Clinical Nutrition

1. Clinical Nutrition Pranithi Hongsprabhas MD.

2. Objective • Etiology of PEM • Classification • Diagnosis/assessment • Complication • Management of PEM • treatment option • complication • monitoring

3. References • Shils M, Olson JA, Shike M, Modern Nutrition in Health and Diseases.1999 • Rombeau JL, Rolandelli RH. Clinical nutrition: Parenteral Nutrition. 2001 • Rombeau JL, Rolandelli RH. Clinical nutrition: Enteral Nutrition.1997. WD400 • เอกสารประกอบการสอน: โภชนาการคลินิก 2544.

4. Malnutrition • Over nutrition • obesity • dietary induced dyslipidemia • Under nutrition • protein energy nutrition • specific nutrient deficiency

5. Malnutrition Hospital setting • 30-60% malnourished, ~ 10 - 25% severe • get worse in hospital • high morbidity, prolonged hospital stay • higher mortality

6. Diseases and Conditions Predisposing to Malnutrition • Decreased intake • Altered metabolism • Increased losses • Decreased absorption • Increased requirement Hensrud DD. Nutrition screening and assessment. Med Clin North Am 1999;83:1525-47

7. Maldigestion Pancreatic disease Liver disease Malabsorption Small bowel diseases Surgical resection gastric resection short bowel syndrome segmental resection Drugs: laxative, alcohol, antacid Decreased Absorption

8. Life cycle growth pregnancy lactation Severe illness SIRS Wasting diseases HIV cancer advance pulmonary/cardiac disease Hyperthyroidism Strenuous physical activity, muscle contraction Increased Requirement

9. Simple Starvation: Marasmic Wasting • Total or partial cessation of energy intake • Short term starvation (<72 hr) • glycogenolysis: glucose • gluconeogenesis: glucose • lipolysis: FFA, glycerol • Prolonged starvation (>72 hr) • decreased RMR, DIT, activity • decreased gluconeogenesis from aa, lactate • increased tissue utilization of ketone,FFA

10. Marasmus: Simple starvation • decreased metabolic rate • weight loss mainly from fat and also LBM • impaired wound healing and immune function • Normal albumin level Bone and skin appearance

11. Stress Starvation • Response to starvation and inflammation • Days to weeks or months • Depend on hormonal and cytokine control Cytokine response • vascular permeability • catabolic (IL-1, TNF) • increased RMR • decreased LBM • increased protein breakdown Hormonal response • aldosterone/ADH • salt/ water retention • epinephrine, glucagon,cortisol • lipolysis • gluconeogenesis • severe protein catabolism

12. Stress Starvation • Change of body composition • ECF expansion / Wt gain • body cell mass and ICF decline • Loss of body protein: functional change • respiratory muscle • wound healing • immune response • Catabolic state cannot be reversed by nutrition alone

13. Stress Starvation • Kwashiorkor or hypoalbuminemic malnutrition • low albumin level /edema • poor wound healing and immune response • higher morbidity and mortality

14. Chronic Stress Starvation • Mild -moderate stress + starvation • Develops in months

16. End Organ Responses in Malnutrition

17. End Organ Responses in Malnutrition

18. End Organ Responses in Malnutrition

19. Other Complications of PEM • Wound healing • collagen • tissue proliferation • Immune response • impaired CMIR Final outcome • higher infection rate, poor response, high complication • impaired healing • prolonged hospital stay • high mortality

20. How to Detect Patients at Risk? • Nutritional screening • Nutritional assessment

22. Subjective Global Assessment • History • wt loss • dietary change • significant GI symptoms • functional ability • degree of stress • PE • degree of fat loss • muscle wasting • edema/ ascites • clinical signs of nutritional deficiency

24. SGA (cont)

25. SGA (cont) • Class A: • no change in BW, normal intake, • < 5 % wt loss, or > 5% wt loss but recent gain and improve appetite • Class B: • 5-10% wt loss without recent stabilization or gain, poor dietary intake and mild loss of subcutaneous tissue • Class C: • ongoing wt loss of > 10% with severe subcutaneous tissue loss and muscle wasting often with edema

26. Physical Examination • General • Specific nutritional examination

27. General: muscle wasting

28. Flaky paint dermatosis: protein deficiency

29. Essential fatty acid deficiency syndromes (EFADs)

30. Zinc deficiency

31. Pellagra

32. Pellagra • dermatitis • dementia • diarrhea • death • niacin deficiency

33. Riboflavin deficiency

34. Vitamin C deficiency Perifolicullar pitichea

35. Vitamin K deficiency

36. Anthropometric Study

37. Anthropometric Measurement • Skinfold thickness: • Mid arm cir (MAC), Mid arm muscle cir. (MAMC), mid arm muscle area • limitation • fluid • technique: reproducibility • do not reflect variation in bone size, skin compressibility

38. Laboratory Assessment: Biochem • electrolytes • hepatic secretory protein

39. Low alb correlated with poor clinical outcome: prognosticator Low alb < 2.5 associates with hypooncotic effects affected by non nutritional factors fluid stress prioritization leakage Serum Albumin

40. Prealbumin • T 1/2 2-3 d • Decreased in liver failure, acute stress • response to nutritional support • increased in renal failure

41. Transferrin • Decreased in liver failure, acute stress • increased in IDA Retinol Binding Protein • Decreased in liver failure, acute stress, vitamin A deficiency • renal failure

42. Creatinine Height Index • Correlates with lean body mass • CHI = actual 24-hr Cr excretion expected Cr excretion • estimated 18-20 kg muscle produce 1 g Cr • expected Cr excretion • female 18 mg/kg • male 23 mg/kg • interpretation • > 80 % 0-mild depletion • 60-80% moderate depletion • < 60% severe depletion Factors affecting CHI reliability • renal insufficiency • rhabdomyolysis • bed rest • catabolic state • incomplete collection

43. Creatinine Height Index/ Excretion Factors affecting CHI reliability • renal insufficiency • rhabdomyolysis • bed rest • catabolic state • incomplete collection

44. Functional Assessment • Somatic protein • handgrip strength • lung mechanic: negative inspiratory pressure, maximum ventilatory vol • muscle stimulation • Immune response • Delayed type cutaneous response • total lymphocyte count

45. Immunocompetence • Malnutrition: immunocompromized • DHR, total L count :detect malnutrition related immuno-suppression • DHR affected by hepatic failure, e’lyte imbalance infection, renal insufficiency • TLC <1500mm3 affected by infection, stress, chronic diseases • in most hospitalized patient : DHR, TLC not useful in nutrition assessment

46. Nutrition Support

47. Nutritional Support Indication • NPO > 10-14 day • PEM or at nutritional risk • Inadequate oral intake • Maldigestion, malabsorption • Nutrient loss fistula, dialysis, drainage • Hypercatabolic state: sepsis, burn, multiple trauma • Perioperative severely malnorished • Undergoing BMT

48. Improve nutritional depletion malnourished/ low catabolism Maintain nutritional status/ prevent malnutrition malabsorption unable to eat Minimized nutritional related complication critically illness moderate hypercatabolic state Improve clinical outcome perioperative nutrition nutrition in BMT trauma Nutrition Aim/ Goal

49. Nutrition Requirement

50. Energy Requirement • Estimated • Harris-Benedict equation • Kcal/kg/d • Measured • indirect calorimetry