last. Gastroenterology. 2014;146(1):10-12.

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